9.

2: Searching the Literature

A good search strategy is one that is sensitive, specific, and systematic.

 The search strategy should be sensitive, so important information is not missed.

 It should be specific, so you don‟t have to work through hundreds or even
thousands of articles to find the one that meets your criteria.
 By systematic we mean that there is a carefully defined strategy that can be
repeated by others if necessary..

There is a balance between sensitivity (needed for completeness) and specificity

(needed for efficiency). A faculty member doing a quick review of the literature for a
lecture will emphasize specificity, but a researcher doing a formal systematic review
should emphasize sensitivity.

The most important resource for researchers doing a systematic review in the United
States (and in many other parts of the world) is the Medline database of the National
Library of Medicine. The bulk of this section will focus on how to effectively and
efficiently search Medline. Other important resources that can help you expand your
search are listed below:

Resource Web site Comment

Cochrane Database of Systematic A collection of over 4000 systemiatic reviews, it can g
www.cochrane.org
Reviews articles.
Over 600,000 clinical trials of treatment, including ma
Cochrane Controlled Trials Register www.cochrane.org
unpublished research and phase 3 and 4 trials from dr
Database of Abstracts of Reviews of This is a database that summarizes published systema
Effectiveness (DARE) and etiology as well as treatment. DARE will also pro
EMBASE This is a bibliographic database that covers more Euro
PsycINFO This is a bibliographic database with a focus on psych
AIDSInfo This is a bibliographic database with a focus on HIV d
AGELINE This is a bibliographic database with a focus on geriat

There are other potentially useful databases depending on your topic. Ask a medical
librarian for help, as he or she will have knowledge about the available databases,
knowledge about search protocols specific for each database, and experience in
clarifying your search strategy. Specifics on search protocols for each database are
beyond the scope of this course. A librarian will also be able to assist you in getting
the full text of the articles as noted above.
Searching Medline for a Systematic Review

Before delving further into the mechanics of searching, it is important to review a few
basic concepts. Medical Subject Heading (MeSH) terms are a very detailed taxonomy
of keywords developed by the National Library of Medicine to describe anything in
biomedicine, from "axon" to "zygomatic arch". In general, it is best to use one of
these terms when constructing your search. This will save you the work of having to
think of and search on alternate spellings and related terms for you topic. The NLM
has a MeSH browser at their PubMed site (
http://www.nlm.nih.gov/mesh/meshhome.html) that helps you identify the best term.
For example, when searching on "intrauterine growth retardation", it is important to
know that the corresponding MeSH term is "fetal growth retardation".

Another option when searching is to use words in the title or abstract, also called "free
text' or 'text word' searching. This is generally going to give you a broader, more
sensitive, but much less specific list of articles than using the MeSH keywords. For
example, searching for the word "hypertension" in the title or abstract will return
every article that uses that word anywhere in the title or abstract. While some of the
articles are relevant, in most hypertension is probably a comorbidity and not central to
the topic of the research article. On the other hand, the MeSH system is only as good
as the people at NLM assigning the keywords. If someone at NLM scans an article
and fails to index the article on a relevant MeSH term, you won't find it if you limit
yourself to MeSH searches.

Boolean logic sounds intimidating, but is really very simple. The terms AND, OR,
and NOT are the most commonly used, and help you craft a search strategy that is
either very broad (sensitive), very narrow (specific) or otherwise optimized to meet
your needs. Here is what these terms mean in English, and how to use them:

Term Example How to use it

AND diabetes AND Only return articles that are indexed on both diabetes and hypertension.
hypertension This makes a search narrower and more specific; articles indexed on one
term but not the other are excluded.
OR diabetes OR Return all articles that are indexed on either diabetes OR hypertension.
hypertension This makes a search more broad and sensitive; articles indexed on either
term, as well as those indexed on both terms, are returned.
NOT diabetes NOT Return all articles indexed on diabetes, but exclude those that are also
hypertension indexed on hypertension. This can be helpful in narrowing your search.
For example, if you are interested in recent articles on the treatment of
Lyme disease only, you may want to use the strategy "Lyme disease
AND 2002(year) NOT immunization" since the literature has been full
 of articles on immunization lately. Use „Not‟ only when absolutely
necessary as you might exclude articles that are relevant to your search.

You can increase your precision by using the proximity operator ADJ (adjacency).
Proximity operators allow you the flexibility to specify how close your terms appear
to each other and that they be in no particular order. In contrast, AND merely requires
that both words be somewhere in the document, while an exact phrase search (you do
this by enclosing words in quotes, i.e. "venous thromboembolism") requires that the
terms be next to each other in that exact order. Two other proximity operators are
"With" and "Near". Since the proximity searching terms are often used
synonymously, check the help screen of the database you are searching to see which
ones are used and how. ADJ is the one most frequently used.

