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Ovid: Hospital Epidemiology and Infection Control

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Mayhall, C. Glen

Hospital Epidemiology and Infection Control, 3rd Edition

Copyright 2004 Lippincott Williams & Wilkins


> Table of Contents > XIV - T he Literature in Hospital Epidemiology and
Infection Control > C hapter 92 - Searchi ng the Litera ture in Hospital
Epidemiology and Infection Control

Chapter 92
Searching the Literature in Hospital
Epidemiology and Infection Control
Cynthia J. Walker
K. Ann McKibbon
Fiona Smaill
R. Brian Haynes
Since the second edition of this book was published in 1999, access to
healthcare literature has continued to become easier, faster, and more
widespread. The Internet features prominently as a primary repository
for healthcare information. Indeed, many of the traditional forms of
literature such as journal articles and books are available in their
entirety on the Internet. More quality-filtered and patient-ready
resources are available to help streamline the search for information.
Finally, a new form of technology has invaded the information scene:
the handheld or personal digital assistant (PDA).
In this updated chapter, we explore the improvements in information
access to evidence-based resources with relevance to infection control.
We review these new resources and improvements in old ones as they
relate to three areas in which a healthcare professional would require
high-quality information: (a) solving clinical problems, (b) keeping upto-date, and (c) setting clinical policy.

USING THE LITERATURE TO SOLVE CLINICAL


PROBLEMS
Quick and efficient access to high-quality reliable information is never
so important as when faced with a pressing clinical problem. This is
especially true in the rapidly changing field of infection control in which
practices and policies are subject to frequent changes and
amendments. To make informed clinical decisions, recent reports are
needed of systematic reviews or major preplanned human
investigations relevant to the clinical setting. One could rely on one's
colleague down the hallif one has a colleague and he or she is more

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up to date and has time when one needs them or one can search the
literature to find the current best evidence by carefully defining the
clinical question, choosing the most appropriate information source,
and designing a search strategy (1).
Until recently, textbooks were often sources for basic information that
did not change quickly (2). Anatomy plus physiology and other such
basic science subjects lend themselves well to the publication pace of
textbooks. With the publication potential of the Internet, however,
clinical practice textbooks have entered an evidence-based era.
Many textbooks are now available on the Internet and integrate
evidence-based information with specific clinical problems. In addition,
they are updated more or less regularly. Up-To-Date
(http://www.uptodate.com) is an evidence-based electronic textbook
[Web-based and compact disc read-only memory (CD-ROM)] for general
internal medicine and a growing number of other specialties. WebMD
Scientific American Medicine http://www.samed.com) is also available
on the Internet and CD-ROM.
Clinical Evidence, from the BMJ Publishing Group, is a dynamic
electronic synthesis of evidence from randomized trials, published in
print, on CD-ROM, and on the Internet in unabridged, concise, and PDA
formats. Organized by clinical area, the focus of each section is a
selection of clinical questions and answers most often related to
therapies. New and updated topics are posted online each month. The
questions in Clinical Evidence concern the benefits and harms of
preventative and therapeutic interventions, with emphasis on outcomes
that matter to patients.
The Physicians' Information and Education Resource (PIER) is a new
Web-based service from the American College of Physicians-American
Society of Internal Medicine (ACP-ASIM)
(http://www.pier.acponline.org). Volunteer physician editorial
consultants review the literature and prepare PIER modules for specific
topics. The consultants are given recent citations to relevant articles
obtained through filtered electronic searches. The modules are updated
quarterly and made available on the Internet. Coverage includes
diseases, screening and prevention, complementary and alternative
medicine, ethical and legal issues, and procedures. The design of
Clinical Evidence and PIER also make them useful for keeping up with
the medical literature and for providing basic knowledge on healthcare
topics.
The Cochrane Library contains the collected work of the Cochrane
Collaboration, an international organization that prepares, maintains,
and disseminates systematic reviews of controlled trials of healthcare
interventions (note that topics such as
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diagnosis and prognosis are not covered). Within the Cochrane Library,

