Information Online : Medical Databases

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Information Online Medical Databases
Internet Resources

• Kathy Davies
• ECM II
• August 17, 2005

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Benefits of EBM Practice

• Improved Patient Care
• Progression of coronary artery calcium and risk
  of first myocardial infarction in patients
  receiving cholesterol-lowering therapy.
• Raggi P, Callister TQ, Shaw LJ.
• Arteriosclerosis, Thrombosis, and Vascular
  Biology
• 2004 Jul24(7)1272-7. Epub 2004 Apr 01.

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Objective To evaluate the association between
physician-diagnosed asthma and the subsequent
development of COPD

• Results
• Subjects with active asthma (n 192) had
  significantly higher hazard ratios than inactive
  (n 156) or nonasthmatic subjects (n 2751) for
  acquiring COPD. As compared with nonasthmatics,
  active asthmatics had a 10-times-higher risk for
  acquiring symptoms of chronic bronchitis (95
  confidence interval CI, 4.94 to 20.25),
  17-times-higher risk of receiving a diagnosis of
  emphysema (95 CI, 8.31 to 34.83), and
  12.5-times-higher risk of fulfilling COPD
  criteria (95 CI, 6.84 to 22.84), even after
  adjusting for smoking history and other potential
  confounders.
• Conclusions
• Physician-diagnosed asthma is significantly
  associated with an increased risk for CB,
  emphysema, and COPD.

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Practice Not Based on Evidence

• Common Practice Can Be Wrong
• Risks and benefits of estrogen plus progestin in
  healthy postmenopausal women principal results
  From the Women's Health Initiative randomized
  controlled trial.
• JAMA. 2002 Jul 17288(3)366-8

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Hormone use in healthy postmenopausal women

• Objective To assess the major health benefits
  and risks of the most commonly used combined
  hormone preparation in the United States
• Design Randomized controlled primary prevention
  trial of 16608 postmenopausal women
• Results statistically significant increase in
  the risk of heart disease, breast cancer, stroke
  and blood clots
• Conclusion regimen should not be initiated or
  continued for primary prevention of CHD.

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Where To Find the Evidence ?

• MEDLINE
• Cochrane Databases
• InfoPoems
• Micromedex Disease Drug Information
• Disease Topics
• Database Search

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MEDLINE Searching Tools

• PICO Method
• MeSH (Medical Subject Headings)
• Search Options to focus citations
• Limits Subheadings
• Boolean Operators
• EBM search Filters

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PICO Method

• Identify key pieces of data to build search
• P Patient and/or Problem (age/gender)
• I Intervention (treatment or procedure)
• C Comparison (with alternative treatment,
  standard treatment or None)
• O Outcome desired ( patient improvement)

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Medical Subject Headings

• Controlled Vocabulary
• Official Term for Disease, Anatomy or Topic
• MeSH automatically includes more narrow terms
  with broader ones
• Click Directly on Term to View Tree
• Searching Bronchiolitis also find article(s)
• Bronchiolitis Obliterans
• Bronchiolitis, Viral

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Medical Subject Headings

• Consider Scope or Usage of MeSH Terms
• Click the I Button to view Definition
• Similar Terms can have different meanings
• Choose Term to Reflect Information Sought
• Example antineoplastic agents VS.
  anticarcinogenic agents

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Antineoplastic Agents

• Substances that inhibit or prevent the
  proliferation of neoplasms

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Anticarcinogenic Agents

• Agents that reduce the frequency or rate of
  spontaneous or induced tumors independently of
  the mechanism involved. They differ from
  antineoplastic agents in that they prevent
  neoplasms from forming.

