1. EBM Journal Club
Yale Pediatrics

2. 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.

3. 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!

4. 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

5. 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

6. 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.

7. 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)

9. 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

10. 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?”

11. 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

12. 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.

13. 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?

14. 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.

15. 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.

16. 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

17. 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

23. 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

24. 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

25. The Cochrane Library

27. 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

28. EBM Resources Interactive Tutorial
Toolkits (include NNT, confidence interval calculators, PDA downloads, additional worksheets)
Links Available via the Yale Pediatric Journal Club Website

29. Upcoming Attractions

30. 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