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
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 PPatient/Population/Problem IVariable of Interest CComparison/Control OOutcome
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 QuestionStudy Design Intervention/TherapySystematic Review/Meta Analysis Randomized (efficacy) Cohort study (effectiveness) Etiology/HarmCohort Case Control Case Series Diagnostic TestingCohort Cross-sectional PrognosisCohort Case Control Case Series Different types of questions are addressed by different types of study designs
How to find evidence to answer question Databases of primary research PUBMED/MEDLINE www.ncbi.nlm.nih.gov/pubmed/ www.ncbi.nlm.nih.gov/pubmed/ Free EMBASE Proprietary Cochrane Library Data base of systematic reviews www.thecochranelibrary.com/view/0/index. html www.thecochranelibrary.com/view/0/index. html
Other sources ACP Journal Club annals.org/journalclub.aspx annals.org/journalclub.aspx Evidence Updates plus.mcmaster.ca/EvidenceUpdates/ plus.mcmaster.ca/EvidenceUpdates/ Essential Evidence Plus www.essentialevidenceplus.com/ 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
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 2-4 th 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
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?