1. 1 Topic 6 CRITICAL APPRAISAL OF MEDICAL ARTICLES Jarmila Potomková Medical Librarian Jan Strojil Department of Pharmacology Palacky University Faculty of Medicine Olomouc, Czech Republic Updated February 2009 potomkov@tunw.upol.cz

2. 2 CRITICAL APPRAISAL IN GENERAL Technique, skill  Increasing effectiveness of your reading  Excluding poorly designed studies  Helping decide which articles could influence your daily work which are unsuitable.

3. 3 Searching for Best Evidence „Well-built Questions“ Crohn´s Disease: A Role of Psychotherapy

4. 4 Live Case Scenario University Hospital Olomouc : 2007  Case 16-year old boy, Crohn´s diasease diagnosed in the age of 13; Hospitalized for relapse of disease; In a series of interviews he disclosed pharmacologic treatment noncompliance

5. 5 Foreground Question: PICO Format  P/Patient, population, problem adolescent boy; Crohn´s disease/relapse  I/Intervention drug treatment  C/Comparison druh treatment + psychological therapy  O/Outcome improved quality of life

6. 6 Background Question What is Crohn´s disease?  Crohn's disease is a chronic inflammation of the intestinal wall that may affect any part of the digestive tract.  In the past few decades, Crohn's disease has become more common worldwide. It is most common among populations living in northern climates in developed areas of the world. It occurs about equally in both sexes, often runs in families. Most people develop Crohn's disease before age 35, usually between the ages of 15 and 25.  Typical symptoms include chronic diarrhea (which sometimes is bloody), crampy abdominal pain, fever, loss of appetite, and weight loss.  Although Crohn's disease has no known cure, many drugs help reduce inflammation and relieve symptoms.. Source: Merck Manual – Home Edition. Available from: http://www.merckmanual.com

7. 7 Merck Manual – Home Edition

8. 8 PubMed Search Consolidation Search Strategy  Selection of search terms Keywords Phrases Synonyms  Combination of search terms Boolean logic  Application of limits Occurrence of search terms  Title, Title/Abstract, All fields Types of articles Age groups Etc.

9. 9 Boolean logic  AND: Combines terms to limit your search as both concepts must be present in all retrieved articles Example: Crohn* AND psychotherapy  OR: Widens your search as either term can be present in all retrieved articles Example: psychotherap* OR psycholog* OR counsel* OR educat*  NOT: Limits your search by excluding a concept as one term must be present and the second term must not be present Example: Crohn* NOT surgery

10. 10 Truncation *  PubMed finds all terms that begin with a given text string  Example  Crohn*  PubMed retrieves: Crohn disease, Crohn´s disease,,,,,,,,,

11. 11 Crohn´s disease : a role of psychotherapy Search terms Crohn(´s) disease Psychotherapy Psychological therapy Counselling Patient education Psychosomatic

12. 12 Search Strategy Suggestions Step 1 Crohn* Limits: Title Step 2 psychotherap* OR psycholog* OR psychosomatic OR counsel* OR educat* Limits: Title/Abstract Step 3 Combine searches #1 AND #2 Step 4 Limits: Type of article/Randomized controlled trial

13. 13 Combine Searches

14. 14 Combine Searches - Results

15. 15 Limits: Type of Article: Randomized Controlled Trial

16. 16 Original Articles Randomized Controlled Trials

17. 17 PubMed Search Results  All: 145 Reviews: 24  Traditional („narrative“)  Systematic + Meta-analysis (pre- determined criteria of study inclusion) Randomized Controlled Trials: 9

18. 18 Example of Randomized Controlled Trial  Keller W. et al.  Effect of psychotherapy and relaxation on the psychosocial and somatic course of Crohn's disease: main results of the German Prospective Multicenter Psychotherapy Treatment study on Crohn's Disease.  J Psychosom Res. 2004;56(6):687-96. J

19. 19 RCT for Critical Appraisal

20. 20 CASP – Critical Appraisal Skills Programme: Appraisal Tools http://www.phru.nhs.uk/Pages/PHD/CASP.htm

21. 21 CASP RCT – Screening Questions

22. 22 Any Published Comments on Article?

23. 23 Commentary

24. 24 Professional Databases with Critically Appraised Topics Clinical Evidence http://www.clinicalevidence.comhttp://www.clinicalevidence.com (fee)  Systematic reviews Question(s)  Option(s)  Grades of evidence Beneficial Likely beneficial Trade off between benefit and harm Unknown effectiveness Unlikely beneficial Etc.

25. 25 Clinical Evidence Interventions: Questions