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Search Options Subheadings

• Subheadings are attached to MeSH term
• Subheadings narrow focus of term
• Example breast neoplasms/diagnosis
• Finds articles on detection of breast neoplasms
• MRI, needle biopsy, mammogram
• NOT specific treatments or genetic info
• Slash (/) equivalent to of

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Search Options Boolean Operators

• AND
• Include multiple terms in search
• Breast neoplasms AND uterine neoplasms
• OR
• Any term listed (conditions occur together)
• Anemia, Sickle Cell OR Tuberculosis
• NOT
• Eliminate certain terms from search
• Glaucoma NOT Glaucoma, Neovascular

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Search Options Limits

• Apply limits to set with all desired terms
• Usually the last step in searching
• Restrict results to specific
• Population, Gender, Language
• Age Group, Publication Type
• Journal Subsets, Range of Years
• Use CTRL key to select multiple limits
• Example Newborn Infant Infant

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Big Four Clinical Questions

• Therapy
• Efficacy safety of treatment
• Is the treatment effective and not harmful?
• Diagnosis/Screening
• Precision and accuracy of diagnostic tests
• Preventing false positives not missing existing
  conditions

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Big Four Clinical Questions

• Prognosis
• Power of predictive markers
• Determine who has increased risk for condition
• Long Term Outcome for patient
• Etiology (Harm/Benefits)
• Assess treatment benefit to patient
• Risks of treatment

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Clinical Question Therapy

• Does using botulism toxins improve spastic
  muscle symptoms commonly experienced by patients
  after a stroke?

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PICO Elements

• P stroke
• I botulism toxins
• C No treatment
• O reduce spastic muscle symptoms

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Building A Search

• 1 exp Botulinum Toxins/ 3794
• 2 exp Muscle Spasticity/ 1384
• 3 exp Cerebrovascular Accident/ 22606
• 4 1 and 2 and 3 43
• 5 limit 4 to (humans and english language and
  "therapy (optimized)") 18

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Clinical Question Etiology

• Are lifestyle changes effective in reducing
  the development of diabetes mellitus in patients
  with impaired glucose tolerance?

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Building A Search

• 1 exp DIABETES MELLITUS/ 72656
• 2 exp Glucose Intolerance/ 2073
• 3 exp Life Style/ 16604
• 4 1 and 2 and 3 92
• 5 limit 4 to (humans and english language and
  "etiology (optimized)") 38

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Clinical QuestionPrognosis

•  Does using corticosteroids in patients with
  asthma reduce the need for hospitalizations over
  time?

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Building A Search

• 1 exp Adrenal Cortex Hormones/ 30751 2 exp
  ASTHMA/ 27476
• 3 exp HOSPITALIZATION/ 41479
• 4 1 and 2 and 3 67
• 5 limit 4 to (humans and english language and
  "prognosis (optimized)") 20

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Clinical QuestionDiagnosis

• Should the possibility of celiac disease be
  routinely investigated in the diabetic patient
  population?

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Building A Search

• 1 exp Celiac Disease/ 3372
• 2 exp Diabetes Mellitus/ 72656
• 3 1 and 2 184
• 4 limit 3 to (humans and english language and
  "diagnosis (optimized)") 20

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Cochrane Databases

• ACP Journal Club
• methodologically sound clinically relevant
  studies selected for publication
• an enhanced abstract of the chosen articles
• value of the article for clinical practice.
• DARE (Reviews of Effectiveness)
• critical assessments of systematic reviews
• variety of medical journals included

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Cochrane Databases

• Controlled Trials
• 300,000 controlled health care trials referenced
• Found by handsearching database searching
• Includes indexed controlled trials in MEDLINE
• Systematic Reviews
• Systematic reviews prepared by Cochrane
• Includes completed reviews protocol for reviews
  in progress

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Cochrane Databases

• Much smaller than MEDLINE
• Some are expert opinions/commentary
• Focus on common conditions
• May miss articles on your topic

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What is InfoPoems?

• Pre-selected evidence based resources
• Focus on patient care of common conditions not
  a comprehensive research source
• InfoRetriever set of EBM databases
• Keyword Multi-database searching
• Includes Cochrane, guidelines, calculators
• Daily Poems
• Reviews 100 journals monthly
• Selects 1-4 for POEM inclusion

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InfoRetriever Search Databases

• Cochrane Database (abstracts only)
• EBM Guidelines
• National Guidelines Clearinghouse others
• Clinical Decision Rules
• Estimate clinical probabilities
• select appropriate/effective tests for
• determine risk for specific disease

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InfoRetriever Search Databases

