How to search for

EBM resources
Prof Eiad Al-Faris MD, MSc, MMEd,
MRCGP
Consultant Family Medicine
Prof. King Saud University
Supervisor -King Saud University
chair for medical education
 Outline
Introduction
Definition of EBM
Steps of EBM
Practical search
Conclusion
Closure
INFORMATION ?250,000

100,000
EXPLOSION
10,000

MEDICAL JOURNALS
1900 1990 2000
3
 Rule 31 Review the World Literature
Fortnightly*

5,000?
2500000
per day
Medical Articles per Year

2000000

1500000

1000000
1,260
55 per per day
500000 day
0
Trials MEDLINE BioMedical
 Clinical Scenario
Ibrahim is a 60 years old teacher, he
is known case of hypertension. He
presented to the ED with severe
chest pain for the last two hours.
In addition to hitory / exam and ECG,
you wonder should you request for
the timely diagnosis: troponin or
creatine kinase- MB or both?
When confronted with a
clinical question, whom
usually you consult?
 Colleagues- experts

A great source of information.

Quick, affordable and accessible.
But potentially very biased:
Variability
Not updated
 Textbooks

Rapidly out-of-date (2-4y).

They are a good source of background
information (pathophysiology),
but a poor source of information for
most foreground questions (clinical).
Burn your traditional textbooks
 EBM is

The integration of the current best

evidence (from research) with our
clinical expertise and patients
values.
Three (Es)- EBM Components
Hierarchy of Evidence
Meta-analysis of RCTs
Multi-centric large RCTs

Single Centre RCT

Observational studies
patient-important outcomes

Clinical experience

Basic research
test tube, animal, human physiology 13
 6 As to practice EBM

Assess Ask clinical

your patient questions

Acquire the Appraise

Evidence(s) the evidence(s)

Apply The Assess

best evidence
Yourself
to patient
 Assess Your Patient

History
Physical examination
Objective data labs, x-rays

Formulate differential diagnosis

Pretest probability of disease
 6 As to practice EBM

Assess Ask clinical

your patient questions

Acquire the Appraise

Evidence(s) the evidence(s)

Apply The Assess

best evidence
Yourself
to patient
To answer a clinical question
effectively, First, turn your scenarios
into 'well-built' clinical Q.
Four domains: PICO
1) the patient (problem)
2) the intervention or exposure
3) the comparison (intervention)
4) the clinical outcomes
 Clinical Scenario
Ibrahim is a 60 years old teacher, he
is known case of hypertension. He
presented to the ED with severe
chest pain for the last two hours.
You wonder should you request
troponin or creatine kinase- MB or
both?
 For middle aged HTN men
with chest pain, Which is
more valid for the
diagnosis of IHD, troponin
or creatine kinase-MB or
both?
What do you think?
What would you do?
Treponine or creatine kinase-MB
1. Patient population. Patients attending the ED
with chest pain
2. Intervention. Troponine

3. Comparison creatine kinase-MB

intervention.

4. Outcomes. Accuracy of diagnosis of IHD

In Patients attending the ED with chest pain

, is troponine as compared to creatine kinase-MB
more valid for the diagnosis of ischemic heart disease?
video
 For healthy adults is
it worthwhile to give
aspirin as prophylaxis
to reduce MI and or
stroke ?
To answer a clinical question
effectively, First, turn your scenarios
into 'well-built' clinical Q.
Four domains: PICO
1) the patient (problem)
2) the intervention or exposure
3) the comparison (intervention)
4) the clinical outcomes
Aspirin and Primary Prevention
1. Patient population. Asymptomatic adults with
no risk factors
2. Intervention. Aspirin

3. Comparison Placebo
intervention.

4. Outcomes. Incidence of CV events

In asymptomatic adults no risk factors, would the

use of aspirin reduce the incidence of cardiovascular
events?
Ask Clinical Questions (PICO)
Components of Clinical Questions (PICO)

Patient/ Intervention/
Population Comparison Outcome
Exposure

In patients with does early treat- compared to decrease cardio-

acute MI ment with a statin placebo vascular mortality?

In women with what is the compared to for diagnosing

suspected accuracy of exercise significant
coronary disease exercise ECHO ECG CAD?

In post- does hormone compared to no increase the

menopausal replacement HRT risk of
women therapy breast cancer?
Patients Name Learner:

3-part Clinical
Target Disorder: Question

Intervention (+/- comparison):

Outcome:

Date and place to be filled:

Presentations will cover:

1. search strategy;
2. search results;
3. the validity of this evidence;
4. the importance of this valid evidence;
5. can this valid, important evidence be applied to your patient;
6. your evaluation of this process.
 Types of clinical questions
Therapy and harm: how to select treatments to
offer patients that do more good than harm

Diagnostic tests: how to select and interpret

diagnostic tests, in order to confirm or exclude a
diagnosis

Prognosis: how to estimate the patient's likely

clinical course over time
 Acquire the Best Evidence
Secondary sources Unfiltered Sources
Cochrane Library (www.update-
software.com/cochrane) MEDLINE
Up-to-Date (www.uptodate.com) (www.pubmed.gov)
Clinical Evidence Google
(www.evidence.org) (www.google.com
Ovid (www.ovid.com)

