Contents
Contents:

Constructing your question so the computer understands you

Help on choosing resources

Tips on searching specific resources

Third year medical student informatics course

About Medical Evidence:

Assessing medical evidence

Systematic Reviews

Problems with the computer?

Problems with the software?

Problems with the printer?

Problems with the internet? (if your computer uses a modem)

How to minimize, move, and close all the little windows

What are the LifeLong Learning computers?


Formulating your question so the computer can understand you

You should phrase your question into the following format (the last two parts are not usually needed):

Disease or patient population

Test or treatment

(Comparison)

(Outcomes)

Example: In patients with systolic dysfunction, does digoxin help (compared to placebo, reduce mortality)?

If you cannot construct a specific question in the above format, the you probably have a background question.


Help on choosing resources

First, decide whether you have a background question or a foreground question:

Background questions are best answered by easy to read texts (as compared to reading original research) such as the following:

Scientific American

Drug information resources

Practice guidelines:

Temporary URL:

http://merece.uthscsa.edu/med/guides.htm

Soon (1998), the Federal Government will have an online clearing house for guidelines from other organizations

Fulltext review articles from MEDLINE

Foreground questions can be answered with the above resources, but more up-to-date answers can be found by consulting systematic reviews, or if that fails, by consulting original research:

Finding systematic reviews with the DARE database and Cochrane Library

Internet version

CD-ROM version

Finding systematic reviews with MEDLINE

OVID

PubMed:

http://merece.uthscsa.edu/med/medline/pubmed.htm

Finding original research with MEDLINE

OVID

I do not have a specific question, I just want to see recent important medical news:

Online Journal Clubs and journal websites


Background questions
Background questions are broad, without a specific question.

For example:

How is heart failure diagnosed and treated?


Foreground questions
Foreground questions are specific.

For example:

How is effective is digoxin in reducing mortality in patients with heart failure?


Tips on searcing specific resoures
Tips on searching specific resources

Scientific American

USP Drug Index

Cochrane Library (CD-ROM)

Best Evidence (ACP Journal Club – CD-ROM version)

OVID / MEDLINE

Online Journal Clubs


Third year medical students informatics course

Session 1 - Medical Evidence

Levels of evidence

Other markers of quality:

Peer review

Attribution

Systematic Reviews

Foreground vs background questions

Session 2 - Basic OVID

Session 3 - Advanced OVID

Formulating your question so the computer can understand you

Using hedges/filers

Using single best search terms (when hedges are not available)

What if I find too few or too many articles

Fulltext review articles with OVID

Session 4 Internet and CD ROM resources

Scientific American

USP Drug Index

Cochrane Library (CD-ROM)

Best Evidence (Journal Club- CD-ROM version)

Keeping up-to-date


Peer review
Peer review has been shown to improve (somewhat) the readability quality of and evidence in journals.


Attribution
Attribution means that the text you are reading cites evidence by using footnotes.


Comparing textbooks

Scientific American Textbook of Medicine:

SAM is the only textbook of medicine of medicine that makes extensive use of footnotes and references. Although no textbook of medicine is truly evidence based (eg, composed entirely of systematic literature reviews), SAM at least cites the evidence used.

Merck Manual:

Although the Merck Manual may not be as comprehensive as SAM within internal medicine, the Merck Manual also covers all other medical fields (such as OB-Gyn, etc.).


Using Scientific American Textbook of Medicine

You can easily select to locate your topic by either searching or using the Table of contents.

Tip: Searching is usually best.

Here are some tips for when you are looking at your results:

(see picture below)


Comparing Drug Information Reference
Comparing Drug Information References

United States Pharmacopeia Drug Information:

This is a comprehensive database. It is difficult to navigate, but is much easier if you use the following tips for the USP Drug Index

MicroMedex includes:

MARTINDALE textbook published by the Royal Pharmaceutical Society of Great Britain

PoisonDex

DrugDex

FDA website:

This site is best for looking up rare, but serious side effects of drugs, and for looking up FDA approval status

Clincial Pharmacology Online:

This site has very brief monographs (unless you buy a password), but is good for pictures of pills.


