Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello. Hi. Hello. Can, um, can you guys hear and see me? We'll just give a few minutes. Oh, great. Wonderful. Ok, great. Um, hi, everyone. My name is Sam. Sama. Um, I'm currently enough to in London. Um, well, we'll just give a few more minutes for more people to join. But in the meantime, can you guys tell me where, where you're working and, um, where you're at? I'm currently in, um, I'm currently in Toronto, which is why it's really bright right now. Pretty sure it's around 7 p.m. in, uh, London Clinical Fellow in medicine. Well done. Nice. Very good. Great. Mhm. Ok, great. Just give it another minute or so and then get started radiography student. Wow, that's really good. Birmingham. I don't think I've been to Birmingham. I've only been to, um, I haven't really gone outside of London. Um, should definitely go around, see different areas there. It'd be nice. Ok. Um, so I don't know if anyone here has already attended the introduction set, uh, presentation. There was one that was done in January. I know it was, it's been a bit of a while since. Um, so, yeah, this is just a series based on the feedback that I got a lot of people wanted a little bit more um an in depth uh series before we continue. So, no, no worries, no worries at all. Well, the recordings are available. So if you wanna go back and take a look at it after the session, you're more than welcome to. If you haven't, don't be, don't, don't um don't get worried. Uh I'm just gonna do a quick recap before we continue so that everyone is caught up to speed. And again, this is a very open learning environment. So please, if you have any questions at all, feel free to ask. I have my phone here with all the chat. What's the title? Um the title of this session or uh this session is formulating po which is the clinical question and we're just gonna discuss the study designs. Um If you're talking about the introductory series, it's, it can be found on metal. Oh, yes. Yeah. So the previous one is basically Journal club introduction. Um You can find it. If you look up um mind the bleep Journal Club on metal, it'll be, it'll be there. Um So basically that session is giving an overall um like an overall cover of the different things that I'm gonna be discussing in these three in this crash course, basically. So uh no worries. We have today's session, tomorrow's session and after tomorrow's session, um it's best if people can join live. So if you have any questions, I'd be able to answer them to the best of my ability. If you're not able to join, that's no problem at all. The recordings will be available for you to look back into. Um, these sessions are there to help you in terms of getting um more comfortable with evidence-based medicine, the concept of journal clubs. And um also if you are interested in taking part in our competition, which I'll talk about in a second. Um The series will give you a little bit of like a, a little bit of a foundation or, or um a little bit of a basic starter kit if you will um to help you get going with that. Ok. I think we've waited um, for some time now I'm gonna get started. I'm gonna start by sharing my screen. Uh How do I do this again? No, not this one. Yes, there we go. Ok. Can everyone see what I'm seeing right now? A um the hold on, let me see if I can go back. OK. Go back. Ok. Ok. Oh. Mhm. It's just me repeating myself one second. Da da da, da, da da. Come on. Come on. Ok. All right. I think we're good to go. All right. So welcome everyone to the first part of our Evidence based medicine crash course. So, uh this lecture I know we've booked the hour. I don't think it's gonna take up all that much time. The point of it is to give you a bit of information to help you get comfortable with evidence based medicine, um journal club information. And it's, it's just a really straightforward uh lecture. If you have any questions at all, please feel free to ask. Um And welcome. Um So without further ado, let's get started, this is just a bit of an agenda on what I'm gonna cover. I'm gonna start off by talking about the competition that we have. Uh We're gonna get those details up for you as soon as possible. Uh Also, I know some of you guys haven't attended the introduction, so I'm just gonna do a quick recap to get everyone up to speed. Uh And then after that, we're gonna jump right into the actual presentation. We're gonna start with developing the clinical questions. So talking about what it is and um how to actually do it. We're gonna go over an example and then after that, I'm gonna talk about the different types of study designs and we're gonna put it all together and do practice questions. This is supposed to be an interactive session. So the more you put into it, the more you can get out and please like uh this is a very friendly, relaxed environment. So uh the more interactive you are the better. OK, great. OK. So um basically this journal club series is gonna have these lectures to give you a bit of information and then we're gonna start with the competition. So it's gonna be on a monthly basis. Um, and what's gonna happen is we're gonna have these dates and details. You're gonna make a presentation on a topic that you're interested in. Something that you're enthusiastic about. You submit it to us, we're gonna take a look at it and based on that, we're gonna announce a winner that we're gonna post on our website or on our social medias. And of course, we'll also have some runner ups and the, the winner or the first place will have the opportunity to present and be one of the finalists. Um The runner ups will also have an opportunity to