1. UNM FM Journal Club A New Paradigm and Example July 16, 2014

2. Types of clubs

3. Our reality

4. 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

5. Journal Club Intern PGY2 Peanut Gallery PGY3

6. 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

7. 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

8. 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.

9. 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

10. How to pick an article

11. 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

12. 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/

13. 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

14. 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

15. Presentation  Question  Background-why is this issue important  Epidemiology  Impact on patient/population  Study  Purpose  Study Design  Population  Variable of interest  Comparison  Outcome  Results

16. 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

17. Example of how it will work

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. Outcome  Accurate diagnosis of BV by amine odor only vs. gold standard  Sensitivity, specificity

25. 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

26. +- +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 = 70 0.33*104 = 34 0.07*165= 12 0.93*165= 153 N + test = 70 + 12 = 82 N - test = 34 + 153 = 187 PPV = 70/82 = 85% NPV = 153/187=82% LR+ = 0.67/0.07 = 9.6 LR- = 0.33/0.93 = 0.35

27. 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)

28. 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?

29. 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?

30. Questions? Thanks for your attention