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Session 6 - Live Rapid Review for BPS Exams

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Summary

Core Theme

This content is a comprehensive rapid review session for BPS exams, covering a wide range of disease states and concluding with a detailed explanation of evidence-based medicine (EBM), biostatistics, and clinical literature evaluation. It aims to reinforce core concepts for exam preparation.

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Okay. Well, welcome everybody. It's good

to have you for this uh last session for

rapid reviews for BPS exams where we

cover a lot of the core disease states.

We've got some additional disease states

to cover and then we will end with everybody's

everybody's

favorite subject that you just,

you know, get super excited about and

drool over and everything else. That's

your evidence-based medicine,

bioatistics, and clinical literature

evaluation. We will be uh probably

finishing up some of the disease state

stuff a little bit early and we may even

start the EBM uh because it's just a

little bit longer than the traditional

hour. Uh but I want to make sure we get

that rapid review, hit the high points.

Uh so hope everybody's got your your cup

of coffee,

okay? coffee

um with you and your pen paper. But

really what we want this to be is really

sit back and you should be just sort of

absorb it. Should be really just kind of

going through the core concept should be

ringing a bell. Should make sense to

you. Um it is not meant to be primary

teaching. So I just wanted to make sure

to establish those ground rules here. Um

the idea is that you've already gone

through some of this. Oh, but we have

some good news to share, but not until

the end. And it's specifically for you.

I think you'll be very happy and excited

about some of the news that I got to

share, but it is just for you. All

right. Anybody know Nacho Libre? I hope

I I hope that I'm not the only one who's

old. Uh, but Nacho Libre is like one up

there with um Napoleon Dynamite that,

you know, you got to put on the bucket

list. Okay. So, uh Jack Black

um showing off his uh masculinity there.

All right. So, to come.

Hopefully, at this point in the review

process, you are not psychotic.

You are. We can treat acute agitation.

So, hopefully you're not angry,

aggressive, hostile like Busty. Just get

started, will you? Right. No. Uh but we

all have seen this in clinical practice

and where people with some psychiatric

illness for some reason or drug induced

um you know have an exacerbation usually

due to non-compliance. There are

different scales uh that you can use to

help assess those. You don't need to

memorize what the scale is. Um just

being familiar with the RAS and the SAS.

Um you can try to counsel people down,

redirect them. Most of the time that

doesn't work, at least in my experience,

because I'm seeing them these folks on

the other side when police or law

enforcement bring them in or EMS brings

them in and they're under, you know, uh,

restraints or they're requiring four or

five guards to hold them down. Uh, but

if you can, try to place them separate

to the public. try to put them in a

quiet space, especially if they are

having hallucinations,

uh whether that's visual or auditory,

and try to do your best to redirect them

because really where you're headed is am

I going to have to physically or

chemically restrain this patient, right?

So physical restraints can be twopoint

or fourpoint. There's a lot of rules

because obviously you're basically

overriding someone's ability and and

holding them down. uh you have to many

times it's wise to have a second health

care provider weigh in and have an

agreement that for the safety of the

patients own care but also for the

safety of the staff and the environment

that you need to do that. So once you

get to that point if that doesn't work

you may be finding yourself having to

use chemical restraints. The use of the

chemical restraint will be dependent on

what is the underlying problem. So if

it's underlying psychiatric you can use

some of the antiscychotics like

aloperidol or immediate release or

injectable not long acting alanzipene

and zyprazadone those kind of agents. If

you got someone who's just mildly

agitated sometimes but again most of my

experience says that you won't get that

to happen. They will take oral agents

which can include both oral lanzipene or aapiprazole.

aapiprazole.

uh if you have sympathomimedic mediated

uh aggression of cocaine, amphetamines

and these other things, you don't want

to give antisycotics because they can

lower the seizure threshold and that's

where benzoazipines become the preferred

if you have no IV access and for the

rapid absorption mazzelam uh is your

primary if you want quick onset but

Adavan if you want somewhat of a delayed

onset but it'll last longer. So IM tends

to be something that we uh use. Now

moving on to attention deficit

hyperactivity disorder. Remember these

patients can present with two different

types or degrees. Some are more

hyperactive, some are more of uh

inattention. Um and so that's why you

see predominantly inattentive,

predominantly hyperactive. Um many times

these kids and there is even adult

versions, they're just have a hard time

paying attention. they get easily

distracted. Uh they can't follow through

and complete tasks. And a lot of this

stuff comes up usually in school. So

they need six or more symptoms um to be

present for at least six months. And we

need to get information from at least

two settings, usually home and school.

And so that needs to be documentation

from both a parent plus teacher or the

clinician um as part of this diagnosis

so that we don't just label everybody

because we're going towards a controlled

substance. So, we know with most

psychiatric illnesses and and psychiatry

that cognitive cognitive behavioral

therapies plus drug therapy tend to work

best versus just throwing drugs at them.

And then there's the two main classes,

stimulants, non-stimulants. Dr. Boland,

I think you have something here for us

that you want to also add. Yeah, just a

quick addition uh to remind you or if

you weren't aware uh listexetamine or by

vans uh can also be used for binge

eating disorder. Um so that's kind of

one of the unique things that you may

see uh you know in a case or something

like that. They may be trying to lead

you down that path.

>> Yeah. And if you a lot of people have

migrated toward the non-stimulants

because of the controlled substance

issues and it's just it is a pain in the

rear end to have to get refills and you

know work with a pharmacy and have a

certain number of supply and not being

able to get it refilled on a particular

I mean it's a it's a big hassle for the

providers as well. So we have

adamoxitine we also have long acting uh

uh clonedine which we know is an

anti-hypertensive alpha 2 agonist and

guanosine and unique formulations for

that particular disorder. All right. So

now if your anxiety hasn't been ramped

up a little bit, we're going to uh talk

about anxiety disorder. Uh these result

in both cognitive as well as

psychosocial uh manifest in physical

symptoms. And a lot of times what I see

are patients presenting to like the

department with most commonly chest pain

or feeling the sensation that their

airway is closing up when in reality uh

anatomically nothing is happening. Uh

but it doesn't matter in their mind it

is happening. Okay. And so a lot of

times just allowing the patient to

express what their concern is and not

dismissing their feelings um helps them

to reduce their anxiety, but then

pointing to objective information to

help them to kind of calm down because

they're usually have gotten themselves

so worked up that they just need

somebody to talk sense into them and

many times they come in to make sure

nothing is going on. So cognitive from a

preventative standpoint, you've got

cognitive behavioral therapy just like

with ADHD. Okay? I don't think we should

forget about that, which is why it's re

uh printed here. But then

anti-depressants. Um, and if you're

going to use anti-depressants, it is

typically starting off at a low dose

with slower titrations because many of

them, specifically the SSRIs or agents

that have uh mixed um serotonin and

norepinephrine activity, um, like

venaxine and such. They're good

medicines for prevention, but if you

start them at too high, too rapidly, you

can exacerbate

uh, their condition. And I've seen that

over and over and over again in real

world practice. And then lastly, there's

boost um as well. Dr. Boland, I think

you had something to for this one.

>> Yeah, I just wanted everybody to kind of

notice that benzoazipines are not here.

They're not on this list. So, they

should be used

>> Excellent point.

>> Uh sparingly uh and for the right

reasons, for the right length of time.

So, it should never be long term. Uh

that's not an effective way to manage

it. Um and then also you know definitely

start low but realize that you may end

up on even higher doses than uh or you

may see even higher doses uh than for

depression u and you may need to give

the patient more time. So you know you

might need 10 to 12 weeks uh to see full

benefit for um for this. So

>> key is just titrate it slow because you

you you got it that's why it takes

longer. And to Dr. Bolan's point, uh,

when somebody does come in with an acute

exacerbation, bzzodazzipines get them

under that control quicker. None of

these are going to do that, uh, for

acute management. And sometimes we

patients will be discharged with one or

two pills simply to just buy them a

little bit of transition um, in case it

does exacerbate um, or using even um,

medications like hydroxazine, which just

basically sedate the patient a little

bit during that transition. But

absolutely you don't see benzo on there

for chronic. We really need to avoid

doing that. So the panic disorder is

sort of the more extreme version and

very quick rapid uh onset of these

changes that results in a change of

behavior. Um they also uh result in um

usually uh tacocardia diaphoresis. The

chest pain is more magnified. So that

really at this point um if they've gone

beyond their 20 minutes, which is when

most panic dis attacks kind of start to

calm down. Uh if they gone beyond that

and they're still pretty anxious and

having these symptoms, then

benzoazipines are probably the only

thing they're going to get there. If the

patient were to be pregnant, which then

benzoazipines are contraindicated, then

you should think about hydroxazine in

that situation. And then of course

chronic preventative therapies, same

things. uh just with uh uh general

anxiety disorder, obsessivecompulsive

disorder, there's two parts. There's the

obsession piece where you have these

thoughts and these urges that are really

technically unwanted. They don't desire

to have them, but it results in some

significant psychological distress. And

then it results in the compulsion piece,

which is now their behavior is being

modified to react to the obsessions that

they're having. And so what ends up

ultimately happening is that they have a

problem, you know, showing up to work or

finishing an activity because they get

distracted or delayed because of the

comp uh compulsive nature of their

responding to the obsession itself. Um

and sometimes it's so excessive that it

could actually start to cause them

physical harm. So for example, washing

their hands, their their their skin can

literally start to develop a dermatitis

and start to you know crack. So just

like with other psychiatric illnesses,

cognitive behavioral therapy and just

like with major depressive disorder and

just like with general anxiety disorder

and prevention, uh SSRIs are still the

drug of choice um as much as possible.

Um TCAs or other uh drugs that have

mixed TCA uh norepinephrine serotonin

effects um are also helpful. And then um

I don't think Booone is actually

supposed to be there. I'm sorry about that.

that.

uh moving on to bipolar disorder. So if

you think and break down the word

bipolar is two sides. Okay. And whereas

unipolar is usually just mania or

depression. With bipolar disorder you

have m you have both. You have manic or

hypomomanic episodes mixed with

depressive episodes and they cycle up

and down. The frequency of the cycling

seems to influence it. also the degree

of uh mania. So hypomomania patients can

still be functional whereas manic

patients can tend to have psychotic you

know this is where that you've heard the

stories of people you know thinking

they're some you know god or they're

running down the street naked or they're

you know giving birth to Jesus and all

these like weird like bizarre things but

it in reality for them that is real um

so we do need to be sensitive to that um

and we need to look at in their history

how frequent do they cycle So in the acute

acute

uh especially most commonly we see them

in the manic episode many times you're

treating them just like you would acute

agitation right antisycchotics

plus or minus benzo or if there's a drug

induced maniac manic episode then

benzoazipene by itself from the

preventative side then you start moving

to mood stabilizers and so you have the

traditional agents like lithium balproic

acid carbomasopene which are still very

appropriate for many patients. But now

you obviously and they've been around

for a while are the antisycchotics which

also have those indications as well. Um

so just keep that in mind um in the

background there a little bit. Um moving

on to major depressive disorder. So this

would be the unipolar depression. So in

a history you don't have any episodes

where the patient is cycling and they

have hypomomania or mania. uh many times

they have some manifestation. So they

have to have five of the major

depressive features for a period of

time, right? So it can't just be like,

oh, today I don't feel well, so we're

going to give you a diagnosis of

depression or I slept in because I just

don't feel like it, you know, getting

up. That doesn't mean that the patient

is depressed. And and that's why you

have to look for a pattern and it needs

to remain in present for a period of

time and it's usually affecting their

mood and their withdrawing from things.

So think about food. It could be

increasing the eating um because it

gives you uh pleasure. Uh but it could

also be the removal of food or sleep.

It's the same thing. Insomnia or

sleeping too much. Uh people not showing

up to events and participating in things

that they would otherwise normally um

you know uh be a part of. So anti-depressants

anti-depressants

um this class has grown u still I would

say largely especially from a cost

effectiveness analysis the SSRIs are

still largely um the drugs of choice in

this but you have cognitive behavioral

therapy um if you have resistant cases

ect is actually very effective um I've

actually seen it done numerous times in

patients um and it's very striking how

much it does improve uh improve

patients. Um Dr. Bolan, did you have

something else that you wanted to um

also add here?

>> Yeah, I was just going to kind of

piggyback on the the SSRI piece a little

bit. Um just you know make sure you note

you know you know for an exam or you

know for practice multiple SSRI trials

are you know your your pathway. So your

first line, second line. Uh then you of

course you know your cognitive

behavioral therapy is is always a part

of that. Um but it you do go through

usually multiple SSRI trials before you

will start adding bupropion or an

antiscychotic or some of the other mood

stabilizers that have evidence uh for that.

that.

>> Yeah. And that's true for the uh anxiety

disorder as well.

um most of the most of the patients if

one doesn't work switching to another

one within the class because you don't

want to just give up on the whole class.

It's kind of like statins in the same

some people tolerate one statin better

over another. Um now again you recognize

that these drugs are not going to work

like that. So you're looking at four to

six weeks before that dose um is going

to be fully manifested. Um you're

changing the biology of the brain. So it

has to recalibrate itself. And so if you

just make an adjustment and you bring

them back within a week and they're not

fully better, that doesn't ramping up

the dose may or may not provide

additional therapeutic benefit, may only

increase their side effects. So most

people will reasonably give three to

four weeks on a particular dose unless

they're getting worse. Um uh someone

asked a question about ketamine um and

the use and I don't know if you're

talking about in a a depression but it

has been used in depression as well for

more resistant cases. It's also been

used um in patients who are agitated as

well. Although you got to be careful u

because of obviously the um you know

manifestations that sometimes can make

them hallucinate and um um experience

you know unusual events and so it could

exacerbate that part of it. Postpartum

depression is really in the context of

the two weeks around

um it doesn't mean that it's just you

know uh some patients will develop some

you know perinatal depression and then

it kind of manifests itself even more progressively

progressively

um uh within that first month after

delivery. And uh I've seen this happen a

couple times too. We've all heard about

it on TV and some of the devastating

cases where you know a mother who would

otherwise do everything they can for

their child child uh you know kills

themselves plus everybody else and and

all their children or just gets rid of

the children. So, it's a very

devastating disease. Um, and it is real

and you do need to can rule out other

underlying problems because postpartum

thyroiditis can also um happen in this

patient population. And so, you want to

rule out other reasons or physical abuse

and other things like that. But, um,

this is not something, you know, to to

ignore an SSRI still. So, I mean, the

good news for some of these things is

that it's pretty straightforward. um and

the same drug classes are largely used

uh most of the time. What drives us to u

pick one agent over another is drug

interactions or side effects um in that

class. So for example, if you you know

have a a patient who's pregnant with um

and you're with depression, then you

probably want to avoid peroxitine

because of the the risk of PPHN, which

is your persistent pulmonary

hypertension of the newborn. um it seems

to be more associated with them. It's

linked in all the classes or in all the

drugs in the class, but it's seems to be

concentrated a little bit more on peroxitine.

peroxitine.

So, PTSD,

um I think this exam is probably going

to cause that for some of you.

Most exams cause PTSD, right? Um so um

you know this is where you know

cognitive behavioral therapies, exposure

response prevention um can be helpful.

Uh there are um um

I just went uh blank on it.

um some of the SS SNRIs, sorry. H

there's one particular drug that has a

little bit more information uh data in

it uh within PTSD and it just slipped my

mind. So I'll have to come back to that

but hopefully we'll you know it'll come

back to me you know when we're in

bioatistics where it matters. um

schizophrenia uh so this is where if we

think about Parkinson's which I think we

went over neurology at the last session

um where remember the dopamineergic

neurons in the substantia are depleted

or they're dying or you know going away

and the dopamineergic input is being

compromised and so we give dopamine

agonist in Parkinson's disease but when

we do that we run the risk of causing

basically symptoms mostly positive

symptoms which are the hallucinations

and the delusions and the psychosis that

are manifested because of too much. So

in the context of schizophrenia, just

think of it the same way. There's too

much dopamine many times maybe some

modulation of the activity of serotonin.

And so a lot of the drugs are antagonist

to that or we're trying to modulate and

create more of a balance. No different

than we're trying to create a balance in

Parkinson's with these neurotransmitters

and tipping the scale from one to too

much causes some of these things. So we

have positive symptoms which are the

more common ones. negative symptoms have

to really do with that uh emotion piece

and this is where people are tend to be

flat and that's where our atypical

antiscychotics have been helpful at

maybe improving a little bit without

causing the the risk of tardype diseases

that we saw with first generation agents

and then mood and cognitive cognition um

also being impaired where they have uh

executive functioning being compromised

at some level they can't do activities

of daily living um so you you need to

look for multiple things. It can't just

be having one thought or you know you

see some shadow on the side of your you

know out of your side of peripheral

vision that doesn't make you

schizophrenic. Um so you have to look at

the number of symptoms and the duration

uh around six months of those symptoms

uh before you kind of label that. So it

requires an appropriate evaluation and

diagnosis. Well, the the drugs of choice

are the antiscychotics and particularly

the atypical antisycchotics because of

their lower risk of tardy disynesia and theoretical

theoretical

some benefits with negative symptoms on

top of your positive symptoms. The what

what drugs do we pick? Well, first most

people just like with anti-depressants

that Dr. Bolan mentioned um you're going

to find that in the literature for psych

psychiatry that most people have to use

two to three different antiscychotics

before they find the one that works for

them and that's just the way it is. The

only evidence that helps us to decide

which one to pick is family history

where there's a genetics. So part of the

area that has the most phcogenetic

research is this psychiatry because have

to do receptor binding and metabolism

issues with the drug therapy. Um but

outside of that what helps us to pick

one over another is mostly side effects

profile. So clausipine and lancipine

have more side effect profiles including

weight gain, risk of diabetes,

hypertension, you know those things that

you know but they're very effective. Um

and then we think about weight neutral.

So if you have a diabetic or obese

patient uh some of these things you know

play a role um in what we what we choose

but then when you one fails then you

have to switch to obviously something

else. Um and then of course social

support systems are a huge uh huge part

of this. Um okay

so all right moving on to insomnia. Uh

there's the short term which may be

related to like people like my job in

the emergency department where we're

always shifting. We're shift work, you

know. Uh I have sleep disturbances all

the time. I'm actually sleeping right

now. Uh but just talking to you. No, I'm

just kidding. Uh

well, not really, but no. Um but and

then there's the quote sort of chronic

um which you know obviously is happening

more frequently throughout the week on a

regular basis over a period of three

months and so people sometimes need um

something to help them to get to sleep

but they also need to set up patterns

that facilitate that and that's where

the non-farmacologic um things become

important. So, cognitive behavioral

therapy, you know, setting up good what

we call sleep hygiene. Um, and there's a

lot of different recommendations like

not watching TV and bed and playing

video games while you're laying in bed.

All these things that, you know, bed is

for sleeping, right? So um so making

sure that you you know compartmentalize

some of your activities so that you

facilitate even that circadian shift um

and mental adjustment that needs to

happen. Um from there many people you

know you can try a number of different

agents but obviously the

non-benzodazipene hypnotics help people

um to not only get to sleep but may

impact the the latency of the sleep. Uh

and then melatonin um you know

supplements whether it's over the

counter or you know some of the agents

you can get prescription wise can

sometimes uh be helpful but the the

problem with this area is the people

with the chronic tend to stay on the

drugs and most of the way these drugs

should be used is really for shortterm

use two to four weeks um in particular.