present. It's gonna be in a separate, um, it's gonna be in a separate session and, um, all of the winners and the runner ups will all get, um, certifications and awards and also in terms of the finalist. If, for whatever reason, the first place winner is not able to participate, then the runner up will take over their place. And, um, by being a finalist, what ends up happening is after a few months, we're gonna have, let's say six finalists. Uh, we're gonna go over back, gonna go over the recordings of these presentations that they've done and select a winner who becomes, uh, the jour, uh, mind the Bleeps Journal Club National winner. So it's a pretty big thing and if you do end up winning it, it's gonna give you a very competitive edge when you're training, when you're trying to enter into training posts or if you wanna boost your CV. Um So that's an a uh an advantage of joining our competition, but other aspects of, of it as well. Um This is a great opportunity for you to gain some skills in terms of journal club, at whatever stage you are, in terms of your career, you're gonna need to participate in part uh in presentations like this. So this will give you a bit of an understanding and help you to sort of um refresh your memory for medical school and um it make the process a little bit easier. Um So yeah, in terms of our journal club page, it's not up on mindedly just quite yet, but once it's up and uh but just please keep an eye on our socials, it'll be up and running soon and all the information will be there. Um Yeah, so this is the other part that I talked about in terms of our runner ups guaranteed, you'll present and receive a certificate. But um if a first place winner is not able to participate, then the runner up will take their place and they'll become a finalist in our compe in our national winner competition. So I hope you guys participate. This is a great learning environment. Um You get to, you know, learn a lot from these presentations uh from your own presentations and from those of the people around you. So uh please participate, you never know. You know. So uh that's in terms of our competition. OK. So let's get into the actual presentation aspect of it. So Journal Club, um this is something that takes pla uh takes part in every single uh specialty in any single, any per any specialty that you're in. So these are meetings in with healthcare professionals, they make a presentation and discuss and review recent research articles from medical journals. Um As you know, medicine is a very um is a fast developing specialty. Things that we may know now in terms of guidelines will change very shortly, which is why these journal clubs are so important. They keep us up to date in terms of our medical knowledge and our um practices. OK. Um So these presentations are helpful because they uh you're able to critically evaluate and discuss findings as well as the implications of these studies. Um It's helpful not only to the presenter but also to the audience. Um Here's a list of the benefits for joining journal club. I've already covered a few of it encourages critical thinking and analysis of research, improves knowledge and understanding of current research and best practices provides an opportunity for peer review and feedback on research. This pertains more for um those of us who are involved in the research aspect of um of like medicine. Um So if uh if someone is doing, for example, a master's or a phd in something um medical related. Um If they're defending their thesis, this would definitely be helpful in that aspect. Um Maybe some of you who are doing an S FP may find this um at this point helpful as well, uh enhances communication and collaboration among healthcare professionals and identify gaps in current knowledge and research needs. So, uh in terms of a presentation flow chart, there's five different constituents. Um So the first one is a clinical encounter. So this is something that you may have seen on the wards on your day to day job. And it's, there's something about it that's missing that you don't understand or something that's that you want to learn more about. Um So once you have this encounter, you have a question that you wanna build. This is po or the clinical question and this is the first half of this presentation and I'll discuss more about that. So once you develop the clinical question, you go on to do your literature search. So you go to different databases like PUBMED. Um And you do your research, you look for different articles that talks about your clinical question that answers your clinical question. Um If you're lucky, you may find a lot of different research articles that cover your question. And at that point, you have a group of papers to choose from and you have to choose your literature and there's an art to doing this. I've covered this in the introductory series and we'll discuss it, we'll touch on it during this um course as well. And then the last part is the critical appraisal. And this is the most important aspect of a journal club presentation. And this will be the third aspect of this um of this crash course, which will happen after tomorrow. But our focus for right now is developing the clinical question. OK. So po is a mnemonic that we use to develop the clinical question. The P stands for population I is intervention C is control or comparison and O is for outcome, this will make more sense as we go over it. Um Here's a little bit of a detailed picture just so you can see what, what I'm referring to. So when you have an encounter, there may be a population, a patient or a problem that you're looking into. Um So what