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Yes, perfect. Ok, great. So welcome everyone. Um Thank you so much for joining me for the last part of our Journal Club, Evidence Based Medicine Series. Um My name is Sa I'm a foundation year two doctor. I'm working in South London and um we're, this is part of the Mind the Beliefs uh Journal Club Series. Um We're just gonna cover the third or the final part of the series and afterwards, we're gonna move on into the competition and I'll talk a little bit more about that. Um But let's let me just talk a little bit about the agenda for today. So, um as I mentioned before, I'm just gonna go go over a quick introduction and a recap of Journal Club uh to get everyone up to speed and then we're gonna jump into our topic right away. So, uh it's gonna talk, it's gonna cover understanding, critical appraisal, utilizing the tools that are available. These are gonna make your life so much easier when it comes to critical appraisal. And then uh I'm gonna go over an example for a journal club presentation that I've done for my pediatrics placement. Um And you guys are more than welcome to ask questions in the chat. Um Bring up any points um just to get into the um mode of discussion. And then we're gonna do a little fun interactive ment meter pull based on this critical appraisal just to sort of solidify the learning point here and then just some a few concluding points and uh please ask any questions if you have any at any point, I can see the chart here. So, um but anyhow, uh so I'm just gonna cover a little bit about the present, the competition that we have. Um So we're gonna have all the information available on our newsletter. Um And for this competition, you have to prepare a journal club presentation and we'll announce a winner who will have an opportunity to present and be one of the finalists who will and one of the finalists will be deemed the winner of mind the Bleeps Journal Club um throughout the UK and even abroad because I think there are some people from abroad here as well, which is great. Um But yeah, why join in? Uh you'll gain confidence. Uh You devi you'll build your CV uh wherever you are, wherever you're working. Um It's a great way to stand out. Um And if you're applying for training posts, it's also great to give you a bit of a competitive edge. Um It's also a great learning opportunity. Um You'll get to, you know, update your medical knowledge you'll have, you'll be involved in a lot of stimulating discussions. And um yeah, and you, you'll also get certifications whether you're actively or passively um um participating. But yes, so I know I've mentioned in the previous presentations that there's gonna be a journal club page. Um, but there's been a bit of a change. Instead, we're gonna go with the newsletter. So the QR code here at the bottom, right is for our newsletter. So if you're to scan that with your phones, you'll be able to um sign up with your emails and just keep an eye out for the journal club updates there. You'll get all the details in terms of um presentations, submissions and um important dates and of course, uh our winners um and don't worry if you're not able to scan it now I'll put um, I'll put it into the chart as well later on in the presentation. No voice or slides. Um is, is everyone not able to hear me? Mm. Um maybe to try logging in and coming back. Uh again, I'm, I'm not, I'm very, very sorry. Ok, for me I can hear and see everything. Um Yeah, may maybe to try try to like um sign out and sign in again. Maybe it'll, it'll, it'll start working. Um Yeah, apologies. Um but yeah, uh try try that. I think it will, it will, it will start running again. Um um ok. Right. So that's that. Um Yeah, a little bit about the winners. If you're, if you're fir if you want first place, we'll get to present. Um, but also we wanna make sure that we get as much learning from this as possible. So we'll also have some runner ups who will be emailed personally and told that they, they are runner ups, they'll also have opportunities to present in other um, presentations. Um, but should the first place winner not be able to present then? That case, the runner up will take their place and they will be named one of the finalists to become our national winner. Um Oh, I'm very sorry, Manar. Um Yeah, try, try signing in and uh signing out and signing in again. Uh Don't worry if you've missed any part of it, the recording will be available on metal and I'll try to make it available on youtube as well. Um Yeah. Um ok, so this is the quick recap. Um What is Journal Club? These are regular meetings in which healthcare professionals discuss and review recent research articles from medical journals. Um You may have seen these in your medical training um and you may have seen these as well uh at work. Uh It gives you an opportunity to critically evaluate and discuss findings as well as the implications of studies within your own um uh local guidelines and it helps you to stay up to date on the latest research. So what are the benefits of Journal Club engages critical thinking and analysis of research. It improves your knowledge and understanding of current practices. Uh It provides an opportunity for peer review and feedback on research. This pertains more if uh more for those of you who are uh currently involved in research and are in the process of making a publication um enhances communication collaboration. And also um it can help you to identify gaps in your current knowledge and research needs. So, any journal club presentation will have this basic flow chart. So you may come across something at work. Um And this is known as a clinical encounter and you may have a question uh which then you'll um create into a clinical question by the format of po um and you'll see what this is. When I do the example, you'll do your literature search, you'll choose which literature you want. And then after that, you'll do a critical appraisal which you'll share with your um colleagues. And you'll see an example of this when we go through the presentation. OK. So what is critical appraisal? Um critical