Nephrology 15 (2010) 1219

C l i n i c a l R e s e a rc h f o r N e p h ro l o g i s t s

How to get the most from the medical literature: Searching the medical literature effectively
nep_1263 12..19

ANGELA C WEBSTER,
1 3

1,2,3

NICHOLAS B CROSS,

4,5

RUTH MITCHELL2 and JONATHAN C CRAIG1,2

Sydney School of Public Health, University of Sydney, Sydney, 2Cochrane Renal Group, Centre for Kidney Research, Childrens Hospital at Westmead, and Centre for Transplant and Renal Research, University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia; and 4Department of Nephrology, Canterbury District Health Board, and 5Department of Medicine, University of Otago, Christchurch, New Zealand

KEY WORDS: bibliographic databases, epidemiology, evidence-based medicine, information management, information storage and retrieval, MEDLINE. Correspondence: Dr Angela C Webster, School of Public Health, Edward Ford Building A27, University of Sydney, Sydney, NSW 2006, Australia. Email: angela.webster@gmail.com Accepted for publication 28 November 2009. Accepted manuscript online 17 December 2009. doi:10.1111/j.1440-1797.2009.01263.x

ABSTRACT:
Different clinical questions are best answered using different study designs. This paper describes the best methods for nding relevant studies for wellframed clinical questions. We focus on which database is best to search to answer your question, describe the structure of effective search strategies and explore ways to develop appropriate search terms. We illustrate these with sensitive and specic search strategies to answer different clinical questions arising from a hypothetical clinical scenario typical of a nephrologists everyday practice.

SUMMARY AT A GLANCE
This review outlines the most time-efcient and effective strategies to search the literature to answer targeted clinical questions. You are taken through a step-by-step approach to enable you to best utilise current contemporary search tools and databases.

Different clinical questions are best answered using different study designs. This paper describes the best methods for nding relevant studies for well-framed clinical questions. We focus on which database is best to search to answer your question, describe the structure of effective search strategies, explore ways to develop appropriate search terms, and illus-

trate these with sensitive and specic search strategies to answer different clinical questions. In an earlier paper in this series we outlined a hypothetical clinical scenario. We will use the same example to demonstrate how to search the medical literature effectively:1

Source of funding and disclosure of potential conicts of interest: There was no nancial support for this work. ACW teaches a course called literature searching which is part of the Clinical Epidemiology degree programme, and JCC is the Sub-Dean of Clinical Epidemiology at the Sydney School of Public Health, University of Syndey. No author declares any other potential conict of interest. Authorship contributions: ACW conceived and designed the paper, created the tables and gures, and drafted and revised the manuscript. NBC contributed to the design of the paper, and drafting and revision of the manuscript. RM designed the search strategies, and contributed to drafting and revision of the manuscript. JCC contributed to the design of the paper, and drafting and revision of the manuscript. Want to learn more about how to search the biomedical literature more effectively? Feel that you could do more to improve your information literacy? The University of Sydney offers a Masters level online distance learning short course on Literature Searching through its Clinical Epidemiology professional development programme. See http://www.health.usyd.edu.au/future/profdevelopment/introclinepi.php or contact the corresponding author for more details.
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Searching the medical literature effectively

A 20-year-old Caucasian man with hypertension is referred to you. He has a family history of adult (autosomal-dominant) polycystic kidney disease (APKD). His father received a kidney transplant at the age of 55. He is shocked to learn that he could have kidney disease, because he had a renal ultrasound scan at the age of 15 (soon after his father commenced dialysis) that was normal. Examination reveals an overweight man (body mass index 28.5), with blood pressure 150/90 on two occasions. Urinalysis and modication of diet in renal disease estimated glomerular ltration rate are normal.

