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  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  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 pick an article

How to find evidence to answer question  Databases of primary research  PUBMED/MEDLINE   Free  EMBASE  Proprietary  Cochrane Library  Data base of systematic reviews  html 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 

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 2-4 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

+- +67% N=70 7% N=12 -33% N=34 93% N=153 BV diagnosed by gram stain Presence Amine odor 100% N= % N= *104 = *104 = *165= *165= 153 N + test = = 82 N - test = = 187 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  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