appraisal basically assesses the import the relevance and the trustworthiness of any published papers. So it's important because it helps you to determine the liability and validity of any research that's been uh published. And it plays an important role in everyday health care decisions. So, um when you go into PUBMED um or any of these databases and you're reading through a research paper. Um, uh, unfortunately, not everything that is researched can pertain to you and not everything that is researched or, um, can be relied on, which is why the critical appraisal is important to be looked into. Um So this is what this little discussion is about. So you may wonder if someone is doing a research project, wouldn't they do their best in order to ensure that their research is valid? They do but not, it's not always, it doesn't always carry through and sometimes it doesn't pertain to you. Um And this will also make sense as we go through the presentation. Um but just a little bit more to explain on this. Um So let's just say you have a clinical question and through your research, you found two different studies that answers your clinical question and you notice in the first study, the answer or, or the outcome has a 90% positive outcome. And in another study, you find that it actually has a very high negative outcome. Which one should you believe? Which one is the right answer? So this is how critical appraisal can help you. Um And this is a big umbrella term. But if you were to break it down, it consists of these three subcategories, it consists of uh the reliability of research, its validity as well as the clinical relevance. Um And I just wanted to give a little bit of an example here about these two studies um, and show you what I, what I'm referring to. So, let's just say that you, there's a company who created a muscle building product and they wanna test it out. So you have two studies that run and they do a randomized control trial. So, in the first study that they do, they tell you, oh, this muscle building product has a 90% it's, it's effective and 90% of the people agree with it. And the next study says, no, actually 90% of the people don't agree. So when you look into the first study and you look at the randomized control trial, you'll see that the intervention group, uh sorry, the control group is a random group of people that selected from a certain population. Ok. Fair enough. But the group, the intervention group, which is being given this muscle building product are those who already work out or have like a high amount of, um, muscle in their body. Um So the results of this are gonna be biased because the groups are not the same. There are a lot of differences, you know. Um, if you look at the second study, you'll find that the intervention group as well as the control group, the populations are very similar to one another. Um So 11 group is given the intervention and the other is given a placebo, they'll report that it's, it's not that effective. So, based on the methods for these two studies studied B would be the more reliable one. So the process that I just broke down for you is actually part of critical appraisal. So this is just an example, but I hope it's coming together a little bit for you now and please um stop me at any point. If you have any questions, I'd be more than happy to answer. OK. So as I mentioned earlier, a critical appraisal can be broken down into three different um subcategories. Um So the first part is reliability, the second, the validity and the third, the clinical relevance. So within each, there are certain list of questions that you can look into, excuse me, which can explain what each one is about. So in terms of reliability, can the results of the study be reproduced? Has the research been conducted in such a way to m as to minimize bias? And does the paper have internal validity? Um internal validity is a concept that we've covered um very um thoroughly in the introductory um uh session. So if you look back, you can find more about it over there. But basically, it talks about the fact that the paper is um conducted in a very fair and square manner. Um So if we were to look back at this study over here, we can say that this one minimizes bias. This one introduces a different type of bias. So this study a is not as reliable as study B validity, you're looking at the results. So what does the study show, how close are the results from the truth? So you may have a clinical question and it has a true answer. You conduct a research study or you, you look into a research study, but the answers are not close to the truth. You know, it's, it's different. Um And how well do these a uh uh results apply to the population in the study? Is it applicable to the general population? Um And this kind of spills over a little bit into clinical relevance. So, in clinical revel, revel relevant apologies, um you wanna see if it's relevant to your population um have, has have all the important outcomes been considered and have the potential benefits and adverse consequences been taken into um into account. And you can also look into the economic evaluation, some studies take this into consideration. So, um an example would be if a hospital is looking into buying um I is looking into transitioning into robotic surgery for uh patients with high grade endometrial cancer. So they may conduct a study and um have patients obviously uh ethical considerations in mind divided into groups of those who have um open laparotomies versus those who um undergo the surgery, uh surgical resection via robotic surgery and they compare the outcomes. So um these robots are very, very, very expensive. So again, in the surgery you wanna, you wanna take into account the economic evaluation. Um So that's just a small example for that. OK. So, um, the validity of the study, I just wanted to clarify that a little bit. So, um, if you're to imagine a bull's eye over here and you're practicing on a target, um, and the dots represent the arrows that you shoot, you'll notice over here these, um, arrows are neither accurate or, um, or in the same