KNOWING WHERE TO LOOK MEDICAL DATABASES

To effectively search for answers, you rst need to structure your question into an answerable format, using the population, intervention, comparator, outcome (PICO) framework. Once you have established what kind of question you want to ask, you can work out where to look for answers.1 If you are looking for the answer to a question of intervention the best place to start is the Cochrane Library (http:// www.thecochranelibrary.com), looking in the Cochrane Database of Systematic Reviews (CDSR) for systematic reviews and in The Cochrane Central Register of Controlled Trials (CENTRAL) for randomized trials. CENTRAL is a rich source of over 600 000 trials, as it contains both Medline and unique EMBASE records, and over 200 000 records of trials found through hand-searching journals and conference proceedings. Keep in mind that CENTRAL is only updated every 3 months, so you may wish to do a supplementary search of Medline for the newer citations, perhaps the most recent

6 months. If you do not nd answers there, or you want to look for more recent evidence not yet incorporated into Cochrane systematic reviews, then Medline is the next best alternative. For questions of prognosis, aetiology (sometimes called causality) or diagnosis, then Medline is the best place to start your search. Although there are many other databases with overlapping, complementary or unique content areas, each with their own strengths and weaknesses, we have limited this article to the most accessible and most immediately useful to most healthcare workers: The Cochrane Library, and Medline (as accessed via the OvidSP platform). For differences encountered by accessing Medline using OvidSP compared with the Pubmed interface, the reader could read the earlier paper in this series.2 Table 1 summarizes the recommended study designs and databases to search in order to answer the series of clinical questions we developed in the earlier paper when considering the young man with hypertension and a family history of adult autosomal-dominant polycystic kidney disease.1

THE STRUCTURE OF AN EFFECTIVE SEARCH STRATEGY

Once you have worked out where to look, you can return to your PICO framework to help you develop the anatomy of your search strategy. A basic search will include population terms, intervention terms and a methodological lter. A methodological lter works to limit your search, by identifying only papers with appropriate study designs to answer your question. More advanced searches will usually include more terms for population and intervention by combining synonyms, often enhanced by using more advanced search

Table 1 Framed questions using PICO terms, with answers using best study design and recommended database Question type Intervention P I C O P I C O P I C O Diagnosis P I C O PICO framed question In adults with APKD and hypertension Do ACEi Compared with any other antihypertensive Reduce the risk of ESKD? For young adults with APKD with hypertension but normal renal function and no proteinuria What proportion progress to ESKD? In adults with cerebral berry aneurysms What proportion are attributable to having APKD and hypertension, compared with those without either condition? In young adults with a family history of APKD Is abdominal ultrasound scanning Compared with the reference standard (long-term clinical follow up) Accurate for the diagnosis of APKD? Best study designs Systematic review with meta-analysis of RCT or RCT Recommended databases The Cochrane Library (CDSR and CENTRAL), then Medline

Prognosis

Systematic review of observational data or cohort study

Medline

Aetiology

Systematic review of observational data, or cohort study, or for rare disease a casecontrol study Systematic review of cross-section analytic studies or data cross-section analytic study

Medline

Medline

PICO, population, intervention, comparator, outcome see text for additional explanation. ACEi, angiotensin-converting enzyme inhibitors; APKD, adult (autosomal-dominant) polycystic kidney disease; ESKD, end-stage kidney disease; RCT, randomized controlled trial.
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AC Webster et al.

Table 2 OvidSP Medline methodological lters for identifying studies by design Question Intervention Most precise Randomized controlled trial.pt 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 1 2 3 4 5 6 Most sensitive randomized controlled trial.pt controlled clinical trial.pt randomized.ab placebo.ab clinical trials as topic/ randomly.ab trial.ti OR/17 animals/ NOT (humans/ AND animals/) 8 NOT 9 Incidence/ exp mortality/ follow-up studies/ prognos*.tw predict*.tw course*.tw OR/16 Risk*.mp. exp cohort studies between group*.tw OR/13 Sensitiv*.mp diagnos*.mp di.fs OR/13 Review.pt AND Medline.tw. Meta analysis.pt (systematic* AND (review* OR overview*)).tw metaanaly$*.tw meta-analy*.tw OR/15 Most specic Randomized controlled trial.pt

Prognosis

Prognosis/ OR diagnosed.tw OR cohort*.mp OR predictor*.tw OR death.tw. OR exp models, statistical/ risk.mp OR mortality.mp OR cohort.tw Sensitiv*.mp. OR predictive value*.mp. OR accurac*.tw Meta analysis.pt

prognos*.tw OR rst episode.tw OR cohort.tw

Aetiology

relative risk*.tw OR risks.tw. OR cohort stud*.mp. specicity.tw

Diagnosis

Any question requiring systematic reviews

Meta analysis.pt OR (review.pt AND medline.tw)