Using USP Drug Information

Starting a search:

Here are some tips for when you are looking at your results:

Find important topics such as below by 1) click the blue binoculars (circled in blue the picture below) and then 2) copy one of the topics below and paste into the find box:

Indications

Pharmacology/pharmacokinetics

Drug Interactions

Laboratory Value Alterations

Medical Considerations/Contraindications

Patient Monitoring

Side/Adverse effects

Dosing Information

Dosage Forms

Click the file drawer (circled in green in the picture below) to return to your search results.

Click ‘Main’ to quit your current search and return to the main menu.


The Cochrane Library

What is the Cochrane Library?

How to use the Cochrane Library


What is the Cochrane Collaboration
The Cochrane Library consists of five helpful collections of systematic reviews:

Cochrane Collaboration

These are systematic reviews authored by the Cochrane Collaboration.

Database of Abstracts of Reviews of Effectiveness (DARE)

This is four helpful databases of systematic reviews executed by non-members of the Cochrane Collaboration, but collected here.:

1. Structured abstracts - These are structured abstracts of previously published systematic reviews

2. ACP Journal Club abstracts of reviews - This is a collection of structured reviews taken from the ACP Journal Club.

3. INAHTA records. These are reviews made by members of the International Network of Agencies for Health Technology Assessment.

4. Source records - This is a collection of previously published systematic reviews. Unlike #1 above, these have not been quality reviewed.

In addition there is a listing of controlled clinical trials


How to use the Cochrane Library
How to use the Cochrane Library.

To start your search:

* is the wildcard so diabet* searches for diabetes and diabetic.

To enter and combine terms:

After you complete your search, check the results under the following databases:

Cochrane library

DARE

Controlled clinical trials registry (if no hits on one of the

 above databases).


Using ACP Journal Club and Best Evidence

There are two ways to search the ACP Journal Club:


Comparing ways to access MEDLINE

PubMed – fastest method for searches that will not be complicated. Also, PubMed is the most up to date way to access MEDLINE. Fulltext of articles rarely available.

OVID – slower, but better for complicated searches. Fulltext of articles may be available.


OVID - tips
Using OVID for MEDLINE searching

Constructing your question so MEDLINE understands you

Truncating, exploding, focusing, combining

Using hedges/filers

What are hedges?

What if I find too few or too many articles

Finding fulltext review articles

I need a password


OVID passwords
I need an OVID Password

Call 567-2450 for help or ‘Handouts (for providers)’ from main screen to print a copy of the registration form that you can fax to the library (567-2490).


Basic tips for OVID
A few basic basic tips for OVID

1. Either start your session either with a hedge (if you have a Foreground question) or limit your topic to fulltext/reviews (if you have a background question).

2. Combine the last line of the hedge with your topic using a textword and/or MeSH word.

Textword searching for textwords in the title or abstract. This avoids MeSH words that may have been inaccurately coding by the National Library of Medicine. Textword searching is also faster than MeSH words. Enter your term as follows:

diabet$.tw.

$ indicates wildcard, so diabetes or diabetic is sought

If you want your word to be a focus of the article, restrict your search to the title as follows:

diabet$.ti.

MeSH searching. This is good for diseases that have many names, such as Bell’s palsy, which may have the textwords Bell’s palsy, seventh nerve palsy of facial nerve palsy. However, usually you should explode MeSH words. For example, the MeSH word respiratory tract infections does not include bronchitis unless the explode the term:

exp respiratory tract infections/

If you want your term to be a focus of the article, OVID will give you that option and your search line will look like:

*respiratory tract infections/

or

exp *respiratory tract infections/

3. Combining terms:

Simply type in the lines of the search that you want to combine:

1 and 2

1 or 2

1 not 2


Using Hedges
Improving MEDLINE with presaved searches (‘Hedges’)

Studies have shown that MEDLINE is very difficult and time consuming for physicians to use. AFTER two one-hour training sessions, physicians only can find about half of the articles relevant to their question (reference).

Unfortunately, MESH headings are not always accurately assigned by the National Library of Medicine (reference)

The solution is to start all of your MEDLINE sessions with presaved searches (hedges). These are fast, easy to use, and usually capture over 90% of relevant articles (reference).