you do is you write on a piece of paper P IC O down like this and you start with pee what is the population, the patient or problem that you're trying to address? OK. What is it that you're interested in? And then I is the intervention or the indicator. So anything um any intervention or, or exposure that you're considering for the study? C is the comparison or control? Some clinical questions might be uh you may have an intervention and the second the C might be a control or maybe one intervention and you're comparing it with a second intervent intervention in which case your c would be a comparison and o is the outcome that you're looking for? Um Does this make so sense so far? Does anyone have any questions also, if I'm speaking too quickly, please let me know and I can slow down any questions so far. No. OK. I'll keep going. Um OK, so there clinical questions can have different things that you're looking into. Yeah. Ok. No, thank you. Um Yeah. So clinical questions can have uh can be a question in regards to therapy, etiology, a diagnosis, prevention, prognosis, et cetera. So different clinical questions require different research designs, right? So if you're ask if you're looking for an answer, you have to make sure that the question you're asking is as accurate as possible, which is why developing a clinical question is so important. You have to do it as uh you have to be as specific as possible. So once you have a clinical question, you have to determine. What kind of a question is it? What's the, what's the outcome that you're looking for? And then based on that there are different research, study designs that are available, which can answer your question. OK. The ones that are bolded are the best, uh the best ones, the most recommended for the type of clinical question that you're asking. Um at times the question you're asking may not have a lot of research that's uh that's out about, that's sorry, it may have a lot of research papers that are out already. So you have quite a few to choose from. So the ones that are bolded are the ones that are the most recommended, right? But other times maybe that you may have like a cohort study that's available in, in which case, you can use it for a clinical question for therapy. This will make more sense as we go through it. Um ok. So this is a clinical encounter right now. What I'm gonna do is I'm gonna go over how to actually formulate AP O question. So this is a clinical encounter. I'm gonna read it out loud. We have Mister JD. He's a 55 year old male who has persistent uncontrolled hypertension despite taking his medications regularly as prescribed. His past medical history is significant for hypertension diagnosed five years ago. His medications, he only takes amLODIPine 5 mg daily in the past week. Two of his BP readings were noted to be 100 50/90 millimeters of mercury and 100 65/94 millimeters of mercury respectively. He's concerned that his BP readings have been high despite being fully compliant with his medication and he's been properly implementing the recommended lifestyle modifications, right? So, as his family doctor, you're considering whether to increase his amLODIPine dose or to consider a combination therapy with a beta blocker. So this is the clinical encounter we have in mind. So the next step is to do the po OK. Um I've already put it in here just so that we can go over it as an example in terms of developing this question, you wanna be as specific as possible. So for population you can say in adult patients with hypertension, but it can be a little bit more specific. So um can you guys think of anything to make the statement a little bit more detailed? How can we make this more detailed based on our clinical encounter? And I'll go back here just to help you guys out. What can you add on for pee to make it a little bit more specific age? Yes. Very good. Yeah. Male. Yes, very good. Very good compliance. OK. Complaint or compliance complaint. Mm Yeah. Hypertensive or male. Exactly. Yes. So male patients aged 55. So let's be available. The feedback form be close it. Yes. Exact. Yes, it will. So um the recording for this will be available later and you can also fill in the feedback form and you'll get the certificate patients on calcium channel blockers. Uh Exactly. So for population, you can say in adult male patients over the age of 50 with hypertension, existing hypertension medication. Yes. Um those ones can kind of fall a little bit more into our I and C. So in terms of intervention, um we can say combination therapy of a calcium channel blocker with a beta blocker. So in this case, our calcium channel blocker is the amLODIPine staying as 5 mg in terms of dosage. And you're thinking of adding a beta blocker. Um and then c because we are thinking about adding increasing sorry the dose of his amLODIPine, it wouldn't technically be a control, it would be a comparison, right? So the use of combination therapy of a calcium channel blocker with a beta blocker or increasing a higher dose in monotherapy. So in this case, increasing his um amLODIPine dose and the outcome that we're looking for is a reduction in BP levels. So that would be your clinical question. OK. So now we have our clinical question. Um let's talk a little bit about study designs and we'll put the whole thing together. So this is a little bit of um a chart that I've put here for, for those of you who are visual learners and what's underlined here are three different types of study designs. There are more, but this is a way to um make it easy to remember what those types are. Um whatever is highlighted in blue is what we're gonna discuss in the