Uh let's see. So drugs of abuse, we got

smoking sessation. Um that's not rocket

science. I think the thing that may come

up is, you know, patients when you're

going through that, you need to think of

the um you know, the five A's um to

assess and and and advise them so that

they pick the right date, time, have a

plan. But then you also need to factor

in like withdrawal symptoms and that's

where their packear history comes in. So

there's a number of different

calculations and things that you know

sometimes show up on on the exams. U I

don't think they're going to ask you to

calculate it, but just remember that you

take the packs per day. You multiply the

number of years and that's their pack

year history. And obviously the number

of packs that they smoke, if they're

going to go through withdrawal, that may

influence how you use nicotine

um kind of replacement therapy on top of

uh cognitive behavioral therapies and

social support plus drug therapy. Uh Dr.

Boland, I think you wanted to uh add

some stuff here. Yeah, just remembering

that combination therapy is typically

more effective and if there's been

previous quit attempts, you're

definitely going to, you know, start in

in that direction. Um, you know, and

consider any behavioral cues that you're

getting or for sure have that discussion

with the patient uh to try and help

determine which is the best or the worst

uh you know to choose from the nicotine

replacement therapies because they're

still uh despite having some oral drugs

and things like that, they're still the

the the first line uh agents and even

recommended you know for second, third,

fourth trials, you know, whatever. um

you know to be used for for patients.

>> Yeah. And I mean obviously we recognize

you know some of the patients you should

avoid drugs and don't forget the you

know bupropion and the risk of small

risk of seizures.

All right. Um alcohol uh use and abuse

disorder. Um so most of the time these

patients present um usually intoxicated

um and so that's where intoxication

alcoholic ketoacidosis where they have

an acidbased disturbance basically

because they their major form of

nutrition is alcohol. So their glycogen

stores are low. So they don't have

hyperglycemia. They have uglycemia with

basically findings that would be

consistent with a DKA pattern. Um and so

where the other ones the long-term

complications come from significant

nutritional deficiencies and

particularly the um B complex vitamins

uh B12 in particular. So uh and also

thamin. So thamin actually gets

compromised at the GI level uh because

of changes in re uh transporters and

stuff. So that's why we actually in the

acute area of the abuse have to or you

should traditionally bypass the GI tract

um with a parental agent of thyon

replacement to maximize you know what

the brain gets so that we don't facilitate

facilitate

uh um complications when they ingest

glucose remember especially if they

haven't been doing that. Um so your you

know non-farmacologic and be cognitive

behavioral therapies to also include

programs like alcoholic anonymous if

you're having acute withdrawal yes they

need to be usually hydrated because of

their uh only substance being alcohol

but that's where your thamin and then

some dextrosebased

infusion to manif maximize the ATP

production um in their brains in

particular uh and then most of the time

they need to be on um benzo

You can certainly start off with intermittent

intermittent

bzoazipines and and monitor

their symptoms of withdrawal. But if

they're not responding or they're

requiring repeated escalating doses,

then many times these patients have to

be put on drips and many times even

admitted to it like a step down unit or

something where they can be monitored

closely to avoid withdrawal seizures um

that unfortunately carries a significant

mortality if it starts to happen. And

then we have the abuse deterrent agents

um that are listed at the bottom in

particular most historically do dulfam

that try to create some uh behavioral

modifications because we don't want to experience

experience

um some you know side effect

amphetamines u you know this is your

like your cocaine and and

methamphetamines where basically you're

increasing um the concentrations of

norepinephrine in the synaptic clft

You're also um increasing uh

dopamineergic neuro neurotransmission

and so you're stimulating the reward

pathway which you know again too much

dopamine can cause people to hallucinate

which is why they have psychotic

features but then you also get the

sympathomimedic activity. So you get the

tacocardia, chest pains, hypertension.

Uh they can have vasos spasms of their

vessels where they develop hypoxia to

the tissue distal to the spasm and so

and even hyperothermia um and in the

context especially if they're not able

to sweat very well. Um so in the acute

side especially if they're having a like

amphetamine induced MI uh where they're

having a basos spasm not necessarily

around around a athoscotic plaque the

the the drug of choice is benzo even if

they're not having an MI the drug of

choice many times is a benzoazipene IV

fluids um so that they um can calm down

a little bit and then um you know if you

Not sure why that oh because of the

benzoazipines but that that I'm not sure

why that actually says that that's

actually I think that's a mistake that's

for the benzo more for

um patients that have if they're use abusing

abusing

cocominant medication. So sorry about

that. marijuana probably the biggest

thing um that's showing up and becoming

a bigger problem is the canabonoid hyperemmesis

hyperemmesis

uh syndrome basically they get

themselves into a cyclic vomiting

scenario uh where they can't stop and

they get um they're very uncomfortable

looking I don't know if you've ever seen

these patients but they usually

obviously present to me uh and they just

cannot stop dry heaving or vomiting and

so they start developing electrolyte

abnormalities ies um they start

developing acid base disturbances

because of all the vomiting and then

they are dehydrated. So there are a

number of different things that people

try u prior to one is uh this they try

to get in the shower um seems to be one

of those things that people have tried

uh sniffing isopropyl alcohol uh pads

the little pads um can sometimes you

know offset that. I've not seen that

personally work. Um the evidence um is

really unfortunately around um two drugs

in particular um uh haloperidol and

capsation. And you might say what why

would I what's capsation? Yeah. So

literally you take capsation cream and

you like rub it all over their chest and

abdomen. And if you think about

capsation um being a vanilloid receptor

one agonist basically it's stimulating

these nerves so much at a higher

intensity that it creates pathways that

interrupt some of the you know cyclic

pattern. So just like with cold therapy,

it's triggering a different type of

nerve conduction that stops and

intersects c different types of pain

receptors that would normally trans up

transmit up the spinal cord. Um so it's

weird, but it actually is one of the

recommended um treatments. All right, to

kind of keep us moving along because we

do have to get to um

uh the EVM stuff. Um so ARDS

usually um this uh Q respiratory

distress syndrome uh typically occurs in

different phases depending on when

you're seeing the patient obviously in

the man onset of their underlying

problem. These patients typically

develop severe dysmia, usually have

crackles, and they're hypoxic. And so

what ends up happening is you start to

give them more oxygen, and sometimes you

have to give them FiO2s that are so high

that you create free radicals that only

cause the process to worsen. Um, and so

it becomes a little bit of a slippery

slope. And that's where ventilation um

mechanisms or strategies that you see

listed there where you flip people into

prone positions and you maximize

ventilation and profusion so that we can

reduce the amount of oxygen that we get

to maximize the ventilation profusion um

strategies without also trying to put

too much pressure. uh because as the

airways start to stiffen and become fi

more fibrootic, you have to push more

pressure to open them up. Um and then

pharmacologic treatment to consider to

avoid again putting too much pressure to

cause bar trauma in these patients is

that you relax the muscles and you try

to reduce some of the inflammation. So

methyl prediniscolone and um some of

your neuromuscular blockers in

particular like rockuronium

um that last a little longer can relax

those muscles to make it easier to

inflate those lungs and then if there's

certainly fluid overload get rid of

that. All right, moving on to asthma and

COPD. These are your obstructive airway diseases.

diseases.

Um, and so remember there with COPD

there's typically a remodeling of the

airway but that results in a low

compliant airway that basically falls or

collapses on itself. Whereas in asthma

you have a response to it some

environmental trigger or allergen that

causes a bronco spasm and that's usually

at the level of the bronchioles where

there's no cartilagynous rings and

that's where the smooth muscle is and so

they spasm at that that point. So they

get cough, shortness of breath, they

when they're laying flat, it tends to

make it a little worse. They get up in

the middle of the night coughing,

wheezing, and that's kind of like one of

your indicators. So you have to do

pulmonary function tests, which is a

closed system. And we measure the FEV1,

which is the volume of air being expired

in the first second under a forced

exhalation. And then you look at the

force vital capacity. And we measure

those those numbers and we put them in

ratios that kind of put them in a bucket

to look for restrictive patterns versus

obstructive patterns. And like I said

ago, asthma, COPD are more obstructive

uh patterns. So um Dr. Bullet and do you

want to comment here on the treatment

because there have been some subtle

small changes and and people get

hyperfocused on some of these changes

but um there's a couple reasons for them

but did you want to jump on this real

quick because we got a lot a lot of

drugs that have been growing in this class.

class.

>> Yeah. So now uh what's important to know

is that for steps one and two you can

use um an a steroid you know um the

inhaled corticosteroid sorry almost lost

that uh the inhaled corticosteroid and

foroterol combination PRN so that can be

used as your controller and your

reliever um you know which is a change

now you can still use your short acting

uh beta agonist as well, but they do

recommend that you use um the steroid

along with it when you do use it. Um if

you're if you're going that route still

um with steps one or two um but the kind

of your primary pathway now is your ICS

and your formoterol and the one with the

evidence is actually boudinite and formoterol.

formoterol.

Um so if you're a purist uh there you

go. Um, and don't forget like on this on

the exam they can ask you about

counseling points and we should all be

reminded about you know appropriate

counseling points for the different

inhalers and things like that.

>> So yeah, part of the reason for that

recommendation uh was also for

convenience um because if you formulate

a medication that's combined one less

inhaler they have to carry around. If

you have to do multiple techniques on

different types of inhalers then you

screw it up more. So there's a number of

reasons that went into that but it does

not negate the fact that you can still

use a short acting betagonist still PRN

but yes they need to be on inhaled

steroid and of course you see the

evolution of the biologic agents

basically that are reserved for patients

who have refractory to you know they've

they've on two or three drug regimens

and you're also treating the underlying

um allergies. So just keep those subtle

things in mind. Um there when you have

an acute exacerbation

obviously straightforward they're

usually having expiratory wheezes that

are sometimes even audible but usually

they're listen you can hear them on

exam. Uh basically you want to rule out

any pneumothorax and pneumonia so they

usually get a chest x-ray uh many times

especially if they are developing

hypoxia from it and needing supplemental

oxygen. Um and in this case if they're

really you know working hard um this is

where you can do inline nebulization

therapy with combination you know short

acting beta agonist in combination with

a short acting muscerinic uh using CPAP

or BiPAP me uh which are non-invasive

ventilation um techniques u if those are

not working or there's a contra

indication to non-invasive i.e. they're

not awake or they're becoming lethargic

uh or that the the airway is impending

um closure then you can intubate them.

Although I will tell you once you get an

aszmatic on the ventilator it is trouble

to um ventilate them and hard to get

them off. So we really really try to

avoid doing that and that's where we'll

start them on steroids but steroids are

not going to work acutely but get them

going early and we usually give them

parentally even though oral steroids can

be absorbed just as good as IV but when

you have a lot of uh repeated doses of

short acting betagonists or uh agents

you can get patients to where they get

tacoc cardic and they can even vomit so

we don't want to compromise the

absorption of medications and if you

have access to another route or another

medication just give it parentally to

ensure that these patients don't vomit

in the midst of especially having a byprowing

in mag. Now the magnesium IV

administration works as like a calcium

channel blocker to relax the bronchules

typically is more studied in COPD. When

we think about COPD again there's

remodeling of the airway uh changes in

the structure and part of that structure

is that it collapses on itself. um

typically associated with initial phase

of bronchitis and then it goes to the emphymic

emphymic

uh pathway where they don't make as much

sputum after a significant amount of

destruction. Um but they still have low

FEV1s FC's that are still less than 70%.

Um and this is where combination therapy

has definitely been shown to be helpful

especially like triple therapy where

they have a inhaled cortical steroid

especially for moderate to severe cases

has definitely been shown to be helpful

on top of that with a long acting

muscerinic and a long acting um beta

agonist agent improves their symptoms uh

to prevent um

you know uh basically their

exacerbations or their symptoms. Once

they have an exacerbation, now

something's triggered it. Many times

it's smoking or viral infection or

something. So that's why you want to

look for those things and do a chest

X-ray or consider additional workup to

rule out things. Um but uh these

patients tend to have significant uh

accessory muscle use. They also benefit

from initial um non-invasive uh

ventilation strategies, BiPAP, CPAP with

inline um nebulized therapies, steroids

and then magnesium. Um whereas

antibiotics is controversial and this is

where antimicrobial stewardship um kind

of comes in and Dr. Bolan I think you

know with some of the antimicrobial

stewardship that you've done you want to

comment on some of this?

>> Yeah. So usually when you think about

needing antibiotics um you're looking at

if they've had the increased sputum

volume purulence and disysmia or if

they've had the increased purulence plus

one of the others. Uh so you've got to

have that increase in uh purulence there

to really before you should consider

them. And then remember you're trying to

cover strep numo h flu and mcat. Um so

you're looking at uh you know basically

augmenting a moxicylan clavulonate a

macrolyte or a tetracycline. So um you

know be sure you use them you know when

it's truly indicated and you're not

using something that would be uh

inappropriate or too broad or have you

know higher risks of other adverse effects.

effects.

>> Yeah. You see on here there's also under

the classic findings pulmonary embolism.

Interestingly, there's about a third of

patients who present to the emergency

department based on evidence who

actually are having a PE. So, if you're

not responding to traditional therapy,

don't anchor at the diagnosis of COPD

exacerbation in the traditional sense,

uh recognize that there are small

percentage of patients that go on and

are presenting because they have a

pulmonary embolism. It's actually

striking the number of people who have

that. Um, and part of that's because

they're sedentary because they can't

exert themselves. Um, so they sit for

prolonged periods of time. Um, okay. Um,

cystic fibrosis. This is obviously a

genetic problem in the CFTR

mutations where they basically have a,

you know, their sodium chloride channels

are messed up and so they get these

secretions um, that build up and that

are very viscous and basically cause,

you know, clog up things. And most

commonly we think of the airway but it

can occur in the GI tract as well. It

can affect other organs which is why

they patients will have um uh vitamin uh

deficiencies. They have weight loss

because they work so hard to breathe and

then they don't bring in enough

calories. Um newborns will have these

ilases form from bowel obstructions

essentially. uh but most of the time

they have uh traditional cystic fibrosis

patients have bronchiacttois and

bronchitis that's chronic in nature.

They typically get infected a lot with

and are very commonly colonized with

sudamonus um which then points to why we

pick antibiotic therapies that have

antisetudonal um coverage. So when you

think about um agents or things that you

uh use, so you see airway clearance

therapies, this is a lot of times uh

chest physiootherapy can sometimes be

helpful for these patients to loosen the

secretions to help them to get them out.

Uh bronco dilators obviously mucalytics

on occasion um can help break down some

of those in some patients. And then of

course if they have GI um manifestations

uh with the with the pancreas not

working and they have low uh they're

losing weight that's where they need

panker lipase they need vitamin K or

vitamin supplementation which is a lot

of times some some things that we tend

to forget about uh hemoptsis the only

thing I really want to say about this is

that you know there's a lot of reasons

for it the airways are highly

vascularized for obvious reasons because

you're ventilating and profusing

So blood is coming by to get that

oxygen. So there's a lot of blood

vessels and when you have inflammation,

irritation from bronchitis or pneumonia

or you know a PE or something I mean you

can have anything can cause some blood

to leak into uh your airway and you can

cough it up and pe it scares people um

pretty bad when they see blood in their

sputum but it's quite often is very

common especially in bronchitis. And so

for the most part, you just treat the

underlying problem. It's a if it's a

viral infection that you can treat like

COVID or influenza. Um you know, then

treat it. You know, it's if otherwise

you have to just kind of make sure they

don't have it's not progressing and that

if uh they're not having hypoxia from

it. Um so if they do progress, um then

you have to start thinking about

cancers. you have to think about

potential uh that they they will need

oxygen therapy and if they're on anti-coagulants

anti-coagulants

or the vessels open up further and

that's when transmic acid um can

sometimes be also useful but they're

going to have to have a broncoscopy

which is obviously a pulmonologist

getting involved.

Pneumathorax is a sudden uh collapsing

of the lung. So um it can be from a

number of reasons. Most people think of

traumatic pneumthorax. So you get

stabbed essentially and so it creates a

communication piece to the uh uh

atmosphere uh pressure becomes equal to

the plural space pressure um and so the

lung essentially collapses into its

normal anatomic position um and so they

become short of breath. If there's a

valve that's created and that traps

here, you can develop tension

pneumothorax which then builds up,

builds up, builds up and starts to push

the heart and the aorta to the side and

these patients can that can be

life-threatening where you need to do

what is called

needle decompression. Basically, you put

a needle into their chest and let the

air out and then you have to put a chest

tube in essentially. So that's what tube

thorostomy is. Um you know you you

basically cut a hole right above the rib

and you know around the fourth or fifth

intercostal space and you insert the

chest tube um and put it to negative you

know suction and um put it through you

know some sort of um fil you know

filtering some something that traps the

air out from going back in. Um so they

have like a plurvback or something and

basically the lung reexpands and it will

actually reexpand fairly quickly. they

tend to start breathing much faster and

better. The problem is the problem with

it is that people don't like the chest

tube. It hurts. I mean that's a very

painful invasive procedure to have a

tube in your chest wall and as you're

taking a breath that lung is basically

rubbing up and down on the surface of

the um uh chest tube. So um so that's

kind of uh psych and uh pulmonary. Uh

for purposes of time um I'm going to go

ahead and just start um the initial

phase of this lecture because it's a

little bit longer. It's an important

one. So we'll just cover essentially

what is evidence-based medicine because

then we're going to break it down into

its parts and review those key

components. Um and then so we're going

to pause here in just a in just about

five minutes or so and then take a five

minute break. Dr. Bolan's going to uh

check off um from the session and then

we'll finish it up. So as a reminder,

you know, we we will have some good news

to share. So I'm going to you know get

to that towards the end, but I wanted to

remind you that um you know, hang around

uh because we're going to be pushing

some things and some content to you

guys. and want you guys to be aware of

of what it is and uh but I want to get

through the content first. Um so I think

you'll I think it'll be worth your time

especially for some of your exams. So

what is evidence-based medicine? Well,

back in 1992 there was a EBM working

group which is largely a group of

providers out of Canada um at a medical

residency training program. There were

some um providers mostly physicians uh

from the United States involved in other

places but most of it originated Canada

and really was a philosophy of how to teach

teach

medical physicians how to think and it

was based on answering asking an

appropriate clinical question and then

how do you go and find the right answer

versus the old school of teaching was I

tell you how to do it and that's how you

do it. Well, that doesn't always clearly

work, right? Um, so we've moved away

from just because I said it's true

doesn't mean it is. Um, but it was a new

paradigm in the way we think. And so

there's a vin diagram is a classic way

to present the theory or philosophy of

evidence-based medicine where you have

these three circles that when they come

collectively together appropriately in

balance key words there um you have what

is considered to be part of the approach

to evidence-based medicine. That means

you're taking the best available

evidence and if the best available

evidence that exists on the clinical

question that you're trying to answer is

a case series, then that's the best

available evidence recognizing that that

evidence largely is high risk for bias.

It also does not detract or suggest any

way, shape or form that clinical

experience or expertise is not

important. It is. You cannot just read a

journal article and know how to take

care of patients. Doesn't work.

Otherwise, I wasted four years of my

life doing a medical residency. So, you

know, there's a reason why residency

training is done uh and why clinical

experience has some degree of value.

There's a practical application to real

world practice. And then, of course,

there's the patient specific factors

where even shared decision- making

should be included. So, when all those

things come together, you are doing EBM.

There's typically the what we call the

five A's or the five steps of

evidence-based medicine and that's the

process by which you ask an appropriate

and that's key word an appropriate

question. Okay. So there's parts of a

question pico peacott

um and then you go and you search you

acquire that evidence and then once

you've found the evidence and you think

that you found the best available

evidence depending on how much time you

have you will critically appraise or

systematically review that paper. Then

you're supposed to determine if it's

internally valid. Can I externally apply

it to the patient population that I need

it to apply to? And if yes, then you

apply it. But you're technically

supposed to assess the impact of your

own decision. That means you're

basically doing a a study of yourself

and your own activities, which most

people, you know, don't do. And so when

we think about asking a an appropriate

clinical question, most people think of

pico and they stop at PICO.