place. So this is unreliable. And Unido we don't want this. We wanna get this when we do research. So we want a research study that is both reliable and valid. OK. So validity focuses on how close these dots are to the truth, which is our bulls eye reliability focuses on how many times you can redo the experiment and get results within the same region. So if you look over here, this result is valid because the outcomes are within the bull's eye and it's reliable because no matter how many times the study is repeated, it's within the same proximity. This one is reliable. So when you do the experiment many times you get the same um type of answers, but it's not valid because it's nowhere near the truth. So um this is a good diagram to help you remember the differences between reliability and validity. Um And also, I've just included a little bit of the internal validity here. So you're assessing the accuracy of the studies of the study design. Um And whether it allows for valid causal inferences. So it looks into things like the study design randomization and control of confounding variables. OK. Um Sorry, II realize this is a little bit back and forth, but I was just apologies on that. Um OK, so in terms of the clinical relevance recording being made a fee up from the posted li Yes, yes, they will be. Um Yeah. So in terms of clinical relevance, um as I mentioned before, you wanna see if it's available in real world health care. Um It ri bridges the gap between research and health care and it looks at the impact of the research on patient outcomes and clinical decision making. Um So I know that's a lot to take into consideration. Um which is why there are tools that are available to make this process much easier. So your job as someone who is participating and just listening to a journal club um presentation at work is to take in the details of the of the um of the journal club presentation and then answer the questions that are available on these tools. Um The critical appraisal skills program has their list. Um And if you can Google it, you can find so many different ones out there um that are available for you to use. But this is one of the most common ones that we tend to use. Yeah. So these uh so when you go on the website, they have their critical appraisal checklists and they have ones available for different types of study design. So the randomized controlled trials, um all, all sorts of, uh all sorts of studies. So how do you know that you're doing it correctly? Um You have a thorough, first of all, you have a thorough understanding of the research that's being presented and you're aware of any limitations or potential bias in the research, you're using the checklists that are made available to you. Um And again, looking through the research methods, you're assessing the validity and reliability of it, um you're reading through the results and conclusions and you're watching out for antibodies that could have influenced these conclusions. Um and lastly, relevance and applicability. So how relevant is this study to me? So, um it wouldn't really make sense to look into a journal club presentation for pediatrics if you're an adult medicine as an example. Um OK, so now we're at the actual um example over here. Um So we're gonna run through this and at the end, there's gonna be a ment meter quiz or po poll where you guys can answer questions based on a simplified version of the critical appraisal checklist just to help solidify that answer. Um So this is a history of presenting complaint. We have a six year old girl who was brought to hospital by her parents with a two day history of diarrhea. Um She was given amoxicillin to treat a recent ear infection. Um She's been having three watery stools per day, which began two days after starting her antibiotic. There's no blood in the stools, but her parents are concerned that it isn't resolving. Um She's had no other sta another, no other symptoms. And a stool sample was sent for culture and immunoassay on examination. She's like slightly tachycardic, otherwise it's unremarkable or mucous membranes are slightly dry. Um And she was diagnosed with antibiotic associated diarrhea or a ad? Ok. So the, so this over here is the clinical encounter, this may be a case that you would have seen on the ward. Um And you wanna create a clinical question. So I mentioned po earlier and I've discussed this in previous presentations, but po is a aic that stands for population intervention comparison and outcome. So you have a certain um clinical encounter, you have your question and you just fill in the blanks. So who's the population Children with antibiotic associated diarrhea intervention, prophylactic administration of a probiotic in combination with antibiotics? Um Comparison is no probiotic. So they would get a placebo instead along with antibiotic treatment. And the outcome you wanna see is measured by significant reduction in a ad cases. So the clinical question is asking on whether uh prophylactic administration of probiotic along with antibiotics would help reduce the amount of AAD cases. Ok. So this clinical question focuses on therapy, prevention and quality improvement, all of which are best answered with a randomized controlled trial. Um, does that make sense so far? All right, great. So, you have your clinical encounter, you have major question and now it's time to do the research. So when you're doing your research, you can collect a certain list of keywords pertaining to your question. So the ones that I've picked is probiotics, prevention, diarrhea, antibiotics, Children risk, um, you take these words and then you plug them into a database. You can choose whichever database you want. I've chosen PUBMED and then you can get a list of different um research articles from there. You can apply different filters. Um I wanted randomized controlled trials and ones within the last done, one done in the last five years. Um That way it's up to date. And uh from there, I had a couple more and from uh from there, II picked uh a journal from Jamma Pedia Pediatrics and this was the article that I came