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Do you run a journal club? A helpful insight from thisissue,itistheuseoftheABCDscore,whichtellsuswho someone at our recently finished 3 day EBM workshop needs urgent investigation after a transient ischaemic attack in Oxford was that many journal clubs are boring (TIA). The likelihood of stroke is very high in the first days because the articles are quickly trashed as poor research and and weeks after a TIA, and reducing risk then is vital. We nothing changes. Since only 1 in 20 articles passes the EBM have previously published an evaluation of the ABCD rule, journal’s validity criteria, this is likely to occur 19 out of 20 but Johnston et al have further validated the score and times for journal articles that simply look "interesting." So for confirmed it is highly predictive. Of course, this needs to link journal clubs you might like to consider either articles from to a rapid evaluation service, so you might need a little local EBM or at least make sure that you screen articles for basic validity before the session. In this issue there is also some good Among the others I will try out is teaching male patients advice from Schwartz on how to make a clear succinct with lower urinary tract symptoms a few simple things for presentation at journals clubs. Along with good food and self management (Van der Muelen). The intervention has 1 coffee, we think this should be mandatory! of our better NNTs, and is relatively simple and harmless.
We note, though, that our current criteria of requiring a Also, although it won’t directly change my practice, it’s useful randomised trial for all treatments, may have to be slightly to know that SSRIs can start to work in depression within a modified. One of the editors recently published an article on week, with a close to linear build up of response over the first when randomised trials are not needed (BMJ 2007 Feb 17;334:349–51). This was triggered by his successful use of Unfortunately, some widely used interventions seem to the "parent kiss" method to remove a bead lodged in a young have small or non-existent benefits. What appears to be the patient’s nose. It seems some treatments have such a rapid definitive trial of whether to start mammographic screening and dramatic effect that trials are not needed to pick the at 40 years of age or later didn’t find a statistically significant treatment signal from the prognostic noise. But currently the reduction in breast cancer mortality (Moss). Similarly, a large list of such dramatic treatments is pretty short.
trial of tympanostomy tubes did not show improvement inlanguage outcomes (Paradise). I am sure neither of these will To keep our practice up to date, it is helpful to ask with each issue of EBM what things you might start doing and what things you might stop? If I had to pick 1 change to make from Improving journal club presentations, or, I can present that paper Fifteen years ago we sought to develop a method for reasonedthat,justaslearnersprogressfrommeanderingand teaching residents how to make lean, pithy journal club imprecise case presentations on clinical clerkships to brief, presentations. Our aim was to help them distill an article utilitarian sign-outs as senior residents, journal club pre- down to its core while systematically reviewing its validity senters can learn to efficiently convey the essence of an and telling a compelling story. Others have created successful journal clubs by explicitly linking the educational experience We introduce this model of journal club presentation to to questions raised in caring for patients.1 medical residents in a small group workshop early during Brief article presentations are structurally similar to the internship and then deepen residents’ skills during our brief case presentations we do all the time. On work rounds, clinical epidemiology course in the second year.2 Residents’ morning report, or sign-out, the goal is to communicate the skills are reinforced and refined throughout residency at a essential information about a patient in a concise, mostly weekly journal club attended by 10–20 residents, fellows, and standardised format that is easily digested by the listener. We We use the following 10 step guideline to help presenters ‘‘Does high dose atorvastatin for 5 years reduce the incidence of increase efficiency in assessing a study’s validity and results stroke among patients with recent stroke or TIA and no known and to increase confidence in limiting a presentation to the core essentials. Faculty members model the process andresidents learn through reflective practice.
4. STATE THE IMPORTANCE/RELEVANCE/CONTEXTOF THIS QUESTION Following this 1 line description of the study and statement of the question, concisely state the importance of this question.
Start your article presentation with a brief case presentation, This information can usually be found in the author’s or briefly explain how the article is relevant to a patient or introduction where they put their study in the context of other problem you are considering. This helps listeners more fully literature. This context can be described in 1–3 sentences.
engage with your presentation and makes it more of a story.