I I disagree with that. Um I think

that's inappropriate and lacks the

completion of the thought of the

question because not a if I ask a

question about chest pain and I'm in a

family medicine clinic with Dr. Boland

or I'm in the emergency department, I'm

in two different environments or

settings in the clinical environment.

patients I would hope that are

presenting to me in the emergency

department with chest pain are slightly

different than the patients presenting

to Dr. bowl and telling a a cow joke,

right? So big difference. So the the

timing of the outcome might be

applicable. Well, let's say I'm giving

uh tpa for an acute eskeemic stroke.

Well, I don't want to know what happens

in a year. I'm treating a patient right

here in the emergency department. So my

timing of my outcome and my setting

might be acute and relevant. And so the

type of data that I'm looking for needs

to align with this. So the the reason

you ask a good question or structured

question is so that you can go and find

the right type of evidence. So what are

the types of evidence that line with the question?

question?

So most of the time most people are

doing this top row which is therapy or

treatments right we're thinking about

the new drug you know compared to what

we used to do and the difference between

pico or pco is I is the intervention or

the new drug or E is the exposure to the

new drug. Okay but again I would be an

advocate of the TNS being incorporated

in there. So you consider the timing of

the outcome that you want. Is it acute

time outcomes like in the first hour or

the first 24 hours, one month or is it

six years? I mean that's obviously two

different things. Um but you know the

type of evidence that we traditionally

look at if there's available is a

Cochran review of good randomized

control trials but just remember a

systematic review to meta analysis can

be junk in which produces junk out. So

just because something is published as a

meta analysis doesn't mean that it's

good information. even if it's a Cochran

review. Cochran will tell you it sucks,

don't use it. But you need to know that

the data that's out there doesn't look

good. And so that's good to know. Um

whereas diagnosis is pyro or per and

this is where the I is the new

intervention or new test and the R is

the reference standard. Um, and so it's

just helpful to see this if you're doing

um behavior analysis of the patient and

their response to treatment, how they

feel, what their experience was. Well,

that's a qualitative study, right? And

so the type of data that you look at,

the type of question and the structure

of that question then points to

what uh type of data that you go looking

for. And that's the next phase. And so

we're going to pause here. So I will see

you guys back in approximately five

minutes and we will continue on with EBM bioatistics

bioatistics

and literature evaluation. Thanks Dr.

Boland for being with us and for the

additional contributions throughout this

series. Um Dr. Boland has also uh is

part of the reason you're getting a

gift. Um so we have leveraged her um

extensive background and unique skill

set of doing things inpatient,

outpatient, even in the emergency

department. But more importantly, a lot

of the outpatient work that she's done

over the past 10 years in in particular

and family medicine clinics um is going

to be brought to you guys in addition to

some other fun things. So see you guys

in five minutes. Thanks Dr. Boland.

>> You're welcome. We'll see you again soon.

soon. >> Yep.

Okay. Hopefully everybody had a good quick

Hopefully everybody had a good quick break and um I do want you guys to know

break and um I do want you guys to know that um I there's quite a few comments

that um I there's quite a few comments and um questions. I'm going to have to

and um questions. I'm going to have to try to save it towards the end so that

try to save it towards the end so that we can try to get through some of this.

we can try to get through some of this. Um, but we'll we'll kind of come back to

Um, but we'll we'll kind of come back to a few of the points that some of you

a few of the points that some of you have asked um as much as I can. So,

have asked um as much as I can. So, moving forward. Um, so now we've just

moving forward. Um, so now we've just finished again step one of asking the,

finished again step one of asking the, you know, appropriate clinical question.

you know, appropriate clinical question. And so, we'll use one as a an example to

And so, we'll use one as a an example to help guide us through a process a little

help guide us through a process a little bit. um and we'll use one that we've

bit. um and we'll use one that we've discussed in a you know previous case

discussed in a you know previous case and stuff like that and one is that

and stuff like that and one is that there is there any benefit

there is there any benefit neurologically

neurologically uh to the use of steroids and and

uh to the use of steroids and and bacterial menitis and so if you were to

bacterial menitis and so if you were to you know create your clinical question

you know create your clinical question in the format of a peacock this would

in the format of a peacock this would look a little bit like it is so this is

look a little bit like it is so this is what mine looks like and the reason that

what mine looks like and the reason that you want to consider doing this is

you want to consider doing this is because you have to think about the

because you have to think about the search terms that you're going to use

search terms that you're going to use that align with your intervention or

that align with your intervention or your outcome like what terms so that

your outcome like what terms so that when you then do a search you should

when you then do a search you should take the the right side of this column

take the the right side of this column and as you're skimming over it does the

and as you're skimming over it does the papers peacots

papers peacots align with your peacots if it doesn't

align with your peacots if it doesn't don't use it okay um and that's one of

don't use it okay um and that's one of the reasons why we do that so then

the reasons why we do that so then you've got to dive into various sources

you've got to dive into various sources of the literature and it depends on the

of the literature and it depends on the type of data that you're looking for and

type of data that you're looking for and maybe even the environment or setting um

maybe even the environment or setting um that the question is related to. So

that the question is related to. So senol for example is related to allied

senol for example is related to allied health, nursing, uh physiootherapy,

health, nursing, uh physiootherapy, social services whereas MBASE, Medline

social services whereas MBASE, Medline are going to have your more treatment uh

are going to have your more treatment uh focused things that are traditional

focused things that are traditional whereas MBASE maybe doesn't cover uh

whereas MBASE maybe doesn't cover uh nonhuman medical devices and other

nonhuman medical devices and other things. it's more emphasis on drug

things. it's more emphasis on drug therapy tends to be a little bit more

therapy tends to be a little bit more European whereas PubMed or Medline is

European whereas PubMed or Medline is everything you know human non-human

everything you know human non-human uh drug therapy non-drug therapy can be

uh drug therapy non-drug therapy can be all kinds of of things um obviously you

all kinds of of things um obviously you might say well that's good well it's

might say well that's good well it's good until you get 50,000 results and

good until you get 50,000 results and you have to narrow it down and that's

you have to narrow it down and that's where your limitations or you know

where your limitations or you know advanced search settings kind of come in

advanced search settings kind of come in secondary sources of the literature

secondary sources of the literature typically are summarizing

typically are summarizing the evidence right they're compiling it

the evidence right they're compiling it together like a journal club or clinical

together like a journal club or clinical evidence uh UK nice some of the clearing

evidence uh UK nice some of the clearing uh UK uh the US national guideline

uh UK uh the US national guideline clearing house which used to be around

clearing house which used to be around those types of services basically are

those types of services basically are compiling the evidence for you into

compiling the evidence for you into groups and kind of give you summaries

groups and kind of give you summaries whereas tertiary sources are more

whereas tertiary sources are more surface level reviews think of it as

surface level reviews think of it as like encyclopedia. U it may be

like encyclopedia. U it may be referenced and they may refer to some of

referenced and they may refer to some of the primary references but sometimes

the primary references but sometimes they don't. Sometimes they're referring

they don't. Sometimes they're referring to other tertiary sources and you never

to other tertiary sources and you never get to the real evidence or the evidence

get to the real evidence or the evidence isn't being utilized in a complete

isn't being utilized in a complete manner. Um so a good example of that is

manner. Um so a good example of that is faux med which is the free online free

faux med which is the free online free online access to medical education

online access to medical education sources which are largely blogs where

sources which are largely blogs where people publish information for free

people publish information for free which is they're typically plagued with

which is they're typically plagued with issues of per not being peer uh reviewed

issues of per not being peer uh reviewed or being updated. Um but up to-date is

or being updated. Um but up to-date is probably the more common uh version of

probably the more common uh version of this that most people are familiar with

this that most people are familiar with but don't forget about your textbooks

but don't forget about your textbooks and things. So depending on the type of

and things. So depending on the type of question may influence which source of

question may influence which source of data databases that you search. So as

data databases that you search. So as you start diving into searching, you're

you start diving into searching, you're thinking about the results. How do I

thinking about the results. How do I narrow in on the most important results

narrow in on the most important results without missing the right paper? That

without missing the right paper? That has to do with search sensitivity and

has to do with search sensitivity and specificity. So sensitivity is I want to

specificity. So sensitivity is I want to expand the search because I don't want

expand the search because I don't want to miss the best paper. This is

to miss the best paper. This is typically what strategy is done in

typically what strategy is done in systematic reviews. So you get the

systematic reviews. So you get the impact at the bottom is that you get a

impact at the bottom is that you get a larger number of results. If you think

larger number of results. If you think about the boolean language that you're

about the boolean language that you're using in your search, it's the this or

using in your search, it's the this or this. Well, that obviously includes

this. Well, that obviously includes results that have, you know, one of

results that have, you know, one of those other things. So it's going to

those other things. So it's going to significantly increase it, but it will

significantly increase it, but it will make sure that you don't miss it. And so

make sure that you don't miss it. And so D uh search sensitivity will increase

D uh search sensitivity will increase the results, make it less likely that

the results, make it less likely that you're going to miss the paper. So

you're going to miss the paper. So again, most commonly done in a

again, most commonly done in a systematic review that prepares for a

systematic review that prepares for a meta analysis. The next is search

meta analysis. The next is search specificity, which is where you're

specificity, which is where you're trying to narrow it down and get rid of

trying to narrow it down and get rid of some of the extra results, which puts

some of the extra results, which puts you then at some point a risk of missing

you then at some point a risk of missing the paper, especially if you use the

the paper, especially if you use the wrong key words. And with that boolean

wrong key words. And with that boolean language would be and or not this. So

language would be and or not this. So you're being more restrictive in what

you're being more restrictive in what you do which gives you fewer results. Um

you do which gives you fewer results. Um so I mean hopefully that makes sort of

so I mean hopefully that makes sort of sense. But if we come back to our

sense. But if we come back to our clinical question about neurologic

clinical question about neurologic benefits with steroids and we break down

benefits with steroids and we break down the question and we think about trying

the question and we think about trying to find those key words that that put

to find those key words that that put sensitivity and specificity in the

sensitivity and specificity in the context of searching strategies into

context of searching strategies into context. You can do that here. Like

context. You can do that here. Like think about your intervention steroids.

think about your intervention steroids. Well, what kind of steroids is it? A

Well, what kind of steroids is it? A particular steroid in that you want to

particular steroid in that you want to know. So there's you know what if you

know. So there's you know what if you use the word gluccocorticoid

use the word gluccocorticoid corticosteroid

corticosteroid are we talking about androgens? Are we

are we talking about androgens? Are we talking about testosterone and estrogen?

talking about testosterone and estrogen? Well no right. So you have to go through

Well no right. So you have to go through a little bit of this strategy in your

a little bit of this strategy in your mind so that when you're putting your

mind so that when you're putting your search term together, you see that we're

search term together, you see that we're using or or or. Why would we do that?

using or or or. Why would we do that? Well, we don't want to miss the best

Well, we don't want to miss the best available evidence in the context of

available evidence in the context of evidence-based medicine. But doing this

evidence-based medicine. But doing this using those ors like that would increase

using those ors like that would increase our search results, which would increase

our search results, which would increase our search sensitivity. Same thing with

our search sensitivity. Same thing with outcome. What do you mean by neurologic

outcome. What do you mean by neurologic outcome? Is that being dead or alive

outcome? Is that being dead or alive neurologically? Is that being, you know,

neurologically? Is that being, you know, uh being able to walk? You know, I mean,

uh being able to walk? You know, I mean, what is it? Um, you know, not able to

what is it? Um, you know, not able to hear. I mean, so there's a number of

hear. I mean, so there's a number of different things that you could utilize

different things that you could utilize depending on the question. And so, if

depending on the question. And so, if you were to do a search, this would be

you were to do a search, this would be one of the landmark papers you would not

one of the landmark papers you would not want to miss. But you can see here that

want to miss. But you can see here that in the in the main title of the study

in the in the main title of the study dexamethasone in adults with bacterial

dexamethasone in adults with bacterial menitis they didn't use corticosteroid

menitis they didn't use corticosteroid they didn't use mineral I'm sorry uh uh

they didn't use mineral I'm sorry uh uh gluccocorticoid

gluccocorticoid they used the the actual type of the

they used the the actual type of the name of the steroid itself dexamethasone

name of the steroid itself dexamethasone and there's reasons physicologically and

and there's reasons physicologically and physiologically that for that but if you

physiologically that for that but if you take the paper and then you start going

take the paper and then you start going through the patient population the

through the patient population the intervention the you know the

intervention the you know the comparative group the outcome you can

comparative group the outcome you can see that your peacots and the paper's

see that your peacots and the paper's peacots start to align. Well, that's a

peacots start to align. Well, that's a paper worth reading, especially when it

paper worth reading, especially when it is a a randomized control trial, which

is a a randomized control trial, which tend to have lower risk for bias. So,

tend to have lower risk for bias. So, now you find papers or let's say you

now you find papers or let's say you only have a few minutes and so you do a

only have a few minutes and so you do a different type of search strategy that

different type of search strategy that just gets you to, you know, a piece of

just gets you to, you know, a piece of evidence,

evidence, right? depending on how much time you

right? depending on how much time you have. Um, you need to appraise it. Um,

have. Um, you need to appraise it. Um, and so it says here, appraise the

and so it says here, appraise the evidence in a systematic way. So most

evidence in a systematic way. So most people think of cats or critical

people think of cats or critical appraisal tools, which are tools that

appraisal tools, which are tools that were designed to help us walk through

were designed to help us walk through step-wise approach to reviewing a paper

step-wise approach to reviewing a paper so that we don't miss something. I find

so that we don't miss something. I find that most people, most residents and

that most people, most residents and students, they they don't have a good

students, they they don't have a good method for reviewing the paper and so

method for reviewing the paper and so they miss things and they don't ask

they miss things and they don't ask themselves the proper questions and so

themselves the proper questions and so when it comes time to journal club and

when it comes time to journal club and people like me show up and you ask a you

people like me show up and you ask a you know straightforward question they are

know straightforward question they are caught off guard. So critical appraisal

caught off guard. So critical appraisal tools were developed especially early on

tools were developed especially early on to help people learning this process to

to help people learning this process to create basically a systematic approach

create basically a systematic approach to reviewing a paper. And so when we

to reviewing a paper. And so when we think about critical appraisal tools, we

think about critical appraisal tools, we really should be calling them SATs. Uh I

really should be calling them SATs. Uh I trained at Oxford in the evidence-based

trained at Oxford in the evidence-based healthcare program there. And they were

healthcare program there. And they were also very big advocates of not using the

also very big advocates of not using the word critical appraisal tools because

word critical appraisal tools because critical tends to be negative. We always

critical tends to be negative. We always want to tear apart a paper. That's not

want to tear apart a paper. That's not appropriate because no research is

appropriate because no research is perfect. There's always something wrong

perfect. There's always something wrong with every study. I don't care who you

with every study. I don't care who you are, right? And anybody that's a

are, right? And anybody that's a clinical search knows that to be true.

clinical search knows that to be true. So it really should be a systematic

So it really should be a systematic appraisal tool because that's what we're

appraisal tool because that's what we're wanting to do is be systematic and

wanting to do is be systematic and reproducible when we read one paper over

reproducible when we read one paper over another. Our approach is the same. And

another. Our approach is the same. And so there's different validated tools

so there's different validated tools that are worth noting because sometimes

that are worth noting because sometimes that's a good test question. What

that's a good test question. What particular appraisal tool would be

particular appraisal tool would be useful in evaluating this type of paper?

useful in evaluating this type of paper? Very straightforward. So guidelines use

Very straightforward. So guidelines use grade most commonly now agree systematic

grade most commonly now agree systematic review. Prisma is the main one. Amstar

review. Prisma is the main one. Amstar has also been validated. Quatis 2 for

has also been validated. Quatis 2 for diagnostic studies. So those are the

diagnostic studies. So those are the things that you kind of you know want to

things that you kind of you know want to know. But why do we care? I mean like

know. But why do we care? I mean like the you know I use this sort of approach

the you know I use this sort of approach to like so what? Who cares? I mean why

to like so what? Who cares? I mean why are you teaching me this crap? You know

are you teaching me this crap? You know why are we expected to know this?

why are we expected to know this? Because at the end of the day you've got

Because at the end of the day you've got to externally apply the information.

to externally apply the information. Right? When you are appraising a paper,

Right? When you are appraising a paper, you're trying to discern is it

you're trying to discern is it internally valid because if it's

internally valid because if it's internally valid, then there's external

internally valid, then there's external validity, I hope, or you shouldn't be

validity, I hope, or you shouldn't be doing it. But you've got to apply the

doing it. But you've got to apply the evidence. That means some patient who's

evidence. That means some patient who's someone's mom, dad, sister, brother,

someone's mom, dad, sister, brother, loved one, friend here is going to be

loved one, friend here is going to be the recipient of your decision or their

the recipient of your decision or their recommendation through another provider

recommendation through another provider who's going to make a decision. Right?

who's going to make a decision. Right? So that's why it matters. So we have to

So that's why it matters. So we have to think through the things that would

think through the things that would compromise

compromise basically internal validity. So we think

basically internal validity. So we think about the the type of data that we're

about the the type of data that we're going for. I mentioned this earlier.

going for. I mentioned this earlier. There's the qualitative and there's

There's the qualitative and there's quantitative. Qualitative is more about

quantitative. Qualitative is more about the human experience with something,

the human experience with something, right? You're interviewing participants.

right? You're interviewing participants. Well, that's high risk for the

Well, that's high risk for the researchers bias to be introduced

researchers bias to be introduced because they're interpreting what the

because they're interpreting what the patient is saying. All right? So, high

patient is saying. All right? So, high risk for bias. Whereas quantitative

risk for bias. Whereas quantitative research, which is what most of us think

research, which is what most of us think about, although qualitative research is

about, although qualitative research is on the rise, we're going to see more of

on the rise, we're going to see more of it because we do should be impacting

it because we do should be impacting patients perception. So, we remain

patients perception. So, we remain compliant and adherent or if not, why

compliant and adherent or if not, why not? and how those strategies should

not? and how those strategies should change. But quantitative is taking

change. But quantitative is taking something and we measure it. We quantify

something and we measure it. We quantify it into numbers, something that we can

it into numbers, something that we can wrap our minds around and measure like a

wrap our minds around and measure like a blood pressure or a lab. Okay, those are

blood pressure or a lab. Okay, those are pretty straightforward. Just lower risk

pretty straightforward. Just lower risk for bias because it is what it is.

for bias because it is what it is. You're either dead or alive or the value

You're either dead or alive or the value was you either achieved the blood

was you either achieved the blood pressure goal or you didn't. Right? So

pressure goal or you didn't. Right? So make sure you understand

make sure you understand sort of the big you know categories or

sort of the big you know categories or buckets. Now if we step into study

buckets. Now if we step into study design the most fundamental basic study

design the most fundamental basic study design is descriptive. You're just

design is descriptive. You're just describing and documenting an

describing and documenting an experience.

experience. That type of data doesn't change

That type of data doesn't change practice for almost most part unless

practice for almost most part unless it's the only stuff that exists and you

it's the only stuff that exists and you have to make a decision. Right? That's

have to make a decision. Right? That's your case reports case series.

