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Question from scenario 65-year-old male had been waking frequently at night due to urgency to void. His urologist has diagnosed Benign Prostatic Hyperplasia (BPH). In reviewing the literature alpha-antagonists also called alpha-blockers are prescribed. The patient is getting more irritable at home and is suffering from concentration problems at his high–tech job. The physician is concerned with patient compliance with his medication.

P I C O ======== 65 year old male with Benign Prostatic Hyperplasia finasteride terasozin most efficacious relief of BPH symptoms PICO

Keywords describe the main idea of your topic/concept Keywords are located in the Title, Author, Subject/Descriptor, Abstract, and Journal fields Use keyword searching when articles have not been indexed with subject headings Negative - Have to use synonyms (all the ways an author may have expressed and/or spelled the topic) Ex: back pain OR back pains OR backache OR backaches OR back ache OR back aches, OR pain, back etc. Negative - More articles, tends to be less relevant Keyword Searching

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“benign prostatic hyperplasia” Click Search

Results in the first search set Results in the first search set finasteride Click Search

Results in the second search set Results in the second search set Click Search finasteride

Select sets to Combine Click And

Boolean Logic - AND finasteride benign prostatic hyperplasia AND

Results of the AND combination Results of the AND combination

terazosin Click Search

Results of the third search set Results of the third search set

Select sets to Combine Click And

Results of the AND combination Results of the AND combination

Select sets to Combine Click And

Results of the AND combination Results of the AND combination Results have narrowed to a manageable number of articles

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Search Results

Articles with answer to PICO question Articles with answer to PICO question

EBM Journal Article Literature Databases

Note that the results are sorted by database – in this case the Cochrane Database of Systematic Reviews Scrolling through the results

there are results from ACP Journal Club

results from Database of Reviews of Effects (DARE)

and results from Cochrane Central Register of Controlled Trials

Cochrane Database of Systematic Reviews

What is a Systematic Review? From: Cochrane Collaboration at Systematic review A review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyze and summarize the results of the included studies. Meta-analysis The use of statistical techniques in a systematic review to integrate the results of included studies. Sometimes misused as a synonym for systematic reviews, where the review includes a meta- analysis.

Systematic Reviews assess randomized trials and provide a comprehensive summary of the available evidence. Over 800 international journals are searched to locate articles. a Systematic Reviews contain all known reference to trials on a particular intervention. Evidence is assessed with explicit quality criteria to minimize bias ensure reliability. Trials that meet assessment criteria can be combined to produce a more statistically reliable result. Data from studies are often combined statistically to increase the power of the findings of numerous studies, which on their own may be too small to produce reliable results. Authors, who participate with the Cochrane Collaboration, appraise and synthesize evidence from as many relevant scientific studies as possible.

Click EBM Topic Review

The EBM Topic Review is a methodological summary of the complete systematic review article

Topic reviews are prepared by an author team including subject experts, peer reviewers, librarians, methodologists, and copy and content editors.

Article as PDF

96 pages complete article

Search strategy done for this review.

Subject heading used in the search.

ACP Journal Club

Study categories include: a a Prevention or treatment Diagnosis Prognosis Etiology Economics Clinical prediction guides Differential diagnosis ACP Journal Club is a joint online journal: ACP Journal Club by the American College of Physicians Evidence-Based Medicine by the British Medical Journal Group Over 100 clinical journals are screened for original studies that are methodologically sound & clinically relevant. Information summarized in structured abstracts include: aA Study Selection Data Extraction Results Conclusions

Information summarized in structured abstracts include: Study Selection Data Extraction Results Conclusions

ACP Journal Club includes brief commentaries on: a aa Context Clinical applications of findings

DARE

DARE includes Over 3000 abstracts of systematic reviews that have been quality assessed Reviews answer questions about specific interventions

Authors’ conclusions Critical commentary Implications

Cochrane Central Register of Controlled Trials

Click Complete Reference

CCRT does not contain full text. Access full text through Gold Rush. The Cochrane Central Register of Controlled Trials 3/5th’s records are from PubMed Relevant records from Embase Other published and unpublished sources Reports from conference proceedings

The Cochrane Central Register of Controlled Trials also searchable by PubMed’s Medical Subject Headings Subject Heading searches yield easier and more accurate search results

Keywords VS Subject Headings Subject headings: Also called controlled vocabulary words (thesaurus) – links your synonyms and different spellings to one word or phrase Standardized set of terms usually identified and defined by subject indexers Articles have been indexed and given subject headings Finds less articles but are more relevant Negative – May miss articles not indexed

Advanced Searching Techniques

By entering an asterisk at the end of part of a word, the computer searches for any suffix of that word: Example: gene* can yield genes generation genetic genetics This is called truncation.

