How to Read And Critically Review a Manuscript

Welcome to PICU Doc On Call, a podcast dedicated to current and aspiring intensivists. My name is Pradip KamatMy name is Rahul Damania, a current 2nd year pediatric critical care fellow. We come to you from Children's Healthcare of Atlanta and the Emory University School of Medicine Atlanta, GAToday's episode is dedicated to How to Read And Critically Review a Paper not only for the Journal club presentation at the fellows conferences but also for use in your clinical practice as a pediatric intensivist.We are delighted to be joined by Jocelyn Grunwell, MD, PhD. Dr. Grunwell is an Assistant Professor of Pediatrics-Pediatric Critical Critical Care at Emory University School of Medicine in Atlanta, GA. She is a K-scholar with research interests in mitochondrial dysfunction in critical illness, the airway immune response in pediatric acute respiratory distress syndrome, and near-fatal asthma. She is on twitter @GrunwellJocelyn.Rahul: Dr Grunwell welcome to picu doc on call. We are delighted to have you on our podcast today to discuss how to read & critically review a manuscript.Grunwell: Thank you Rahul and Pradip for having me on PICU DOC on Call. I have no conflicts of interest or financial disclosures.Q1. Rahul: Dr Grunwell: Why should a pediatric intensivist (whether in training or as a faculty) read journal articles?Grunwell: There are several reasons you might want to read journal articles, and your reading should be tailored to your goals. For example, first, you may want to learn more about a clinical topic to understand how to diagnose, treat or manage a disease. 2nd you may want to find the best evidence for how to treat a patient. 3rd, you may want to learn about the basic biology or mechanisms of a disease. Finally, you may want to identify gaps in a particular field of research to develop a research plan and write a proposal to explore a new research area.Q2: Dr Grunwell: Where do you find manuscripts relevant to intensivists?First, I would like to suggest that the learners and faculty in pediatric critical care make a habit of reading at the very least the abstracts in various pediatric journals even if they don't have the time to read an entire article. I generally go to Pediatric Critical Care Medicine, Critical Care Medicine, Critical Care Explorations, Pediatrics, Journal of Pediatrics, NEJM, JAMA Pediatrics, and the family of American Thoracic Society journals on a weekly basis. You can set-up your account so that the table of contents of these journals will be emailed to you. There are apps available, such as ReadQxMD, where you can be alerted to new content of interest to you. You can sign up and follow the accounts of several journals of interest to you on Twitter. There is also a useful, free website sponsored by Dr. Hari Krishnan called picujournalwatch.com in which Dr Krishnan has journal articles well-organized. The website is constantly updated to show the latest manuscripts relevant to our field. You can keep your articles organized by topic in software such as EndNote. Also doing a search on PubMed, OVID etc. can also be helpful to find latest information on a topic. Talking to a medical library scientists is very useful to structure a systematic search for articles or to get a article from a journal that is not available at your institution.Q3: Dr Grunwell can you define the term level of evidence?Grunwell: the term level of evidence - or traditional hierarchy of evidence - refers to what degree that information can be trusted based on the study design.The most common question is related to therapy or an intervention. Levels of therapy are typically represented as a pyramid with systematic reviews or meta-analyses positioned at the top of the pyramid followed by well-designed randomized control trials, and then observational studies. Observational studies include cohort studies or case-control studies. Case studies, laboratory-based studies with animal or in vitro models (aka: preclinical studies), and consensus or expert opinion lie at the bottom of the pyramid hierarchy. Based on this pyramid structure of evidence, the message is clear: Not all evidence and information is equivalent.Q3. Pradip: Dr. Grunwell what is a critical appraisal of a manuscript and how does it help us?Grunwell: Critical appraisal is the systematic evaluation of clinical research papers and it is used to judge the article's trustworthiness, its value and relevance in a particular context. Critical appraisal helps you to systematically evaluate whether:The study addresses a CLEARLY FOCUSED QUESTIONThe study uses VALID METHODS to address this questionThe valid results of the study are IMPORTANTThe VALID, IMPORTANT results are APPLICABLE to your patients or populationSo the goal of learning critical appraisal helps you:identify the most relevant papersdistinguish evidence from opinion, assumptions, misreporting, and beliefsPassess the validity of the studyassess the usefulness and clinical applicability of the studyrecognize any potential for bias.Q4. Dr Grunwell what are some of the key components of the appraisal process of a manuscript?I generally ask 3 preliminary questions when I look at a paper:What was the research question and why was the study needed? ( After a brief background about the topic under study, the paper's introduction should clearly state the research question and the hypothesis.)What was the research design? (For example, is this a primary or secondary study; If primary, then was it a laboratory experiment, clinical trial, survey, observational, or a case series study? If secondary, then was it a review or a clinical guideline, decision analyses, or economic analyses)?Was the research design appropriate to the question? It can be helpful to categorize the study into a therapeutic, diagnostic, prognostic, randomized control trial, qualitative, an epidemiologic/descriptive study, or a meta-analysis. There are evidence-based medicine worksheets that can help you structure a formal review and make sure you consider all aspects of the study. These worksheets can be found in many different languages at the Centre for Evidence-Based Medicine at The University of Oxford in the United Kingdom under Critical Appraisal Tools. The web address will be in the show notes (https://www.cebm.ox.ac.uk/resources/ebm-tools/critical-appraisal-tools) The Evidence-Based Medicine Toolbox from Toronto, Canada also have critical appraisal worksheets and resources to learn evidence-based medicine. This link will also be available in the show notes? https://ebm-tools.knowledgetranslation.net/.OK to summarize, understand the question and the study design and then assess whether the appropriate design was used to answer a central question!Q5. Dr Grunwell what is a general framework of how we should approach a manuscript?Dr Grunwell: In order to explain the structure of a scientific paper, I use the analogy of a story. Think about your favorite fairy tale: there is a beginning - where the scene is set and the characters are introduced; there is a middle - where the action happens, and there is an ending - where there is a lesson learned or a moral of the story. By analogy, every scientific paper has an introduction - where you set the background and importance of the question and introduce the subject matter - the who, the what, and the why of the study). The middle of the article is where the action happens - you explain how you did the study in the methods section and what happened (what you found) in the results section. Finally, the article has an ending where you discuss the results within a larger context of other studies by comparing and contrasting, noting similarities and explaining discrepancies to other work, and acknowledging limitations. Finally you make a conclusion based on your results - can you recommend this therapy or diagnostic study for your patients?.I really like the story analogy as this really frames our next segment of how to systematically read a scientific paper.Q6. Dr Grunwell: What is the first step in the critical appraisal of the scientific paper?A good first step would be just to skim through an article (start with the abstract) to understand the aims, key data and conclusions. Early considerations as you are skimming through the manuscript)-Main question - Relevant? Interesting?Original topic - Address a gap? Clear & easy to read?Conclusions consistent with the evidence presented?Do the experiments/data address the main question?Is there a disagreement with current consensus & is this disagreement justified by the data gathered?Do the Tables & Figures tell the story/add to the paper?This is a bird's eye view to get yourself oriented.Dr. Grunwell, in general, how does the introduction help you as you critically appraise a manuscript?Grunwell: When we look at the introduction we can formulate the problemDefine who the question is about? (how would I describe a group of patients similar to this one)Define which maneuver you are considering in this patient or population and if necessary, a comparison maneuver: (drug treatment vs. standard therapy or placebo)Define the outcome:...