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Um So thank you so much for joining me and thank you for taking the time to fill out the registration form. Um With the details that all of you have provided, you've had a lot of great input, which we'll be using in the series to help you um get the most out of it. Um So from what I can see from the poll results, some of you have mentioned that you've attended and presented in journal clubs in the past, but quite a few others have never been involved and would like to learn more about it. So this is what this introductory webinar will cover also. Yes, the chat box is available to you. If you have any questions, please feel free to ask in the chat box and I'll do my best to answer them. Um And I'll make this session as interactive as I can. OK? OK. So in the agenda for today, I'm gonna start with a quick introduction covering the benefits of active and positive participation. Um And next, I'll move on to the flow chart. So this will cover the constituents of in every journal blood presentation. And then I'll go through each individual constituent and provide an example to help solidify the concept. Um The last section of any journal presentation is the critical appraisal. It's really essential, which is why it has its own section in the agenda. And um as well as a checklist which I'll be explained. Um I'll also cover some quick tips with you when you're making your presentations, whether it be for the competition or work or both. And lastly, I'll go over the details of our competition which is open for everyone to join in on, I did wanna mention quickly that in the poll, we had a lot of different topics that people wanted to see or present. So for this reason, um for the competition, you're free to choose your own topic. But more on that later, let's um cover the basics first. OK. So what is Journal Club? Journal Club are regular meetings in which healthcare professionals discuss and review research articles. So a presenter would take an article for their presentation and send it up to their colleagues ahead of time. This would give everyone a chance to read through the article and have an idea of what the top will be ahead of time. Um It also gives them the opportunity to come up with questions or points to discuss after the presentation, which is what uh Journal Club is all about. So the article is critically evaluated and it helps people to stay up to date on the latest research just wanted to double check questions before. Is this session recorded? Yes. Yes, yes, it will be. Um Right. So um as you can see, there are many different benefits to getting involved with journal clubs um as an active or positive participant. So I'm just gonna read through them. So the first one is it encourages critical thinking and analysis of research. It also helps to improve knowledge um and and understanding of current research as well as best practices. It also provides an opportunity for peer review and feedback on research. So, peer review is something that is often used in the process of scholarly uh publishing and it's used as as research before its actual publication. Um For the last, the second last point, it enhances communication and collaboration among healthcare professionals. But it also helps to identify uh gaps in current knowledge and research. And of course, for any of you who are in training, it will help you to build your portfolio for training applications to give you a bit of an edge. Um It also helps you to stay up to date on the latest advancements in medicine when you're working on your day to day um um specialties. OK. So now we're getting to the the journal Club flow chart. So this is basically the five constituents of any journal club presentation. Uh So your presentation is gonna start with a clinical encounter. So this may be a case that you've seen on the wards, obviously taken with the permission and ensuring patient confidentiality. So you have to make sure that the patient is uh information is confidential and you have their permission to share um in, in, in the journal. And um when you're presenting it, make sure that you keep it brief and to the point. So after the clinical encounter, you have to display the clinical questions. So based on the clinical encounter, you had, what gap of knowledge have you identified that you're not trying to answer your presentation? Oftentimes the format of the clinical question falls in manic po you may not, you may or may not have come across this in the past. Um But just out of curiosity, um how many of you are familiar with po has anyone, has anyone heard of uh PPI before? Ok. Oh I was asking if uh you've ever heard of the mnemonic PTO P IC O? Um No worries at all. No worries at all. No worries at all. I'm gonna cover it now, but I was just curious to see um if, if, if it's something that um a lot of, so it's just a bit of a mixed answers. No worries at all. Um So po is a mnemonic where um that you basically use in order to create your clinical question. Um So I'm just gonna go ahead and talk about what each one stands for. So the P stands for a population a patient or a problem? So what is it exactly that you're looking into? Um what cohort is involved? You must be specific. That's Pete. Um So that is II is introduction or indication. What is it in particular that you're considering? Um This can be a medication, a procedure or a scoring criteria? C stands for comparison or control. So what are you comparing those above? So what are you comparing with against the intervention or the indicator group? Um So if your eye is an inflamation, for example, let's say a medication or given condition C can be a control room. Um And I feel like this would start to make more sense as we go through an example. OK. And uh lastly