BACKGROUND QUESTION

CLINICAL SCENARIO

FOREGROUND QUESTION

CLINICAL QUESTION

P (Problem or Patient orPopulation)

I (intervention/indicator)

C (comparison)

O (outcome of interest)

SEARCH TERM/KEYWORD
Does hand washing among healthcare workers reduce hospital acquired
infections?
The question above includes the PICO elements:

P (Problem or Patient or Population) hospital acquired infection

I (intervention/indicator) hand washing
no hand washing; other solution;
C (comparison)
masks
O (outcome of interest) reduced infection

. Plan a search strategy

by identifying the major elements of your question, and translate natural
language terms to subject descriptors, MeSH terms, or descriptors.
 TIP:
start with the P and the I only to begin your search and keep
initial search results broad:

A simple database search strategy should begin with the P AND I

term mapped to database

natural language
vocabulary
P cross infection [MeSH]
(Problem/Patient/Population)=
hospital acquired infection cross infection [CINAHL]

I
hand disinfection [MeSH]
(intervention/indicator)
handwashing [CINAHL]
=hand washing
 FREELY AVAILABLE

www.tripdatabase.com

www.evidence.nhs.uk

www.medicine.ox.ac.uk/bandolier/
knowledge.html.

www.intute.ac.uk
 A simple database search strategy should begin with
the P AND I:
cross infection AND (Handwashing OR Hand
disinfection)

Start with both CINAHL and Medline/PubMed

as initial article databases for a scoping search for most
health sciences questions. If your topic has a
behavioral/mental health component, also try
PsycINFO.

Link to a detailed search:

Does hand washing among healthcare workers reduce
hospital acquired infections?
KEYWORD OF SEARCHING

• http://bmj.com
• http://adc/bmjjournals.com
• MEDLINE/PubMed
• EMBASE
• MDConsult
• AAP Journal Club
• Cochrane Library
• www.Pubmed.gov
• www.tripdatabase.com
• www.evidence.nhs.uk
• www.intute.ac.uk
 INITIAL SEARCH RESULT

After viewing the initial search results

1. Narrow your search with terms for the Comparison,
Outcome, Time factors or Type of study.
2. You may view results, abstracts, and full text of
articles to view the comparison and outcome elements.
3. Use database filters, explained in Filtering the Evidence.
 Search Strategies
for Foreground Questions
Question Natural Terms translated to
language Subject Sample PubMed
terms headings/MeSH Searches
terms/Descriptors
[Database]
Does hand
washing Hand Hand disinfection
among washing [MeSH]AND Cross Link
healthcare Hospital infection [MeSH] to Handwashing
workers acquired AND hospital
reduce infection acquired infection
hospital
acquired
infections?
What is the
effectiveness
of
continuous
passive
motion CPM arthroplasty, Link to in sample
therapy therapy replacement, knee CPM Therapy
(CPM Knee [MeSH] AND AND knee
therapy) replaceme motion therapy, replacement in
following nt continuous passive sample PICO (T)
knee [MeSH] searches
replacement
in achieving
optimal
range of
motion?
 Is the
incidence pneumonia, Link
of ventilator to Ventilator-
ventilator- associated associated
associated ventilator
[MeSH] Pneumonia
pneumonia associated (Nursing AND nurse-
decreased pneumonia
nurse- staff, hospital patient ratios 
by a higher [MeSH]OR
patient in Sample
nurse- Personnel PICO (T)
patient ratio
staffing and searches
ratio? scheduling
[MeSH])
 Research Question: Initial search term Added term(s)
queried (descriptors or
key words)
harvested from
relevant results:

What are the best catheter-associated Catheter-

practices for reducing urinary tract Related
the incidence of infection Infections
catheter-associated [MeSH]
urinary tract infection? (broader term)
OR Urinary
Catheterization
AND Cross
Infection
[MeSH]
OR
Clinical question: In patients with suspected schizophrenia, is magnetic resonance
imaging (MRI) compared with computed tomography (CT scan) more accurate in
diagnosing schizophrenia?

Potential Search Examples of Search Examples of Search

PICO Components
Terms Strategies (PubMed) Strategies (Ovid Medline)

patients with
exp Schizophrenia/ OR
P suspected schizophrenia Schizophrenia
Schizophreni*.ti,kw.
schizophrenia

exp Magnetic Resonance

magnetic magnetic Magnetic Resonance
Imaging/ OR"Magnetic
I resonance resonance Imaging OR MRI OR
Resonance".ti,kw.OR(MR
imaging (MRI) imaging (MRI) NMR
I OR NMR).ti.