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the Cochrane Database of Systematic Reviews (CDSR) contains reviews


that have high standards for finding, rating, summarizing, and
reporting the evidence from trials (1). The Cochrane Library is
searchable, contains almost exclusively controlled trials and systematic
reviews, and is much smaller than MEDLINE, so that methodologic
filtering is not needed and a simple, even one-word, search strategy
will likely retrieve high-quality evidence with a clinical bottom line.
Furthermore, the Cochrane Library is cumulative, and the reviews are
regularly updated or tagged as no longer current, if not updated within
a specified period. The Cochrane Library also contains summaries of
non-Cochrane systematic reviews, citations on how to do systematic
reviews, and a huge database of citations of clinical trials, many of
them not available on MEDLINE. The Cochrane Library is available on
CD-ROM and the Internet as a stand-alone resource and in other
services, such as Ovid's Evidence-Based Medicine Reviews. If
one choose not to subscribe to it, one's health sciences or hospital
library likely does. Abstracts of Cochrane reviews and the abstracts of
other systematic reviews (but not the rest of the library) are also
available for free on the Internet at the U.K. Cochrane site
(http://www.cochrane.org) and other Web sites.
MEDLINE is the most likely general source to turn to when one's
specific information sources fail or when one is faced with a nonroutine
clinical problem. It should not be consulted first if one knows of a
specific source that is current, of high quality, and tailored to the
problem being dealt with, as we describe later. MEDLINE is the largest
readily available database of biomedical journal citations and is now
available in full or subset form for free on many Web sites, one of them
produced by the U.S. National Library of Medicine (NLM). It is also
more up-to-date than ever, with leading journals providing electronic
copy for close to date-of-publication posting.
PubMed (http://www.ncbi.nlm.nih.gov/entrez/) is the MEDLINE search
interface produced by the NLM in conjunction with the U.S. National
Center for Biotechnology Information. PubMed provides on-line access
to literature citations and links to full-text journals at Web sites of
participating publishers. (User registration, a subscription fee, or some
other type of fee may be required to access the full text of articles for
some journals.) PubMed also contains PREMEDLINE citations: basic
citation information and abstracts are entered or downloaded daily
before the full records that contain MeSH terms, publication types, and
other indexing data are prepared and added to MEDLINE. Furthermore,
it has a clinical query feature
(http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.html) that
allows a search strategy to be fine tuned using methodologic terms so
that retrieval will be more clinically applicable. For example, if one's
question has to do with the cause, course, diagnosis, prevention, or
treatment of a clinical problem, one could go directly to the clinical

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query screen and indicate the study category in which one is interested
and whether one would like a sensitive (maximal retrieval of
relevant articles, with a high rate of false-positive articles) or
specific (lower retrieval of relevant articles with fewer false
positives) approach. After content words on the clinical problem of
interest are entered, one proceeds with the search and complex
pretested search strategies are automatically invoked, optimizing the
yield of clinically relevant studies (3). In the near future, updated
clinical queries will be available. These queries will be expanded from
therapy, diagnosis, prognosis, and etiology to include clinical prediction
guides, economics, qualitative studies, and systematic reviews (4).
PubMed also has a related articles feature that allows the
searcher to view citations related to an individual citation retrieved in a
search without having to do another search. Thus, if one finds a study
that is right on target, one can click on the [Related Articles] link and
retrieve more articles on the same topic sorted in order of relevance.
Although powerful and free, MEDLINE is not the only large biomedical
database. EMBASE/Excerpta Medica and the Cumulative Index to
Nursing and Allied Health Literature (CINAHL) are also available and
are useful to the infection control professional in search of information.
Both EMBASE and CINAHL (as well as MEDLINE) are available on the
Internet through Ovid (http://www.ovid.com). Ovid provides a frontend search engine that has user fees, but many health sciences and
hospital libraries provide it because it offers access to several different
databases using the same user-friendly search interface and integration
of database searching with a strong collection of full-text clinical
journals. In addition to databases of citations to articles, Ovid provides
access to books, a diagnosis program, and Evidence-Based Medicine
Reviews, a multifile database that allows simultaneous searching of
evidence-based medicine databases including ACP Journal Club and
databases within the Cochrane Library.