Here is an example of using the ADJ proximity operator:

likelihood adj3 returns articles where likelihood and ratio are within 3 words of each other in
ratio$.tw. any order. "adj3" means "adjacent within 3 words", and "tw" is text word

Field Searching

You can narrow your search by specifying which field or fields to search. The fields
most often searched are Title and Abstract. Publication Types is also often searched
in MEDLINE. This will help to avoid retrieving articles or reviews where your term is
a co-morbidity or on the exclusion list. Here are two examples of using field
searching:

(sensitivity or returns articles where either sensitivity or specificity appear in the

specificity).ti,ab. title or abstract
practice guideline.pt. returns articles that are labeled as practice guidelines in the
Publication Types field. Used in MEDLINE

Steps in a Good Search

1. List the databases that you plan to search (i.e. Medline, Cochrane Controlled
Trials Register, Cochrane Database of Systematic Reviews, and DARE).
2. Decide whether it is appropriate to limit the search temporally - perhaps it only
makes sense to go back 10 years for a study of the accuracy of computed
tomography for pulmonary embolism, since the technology has evolved
considerably since it was first invented.
3. Decide what kind of study design(s) are acceptable (e.g. only RCTs, or any
clinical trial, or observerational and experimental designs).
4. Write down your research question, i.e. . “How beneficial are insulin sensitizer
medications in patients with diabetes mellitus?”
5. Identify the key concepts in your question. In the example above, those
concepts would be "insulin sensitizer medications" and "diabetes mellitus"
6. Next, think of all the alternate words that could be used for these concepts and
write them down. This includes: synonyms, alternative spellings (British,
American, misspellings), abbreviations, more specific terms (drug name versus
drug class), etc. You will want to note what terms you want to exclude as
well. For example, is this search for Diabetes type II or type I? Insulin
dependent or non-insulin dependent? Your list will now look something like
this:

Insulin sensitizer medications Diabetes mellitus

Diabetes Mellitus Type 2 diabetes
Thiazoles NIDDM
Glitazones Diabetes mellitus Type 1
Gliclazide IDDM
Glipizide
Glyburide
Tolazimide
Tolbutamide
Acetohexamide
Carbutamide
Chlorpropamide
Thiazolidinediones
Rosiglitazone
Pioglitazone
Actos
brl49653
Avandia
metformin
antidiabetic
insulin$

7.
There are several ways to generate your list of search terms – your existing
knowledge of the disease or drug names; looking through the Medical Subject
Headings (MeSH) (http://www.nlm.nih.gov/mesh/meshhome.html); running a
preliminary search and noting the terms used in the titles and abstracts as well
as the subject headings assigned, etc. You will probably use a combination of
methods.
Developing your Search Strategy

There are several approaches to developing a search strategy. The one presented here
focuses first on the specificity and then on the sensitivity of the search strategy.

It‟s important to make your search specific because it will help you avoid unnecessary
work. In order to do so, first determine what criteria are absolutely necessary for you
to accept the article; that is, you wouldn‟t consider any articles that did not meet these
criteria. Then, within those criteria, decide which are either searchable or useful for
limiting your search. You will find that some of your specific requirements, e.g. study
duration more than one month, may be involved at the selection step, but do not
translate well into a search strategy. Other criteria, e.g. randomized controlled trial as
a study methodology, can be very useful in narrowing your search strategy. You may
need to discuss this with a librarian who understands the databases you will be
searching.

You can start with the PICO components of your question and determine which are
searchable and which may be spread out into multiple terms. For example, the
Population component may often become multiple search criteria. If you are only
interested in hypertensive diabetics, then hypertension and diabetes are both necessary
specific criteria for your review, and they become two separate concepts in defining
your search. On the other hand, outcomes may not be searchable with specificity and
may be dropped from the search strategy, but remember them for the selection step
(i.e. selecting articles for your systematic review). Once you have determined all of
the specific concepts that will be useful for limiting your search, you can combine
those terms with AND as each one of these terms is a necessary component for you to
be interested in an article.

