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Information at Point of Need “We believe the best use of information technology provides health care information at the point of need and in the manner in which it can best be utilized.” ©Sandra A. Martin Source: Martin, S. A., Shreeve, S. & Prislin, M. (1999). Development of a longitudinal patient-care oriented informatics curriculum featuring web-based instructional and assessment tools. Association of American Medical Colleges Annual Meeting. Background vs. Foreground Questions Asking questions about your proposed topic helps to clarify your knowledge gap Type of question helps to determine which sources are most likely to have the answers you need Background Questions Generally ask who, what, why, where or how about a single concept Examples: What are the contraindications for the use of timolol to treat glaucoma? What are the risk factors for glaucoma? Answers to Background Questions Require general knowledge of disease and therapeutic processes Quickest places to find answers in drug monographs and review articles Foreground Questions Usually compare two or more concepts – drugs, treatments, tests, prognosis of two groups, harms or benefits of two approaches, etc. Example: Is latanoprost as effective as travoprost or bimatoprost in achieving 24-hour control of IOP in patients with POAG? Answers to Foreground Questions Require precise information about complex issues Sources should provide current, original clinical research data – Pub Med / The Cochrane Library جستجوی شواهد برای تهیه راهبرد جستجو ،ابتدا اجزای پیکو را مشخص میکنیم. مترادف هر یک از اجزا را پیدا میکنیم. از ترکیب اجزای پیکو راهبرد(های) جستجو را تهیه میکنیم. 8 جستجوی شواهد P I Filter (P AND I AND C AND O) C 9 O 9 )(ادامه جستجوی شواهد In children with colds, are zinc lozenges safe and effective for relief of cold symptoms? Question part Question term Population/problem Child; Cold Synonyms Children, youth; Common cold, rhinovirus Lozenges, Zinc acetate, Zinc gluconate Intervention Zinc Comparator No zinc – – – Outcome 10 )(ادامه جستجوی شواهد راهبردهای جستجو به وجود،از ترکیب واژههای مختلف :میآید (Population/Problem OR synonym1 OR synonym2…) AND (Intervention OR synonym1 OR synonym2…) AND (Comparator OR synonym1 OR synonym2…) AND (Outcome OR synonym1 OR synonym2…) 11 )(ادامه جستجوی شواهد Child AND Cold AND Zinc (Child OR Children OR youth) AND (Cold OR Common cold OR Rhinovirus) AND (Zinc OR Zinc acetate OR Zinc glocunate) 12 جستجوی شواهد انواع سؤال بالينی عامل بیماری – تشخیص – درمان – پیشگیری – پیشآگهی – 13 (ادامه) جستجوی شواهد انواع مطالعه (ادامه) کارآزمایی بالینی – مطالعه کوهورت (همگروهی) – مطالعه مورد -شاهدی – مطالعه مقطعی – مشاهده بالینی (گزارش موردی ،گزارش سری موارد) – 14 جستجوی شواهد 15 (ادامه) )(ادامه جستجوی شواهد نوع سؤال و نوع مطالعه Question Best study designs INTERVENTION Randomized controlled trial (RCT) AETIOLOGY AND RISK FACTORS FREQUENCY AND RATE DIAGNOSIS PROGNOSIS AND PREDICTION Randomized controlled trial (RCT) Cohort study Case-control study Cohort study Cross-sectional study Cross-sectional study with random or consecutive sample Cohort/survival study 16 )(ادامه Level Intervention I Least Biased جستجوی شواهد Diagnosis Etiology Systematic review of Systematic review of Systematic review of Systematic review of level II studies level II studies level II studies level II studies II Randomized controlled trial Cross-sectional study among consecutive presenting patients II One of the following: One of the I Non-randomized following: experimental study Cross-sectional Analytical study among observational studies non-consecutive patients Diagnostic casecontrol study Case series I Case series V Most biased Prognosis Inception cohort study Prospective cohort study One of the following: Untreated control patients in a randomized controlled trial Retrospectively assembled cohort study Case series. or a cohort study of patients at different stages of disease One of the following: Retrospective cohort study Case-control study A cross- sectional study 17 جستجوی شواهد (ادامه) برای پاسخ به یک سئوال بالینی همه مطالعات ارزش یکسانی ندارند. رتبهبندی مطالعات از نظر احتمال سوگیری و امکان پاسخدهی بهتر به انواع سؤاالت ،به ما کمک میکند برای پاسخ به سؤال خود بهترین شواهد ممکن را جستجو و پیدا کنیم. 18 )(ادامه جستجوی شواهد سازماندهی شواهد در پایگاههای دادهای Systems Computerized decision support systems Synopses Evidence-based Journal abstracts Syntheses Cochrane reviews abstracts Single Studies Original published articles 19 The Case We will focus on the following patient case: Mr. J. is a 70-year-old African American man with a history of acute myocardial infarction (MI) six weeks ago. He appears to be doing well on medical therapy (including aspirin, beta blocker, ACE inhibitor, and statin), though post-MI echocardiography has shown a low left ventricular ejection fraction (LVEF) of 30%. Mr. J. is very close to his grandchildren and reports that his eldest granddaughter just got into law school. He is concerned that, given the state of his heart, he will not survive to see her graduate. Mr. J's physician tells you that several studies have investigated whether prophylactic placement of an implantable defibrillator can reduce mortality in patients such as Mr. J. who have problems with ejection fraction following an MI. She tells you to find evidence that would indicate whether or not Mr. J. might benefit from implantation of a defibrillator. You are asked to do a PubMed search and bring the answer to morning rounds. Formulating your Question One of the most important steps in doing a PubMed search is creating a focused question. PubMed includes over 18 million citations, but not all of them will meet your information needs. Think about your topic and formulate a specific question that will help you retrieve and identify relevant information. The following framework, often referred to as PICO or PICOTT, helps you to identify the important elements of a question (the who, what and why). Patient Problem – Describe the primary condition or patient's problem. Intervention, diagnostic test, prognostic factor, or exposure - What treatment, test, or exposure are you considering? Comparison - What are you comparing this to? (You don't always have an active