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.