A Specialized Information Center The Clinical Neurology Information Center* BY WALTER J. FRIEDLANDER, M.D. Director and Professor ofNeurology
Clinical Neurology Information Center University of Nebraska Medical Center
Omaha, Nebraska ABSTRACT The history, philosophy, and methodology of a unique specialized medical information center are reported. The Clinical Neurology Information Center is an educational information service (giving its audience information which can be the basis for formulating their own questions) rather than an instructional information service (giving information in reply to questions). Clinical, as well as basic neuroscience, information is culled by professional neurologists from 855 medical periodicals. The essence of each article is summarized in a single sentence ("terse conclusions") or a bibliographic reference only is given; this material is published every two weeks in the Concise Clinical Neurology Review (CCNR). The format of the CCNR is such that the reader should be able to scan a very large amount of current literature by investing only twenty to thirty minutes every two weeks. The values of this system as well as some of its problems are discussed.
IN the mid-1960s the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) made a decision to invest in information services. This was to be the Neurology Information Network (NIN). Several information centers were established and supported by contracts. All the centers were not begun at the same time, but eventually established were the Brain Information Service (BIS) at UCLA, which specialized in basic neuroscience; the Hearing, Speech and Communication Disorders Information Center at Johns Hopkins; and an information center dealing with vision disorders at Harvard. An information center concerned with the clinical aspects of neuroscience was contemplated. This was at a time when there was a great deal of interest in the major clinical breakthrough of levodopa for the treatment of Parkinson's disease. Hence, an information center concerned with this was established at Columbia.
There have been other aspects of the NIN, but these were its major investments. Of these original major investments only the BIS at UCLA continues at the present time. In about 1970 NINCDS decided to implement its original idea of a center dealing with clinical neurology information. A contract was awarded to the University of Nebraska Medical Center in 1972 to establish the Clinical Neurology Information Center, CNIC. Much of our success, but I doubt any of our failings, has resulted from the help offered by our distinguished Advisory Boardt and from the consecutive directors of the University of Nebraska Medical Center's Library of Medicine, Bernice Hetzner, David Bishop, and Robert Braude. There was no formal statement concerning our mission, and what we are doing now is something that has gradually developed over the last seven years. We have not grown entirely in a planless fashion; but on the other hand, our original ideas were rather vague, although not at all lacking in grandiosity. We have evolved our present activity partly through trial and error but also through a philosophy, which has developed over this time, concerning our function in the particular world assigned to us by NIH. This philosophy is based on the assumption that there is such a tremendous amount of new medical information being produced that it is impossible
tAt present the Advisory Board consists of Eben Alexander, Jr., M.D., Bowman Gray School of Medicine of Wake Forest University; Donald R. Bennett, M.D., University of Nebraska College of Medicine; Robert J. Joynt, M.D., University of Rochester School of Medicine and Dentistry; Henry C. Schwartz, M.D., Washington University School of Medicine; William A. Sibley, M.D., University of Arizona Medical Center; Maurice W. VanAllen, M.D., University of Iowa College of Medicine; and Arthur A. Ward, Jr., M.D., University of Washington School of Medicine. Henry *Presented January 12, 1978, at the dedication of the Heyl, M.D., Dartmouth College Schookof Medicine, Creighton University Bio-Information Center, now deceased, was an original member and was particuCreighton University, Omaha, Nebraska. larly important in our initial stages.