In addition, you should start by using the hedge for (see systematic reviews to learn more).

How to use hedges

What hedges are available

This is too hard, tell me the single best search term


Haynes RB, et al. Online Access to MEDLINE in clinical settings: a study of use and usefulness. Ann Intern Med 1990;112:78-84.


Wilcznski NL et al. Reasons for the loss of sensitivity and specificity of methodologic MeSH terms and textwords in MEDLINE. Proceedings - the Annual Symposium on Computer Applications in Medical Care: 436-40. 1995.


Haynes RB et al. Developing optimal search strategies for detecting clinically sound studies in MEDLINE. J Am Informatics Assoc 1994;1:447-58.


I do not have access to any hedges.
Single best search term

If you cannot access the hedges, the following are the single best search terms (reference). These are easier to remember than the complete hedges. Although single terms do not perform as well as hedges, these singles terms will improve the searching of physicians who do not use them reference.

Search strategy	sensitivity	specificity

For studies of treatment:

clinical trial (pt)	93	92

For studies of diagnosis:

di.xs.	80	77

For studies of prognosis:

exp cohort studies/	60	80

For studies of etiology or cause:

risk (tw)	67	79

Note: there is no adequate single search term to look for systematic reviews.


clinical trial as a Publication Type


‘(xs)’ means ‘pre-explosion’ of di (the sub heading ‘diagnosis’).

This includes the subheadings:

pa	pathology

ra	radiography

ri	radionuclide imaging

us	ultrasonography


Explode (include all narrower MeSH headings) within the MeSH heading cohort studies.


risk as a textword in the title or abstract


Medical Subject Heading:

These are keywords assigned (not always reliably) to an article by the National Library of Medicine (the creators of MEDLINE).


What if I get too few or too many articles?
What if I find too few or too many articles?

After you combine your topic and the appropriate filter (or single best search term), then scan your results. If you retrieved too many or too few, do the following:

If you get too many citations:	If you get too few citations:
If you used a MeSH heading, require it to be a focus.  Example: change pneumonia/ to *pneumonia/	Search your topic as both a MeSH heading and text word.
If you used a textword, require it to be a title word. Example: change diabet$.tw. to diabet$.ti.	Choose a broader MeSH heading and then explode it.  Ex: change pneumonia/ to exp respiratory tract infections/
Limit to AIM journals	Truncate text words with ‘$’. Example: change diabetes.tw. to diabet$.tw.
Narrow your question!	Think of additional MeSH headings and textwords that may also identify your topic.
Add more concepts from you well built question. Eg the outcome or the comparison.	Broaden your question: Example: change how to diagnose disease X with test Y to how to diagnose disease X with any test.


Example of presaved MEDLINE search
How to use hedges (filters) with OVID Client:

Imagine your patient is entering septic shock:

Should you give him/her steroids? - You need  an accurate answer and you need the answer quickly.

Start OVID Client.

First, click ‘File’

    Next, click ‘Open’

Next, ‘click ‘Strategy’

    Then ‘click’ Hard drive’

The following list of Hedges appears:

Now, execute the strategy “1-sysrev” (yellow)

The following is the result:

Now enter the textword sepsis:

Now combine the hedge and sepsis:

Now view the titles of the resulting eleven articles:

The third and fourth titles (yellow) look good, so view the third one:

SO, you quickly learned that steroids may harm (yellow), rather than help your patient.


What presaved searches are available?
What presaved searches (‘hedges’) are available?

The following presaved searches are available:

sens	spec

Systematic reviews	NA	NA

High quality general medicine journals

Practice Guidelines	NA	NA

Treatment studies	99	74

Diagnosis studies	92	73

Prognosis studies	92	73

Etiology/causation studies	82	70


How to use presaved searches
Presaved searches are available by the following means:

VA hospital: use OVID Client on the Life Long Learning computers.

See example of how to quickly do this.

Downtown clinic: hedges are not available on the computerLearning. See either OVID WEB (below) or  how to use a single best search term

Your home computer or Briscoe library:

OVID Client (best):

Download the searches from the hard drive of any

Life Long Learning computer to your own floppy.

