EBM Journal Club Yale Pediatrics 2006-2007

Goals of Pediatric Journal Club To answer important clinical questions using the available medical literature To learn and apply basic critical appraisal skills based on the type of question being answered To validate or change your clinical practice or institute new practices based on critical appraisal of the medical literature To practice and teach these skills to each other in real clinical situations during morning rounds, on-call, during morning report or discharge conference, in the clinic, etc.

Journal Club Format Third year Pediatric and Fourth year Med-Peds residents will each be assigned a faculty preceptor Each resident should meet with their preceptor 2-3 times prior to the presentation of their journal club, ideally starting at least 2 weeks before the presentation date Each journal club should start with a clinical question based on an actual patient!

Journal Club Format With the help of your preceptor, perform a literature search and choose a key article that addresses your question (Medical Librarians can also help with this step!) Use the User’s Guide to the Medical Literature and/ or Sackett’s EBM book to assess the validity, importance, and applicability of the results depending on the type of study you are appraising (this is the really important part!) On-line User’s Guide, Critical Appraisal Worksheets, and other toolkits will be available through links on the website

Format for the Presentation Present the clinical scenario and your clinical question Review the search strategy used Review the critical appraisal Address how the results may apply to your patient and/or to future patients

What is EBM? “Evidence based medicine is the integration of individual clinical expertise with the best available external evidence from systematic research” Sackett D. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312:71-72.

Use of EBM in Clinical Practice The Five Steps of EBM Ask answerable clinical questions Search relevant literature efficiently Appraise found data critically Apply valid evidence into clinical decision-making Evaluate and improve the process for future use (Onady & Raclich, Pediatrics in Review September 2002)

Building a good question Start with a patient or problem Define the intervention you are interested in (can be a prognostic factor, treatment, diagnostic test, etc.) Define a comparison intervention, if relevant Define the clinical outcome that you are interested in

Comparison intervention Outcomes Patient or Problem Intervention Comparison intervention Outcomes Tips for Building Describe a group of patients similar to your own What intervention are you considering What is the main alternative to the intervention What do you hope to accomplish with the intervention Example “In patients with anemia of prematurity… …does treatment with erythropoietin… …when compared with standard therapy alone… …lead to a decrease in the number of needed transfusions?”

Common types of questions ? about THERAPY ? about ETIOLOGY or HARM ? about DIAGNOSIS and SCREENING ? about PROGNOSIS Categorizing your question will help you in searching for the evidence

A 2-year-old patient presents with a 12-month history of recurrent wheezing, cough, dyspnea, and mucopurulent nasal discharge. There are no smokers in the household, and all pets have been removed. Antibiotics and antihistamines have been tried without sustained benefit. Physical exam demonstrates normal growth and normal vital signs. Thick yellow nasal discharge is noted, and bilateral expiratory wheezes are heard on chest auscultation.

Some Clinical Questions from 2005-2006 Journal Club In patients with Type I Diabetes, is inhaled insulin as effective as subcutaneous insulin as measured by the HgbA1C? In patients who are diagnosed with mild-moderate VUR after an episode of acute pyelonephritis, will prophylactic antibiotics decrease the incidence of recurrent UTI? In young infants at risk for rotavirus, which of the two new rotavirus vaccines is most efficacious at preventing severe rotavirus gastroenteritis while minimizing occurrence of adverse events? In VLBW infants, do probiotics decrease the incidence of NEC, without significant adverse effects?

Where are the answers????? Current texts or on-line texts/ review articles, MD Consult are good places to answer “background questions” Focused searches of the literature are most likely to lead you to useful answers to foreground questions.

What databases are available? MEDLINE Most comprehensive, sometimes hard to find what you are looking for Available through Ovid Technologies, Pubmed, BioMedNet Cochrane Library Compendium of systematic reviews, available through OVID EBM Reviews Includes Cochrane Library plus several other EBM databases (Best Evidence, DARE, ACP Journal Club), available through OVID Others: Aidsline, Cancerlit, Healthstar, etc.

How do I access these databases? PubMed is available free of charge through the internet: website address is in the handout Most other databases and database packages are available by subscription Best option for free access to many different databases is to log onto the medical library proxy server

Search strategy Select your most likely source Often helpful to start by searching EBM reviews looking for critically appraised studies and/or systematic reviews and then go on to a standard Medline search if no luck Depending on when you need the information and what you need it for you can design a search with high specificity or high sensitivity Both Ovid and Pubmed allow you to select filters to maximize your chances of obtaining helpful results

Systematic Reviews Identify a focused research question Identify inclusion and exclusion criteria for studies to be included Include a full description of the search strategy Assess validity of each primary trial Outcome data are extracted and tabulated for each included trial A “typical effect” weighted average for each outcome is then calculated

Resources for Systematic Reviews for Pediatricians Cochrane Collaboration DARE (Database of Abstracts of Reviews of Effectiveness) ACP Journal Club Journal of Pediatrics Archives of Pediatrics and Adolescent Medicine Pediatrics

The Cochrane Library

Oxford Centre for EBM Levels of Evidence (May 2001) for Therapy or Harm Questions Type of Evidence 1 Systematic Review of RCTs with homogeneity Individual RCT with narrow confidence interval 2 Systematic Review of cohort studies with homogeneity Individual Cohort study or low quality RCT Outcomes Research; Ecological studies 3 Systematic Review of case-control studies with homogeneity Individual Case-Control Study 4 Case series and poor quality cohort and case-control studies 5 Expert opinion without critical appraisal, or based solely on physiology or bench research

EBM Resources Interactive Tutorial www.hsl.unc.edu/services/tutorials/ebm/index.htm Toolkits (include NNT, confidence interval calculators, PDA downloads, additional worksheets) www.mclibrary.duke.edu/training/pdaformat/ebm.html http://www.cebm.utorontl.ca/ www.uic.edu/depts/lib/lhsp/resources/ebm.shtml http://www.cebm.net/toolbox.asp www.med.ualberta.ca/ebm/ebm.htm Links Available via the Yale Pediatric Journal Club Website

Upcoming Attractions

Introduction to Critical Appraisal Of The Medical Literature Monday August 14 Matt Bizzarro Monday Aug 28 Keith Cross Introduction to Critical Appraisal Of The Medical Literature Journal Club Kick-off