The most sensitive Intervention lter is the Cochrane Highly Sensitive Search Strategy for identifying randomized trials in Medline: sensitivity- and precisionmaximizing version (2008 revision).3 The most precise, sensitive and specic lters for Prognosis, Aetiology and Diagnosis questions are the same as the Clinical Queries lters available under Limits in OvidSP Medline.46 .ab, abstract; exp, exploded MeSH; .fs, oating subheading; .pt, publication type; .ti, title; .tw, textword; /, all sub-headings; *, indenite truncation; most precise, best balance between sensitivity and specicity; most sensitive, retrieves high proportion of relevant articles (but may also retrieve high number irrelevant articles); most specic, excludes most irrelevant articles (but may also exclude high number of relevant articles).

functions, and with a more complex methodological lter. Table 2 lists optimal methodological lters for different study designs when accessing Medline via the OvidSP platform depending on whether you want a quick, or a comprehensive answer.36 When searching the CDSR for systematic reviews or CENTRAL for randomized trials, no methodological lter is needed, as these databases are already limited to literature of specic study design.

UNDERSTANDING BOOLEAN LOGIC COMBINING TERMS WITH AND, OR AND NOT

Boolean logic is named after the English mathematician and philosopher George Boole (18151864), who remained an obscure academic during his own lifetime. Booles algebraic system of organizing data into sets was eventually recog14

nized for its brilliance, although not until several generations after his death. Boolean logic is the basis for many automated systems we take for granted including electronics, computer hardware and software, and most digital applications. It is also central to an effective search strategy. It is surprisingly easy to get muddled when using Boolean operators, particularly with ANDs and ORs, so it can be helpful to draw out your search in a series of Venn diagrams as demonstrated in Figure 1. It is possible to construct a search that yields zero results. The reason for zero results can usually be traced back to an error in the use of Boolean terms that excludes all possible sets (or failing that, to a spelling error in a search term). If you nd you have made an error, rather than scrapping your entire search strategy and starting again, you can opt to remove one line (and any dependant sets) from your strategy, and then rework with your remaining terms.
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Searching the medical literature effectively

Boolean operator

Search terms combined IgA nephropathy AND nephrotic syndrome

Resulting set of citations

Description

AND

IgA nephropathy

Nephrotic syndrome

All citations on IgA and nephrotic syndrome

OR

IgA nephropathy OR nephrotic syndrome

IgA nephropathy

Nephrotic syndrome

All citations on IgA plus all citations on nephrotic syndrome (including all on both) All citations on IgA except those also on nephrotic syndrome

NOT

IgA nephropathy NOT nephrotic syndrome

IgA nephropathy

Nephrotic syndrome

Mixing operators: NESTING

steroids AND (IgA nephropathy OR nephrotic syndrome)

IgA nephropathy

Nephrotic syndrome

steroids

All citations on steroids which are also on either IgA or nephrotic syndrome (or both)

Tip: If you dont put in the brackets when NESTING, the command is processed strictly from left to right, with different results

steroids AND IgA nephropathy OR nephrotic syndrome

IgA nephropathy

Nephrotic syndrome

steroids

All citations on nephrotic syndrome plus citations on IgA and steriods

Fig. 1 Understanding and using Boolean operators AND, OR and NOT.

