6/30/2008

Using PubMed

• Navigate PubMed's
Searching for Medical home page
• Use the sidebar to
Literature using Pub Med access PubMed
services and
resources
• Features bar
Nilo C. de los Santos, M.D. • Enter queries to
search
• Understand and
use Boolean
operators

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Searching in PubMed What is searched?

• Basic • Automatic Term Mapping

• Advanced • MeSH Translation Table (“Medical
• MeSH Subject Headings”)
• Journals Translation Table
• Author Index

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Scenario The EBM Process

• A 67 year old has a history of congestive heart • You think she should also be taking
failure brought on by several myocardial
infarctions. She has been hospitalized twice digoxin but you are not certain if this
within the last 6 months for worsening of heart will help keep her out of the hospital.
failure. At the present time she remains in
normal sinus rhythm. She is extremely diligent
• You decide to research this question
about taking her medications (Enalapril, Aspirin before her next visit.
and Simvastatin) and wants desperately to stay
out of the hospital. She lives alone with several
cats.

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Anatomy of a good clinical

question
• The next step in this • How would you describe a
process is to take the Patient or problem group of patients similar to
identified problem and yours?
construct a question that • What are the most important
is relevant to the case characteristics of the
patient?
and is phrased in such a
• This may include the primary
way as to facilitate problem, disease, or co-
finding an answer. existing conditions.
• This is called • Sometimes the sex, age or
race of a patient might be
"constructing a well relevant to the diagnosis or
built clinical question." treatment of a disease.

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Anatomy of a good clinical Anatomy of a good clinical

question question
Intervention • Which main intervention,
Comparison • What is the main
prognostic factor, or exposure alternative to compare
are you considering?
• prognostic factor with the intervention?
• What do you want to do for the
• Are you trying to decide
• exposure patient? Prescribe a drug?
Order a test? Order surgery? between two drugs, a
• What factor may influence the drug and no medication
prognosis of the patient? Age? or placebo, or two
Co-existing problems? diagnostic tests?
• What was the patient exposed • Your clinical question
to? Asbestos? Cigarette
smoke?
does not always need a
specific comparison.

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Anatomy of a good clinical The clinical question might

question be
Outcomes • What can you hope to • In elderly patients with congestive
accomplish, measure,
improve or affect? heart failure, is digoxin effective in
• What are you trying to reducing the need for
do for the patient?
rehospitalization?
• Relieve or eliminate
the symptoms?
• Reduce the number of
adverse events?
• Improve function or test
scores?

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The structure of the question Formulate the strategy

• Example: In elderly patients with congestive heart
might look like this: failure, is digoxin effective in reducing the need for
rehospitalization?
Patient / congestive heart failure, elderly
Problem
PICO Our Question Search Terms
Intervention digoxin Patient congestive heart congestive
Comparison, if none, placebo Population failure, elderly heart failure
any
Intervention digoxin digoxin
Outcome primary: reduce need for hospitalization
Outcome rate of hospitalization
secondary: reduce mortality
hospitalization

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MEDLINE
Clinical Clinical Strategy
Type of question
Question Scenario
Patient Population congestive heart heart failure, congestive
failure, elderly limit to age • Two additional elements of the well-
Intervention digoxin digoxin built clinical question are the type of
Comparison none or placebo question and the type of study.
(if any)
Outcome rate of hospitalization hospitalization
• This information can be helpful in
Type of Question therapy
focusing the question and determining
Type of Study RCT limit to RCT as publication the most appropriate type of
type evidence.

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Type of Type of Study

Question
Common types of questions
Therapy RCT>cohort > Case control > Case series related to clinical tasks
Diagnosis Prospective, blind comparison to a gold standard
Diagnosis How to select and interpret diagnostic tests
Etiology/Harm RCT > Cohort > Case control > Case series Therapy How to select treatments to offer patients that do
more good than harm and that are worth the efforts
and costs of using them
Prognosis Cohort study > Case control > Case series
Prognosis How to estimate the patient's likely clinical course
Prevention RCT>Cohort study > Case control > Case series over time and anticipate likely complications of
disease
Clinical Exam Prospective, blind comparison to gold standard Harm/Etiology How to identify causes for disease (including
iatrogenic forms)
Cost Economic Analysis

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Search Step 1
• Search each important
concept separately
• Enter the term:
congestive heart
failure
• PubMed attempts to map your
term to an appropriate
Medical Subject Heading
(MeSH)
• Click on Details to see what
terms PubMed used in its
search. You want to be sure it
found the appropriate MeSH
Terms and Text Words.
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• Next, Clear the search box
and enter the term for the
intervention, digoxin
• Again, PubMed attempts to
map your term to an
appropriate Medical Subject
Heading (MeSH)
• Click on Details to see what
terms PubMed used in its
search. You want to be sure it
found the appropriate MeSH
Terms and Text Words.
• Next, Clear the search box
and enter the term for the
outcome, hospitalization
• Again, PubMed attempts to
map your term to an
appropriate Medical Subject
Heading (MeSH)
• Click on Details to see what
terms PubMed used in its
search. You want to be sure it
found the appropriate MeSH
Terms and Text Words.

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Step 2 Step 3

• Combine the separate • The best evidence for a

sets of articles therapy question is a
• Click on History to view RCT
the 3 separate sets of • Limit the results to
articles you retrieved. randomized controlled
You need to combine trial as a publication
them to identify those type.
articles that contain all 3
terms. • If needed, we can also
limit to English language,
• In PubMed you must human, and age group.
use the “#”

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Review the results

• Review the titles and

abstracts to identify
potentially relevant
Thank you
articles.
• While article #17 seems
more appropriate for
information about
hospitalization, we
chose #18 because it is
the original DIG Study.

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