for OO stands for outcome. So here it's, you're trying to say what you're trying to accomplish. What is the end goal? I just wanna double check before we continue you. If everyone is clear on that. Does anyone does, does that make sense? Fantastic. All right. So what I have here is a clinical encounter just to give you a bit of an uh an example. And we're gonna work through AP O format for this clinical encounter in the next month. OK. So I'm just gonna read it out loud. So Mister JD is a 55 year old man, he has persistent uncontrolled hypertension despite taking his medications regularly as prescribed. His past medical history is significant for hypertension which was diagnosed five years ago, in terms of medications, he takes 5 mg of amLODIPine every day. In the past week, two of his BP readings were noted to be 100 and 50/90 as well as 100 64 100 and 65. Over 94. He's concerned that his BP readings have been high despite being fully compliant with this medication and implementing the recommended lifestyle modifications. So, at this point, you're considering making a change in terms of his medications and two of the options that you're thinking about is possibly increasing the amLODIPine dose or trying a combination therapy with a beta blocker. Ok. So let's try to do AP O for this and I'm going to ask you guys to come up with these. So I'm sorry, I'm just gonna have to go a little bit back and forth. But for p population or, or patient or problem, what, what would you put for that one as an example? So, um based on the clinical encounter that we've had um ok, 57 year old male, elderly. Ok. Very good. Um Now with hypertension above 55. Yes. Yes, excellent, very good, very good. So exactly. Um so you could say in adult patients with hypertension, um you can make it as specific or as general as you want, the more specific, the better. Um So yeah, for II is intervention. So what intervention are we specifically trying to implement here. Yes, uncontrolled hypertension. Uh Very good. Yeah. Um you can, you have to be a little bit more specific. So in this case, you wanna see um if you want, if you should try to increase the, you should, if you should sorry, try a combination therapy of a calcium channel blocker which which is the amLODIPine with a beta blocker. That's the intervention. Um the comparison or the control group. In this case, we're doing a comparison because we're increasing his amlo. Um That's what we would proceed. Um You wanna see if it's effective in increasing the BP and the outcome is basically measured by a reduction of BP levels. OK. So this basically gives you the format for your clinical question that you're going to use in your journal presentation. So um through your career, you're gonna come across countless encounters and you'll find that not every single clinical question pertains to therapy, sometimes it can be used to answer all sorts of things and here's a table to show that. Ok. So clinical questions can pertain to therapy, etiology, diagnosis, prevention, um prognosis, meaning quality improvement costs. There's a lot of things that you can have clinical questions for. Um So there and for each one, there's an appropriate study or research design that's correlated with it. Um there can be more than one appropriate study design for a given clinical question. But um as you can see here, the folded ones are the ones that are usually um the best for that given clinical question. Um And in your own research, you can look tables up like this. Um Can anyone tell me based on the example that we've had? So this is our po just to help refresh your memory um based on our clinical question, do you know what we're looking for in terms of a research, a su a suggested research done? But uh first of all, uh what type of clinical question is it? What what are we looking for? Is it a therapy, etiology, diagnosis? But what are we looking for? Therapy? Yes. Very good. Exactly. Therapy. So based on that, we would want to do a systematic review of me. Sorry. Uh a randomized controlled trial of or a meta analysis. Um Yeah. So we can use one of those. So what I have here is what is known as a higher key of evidence. So there's different types of studies that are out there and um they're put here on different levels and the levels are assigned to studies based on the design, the quality of the study and applicability to patient care. So the higher levels of evidence have less risk of bias and you can always refer to this as well during your literature search. Um So the higher you go on the pyramid, the more uh the more the stronger the type of study that it is. So I've been talking a little bit about literature search. So what do I mean by that? Um this is basically where you start to look for the article that you're gonna include in your journal book. So there's a few steps when you're doing a literature search, you can start by defining some key words related to your case. Um So general things you can use it from your clinical question, you can use it from your encounter. Um and you use these words in the databases. So uh based on our case from Mister JD, what are some keywords do you think that are related to the case you can use to look up um articles that are related to it? Waters and keywords. So if you, if you were mentioning it earlier, um you can, you can use those words as well. Hypertension. Yes. Very good. What else think about the um the intervention that we're talking about or the comparison of the words that we use in the in amLODIPine? Yes. Very good. Excellent. What else? Control hypertension? You're more specific here, which is good. Combination therapy. Yes. Exactly. Very good beta blocker. Really good. Really good. Yes, exactly. AmLODIPine plus beta blocker. Yes. Yes. So um all of these words you