JMLA Case Studies in Health Sciences Librarianship

TV shows prompting bioethics discussions

2009-01-26T07:47:00.000-08:00

In this week's AMNews: TV doctors' flaws become bioethics teaching moments -- comments on a recent study examining medical students' TV viewing habits.

Dr. House is the fictional protagonist of Fox TV's "House," a medical mystery drama that last year drew an average 16.2 million viewers weekly. The bad-boy antics that made the master diagnostician a hit with American viewers also have made him popular among medical students, according to a December 2008 study in The American Journal of Bioethics.

The survey of nearly 400 medical and nursing students at Johns Hopkins University in Maryland found that 76% of doctors in training watch "House" and 73% watch ABC's hospital soap opera "Grey's Anatomy." Nearly 40% watch NBC's "ER" and one in five tunes in "Nip/Tuck," which airs on the FX cable network. Eighty-five percent of medical students said they watched a medical drama in the prior year.

The AJOB paper itself: Matthew Czarny, Edwin Bodensiek, Ruth R. Faden, Marie T. Nolan, Jeremy Sugarman. Medical and Nursing Students' Television Viewing Habits: Potential Implications for Bioethics 2008. The Am J Bioethics 2008 Dec; 8(12):1.

Personalized genetic prediction

2009-01-20T07:54:00.000-08:00

Commentary on the current state of genetic testing for personalized medicine, including promise as well as challenges that still need to be tackled..

Personalized Genetic Prediction: Too Limited, Too Expensive, or Too Soon?
John P.A. Ioannidis
Ann Intern Med 2009;150 139-141
http://www.annals.org/cgi/content/full/150/2/139?etoc

“Genetic epidemiology has identified many common genetic variants that are associated with common diseases, and the list is growing monthly (1, 2). This success has boosted expectations for personalized genetic prediction. According to these expectations, genetic information can tell people about their risk for various diseases and which medications they should use or avoid. However, 2 articles in this issue (3, 4) suggest that this promise may be exaggerated and premature.”

New JAMA users' guide article

2009-01-06T14:34:00.000-08:00

In today's JAMA -- John Attia; John P. A. Ioannidis; Ammarin Thakkinstian; Mark McEvoy; Rodney J. Scott; Cosetta Minelli; John Thompson; Claire Infante-Rivard; Gordon Guyatt. How to Use an Article About Genetic Association: A: Background Concepts. JAMA 2009;301 74-81.

The start of a 3-article series about how to read a genetic association study.

Update: the 2nd and 3rd articles are now available too.

- Attia J, Ioannidis JPA, Thakkinstian A; et al. How to use an article about genetic association: B: are the results of the study valid? JAMA. 2009;301(2):191-197.

- John Attia; John P. A. Ioannidis; Ammarin Thakkinstian; Mark McEvoy; Rodney J. Scott; Cosetta Minelli; John Thompson; Claire Infante-Rivard; Gordon Guyatt. How to Use an Article About Genetic Association: C: What Are the Results and Will They Help Me in Caring for My Patients? JAMA 2009;301 304-308.

Limited usefulness of private-sector medication information

2008-12-19T08:34:00.000-08:00

From the FDA: "Study Finds Much of Private-Sector Consumer Medication Information Not Consistently Useful" (12/16/2008)

A study released today by the U.S. Food and Drug Administration found that the printed consumer medication information (CMI) voluntarily provided with new prescriptions by retail pharmacies does not consistently provide easy-to-read, understandable information about the use and risks of medications.

The study, Expert and Consumer Evaluation of Consumer Medication Information, showed that while most consumers (94 percent) received CMI with new prescriptions, only about 75 percent of this information met the minimum criteria for usefulness as defined by a panel of stakeholders. In 1996, Congress called for 95 percent of all new prescriptions to be accompanied by useful CMI by 2006.

Cyberchondria

2008-12-19T08:21:00.000-08:00

One more from the WSJ's Health blog -- summary of a recent Microsoft study about how people search for health information: Cyberchondria: it's not just in your head.

Is that burning feeling heartburn or a heart attack? Quick, your brain says to the hand not clutching your chest, type “chest pain” into Google and let’s get to the bottom of this.

What happens next, for many people, is a descent into worst-case scenarios, fueled by the ready availability of information on the Web about medical conditions both rare and common. Obscure or serious medical problems can bubble up to the first page of search results, where anxious searchers can quickly conclude their symptoms result from scary but unlikely causes. Before you can say, “Google,” there’s another case of cyberchondria on the loose.

Negative studies going unpublished

2008-12-19T08:17:00.000-08:00

Brief item on the Wall Street Journal Health blog -- "How many negative drug studies still go unpublished?" -- includes highlights from the last year's studies on publication bias and news items about pharma potentially suppressing release of some results.

Latest JMLA case

2008-12-04T08:07:00.000-08:00

In case you haven't seen it yet, check out the latest installment in the JMLA case study series -- The role of the medical librarian in the basic biological sciences: a case study in virology and evolution by Michele Tennant and Michael Miyamoto.

This case challenges us to apply our medical knowledge building and searching skills to the field of virology, touring us through basic virology concepts and considering the implicit nature of the answer for the question featured in the case.

The next case will tackle a selection of veterinary and zoological medicine topics and will appear later next year.

New IOM report on resident work hours

2008-12-04T07:41:00.000-08:00

The Institute of Medicine has released new recommendations for resident work hours, including protected time for sleep intervals during call and longer shifts, off-time, and other issues. The full-text of the report is online here and links to a few commentary pieces below:

- NEJM article, including table comparing new recommendations to the existing ACGME recs
- New York Times article
- ACGME press release about the report, including mention of a pending March 2009 conference on work hours

Wikipedia for Drug Information

2008-11-25T14:20:00.000-08:00

Several posts on this blog have looked at the varying ways Wikipedia can be used for addressing medical concepts. Reuters Health reports today on a study from researchers at Nova Southeastern University that compares the scope, completeness, and accuracy of drug information in Wikipedia when comparted to Medscape Drug Reference (MDR).

Using assessments in 8 categories of drug information, the study authors report that Wikipedia answered fewer drug questions than MDR (40% vs. 82.5%, p<0.001) see PubMed abstract.

Interesting article. Did you know to date there are over 30 articles in Pubmed referencing Wikipedia? More than 50 mention wikis in general?

Understanding cancer

2008-09-19T08:52:00.000-07:00

A few of our search challenges have focused on a cancer-related topic - for those interested in understanding more about how cancer develops, etc., check out these two posts from denialism blog at ScienceBlogs:
Cancer 101
Cancer 102

C. diff in the news again

2008-09-17T07:44:00.000-07:00

Our second JMLA case discussed Clostridium difficile infection, and this type of healthcare-acquired infection continues to gain notoriety, now being billed by some as "the new MRSA" -- see this brief item in the WSJ Health blog and this longer piece in the Wall Street Journal itself.

Medication errors

2008-08-27T11:16:00.001-07:00

A nice brief piece from NPR's Day to Day today, discussing outpatient medication errors--touches particularly on patient education and doctor/patient communication as key to addressing the issue.

Painkillers, sleeping pills and anti-anxiety drugs are being prescribed to out-patients in high doses, without the oversight of a doctor. A new study found that in the last 20 years there has been a 500 percent increase in the death rate from medication errors made at home. Medical contributor Dr. Sydney Spiesel discusses the data with Alex Chadwick.

July JMLA case

2008-08-11T09:44:00.000-07:00

The latest JMLA case, Addressing Hemolysis in an Infant Due to Mother–Infant ABO Blood Incompatibility, is available in the July issue of the journal.

The question that this case focuses on: Is [intravenous immunoglobulin G] a safe and effective alternative to exchange transfusion in a premature infant with hemolysis and hyperbilirubinemia secondary to ABO incompatibility, who has failed phototherapy?

See the full-text of the case for definition of the medical terms, discussion of the search, and an analysis of the literature on this topic!

Adoption of electronic medical records

2008-08-11T09:39:00.000-07:00

This week's MedlinePlus podcast from the National Library of Medicine covers data about provider and patient perceptions and adoption of EMRs; Rob Logan PhD is filling in for Dr Lindberg this week. The transcript of the podcast is here and the MedlinePlus topic page on EMRs is here.

Learning about qualitative research in today's BMJ

2008-08-08T08:50:00.000-07:00

This week's British Medical Journal includes several great overview/tutorial pieces about aspects of qualitative research:

- Ayelet Kuper, Scott Reeves, and Wendy Levinson. An introduction to reading and appraising qualitative research. BMJ 2008;337:a288

- Ayelet Kuper, Lorelei Lingard, and Wendy Levinson. Critically appraising qualitative research. BMJ 2008;337:a1035

- Scott Reeves, Ayelet Kuper, and Brian David Hodges. Qualitative research methodologies: ethnography. BMJ 2008;337:a1020

- Scott Reeves, Mathieu Albert, Ayelet Kuper, and Brian David Hodges. Why use theories in qualitative research? BMJ 2008;337:a949

- Brian David Hodges, Ayelet Kuper, and Scott Reeves. Discourse analysis. BMJ 2008;337:a879

- Lorelei Lingard, Mathieu Albert, and Wendy Levinson. Grounded theory, mixed methods, and action research. BMJ 2008;337:a567

Search challenge 11

2008-08-04T14:14:00.000-07:00

This month's topic: What information (online or print) and support resources are available for children with wheat allergy and their parents?

Post your suggestions in the comments and come back on Tuesday Sept. 2 for more discussion!

Search challenge 10: strategies

2008-08-04T07:59:00.000-07:00

Search challenge 10 examines the issue of how to decide on appropriate screening practices for breast cancer in a young woman whose grandmother developed breast cancer at a relatively young age.

A search that incorporates the main "components" of the question might look something like:
("Breast Neoplasms/diagnosis"[Majr] OR breast neoplasms/genetics[majr]) AND (inherited[tiab] OR familial[tiab] OR high risk[tiab] OR family history[tiab] OR grandmother[tiab] OR pedigree[tiab] OR second degree[tiab] OR heredity[tiab] OR hereditary[tiab]) AND (age factors[mh] OR risk[mh] OR predictive value of tests[mh] OR sensitivity and specificity[mh]) AND (diagnostic imaging[majr] OR mass screening[majr]) AND english[la] AND humans[mh] NOT (case reports[pt] OR letter[pt] OR comment[pt] OR editorial[pt])

A few good articles on the topics, drawn from PubMed and a Google search:
Claus EB, Risch N, Thompson WD. Autosomal dominant inheritance of early-onset breast cancer. Implications for risk prediction. Cancer. 1994 Feb 1;73(3):643-51. PMID: 8299086

Kriege M, Brekelmans CT, Obdeijn IM, Boetes C, Zonderland HM, Muller SH, Kok T, Manoliu RA, Besnard AP, Tilanus-Linthorst MM, Seynaeve C, Bartels CC, Kaas R, Meijer S, Oosterwijk JC, Hoogerbrugge N, Tollenaar RA, Rutgers EJ, de Koning HJ, Klijn JG. Factors affecting sensitivity and specificity of screening mammography and MRI in women with an inherited risk for breast cancer. Breast Cancer Res Treat. 2006 Nov;100(1):109-19. Epub 2006 Jun 22. PMID: 16791481

Kriege M, Brekelmans CT, Boetes C, Besnard PE, Zonderland HM, Obdeijn IM, Manoliu RA, Kok T, Peterse H, Tilanus-Linthorst MM, Muller SH, Meijer S, Oosterwijk JC, Beex LV, Tollenaar RA, de Koning HJ, Rutgers EJ, Klijn JG; Magnetic Resonance Imaging Screening Study Group. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med. 2004 Jul 29;351(5):427-37. PMID: 15282350

NCCN practice guidelines in oncology: Breast cancer risk reduction, 2008. Vol. 1, http://www.nccn.org/professionals/physician_gls/PDF/breast_risk.pdf

NCCN practice guidelines in oncology: Breast cancer screening and diagnosis, 2008. Vol. 1, http://www.nccn.org/professionals/physician_gls/PDF/breast-screening.pdf

NCCN practice guidelines in oncology: Genetic/familial high risk assessment: Breast and ovarian, 2008. Vol. 1, http://www.nccn.org/professionals/physician_gls/PDF/genetics_screening.pdf

Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, Morris E, Pisano E, Schnall M, Sener S, Smith RA, Warner E, Yaffe M, Andrews KS, Russell CA; American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007 Mar-Apr;57(2):75-89. Erratum in: CA Cancer J Clin. 2007 May-Jun;57(3):185. PMID: 17392385

Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP 3rd, Foster RS Jr, Hendrick E, Eyre HJ, Sener S; American Cancer Society High-Risk Work Group;American Cancer Society Screening Older Women Work Group; American Cancer Society Mammography Work Group; American Cancer Society Physical Examination Work Group; American Cancer Society New Technologies Work Group; American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast cancer screening: update 2003.CA Cancer J Clin. 2003 May-Jun;53(3):141-69.PMID: 12809408

Yu J, Park A, Morris E, Liberman L, Borgen PI, King TA. MRI screening in a clinic population with a family history of breast cancer. Ann Surg Oncol. 2008 Feb;15(2):452-61. Epub 2007 Nov 17. PMID: 18026801

Health literacy and the emergency room

2008-07-14T09:45:00.000-07:00

A multicenter, cross-sectional study in last month's Academic Emergency Medicine administered a short health literacy assessment questionnaire to 300 patients in 3 Boston emergency rooms. In addition to examining raw scores, investigators also looked at correlations with other sociodemographic variables.

