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Journal Club - a hands on guide for physicians

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Journal Club

 

“A hands on Guide for Physicians”

 

by

 

Dr Shahan Waheed

 

Shakespir Edition

 

Copyright 2016 by Shahan Waheed

 

 

Contents

 

 

 

 

 

 

About the authors

Introduction

Acknowledgements

 

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p<>{color:#000;}. Understanding the Basics 6

 

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p<>{color:#000;}. Setting up stage 11

 

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p<>{color:#000;}. Gearing up – Frame a clinical question 14

 

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p<>{color:#000;}. Literature search – what are the options? 16

 

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p<>{color:#000;}. The Skeleton of an article 20

 

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p<>{color:#000;}. Appraise the evidence 23

 

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p<>{color:#000;}. How to make an effective presentation? 29

 

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p<>{color:#000;}. Further reading 33

 

References

 

 

About the Authors

 

 

 

 

 

 

Shahan Waheed

 

Instructor in the department of Emergency Medicine with a passion for clinical research and Emergency Medicine education. Working presently in the department of emergency medicine, Aga Khan University Hospital, Karachi, Pakistan. He has multiple publications to his credit related to emergency medicine and traumatic brain injuries.

 

Nadeemullah Khan

 

Associate Professor of Emergency Medicine and a Consultant toxicologist. He is Diplomate American Board in Internal Medicine with post-doctoral toxicology training from John’s Hopkins School of Public Health. He is associated with AKU since 2001. He is also head of EM fellowship committee at CPSP and program director of Emergency Medicine Residency Program at AKU. He has multiple publications to his credit related to emergency medicine and toxicology and is a reviewer of toxicology related articles in journals

 

Rubaba Naeem

 

Research Coordinator in the department of Emergency Medicine Aga Khan University Hospital. She is Masters in Sociology and has done a short diploma in of Epidemiology and Biostatistics. She is an active member of the research team at DEM-AKUH since 2010 and grant coordinator since 2012.

 

 

Waqaas Akmal Butt

 

Third year MBBS student currently enrolled in the Aga Khan University, Karachi.

 

Muhammad Akbar Baig

 

An emergency physician with a passion for education and clinical research. Working as an instructor in the department of emergency medicine, Aga Khan University Hospital. He has multiple publications in his name and has interest in trauma and critical care.

 

 

 

 

 

 

 

 

 

 

 

Introduction

 

Journal Club presentations has always been a daunting tasks for the postgraduate trainees. There is no such text that can guide the trainee to this important and difficult task. It is just like learning a foreign language – wherever you start, you come across unfamiliar words and concepts. However, the key to success here as in other subjects is persistence. The primary aim of this handbook is to equip the trainee with the essential steps of the journal club in a short possible time. The busy schedule and the long hours of the post graduate trainee makes it difficult to master resulting it as a burden that trainee has to gone through.

Journal club presentation skills allow the trainee to prioritize evidence that can improve outcomes. Such is the importance of acquiring these skills that journal club presentations are now an important essence in postgraduate medical and dental training.

The book is a one-stop solution for all medical trainees. Based on our clinical research experience, we took a unique back-to-basics approach that provided a logical and comprehensive review of the subject.

We hope that this book will prove to be an indispensible tool for journal club presentations for the postgraduate trainees.

 

 

Acknowledgements

 

 

 

 

 

I would like to thank Dr Uzma Rahim Khan: my understanding and interest of clinical research would have faded if you have not supported and helped me.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chapter 1

 

Understanding the Basics – What is journal club and Evidence based medicine?

 

 

Introduction:

 

Journal club presentations have always been a daunting task for junior and senior residents because of the meager understanding of the principles that hold its foundation. Whether being an emergency physician, an internist, a surgeon or a trainee in any medical specialty, journal club presentations have been a difficult job for many. In Montreal in 1875, Sir William Osler is considered to have conducted the first journal club at McGill University. He suggested that the physicians read literature with two objectives; the first is to get acquainted with the current knowledge on a subject and the steps by which it has been developed. The second objective is to understand and analyze your case. It is essential for the presenter to first identify the reasons for making him/her present in a journal club session. The journal clubs are meant to increase the individual understanding of a research paper in order to improve patient care. There are numerous factors that are considered integral for the success of a journal club session and one of the most important is creating interest. We believe that in order to develop interest in a trainee the understanding of the subject is a prime task one should consider. In this chapter and the other we will discuss some important concepts that will help you develop skills in journal club presentations.

 

Journal Club (JC):

 

It is a group of people who gather to discuss the merits and clinical utility of articles that are relevant to one’s practice.