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for one individual working in a particular field to cope with any more than a relatively small frac-
tion of it. As a result, there is a marked and growing disparity between new information available and new information utilized. Our mission, then, should be to devise and utilize methods that will increase the exposure of our specific population, clinical neuroscientists, to new information. We have defined clinical neuroscientists as professionals who are directly or indirectly involved in the application of knowledge of the nervous and muscular systems to the care of patients. This includes professionals engaged in research, teaching, or clinical practice. In defining our population we have included the term "indirectly involved" because we want to incorporate basic science research; even though the application of such research to clinical practice may not immediately be evident, future advances in clinical medicine are in good measure dependent on the knowledge generated by basic research. Hence, the areas of our information center's interest are: neurology (including, of course, pediatric neurology), neurosurgery, neuroradiology, neuroophthalmology, neuro-otology, the neurological aspects of speech pathology, physical medicine and rehabilitation, psychiatry, general medicine, pediatrics, and surgery, as well as the basic sciences of neuroanatomy, neurochemistry, neuropathology, neuropharmacology, neurophysiology, and neuropsychology. It has appeared to us that, as an information service, we could function in one of two ways. We could be either primarily an educational information center or primarily an instructional information center. The definitions of these two types of centers are to be found in the etymologies of the words. Education is from the Latin e or ex meaning "out" and ducere meaning "to lead"; to educate is to lead or to draw out. Instruction is from the Latin in and struere which together mean "to pile"; instruction means to pile in. Hence, an educational center gives information that can lead a person or draw things out; that is, it can give a person information from which he can formulate questions. On the other hand, an instructional center gives or piles in information in reply to questions. Of course, these two types of information centers are not mutually exclusive, but there is a basic difference in where the emphasis is placed. It is inappropriate to make value judgments about these two types of information sources. Both are essential for science. There needs to be 310
knowledge in order to ask the right questions, but it is futile to ask questions unless there is some hope of getting answers. CNIC has chosen to be primarily an educational information center. One of the important reasons we selected this function was that, if we were primarily an instructional center, we would be largely duplicating the functions of NLM and, to a certain extent, of BIS. Hence, our mission as we see it now is to be primarily an educational information center for clinical neuroscientists. We are attempting to fulfill this mission by reviewing a very large amount of literature and then organizing and presenting this in such a fashion that it can be quickly and efficiently scanned by our population, in order that they may continue their education concerning pertinent new information. Toward this end, we are devoting most of our time and energy to publishing the Concise Clinical Neurology Review (CCNR). Feeling that there is probably a rate of delivery of information that achieves an optimum level of acquisition-neither too small amounts given too frequently nor too large amounts given at too great an interval-we have elected to deliver the sum of our reviews of over 855 medical periodicals* every two weeks. The format that has been developed should permit our readers, by investing twenty to thirty minutes every two weeks, to become acquainted with the large amount of information harvested from all these journals. Last year, each biweekly issue contained an average of 463 references; the average number of pages containing these references in each issue was 23, and the average number of total pages in each issue (which would include the index, addresses for reprints, and so on) was 41. In 1977 there was a total of 11,110 references. Forty-three hundred of these (38% of the total references) were "terse conclusion," a term devised, I believe, by Charles Bernier; the remaining 62% were articles in which we gave a bibliographic reference only. A terse conclusion, at least as we use the term, is a single sentence which gives the essence of the article. In order to keep within the bounds of a single sentence, it is necessary, at times, to use rather lengthy sentences with such devices as semicolons and parentheses. These abstracts give little emphasis to methodology but, on the other hand, usually give some *Of these periodicals, 40 may be classified as clinical neurology, 440 as clinical nonneurology, 18 as basic neurology, and 357 as basic nonneurology titles. Bull. Med. Libr. Assoc. 66(3)July 1978
THE CLINICAL NEUROLOGY INFORMATION CENTER
