UNM FMJournal Club

A New Paradigm and ExampleJuly 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

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

Intern

PGY2

Peanut Gallery

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

P I C O One model for developing clinical

question

4 components P Patient/Population/Problem I Variable of Interest C Comparison/Control O Outcome

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

Question Study Design

Intervention/Therapy

Systematic Review/Meta AnalysisRandomized (efficacy)Cohort study (effectiveness)

Etiology/Harm CohortCase ControlCase Series

Diagnostic Testing Cohort Cross-sectional

Prognosis CohortCase ControlCase Series

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

How to pick an article

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

ACP Journal Club annals.org/journalclub.aspx

Evidence Updates plus.mcmaster.ca/EvidenceUpdates/

Essential Evidence Plus www.essentialevidenceplus.com/

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

Limiting by Language Humans Study Design

For more details, see hand out

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 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

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

Challenge: Figuring out ways to engage the group

Example of how it will

work

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

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

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

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

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

Gram stain for everyone Separate slide Sent to outside hospital lab Standardized 0-10 point score Nugent criteria, score of 7+ gold

standard

Outcome

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

Sensitivity, specificity

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

+ -

+ 67%N=70

7%N=12

- 33%N=34

93%N=153

BV diagnosed by gram stain

Presence Amine odor

100%N=104

100%N=165

0.67*104 = 700.33*104 = 340.07*165= 120.93*165= 153

N + test = 70 + 12 = 82N - test = 34 + 153 = 187

PPV = 70/82 = 85%NPV = 153/187=82%

LR+ = 0.67/0.07 = 9.6LR- = 0.33/0.93 = 0.35

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 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

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? Thanks for your attention