your case reports case series. Qualitative

Qualitative does not prove causality. If you want to

does not prove causality. If you want to prove causality or you want to get to a

prove causality or you want to get to a close point of association so much so

close point of association so much so that it helps drive more internal

that it helps drive more internal validity then you got to do an

validity then you got to do an explanatory analytic study. So there's

explanatory analytic study. So there's two bare then subbuckets you have your

two bare then subbuckets you have your experimental and observational. So

experimental and observational. So remember your observational studies the

remember your observational studies the inter the researcher

inter the researcher okay doing the study is not doing an

okay doing the study is not doing an intervention there's nothing being done

intervention there's nothing being done to the patients the patients have either

to the patients the patients have either self-exposed themselves to something or

self-exposed themselves to something or have already been exposed to something

have already been exposed to something and the researchers just really

and the researchers just really observing what happens as a result of

observing what happens as a result of that exposure. Right? So basically

that exposure. Right? So basically people who do us, you know, a rapid

people who do us, you know, a rapid review course in preparation for their

review course in preparation for their board exam versus people who don't. If I

board exam versus people who don't. If I don't force you into that intervention

don't force you into that intervention and we just say, "Well, ask everybody as

and we just say, "Well, ask everybody as they come in and take the test, you

they come in and take the test, you know, did you take a review course? Yes

know, did you take a review course? Yes or no?" And then see what the results

or no?" And then see what the results are. You're just observing the outcome

are. You're just observing the outcome and impact of that exposure. So while it

and impact of that exposure. So while it may provide you some association, it

may provide you some association, it doesn't still fully prove causality. You

doesn't still fully prove causality. You can't say oh well that was the ultimate

can't say oh well that was the ultimate reason for their success one way or the

reason for their success one way or the other right so it's multiffactorial but

other right so it's multiffactorial but we have case controlled studies cohort

we have case controlled studies cohort studies cross-sectional studies and then

studies cross-sectional studies and then correlational analysis whereas

correlational analysis whereas experimental the things like randomized

experimental the things like randomized control trials and then randomized

control trials and then randomized control trials are broken down even

control trials are broken down even further into those that are explanatory

further into those that are explanatory studies or pragmatic. Now when you think

studies or pragmatic. Now when you think explanatory these are the highly

explanatory these are the highly controlled small single-c centered

controlled small single-c centered studies that are run by per protocol

studies that are run by per protocol they want to know they're purists

they want to know they're purists under pure ideal circumstances without

under pure ideal circumstances without any clutter what is the intervention

any clutter what is the intervention doing well that's not always real world

doing well that's not always real world and that's why people do pragmatic

and that's why people do pragmatic studies which get really into the

studies which get really into the intention to treat right because we all

intention to treat right because we all see people in clinic or in the hospital

see people in clinic or in the hospital or our units depending on where you work

or our units depending on where you work and we do these interventions but do we

and we do these interventions but do we see the same results as we read about in

see the same results as we read about in a paper and the answer is no because we

a paper and the answer is no because we are isolated in a small sample size and

are isolated in a small sample size and only seeing a portion of the picture

only seeing a portion of the picture which is what intention to treat

which is what intention to treat analysis is trying to do is say in the

analysis is trying to do is say in the real world this is the impact that this

real world this is the impact that this clinical trial has so now let's think

clinical trial has so now let's think about some of those studies so we're in

about some of those studies so we're in the pearls for the observational

the pearls for the observational studies, not the explanatory studies

studies, not the explanatory studies like randomized control trials or

like randomized control trials or crossover studies.

crossover studies. Okay, so case control. So these are

Okay, so case control. So these are typically you're looking for key words

typically you're looking for key words because they may give you a case or I

because they may give you a case or I describe a type of paper or study that

describe a type of paper or study that was done and they may ask you what type

was done and they may ask you what type of study it was or they may ask you're

of study it was or they may ask you're trying to answer this question or answer

trying to answer this question or answer this hypothesis.

this hypothesis. which study type would be most

which study type would be most appropriate. So you're looking for

appropriate. So you're looking for keywords.

keywords. So they tell you something was done

So they tell you something was done retrospectively or there was some going

retrospectively or there was some going back in time looking at exposure or risk

back in time looking at exposure or risk factors that were exposed to in one

factors that were exposed to in one group over another. That is almost

group over another. That is almost always a case controlled study. When do

always a case controlled study. When do we do those most commonly? Looking at

we do those most commonly? Looking at rare events or rare diseases. Why?

rare events or rare diseases. Why? Because in a case control I already know

Because in a case control I already know the outcome. I'm going backwards to look

the outcome. I'm going backwards to look to see what happened as a result of

to see what happened as a result of that. And so, um, this is where rare

that. And so, um, this is where rare diseases become irrelevant. Whereas a

diseases become irrelevant. Whereas a cohort wouldn't do rare diseases because

cohort wouldn't do rare diseases because if I take a group of people out of the

if I take a group of people out of the population and I have to study them for

population and I have to study them for 20 years, at the end of 20 years, I'm

20 years, at the end of 20 years, I'm going to go, hey, nobody had it. Well,

going to go, hey, nobody had it. Well, you just wasted 20 years of your life.

you just wasted 20 years of your life. Okay? And exposing those patients to

Okay? And exposing those patients to nothing. Um, questionnaires and things

nothing. Um, questionnaires and things like that. So these questions will not

like that. So these questions will not ask you about prevalence. They will not

ask you about prevalence. They will not ask you about incidents. They will not

ask you about incidents. They will not be studying rare disease um sorry they

be studying rare disease um sorry they they'll be looking for rare diseases and

they'll be looking for rare diseases and they already have the end points.

they already have the end points. Whereas cohort uh studies again it's

Whereas cohort uh studies again it's part of the observational. You grab a

part of the observational. You grab a cohort of people and you look for those

cohort of people and you look for those that were exposed to something or not

that were exposed to something or not and then you're following them forward

and then you're following them forward in time usually prospectively.

in time usually prospectively. There are such things as retrospective

There are such things as retrospective cohort studies where you go back in time

cohort studies where you go back in time and you say, "Okay, this is my starting

and you say, "Okay, this is my starting point and I'm going to look at the data

point and I'm going to look at the data that's already happened retrospectively

that's already happened retrospectively but in a forward fashion." That is a

but in a forward fashion." That is a retrospective cohort study where we

retrospective cohort study where we assess data in intervals, right? Okay.

assess data in intervals, right? Okay. Think about the women's health study

Think about the women's health study like it's a big study. Framingham, you

like it's a big study. Framingham, you know, these they they repeat these

know, these they they repeat these studies asking these questions on a

studies asking these questions on a large group of the of a population and

large group of the of a population and they look at the natural h history and

they look at the natural h history and that gives us incidents. Remember

that gives us incidents. Remember incidence versus prevalence. Incident

incidence versus prevalence. Incident give is based on a time interval. So

give is based on a time interval. So between one segment time of to another

between one segment time of to another whereas prevalence is a snapshot today

whereas prevalence is a snapshot today right now.

right now. So questions will not be looking and

So questions will not be looking and studying rare diseases because again you

studying rare diseases because again you don't want to have to study something

don't want to have to study something for 20 years to find out you missed it.

for 20 years to find out you missed it. Okay, no one had it. Uh and then we will

Okay, no one had it. Uh and then we will not be doing interventions. This is

not be doing interventions. This is still just like case controlled studies

still just like case controlled studies still part of the um observational study

still part of the um observational study design. Now cross-sectional

design. Now cross-sectional uh you need to think of it as a

uh you need to think of it as a snapshot. You're cross-secting

snapshot. You're cross-secting a group of people and you say what is

a group of people and you say what is the how many people today have a

the how many people today have a diagnosis of lung cancer that is

diagnosis of lung cancer that is prevalence. It's a snapshot. It's a one

prevalence. It's a snapshot. It's a one point in time and it always is assessing

point in time and it always is assessing prevalence. It will never be able to

prevalence. It will never be able to answer

answer um incidents because you don't have a

um incidents because you don't have a time interval. So it's just done at a

time interval. So it's just done at a point in in time. So again, these are

point in in time. So again, these are hopefully these little pearls. Like if

hopefully these little pearls. Like if if I had to just nail it down, uh this

if I had to just nail it down, uh this is why you would do this. Okay,

is why you would do this. Okay, sorry that uh that's crossover study. So

sorry that uh that's crossover study. So now we're into the explanatory study. So

now we're into the explanatory study. So you have your randomized control trials

you have your randomized control trials and you have your crossover study.

and you have your crossover study. Crossover studies, the researcher is

Crossover studies, the researcher is doing something to the patients. There

doing something to the patients. There is an intervention being made. you're

is an intervention being made. you're just repeating the intervention in both

just repeating the intervention in both groups. So you randomly assign them to

groups. So you randomly assign them to one of two groups. You apply the

one of two groups. You apply the intervention to one of them, the other

intervention to one of them, the other one you don't. You follow measure your

one you don't. You follow measure your outcomes or your variables, you know, at

outcomes or your variables, you know, at the end. Then you stop the

the end. Then you stop the interventions. There's a wash out

interventions. There's a wash out period, okay, where the intervention

period, okay, where the intervention needs to go away. Okay. And that wash

needs to go away. Okay. And that wash out period will vary in time based on

out period will vary in time based on the intervention's

the intervention's ability to hang around and influence

ability to hang around and influence things. Okay. So if it's an antibbody

things. Okay. So if it's an antibbody study for example, your wash out period

study for example, your wash out period should be weeks if not months because

should be weeks if not months because the halflife of most antibodies that

the halflife of most antibodies that takes that long, right? Versus if it's

takes that long, right? Versus if it's an esmol drip or the use of adenosine

an esmol drip or the use of adenosine for a cardiac procedure, well it's gone

for a cardiac procedure, well it's gone in seconds, right? So I mean you know

in seconds, right? So I mean you know that wash out period is very different

that wash out period is very different between those two interventions because

between those two interventions because of the type of um

of the type of um um

um agent intervention that's being used

agent intervention that's being used right now. Why would we do this? Well

right now. Why would we do this? Well most of the time a crossover study takes

most of the time a crossover study takes longer because you have to repeat the

longer because you have to repeat the study twice. But now the patients are

study twice. But now the patients are serving as their own controls. when they

serving as their own controls. when they serve as their own controls,

serve as their own controls, you now remove confounders influencing

you now remove confounders influencing it. So the internal validity starts to

it. So the internal validity starts to go up. Okay? So your power goes up with

go up. Okay? So your power goes up with even a fewer number of patients. So when

even a fewer number of patients. So when would I consider using this? Let's say I

would I consider using this? Let's say I don't have access to a large number of

don't have access to a large number of patients and but I want to maintain good

patients and but I want to maintain good power. Okay. Well, then a crossover

power. Okay. Well, then a crossover study is helpful because you can use

study is helpful because you can use those fewer patients, still maintain

those fewer patients, still maintain power. It's just going to take you

power. It's just going to take you longer to get it done. Whereas a

longer to get it done. Whereas a randomized control trial patient is the

randomized control trial patient is the intervention is still being made by the

intervention is still being made by the researcher, but in this case, the

researcher, but in this case, the patients don't serve as their own

patients don't serve as their own controls. they're being compared to

controls. they're being compared to another group who should have baseline

another group who should have baseline characteristics that look similar to

characteristics that look similar to them because we don't want a bunch of

them because we don't want a bunch of confounders influencing

confounders influencing uh the outcome, right? So, it's

uh the outcome, right? So, it's prospective. Patients get randomly

prospective. Patients get randomly assigned to this or that and they're

assigned to this or that and they're followed forward in time. They measure

followed forward in time. They measure the outcome and that's the end of the

the outcome and that's the end of the study. So, there's no wash out period,

study. So, there's no wash out period, there's no crossover,

there's no crossover, that kind of stuff. And we tend to think

that kind of stuff. And we tend to think these are more robust than the most

these are more robust than the most robust and and the gold standard. It's

robust and and the gold standard. It's true. Um it does help to prove causality

true. Um it does help to prove causality and has the least amount of bias. Well,

and has the least amount of bias. Well, that's why is it important? Well,

that's why is it important? Well, because it comes down to bias. So

because it comes down to bias. So remember your clinical trials as a

remember your clinical trials as a well-designed randomized control trial

well-designed randomized control trial will have the least amount of bias

will have the least amount of bias compared to a qualitative study which

compared to a qualitative study which has the most amount of bias. So if you

has the most amount of bias. So if you want to pro uh prove causality,

want to pro uh prove causality, you need a study design that reduces

you need a study design that reduces bias and increases internal validity um

bias and increases internal validity um in a proper way.

in a proper way. If you're looking for associations and

If you're looking for associations and you can't prove causality and you're not

you can't prove causality and you're not making an intervention,

making an intervention, then you're doing observational studies

then you're doing observational studies which are your cohort case controlled

which are your cohort case controlled cross-sectional studies. Uh and then you

cross-sectional studies. Uh and then you got your descriptive studies which are

got your descriptive studies which are case reports and case series which are

case reports and case series which are really more hypothesis generating. And

really more hypothesis generating. And then of course lastly your qualitative

then of course lastly your qualitative study is the human experience. Okay?

study is the human experience. Okay? So I've sort of beat this up to a pulp

So I've sort of beat this up to a pulp here but why is it important?

here but why is it important? Well it gets down to internal validity.

Well it gets down to internal validity. Do you believe

Do you believe that the study design that was

that the study design that was implemented and the way the

implemented and the way the interventions were assessed

interventions were assessed believe that the results that were

believe that the results that were produced are real or are they due to a

produced are real or are they due to a confounder or a certain amount of bias?

confounder or a certain amount of bias? If that is going to be different from

If that is going to be different from one person to another, there is no

one person to another, there is no measurable external validity, you know,

measurable external validity, you know, like

like >> there's no way of doing it, right? You

>> there's no way of doing it, right? You have to discern

have to discern that for yourself. That's where some of

that for yourself. That's where some of the debate kind of, you know, comes in

the debate kind of, you know, comes in because if something is not internally

because if something is not internally valid, it cannot be externally valid. I

valid, it cannot be externally valid. I mean, I hope that makes sense. You

mean, I hope that makes sense. You should never be applying something that

should never be applying something that you know is trash to a patient.

you know is trash to a patient. So I mean that's where skimming your

So I mean that's where skimming your paper and sometimes you know I tell

paper and sometimes you know I tell people don't I tell my residents don't

people don't I tell my residents don't ever practice abstract medicine where

ever practice abstract medicine where you read the abstract and you felt like

you read the abstract and you felt like you read the paper.

you read the paper. You read the abstract and you skim it to

You read the abstract and you skim it to see if it meets a certain pico or

see if it meets a certain pico or peacocks in your mind and you're making

peacocks in your mind and you're making quick judgments about the type of

quick judgments about the type of evidence you're looking for and the type

evidence you're looking for and the type of internal validity that you need.

of internal validity that you need. Right? So that is appropriate, but I'm

Right? So that is appropriate, but I'm not going to just stop at the abstract.

not going to just stop at the abstract. I'm using the abstract as a filtering

I'm using the abstract as a filtering point to get to the paper. That's

point to get to the paper. That's totally different.

totally different. So most people get hung up that, you

So most people get hung up that, you know, they've read the, you know,

know, they've read the, you know, introduction, they've read the methods

introduction, they've read the methods section and they get into the patient

section and they get into the patient population and they get into the study

population and they get into the study design and they're doing okay and then

design and they're doing okay and then it comes to all right, how am I how is

it comes to all right, how am I how is the researcher assessing this data and

the researcher assessing this data and is it appropriate? That's where most

is it appropriate? That's where most people start to break down and cry. All

people start to break down and cry. All right? Or as most journal clubs I

right? Or as most journal clubs I attend, the person leading the journal

attend, the person leading the journal club does whatever in their power to

club does whatever in their power to skip over this section as fast as they

skip over this section as fast as they can or to create such a distraction that

can or to create such a distraction that it gets missed and no one notices it. I

it gets missed and no one notices it. I never let that happen. Just kidding.

never let that happen. Just kidding. That's important, right? And we're

That's important, right? And we're intimidated by it. That shouldn't be

intimidated by it. That shouldn't be difficult. Um, and so if you follow me

difficult. Um, and so if you follow me at this point, um, again, hopefully

at this point, um, again, hopefully you've reviewed this, and those of you

you've reviewed this, and those of you that are, you know, premium members, um,

that are, you know, premium members, um, with us in particular, you get access to

with us in particular, you get access to our full review. You do not want to go

our full review. You do not want to go into any one of the BPS exams not

into any one of the BPS exams not feeling solid on this. You will fail. I

feeling solid on this. You will fail. I mean, just you can get all the other

mean, just you can get all the other crap right, you're going to fail. Um, I

crap right, you're going to fail. Um, I mean, that's just our experience. That's

mean, that's just our experience. That's what people tell us. And most people

what people tell us. And most people tell us that this was perfect. Okay? So

tell us that this was perfect. Okay? So pay attention. Listen. I'm going to hit

pay attention. Listen. I'm going to hit the nuts and bolts. Right? So if you

the nuts and bolts. Right? So if you have not memorized this chart, you need

have not memorized this chart, you need to memorize it and you need to

to memorize it and you need to regurgitate it in the first two minutes

regurgitate it in the first two minutes you walk into that room and you put your

you walk into that room and you put your pen and paper down and you write down a

pen and paper down and you write down a couple things that you need to remember.

couple things that you need to remember. This is one of them. Okay? Just jot it

This is one of them. Okay? Just jot it down quickly. Get it out of your mind.

down quickly. Get it out of your mind. Move on with your life. But it you don't

Move on with your life. But it you don't want to be stressing about it and trying

want to be stressing about it and trying to Well, what does that chart say on row

to Well, what does that chart say on row two? I mean, these are give me

two? I mean, these are give me questions. Okay. So, let's just walk

questions. Okay. So, let's just walk through some of this stuff. So, at the

through some of this stuff. So, at the top here, the columns have to do not the

top here, the columns have to do not the last column. That's a measure of

last column. That's a measure of correlation, which we're not really

correlation, which we're not really going to focus on right now. Uh, but

going to focus on right now. Uh, but these talk about the number of groups

these talk about the number of groups and how those groups are. Are they the

and how those groups are. Are they the same people? Are they different? Are

same people? Are they different? Are they independent of each other? Or are

they independent of each other? Or are they related? Right? So when you have

they related? Right? So when you have related groups, you have the same

related groups, you have the same patient in all arms of the study.

patient in all arms of the study. Whereas independent like in a randomized

Whereas independent like in a randomized control trial, they're in two different

control trial, they're in two different groups. They do not are not the same

groups. They do not are not the same people. Okay? They're two different

people. Okay? They're two different biologic beings. Now, where do the same

biologic beings. Now, where do the same patients come in? Most commonly, we

patients come in? Most commonly, we think of crossover studies. Okay? Or

think of crossover studies. Okay? Or let's say you're using some intervention

let's say you're using some intervention on the same patient, right? I'm putting

on the same patient, right? I'm putting a lotion on this arm and a lotion on

a lotion on this arm and a lotion on this arm or eye drop in one eye and eye

this arm or eye drop in one eye and eye drop in the other eye. Okay, I mean it's

drop in the other eye. Okay, I mean it's localized enough that likely the

localized enough that likely the systemic exposure is low theoretically

systemic exposure is low theoretically in most cases, right? Whereas

in most cases, right? Whereas independent groups basically are most

independent groups basically are most commonly in a a crossover or I'm sorry

commonly in a a crossover or I'm sorry randomized control trial or a case

randomized control trial or a case controlled study where you

controlled study where you retrospectively are going back in time.

retrospectively are going back in time. cohort studies as well because remember

cohort studies as well because remember they get expos put into exposure groups

they get expos put into exposure groups um of whatever happened right but so but

um of whatever happened right but so but they're technically different there is a

they're technically different there is a small little caveat to randomized

small little caveat to randomized control trials and PE people if you

control trials and PE people if you overly randomize them to so much degree

overly randomize them to so much degree that they start looking exactly the same

that they start looking exactly the same like for every 41year-old Caucasian

like for every 41year-old Caucasian female uh that's 5 foot six and lives

female uh that's 5 foot six and lives lives in this state and weighs this much

lives in this state and weighs this much gets in this group and the same person

gets in this group and the same person gets in this group. I mean that's pretty

gets in this group. I mean that's pretty significant. They start to look alike

significant. They start to look alike where statistically they start getting

where statistically they start getting treated as if they are related even

treated as if they are related even though their genetics

though their genetics and they're they're two biologically

and they're they're two biologically different sub people. All right. Um and

different sub people. All right. Um and so that's what those row the columns

so that's what those row the columns represent up here that we need to think

represent up here that we need to think about. How many groups and are they

about. How many groups and are they independent or are they related? So,

independent or are they related? So, let's look at an example. This is the

let's look at an example. This is the ISIS 2 trial, which was a landmark

ISIS 2 trial, which was a landmark study. I like to use it because it's

study. I like to use it because it's landmark. You need to know it anyway.

landmark. You need to know it anyway. Um,

Um, not the minutia of it, but what it was

not the minutia of it, but what it was about, right? This is the study that got

about, right? This is the study that got aspirin on the map. Okay. So, this was a

aspirin on the map. Okay. So, this was a 2x two factorial design. So, basically a

2x two factorial design. So, basically a 2 by two box created, which we'll show

2 by two box created, which we'll show you. It says and they're telling you

you. It says and they're telling you half of all the patients were randomly

half of all the patients were randomly allocated to receive this

allocated to receive this and half of the patients were to

and half of the patients were to randomize to receive a matching placebo.

randomize to receive a matching placebo. Then it goes on to say half of the all

Then it goes on to say half of the all patients were then further randomized to

patients were then further randomized to either get aspirin or a matching

either get aspirin or a matching placebo. So what does that look like?

placebo. So what does that look like? Well, this is a 2 by two.