Dynamed (www.dynamed.com)

We need to focus and familiarize

yourself with few of them
 Systems

Summaries

Synopsis of
Syntheses

Syntheses

Synopsis of
Studies

Studies
 Summaries
Clinical Evidence www.clinicalevidence.com
Dynamed
www.ebscohost.com/dynamed/default.php
Physicians Information and Education
Resource (PIER) pier.acponline.org
UpToDate www.uptodate.com
Clinical Practice Guidelines
National Guidelines Clearinghouse
www.guideline.gov
 Synopses of Syntheses
Evidence Based Abstraction Journals e.g.
ACP Journal Club www.acpjc.org
Evidence Based Medicine ebm.bmj.com
Evidence Based mental health
ebmh.bmj.com
The database of abstracts of reviews of
effects (DARE) www.crd.york.ac.uk
 Syntheses
ACPJC plus (plus.mcmaster.ca/acpjc)
EvidenceUpDates
http://plus.mcmaster.ca/evidenceupd
ates
The Cochrane Library
www.thecochranelibrary.com
 Synopsis of Studies
Evidence-Based Abstraction Journals
 Studies
www.pubmed.gov
Clinical queries
Special queries: for health services and
qualitative research
www.nlm.nih.gov/bsd/special_queries.htm
l
 Federated Search Engines
SUMSearch sumsearch.uthsca.edu
TRIP Turning Research Into Practice
www.tripdatabase.com
Practice searching the pubmed and the
other forgiving sources for the
following scenario
 Saud is a 30 years old teacher, he is
known case of severe allergic rhinitis.
He presented to your clinic for follow
up, he is having a flare up of rhinitis
symptoms, and he wants to get refills
of the antihistamine pills that he used
to get from his physician.
You wonder should you prescribe
intranasal steroids or refill the
antihistamines?!
 Pre-filtered Sources:
Cochrane Library
http://www.thecochranelibrary
.com
Up-to-Date
www.uptodate.com

Clinical Evidence
www.clinicalevidence.org 38
 ACP Journal Clubwww.acpjc.org

InfoRetriever
www.infopoems.com

MD Consult www.mdconsult.com

Medscape www.medscape.com

Dynamed www.dynamed.com
39
 POEM Vs. DOE

POEM: Patient-oriented evidence that

matter
mortality, morbidity, quality of life

DOE: Disease-oriented evidence

pathophysiology, pharmacology, etiology
Comparing DOE and POEM

DOE POEM

Antihypertens Lowers Blood Mortality

therapy Pressure MI
CVA
Screening for PSA screening Unknown whether
prostate CA detects PSA screening
Prostate CA at reduces Mortality
an early stage
 40DOE POEM

Clofibrate Clofibrate decreases CV It Increases overall

decreases mortality/ mortality
Morbidity
cholesterol

blockers are blockers are

contraindicated for indicated for heart
heart failure patients failure patients

Antiarrhythmic A Antiarrhythmic A Antiarrhythmic A

decreases PVCs decreases symptoms increases mortality

The cardiac arrhythmia suppression trial. N Engl J

Med 1991.
42
 DOE POEM
Clofibrate Clofibrate decreases CV It Increases overall
decreases mortality/ mortality
Morbidity
cholesterol

blockers are blockers are

contraindicated for indicated for heart
heart failure patients failure patients

Antiarrhythmic A Antiarrhythmic A Antiarrhythmic A

decreases PVCs decreases symptoms increases mortality

The cardiac arrhythmia suppression trial. N Engl J

Med 1991.
43
 DOE POEM
Clofibrate Clofibrate decreases CV It Increases overall
decreases mortality/ mortality
Morbidity
cholesterol

blockers are blockers are

contraindicated for indicated for heart
heart failure patients failure patients

Antiarrhythmic A Antiarrhythmic A Antiarrhythmic A

decreases PVCs decreases symptoms increases mortality

The cardiac arrhythmia suppression trial. N Engl J

Med 1991. 44
OBJECTIVE: The aim of this study was to evaluate the diagnostic
efficacy of multiple tests-heart-type fatty acid-binding protein (H-
FABP), cardiac troponin I (cTnI), creatine kinase-MB, and
myoglobin-for the early detection of acute myocardial infarction
among patients who present to the emergency department with
chest pain.
METHODS: A total of 1128 patients provided a total of 2924 venous
blood samples. Patients with chest pain were nonselected and
treated according to hospital guidelines. Additional cardiac
biomarkers were assayed simultaneously at serial time points using
the Cardiac Array (Randox Laboratories Ltd, Crumlin, United
Kingdom).
RESULTS: Heart-type fatty acid-binding protein had the greatest
sensitivity at 0 to 3 hours (64.3%) and 3 to 6 hours (85.3%) after
chest pain onset. The combination of cTnI measurement with H-
FABP increased sensitivity to 71.4% at 3 to 6 hours and 88.2% at 3
to 6 hours..
Receiver operating characteristic curves demonstrated that H-
FABP had the greatest diagnostic ability with area under the
curve at 0 to 3 hours of 0.841 and 3 to 6 hours of 0.894. The
specificity was also high for the combination of H-FABP with
cTnI at these time points. Heart-type fatty acid-binding protein
had the highest negative predictive values of all the individual
markers: 0 to 3 hours (93%) and 3 to 6 hours (97%). Again, the
combined measurement of cTnI with H-FABP increased the
negative predictive values to 94% at 0 to 3 hours, 98% at 3 to 6
hours, and 99% at 6 to 12 hours.
CONCLUSION: Testing both H-FABP and cTnI using the
Cardiac Array proved to be both a reliable diagnostic tool for the
early diagnosis of myocardial infarction/acute coronary
syndrome and also a valuable rule-out test for patients presenting
at 3 to 6 hours after chest pain onset
The Cochrane library
Tripdatabase
Dynamed
Prevention & Treatment
If EBM looks impossible then
resign it!
98
Secondary Sources of
Evidence