Older age, less education, and lower income were all associated with reduced functional health literacy. Associations with ethnicity, race, and language were not statistically significant in the multivariate analysis (i.e. after correcting for other variables).

The authors note "In this sample, one-quarter of ED patients would be expected to have difficulty understanding health materials and following prescribed treatment regimens. Advanced age and low socioeconomic status were independently associated with limited health literacy. The ability of a significant subgroup of ED patients to understand health information, especially during illness or injury, requires further study."

One potential limitation that comes to mind - a cross-sectional study gives just a snapshot, rather than a longitudinal assessment -- the questionnaire results reflect each individual's completion of a brief test during their stay in the ED setting, which is a fairly difficult environment given the complexity of this kind of healthcare encounter (stress of the health condition, urgency, family issues, financial considerations, etc.). The competing concerns of the environment may shift individual test results downward. If you tested the same person while they were going to a routine visit at their doctor, their results may be different.

On the other hand, the methods of the current study would seem to give an accurate picture of functional health literacy at the moment of crisis, which speaks more to how people may (or may not) be able to handle, process, and retain information in that particular setting.

So, having a librarian stationed in the ED might not, then, be a good idea, but do other strategies come to mind for aiding individuals with lower health literacy in this setting?

Reference: Ginde AA, Weiner SG, Pallin DJ, Camargo CA Jr. Multicenter study of limited health literacy in emergency department patients. Acad Emerg Med. 2008 Jun;15(6):577-80. PubMed abstract

Change in drugmaker swag

2008-07-10T07:11:00.000-07:00

via WSJ's Health blog -- Drugmakers pulling plug on free pens, mugs, and pads -- talks about this revision to the PhRMA Code (voluntary guidelines for pharma marketing activities), authored by the pharmaceutical industry's trade group, which is calling for more responsible marketing by eliminating some of the freebie gifts. It doesn't, however, set explicit limits on spending for physician consulting and speaking engagements, but recommends internal limits and tracking procedures be put in place.

The full PhRMA marketing code is here; more in the WSJ and the New York Times.

Violence against nurses

2008-07-09T08:41:00.000-07:00

It seems like we get a search request on this topic every couple of years or so and yesterday's New York Times has a great piece by David Tuller summarizing recent stats about violence against nurses and workplace prevention strategies -- "Nurses Step Up Efforts to Protect Against Attacks" (via The Pump Handle)

For more info, a quick PubMed search - nurse-patient relations[majr] AND violence[majr] (does include some false drops about screening for abuse, domestic violence, elder abuse, etc.)

PubMed as a verb

2008-07-08T12:20:00.000-07:00

DrugMonkey ponders the changing role of PubMed with increasing focus on open access -- "I'll PubMed it and find out"

Most of the audience for this blog will be familiar with the use of "Google" as a verb to describe searching the World Wide Web for information on a given topic. "I googled a half-dozen mojito recipes which we tried out on the Fourth". "Did you google your blind date/new postdoc to make sure he isn't a psycho?". "You got dinner plans after the conference sessions end for the day? No? Lemme google up some restaurants."
...
Lagging well behind this transformation of our information-age lives, but assuredly steaming right along behind, is the verb-ification of PubMed. For some of us, it is here already. This is the area where I am sympathetic to the antics of the Open Access Acolytes™.

Search challenge 10

2008-07-08T09:04:00.000-07:00

For this month's search challenge, a question from a primary care physician: A woman's maternal grandmother had breast cancer at the age of 36. As a result, her ob/gyn is recommending screening to begin at 31. What is the evidence for determining when to begin screening patients who have second degree relatives with breast cancer? Is imaging other than mammogram (e.g. MRI) preferred? Does the presence/absence of BRCA 1/2 mutations affect these recommendations?

Post your suggestions in the comments! I'll pull our thoughts together for a follow-up post on the first Monday of August.

Search challenge 9: strategies

2008-07-08T08:36:00.000-07:00

Search challenge 9 was "Can you find literature that discusses physician/nurse collaboration and communication, and assessments of associated effects on nurse retention?"

One commenter posted a CINAHL strategy and found some dissertations that may be useful in aiding a literature review, also noting that a PubMed on the search might be more difficult since some of the most relevant indexing terms are unique to CINAHL.

From a few quick searches, the main term that seems to be useful in PubMed is the MeSH term "Physician-Nurse Relations" -- restricting to "major" and a few other things brings it down to about 500 hits, including ~180 in the last two years

"Physician-Nurse Relations"[Majr] AND eng[la] NOT (case reports[pt] OR letter[pt] OR comment[pt] OR editorial[pt] OR news[pt] OR newspaper article[pt])

ANDing a string like (job satisfaction[mh] OR personnel turnover[mh] OR retention[tiab] OR retaining[tiab] OR retain[tiab] OR retained[tiab] OR turnover[tiab]) was fairly effective in finding a few studies that looked at the retention/turnover issue. Other MeSH terms also seemed to pop up in the indexing of the more relevant items -- "communication," "attitudes of health personnel," "cooperative behavior," "burnout, professional," and the "psychology" subheading (attached to various MeSH terms).

EMRs in ambulatory care

2008-07-07T08:29:00.000-07:00

Last week's NEJM has a large survey of opinion and usage of EMRs by ambulatory care physicians (n=2758):

DesRoches CM, Campbell EG, Rao SR, Donelan K, Ferris TG, Jha A, Kaushal R, Levy DE, Rosenbaum S, Shields AE, Blumenthal D. Electronic health records in ambulatory care--a national survey of physicians. N Engl J Med. 2008 Jul 3;359(1):50-60.

excerpt from the abstract:

Results: Four percent of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. In multivariate analyses, primary care physicians and those practicing in large groups, in hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records. Physicians reported positive effects of these systems on several dimensions of quality of care and high levels of satisfaction. Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records.

Conclusions: Physicians who use electronic health records believe such systems improve the quality of care and are generally satisfied with the systems. However, as of early 2008, electronic systems had been adopted by only a small minority of U.S. physicians, who may differ from later adopters of these systems.

Health privacy framework for Google and Microsoft

2008-06-26T07:45:00.000-07:00

via the WSJ Health Blog: Google, Microsoft Agree to Health Privacy Standards (endorsed by AAFP and AARP, among others)

The 8MB full framework document is available for downloading here (along with a Flash presentation of key issues and points).

Million-dollar babies

2008-06-13T10:09:00.000-07:00

The July case study, due out in the next JMLA issue sometime next month, focuses on care of a baby in a neonatal intensive care unit (NICU). This week, Business Week considers the ethics and economics of NICU care - "Million-Dollar Babies."

Another partner for Google Health

2008-06-13T08:27:00.000-07:00

Blue Cross Blue Shield of Massachusetts announces collaboration with Google Health - from WSJ Health blog: Massachusetts Blues team up with Google on records

Patients will be able to view their treatment details on-line based on the insurers’ records. Information in the records would come from doctors as well as laboratories and pharmacies. Other health-care history that doesn’t come from insurance claims records would have to be entered by patients’ doctors, however.

URL decay in Medline abstracts

2008-06-11T10:05:00.000-07:00

Published today in BMC Medical Informatics and Decision Making:

Ducut E, Liu F, Fontelo P. An update on Uniform Resource Locator (URL) decay in MEDLINE abstracts and measures for its mitigation. BMC Medical Informatics and Decision Making 2008, 8:23.

An excerpt from the abstract:

Methods: MEDLINE records from 1994 to 2006 from the National Library of Medicine in Extensible Mark-up Language (XML) format were processed yielding 10,208 URL addresses. These were accessed once daily at random times for 30 days. Titles and abstracts were also searched for the presence of archival tools such as WebCite, Persistent URL (PURL) and Digital Object Identifier (DOI).

Results: Results showed that the average URL length ranged from 13 to 425 characters with a mean length of 35 characters [Standard Deviation (SD) = 13.51; 95% confidence interval (CI) 13.25 to 13.77]. The most common top-level domains were ".org" and ".edu", each with 34%. About 81% of the URL pool was available 90% to 100% of the time, but only 78% of these contained the actual information mentioned in the MEDLINE record. "Dead" URLs constituted 16% of the total. Finally, a survey of archival tool usage showed that since its introduction in 1998, only 519 of all abstracts reviewed had incorporated DOI addresses in their MEDLINE abstracts.

(A quick search of PubMed using the search "http*[tiab]" (without the quotes) yields some examples of URLs included within the abstract)

Atlantic Monthly: Is Google Making Us Stupid?

2008-06-10T14:22:00.000-07:00

Nicholas Carr has an interesting piece in the July/August Atlantic Monthly, pondering the effect of the internet and the quick availability of easily digested pieces of information via Google on one's ability to read and enjoy longer essays, books, etc.

My mind isn’t going—so far as I can tell—but it’s changing. I’m not thinking the way I used to think. I can feel it most strongly when I’m reading. Immersing myself in a book or a lengthy article used to be easy. My mind would get caught up in the narrative or the turns of the argument, and I’d spend hours strolling through long stretches of prose. That’s rarely the case anymore. Now my concentration often starts to drift after two or three pages. I get fidgety, lose the thread, begin looking for something else to do. I feel as if I’m always dragging my wayward brain back to the text. The deep reading that used to come naturally has become a struggle.

(via Lifehacker)

More piloting of patient e-health records

2008-06-09T07:13:00.000-07:00

Via today's Wall Street Journal: Microsoft, Kaiser to Launch New Health-Records Program--

Microsoft Corp. and healthcare giant Kaiser Permanente plan to launch a pilot program to exchange patient information, the latest in a series of efforts to allow people to better maintain control over their health records.

The effort will involve securely transferring data maintained in Kaiser's personal health record -- an online repository containing data about topics such as patients' test results, prescriptions and immunizations -- to Microsoft's HealthVault, a Web-based service that allows patients to store and manage medical data from a variety of Web sites and selectively share information with them.

The program will initially roll out to ~156,000 Kaiser Permanente employees.

Also in...
- Kaiser Permanente press release
- the New York Times

Google advanced search update

2008-06-06T11:20:00.000-07:00

Making Boolean searching easier in Google advanced search, via Lifehacker

Google adds a little Javascript magic to their Advanced Search page, which now dynamically builds your query using operators like OR, -, and quotes around exact phrases.

Search challenge 9

2008-06-02T16:12:00.000-07:00

This month's search challenge has two parts: Can you find literature that discusses physician/nurse collaboration and communication, and assessments of associated effects on nurse retention?

In the comments, please share your thoughts on appropriate terms, databases, other resources, good articles, etc!

IOM report on medical care for the elderly

2008-05-30T10:27:00.000-07:00

The Institute of Medicine recently released a report from the workgroup charged with assessing geriatric care in the US, including how our clinicians are trained, trends in the expected demand for geriatric care and the clinical workforce that cares for them -- it also proposes recommendations for changes that need to happen to effectively meet the needs of this growing group. The report is titled "Retooling for an Aging America: Building the Health Care Workforce" and you can read it for free on the IOM website.

