Equipment Resources
September 2008. "Life-Threatening Asthma: Pathophysiology and Management"
June 2008. "Patent Foramen Ovale in Pulmonary Medicine"
May 2008. "Mechanical Ventilation for Severe Asthma"
April 2008. "Aerosol Delivery During Mechanical Ventilation: From Basic Techniques to New Devices"
March 2008. "Acute Pulmonary Embolism"
January 2008. "Non-Invasive Positive Pressure Ventilation in Acute Respiratory Failure"
Why have a Journal club to discuss studies/papers?
It is every practitioners responsibility to practice at the highest level they
are capable of. This includes physicians, nurses, respiratory therapist's and
any other practitioner. It is incumbent upon us all to remain as up-to-date as
possible in order to make sound clinical decisions, and recommendations to
protect our patients from unsafe practices.
"Good doctors (read practitioners) use both
individual clinical expertise and the best available external evidence, and
neither alone is enough. Without clinical expertise, practice risks becoming
tyrannised by evidence, for even excellent external evidence may be inapplicable
to or inappropriate for an individual patient. Without current best evidence,
practice risks becoming rapidly out of date, to the detriment of patients."
Sackett DL. BMJ 1996
In order to do this you must incorporate every day anecdotal experiences with
EVIDENCE. You must constantly re-evaluate the literature and use your knowledge
in your every day practice AND your every day education of others.
The big push these days is to practice evidence based medicine. In our
case evidence based respiratory care. In order to do this, we must have a
very strong knowledge of the current literature and support for the therapies
that we provide. You are the expert's in this area. You have to know more about
these therapies than anyone else. You should be able to offer you opinions,
provide anecdotal experience, and most importantly provide evidence based
support for your opinions.
Remember, when someone wants to make changes to a standard of care, it is
incumbent upon them to provide support that their new standard of care will
benefit the patient. In order to do this you must be familiar with the
literature. Knowledge of current evidence makes you a valuable part of the team,
and not just a technician that turns a dial, or blindly follows direction. Your
knowledge of the literature can impact patient survival-mortality/morbidity on a
daily basis.
The following are helpful "pointers" and links that may be useful when
looking for, reading, and interpreting the literature.
Types of Studies: There are basically two categories that studies fall into. Interventional
and Observational.
Interventional Studies: Clinical Trials and Basic Experimental
Research
1) Clinical trials. Example Phase 1-4 clinical trials are
performed to determine efficacy of new medicines or
equipment. Each trial uses an increasingly lager group of
patients. See the below link.
The following link will take you to the NIH's clinical trial network. Very
useful when searching for and understanding current clinical trials:
http://clinicaltrials.gov/
Describes in detail the description of a clinical trial:
http://clinicaltrials.gov/ct
There are several types of clinical trials:
Randomized - A randomized controlled trial (RCT) is a scientific
procedure most commonly used in testing medicines or medical procedures. RCTs
are considered the most reliable form of scientific evidence because it
eliminates all forms of spurious causality. RCTs are mainly used in clinical
studies, but are also employed in other sectors such as judicial, educational,
social research. Clinical RCTs involve allocating treatments to subjects at
random. This ensures that the different treatment groups are 'statistically
equivalent'.
Sellers of medicines throughout the ages have had to convince their consumers that the medicine works. As science has progressed, public expectations have risen, and government health budgets have become ever tighter, pressure has grown for a reliable system to do this. Moreover, the public's concern for the dangers of medical interventions has spurred both legislators and administrators to provide an evidential basis for licensing or paying for new procedures and medications. In most modern health-care systems all new medicines and surgical procedures therefore have to undergo trials before being approved.
Blind - Blinding is a basic tool to prevent conscious and unconscious bias in research. For example, in open taste tests comparing different product brands, consumers usually choose their regular brand. However, in blind taste tests, where the brand identities are concealed, consumers may favor a different brand. Single blind describes experience wherein information that could introduce bias or otherwise skew the result is withheld from the participants. Unlike in a double blind experiment, the experimenter will be in full possession of the facts. A trivial example of a single-blind experiment would be the "Pepsi challenge".In a single blind experiment, the individual subjects do not know whether
they are so-called "test" subjects or members of an "experimental
control" group. Single-blind experimental design is used where the
experimenters either must know the full facts (for example, when comparing sham
to real surgery) and so the experimenters cannot themselves be blind, or where
the experimenters will not introduce further bias and so the experimenters need
not be blind.
In a double-blind experiment, neither the individuals nor the researchers know who belongs to the control group and the experimental group. Only after all the data are recorded (and in some cases, analyzed) do the researchers learn which individuals are which. Performing an experiment in double-blind fashion is a way to lessen the influence of the prejudices and unintentional physical cues on the results. Random assignment of the subject to the experimental or control group is a critical part of double-blind research design. The key that identifies the subjects and which group they belonged to is kept by a third party and not given to the researchers until the study is over. Double-blind methods can be applied to any experimental situation where there is the possibility that the results will be affected by conscious or unconscious bias on the part of the experimenter.