QUICK AND EASY VERSUS COMPREHENSIVE SEARCHING STRATEGIES

Searches are undertaken for different reasons. Sometimes you need a quick answer, and so you want a small set of relevant citations in the quickest possible time (a specic search). Another instance might call for a thorough and comprehensive search that identies all the relevant citations (and perhaps in the process identify some that are not relevant). This can be achieved by spending more time developing your strategy to be sure you capture all the evidence (a
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sensitive search). When constructing a search strategy there are often many different ways to arrive at the same, or very similar results, and there are no perfect search strategies. Often the way you approach constructing a search strategy to answer your clinical question, and the time it takes you to nd your answer, will be a combination of your searching experience and your user preferences. When designing search strategies for CDSR or CENTRAL in the Cochrane Library, or Medline, it helps to understand how biomedical publications are indexed. Medical Subject Headings (MeSH) are based on a controlled vocabulary the15

AC Webster et al.

saurus of medical subject headings, and are applied to publications indexed in Medline by the National Library of Medicine. MeSH include both an alphabetical and hierarchical listing of related sets that allow you to browse lists for specic terms, organized into trees. By typing polycystic kidney disease into the Advanced Search in Ovid Medline, ticking the Map term to Subject Heading box and pressing Search, you can map the relevant MeSH headings and decide which you want to include. For this example, under the MeSH Kidney Diseases, Cystic, you will nd Medullary Sponge Kidney, Multicystic Dysplastic Kidney and Polycystic Kidney Diseases. Below the Polycystic Kidney Diseases MeSH term in the tree you will nd two further MeSH options: Polycystic Kidney, Autosomal Dominant and Polycystic Kidney, Autosomal Recessive. Exploding MeSH terms from higher up the tree will include all those citations indexed with MeSH that come below the selected MeSH in the tree (so ticking the Explode box for Kidney Diseases, Cystic, would include all the MeSH under it). Sometimes this might be what you want to do, but on other occasions, you may want to be more specic in your selection (selecting Polycystic Kidney, Autosomal Dominant will include only citations indexed with this MeSH, as there are no further branches below this MeSH term). For better results, population and intervention terms should be entered as appropriate MeSH terms, rather than

using just key words or text words. You can combine MeSH terms with appropriate Boolean operators, and add the suitable methodological lter. Each term is submitted separately into OVID and returns a subset of results that can then be further combined or limited using Boolean operators. Tables 35 show examples of what quick and easy (specic) searches might look like for the questions we developed in an earlier article in this series, and that are repeated in Table 1.1

TIPS FOR MORE COMPLEX SENSITIVE SEARCH STRATEGIES

There are many ways to rene your search strategy, and they all involve experimentation and iteration. By adding terms and looking at of the kind of citations returned, or by including or excluding subsets (with careful use of Boolean operators), you can work out which combinations are likely to result in the right balance of relevant and irrelevant citations to answer your question. A more comprehensive and thorough sensitive search strategy usually involves adding additional terms for the population and intervention, and combining with a more complex methodological lter (see Table 2).36 The additional terms for population and intervention usually involve adding more related MeSH headings,

Table 3 Examples of specic and more sensitive search strategies for an intervention question: In adults with APKD and hypertension do ACEi compared with any other antihypertensive reduce the risk of ESKD? The Cochrane Library CDSR (use Advanced Search) Population terms Polycystic kidney disease* (in title eld) CENTRAL (use MeSH Search and Search History) 1 MeSH descriptor (this term only): Polycystic Kidney, Autosomal Dominant 2 (polycystic next kidney next disease*):ti,ab,kw 3 (APKD OR ADPKD):ti,ab,kw 4 #1 OR #2 OR #3 Specic (quick) Medline (via OvidSP) Sensitive (thorough)

1 *Polycystic Kidney Diseases/ 2 *Polycystic Kidney, Autosomal Dominant/ 3 OR/12 AND 4 exp Antihypertensive Agents/

Combined with Intervention terms

AND 5 MeSH descriptor Angiotensin-Converting Enzyme Inhibitors explode all trees 6 (angiotensin next converting next enzyme next inhibitor*):ti,ab,kw 7 (ace next inhibitor*):ti,ab,kw OR ACEi 8 etc. (list names of specic ace inhibitors) 9 #5 OR #6 OR #7 OR #8

1 Polycystic Kidney Diseases/ 2 Polycystic Kidney, Autosomal Dominant/ 3 autosomal dominant polycystic kidney disease*.tw 4 (APKD OR ADPKD).tw 5 OR/14 AND 6 exp Angiotensin-Converting Enzyme Inhibitors/ 7 ace inhibitor*.tw. 8 angiotensin-converting enzyme inhibitor*.tw. 9 ACEi.tw. 10 (list names of specic ACE inhibitors).tw 11 OR/610