 

Types of Journal clubs:

 

The journal clubs are aimed at updating knowledge related to one’s interest and updating clinical practice. It is also aimed to develop teaching and learning critical appraisal techniques with evidence-based medicine. Following are the different types of journal club activities that are encountered in the literature.

 

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p<>{color:#000;}. Innovative Journal club

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p<>{color:#000;}. Problem based journal club

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p<>{color:#000;}. Critical appraisal journal club

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p<>{color:#000;}. Evidence based journal club

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p<>{color:#000;}. Alternative journal clubs

 

Goals of a Journal club:

 

The journal club presentations are intended for learning and developing skills for the practice of medicine. Below are a few of the potential goals that a journal club of a trainee program possesses;

 

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p<>{color:#000;}. Introduction of a medical field of practice to the trainees

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p<>{color:#000;}. Developing knowledge of recent advances in medical practice

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p<>{color:#000;}. Learning how to critically appraise an article

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p<>{color:#000;}. To learn biostatistics

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p<>{color:#000;}. Building database of reviewed material

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p<>{color:#000;}. Extracting literature through effective literature search

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p<>{color:#000;}. To review the finding of an article that is not being practiced

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p<>{color:#000;}. To develop and sharpen presentation and teaching skills

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p<>{color:#000;}. Identifying the areas of future research

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p<>{color:#000;}. To be abreast with the practice of new diagnostic and treatment strategies

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p<>{color:#000;}. Improving ones clinical acumen

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p<>{color:#000;}. To provide a platform to discuss controversies in diagnosis and treatment of particular medical problems with colleagues.

 

Evidence-based medicine (EBM):

 

It has a significant impact since its inception in early 1990s on improving healthcare outcomes. It is a phrase that is used to describe the process of practicing medicine with the amalgamation of available research evidence, clinical expertise and patient values. The commonly used definition of EBM is

 

“The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.”

 

 

 

 

 

Figure 1: Elements of Evidence-based medicine ( fig. 1 needs to be referenced in the text

 

5 – Steps of the Practice of Evidence Based Medicine (EBM):

 

The practice of evidence-based medicine begins with the formulation of a structured clinical question about an aspect of patient management. This is followed by the search of the best evidence with which to answer the question. The collected evidence is then evaluated, critically appraising the evidence for its validity, applicability and impact. The results of the appraisal are applied to clinical practice, integrating the critical appraisal with clinical expertise and the patient’s circumstances. The next step is the implementation and the monitoring of the process. The final step is aimed to evaluate the effectiveness and efficacy of the process and to identify ways of improving them for the future. The aforementioned steps are shown in figure 2 below;

 

 

Figure 2: Evidence-Based Medicine: The 5 Steps

 

Critical appraisal:

 

Critical appraisal is an important step in the process of evidence-based medicine. The reason of it being a core (?) those different studies that are being selected might draw conflicting conclusions. Also, actual medical practice rarely follows the restricted environments in which clinical trials are conducted. So we do it in order to apply, implement and monitor the evidence that can be reproduced into the practicing clinical environment.

 

It is a process of evidence-based medicine that helps the clinician evaluate the research and decide which research evidence can have a beneficial clinical impact on their patients. It allows the clinician to exclude research that is not confirming the areas of medical practice because of its poor design. It is not that the critical appraisal has any impact on the improved clinical outcomes, it is when the results drawn from the appraised studies are applied to everyday practice and the outcomes are followed for patient improvement. It assesses the validity of the clinical research and statistical techniques that are employed in the studies and generates clinically beneficial information from it. Two major questions are answered in the critical appraisal process:

 

#
p<>{color:#000;}. Internal validity – This refers to how well an experiment is done, especially whether it avoids confounding (more than one possible independent variable [cause] acting at the same time). The less chance for confounding in a study, the higher its internal validity. It simply means that within the confines of the study the results appear to be accurate.

#
p<>{color:#000;}. External validity – This is defined as the ability to generalize the study results to other groups, population and settings beyond those in the current experiment or study.

 

Reliability:

 

In order for the results from a study to be considered valid, the measurement procedure must first be reliable. Reliability, in simple terms, describes the repeatability and consistency of a test.

 

Efficacy:

 

It is the impact; the interventions have under optimal conditions. It shows that the internal validity is present

 

Effectiveness:

 

It describes whether the interventions have the intended or expected effect under ordinary (clinical) circumstances. It shows that the external validity is present.

