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i n f o p o e m s These InfoPOEMs® are selected by JNMA InfoPOEMS Editor Gregory E. Gilbert, MSPH, (Gregory.E.Gilbert@ gmail.com) and Associate InfoPOEMS Editor Amy H. Wahlquist, MS, from www.infopoems.com. InfoPOEMs® are created by experts who continuously survey medical journals worldwide. They identify and summa- rize valid and clinically applicable new evidence. For more information or to subscribe to e-mail alerts of InfoPOEMs®, please visit www.infopoems.com. STUDY LEVELS OF EVIDENCE (LOE) events, and the reporting of results From the Centre for Evidence-Based Tight Glycemic was sufficient to calculate individ- Medicine, Oxford. For the most up-to- Control May Decrease ual event rates. Please note that date levels of evidence, see www.cebm. net/levels_of_evidence.asp) Cardiovascular End they excluded 6 large trials because Points in Patients With cardiovascular events were not part Therapy/Prevention/Etiology/Harm: Type 2 Diabetes Mellitus of the primary study outcomes or 1a: Systematic reviews of randomized because the original papers did not controlled trials Clinical Question report individual event rates. Since 1b: Individual randomized controlled Does tight glycemic control there were only 5 studies included trials 1c: All or none randomized controlled decrease the rate of cardiovascular (33 000 patients), this is a big con- trials complications in patients with type cern. Some analysts would have 2a: Systematic reviews of cohort studies 2 diabetes mellitus? contacted authors to obtain missing 2b: Individual cohort study or low- data. Additionally, if cardiovascular quality randomized controlled Bottom Line event rates are measured in a com- 2c: “Outcomes” research, ecological studies If the authors of this systematic parable manner, it shouldn’t matter review have captured all the rele- if these were primary or secondary Diagnosis: vant studies, tight glycemic control end points. In the studies the authors 1a: Systematic review of level-1 decreases the rate of cardiovascular chose to include, the overall rate of diagnostic studies complications in patients with type nonfatal myocardial infarctions was 1b: Independent blind comparison of an appropriate spectrum 2 diabetes mellitus. There is strong 10 per 1000 patient-years in inten- of consecutive patients, all of reason to believe, however, that by sively treated patients compared whom have undergone both the excluding studies in which cardio- with 12.3 in control patients. The diagnostic test and the reference standard, or a clinical decision rule vascular outcomes were secondary, rate of coronary events was 14.3 not validated on a second set of and by relying solely on the pub- and 17.2, respectively, per 1000 patients lished outcomes (and not contact- patient-years. The rate of strokes 1c: Absolute SpPins and SnNouts ing authors for additional data), the (approximately 7 per 1000 patient- 2a: Systematic review of level >2 authors had incomplete data from years) and the total death rate were 2b: Independent blind or objective comparison, study confined which to draw their conclusions. comparable regardless of treatment to a narrow spectrum of study (LOE = 1a-) (approximately 18 deaths per 1000 individuals, or a diagnostic clinical patient-years). The average differ- rule not validated in a test set Study Design ence between glycohemoglobin lev- Prognosis: Meta-analysis (randomized con- els in patients treated with inten- 1a: Systematic review of inception trolled trials) sive care and with usual care was cohort studies approximately 1%. In these studies, 1b: Individual inception cohort study Funding blood pressure control and control with >80% foll
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