Assist. Prof. Sakda Arj-Ong Vallipakorn, MD, PhD.,

Transcription

1 Assist. Prof. Sakda Arj-Ong Vallipakorn, MD, PhD., MSIT(Information Technology), MAIS(Information Science) Pediatrics, Pediatric cardiology, Pediatric Emergency Medicine, Emergency Physicians, Family Physicians Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University

2 Not known resource based of searching Not known the techniques of searching Can search, but result wide ( non-specific) Can search, but result cannot answers our questions

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4 Answer patient s questions Answer ourselves/our colleagues Gather information for a topic reviews or presentations To produce extensive searching before conducting another research or systematic review

5 Patient Profile A man 40 year old Chief Complaint Lt. Facial palsy 1 day PTA Patient Profile 1 Day PTA, Lt. Facial palsy came with rash at Lt. ear. Previously no any illness and other infections before.

6 Physical Examination Ears Rt: Multi stages vesicles at EAC, erythematous skin, dry scales, cannot see TM Lt: Normal Rt Facial palsy, LMN, House- Brackmann grade VI (Total paralysis) Other cranial nerve exams and neuro exams are grossly intact, other ENT exams normal

7 Your Diagnosis? You want to know whether you should prescribe medications to this patient?

8 Your Diagnosis: Herpes Zoster Oticus (Ramsay Hunt Syndrome) You want to know whether you should prescribe acyclovir, an antiviral agent, to this patient

9 Identify problem Define a structured question (PICO) Find the best evidence How valid is the evidence? What are the results? How should I apply the results to patient care?

10 Background questions What is this disease? What are possible therapeutic options? Foreground questions Is surgery better than medication? What is the most accurate diagnostic investigation? Background Foreground Experience with condition

11 Vary to types of the studies Diagnosis Prognosis Therapeutic Prevention Harm

12 Forming Clinical Question (PICO) Patient Intervention Comparison Outcome (Time limit) Objectives of searching Answer bedside question (PICO(T)) (P-I-C-0) For collective reviews or meta-analysis

13 Describe the patient/problem that you came into contact with and are relevant to your practice

14 Drug therapies, surgical treatment, Intervention counseling or factors that are different Drug A vs. Drug B Mastectomy vs. Radical Mastectomy TV Program vs. None May also be diagnostic tests Diagnosis A vs. Diagnosis B

15 Standard therapy May also be no intervention / placebo / alternative treatment / exposure / another diagnostic test

16 Outcome which is relevant to your patient/problem May need to consider what exactly is important to you and your patient (Patient-oriented outcomes)

17 Patient Profile A man 40 year old Chief Complaint Lt. Facial palsy 1 day PTA Patient Profile 1 Day PTA, Lt. Facial palsy came with rash at Lt. ear. Previously no any illness and other infections before.

18 Physical Examination Ears Rt: Multi stages vesicles at EAC, erythematous skin, dry scales, cannot see TM Lt: Normal Rt Facial palsy, LMN, House- Brackmann grade VI (Total paralysis) Other cranial nerve exams and neuro exams are grossly intact, other ENT exams normal

19 Your Diagnosis: Herpes Zoster Oticus (Ramsay Hunt Syndrome) You want to know whether you should prescribe acyclovir, an antiviral agent, to this patient

20 P: Patient with a diagnosis of Herpes Zoster Oticus I: Acyclovir C: No treatment with acyclovir O: Facial palsy recovery rate

21 68-year-old woman with well controlled DM came to you to ask what she recently see an article about influenza vaccination. She ask for your advice. P I C O

22 68-year-old woman with well controlled DM came to you to ask what she recently see an article about influenza vaccination. She ask for your advice. P Elderly woman with Diabetes I Influenza vaccination C No treatment O Prevention of influenza (Incidence of influenza)

23 50-year-old man presented with chronic constipation. He has family history of CA Colon. He ask you for accuracy of screening CT scan. P I C O