The IOM's overview notes:

The resulting report, Retooling for an Aging America: Building the Health Care Workforce, says that as the population of seniors grows to comprise approximately 20 percent of the U.S. population, they will face a health care workforce that is too small and critically unprepared to meet their health needs. The committee concluded that if our aging family members and friends are to continue to live robustly and in the best possible health, we need bold initiatives designed to

- explore ways to broaden the duties and responsibilities of workers at various levels of training;
- better prepare informal caregivers to tend to the needs of aging family members and friends; and
- develop new models of health care delivery and payment as old ways sponsored by federal programs such as Medicare prove to be ineffective and inefficient.

The AMNews also has a nice synopsis of the report and links to the AMA's initiative focusing on caring for the elderly and several advocacy initiatives related to geriatric health.

Update on search challenge 4

2008-05-20T14:47:00.000-07:00

Search challenge 4 (here and here) looked at the incidence of vasovagal syncope among blood donors.

This week's JAMA includes an article that adds an interesting perspective on this question, one I hadn't considered before -- a study by Eder et al. employed Red Cross data to examine adverse events in 16 and 17 year old blood donors, and found a higher incidence of complications and related injury -- might be an interesting way to parse through the results of the PubMed strategy we came up with in the strategies for search challenge 4, to share with the reader the possibility that the incidence of fainting might vary with age and perhaps other variables in the included data (e.g. gender, ethnicity, weight and BMI).

So then, using our searching expertise to provide data that answers the question "what is the overall incidence of fainting in the blood donor population?" as well starting to get at the question "how do we know who might be at greater risk of this adverse event?"

The JAMA reference: Anne F. Eder, MD, PhD; Christopher D. Hillyer, MD; Beth A. Dy, BS; Edward P. Notari IV, MPH; Richard J. Benjamin, MD, PhD. Adverse Reactions to Allogeneic Whole Blood Donation by 16- and 17-Year-Olds. JAMA. 2008;299(19):2279-2286.

Search challenge 8: strategies

2008-05-20T13:52:00.001-07:00

I know, I've gotten behind in the search challenges -- I've realized that they take a little more time to pull together than I had expected (mostly because I love searching so much that I can't help but spend time in the search..), so I'm going to start posting them on a monthly basis, rather than weekly, to give myself and all the wonderful commenters a chance to really kick the tires of each of these... I'll post the new challenge and the preceding strategies, on the first Tuesday of every month, starting Tuesday June 3rd.

Until then, thoughts on search challenge 8 with help from Matt and Rachel, the two commenters on this challenge...

Tips for setting up automatic searches in PubMed using MyNCBI--
- using the preview/index feature to search for alternate spellings/misspellings for your institution's name, the authors you want to track, and OR-ing them all together
- building a search hedge using the author names for a given department (right now I'm working on one that tracks all of our Biomedical Informatics faculty publications, in a few different databases)

Other tips: using Google Alerts, topix.net, the librarian's RSS engine LibWorm, automated searches in other databases (e.g. Web of Science, CINAHL)

Who to share search results with: opportunities for communicating with institutional leadership, the communications/PR department, other departments in the institution that publish or otherwise appear in the news media frequently, the institution's office of Research or equivalent body.

Other thoughts or suggestions?

Will post the next challenge on June 3rd!

Google Health launched

2008-05-20T12:26:00.001-07:00

Google Health launched to the public yesterday-

More news here:
- WSJ blog
- AP story

And Google Health itself, of course:

Google Health puts you in charge of your health information. It's safe, secure, and free.

Organize your health information all in one place
Gather your medical records from doctors, hospitals, and pharmacies
Keep your doctors up to date about your health
Be more informed about important health issues

Search challenge 8

2008-04-29T07:56:00.000-07:00

With the ever-increasing growth of the medical literature, as well as seemingly increasing public scrutiny of the happenings at our medical institutions, it seems like finding good ways to "track" the publications of an institution and also how it's being mentioned in the popular media are challenges that health sciences librarians are being called to help address.

So, for this week, a multi-part search challenge:
- What strategies do you use to track what people from your institution (hospital, medical school, etc) are publishing (e.g. what databases, terms, other resources)?
- How do you track mentions of your institution in the popular media?
- How often do you update such searches?
- Who "needs" this information at your institution?

Search challenge 7: strategies

2008-04-29T07:44:00.000-07:00

Last week's search challenge explored whether there is evidence in the literature to support the use of nutritional therapy in patients with pressure ulcers.

A PubMed search strategy that seems to work well:
(pressure ulcer[mh] OR pressure ulcer*[tiab] OR decubitus ulcer*[tiab]) AND (nutrition[tiab] OR nutritional[tiab] OR nutrition therapy[mh] OR diet therapy[sh] OR vitamins[mh] OR vitamin[tiab] OR vitamins[tiab]) AND eng[la] AND humans[mh]

I also tried the MeSH term "nutritional support," since I was seeing some articles that looked at feeding regimens which are often indexed in this broad MeSH category, but didn't find that it added anything to the retrieval, probably because of the text words I'd included.

In reviewing the results, there's a meta-analysis that includes the literature through 2004: Stratton RJ, Ek AC, Engfer M, Moore Z, Rigby P, Wolfe R, Elia M. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005 Aug;4(3):422-50 (PubMed abstract) -- this meta-analysis included studies that focused on either enteral nutrition formulas or other oral supplements (e.g. vitamin C). The meta-analysis seemed well-executed and had clear inclusion/exclusion criteria; it also provided a good overview of the previous literature on this topic.

For this kind of question, I think I'd be comfortable providing a good meta-analysis accompanied by any high-quality references (e.g. trials or cohorts) published since the time it was executed; I'd also want to look at the kinds of things that they excluded and consider whether any of those need to be mentioned. For example, there might be therapies represented in small experimental studies that wouldn't make it into a meta-analysis but still would be useful to mention to the requester as a potential option, so that I'd feel like I was thoroughly representing all of the possible "options" that are in the literature.

Search challenge 7

2008-04-21T13:13:00.000-07:00

Since this month's case study focuses on a geriatric issue, this week we'll tackle a geriatrics-focused search question: Does improved nutrition (defined broadly to include controlled diet, supplementation, PEG feeding, etc.) help older patients heal a pressure ulcer more quickly and/or more effectively?

Search challenge 6: strategies

2008-04-21T12:46:00.000-07:00

As Martin points out in his comments on search challenge 6, some of the review-level literature on this topic is older than we've seen for some of the other search challenges.

If you enter "ischemic stroke" into the Entrez MeSH Browser, it links you to "Brain Stem Infarctions" - combining a location (the brain stem) with a particular kind of damage (infarction, i.e. tissue death due to lack of oxygen, often due to reduced blood supply). Infarction is one of the potential downstream effects of ischemia, either due to the length and/or the severity of the ischemic event.

Typing "ischemia" into the MeSH Browser lists "Brain Ischemia" as the 6th hit in the terms retrieved, defined in its scope note as

"Localized reduction of blood flow to brain tissue due to arterial obstruction or systemic hypoperfusion. This frequently occurs in conjunction with brain hypoxia (HYPOXIA, BRAIN). Prolonged ischemia is associated with BRAIN INFARCTION."

"Stroke" is also a MeSH term, defined as

"A group of pathological conditions characterized by sudden, non-convulsive loss of neurological function due to BRAIN ISCHEMIA or INTRACRANIAL HEMORRHAGES. Stroke is classified by the type of tissue NECROSIS, such as the anatomic location, vasculature involved, etiology, age of the affected individual, and hemorrhagic vs. non-hemorrhagic nature."

So I tried this search: brain ischemia[majr] AND stroke[majr] AND (etiology[tiab] OR etiology[sh] OR etiologic[tiab] OR cause[tiab] OR causes[tiab])
limited to All Child, and retrieved ~1000 citations.

And narrowing to exclude some of the (arguably, of course) lesser publciation types like this:
brain ischemia[majr] AND stroke[majr] AND (etiology[tiab] OR etiology[sh] OR etiologic[tiab] OR cause[tiab] OR causes[tiab]) NOT (case reports[pt] OR letter[pt] OR comment[pt] OR editorial[pt] OR news[pt])

reduced the retrieval to ~500 citations. I noticed that a number of the first several pages of hits discussed neonatal and infant stroke; for a "real" request, I imagine that I would either know what pediatric age group the requester is interested in, from our reference interview, or would need to get back in touch to see if we should define "pediatric" as all children, infants only, etc. Narrowing to English language narrows the set even further.

A quick Google search also revealed a report from the National Institute of Neurological Disorders and Stroke from 2005, "Recognition and treatment of stroke in children," which includes a section on etiology and risk factors.

UpToDate, for those who have access, also has a nice overview titled "Ischemic stroke in children and young adults: Etiology and clinical features."

Though I excluded case reports from one of the strategies above, this would likely be a question where I would really want to take a close look at the cases reported in the literature as a complement to the more "synthesized" material from the NINDS report, the UpToDate entry, and the review articles -- there are likely instances of ischemic stroke in children that have made their way into the case literature that have not yet entered into the larger case series or other retrospective works that still may be very useful in gaining a broad perspective on why a given child might have developed an ischemic event.

Adding "risk factors" to the etiology portion of the search string might also be useful too, though it does increase the volume of search retrieval.

EHRs in NEJM

2008-04-18T09:50:00.001-07:00

This week's New England Journal of Medicine includes several articles discussing electronic health records.

- Two perspective pieces: Personally Controlled Online Health Data — The Next Big Thing in Medical Care? by R. Steinbrook and Off the Record — Avoiding the Pitfalls of Going Electronic by P. Hartzband and J. Groopman

- A Sounding Board piece: Electronic Health Records, Medical Research, and the Tower of Babel by R. D. Kush, E. Helton, F. W. Rockhold, and C. D. Hardison

Each item gives a little bit different perspective on the potential benefits and pitfalls of electronic health records and strategies for implementing and using them. Steinbrook focuses on consumer involvement in health care and issues of data ownership and portability, while Hartzband and Groopman focus on the clinician perspective. Kush et al. consider data standards for EHRs in relationship to clinical research.

Another Sounding Board item in this issue, Tectonic Shifts in the Health Information Economy by K. D. Mandl and I. S. Kohane, talks about HIPAA in relationship to portals like Google Health and Microsoft Health Vault, among many other interesting things.

Narratives in clinical practice

2008-04-17T08:03:00.000-07:00

I just found this brief article in my stack of "to be read" papers as I moved to a new office space -- I had printed it because it provides a really interesting take on the utility of the case report or case narratives in clinical practice.

Citation: Campo R (2006) “Anecdotal Evidence”: Why Narratives Matter to Medical Practice. PLoS Med 3(10): e423

Rafael Campos focuses on the potential usefulness of cases in generating research hypotheses, prompting connections between topics, visualizing new possibilities...

He notes,

The inscrutably enduring power of the anecdote itself is what incites all our most fearsome defenses. So furious are we in our rejection of the merely anecdotal one cannot help but begin to wonder at it. What is it in the ostensibly harmless tale my great-grandfather told about the secret of his longevity being the small glass of bitters mixed with a raw egg he downed before bedtime each night since the age of ten that rallies us to spend billions of dollars in grants from the National Institutes of Health , disbursed every year to scientists seeking their own more explicitly pharmaceutical recipes for living longer? Why does our clinging to superstition and our willingness to be intrigued by mystery provoke such an angry, unrelenting diligence? An anecdote, after all, is just a story.

The irony in our growing intolerance of the anecdote is that storytelling is full of lessons in imagination and invention so beneficial to the creative investigator.

Search challenge 6

2008-04-14T15:31:00.000-07:00

This week's search challenge is another question that takes a look at the pediatric literature: What are the causes of pediatric ischemic stroke?

A few related issues to consider:
- how important are case reports for this question?
- is there a reference text or other resource that is useful, in addition to Medline?
- how broad does a Medline search need to be to retrieve most of the "good" items for this question?