across. So, um multispecies Probiotic for the prevention of antibiotic associated diarrhea in Children. It's a randomized controlled trial and it was done within the last five years. Um So again, just a point something to point out when you're doing a journal clock presentation, you, the um article would have been sent ahead of time for your colleagues to read through, but some of them may have not. So it's very important to explain the different aspects of it and you can use it um to help out in your presentation as well. Um What I like to do is include a slide that talks about why I picked this article in particular. So uh I did this presentation during my Peds placement. Um So again, I said it's, it's relevant clinically. Um It's recent in terms of its data publication, I felt that it had a strong methodology which will be covering and had a plausible sample size. So um the next few slides are gonna talk about the actual constituents or what's included in this article just so that everyone is up to date and it makes sense. So, uh antibiotic associated diarrhea, they've created a specific definition for it. Three or more watery stools per day in a 24 hour period caused by either C defic ae or of otherwise unexplained etiology after testing for common predefined diarrheal pathogens. Um Yeah. So having a specific criteria is helpful because um it, it helps you to figure out which patients to include in the study uh which brings me over to the inclusion and exclusion criteria. Certain studies will include a LA population and from that, after doing some screening, they may include certain individuals and exclude others for different reason. So, as you can see from this study, they have a very long list in terms of exclusion criteria. Um This includes patients already on antibiotics, already on probiotics on PPI S. Uh and those who have been severely ill, basically um inclusion uh those uh who are three months of age to 18 years of age um and have been recruited within 24 hours of starting a bro broad spectrum antibiotic. And of course, they're signed an informed consent. Um So you could talk a little bit about the procedures and interventions. So, in this study, um the intervention group has received um a probiotic in these brown sachets. There are two sachets that are taken daily with antibiotic treatment for seven days uh for throughout the treatment and seven days post. Um and it talks a little bit about the duration when to start it and more details about the probiotic and then the actual um scales that they used in order to assess the patient's diarrhea. Um And should the patient have diarrhea, what to do in that case? Um So they would tell them to provide a stool sample which is sent for immunoassay and cultures. So these, they had some primary and secondary outcomes. So based on the results they've had um there are different patients who had these different outcomes and they've placed them into primary versus secondary. Um In the study, I should note that this aspect of it was very weak because their primary and secondary outcomes were not clearly defined. There was a lot of overlap. So it did cause a little bit of confusion. And I feel I find that this is a very weak aspect of this research article. Um despite having very specific parameters. Um Having three or more watery stools within 24 hours can be something that they picked him from your sister. See anything. Um This um maybe you can email support at me all.org try signing out and signing in. Uh I'm very sorry guys, I'm not sure why it's not working for some um but try signing in and signing out it, it may refresh again. Um Yeah, so the primary outcome is three or more watery stools within 24 hours, they had secondary outcomes as well. So these are patients who have had outcomes that kind of fall in between um certain categories. Um So they included them, but as you can see, they also included three or more watery stools within 24 hours. So this part was very, very much confusing. Um So that was definitely a weak aspect of the paper. Um But this as this aspect of the paper is what made me feel that it had a very um reliable uh study design. So first of all, it was randomized, quadruple blind and placebo controlled trial. So the patients are not aware uh for those who are able to are old enough to comprehend, are not aware if they're on probiotics or if they're on um just regular sachets that don't include the probiotics, the patient's caregivers, so their guardians, their parents are unaware. Um the researchers are not aware. So nobody actually knows whether patients are in the control or the intervention group. Um until the end of the study, in order to ensure that there is no uh bias that's introduced, no selection bias, they're randomized. So you have a certain population that was selected, they were randomized into two different groups and this was done by a computer. Uh They were blinded again, participants, caregivers, investigators and outcome assessors. Um in order to ensure that the groups are very much unsure of which groups they're in. Uh they're given um identical packaging and it looks the same in terms of appearance, taste and smell. So it's very strong in terms of its methods. Um which is why I feel that it's reduced quite a bit of the bias and increased its reliability. So this is a breakdown of what I was mentioning before. So they've had over 700 individuals, uh 427 were excluded and these were the reasons why they've ended up with 350 which were randomized into the intervention and placebo group and they were followed through some were lost to intervention and the reasons why were included and they were still in the paper um in order to reduce the likelihood of attrition bias. So a little bit more about here. Um This study took place actually over Poland and Netherlands and um it was both in inpatient and outpatient um um environments. So, the antibiotics that these patients were on are listed over here and the diseases that they were commonly being treated for are, are also listed over here. Um But yeah, um something that I thought was very interesting and not uh