24 50-year-old man presented with chronic constipation. He has family history of CA Colon. He ask you for accuracy of screening CT scan. P Patient with chronic constipation, family Hx of CA Colon I Screening CT Colonography C Endoscopy O Diagnosis of CA Colon

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26 Text Books Staffs, Senior, Friends etc. DB EBM eg. UpToDate Google? Google Scholar PubMed Ovid SCOPUS

27 Systems Regularly updated evidence & Some CPG -Guideline Synopses Pre-appraised journals and databases Summaries Well conducted Systematic Review Studies Original primary studies

28 Regularly updated evidence Sometimes with guidance/recommendations PIER: UpToDate: (Rama: library.ra.mahidol.ac.th/utd/) BMJ Clinical Evidence:

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34 Pre-appraised journals and databases ACP Journal club: InfoPOEMs: EBM Journal (by BMJ):

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36 Systematic reviews that are well conducted The Cochrane Library:

37 thecochranelibrary.com cochrane.org Professor Archibald Leman Cochrane, CBE FRCP FFCM, ( ) From Cardiff University Library, Cochrane Archive, University Hospital Llandough. The Cochrane Collaboration founded with respected to Archie Cochrane ( ) Database of Systematic Review

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41 Original primary studies Randomized/Nonrandomized Controlled Trials Cohort studies Case-control studies Cross sectional studies Case reports

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52 Search Engine PubMed Ovid Scopus Database(s) MEDLINE MEDLINE, EMBASE, SCOPUS

53 Search Engine ระด บความง าย ข อด -ข อเส ยอ น Google Google Scholar PubMed Scopus Ovid Garbage +++ More Open, can't guess Miss some Journals Difficult to use, large DB, Cost Difficult to use, large DB, Cost

54 Free search engine Comprises of MEDLINE database Maintain by US National Library of Medicine, National Institutes of Health First released in 1996 Accessed from

55 1946 to present materials 5,600 journals in 39 languages 2,000-4,000 references added each day Biomedicine and health

56 ID (PubMed ID) Author Title Abstract Publication Type Publication Date, Time Publication Journal Keyword

57 Sequences by Question Sequences by Important

58 P: In patient with a diagnosis of Herpes Zoster Oticus I: Acyclovir C: No treatment with acyclovir O: Facial palsy recovery rate

59 Herpes Zoster Oticus Ramsay Hunt Syndrome Acyclovir

60 PubMed (MEDLINE database)

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63 Publication Types

64 Many and Many need limit Can t find article Wrong word search? Is PICO Question appropriate? Keyword EBM based Search Term? Wide or Narrow?

65 Clinical important Methodology Statistical techniques MEDLINE: MESH Terms

66 Human languages MesH Advances Search

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75 Use MESH terms Use search operators AND OR NOT and () Use limits to filter unwanted results Create a My NCBI account (free) for saving your collection of articles for later use Collection Saved search

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78 1. MESH 2. Search Operators 3. Limits 4. Clipboard 5. Save searches 6. Advanced search 7. Citation matcher 8. Clinical Queries 9. Retrieval of full text paper

79 Medical Subject Heading Tag of subject in database

80 Truncated search term (wildcards) flavor* = flavoring + flavored + flavors synerchi* = synerchiae + synerchia Combining search terms (Always Capitalized Booleans!) AND OR NOT ( ) : eg. Measles AND (children OR adult)

81 Filter unwanted results Age: infants, adults, Article types: original studies, RCTs, Meta-analysis, Article language Done on human Recently published

82 Stored items for later review Max 500 items 8 hours before deleted Send to collection instead if you want to permanently stored (Need My NCBI account)

83 Save for later updates Useful when you re doing systematic review Can also automatically updates

84 Search in command line-based Use # for referring to previous searches Operators: AND, OR, NOT, and ()

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93 Download History Recent queries in pubmed Search Query Items found Time #4 Search ((Ebola) AND ((Zmab) OR Monoclonal antibody)) AND Survival 20 23:52:42 #3 Search Survival :44:46 #2 Search (Zmab) OR Monoclonal antibody :44:18 #1 Search Ebola :43:53

