BMC Emergency Medicine Journal Club

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BMC Emergency MedicineJournal Club

• Topic Journal Club About Journal Club
• July 2008

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The Origins of Journal Club

• The biography of Sir James Paget describes a
  regular gathering of self-elect students who
  met in a room over a bakers shop near St.
  Bartholomews Hospital to read journals or play
  cards (1835-1854).

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The 1st Official Journal Club

• 1875
• Sir William Oslers Journal Club in Montreal

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Journal Clubs Abound

• Residency training
• CME
• Innovative formats and forums

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BMC EM Journal Club
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BMC EM Journal Club

• Since 1986 at BCH
• Joseph Kahn, MD
• Faithful, conscientious, dedicated steward of the
  written word and defender of evidence-based
  medicine

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1986 2008
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1986 2008
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Annals of Emergency Med 1986
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Annals of Emergency Med 1986
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Annals of Emergency Med 1986
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Back to 21st Century
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Todays Agenda

• History of Journal Club
• Joseph Kahn Award
• Publications about Journal Club
• Brief Review of 4 Articles

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EM Lit on Journal Club

• Jouriles NJ. Emergency medicine journal clubs.
  Acad Emerg Med 19963872
• Burstein J. Enhancing the value of journal club
  use of a structured review instrument. Am J Emerg
  Med 199614561
• Kuhn GJ. A survey to determine the prevalence and
  characteristics of evidence based medicine in
  emergency medicine residency programs. J Emerg
  Med 200528353.

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JC about JC

• Alguire PC A review of journal clubs in
  postgraduate medical education. J Gen Intern Med
  199813347.
• Objective To summarize elements of successful
  clubs and their effect on postgraduate reading
• Methods Medline 1966-1997

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Alguire 1998

• Conclusions
• Journal clubs are educationally diverse.
• Journal clubs with high attendance and longevity
  are characterized by mandatory attendance,
  availability of food, and perceived importance by
  the program director.
• Studies have failed to demonstrate that
  residents read more or read more critically.

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Our JClub Goal

• Studies have failed to demonstrate that
  residents read more or read more critically.
• To get us all to read more and read more
  critically.

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JClub Objectives

• To make us experts in our own literature

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Article 1

• Annals of Emerg Med Jun 200851697

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Byyny 2008

• Background CT scan technology has evolved since
  original research on CT sensitivity for SAH
• Objective Are new generation CTs better?
• Methods Retrospective (2001-2004), single
  institution, all with ICD-9 SAH

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Byyny 2008

• Results
• N149 139 by CT, 10 by LP
• Overall CT yield 93 (95CI 88-97)
• Normal MS and HA, CT scan sensitivity was 91
  (95CI 82-97)
• Conclusion Non-contrast CT exhibits inadequate
  sensitivity to rule out SAH

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JClub Objectives

• To make us experts in our own literature
• To translate Dowling JClub lessons to ED

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Byyny 2008

• Bottom Line Review

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Byyny 2008

• Bottom Line Review 3 ½ Joes
• Lesson Do not ditch the LP

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JClub Objectives

• To make us experts in our own literature
• To translate Dowling JClub lessons to ED
• To link primary literature to monthly topic
• July 2008 Signs and Symptoms

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Article 2

• Am J Med Sc 1942 20314

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Schiff 1942

• Background It is unknown how well blood in stool
  is associated with ulcer bleeding rate or timing
• Objective To determine if upper GI blood affects
  blood detection in a patients stool
• Methods Human volunteers drank 3 week old
  citrated blood mixed with Vichy water to
  disguise the taste

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Schiff 1942

• Key Results
• A tarry stool may result from ingestion of 100cc
  of blood
• Gross blood and tarry stools may continue for up
  to 8 days after intragastric ingestion of
  1000-2000cc
• Occult blood in stool can persist for as long as
  10d after 250cc PO or 12d after 2000cc
  intragastric
• Authors Conclusion Passage of a tarry stool
  doesnt indicate occurrence of severe GI bleed.
  Persistence of tarry stool or occult blood
  doesnt indicate continuation of such GI bleed

