1. 1 WORK ON COMPUTERS Winter Semester : List of Topics 1. Medical literature as a resource for evidence based medicine. An overview. 2. Biomedical literature resources and hierarchy of evidence. 3. MEDLINE - the most important biomedical database. PubMed online training. 4. MEDLINE - sample searches. Search strategy tips, Boolean operators, working with search results. MeSH, links to fulltext articles.

2. 2 CLINICAL QUESTION FOR TODAY Author: Prof. V. Mihál, MD, PhD. Vaccination for prevention of otitis media in children

3. 3 Topic 1: Consolidation Google Search & Document Types

4. 4

5. 5 Self-study Assignment 1  Identify types of first 40 documents, eg. Company websites Journal articles  Fulltext version  Bibliographic record only  Bibliographic record + abstract Database Educational material (universities, professional societies) Patents Patient information Library catalogs Business information (eg.pharmaceutical companies) Others (specify)

6. 6 Quality of Internet Resources  eEurope 2002: Quality Criteria for Health related Websites Communication from the Commission to the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions

7. 7 European Commission „Quality Criteria for Health Related Websites“ Published 2002 1. Transparency and Honesty  Provider of site - including name, physical address and electronic address of the person or organisation responsible for the site  Purpose and objective of the site  Target audience clearly defined (further detail on purpose, multiple audience could be defined at different levels).  Sources of funding for site (grants, sponsors, advertisers, non-profit, voluntary assistance).

8. 8 European Commission „Quality Criteria for health Related Websites“ 2. Authority  Clear statement of sources for all information provided and date of publication of source.  Name and credentials of all human/institutional providers of information put up on the site, including dates at which credentials were received.

9. 9 European Commission „Quality Criteria for health Related Websites“ 3. Updating of information  Clear and regular updating of the site, with date of up-date clearly displayed for each page and/or item as relevant.  Regular checking of relevance of information.

10. 10 European Commission „Quality Criteria for health Related Websites“ 4. Privacy and data protection 5. Accountability (user feedback, trustworthy linking to other websites, editorial policy) 6. Accessibility (general findability, searchability, readability, usability, etc.).

11. 11 Journal Articles : Categories  Original articles / clinical research results Randomized controlled trials Cohort studies Case reports + case series Editorials, letters to editor, comments….  Reviews / secondary research Critically appraise contents & methodology of published original studies (>2) to help readers orientate in the never-ending information explosion…..

12. 12 Pyramid of Evidence

13. 13 Original Articles Randomized Controlled Trials

14. 14 Original Articles Randomized Controlled Trial : Example Fireman B. et al. Impact of the pneumococcal conjugate vaccine (PCV) on otitis media. Pediatric Infectious Diseases Journal 2003; 22:10-16. Institution:Kaiser Permanente Vaccine Studies Center, Oakland, CA, USA.  Objectives: To examine impact of PCV on incidence of otitis media; to assess if effectiveness of the vaccine wanes after after age 24 months and varies by race, sex or season.  Design, setting, participants: 1995 – 1998 37 868 children were randomized (allocated by random) to receive  PCV vaccine OR  Control vaccine Follow-up until April 1999  Intervention: Primary series at 2, 4 and 6 months; booster at 12 to 15 months.  Results: Control children averaged 1.8 otitis visits/year PCV vaccinees had fewer otitis visits in every age group, sex, race and season. PCV vaccine reduced  otitis visits by 7.8%  antibiotic prescriptions by 5.7%.  Conclusions: In children followed up to 3.5 years, PCV provided a moderate amount of protection against ear infections while reducing frequent otitis media procedures by greater maounts.

15. 15 Original Articles Cohort Studies

16. 16 Original Articles Cohort Study : Example T.Heikkinen et al. Influenza vaccination in the prevention of acute otitis media in children. American Journal of Diseases of Children 1991; 145(4):445-448. Institution: Department of Pediatrics, University of Turku, Finland.  Objectives: We studied a new approach to the prevention of acute otitis media through the administration of influenza vaccine  Participants: Group of vaccinees: 187 day-care center children aged 1 to 3 years before the influenza A epidemic of 1988- 1989. Comparison group: 187 unvaccinated children of similar age and background.  Follow-up: During the 6-week study period, influenza A infection was diagnosed in 5 (3%) of 187 vaccinees, and in 29 (16%) of 187 controls.  Acute otitis media developed in 3 (60%) of 5 vaccinees with influenza A infection compared with  18 (67%) of 27 controls (excluded were two children with a double viral infection).  Outcome: The incidence of acute otitis media associated with influenza A was reduced by 83% in the vaccinees. The total number of children with acute otitis media in the vaccine group was 35, compared with 55 in the control group, disclosing a 36% reduction among the vaccinees.  Conclusions: Influenza vaccination decreased the incidence of acute otitis media in children during an influenza A epidemic, suggesting also that other vaccines against respiratory viruses may be an effective way to reduce the incidence of acute otitis media.

