CLINICIAN-ORIENTED INFORMATION
The fundamental basis of current medical knowledge is the peer-reviewed,
published journal articles that make up the medical literature. Papers published
after the mid-1990s are now largely available on the web as "full text" (complete
manuscript with figures) for clinicians and in some cases the public at large. Digital
access to published articles will be discussed in the next section. Of most direct
clinical utility are practice guidelines.[4]
These
thoughtful distillations of the literature combined with expert practice experience
are peer reviewed or consensus based and are
Figure 80-2
The uniform resource locator (URL). A URL is composed
of four major components: protocol, address, directory, and file name, written together
in sequence to exactly specify a web resource. Web browsers often permit one to
skip the http:// but all other components are required. If no directory or file
is included, the remote web server will provide a default "front" page.
available from the ASA, other professional medical societies, and governmental agencies.
In particular, the best source for practice guidelines spanning the entire field
of medicine is the National Guideline Clearinghouse (NGC) at www.guideline.gov.
The NGC is the result of a partnership of the federal Department of Health and Human
Services, the American Medical Association, and the American Association of Health
Plans. The NGC solicits guidelines and protocols from a variety of sources, including
those just listed. The entries are then re-reviewed with an emphasis on the extent
of scientific evidence for the guidelines. The NGC website allows the reader to
search for keywords or to browse the collection by disease or submitting organization.
Other useful features include the ability to compare guidelines for similar diseases
or conditions or to read prepared summaries of related guidelines. At the end of
2003, the NGC site held 335 protocols that touched on anesthetic management. At
this time, only 2 of the ASA practice guidelines (of 14 published) had been reviewed
and included in the NGC. The remainder of the ASA practice guidelines are available
at http://www.asahq.org/publicationsandservices/practiceparam.htm.
Another valuable, reliable site of clinically oriented material
is managed by the National Library of Medicine (NLM). Though best known for the
MEDLINE database (which is detailed later), the NLM provides many resources for clinicians,
researchers, and the public. The NLM was established in 1836 by the Surgeon General
of the U.S. Army. Since the turn of the 20th century it has been the largest biomedical
library collection in the world. The mandate of NLM is to "assist
the advancement of medical and related sciences and to aid the dissemination and
exchange of scientific and other information important to the progress of medicine
and to the public health" (US CFR 42.6A.IIId.1.286). The NLM therefore
collects and
indexes the world's peer-reviewed medical literature into a database called MEDLINE,
as well as massive databases of genomes, proteomes, protein structures, and so forth.
At present, MEDLINE contains over 14 million bibliographic citations from over 4600
biomedical journals. The database contains simple bibliographic entries starting
in 1953; citations later than the 1970s are likely to contain abstracts, and those
published after the late 1990s often have hyperlinks to the complete text of the
article. The NLM has been in the forefront of the effort to make reliable health
information available to practitioners and the general public. A condensed view
of the information available at the NLM can be found at http://www.nlm.nih.gov/hinfo.html.
This last URL is the gateway to all the NLM sites, some of which will be covered
in detail later.
CLINICAL ALERTS.
The NLM serves as a repository of major, clinically significant
results obtained from medical studies funded by the National Institutes of Health
(NIH). The results heralded by a Clinical Alert are expected to have an impact on
morbidity and mortality. The URL for Clinical Alerts is http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html.
CLINICAL QUERIES.
This NLM service provides a method of searching for papers from
the overall medical literature that are particularly valuable for clinical practice.
The Clinical Query system uses a system of specially selected keyword filters[5]
to preselect papers of high scientific quality and clinical relevance. The strategies
used by this query system can be directed to focus on diagnosis, prognosis, prevention,
or treatment of medical disorders. The use of filters by users is described later
in the PubMed section. Another feature of the Clinical Query web page is a filter
setting to obtain citations with a particular emphasis on systematic reviews, meta-analyses,
reviews of clinical trials, evidence-based medicine, consensus development conferences,
and guidelines related to a medical condition or therapy. The Clinical Query web
page is found at http://www.ncbi.nlm.nih.gov:80/entrez/query/static/clinical.html.
The major journals covering the field of anesthesiology are available
on the web with the full text of articles back to the late 1990s. Although the journal
articles are accessible
Figure 80-3
The Entrez face of MEDLINE, usually referred to as PubMed.
from the NLM MEDLINE database, direct access through the publisher websites includes
the otherwise inaccessible full text of editorials, letters to the editors, and other
special features. The URLs of some major journals are listed in Table
80-1
.
Commercial enterprises have created several clinical medical websites
that are marketed as having value added beyond that contained in the free public
access governmental sites. An example is MDConsult (http://www.mdconsult.com), a
service of the Elsevier Publishing Corporation. In addition to its own version of
access to MEDLINE and a list of practice guidelines, MDConsult also provides access
to electronic, downloadable textbooks of various medical specialties, the full text
of many medical journals, and decision-support software for clinicians.