To increase the sensitivity of your search and not miss important information, you
want to consider all the possible “synonyms” for your specific concepts or terms.
Consider other names for the term, such as related names, different disease
classifications, British spelling, acronyms and even sometimes misspellings. Also
consider more specific concepts such as specific drug names and more general
concepts such as drug classes. Consider approaching your search both in text-word
form and with MeSH terms. For example, the following terms could all be used to
search for GERD:
gastroesophageal reflux; gastro-oesophageal reflux; GERD; GORD
Once you have decided upon all the terms that you will use to search for a concept,
combine them with OR. For example, you could type a search for GERD as follows:

"gastroesophageal reflux" OR "gastro-oesophageal reflux" OR GERD OR GORD

When you have all of the terms for each concept in your selection criteria, you will
combine them using both AND and OR. For example, a search strategy looking for
randomized controlled trials of hypertensive diabetics developed in this fashion may
look like:

(hypertension OR hypertensive) AND (diabetic OR diabetes) AND (RCT OR

"randomized controlled trial" OR "clinical trial")
You can see that search strategies can get long quickly. To save time, consider using
truncation. Truncation (also called wildcards) is the use of a symbol to stand in for a
word ending. You type the beginning or “trunk” of a word and then place a symbol
(an asterisk * in Medline) at the end of the group of letters to retrieve all possible
variations. For example, truncating on “child*” retrieves any word beginning with
"child", such as child, children, and childhood.

There are a number of ways to go beyond the initial Medline search strategy. Other
databases have been mentioned above, but your ability to use them may be limited by
availability at your institution. Some may only be necessary for certain questions.
Contacting experts in the field is time consuming, but may be the only way to uncover
otherwise unknown information such as unpublished studies. A basic search strategy
for a systematic review is shown below:

1. Search DARE and the Cochrane Database of Systematic Reviews to identify

previous systematic reviews related to your topic, and review their
bibliographies.
2. Search Medline.
3. Search the Cochrane Controlled Trials Register on your topic, as it includes
many articles not in Medline and is widely available.
4. Contact experts in the field for unpublished studies.

Note that use of low quality reviews, as an adjunct to your searching, does not lower
the quality of your review.

Optimal Search Strategies

A growing body of research has developed to help optimize search strategies.

Researchers have tried thousands of different combinations of search terms to identify
those that are best for sensitive or specific searches (Haynes, 1995). They are
summarized below, using the example of the term hypertension:

Type of Sensitive Specific

search
Clinical hypertension AND (predict$ OR clinical$ OR predict$.ti. AND rule$ AND
decision rule outcome$ OR risk$) hypertension
Etiology hypertension AND (exp cohort studies OR exp hypertension AND (case-control
risk OR odds (tw) and ratio: (tw) OR relative studies OR cohort studies)
(tw) and risk (tw) OR case (tw) and control:
(tw)))
Diagnosis hypertension AND (exp sensitivity a#d hypertension AND (exp
specificity OR sensitivity (tw) OR diagnosis& sensitivity a#d specificity OR
(sh) OR diagnostic use (sh) OR specificity (tw)) predictive (tw) and value: (tw))
Treatment hypertension AND (randomized controlled trial hypertension AND ((double (tw)
(pt) OR drug therapy (sh) OR therapeutic use AND blind: (tw)) OR placebo:
(sh) OR random: (tw)) (tw))
Prognosis hypertension AND (incidence OR exp mortality hypertension AND (prognosis
OR follow-up studies OR mortality (sh) OR OR survival analysis)
prognos: (tw) OR predict: (tw) OR course: (tw))

Issues to consider if you are retrieving too many articles in your search to be
workable:

 Do your “terms” match the terms in the database you are searching?
 Can you find a common “weed” that is clearly not of interest? Adding a NOT
criterion to your search strategy is one way of handling this. For example, if
you are interested acute bronchitis, but have lots of results for acute
exacerbation of chronic bronchitis, you could add a "NOT chronic" term.
 Perhaps you have to narrow your clinical question?
 Maybe too many is not too many. How many of the articles can be easily
excluded by a review of the abstracts? A large retrieval of titles does not
require a large retrieval of articles.

What if no articles (or not enough) are retrieved?

 Do your “terms” match the terms used in the database you are searching?
 Can you determine which search criterion leads to severe limitations? Are
these limitations truly appropriate? What is the best possible answer with
knowledge of these limitations?
 Consider text word searching instead of limiting your search to mesh terms.
Use synonyms and truncation.
 Do you want to broaden your clinical question?
 Do you want to search other databases?
  Find a representative article and search for “related articles” in PUBMED or
look at the mesh headings in that article.
 Ask for help!

Finally, here are some tips if you are a clinician just wanting a "quick and dirty"
search for a clinical question:

1. Go to the Clinical Queries site in PubMed

2. If a question about treatment, enter the intervention (i.e. "azithromycin" or
"laparoscopy") and the disease (i.e. "acute bronchitis" or "cholelithiasis")
3. Use quote marks to keep words together that belong together. For example,
searching acute and bronchitis as separate words may return "acute
exacerbation of chronic bronchitis" (probably not what you want) while putting
quotes around it helps focus your search
4. Once you find a great article, click on the "Related articles" link to the right of
the screen.

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