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searching the medical information

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What is available on the Internet?

Information to download using file transfer protocol Presented in different formats (docs, pictures, data)

Medical papers Medical information, photos, pictures

Searching data

Electronic mails to communicate with other people Personal email Mailing list Attachments

World wide web (WWW), surfing websites/pages

Internet Relay Chat (IRC) E-conference / video conferencing Newsgroups /Usenet

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Getting connected

Company access

Corporate account

Local Area Network

Telephony, Satellite / broadband / cable tv

Personal access

Using Internet Service Providers

CBN, Centrin, AT&T, Telkomnet etc

Personal equipments

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Web surfing

More than 10 millions computersconnected to the Net -> Internet ..

Once connected to the Net, the wholesites is assessable free or with passwords

Web browser Internet Explorer, Netscape, Opera, etc

Sites -> URL -> http://www.ika-fkui.com Security issues !!

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The patient situation,population, or problem ofinterest.

The main intervention,defined very broadly,including an exposure, adiagnostic test, a

prognostic factor, atreatment, a patientperception, and so forth.

Acomparison intervention orexposure, if relevant.

The clinical outcomes ofinterest, including a timehorizon if relevant.

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Medical information . (3)How to find current best evidence,formulate. the key question to seek an answer

the best answer to the clinical problemthat you currently have stored in yourbrain (being as quantitative as possible)

the evidence resources (both traditionaland avant garde) that you would consultto find best current answers.

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Clinical problem

Define important,

searchable question

Select most

likely resource

Design searchstrategy

Summarized

the evidence

Apply

the evidence

Design searchstrategy

Summarized

the evidence

Select second most

likely resource

Pooryield

Generalsearch

strategy

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Convert your question to a search strategy

How?

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Asking Answerable Clinical QuestionsPatient

(For which patient/population or problem do you needinformation?)

Intervention(What medical event do you need to study the effectof?)

Comparison(What is the evidence that the proposed interventionproduces better or worse results than no interventionat all, or a different type of intervention?)

Outcome(What is the effect of the intervention?)

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Where to find the evidence for yourquestion?

Books

Library databases

Online bibliographic databases

Cohrane Database of Systematic Reviews

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US National Library of Medicine:

24,000 journals

4,000 indexed in MEDLINE

Science Citation Index (SCI):

5,600 leading journals in different fields of science

Current Contents/Clinical Medicine:

1150 journals

Searching for the Evidence

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Search strategies for MEDLINE

Thesaurus searching

Textword searching

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Define keywords

MeSH terms

Non-Hodgkins Lymphoma Non-Hodgkin Lymphoma

Lymphoma, non-Hodgkin

Lymphoma, non-Hodgkins

Textwords

Important keywords notincluded in the MeSHtesaurus

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Check whether your keywordsare listed in MeSH

Consider text wordswhen a MeSH term does not exist

for your concept

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Boolean operators

AND

OR

NOT

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Strategy of using Boolean operators:first increase sensitivity, then specificity

1. One keyword concerning the patient

2. Another keyword concerning the patient

3. #1 OR #2

4. One keyword concerning the intervention

5. Another keyword concerning the intervention

6. #4 OR #5

7. One keyword concerning the outcome

8. Another keyword concerning the outcome

9. #7 OR #810. #3 AND #6 AND #9

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Sensitivity and Specificity

Sensitivity likelihood of retrievingrelevant items

Specificity likelihood of excludingirrelevant items

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How to increase sensitivity?

1. Expand your search using (broader termsin) the thesaurus.

2. Use a textword search of the database.

3. Use truncation and wildcards to catchspelling variants.

4. Use Boolean OR to make sure you haveincluded all alteratives for the terms youare after.

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Truncation

vaccin*

vaccine, vaccines, vaccination

seizure$

singular and plural

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Wildcards

gyn?ecology

gynaecology, gynecology

randomi?*

randomisation, randomization,randomised, ...

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How to increase specificity?

1. Use thesaurus to identify more specificheadings.

2. Use more specific terms in textword

search.

3. Use Boolean AND.

4. Limit the search by publication type, year

of publication, patients age, etc.

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Limits

Type of publication Age group Gender Year of publication Language

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Identify the type of article

Diagnosis

Prognosis

Therapy/prevention Harm/etiology

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Identify the type of research that is mostlikely to answer your question

Question Study design Chances for finding asystematic review?