can put them um put them with commas in the middle in the databases which I'm gonna show you um in order to find articles that are specifically pertaining to your case. OK. So, and there's different databases that are available. Um Some of these may look familiar. Um So you find your keywords, you find a database, you plug those keywords in the, in the database and you click search, what comes up next is a probably a very, very large um list of articles. So what you can do is you can apply filters and limits um to reduce that list to find the best article for your clinical question. So there's different, different filters that you can apply. Um, some of them can be things like publication date. So maybe you wanna take a look at articles that were only published in the past year for past five years, maybe even 10 years. Um And you can also look on, look at the uh type of study that you have. So if you wanna take a look at this randomized controlled trial trials, case control studies, cross sectional studies, so on and so forth. You put those filters, you'll come to a few articles and you put, and you have a read through it basically. Um, from there you can pick whichever one is the best one and, um, you can evaluate the quality, quality of it using a critical appraisal. OK. And I'll talk about that. Um OK. Um, so now I'm gonna show you how that works with our example. So, um, for our database, I select the of med and these are the keywords that I put in exactly like you mentioned before. Monotherapy, combination therapy, antihypertensives, amLODIPine, ther uh you can put it in any way that you want the position and in terms of filters and limits, I want to take a look at randomized controlled trials because um as we were taking a look before in the different types of study designs, um the randomized controlled trials are the best studies suited for the clinical question that we have. And um initially I put it in the last year because I wanted the most up to date. But unfortunately, it didn't give me a lot of um uh a lot of articles. So I said in the last five years and I came across a few. So I went through these articles and I found this one which I thought was very, very good. Oh, sorry. So I found this article, um, apologies. I just want to cover a couple of points before we continue. Um just in regards to choosing your article. OK. Firstly, you have to pick a primary research paper. This will make the process of doing a critical appraisal much more straightforward. You have to pick a topic that you're interested in. It will show in the work that you put into it and it will make the process much more enjoyable for you. Um Next is not in your audience. So there are many of you from different specialties. So if you're, for example, in AM U, it would make sense to pick a topic in adult medicine. Um If you're in urology, pick a topic within that specialty to make the most adequate transition. Um It will also help to get a very stimulating discussion going after your presentation. Uh four and five tend to go hand in hand. Um So pick a journal article with good quality and make sure that the impact of a journal uh and the impact of a journal all can play a role in that not always, but in most cases, um Does anyone know what I'm referring to when I say uh the impact factor of a journal or it's OK if you're not sure it's OK. Um How good the source is? Yeah. Yes, exactly. It's an indicator of how good the source is. Yes. Yes, exactly. Yes. Um So um it's basically the frequency with which an average article and uh an average journal has uh been cited in a particular time frame. So um influence on the society. Yes. Yes. Um I'll, I'll, I'll give an example of this. So there is uh a, an art uh sorry, a journal known as Nature Nature is one of the world's most cited scientific journals with an impact factor of 64.8. So um the impact factor is of value and what it represents is the total number of citations for a given journal, for example, like nature over the past two years, divided by the total number of publications within the same period So the more citations there are compared to the number of publications, the more impact a journal has. So when you find an article published in the database, it will often show you which journal it was published in it and you can easily Google its impact factor. Um It can sometimes help if you have a couple of articles that you're debating on and you're trying to find, um, a tiebreaker and you've uh gone through every, you've exhausted the list. Otherwise you can definitely use the impact factor to help you. Mhm So, so when presenting um back to our example, when presenting a case, these, this article is the one that is best suited for this question. It's a randomized controlled trial that compares the outcomes of two groups. So the first one is up titration of amLODIPine or using a low dose combination therapy with amLODIPine. And um when you're showing this article in your presentation, you need to provide the geographic details of the paper selected and state why this paper was chosen? For example, it was the most relevant, it was the most up to date. It had an adequate uh participant numbers. It had good methodology or et cetera. So this is the part of the presentation where you cover each section of the paper, giving extra attention to things like methodology, results, discussion and so on. If there is a table involved in the study, it would be a good idea to include a slide with this table and you could use it as an opportunity to point out certain aspects of it um and strengthen your critical appraisal. So for example, um if the study is not exactly um strong or if it's poor, uh if you can say, for example, due due to certain things, you can support that by saying, for example, if the