Further Reading, Keeping Up-to-date and Retrieving Information

It was not intended for this textbook to be a comprehensive discussion of neurology, but rather to put down on paper the simple concepts that have been developed over more than 30 years of teaching. The aim has always been to make the learning (and the practice) of clinical neurology more interesting and less intimidating for the non-neurologist (medical students, hospital medical officers, physician trainees, general physicians and general practitioners). Most of the chapters have been written from a symptom rather than a disease oriented approach and have discussed the more commonly encountered neurological disorders.

The basics of practising medicine will never change dramatically as a result of new technologies or the World Wide Web, but these will change the way healthcare is delivered. This is not because of the technology itself or the attention it receives, but because patients will need and demand this kind of knowledge and expertise. Doctors of the 21st century must be ready and qualified to meet these expectations.

This chapter suggests techniques that can be employed to ‘keep up-to-date’ which, with the rapidly expanding knowledge base and the vast array of journals and web sites, at times seems an almost impossible task. It also contains recommendations for further reading, including other books that this author has constantly referred to for additional information.

KEEPING UP-To-Date

The amount of information available to the clinician is mindboggling. Typing the word ‘stroke’ into Google retrieves 49,000,000 hits! This is reduced to 1,580,000 for Google Scholar and 145,200 in PubMed. This has been referred to as ‘information overload’ [1].

Although it is impossible to read every article this should not be used as an excuse to read none.

As Glasziou pointed out, only 1 in 18 articles fulfil evidence-based medicine criteria, indicating that for the uninitiated there are vast numbers of potentially misleading papers in the literature. There are a number of books [2, 3]² and articles in journals [4–23] that discuss how to read the medical literature. Unfortunately, most medical practitioners never acquire the skills or have the time to read journal articles thoroughly. Most rely on information from colleagues, pharmaceutical company representatives, clinical scientific and education meetings, review articles and resources such as the online subscription service ‘up-to-date’ (http://www.uptodate.com/home/index.html) to try and keep their knowledge current.

The McMaster group devised a simple and effective strategy for filtering papers [24]. They suggested the approach illustrated in Figure 15.1.

FIGURE 15.1 The McMaster group devised a simple and effective strategy for filtering papers Adapted from Clinical Epidemiology. A Basic Science for Clinical Medicine, by DL Sackett, RB Haynes, P Tugwell, 1985, Little, Brown, p 370

The next step depends on the nature of the paper:

• Diagnostic test. Was there an independent ‘blind’ comparison with a ‘gold standard’ of diagnosis?

• Clinical course and prognosis. Was there an ‘inception cohort’?³

• Determining aetiology. Were the basic methods used to study causation strong?

• Distinguishing useful from useless or harmful therapy. Was the assignment of patients to treatments really randomised?⁴

If the answer to the relevant question was ‘yes’, the next step is to read the patients and methods section to see if the study has been well conducted. In the end, after reading the paper you have to decide whether you will allow the results of this paper to influence the management of your patients.

Learning is only beginning, not ending, the day a medical student graduates. All clinicians must for the benefit of their patients commit to a lifelong learning process in order to keep up-to-date.

Working with a group of colleagues who meet on a regular basis to discuss cases and papers in the literature is probably one of the most effective ways of keeping up-to-date. If each person has a different subspecialty area of interest they would tend to keep abreast of the literature in that area and can share their knowledge with the others. Attendance at national and international meetings is a second way of keeping abreast of the latest developments. Pharmaceutical company sponsored guest speakers at meetings is also common, but it is important to remember that this guest speaker usually has a point of view that is positive towards the products that the company markets; otherwise they would not be invited to speak.

Another useful technique is to peruse the contents page of a journal for articles of interest, particularly those that have an associated editorial. In particular, the three major journals, the British Medical Journal, the Lancet and the New England Journal of Medicine, may be scanned in this way to retrieve neurology-related and other articles of interest. The clinicopathological conferences in the New England Journal of Medicine are a wonderful source of information.⁵

Perhaps the most effective method of gaining new knowledge is retrieving information about a particular problem that you are dealing with at that time. Ready access to the Internet makes it possible to find relevant papers even during a consultation with the patient, e.g. when you wish to give the patient additional information. The Internet can help sort out a difficult diagnostic problem such as that discussed in Chapter 6, ‘After the history and examination, what next?’ Most frequently, the question that arises relates to the latest diagnostic test or criteria for a particular entity or the optimal treatment for a particular condition. It is not possible to retrieve and evaluate all this information at the time of consultation. A suggestion is to review the literature on a particular disease on a regular basis, adding to your database of knowledge by retaining the previous reviews.