second aspect of this uh study. But let's focus on this for now. So um these are three different study designs. We have what are known as case controls, cross sectional studies as well as cohort studies. And if we were to look at this as if it's a chart, we can say that the um X axis here is a measurement of time. OK? We have present what we can sorry past and what we can consider here is the present. Um And I'm gonna say that in quotations cause it's not technically the same thing and the future. So case control studies, these studies look for their answer in the past. OK? So they look back in time, cross sectional studies look for prevalence. So things that are happening within a certain time period. So you're taking a snapshot. OK. And cohort studies are studies that start at some point and follow through with patients. So the answer for cohorts cohort studies is in the future. Um And I'm gonna talk about these in a little more detail to make it makes sense and I'll provide some examples as well. OK. So case control study um while we're going over this, you can think of this uh in the case of Sherlock Holmes. Um So detective who would look at a crime scene and you're looking, you're doing your investigations to s to look back in time what has caused this outcome. Um So for case control studies, you're identifying individuals with a particular outcome and in individuals without that outcome. So researchers would look back to see if exposure to certain factors differs between the two groups. Um So examples of case con clinical questions for case control studies would be like what is the cause of lung cancer or does a history of smoking significantly impact the prognosis compared to nonsmokers as assessed by survival rates and disease progression. So if you were to take a look over here, this is a bit of a diagram to help look at this over here in the black arrow. This is a represent representation of the progression of time. What we have here is the onset of study. This is where we start and we go backwards to see what has caused this outcome. So again, progression of the case control studies goes back in time. So let's just say in this study, you have a population with lung cancer. Let's just say you collected 50 people who have lung cancer and 50 people who are healthy. You do a lot of interviews and discussions and you're asking them in terms of their history and when you go back in time, you're gonna see, OK. Um In the population with lung cancer, most of them were smokers, not many were nonsmokers or those that are healthy, you go back in time, most of them were non-smokers and not as many were smokers. So in this case, you might think, OK, there's a very strong association between smoking and lung cancer. So this would be a case control study and these types of studies are good for determining the cause or the harm. But it can also help to determine a prognosis. So after having this study, you may look at a population and think, ok, those with lung, uh those who are smoking currently, what is their outcome going to be? How likely are they to develop lung cancer? So, that's a case control study, right? Um So now I'm gonna talk about cross sectional study. This is the one that measures prevalence. So, um these studies um basically try to figure out how many people with a certain condition um within a population at a single uh exist at a single point in time. So it's like a snapshot of the population at that moment, which is why I've given this, this picture. So an example of this would be how many cases of lung cancer uh were in England in 2022. So you can have the progression of time here. You have 2020 2021 and a snapshot or like uh a cross section of 2022 and you'd find, oh, there was over 43,000 cases. Um And just to make this a little bit clear, um in terms of definitions, prevalence is how uh how, how common apa disease process is found in a speci in a specified at risk population at a specific point or d uh during a specified time period. Um A nonmedical example or something else that can make this a little bit easier to understand is if you guys are familiar with these, these are gumball machines. You can kinda see them outside of supermarkets. Um and you put the coin in and you can take them and obviously the number in there is not gonna stay the same. It's gonna change over time. Uh It gets refilled and people take out some. So you wanna for a prevalence question could be how many gum balls were in the machine? Last Friday? So you look in last Friday, OK. This there were 50 in here. So that would be a an example of prevalence. So in terms of cross sectional studies, you're trying, there are clinical questions that answer um they give you an answer in terms of prevalence. Um I hope that makes sense, please. If you have any questions, let me know and I'll answer them. OK. So we've talked about cross uh case controls which look back in time, cross sectional, which look at cases within um the present or within a certain time period. And now we're gonna talk about cohort studies which look into the future, right? So participants are a group based on exposure to certain factors and followed over time to see how that exposure affects outcomes. Um Again, if we take our smoking example, how does smoking affect a given population? So progression of time progression of cohort studies, they're, they're equivalent, they're, they don't go in opposite directions, they're in the same direction. So you take a group of people who are smokers and those that are nonsmokers, you follow them over time and you see how many develop lung cancer and how many stay healthy. Ok. So this type