"Tomography, X-Ray exp Tomography, X-Ray

computed computed
Computed"[Mesh] OR Computed/OR("comput*
C tomography (CT tomography (CT
“computed tomography” tomography" OR
scan) scan)
OR CT CT).ti,kw.

exp
Accurate
O diagnosis Diagnosis Diagnosis/ORdiagnos*.ti,
diagnosis
kw.
 Clinical scenario
Roger, a 26 year old student, has been diagnosed with
major depression. He has tried three different
antidepressant medications in the past with no
improvement. Reluctant to try a further prescribed
medication he asks about non-pharmacologic
alternatives. You have heard that repetitive transcranial
magnetic stimulation has been trialed for treatment
resistant depression but you are not sure if its
effectiveness has been proven.
You tell Roger that you will look into this for him.
 PICO
Patient: Patients with major, treatment-resistant depression

(treatment failure after two or more courses of

antidepressants)

Intervention: Repetitive transcranial magnetic stimulation

(rTMS)

Comparison: No rTMS

Outcomes: Reduction in depressive symptoms, improved

quality of life, remission of illness.
 Clinical question

In patients with major, treatment-resistant

depression,
is
repetitive transcranial stimulation
effective
in treating
the
depression?
 CONCEPTS

Concept 2:Repetitive
Concept 1:Treatment-resistant
transcranial magnetic
depression
stimulation
Treatment-resistant
depression/depressive
disorderTreatment-resistant major
depressive disorderTreatment- Repetitive transcranial magnetic
resistant MDDTreatment-refractory stimulationr TMS Deep repetitive
depression/depressive transcranial magnetic
disorderPharmacoresistant stimulationDTMS
depression/depressive
disorderMedication-resistant
depression/depressive disorder
 Question: How many men with no comorbidities diagnosed with
localized prostate cancer (with a certain pathologic finding) after
the age of 65 die of their cancer?

TRIP “localized prostate cancer” AND 10 articles including Sandblon et. al.
“Cause of death”  select
prognosis
PubMed Clinical queries“Prostate, 208 articles (too many) ► limit: Engl,
neoplasm” [Mesh]/ mortality Human, Core Journals  64 articles
[major subject heading]And including Tewari, et. al. and
check box: prognosis Albertson, et. al.
MeSH “Prostate, neoplasm” 650 articles (too many)► limit: age
[Mesh]/ mortality. “Prostate, >65, English, Human  375 hits►
neoplasm” [Mesh]/ mortality limit: core clinical journals  126
AND “survival rate” [Mesh] hits► added “Prostate-specific
“Prostate, neoplasm” [Mesh]/ antigen” [Mesh]  33 articles
mortality AND “life expectancy” including Albertson, et. al. 175
[Mesh] articles► limit: English, Human, Core
Clinical Journals  60 articles
including Tewari, et. al. and
Gronberg, et. al. 46 articles, including
Chodak, et. al.
 Question: In patients with diabetes requiring insulin,
does the addition of metformin improve outcomes
Cochrane “metformin AND diabetes” 18 hits: including review by
Goudswaard.Goudswaard AN,
Furlong NJ, Valk GD, Stolk RP,
Rutten GEHM. Insulin
monotherapy versus
combinations of insulin with oral
hypoglycaemic agents in patients
with type 2 diabetes mellitus.

Clinical Search term: “metformin” Various articles. None

Evidence relevant.Also scanned
‘endocrinology’ section and
‘glycaemic control’ section: no
relevant articles.
TRIP “metformin AND 6 therapy articles: none
insulin AND relevant204
mortality”“metformi articlesLimits: RCT,
n AND insulin and Human, Engl – 41
diabetes” articles including:1:
Goudswaard AN et al.
Starting insulin in type
2 di...[PMID:
15125825]2: Yki-
Jarvinen H et al.
Comparison of bedtime
insulin...[PMID:
10068412]
Pubmed MeSH “Insulin"[MeSH] AND 466 items.Limits: RCT, English, Human
("Diabetes melitis, type 2 OR – 122 articles. Limits: RCT, Engl,
Diabetes Melitis"[MeSH]) AND Human, Core Clinical journal – 27 articles
“metformin” [MeSH] including1: Aviles-Santa L, Sinding J,
Raskin P. Effects of metformin in patients
with poorly controlled, insulin-treated type
2 diabetes mellitus. A randomized, double-
blind, placebo-controlled trial. Ann Intern
Med. 1999 Aug 3;131(3):182-8. 2: Yki-
Jarvinen H, Ryysy L, Nikkila K, Tulokas
T, Vanamo R, Heikkila M. Comparison of
bedtime insulin regimens in patients with
type 2 diabetesmellitus. A randomized,
controlled trial. Ann Intern Med. 1999
Mar 2;130(5):389-96.
Clinical queries (systematic 10 articles including1: Daniel JR,
reviews)“Insulin"[MeSH] AND Hagmeyer KO. Metformin and insulin: is
("Diabetes melitis, type 2 OR there a role for combination therapy? Ann
Diabetes Melitis"[MeSH]) AND Pharmacother. 1997 Apr;31(4):474-80.
“metformin” [MeSH] Review. 2: Slama G. The insulin sparing
effect of metformin in insulin-treated
diabetic patients. Diabete Metab. 1991
May;17(1 Pt 2):241-3.
 In a 62year old male with known CAD s/p CABG
(Coronary Artery By Pass Graft) what is the risk of recurrent MI
if he has normal cholesterol levels?

