Using UBC Library to Find Drug Information 2014

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An all-day session with UBC Pharmacy Residents, 2014

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  • http://hlwiki.slais.ubc.ca/index.php/Five_steps_of_EBM
  • Background questions ask for general knowledge about an illness, disease, condition, process or thing. These types of questions typically ask who, what, where, when, how & why about things like a disorder, test, or treatment, etc.
    For example
    How overweight is a woman to be considered slightly obese?
    What are the clinical manifestations of menopause?
    What causes migraines?
    Foreground questions ask for specific knowledge to inform clinical decisions. These questions typically concern a specific patient or particular population. Foreground questions tend to be more specific and complex compared to background questions. Quite often, foreground questions investigate comparisons, such as two drugs, two treatments, two diagnostic tests, etc. Foreground questions may be further categorized into one of 4 major types: treatment/therapy, diagnosis, prognosis, or etiology/harm.
    For example
    Is Crixivan effective in slowing the rate of functional impairment in a 45 year old male patient with Lou Gehrig's Disease?
    In pediatric patients with Allergic Rhinitis, is Intranasal steroids more effective than antihistamines in the management of Allergic Rhinitis symptoms?
  • P = Patient, Problem, Population (How would you describe a group of patients similar to you? What are the most important characteristics of the patient?)
    I = Intervention, Prognostic Factor, Exposure (What main intervention are you considering? What do you want to do with this patient? What is the main alternative being considered?)
    C = Comparison (Can be None or placebo.) (What is the main alternative to compare with the intervention? Are you trying to decide between two drugs, a drug and no medication or placebo, or two diagnostic tests?)
    O= Outcome (What are you trying to accomplish, measure, improve or affect? Outcomes may be disease-oriented or patient-oriented.)
  • Journals – may be better to use UBC library index
  • No longer has Merck Index
  • NICE guidance – hard to naviagate – have to click on lots of different screens to get where you need to go.
  • Drug link  LexiDrug monograph
    Reference link  Medline abstract
  • Micromedex - http://www.micromedexsolutions.com/home/dispatch
    phsa
    Vancouver

    Lexi-comp online http://online.lexi.com/crlsql/servlet/crlonline
    bcdpic
    lexicomp