 

Chapter 2

 

Setting up the stage

 

The journal club presentation follows a stepwise methodological approach with the formulation of a clinical question that is based on the clinical encounter that one experiences during the practice or while reading the literature. This formulation of the question is based on a structured pattern that involves the population, intervention, comparison, outcome and study design (the famous PICOD). This is followed by the search for the evidence for the question that you have in your mind following the pyramid in Figure 3. This process is followed by the selection of the best evidence that is relevant, focused, up to date and has a appropriate study type and ending in a final step of the critically appraising an article. The steps mentioned above are seemingly complex but once followed is a structured way of making your presentation the best. The steps are shown in a flow chart in Figure 4.

 

 

Figure 3: Hierarchy of evidence

 

Questions faced during a clinical practice Journal Club Presentation

 

 

 

 

 

 

[
**]

 

 

 

 

 

Figure 4: Flow chart showing the steps involved in a journal club presentation

 

Making your journal club successful:

 

There are many factors that are important for the success of a journal club in training:

 

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p<>{color:#000;}. Attendance – the journal clubs must be incorporated as a part of the training in residency as discussed before. The attendance of the residents must be considered essential and the trainee must be freed from their responsibilities on the day assigned so that they could learn at ease.

 

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p<>{color:#000;}. Resident Journal Club – the journal clubs are meant to make the trainee learn the skills that are essential for the critique of medical literature and to gather evidence that can be applied in day to day practice. The journal club must be separate from the faculty journal club in order to promote ease in which the trainee can present the article. The final journal club during which all the trainees and faculty can present their journal clubs for the year and learn the experiences they have gained in the year follows the presentation.

 

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p<>{color:#000;}. Planning teaching sessions of critical appraisal skills.

 

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p<>{color:#000;}. Provision of sustenance

 

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p<>{color:#000;}. Selection of articles that are relevant to the specialty

 

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p<>{color:#000;}. Providing a space to discuss the controversial issues in the practice

 

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p<>{color:#000;}. The journal club presentations must be kept to a minimum in the assigned day of the week.

 

Chapter 3

 

Gearing up – Frame a clinical question

 

Introduction

 

To develop questions is not an easy task. The primary step in the journal club is the formulation of a question that must follow a structured approach with the four components of Patient, Intervention, Comparison and Outcome. It is an important step in the journal club presentation as you can appreciate in the chapters to follow. The question formulation steps will be discussed in the following paragraphs.

 

The Approach

 

Many research geeks spend much of their time in making their question appropriate before embarking further on to their journal club presentations. I believe that it is the best approach as it helps in getting a search strategy that is appropriate and the end result is expected to be flawless. If there is difficulty encountered in formulating a question it is recommended to first jot it down on a paper in free form and then it can be reconstituted as per the PICO format.

 

The Background and Foreground Questions:

 

The questions can be classified either as background or foreground questions (Figure 5). It is generally considered that questions encompassing a clinical problem or a disease are called “Background Questions”. These questions are focusing on the what, when, how and where of a disorder, disease or treatment. These questions are typically answered by going through review books or textbooks.

 

The “Foreground questions”, on the contrary, include interpretation of a disease or therapy and the consideration of a risk versus benefit for the group or patients. These are complex questions that are typically answered by the primary or pre-assessed studies in the literature. The questions are typically made to compare either the two drugs, treatments or the diagnostic methods.

Introduced in 1995, PICO (population, intervention, control and outcomes) is a known recommended strategy in medical literature for framing a “Foreground Question”. The approach is useful for the identification of relevant information from medical literature.

Background

Foreground

Figure 5: The scheme of Background and Foreground Questions

 

 

Question components:

 

A question comes into the mind of a physician in a form that makes finding answers in the literature a difficult task. Dissecting the question in to its component parts and restructuring it so that it is easy to find the answers is an essential step in the journal club presentation. The questions parts are:

 

#
p<>{color:#000;}. Patient/Problem – it means addressing a specific population, its important characteristics and the demographic information.

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p<>{color:#000;}. Intervention or treatment of interest – it means the treatment, procedure, diagnostic test, and risk or prognostic factors.

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p<>{color:#000;}. Comparison or control – it means comparing new therapy with the existing one.

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p<>{color:#000;}. Outcome – it means the effect of the intervention. A good primary outcome must be easily quantifiable, specific, valid, reproducible and appropriate to the research question.

 

The above mentioned components can be practiced by an example below:

 

A resident on call receives a middle aged male with sudden onset of severe headache. The patient was diagnosed with subarachnoid hemorrhage. The consultant on call has advised to give the patient nimodipine (a calcium channel blocker). You are concerned and wanted to know if other calcium channel blockers like amlodipine are similarly beneficial in subarachnoid hemorrhage. The resident carries out a search of the medical literature using the PICO search strategy shown in the Table 1:

 

<>.
p<>{color:#000;}. Patient or Problem
<>.
p<>{color:#000;}. In a man with subarachnoid hemorrhage
<>.
<>.
<>.