A major problem is the growing number of institutions and companies vying to provide online information. It is almost impossible to choose between them. In essence all these entities are retrieving the same literature and trying to put it into a digestible form. It is suggested that you sample a few and find one that meets your needs before committing to a subscription.

RETRIEVING USEFUL INFORMATION FROM THE INTERNET

Entrez–PubMed is the database used by most clinicians. A more detailed description on free-access and biomedical databases other than PubMed can be found in the article by Giglia [25].

Biomed–Central, the open access publisher, maintains a catalogue (http://databases.biomedcentral.com/browsecatalog) of more than 1000 databases. Some databases contain experimental data; others provide synopses of public information; and most are freely accessible. In the subject area there are options to search neurology or neuroscience (http://databases.biomedcentral.com/search), and under the content section the options include disease, experimental data, images, journal articles and links to other sources, to mention only a few.

Evidence-based medicine databases

There are many evidence-based medicine databases, but unfortunately most require payment for access.

• Abstracts can be viewed on the Cochrane review (http://www.cochrane.org/index.htm), but payment is required for the full article.

• Netting the evidence (http://www.shef.ac.uk/scharr/ir/netting) is a British-based website that is intended to facilitate evidence-based healthcare by providing support and access to helpful organisations and useful learning resources, such as an evidence-based virtual library, software and journals. The resources can be browsed by type, and a search facility is available.

• The aim of the Turning research into practice (TRIP) database (http://www.tripdatabase.com) is to allow health professionals to easily find the highest quality material available on the web – to help support evidence-based practice. This is a very interesting and user-friendly tool.

• The QuickClinical (QC) information retrieval system (http://www.chi.unsw.edu.au/chiweb.nsf/page/QuickClinical) is a new type of evidence-access technology that utilises intelligent search filter technology to model typical clinical tasks such as ‘diagnosis’ or ‘prescribing’ to ensure that only the most relevant evidence is retrieved. This means clinicians are more likely to search and, when they do search, are more likely to find information that changes their practice.

• The aim of the Centre for Evidence Based Medicine (http://www.cebm.net) is to develop, teach and promote evidence-based health care and provide support and resources to doctors and healthcare professionals to help maintain the highest standards of medicine.

• The National Guideline Clearinghouse™ (NGC) (http://www.ahrq.gov/) is a public resource for evidence-based clinical practice guidelines. NGC is an initiative of the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services. NGC was originally created by AHRQ in partnership with the American Medical Association and the American Association of Health Plans (now America’s Health Insurance Plans [AHIP]). It also offers synthesis of selected guidelines (http://www.guideline.gov/compare/synthesis.aspx) and expert commentary on issues (http://www.guideline.gov/resources/expert_commentary.aspx).

• Clinicians Health Channel (http://www.hcn.com.au/profiles/shared/component/use/) is sponsored by the Victorian Department of Health and is for the benefit of clinicians working in the Victorian public health sector. It provides access to journals, books, evidence-based practice resources, drug information resources and citation databases.

Searching strategies in PubMed and other search engines

The traditional approach to searching the literature has been with PubMed (http://www.ncbi.nlm.nih.gov/pubmed/), which is a service of the US National Library of Medicine and the National Institutes of Health. It is the integrated, text-based search-and-retrieval system used at The National Centre for Biotechnology Information (NCBI) for the major databases, including PubMed, Nucleotide and Protein Sequences, Protein Structures, Complete Genomes, Taxonomy and others.

There are tutorials available for using PubMed (http://www.nlm.nih.gov/bsd/disted/pubmed.html). There is also a PDF designed to print and tri-fold (http://nnlm.gov/training/resources/pmtri.pdf).