    Medscape http://www.medscape.com/pharmacists
    kemcinnes
    4Tlang





  • Using UBC Library to Find Drug Information 2014

    1. 1. UBC Pharmacy Residents Library Workshop “Introduction to the UBC Library & Finding Drug Information Efficiently” What are your goals in finding drug information? Dean Giustini (DG) – UBC Biomedical Branch librarian Ursula Ellis (UE) – UBC Reference Librarian, Woodward Library
    2. 2. Your thoughts… • What do you find most challenging about finding “reliable” drug information? • Depends on your goals
    3. 3. Provide Direct Patient Care as a Member of Interprofessional Teams The [pharmacist] shall be proficient in providing evidence-based direct patient care as a member of interprofessional teams http://www.cshp.ca/programs/residencytraining/CHPRBinfo_e.asp
    4. 4. Provide Medication and Practice-Related Education The [pharmacist] shall respond to medication/practice-related questions &educate others. http://www.cshp.ca/programs/residencytraining/CHPRBinfo_e.asp
    5. 5. Objectives By the end of this session, you should be able to: • Describe systematic approaches to find drug information • List some useful sources of drug information • Describe search concepts ie., boolean operators, controlled vocabulary (MeSH) & “tree structure”, explode, focus, limit(s) • Conduct efficient searches in pharmacy literature • See benefits of print and e-resources, and some limitations
    6. 6. Systematic approach to drug information 1. Obtain demographics of requestor 2. Obtain background information for the situation 3. Determine and categorize the ultimate question 4. Develop strategy, conduct search 5. Critically evaluate information 6. Formulate and provide response 7. Follow-up, document See Nathan JP. Drug information--the systematic approach. J Pharm Pract. 2013; 26: 78-84. PMID 23519502
    7. 7. Systematic approach to drug information 1. Obtain demographics of requestor 2. Obtain background information 3. Determine and categorize the ultimate question 4. Develop strategy, conduct search 5. Critically evaluate information 6. Formulate and provide response 7. Follow-up, document
    8. 8. Drug Information Categories • Therapeutics • Dosage/route • Adverse Drug Reaction • Pregnancy • Lactation • Identification • Availability • Compatability • Pharmacology • Pharmacokinetics • Ingredients • Alternative/complementary therapies Can I use diltiazem to manage focal atrial tachycardia?
    9. 9. Drug Information Categories • Therapeutics • Dosage/route • Adverse Drug Reaction • Pregnancy • Lactation • Identification • Availability • Compatibility • Pharmacology • Pharmacokinetics • Ingredients • Alternative/complementary therapies Which of this patient’s medications can exacerbate ulcerative colitis?
    10. 10. Drug Information Categories • Therapeutics • Dosage/route • Adverse Drug Reaction • Pregnancy • Lactation • Identification • Availability • Compatibility • Pharmacology • Pharmacokinetics • Ingredients • Alternative/complementary therapies What are the risks to the fetus from accidental exposure to MMR vaccine in the first trimester?
    11. 11. Drug Information Categories • Therapeutics • Dosage/route • Adverse Drug Reaction • Pregnancy • Lactation • Identification • Availability • Compatibility • Pharmacology • Pharmacokinetics • Ingredients • Alternative/complementary therapies Can Arnica tablets cause bradycardia?
    12. 12. Systematic approach to drug information 1. Obtain demographics of requestor 2. Obtain background information 3. Determine and categorize the ultimate question 4. Develop strategy, conduct search 5. Critically evaluate information 6. Formulate and provide response 7. Follow-up, document
    13. 13. Where do you begin? • General  specific • Background knowledge  foreground knowledge • Tertiary  primary Textbooks/e-books Point-of-care tools Use Secondary sources (Medline, Embase, Cochrane) to find primary literature General knowledge about Rx or disease Specific knowledge to inform clinical decisions
    14. 14. PICO framework P - Patient problem I – Intervention C – Comparator or control O - Outcome • PICO was developed for intervention/therapy questions • Define clinical question & guide searching • A clinical question is more likely to be answered when intervention / outcomes are specified • Not all questions fit PICO framework • Not necessary for “background” questions
    15. 15. Tertiary resources
    16. 16. E-Books @ UBC Library
    17. 17. Access Medicine 88 titles (e-Books) • G&G Pharmacologic Basis of Therapeutics • Katzung’s Basic & Clinical Pharmacology • Harrison’s Principles of Internal Medicine • Olson’s Poisoning & Drug Overdose • Cardiology, emergency medicine, more…
    18. 18. Books@OVID 15 titles • Briggs Drugs in Pregnancy & Lactation (8th) • Wallach Interpretation of Diagnostic Tests • Oski’s Pediatrics • Marino The ICU Book
    19. 19. ClinicalKey Designed for quick answers to clinical questions • Easy access to in-depth information for 30+ clinical specialties, and includes: • Goldman-Cecil Medicine • Harriet Lane Handbook, The
    20. 20. Medicines Complete Three excellent texts • AHFS Drug Information – References included in electronic version – Monthly updates • Martindale: The Complete Drug Reference – Quarterly updates • Stockley’s Drug Interactions – Quarterly updates
    21. 21. Natural Medicines • Covers herbal medications • International research collaboration • Has evidence grades • Peer-reviewed • References included (hyperlinks to PubMed, etc) • Interaction checker • Updated daily
    22. 22. e-Therapeutics • Comprehensive drug information resource produced by the Canadian Pharmacists Association. Includes e- CPS and a drug interactions module. • e-CPS • Clinical monitoring tools • Drug interactions with food • Drug use guides (dentistry, pregnancy, lactation) • Info on latex and nonmedicinal ingredients • Drug Interactions