comparison.) Outcome - Describe what you and the patient want to have happen. TT - Type of Question/Type of Study Type of Question and Study You also need to think about the type of question you are asking. Some types of questions may require a certain type of study [PDF]. For example, if you are interested in whether a drug is effective in treating a particular disease, you would look for randomized controlled trials. Type of Question Type of Study* Therapy-- how to select treatments that do more good than harm and that are worth the efforts and costs of using them RCT (randomized controlled trial)> prospective cohort Can also be answered by a meta-analysis or systematic review Diagnosis-- how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis, based on their precision, accuracy, acceptability, expense, safety, etc. prospective, blind comparison to a gold standard Prognosis-- how to estimate the patient's likely clinical course over time and anticipate complications of disease cohort study > case control > case series Etiology/Harm-- how to identify causes for disease (including iatrogenic forms) RCT** > cohort > case control > case series PICOTT Using our case, we can describe the patient problem, intervention, comparison, and outcome and note the type of question and the corresponding type of study. PICOTT: Our Case: male, African American, history of Patient Problem myocardial infarction and low left ejection fraction Intervention implantable defibrillator Comparison none Outcome reduce risk of death; reduce mortality Type of Question therapy Type of Study randomized controlled trial Forming the Clinical Question Your clinical question would be something like: In patients with a history of acute MI and low left ejection fraction, will an implantable defibrillator help reduce mortality? Formulate the Strategy using Key Concepts Now, what would you search? Using the PICOTT framework helps you set up your search strategy. You don't always need to include all concepts in a search such as race, gender, or age. But having these concepts defined in the PICOTT will help you choose the most relevant articles later on. (Even if you think age is important here, you don't need to include it in your search at the beginning; rather wait until the end to limit by age group on the Limits page.) *This is a therapy question. We will get at the concept of therapy by searching for the type of study that correlates with it (RCT). PICOTT: Our Case: Key Concepts: male, African American, history myocardial infarction Patient Problem of myocardial infarction and low low left ejection fraction left ejection fraction Intervention implantable defibrillator implantable defibrillator Comparison none reduce risk of death; reduce Outcome mortality mortality Type of Question therapy * Type of Study randomized controlled trial randomized controlled trial Search strategy myocardial infarction OR low left ejection fraction AND implantable defibrillator AND mortality Exercises: PICO scenarios Medical students Group 1 Aspirin for the primary thrombosis prevention in the antiphospholipd syndrome The accuracy of single serum progesterone measurement in the diagnosis of ectopic pregnancy Antibiotics versus placebo for postoperative infection after appendicectomy Group 2 In diabetic patients does aspirin prevent CVD In elderly patients does MD intervention therapies reduce the incidence of falls In patients with suspected heart failure does BNP accurately predict disease compared to the gold standard Group 3 Does Steroid Treatment improve renal recovery in patients with induced acute interstitial nephritis Is early compared to late haemodialysis better for survival in critically ill patients with ARF ( acute renal failure) Does pre operative compared to post operative chemo and radiotherapy improve survival in rectal cancer patients with resectable disease Group 4 Does a statin reduce CVD in Middle aged men with no IHD, but a high cholesterol What is the evidence that every pregnant women needs to have folic acid to reduce neural tube defects Does CPAP improve mortality in pulmonary odema What is the evidence goserelin reduces chronic pelvic pain Group 5 Is aspirin effective in primary prevention of CVD in diabetics Is vitamin c effective for the symptoms of the common cold In patients with FH of thalassaemia does using a risk counselling tool increase number going to screening Antibiotics versus placebo for postoperative infection after appendicectomy PICO Exercises/ nursing students A 72 y/o male with osteoarthritis wants to take glucosamine and chondroitin sulfate instead of other meds. Is there any evidence of effectiveness? A women in her mid 40s with a family history of breast cancer is scheduling her yearly breast exam. Should an MRI or a mammogram be scheduled? A nurse in the ICU asks about the care of patients with head injuries. She’s wondering if elevating the head of the bed 30 degrees will reduce intracranial pressure. John is 3 years old, has an ear infection and hates taking medicine. He’s already taken the antibiotic for 6 days and is feeling better. His parents want to know if they can stop. Is the short course (< 7 days) as effective as the long course (14 days) in treating otitis media in children? You have an infant with suspected congenital heart disease and order an MRI. The parents request an echocardiogram. Which test should be performed or both? In children with asthma, 2mg/kg of prednisone is commonly used. In other countries the usual dose is 1mg/kg. Which is more effective in reducing length of exacerbations? A nurse in the PACU (post-anesthesia care unit) is interested in ways to decrease the use of pain medication in post-op patients. She’s wondering if classical music or guided imagery might be efficacious. A nurse in the ICU asks about the care of patients with head injuries. She’s wondering if elevating the head of the bed 30 degrees will reduce intracranial pressure. John is 3 years old, has an ear infection and hates taking medicine. He’s already taken the antibiotic for 6 days and is feeling better. His parents want to know if they can stop. Is the short course (< 7 days) as effective as the long course (14 days) in treating otitis media in children? Thanks