Diagnosis cross-sectional

Prognosis cohort

Etiology/harm 1) cohort

2) case-control

Therapy/prevention 1) randomized control trial

2) non-randomized control trial

3) cohort

4) case-control

Patients' experiences qualitative studies

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Samples of Medical Information Search Engines

BMJ

Free Medical Journals

SumSearch

Cat Maker, software :

appraising an article critically,

Make a report (CAT)

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EBM Links :

Clinical Governance & Evidence Based Medicine Resourceshttp://www.chi.nhs.uk/eng/cgr/index.shtml This site provides links to web sites, articles and books relating to evidence-based practise.

Bandolierwww.jr2.ox.ac.uk/Bandolier/ Bandolier is produced monthly in Oxford for the NHS R&D Directorate. It contains bullet points (hence its

title) of evidence-based medicine. No information is provided on how topics are selected for discussion. Asearch engine for the site is provided. Other useful information provided includes information on pain

research and an easy-to-use NNT calculator. The site also provides links to other good websites such as theOxford Pain Relief website which has a database of NNTs for various analgesics.

Best BETShttp://www.bestbets.org/ Best Evidence Topics (BETs) were developed in the Emergency Department of Manchester Royal Infirmary,

UK, to provide rapid evidence-based answers to real-life clinical questions, using a systematic approach toreviewing the literature. BETs take into account the shortcomings of much current evidence, allowingphysicians to make the best of what there is.

Center for Clinical Effectivenesswww.med.monash.edu.au/healthservices/cce/

This site is operated through the Monash Medical Center in Australia. The site offers users full evidencereports on a number of topics. As well, it provides good links to similar websites, which are separated bycategory, making the site easy to use. Finally, the Center has a section of its website where you can actuallysubmit clinical questions regarding patients and they will research the topic of interest and respond directlyto your question.

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EBM Links :Centre for Evidence-Based Medicine

cebm.net The NHS R&D CEBM was established in Oxford as the first of several centres around the UK whose goal is to

promote evidence-based health care and to provide support and resources to others trying to practice andteach EBM. The website includes an EBM Toolbox with various tools for practising and teaching EBM, theCATMaker (a software programme allowing the user to create 1-page summaries of the evidence), a calendarof EBM events, and links to other EBM sites.

Centre for Evidence-Based Mental Healthhttp://www.cebmh.com/ The aim of the CEBMH is to promote and support the teaching and practice of evidence-based mental health

care. This site provides materials to help develop skills in practising EBMH and is aimed at users trying toprovide training courses and at people wanting to improve their EBMH skills by working through some onlinetutorials for practising EBMH.

Links to other useful resources including the full text online journal Evidence-Based Mental Health are alsoavailable from this site. The site is regularly updated (every Friday at 6pm GMT), and the most recentadditions are highlighted on the homepage. The EBMH journal is updated quarterly and runs alongside thepaper version of the journal.

Centres for Health Evidencehttp://www.cche.net/

The principal task of Centres of Health Evidence (CHE) is to package, disseminate, and present healthknowledge in ways that facilitate its optimum use. Within the CHE, staff will monitor knowledge-basedsoftware and literature from a variety of public and private sources. Significant resources are identified andstructured abstracts are developed to alert the user to the quality of evidence and how the needs of specificpatients, practitioners and settings are addressed in these resources.

This web site hosts the Users Guides to the Medical Literature produced by JAMA.

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EBM Links :Clinical Assessment of the Reliability of the Examination

http://www.carestudy.com/ This site provides all the protocols that the study group is involved with and instructions on how to join the group. Protocol

development, investigator recruitment, patient enrollment and date entry are all done via the Internet.

Clinical Decision Rules, The Samuel Bronfman Department of Medicinehttp://www.mssm.edu/medicine/general-medicine/ebm/ This is a great site providing clinicians with valid clinical decision rules. Clinicians just need to fill in the information for their

patients and then it will derive the post-test probabilities.

Clinical Evidencehttp://www.clinicalevidence.org/ Clinical evidence is a six monthly, updated compendium of evidence on the effects of common clinical interventions, published by

the BMJ Publishing Group. It summarises the best available evidence and focuses on the effects of preventative and therapeuticinterventions as demonstrated by randomised trials and systematic reviews of such trials.

