Medical Literature as a Resource for Evidence-Based Medicine.

An Overview.

dr. Agus Budi Utomo

List of Topics
Medical literature as a resource for evidence based medicine. An overview. Biomedical literature resources and hierarchy of evidence. MEDLINE - the most important biomedical database. PubMed online training. Sample searches. Search strategy tips, Boolean operators, working with search results. MeSH, links to fulltext articles.

Topic 1: AGENDA

1A: Searching for evidence

What is evidence-based medicine? Background vs. Foreground questions Books Search engines

1B: Clinical questions

1C: Searching tips:

Google www.google.com (various doucments) Scholar Google www.scholar.google.com (journal articles) Scirus www.scirus.com (various SCIENTIFIC documents) MEDLINE (journal articles bibliographic records) 3

Databases

1A: Searching for evidence

What is evidence-based medicine?

Why is EBM Important?

MEDLINE
400,000 new entries added each year

To keep up-to-date
Need to read 6,000 articles each day

Why is EBM Important?

Lag time from time of knowing to time of implementation
13 years for thrombolytic therapy 10 years for corticosteroids for acceleration of fetal lung maturity

(Antman EM, JAMA, 1992)

Motivation: EBM Successes

Theophylline and asthma
We were doing the wrong thing
Littenberg, 1988

Beta blockers and MIs

We werent doing the right thing
Yusuf, 1987

Traditional Approaches
Self-reported reading time per week. (University setting)
Medical students 60 min. Interns none Senior residents 10 min. Fellows 45 min. Attendings graduating Post 1975 60 min. Pre 1975 30 min.

There is simply no way we can keep up to date in medicine using traditional approaches!

EBM : Lifelong Process

The practice of evidence-based medicine is a process of lifelong, self-directed, problem-based learning; Caring for patients creates the need for clinically important information about

Diagnosis Prognosis Therapy and other clinical and health care issues.
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EBM: Role of Literature

Evidence-based medicine "converts reading and appraising the biomedical literature into the pragmatic process of
using the literature to benefit individual patients, while simultaneously expanding the clinician's knowledge base."

Bordley DR. Evidence-based medicine: a powerful educational tool for clerkship education. American Journal of Medicine 1997;102(5):427-32.

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Motivation: EBM Successes

Theophylline and asthma
We were doing the wrong thing
Littenberg, 1988

Beta blockers and MIs

We werent doing the right thing
Yusuf, 1987

Research Evidence Decision Making

Clinical Expertise

Patient Preference

Evidence Based Medicine: A Process

Patients

Ask Questions

Appraise

Searching

Validity

Results

Applicability

1B: Clinical Questions

Two Layers Background & Foreground Questions

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Asking the Precise Question

Background questions Basic aspect of a disease
Pathophysiology Etiology Basic treatment

Foreground questions Specific knowledge Have 4 parts: Patient/problem Intervention Comparison intervention Clinical outcomes

Who, what, when, how

Background or Foreground?
What is asthma?

Is prednisone helpful in asthma?

What are the newest medication for asthma? Does atrovent used acutely make you feel better?

Background or Foreground?
What is asthma? (B)
What are the newest medication for asthma? (B) Does atrovent used acutely make you feel better? (F) Is prednisone helpful in asthma? (F or B) Foreground if compare to other drugs Background if interested in how it works

Foreground (Specific) Questions

3 or 4 essential components

Example: In young children with recurrent of acute otitis media (AOM), should doctors recommend vaccination to reduce frequency of AOM episodes?
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Patient and/or problem Intervention (diagnosis, treatment..) Comparative intervention (optional, include if relevant) Clinical outcome (cured disease, relief, alleviation, prognosis)

Structure of a Well-built Question

Patient or population
Be specific to capture the group you want Ex: Children w/ asthma

Intervention
Be specific

Comparison group (if any)

Compare to standard therapy or test

Outcome
Be precise What are the outcome of interest

Formulating the Clinical Question PICO

Patient Intervention Comparison (if relevant) Outcome

In patients with does the use of asthma discharged inhaled and both home from the oral corticosteroids emergency department

compared with oral steroids alone

lead to a reduction in asthma relapse?

Can You Identify PICO?

In children under 6 months, how does sleeping on back compared to sleeping on the stomach in terms of risk of SIDS?

In children under 6 months (P), how does sleeping on back (I) compared to sleeping on the stomach (C) in terms of risk of SIDS (O)?

Can You Form a PICO Question?

