Best Evidence = Best Practice
Understanding outcomes and the potential benefits of a therapy
you are considering for your patient is an important component of
Evidence-Based Medicine. The flip side of the coin, however, is equally important. Will the therapy harm my patient? Often, the Evidence-
Based literature you find will discuss both and you will need to discuss with your patient the benefits of the therapy weighed against the risk of adverse effects. At other times, the information on harm is not that
clear and the risk of a therapeutic intervention will not appear until the
MeSH is the controlled vocabulary that is used in MEDLINE
(PubMed). By using MeSH terms as opposed to keywords in a
search, you can increase the relevance of your findings. While
articles on benefit, as you have learned, can be easily found using
the PubMed “Clinical Queries” and “mapping” features, it’s a bit more
tricky with harm. Within most MeSH terms are “subheadings”.
These subheadings can be used to focus on a particular aspect of a
subject and are a rich source for harm/risk-related terminology.
The fol owing case demonstrates how you can apply subheadings
when looking for evidence on risk and harm.
S. is a 5-year old girl who was diagnosed with Selective Mutism
and prescribed Prozac, 30 mg/day. Two weeks later, S. returns to your
clinic after experiencing confusion, nausea and excessive tiredness. Her mother asks you if the newly-prescribed Prozac might be contributing to
her new symptoms, especially since a search of your drug database indicates that the initial dosage was on the high end of the scale for
pediatric dosing. You want to search the literature to see if there are any indications that Prozac might be the culprit and if it is indeed the
P=5 year-old girl with selective mutism I=Prozac (fluoxetine) O=reduction/elimination of negative symptoms
When looking for good evidence surrounding issues of harm,
many of the standard EBM search tools do not work as they otherwise
would. The best way to approach this search would to:
1. Go to PubMed but not clinical queries right away!
2. Go to the MeSH database on the left navigation bar, just above Clinical Queries
3. Search for Prozac (fluoxetine WILL appear on your list – PubMed mapping at work!)
4. Open Fluoxetine and under subheadings, choose adverse effects and toxicity
5. In the gray area near the top of the page, find the Send To drop-down box.
Choose Send to Search box with AND
6. Don’t search yet! Next, select and copy what you see in the box (it should read
("Fluoxetine/adverse effects"[Mesh] OR "Fluoxetine/toxicity"[Mesh]))
7. Open Clinical Queries and paste the data into Clinical Study Category search box,
8. From here, you MAY want to use the Limits tab to limit for current date range and
age group. THIS wil give you a focused, harm-based search with good evidence.
Wow! Not the easiest search on record but by learning how to use
the MeSH database in conjunction with Clinical Queries, you will have an easier time finding solid Evidence-Based information on therapy’s evil twins harm and risk.
Lamar Soutter Library, University of Massachusetts Medical School
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