Other search techniques: Can use Boolean OR to combine synonyms Example: alpha-antagonists or alpha-blockers or alpha-antagonists alpha-blockers

Possible search strategies for the other PICO questions

Assignmen t

Reading Assignment Building Focused, Well-Articulated Clinical Questions What makes a clinical question well built? First, the question should be directly relevant to the problems at hand. Next, the question should be phrased to facilitate searching for a precise answer. To achieve these aims, the question must be focused and well articulated for all 4 parts of its 'anatomy' (known as PICO): 1) the Patient, population or problem being addressed What are the characteristics of the patient or population? What is the condition or disease? 2) the Intervention being considered which could include: exposure, diagnostic test, prognostic factor, therapy, patient perception What do you want to do with this patient? Treat, diagnose, observe? 3) the Comparison intervention or exposure, when relevant relevant most often when looking at therapy questions What is the alternative to the intervention? Placebo, different drug, surgery? 4) the clinical Outcomes of interest What are relevant clinical outcomes of interest to you and your patient? Morbidity, death, complications? Asking focused, four-component questions takes practice. Doing it well requires that you have insight into what you do not know, coupled with curiosity and a willingness to learn. Also, knowing how questions arise, where they come from, and how to recognize and articulate them can help you refine your skills. How do clinical questions arise? During a patient encounter, the clinician may be uncomfortable making a decision until more is known. It is recommended that you quiet your emotions while turning your implicit knowledge gaps into explicit questions. Most clinical questions arise from the following six aspects of clinical work: 1) Clinical evidence: how to gather clinical findings properly & interpret them soundly. 2) Diagnosis: how to select and interpret diagnostic tests. 3) Prognosis: how to anticipate the patient's likely course. 4) Therapy: how to select treatments that do more good than harm. 5) Prevention: how to screen and reduce the risk for disease. 6) Education: how to teach yourself, the patient, and the family what is needed.

How can you recognize and formulate clinical questions as they occur? First, pay careful attention to the questions that spontaneously occur to you. Listen for the 'question behind the question.' Next, try saying your questions out loud or writing them down with all four components included. Then build your question in two steps, starting with the 'location,' such as 'my question is about therapy,' Ask yourself what type of clinical scenario would you like to consider: Therapy? Prognosis?Diagnosis?Harm? Then, articulate all four PICO components explicitly. See the example below. What if too many questions arise? Select from the many questions the few that are most important to answer right away. Ask yourself, "What is the most important issue for this patient now? What issue should I address first? Which question, when answered, will help me most? PICO Example: Patient or Problem: 65-year-old man with a stroke & moderate carotid stenosis Intervention: ASA (acetylsalicylic acid) Comparison Intervention: Placebo Outcome: Stroke becomes a focused, well-built question. Focused, Well-Built Question: In a 65-year-old man with a stroke and moderate carotid stenosis, can ASA decrease the risk of another stroke compared with no treatment? Additional Practice If you would like additional practice formulating articulate questions using a web tutorial go to: Answering Clinical Questions After the patient care problem(s) has been articulated into a focused, well-built question, the next step is to search the literature. A variety of EBM resources will be explored in the library teaching sessions. Taken from: The well-built clinical question: a key to evidence-based decisions by W. Scott Richardson, MD, et al. in ACP Journal Club. 1995; 123 (Nov-Dec): A-12. Centre for Evidence-Based Medicine, University Health Network, University of Toronto Libraries, (2004). Practising EBM. Retrieved May 8, 2007, from Practising EBM: Formulating Answerable Clinical Questions Web site: University of Washington Health Sciences Libraries, ( ). Construct Well-Built Clinical Questions Using PICO. Retrieved May 9, 2007, from HealthLinks, Toolkits, Care Provider, Evidence Based Practice Web site: rev.2 05/09/07

Create a PICO using the PICO Worksheet

Assessmen t

1) Using the PICO formulation helps to organize issues of research in clinical cases. True False 2) The “I” in the PICO formula stands for IDEA. True False Assessment

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