sample size is too small, it can introduce bias or if the P values show that the results in a particular point were insignificant. Um If the study is missing those details, you can also use this point to prove that the opposite is true. So for example, if the sample size is adequate with the P values, um what the P values are and uh how the study contains intern mobility, I'll talk more about how just a couple of points when you're presenting um your article. Although in most cases, it is set out, you can send it out ahead of time for the audience to read. It may not be fresh in their minds. So uh maybe not everyone has had a chance to read it. So when you're giving your presentation, make sure that you provide a brief background on the paper, that way you make sure that everyone is on the same page when you're starting out. Um Another thing to point out is that you shouldn't be afraid to question the paper. Sometimes a literature search may not yield the best results. And it could be that the clinical question is something that still needs more research but, but this shouldn't deter you sorry from presenting the topics given that there is still enough information to present. So all of these tends to fall under the category of critical appraisal. Sometimes in cases like this, you can add some slides to your powerpoint that cover how the article or research project can be improved, you know. Um so there's some flexibility as to how it can be. Um And you know, you can talk about how the methods can be improved or maybe that the the sample needs to be larger in order to reduce the amount of bias cause. Um And lastly, another point to keep in mind uh in terms of the timing of the presentation is to keep each live for about a minute. On average, there are exceptions to this, but the point is to keep track of your questions, influence on the society. Sorry. Um In what terms on? Oh yes, influence uh influence on, sorry before. OK. OK, great. So now we can get to the critical appraisal section. Um Let's say that you create a question and um during your literature search to come across two articles that answer your question. But one of the outcomes uh and the outcomes for both of them contradict the other. How can you tell which of the two reports is reliable and trustworthy? So this is where critical appraisal comes to play. So what exactly is it um critical appraisal. It's the process of carefully and systematically examining research to judge its trustworthiness, its value and relevance in a particular context. Um It assesses things like reliability, validity and the clinical relevance of a particular research article. Uh When it comes to research, unfortunately, not everything that is publicized is reliable or accurate, it can be prone to bias and can draw false conclusions. So I've got a couple of points under research A and research B. Um you can see um I've mentioned sample size and methodology which I've touched on a little bit. So the reason that it's important to have a large sample size because it gives more power to the study and in terms of methodology, um if it's not done properly, it can introduce bias by its own means and draw conclusions, right? And I'll cover that in a minute. So critical appraisal can be, can have different um subcategories. But those three tend to be the most popular or the main things. OK. So when I say reliability, it's things like can the results be reproduced? Has the research been conducted in such a way as to minimize bias? Does the paper have internal validity? I wouldn't cover the types of bias and ways to minimize it in the next slide. So um the second point is validity. Um what does the study show? How close are the results to the truth. How well do these results apply to the population in the study? And is it applicable to the general population for clinical relevance? It's things like have all the uh important outcomes been considered? Um have, have they looked at the potential benefits consequences? Sometimes even the economic evaluation can be taken into consideration. Um So now I'm just gonna touch on the uh reliability in the study and this is gonna focus mostly on the types of biases. So in a perfect world research would be completely free for bias. But in a real world scenario, researchers have to do all they can to minimize it. Um Can anyone tell me what I mean? When I say bias, what is science can give any um definition as best as you can? Mhm um So bias is non random error that leads to deviation and results from the truth. So basically any trend that can lead to conclusions that are different from the truth and one outcome is systematically favored over the other. Um There are different types of bias. The first is selection. This is when there is a non random assignment of participants to a study group. And um this is usually done so that one known outcome will occur and oftentimes individual in the sample group may not be a realistic representation of the population from which the sample was drawn. So again, it's non random. So here's the drawing that illustrates selection product say someone made a product and advertised it, claiming that it helps to build muscle. And their marketing shows that 90% of the people have tried the product agree that works. But let's say someone else does the research and their results show that uh it has a 90% failure rate. Which one can we believe? Um when we look into the individuals who are picked from the first research project might find that um they were only bodybuilders within the intervention group um who may already have great muscle mass and their success is due to their workouts and only diets. Um It's not exactly a sample that represents the population as a whole, not everyone is a body builder. Um In the second study, the sample