CHMC PGY-1 FP Residents

Evans Whitaker, MD, MLISNorris Medical Library2003 Zonal Ave.Los Angeles, CA 90089-9130ewhitake@usc.edu, 323 442 1128

Background questions USC grad? Familiar with Norris home page? Are you comfortable with electronic

resources – ebooks, ejournals? How comfortable are you with EBM? What did you think of the UMASS EBM

online tutorial/quiz? Are you comfortable with MEDLINE

searching? What interface have you used (PubMed, Ovid)? Do you know what MeSH means?

Have you used EndNote or RefWorks?

Outline for Today

I. Access to USC resourcesII. Lightning tour of Norris ResourcesIII. EBM Primer and SourcesIV. MEDLINE – Ovid and a little PubMedV. Miscellany

Access to USC Resources

USC Proxy Server

General Information For biomedical information make Norris

Medical Library your home base (http://www.usc.edu/nml ) -- bookmark it!

By beginning your information seeking at the Norris homepage you will have full-text access to everything to which USC subscribes.

Tour of Norris Homepage

Moving from Left to Right…the Key Points

• Journals– All USC eJournals – lists every electronic journal in the USC system

• Books/Multimedia• Databases

– Ovid MEDLINE -- – PubMed @USC --– Other USC Databases – A-Z

• ERIC – education database• PsycInfo• Sociological Abstracts• Wilson Education Full Text

• Key Resources for: “portal” for selected sources for various groups• eResources Search eResources database drop down box choose Education.

This leads to a hodge-podge of ebooks, databases, websites, etc.– Research and Development Resource Base (http://128.100.115.20/) bibliographic database,

source of Continuing Education & Knowledge Translation, Interprofessional Literature, and Faculty Development.

• Catalogs– HELIX -- Norris Medical and Wilson Dental Libraries– ADVOCAT -- USC Law Library– HOMER -- All other USC libraries

• Quicklinks -- many common resources listed in drop down menu.• HELP – leads to phone, IM, and email connections to medical librarians. We can help with

devising searches, finding information sources, troubleshooting, etc. IM and phone hours are M-F 9-5. There is one working day turnaround on email questions.

Clinical Information Resources

Designed for rapid information finding, fast enough for clinical work

UpToDate ACP Pier Essential Evidence, nee InfoRetriever Clinical Evidence (evidence based) Epocrates – pharmacy, drug interactions LexiComp – pharmacy, drug interactions

Books

Electronic books will be the most practical for you…

Two sources: HELIX – the Norris Library Catalog (best

for known book Multi Ebook Search (from the QuickLinks

menu) searches within >700 ebooks

Journals

Electronic journals Two sources

All USC eJournals – as it sounds HELIX – Medical library catalog

EBM Resources OVID

Cochrane Database of Systematic Reviews ACP Journal Club Database of Abstracts of Reviews of Evidence

(DARE) Clinical Evidence (search for title) National Guideline Clearinghouse TripDatabase SumSearch User's Guides to the Medical Literature “How to Read a Paper”

MEDLINE

Ovid MEDLINE PubMed (use PubMed@USC to get

full-text links)

EBM Resources

Evidence-Based Medicine Simple concept – “use the best information

available to take care of your patients” It is a formalization of good practices in

information finding, evaluation, and application

EBM has appeared on the scene in the last 15 years or so due to a combination of factors – computers and changing healthcare environment.

Process begins and ends with the patient

EBM step by step

5 Steps Formulate search (PICO, searchable

question) Track down the best information (in Evaluate results (Assess methodology

and statistics) Apply results to practice Reevaluate effectiveness

Background and Foreground

Background and Foreground

Relevant in choice of materials Background

Texts, review articles might be best source

Foreground Primary research literature is best source

Evidence Pyramid

Source: http://library.downstate.edu/EBM2/2100.htm

The Evidence Pyramid

Those layers nearest the top are the preferred information in EBM

Many questions in medicine do not have answers, many do not have systematic reviews, meta analyses, RCTs, or even cohort studies.

Means we have to make use of the best available information.

PICO

Assists formulation of the clinical question.

Grown from the EBM movement of the last 15 years.

P Population, Patient, or Problem

I Intervention or Exposure

C Comparison (optional)

O Outcomes

Question type

Population Intervention/

Exposure Outcome

Best Feasible

Study Design

Suitable Databases

Best Single MEDLINE Search

Term for Appropriate Study

Type Diagnosis In patients

with lung cancer

What is the test performance of CT scan

For detecting mediastinal metastatic disease

Cross sectional analytical study

Best Evidence, UpToDate, MEDLINE

Sensitivity as a MeSH or key or title word

Treatment In patients with HTN and DMII

Does a target BP of 80 compared to a DBP target of 90

Lower risk of stroke, MI, cardiovascular death, and all-cause mortality

RCT or systematic review of RCTs

Cochrane, Best Evidence, UpToDate, MEDLINE

Meta-analysis or Clinical trial or Randomized Control Trial as “publication types”

Prognosis In young men with atypical chest pain

Sent home from the ER, in the next 72 hours

Suffer appreciable rates of unstable angina, heart failure or arrhythmia, MI or sudden death

Cohort study

Best Evidence, UpToDate, MEDLINE

Explode cohort studies as MeSH term

Harm In men Does vasectomy

Cause testicular cancer

Cohort study, population- based case- control trial

Best Evidence, UpToDate, MEDLINE

“Risk” as MeSH or as title or keyword

Adapted from: Guyatt, G., Rennie, D. (eds.). 2002. User’s guides to the medical literature. NY: JAMA, p. 43.

Evaluate Results

I am no biostatistician, I have used the simplified approach of Trisha Greenhalgh, MD when I have had to analyze a paper.