Case Scenario: Solving a Problem of


Treatment
An aggressive, bottom-line obsessed administrator in your hospital is
looking for ways to save money. She requests that you consider
reverting from antimicrobial-coated catheters in the intensive care unit
to less expensive, uncoated catheters. She demands that you show that
the coated catheters are worth their higher cost. You seek to do so as
quickly as possible.
Because you are pushed for time and you know that you want highquality, patient-centered information, you start with ACP Journal Club
(http://www.acpjc.org). Your initial search is effective using two
wordscatheter and infection. You retrieve 30 hits, most
of them directly relevant. Two very relevant studies (5, 6) show that

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the coated catheters are effective. The systematic review by Mermel


(5) showed that they are more effective than noncoated catheters and
Veenstra et al. (6) provided data that showed that the coated ones are
cost effective.
Although the http://www.acpjc.org search was successful, it is worth
taking a quick look in the Cochrane Library, another high-quality
information source. You call up the Cochrane Library online, and in the
searchphrase window you type impregnated catheter.
There is one review in the CDSR, but it is not very relevant, because it
pertains to umbilical artery catheters in newborns in the neonatal
intensive care unit (7). In the Cochrane Central Register of Controlled
Trials (CENTRAL), there are citations with abstracts to five randomized
trials, all from 1997 to 1999. Running the search again with coated
catheter you find no systematic reviews but 11 more randomized
trials in the CENTRAL database. CENTRAL contains specialized registers
of citations submitted by Cochrane groups and other organizations from
many
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journals and other sources that are not included in MEDLINE. Potential
records from CENTRAL are assessed with quality control procedures to
ensure that only reports of definite randomized controlled trials or
controlled clinical trials are included.
Just to make sure that you did not miss any important studies on
coated catheters, you go on the Internet and pull up the clinical query
option for PubMed. You pick the therapy category, select the
sensitivity search option, and then type impregnated central
venous catheters in the search window. You retrieve 23 citations,
several of which look relevant including the already seen systematic
review by Mermel (5) and the cost-effectiveness study by Veenstra et
al. (6).
Another method for effective clinical-based searching is to search only
for articles that are clinical trials. For an article to be indexed with the
publication type clinical trial, it must be a preplanned,
usually controlled clinical study of the efficacy, safety, or optimum
dosage schedule of one or more therapeutic, diagnostic, or prophylactic
drugs, devices, or techniques in humans selected according to
predetermined criteria of eligibility and observed for predefined
evidence of favorable and unfavorable effects (8). The citations you
retrieve using the clinical query feature in PubMed or the publication
type clinical trial are more likely to be ready for clinical
application and to help you make an informed patient-care decision
than if you had not included any methodologic filtering in your search
strategy.
The previous scenario illustrates a search for quality-filtered prevention
literature. Reports of applied clinical research have two features in

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common: they are designed in advance to follow a study protocol and


they are comparative. Criteria exist for studies from each of the four
categories of therapy and prevention, diagnosis, etiology and
causation, and prognosis and natural history, as well as economic
evaluations, decision analysis, quality of life, clinical utilization,
reviews, guidelines, clinical prediction, and qualitative studies (9).
Searching on the Internet is another route to take to help solve patient
problems. However, only a small proportion of the content has been
peer reviewed or provides enough information so that you can do your
own evaluation on the material found. One of the most effective, and
certainly the most used, search engines is Google
(http://www.google.com/). No single search engine searches more than
30% to 40% of the current Web content, so a variety of search
approaches may be warranted for comprehensive Internet searching.
Google's search function lets you type in words or concepts of interest
and then retrieves Web sites that contain these terms ranked in the
order of how many other sites have linked to the original sitesort of
a quality indicator. Typing in the very specific phrase intravascular
catheter infections prevention provided access to 3,030 Web pages in
0.14 seconds. The first two link to the U.S. Centers for Disease Control
and Prevention (CDC) 2002 Guidelines for the Prevention of
Intravascular Catheter-Related Infections (10). This 36-page
guideline includes an analysis of previous studies and cites both the
Mermel and Veenstra et al. studies along with many original studies.
O'Grady et al. (10) stated that although the coated catheters are more
expensive, they reduce infections and costs. All the evidence found to
date seems to support the added initial expense of the coated
catheters.
Another approach to searching the Internet is to use one of the new
question-answering systems (e.g., AskJeeves at http://www.ask.com or
AnswerBus at http://www.coli.uni-sb.de/~zheng/answerbus/). Asking
Jeeves How do I prevent intravascular infections? produced links
to both U.S. and Canadian guidelines. The AnswerBus did not provide
links to any site.