is from both groups and um there's individuals are selected at random and people from all walks of life are included. The sample is more representative of the population. The study is meant to correlate with. So this study b would be a more reliable study because of the methods and the samples and how they've been randomized into those two different groups. Um Of course, there's different types of bias that are present, there's performance detection as well as attrition bias and so on. Um So performance bias is unequal provision of care apart from treatment under evaluation. So this type of bias occurs um as the study is progressing. So, um researchers, for example, may um give more attention to one group compared to another. So from our example, earlier with Mr JB, in the article, if the researchers were aware of whether a patient is receiving monotherapy or combination therapy, knowing the hypothesis, they may consciously or unconsciously try to sway the results in favor of the hypothesis. Um This is why often double blinded studies tend to contain more validity. Um Next, we have detection bias. Um This is biased uh based on the outcome. So this is after a study has been uh conducted and the researchers are taking a look at the outcome, they may pay more attention to one study compared to the other. Um attrition bias occurs when there's systematic systematic differences between those two. those who complete a study and those who drop out or are lost, follow up, especially if the reasons for attrition are related to the study outcomes. So, um there are a few ways to reduce bias and we do this of course to increase and improve the reliability of a research study. This is a bit of a of a busy slide, but I'm just going to skip through it. Um The recording for this will be available. So you can definitely um have a look back at this in more detail. But randomization is kind of what I was covering for. So assigning participants treatment and control groups at random and giving them equal chance of being assigned to either group blinding is when you withhold information um that could potentially influence study results. So you can blind um the research participants and there's something called double blinding in which also the researchers are unsure of uh the which the participant unsure of where the participants are in the study in terms of whether they're the intervention group or the um control group. And also that's like a similar to allocation concealment. Um something that's commonly used in randomized controlled trials to provide selection bias and they can seal the allocation to all these surgeries. Um Followup, this helps to reduce attrition. V as I mentioned before, uh helps to identify any variables and enhances internal ability. There's also things like intention to treat analysis as well as a which I OK. Um the validity of a study. So in the critical appraisal process so far, we've covered the reliability of the study types of bias and how to minimize it. Now we have to cover the validity. So uh on the diagram of th the pain is hard illustration that's often used to help differentiate between reliability and validity. So imagine you're an archer, for example. Um and you've developed the scale to shoot arrows consistently just above the bulls eye and you can do this from anywhere. Um That's great and that shows reliability in your methods. But the point is to get the bulls eye and that's the validity. Um It focuses on how close we are to the truth does the study actually answer the question that's being asked, how accurate is the meas measurement? Um And in research, our target is to make sure that we are the bottom right one, we wanna get the most reliable and most valid um research. So there is a section and critical appraisal that focuses on the relevance of the study to real world health care. You've done all of this work, but how is it going to be beneficial if it isn't relevant or cannot be applied? This is where the research can have an impact on clinical decision making where it takes into account factors like adverse events, pros and cons and perhaps even economic evaluation if it's uh a large investment. So for example, if you're assessing the uh efficiency of robotic surgery versus laparotomy prevention for endometrial cancer. So that's just um an example of something of a study where you'd want to evaluate it economically. Um This is a lot of information to try to keep track of when you're critically appraising a journal article and especially during a presentation, which is why there are tools out there. Um checklists to help simplify the process. A critical appraisal skills program is one of them that help to create many checklists for any given study design, which you can provide to the audience for the discussion aspect of journal club at the end and you can make make a verdict on each of these points. So um the last thing I wanted to mention before I talk about the competition is the quick tips. So it's important to keep your presentation uh under 30 minutes, uh focus on the key points and a lot of time for this discussion and questions. OK. So now for the competition, so the series will run on a monthly basis. Um As I mentioned at the beginning of the presentation, we had a lot of different topics that people wanted to present or um just part um uh uh listening to. So if you are interested in taking part in this competition, um we will leave the topics up to you to decide on. So make a presentation submitted to mind the bleed. We'll announce the winner on our page and invite a specialist from your topics field to help lead the discussion on the webinar and individuals that are attending the session are also invited to, you know, bring up points discussions um for, for the journal presentation.