• Diagnostic Test Calculators
• Ex likelihood of breast cancer
• History Physical Exam calculators
• Griffiths 5 Minute Clinical Consult
• Overview of topic
• ICD 9 Codes
• Search by number or alphabetical list

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Micromedex

• Disease Section
• Disease Databases include
• Emergency medicine, general medicine,
• Reproductive toxicology summary information
• Disease Topics include
• Disease summary treatment
• Differential Diagnosis

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Micromedex

• Drug Information
• Martindale's Drug Information USP DI
• Toxicology Interaction data
• Patient Care Information included
• General information
• Discharge Aftercare instructions
• Can be downloaded to PDA

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STAT Ref

• Electronic medical texts calculators
• Key medical texts
• Harrisons Internal Medicine
• ACP PIER
• Guide To Laboratory Diagnostic Tests
• Calculators
• Unit converters, med equations
• Decision Trees, specialty pages

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Internet Health Care InformationWhy you need
to surf the Net

• Obesity is Risk Factor For Aggressive Prostate
  Cancer
• http//www.mcg.edu/news/2005NewsRel/Terris30505.ht
  ml
• Clinical AlertUse of Non-Steroidal
  Anti-Inflammatory Drugs Suspended in Large
  Alzheimer's Disease Prevention Trial
  http//www.nih.gov/news/pr/dec2004/od-20.htm

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Internet Health Care InformationWhy you need to
surf the Net

• Your Patients Are Already There
• 52 million use Internet for health care
  decisions 55 of searchers seek health
  information
• 50 of searchers ask new questions or request
  second opinion after reading Internet information
• 28 of searchers use Internet information in
  deciding consult a physician
• The Online Health Care Revolution
• http//www.pewinternet.org/PPF/r/26/report_display
  .asp

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Indexing of the Internet

• Estimated over 3 billion web pages
• No single web search engine indexes more than
  about 16 of the web
• Steve Lawrence C. Lee Guiles
• Accessibility of information on the web
• Nature 400(6740) 107-109, July 8, 1999

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Search Engine Techniques

• Search Engine Math Special Characters
• Quotes for Phrases
• Plus or Minus symbols
• Search in specific field i.e. URL,title
• Advanced or Power Search options
• Use Boolean operators (AND OR NOT)

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Search Engine Techniques

• Understand results ranking system
• Featured Sites Vs. Matching Query
• Consider a specialized search engine
• Be aware of case sensitivity
• Be as specific as possible
• Have a back-up search engine

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Evaluating Internet ResourcesInformation Source

• Domain- .gov, .edu, .org or .com
• Who is responsible for site content?
• Credentials of site manager/owner
• Personal Opinion present?
• Bias or commercial slant?

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Evaluating Internet ResourcesAccuracy of
Information

• Consistent with other sources
• Is the information relevant and/or unique?
• Is a disclaimer present regarding medical
  information?
• Any awards for quality?
• Health on the Net, E-health Seal, etc

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Evaluating Internet Resources Current
Information

• Current Information or Last Years News
• Site updated as new research develops?
• Site maintained links kept current?
• Listed Web Site Manager/Owner?

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Evaluating Internet ResourcesSite Links

• Complete Web Site or single page?
• Online article from journal publication?
• Additional resources listed for users
• References provided for information
• Site Reviewers?

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Evaluating Internet ResourcesSite Appropriate

• Purpose of Site/Organization
• Intended Audience of site- Consumer or Health
  Care Professional
• Site addresses information need
• Site map or Search Form present to help navigate
  the site

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Internet Road Maps Health Professionals

• HealthWeb
• http//www.healthweb.org/
• Evaluated non-commercial Internet health
  resources
• Divided into sub-topics
• Clinical, Consumer Health, Education
• Organizations
• EBM Links
• Collection of EBM Resources
• Reading papers, understanding terms, tool kits
• http//www.mcg.edu/Library/eresources/evibasmedic.
  html

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Internet Road Maps Patients Consumers

• MEDLINEplus
• http//www.medlineplus.gov
• Links to gov, edu or org sites only
• Organized into Diagnosis, Treatment,
  Organizations, Spanish language, etc
• HealthFinder
• http//www.healthfinder.gov
• Spanish Kids version
• Health Topics Health Care Information