basis for the conclusions of the articles. For example, an abstract would avoid going into the details of the methods used to select a group of epileptics treated with Valporate, but it would not be so limited as to merely state, "Valporate is useful in epilepsy." Rather, it would say, "15/20 (75%) petit mal epileptics were markedly improved and 3/20 (15%) were made worse by Valporate; the commonest side-effect was drowsiness (65%) and there were no serious sideeffects." Probably the most important, and perhaps unique, feature of CCNR is the terse conclusion; it is the most time consuming on our part. It should be emphasized that, because judgments have to be made as to what is the essence of a paper, a necessary component of our service is that the abstracting be done by experienced, mature professional clinical neuroscientists. Acquiring this sort of professional has not been an easy task. The relatively young clinical neuroscientist may lack some of the necessary experience and maturity. Probably a more important limitation on younger professionals is the anonymity involved in this sort of work, contrary to the need by such a person to establish the personal reputation for publication required to progress in academia. Older professionals may be too set in their ways to feel comfortable with this new type of information system. Also, although some of my colleagues have said that they envy my sitting around all day reading medical journals and being paid for it, the fact is that the effort required has all the characteristics of a "job": long hours, responsibility for meeting goals, considerable monotonous routine only occasionally interspersed with a pleasant-in this case intellectual-experience, and only rare rewards for work well done. Hence, older professionals, particularly those about to or actually retired, will usually not be good candidates for this sort of work. It should also be pointed out that professionals who seek this sort of work because they believe they will learn a lot of clinical neuroscience will be in for a disappointment. The amount and scope of the literature that is worked with prevents much retention; most of what is read goes in one eye and out the other ear. FORMAT OF CCNR
The material is first divided into categories. The three main sections are "Basic science," "Clinical science," and "Miscellaneous." The "Basic science" section is clearly identified by being Bull. Med. Libr. Assoc. 66(3)July 1978
printed on pink sheets, whereas the "Clinical science" section is on white paper. In this way, a reader not interested in basic science can easily skip to the clinical material or vice versa. These three sections are, in turn, divided into subsections which are the same from one issue to another, whether or not there is anything included within these subsections in a particular issue. For example, the "Basic science" section always includes the subsections Neuroanatomy, Neurochemistry, Neuropathology, Neuropharmacology, Neurophysiology, and Neuropsychology. The first four of the thirty-one subsections of the "Clinical science" section are Aging, Basal ganglion disorders, Behavioral disorders, and Cerebrospinal fluid. The third section, "Miscellaneous," is usually quite small; it consists of two subsections: Death and Other. The latter subsection includes things that we believe are pertinent but cannot be placed elsewhere (for example, neurology manpower or education) or an occasional article unrelated to clinical neuroscience, but which seems to be particularly interesting or unusual. These subsections are listed alphabetically. The cover of each issue contains a table of contents which lists the subsections and their paginations within that issue of CCNR. Under each subsection are numerous subsubsections. A subsubsection will be included in a particular issue only if there are references to this topic in that particular issue. For example, under the subsection Epilepsy there may be the subsubsections, again in alphabetical sequence: Adult onset; Biochemistry; Convulsants; Treatment, hydantoins; and Type, psychomotor; or under Tumors there may be: Experimental; Glioma; and Treatment, medical. The titles of the subsubsections are those that are used in the index that appears at the end of each issue and in the cumulative index, which appears at the end of each volume of thirteen issues. The various references are cross-indexed so that, if there is a variety of material in an article or if readers might look for it under several different terms, the reference can be easily located. Some consistency of the terms used in the subsubsections is of value, so that the reader will become accustomed to looking for particular information in particular areas; this consistency is also, of course, a necessity for indexing. We have developed our own thesaurus of 1,879 terms. This is a dynamic list to which we add new terms or modified terms as new knowledge is developed. Because we have a very small number of professionals reading the literature and indexing
