CRITICAL

APPRAISAL
Group: 16
GROUP MEMBERS
Group leader:
• Genelyn A Zaspa 20002596810
Group members -
• Abhishek Kumar 20003089610
• Ajinkya Sapkal 18004659500
• Akash Chavhan 18004635400
• Atul Deshmukh 18004517300
• Deodutt Rohankar 18004635500
• Ganesh Rasal 18004635600
• Greeva Sanghavi 21008761410
CONTENTS

• Clinical Dilemma
• Search Process and Results
• Description of Selected Study
• Critical Appraisal
• Applicability
• Resolution
GENERAL DATA

• Name of Patient : Amitabh Bachhan

• Age : 40
• Sex : male
• Nationality : India
• Address : Nagpur,India
• Occupation : Bank Manager
• Date of Consult : January 10,2022
• A 40 year old Bank manager presented with of unintentional weight
fluctuations from past 6 months prior to hospital visit. He was
diagnosed with diabetes mellitus type-2 last year and was prescribed
metformin and lifestyle modifications. He has been trying to lose
weight and increase his exercise for the past 6 months without success.
He had been started on glyburide (Diabeta), 2.5 mg every morning, but
had stopped taking it because of dizziness, often accompanied by
sweating and a feeling of mild agitation, in the late afternoon,
prescribed metformin, 500 mg twice a day
 CHIEF COMPLAIN
• Weight Fluctuation
• Fatigue
 HISTORY OF PRESENT
ILLNESS
• Weight fluctuation in past 6 months
PAST MEDICAL
HISTORY :
• Medical history : Type 2 diabetes (recent diagnosis).
• Surgical history : Pyloric stenosis surgically repaired as a neonate.
• Medications : Metformin 500 mg twice times a day.
• Allergies : No known allergies
 FAMILY HISTORY
• 2 generation for Diabetes Mellitus Type2
• No family history of
i. Hypertension,
ii. Heart diseases
iii. No chronic diseases
PERSONAL/SOCIAL
HISTORY
• No alcohol intake
• Non smoker
• No recreational drug use
• Married
• No recent travel
PHYSICAL
EXAMINATION
BLOOD PRESSURE 130/90 mmHg

RESPIRATORY RATE 18

TEMPERATURE 36.8˚ C

HEART RATE 72
PHYSICAL
EXAMINATION
CVS – NO palpitation,syncope, angina
Pulmonary – mild dyspnea, breathlessness.
GI –NO nausea , vomiting,diarrhea, constipation, abdominal
pain, jaundice
Renal – NO frequency, urgency, hematuria, oliguria, loin pain

CNS – NO headache, tingling or numbness, weakness of both

upper & lower limbs, fits, change in sensorium.
Hematology - No pertinant findings
PHYSICAL
EXAMINATION
Musculoskeletal - NO pertinent findings.
Skin - NO pertinent findings.
Psychiatric - Low mood for the past 2 months. He is asking
you to authorize 2-weeks of sick leave as he struggles at work
due to poor concentration.
PHYSICAL
EXAMINATION
• Weight: 178 lb; height: 5′2″; body mass index (BMI): 21.4 kg/m2
• Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm
140/90 mmHg
• Pulse: 88 bpm; respirations 20 per minute
• Eyes: corrective lenses, pupils equal and reactive to light and
accommodation, Fundi-clear, no arteriovenous nicking, no retinopathy
• Thyroid: Nonpalpable
• Lungs: Clear to auscultation
• Heart: Rate and rhythm regular, no murmurs or gallops
• Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis
pedis pulses 2+ bilaterally
 INVESTIGATION
• Glucose (fasting): 134 mg/dl (normal range: 65–109 mg/dl)
• Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)
• Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)
• Sodium: 141 mg/dl (normal range: 135–146 mg/dl)
• Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)
• Lipid panel -
    • Total cholesterol: 162 mg/dl (normal: <200 mg/dl)
    • HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)
   • LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)
    • Triglycerides: 177 mg/dl (normal: <150 mg/dl)
    • Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)
INVESTIGTION

• AST: 14 IU/l (normal: 0–40 IU/l)

• ALT: 19 IU/l (normal: 5–40 IU/l)
• Alkaline phosphatase: 56 IU/l (normal: 35–125 IU/l)
• A1C: 8.1% (normal: 4–6%)
• Urine microalbumin: 45 mg (normal: <30 mg)
 DIFFERENTIAL
DIAGNOSIS
• Congestive Heart Failure

• Coronary Heart Disease

PLAN
Pharmacological management
• Metformin 500 mg, twice a day.