Search challenge 5: strategies

2008-04-14T14:41:00.001-07:00

In the comments on search challenge 5, Heather proposed an Ovid Medline strategy combining the concepts in a straightforward and effective way, retrieving just under 10 citations:

1 exp Osteomyelitis/di [Diagnosis]

2 exp Arthritis, Infectious/di [Diagnosis]

3 1 or 2

4 exp C-Reactive Protein/

5 erythrocyte sedimentation rate.mp. [mp=title, original title, abstract, name of substance word, subject heading word]

6 4 and 5

7 3 and 6

Another strategy, this one in PubMed format, has a little bit broader retrieval at about 30 citations:

"Blood Sedimentation"[Mesh] AND "C-Reactive Protein"[Mesh] AND ("Osteomyelitis"[Mesh] OR "Arthritis, Infectious"[Mesh]) AND (English[lang] AND ("infant"[MeSH Terms] OR "child"[MeSH Terms] OR "adolescent"[MeSH Terms]))

When I see these sizes of retrieval, I see it as a challenge to think even more broadly in terms of synonyms, abbreviations, etc. This search retrieves ~ 70 citations, adding some "false drops" but also including a few items that might be useful in addition to the hits from the above searches:

(blood sedimentation[mh] OR esr[tiab] OR erythrocyte sedimentation[tiab]) AND (c-reactive protein[mh] OR crp[tiab]) AND (osteomyelitis[mh] OR osteomyelitis[tiab] OR arthritis, infectious[mh]) AND eng[la]

Search challenge 4: strategies

2008-04-14T09:32:00.000-07:00

In the comments on search challenge 4, Martin noted:

"Syncope, Vasovagal"[Mesh] AND "Blood Donors"[Mesh] gives 21 hits, the first one (17655598) is an intervention study, indicating that syncope incidence is quite different among subgroups. This make giving a general answer more difficult.

Some data on incidence comes from (16202053), which suggests a 0.9% incidence.
Other studies go for vasovagal reactions (not limiting to syncope) and, of course, give much higher numbers.

Data on the consequence of syncope comes from (11778059).

I tried a search that was a little more broad, which did draw in a few tangential things (like how to prevent/reduce complications such as fainting during or after blood donation) but still didn't yield an overwhelming volume, about 90 citations:

(vasovagal OR vagal OR fainting OR syncope) AND (blood donors OR blood donation)

As I was looking through the articles and a broad Google retrieval, I noted that there was a significant body of older literature that looked very relevant and potentially useful. IndexCat, the online system which allows users to search volumes from the Index-Catalogue of the Library of the Surgeon-General's Office. The database currently contains Series 1-5 of the Index (1880-1961), which includes 61 volumes in the 5 series, covering reports, journal articles and other materials from 1880 to 1961. Some of the WWII literature, with huge blood drives to support the war effort, had great surveillance data on side effects.

A quick overall summary (with a few sample articles thrown in for good measure): The majority of the original studies on this question were done between the 1940s and 1960s. Much of the data was generated from the mass blood drives conducted for WWII. Later articles refer to the earlier ones for incidence/frequency rates and are more concerned with predicting which donors are likely to exhibit negative reactions. Reported incidence rates range from less-than 1% to 10%; it is important to recognize that the definitions of syncope (fainting) varied somewhat from study to study.

Reference #1: Callahan R, Edelman EB, Smith MS, Smith JJ. Study of the incidence and characteristics of blood donor "reactors." Transfusion 1963; 3: 76-82.

This article reports on a retrospective review of the records of the Milwaukee Blood Center for blood donors from 1958 to 1962 with a more detailed analysis of the reactor records for the year 1960. They report an overall donor reaction rate of 4.5 percent with a higher rate seen in females. Reactions include mild, moderate and severe, where actual syncope is considered a 'severe' reaction. Of the reactions for all years, such severe reactions had a frequency of 5.7%. For the year 1960, 6.2% of the reactions were considered to be severe. Note that these results are retrospective and thus are subject to errors in recording and interpretation.

Reference #2: Moloney WC, Lonnergan LR, McClintock JK. Syncope in Blood Donors. N Engl J Med 1946; 234: 114-118.

This article reports a pair of prospective studies on the frequency and characteristics of syncope in blood donors. The first series was composed of 6,882 donors bled between 1942 and 1943; 162 total cases of syncope were identified with 17 'severe' cases. A severe case is defined as one in which loss of consciousness or convulsions were seen. The second series was composed of 9, 251 donors bled during 1943; of these 527 syncope cases were identified with 158 'severe' cases. The authors examine multiple factors including donor characteristics and environment. They report that younger donors, particularly women, were more prone to fainting.

Reference #3: Trouern-Trend JJ, Cable RG, Badon SJ, Newman BH, Popovsky MA. A case-controlled multicenter study of vasovagal reactions in blood donors: influence of sex, age, donation status, weight, blood pressure and pulse. Transfusion 1999; 39: 316-320.

This retrospective case-controlled study examined 1,890 blood donors with reported syncope from three U.S. blood centers, 1994-1995. These were compared to case-controls and random population controls in a logistic regression analysis to determine which of several factors correlated with the incidence of syncope. The authors report that age, weight and donation status (first-time or repeat donor) were significant but that sex, blood pressure and pulse were not. For the frequency of reactions in blood donors, they quote a 2-5% rate of vasovagal reactions and a 0.08-0.34% of syncope, based on nine previous reports in the literature including the Callahan article.

Reference #4: Greenbury CL. An analysis of the incidence of "fainting" in 5, 897 unselected blood donors. Br Med J 1942; 1: 253-255.

This study examined the incidence of syncope in blood donors and the influence of age, sex, occupation, lack of food, fatigue, and room temperature on it. A donor was considered to have fainted if any of the fainting-associated symptoms required an interruption of routine. Donors who fainted after leaving the building were not included. 5, 897 donors were randomly chosen (4127 females, 1760 males) from four London sectors. The percent fainting varies among age-grouped males and females from 1.63% to 7.62%. Incidence declined non-uniformly with age in both males and females. In most age groups, females had higher incidence rates. Incidence was higher in clerical workers compared to all other occupation groups. Hours of work (fatigue) and room temperature had no effect. Among female clerical workers, aged 18-25, time from last meal was sigificant, otherwise, it was not.

Reference #5: Boynton MH, Taylor ES. Complications arising in donor in a mass blood procurement project. Am J Med Sci 1945; 209: 421-436.

This article review the various types complications of blood donation seen among the millions of donors collected by the Blood Donor Service of the American Red Cross from 1941 to 1944. They classify complications into four categories, with group 2 being the one that includes 'faints' (syncope). They list four frequency figures from the literature: 2.8%, 5.5%, 4.2%, and 8.9%. The latter is noted to be simply a subjective report by donors that they suffered an ill-effect. The authors here report data on 2294 'reactors' - the frequency of symptoms within the group, ranging from pallor to loss-of-consciousness-to incontinence, and state that their results are in general agreement with the finding of the British Medical Council report.

Reference #6: Subcommittee of the Blood Transfusion Research Committee. Fainting in blood donors. Br Med J 1944; 1: 279-286.

In this study, several blood centers in England and Scotland were required to complete a record card for any donor who fainted during a blood collection procedure. A donor was considered to have 'fainted' if they showed signs and symptoms related to fainting which required a delay or change in normal procedure. Multiple symptoms were recorded. The next donor after the symptomatic one, bled by the same person, was recorded also as a control. They report the frequency of recorded faints in two Centers as 5.4% and 5.7% respectively. The effects of various factors on fainting and the incidence of specific symptoms are shown in Tables I - XI.

Reference #7: Poles FC, Boycott M. Syncope in blood donors. Lancet 1942; 2: 531-535.

This article reports on the experience of the British Army Blood Transfusion Service. Of their first 10,000 donors bled, they record a 2.8% fainting incidence. They define this as any case in which the donor lost consciousness or could not sit or stand without doing so. In one series of 4306 donors, they report 116 faints with a varied time of onset.

April JMLA posted in PubMed Central

2008-04-01T13:01:00.000-07:00

And with it, the next installment in our case study series:

Cahall M, Jerome RN, Powers J. The impact of a literature consult service on geriatric clinical care and training in falls prevention. J Med Libr Assoc. 2008 April; 96(2): 88–100.

The case:
You frequently collaborate with a geriatrician in the adult primary care clinic of your large academic medical center. On a routine visit to his office to discuss his current needs for clinical evidence, he requests that you analyze the literature on effective interventions to reduce accidental falls in older persons. As he also provides geriatric care at the local Veterans Administration hospital and is the medical director at several local nursing homes and home health agencies, he notes that he is interested in literature describing interventions for use in private homes as well as those implemented in institutional settings.

More in the full article here.

Search challenge 5

2008-04-01T12:58:00.000-07:00

I'm still working up the post on the strategies for search challenge 4 (and may have to surrender my secret librarian decoder ring if I can't figure out what I'm doing wrong with my IndexCat search for fainting after blood donation...if you have tips, please contact me!), but in the meantime, a search for this week -- we had a request from a reader for comparison-focused searches - comparing different treatments, diagnostic tests, etc.

So a comparative search for this week: How do the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) diagnostic tests compare and is it necessary to do both tests in pediatric patients with suspected osteomyelitis and/or septic arthritis?

National Health Data Network and personal health records

2008-03-28T14:56:00.000-07:00

From iHealthBeat: "National Health Data Network To Include Google, Microsoft PHRs"

Federal officials plan to integrate the Nationwide Health Information Network with personal health record databases launched by Google and Microsoft, according to Charles Friedman, COO of the Office of the National Coordinator for Health IT, Government Executive reports. Friedman made the announcement at the Defense Health Care IT Conference at Georgetown University in Washington, D.C., on Wednesday.

Health and older Americans

2008-03-28T11:08:00.000-07:00

Report released yesterday by the National Institute on Aging and the National Center for Health Statistics, among others from the Federal Interagency Forum on Aging-Related Statistics -- Older Americans 2008: Key Indicators of Well-Being, including a special section on literacy and health literacy

More:
- the press release
- PowerPoint slides of charts
- US News & World Report article on the report

African American health literacy

2008-03-27T07:10:00.001-07:00

Aetna has put out an African American history calendar this year focusing on health literacy. Each day features facts from African American history (on today in 1924, jazz singer Sarah Vaughan was born) and each month features pictures and profiles of individuals involved in promoting health literacy in different venues (including December - in the library, covered more in an item here in the Charleston Post & Courier).

The introduction to the calendar, Marginal literacy: a growing issue in health care, further discusses both literacy and health literacy issues among African Americans

You can download the calendar from the Aetna site or order your own fancy copy from the company for $4.

(Also, to find literacy programs focused on basic reading proficiency in your area, consult America's Literacy Directory)

Search challenge 4

2008-03-25T08:04:00.000-07:00

This week's search challenge question:

What is the incidence of vasovagal syncope in blood donors?

Hint: this one might require some older literature and other things beyond PubMed...

Share your thoughts in the comments!

Search challenge 3: strategies

2008-03-24T13:18:00.001-07:00

In the comments on last week's search challenge, margaret recommended a simple search strategy that seems to locate a number of the key items for the question about breastfeeding during methadone maintenance:
"Milk, Human"[MAJR] AND "Methadone"[MAJR] AND "Infant, Newborn"[MeSH Terms]

A search like this may also be worth considering:
methadone[mh] AND (breast feeding[mh] OR milk, human[mh] OR lactation[mh])

It retrieves about 40 citations and it's a little bit broader than the search above and brings in some related issues of potential interest to the health care team, such as psychological effects of breastfeeding for the mother and child in this situation and the effect of methadone on the mother's ability to lactate.

Commenter dewey_decimal reminds us to consult LactMed, the drugs and lactation database from NLM, which provides a succinct and well-referenced overview of the use of this drug during lactation and breastfeeding (also see the LactMed factsheet from NLM for a more detailed description of this resource).

Ethical considerations in organ donation

2008-03-19T16:12:00.001-07:00

This week's New England Journal of Medicine includes a perspective piece by Dr. Robert Truong, "Consent for Organ Donation — Balancing Conflicting Ethical Obligations," addressing some of the ethical issues we briefly touched on in a previous JMLA case study about medical support of potential organ donors. Truong discusses potential conflicts between the clinical, the organ procurement organization (OPO), and the potential donor's family, and examines the process of informed consent for these patients and problems with how that process plays out in real life.

This NEJM issue also includes a reaction from one OPO, the New England Organ Bank, printed as a letter to the editor.

Search challenge 3

2008-03-17T15:28:00.001-07:00

For this week, we'll tackle a pediatric question.

The question: For babies exposed to drugs in utero, particularly opioids, should breastfeeding be encouraged while the mother is on a methadone drug cessation program?

Share your questions and strategies in the comments!

Search challenge 2: strategies

2008-03-17T14:44:00.000-07:00

Search challenge 2 looks at identifying articles that discuss prognosis, with traumatic brain injury as one example "disease" for which one might want to find prognosis information.