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what they read, and because the index is not designed for long-term retrospective retrieval (which necessitates a long-term consistency), we are not tied down to a rigid system which moves almost imperceptibly, such as MeSH. Under each subsubsection, the terse conclusions appear first. These are presented one sentence after another, with all the abstracted material under a single subsubsection making up one paragraph. When several papers can be abstracted in the same sentence, this is done. For example, there may be several references in the same journal or in different journals, to be included in one particular issue of CCNR, on the use of drug X against meningococcic meningitis that can be summarized in a single sentence; the information to be gained from one paper that states that drug X worked in 8/12 patients and from another that states that it worked in 10/15 patients is that drug X worked in 18/27 patients. We feel it is particularly useful that the only distraction between sentences is the number of the complete reference, each of which is listed at the back of each issue. The advantage of this method of presentation is that it offers first to the reader what he is primarily interested in-educational information-without the distraction of "noise" from listing the authors, the journal, pagination, and so on. We feel, too, that presenting the educational information in the format described above (rather than in sequential paragraphs for each reference, as is frequently done by other information services-for example, Excerpta Medica, Biological A bstracts, or Chemical Abstracts), allows the reader to scan the material and to cope with it more efficiently. We have avoided what is commonly done by a number of abstracting services that list their abstracts sequentially in paragraphs headed by titles, authors, and so forth printed in more-prominent print than the abstract, thus diminishing the importance of the abstract. This sort of presentation seems more applicable to an instructional information source than to an educational information source. Immediately below each paragraph those papers that properly belong under a particular subsection, but where the reference only is given, are listed sequentially. Each of these references is marked by a code to indicate what type of paper it is: CR for a case report, DA for a paper that is a descriptive analysis beyond just a case report, R for a review, and M for a paper that describes only a method or instrument. How do we decide to abstract some papers and 312
to give only the references for others? Essentially, all articles are abstracted except if: 1. The article does not offer itself to the simple summarization of a terse conclusion; this applies particularly to review papers. 2. The title of the article is itself an adequate summary; this applies particularly to case reports. 3. The content of the paper seems to be at a considerable distance from clinical use but is included, almost invariably in the "Basic science" section, for the sake of completion. 4. The article is one that is evidently within our scope but contains material beyond the ken of our limited number of reviewers, and a reliable summary is in jeopardy. There are several areas that we have decided to include in our purview that on the surface may seem beyond the range of a specialized neurology information center. For example, under the subsection "Vascular" we will include some articles dealing with hematology, hyperlipidemia, arteriosclerosis, or hypertension, even though these particular articles make no direct reference to neurological disorders. We do this because we recognize that establishing neurology as something unique unto itself is an arbitrary decision made by specialists for their own convenience. Although neurologists would like to believe that all other bodily systems are there only as slaves to maintain nervous functions, the fact is that there are other systems which cannot be neatly dissected away from the nervous system and thus ignored. Platelets aggregate wherever there is blood and form thromboses and emboli which can cause strokes; one of the commonest causes of death from hypertension is a cerebrovascular accident; and the mechanism for arteriosclerosis in the abdominal aorta may well be the same as that which causes arteriosclerosis in the carotid artery. Obviously some selection has to be made as to which nonneurological articles are to be included in our review, or we would have, in addition to a neurology information service, a cardiovascular information center, a hematological information center, or even a general medical information center. Here again, the importance of having experienced, mature neurological professionals doing our work is evident. Another area where a neurological professional is needed is in decision making concerning what material in an ostensibly nonneurological article would be of interest to clinical neuroscientists. An example of this is a paper in the Archives of Bull. Med. Libr. Assoc. 66(3) July 1978
THE CLINICAL NEUROLOGY INFORMATION CENTER
Diseases of Childhood, recently abstracted and entitled "Role of infection in the death of children with acute lymphoblastic leukemia." The title, the summary of the article, and the bulk of the paper made no reference to neurology. However, one of the tables contained pertinent information, and from this the following terse conclusion was composed: There was a neurological cause of death in at least 7/24 (29%) children who died with acute lymphoblastic leukemia; all 7 had an infection (E. coli meningitis-2, Staph. aureus meningitis-1, who also had a cerebral hemorrhage, mucor meningitis-1, mumps encephalitis-1, and measles encephalitis-2).