PubMed is the main database that most clinicians would use to retrieve the more scientifically valid information. On the top left side there is a dropdown box that contains other databases such as journals and OMIM (Online Mendelian Inheritance in Man). At OMIM you can search the individual chromosomes and also mitochondria just by ticking the box next to the relevant chromosome.

Exporting references to a reference manager: It is possible to export the references into a reference management program such as Endnotes or Reference Manager. To export to Endnotes the references need to be converted to text files (^∗.txt).⁶ The text file is saved onto the disc. In the Endnotes program go to file and select the import option. Set the import option to ‘PubMed (NLM)’, duplicates to ‘discard duplicates’ and text translation to ‘no translation’. Then simply select ‘import’ and choose the directory where the text file is to be saved. Inside the individual reference you can link to a downloaded PDF.

PubMed and MedlinePlus allow searching by topics, authors or journals. The evolution of ontological derivation (a systematic arrangement of all of the important categories of objects or concepts that exist in some field of discourse, showing the relations between them) and semantic search engines (which improve online searching by using data from semantic networks) is changing the way searches are performed and adds a deeper layer of complexity to the interrogation of the wealth of defined medical knowledge. A semantic network is a network that represents semantic relationships between the concepts and the interpretations of a word, sentence or other language form to disambiguate queries and web text in order to generate more relevant results. Semantics is the branch of the science of language concerned with meaning.

ALTERNATIVE SEARCH ENGINES USING THE SEMANTIC WEB

Most of the alternative search engines rely on answering a question, but also on phrases and keywords. There are many semantic-based alternative search engines; only a few will be discussed here.

GoPubMed: GoPubMed (http://www.gopubmed.org) retrieves PubMed abstracts for your search query and sorts relevant information into categories. It lists the title of the article, and there is the ability to look at the abstract or link to a specific article by selecting the author icon or to go to the journal by selecting the journal icon. This is often useful as it is not uncommon for two or more related articles to be printed in the same volume. Other functions in GoPubMed include:

• What collates abstracts according to the concept hierarchies of GO and MeSH – providing a combined search across the fields of molecular biology and medicine.

• Where provides information about geographic localisation of people, research centres and universities, as well as journals in which retrieved papers were published. The journals are separated into top high impact and more top journals. There is an option to search for a specific journal and to look at reviews only.

• When is the citations time machine. You can see articles published today, last week, last month, last year, during the last 5 years or specify a date.

SearchMedica: This is a great ‘professional medical search’ resource. SearchMedica (http://www.searchmedica.com) is a search engine that scans reputable journals, systematic reviews and evidence-based articles to provide search results. Although SearchMedica displays fewer results than standard search engines, it is accurate, clinically relevant and surprisingly comprehensive. There are options to scan the entire Web or just recommended medical sites and an option to choose mental/nervous system. The limitation is that there are a restricted number of users and it is not always possible to access this website.

Hakia–PubMed: Hakia (http://www.hakia.com) is a true general semantic Web search engine and believes that searchers suffer from information pollution! Hakia semantic technologies have developed a dedicated semantic medical search of PubMed (that has moved away from the popularity-ranked results) to provide credible and relevant search results (http://pubmed.hakia.com/). Credible sites are those that have been vetted by librarians and other information professionals.

Webicina: Webicina (http://www.webicina.com) was designed to help doctors from all the medical specialties, and patients as well, to get closer to the Web 2.0-based world. E-patients are tech-savvy members of the community trying to find reliable medical information on the web who want to communicate with their doctors via e-mail or skype and store their medical files online. The number of e-patients is growing rapidly while the number of web-savvy doctors is not.

The problem with all search engines is that none is able at this stage to sort the wheat from the chaff. They cannot differentiate between papers that should influence management and those that should be ignored. Although evidence-based medicine is the ideal, in many instances there simply is NO evidence one way or another to guide treatment. Under these circumstances the pros and cons of the treatment you elect to recommend need to be discussed with the patient.

GENERAL NEUROLOGY WEBSITES

• Cochrane Collaboration (http://www.cochrane.org/index.htm). The aim of the Cochrane Collaboration is improving healthcare decision making globally, through systematic reviews of the effects of healthcare interventions. Unfortunately, many reviews conclude that there is insufficient evidence and that further studies are needed.