Clinical Examination Research Interest Grouphttp://www.sgim.org/clinexam.cfm This site outlines the activities of the Clinical Examination Research Interest Group which includes the Rational Clinical

Examination Series published in JAMA. This is a series of more than 30 systematic reviews which address the precision andaccuracy of various elements of the clinical examination. The site provides a complete listing of all of these articles and links to

Clinical Resources, Clindx Update Listserv & Bibliography

clinical.uthscsa.edu/clindx/update.htm This webpage lists evidence-based articles on clinical diagnosis and the clinical examination. They have created a service that will

help keep you up-to-date on the latest and best evidence on the medical history or physical examination. This information shouldbe useful to both clinicians and clinical educators. To get the information, you simply need to subscribe to the ClinDX listserv.Once you enroll, listserv will e-mail you the current links (from above) to recent articles, every month, on the medical history andclinical examination.

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EBM Links :Critique et Pratique

www.crsfa.ulaval.ca/umf This site is in French only. It uses EBM guides for critically appraising articles from recent issues of well

known medical journals and provides a clinical bottom line for each. A brief glossary of EBM terms isavailable on this site and a search engine is also available.

EPIQ (Effective Practice, Informatics & Quality Improvement)http://www.health.auckland.ac.nz/population-health/epidemiology-biostats/epiq/ EPIQ (Effective Practice, Informatics & Quality Improvement) was established in 2002 to support effective

evidence-based practice, health informatics and quality improvement initiatives in the health and disabilitysupport sectors. EPIQ is a collaboration of academics, clinicians and other health sector professionals andreplaces EPI (the Effective Practice Institute).

Evidence-Based Medicineebm.bmjjournals.com Evidence-Based Medicine is a journal released every other month which alerts clinicians of important

advances in general and family practice, internal medicine, surgery, psychiatry, pediatrics and obstetricsand gynecology. This is accomplished by selecting from the biomedical literature those original and reviewarticles whose results are most likely to be true and useful.

Evidence-Based Mental Healthhttp://ebmh.bmjjournals.com/ Evidence-Based Mental Health is a journal released four times a year which alerts clinicians working in the

field of mental health of important and clinically relevant advances in treatment, diagnosis, aetiology,prognosis/outcome research, quality improvement, continuing education, economic evaluation andqualitative research. This is accomplished by selecting original and review articles whose results are mostlikely to be accurate and clinically useful.

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EBM Links :Evidence-Based Nursing

http://ebn.bmjjournals.com/ Evidence-Based Nursing is a journal released four times a year which alerts practising nurses of important

and clinically relevant advances in treatment, diagnosis, aetiology, prognosis/outcome research, qualityimprovement, continuing education, economic evaluation and qualitative research.

Evidence-Based Pediatricswww.med.umich.edu/pediatrics This site is a resource for evidence-based pediatrics provided through the University of Michigan. The site

includes a list of CATs, a CAT template (step by step guide on how to create a CAT), guidelines for starting ajournal club and links to other websites.

Evidence-Based Practice Centershttp://www.ahrq.gov/ The Agency for Health Care Policy and Research (AHCPR) has 12 centers in the United States for developing

evidence reports and technology assessments of diagnostic and therapeutic interventions used in a variety ofclinical conditions. The partners of AHCPR use the products of Evidence-Based Practice Centers to developand implement practice guidelines and other clinical quality improvement tools. The site contains evidencereports as well as links to each of the 12 centers across the US.

McMaster Health Information Research Unithiru.mcmaster.ca/ The goal of HIRU is to improve the effectiveness and efficiency of health care by providing innovative

evidence-based information products and systems to health professionals, patients, policy makers, and thepublic. It is involved in a number of initiatives including being the location for: a national centre for theCochrane Collaboration; HEALNet; an Evidence-based Practice Centre; Cancer Care Ontario and a variety ofevidence-based publications.

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EBM Links :National Library of Medicines Health Services/Technology Assessment Text (HSTAT)

gateway.nlm.nih.gov/gw/Cmd This site is basically a very detailed search engine. It contains holdings from the AHCPR support guidelines,

the AHCPR technology assessments and reviews, ATIS (HIV/AIDS technical information), NIH Warren G.Magnuson Clinical Research Studies, NIH Consensus Development Program, PHS Guide to ClinicalPreventative Services (1989) and SAMHSA/CSAT Treatment Improvement Protocol (TIP).