The Clinical Queries filters in PubMed, developed by Haynes et al, give us two options for finding prognostic studies:

- the sensitive/broad search hedge: (incidence[MeSH:noexp] OR mortality[MeSH Terms] OR follow up studies[MeSH:noexp] OR prognos*[Text Word] OR predict*[Text Word] OR course*[Text Word])

- the specific/narrow hedge: (prognos*[Title/Abstract] OR (first[Title/Abstract] AND episode[Title/Abstract]) OR cohort[Title/Abstract])

For the brain injuries search, I tried a search like this:
brain injuries[majr] AND ("prognosis"[MeSH Terms] OR "Recovery of Function"[mh] OR outcome[tiab] OR outcomes[tiab] OR recovery[tiab] OR reverse[tiab] OR reversible[tiab] OR death[tiab] OR improvement[tiab] OR improve[tiab] OR mortality[sh] OR improved[tiab] OR prognosis[tiab] OR prognostic[tiab])

but it was a little too broad - I think partly because the term "outcomes" is so common in research but doesn't always mean clinically-relevant outcomes, so then I tried to narrow this part by thinking of what outcomes are important in trauma, and refined the search to this:
brain injuries[majr:noexp] AND ("prognosis"[MeSH Terms] OR "Recovery of Function"[mh] OR mortality[tiab] OR prognosis[tiab] OR prognostic[tiab] OR survival[tiab] OR Glasgow outcome scale[tiab] OR functional[tiab]) AND humans[mh] AND eng[la] NOT (case reports[pt] OR letter[pt] OR comment[pt] OR news[pt] OR editorial[pt])

which returned about 1200 hits from the last 5 years, which is still a lot.

When you start browsing through the list, a lot of them do look at outcomes, but there are a myriad of outcomes - For this search, I think a good next step would be to continue with the requester and figure out what exactly they mean by outcomes - more immediate outcomes like in-hospital mortality, or longer term things like mortality at 30 days, functional outcome, lost work, other morbidity (e.g. posttraumatic seizures). Understandign this would be useful in refining the search or at least informing how we look at the retrieval.

Other thoughts for refining this search?

Another online searching practice opportunity

2008-03-11T08:02:00.000-07:00

The Pacific Northwest region is currently doing an online seminar called "Awakening the Searcher Within."

This bi-weekly web session includes a different question to work on for each session.

If you're interested in joining in, you can find more information at: http://nnlm.gov/pnr/dragonfly/2008/01/30/awakening-the-searcher-within/

Searching: purpose of question and time frame

2008-03-11T06:59:00.000-07:00

Martin posted a great comment on the search strategy for Search Challenge #1, noting:

I think the strategy depends a lot an the situation: if you want to answer a clinical question rapidly, I go for (systematic) reviews first than do a narrow search as an update to the review.
If the task is to do a systematic review, the strategy must be much more detailed and refined.
Maybe you could define the timeframe for the next challenge...

For these first two questions, I have been thinking of them as basic patient care questions, with about a few days to a week turnaround time.

For last week's question, I think Martin's approach is very reasonable and a judicious use of time - selecting the Cochrane systematic review and the trials published since the date that the search in the systematic review was last updated.

As he noted, if this search request was from someone working on a systematic review or other project requiring comprehensive retrieval, the search would need to be much broader and more complex and would also need to include resources beyond PubMed (the Cochrane strategies include great examples of strategy complexity and broader resource selection) .

We'll have one of our future search challenges examine a hypothetical systematic review topic so we can consider what that means for the strategy and for which resources we search.

Search challenge #2

2008-03-10T11:09:00.000-07:00

We've had a few suggestions from readers for topics to tackle in the challenge - we appreciate the feedback very much and please continue to share your ideas!

For Search Challenge #2, we've selected one of these reader suggestions - one reader noted that she finds prognosis searches to always be challenging, commenting that the Clinical Queries filters in PubMed provide some help but that she'd like to get a better sense of how colleagues approach these searches.

So this week's question has a broad issue:
- Do you have a "hedge"/strategy that you reuse for identifying studies that include data on prognosis?

And a more-focused part to try this search with an actual topic:
- How does the literature describe prognosis (e.g. mortality, functional outcome, etc.) in adult patients with moderate to severe traumatic brain injury?

Please share your ideas in the comments!

(P.S. to keep things more simple on our end, we'll post the "answers" to the search challenge and the new challenge on Mondays, instead of the Monday-Friday schedule we'd originally noted)

Search challenge 1: strategies

2008-03-10T07:48:00.000-07:00

In the comments on Search Challenge #1, readers proposed several great search strategies and included a few example articles too. In addition to reader-developed strategies, one commenter also included the strategy used in a Cochrane review titled "Support surfaces for pressure ulcer prevention," which fairly comprehensively addresses multiple synonyms for each of the concepts in the question (e.g. multiple words for beds and mattresses, including product trade names).

The Cochrane strategy published in the systematic review is focused on searching the Cochrane Controlled Trials Register via Ovid, which allows proximity operators (e.g. "next") to aid keyword searching, an option not available in PubMed, so creating a workable strategy for PubMed is probably a good supplement to using such an approach.

The systematic review also references the broader search strategies in multiple databases used by the Cochrane Wounds Group, which include strategies Ovid-focused strategies for Medline, CINAHL, the British Nursing Index, and EMBASE. This strategy also notes other databases and resources that may be useful in identifying relevant literature for wound care and prevention topics.

In addition to these strategies, I found a fairly simple PubMed search to be useful in identifying quite a few of the clinical trials and other primary studies of bedding- and bed- related strategies for reducing the incidence of pressure ulcers:

(beds[majr] OR bedding and linens[majr]) AND (pressure ulcer[majr] OR pneumonia[mh] OR complications[sh] OR complications[tiab] OR adverse events[tiab]) AND humans[mh] NOT (case reports[pt] OR letter[pt])

I'd originally just included the MeSH term "beds", then added the "bedding and linens" term when I realized that my initial strategy was excluding some of the big RCTs of mattress supplemental products that were included in the Cochrane review (I'm probably not alone in using the references of articles I retrieve as a "quality check" on my search strategy). In reading some of the abstract and articles, it seemed as if pneumonia was the other main complication that bed-focused techniques were used to prevent, so I tried broadening the search strategy to include pneumonia plus other (as yet unknown to me) potential complications, which added about 100 additional citations to the retrieval:

(beds[majr] OR bedding and linens[majr]) AND (pressure ulcer[majr] OR pneumonia[mh] OR complications[sh] OR complications[tiab] OR adverse events[tiab]) AND humans[mh] NOT (case reports[pt] OR letter[pt])

Then limiting to English language articles further reduced the set to about 600 citations, which is still a fairly large retrieval.

Some of the "false drops" and less relevant/useful items I noticed in the retrieval for this strategy:
- netting over the bed to prevent malaria
- elevating the head of a standard hospital bed to prevent pneumonia
- one to two page educational briefs in nursing- and rehabilitation- focused journals
- pillow selection
- equipment used during an intraoperative period or during prehospital transport
- cooling blankets
- simulation studies

A few questions for our hypothetical requestor that might help us refine the search strategy:
- are they interested only in mattresses and beds, or would other devices (e.g. mattress overlays) be of interest too?
- are they interested in the long-term care literature (e.g. nursing homes, chronic care) in addition to the acute-stay inpatient literature?

This search also made me think about an issue that I've heard often in colleague discussions - how many references are you comfortable browsing through to develop a bibliography for a search? I don't have any problem paging through a few hundred results for a topic like this, when so many of the citations retrieved by the search seem relevant, but I know I've heard colleagues say that they would try to develop a much more narrow strategy as an initial approach, then broaden if it seems necessary. Your thoughts on this and the strategies above and in the comments?

We'll be posting Search Challenge #2 later today...

New feature: weekly search challenge

2008-03-03T14:33:00.000-08:00

We've had feedback from readers of the case study column that are interested in getting more "in-depth" into the process of designing a search strategy for patron questions - what terms are useful for a topic, what terms aren't, what databases and other resources are necessary to make sure you've identified as much as possible, etc.

To this end, we're going to start posting a "search challenge" question each Monday. We encourage you to post your ideas and questions in the comments or to us by email (using our profile links above). You can also feel free to "reference interview" us by posting questions for clarification or more detail as needed.

Then, each Friday we'll post a search strategy and other thoughts on that question. We hope this will add to the usefulness of the cases by giving another outlet for developing searching skills and discussing strategies with colleagues.

So, this week's question is:

Does the use of a pressure-reducing bed or mattress lead to a reduction in the incidence of pressure sores or other complications in an adult hospital in-patient population?

C. diff news from the UK

2008-02-28T07:42:00.000-08:00

From today's BBC News - Dramatic rise in C. diff deaths

The number of deaths linked to hospital bug Clostridium difficile has soared in England and Wales, figures from the Office for National Statistics show.

Between 2005 and 2006 the number of death certificates which mentioned the infection rose by 72% to 6,480, most of which were elderly people.

In over half of cases, it was listed as the underlying cause of death.

It is thought that some of the increase may be due to more complete reporting on death certificates.

During the same time period, deaths due to MRSA (Methicillin-resistant Staphylococcus aureus) remained fairly steady.

Brian Duerden, chief microbiologist at the Department of Health, notes that the NHS has launched a number of efforts to reduce nosocomial infections since 2006, including clinician education about hand-washing, a bare-below-the-elbows dress code, and other hygiene and monitoring provisions.

More on Google Health

2008-02-28T07:03:00.001-08:00

Via the Wall Street Journal's Health blog - Google Unveiling Personal Health Records Service - apparently the service will be revealed at a session of the Healthcare Information and Management Systems Society meeting in Orlando today.

Patients will be able to enter basic medical data into an online repository, and invite their doctors to electronically submit information as well, the WSJ says.

(also a full WSJ article on the topic, which briefly talks about Microsoft's HealthVault too)

Update:
A brief overview of today's presentation in Orlando here at Wired News and here at InfoWorld

Keeping up with C. diff

2008-02-21T12:04:00.000-08:00

The BioMed Central journal Critical Care this month includes a review and a commentary piece discussing developments in our understanding of Clostridium difficile and associated colitis.

Described as a good reference for clinicians faced with this issue, the authors Carolyn V Gould and L Clifford McDonald, from the Centers for Disease Control, detail the pathogenesis, diagnosis and possible treatment strategies in this most topical of hospital-acquired infections. The onus is on healthcare professionals to maintain awareness of the changing epidemiology of the disease, as well introducing measures to reduce the risk to patients.

Google Health

2008-02-21T11:01:00.000-08:00

On the Google Blogscoped blog it is being reported that Google has been making progress with their health record application, Google Health. This has been in the making for awhile now, as over the past year Google has been speaking quite publicly about their efforts. As the Google Blogscope reports, the login page for Google Health listed these features of the system:

* Build online health profiles that belong to you
* Download medical records from doctors and pharmacies
* Get personalized health guidance and relevant news
* Find qualified doctors and connect to time-saving services
* Share selected information with family or caregivers

Google is often criticized with regards to their privacy policies as it remains nebulous exactly how much information they store and capture about any one individual's activities in their applications (more on privacy concerns discussed on ZDNet and Search Engine Land). However, the company seems strongly committed to developing this tool.

This week, Google Health is making news again, as the Cleveland Clinic announces a partnership with Google to pilot Google Health for personal health records.

More on the partnership:
- the Cleveland Clinic press release
- Wall Street Journal's Health blog
- New York Times coverage
- Wired News coverage (AP wire)

Patient portals

2008-02-18T09:04:00.001-08:00

An item in this month's Surgery News newsletter from the American College of Surgeons
Patient portals: not the open floodgates physicians fear (PDF) summarizes a presentation at this year's ACS congress by Dr. Gretchen Purcell about the MyHealthAtVanderbilt site and other electronic patient portals.

Two studies referenced in the article:
Bergmo TS, Kummervold PE, Gammon D, Dahl LB. Electronic patient-provider communication: will it offset office visits and telephone consultations in primary care? Int J Med Inform. 2005 Sep;74(9):705-10. PubMed record

Lin CT, Wittevrongel L, Moore L, Beaty BL, Ross SE. An Internet-based patient-provider communication system: randomized controlled trial. J Med Internet Res. 2005 Aug 5;7(4):e47. PubMed record

An attending's perspective on information in medicine

2008-02-06T14:16:00.000-08:00

This week’s JAMA has an interesting piece written from the perspective of an attending physician, considering how the role of the mentor in clinical medicine has evolved with increasing availability of information (mentions PDAs, UpToDate, PubMed, among other things).