of study basically answers again, much like the case control studies, uh prognosis etiology or harm. All right. So we've talked about case control, we've talked about cross sectional, we've talked about cohort. There's a couple more that are pretty common. I'm just gonna cover those very quickly. And um obviously, there are other types of case. Uh There are other types of study designs, but these are some of the more common ones that you may come across during your um your research. So uh in this one, participants are grouped randomly into either a control or intervention group and then they're monitored over time. So if we take our case from uh before with Mister JD, our 55 year old gentleman with uncontrolled hypertension. Um And again, we have the progression of time. We take a population with uncontrolled hypertension who are on 5 mg of amLODIPine. OK? And we're gonna split them. So let's just say there's 100 we'll split them into 50 over here and 50 over here 50 will increase their amLODIPine drug dose and 50 will add on a beta blocker, beta blocker to their amLODIPine and then follow them over time and see which one of these groups will have a will show a better control or a reduction in terms of their BP and that's a randomized controlled trial. These are very, very good because um they try to minimize bias and they try to um uh conduct the study without in uh including a lot of variables. And they're very good in answering questions in regards to therapy or diagnosis. Ok. So, um I'm gonna talk about systemic reviews and meta analyses. Um They're very similar um but I'll explain a little bit in more details. So sometimes you may have a uh there may be uh a clinical question that has a lot of background research that has been done. So you may find a lot of papers, what some groups may do. What some researchers may do is that they will look through these papers and put them together to create one research paper and that is known as a systematic review. So they take primary research studies to provide a secondary research study. Um And these are excellent because they can answer a list of different types of questions. Um Now, with some of the, so in terms of systematic review, in terms of meta analyses, they're quite similar to systematic reviews. Um but it's basically similar, but they are incl it's a section that's included within systematic reviews. So again, you have different research papers, um a researcher will put them together to create a systemic review. And if the papers that they include are similar enough to compare, they'll include a small section known as a meta analysis within a systematic review, which helps to compare the different studies and give you a better idea of um uh like a better um a uh analysis of the results. And again, these kinds of uh these kinds of um research papers can answer quite a few questions as well. Um So you've created your clinical question and you can tell, oh, this is a therapy question. This is an etiology. this is a diagnosis, et cetera. Can you repeat this, please? Uh which section you are you talking about meta analysis versus systemic reviews? OK. So in terms of systemic reviews, let's just say you have paper, a paper B and paper C. So these three papers can be put together by researchers to create what is known as a systematic review. So these research papers are primary, which means a research was conducted, you know, with patients and um a systematic review just basically puts it all together into one paper. So if these papers are similar enough, what can happen is within a systematic review, they can put a small section known as a meta analysis. So the meta analysis will um compare the different outcomes within these papers. Um and it will give you a more clear picture of what the results would look like. Um So it's a bit, it's a bit, it's basically a step further. So not every systematic review is going to have a meta analysis, but a meta analysis is going to be included in every systematic uh in um in wait, wait, did I switch that? Um not every systematic review will have a meta analysis but a meta analysis will uh if there is a meta analysis, it would be in a systematic review. So a meta analysis is a section, an extra piece that analyzes a data further within a systematic review. Um So it's like taking a step further to look more, more specifically into the results and analyze them. Not every systematic review will have it. Um Especially if the different papers that are put together for a systematic review are not similar enough to uh to create a meta analysis. Um Is that, does that make sense? OK. Great. Cool. Um OK. So, right. OK. So um you have your clinical question, you may find OK. My question has so many different papers out there. Um Or maybe my question is regarding to therapy and I found a lot of different papers, some of them are randomized controlled trials and some of them are meta analyses or systematic reviews. For example, um which one would I pick? Which one would be better? What's what can I use as a tiebreaker? There's different things that you can take into consideration. Um One of the things is, is something called an impact factor of a journal. So this is how many times a certain journal has been cited? Basically the power of a journal article. But let's just say you come across one where the po the in uh impact factor is similar. Um The point I'm trying to make is how can you choose between the two? This is where the hierarchy of evidence, um the pyramid of hierarchy of evidence comes into play. So this is something again, you can look up online and it gives you the order of what type of