noteworthy was that the fact that was the fact that the last participants in both groups were similar. So the number within each was similar. So at the end of the day, the overall population or sample size did go down. However, there were no large discrepancies between either group. So that's, that was something that was positive. Um So here's a table that talks about the results. Um So you have the outcomes that were measured here, these include both primary and secondary outcomes. So, uh antibiotic associated diarrhea, those that had severe outcomes versus mild et cetera. And um we have those that are in the probiotic group versus the placebo group. Um And we've talked about the uh sorry over here in the air. What we can see here. Basically, the outcome of this article was that there's no strong or significant significant um difference between the groups that were given the um probiotic versus the group that was given the placebo. So at the end of the day, it didn't make much of a difference. However, uh the study did find that those who generally did have issues with diarrhea had a significant difference in terms of the uh incidences of diarrhea that they were having. So the probiotic was helpful for those who generally had diarrhea, but it didn't make much of a difference for those who were diagnosed with antibiotic associated diarrhea. Um Just something interesting to know is that while uh certain research papers may have a certain hypothesis that they're trying to prove, uh there are certain um incidental findings that um they come across in research which can be helpful in other um in other aspects of medicine. But yes, so they included the confidence intervals, the P values. Um A all of these values were included in the um analysis and this will be relevant when we do our ment meter. Oh, so as I mentioned before, in terms of the outcome, there was no significant reduction in the overall risk of antibiotic associated with di diarrhea with probiotics. Um But it did help patients who did have uh diarrhea more frequently and it reduced the amount of um incidences. Um So yeah, this just goes a little bit more into the critical appraisal aspect of it. Um I'll say that this as this paper was very reliable because of the randomization, blinding allocation, concealment, follow up and intention to treat analysis aspects that were included. Um Also in terms of the validity. Um something that was interesting was the fact that these populations are not within the same country and uh certainly their guidelines would differ from one another. So um it could cause some issues in terms of the results there. Um And also there was a large difference in terms of follow up between participants in the Netherlands and Poland, um which was something to take into consideration. Um But yeah, economic evaluation as well. I talked a little bit about this earlier in a different case, but it also pertains here because probiotics are costly. Um So this study would be helpful um to take uh the economic evaluation aspect of it into consideration. Um because there's no significant difference, it, it's not something that would be worth um investing into. Um But yeah, um something that I mentioned earlier in terms of the inclusion versus exclusion criteria, if you remember the exclusion criteria was quite large. So um next steps would be perhaps to repeat the study, but you have a larger inclusion criteria um to see if that would make any difference. And the last aspect of this was basically the clinical revel relevance. So ty tying it back into our guidelines. Um So as you can see, we don't offer probiotics to help prevent these types of infections. But yes. OK. So uh we're finally to the ment meter aspect of things. So if you can scan this code and we can do the um ment meter quiz, um it's basically up to your own opinion. So let me open it up for my I as well. Let me just get this set up. Um I'll explain in the meantime, the cash checklist on the right. Don't worry about that. In the meantime, um I'm just basically uh trying to show you trying to give you the QR link if you wanna take a look at the um the checklists in detail, but this Manter um uh aspect of it is just to take a look at the uh a simplified version of it. Sorry, let me just get it up and running. Ok. Sorry one moment. 622 24. Sorry guys, I just need a quick moment to get this running. Um OK. Ok, great. Uh So it's now up and running. Are you guys able to join in? Can you guys see the first question? Oh, not sure if it's working. Yeah, that's, that's actually the last uh sl slide of it. Um OK. I'll, I'll talk through the first few and then we can, we can go to, we can go through it. Um I wonder why it's doing that? Oh, that's unfortunate. Oh, ok. Oh, you guys are already answering? Ok. On the last one? Yeah, I can't, I can't seem to get the other aspects of it going. Um Oh, I'll just talk through it. Basically. The first question was, um based on the presentation, do you find that the study design is valid for the randomized controlled trial? So you basically answer yes. No or can't tell. Um Second one was the um study methodologically sound again. Yes. No. Or can't tell. Um were the effects of the intervention reported? Um Were they, were, were they reported Oh, this is very glitchy. Oh, and um, will the results help locally? Um, but yeah, these are just some things to take into consideration. Um. Ok. Oh, yeah. Oh, I can see some of you guys answering here. Ok. Gastroenterology, hepatology, surgery, endoscopy, specialty medicine. Ok, great. All right. Thank you so much for, um, putting in your, um, answers for the specialty. You'll definitely take that into consideration. Um, but yeah. Ok, great. Um So I'm so sorry, guys, I didn't manage to get the rest of it going. Um, but thank you so much for bearing with me. Um So that's the end of the presentation. Again. This is the QR code if you wanna sign up to um our newsletter in order to get updates in terms of the competition. Um And don't forget to fill in the feedback form and get your certificate. We look forward to seeing you all soon and thank you.