‘‘Therapy with statins reduces the risk of stroke among patients For example, ‘‘An otherwise healthy 68 year old man came to see with coronary heart disease and those at increased risk of me after he suffered a transient ischaemic attack (TIA) and I cardiovascular (CV) disease. No studies thus far, however, show wondered if he should be on a statin even though his risk of cardiac that statin treatment decreases the risk of recurrent stroke among otherwise healthy patients with a history of stroke or TIA.’’ 2. EXPLAIN HOW YOU CAME ACROSS THIS ARTICLE Very briefly describe the search strategy you used to track Following this brief background, 1 way of briefly describing ‘‘I found this paper by searching Medline using the terms the methods is to give a bit more detail on the Patients, Intervention, Comparison, and Outcomes (PICO) related to inhibitors, and the Clinical Query for therapy (maximising specificity) which identified 9 articles.’’ P—‘‘The study included 4371 patients, 60% men with an average age of 63 years and mean LDL cholesterol of 133 mg/dl. All patientshad a recent stroke (69%) or TIA (31%). Those with atrial fibrillation, embolism from other cardiac sources, and subarachnoid In a case presentation we start with some standard descriptors of the patient followed by the chief complaint or STATEMENT IC—‘‘Atorvastatin 80 mg daily or identical placebo.’’ O—‘‘After a median of 4.9 years of follow up, the primary outcome was incidence of fatal or non-fatal stroke, and all cause This is a 55 year old male smoker from Bangladesh who death. Secondary end points include a composite end point of stroke or presented with 2 hours of burning chest pain and is TIA, major coronary event, major CV event, acute coronary event, any coronary event, revascularisation, and any CV event.’’ When presenting an article, we can think of some standard 6. STATE YOUR ANSWERS TO THE CRITICALAPPRAISAL QUESTIONS ON VALIDITY N What type of question was asked—for example, diagnos- Next, briefly answer the appropriate critical appraisal questions tic, therapeutic, prognostic, aetiologic, or economic? on validity using the JAMA users’ guides to the medical literature5 N What type of study (method) was used—for example, and elaborate with some explanation, questions, or concerns if randomised controlled trial, retrospective cohort, case needed. Although it is a bit formulaic to go through each control, meta-analysis, cross-sectional, descriptive, deci- question, it is a good habit to develop, and use of the GATE frame makes it easier.6 Remember, if you suspect bias, consider N Where was the study done (if relevant)—for example, not only its possible presence, but also its direction, magnitude, multicentre, veteran affairs centre, population based, and impact on the study’s conclusions; not all flaws are fatal. Be Antarctica, New York City, academic medical centre, or cautious to not get lost in the statistics/analysis section.
Remember, ‘‘Statistics are a tool while study methods rule!’’ N Any other outstanding features—for example, well known For a study of the efficacy of therapy, these questions apply: N Did the experimental and control groups start out with a So we might start by saying, ‘‘This was a multinational, randomised, controlled trial of therapy, and the first study designed to – Was randomisation concealed? YES.
– Were patients analysed in the groups to which they were randomised? YES—intention to treat analysis.
The chief complaint of an article is the research questionor hypothesis to be tested. A well built research question – Were groups similar re known prognostic factors? has 4 basic components (PICO—see section 5 below):3 Did the experimental and control groups retain a similar Intervention or exposure—what therapy, risk factor, tests,etc.? – Were patients, clinicians, and outcome assessors aware N Comparison or control–what alternative to intervention or of group allocation? NO—all were blinded to random N Outcome—clinical, functional, economic, etc.? – Was follow up complete? YES and similar in each group.