Well, this is a 2 by two. Not rocket science. Okay, but how do you

Not rocket science. Okay, but how do you wrap your mind around it? Because if you

wrap your mind around it? Because if you read some of that, like if you're not

read some of that, like if you're not used to doing this, you might start

used to doing this, you might start getting confused. But just draw it,

getting confused. But just draw it, write it out. That's why we teach the

write it out. That's why we teach the skeletons of a study design in our full

skeletons of a study design in our full lectures because you visually need to

lectures because you visually need to see something. So if you do this, you

see something. So if you do this, you got your aspirin and placebo group, you

got your aspirin and placebo group, you got your stepinace and placebo group.

got your stepinace and placebo group. Well, then what do you do? Well, you

Well, then what do you do? Well, you just line them up, right? You got a

just line them up, right? You got a streptokinace aspirin treated group. You

streptokinace aspirin treated group. You got those who receive streptoccin plus

got those who receive streptoccin plus placebo. You got placebo plus aspirin.

placebo. You got placebo plus aspirin. And then you got placebo plus placebo.

And then you got placebo plus placebo. There's four separate groups here. The

There's four separate groups here. The way that they described it in the study

way that they described it in the study design, they are independent of each

design, they are independent of each other. They said they were allocated to

other. They said they were allocated to this or to this or they got this. So

this or to this or they got this. So there are four separate groups. There

there are four separate groups. There was no comment terminology that said

was no comment terminology that said anything about wash out periods crossing

anything about wash out periods crossing over nothing. So don't make it up if it

over nothing. So don't make it up if it doesn't exist. Okay.

doesn't exist. Okay. This is the uh data or the chart from

This is the uh data or the chart from the actual paper. So you see that

the actual paper. So you see that there's the streptokinace allocation,

there's the streptokinace allocation, the aspirin allocation and then the

the aspirin allocation and then the combination.

combination. Okay. And that's where the four groups

Okay. And that's where the four groups you should be able to see the four

you should be able to see the four groups.

groups. Okay? So that's your streptoinase,

Okay? So that's your streptoinase, aspirin, streptoccin, and aspirin. And

aspirin, streptoccin, and aspirin. And then your both of your placebo groups.

then your both of your placebo groups. Those are your four groups. Okay? So

Those are your four groups. Okay? So when you read something and you're

when you read something and you're mapping out in your mind, it should make

mapping out in your mind, it should make sense to you when you're reading the

sense to you when you're reading the paper. So, if we have four groups that

paper. So, if we have four groups that are independent of each other, where are

are independent of each other, where are we at on this chart?

we at on this chart? Sorry, that was

Sorry, that was you're right here. I think I'm trying to

you're right here. I think I'm trying to get into the related groups next, but

get into the related groups next, but you're on this column. So, that means

you're on this column. So, that means that your statistical analysis is

that your statistical analysis is somewhere in here. Well, which one do I

somewhere in here. Well, which one do I pick? Well, it depends on the type of

pick? Well, it depends on the type of data you're talking about, which is the

data you're talking about, which is the outcome.

outcome. Now, what about related samples? Okay,

Now, what about related samples? Okay, three or more related. How can that

three or more related. How can that happen? Well, think about a case

happen? Well, think about a case controlled study. Remember, I've got

controlled study. Remember, I've got cases and I can go backward in time in a

cases and I can go backward in time in a group of people. I can have a single

group of people. I can have a single study group. These are all people with

study group. These are all people with heart attacks, right? And then I go

heart attacks, right? And then I go backward in time and I look for three

backward in time and I look for three different sets of lipid profiles. And at

different sets of lipid profiles. And at each point of those lipid profiles, I'm

each point of those lipid profiles, I'm measuring

measuring the number of people who had an event

the number of people who had an event and went, right? Or the change in their

and went, right? Or the change in their lipid profiles and the impact. But if I

lipid profiles and the impact. But if I take those patients and I'm comparing

take those patients and I'm comparing lab one versus lab two and lab two

lab one versus lab two and lab two versus lab three or lab one versus lab

versus lab three or lab one versus lab three. Now I'm doing in inside I'm doing

three. Now I'm doing in inside I'm doing internal comparisons

internal comparisons and that's when you fall into

and that's when you fall into a three or more related groups. The

a three or more related groups. The classic way that this ends up happening

classic way that this ends up happening prospectively

prospectively is in a crossover study because we get

is in a crossover study because we get patients at baseline data.

patients at baseline data. We measure again the outcome data uh in

We measure again the outcome data uh in this group over here at the end of the

this group over here at the end of the initial treatment. We then wash this

initial treatment. We then wash this out. We measure it again

out. We measure it again in the same group of people and then we

in the same group of people and then we measure it again. We have four sets

measure it again. We have four sets of points of measurement and all

of points of measurement and all patients end up going through both arms.

patients end up going through both arms. So they become their own controls. So

So they become their own controls. So they're related to each other at all

they're related to each other at all points.

points. Okay.

Okay. So I hope that made sense in picking the

So I hope that made sense in picking the the two groups are the easiest ones. I

the two groups are the easiest ones. I think that's why I showed you the

think that's why I showed you the examples of the

examples of the you know two three or more. Now we need

you know two three or more. Now we need to think about the row. What type of

to think about the row. What type of data? Okay. So when we think of nominal

data? Okay. So when we think of nominal data we're thinking or we use the

data we're thinking or we use the terminology categorical which most

terminology categorical which most commonly is dichomous or binomial in its

commonly is dichomous or binomial in its distribution. Why? Dotmomous.

distribution. Why? Dotmomous. Bomial

Bomial because it's usually a yes or no. One or

because it's usually a yes or no. One or the other male or female right there.

the other male or female right there. You're dead or you're alive. you either

You're dead or you're alive. you either achieved the blood pressure goal or you

achieved the blood pressure goal or you didn't. Right? So, it's dichomous and it

didn't. Right? So, it's dichomous and it creates a binomial distribution in the

creates a binomial distribution in the data points. But there's no sense of

data points. But there's no sense of ranking or order. Now, you might go

ranking or order. Now, you might go busside, come on. I mean, being dead is

busside, come on. I mean, being dead is probably lower ranking than being alive.

Yes. But remember, it's just one or the other. There's no sense of ranking or

other. There's no sense of ranking or measurable order that you can create and

measurable order that you can create and the magnitude of difference while in the

the magnitude of difference while in the context of mortality

context of mortality you know consciously is say one is bad

you know consciously is say one is bad and one is not okay

and one is not okay that's not true for all patients

that's not true for all patients sometimes death is better for some

sometimes death is better for some patients like they want I've had

patients like they want I've had patients tell me I would rather be dead

patients tell me I would rather be dead than be staying alive because I'm

than be staying alive because I'm miserable Right? That's a whole separate

miserable Right? That's a whole separate debate. But the reality is that's in the

debate. But the reality is that's in the eye of the beholder, the person. Right?

eye of the beholder, the person. Right? So if you are if you're reading a study

So if you are if you're reading a study and the final outcome or objective,

and the final outcome or objective, i.e. the type of data question you're

i.e. the type of data question you're trying to answer is a yes or no or this

trying to answer is a yes or no or this or that

or that then you're in you're in nominal data

then you're in you're in nominal data especially if there's no sense of order.

especially if there's no sense of order. Now ordinal data has a sense of order.

Now ordinal data has a sense of order. ordinal order. There's a sk a ranking to

ordinal order. There's a sk a ranking to it and it's usually in a scale. But the

it and it's usually in a scale. But the problem with ordinal data is it doesn't

problem with ordinal data is it doesn't follow a normal distribution. So it's

follow a normal distribution. So it's not considered parametric data. There's

not considered parametric data. There's some usually outlier. That means the

some usually outlier. That means the median, mean, and mode are not in a

median, mean, and mode are not in a perfect alignment. Okay. The other thing

perfect alignment. Okay. The other thing that's important is when you're

that's important is when you're assessing the data, since there's an

assessing the data, since there's an order,

order, the magnitude of difference between each

the magnitude of difference between each level or order is not the same.

level or order is not the same. Not the same. So, let's look at some

Not the same. So, let's look at some examples. Think of New York heart

examples. Think of New York heart functional classification, which is a

functional classification, which is a subjective interpretation

subjective interpretation by the patient of their symptoms.

by the patient of their symptoms. Subjective. You can't measure it. Okay.

Subjective. You can't measure it. Okay. Well, how do you feel? Well, I'm short

Well, how do you feel? Well, I'm short of breath. Well, is that mild, moderate,

of breath. Well, is that mild, moderate, severe? I'm just short of breath.

severe? I'm just short of breath. Severe. Right. So, what is class one

Severe. Right. So, what is class one versus class two? Well, there's a

versus class two? Well, there's a magnitude. Clearly, there's a sense of

magnitude. Clearly, there's a sense of order, right? Class one is not near as

order, right? Class one is not near as bad as class three, and class two is not

bad as class three, and class two is not as bad as class 4. There's a step-wise

as bad as class 4. There's a step-wise order. It gets worse,

order. It gets worse, right? But the magnitude of difference

right? But the magnitude of difference is not measurable and is subjective.

is not measurable and is subjective. So class one to class two

So class one to class two versus class two to class 3, class 3 to

versus class two to class 3, class 3 to class 4. If you line those magnitudes of

class 4. If you line those magnitudes of difference up, that is what you see

difference up, that is what you see roughly. If that's the case, it cannot

roughly. If that's the case, it cannot be continuous and it can't be

be continuous and it can't be nominal. So there's a sense of order,

nominal. So there's a sense of order, there's a sense of rank, but the

there's a sense of rank, but the magnitude of difference is not the same.

magnitude of difference is not the same. So we talked about class uh uh heart

So we talked about class uh uh heart failure classification.

failure classification. Think about pain, mild, moderate to

Think about pain, mild, moderate to severe. Well, what there's a sense of

severe. Well, what there's a sense of ranking. It gets worse.

ranking. It gets worse. But what's the magnitude of difference

But what's the magnitude of difference between mild and moderate? And is that

between mild and moderate? And is that the same magnitude of difference between

the same magnitude of difference between moderate and severe?

moderate and severe? I don't know. I mean, how do you measure

I don't know. I mean, how do you measure it? How do you measure pain? Well, you

it? How do you measure pain? Well, you can say, "Oh, I did a pain scale." Well,

can say, "Oh, I did a pain scale." Well, then you have to define the intervals

then you have to define the intervals then.

then. So, what change is between mild to

So, what change is between mild to moderate? Is that the same as going from

moderate? Is that the same as going from moderate to severe? And if it's not,

moderate to severe? And if it's not, then you're dealing with ordinal data.

then you're dealing with ordinal data. Think of the well score for determining

Think of the well score for determining someone's risk of having a pulmonary

someone's risk of having a pulmonary embolism, a risk ratification tool.

embolism, a risk ratification tool. So, you got low, moderate, or high

So, you got low, moderate, or high probability. The magnitude of difference

probability. The magnitude of difference is not the same between those.

is not the same between those. It's not.

It's not. Okay. Is there a sense of order, sense

Okay. Is there a sense of order, sense of rank? Yes.

of rank? Yes. Now, when you start adding numbers to

Now, when you start adding numbers to it, that starts to merge into

it, that starts to merge into continuously treated data because now

continuously treated data because now the patient, especially pain,

the patient, especially pain, is consistent about how they perceive

is consistent about how they perceive their pain. Okay? And the scale can be

their pain. Okay? And the scale can be considered continuous at that point on

considered continuous at that point on sometimes, but most people tend to error

sometimes, but most people tend to error and treat it as ordinal to be on the

and treat it as ordinal to be on the safe side.

safe side. So with continuous data, we have a sense

So with continuous data, we have a sense of order and rank, but the data is

of order and rank, but the data is distributed normally. So that means

distributed normally. So that means there's no outliers. And now the

there's no outliers. And now the magnitude of difference is the same. So

magnitude of difference is the same. So let's think about blood pressure.

let's think about blood pressure. As I go up in blood pressure, each level

As I go up in blood pressure, each level that I go up is one one one one

that I go up is one one one one millimeters of mercury pressure. It's

millimeters of mercury pressure. It's the same. So there's a sense of order,

the same. So there's a sense of order, there's a sense of rank, the magnitude

there's a sense of rank, the magnitude of difference is the same.

of difference is the same. Now I can take blood pressure and make

Now I can take blood pressure and make it nominal because I say in my outcome

it nominal because I say in my outcome that I want to know how many people

that I want to know how many people achieve a blood pressure goal of 130 or

achieve a blood pressure goal of 130 or not.

not. So that's either a yes or no. You either

So that's either a yes or no. You either got less than 130 millimeters of record

got less than 130 millimeters of record pressure or you didn't.

pressure or you didn't. But if I ask and say I want to know what

But if I ask and say I want to know what this new drug's effect is on the average

this new drug's effect is on the average reduction in blood pressure, now I'm

reduction in blood pressure, now I'm treating it as continuous. So that's why

treating it as continuous. So that's why it is so

it is so important

important that you not only know what the question

that you not only know what the question is that's being asked, which goes all

is that's being asked, which goes all the way back to even pico picots,

the way back to even pico picots, okay? but that you understand what type

okay? but that you understand what type of data it is because then you pick the

of data it is because then you pick the wrong statistical analysis. So classic

wrong statistical analysis. So classic example of continuous data are things

example of continuous data are things that you can measure

that you can measure labs pulse temperature blood pressure.

labs pulse temperature blood pressure. But if you put a cut point like you're

But if you put a cut point like you're doing screenings for diabetes,

remember you have pre-diabetes or they a diabetic. Well, that's a cut point. So

diabetic. Well, that's a cut point. So they're either above it or they're below

they're either above it or they're below it.

it. Okay, that's changes things.

Okay, that's changes things. So that gets to the type of data. So

So that gets to the type of data. So let's think about some examples. Okay,

let's think about some examples. Okay, applying a new drug is being evaluated

applying a new drug is being evaluated to see if there is a mortality benefit.

to see if there is a mortality benefit. So what is the question

So what is the question at the end of the study? Okay, send me

at the end of the study? Okay, send me patient, you know, uh number 15.

patient, you know, uh number 15. What's my question? Are you dead or are

What's my question? Are you dead or are you alive?

you alive? Well, they're in a bag, sir. Well, okay.

Well, they're in a bag, sir. Well, okay. One or the other, right? So, if they're

One or the other, right? So, if they're dead or alive, there's no sense of

dead or alive, there's no sense of order. There's no sense of ranking.

order. There's no sense of ranking. There's no magnitude of difference.

There's no magnitude of difference. between them. So it's nominal, it's

between them. So it's nominal, it's dichomous. There's a binomial

dichomous. There's a binomial distribution that you can start to see

distribution that you can start to see happening. Okay? They might, by the way,

happening. Okay? They might, by the way, give you graphical data

give you graphical data and ask you to describe what type of

and ask you to describe what type of data do you think it is or best

data do you think it is or best describes it. That's fair.

describes it. That's fair. If they give you a bell curve and they

If they give you a bell curve and they tell you the mean, median, and mode are

tell you the mean, median, and mode are roughly the same or they show those

roughly the same or they show those numbers to you and they're roughly

numbers to you and they're roughly equal, that is parametric data until

equal, that is parametric data until proven otherwise. That is likely

proven otherwise. That is likely continuous data if you have to guess.

continuous data if you have to guess. Okay? So you can work both directions.

Okay? So you can work both directions. All right. Are there any differences in

All right. Are there any differences in outcome based on gender, male or female?

outcome based on gender, male or female? Okay. Yes or no. So the end of the

Okay. Yes or no. So the end of the study, does it impact it? Is there a

study, does it impact it? Is there a magnitude of difference? Not going to go

magnitude of difference? Not going to go there,

there, right? But you know, it's nominal data.

right? But you know, it's nominal data. What about taking blood pressure and

What about taking blood pressure and creating a cut point, right? So I want

creating a cut point, right? So I want to achieve a goal. We're all goal driven

to achieve a goal. We're all goal driven guidelines and metrics. How many

guidelines and metrics. How many patients are at goal?

patients are at goal? Well, we're thinking of like hemoglobin

Well, we're thinking of like hemoglobin A1C's, LDLs,

A1C's, LDLs, you know, their blood pressure. Well,

you know, their blood pressure. Well, when you have a cut point, you are now

when you have a cut point, you are now turning continuous data into a yes or no

turning continuous data into a yes or no question. So, is there a sense of order?

question. So, is there a sense of order? Well, we yeah, you can say, well, I

Well, we yeah, you can say, well, I think it's better to be less than

think it's better to be less than greater than. Sure. But there's no sense

greater than. Sure. But there's no sense of ranking or order. And the magnitude

of ranking or order. And the magnitude of difference is not the same because

of difference is not the same because it's yes or no. Okay, you didn't say

it's yes or no. Okay, you didn't say like the average. What if somebody's

like the average. What if somebody's less than 130? What if that's 90

less than 130? What if that's 90 millimeters of mercury pressure and the

millimeters of mercury pressure and the ones above it are 132? A big difference.

ones above it are 132? A big difference. Okay, so they're not the same. So it's

Okay, so they're not the same. So it's being treated when you have a goal as

being treated when you have a goal as nominal. So in this case, if I have two

nominal. So in this case, if I have two independent groups that were randomly

independent groups that were randomly assigned to give a new blood pressure

assigned to give a new blood pressure medication and I wanted to see those who

medication and I wanted to see those who got the blood pressure medication versus

got the blood pressure medication versus placebo and how many have achieved their

placebo and how many have achieved their goals.

goals. Well, I've got two independent groups.

