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Medical Literature as a

Resource for EvidenceBased Medicine.


An Overview.

dr. Agus Budi Utomo


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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

1B: Clinical questions

What is evidence-based medicine?


Background vs. Foreground questions

1C: Searching tips:

Books
Search engines

Google www.google.com (various doucments)


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

Databases

MEDLINE (journal articles bibliographic records)


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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.
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American Journal of Medicine 1997;102(5):427-32.

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

Appraise

Ask Questions

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

Who, what, when, how

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

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

Patient and/or problem


Intervention (diagnosis, treatment..)
Comparative intervention (optional, include if relevant)
Clinical outcome (cured disease, relief, alleviation,
prognosis)

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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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

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
Books
Search engines

Google www.google.com (mixed documents


Scholar Google www.scholar.google.com
(journal articles)

Scirus
documents)

www.scirus.com (various SCIENTIFIC

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Searching Tips: Books

Online library catalogs

[US] National Library of Medicine LocatorPlus


www.locatorplus.gov
Example:

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

[US] National Library of Medicine LocatorPlus


www.locatorplus.gov
Example:

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

[US] National Library of Medicine LocatorPlus


www.locatorplus.gov
Example:

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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Books
1C: Searching
Tips
Search engines

www.google.com
(mixed documents

Google

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

Look for a

Intervention/Therapy

Randomized controlled trial

Diagnosis/Screening
To assess the accuracy of the test

Cohort study

To assess effect of test on health


outcome

Randomized controlled trial

Prognosis

Longitudinal cohort

Etiology/Risk factors

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

Ovid

EMBASE

Pubmed

CINAHL

Dialog
LEXIS/NEXIS

Personal PC
Library PC

Self-study Assignment 1
Notes

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