Methodological lter

No need for lter (CDSR only contains systematic reviews, and CENTRAL only contains randomized trials)

AND See Table 2 for suggested specic and sensitive lters for systematic reviews or randomized trials

ACEi, angiotensin-converting enzyme inhibitors; ADPKD, autosomal-dominant polycystic kidney disease; APKD, adult (autosomal-dominant) polycystic kidney disease; ESKD, end-stage kidney disease.
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Table 4 Examples of specic and more sensitive search strategies for the prognosis, and aetiology questions developed from the clinical scenario of a young man with hypertension and a family history of autosomal-dominant polycystic kidney disease Prognosis Question For young adults with APKD with hypertension but normal renal function and no proteinuria what proportion progress to ESKD? Specic 1 *Polycystic Kidney Diseases/ 2 *Polycystic Kidney, Autosomal Dominant/ 3 OR/12 Sensitive 1 Polycystic Kidney Diseases/ 2 Polycystic Kidney, Autosomal Dominant/ 3 autosomal dominant polycystic kidney disease*.tw 4 (APKD OR ADPKD).tw 5 OR/14 AND 6 Kidney Failure/ 7 Kidney Failure, Chronic/ 8 exp Renal Dialysis/ 9 (endstage kidney OR endstage renal OR end-stage kidney OR end-stage renal).tw 10 dialysis.tw 11 OR/610 Aetiology In adults with cerebral berry aneurysms what proportion are attributable to having APKD and hypertension, compared with those without either condition? Specic Sensitive 1 *Intracranial Aneurysm/ 1 Intracranial Aneurysm/ 2 berry aneurysm*.tw 3 OR/12

Population terms

Combined with Intervention terms

AND 4 Kidney Failure/ 5 Kidney Failure, Chronic/ 6 exp Renal Dialysis/ 7 OR/46

AND 2 Polycystic Kidney Diseases/ 3 Polycystic Kidney, Autosomal Dominant/ 4 exp Hypertension/ 5 OR/24

AND 4 Polycystic Kidney Diseases/ 5 Polycystic Kidney, Autosomal Dominant/ 6 autosomal dominant polycystic kidney disease*.tw 7 (APKD OR ADPKD).tw 8 exp Hypertension/ 9 hypertens*.tw 10 OR/49

The searches in the table above can then be combined (using AND) with the appropriate methodological lters from Table 2. An asterisk at the beginning of a Medline MeSH term limits the search to articles where that concept has been indexed as the main focus. ADPKD, autosomal-dominant polycystic kidney disease; APKD, adult (autosomal-dominant) polycystic kidney disease; ESKD, end-stage kidney disease.

and adding synonyms as text words to capture any relevant studies not indexed through the MeSH headings. Additional relevant MeSH headings can be identied by searching on the tree for related MeSH, or by using the Search tools tab. Alternatively, if you have identied one relevant citation, work backwards by checking to see how it has been indexed, by clicking to display complete reference and checking which MeSH terms were applied. Synonyms can be added by using the .tw sufx; this will identify citations where the specied text word appears in either the title or abstract of a citation. See Tables 3 and 4 for how this might work, and Table 5 for a worked example with explanations. Where you want to add terms which may be spelt in several ways then there are some useful short cuts you can employ. An indenite or unlimited truncation is represented by *. By adding * to the stem of a text word, you will capture all endings. For example, vaccin*.tw will capture all of: vaccine, vaccines, vaccinated, vaccination. You can see examples of the unlimited truncation * being used in the illustrative search strategies in Tables 25. Some text words vary their spelling within the word, in which case adding ? will ensure Medline searches for words with either zero or one extra character in place of the ?. For example, typing p?ediatric.tw will nd words in title and abstract spelt both
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paediatric and pediatric. If you are searching for a concept usually described using more than one word, then adding the term adj (short for adjacent) is often useful. In Medline, by typing angiotensin.tw adj10 inhibitor.tw your search will identify citations where the words angiotensin and inhibitor appear within ten words of each other in the title or abstract. For CDSR and CENTRAL searches, you can achieve a similar outcome to the adj function by using the word next or near/n. Tables 35 show examples of these short cuts in action. Developing a good search strategy can take time and several iterations. Experimenting by adding and removing different terms is part of the process of rening your search until it is t for purpose. As you gain experience of how different MeSH and text word terms behave, by checking the resultant citation sets they produce, you will nd searching for answers becomes easier and quicker. Information management is an evolving eld, and new innovations to make searching the medical literature easier and better are the subject of much research activity. In addition to the possibilities we have outlined above, future innovations may include lters to limit citation sets by medical discipline, as well as improved methods lters for diagnostic test studies.6,7
17

