E- Incident #U02401 Mediated User Effective A family physician practicing in a metropolitan area was seeking the most recent information on managing weight loss, intestinal problems, and depression for a woman patient with Crohn's disease. The patient had lost a lot of weight, which was endangering her health, had other intestinal problems, and was suffering from depression. A hospital librarian carried out a MEDLINE search with abstracts of the citations. The physician obtained several good review articles and additional articles on intestinal complications and nutritional support. The patient was treated with home hyperalimentation, wherein an intravenous catheter is used for providing sugars, fats, and proteins. It was decided that surgery was unnecessary. She returned home, gained weight, became pregnant, and generally did well. Eventually surgery may be required because her Crohn's disease remains active. Incident #U02402 Mediated User Effective A family practice resident at a small rural hospital was seeking morbidity and mortality data about trials of vaginal delivery after caesarian section, because the hospital policy was to advise repeat caesarian section, and vaginal delivery was tried only when requested by the mother. She wanted to learn more about the clinical research on the topic in order to advise her patients. The hospital librarian carried out a MEDLINE search and located specific studies showing that morbidity and mortality were lower for vaginal birth after caesarian section. She now can explain the issues to her patients with previous caesarian sections and advise them to request a trial of vaginal delivery if they want one. Of three patients with previous caesarian section who wanted vaginal deliveries, one developed a complication and a caesarian section when the resident was not present, and another changed her mind and decided to have a repeat caesarian section. Incident #044301 End User Ineffective An academic oncologist in a medical school was writing an article on a study she had done on the recurrence of breast cancer in the chest wall. She wanted to review the literature on clinical studies of patients who had been treated with surgery and adjuvant chemotherapy only, and later had a recurrence in the chest wall with no other evidence of cancer. Using direct access, she searched MEDLINE from her office and found only four articles on this subject. The search results were somewhat unsatisfactory because the physician had difficulty isolating this particular therapeutic sequence from studies of patients with mastectomies followed by different types of surgery and therapies. She was pleased, however, to have found one particular article by a researcher who was very likely to review her manuscript for publication. As a result of her own study, her advice to patients has changed; experts were previously recommending only surgery and chemotherapy alone, which she showed resulted in a high incidence of chest wall recurrences, as high as 40% in large primary tumors with positive axillary nodes. She now recommends post-operative radiation in these patients. Incident #045201 End User Effective The head of maternal and child health at a hospital needed to revise an old policy and procedures for managing strep infections. He needed new information on strep throats, specifically, proper antibiotic treatment. His Grateful Med search produced the information that answered all of his questions, and he was able to rewrite the hospital's policy, including a fact sheet with a summary of recent and old clinical findings, indications for throat cultures, and treatment. At the date of this report, the physician had just finished preparing the policy He feels that it is a good one and will lead to patients getting better care and staff feeling more comfortable with a consistent approach to treatment. Incident #045202 End User Ineffective A pediatrician, in a small community, was asked by a colleague to do a search for the latest literature on the diagnosis and treatment of thrombocytopenia, because he had an inpatient with the disorder. He did a MEDLINE search using Grateful Med from home, but found nothing useful. He either found thousands of citations or nothing. His colleague treated the patient without new information, but the outcome for the patient was not known by the respondent. Incident #046602 End User Effective Two years ago, a research scientist in a medical school was planning an approach to the problem of transforming plants to produce ovalbumin (chicken egg white). He needed to find the gene sequence and he had forgotten where it had been published. He carried out a MEDLINE search from the laboratory office and found a series of papers, which he was not aware of, that contained the properties and the sequence of the ovalbumin gene and techniques for its isolation and utilization. Given this information, his team devised a long-term research project to clone the gene into a plasmid with which they could transform plants to increase their nutritional value. They were successful in transforming carrot, potato, and petunia plants to produce ovalbumin. Recently, he reported their findings at a professional meeting, and the study has been funded for another three years. Ultimately, these plants, which are more nutritious, may become commercially available. Incident #U07402 Mediated User Effective A psychiatric social worker had several autistic children as patients. They had good language and learning skills but were significantly depressed. She had heard from a psychiatrist about a new syndrome called Aspeger's syndrome that seemed to describe these children, and wanted to know more about it. She asked a medical librarian to conduct the search and learned that there is disagreement about whether or not the syndrome really exists. However, researchers agreed that there is cyclic depression overlaying some cases of autism and that it may be familial. The information helped the social worker convince the hospital review board that autistic children may become depressed. She was able to get more psychotherapy for the patients as well as better counseling for families and teachers on how to deal with them on a daily basis. Incident #074503 End User Effective A question was raised in the AIDS clinic of an academic medical center concerning the utility of beta2-microglobulin test for assessing the activity of HIV infection. A specialist in gastroenterology and infectious diseases wanted to research the topic to prepare a presentation to the AIDS Clinic staff. Using Grateful Med, he did a MEDLINE search at home and obtained information that the test is a measure of disease activity because beta2-microglobulin is shed by cells that are turning over or dying. It is also an index of white blood cell turnover. It was clear that elevated beta2-microglobulin is not a specific test for AIDS and could only indicate how rapidly lymphocytes were being destroyed. He made the presentation and the staff decided not to use the test because of the high cost. They will now know how to interpret the test results if someone else orders it. Incident #T00801 Mediated User Effective A woman, who had had a giant cell tumor removed from her metatarsal several years previously, was found to have recurrent tumors in that foot. The physician assistant was asked to obtain a literature search because a consultant had suggested either amputation or osteotomy as treatment options. The attending physician needed to know what the indications are for amputation. At the medical school library, a MEDLINE search was requested. The articles obtained made it clear that amputation was not indicated if the recurrent tumors were not malignant on biopsy. The physician performed an osteotomy and biopsy, which was negative. The patient's foot was saved and she is doing very well.