Well, I've got two independent groups. I'm treating it as nominal data. I'm

I'm treating it as nominal data. I'm either going to pick a kai squared or a

either going to pick a kai squared or a fiser exact. And you may say, well, what

fiser exact. And you may say, well, what happens best I if they put both answer

happens best I if they put both answer choices there? Okay,

choices there? Okay, quite honestly this day and age

quite honestly this day and age it really doesn't matter because

it really doesn't matter because Fischer's exact was just easier to

Fischer's exact was just easier to calculate when it was a smaller. It's a

calculate when it was a smaller. It's a exact number whereas kai squared is not

exact number whereas kai squared is not the exact but as you get up large in

the exact but as you get up large in samples where you would use a kai

samples where you would use a kai squared it's the fiser's exact almost

squared it's the fiser's exact almost looks exactly the same. It's just really

looks exactly the same. It's just really hard to calculate manually. But who on

hard to calculate manually. But who on earth is calculating a fissures exact

earth is calculating a fissures exact manually anymore? Nobody. Because you

manually anymore? Nobody. Because you have SPSS or you have SASS and all these

have SPSS or you have SASS and all these other programs that can do it for you in

other programs that can do it for you in milliseconds.

milliseconds. Okay. But the reality is small sample

Okay. But the reality is small sample sizes or where the frequency of

sizes or where the frequency of distribution of the occurrence in one

distribution of the occurrence in one group is less than 5% or current less

group is less than 5% or current less than 20. Many times people will choose

than 20. Many times people will choose Fischer's exact, but they're going to

Fischer's exact, but they're going to make it very clear to you if they want

make it very clear to you if they want you to split airs. Okay? But if the

you to split airs. Okay? But if the sample size is large, you could use

sample size is large, you could use either one. It's just if it's small.

either one. It's just if it's small. Well, what's small? Some people say 30,

Well, what's small? Some people say 30, some people say 20. I've read papers on

some people say 20. I've read papers on both. So, it will be clear that it's a

both. So, it will be clear that it's a very small sample size, probably less

very small sample size, probably less than 20. Okay. All right. All right. So,

than 20. Okay. All right. All right. So, a randomized control trial was done

a randomized control trial was done to assess the average reduction in blood

to assess the average reduction in blood pressure with a new anti-hypertensive

pressure with a new anti-hypertensive medication compared to placebo.

medication compared to placebo. So now in the average group or reduction

So now in the average group or reduction in the patients receiving it was

in the patients receiving it was receiving placebo was five. Those who

receiving placebo was five. Those who got the new drug on average had eight

got the new drug on average had eight millimeters of mercury pressure. Is that

millimeters of mercury pressure. Is that statistically significant? That's your p

statistically significant? That's your p values, right? Is it clinically

values, right? Is it clinically relevant? That's ter that is determined

relevant? That's ter that is determined by you, not a p value. Okay. Is it

by you, not a p value. Okay. Is it clinically relevant? Okay. Well, that

clinically relevant? Okay. Well, that may be depend on a few other things. Is

may be depend on a few other things. Is there a sense of ranking in the

there a sense of ranking in the situation? Yes. Okay. Is there a sense

situation? Yes. Okay. Is there a sense of order? Yes. And is the magnitude of

of order? Yes. And is the magnitude of difference the diff the same in blood

difference the diff the same in blood pressure? Yes. Okay. So, we can measure

pressure? Yes. Okay. So, we can measure it. So, this is continuous data. So we

it. So, this is continuous data. So we have two independent groups with

have two independent groups with continuous data. It's going to be a

continuous data. It's going to be a student's t test or man Whitney u. Well,

student's t test or man Whitney u. Well, you see man Whitney u showing up in the

you see man Whitney u showing up in the ordinal data.

ordinal data. Okay. So when would you choose a man

Okay. So when would you choose a man whitney u for measurement of a

whitney u for measurement of a continuous variable? When there is an

continuous variable? When there is an outlier,

outlier, when your median and your mode, I'm

when your median and your mode, I'm sorry, your median and your mean are not

sorry, your median and your mean are not lining up or they show you a

lining up or they show you a distribution of data and it's skewed to

distribution of data and it's skewed to the left or to the right. That means you

the left or to the right. That means you have a tail. It's not this perfect

have a tail. It's not this perfect binomial distribution. There's some tail

binomial distribution. There's some tail and then there's a peak at the end,

and then there's a peak at the end, right? one way or the other, left skewed

right? one way or the other, left skewed or right skewed, positively or

or right skewed, positively or negatively skewed, something is pulling

negatively skewed, something is pulling the average and it's usually an outlier

the average and it's usually an outlier to a difference. And that's why you use

to a difference. And that's why you use a median in that situation because you

a median in that situation because you don't want the outlier

don't want the outlier that doesn't reflect largely of the

that doesn't reflect largely of the group to influence it because remember

group to influence it because remember you're studying a sample out of the

you're studying a sample out of the population

population and you're trying to extrapolate it back

and you're trying to extrapolate it back to the population. All right. So, I

to the population. All right. So, I mentioned P values

mentioned P values and what do they tell you and what do

and what do they tell you and what do they not tell you? Don't fall into this

they not tell you? Don't fall into this trap. But they may ask you to interpret

trap. But they may ask you to interpret a p value like literally what does a

a p value like literally what does a number mean? Not is it significant or

number mean? Not is it significant or not? I mean 5-year-old can do that with

not? I mean 5-year-old can do that with a little basic instruction, right? So

a little basic instruction, right? So the study endpoint of a p value that

the study endpoint of a p value that found the p value to be 0.003.

So how would you define that and you compare it to another study endpoint of

compare it to another study endpoint of 0.001?

0.001? Well

Well remember

remember which one is more significant. All

which one is more significant. All right. So, it says here the question is,

right. So, it says here the question is, which of the following results has the

which of the following results has the greater clinical significance? And the

greater clinical significance? And the answer is neither one of them because P

answer is neither one of them because P values have nothing to do with clinical

values have nothing to do with clinical significance or even clinical relevance.

significance or even clinical relevance. It just tells you whether or not the

It just tells you whether or not the results that you found

results that you found are due to chance or random error.

are due to chance or random error. That's it. So if you interpret that a p

That's it. So if you interpret that a p value of 0.003,

value of 0.003, you move the decimal point over two

you move the decimal point over two places and you get there is a

places and you get there is a 3% chance

3% chance that the results of this clinical trial

that the results of this clinical trial that was done are due to random error or

that was done are due to random error or by chance alone. Well, that's pretty

by chance alone. Well, that's pretty small. Well, what does that mean? That

small. Well, what does that mean? That means the results are real.

means the results are real. If I'm gonna gamble, they're probably

If I'm gonna gamble, they're probably real. That means the real thing is

real. That means the real thing is probably true, valid. Now, I so may have

probably true, valid. Now, I so may have to ask myself, is that difference

to ask myself, is that difference clinically significant or relevant? But

clinically significant or relevant? But that's a separate question.

that's a separate question. The 01 is a 1% chance due to random. So

The 01 is a 1% chance due to random. So as the p value gets smaller, that's why

as the p value gets smaller, that's why we want small p values because we want

we want small p values because we want the chance of it being random error or

the chance of it being random error or chance alone to be low. Okay, confidence

chance alone to be low. Okay, confidence intervals are looking at where is the

intervals are looking at where is the true population result. So when we get a

true population result. So when we get a 95% confidence interval, we have to look

95% confidence interval, we have to look at the type of data. Are we dealing with

at the type of data. Are we dealing with ratios or um or not? So study endpoints

ratios or um or not? So study endpoints like hazards ratios, relative risk, risk

like hazards ratios, relative risk, risk ratio. If the 95% confidence interval

ratio. If the 95% confidence interval includes 1.00,

includes 1.00, it cannot be statistically significant.

it cannot be statistically significant. Cannot.

Cannot. Okay.

Okay. Um so these are examples for which both

Um so these are examples for which both of these do not include 1.00

of these do not include 1.00 and therefore have p values that are

and therefore have p values that are less than 0.05. What are they? What are

less than 0.05. What are they? What are the exact p values? I don't know. You

the exact p values? I don't know. You can't discern that from this. You just

can't discern that from this. You just know it is statistically

know it is statistically significant. Okay.

significant. Okay. Now, how do you interpret the relative

Now, how do you interpret the relative risk? So, you can see relative risk of

risk? So, you can see relative risk of studying 0.1 is a relative risk of 665.

studying 0.1 is a relative risk of 665. That's not 65% reduction in the risk.

That's not 65% reduction in the risk. That's the wrong answer. They will have

That's the wrong answer. They will have it as an answer choice guaranteed.

it as an answer choice guaranteed. They're looking for the person to

They're looking for the person to understand it. Remember it's the

understand it. Remember it's the difference from one because one is no

difference from one because one is no difference.

difference. So you have to do 1 minus 65 and you

So you have to do 1 minus 65 and you get.35. And therefore that is a 35% of

get.35. And therefore that is a 35% of the risk

the risk of whatever outcome you were talking

of whatever outcome you were talking about was removed from that patient

about was removed from that patient population because of the intervention.

population because of the intervention. So that's why in most cases we want

So that's why in most cases we want relative risk to be less than one. But

relative risk to be less than one. But if you're talking about survival, I

if you're talking about survival, I might want the relative risk to be

might want the relative risk to be greater than one.

greater than one. Okay? Or it's above one. I don't want

Okay? Or it's above one. I don't want less people surviving because of the

less people surviving because of the intervention. So you have to get

intervention. So you have to get oriented because if you're talking about

oriented because if you're talking about ratios, then it if it includes 1.0, then

ratios, then it if it includes 1.0, then it cannot be statistically significant.

it cannot be statistically significant. If you're talking about means or

If you're talking about means or averages, now you're getting into 0.0 in

averages, now you're getting into 0.0 in the confidence interval. And if it

the confidence interval. And if it includes that it cannot be statistically

includes that it cannot be statistically significant. Now number needed to treat

significant. Now number needed to treat and number needed to harm. You should be

and number needed to harm. You should be able to calculate this and calculate it

able to calculate this and calculate it very quickly. It is not hard and they're

very quickly. It is not hard and they're calculated exactly the same. So there's

calculated exactly the same. So there's nothing difficult about it. You're just

nothing difficult about it. You're just taking the reciprocal of the absolute

taking the reciprocal of the absolute risk reduction. Okay. Or absolute

risk reduction. Okay. Or absolute relative risk increase. Okay. So number

relative risk increase. Okay. So number needed to treat is how many patients do

needed to treat is how many patients do I have to treat for one of those to

I have to treat for one of those to benefit. So guess what you want NT

benefit. So guess what you want NT to be a very low number whereas number

to be a very low number whereas number needed to harm is how many patients do I

needed to harm is how many patients do I have to treat before one patient gets

have to treat before one patient gets harmed and we want N&H to be a big

harmed and we want N&H to be a big number right we don't want many people

number right we don't want many people to have a bad experience but if someone

to have a bad experience but if someone does we want it to be after a million

does we want it to be after a million people got it one person had an out a

people got it one person had an out a bad reaction Okay.

Okay. So, we usually want a large number needed to harm and a small number

number needed to harm and a small number needed to treat. That's an easy test

needed to treat. That's an easy test question to give you, okay, is to to to

question to give you, okay, is to to to ask you what are the characteristics of

ask you what are the characteristics of an ideal number needed to treat or an

an ideal number needed to treat or an ideal number needed to harm. No

ideal number needed to harm. No different than the therapeutic index of

different than the therapeutic index of a drug. The LD50 divided by the ED50.

a drug. The LD50 divided by the ED50. You want the LD50 to be very large

You want the LD50 to be very large compared to the ED50. Why? Because if

compared to the ED50. Why? Because if you accidentally overdose, you are not

you accidentally overdose, you are not going to die. So the larger the

going to die. So the larger the therapeutic index, the safer the drug.

therapeutic index, the safer the drug. Okay?

Okay? So let's do an example here. So you do

So let's do an example here. So you do drug X versus placebo. Patients are done

drug X versus placebo. Patients are done in a randomized control trial. We follow

in a randomized control trial. We follow the patients for four weeks and we

the patients for four weeks and we assess whether or not they develop a

assess whether or not they develop a acute mocardial infarction. So we have

acute mocardial infarction. So we have two independent groups.

two independent groups. There's no crossover. There's no wash

There's no crossover. There's no wash out period. They're independent of each

out period. They're independent of each other and the determination of the

other and the determination of the outcome is did they have a heart attack

outcome is did they have a heart attack or not. So we're talking about nominal

or not. So we're talking about nominal data. Group A that got the drug had 5%

data. Group A that got the drug had 5% of them had an MI whereas the placebo

of them had an MI whereas the placebo group 15. So you can just see that the

group 15. So you can just see that the patients who got the drug had less heart

patients who got the drug had less heart attacks just period just looking at it.

attacks just period just looking at it. So how much of a benefit right? So

So how much of a benefit right? So remember it's the difference. So it's a

remember it's the difference. So it's a subtraction. So you take the incidence

subtraction. So you take the incidence of the two

of the two just subtract it. So 0.15 minus 005 is

just subtract it. So 0.15 minus 005 is 010. You take the reciprocal 1 divided

010. You take the reciprocal 1 divided by10.

by10. So this math is almost something that

So this math is almost something that you can do in your head or with a simple

you can do in your head or with a simple calculator on the computer and the

calculator on the computer and the answer is 10. Now you don't just stop

answer is 10. Now you don't just stop right there. You have to put the 10 in

right there. You have to put the 10 in the context of the study. So, you have

the context of the study. So, you have to treat 10 patients for four weeks with

to treat 10 patients for four weeks with this new drug X for one patient to not

this new drug X for one patient to not experience a heart attack. Is that worth

experience a heart attack. Is that worth it? Well, it depends maybe on the cost

it? Well, it depends maybe on the cost of the drug. It depends on um what it

of the drug. It depends on um what it costs to have a heart attack. I mean,

costs to have a heart attack. I mean, quite honestly, it's cheaper if you die.

quite honestly, it's cheaper if you die. Most cases, right? I mean, just think

Most cases, right? I mean, just think about it. You don't have to go to doctor

about it. You don't have to go to doctor visits and be on four medications and go

visits and be on four medications and go to Kath lab or be in the ICU or all

to Kath lab or be in the ICU or all these things. Get a helicopter ride if

these things. Get a helicopter ride if you're in the rural area. I mean, a

you're in the rural area. I mean, a helicopter taxi trip to the hospital is

helicopter taxi trip to the hospital is $35,000.

It's a lot of money, right? So, you you have to think through these are what

have to think through these are what makes the decisions a little bit hard.

makes the decisions a little bit hard. Now, let's throw back in here of

Now, let's throw back in here of application. What statistical test

application. What statistical test should we have done? We have two

should we have done? We have two independent groups. Nominal data again

independent groups. Nominal data again kai squared or fissures exact depending

kai squared or fissures exact depending on the sample size and the frequency of

on the sample size and the frequency of occurrence. Well, what about number

occurrence. Well, what about number needed to harm? Same thing. So this is

needed to harm? Same thing. So this is the cure study looking at those tree

the cure study looking at those tree with aspirin in the group A. They look

with aspirin in the group A. They look at the risk of bleeding 2.7%. You can

at the risk of bleeding 2.7%. You can see the people that take aspirin plus

see the people that take aspirin plus plavix

plavix clearly have more bleeding. Duh.

clearly have more bleeding. Duh. Okay. Well, is it that relevant? Well, I

Okay. Well, is it that relevant? Well, I guess define bleeding. Oh, um, blood

guess define bleeding. Oh, um, blood came squirting out of the eyeball and

came squirting out of the eyeball and they died. Oh, that's that's kind of

they died. Oh, that's that's kind of relevant, right? Spontaneous subaractoid

relevant, right? Spontaneous subaractoid hemorrhage or subdural hematomas or

hemorrhage or subdural hematomas or epidural hematomas. Okay, that's kind of

epidural hematomas. Okay, that's kind of relevant, right? So, you do the same

relevant, right? So, you do the same thing. You just take the difference in

thing. You just take the difference in the incidence. So, 0.037

the incidence. So, 0.037 uh minus 0.027, you get 0.01. take the

uh minus 0.027, you get 0.01. take the reciprocal of it, you get a 100. So I

reciprocal of it, you get a 100. So I have to treat a 100 patients with

have to treat a 100 patients with aspirin and copitigil for one of them to

aspirin and copitigil for one of them to have a major bleed. Okay? So again, you

have a major bleed. Okay? So again, you want to go, well, what's a major bleed

want to go, well, what's a major bleed and and how long do I have to treat

and and how long do I have to treat them? Well, that go back to the original

them? Well, that go back to the original data. All right, let's uh finish off by

data. All right, let's uh finish off by talking about systematic reviews and

talking about systematic reviews and meta analysis since they are growing in

meta analysis since they are growing in their um you know, basically

their um you know, basically publications, more people are doing

publications, more people are doing them. Um, I see people misunderstanding

them. Um, I see people misunderstanding uh systematic reviews and meta analysis

uh systematic reviews and meta analysis because they just assume, oh, it's a

because they just assume, oh, it's a meta analysis. It must that's the best

meta analysis. It must that's the best thing you want because they see the

thing you want because they see the pictures of the pyramid where meta

pictures of the pyramid where meta analysis is at the top. The underlying

analysis is at the top. The underlying assumption about a meta analysis being

assumption about a meta analysis being at the top is that it's got good data

at the top is that it's got good data coming in. If it's junk in, it's junk

coming in. If it's junk in, it's junk out. Okay?

out. Okay? So, a systematic review is almost always

So, a systematic review is almost always done before a meta analysis.

done before a meta analysis. So systematic is reproducible follows

So systematic is reproducible follows rules just like a clinical trial has

rules just like a clinical trial has inclusion exclusion criteria is rules

inclusion exclusion criteria is rules that are a priority defined.

that are a priority defined. Okay. And it's a review of studies that

Okay. And it's a review of studies that means clinical trials with data not

means clinical trials with data not review articles. A systematic review is

review articles. A systematic review is not a review article because review

not a review article because review articles can put whatever they want in

articles can put whatever they want in there. Yes, they summarize, reviews,

there. Yes, they summarize, reviews, studies, they may review a newspaper

studies, they may review a newspaper article or someone's opinion or give

article or someone's opinion or give their own opinion or all this stuff. And

their own opinion or all this stuff. And there's no inclusion and exclusion

there's no inclusion and exclusion criteria or protocol that is followed in

criteria or protocol that is followed in writing a review article. But at the end

writing a review article. But at the end of a systematic review, you are just

of a systematic review, you are just qualitatively

qualitatively summarizing in words

summarizing in words and articulating what did these studies

and articulating what did these studies find.

find. Okay? Whereas a metaanalysis takes it to

Okay? Whereas a metaanalysis takes it to the next level and does say okay let's

the next level and does say okay let's take all those studies that were done in

take all those studies that were done in the systematic review and let's pull all

the systematic review and let's pull all their data together and quantitatively

their data together and quantitatively come up with a number or what is called

come up with a number or what is called a pulled estimate or sometimes also

a pulled estimate or sometimes also referred as a summary statistic.

referred as a summary statistic. People use different lingo but it's the

People use different lingo but it's the overall outcome and what is the

overall outcome and what is the magnitude of the effect. Well, most of

magnitude of the effect. Well, most of the time these are presented in forest

the time these are presented in forest plots. And this is an example of a

plots. And this is an example of a forest plot from a stroke study where

forest plot from a stroke study where TPA was followed by endovvascular

TPA was followed by endovvascular therapy. And you can get oriented by

therapy. And you can get oriented by just looking at it. But a forest plot

just looking at it. But a forest plot got its name because they turned the

got its name because they turned the thing or someone's paper got turned

thing or someone's paper got turned around and said, "Looks like a forest.