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Hits Explanation and comments 1 585 4 849 100 085 185 244 327 1 202 764 1 215 879 21 / indicates a MeSH term. Do not explode this MeSH term, as you will also retrieve articles about autosomal recessive PKD. An asterisk limits retrieval to articles where this MeSH term is considered by the indexer to be a main concept. Because Polycystic Kidney Diseases/ has not been exploded, we need to include this MeSH term in our strategy. This step combines the population terms to create a Boolean set of citations indexed with either of the terms in lines 1 or 2. exp explodes this term to include the specic types of ultrasonography included in the tree beneath this term, but the asterisk limits the set to those articles where ultrasonography is a main focus or concept. This step creates a Boolean set of citations indexed with both the population terms and the test terms from our clinical question. This methods lter is the most specic strategy for nding articles about diagnostic accuracy. This step creates a Boolean set where population and test terms have been used by the indexer, but have also been indexed with the methods lter for diagnostic test studies. You can see that although this search strategy was quite quick and succinct, it has been too specic for this topic. The only article retrieved is from 1984. So to answer the clinical question, you need to develop a strategy that is more sensitive. You will need to make your population and/or test terms more sensitive, and/or apply a more sensitive diagnostic methods lter. This step improves on the previous test term. The asterisk has been removed, which will include all citations indexed with this term, together with all indexed with other terms that are beneath Ultrasonography in the tree, resulting in a more sensitive search on this term. This step improves on the previous methods lter. This is the optimized diagnostic lter best balance between sensitivity and specicity.

Table 5 Worked example of development of a specic and a more sensitive search strategy for a question of diagnosis, with results (Ovid Medline 1950 to November Week 1 2009) and explanation of the search terms used

AC Webster et al.

Line

Search term

Specic search (smaller set of some relevant citations in the quickest possible time) 1 *Polycystic Kidney Diseases/ 3 275

