Obstetrics and Gynecology Residents: EBM Review and Practice

Provides specialty based search examples for practicing the EBM steps related to asking clinical questions and acquiring evidence..

Patient Scenario

For a 33 year old pregnant female in her second trimester, what is the evidence available to support the choice between laparoscopic appendectomy or open appendectomy with the best clinical outcome?

PICOTT Analysis of the Clinical Question

Patient / Problem Female, Pregnant, with Acute Appendicitis
Intervention Laparoscopic Appendectomy
Comparison Open Appendectomy
Outcome Successful removal of Appendix
Type of Question Therapy
Type of Study Systematic Review of RCTs > individual RCTs > cohort studies

PICOTT to Search

Select words from the PICOTT concepts to guide the development of a PubMed search. Remember:

  • Start with key concepts. You do not need to use all of the concepts or all the words.
  • Gender and specific age limits are usually added after a preliminary search unless they are central to the clinical question.
  • Consider alternate word endings, especially for key concepts.
  • Consider synonyms.
  • Use an OR to combine alternate word endings and enclose the set of similar words in parentheses.
Question Search Terms
Female, Pregnant, Second Trimester Female AND (pregnancy OR pregnancy complications OR pregnant)
  AND
Laparoscopic Appendectomy

(appendicitis OR appendectomy) AND (laparoscopy OR laparoscopic)

  AND
Open Appendectomy

(appendicitis OR appendectomy)

  AND
Study design filters Systematic Review of RCTs > individual RCTs > cohort studies

 

Preliminary search:
Female AND (pregnancy OR pregnancy complications OR pregnant) AND (appendicitis OR appendectomy) AND (laparoscopy OR laparoscopic)

Try running this search (cut and paste search terms above) in Pubmed.    Look at the results of this search. 

Evaluate the Search

Run the search in PubMed:

  • On 01/26/2015, this search found 222 articles, with many articles looking relevant to our question. 
  • These results give us quite a few articles to look at for this search.  Is it too many?
  • There are also case reports in this results list that would not be relevant to our search.

Check the Search Details:

("female"[MeSH Terms] OR "female"[All Fields]) AND (("pregnancy"[MeSH Terms] OR "pregnancy"[All Fields]) OR ("pregnancy complications"[MeSH Terms] OR ("pregnancy"[All Fields] AND "complications"[All Fields]) OR "pregnancy complications"[All Fields]) OR ("gravidity"[MeSH Terms] OR "gravidity"[All Fields] OR "pregnant"[All Fields])) AND (("appendicitis"[MeSH Terms] OR "appendicitis"[All Fields]) OR ("appendectomy"[MeSH Terms] OR "appendectomy"[All Fields])) AND (("laparoscopy"[MeSH Terms] OR "laparoscopy"[All Fields]) OR ("laparoscopy"[MeSH Terms] OR "laparoscopy"[All Fields] OR "laparoscopic"[All Fields]))

  • Look for terms that did not map to a MeSH term, or did not map effectively to a MeSH Term.

Revise the Search:

  • Try limiting by Type of Article, looking for Systematic Review or Meta-Analyses.
  1. Use the Article Type filter(on the left hand side of the Pubmed record)to see if there are Meta-Analysis or Systematic Reviews to limit your results.   There are 9 results.
    • Search details:  ("female"[MeSH Terms] OR "female"[All Fields]) AND (("pregnancy"[MeSH Terms] OR "pregnancy"[All Fields]) OR ("pregnancy complications"[MeSH Terms] OR ("pregnancy"[All Fields] AND "complications"[All Fields]) OR "pregnancy complications"[All Fields])) AND (("appendicitis"[MeSH Terms] OR "appendicitis"[All Fields]) OR ("appendectomy"[MeSH Terms] OR "appendectomy"[All Fields])) AND (("laparoscopy"[MeSH Terms] OR "laparoscopy"[All Fields]) OR ("laparoscopy"[MeSH Terms] OR "laparoscopy"[All Fields] OR "laparoscopic"[All Fields])) AND (Meta-Analysis[ptyp] OR systematic[sb])                                                                                                                                 
  2. Try using Clinical Queries/Systematic Reviews to find additional articles.   Click here to search Pubmed using the Clinical Queries/Systematic Review filter.
  • Search details are:  systematic[sb] AND (systematic[sb] AND ((("pregnancy"[MeSH Terms] OR "pregnancy"[All Fields]) OR ("gravidity"[MeSH Terms] OR "gravidity"[All Fields] OR "pregnant"[All Fields])) AND (("appendicitis"[MeSH Terms] OR "appendicitis"[All Fields]) OR ("appendectomy"[MeSH Terms] OR "appendectomy"[All Fields]))) AND (Meta-Analysis[ptyp] OR systematic[sb]))
  • This search found 33 articles.     Notice how Pubmed Clinical Queries added terms to our search strategy. 

Review the Results:

  • You notice that all of the 9 articles found by limiting the search to Meta-Analyses OR Systematic Reviews are included in the Clinical Queries set of 33. 
  • The Systematic Review filter found a possibly relevant "baseline" meta-analysis that included a comparison of the two methods:
    • Wilasrusmee C, Sukrat B, McEvoy M, Attia J, Thakkinstian A. Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg. 2012 Nov;99(11):1470-8. Pubmed ID:  23001791
  • Here is another systematic review from the search results.                                                                              
    • Walker HG, Al Samaraee A, Mills SJ, Kalbassi MR. Laparoscopic appendicectomy in pregnancy: a systematic review of the published evidence. Int J Surg. 2014 Nov;12(11):1235-41. PubMed PMID: 25219891.

End the Search:

This patient scenario is an example of a clinical question where there appears to be evidence that is specifically relevant to the clinical question we asked. 

 

 

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