KEEPING UP WITH THE MEDICAL LITERATURE


Health professionals typically rate journal reading as their preferred
means of keeping current, but more than 15 years ago, Covell et al.
(11) demonstrated that this was highly overrated as a method for
keeping up-to-date. Journal reading is still recommended for keeping
up-to-date but with a critical appraisal approach, so that a
reader quickly and systematically detects the original studies and
reviews that are more likely to be useful to his or her practice (12).
The medical literature has continued to grow at an increasing rate since
the mid-1980s, so the challenge of keeping up-to-date might be
considered greater than ever. However, substantial improvements have

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occurred in information processing as well to compensate somewhat for


the increased amount of publication.
We consider the journal literature first. Publishing in peer-reviewed
print journals is still the most common form of spreading the word
about advances in medicine, although this may change with the advent
of on-line journals. ACP Journal Club, a bimonthly publication of the
ACP, contains 25 structured abstracts and accompanying commentaries
of original studies and systematic reviews of interest to general
internal medicine, including infectious diseases. The articles, both
original studies and systematic reviews, are selected from
approximately 115 journals according to explicit rules of sound
methodology and pertain to the treatment or prevention, diagnosis,
prognosis, or etiology of disease (13). Also included are sound studies
of clinical prediction, economics, differential diagnosis, and quality
improvement. Following our clinical example, studies and reviews of
catheter infections and their prevention have appeared several times a
year in ACP Journal Club and include the Mermel and Veenstra et al.
articles (5, 6).
Evidence-Based Nursing is a quarterly journal published by the BMJ
Publishing Group that aims to bring high quality studies and reviews to
the attention of nurses attempting to keep pace with important
advances in their profession. It follows a production procedure similar
to that of ACP Journal Club. Evidence-Based Medicine, also published
by the BMJ Publishing Group and aimed at primary care physicians,
abstracts studies in family medicine, pediatrics, surgery, psychiatry
and psychology, and obstetrics and gynecology, in addition to internal
medicine. The abstracts for these journals are prepared by research
staff with methodologic expertise and report enough information about
the methods of the studies that readers can judge for themselves the
strength of the research and the applicability of the findings to their
own patients.
Furthermore, in many instances, additional numerical results not
provided in the original article are obtained or calculated and included
in the abstract, such as relative risk reductions, confidence intervals,
and numbers needed to treat to prevent a bad outcome or achieve a
good outcome. The abstracts and commentaries
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have several steps in the production process to ensure their accuracy
(13). ACP Journal Club, Evidence-Based Nursing, and Evidence-Based
Medicine are also available on the Web sites of their respective
publishers (http://www.acpjc.org/, http://www.ebn.bmjjournals.com/,
and http://www.ebm.bmjjournals.com/). ACP Journal Club is also
available on Ovid in the Evidence-Based Medicine Reviews.
MEDLINE can also be used to keep up to date, because it is updated
frequently: weekly for most on-line or Internet versions and daily in