Click ‘start’ from the lower left corner of the Intro screen.

Click ‘Download’

Download the OVID searches and the help file.

OVID WEB:

First, get an OVID password

Next, go to Briscoe Library, or other place to access OVID TELNET.

Loggin with your password.

Run each presaved expert search

After each search, save the strategy as a permanent search.

The strategies are now available on OVID WEB when you sign in with your password.

OVID telnet (the strategies are already loaded)

Press control and F simulataneously, then:

    File

   Open

Open expert search


OVID WEB

Once you have your password, you can access OVID WEB at home through the Division of General Medicine homepage (http://merece.uthscsa.edu/med/gim.htm) or directly to OVID at the school (http://ovid.uthscsa.edu/ovidweb/ovidweb.cgi).


Finding fulltext review articles

First identify your topic. In this example, I want a review article about valvular heart disease:

When seeking review articles, consider searching title words (rather than textwords), or if you like to search with MeSH terms, require that the terms are the focus of the article.

Apply Fulltext limit:

Apply Review limit:

OVID suggests there are 19 fulltext review articles. View these articles:

After displaying the first article, click ‘Title’ (red) to display the titles only.

(scroll down to the bottom right of this picture if you cannot see the red circle)

The third article (red) looks very good, so select it.

Click either of the two red circle to display the fulltext:

And now you can read the article:


Medical Evidence

What is ‘solid’ or ‘clear’ evidence to support your decisions?

Producers of “evidence-based”, such as:

United States Public Service Preventive Services Guidelines

Canadian Task Force on the Periodic Health Examination

ACCP Consensus Conference on Antithrombotic Therapy

use objective measures of quality of evidence. An example is from the ACCP:

Level I+: Multiple randomized controlled trials (RCT) that all agree

(especially when pooled in a systematic review or meta-analysis)

Level I-: Multiple RCTs that may not agree, but:

most studies agree

the pooled result is significant

Level II: Same as above, but the results only tended to benefit, without statistical signficance.

Level III: Nonrandomized concurrent cohort studies.

Level IV: Nonrandomized, historically controlled, cohort studies.

Level V: case series (eg, no controlls)

Not even classified: case report

Other markers of quality:

Peer review

Attribution


Cook DJ, et al. Chest 1995;104:227s.


Systematic reviews

What is a systematic review and how to understand one

What is so good about a systematic review?


What are systematic reviews?

Systematic reviews are review articles that are highly accurate and objective (usually). They are identified by having the following:

A highly structured and thorough literature search

Explicit criteria on including articles

Graphical results, that when numerically pooled are called

meta-analysis (an example is below)

Example (see below for how to easily read this figure):

See below

Study 1:

The dot indicates a relative risk (RR) of less than 1, so drug A helped.

However, its horizontal line (confidence interval) crosses the vertical line indicating there is a statistical chance the RR is greater than one. Thus the study is statistically INSIGNIFICANT.

Study 2:

Drug A SIGNIFICANTLY helps.

Study 3:

Drug A INSIGNIFICANTLY helps.

Study 4:

Drug B SIGNIFICANTLY hurts.

The pooled results for drug A show:

Drug A SIGNIFICANTLY helps.

Note the results are HETEROGENEOUS or NOT HOMOGENOUS. But when the study that used drug B is deleted, the results are HOMOGENOUS (without outliers) and significant. Good meta-analyses should show this type of figure so you can look for outliers.


What is so good about systematic reviews?
Most of us like to read traditional narrative review articles or textbooks. They are friendly and easy to read.

Most of us like to read traditional narrative review articles or textbooks. They are friendly and

easy to read. HOWEVER, the Antman EM et al. JAMA 1992;268:240

tracked medical research and recommendations about beta-blockers after an infarction.  They

found that traditional reviews were slow to identify the usefulness of beta-blockers and some

articles never did make the correct recommendation. However, meta-analysis correctly identified

the role of beta-blockers.