Some decisions have had to be made about what articles to exclude. A number of these have been formulated into more-or-less standard policies. Some of these are: 1. Most review articles or editorials are excluded unless they have at least six references. The number six was arrived at arbitrarily. 2. No "Letters to the editor" are included unless they are bona fide case reports or reviews as I have defined these. 3. Abstracts of papers presented at meetings are almost always excluded, as are "news items"; if the material is noteworthy it is likely to be published eventually. The value of abstracted abstracts is open to question. 4. Papers concerning psychopharmacology are included only if they deal with CNS action; in other words, a paper concerned with the clinical effect of a drug in 100 schizophrenics would be excluded, whereas a paper dealing with the action of that same drug on the hippocampus would be included. Most of the journals that we review publish their articles in English. Articles in a foreign language are included only if they contain a meaningful summary in English. At present, we are examining a number of German, French, Italian, Spanish, South American, and Japanese journals. We have plans to use some Russian journals in the near future. Each issue of CCNR contains a list of the addresses of the authors in order that reprints may be requested. We hope that this format, with its sections, subsections, and numerous subsubsections and its prose presentation of terse conclusions, allows our readers to quickly and efficiently scan a large amount of material and to be educated in those Bull. Med. Libr. Assoc. 66(3)July 1978
topics that are of special interest and pertinence to him. How do we find the material to include in CCNR? As I noted, we review 855 medical periodicals. Some of these, of course, are weeklies, others monthlies or quarterlies. At present, we are looking at only one annual, the Proceedings of the Australian Association of Neurologists. We do not look at books or separately issued annual reviews. Sixty-nine journals (about 8% of all the journals we examine) are subscribed to by CNIC. These journals were selected primarily because they contain the majority-perhaps 65%-of the references that we use. Every article in these journals is scanned. We make an effort-and this has been largely successful-to include the terse conclusions or references from these journals in the issue of CCNR that will be mailed from our office within four to six weeks from the time we receive the journal in our office. This means that most of each issue of CCNR has current-four-
to-six-week-old-material. The "Life science" section and the "Social and behavioral sciences" section of Current Contents are reviewed. Any title listed that appears in any of the 703 journals (82% of all the journals we scan) subscribed to by the University of Nebraska Medical Center library, other than the ones that CNIC subscribes to, and that seems likely to be of interest is checked. The journals with these articles are pulled, the article is scanned, and those that are appropriate are included in CCNR. We obtain about 20% of our terse conclusions and references from these journals. The remaining eighty-three journals (10% of all the journals we scan) are not subscribed to by CNIC and are not listed in Current Contents. These are journals in the University of Nebraska Medical Center's library that, based on experience, have a fair possibility of containing usable articles. These journals are periodically pulled from the library, their table of contents examined, and pertinent articles scanned. We obtain about 15% of our articles from thesejournals. We are aware that the use of the last two sources of journals places a considerable burden on the Medical Center's library. These are relatively current journals and from the time we pull them until we return them to general library use two to six weeks may pass. The library is informed of each journal that is pulled and if any are needed again by the library, while in use by CNIC, they are immediately returned. However, there is no 313
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doubt that CNIC represents a logistic problem to the library. Without the very close cooperation of a large medical library this, or a similar information service, would be difficult. Because of federal regulations, printing and distributing our publication cannot be done at government expense. Hence, a charge is made to our subscribers, numbering over fourteen hundred, which covers these items. We estimate that CCNR is seen by about forty-two hundred to fifty-six hundred clinical neuroscientists, students, house-officers, and other professionals.
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I believe our information center is successful, although both NINCDS and CCNR have given considerable thought to how we can determine how useful we really are. This is a common problem for information services, and as far as I know no really good measuring devices have been invented. We are continuing largely in the belief that, utilizing the methods I have described, we should be useful.
Received January 27, 1978; accepted March 13, 1978.
Bull. Med. Libr. Assoc. 66(3) July 1978
Clinical Neurology Information Center University of Nebraska Medical Center
Omaha, Nebraska ABSTRACT The history, philosophy, and methodology of a unique specialized medical information center are reported. The Clinical Neurology Information Center is an educational information service (giving its audience information which can be the basis for formulating their own questions) rather than an instructional information service (giving information in reply to questions). Clinical, as well as basic neuroscience, information is culled by professional neurologists from 855 medical periodicals. The essence of each article is summarized in a single sentence ("terse conclusions") or a bibliographic reference only is given; this material is published every two weeks in the Concise Clinical Neurology Review (CCNR). The format of the CCNR is such that the reader should be able to scan a very large amount of current literature by investing only twenty to thirty minutes every two weeks. The values of this system as well as some of its problems are discussed.
