PBL Information Resources and Tools for the First Year: Case #16: Candy Mondragon -- Pop Goes the Knee

Not so many electronic books this week, but a couple of ones in print that you might just have to check out.

Searching Google for some info?  Don't forget to specify the types of sites you want to see.  Use site:org or site:gov to get results from private organizations or government organizations that have information matching your search terms.

Not finding what you need?  Having trouble using one of our resources?  Please let us know.

Ask Karen - you can reach me at 858-534-1199 or at kheskett@ucsd.edu

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Physical Exams

In the time of COVID, not a thing you can do in person. However, we do have a couple of great resources to give you the how-to knowledge and the visual aspect.  

For those questions that are more clinically oriented, the point of care tools (Up to Date and Medscape) will help you understand better the tests used for evaluating the knee and imaging the knee.

Building the Differential Diagnosis List

These point of care, decision support tools often have some differential diagnosis information.  But there may be other tools that are a bit more effective.  Give them a try for knee pain or swelling and see what they might suggest.

Thinking Through the DDX

Dr. Lopez recommends a slight modification of the mnemonic OLD CARTS by making it MI OLD CARTS.  Dr. Goldberg's online guide explains OLD CARTS.  The revised version adds mechanism (M) and injury (I) to the others of: onset, location, duration, aggravating/relieving factors, temporal factors, severity.

Quickly Find the Conclusions You Need:  Use Evidence-based Medicine Short Cuts, 

(In other words, this is a long explanation for using PubMed to get a small number of articles.)

An evidence-based practice is one that acknowledges that care needs to be based on the most current evidence and acknowledges that the knowledge about most effective care changes over time.  Therefore, many questions may arise about the best mode of care and will need to be searched to make sure you are basing treatment options on the latest information.  EBP or EBM is a process that starts with:

• Assessing your patient and your information need
• Asking a well-formed clinical question (PICO)
• Acquiring the best evidence you can find
• Analyze the information you found
• Apply that information to your patient

You'll notice that it all begins and ends with the patient and that is an important concept at UCSD Medical Center.

That is a very brief description, and what does that mean when searching?  Since you have already assessed your patient (mostly, anyway) and know what information you need, let's start with "Asking a well-formed clinical question."  The mnemonic PICO is used to help guide you.

P = Patient and problem

I = Intervention

C = Comparison

O = Outcome

From these 4 categories, you can draw your search terms and also know if you need to apply filters when searching PubMed.  From the main PubMed page, scroll down to use the Clinical Queries link.  

So, depending upon your question, how would that play out with Candy?  If your question was about the best imaging for diagnosing her situation - perhaps using MRI?  What is the comparison test - would that be CT or xray?

Try this out in PubMed's Clinical Queries  - designed specifically for EBM questions. 

After typing  knee ligament  add in the ct & mri, then adjust for Diagnosis (in the drop-down box). Check out the results.

One more step to further narrow your list - use the filter for Adult so PubMed can serve up the articles that are most relevant.  You might need to scroll through them a bit, but there will be some good things - such as the American College of Radiology's guideline article.

And, don't forget that the new PubMed makes it easy to grab the citation for any article.  

An alternative search in Clinical Queries

An aspect of EBP is the analysis of the information you find, so it helps to specify what you hope to find.  Next year in EBMI you will know more about specificity and sensitivity of tests, but for now, just add sensitivity to a knee exam text. 

Another Diagnositic search to try in PubMed Clinical Queries might be one of the diagnostic tests and include the word sensitivity (looking for the sensitivity of a certain test).  So try the following - make sure the Diagnosis option is selected:

knee mcmurray's sensitivity

Knee Injury, treatment or repair: What's the Evidence?

What if your question is to find the evidence for (or against) a specific procedure?  What do you do when a resource says to do something but doesn't tell you the evidence behind the recommendation?  Or, what about those situations where the tools like Up to Date don't really cover the topic completely?  In situations like this, you will need to go to the journal literature to see if studies have been done on the topic.  

Next year, you will have more information on the types of studies and the evidence each study conveys.  The following graphic represents an overview of the evidence different types of articles convey.  Best bests are at the peak, but not everything topic is already synthesized or filtered and ready for your consumption.  Lower levels of evidence are still important and have valuable information.  Always look for the highest level of evidence you can find.

So, what if we wanted to evidence on treatment for knee injuries?  Up to Date is probably your first thought.  However, one of the limitations of Up to Date is that many of their treatment recommendations are expert opinion - they do not show the levels of evidence upon which their opinion is based. (If you have ever looked at Natural Medicines database, you would see how those levels impact the treatment remarks.)  Maybe your patient is different than the usual patient and you need to know be certain the research included patients like yours.  In those cases, you need to get to the primary research material. 

Looking at the peak, one of the best types of evidence is a systematic review.  Often, the Cochrane Library is a great place to find these.  The Cochrane Library is several different types of resources and in a search for information on knee injuries and treatment or repair (or insert the term of choice), you will find a variety of systematic reviews and on another tab, some studies.

If you prefer, PubMed is also a place to find the synthesized information of systematic reviews and also the primary literature from studies.  You could use the Clinical Queries tool as described above.  Or, you could just use the regular PubMed search and if needed, apply filters for types of article such as Clinical Trial or better, Randomized Clinical Trial which has a very high level of evidence. With PubMed's Best Match sort order, a quick scan of the titles should help identify pertinent articles.

* Note:  Remember, asking "what is the evidence for ..." is a great question to ponder.  Did you know it is only within the 20 years that hormone therapy, a main stay  treatment for decades for post-menopausal women was actually investigated.  The evidence did not support the "expert opinion" that went unchallenged for so long and actually harmed women more than it helped.  It is good to ask questions.

Finding Cost Information    

Cost of care can be a moving target and difficult to find.  Insurance coverage factors in, and the facility or doctor you go to may charge differently than someone else down the street.  Is there even a bottom-line dollar amount? 

• You can also call a facility and ask the cost.  Most facilities will give you that information.  However, there is a mandated reporting tool if you prefer that.
• Starting a few years ago, hospitals were mandated to report the cost of their services, so, you can see what the starting point is:  California's "Hospital Chargemaster".  However, the total patient cost may include not only the hospital or clinic charge but also the doctor's services.  Therefore, some phoning (e.g., medicare, hospital or insurance company) may be involved with this one.
• A newer tool from New Health Care might be the most efficient method to some of this information.  Since they do not provide detail on where the information comes from that is an important aspect to be aware of - it does not mean don't use it, but just be aware of this.  Again, calling might be a good follow up.

MedlinePlus is a great place to find consumer-friendly materials along with directories, a dictionary & encyclopedia, and more.  Take a look and see what you find - try knee injury or rice and injuries.