around and said, "Looks like a forest. Those look like trees." I guess if

Those look like trees." I guess if you're smoking marijuana, yes, that is

you're smoking marijuana, yes, that is probably the case. But that's how it got

probably the case. But that's how it got its name. When you're reading a forest

its name. When you're reading a forest plot, get oriented. That means look at

plot, get oriented. That means look at the data. So they're telling you this is

the data. So they're telling you this is odds ratio. Okay, that's what type of

odds ratio. Okay, that's what type of data you're talking about. They also

data you're talking about. They also tell you which side of the line that's

tell you which side of the line that's going down the middle which is the point

going down the middle which is the point of no difference.

of no difference. Okay, is it favoring the standard

Okay, is it favoring the standard therapy which is not doing endovvascular

therapy which is not doing endovvascular therapy or favoring endovvascular

therapy or favoring endovvascular therapy? And you can just clearly see

therapy? And you can just clearly see without knowing a single thing about any

without knowing a single thing about any of these papers that they all seem to be

of these papers that they all seem to be lining up saying endovvascular therapy

lining up saying endovvascular therapy is beneficial.

is beneficial. Now the line of no difference or no

Now the line of no difference or no significance is one because you're

significance is one because you're talking about a ratio. What if it was

talking about a ratio. What if it was relative risk? Still be one. What if I

relative risk? Still be one. What if I was talking about hazards ratio? Still

was talking about hazards ratio? Still be one. What if I was talking about a a

be one. What if I was talking about a a risk ratio? Still be one. One one one.

risk ratio? Still be one. One one one. So again goes back to that 95%

So again goes back to that 95% confidence interval. That is the line of

confidence interval. That is the line of no significant that means the number

no significant that means the number numerator and the denominator are the

numerator and the denominator are the same. They are therefore equal. Okay.

same. They are therefore equal. Okay. The square uh is called a blob and the

The square uh is called a blob and the size of that blob is influenced by the

size of that blob is influenced by the size of the study. So usually as the

size of the study. So usually as the sample size goes up the size of the blob

sample size goes up the size of the blob goes up. The reason that the blobs are

goes up. The reason that the blobs are important is you have to put the blob in

important is you have to put the blob in the context of the summary statistic or

the context of the summary statistic or pulled estimate at the bottom. the big

pulled estimate at the bottom. the big diamond. And you see that most of the

diamond. And you see that most of the data is that's influencing the summary

data is that's influencing the summary statistic or pulled estimate is the

statistic or pulled estimate is the largest blob because it's just linearly

largest blob because it's just linearly lining up to it. The lines that are

lining up to it. The lines that are going around it represent the confidence

going around it represent the confidence interval. So if those confidence

interval. So if those confidence intervals do not cross the line of no

intervals do not cross the line of no difference, guess what? Then all of

difference, guess what? Then all of these studies are statistically

these studies are statistically significant. Okay? And so that's this

significant. Okay? And so that's this pulled summary statistic or pulled

pulled summary statistic or pulled estimate. Now when you look at this in

estimate. Now when you look at this in closer that is the point estimate that

closer that is the point estimate that point where the arrow is pointing right

point where the arrow is pointing right the sides represent and the width of

the sides represent and the width of that diamond correspond to the

that diamond correspond to the confidence interval for the pulled

confidence interval for the pulled estimate. So when you look at these two

estimate. So when you look at these two pulled results, which one has a larger

pulled results, which one has a larger 95% confidence interval?

95% confidence interval? pulled result two. Okay, probably due to

pulled result two. Okay, probably due to smaller sample sizes whereas pulled one

smaller sample sizes whereas pulled one you can just infer probably has a larger

you can just infer probably has a larger sample size. Now we told you that the

sample size. Now we told you that the the the blob size is influenced by the

the the blob size is influenced by the number of patients and you can just see

number of patients and you can just see now that when you give when we give you

now that when you give when we give you the rest of the image that when you look

the rest of the image that when you look at the forest plot it should line up

at the forest plot it should line up with your data. If it doesn't then

with your data. If it doesn't then something's wrong. They're not telling

something's wrong. They're not telling the truth somewhere. That's why you need

the truth somewhere. That's why you need to know how to read and interpret some

to know how to read and interpret some of this stuff. But clearly, if you look

of this stuff. But clearly, if you look at the totals there, 103, 98, 267, 150,

at the totals there, 103, 98, 267, 150, 35, those are the number of patients.

35, those are the number of patients. Clearly, the largest blob, which is has

Clearly, the largest blob, which is has the greatest influence on the poolled

the greatest influence on the poolled estimate has the is also the largest

estimate has the is also the largest study, whereas the smallest study has

study, whereas the smallest study has the smallest blob and a very wide

the smallest blob and a very wide confidence interval. And it only had 35

confidence interval. And it only had 35 patients, extend 1A. And the reason

patients, extend 1A. And the reason extend 1A uh only has one patient is

extend 1A uh only has one patient is because it was stopped early. It was

because it was stopped early. It was considered unethical to continue the

considered unethical to continue the study because the other p papers

study because the other p papers basically all came out in the same year.

basically all came out in the same year. You can see the year 2015 2015 2015

You can see the year 2015 2015 2015 that it was considered unethical to

that it was considered unethical to continue to do extend 1A at that point.

continue to do extend 1A at that point. So they stopped the study. Does that

So they stopped the study. Does that mean extend 1A is irrelevant? No.

mean extend 1A is irrelevant? No. group of researchers

group of researchers did an appropriate systematic review

did an appropriate systematic review included all data. Okay.

included all data. Okay. All right. So, that was uh a the

All right. So, that was uh a the quickest and most efficient

quickest and most efficient um

um EBM rapid review that I could uh

EBM rapid review that I could uh possibly pull off for you. Um, and

possibly pull off for you. Um, and hopefully you found that to be useful at

hopefully you found that to be useful at covering the most likely high yield

covering the most likely high yield points of interpretation and

points of interpretation and application. And you're like, "All

application. And you're like, "All right, bust eye. So, uh, now that I'm,

right, bust eye. So, uh, now that I'm, uh, drooing on myself and have a flat

uh, drooing on myself and have a flat effect, what is some of the good news?"

effect, what is some of the good news?" Because I told you guys I had some good

Because I told you guys I had some good news for you. And we do. We're excited

news for you. And we do. We're excited about some new content and we worked

about some new content and we worked hard. We had some technological issues

hard. We had some technological issues with some of the rendering of the videos

with some of the rendering of the videos and using a new format and studio that

and using a new format and studio that we are um doing. Um so it took a little

we are um doing. Um so it took a little bit longer but we I worked really hard

bit longer but we I worked really hard told the team we've got to get it out

told the team we've got to get it out because these folks have got exams

because these folks have got exams coming up. And so we have a number of

coming up. And so we have a number of new series that we're pushing to your

new series that we're pushing to your accounts uh free. Okay. So you'll start

accounts uh free. Okay. So you'll start seeing these. you will receive an alert

seeing these. you will receive an alert uh which is either in the form of some

uh which is either in the form of some sort of email or something like that. Um

sort of email or something like that. Um you will also if you just open up your

you will also if you just open up your account you'll start to see the content.

account you'll start to see the content. So the team is still programming

So the team is still programming everybody's accounts

everybody's accounts uh to get access to this. Um I wanted to

uh to get access to this. Um I wanted to go through some of these. There's

go through some of these. There's another slide on here with some more

another slide on here with some more content. So some of this is applicable

content. So some of this is applicable to some of you and more. Right? So, the

to some of you and more. Right? So, the BPS reviews have been trying to hit a

BPS reviews have been trying to hit a number of different areas that depending

number of different areas that depending on what exam you're taking, it it

on what exam you're taking, it it applies. But in our antimicrobial

applies. But in our antimicrobial stewardship series,

stewardship series, um there are 19 focused lectures ranging

um there are 19 focused lectures ranging on topics of how bacteria become

on topics of how bacteria become resistant, you know, uh antibiotic side

resistant, you know, uh antibiotic side effects and reviews, but also clinical

effects and reviews, but also clinical environments. So it's not just

environments. So it's not just antimicrobial stewardship in the ICU or

antimicrobial stewardship in the ICU or the hospital but antimicrobial

the hospital but antimicrobial stewardship especially by the guidelines

stewardship especially by the guidelines CDC

CDC IDSA

IDSA um

um uh

uh Chia those other groups uh even JCO

Chia those other groups uh even JCO accreditation standards represent all

accreditation standards represent all clinical environments. So we cover also

clinical environments. So we cover also nursing homes,

nursing homes, uh outpatient,

uh outpatient, uh clinic, family medicine, ambulatory

uh clinic, family medicine, ambulatory care, dentistry, the emergency

care, dentistry, the emergency department and then of course hospital

department and then of course hospital uh environment and then we also have a

uh environment and then we also have a series of review of high-risk diagnoses

series of review of high-risk diagnoses that are metrics for many institutions

that are metrics for many institutions for inappropriate

for inappropriate antibiotic use. So things like strep

antibiotic use. So things like strep fngitis, bronchitis, sinocitis, UTI,

fngitis, bronchitis, sinocitis, UTI, uh pneumonia,

uh pneumonia, um

um soft tissue infections, all those high

soft tissue infections, all those high risk um things. So we're super excited

risk um things. So we're super excited about this. We spent a lot of time

about this. We spent a lot of time developing it, went through lots of

developing it, went through lots of guidelines and material. It's fairly

guidelines and material. It's fairly robust. Um, and we tried to keep the

robust. Um, and we tried to keep the lectures focused and small enough to

lectures focused and small enough to where you could spend time focusing on

where you could spend time focusing on the area that's relevant for you. So,

the area that's relevant for you. So, super excited about that. It will also

super excited about that. It will also come with an ebook to your accounts um,

come with an ebook to your accounts um, as well. So, for your BCIDP folks, for

as well. So, for your BCIDP folks, for sure, hands down. Some of you BCPS

sure, hands down. Some of you BCPS people that are in the inpatient and

people that are in the inpatient and need some additional, there's some

need some additional, there's some content in there for you. uh BCAACP the

content in there for you. uh BCAACP the outpatient antimicrobial stewardship is

outpatient antimicrobial stewardship is there for you. Uh so super excited about

there for you. Uh so super excited about that. Uh then to dive a little bit

that. Uh then to dive a little bit deeper into those of you at ambulatory

deeper into those of you at ambulatory care family medicine

care family medicine um you know folks we have uh Dr. Boland

um you know folks we have uh Dr. Boland put together and and I um because prior

put together and and I um because prior to emergency medicine I did a lot of

to emergency medicine I did a lot of ambulatory care, primary care medicine.

ambulatory care, primary care medicine. Um we did seven focused lectures on

Um we did seven focused lectures on primary prevention topics. Um not only

primary prevention topics. Um not only addressing the newly released uh healthy

addressing the newly released uh healthy people 20 uh the 2030

people 20 uh the 2030 uh guidelines but also things like

uh guidelines but also things like public health screening exams, you know,

public health screening exams, you know, labs and screening tools and patient

labs and screening tools and patient populations from pediatrics to women's

populations from pediatrics to women's health to oncology patients, uh

health to oncology patients, uh infectious diseases. Um so cancer

infectious diseases. Um so cancer screenings and all the nine yards. Uh so

screenings and all the nine yards. Uh so this is a a really unique um compilation

this is a a really unique um compilation of topics related to primary prevention

of topics related to primary prevention which should be our focus uh in

which should be our focus uh in healthcare and this movement is growing.

healthcare and this movement is growing. The next is an obesity series. There's

The next is an obesity series. There's been a lot of evolution of drugs um even

been a lot of evolution of drugs um even including some of the diabetic drugs in

including some of the diabetic drugs in this group. So there's three focus

this group. So there's three focus lectures on obesity. We do a general

lectures on obesity. We do a general overview and then we dive a little

overview and then we dive a little deeper or Dr. Boland does dive a lot

deeper or Dr. Boland does dive a lot deeper into lifestyle, nutrition,

deeper into lifestyle, nutrition, activity issues and then there's even

activity issues and then there's even been some position statements and some

been some position statements and some guidelines that have been published

guidelines that have been published recently in the context of obesity as it

recently in the context of obesity as it relates to cardiovascular disease

relates to cardiovascular disease specifically.

specifically. Um that's we're digging deeper because

Um that's we're digging deeper because of our our culture and the number and

of our our culture and the number and the endemic uh epidemic of obesity in

the endemic uh epidemic of obesity in this country. And then lastly um the

this country. And then lastly um the diabetes section. We know that like

diabetes section. We know that like oncology and some other areas some

oncology and some other areas some topics get uh updated more frequently

topics get uh updated more frequently and so you have to be careful with this

and so you have to be careful with this on some exams. But we felt like these

on some exams. But we felt like these lectures are now contentwise

lectures are now contentwise sufficient uh for some of the new data

sufficient uh for some of the new data that's come out in the last 6 to 12

that's come out in the last 6 to 12 months. Um and so we did an updated type

months. Um and so we did an updated type one and type two lectures. Um and Dr.

one and type two lectures. Um and Dr. Bolan went into uh greater detail on

Bolan went into uh greater detail on some of the technology monitoring issues

some of the technology monitoring issues like um continuous glucose monitoring

like um continuous glucose monitoring strategies and things like that that are

strategies and things like that that are applicable.

applicable. um and then went into some what we call

um and then went into some what we call special focal focused series on the

special focal focused series on the GLP-1 receptor agonist and the SGLT2

GLP-1 receptor agonist and the SGLT2 inhibitors in the context of all these

inhibitors in the context of all these new indications

new indications uh within context of heart failure, CKD

uh within context of heart failure, CKD and CBD. So all of these topics as it's

and CBD. So all of these topics as it's applicable to your exam and review will

applicable to your exam and review will be pushed to your accounts

be pushed to your accounts free to you guys. We are pumped and

free to you guys. We are pumped and excited about that. They will become

excited about that. They will become standard parts of our packages moving

standard parts of our packages moving forward. For those of you taking future

forward. For those of you taking future exams, we have other um

exams, we have other um content that is going to be um coming

content that is going to be um coming out. So, we're constantly investing in

out. So, we're constantly investing in new content, constantly bringing you

new content, constantly bringing you guys new uh QBank. By the way, for

guys new uh QBank. By the way, for antimicrobial stewardship, there's also

antimicrobial stewardship, there's also been over 50 new questions added to the

been over 50 new questions added to the Qbank uh for you guys. So, I think

Qbank uh for you guys. So, I think there's maybe 60 questions. So, that's

there's maybe 60 questions. So, that's quite a bit of practice for that. And

quite a bit of practice for that. And part of this comes back from feedback

part of this comes back from feedback from you guys. So I I share that with

from you guys. So I I share that with you in part so that you guys hear and

you in part so that you guys hear and recognize that um we do listen

recognize that um we do listen um to you. Your feedback is important.

um to you. Your feedback is important. Obviously no source and no company is

Obviously no source and no company is perfect. We try our best to uh work for

perfect. We try our best to uh work for you and give you the best review. We

you and give you the best review. We also try to be careful of giving you too

also try to be careful of giving you too much minutia that is too new that you

much minutia that is too new that you perceive that it's on the exam. So there

perceive that it's on the exam. So there is an element of an interval between

is an element of an interval between when data comes out and becomes standard

when data comes out and becomes standard practice. So like for example, I think

practice. So like for example, I think the SGLT2 inhibitors and GLP1 uh data

the SGLT2 inhibitors and GLP1 uh data was not initially clear how it was going

was not initially clear how it was going to unfold, but it is clearly unfolded in

to unfold, but it is clearly unfolded in a pattern that has now been incorporated

a pattern that has now been incorporated into um guidelines to where now there

into um guidelines to where now there are even subsp specialcialized position

are even subsp specialcialized position statements on these topics. And so we

statements on these topics. And so we felt like hands down we've got to do it.

felt like hands down we've got to do it. it is now in the standards of care um

it is now in the standards of care um and being implemented. So I hope that

and being implemented. So I hope that you guys

you guys um

um I hope that you guys um find that to be

I hope that you guys um find that to be helpful. So

with that we're going to go back to some of the earlier comments. Uh there was a

of the earlier comments. Uh there was a question from Jennifer about major

question from Jennifer about major depressive disorder and the use of the

depressive disorder and the use of the combination fluoxitine olanzipene

combination fluoxitine olanzipene uh formulation which is also you uh

uh formulation which is also you uh sometimes used for bipolar disorder and

sometimes used for bipolar disorder and treatment resistant major depressive

treatment resistant major depressive disorder and the answer to that is

disorder and the answer to that is absolutely. Um, so when you think about

absolutely. Um, so when you think about patients who have resistant depression,

patients who have resistant depression, you have to, you know, think about

you have to, you know, think about biologically what's going on, why, think

biologically what's going on, why, think outside the box. Um, remember bipolar

outside the box. Um, remember bipolar patients

patients um, go through both depression and

um, go through both depression and mania. So the reason some of these

mania. So the reason some of these combination drugs become useful in

combination drugs become useful in certain patient populations is many

certain patient populations is many times they probably have underlying

times they probably have underlying problems in other areas and so the drugs

problems in other areas and so the drugs can be useful to more than one

can be useful to more than one situation. So thinking outside the box

situation. So thinking outside the box for the alternative is definitely worth

for the alternative is definitely worth knowing. So Jennifer, excellent,

knowing. So Jennifer, excellent, excellent question. Uh, Amanda brought

excellent question. Uh, Amanda brought up the um answer to my PTSD, which I

up the um answer to my PTSD, which I could I was it was on the tip of my

could I was it was on the tip of my tongue, but the ben the vaccine um is

tongue, but the ben the vaccine um is one of the po more common ones that

one of the po more common ones that probably would get show up on um

probably would get show up on um uh

uh boards. Uh there was a question about

boards. Uh there was a question about one of the new um agents that is used

one of the new um agents that is used for uh bipolar uh I think it's lumatada

for uh bipolar uh I think it's lumatada parano or something like that. I can't

parano or something like that. I can't remember exactly how to say it. Uh I

remember exactly how to say it. Uh I don't have personal experience with that

don't have personal experience with that and um comments other than it is

and um comments other than it is indicated for um schizophrenia

indicated for um schizophrenia um in in patients with psychotic

um in in patients with psychotic disorders. I don't have much experience.

disorders. I don't have much experience. Sorry about that Jennifer. Um

Sorry about that Jennifer. Um let's moving on to how long should you

let's moving on to how long should you give uh I thamin IV before you consider

give uh I thamin IV before you consider transfer to uh PO Betsy that's an

transfer to uh PO Betsy that's an excellent uh question. Um so most people

excellent uh question. Um so most people need probably three to four um

need probably three to four um doses to replenish them. If you

doses to replenish them. If you replenish them with uh 100 milligrams of

replenish them with uh 100 milligrams of thamin, most of the time that gets them

thamin, most of the time that gets them up enough to where if you if they stop

up enough to where if you if they stop drinking, Jennifer or Betsy, the um the

drinking, Jennifer or Betsy, the um the gastritis and then the transporters will

gastritis and then the transporters will slowly start to upregulate again. So, it

slowly start to upregulate again. So, it just takes, you know, a couple weeks,

just takes, you know, a couple weeks, but when you've parentally administered

but when you've parentally administered multiple doses of thyin, they can

multiple doses of thyin, they can usually make it through that way. Uh

usually make it through that way. Uh Jennifer asked the question about um

Jennifer asked the question about um is it better to use combination inhalers

is it better to use combination inhalers or individual agents in separate

or individual agents in separate inhalers? So the current

inhalers? So the current uh guidelines and part of the reason for

uh guidelines and part of the reason for the push for inhaled cortical steroids

the push for inhaled cortical steroids with promoterol in particular and the

with promoterol in particular and the reason they use foterol not like someol

reason they use foterol not like someol or is because the onset of action is 15

or is because the onset of action is 15 minutes 10 to 15 minutes so it's shorter

minutes 10 to 15 minutes so it's shorter that's why people can use foroterol for

that's why people can use foroterol for exercise induced asthma you can actually

exercise induced asthma you can actually take an inhalation before but but but

take an inhalation before but but but really what it boils down to is what I

really what it boils down to is what I said earlier is that they're trying to

said earlier is that they're trying to push convenience, adherence, and

push convenience, adherence, and compliance. So, if you have a potential

compliance. So, if you have a potential uh dry powder inhaler and a meterd dose

uh dry powder inhaler and a meterd dose inhaler that's aerosolized,

inhaler that's aerosolized, uh that requires two different

uh that requires two different techniques. We already know that most

techniques. We already know that most patients don't even know one of the

patients don't even know one of the techniques correctly. So, if you ask a

techniques correctly. So, if you ask a patient to take two different inhalers,

patient to take two different inhalers, one, they have to carry two different

one, they have to carry two different devices around. So, it's risk of losing

devices around. So, it's risk of losing something. Second is you need sometimes

something. Second is you need sometimes the extra amount of work to do more

the extra amount of work to do more inhalations and then the third is uh

inhalations and then the third is uh compliance with the technique. Um so

compliance with the technique. Um so that was in part the reason for their

that was in part the reason for their recommendation. The other one was

recommendation. The other one was evidence that these patients that are on

evidence that these patients that are on who are using inappropriate short acting

who are using inappropriate short acting beta agonist for their symptom control

beta agonist for their symptom control which they really should have been on

which they really should have been on inhaled cortical steroids. They're

inhaled cortical steroids. They're trying to

trying to rem push providers to be more aware of

rem push providers to be more aware of the fact that if your patient has even

the fact that if your patient has even mild symptoms and you're using short

mild symptoms and you're using short acting beta agonists to manage that,

acting beta agonists to manage that, those patients have worse outcomes.

those patients have worse outcomes. Think about it. When I get a patient who

Think about it. When I get a patient who comes in emergency department with an

comes in emergency department with an acute exacerbation and they've already

acute exacerbation and they've already been using their aluterol

been using their aluterol ns or inhalers, what am I going to give

ns or inhalers, what am I going to give them? More albuterol? I mean all the

them? More albuterol? I mean all the receptors are occupied at that point. So

receptors are occupied at that point. So that's why I've got to be creative and

that's why I've got to be creative and use like short acting muscerinic

use like short acting muscerinic antagonist or go to um you know bypass

antagonist or go to um you know bypass procedures or even IV magnesium to try

procedures or even IV magnesium to try to relax those airways. Uh so so I hope

to relax those airways. Uh so so I hope I answered uh the question uh for you.