    23. 23. Don’t forget good, old print books!
    24. 24. Limitations with print • Lag time – Check frequency of editions, updates, most recent references cited • Incomplete information – Consider depth and scope • Authorship • Qualifications and expertise
    25. 25. Clinical Practice Guidelines • British Columbia- guidelines from MOH and BCMA – www.bcguidelines.ca – Can download all or access via computer or mobile device (iPod/iPhone app no longer being supported) – Provides guidelines via topics as well as patient information guides, flow sheets and summaries – “GPAC has engaged practicing physicians in B.C. - including general practitioners and specialists - to evaluate clinical evidence, and publish clinical practice guidelines on numerous conditions, with particular focus on circumstances in British Columbia.”
    26. 26. Clinical Practice Guidelines • CMA Infobase: Clinical Practice Guidelines – http://www.cma.ca/cpgs – Canadian Medical Association – 1200 publicly accessible evidence based CPG developed by medical or health organizations in Canada • Developers are national or provincial agencies – Can search by conditions, specialties
    27. 27. Clinical Practice Guidelines • National Guidelines Clearinghouse – http://www.guideline.gov • US based • TOPIC: disease/condition; treatment/intervention; health services administration • Organization • May be useful when local or national guidelines are not available • NICE Guidance (National Institute for Health and Clinical Excellence) – http://www.nice.org.uk/guidance/index.jsp?action=find – NICE Pathways (http://pathways.nice.org.uk) • Interactive. Brings all related NICE products on a topic in a single interface
    28. 28. Clinical Practice Guidelines • SIGN (Scottish Intercollegiate Guidelines Network) – http://www.sign.ac.uk – Search by topic or assigned guideline number – Easy to see if current, out of date or withdrawn – Levels of evidence provided – Apps available for smart phones; iPad • TRIP Database (Turning Evidence into Practice) – http://www.tripdatabase.com – Clinical search engine to find high-quality research evidence to support practice – Meta database – combs through all guidelines – Guidelines from around the world – PICO search; Advanced search
    29. 29. Point of Care Tools (subcription needed for full access) (free but need login) From BMJ – subscription needed
    30. 30. Point of Care Tools
    31. 31. • From BMJ – Subscription based – App is $49.99 (Clinical Evidence Unbound) – 2000 treatments for over 200 medical conditions “Clinical Evidence comprises an international database of high-quality, rigorously developed systematic overviews assessing the benefits and harms of treatments, and a suite of EBM resources and training materials.”
    32. 32. • Clinical reference database with more than 3100 evidence based clinical summaries, updated daily • App for smart phones, tablets
    33. 33. • AKA Medscape • http://emedicine.medscape.com • Free but need to register • “Medscape from WebMD offers specialists, primary care physicians, and other health professionals the Web's most robust and integrated medical information and educational tools. After a simple, 1-time, free registration, Medscape from WebMD automatically delivers to you a personalized specialty site that best fits your registration profile.”
    34. 34. • www.uptodate.com • Subscription required • Free area (but need to register: www.freeuptodate.com) • “The knowledge contained in UpToDate is evidence- based and continuously updated, but it is not merely an aggregation and report of the latest research; UpToDate presents a comprehensive synthesis of the evidence, followed by recommendations that can be acted on at the point of care.”
    35. 35. Point of Care Tools Ketchum AM, et al. Type of evidence behind point-of-care clinical information products: a bibliometric analysis. J Med Internet Res. 2011; 13(1):e21.
    36. 36. Point of Care Tools Ketchum AM, et al. Type of evidence behind point-of-care clinical information products: a bibliometric analysis. J Med Internet Res. 2011; 13(1):e21.
    37. 37. Point of Care Tools Ketchum AM, et al. Type of evidence behind point-of-care clinical information products: a bibliometric analysis. J Med Internet Res. 2011; 13(1):e21.
    38. 38. Point of Care Tools Ketchum AM, et al. Type of evidence behind point-of-care clinical information products: a bibliometric analysis. J Med Internet Res. 2011; 13(1):e21. BMJ Clin Evidence DynaMed FirstConsult UpToDate
    39. 39. Point of Care Tools Ketchum AM, et al. Type of evidence behind point-of-care clinical information products: a bibliometric analysis. J Med Internet Res. 2011; 13(1):e21. “… summary products, such as POC products, vary in content as determined by differences in literature cited for the same topics in different products, quality regarding types of evidence cited, and currency. There are no standards for guidance on developing content for these products. Users should be aware of this and judiciously appraise POC product information content when using resources to obtain information for applying evidence-based practice principles.”
    40. 40. Web of Science (WoS) • Who: Thomson Reuters • What: articles from 7,500 scholarly and technical journals from more than 3,300 publishers in over 80 countries; conference proceedings (abstracts) • Why: Another large biomedical database – good for conference abstracts, and for citation tracking* • Where: Web of Science (indexes and databases) • How: keyword searching (dropdown menu)
    41. 41. More advanced stuff…
    42. 42. Grey literature • Adverse drug reactions/pharmacovigilance – National pharmacovigilance programs – Reactions Weekly (Springer Link) • Health Technology Assessments – CADTH, FDA, EMA, UK, Spain • Systematic reviews, scientific discussion papers – insider look at unpublished data made available to regulators