• European Federation of Neurological Societies (EFNS) (http://www.efns.org/content_old.php?myaction=viewsub-1-1-6). The EFNS represents the national neurological societies of 40 European countries.

• Internet Drug Index (http://www.rxlist.com/). This provides an alphabetical list of drugs, a pill identifier and an explanation of diseases, conditions and tests.

• World Federation of Neurology (WFN) (http://www.wfneurology.org/). The WFN is the international body representing the specialty of neurology in more than 100 countries/regions of the globe. The WFN has these neurological societies as its members, and their individual members are in turn WFN members through the association. The purpose of the WFN is to improve human health worldwide by promoting prevention and the care of persons with disorders of the entire nervous system by:

• fostering the best standards of neurological practice

• educating, in collaboration with neuroscience and other international public and private organisations

• facilitating research through its research groups.

COUNTRY-BASED NEUROLOGY WEBSITES

North American websites

• American Academy of Neurology, http://www.aan.com/

• American Neurological Association, http://www.aneuroa.org/

• Canadian Neurological Sciences Federation, http://www.ccns.org/

• National Institutes of Health – Brain and Nervous System, http://health.nih.gov/search.asp/3

European websites

• European Federation of Neurological Societies, http://www.efns.org/content_old.php?myaction=viewsub-1-1-6# (This URL will link to the neurological societies of 40 countries.)

Asia and Pacific websites

• Asia ASEAN Neurological Association, http://www.asean-neurology.org/

• Australian and New Zealand Association of Neurologists, http://www.anzan.org.au/index.asp

• Hong Kong Neurological Society, http://www.ns.org.hk/

• Japanese Society of Psychiatry and Neurology, http://www.jspn.or.jp/english/index.html

• Korean Neurological Association, http://www.neuro.or.kr/eng/

• Malaysian Society of Neurosciences, http://www.neuro.org.my/

• Neurological Society of India, http://www.neurosocietyindia.com/

• Neurological Society of Thailand, http://thaineurology.com/index.html

• Pakistan Neurological Society, http://www.pakns.org/

• Philippine Neurological Association, http://www.pna.org.ph/

• Singapore Clinical Neuroscience Society, http://cnssingapore.blogspot.com/

WEBSITES RELATED TO THE MORE COMMON NEUROLOGICAL PROBLEMS

Clinical trials

The following are very useful and readily accessible resources.

• The National Institutes of Health has a website (http://www.clinicaltrials.gov/) dedicated to clinical trials that has in excess of 70,000 registered trials. These can be searched by topic and country, e.g. headache, stroke etc. The website comments on whether the trial is recruiting or not and whether completed. Links are provided to the most up-to-date information, including when the results have been published linked to abstracts on PubMed.

• It also has a website dedicated to neurological disorders listed alphabetically (http://www.ninds.nih.gov/index.htm).

• There is a section dedicated to patient resources also listed alphabetically (http://www.ninds.nih.gov/find_people/voluntary_orgs/organizations_index.htm).

Cerebral vascular disease

• American Stroke Association, http://www.strokeassociation.org/presenter.jhtml?identifier=1200037

• Stroke Trials Registry, http://www.strokecenter.org/trials/

• Washington University Internet Stroke Centre, http://www.strokecenter.org/prof/

• Cochrane Library Stroke Reviews, http://www.cochrane.org/reviews/en/topics/93_reviews.html

Epilepsy

• International General Epilepsy Sites, http://www.epinet.org.au

• International League against Epilepsy, http://www.ilae-epilepsy.org/

• Scottish Intercollegiate Guidelines Network, http://www.sign.ac.uk/guidelines/fulltext/70/index.html; PDF version, http://www.sign.ac.uk/pdf/sign70.pdf

• American Epilepsy Society, http://www.aesnet.org/

• Epilepsy Society of Australia, http://www.epilepsy-society.org.au/pages/index.php, http://www.epilepsyaustralia.org/

EPILEPSY TREATMENT GUIDELINES

• American Epilepsy Society Guidelines and Practice Parameters, http://www.aesnet.org/go/practice/guidelines/guidelines-and-practice-parameters