I answered uh the question uh for you. Um

Um so

so um

um so I think there was somebody K asked a

so I think there was somebody K asked a question about the what does MCAT stand

question about the what does MCAT stand for in the context of COPD

for in the context of COPD exacerbations. This is a an assessment

exacerbations. This is a an assessment tool that looks at the number of

tool that looks at the number of exacerbations

exacerbations and you're categorizing the patient for

and you're categorizing the patient for basically the risk. Um it's the gold

basically the risk. Um it's the gold COPD

COPD uh recommended screening tool that helps

uh recommended screening tool that helps you to put the patient in a particular

you to put the patient in a particular bucket. Um

uh so question about the pneumonia vaccine 20 uh is it too new for the

vaccine 20 uh is it too new for the exam? Most likely. They won't get

exam? Most likely. They won't get specific anyway with you on the on the

specific anyway with you on the on the formulation. In my opinion, they won't

formulation. In my opinion, they won't they'll just keep it into the pneumonia,

they'll just keep it into the pneumonia, you know, vaccine against strep

you know, vaccine against strep pneumonia.

pneumonia. Uh let's see. So, Miranda asked a

Uh let's see. So, Miranda asked a question. I thought for COPD that I

question. I thought for COPD that I inhaled cortosteroid wasn't recommended

inhaled cortosteroid wasn't recommended due to increased infections. Uh I don't

due to increased infections. Uh I don't believe that's the case. But when we

believe that's the case. But when we talk about inhaled cortical steroids in

talk about inhaled cortical steroids in the context of COPD,

the context of COPD, we're talking about moderate to severe

we're talking about moderate to severe cases

cases and patients already on therapy. The

and patients already on therapy. The addition of those because remember there

addition of those because remember there are pe patients who have uh asthma COPD

are pe patients who have uh asthma COPD overlap syndrome which means they have a

overlap syndrome which means they have a hyper reactive airway component to their

hyper reactive airway component to their disease. Um and there have been a number

disease. Um and there have been a number of studies that have shown in those

of studies that have shown in those patients in particular

patients in particular um specifically that group uh they do

um specifically that group uh they do better with it. Now yes I mean can you

better with it. Now yes I mean can you get more infection? Sure. If you use it

get more infection? Sure. If you use it wrong and does it increase her

wrong and does it increase her absolutely you're giving a steroid. Um,

absolutely you're giving a steroid. Um, so it's small, but you're weighing the

so it's small, but you're weighing the sort of risk versus benefit ratio,

sort of risk versus benefit ratio, especially for exacerbation into the

especially for exacerbation into the hospital where they can become hypoxic

hospital where they can become hypoxic and even die from it. All right. So,

and even die from it. All right. So, there was a question about would you

there was a question about would you explain uh this is from Han. He he says

explain uh this is from Han. He he says or she says says uh

or she says says uh would you explain the again the

would you explain the again the difference between case controlled study

difference between case controlled study a retrospective cohort in a prospective

a retrospective cohort in a prospective study? Okay.

study? Okay. So a case controlled study

So a case controlled study is

is in a retrospective

in a retrospective cohort study.

a case controlled study, you already have the diagnosis.

have the diagnosis. You already have the diagnosis. Okay?

You already have the diagnosis. Okay? And you are only retrospectively going

And you are only retrospectively going back in time looking for an exposure.

back in time looking for an exposure. What is a retrospective cohort study?

What is a retrospective cohort study? Knowing that cohort studies are

Knowing that cohort studies are typically followed forward in time and

typically followed forward in time and we collect data on a group of people

we collect data on a group of people usually prospectively. That is the most

usually prospectively. That is the most common

common way cohort studies are being done. But

way cohort studies are being done. But remember in both not there's usually no

remember in both not there's usually no intervention being made. There's just

intervention being made. There's just been an exposure.

been an exposure. Okay? So these are observational

Okay? So these are observational studies. The researcher is not doing

studies. The researcher is not doing anything. In a retrospective cohort

anything. In a retrospective cohort study, you may not know yet what are the

study, you may not know yet what are the end points or the outcomes.

end points or the outcomes. So let's say for example, follow me. I

So let's say for example, follow me. I have a group I have a database of

have a group I have a database of Medicaid patients. I used to serve on

Medicaid patients. I used to serve on the Texas

the Texas state pnt committee where we reviewed

state pnt committee where we reviewed Medicaid data and our patient

Medicaid data and our patient population.

population. I can go into that database

I can go into that database retrospectively. So the data is already

retrospectively. So the data is already there. I don't I want to go okay out of

there. I don't I want to go okay out of this group of people I want to break

this group of people I want to break them up into those that were exposed to

them up into those that were exposed to this drug and those that were not

this drug and those that were not exposed to this drug and I want to look

exposed to this drug and I want to look at the data forward even though it's

at the data forward even though it's retrospective and I'm looking for this

retrospective and I'm looking for this outcome of lung cancer or a endpoint.

outcome of lung cancer or a endpoint. So that's how it's different than a case

So that's how it's different than a case controlled study is that I don't know

controlled study is that I don't know the outcome in the patient before I

the outcome in the patient before I start. Case controlled study, you know

start. Case controlled study, you know the outcome before you start. Period.

the outcome before you start. Period. Okay. I hope that helped.

Okay. I hope that helped. It does require you to think of the

It does require you to think of the method and the sequence of steps that

method and the sequence of steps that you're going through and the structure

you're going through and the structure of the methodology. That's why I'm a

of the methodology. That's why I'm a huge advocate if you watch in our

huge advocate if you watch in our lectures that I and when I do study

lectures that I and when I do study design review I give you a skeleton and

design review I give you a skeleton and I showed you a couple here

I showed you a couple here a skeleton of because visually you need

a skeleton of because visually you need to see it what's happening and when do

to see it what's happening and when do you do what and how is the person being

you do what and how is the person being treated. So remember,

treated. So remember, if you ever get told that the

if you ever get told that the researchers made no intervention,

researchers made no intervention, you're probably in an observational

you're probably in an observational study bucket. Okay? Especially if we're

study bucket. Okay? Especially if we're following them and looking at their data

following them and looking at their data retrospectively or prospectively.

retrospectively or prospectively. Okay, so someone gave me some data.

Okay, so someone gave me some data. I appreciate that. Uh, hi. Can you

I appreciate that. Uh, hi. Can you interpret the uh

interpret the uh confidence interval with a negative

confidence interval with a negative hazards ratio?

and the confidence interval is -2.00 to05.

Okay. So hazards ratios is means that there's an incidence of

is means that there's an incidence of there's the incidence of the exposed

there's the incidence of the exposed group divided by the incidence of the

group divided by the incidence of the non-exposed group. Okay. So there's a

non-exposed group. Okay. So there's a numerator and there's a denominator.

numerator and there's a denominator. So if this confidence interval included

So if this confidence interval included 1.0,

1.0, it could not be statistically

it could not be statistically significant.

significant. Okay?

Okay? could not be statistically significant.

could not be statistically significant. So this since both numbers are in the

So this since both numbers are in the negative

negative then it would be less than one.

then it would be less than one. Okay.

Okay. Um and so would be statistically

Um and so would be statistically significant. The p value would be less

significant. The p value would be less than 0.5. I don't know what else to say.

than 0.5. I don't know what else to say. That's

That's kind of it. What data did you get this

kind of it. What data did you get this from?

from? if you're still there.

if you're still there. I'll I'll leave it up just in case you

I'll I'll leave it up just in case you come back on. So, couple people saying

come back on. So, couple people saying thank you. You're welcome.

thank you. You're welcome. Uh so, there was a question about the

Uh so, there was a question about the live Q&A on uh Monday, April 11th, and

live Q&A on uh Monday, April 11th, and the answer was it was cancelled. Um part

the answer was it was cancelled. Um part of it was we this is the first time we'd

of it was we this is the first time we'd ever done it.

ever done it. um there were fewer people joining so we

um there were fewer people joining so we didn't know how much of a need it was

didn't know how much of a need it was um and it seemed like at the beginning

um and it seemed like at the beginning that people utilized the live study

that people utilized the live study group sessions where we just were

group sessions where we just were available for Q&A

available for Q&A um and it was our first time to also do

um and it was our first time to also do spe focused ones where we had Dr.

spe focused ones where we had Dr. Travers and Dr. butts to do specifically

Travers and Dr. butts to do specifically oncology.

oncology. Um it seemed like it went overall very

Um it seemed like it went overall very well and we opened it up to the entire

well and we opened it up to the entire public as a service to the profession.

public as a service to the profession. Um but it also seemed like as time was

Um but it also seemed like as time was going on they were dropping off. Um so

going on they were dropping off. Um so you know give us feedback if you guys

you know give us feedback if you guys like those and you want more of them.

like those and you want more of them. That's helpful to know. If only doing

That's helpful to know. If only doing you know a couple here and there is all

you know a couple here and there is all that's necessary as you study. we just

that's necessary as you study. we just realized or I remember back in the day

realized or I remember back in the day when we were studying um I didn't have

when we were studying um I didn't have access to other folks and we've

access to other folks and we've encountered people who reach out to us

encountered people who reach out to us and ask us questions and so we wanted to

and ask us questions and so we wanted to um we wanted to try

um we wanted to try to

to help you guys and be available. Um

help you guys and be available. Um so um that's it was our first stab at

so um that's it was our first stab at it. So, please send us feedback if you

it. So, please send us feedback if you have opinions, but yes, the April 11th

have opinions, but yes, the April 11th is is okay. Uh, so

is is okay. Uh, so all right. So, several of you are saying

all right. So, several of you are saying thank you. You're welcome. Someone's

thank you. You're welcome. Someone's asking um

asking um is it Primlada? I think I said your

is it Primlada? I think I said your hopefully I said your name right. Um, so

hopefully I said your name right. Um, so it's asking about a practice test for

it's asking about a practice test for BCPS.

BCPS. So that has been asked for probably a

So that has been asked for probably a year and a half now and I have been

year and a half now and I have been slightly reluctant to

slightly reluctant to uh release it without proper testing and

uh release it without proper testing and I we've had some delays in that because

I we've had some delays in that because we also wanted to make it adequate

we also wanted to make it adequate length.

length. So has you guys know writing questions

So has you guys know writing questions that are you want to see if there's some

that are you want to see if there's some level of validity to them. Um and so we

level of validity to them. Um and so we are approaching

are approaching um getting that closer. So the the goal

um getting that closer. So the the goal um is by fall, but I can't promise

um is by fall, but I can't promise anything because I don't want to release

anything because I don't want to release something that you too because I what I

something that you too because I what I fear is that too many people are going

fear is that too many people are going to rely on it and I don't want to

to rely on it and I don't want to mislead anybody. So, I know some of you,

mislead anybody. So, I know some of you, so we do want beta testers. And so, if

so we do want beta testers. And so, if you're interested in being a beta tester

you're interested in being a beta tester of content, the other thing that that

of content, the other thing that that we're looking for beta testers for is we

we're looking for beta testers for is we have the preliminary

have the preliminary um course for BCM.

um course for BCM. This is the emergency medicine

This is the emergency medicine uh review, which sounds like it got

uh review, which sounds like it got delayed. It was supposed to be this

delayed. It was supposed to be this fall. Uh but it looks like the first

fall. Uh but it looks like the first session for that exam is not going to be

session for that exam is not going to be until the spring, my understanding.

until the spring, my understanding. Um but we have the first set of lectures

Um but we have the first set of lectures and then we have uh which will keep

and then we have uh which will keep somebody busy for quite a while. Um the

somebody busy for quite a while. Um the um we also have um almost 200 questions

um we also have um almost 200 questions that are very specific

that are very specific uh to uh emergency medicine um that

uh to uh emergency medicine um that we I put together. So but there'll be

we I put together. So but there'll be more. So, what will happen for any of

more. So, what will happen for any of the anybody that wants to beta test?

the anybody that wants to beta test? Um, again, if you don't mind sending us,

Um, again, if you don't mind sending us, we're going to actually reach out to

we're going to actually reach out to people and send an email or like a

people and send an email or like a Mailchimp type of thing with, you know,

Mailchimp type of thing with, you know, hey, join us if you want to be a beta

hey, join us if you want to be a beta tester uh on some of this stuff. Um, and

tester uh on some of this stuff. Um, and then what will happen is we will just

then what will happen is we will just keep releasing the data or the sorry

keep releasing the data or the sorry data. We'll keep releasing the new

data. We'll keep releasing the new content into your account, just pushing

content into your account, just pushing it live.

it live. Kind of like we're doing with this new

Kind of like we're doing with this new content here. We're just giving it to

content here. We're just giving it to everybody who's a current customer for

everybody who's a current customer for free.

free. Um,

Um, let's see. There were

there want somebody wants more questions and psych from Amy. Absolutely. Uh we've

and psych from Amy. Absolutely. Uh we've been trying to actually hire some more

been trying to actually hire some more psychiatry

psychiatry clinical pharmacists and we're having a

clinical pharmacists and we're having a difficult time finding people that want

difficult time finding people that want to write. That's kind of weird. We had a

to write. That's kind of weird. We had a group and you know a couple of them

group and you know a couple of them moved on to do some other things. So if

moved on to do some other things. So if you have friends or colleagues that are

you have friends or colleagues that are B they have to be BCP certified

B they have to be BCP certified um in order to do it. Um, but if you

um in order to do it. Um, but if you know of anybody or you have colleagues

know of anybody or you have colleagues in your own environments

in your own environments or friends that are BCPP, psychiatry

or friends that are BCPP, psychiatry trained and certified, uh, please ask

trained and certified, uh, please ask them to reach out to me. And by the way,

them to reach out to me. And by the way, any of you are on LinkedIn, I'd love to

any of you are on LinkedIn, I'd love to connect with you. Send me an email or

connect with you. Send me an email or invite or whatever. It's nice to follow

invite or whatever. It's nice to follow to see what you guys are doing. And many

to see what you guys are doing. And many times once you take your test, uh, we

times once you take your test, uh, we look for contributors. And so we want

look for contributors. And so we want more people to be engaged. Um so we pay

more people to be engaged. Um so we pay people and we have writers. We have a

people and we have writers. We have a whole group big big big big group of

whole group big big big big group of writers. Um but they're people that

writers. Um but they're people that represent all areas of the uh profession

represent all areas of the uh profession and practice. So um just reach out to me

and practice. So um just reach out to me via LinkedIn. That's probably the

via LinkedIn. That's probably the easiest way or via customer service.

I think that's it. Any other questions? um

um because otherwise we're kind of at the

because otherwise we're kind of at the end. It's been great being with you

end. It's been great being with you guys. Thank you for those of you that

guys. Thank you for those of you that stuck with it. I wish you the best.

stuck with it. I wish you the best. Please let us know um how you did, how

Please let us know um how you did, how you felt like some of the material

you felt like some of the material helped. I know it's a lot of information

helped. I know it's a lot of information to go through. Um and I know it probably

to go through. Um and I know it probably at times was painful. You want to quit.

at times was painful. You want to quit. If you decide that you delay your exam

If you decide that you delay your exam or something and you have an account and

or something and you have an account and you need to extend it or something,

you need to extend it or something, please don't be afraid to reach out to

please don't be afraid to reach out to us. We my customer service team and Dr.

us. We my customer service team and Dr. I mean sorry Carrie Hughes who's the

I mean sorry Carrie Hughes who's the director of customer service knows that

director of customer service knows that she has the full authority to take care

she has the full authority to take care of our customers and um our whole team

of our customers and um our whole team functions like that. So, if we can help

functions like that. So, if we can help you, obviously we have to keep stay, but

you, obviously we have to keep stay, but if we can help you, please don't um you

if we can help you, please don't um you know, don't hesitate to reach out um on

know, don't hesitate to reach out um on anything that you ever need in the

anything that you ever need in the future. We're also going to be releasing

future. We're also going to be releasing some new CE programs

some new CE programs um as well um that you know, if you're

um as well um that you know, if you're looking for stuff or you know those

looking for stuff or you know those institutions if you need it. There's

institutions if you need it. There's also group discounts. So, if we're

also group discounts. So, if we're having a lot more hospitals reach out to

having a lot more hospitals reach out to us. So if you're a part of a hospital

us. So if you're a part of a hospital group, uh we do offer group discount. So

group, uh we do offer group discount. So uh many times what we'll do is a

uh many times what we'll do is a director or somebody that's a you know

director or somebody that's a you know kind of the decision maker or lead in

kind of the decision maker or lead in your in your department if you get a

your in your department if you get a group what we will do is send you either

group what we will do is send you either a special coupon or we will set up an

a special coupon or we will set up an event page for your group or your

event page for your group or your hospital uh with special rates that only

hospital uh with special rates that only apply to that group. Usually we have to

apply to that group. Usually we have to have a list or a roster something like

have a list or a roster something like that but it's pretty easy. We do it all

that but it's pretty easy. We do it all the time for people. Um

I think that's it guys. So thanks so much for being here. Thanks so much for

much for being here. Thanks so much for your investment into your own knowledge.

your investment into your own knowledge. I'm proud of you guys and think you will

I'm proud of you guys and think you will do well. Having said that we'll see you

do well. Having said that we'll see you soon. Take care.

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YouTube Transcript:Session 6 - Live Rapid Review for BPS Exams