1. Efficient Searching of the Literature & Critical Appraisal Rick Wallace March 9, 2007

2. Public Service Professional Librarians  Nakia Carter, MLS  Maylene Qiu, MLS  Rick Wallace, MLS

3. My Philosophy of the Literature- EBM: 6 Steps  Patient/Problem  Question  Search  Critical Appraisal  Application  Evaluation

4. Before You Search  You must have a patient/problem- Step #1  You must have a searchable question- Step #2

5. Clinical Scenario- Patient & Question  In pediatric patients with acute asthma exacerbation, does the inclusion of inhaled steroid improve outcomes such as hospitalization rates, length of stay, etc.

6. PICO the Question  P OPULATION/ PATIENT  I NTERVENTION  C OMPARATIVE INTERVENTION  O UTCOME

7. Our Scenario  Population- Pediatric patients w/ acute asthma exacerbation  Intervention- Inhaled steroids  Comparative- None  Outcome- Improve hospitalization rates -Generally Improved M&M

8. ANSWERABLE Well-Built, ANSWERABLE Clinical Question  In pediatric patients with acute asthma exacerbation (P), do inhaled steroids (I/C) improve hospitalization rates (LOS, etc.), and general morbidities (relief of symptoms, reduction of side effects, etc.) (O) ?

9. Step #3: Searching- Two processes  Choose database  Search database

10. Skill #1- Choice of Database(s) Search How to Search What to Search

11. What to search? Primary Literature Secondary Literature Decision- What database do I search?

12.  Evolution of the Secondary Literature InfoMastery- reduces the need for expertise in steps 3 & 4 Secondary Literature Classic EBM- 6 steps

13. Secondary Databases  Transparent- levels of evidence  POEMS  Pre-validated  High level of evidence- evidence pyramid  Concise summaries to reduce work

14. Some Secondary Databases  UpToDate  Inforetriever  DynaMed  Clinical Evidence  Cochrane Database of Systematic Reviews  DARE/CCTR  FPIN  ACP Journal Club  National Guideline Clearinghouse  FirstConsult  PIER

15. Primary Databases  PubMed (MEDLINE)  MDConsult (textbooks)  StatRef (textbooks)

16. How to Search

17. Secondary Database- UpToDate  Search “asthma”  Asthma exacerbation Pediatrics-Pharmacologic Tx of Acute asthma exacerbation Inhaled steroids

18. Secondary Database- Inforetriever  Asthma  Managing acute asthma exacerbations (LOE = 1a) Guideline- “Managing an acute exacerbation of asthma Initial therapy- #3- corticosteroids

19. Secondary Database- DynaMed  Asthma  Asthma exacerbation Steroids (click for details) Inhaled topical steroids…

20. Secondary Database- Clinical Evidence  Asthma  Asthma and other wheezing disorders in children Corticosteroids (high dose inhaled)

21. Secondary Database- Cochrane Database of Systematic Reviews  asthma AND (child OR adolescent OR infant) AND (steroid* OR corticosteroid*) AND (inhale* OR nebulize*) AND (exacerbat*) – searched as tw  #23. Corticosteroids for hospitalised children with acute asthma  Note: we have already searched CDSR by searching other databases  Also DARE and CCTR

22. Secondary Database- AHRQ Evidence Reports  Asthma  Use “find”

23. Secondary Database- National Guideline Clearinghouse  asthma AND inhale* AND Exacerbate*

24. Secondary Database- ACP Journal Club

25. Secondary Database- FirstConsult

26. Primary Databases  “raw”- not pre-validated  Not transparent  Not summarized- lots of work- work equation  All levels of evidence- well done RCT with 10,000 pts. versus individual case study

27. Primary Databases- PubMed  PICO- MESH

28. MeSH- Medical Subject Headings  What?  Thesarus used to index citations in MEDLINE  MEDLINE vs PubMed  Updated to reflect changes in medicine  Why?  Higher retrieval of relevant articles  Synonyms  Search stop words: Hepatitis A

29. MeSH  Major/ non-major  Explosions  Sub-headings  Boolean  Tree structure  Pass out thesari

30. PICOMeSH  Population- Pediatric patients w/ acute asthma exacerbation  Intervention- Inhaled steroids  Comparative- None  Outcome- Improve hospitalization rates; generally improved M&M  Population- Asthma/tx; All Child  Intervention- Steroids/ tx use  Comparative- none  Outcome- length of stay; outcome assessment

31. Pearl Searching  Do a text word search  Look at the citation display  Do subject search with MeSH

32. Example  Question: Is the development of breast cancer affected by the intake of dietary fat?  Text word search- breast cancer fat  Relevant article-  Browse MeSH- review scope note, subheadings, etc.

33. Narrowing retrieval  Combine sets  Use Boolean AND  Limits- human, age, gender, language, publication type, date range

34. Example  In patients with asthma do steroids affect the outcome?  Search- asthma/ drug therapy  Major Mesh, English, human, last 5 years

35. Searching for Evidence  Use a publication type  Use a hedge  Use clinical queries filter

36. Other  My NCBI  Related Items  Displays  Save  SFX  LoansomeDoc  Details- automatic mapping

37. Exercises  Take a clinical scenario  PICO it  Construct a well-built clinical question  List type of clinical question  List best type of literature to answer it  Do a search – save search strategy and results- try at least one secondary database and PubMed