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The Cochrane Library

http://www.cochrane.org/

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The Cochrane Library

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 Clinical Scenario

Khalid is a 40 years old smoker, would like to

quit smoking, he tried to do that, by himself,
several times over the last two years, but he
could not tolerate the withdrawal symptoms.
Recently he read an article in the newspaper
reporting that anti-depression medications
can be used to help smoker to quit, he would
like your advise about this issue!
You wonder what is the role of
antidepressants in smoking cessation?!
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 Formulating clinical questions

Patient/ Population : Smoking

Cessation
Intervention :
Antidepressants
therapy
Comparison : Placebo
Outcome : Rate of smoking
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Cessation
The Cochrane Database of Systematic
Reviews
Live Demonstration

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 Clinical Scenario
Ibrahim is a 30 years old teacher, he
is known case of allergic rhinitis. He
presented to your clinic for follow up.
He is having a flare up of rhinitis
symptoms, and wants to get refills of
the antihistamine pills that he used to
get from his physician.
You wonder should you prescribe
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intranasal steroids or refill the

 Formulating clinical
questions
Patient/ Population : Patients with
Allergic Rhinitis
Intervention : Intranasal
steroids
Comparison : Antihistamines
Outcome : Control of
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DARE Live Demonstration

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 ACP Journal Club
Selects articles from the
literature that are original
commented on by clinical
experts.
More than 2000 reviews
currently available.
http://www.acpjc.org/
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 UpToDate

A collection of well-
referenced reviews.
Includes 40,000 pages of
text, 8,000 graphics, and an
extensive drug database.
Updates are made three
times a year.
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contains specialty-focused
information and includes
 Bandolier
Search for systematic
reviews and abstract them
Include NNT tables
http://www.jr2.ox.ac.uk/B
andolier/
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The Therapeutics Initiative
Provide an up-to-date, evidence-
based, practical information on
rational drug therapy
http://www.ti.ubc.ca/index.html

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 Clinical Evidence

Produced by the BMJ

Publishing Group
Updated every six months
www.clinicalevidence.org

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 Other sources of Evidence-
Summaries
InfoRetriever
www.infopoems.com
The CATbank
http://www.minervation.com/cebm2/c
ats/allcats.html
CFP Critical Appraisal Index
http://www.cfpc.ca/cfp/2003/Jun/to
c_page2.asp#critical
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Evidence-Based Guidelines

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 Agency for Health Care
Research & Quality (AHRQ)

Include a comprehensive guidelines for 19

separate conditions.
http://www.ahrq.gov/clinic/cpgarchv.htm.
Include recommendations on a wide range
of clinical preventive services.
Evidence-based Practice Centers (EPC)
Reports:
http://www.ahrq.gov/clinic/epcindex.htm

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 The Canadian Task
Force on Preventive
Health Care
A practical guide for a wide variety
of preventive health interventions
using EBM recommendations.
Include age and sex specific
recommendation tables.
http://www.ctfphc.org/
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Canadian Practice Guidelines
Infobase
The most up-to-date Canadian based
guidelines site.
Most of the guidelines are evidence-
based.
http://mdm.ca/cpgsnew/cpgs/index.a
sp
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 National Guideline
Clearinghouse
Include structured abstracts of
guidelines with links to full-text
guidelines.
Not all guidelines are evidence-based.
http://www.guidelines.gov

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 Guideline Advisory
Committee
Gives quick access to recommended
guidelines for common medical
conditions.
Include summaries and ratings of the
guidelines with full text links to
guidelines.
http://www.gacguidelines.ca/
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 Other sources of Evidence-
based Guidelines
The Scottish Intercollegiate
Guidelines Network (SIGN)
http://pc47.cee.hw.ac.uk/sign/clinical
.htm.
The New Zealand Guidelines Group
http://www.nzgg.org.nz/index.cfm.
The NHS and department of Health
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Technology assessment programme.

EBM Search Engines

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 TRIP Database
The TRIP Database searches more
than 70 sites of high-quality medical
information.
The site is updated monthly.
http://www.tripdatabase.com/

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TRIP Database Live Demonstration

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 Thank You
efarisx2@gmail.com

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