    43. 43. Clinical trial registries Why? • Need to consider all the available evidence in decision making • Publication bias and selective reporting are barriers • Avoid unnecessary duplication of studies and identify gaps in research • Increase awareness of ongoing research –Facilitate recruitment and collaboration • Data checking as part of the registration process may improve quality WHO International Clinical Trials Registry Platform (ICTRP) http://www.who.int/ictrp/trial_reg/en/index.html
    44. 44. Clinical trials registries Primary registries Meta registries *
    45. 45. Clinical trials registries • 1. Primary Register and Trial ID # • 2. Date of Registration in Primary Register • 3. Secondary ID#s • 4. Source(s) of Monetary or Material • Support • 5. Primary Sponsor • 6. Secondary Sponsor(s) • 7. Contact for Public Queries • 8. Contact for Scientific Queries • 9. Public Title • 10. Scientific Title • 11. Countries of Recruitment • 12. Health Condition(s) or Problem(s) Studied • 13. Intervention(s) • 14. Key Inclusion and Exclusion • Criteria • 15. Study Type • 16. Date of First Enrollment • 17. Target Sample Size • 18. Recruitment Status • 19. Primary Outcome(s) • 20. Key Secondary Outcomes WHO 20-item minimum data set Some registries offer more information and bonus features, e.g. links to publications, added annotations; pediatric, geographical and active/complete/resulted filters; international language searching
    46. 46. Clinical trials registries Limitations • Less than ½ of trials registered at ClinicalTrials.gov are published in peer-reviewed journals within 30 months of completion. Median time to publication for those trials that were published: 23 months. ~1/3 of registered trials remain unpublished after median of 51 months after completion. • Despite guidelines, details on therapy and info on outcomes sometimes or often missing. •Other examples… Viability of some registries… e.g. Current Controlled Trials Ross JS et al. BMJ. 2012; 344:d7292. Viergever & Ghersi. PLoS ONE. 2011; 6(2): e14701. doi:10.1371/journal.pone.0014701
    47. 47. Mobile apps • Available for smart phones and tablets • Micromedex (PHSA has this) – Differs from online 2.0 version. DI is free. – Dosing, MOA, available strengths, kinetics, IV compatibility, toxicology • Lexicomp (LMPS – not sure about others) – Same info as online product. Not free. – Drugs, infectious diseases, patient education information – Interactions, iv compatibility, toxicology • Medscape – Same as online version. Both are free. – Drug monographs (not detailed), drug interaction checker, medical conditions, procedures – News – can subscribe to daily news
    48. 48. Communicating 1. Obtain demographics of requestor 2. Obtain background information for the situation 3. Determine and categorize the ultimate question 4. Develop strategy, conduct search 5. Critically evaluate information 6. Formulate and provide response 7. Follow-up, document See Nathan JP. Drug information--the systematic approach. J Pharm Pract. 2013; 26: 78-84. PMID 23519502
    49. 49. Communicating What are the desired characteristics of a drug information response? • timely • current • accurate • complete • concise • well referenced • clear and logical • objective and balanced • free of bias or flaws • applicable and appropriate for specific circumstances • answers important related questions • addresses specific management of patients or situation
    50. 50. Communicating What should a response contain? •Not every response will require all of these components, but in general… • Basic structure: introduction, body and conclusion • A restatement or summary of the question • A statement of any pertinent assumptions made (e.g. age or weight, renal function in the absence of lab data) • A brief summary statement of the response • Discussion - more details supporting your response, including background information, review of evidence (including flaws, biases), other factors considered • Conclusions and recommendations based on, and consistent with, evidence presented • References
    51. 51. Communicating Tips for writing: • Keep it simple • Break complicated discussions into sections and use headings • Some ways to organize and present evidence: – Chronological (e.g. case reports, evolving evidence) – Strength of evidence (increasing, or decreasing) – Compare/contrast (pros/cons – for controversial or equivocal findings) • Use tables to succinctly present data • Do not feel you need to include everything you found, e.g. exclude weaker evidence if stronger evidence exists
    52. 52. Communicating Tips for verbal communication: • If the response is complicated, ask if the requestor has time to discuss it • Should be a dialogue with the requestor (e.g. get feedback – is the information clear and understood? Was the question answered satisfactorily? Is further follow up required?) • Tailor the level of information and terminology to the requestor – be prepared to clarify if necessary • Can follow up with supplementary material
    53. 53. Communicating Tips for verbal communication: • “...good verbal communication skills, from confident delivery to correct pronunciation of all terms, is imperative…” • “Often the delivery of a complete response is analogous to the delivery of a presentation or lecture – one must be prepared for additional questions and, therefore, the information presented is only part of the responder’s total knowledge and preparation on the subject.” (Malone 2006) Malone PM, Kier KL, Stanovich JE (eds.). Drug information. A guide for pharmacists. 3rd ed. New York: McGraw-Hill; 2006. See also: Nathan JP. Drug information--the systematic approach. J Pharm Pract. 2013; 26: 78-84.

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