Clinical scenario: 5 yo with moderate persistent asthma now in severe acute asthma exacerbation. Intern gave 2 albuterol and orapred with minimal improvement. Intern asks why how good is atrovent?

Searchable PICO Question

P: Population I: Intervention/diagnostic test/risk factor C: Comparison O: Outcome

In children with acute asthma exacerbation (P), will the addition of atrovent (I) to albuterol (C) decrease the rate of hospitalization (O)?

Searching Superhero

Best Bets

1C: Searching Tips

Search engines
Google www.google.com (mixed documents)
Scholar Google www.scholar.google.com (journal articles)

Books

Scirus www.scirus.com

(various SCIENTIFIC

documents)
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Searching Tips: Books

Online library catalogs

Example: [US] National Library of Medicine LocatorPlus

www.locatorplus.gov

Online medical textbooks (some free)

Example: The Merck Manuals:

Merck Manual of Diagnosis & Therapy Merck Manual Home Edition.

A

trusted source for medical information available free online

eMedicineHealth : Dictionary

www.merckmanual.com
Google Book Search http://books.google.com
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LocatorPlus Search Results

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Searching Tips: Books

Online library catalogs

Example: [US] National Library of Medicine LocatorPlus

www.locatorplus.gov

Online medical textbooks (some free)

Example: The Merck Manuals:

Merck Manual of Diagnosis & Therapy Merck Manual Home Edition.

A

trusted source for medical information available free online

www.merckmanual.com

eMedicineHealth : Medical Dictionary

www.emedicinehealth.com
Google Book Search http://books.google.com

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Merck Manual of Diagnosis and Therapy : Otitis media Search

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Merck Manual Home Edition Consumer Information

Simple descriptions for laypeople + medical school beginners Pronunciations of some medical terms.

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Searching Tips: Books

Online library catalogs

Example: [US] National Library of Medicine LocatorPlus

www.locatorplus.gov

Online medical textbooks (some free)

Example: The Merck Manuals:

Merck Manual of Diagnosis & Therapy Merck Manual Home Edition.

A

trusted source for medical information available free online

www.merckmanual.com
Google Book Search http://books.google.com
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Google Book Search Advanced Title Search

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Advanced Book Search Title Search Results

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1C: Searching Tips

Books Search engines
Google

www.google.com (mixed documents)

Scholar Google www.scholar.google.com (journal articles) Scirus www.scirus.com (various SCIENTIFIC documents)
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The Evidence Pyramid

Levels of Evidences
(I-1) a well done systematic review of 2 or more RCTs (I-2) a RCT (II-1) a cohort study (II-2) a case-control study (II-3) a dramatic uncontrolled experiment (III) respected authorities, expert committees, etc.. (IV) ...someone once told me....
http://www.phru.org/casp/
See also AAFP

If your question is about Intervention/Therapy Diagnosis/Screening To assess the accuracy of the test To assess effect of test on health outcome Prognosis Etiology/Risk factors

Look for a Randomized controlled trial

Cohort study Randomized controlled trial

Longitudinal cohort Randomized controlled trial Cohort Case-control

Pre-appraised Resources
Cochrane
http://www.cochrane.org/cochrane/revabstr/mainindex.htm Very high quality reviews Mostly questions of therapy

National Guideline Clearinghouse

http://www.guideline.gov/ Guidelines of varying levels of quality Do broad searches

PEM database
http://researchinpem.homestead.com/homepage.html Not pre-appraised

Pre-appraised Resources
Best Evidence Topics
http://www.bestbets.org Developed in the ED of Manchester Royal Infirmary in UK Usually EM topics Free

Clinical Evidence (CE Concise)

http://www.clinicalevidence.com From UK Focus mostly on therapy Free

Primary Search Engines

Pubmed

Ovid

Primary Search Engines

Both PubMed and Ovid

Contains MEDLINE and other bibliographic databases (Cochrane, EMBASE, etc)

Sells access to the databases to libraries

PubMed MEDLINE vs. Ovid MEDLINE

Same DATABASE Different SEARCH ENGINES
Searching differently may get you slightly different results If you search both databases EXACTLY the same, your results will be the same

What is MEDLINE?
MEDLINE is a DATABASE
MEDLINE is produced by the National Library of Medicine MEDLINE is available free via Pubmed MEDLINE is sold to many vendors, like Ovid, who search the DATA in MEDLINE through different search engines

Database Producer Vendors

Medline EMBASE CINAHL

Ovid Pubmed Personal PC Dialog Library PC LEXIS/NEXIS

Self-study Assignment 1 Notes

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