Crossover - A crossover trial also referred to as a crossover study is one where patients are given all of the medications to be studied, or one medication and a placebo in random order. These studies are generally done on patients with chronic diseases to control their symptoms. The data is analyzed according to the original intention to treat.A crossover study has the advantage over a simple double-blind study that the variability between patients is minimized because each patient crossing over in effect serves as their own control. One disadvantage is that long term effects cannot be tracked with this approach. Another disadvantage is that curative therapies cannot be tested after one another or before a placebo for obvious reasons.
There are some important issues with respect to the design of cross-over studies. Two in particular may often crop up.
First is the issue of order effects, because it is possible that the order in which treatments are administered may affect the outcome. An example might be a drug with many adverse effects given first, making patients taking a second, less harmful medicine, more sensitive to any adverse effect.
Second is the issue of carry-over between treatments. In practice carry-over can be and is often dealt with by the use of a wash-out period between treatments, or by making observations sufficiently later after the start of a treatment period that any carry-over effect is minimized.
2) Basic Experimental Research Used to test hypotheses about biological mechanisms (prospective). These are usually controlled, randomized studies.
Observational Studies: Case reports, Case Series, Case-Control, Cross-Sectional and Cohort.
1) Case report (retrospective) - One case study, ie. regarding a specific patient.
2) Case series (retrospective) - Multiple case studies, regarding a specific patient type.
3) Case - control (retrospective) Case-control studies are one type of epidemiological study design. It is used to identify factors that may contribute to a medical condition by comparing a group of patients who have that condition with a group of patients that do not.
3) Cross - sectional: Cross-sectional studies can be thought of as providing a "snapshot" of the frequency and characteristics of a disease in a population at a particular point in time. This type of data can be used to assess the prevalence of acute or chronic conditions in a population. However, since exposure and disease status are measured at the same point in time, it may not always be possible to distinguish whether the exposure preceded or followed the disease. The cross-sectional survey--which, like a
snapshot, "freezes" a specific moment in time--aims at finding the same kind of relationships that might be shown by the "moving
picture" of the cohort study, but at far less cost. In a cross-sectional survey, a specific group is looked at to see if a substance or activity, say smoking, is related to the health effect being investigated--for example, lung cancer. If a significantly greater number of smokers already have lung cancer than those who don't smoke, this would support the hypothesis that lung cancer is caused by smoking.
4) Cohort (prospective): A cohort study is a form of longitudinal study used in medicine and social science. It is one type of study design and should be compared with a cross sectional study. A cohort is a group of people who share a common characteristic or experience within a defined time period (e.g., are born, leave school, lose their job, are exposed to a drug or a vaccine, etc.). Thus a group of people who were born on a day or in a particular time period, say 1948, form a birth cohort. The comparison group may be the general population from which the cohort is drawn, or it may be another cohort of persons thought to have had little or no exposure to the substance under investigation, but otherwise similar. Alternatively, subgroups within the cohort may be compared with each other.
How to search for evidence and data. The following are links that I have found very helpful when searching for specific literature that I am looking for. They may or may not be helpful to you.
Probably the one that I use most often now days is Google Scholar. It is very easy to use, and I almost always find at least one reference regarding the topic I am looking for.
http://scholar.google.com/
The following is a link for PubMed. It is an excellent resource for searching for papers by author, subject, journal etc. A little more complicated but very useful.
http://www.ncbi.nlm.nih.gov
Probably one of THE most comprehensive guides to Evidence Based Medicine can be found at the following link. Very complex, but worth looking at and saving for a reference.
http://www.cche.net/usersguides
The following is a link to Respiratory Care (Journal for AARC). If you are member, (and you should be) you can log on and search for articles published within the Journal.
http://www.rcjournal.com/
There are many other resources that you will stumble across while searching for topics of interest. Please feel free to pass along any links or resources that you find, or already use.
OK. Here is how the Journal club will operate. How often we send a new paper/topic out to discuss will depend on interest and participation, so that will be played by ear. Most likely we will discuss ONE topic per month.
1) A specific paper or topic will be determined. I will decide them at first until everyone gets the hang of the process.
2) You (staff), search for topics that you are interested in discussing. You send them to me, and I will convert them to PDF files and send them to staff.
3) Once you receive the topic of the month, you are encouraged to comment on the topic, and or send other papers or evidence that you find or are aware of pertaining to the topic. All comments or correspondence should be sent to me, and I will organise them, and re-send to the whole staff in one neat little package.
4) We will discuss the topic at the end of the time period, probably a month, and possibly at the staff meeting.
OK. I know I have hit you with a lot of information here. Please look everything over, and feel free to respond with any questions you might have. We will work out the bugs as we go along. More specific information will be forthcoming, but I wanted to give everyone a little bit of time to provide any recommendations or suggestions that you might have.
The MAIN objective here is for all of us to have a better idea and understanding of the current literature that pertains to our profession and to be able to apply it to our practice of respiratory care. Just as important is our ability to intelligently recommend and encourage our physician colleagues to utilize evidence based therapies as well.
I am open to any question, recommendation or suggestion that you may have to facilitate the process.
Keith