An excerpt:

It has become increasingly clear to me that with the information revolution in full throttle, the role of the clinical attending has changed drastically and continues to evolve. Besides using rounds to discuss many of the social, ethical, and professional issues surrounding a patient's care, I increasingly find myself teaching less about the current state of information and more about how things have changed and how our understanding of an illness or treatment has evolved to where it is currently. I teach about multiple portals—how there is no single way to approach a case and how the one we choose may not be the only or even the best strategy despite our attempts to get the facts right and review the relevant data. I have the distinct impression that my mentors possessed a degree of certainty that in hindsight I am not sure was warranted. In this era of evidence-based medicine, I am more likely to point out how scanty the evidence actually may be when making a decision. Although I may refer to the "classic" article in a particular field, all too often I will point out how in retrospect it looks much less convincing than when it was first published just 10 years ago. Rather than giving my team answers, I am more likely to ask them to formulate a question that interests them regarding a specific case, then investigate the data, and report back to the group. The group can then try to digest this information and place it in the context of the case at hand.

Reference:
Horowitz HW. The Interpreter of Facts. JAMA 2008;299: 497-498.

Health literacy promotion strategies in primary care

2008-01-31T06:43:00.000-08:00

Sponsored by the Commonwealth Fund in NY and Kaiser Permanente, an examination of health literacy-related "promising practices" for clinicians and office staff in the primary care setting - "Health Literacy Practices in Primary Care Settings: Examples from the Field"

This report presents findings from a 2005 study in which the Association of Clinicians for the Underserved first did an online survey of health care facilities across the country and then followed it up with visits to five selected sites for staff and patient interviews. The study identified five health literacy practices that staff considered especially valuable for their group’s patients and potentially applicable to other clinics: a team effort, beginning at the front desk; use of standardized communication tools; use of plain language, face-to-face communication, pictorials, and educational materials; clinicians partner with patients to achieve goals; and organizational commitment to create an environment where health literacy is not assumed.

(via the Health Policy blog)

January 2008 issue available online

2008-01-25T07:30:00.000-08:00

The January 2008 issue of the Journal of the Medical Library Association is now available in PubMed Central.

This issue includes the next installment in our case study series; this month's article
is titled, "Synthesis of informatics literature to support institutional policy statement development" and focuses on expert searching and literature summarization to support decisions by healthcare administrators.

An excerpt from the case:

In this hypothetical case, you are approached by one of your hospital's administrators. She is the chair of the hospital's policy development committee and asks you to locate information regarding patient perceptions of their access to their own electronic health records (EHRs) to support the development of an administrative policy statement for your institution. Committee members include clinicians and informaticians who have considerable background knowledge of the matter but also value your expertise in information filtering and synthesis. Thus, the committee requests a comprehensive analysis supporting this initiative.

Reference:
Koonce TY, Sathe NA, Giuse DA, Jirjis J. Synthesis of informatics literature to support institutional policy statement development. J Med Libr Assoc. 2008 January; 96(1): 3–11.

Additional posts related to this case to follow...

Health literacy and Magic Johnson

2008-01-24T06:51:00.001-08:00

Magic Johnson Enterprises and Aetna have announced a new partnership focused on urban businesses:

Working together, the two companies will strive to empower businesses and ethnically diverse communities to make informed choices about their health care options by improving health care literacy, showing them the benefits of wellness, exercise and healthy eating, and other initiatives...

The principal goals of the relationship are to:

-- Create a dialogue and action in diverse urban communities to help people understand the health resources, products and services available to them, and encourage them to take a more active role in their health and wellness.

-- Give credible voice, via a recognized and respected leader, to major issues in health care such as the need to improve "health literacy." This will include community events and community-based initiatives to increase people's comfort with the language of health care, as well as encourage better understanding of treatment needs and better adherence to a physician's care plan.

-- Raise awareness of racial and ethnic inequality in health care within these communities to empower people to ask questions, seek answers and create a demand for high-quality health care that respects their cultural preferences.

(the project website, which doesn't include much more information yet)

Consumer health: searching confidence

2008-01-23T13:25:00.000-08:00

From the Patient Centered Health Information Technology blog - “Confidence” in Health Searches a Poor Indicator of Finding Good Information talks about a new study from the Journal of Medical Internet Research noting:

1. Searching high-quality online resources improves consumers’ health knowledge; and
2. Consumers’ degree of “confidence” in their answers is not a good indicator of whether their answers are correct.

The JMIR study:
Lau AYS, Coiera E. Impact of Web Searching and Social Feedback on Consumer Decision Making: A Prospective Online Experiment. J Med Intern Res 2008;10(1):e2.

Health literacy training

2008-01-23T13:21:00.001-08:00

From the MidContinental Region NN/LM blog:

The Health Resources and Services Administration offers a new, free, online course, "Unified Health Communication 101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency”. Those taking the course can receive five credits (CEU/CE, CHES, CME, CNE). The course is valuable for librarians as they reach out to provide support and information to the public and health professionals and would provide them another option to obtain continuing education units. In addition, The Unified Health Communication course complements The Medical Library Association and National Institutes of Health/National Library of Medicine (NLM) work in literacy research, curriculum design and hospital outreach. Freely share this information with other colleagues. http://www.hrsa.gov/healthliteracy/training.htm

Vancomycin

2008-01-17T15:05:00.000-08:00

There's a really thorough discussion of the history of vancomycin and how its use has evolved in the 50+ years it has been available in the US in this 2006 article:
Levine DP. Vancomycin: a history. Clin Infect Dis. 2006 Jan 1;42 Suppl 1:S5-12.

The Wikipedia entry on this antibiotic also gives a little history and briefly discusses vancomycin resistance. For a better examination of vancomycin resistance, consider this CDC page on vancomycin-resistant Enterococcus and this one on vancomycin-resistant Staphylococcus.

Pharmacokinetics and pharmacodynamics

2008-01-17T14:54:00.001-08:00

The October 2007 JMLA case talks a lot about how drugs, in this case vancomycin, work within the body, and how clinicians and researchers explore and understand these mechanisms -- pharmacokinetics and pharmacodynamics are two key concepts introduced in the case and worth further exploration.

Pharmacokinetics: This PowerPoint presentation from the University of Connecticut, A Short Course in Pharmacokinetics, gives a great overview of what pharmacokinetics is, what it means for drug delivery and metabolism in humans, and an explanation of a lot of related terminology.

This one from Kennesaw is also a good basic introduction.

Pharmacodynamics: This overview from Howard University provides a great discussion of pharmacodynamics and how this concept is used to explain and understand how drugs actually affect the human body and its systems.

PCR, set to music...

2008-01-11T11:27:00.001-08:00

Scientists for Better PCR has put together a great music video describing the PCR technique and its history, in the style of "We Are the World," seems to be sponsored by BioRad Labs and has a little advertisement for their equipment at the end.

(via several of the ScienceBlogs)

Developing antibiotic resistance

2007-12-20T14:14:00.000-08:00

Bacterial resistance to antibiotics has come up in several of our case studies - a post this summer from the Wall Street Journal Health Blog discussed a paper from PNAS about this very topic and highlights how quickly some bacterial strains are able to develop mutations that reduce or completely impair the effectiveness of some antibiotics against them - "Evolution in Real Time: How Bacteria Beat Antibiotics":

The microbes that killed an unnamed patient seven years ago accumulated 35 separate genetic mutations during a 12-week hospital stay, allowing the bugs to thwart every antibiotic doctors threw at them, a painstaking scientific investigation has found.

The study itself: Mwangi MM, Wu SW, Zhou Y, Sieradzki K, de Lencastre H, Richardson P, Bruce D, Rubin E, Myers E, Siggia ED, Tomasz A. Tracking the in vivo evolution of multidrug resistance in Staphylococcus aureus by whole-genome sequencing. Proc Natl Acad Sci U S A. 2007 May 29;104(22):9451-6.

Clinical trials

2007-12-07T12:03:00.000-08:00

The PLoS Medicine blog has a very interesting brief piece ("Quackbusters") that links to more information about key issues related to the role of the clinical trial and clinical trial registries as one potential solution to address publication bias.

(there's also a great discussion of why there need to be therapeutic trials specifically in children if we're to understand how to treat pediatric conditions, i.e. they can't be treated as if they're just miniature adults - related to a new WHO initiative "Make medicines child sized")

October case posted: The evidence behind vancomycin dosing

2007-11-01T14:37:00.000-07:00

The October 2007 issue of the JMLA is up in PubMed Central, including the October case study, "Approaching and analyzing a large literature on vancomycin monitoring and pharmacokinetics."

An excerpt from the case:

At morning rounds in your hospital's intensive care unit, a resident from the team presents a 55-year-old woman (weight 129 lbs) with a past medical history of multiple sclerosis, cerebellopontine angle meningioma, hypothyroidism, and a neurogenic bladder requiring a Foley catheter. This patient was transferred from her nursing home 3 days ago with a fever and altered mental status. Results from the nursing home bacterial culture of the patient's urine revealed Gram negative rods. Bacterial culture of blood drawn from her peripheral intravenous (IV) line at the nursing home indicated Gram positive cocci. Blood cultures redrawn upon hospital admission are still pending and require confirmation.

According to the patient's chart, she began empiric treatment at the nursing home with vancomycin (1,000 milligrams [mg] intravenously every 12 hours) and piperacillin-tazobactam (3.375 g IV every 6 hours) for urosepsis 4 days ago. The patient's current serum creatinine is 0.56 micrograms per deciliter (mg/dL) (normal range: 0.6–1.1 mg/dL) [1], and her estimated creatinine clearance is 104 milliliters per minute (mL/ min) (normal range: 88–128 mL/min) [2]. Her current body temperature is 97.2° Fahrenheit. Today is day 4 of this patient's vancomycin and piperacillin-tazobactam regimen and hospital day 3.

In reviewing the plan for the next twenty-four hours, the attending physician notes that the patient currently has a standing order for a laboratory test of the vancomycin trough level in her serum, with the blood sample to be taken just prior to the next dose of the drug. On day three of antibiotic therapy, the patient's serum vancomycin trough level was eleven mcg/mL, and, on day four, the trough was eighteen mcg/mL. The institution's target range for the serum trough level of vancomycin is five to twenty mcg/mL.

The attending physician initiates a discussion with the team—including a fellow, three residents, a pharmacist, a dietitian, the unit's nurses, and you, as the team's librarian—about monitoring of vancomycin. The clinician queries the team about the rationale for the standing order for vancomycin trough monitoring. The residents indicate that they often order this lab test when a patient is receiving vancomycin in an attempt to ensure therapeutic effectiveness and to prevent adverse effects of the drug but are not aware of any documentation behind the practice. The pharmacist comments that clinical practice can sometimes evolve before supporting evidence exists and that standards of practice at a hospital may not always be supported by evidence from the literature. In response to this discussion, the group asks you to identify any evidence supporting or disproving the practice of routine monitoring of trough levels in patients being treated with vancomycin in the adult critical care setting. Figures 1 and 2 provide elaboration from the team's attending physician and pharmacist on the significance of this question to clinical practice on the unit.

Additional discussion to follow soon!

Reference:Lee P, DiPersio D, Jerome RN, Wheeler AP. Approaching and analyzing a large literature on vancomycin monitoring and pharmacokinetics. J Med Libr Assoc. 2007 October; 95(4): 374–380.

MLA committee membership reminder

2007-10-05T09:51:00.000-07:00

The deadline for applying for membership on one of the many interesting Medical Library Association committees is quickly approaching - members have until Oct. 31 to complete the application, available online in the members-only section of MLANET.

The JMLA editorial board functions as an MLA committee and if you're interested in serving on the board, see this post for more information.

CAPHIS in Library Journal

2007-10-02T08:02:00.000-07:00

In yesterday's Library Journal, there's a nice brief piece on collection development in neuroscience that mentions MLA's Consumer and Patient Health Information Section newsletter.

A Healthy Dose of Skepticism

2007-09-28T12:20:00.000-07:00

The Wall Street Journal recently published two pieces (one article, and one on the WSJ Health Blog) on the basic theme of whether scientific research can be trusted, and referring to an essay by John P. A. Ioannidis, Why Most Published Research Findings Are False.