• American Academy of Neurology Practice Guidelines on the Use of Newer Seizure Medicines in New Onset Epilepsy, http://aan.com/professionals/practice/pdfs/patient_ep_onset_c.pdf

• Practice Guideline on the Use of the Newer Seizure Medicines in Refractory Epilepsy, http://aan.com/professionals/practice/pdfs/patient_ep_refract_c.pdf

AVAILABLE TREATMENTS FOR REFRACTORY EPILEPSY

• American Academy of Neurology Treatments for Patients with Refractory Epilepsy, http://aan.com/professionals/practice/pdfs/patient_ep_treatment_b.pdf

• Canada-Ontario New Epilepsy Treatment Guidelines, http://www.epilepsyontario.org/client/EO/EOWeb.nsf/web/New+Epilepsy+Treatment+Guidelines

• National Institute for Health and Clinical Excellence (NICE) (UK), http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=10954

Headache

• American Headache Society, http://www.achenet.org/resources/information/index.asp

• The Migraine Trust, http://www.migrainetrust.org

• The National Headache Foundation, http://www.headaches.org

• National Institute of Neurological Disorders and Stroke, http://www.ninds.nih.gov/disorders/migraine/migraine.htm

Parkinson’s and movement disorders

• National Institute of Neurological Disorders and Stroke, http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm

• Parkinson’s Disease Foundation (USA), http://www.pdf.org/

• Parkinson’s Disease Society (UK), http://www.parkinsons.org.uk/

• Tourette syndrome, http://www.tsa-usa.org/

Multiple sclerosis

• Multiple Sclerosis Society (UK), http://www.mssociety.org.uk/for_professionals/resources/official_documen.html

• National Multiple Sclerosis Society (USA), http://www.nationalmssociety.org/index.aspx

• MS Australia, http://www.msaustralia.org.au/

• British Medical Journal (UK), http://www.bmj.com/

• New England Journal of Medicine, http://content.nejm.org/

Specific neurology journal websites

The journals marked with an asterisk (^∗) were rated as the top 5 in a questionnaire of members of the World Federation of Neurology [26].

• Acta Neurologica Scandinavica (Sweden), http://www.wiley.com/bw/journal.asp?ref=0001-6314&site=1

• Annals of Indian Academy of Neurology (India), http://www.annalsofian.org/

• Annals of Neurology^∗ (USA), http://www3.interscience.wiley.com/journal/76507645/home?CRETRY=1&SRETRY=0

• Archives of Neurology (USA), http://archneur.ama-assn.org/

• Brain^∗ (UK), http://brain.oxfordjournals.org/

• Cerebrovascular Diseases, http://www.online.karger.com/ProdukteDB/produkte.asp?Aktion=JournalHome&ProduktNr=224153

• Chinese Journal of Cerebrovascular Diseases, http://chinanew.eastview.com/kns50/Navi/item.aspx?NaviID=1&BaseID=NXGB&NaviLink=%e4%b8%ad%e5%9b%bd%e8%84%91%e8%a1%80%e7%ae%a1%e7%97%85%e6%9d%82%e5%bf%97

• Chinese Journal of Neurology, http://zhsjk.periodicals.net.cn/ http://chinanew.eastview.com/kns50/Navi/item.aspx?NaviID=1&BaseID=ZHSJ&NaviLink=%e4%b8%ad%e5%8d%8e%e7%a5%9e%e7%bb%8f%e7%a7%91%e6%9d%82%e5%bf%97

• Epilepsia (USA), http://www.wiley.com/bw/journal.asp?ref=0013-9580

• European Journal of Neurology, http://www.wiley.com/bw/journal.asp?ref=1351-5101

• Headache (USA), http://www.wiley.com/bw/journal.asp?ref=0017-8748

• Journal of Clinical Neuroscience (Australia), http://www.elsevier.com/wps/find/journaldescription.cws_home/623056/description#description

• Journal of Neurology, Neurosurgery, and Psychiatry (UK), http://jnnp.bmj.com/

• Journal of the Neurological Sciences (USA), http://www.elsevier.com/wps/find/journaldescription.cws_home/506078/description#description