IN the mid-1960s the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) made a decision to invest in information services. This was to be the Neurology Information Network (NIN). Several information centers were established and supported by contracts. All the centers were not begun at the same time, but eventually established were the Brain Information Service (BIS) at UCLA, which specialized in basic neuroscience; the Hearing, Speech and Communication Disorders Information Center at Johns Hopkins; and an information center dealing with vision disorders at Harvard. An information center concerned with the clinical aspects of neuroscience was contemplated. This was at a time when there was a great deal of interest in the major clinical breakthrough of levodopa for the treatment of Parkinson's disease. Hence, an information center concerned with this was established at Columbia.
There have been other aspects of the NIN, but these were its major investments. Of these original major investments only the BIS at UCLA continues at the present time. In about 1970 NINCDS decided to implement its original idea of a center dealing with clinical neurology information. A contract was awarded to the University of Nebraska Medical Center in 1972 to establish the Clinical Neurology Information Center, CNIC. Much of our success, but I doubt any of our failings, has resulted from the help offered by our distinguished Advisory Boardt and from the consecutive directors of the University of Nebraska Medical Center's Library of Medicine, Bernice Hetzner, David Bishop, and Robert Braude. There was no formal statement concerning our mission, and what we are doing now is something that has gradually developed over the last seven years. We have not grown entirely in a planless fashion; but on the other hand, our original ideas were rather vague, although not at all lacking in grandiosity. We have evolved our present activity partly through trial and error but also through a philosophy, which has developed over this time, concerning our function in the particular world assigned to us by NIH. This philosophy is based on the assumption that there is such a tremendous amount of new medical information being produced that it is impossible
tAt present the Advisory Board consists of Eben Alexander, Jr., M.D., Bowman Gray School of Medicine of Wake Forest University; Donald R. Bennett, M.D., University of Nebraska College of Medicine; Robert J. Joynt, M.D., University of Rochester School of Medicine and Dentistry; Henry C. Schwartz, M.D., Washington University School of Medicine; William A. Sibley, M.D., University of Arizona Medical Center; Maurice W. VanAllen, M.D., University of Iowa College of Medicine; and Arthur A. Ward, Jr., M.D., University of Washington School of Medicine. Henry *Presented January 12, 1978, at the dedication of the Heyl, M.D., Dartmouth College Schookof Medicine, Creighton University Bio-Information Center, now deceased, was an original member and was particuCreighton University, Omaha, Nebraska. larly important in our initial stages.