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the PubMed system. Searchers can thus run frequent broad-based


searches to obtain the most recent citations on a topic they want to
follow. Catheter infection might be a useful search to run weekly
if one wanted to keep current with all the research on the topic. For
example, on January 13, 2003 we ran this search and found another
relevant guideline that had been entered into the MEDLINE system on
January 9, 2003 (14).
Most healthcare organizations have a Web presence and many
have current awareness features that one can tap into to keep up to
date. The Web site for the Society for Healthcare Epidemiology of
America, Inc. (SHEA) (http://www.shea-online.org) is a good starting
point for Web searching because it provides a page of links to other
infection control sites including government (state, national, and
international), other organizations, and related information resources.
Furthermore, many of the various organizations have e-mail discussion
lists (listservs) that one can join to receive and participate in
correspondence on topics of interest. One should note that these
discussion lists are anecdotal in nature and are simply exchanges of
opinions among health professionals. It is up to the reader to judge the
validity of individual comments.
The CDC Web site (http://www.cdc.gov) provides a wide array of
documents including the CDC prevention guidelines, the Morbidity and
Mortality Weekly Reports, and links to many other health resources,
both within the United States, including the state departments of
health services, and worldwide. The CDC Web site allows searches
using boolean logic in an advanced search mode (and's and or's), so
that a searcher can combine words to expand or pinpoint retrieval.
For keeping up to date, one can subscribe to a CDC mailing list and
receive only the tables of contents or the entire documents for such
items as the Journal of Emerging Infectious Diseases, human
immunodeficiency virus (HIV)/acquired immunodeficiency syndrome
publications, and Morbidity and Mortality Weekly Report. The Division
of Healthcare Quality Promotion provides information on the prevention
and control of nosocomial infections (http://www.cdc.gov/ncidod/hip).
It has guidelines, recommendations, and answers to frequently asked
questions on topics such as outbreaks, occupational exposure to HIV,
needlestick injuries, and child care. Of note is their 2002 Guideline
for Prevention of Intravascular Catheter-Related Infections
(http://www.cdc.gov/ncidod/hip/IV/IV.HTM) already identified in our
Internet search. The CDC Web site also indicates which documents have
recently been added and which are expected soon. It ranks its top
challenge as reducing catheter-associated adverse events by 50%
among patients in healthcare settings.
The Web site for the Hospital Infection Society (http://www.his.org.uk)
in the United Kingdom includes the abstracts of articles in the Journal

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of Hospital Infection, lists future scientific meetings, and has an e-mail


discussion list. The Web site for the Faculty of Medicine at Universit
Catholique de Louvain in Brussels
(http://www.md.ucl.ac.be/entites/esp/hosp/infcon.htm) has a database
of many hundreds of selected articles with abstracts in the area of
infection control that is updated quarterly. It also links to journals on
infection control and hospital epidemiology for scanning tables of
contents to identify potentially relevant citations.
The Association for Professionals in Infection Control and Epidemiology
(APIC) has a Web site (http://www.apic.org) that updates professionals
about courses and educational activities, upcoming conferences, and
publications (such as the APIC Text of Infection Control) that can be
ordered from the Internet. Professional resources provided on the APIC
Web site include a discussion forum in which infection control
professionals can discuss issues with each other; find or list job
postings; and access a resource list, a searchable abstract database,
and an open e-mail list server.
The Program for Monitoring Emerging Diseases (ProMED)
(http://www.fas.org/promed) is a free electronic conferencing system
formed by the Federation of American Scientists to create a global
system of early detection and response to disease outbreaks. It also
has a search engine for archived e-mail correspondence.
Individual clinicians can keep in touch with a variety of health
organizations through Web sites as an increasing number of
organizations post their latest information on the Internet. By
subscribing to some of the many list servers and discussion lists of the
aforementioned organizations, one can participate in real time
discussions on topics of interest, and current information such as the
latest journal contents or knowledge of outbreaks comes automatically.
Unfortunately, for most of these services, one will need to do an
assessment of the validity and relevance of the information. The
relevance check is pretty easy, but checking the sources for scientific
merit requires skill and time.
Several of the aforementioned resources are now available in a format
for the latest in computer gadgetry: the handheld or PDA. PDAs have
been embraced by many in the medical community, because they can
store surprisingly large amounts of information and can be used in any
location by virtue of their small size and portability (15, 16). Many
sources of information exist for clinicians interested in PDAs and one
such site is Evidence-Based Medicine Tools for the PDA
(http://www.ils.unc.edu/~caham/ebmtools/ebmtools.html). Categories
of applications and services include drug information (especially
ePocrates http://www.epocrates.com/), news and abstracting services,
healthcare literature summaries and full text, guidelines and
summaries, textbook information, diagnostic aids, statistical and

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numerical calculators, and clinical prediction guides. A listing of


available resources in this chapter would not be very helpful because of
the rapid rate of change, so we urge those who are interested in
acquiring a PDA to consult peers and use the Internet to learn about
and acquire clinical resources for downloading.

