Yale Pediatrics 20062007

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Yale Pediatrics 2006-2007
EBM Journal Club
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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.

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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!

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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 Users Guide to the Medical Literature
  and/ or Sacketts 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 Users Guide, Critical Appraisal
  Worksheets, and other toolkits will be available
  through links on the website

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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

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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 isnt. BMJ 1996 31271-72.

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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)

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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

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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

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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.
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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 withmild-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 vaccinesis most
  efficacious at preventing severe rotavirus
  gastroenteritis whileminimizing occurrence of
  adverse events?
• In VLBW infants, do probiotics decrease the
  incidence of NEC, without significant adverse
  effects?

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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.

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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.

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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

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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

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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

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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

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The Cochrane Library
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Oxford Centre for EBM Levels of Evidence (May
2001) for Therapy or Harm Questions
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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
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Upcoming Attractions
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Monday August 14 Matt
Bizzarro Monday Aug 28 Keith
Cross
Introduction to Critical Appraisal Of The Medical
Literature
Journal Club Kick-off