 

Table 1: An example of the PICO

 

Chapter 4

 

Literature search – what are the options?

 

Literature search is a first and foremost step for preparation of journal club presentation. It is about knowing the already existing critical opinions/theories and to identify a study that will help answer the question. A good starting point is The Cochrane Library as it provides gold standard evidence to help answer clinical uncertainties. If there isn’t a Cochrane Systematic Review then try PubMed or one of the Healthcare Databases. It’s also worth having a look at the Reproductive Health Library (RHL). The paper selected for presentation at Journal Club should be clinically relevant to help answer uncertainty. The first step is to determine which databases to consult to locate the material related to the topic or clinical question. Where to start? It depends on the nature of the topic or clinical question. Many databases are subject or discipline specific. For example, to locate a systematic review related to a clinical question, the Cochrane Library database or the PubMed/MEDLINE database would be good starting points.

 

Different types of databases

 

*
p<>{color:#000;}. Multi-disciplinary journal databases Resources:

 

Such as Academic Search Complete, Academic OneFile and JSTOR contain journal content across a large range of academic subjects. Often multi-disciplinary databases will contain professional and trade journals as well as academic peer-reviewed journals. You will however usually be able to restrict your search to just find academic peer-reviewed journals.

 

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p<>{color:#000;}. Subject specific databases:

 

Contain journal articles and/or other types of content relevant to a specific subject or group of related subjects. Examples include PsycArticles, Education Research Complete, Westlaw and International Index to Performing Arts.

 

*
p<>{color:#000;}. Publishers’ databases

 

Databases such as Science Direct, Pubmed and Sage Journals contain journal content published by a particular publishing company. Such resources may also have a subject focus or may be multi-disciplinary.

 

*
p<>{color:#000;}. Other types of content

 

Remember Online Library allows access to a large number of databases containing other relevant non-journal content that may contribute to your literature search such as E-books, newspapers, images, audio & video, legal and Government information and Encyclopedias.

 

Below is a list of resources to consider referring to for a feel of the literature.

 

*
p<>{color:#000;}. The WHO Reproductive Health Library http://apps.who.int/rhl/en/

*
p<>{color:#000;}. The Cochrane Library http://www.thecochranelibrary.com/view/0/index.html

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p<>{color:#000;}. BWH Guidelines (see BWH Intranet) National Institute for Health and Clinical Excellence http://www.nice.org.uk/guidance/index.jsp

*
p<>{color:#000;}. International guidelines, major trials and critically appraised topics TRIP http://www.tripdatabase.com/

 

Figure 6 below shows how steps interact as you move through the literature search and review.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 6: steps of literature search and review.

 

 

Keywords:

When constructing a search query based on a topic or clinical question for a quality literature search, searches using keyword terms such as controlled vocabularies/thesauri, keywords that appear in the record of the work, i.e., natural language keywords, and author-supplied keywords are highly recommended. There is no right or wrong method to start the process of formulating search queries. Many databases allow flexible combinations of multiple single keyword queries into a single search string. If you are not familiar with your topic or clinical question, try a search engine such as Google or Google Scholar to help identify key terms related to the subject.

The idea is to experiment and “get your hands dirty” with various queries on different databases, using keywords from controlled vocabularies and natural language. Review the list of keywords identified for the research question and think about ways to combine some of these keywords in a search query. No two databases will produce identical results based on the same search query; for best results use multiple databases and a variety of terms/keywords. As each new query is tested out, review the results, and document the query and database used.

Literature search is not an easy task. It goes beyond a cursory search of the literature to selecting appropriate databases, creating a series of search queries using relevant keywords including controlled vocabulary keywords, reviewing each result, filtering out non-relevant results based on specific criteria, reading the full-text content of the selected results and performing a critical appraisal of the literature to understand the context of a topic or to answer a clinical question. Components of a quality literature search include:

 

*
p<>{color:#000;}. Use of more than one database or resource including the Web

*
p<>{color:#000;}. Use of appropriate databases

*
p<>{color:#000;}. Identification of appropriate keywords including controlled vocabulary keywords

*
p<>{color:#000;}. Developing queries using controlled vocabularies and keywords based on natural language for each database or resource used

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p<>{color:#000;}. Formulating a structured question using a PICO analysis if the topic is based on a clinical question

 

 

Search Steps

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 7: The systematic literature search

 

After completing a quality literature search, the user should have a thorough understanding of the topic, be able to demonstrate knowledge of the topic, provide original concepts to supplement or expand on the topic, and for clinical questions, be able to locate the best evidence for answering the question.