study is better compared to the others. Cause some of them are more uh some of them are stronger studies based on the designs. Yes. So the ones at the very top are the best and as you go down, they become weaker in terms of their evidence. Um So if you have a clinical question and you have two research papers, one is a randomized controlled trial. And another is for example, a systemic systematic review, which one can you choose systematic reviews are technically better than randomized controlled trials. So that that can be something that you take into consideration when you're doing a presentation in journal club and you come across a literature, literature search and you choose your article at times, you have to explain in your presentation why you picked that article. You can say um this is a systematic review. It has a lot of evidence or the article in which I found this uh the journal in which I found this article has a very high impact factor. Um or the the way that the study was conducted could uh gives us a lot of it reduces the risk of bias and whatnot. Um So you have to explain. So this is one way that you can uh systematically choose the best type of article for your journal club presentation and it gives you a nice little explanation on the side on um if you're, if you're still have, if you're still struggling. OK. So, and oh sorry, I forgot to mention one more thing in terms of this chart. You can also Google this. Um And you can find the different types of um run uh different types of uh studies to correlate with your question. Um And I just wanna solidify one concept before we move on to the practice questions so that it could make a little bit of sense. Um Our example with Mister JD who has uncontrolled hypertension, we've done a clinical question where we're trying to compare two different forms of therapy and see which one is the best in terms of controlling his uh hypertension. If you had to tell me what type of clinical question it is, where would you categorize that question? What would you say this po question is, would you say um Mister J D's clinical question best correlates with prevention. Is it best for therapy? Is it best for prognosis? Which one? Therapy? OK. Yes. Therapy. Yeah, exactly. So your, your the clinical question is asking about therapy. So, in this terms, the best type of studies that we can use for these are randomized controlled trials or meta analysis. If you can't find these, you can also use. Oh, the question was. So um earlier, we did an example with Mister JD, our 55 year old gentleman with uncontrolled hypertension. So we formulated a clinical question where we were trying to compare on whether it's better to increase his amLODIPine dose or if we should keep it as it is, but also introduce a beta blocker like bisoprolol to control his BP. So in terms of this clinical question, we're trying to figure out what type of therapy is better for uh better in controlling BP. So our po or our clinical question is best is a therapy question. So in terms of therapy, the best type of research design is a randomized controlled trial or a meta analysis. Uh Does that, does that answer your question? Don't feel shy if you want me to repeat it again. II, it's no problem at all. OK. No problem at all. No worries. OK. Um All right. So we've got, we've come to the last part of this presentation. We're almost through it guys. This is the part where you have to be as interactive as possible. OK. Oh Good. Um So now we're gonna put it all together and we're gonna go over three different examples and then we're done. So I'm gonna give you a clinical encounter, we're gonna read it together and then we're gonna create a clinical question using po and you're gonna tell me what's the best study design and answered it. Great. Um Yeah, and you're gonna tell me what's the best design suited for this clinical question? We're gonna do three examples. Sorry, it's not actually 45 sides. OK. So uh this is our first one. It's a pediatrics uh related question. We have JD is a six year old girl who was brought to the hospital by her parents with a two day history of diarrhea. She was on amoxicillin to treat a recent ear infection. Her parents describe her having three watery stools per day, which began two days after starting her antibiotic, there is no blood in the stool, but her parents are concerned that it isn't resolving. So she's had an ear infection. She was prescribed amoxicillin. And after she started taking her antibiotics, she developed diarrhea. So she was having three watery stools per day and it's been ongoing for more than 48 hours. She has no other symptoms and her stool sample was sent for culture and immunoassay on examination. She's slightly tachycardic but otherwise vitals are unremarkable. She appears uh clinically well, but oral mucous membranes are slightly dry. Abdomen is soft, no 10 nontender and there's no distension. So after all, the di everything was taken into consideration, she was diagnosed with antibiotic associated diarrhea or a ad um her parents have been doing a little bit of research and they asked if they had given her some probiotics alongside with the antibiotics would have, that would have, would that have been helpful? Um So if, when she started her amoxicillin, if she was given a probiotic, would it have prevented her from developing antibiotic, associated diarrhea? Um I hope that makes sense if there's any questions. Let me know. OK, so this is the part where you guys have to be a little bit interactive and tell me. So in terms of population or patient, what can we put here? Pediatric group? OK. Um Can you be a little bit more