Ioannidis's points are neatly summed up by this passage in the introduction to the freely available essay:

The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance.

In other words, the methods matter, as does bias and the type and size of the finding. In his recent article, in the Wall Street Journal, Robert Lee Hotz points out that while research methods matter, it is also procedurally difficult for peer reviewers and editors to tease out inappropriate techniques and conclusions:

"...findings too rarely are checked by others or independently replicated. Retractions, while more common, are still relatively infrequent. Findings that have been refuted can linger in the scientific literature for years to be cited unwittingly by other researchers, compounding the errors...No one actually knows how many incorrect research reports remain unchallenged."

In addition, trials that do not demonstrate findings that are suitable to the trial sponsors may be shuttered and never reported in the literature. A related and lengthy piece in a recent New York Times Magazine, "Do We Really Know What Makes Us Healthy?" used hormone replacement therapy as an example throughout to illustrate why it can be difficult to make sense of research findings, including that the first, dramatic reports are likely to garner media attention, while later clarifications may not.

The bottom line? A healthy dose of skepticism is needed when reading research reports, and a good working knowledge of bias, research methodology, and other methods can go a long way.

Clinical Guidelines and Evidence-Based Medicine

2007-09-28T11:24:00.000-07:00

Several medical bloggers have been writing about clinical practice guidelines in the context of evidence-based medicine recently.

First, a refresher - clinical guidelines are intended to inform clinical decision-making. They are generally developed after a review of the medical evidence by experts in a particular field or an organization, and sometimes include expert opinion. They do not create or present new evidence, but generally summarize the quantity and quality of existing evidence, and add a bit of expert opinion on what the recommended course of treatment might be based on those findings. A lengthy definition of evidence-based medicine can be reviewed online, but it essentially boils down to using the triad of best evidence, clinical expertise, and patient preference to guide medical care.

Respectful Insolence points out that problems arise when a guideline attempts to apply findings from a very specific patient population to a more broad one, or vice versa. DB's Medical Rants has a series of three posts on the topic, including discussion of how a patient with multiple diagnoses makes correct interpretation and application of a guideline on one specific diagnosis more difficult. Similarly, Notes from Dr RW reminds us of the PICO system of EBM, and how guidelines may not adequately represent the "P" part - the patient/population. Dr RW notes that simply following guidelines is *not* true evidence-based medicine.

All of these bloggers make an important point - guidelines alone do not evidence-based medicine make, because they may not take into account the patient's preferences, may not represent all or the newest of the evidence, and may not be appropriate to the specific patient situation. Guidelines may serve as a good knowledge-building starting point on a topic, but following them exactly with various patients misses the three-fold nature of evidence-based medicine - patient, provider, and proof.

For more on EBM, check out these resources:
-Introduction to Evidence-Based Medicine, from the Duke University Medical Center Library
-Evidence based medicine: what it is and what it isn't, editorial in BMJ
-Evidence-based medicine: a commentary on common criticisms, commentary in CMAJ

Drug safety news letter from the FDA

2007-09-20T07:12:00.000-07:00

The US FDA has launched the first issue of its new Drug Safety Newsletter this week. It will be published quarterly with the goal of keeping "our medical community posted ... about selected postmarketing drug safety reviews, important emerging drug safety issues, and recently approved pharmaceutical products."

The first issue covers postmarketing surveillance data on:
- rituximab (Rituxan), an immunosuppressant used primarily to treat non-Hodgkin's lymphoma or rheumatoid arthritis: reports of progressive multifocal leukoencephalopathy associated with this agent ("rare fatal demyelinating disease that is caused by a viral infection of the brain following reactivation of the JC or BK polyomavirus (also known as papovavirus) present in about 80 percent of adults")

- modafinil (Provigil), a CNS stimulant used to treat narcolepsy, shift work sleep disorder, and sleepiness symptons associated with obstructive sleep apnea/hypopnea syndrome: reports of serious skin reactions

- temozolomide (Temodar), used to treat astrocytomas, a kind of brain tumor: aplastic anemia (bone marrow doesn't produce enough blood cells)

- deferasirox (Exjade), an oral chelating agent used to treat chronic iron overload due to blood transufions: GI, renal, and hematologic adverse events

The main newsletter page will include an archive of issues, and you can also sign up for email updates as new issues are posted.

More on hospital quality

2007-09-18T14:46:00.000-07:00

The WSJ Health blog discusses hospital quality today too ("More hospitals lag than leap on quality"), noting the release of the 2007 Leapfrog Top Hospitals and Survey Results.

On the survey page, there's a link to the survey methodology which makes for interesting background reading about what indicators they used and how they gathered their data. As noted in the article mentioned in our post earlier today, the Leapfrog data tends to be more infrastructure focused.

Judging the quality of hospital surgical services

2007-09-18T11:31:00.000-07:00

A study by Leonardi et al. published in this month's Archives of Surgery looks at the various sources of general surgery data for comparing hospital performance in the US.

The highlights:

- The authors identified 6 websites containing this kind of data, including 1 government site (CMS's Hospital Compare), 2 nonprofit sites (JCAHO's Quality Check, the Leapfrog Group's Hospital Quality and Safety Survey Results), and 3 proprietary sites (names withheld)

- Sites were rated on accessibility (cost, sign-up required/not required, visibility in terms of where the site appeared in their Google search results); data transparency (data source, statistical/analytical methods, risk adjustment methods); and appropriateness (variety of quality measures employed)

- Government and non-profit sites fared better on accessibility and were also the most transparent in terms of their data sources, statistical methods, and risk adjustmen descriptions.

- The proprietary sites were rated as more "complete" regarding the appropriateness measure, ie. the variety and types of measures used to evaluate quality.

- None of the sources provided real-time data; all data was at least one year old.

- The study also looked at consistency, i.e. whether they got the same results from the different sites, for several procedures. For laparoscopic cholecystectomy, the sites were consistent; hernia repair data varied more widely due to lack of data; and the different evaluation sites provided conflicting results on colectomy.

- Limitations of included sites: lack of working definitions for quality-related terms (e.g. complications); inadequate procedure-level information; concerns about timeliness of data; fragmented and inconsistent data sources supporting the sites

The authors' overall conclusions: Current hospital quality data sources may provide inconsistent results and utilize "suboptimal" measures of quality in some instances. Given the apparent trend toward patient consultation of such indicator sites, surgeon involvement in data gathering and resource refinement may be key ways to improve the utility of these resources.

Reference: Leonardi MJ, McGory ML, Ko CY. Publicly Available Hospital Comparison Web Sites: Determination of Useful, Valid, and Appropriate Information for Comparing Surgical Quality. Arch Surg 2007;142 863-869. Abstract (full-text requires subscription)

Learning more about genetics: SNPs

2007-09-05T14:55:00.001-07:00

One of our future JMLA cases will focus on a genetics/molecular biology scenario. Until then, from time to time we'll post links to "background" resources and topics in this area as we gear up for the case study.

Sandra Porter of Discovering Biology in a Digital World has authored a great post explaining what a single nucleotide polymorphism is - Genetic Variation I: What is a SNP?

For those interested even more explanation, here are a few great links:
- The Human Genome Project: SNP Fact Sheet
- NCBI: SNPs: Variations on a Theme

And if you want to know a few places that you can find SNPs...
- dbSNP and Entrez SNP
- OMIM
- Human Gene Mutation Database
- HapMap

MLA Launches Social Networking Blog

2007-09-04T14:26:00.000-07:00

MLA's Task Force on Social Networking Software unveiled its new blog on August 21st, intended to serve as a "communication device between the task force and MLA members." According to the "About" page, "The scope of this blog includes current awareness information, social networking @ MLA, social networking applications evaluations, task force updates, and IT support information."

Early posts address the MLA social networking survey, anonymous blog authoring and commenting, and writing for the web.

MLA website redesign

2007-09-04T14:19:00.000-07:00

The Medical Library Association has launched a redesigned site.

(The MLA 2008 (Chicago) meeting blog is also up, along with the annual meeting site itself)

Interested in being an editorial board member?

2007-08-24T11:57:00.000-07:00

It's that time of year again - time for MLA members to think about which committees they might want to participate in during the upcoming year.

The JMLA Editorial Board is one of the MLA committee options. Members of the editorial board serve 3 year terms and are typically asked to review 1-2 manuscripts per month. We also hold an editorial board meeting at each MLA Annual Meeting.

The peer reviewer serves as an invaluable adviser to the editorial team and to authors, providing commentary and critique of manuscripts that aid the team in determining the disposition of each article (i.e. acceptance or rejection) and in recommending changes for improving the clarity and quality of prospective articles.

The peer review process requires rigorous attention to detail, some familiarity with research design, an understanding of principles of logical writing, and analytical and critical thinking skills to assess arguments and theses presented in papers.

Our recently launched JMLA Reviewer Tutorial provides an overview of editorial expectations and the time commitment that comes with being part of the editorial board.

The MLA committee application form is available online in the members-only section of MLANET. If you would like to be considered for a spot on the editorial board, we encourage you to indicate your interest on the application form. It will also be very useful to the editorial team if you use Section 4 of the application, Qualifications or Special Expertise, to share with us brief details regarding your interest in the JMLA and relevant experience (writing, editing, etc.).

Please also free to contact us at jmlaeditor[at]vanderbilt[dot]edu if you have questions!

(There are also lots of other great committee opportunities with MLA, so even if the JMLA board isn't your cup of tea, consider other opportunities for getting involved with the organization!)

Web-based Morbidity and Mortality (M&M) Rounds

2007-08-20T08:38:00.000-07:00

For the last several years, the AHRQ has been offering a forum for sharing and discussing issues of patient safety and healthcare quality, web M&M: Morbidity and Mortality Rounds on the Web.

The site includes de-identified cases of medical errors and other safety and quality issues, with accompanying expert commentary on what happened and how the problem might be avoided in the future. There are also forums for discussing each case.

The cases are drawn from all areas of health care and are always interesting, also great for learning more about different areas of medicine. One of the summer cases is informatics related and focuses on a medical error associated with use of an electronic medical record, Copy and Paste, with commentary by William Hersh. His take-home points from this case:

Copying and pasting of patient information has probably been occurring since the beginning of recorded medical information.
EHRs make copying and pasting very easy.
When copying and pasting is done, the physician should be careful to attribute the source and to check that the information being pasted is not erroneous or out of date.
The most effective means for insuring medical plans are carried out is through the use of clinical decision support tools, and such tools are made easier and more acceptable to use when orders are bundled in sets.

The site also includes tutorials on issues related to Spotlight Cases like this one on resuscitation errors, with CME/CEU credit provided, and transcripts of interviews and expert perspectives on safety and quality issues.

More on the TRIP database

2007-08-17T09:50:00.000-07:00

The JMLA this year has published a couple of items on the Turning Research into Practice database (TRIP), including a usability study and a resource review, linked below.

A summer entry in the TRIP blog, Liberating the literature, includes 10 tips for searching TRIP.

Related:
Meats E, Brassey J, Heneghan C, Glasziou P. Using the Turning Research Into Practice (TRIP) database: how do clinicians really search? J Med Libr Assoc. 2007 Apr;95(2):156-63. free via PubMed Central archives

Resource review by Trina Fyfe, J Med Libr Assoc. 2007 April; 95(2): 215–216. free via PubMed Central archives

(thanks to Stephen Barnett and the Evidence-Based Nursing and Midwifery blog)

MedlinePlus surgical video including ileostomy

2007-08-16T07:03:00.000-07:00

The National Library of Medicine announced this week that MedlinePlus has added its first surgical webcast in Flash format.

The webcast, "Total Proctocolectomy for Synchronous Colon and Rectal Cancer," was filmed on July 24 at Retreat Hospital in Richmond, Virginia. At about 10 minutes into the video, the surgical footage includes anatomy of the small and large intestine and creation of an end ileostomy, one of the procedures discussed in the January JMLA case. Very interesting to hear the dialogue between the surgeons decision making and technique during the operation.

A full transcript of the webcast is also available, and additional surgical videos in RealPlayer format are also available on the MedlinePlus Videos of Surgical Procedures page.

The "real" experience of organ donation and transplantation

2007-08-15T14:16:00.000-07:00

A few years ago, our local medical center news paper, Vanderbilt's Reporter, ran a memorable series of articles on tissue and organ donation. Focusing on actual experiences of patients, including recipients and donors and their families, the articles paint a striking picture of the experience of those who receive donated tissues or organs, the families and friends of those who love them, and the donors who make it possible.