 

Chapter 5

 

The Skeleton of a Presentation

#
p<>{color:#000;}. Structure and function of the Presentation: What to write

 

Each of the following sections are included, usually also in this order, though specific presentations may disguise them under different section titles that relate closer to the actual contents of each section. These sections are

 

*
p<>{color:#000;}. Abstract

Introduction

Methods

Results

Discussion

Summary and Conclusions

Acknowledgments

References

 

Each part serves a different purpose and has a narrowly defined content and purpose. Under-standing how each section functions together with the whole will help the author minimize overlap and repetition.

 

The general outline of a presentation with the governing principles outlined above is presented here as follows:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 8: The Skeleton of an article

 

 

 

 

 

 

 

How to Read and Critique a Research Study.

 

*
p<>{color:#000;}. Critiquing the research article

 

*
p<>{color:#000;}. Title – Does it accurately describe the article?

*
p<>{color:#000;}. Abstract – Is it representative of the article?

*
p<>{color:#000;}. Introduction – Does it make the purpose of the article clear?

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p<>{color:#000;}. Statement of the problem – Is the problem properly introduced?

*
p<>{color:#000;}. Purpose of the study – Has the reason for conducting the research been explained?

*
p<>{color:#000;}. Research question(s) – Is/are the research question(s) clearly defined and if not, should they be?

*
p<>{color:#000;}. Theoretical framework – Is the theoretical framework described? If there is not a theoretical framework, should there be?

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p<>{color:#000;}. Literature review – Is the literature review relevant to the study, comprehensive, and includes recent research? Does the literature review support the need for the study? i. Methods – Is the design appropriate for the study? Does the sample fit with the research design and is the size sufficient? Was a data collection instrument needed? How were data collected? Were reliability and validity accounted for?

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p<>{color:#000;}. Analysis – Is the analytical approach consistent with the study questions and research design?

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p<>{color:#000;}. Results – Are the results presented clearly in the text, tables and figures? Are the statistics clearly explained?

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p<>{color:#000;}. Discussion – Are the results explained in relationship to the theoretical framework, research questions, and the significance to nursing?

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p<>{color:#000;}. Limitations – Are the limitations presented and their implications discussed?

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p<>{color:#000;}. Conclusion – Are there recommendations for nursing practice, future research, and policymakers?

 

Chapter 6

 

Appraise the evidence

 

[*(*]Rod Jackson; Shanthi Ameratunga; Joanna Broad; Jennie Connor; et al ACP Journal Club; Mar/Apr 2006; 144, 2; Health & Medical Complete pg. A8)

 

Appraising the literature is the final step for your journal club presentation. There are different tools for appraising the literature selected for the journal club. One such tool that we have tested and tried and found very convenient for diagnostic and therapeutic studies is the GATE Frame (Graphic Appraisal Tool for Epidemiological studies). Another tool that is also very important and can be used for other studies is the CASP (Critical Appraisal Skills Program). The computer assisted critical appraisal tool called CAT maker is a useful tool that can be used to calculate useful clinical statistics and is a useful adjunct to appraise most study types. In the next few paragraphs we will go through a brief overview of the tools that we have discussed in order to provide an overview of how to utilize them in your journal club presentations.

 

GATE (Graphical Appraisal Tool for Epidemiological studies) Frame:

 

The prime advantage of the GATE frame is that it helps appraise the paper in pictorial form. The GATE frame is based on four figures that are triangle, square, circle and arrow as shown in Figure 9 and labeled as PICOT (or PECOT).

 

P

C

E or I

 

T

+

O

 

 

 

 

 

Figure 9. The GATE frame. P = Population, E or I = Exposure or Intervention, C = Comparison, O = Outcome, T = study Time.

 

 

 

 

 

#
p<>{color:#000;}. Triangle:

 

P

 

 

 

a

 

b

c

 

 

 

 

 

Figure 2. Population. a: Source population, b: Eligible population, c: Participant population.

 

 

The triangle in the figure represents the population (P) that is to be studied. The triangle is divided into 3 parts that represent the 3 overlapping levels that are represented as follows (Figure 10);

 

#
p<>{color:#000;}. Source population (Whole triangle) – from which the participants are selected.

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p<>{color:#000;}. Eligible population (Lower 2 levels of the triangle) – includes participants that meet the eligibility criteria.

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p<>{color:#000;}. Participant population (Lowest level (tip) of the triangle) – includes participants that have agreed to take part in the study.

 

#
p<>{color:#000;}. Circle:

 

 

 

E or I

C

 

 

 

 

 

Figure 11. Exposure and Comparison.