Her common sense recommendations are (at least somewhat) realistic for a practicing primary care physician.

MEDLINE and its two avatars

Ovid and PubMed Ovid

commercial product that includes multiple databases, and the option of subscribing to full text of books and journals.

PubMed US governmental bibliographic database collaboration of National Library of Medicine

(NLM), National Center for Biotechnology Information (NCBI), and the National Institutes of Health (NIH). It is free to use and is the only database of its size and scope in the world.

PubMed and MEDLINE

• OvidSP -- different interface and search engine, same contents as MEDLINE.

MEDLINE is a subset of PubMed.

The 2+ million article difference includes articles both articles that are being processed and will move into MEDLINE, and articles which will never be included in MEDLINE (e.g., outside the scope of the database).

(18.6/16.8 as of 08/14/08)

Pros and Cons of Ovid MEDLINE

Pros Easier to learn than PubMed Automatic “mapping” of search terms works

better than PubMed Basic search can be used at the speed of clinical

medicine Basic and Advanced search modes work well

together

Cons Expensive After leaving an academic medical center unlikely

to have access

What Else is in Ovid? EBM (the three below and others)

Cochrane Database of Systematic Reviews DARE (Database of Abstracts of Reviews of Effects) ACP Journal Club

CINAHL -- allied health and nursing database Ovid Healthstar – “contains citations to the

published literature on health services, technology, administration, and research.”

Health and Psychosocial Instruments (HAPI) -- information on measurement tools for healthcare

Books @ Ovid (almost 400 books)

How to search OvidSP Basic

“Natural language” search engine Keep “include related terms” checked Can combine and limit searches Good for a few good articles Useful as a way to find “the right

words” for Ovid Advanced Search Can use at the speed of clinical

medicine

OvidSP Basic – things to know and tips

A good place to start Searches yield 500 or more hits “Good stuff” in the first 20-30. If nothing

relevant is found in that group, reformulate search or move on to Advanced

Based on our experience at NML, use keywords without AND, OR, or punctuation. Seems to retrieve the smallest, most focused set of results

Advanced Ovid Search

Default at Norris Medical Library. Resembles previous versions of Ovid. Steps in a search:

Enter search concepts one at a time. Ovid translates the user’s terms into MeSH terms. User may choose MeSH terms, explode, focus, and apply sub-headings.

Combine concepts Limit results as a last step

Advanced Ovid Search -Tips Subheadings narrow searches. Do not use subheadings unless they match your

needs. Do not overuse subheadings – not all concepts

need them, and few concepts need more than one or two.

Limits narrow searches. Do not overuse limits, try to apply them once at

the end of devising your search. Learn to use the MeSH tree and “scope notes”

Formulate your question Many of the same concepts that apply to EBM also

apply to Ovid searching. First, you identify the “information need”. Define “the clinical question”. Define the “searchable clinical question”, identify

constituent parts of CQ, remove extraneous details. Choose the most appropriate information source in

which to begin your search – it might be a book! Enter your search terms. Review results and reformulate search if necessary.

Searches to try….

Basic “ice cream headache” Basic and Advanced “selenium and

prostate cancer prevention” Advanced “use of antibiotics for

common cold” Others of our devising

Identify, clarify your information need

Formulate the question

Break question into concepts

Enter term for Concept II

Combine concepts with AND or OR

Search

Print, save, email move results to

citation manager

Select best MeSH term

Verify “Explode”Consider “Focus”Consider Subheadings

Select best MeSH term

Verify ExplodeConsider FocusConsider Subheadings

Limite.g. humans, English, age, publication type

Evaluate ResultsIf necessary,

reformulate search

6 Steps to Better Ovid Advanced Searches

1.

2.

3.

4.

5.

6.

Enter term for Concept I

Enter one concept per line, until all entered Remember scope notes and MeSH treeExplode allFocus – use sparinglySubheadings - only use when exactly match your searchLimit last

No

tes:

Miscellany

How to keep up with the information deluge….

eTOCS (JAMA) MyNCBI and Ovid Personal Account UpToDate-”What’s New” Faculty of 1000 – Medicine

How to organize what you have (or will) receive

EndNote/EndNoteWeb RefWorks others

The “elephant in the room”

GoogleScholar -- Advanced Preferences GS is good for preliminary exploration of

an unfamiliar topic. Yields good terms to use in more valid and authoritative search engines.

GS will also occasionally find full text of an article in a journal to which USC does not subscribe.

Scirus.com A search engine devoted to scientific

websites. Easy to use. Higher overall quality of sites than GS.

Can set preferences to link to USC full-text

“Independent” product of publishing giant Elsevier. I have not seen evidence of bias.

Worth a look when exploring a topic.

Tips

Norris as home page, use proxy server. Sign up for a free account with Ovid to save searches and

annotate articles. Sign up for a free MyNCBI account, you can save PubMed

searches, collect articles, and have alerts emailed to you about new articles from saved searches.

Sign up for free eTOCS for those journals whose contents you want to scan regularly.

Sign up for free Web-of-Knowledge/EndNote accounts. This is a nice way to store, organize, and use citations found in your research. Consider Connotea as well.

Consider classes at your local library in PubMed, OvidSP, EndNote, etc.

Final ExamDIAGNOSIS 1. MRI for breast cancer screening, should this be our

method of choice? 2. PSA variations – PSA velocity, PSA density, free PSA

ratios – do these add value to prostate cancer screening?

TREATMENT 3. Low back pain patients -- how effective (to decrease

pain) are chiropractic and acupuncture therapies? Are there studies that compare these modalities?

4.Operative vs. non-operative treatment for acute Achilles tendon ruptures – which is better?

Thanks for your attention

Let us know if you have questions!!