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Victorias Thoughts

• PART I
• How much blood gives 1 tarry stool? 100cc
• Supports conclusion that tarry stool doesnt
  represent severe bleed
• PART II ??
• How large of UGI bleed produces BRBPR? Tarry
  stool?
• Melena or BRBPR doesnt correlate w/ volume of
  blood or location of bleed.
• PART III
• Does chemical test represent ongoing bleed?
• Up to 2 weeks after ingestion- Guaiac

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Favorite Sentence

• The designation tarry was applied by us to a
  glistening stool having the same black color as
  found on a standard paint color chart.

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Victorias Final Word

• Bottom Line Review 2 ½ Joes

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JClub Objectives

• To make us experts in our own literature
• To translate Dowling JClub lessons to ED
• To link primary literature to monthly topic
• To master new scientific vocabulary
• Sensitivity, specificity, alpha and beta
  errors, odds ratio, risk ratio, logistic
  regression, confidence interval, Kaplan-Meier,
  kappa statistic, Wilcoxon, Fishers exact, Bayes
  theorum, z-score

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Article 3
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McLaughlin 2001

• Background Lecturalgia (painful lecture) is a
  frequent cause of morbidity for both teachers and
  learners.
• Objective To devise a schematic for diagnosing
  lecture problems and to provide evidence-based
  recommendations on solving those problems.
• Methods Lit review ? schematic

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Key Results
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Todays Term Lecturalgia

• Bottom Line Review 2 Joes
• Lesson Journal club will not be limited to the
  lecture format

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JClub Objectives

• To make us experts in our own literature
• To translate Dowling JClub lessons to ED
• To link primary literature to monthly topic
• To master new scientific vocabulary
• To inform our own research endeavors

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Article 4

• BMJ 2003 32720

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Smith 2003

• Background It is assumed parachutes work.
• Objective To determine if parachutes minimize
  trauma related to gravitational challenge.
• Methods Systematic review of all
  randomized-controlled trials.

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Smith 2003

• Results
• Search strategy did not find any randomized
  controlled trials of parachute use
• Authors Conclusion
• Effectiveness of parachutes has not been
  subjected to rigorous evaluation
• Only observational data to suggest that
  parachutes reduce morbidity and mortality
• We need double blind, randomized, placebo
  controlled, crossover trail of parachute use

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Lauras Thoughts

• Commentary on EBM which is entertaining and
  thought-provoking
• Conclusions and proposal are not realistic
• Good luck with IRB approval
• Observation data is not always misleading
• Calcium, Vit D and fracture prevention

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Favorite Sentence

• We feel assured that those who advocate
  evidence based medicine and criticize use of
  interventions that lack an evidence will not
  hesitate to demonstrate their commitment by
  volunteering for a double blind, randomised,
  placebo controlled, crossover trial.

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Another great line

• Individuals who use parachutes are likely to
  have less psychiatric morbidity and they may also
  differ in key demographic factors, such as income
  and cigarette use. It follows, therefore, that
  the apparent protective effect of parachutes may
  be merely an example of the healthy cohort
  effect.

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Lauras Final Word

• Bottom Line Review 4 Joes

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JClub Objectives

• To make us experts in our own literature
• To translate Dowling JClub lessons to ED
• To link primary literature to monthly topic
• To learn new lit-relevant terms
• To master new scientific vocabulary
• To remind ourselves daily reading can be fun

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Next Month

• Topic Abdomen / GI
• Residents Kelly Hannigan, EM2
• Rochelle Lima-Babigian, EM1

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Summary

• To make us experts in our own literature
• To translate Dowling JClub lessons to ED
• To link primary literature to monthly topic
• To master new scientific vocabulary
• To inform our own research endeavors
• To remind ourselves daily reading can be fun