17. 17 Original Articles Case Reports + Case Series

18. 18 Review Articles Definition  „Review articles in medical journals summarize large amounts of information on a particular topic;  …..a useful and popular source of information for doctors.  ……some review articles reflect the personal opinions of the author more than the body of knowledge about a topic.  Experts have proposed guidelines for how authors should write review articles in order to avoid personal bias. ……..authors should address a focused question, describe how they searched for and evaluated information, identify gaps in knowledge, estimate risks and benefits of recommended treatments.“ Annals of internal Medicine 1999;131(12):947.

19. 19 Types of Reviews  Traditional („narrative“)  Systematic + Meta-analysis (selection of articles according to pre- determined criteria; statistical analysis)

20. 20 Traditional („Narrative“) Reviews  Frequently found in many journals  Often broad in scope  „Book chapter“  Usually based on incomplete data  Do not use systematic methods identify assess synthesize

21. 21 Systematic Reviews Main Features  Focus on a specific clinical question and conduct an extensive literature search to identify studies with sound methodology.  Studies are reviewed, assessed, and the results summarized according to the pre- determined criteria of the review question.

22. 22 Systematic Reviews & Meta-Analysis Statistical methods

23. 23 Bibliographic Databases „Pathway to Journal Articles“  MEDLINE / PubMed Service of US National Library of Medicine  URL http://www.pubmed.comhttp://www.pubmed.com is an easy and free place to search for answers to foreground questions, and it offers links to a growing number of free full-text articles. Size >18 million records Retrospective since 1950 until present LinkOut feature --- access to fulltext articles through external providers (publishers, info brokers)

24. 24 Use of Boolean Operators  Allows you to combine search terms to better focus your search AND: Combines terms to limit your search as both(all) concepts must be present in all retrieved articles.  Example: otitis media AND vaccin* OR: Widens your search as either term can be present in all retrieved articles  Example: otitis media OR middle ear inflammation NOT: Limits your search by excluding a concept as one term must be present and the second term must not be present  Example: otitis media NOT chronic

25. 25 What is Truncation / Wildcard  PubMed finds all terms that begin with a given text string  Represented by the asterisk (*), sometimes referred to as a „wildcard“. Example  vaccin*  PubMed retrieves: vaccine, vaccines, vaccination, vaccinated, vaccinee(s),,,,,,,,,

26. 26 PubMed Search Strategy Problem/Disease http://www.pubmed.com Step 1 otitis media OR middle ear inflammation* OR middle ear infection* Limits: Title

27. 27 Enter One or More Search Terms & Use Features Tabs Click on Limits

28. 28 Choose Limits : Title 2. Select Title 3. Press Go 1. Scroll Down

29. 29 Step 1 : Results otitis media/title Display Format : Summary

30. 30 Display Format : Summary Record Structure  Author(s) Schmelzle J, Birtwhistle RV, Tan AK.  Article title Acute otitis media in children with tympanostomy tubes.  Journal Can Fam Physician. 2008 Aug;54(8):1123 Volume Issue Page(s)

31. 31 PubMed Search Strategy Intervention/Exposure Step 2 vaccin* Limits: Title/Abstract

32. 32 Step 2 : Clear Search Box + Limits Box

33. 33 Enter New Search Term(s), Choose Limits 2. Select Title/Abstract 3. Press Go 1. Scroll Down

34. 34 Step 2 : Results vaccin*/Title-abstract Display Format : Summary

35. 35 PubMed Search Strategy Combine Searches Step 3 #1 AND #2  Choose additional limits: Ages  Birth-23 months Type of article  eg. Randomized Controlled Trials Etc.

36. 36 Step 3 : Clear Search Box + Limits Box Click on History Click on History

37. 37 Step 3: History Click Query # for More Options Click query # for more options. 2. Click on Preview

38. 38 Combine Searches, eg. #1 AND #2 Click on Preview

39. 39 Results of Step 3: otitis media x vaccin* Choose Age Limits Click on Limits

40. 40 Age Limits Birth-23 months; Pre-school 2-5 years

41. 41 Age Limits Applied: Results

42. 42 PubMed To Be Continued ………………