 

The circle in the gate frame is divided into 2 sections by a dotted line dividing it into 2 groups. The first half represents the exposure (E) group that is also called the Intervention (I) group in a study. The other half of the circle is the comparison © group.

 

#
p<>{color:#000;}. *S *

E or I []
p<>{color:#000;}. C quare:

 

+

O

 

 

 

 

 

Figure 12. Outcomes.

 

 

The study outcomes are shown in the square. The square is divided into 4 sections as shown in the 2 by 2 table. The divided halves of the square is the generic 2 × 2 table of the epidemiologic studies with the dichotomous exposures (E and C) and the dichotomous outcomes (yes and no). In the square any number of categorical exposure and outcome groups can be placed into the GATE frame by adding vertical and horizontal dotted lines that divide the square in to 4 equal parts. Figure 12

 

#
p<>{color:#000;}. Arrows:

Prevalence

 

 

 

 

T

Incidence

 

 

 

 

 

Figure 13. Study Time.

 

The arrow represents the study time (T) that includes the horizontal and vertical arrows Figure 13. The horizontal arrow represents the study outcomes measured at 1 point in time (as in the prevalence or cross-sectional measures). The vertical arrow is used to describe the outcomes that are measured over a period of time (as in the incidence or longitudinal studies).

 

#
p<>{color:#000;}. X factor:

 

It represents the application of evidence into practice that involves the expert practitioner integrating the evidence with important issues, patient choice, and clinical considerations and policy.

 

 

Putting the Shapes all Together:

 

The GATE frame helps appraisers have a good understanding of the questions the study is addressing and how the writers have addressed them. It makes the assessment of the manuscript much easier by identifying the areas that the reviewer must have thrown light on while writing a manuscript. The appraisers, after using the GATE frame, will be prepared to validate the study. The GATE frame validates the manuscript by following an acronym RAAMbo (Represent, Allocation, Adjustment, Accounted, Measured, Blinding, Objective) to help the appraisers focus on important validity issues in the epidemiologic studies. Figure 13. The study report must provide sufficient information to allow the appraiser to determine whom the participants are representing. The aforementioned information is placed on to the three levels of the triangle accordingly. Representativeness is an important part that is considered as a key criterion for determining the generalizability or the external validity of the study findings.

 

The next step is the method of Allocation to comparison and exposure groups. This is of paramount importance for intervention studies. The best way to do it is Randomized allocation through which any imbalances between groups that may influence the occurrence of outcomes (confounding or a mixing of effects) can be avoided. In case of non-randomized studies, the imbalances between the exposure and the outcome can be reduced by Adjustment. It is done by stratifying the compared groups into subgroups (e.g. dividing each of the exposure and comparison groups into subgroups of smokers and nonsmokers) or by using multivariate statistical methods.

 

The study participants that are mentioned in the study must be accounted for at the completion of the study, the numbers at the tip of the triangle as mentioned previously (study participants) must be equal to the number that are mentioned in the circle (i.e. the exposure and comparison groups), this in turn equates to the numbers in the square (the participants with and without the specified study outcome). Also there are studies in which a large proportion of participants remain in the exposure or comparison group in which they were placed, with high compliance, low contamination and low loss to follow up. There may be difficulty in reducing the compliance and loss to follow up as they are difficult to eliminate entirely as a source of differential error. Accuracy of the outcomes measured is the other important validity issue to address in the epidemiological issues.

 

If the use of the RAAMbo appraisal criteria suggests flaws in the study design or conduct, an assessment on the study validity is to be judged. This involves assessment of the likely net impact of the flaws. It is postulated that visualizing the combined impact of the flaws that are assessed in a study using the GATE frame helps in the process of judging the quality of the study with ease and effectiveness.

 

Calculating the Incidence measures of occurrence using the GATE frame:

 

Incidence = number of persons developing an outcome / the number in a population

During time (T).

 

Exposure Group Occurrence (EGO) or Experimental Event Rate (EER)

 

= a / E during T

= a / (a+c) during T

= (a / (a+c)) / T

 

Comparison Group Occurrence (CGO) or Control Event Rate (CER)

 

= b / C during T

= b / (b+d) during T

= (b / (b+d))/T

 

Calculating prevalence measures of occurrence using the GATE frame

 

Prevalence = (number of persons with outcome / number in a population) at time (T)

 

Exposure Group Occurrence (EGO) or Experimental Event Rate (EER)

 

= a / E at T

= a / (a+c) at T

 

Comparison Group Occurrence (CGO) or Control Event Rate (CER)

 

= b / C at T

= b / (b+d) at T

 

Calculating the measures of effect using the GATE frame.