SETTING CLINICAL POLICY


Clinical practice guidelines have metamorphosed from their first
appearance on the healthcare stage, as small local health plans or care
maps developed to reduce variability in care, into a healthcare
industry. Practice guidelines have become ubiquitous
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and are promoted for a number of reasons, including improving the
quality of healthcare, optimizing patient outcomes, discouraging the
use of ineffective or harmful interventions, improving the consistency
of care, identifying gaps in evidence, helping to balance costs and
outcomes, or simply cutting costs. Clinical practice guidelines for
screening, diagnosis, prevention, and treatment are produced by
diverse organizations, from government departments (such as the U.S.
Agency for Healthcare Research and Quality or the CDC), healthcare
associations and specialty societies (such as the American College of
Physicians, the Society for Healthcare Epidemiology of America, and the
Infectious Disease Society of America), and local hospitals. The
definition from the Institute of Medicine in 1990 (17) still applies,
however, at all levels: Practice guidelines are systematically
developed statements to assist practitioner and patient decisions about
appropriate healthcare for specific clinical circumstances. Three
useful Internet sites that list guidelines are the National Guideline
Clearinghouse (http://www.guideline.gov/index.asp), Agency for
Healthcare Research and Quality
(http://www.ahcpr.gov/clinic/cpgsix.htm), and the Canadian Medical
Association (http://www.cma.ca/cma/common/displayPopup.do?
tab=422&=125&pMenuId=4). The first site, the U.S. National Guideline
Clearinghouse, is a valuable site for access to almost any local,
regional, national, or international guideline. It not only lists guidelines
and provides access to the full text of many but also has the capability
of comparing two guidelines in a tabular format.
Infection control is particularly suited to the use of clinical practice
guidelines. If based on sound current evidence, guidelines can greatly
reduce the amount of work of infection control specialists in searching
the literature. Guidelines published in the journal literature are
searchable in MEDLINE by using the publication type field
guideline for administrative procedural guidelines and
practice guideline for specific healthcare guidelines. The Internet
is also an excellent source in which to locate guidelines, particularly
because the entire document is usually posted on the Web site,

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whereas in MEDLINE only the citation and possibly the abstract to the
document is available. The Future Health Care Web site
(http://www.futurehealthcare.com/pages/guidetobestpractices.htm) is
particularly useful for helping to define best practices for quality
assurance activities (18).
We have already identified a recent and relevant clinical practice
guideline on our intravascular coated catheters (10) so we will identify
any more, although several less recent ones exist.

CONCLUSIONS
To conclude our clinical scenario, you give your administrator the data
you find. She is duly impressed with your evidence that the more
expensive coated catheters are actually saving the hospital money and
reducing infections. She thanks you and as you return to your office
and mentally review your information trek. You wonder if this is just
the first of many such evidence assessments you will be asked to
perform.
Persons involved with hospital epidemiology and infection control have
many diverse information needs that include medical and other healthrelated clinical materials, basic science information, management and
educational resources, and policy documents from regional and national
agencies. Today, clinicians are working in a rapidly changing
environment with new discoveries, scarce resources, and new
challenges presented by the changing model of healthcare delivery,
multiresistant microorganisms, emerging pathogens, and outbreak
detection. To succeed, one must develop rapid and efficient ways of
acquiring new relevant information. By investing time in experimenting
with the different resources available, one will be able to develop an
individual strategy for dealing with new clinical problems, keeping upto-date, and effectively implementing new policies. Clinicians are
indeed fortunate that as the need for information increases, the means
for acquiring it continue to evolve and improve.

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