• Self-care management/lifestyle deficits

    • Exercise
    • Diet Control
CLINICAL
DILEMMA
CLINICAL DILEMMA
STATEMENT

Body-Weight Fluctuation Associated With

Increased Risk for Cardiovascular Disease
ANATOMY OF
CLINICAL DILEMMA
Clinical Dilemma
POPULATION Patients with Weight fluctuation with
Diabetes Mellitus type 2
INTERVENTION Lifestyle modification, Metformin 500 mg,
twice a day.
OUTCOME Decreased risk of CVD and all cause
mortality
METHOD Randomized Control Method
SEARCH
PROCESS
AND
R E S ULTS
 SEARCH PROCESS AND
RESULTS
Site we used : PubMed
SEARCH PROCESS AND
RESULTS
SEARCH PROCESS AND
RESULTS
JOURNAL CHOSEN
DESCRIPTION
OF THE
SELECTED
STUDY
DESCRIPTION
This study is the systemic review and meta analysis.

Body-weight fluctuation refers to the repeated loss and regain of

weight within a specific period. Body weight may fluctuate for a
variety of other reasons; for instance, various diseases also can cause
unintentional weight fluctuation which is associated with smoking,
aging and severity of the disease. The association between weight
fluctuation and health outcomes, especially with mortality and
cardiovascular disease (CVD). To clarify the association between
weight fluctuation and risk for death and CVD, we conducted a
systematic review and meta analysis of the available evidence from
published cohort studies.
• TITLE : Body-Weight Fluctuation Was Associated With Increased
Risk for Cardiovascular Disease, All-Cause and Cardiovascular
Mortality: A Systematic Review and Meta-Analysis

• AUTHORS : Huajie Zou1, Ping Yin2, Liegang Liu3,4, Wenhua

Liu5, Zeqing Zhang1, Yan Yang1, Wenjun Li6, Qunchuan Zong7
and Xuefeng Yu1

• PUBLICATION : Specialty section: This article was submitted to

Obesity, a section of the journal Frontiers in Endocrinology
Received: 01 August 2019 Accepted: 09 October 2019 Published:
08 November 2019
SAMPLE ABSTRACT
 COMPARISON OF
ANATOMY Clinical Dilemma Journal Article

Population Patients with Weight fluctuation with Diabetes Patients with Body-weight
Mellitus type 2 fluctuation.

Intervention Lifestyle modification, Metformin 500 mg, twice a Lifestyle modification as preventive
day for blood glucose control. measures for risk associated with
CVD

Outcome Weight management decreases risk of CVD and all Decreased risk of CVD and healthy
cause mortality. living.

Method Randomized Control Trial Random effects model

 SAMPLE
SELECTION
 SAMPLE SELECTION
INCLUSION CRITERIA :
• We included cohort studies conducted in aged 18 years or older and documented
exposure to body-weight fluctuation. Weight fluctuation was defined as weight
gain or loss in a specific period, and change in the opposite direction (loss or
gain) in the next period. It was measured by a continuous variable (i.e.,
coefficient of variation or root mean square error) and/or a categorical variable
(i.e., weight cycle). The stable weight category or lowest category for
continuous variables of weight fluctuation was used as the reference.
• The primary outcomes were risks for mortality from all causes, CVD and cancer,
and the secondary outcome was the risk for morbidity of CVD and
hypertension. Publications that provided adjusted or crude relative risk (RR)
estimates such as risk ratios, incidence rate ratios, hazard ratios or odds ratios
with 95% confidence intervals (CI) for weight fluctuation were eligible. Only
articles published in English were considered.
• Multiple publications from the same cohort study were reviewed, and only the
papers with the longest follow-up for identical outcomes were included.
SAMPLE SELECTION
EXCLUSION CRITERIA :
• After ineligible studies were excluded from the 8,640 studies identified
by the initial search, 23 cohort studies [25 publications (5–29)] were
included in our meta-analysis (Figure 1). Among the 25 publications (23
studies), 20 studies provided statistical results relevant to the meta-
analyses on mortality, 5 studies on CVD and 4 studies on hypertension.
• Articles published in different language were not considered.
• Papers with the short follow-up for identical outcomes were not
included.
• Publications that did not provide adjusted or crude relative risk (RR)
estimate such as risk ratios, incidence rate ratios, hazard ratios or odds
ratios with 95% confidence intervals (CI) for weight fluctuation were
not eligible.
 PA R A M ETER
USED
IN
APPRAISAL
Appraisal of Results
Appraisal of Validity Appraisal of Applicability
APPRAISAL
OF
VALIDITY
 TESTS FOR VALIDITY

• Was the research questioned focused and clearly described?