Part 1 of "The Greatest Gift" focuses on bone marrow donation, Part 2 considers living donor kidney transplantation, and Part 3 provides a transplant surgeon's perspective on the entire process of organ donation and transplantation.

The organdonor.gov site, produced by the US National Organ and Tissue Donation Initiative, also includes great stories of donors and recipients.

For more information on general and specific topics in organ donation, see the MedlinePlus entry on the topic.

More on the Journal of Medical Case Reports

2007-08-02T13:31:00.000-07:00

The BioMed Central blog today posts a video interview with Professor Michael Kidd, editor of the new Journal of Medical Case Reports. He talks about the role of the case report in medicine, multimedia potential of the online format for this journal, and ways that the journal may evolve in the future.

He also talks about the use of case reports in disease discovery and hypothesis generation -- figuring out which research questions need to be pursued next in larger scale clinical studies (e.g. using cases to prompt a cohort study or case control study or clinical trial).

Interventions to change test ordering practices

2007-07-26T10:02:00.000-07:00

(Credit: this post was adapted from a clinical information summary authored by Julie Beauregard, MLIS, Library Fellow, Eskind Biomedical Library, Vanderbilt University Medical Center, Nashville TN)

In the April case study, the team's next step after reading the literature provided by the librarian will likely be to start figuring out how to share the information and how to begin changing the way amylase and lipase are ordered in the Emergency Department. A logical follow-up question from the team would be: What does the literature tell us about how to change physician test ordering behavior, and are there any benefits in terms of cost and clinical outcomes associated with such interventions?

There are several studies investigating the cost savings associated with interventions to reduce the number of unnecessary laboratory tests that are ordered; however, there are very few that evaluate the clinical outcomes associated with this change of test-ordering behavior.

Two articles (Hampers 1999; Neilson 2004) address the clinical outcomes associated with reducing the number of laboratory tests. Based on a telephone survey conduced 7 days after the ED visit, Hampers et al found that there is no significance difference in clinical outcome between the control and intervention groups. A study conducted by Neilson et al also found no significant changes in regards to readmission rates, transfers to intensive care unites, length of stay and mortality in pre- and post-intervention groups.

According to the literature, there are various methods employed to influence changes in physician test-ordering behaviors, including care provider order entry (CPOE); computer-based decision support system (CDSS); providing the physicians with pricing information for each test; feedback reports; and guidelines developed in-house. The article list included below provides representative articles on these intervention methods.

A Dutch study by Verstappen et al (2004) compared the cost effects of feedback only and a newly developed strategy of combining feedback reports, education on evidenced-based guidelines, and quality improvement meetings and found that both interventions reduced the number of tests ordered, but the combined intervention was more successful. Another Dutch study (Poley, 2007) implemented CDSS and found that the cost of blood testing was significantly reduced with the use of CDSS compared with the control group.

Furthermore, guidelines developed by an emergency department (ED) to aid in limiting the number of tests ordered, were associated with a $50-100,000 reduction of charges to insurance companies. Hampers et al (1999) provided physicians with the pricing information for each test and also noted a 27% reduction in testing charges compared with the control group. Neilson et al (2004) implemented 2 interventions; the 1st one reduced open-ended test ordering and the 2nd intervention developed specific ordering constraints. The authors found that ordering rates were significantly reduced with the 1st and 2nd intervention 32% and 52%, respectively.

All of the studies included here found a reduction in laboratory test orders by physicians as a result of an intervention. It should be noted, that there is the potential for publication bias for this topic, in that there may be a tendency to publish studies that show a reduction in cost and/or unnecessary tests.

Selected References
Verstappen WH, van Merode F, Grimshaw J, Dubois WI, Grol RP, van der Weijden T. Comparing cost effects of two quality strategies to improve test ordering in primary care: a randomized trial. Int J Qual Health Care. 2004 Oct;16(5):391-8. PMID: 15375100.

Poley MJ, Edelenbos KI, Mosseveld M, van Wijk MA, de Bakker DH, van der Lei J, Rutten-van Molken MP. Cost consequences of implementing an electronic decision support system for ordering laboratory tests in primary care: evidence from a controlled prospective study in the Netherlands. Clin Chem. 2007 Feb;53(2):213-9. PMID: 17185371.

Sucov A, Bazarian JJ, deLahunta EA, Spillane L. Test ordering guidelines can alter ordering patterns in an academic emergency department. J Emerg Med. 1999 May-Jun;17(3):391-7. PMID:10338227.

Hampers LC, Cha S, Gutglass DJ, Krug SE, Binns HJ. The effect of price information on test-ordering behavior and patient outcomes in a pediatric emergency department. Pediatrics. 1999 Apr;103(4 Pt 2):877-82. PMID: 10103325.

Neilson EG, Johnson KB, Rosenbloom ST, Dupont WD, Talbert D, Giuse DA, Kaiser A, Miller RA; Resource Utilization Committee. The impact of peer management on test-ordering behavior. Ann Intern Med. 2004 Aug 3;141(3):196-204. PMID: 15289216.

MLA President's blog

2007-07-26T08:19:00.001-07:00

Mark Funk, the new president of the Medical Library Association, has launched a blog, Only Connect!.

Mark comments in his inaugural post:

Like my predecessors, I will probably write about my travels and adventures. I’ll also be playing around with WordPress plugins for photos and other cool things. But I hope that this form of communication can be more than reportage. Can we actually develop some kind of dialog? This is as new to me as it is to you. I want to hear from the MLA membership. What do you want in a blog by the MLA president?

(Thanks to David Rothman for the link)

Announcing the July case

2007-07-19T11:39:00.000-07:00

The July 2007 issue of the Journal of the Medical Library Association is now available in PubMed Central, and it includes the next installment in our case study series.

This month's case "Organ preservation in a brain dead patient: information support for neurocritical care protocol development," explores a role for the librarian in shaping the organ donation and procurement process.

An excerpt from the case:

You serve as the liaison to your hospital's [Neurocritical Care Unit] committee, which is charged with identifying and implementing guidelines to assist care providers in using appropriate management strategies for patient care in the unit. This multidisciplinary team also includes physician intensivists, critical care nurses, pharmacists, respiratory therapists, ethicists, and hospital epidemiologists. Given the complexity of the organ donation process, the NCU committee turns its attention to verifying and implementing best practices for organ donor management.
The main concerns during the committee's initial discussion of organ procurement practices center around standardizing different aspects of donor care, including appropriate interventions to maintain organs prior to removal for transplant and to ensure effective and timely communication with family members. The team's goal is to achieve appropriate management of the body from the point at which brain death is perceived to be imminent to the time when organs are removed for transplantation. They hope that by optimizing the unit's practices, they will also ultimately increase the number of viable organs available for transplant. Discussion among group members during the first meeting also indicates that no one is aware of guidelines or studies examining the recommended methods to ensure organ preservation in a brain dead patient.

During the discussion, the team comments that organ preservation in this setting may need to be addressed by literature that evaluates medical, family-based, or staff training strategies to increase the number of successful transplants or improve quality of the organs removed from potential donors. Noting the daunting potential volume and complexity of literature that is needed to guide them in developing a care protocol for brain dead cadaver care, they ask you, as the group's librarian, to aid them in identifying, summarizing, and appraising guidelines and articles addressing these issues.

Reference: Todd PM, Jerome RN, Jarquin-Valdivia AA. Organ preservation in a brain dead patient: information support for neurocritical care protocol development. J Med Libr Assoc. 2007 July; 95(3): 238–245.

New JMLA reviewer tutorial launched

2007-06-29T07:50:00.000-07:00

The editorial team of the JMLA is pleased to announce the launch of the JMLA Reviewer Tutorial.

The expected audience for the tutorial includes the JMLA Editorial Board as well as prospective authors of JMLA articles and those interested in learning more about the peer review process.

Focusing on critical appraisal skills, the tutorial is intended to:
- Provide orientation and professional development for current and incoming JMLA peer reviewers
- Facilitate development of general skills in critically assessing the literature
- Share editorial and peer review expectations for manuscript structure and content with prospective authors of JMLA articles
- Serve as a knowledge management strategy by capturing the JMLA’s peer review process

The tutorial's components include:
- An overview of the role of peer review and JMLA administrative practices and the typical submission-review-disposition workflow
- A detailed consideration of questions to consider in reviewing submitted manuscripts, focused on critiquing key sections of an article (methodology and approach, results, conclusions, implications, writing style)
- Suggestions for developing commentary on the paper and arriving at a final recommendation to the editorial team regarding the article’s disposition
- Sample review comments to illustrate content and tone/writing style
- An example manuscript to allow tutorial participants to exercise their new peer reviewing skills.

We hope it proves useful and please feel free to share any comments or questions with us.

Related:
We also presented a poster about the tutorial at this year's Medical Library Association annual meeting in Philadelphia, available online here (electronic versions of other posters from this year's meeting are also accessible via this list).

Reader questions about the pancreatitis case

2007-06-13T09:59:00.000-07:00

We received a few questions from a group of readers, sent to us by information specialist Ani Orchanian-Cheff, about the April JMLA case on diagnosing acute pancreatitis. Their questions and responses from the case's librarian co-authors, Julie Beauregard and Jennifer Lyon:

We were wondering how many citations you went through in order to find the 4 you ended up summarizing. Some of us thought that you might have gone through the ninety results from your text word search strategy on page 123, while others thought perhaps you went through a combination of the results of all three searches on that page.

We looked at a combination of the results of multiple searches, weeding through the abstracts in the online literature databases to select a smaller number of articles to look at in full-text. We pulled the full-text of about 40 articles. Those were skimmed and pared down based on article type, number of patients, presence of a gold standard for diagnostic criteria and sound methodology -- this process resulted in a smaller number, approximately 10 items, which we read more closely, weighing both their methodology and their relevance to the case at hand. Based on those factors, we chose the final 4 articles to summarize.

A related question was which of your searches was your final/definitive search, or was your final search a combination of the various MeSH and textword suggestions from the search possibilities you outlined. Would you mind sharing it with us?

We used multiple searches with various MeSH terms and textwords and combined the results of those searches, using citation management software (Reference Manager) to eliminate duplicates and organize the results. Between us, we tried over half-a-dozen search combinations and the strategies presented in the article are a synthesis of the most useful elements of the various strategies we tested.

It was interesting for us to see differences in practice patterns. For example, some of us are more apt to point clinicians toward existing guidelines and evidence summaries (such as the Best Evidence Topic Report on the same topic in EMJ), rather than recommending search and appraisal from scratch as you have done.

Our standard practice is to use the primary literature directly as much as possible, unless we receive a direct request for practice guidelines. Often, we will include a guideline or representative review article along with our own summary of the primary data if we feel it is reliable and helpful. However, we sometimes find that practice guidelines or other evidence-summary materials may not fully represent the related primary data or may omit some details of the original research that are relevant to the case at hand. We also find that a thorough consideration of the primary literature proves very useful in gauging the quality and comprehensiveness of review articles and guidelines.

Approximately how long does it take you to do this appraisal and present it in its finished form to the residents?

The time it takes to complete the literature searching, article selection, and summarization process varies from question to question. Some questions have only limited literature available (in which case the search usually is the most time-intensive portion of the process), while others require looking at a larger number of articles (making the article selection and summarization process more time-consuming). Our average time per question ranges from 2.5-3 hours to 12+ hours depending on the complexity and volume of the literature.

We welcome reader questions and comments on the cases via the comments feature on the blog or by email (jmlaeditor@vanderbilt.edu).

More debate on the utility of case reports

2007-05-15T07:01:00.000-07:00

The Scientist posted a news item yesterday, "Case reports: Essential or irrelevant?", discussing reaction of members of other editorial teams to the launch of the new Journal of Medical Case Reports (a BMC title).

Does the medical literature need more case studies? A new journal is betting it does, even as editors at other journals say the answer is no.
Historically, case reports have proven extremely valuable to clinicians faced with diseases they knew little about. But in an age where countries spend more on research than ever before investigating both rare and common diseases, some experts argue that the obscure nature of many case reports makes them of little value to the average practitioner.

The article includes editorial staff commentary from the Lancet, the British Medical Journal, the New England Journal of Medicine, and the American Journal of Medicine.