‘‘Atorvastatin may modestly reduce the risk of recurrent Remember, ‘‘The conclusions givith but the methods taketh cerebrovascular events in patients with recent ischaemic cere- away! Caveat lector—reader beware!’’ brovascular accident or TIA. I will offer this medication to suchpatients but will still focus more on those at higher risk of cardiacevents.’’ 7. SUMMARISE THE PRIMARY RESULTSAt last, the results. Some like to present the bottom line result 10. FINALLY, PREPARE A 1 PAGE SUMMARY OF THE up front in their presentation titles, similar to the format in ACP Journal Club and Evidence-Based Medicine. Alternatively, The summary will serve as your notes for the presentation you can report the results after the descriptors and research and will help guide the group’s attention. It also provides a question. We find that when browsing a journal our eyes go storable record of the article, similar to Critically Appraised from the title (if it sounds interesting) to the conclusions in the abstract. The inner question is, ‘‘If this is true (valid) would it be Believe it or not, you can do all this in 10 minutes easy, 5 interesting or important to me?’’ Or, if you prefer to keep people minutes with very tight editing, and 2–3 minutes hitting just in suspense, save the bottom line answer for the results: ‘‘Atorvastatin reduced the rate of fatal and non-fatal stroke from These guidelines have dramatically improved the enthu- 13.1% on placebo to 11.2%, a statistically significant 16% relative siasm for, quality of, and attendance at our journal clubs, reduction in risk over 5 years. There was no difference in overall which have now been running continuously for more than 15 years. Residents are expected to present the paper in 10 Limit your summary of the results to the primary question minutes, provide a concise 1 page summary using the outline and only present secondary results if they are relevant. It is above, and lead a 20 minute discussion on the clinical and helpful to bring your listeners’ eyes to a particular row on a methodological issues. As a result, residents have improved table or a bar on a graph to illustrate your point. You will not both their presentation and critical appraisal skills. In our insult anyone by taking them by the hand and leading them experience, this approach, familiar to residents because they through the paper. And feel free to play with the numbers.
are parallel to patient case presentations, is easily learned and ‘‘As you can see under secondary outcomes in table 2, major portable. Developed for a smaller group of primary care coronary events were reduced by 35% from 5.1% to 3.4%. The residents, the model is now used for all medical residents primary result suggests an absolute reduction of 2% in fatal and non- and fellows. Slides from these workshops are available at fatal stroke so that we would need to treat 50 patients with 80 mg of www.evidence-basedmedicine.com/. We believe this model has atorvastatin for 5 years to prevent 1 event, a modest impact.’’ contributed to the long running success of our journal club and 8. DESCRIBE WHY YOU THINK THE RESULTS CAN OR made it a lively, relevant, and fun way to simultaneously Finish with your assessment of the study’s external validity— can you apply these results to your patients? Or better, are the patients or setting so different from your own so as to make these findings useless to you? How much might you have to adjust the study findings due to differences between the 1 Phillips RP, Glasziou P. What makes evidence-based journal clubs succeed? study’s patients or setting and your own? 2 Meserve C, Kalet A, Hanley K, et al. Clever nihilism: Do cynics ‘‘Would the efficacy be larger or smaller in older patients? In learn in an evidence based medicine course? Medical Education Online addition, the authors excluded patients at higher risk of haemor- rhagic stroke and, in fact, atorvastatin may have increased the risk of 3 Richardson WS, Wilson MC, Nishikawa J, et al. The well-built clinical question: a key to evidence-based decisions [editorial]. ACP J Club 4 Amarenco P, Bogousslavsky J, Callahan A, et al. High-dose 9. CONCLUDE WITH YOUR OWN DECISION ABOUT THE atorvastatin after stroke or transient ischemic attack. New Engl J Med UTILITY OF THE STUDY IN YOUR PRACTICE—RESOLVE THE 5 The Evidence-Based Medicine Working Group. Users’ guides to the medical literature: a manual for evidence-based clinical practice. Chicago: AMA Press, If you started your presentation with a case, be sure to leave time to come back to the case at the end and try to apply the 6 Jackson R, Ameratunga S, Broad J, et al. The GATE frame: critical appraisal with pictures. Evid Based Med 2006;11:35–8.
study’s findings to your patient or problem. Give the listeners 7 Centre for Evidence-Based Medicine. www.cebm.net/cats.asp (accessed 20 13th Oxford Workshop on Teaching Evidence-Based Practice 10th – 14th September 2007; Oxford, UK.
Director, Centre for Evidence-Based Medicine; The workshop is aimed at clinicians and other healthcare professionals, including those involved in mental health, who already have some knowledge of critical appraisal and experience in the practice of evidence-based health care and who want to explore issues around teaching evidence-based medicine.
Further details can be obtained at www.cebm.net/ or by emailing olive.goddard@dphpc.ox.ac.uk

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