• Journal für Neurologie, Neurochirurgie und Psychiatrie (Austria), http://www.kup.at/journals/neurologie/index.html

• Journal of Neurotrauma^∗ (USA), http://www.liebertpub.com/products/product.aspx?pid=39

• Movement Disorders (USA), http://www3.interscience.wiley.com/journal/76507419/home

• Multiple Sclerosis (USA), http://msj.sagepub.com/

• Neurology^∗ (USA), http://www.neurology.org/

• Neurology Asia, http://neurologyasia.org/journal.php

• Neurology, Neurophysiology and Neuroscience (USA), http://www.neurojournal.com/index

• Pakistan Journal of Neurology, http://www.pakmedinet.com/PJNeuro

• Stroke^∗ (USA), http://stroke.ahajournals.org/

RESOURCES FOR PATIENTS

There are literally thousands of disease-oriented consumer organisations around the world striving to raise money for research into their particular ailment of interest and also aiming to keep their members abreast of the latest developments. The American Academy of Neurology produces regular practice guidelines for both the treating clinician and the patient.

Probably one of the most authoritative is the site sponsored by the United States National Library of Medicine and the National Institutes of Health titled MedlinePlus (http://medlineplus.gov/). MedlinePlus website states that it ‘brings together authoritative information from National Library of Medicine (NLM), the National Institutes of Health (NIH), and other government agencies and health-related organisations. Preformulated MEDLINE searches are included in MedlinePlus and give easy access to medical journal articles. MedlinePlus also has extensive information about drugs, an illustrated medical encyclopaedia, interactive patient tutorials, and latest health news. The help topics section links to the National Institute of Neurological Disorders and Stroke website. It also provides health information in over 40 languages (http://www.nlm.nih.gov/medlineplus/languages/languages.html).

RECOMMENDED BOOKS

Medical practitioners often possess large numbers of medical books, most of which they never read and to some of which they occasionally refer. The problem with textbooks is that most of the information is rapidly out of date; this is particularly the case with investigations and treatment.

Although this book has primarily been written for students and the non–neurologist, it is also potentially suitable for the neurology trainee in the early stages of training. What follows is a list of books (not in any particular order) that this author has collected and enjoyed reading. Many have been useful resources to which he has constantly referred.

Gray’s Anatomy, 40th edn, Susan Standring, Churchill Livingstone. This is a book that one refers to when very detailed neuroanatomy is required.

Mechanism and Management of Headache. 7th edn, J Lance, PJ Goadsby, Elsevier Butterworth–Heinemann, 2004. One of those books to which you will constantly refer.

Aids to the Examination of the Peripheral Nervous System, 4th edn, Brain, WB Saunders Company, 2000. This is a thin paperback book that should be on every desktop. It shows how to examine each muscle, the nerve and nerve root supply and contains excellent illustrations of the individual nerves supplying muscles, the sensory supply to the skin of the nerves and the nerve roots (dermatomes).

Seizures and Epilepsy, J Engel, Jr, FA Davis Company, 1989. An excellent clinical textbook on the subject of epilepsy.

The Diagnosis of Stupor and Coma, Fred Plum, Jerome Posner, Oxford University Press, 2007. One of the neurological classics with a superb description of how to examine the comatose patient and how to use those findings to establish the cause of the coma.

Neurological Aspects of Substance Abuse, 2nd edn, JCM Brust, Elsevier Butterworth–Heinemann, 2004. An excellent reference source for dealing with patients admitted with complications from using recreational drugs.

Cerebrospinal Fluid in Diseases of the Nervous System, 2nd edn, RA Fishman, WB Saunders Company, 1992. An invaluable resource to check the cerebrospinal fluid abnormalities in particular diseases.

McAlpine’s Multiple Sclerosis, 1st edn, WB Matthews, ED Acheson, JR Batchelor, RO Weller, Churchill Livingstone, 1985.

McAlpine’s Multiple Sclerosis, 4th edn, A Compstan, I McDonald, J Noseworthy, H Lassmnaa, D Miller, K Smith, H Wekerle, C Confravreux, Churchill Livingstone, 2005. Both these books are excellent resources on multiple sclerosis.