• Was the inclusion and exclusion criteria clearly defined?
• Did the authors use relevant type of study for the research question?
• Was the study selection process systematic?
• Was the literature research systematic and reproducible ?
• Has the publication bias been prevented as far as possible?
• Were the statistical methods used to combine the studies reported?
 APPRAISAL OF
VALIDITY
Was the research questioned focused and clearly
described?
• Was the inclusion and exclusion criteria clearly
defined?
• Articles published in different language were not
considered.
• Papers with the short follow-up for identical outcomes
were not included.
• Publications that did not provide adjusted or crude
relative risk (RR) estimate such as risk ratios, incidence
rate ratios, hazard ratios or odds ratios with 95%
confidence intervals (CI) for weight fluctuation were not
eligible.
 APPRAISAL OF
Was the study selection
VALIDITY
process systematic?
APPRAISAL OF
VALIDITY
WAS THE LITERATURE SEARCH SYSTEMATIC AND
REPRODUCIBLE ?
APPRAISAL OF
VALIDITY
Has the publication bias been prevented
as far as possible?
Were the statistical methods used to combine the
studies reported?
APPRAISAL
OF
RESULTS
RESULTS
Twenty-five eligible publications from 23 studies with 441,199
participants were included. Body-weight fluctuation was associated with
increased risk for all-cause mortality (RR, 1.41; 95% confidence
interval (CI): 1.27–1.57), CVD mortality (RR, 1.36; 95% CI 1.22–1.52),
and morbidity of CVD (RR, 1.49, 95% CI 1.26–1.76) and hypertension
(RR, 1.35, 95% CI 1.14–1.61). However, there was no significant
association between weight fluctuation and cancer mortality (RR, 1.01;
95% CI 0.90–1.13). No evidence of publication bias was observed (all P
> 0.05) except for studies on all-cause mortality (Egger’s test, P = 0.001;
Begg’s test, P = 0.014).
RESULTS

• Summary RRs
for the
association
between weight
fluctuation and
CVD and
hypertension.
Size of data
markers is
proportional to
the weight of
each report. RR
and 95% CIs
were calculated
 using the

RESULTS

• Hypertension (RR, 1.35, 95% CI 1.14–1.61; P = 0.001)

• CVD (RR, 1.49; 95% CI 1.26– 1.76; P < 0.001)
RESULTS

In this meta-analysis of 25 studies involving more than 400,000 participants,

body-weight fluctuation was associated with a significant increase in risk of all-
cause mortality, CVD mortality, and CVD.
APPRAISAL OF
RESULTS
• Twenty studies were included to analyze the association of weight
fluctuation and the risk of all-cause mortality. The summary RR for all-
cause mortality was 1.41 (95% CI 1.27–1.57; P < 0.001) using a
random-effects model. . The results revealed that weight fluctuation
was associated with an increased risk for CVD mortality. the
association between weight cycling and all-cause mortality did not vary
by BMI or age. However, no association was found between weight
variation and CVD in obese participants (BMI ≥ 30). analysis indicated
that weight fluctuation was associated with a higher risk for
hypertension. No significant heterogeneity was detected.
APPRAISAL OF
RESULTS
• From the perspective of the number of studies, 21 of the 28 reports
showed that body weight fluctuation was associated with increased
risk of all-cause and CVD mortality.
• Subgroup analysis showed that regardless of the method of weight
fluctuation measurement, its association with all-cause and CVD
mortality does exist
• The results from our study found that an increased risk for all-cause
mortality was observed at all ages and that a higher risk of CVD
mortality was observed only in individuals
• Fluctuation in body weight was also associated with an increased risk
for morbidity of hypertension and CVD and for mortality of CVD,
which may account for the increased risk of all-cause mortality.
LIMITATIONS
• Findings from this review are based on observational data, and no causal
links may be concluded
• Different definitions and measurements for weight fluctuation of
included studies may be potential confounding variables, although we
have conducted detailed subgroup, sensitivity and meta-regression
analyses to confirm robustness of the results.
• most studies cannot identify intentional or unintentional weight
fluctuation, which may have different effect on association between
weight fluctuation and health outcomes.
• the present study did not directly compare clinical outcomes of body-
weight fluctuation and maintenance of overweight/obesity or of long-
term and stable weight loss
CONCLUSIONS

• In conclusion, the present systematic review and meta-analysis

revealed that body-weight fluctuation was associated with higher
mortality of all causes and CVD and morbidity of CVD and
hypertension. Future study is needed for the causal links between
weight fluctuation and adverse health outcomes.
APPRAISAL
OF
APPLICABIL
ITY
 APPRAISAL
OF APPLICABILITY
1. According to you, Is that research applicable to all the patients with DM-2 and
weight fluctuations ?
YES
2. Is this study helpful in preventive measures over CVD complications with patients with
body-weight fluctuation?
YES
3. Is study’s findings of any diagnostic tests and procedures appropriate?
YES
4. Do you think the patient, family and or community will be willing to pay
for the Preventive measures in question?
YES
RESOLUTION
The present systematic review and meta-analysis revealed
that body-weight fluctuation was associated with higher
mortality of all causes and CVD and morbidity of CVD
and hypertension. Future study is needed for the causal
links between weight fluctuation and adverse health
outcomes.

As the research clearly shows Body weight fluctuations

increases the risk for CVD, HYPERTENSION and other
causes of mortality, it is very important for us as doctors,
to educate the people about the risks of weight fluctuations
and proper diagnostic tests should be asked in order to
assess the high risk cases with long term weight
fluctuations.
REFERENCES
REFERENCES