specific with antibiotic associated diarrhea? Very good. OK. Good. All right. So we can put that for our population and patient. Very good. Um Great. So in terms of eye, it's the intervention that we're looking into in this case, it's an intervention. What's the intervention? And I'm gonna put the clinical encounter to help you guys a bit. Yes. Probiotics. Very good. Female pediatric with diarrhea. OK. Very good. Taking probiotic would be helpful for a ad condition. Yes. Yeah. Yeah. Very good. So you guys are being specific in terms of intervention, prescribe when prescribing to a child. Exactly. So you can say you can say in population um uh uh like a um uh actually, no, I'm not gonna say anything uh cause the cause the I, I've put the answers in the next slide Um I'm gonna let you guys take the lead on this one. OK. Very good. So we've done population intervention and what's the comparison group? This one's a bit tricky. Um Cause I haven't really mentioned anything about it here. Yeah. Pretty. Yeah. That's, that's a very good way of putting it into. Yeah. Probiotic versus non pro probiotic. Yes. Very good guys. Excellent. When being on antibiotic. Yes. Yes. Exactly. And that's the outcome we're looking at all, right. So we've developed our clinical question and this is what I've put for it. So, Children with antibiotic associated diarrhea, you guys did a better job in being more specific than I am. But yes, Children with antibiotic associated diarrhea, prophylactic administration of a probiotic in combination with antibiotics, right? So the intervention is add a probiotic with antibiotic and the comparison or the control is no prio a probiotic alongside with the antibiotic treatment. So sometimes what we can do is we can give a placebo. Um So a sugar pill and this one, we can give a probiotic pill and the outcome we're looking for is uh measured by significant reduction in a ad cases, right? So we have our clinical question. I've put this chart here to help you guys. What kind of a clinical question do you think it can fall under? What's, which one do you think is best suited? Which one do you think it's the best uh to describe it? Prevention? Yes. Yeah. Prevention. Very good. Yes, exactly. So prevention is the best suited uh category for a clinical question. And in this terms, you would say randomized controlled trial or meta analysis. Also, I'm not sure if you guys noticed, but I just wanted to point it out for all clinical questions cause sometimes the question can have, can fall under more than one category. You can also use systematic reviews or meta analysis for any of these. OK. Um But yeah. OK. Very good. So that was our first one. We have two more therapy and prognosis. Yeah, you could say you could say prognosis, you could say prevention therapy, you can include it. Yeah. Um exa it can work. So this is exactly a good que uh question because it can fall under more than one category. Um If you are struggling, it's always best to think. OK, if this question has three different answers, which one is it most correlated to and use that, you know, to the best of your uh ability and if you can't decide systematic reviews or meta analysis, you can't go wrong with it. OK. Uh Here's our second clinical encounter. We have KM is a 59 year old male with a medical history of epilepsy. He was brought to the hospital by his son. He's feeling generally unwell for the past two weeks with general functional decline. He's been sleeping more, experiencing night sweats as well as weight loss. He's drowsy, Parex and sweaty. Um just generally unwell and you've noticed that he has some swollen lymph nodes in the right axilla act was done alongside with a biopsy and it conf uh it confirmed a diagnosis of diffuse large b cell lymphoma and he was referred to him. So you're the junior doctor in the hematology team and presented the case. Um The medical team believes that he is a perfect candidate for chemotherapy, but there is some uncertainty on whether he would benefit more from R chop versus chop therapy. Um So R chop and trop are different types of chemotherapy regimens. Um The R is just an added a uh aspect of it. So let's try this one. I know this one's a little bit more information in it. Um But let's, let's give it a go. Um Who, who wants to tell me what we would put for a population or patient? 59 year old epileptic male diffuse large B cell lymphoma? Yes. Very, very specific, very good. Keep in mind sometimes that um clinical encounters can have some information there. That is not, I mean, you can use as much of it to your advantage as possible. Um And being as specific as possible is, is a good thing. Um What I found when I was doing my own journal club presentations for work was I would create a uh a question and um sometimes I wouldn't find anything because the question is too specific in which case, you can sort of take out certain details, um go from like the least relevant and work your way across. Hopefully you will come across something and if not, then you've identified a research gap. And yeah, that could definitely lead to something else. Um But yeah, exactly. Very good. You could say population um male with diffuse large b cell lymphoma. So the intervention you're looking at can be um r chop therapy and comparison could be just chop therapy. And the outcome is what can you put for outcome? The chemotherapy. Yeah. So the outcome is, so the chemotherapy is what you're trying to compare in terms of uh there are two different chemotherapy regimens and you're comparing them in the uh intervention and comparison group child versus R job and response. Yes. Yeah. Yeah, exactly. Um