 

Relative Risk or Risk Ratio

 

= the ratio of occurrence (risk) in the exposure group to the occurrence in the comparison group

 

= EGO + CGO (or EER / CER in intervention studies)

 

Risk Difference (RD) or Absolute Risk Difference (ARD)

 

= difference in occurrence (risk) between the exposure group and the comparison group

 

= EGOCGO or

= EERCER

 

Number Needed to Expose (NNE) or Number Needed to Treat (NNT) to reduce (or increase) events by 1 during Time (T)

 

= 1 / (EGOCGO) or

= 1 / (EERCER)

 

CAT Maker:

 

It is a computer assisted critical appraisal tool that instructs the user to enter information (Table 1 and 2), and calculates useful clinical measures (Table 3). A file is generated that can be saved and stored at the BWH library website for all interested parties to view. It is produced by the NHS R&D Centre for EBM in Oxford and is freely available to download at http://www.cebm/index.aspx?o=1216 (4 files are generated, select catmaker.exe). CATmaker can be used for a single study of therapy, diagnosis, prognosis, aetiology / harm, and a systematic review of therapy.

Table 1 – Questions CAT maker asks for a therapy CAT

 

<>.
<>.
<>.
<>.
<>.

 

Table 2 – Questions CAT maker asks for a therapy CAT

 

<>.
<>.
<>.
<>.
<>.

 

Table 3 Important calculations that are used by CAT maker

 

<>.
<>.
<>.
<>.
<>.

Chapter 7

How to make an effective presentation?

 

To convey a strong message to your audience, your presentation matters. Following are some important presentation skills which can turn your boring presentation to an interesting and memorable one.

 

1. Know your audience. Knowing the characteristics of your audience can help you shape your presentation accordingly. Remember, the audiences in your presentations are adults. Adult learners learn best from your presentation if:

*
p<>{color:#000;background:#fff;}. You can ensure that the content of your presentation is relevant to them and that it carries important meaning and purpose for their day to day issues. An emergency medicine resident in USA sent an email to the group before presenting his journal club that says:

You are evaluating a child in ED with head injury who is slightly drowsy. You are considering CT head versus observation. To get the best evidence based answer come to my journal club.

*
p<>{color:#000;background:#fff;}. The learner is actively involved and allowed to reflect his learning experience.

*
p<>{color:#000;background:#fff;}. Positive feedback is given.

*
p<>{color:#000;background:#fff;}. They know that your presentation has a clear goal and that it is attainable too. The aim here is to know what you want your audience to do, think and/or feel at the end of the presentation.

 

In summary, the presenter can make his presentation more effective if he has considered “what does the audience know about the subject and what do they want to know more about it? What problem can you help solve, what do they want to learn from you….”

2. Always start with an introduction. Take half a minute to introduce yourself to all the attendees. 

 

3. Story telling. Stories leave a longer lasting impression. For stories to have an impact it has to have specific details of people, places and things to create imagery. It also needs to have a strong touch of reality. This will help you make your presentation more effective and memorable.

 

4. Designing power point presentations. Using the following tips can make your power point presentation more effective.

 

a. Keep it short

There is an old saying that said – “No one ever complained of a presentation being too short.” Nothing kills a presentation more than going on too long. Remember the 10-20-30 Rule for Slideshows described by Guy Kawasaki of Apple. He suggests that slide shows should:

*
p<>{color:#000;background:#fff;}. Contain no more than 10 slides;

*
p<>{color:#000;background:#fff;}. Last no more than 20 minutes; and

*
p<>{color:#000;background:#fff;}. Use a font size of no less than 30 point.

There are some professors who will penalize a short presentation but for most people a shorter presentation is better.

 

b. Keep it simple

*
p<>{color:#000;background:#fff;}. Do not use too many colors, fonts and styles. Also use the 6×7 rule i.e.

No more than 6 lines per slide and no more than 7 words per line.

*
p<>{color:#000;background:#fff;}. Similarly some statistics are difficult to read in slides. An example is shown below:

 

Total ED patient visits

 

table<>. <>. |<>.
p<>{color:#000;background:#fff;}.  

<>.
p<>{color:#000;background:#fff;}. City 1
<>.
p<>{color:#000;background:#fff;}. City 2
<>.
p<>{color:#000;background:#fff;}. City 3
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.

 

This statistics can be modified to make them simple and meaningful.

 

Total ED patient visits in millions

 

<>.
p<>{color:#000;background:#fff;}. City 1
<>.
p<>{color:#000;background:#fff;}. City 2
<>.
p<>{color:#000;background:#fff;}. City 3
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.
<>.