2 3 4

*Polycystic Kidney, Autosomal Dominant/ OR/12 exp *Ultrasonography/

5 6 7

3 AND 4 specicity.tw 5 AND 6

exp Ultrasonography/

This step creates a set indexed with the original population terms, and with the new more sensitive test terms, and any of the diagnostic lter terms. This set includes two recent reviews from JASN (2007) and CJASN (2006) that might be useful. To be sure you have all relevant published research, you might want to develop an even more sensitive strategy. Sensitive search strategy (comprehensive search that identies larger set containing all the relevant citations and perhaps some that are not relevant) 1 Polycystic Kidney Diseases/ 4 744 Here we have used the same terms as for the specic strategy, but by removing the asterix we include all citations indexed with this term, rather than just those where the term has been judged by the indexer to be the main focus or concept of the citation. To be even more 2 Polycystic Kidney, Autosomal Dominant/ 1 838 sensitive we could explode these terms. 3 autosomal dominant polycystic 1 774 The asterisk at the end of disease is a truncation symbol that will also retrieve diseases. .tw nds articles where this phrase appears in kidney disease*.tw the title or abstract. 4 (APKD OR ADPKD).tw 1 271 This step includes citations where either of these acronyms appear in the title or abstract. 5 OR/14 6 770 This step creates a Boolean set of citations indexed with any of the population terms in the preceding four lines. 6 exp Ultrasonography/ 202 764 We have used the same term from the specic strategy, but added additional test terms subsequently to nd any citation with ultrasound or ultrasonography in the title or abstract. If you wanted to be more sensitive you could put ultrasonogra*.tw which would pick up 7 ultrasound.tw 106 494 ultrasonogram , ultrasonography and ultrasonographic. 8 ultrasonography.tw. 49 080 9 us.fs 151 228 us indicates ultrasound used as a subheading. .fs indicates a oating subheading. Subheadings are given to some MeSH terms to further limit their meaning. Use of subheadings in this regard is not recommended for a sensitive search. However, a oating subheading is a little different, and means you are searching for this ultrasound subheading attached to any MeSH term. It therefore increases the sensitivity of your search once the test terms are combined with population terms and methods lter. 10 OR/69 321 012 This step combines the preceding test term lines into one set. 11 5 AND 10 1 109 This step combines only citations indexed with any of the population terms and any of the test terms. 12 Sensitiv*.mp 914 314 Lines 1215 are the sensitive diagnostic study strategy devised by Haynes et al. for nding diagnostic accuracy articles. .mp indicates a 13 diagnos*.mp 1 513 501 keyword search. It will nd this word in any MeSH term, title or abstract. It is best not to use .mp in your general searching, as it can 14 di.fs 1 636 252 make your search overly sensitive. Here, we use it as part of the devised sensitive diagnostic lter (i.e. along with the terms immediately preceding and following), which was developed after extensive research. 15 OR/1214 3 127 414 This step combines the terms of the sensitive diagnostic study strategy. 16 5 AND 10 AND 15 906 This step combines any citations which have been indexed with population terms and test terms and diagnostic methods terms. A sensitive search is likely to capture the articles you want, but at the expense of retrieving a high number of irrelevant articles, which you need to sift through and discard. 17 5 AND 10 AND the optimized diagnostic lter 81 This step provides a more manageable number of results, which is more sensitive than the specic search above. Additional potentially (Line 9 from the specic search) useful papers retrieved over and above the specic search include a 2009 review in JASN, and the 2005 AJKD paper giving results of the CRISP study.

10

Sensitiv*.mp. OR predictive value*.mp. OR accurac*.tw 3 AND 8 AND 9

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Question: In young adults with a family history of APKD is abdominal ultrasound scanning compared with the reference standard (long-term clinical follow up) accurate for the diagnosis of APKD? ADPKD, autosomal-dominant polycystic kidney disease; AJKD, American Journal of Kidney Diseases; APKD, adult (autosomal-dominant) polycystic kidney disease; CJASN, Clinical Journal of the American Society of Nephrology; CRISP, Consortium of Renal Imaging Studies in Polycycstic Kidney Disease; JASN, Journal of the American Society of Nephrology.

Searching the medical literature effectively

IN SUMMARY
After developing an answerable clinical question, and identifying the optimal study design to answer it, by using the stepwise techniques outlined above and illustrated in tables and gures the reader can learn the skills necessary to perform basic and more advanced search strategies to nd relevant citations in the biomedical literature.
4.

5.

REFERENCES
1. Cross NB, Craig JC, Webster AC. Asking the right question and nding the right answers. Nephrology 2009; 15: 811. 2. Cullis J, Webster AC. Keeping up to date in Nephrology. Nephrology 2009 (in press). 3. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 [updated September 2009]. The

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Cochrane Collaboration, 2008. Available from www.cochrane-handbook.org (accessed 22/09/2009). Wong SS, Wilczynski NL, Haynes RB, Ramkissoonsingh R, Hedges Team. Developing optimal search strategies for detecting sound clinical prediction studies in MEDLINE. AMIA Annual Symposium Proceedings/AMIA Symposium; 2003; 72832. Wilczynski NL, Haynes RB, Hedges Team. Developing optimal search strategies for detecting clinically sound causation studies in MEDLINE. AMIA Annual Symposium Proceedings/AMIA Symposium; 2003; 71923. Haynes RB, Wilczynski NL. Optimal search strategies for retrieving scientically strong studies of diagnosis from Medline: Analytical survey. Br. Med. J. 2004; 328: 1040. Garg AX, Iansavichus AV, Wilczynski NL et al. Filtering Medline for a clinical discipline: Diagnostic test assessment framework. Br. Med. J. 2009; 339: b3435.

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