Keeping up to date
Using computers to keep up to date

Online Journal Clubs

ACP Journal Club (free – except for searching archives)

Reviews articles from 12 major journal that meet explicit quality criteria.

www.acponline.org/journals/acpjc/jcmenu.htm

Bandolier (free):

Detailed reviews of hot topics/articles.

Good graphics.

www.jr2.ox.ac.uk/bandolier

Journal Club on the Web (free):

www.webcom.com/mjljweb/jrnlclb

Journal Watch (fee required):

Reviews newsworthy articles from about 50 major journals.

Links to PubMed.

www.jwatch.org

MD Digests (free):

Reviews of articles in NEJM, JAMA, Lancet, BMJ, Archives.

Links to MEDLINE via SilverPlatter (subscription only)

php2.silverplatter.com/physicians/digest.htm


Problem with the software
Problems with the software?

If your program requires internet access, first click the internet button on the lower right corner of the menu.

If you have lost your work, or the computer or your software is locked up:

1. Use the Taskmanager by either:

Click here for the task manager

or:

VA computers: simultaneously press Ctrl Alt and Delete.

University Computers: simultaneously press Ctrl and Esc

With the Taskmanager, you can either switch to, or close any program.

2. If the Taskmanager did not work, exit and restart Windows.

First, close the internet connection if it is active (check the taskbar or desktop).

Click ‘Start’ at the bottom left corner of the screen.

Click ‘Shut Down’.

Type ‘win’ at the DOS prompt. Press ENTER.

3. If exiting Windows did not work, turn off the computer:

Exit Windows as above.

Turn off the power switch for the computer.

Turn the power switch back on.

If you have important work that you do not want to loose, try the following sequence until the computer is working:

1. If your program requires an Internet connection, see Internet connection

2. Otherwise, exit and restart the program that is not working well.

3. If the above did not work, look at the very bottom on the ‘Intro’ screen.

Close ALL of the programs that are currently open.

Restart your program (and the Internet connection if required).


Problems with the printer
Problems with the printer?

Note: the VA printers are not working well at this time. They can usually print text (not graphics) if you use the generic printer  use the generic printer driver.

1. Make sure the printer is ready:

The power and Online lights should be on and NOT blinking.

2. Try turning the printer off and on.

3. Try changing to ‘generic printer’ at printer setup.

printer setup


Opening and closing Windows
Learning Windows lingo (how to open and close Windows)

‘Task bar / desk top’

At the very bottom of the screen, below the ‘Intro’ screen, is either:

Task bar (Windows95)

Desktop (Windows 3.1).

This section contains the icons for all of the active programs.

Clicking any of the icons will Restore them to the previous status.

‘Minimizing’

Minimize a program (or window)  if you want to TEMPORARILY clear the screen Minimizing places the window on the taskbar or desktop. You can later Restore the program.

Click the area upper right corner, as circled below, of the window you want to minimize. The corner of the window will look like one of the following.

‘Maximizing’

Maximize a program or window to make it occupy the full screen so you can read it easier.

Click the area upper right corner, as circled below, of the window you want to minimize. The corner of the window will look like one of the following.

Moving

Click anywhere along the title bar at the top of the form.

While depressing the right mouse button, drag the form to where you want, then release the mouse button.

‘Closing’

Close a program or window if you are finished with it. Depending on your computer, either click the upper right corner, as circled below,

or the upper left hand corner of the window:

Then click CLOSE:


Problems with the Internet connection

First, look at the very bottom of the ‘Intro screen and make sure the connection is established

Or

Click here

If not, click its icon at the lower right corner of the ‘Intro’ screen.

If the connection is connected, but not working:

Close the connection, and restart the connection.

If the connection still doesn't work, exit and restart Windows.

See problems with software


Life Long Learning computers
Life Long Learning Computers:

The Life Long Learning computers are located:

Internal Medicine Clinic (VA Hospital)

General Medicine Clinic (University Health System - Downtown)

Prime Conference Room (6th floor VA hospital)

Chief Residents’ Office (9th floor University Hospital)

For problems, contact Bob Badgett:

office	617-5238

beeper:	235-3760

email:	Badgett@UTHSCSA.edu