Netting the Evidencewww.shef.ac.uk/~scharr/ir/netting/

The goal of this website is to provide a complete list of evidence-based practice resources that are availableon the Internet. There are more than 140 listings (arranged alphabetically), each of which includes a shortdescription of the resource with a link to it. This list is preceded by a link to "the latest articles on EvidenceBased Medicine from the MEDLINE database". No information is provided on the website about criteria usedfor selecting resources for inclusion. The website is easy to use and a search engine is provided.

NHS Centre for Reviews and Disseminationhttp://www.york.ac.uk/inst/crd/ The NHS Centre for Reviews and Dissemination (CRD) is the sibling of the UK Cochrane Centre and has the

goal of producing reviews concerning the effectiveness and cost-effectiveness of healthcare interventions. Itprovides access to several databases including a database of structured abstracts of good quality systematic

reviews (DARE) which comment on the methodological features of published reviews and summarise theauthors conclusions and any implications for health practice. It also provides the full text Effective HealthCare Bulletin which is a bi-monthly bulletin for decision-makers that examines the effectiveness of a varietyof health care interventions.

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EBM Links :Ovid EBM

http://www.ovid.com/ Ovids goal is "to support and improve information access for researchers, clinicians, and students in

scientific, medical, and academic communities worldwide by providing innovative and interlinked textretrieval software and database solutions."mount sinai hospital intranet accessConnect now to the Ovid viathe Sidney Liswood Library at Mount Sinai Hospital access limited to MSH intranet users.

Ovid provides access to a variety of resources including bibliographic databases (such as MEDLINE, EMBASEand CINAHL); more than 300 full text journals; and other clinical information products such as EvidenceBased Medicine Reviews (EBMR) and some textbooks.

EBMR contains material from Best Evidence (which includes the contents of ACP Journal Club and Evidence

Based Medicine) and the Cochrane Database of Systematic Reviews. It combines Best Evidence and theCochrane Database into a single, fully searchable database with links to both MEDLINE and Ovid full-textjournals. Because the databases are interlinked, users can begin a search in MEDLINE and link from MEDLINEcitations to the abstract and commentary for the relevant article in Best Evidence, to the full text article,and to relevant Cochrane Reviews. Alternatively, MEDLINE searches can be limited to articles retrieved fromBest Evidence.

Physiotherapy Evidence Database (PEDro)http://www.pedro.fhs.usyd.edu.au/ PEDro is an initiative of the Centre for Evidence-Based Physiotherapy (CEBP) and has been developed to give

physiotherapists and others rapid access to bibliographic details and abstracts of randomised controlled

trials, and systematic reviews of randomised controlled trials, in physiotherapy. Most English-language randomised controlled trials and systematic reviews in physiotherapy are on the

database. Trials and reviews in other languages are represented, but probably less comprehensively. Information is also provided on how to critically appraise the trials that have been identified. Links to other

useful websites are also provided. There is no information on how often the database is updated.

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EBM Links :PubMed

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed/ PubMed is an Internet interface for MEDLINE. It is a project developed by the National Center for

Biotechnology Information (NCBI) at the National Library of Medicine (NLM), located at the National Institutesof Health (NIH). If the publisher has a WWW site that offers full text of its journals, PubMed provides links tothat site. In addition, PubMed provides a WWW Citation Matcher service, which allows publishers (or otheroutside users) to match up their own citations to PubMed entries, using bibliographic information such asjournal, volume, issue, page number, and year.

Resources for Practicing Evidence-Based Medicine

pedsccm.wustl.edu/EBJournal_Club.html This site specializes in pediatric critical care (intensive care) medicine. It teaches the user how to use

evidence-based medicine (e.g. how to critically appraise medical literature, how to use and calculaterelevant statistics and how to use systematic reviews). The site also contains links to websites providingCATs, evidence-based medicine groups, databases/directories, journal clubs as well as teaching resources.

SumSearch (formerly SmartSearch)http://sumsearch.uthscsa.edu/ SumSearch is a meta-searching service that searches the following resources:

Textbook. The default textbook to search is the Merck Manual.

MEDLINE for review articles and editorials from high quality, general journals that have full texts available. National Guideline Clearinghouse from the Agency for Health Care Policy and Research (AHCPR)

Database of Abstract of Reviews of Effectiveness (DARE)

MEDLINE for original research.

SUMSearch will also do focused searches depending on the type of information requested. For example, ifthe question being searched is one about the physical examination, SUMSearch will search the databaseBedside Diagnosis.

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