94 P I C O Ebola Zmab or Monoclonal Antibody - Survival or [Death?]

95 P I C O Ebola And Zmab or Monoclonal Antibody - Survival And or [Death?]

96 (Ebola[All Fields] AND (Zmab[All Fields] OR ("antibodies, monoclonal"[mesh Terms] OR ("antibodies"[all Fields] AND "monoclonal"[all Fields]) OR "monoclonal antibodies"[all Fields] OR ("monoclonal"[all Fields] AND "antibody"[all Fields]) OR "monoclonal antibody"[all Fields]))) AND ("mortality"[subheading] OR "mortality"[all Fields] OR "survival"[all Fields] OR "survival"[mesh Terms])

97 Locate an article when you know the author name / title / journal name / vol / pages

98 Answer clinical questions Etiology Diagnosis Therapy Prognosis Clinical Prediction Guides Search filter

99 Category therapy diagnosis etiology prognosis clinical prediction guides Optimized For Sensitive/ Specific sensitive/broad 99%/70% specific/narrow 93%/97% sensitive/broad 98%/74% PubMed Equivalent ((clinical[title/abstract] AND trial[title/abstract]) OR clinical trials[mesh Terms] OR clinical trial[publication Type] OR random*[title/abstract] OR random allocation[mesh Terms] OR therapeutic use[mesh Subheading]) (randomized controlled trial[publication Type] OR (randomized[title/abstract] AND controlled[title/abstract] AND trial[title/abstract])) (sensitiv*[title/abstract] OR sensitivity and specificity[mesh Terms] OR diagnos*[title/abstract] OR diagnosis[mesh:noexp] OR diagnostic * [MeSH:noexp] OR diagnosis,differential[mesh:noexp] OR diagnosis[subheading:noexp]) specific/narrow 64%/98% (specificity[title/abstract]) (risk*[title/abstract] OR risk*[mesh:noexp] OR risk sensitive/broad 93%/63% *[MeSH:noexp] OR cohort studies[mesh Terms] OR group*[text Word]) ((relative[title/abstract] AND risk*[title/abstract]) OR (relative specific/narrow 51%/95% risk[text Word]) OR risks[text Word] OR cohort studies[mesh:noexp] OR (cohort[title/abstract] AND stud*[title/abstract])) (incidence[mesh:noexp] OR mortality[mesh Terms] OR follow up sensitive/broad 90%/80% studies[mesh:noexp] OR prognos*[text Word] OR predict*[text Word] OR course*[text Word]) (prognos*[title/abstract] OR (first[title/abstract] AND specific/narrow 52%/94% episode[title/abstract]) OR cohort[title/abstract]) (predict*[tiab] OR predictive value of tests[mh] OR scor*[tiab] OR sensitive/broad 96%/79% observ*[tiab] OR observer variation[mh]) specific/narrow 54%/99% (validation[tiab] OR validate[tiab])

100 Read all papers and consider Select some Paper from Title & Abstract Answer my question Higher level of evidence Publish in credible journal Publish not long ago

101 Systematic Review & Meta-analysis Randomized Controlled Trials Non-randomised intervention studies Observational studies Non-experimental studies Expert opinion BMJ 2001;323:334.1

102 Top well-known general journals NEJM (New England Journal of Medicine) JAMA (Journal of American Medical Association) BMJ (British Medical Journal) The Lancet Annals of Internal Medicine Pediatrics Annals of Emergency Medicine

103 Impact factor ISI Web of Science

104 Total number of citation in last 2 years/total article publication in last 2 years More impact more citations more read? Reflect a quality of Journal?

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107 Link in PubMed click LinkOut Full Paper from outside Mahidol Ejournal Proxy: guide Mahidol VPN: guide Don t forget your librarian

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110 Facebook.com/ramaclinicalepi