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UNM FM Journal Club. A New Paradigm and Example July 16, 2014. Types of clubs. Our reality. Objectives of Journal Club. Develop clinical question and identify population, intervention, comparison, outcome Search literature efficiently and effectively to find evidence to address question

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Unm fm journal club

UNM FMJournal Club

A New Paradigm and Example

July 16, 2014


Types of clubs

Types of clubs


Our reality

Our reality


Objectives of journal club

Objectives of Journal Club

Develop clinical question and identify population, intervention, comparison, outcome

Search literature efficiently and effectively to find evidence to address question

Critically appraise available evidence and determine if it is valid and if it applies to your patient(s)/population

Gain experience presenting to group

Learn and practice effective teaching strategies


Journal club

Journal Club

Intern

PGY2

PGY3

Peanut Gallery


Pgy2 pgy3

PGY2 + PGY3

Each month, 1-2 PGY3’s and 1-2 PGY2’s will prepare journal club presentation which includes the following:

Develop question

Find article

Prepare presentation

Send materials to rest of group before day of presentation

Present and guide the group through critical appraisal


Well built clinical question

Well Built Clinical Question

  • P I C O

    • One model for developing clinical question

  • 4 components

    • PPatient/Population/Problem

    • IVariable of Interest

    • CComparison/Control

    • OOutcome


Pico t type of question

PICO + T: Type of Question

  • T=Type of Question

  • Different types of questions

    • Intervention/Therapy

    • Etiology/Harm

    • Diagnosis

    • Prognosis

  • Before finding an article that addresses your question, figure out what type of question it is.


Type of study

Type of Study

Different types of questions are addressed by different types of study designs


How to pick an article

How to pick an article


How to find evidence to answer question

How to find evidence to answer question

  • Databases of primary research

    • PUBMED/MEDLINE

      • www.ncbi.nlm.nih.gov/pubmed/

      • Free

    • EMBASE

      • Proprietary

  • Cochrane Library

    • Data base of systematic reviews

    • www.thecochranelibrary.com/view/0/index.html


Other sources

Other sources

  • ACP Journal Club

    • annals.org/journalclub.aspx

  • Evidence Updates

    • plus.mcmaster.ca/EvidenceUpdates/

  • Essential Evidence Plus

    • www.essentialevidenceplus.com/


Searching

Searching

  • Use PICO to formulate search strategy

  • Start with Patient Problem and Variable of Interest. Enter into search field

    • Example: Obesity AND diabetes AND bariatric surgery

  • Limitingby

    • Language

    • Humans

    • Study Design

  • For more details, see hand out


Preparing for the presentation

Preparing for the presentation

  • Team: question, article

  • Consult with TP/SW

  • Send abstract and important tables/figures out to group at least 24 hours prior to Wednesday of Journal club

  • Presentation of question and article

  • Engaging and guiding the rest of the group in the critical appraisal

  • Resources

    • Journal club schedule on WIKI

    • Guide for presentation/appraisal

    • Ideas for group activities


Presentation

Presentation

  • Question

  • Background-why is this issue important

    • Epidemiology

    • Impact on patient/population

  • Study

    • Purpose

    • Study Design

    • Population

    • Variable of interest

    • Comparison

    • Outcome

    • Results


  • Critical appraisal

    Critical Appraisal

    Challenge: Figuring out ways to engage the group

    Determine what the study is about

    Examine research and judge trustworthiness, value and relevance

    Determine if study is done in a way that make findings reliable

    Make sense of the results, in context of decision making for individual patient

    Form/guide to be made available


    Example of how it will work

    Example of how it will work


    Question

    Question

    31 year old female presents with history of vaginal discharge that has fishy odor. Speculum exam done, sample of discharge collected.

    Is it enough to find positive amine odor to make dx

    P = non-pregnant women with vaginal discharge

    I = amine odor as diagnostic test for BV

    C = Gram Stain

    O = Accurate diagnosis of BV

    Type of Question = diagnostic

    Type of Study to look for: Cohort, cross sectional


    Background

    Background

    • Bacterial vaginosis most common vaginal infection among women

    • Prevalence is 9-37%; 22-50% in symptomatic women

    • In pregnant women, BV increases risk of:

      • Preterm delivery

      • PPROM

      • Chorioamnionitis

      • Postpartum endometritis

    • In all women, increases risk of PID


    Diagnosis of bv

    Diagnosis of BV

    • Current gold standard for diagnosis is gram stain.

    • Other reliable diagnostic:

      • DNA probe of vaginal d/c

      • 3 of 4 criteria (Amsel)

        • Presence of thin homogenous discharge

        • Vaginal pH >4.5

        • Positive “whiff” test or release of amine odor with addition of base

        • Clue cells on saline wet preparation

    • Is amine odor enough to make diagnosis


    Article

    Article

    • Citation: Gutman et al.

    • Study purpose: Can diagnosis of BV be made accurately using only 2 of clinical criteria

    • Study design: prospective cohort study

    • Population: 269 women undergoing speculum exam for any reason

      • Excluded if large amount of vaginal bleeding on exam


    Variable of interest

    Variable of interest

    • Odor of discharge collected

      • Specimen collected

        • By 2-4th year OB-GYN residents, research nurse or PI. All trained

        • Did not know BV status of patient

      • Describes specimen collection and preparation-KOH

      • Assessment of smell


    Comparison

    Comparison

    • Gram stain for everyone

      • Separate slide

      • Sent to outside hospital lab

      • Standardized 0-10 point score

      • Nugent criteria, score of 7+ gold standard


    Outcome

    Outcome

    Accurate diagnosis of BV by amine odor only vs. gold standard

    Sensitivity, specificity


    Results

    Results

    • Prevalence of BV in study population was 38.7%

    • Table 1: characteristics of women with an without BV

    • Table 2: Sensitivity/Specificity

      • Sensitivity: 67% (CI: 57-76%)

      • Specificity: 93% (CI: 88-97%)

    • Did not provide PPV, NPV or LR but I can compute them myself


    Unm fm journal club

    BV diagnosed by gram stain

    Presence Amine odor

    0.67*104 = 70

    0.33*104 = 34

    0.07*165= 12

    0.93*165= 153

    N + test = 70 + 12 = 82

    N - test = 34 + 153 = 187

    100%

    N=104

    100%

    N=165

    PPV = 70/82 = 85%

    NPV = 153/187=82%

    LR+ = 0.67/0.07 = 9.6

    LR- = 0.33/0.93 = 0.35


    Interpretation of results

    Interpretation of Results

    • Using amine odor alone vs. gram stain

      • 85% of women who had BV were positive for amine odor

      • 93% of women who did not have BV were negative for amine odor

      • In other words, only 7% of women without BV had amine odor and would have be incorrectly diagnosed with (and maybe treated for) BV (false positives)

      • For my patient, if she has an odor, she has an 85% risk of having BV; if she has no odor; she still has 16% of having BV (False negative)


    Critical appraisal1

    Critical Appraisal:

    • Is the question studied by these investigators similar enough to my question?

    • Is the population studied similar to the population I am interested in (recall: non-pregnant women with vaginal discharge)

    • What are the flaws in the way the data were collected, analyzed? How could this affect the validity of the results.

      • Blinding?

      • Gold standard for everyone?

      • Reliability of data collection?


    Critical appraisal continued

    Critical Appraisal: continued

    • Do I understand the results, do I interpret them the same as the authors?

    • Were the results compelling enough?

      • Clinical significance demonstrated?

    • Are the results applicable to my patient?

    • Can I use this test in my practice?

    • Will I change my practice based on this evidence?


    Questions

    Questions?

    Thanks for your attention


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