 

 

c. Keep it clear

*
p<>{color:#000;background:#fff;}. It is recommended to use contrast colors for back ground and content i.e. either light background or dark content or vice versa.

*
p<>{color:#000;background:#fff;}. Content should not be all in capital letters. This is difficult to read. Use a sentence case. Similarly italics are generally difficult to read on screen, Normal or bold fonts are clearer.

*
p<>{color:#000;background:#fff;}. Use numbers for listing sequences (e.g. 1. Airway 2. Breathing 3. Circulation).

*
p<>{color:#000;background:#fff;}. Use bullets without numbering to show a list that has no priority, sequence or hierarchy.

 

d. Keep the limit of three

*
p<>{color:#000;background:#fff;}. A simple technique is that people tend to only remember three things. So, use a maximum of three points on a slide.

*
p<>{color:#000;background:#fff;}. Similarly in the conclusion/summary slide work out what the three messages that you want your audience to take away are and structure your presentation around them.

5. Rehearse. Practicing can enhance your performance and make you perfect. Many experts say that rehearsal is the single most important thing that you can do to improve your performance. Perform your presentation out loud at least three times. If you can do it in front of some colleague or family member it’s even better.

 

6. Know what slide is coming next. You should always know which slide is coming up next when presenting. It sounds very powerful when you say “On the next slide [Click] you will see…”, rather than a period of confusion when the next slide appears.

 

7. Have a back-up plan. Murphy’s Law normally applies during a presentation. It says “Anything that can go wrong will go wrong.” Technology or multimedia not working, power failure, not enough power leads, loudspeakers not functioning, presentations displaying strangely on the laptop – all of these things can. Have a back-up plan. Take with you the following items – a printed out set of slides (you can hold these up to the audience if you need to), a CD or data stick of your presentation and a laptop with your slides on it. Just in case it goes wrong.

Guess what? When you have back-ups – you seldom need to use them.

 

8. Check out the presentation room. Arrive early and check out the presentation room. If you can make sure of it, see that your slides have been loaded onto the PC and are working on the screen. Work out where you will need to stand.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Further Reading

 

JAMA Articles to Guide Journal Club Preparation

 

 

TITLE JAMA CITATION

How to Use an Article about Therapy or Prevention 1993: 270(21), 2598

(2 parts) Part 2 1994: 271(1), 59

 

How to Use an Article about a Diagnostic Test 1994: 271(5), 389

(2 parts) Part 2 1994: 271(9), 703

 

How to Use an Article about Harm 1994:271(20), 1615

 

How to Use an Article about Prognosis 1994:272(3), 234

 

How to Use an Overview 1994:272(17), 1367

 

How to Use Clinical Practice Guidelines 1995:274(7), 570

(2 parts) Part 2 1995:274(20), 1630

 

How to Use a Treatment Recommendation 1999:281(19), 1836

 

How to Use Guidelines and Recommendations about Screening 1999:281(21), 2029

 

Hamer S and G Collinson (2005). Achieving evidence based practice, 2nd Edition. Bailliere Tindall. London.

Heneghan C (2006). Evidence based medicine toolkit. BMJ Books. London.

Khan, KS et al (2011) Systematic reviews to support evidence-based medicine: How to review and apply findings of healthcare research 2nd ed. London: Hodder Arnold.

Glasziou P et al (2003). Evidence based medicine. BMJ Books. London.

Straus, SE et al. (2011) Evidence-based medicine: how to practice and teach it 4th ed. Edinburgh :Churchill Livingstone.

 

 

34


Journal Club - a hands on guide for physicians

Journal Club presentations has always been a daunting tasks for the postgraduate trainees. There is no such text that can guide the trainee to this important and difficult task. It is just like learning a foreign language – wherever you start, you come across unfamiliar words and concepts. However, the key to success here as in other subjects is persistence. The primary aim of this handbook is to equip the trainee with the essential steps of the journal club in a short possible time. The busy schedule and the long hours of the post graduate trainee makes it difficult to master resulting it as a burden that trainee has to gone through. Journal club presentation skills allow the trainee to prioritize evidence that can improve outcomes. Such is the importance of acquiring these skills that journal club presentations are now an important essence in postgraduate medical and dental training. The book is a one-stop solution for all medical trainees. Based on our clinical research experience, we took a unique back-to-basics approach that provided a logical and comprehensive review of the subject. We hope that this book will prove to be an indispensible tool for journal club presentations for the postgraduate trainees.

  • ISBN: 9781370567294
  • Author: Shahan Waheed
  • Published: 2016-12-29 18:35:20
  • Words: 6427
Journal Club - a hands on guide for physicians Journal Club - a hands on guide for physicians