TRIP “coronary artery 16 articles including

+\ disease”, statin, the 2 cohort studies
“myocardial below. The RCT was
infarction”Prognosis also found in TRIP
PubMed tab although search
criteria are uncertain.
In a 45 yo man with hypertension and a negative renal artery
duplex done for refractory hypertension, what is the value of
an aldosterone-renin ratio in the diagnosis of primary
hyperaldosteronism?

PubMed "Hyperaldosteronism/ 1956 articles645

articles (limit English
diagnosis"[MeSH]"Hyper
= 383 articles and
aldosteronism/ limit published in last
diagnosis"[MeSH] AND 5 years = 83 articles)
"Hypertension"[MeSH]
 Question:
In a 45 yo man w/ urinary hesitancy,
what is the efficacy of doxazosin (vs no
treatment) in the relief of urinary
symptoms?

PubMed MeSH “BPH” and “doxazosin”

 In a 45-year-old Caucasian man with a 20-PY
history of smoking, what is the benefit of
varenicline (Chantix) vs. buproprion for smoking
cessation after one year?

PubMed/ Used MESH terms 5 results, including

MESH “varenicline” and Jorenby, Gonzales, and
“buproprion”  30 Niles articles below.
articles  limit of
RCTs
PubMed Searched 15 articles, including
Clinical “varenicline” under Nides et al. (abstract
Queries “Therapy” clinical below), Jorenby et al.
queries. (abstracte below)
 In patients with clinically suspected chronic
pancreatitis, what is the diagnostic value of
serum amylase and lipase?
PubMed Clinical queries“Chronic 45 articles (none relevant)
pancreatitis”
MeSH 10,888 articles 1090
"Pancreatitis/diagnosis"[MeSH] (no articles: limited to human,
Mesh terms for ‘chronic pancreatitis’) English, and RCT  2
("Amylases/blood"[MeSH:NoExp] articles (neither relevant).
OR "Lipase/blood"[MeSH]) AND 109 articles: limited to
"Pancreatitis/diagnosis"[MeSH] human, English  62 hits,
"Pancreatitis/diagnosis" including Lesi, et. al. 185
[MeSH:NoExp] and chronic AND articles with limitations to
("Amylases/blood"[MeSH] OR human, English including
"Lipase/blood"[MeSH]) “chronic Pezzilli, et. al.
pancreatitis” AND
("Amylases/blood"[MeSH] OR
"Lipase/blood"[MeSH])
www.tripdatabase.com

“chronic pancreatitis”

377 diagnosis articles

 In patients with known COPD, diagnosed by
Pulmonary Function Test, what is the mortality
rate for patients after a first hospitalization?

TRIP “COPD” AND “First 16 prognosis articles:

hospitalization” AND including
“prognosis” Savnajakangas.
►Related articles: 462
articles
PubMed Clinical 11 articles: one relevant
queries“COPD” AND from 1997.
“First hospitalization”
AND clicking off
“prognosis”
MeSH "Pulmonary 22 articles:
Disease, Chronic 5 relevant
Obstructive/mortali
including
ty"[MeSH] AND
“Prognosis”
[MeSH] AND
“exacerbat*” AND
“hospital*”
 In adult patients with severe sepsis, what is the
effect of activated protein C (drotrecogin alfa)
in reducing mortality?
PubMed Clinical Systematic reviews: 3 articles.
queries"Sepsis/mortality"[
MeSH] AND "drotrecogin
alfa activated"[Substance
Name]
MeSH “drotrecogin alfa 166 articles (too many) 60
activated"[Substance articles: limit to Human,
Name] AND English and RCT  11 articles
"Sepsis"[MeSH] including PROWESS trial.
"Sepsis/mortality"[MeSH]
AND "drotrecogin alfa
activated"[Substance
Name]