So this is what I've put um adult patients, obviously, this is extremely detailed. Um But you could take out as much as you can. Um if you c if you don't come across anything in your database searches, uh adult patients diagnosed with DL PCL experiencing these symptoms, treatment with R chop uh treatment with just chop. And the and the outcome you can say is overall survival rate, progression, free survival um response rate, adverse effects, it could take into consideration different outcomes. Uh This was a very long one. Definitely. So in this type of question, what are we looking for here? What type of a clinical question is it, remember we're comparing different types of chemotherapy and we're looking at the response of the patient to these chemotherapy regimens. You're compa or comparing prognosis. Ok. Possibly. Yes. Yeah, you can say the prognosis. Yeah, that can work as well. Um And yeah, and you can also say it's a therapy question as well, but either case works very good. All right. Last one. HP is a 39 year old man from Myanmar who presented to the GP with a petechial rash over his entire body. Wet spots were noted in the oral mucosa. He also complained of fatigue and noted hematuria that began yesterday evening this morning while brushing his teeth. He noticed some bleeding from his gums. He has no past medical history and he's not on any medications. Um He's alert, slightly distressed, has pete rash over the entire body and three wet spots noted in the oral mucosa with the largest measuring 1.3 centimeters in diameter, just pretty large. Uh His vitals are unremarkable. He's hemodynamically stable. Uh They've done a set of bloods on him which showed a platelet count of five, which is dangerously low. Um He was referred to hematology and diagno diagnosed with ITP pending confirmation. Um In this scenario, you're the Hema hematology registrar. You're aware that the first line treatment is steroids, but you're debating on whether prednisoLONE or dexamethasone would be better suited for this patient. Um I believe um guidelines say the, which one was it? PrednisoLONE is normally what's used? I could be wrong. Um But anyhow, this is the clinical encounter. Um last po guys. So what would you put for population? And I'm just gonna go back to help you guys a bit male with? Itp. Very good. Can you be a little bit more specific? Myanmar? OK. Very good. OK. Very good. What would you put for your intervention? Steroids? Exactly. Steroids, prednisoLONE. Yeah. So over here we have two different steroids that we're trying to um compare with dexamethasone group. Yes. Very good. Very good. So I NC are very similar. So sometimes you can um answer them together, you just have to separate them in terms of the po but yeah, you're comparing two different types of uh of um of steroids. So usually um I believe it was the, the um prednisoLONE that's normally used. Oh oops. Oh Anyhow, here's the answers, apologies guys. Um Yeah, exactly. So the comparison that you're comparing that you have is the prednisoLONE and the intervention that you're considering is the high dose DEX. And the outcome that you're looking for is effectiveness in increasing platelet count, resolving symptoms of itp within defined time frame, which one has a better outcome. Um I looked into this. It was actually the high dose DEX just so you guys know um and you can, you can try and put this clinical question maybe after the session, just look it up in PUBMED, you can find some articles. Um And I found this in um this database. I actually don't know how to pronounce it. I'm just gonna type into the group chat over here. Um But I found it in this, um in this database and it had a specific um, article that talked about this, but you can also find it in P Yeah. So in this clinical question, what type, what are we looking for here? We're almost done guys. Let's finish strong. You're doing well. So just to recap, you're comparing on whether a patient should be given. Yeah, therapy, therapy. Very good. Yeah, you could say therapy. Um Yeah, exactly. Therapy would work. So again, randomized controlled trials, meta analysis, systematic reviews. They, they work all, they work pretty well. OK, guys. Uh so well done today. Yes. Systematic reviews. Meta. Very good. Well done. You guys. Um I hope the session was really helpful. I'm just gonna let you know that there's two more presentations that are coming that are gonna follow this one. The next one is tomorrow and we're gonna talk ABC is a statistical analysis and we're gonna cover some um terms in epidemiology. Um And the last one is gonna talk about the critical appraisal. Um They're gonna be all available on med all. Please don't forget to register so you can join live. If you're unable to, the recordings will be available. Um Keep an eye out on our socials for the Journal club page and um the details for our competition. Uh I look forward to seeing you guys there. Um Please don't forget to fill the feedback form and get your certificate. I look forward to seeing you all. Thank you so much for joining. Um I uh hold on, I'm gonna put the, let me, let me put the, the feedback form here. Do you guys have before I go? Do you have any questions? Any questions? No worries. No worries. Glad it was helpful. Um If you guys have any questions, let me know and I can try and incorporate it into tomorrow's session. Great. Thank you so much guys. Thank you. I'm glad it was helpful. Please fill in the feedback form, provide as much feedback as possible cause these sessions are guided by you guys. Um But yeah, thank you so much. Um Take care and I hope to see you guys soon. Thank you. Take care.