Bull. Med. Libr. Assoc. 66(3)July 1978
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for one individual working in a particular field to cope with any more than a relatively small frac-
tion of it. As a result, there is a marked and growing disparity between new information available and new information utilized. Our mission, then, should be to devise and utilize methods that will increase the exposure of our specific population, clinical neuroscientists, to new information. We have defined clinical neuroscientists as professionals who are directly or indirectly involved in the application of knowledge of the nervous and muscular systems to the care of patients. This includes professionals engaged in research, teaching, or clinical practice. In defining our population we have included the term "indirectly involved" because we want to incorporate basic science research; even though the application of such research to clinical practice may not immediately be evident, future advances in clinical medicine are in good measure dependent on the knowledge generated by basic research. Hence, the areas of our information center's interest are: neurology (including, of course, pediatric neurology), neurosurgery, neuroradiology, neuroophthalmology, neuro-otology, the neurological aspects of speech pathology, physical medicine and rehabilitation, psychiatry, general medicine, pediatrics, and surgery, as well as the basic sciences of neuroanatomy, neurochemistry, neuropathology, neuropharmacology, neurophysiology, and neuropsychology. It has appeared to us that, as an information service, we could function in one of two ways. We could be either primarily an educational information center or primarily an instructional information center. The definitions of these two types of centers are to be found in the etymologies of the words. Education is from the Latin e or ex meaning "out" and ducere meaning "to lead"; to educate is to lead or to draw out. Instruction is from the Latin in and struere which together mean "to pile"; instruction means to pile in. Hence, an educational center gives information that can lead a person or draw things out; that is, it can give a person information from which he can formulate questions. On the other hand, an instructional center gives or piles in information in reply to questions. Of course, these two types of information centers are not mutually exclusive, but there is a basic difference in where the emphasis is placed. It is inappropriate to make value judgments about these two types of information sources. Both are essential for science. There needs to be 310
knowledge in order to ask the right questions, but it is futile to ask questions unless there is some hope of getting answers. CNIC has chosen to be primarily an educational information center. One of the important reasons we selected this function was that, if we were primarily an instructional center, we would be largely duplicating the functions of NLM and, to a certain extent, of BIS. Hence, our mission as we see it now is to be primarily an educational information center for clinical neuroscientists. We are attempting to fulfill this mission by reviewing a very large amount of literature and then organizing and presenting this in such a fashion that it can be quickly and efficiently scanned by our population, in order that they may continue their education concerning pertinent new information. Toward this end, we are devoting most of our time and energy to publishing the Concise Clinical Neurology Review (CCNR). Feeling that there is probably a rate of delivery of information that achieves an optimum level of acquisition-neither too small amounts given too frequently nor too large amounts given at too great an interval-we have elected to deliver the sum of our reviews of over 855 medical periodicals* every two weeks. The format that has been developed should permit our readers, by investing twenty to thirty minutes every two weeks, to become acquainted with the large amount of information harvested from all these journals. Last year, each biweekly issue contained an average of 463 references; the average number of pages containing these references in each issue was 23, and the average number of total pages in each issue (which would include the index, addresses for reprints, and so on) was 41. In 1977 there was a total of 11,110 references. Forty-three hundred of these (38% of the total references) were "terse conclusion," a term devised, I believe, by Charles Bernier; the remaining 62% were articles in which we gave a bibliographic reference only. A terse conclusion, at least as we use the term, is a single sentence which gives the essence of the article. In order to keep within the bounds of a single sentence, it is necessary, at times, to use rather lengthy sentences with such devices as semicolons and parentheses. These abstracts give little emphasis to methodology but, on the other hand, usually give some *Of these periodicals, 40 may be classified as clinical neurology, 440 as clinical nonneurology, 18 as basic neurology, and 357 as basic nonneurology titles. Bull. Med. Libr. Assoc. 66(3)July 1978
THE CLINICAL NEUROLOGY INFORMATION CENTER
basis for the conclusions of the articles. For example, an abstract would avoid going into the details of the methods used to select a group of epileptics treated with Valporate, but it would not be so limited as to merely state, "Valporate is useful in epilepsy." Rather, it would say, "15/20 (75%) petit mal epileptics were markedly improved and 3/20 (15%) were made worse by Valporate; the commonest side-effect was drowsiness (65%) and there were no serious sideeffects." Probably the most important, and perhaps unique, feature of CCNR is the terse conclusion; it is the most time consuming on our part. It should be emphasized that, because judgments have to be made as to what is the essence of a paper, a necessary component of our service is that the abstracting be done by experienced, mature professional clinical neuroscientists. Acquiring this sort of professional has not been an easy task. The relatively young clinical neuroscientist may lack some of the necessary experience and maturity. Probably a more important limitation on younger professionals is the anonymity involved in this sort of work, contrary to the need by such a person to establish the personal reputation for publication required to progress in academia. Older professionals may be too set in their ways to feel comfortable with this new type of information system. Also, although some of my colleagues have said that they envy my sitting around all day reading medical journals and being paid for it, the fact is that the effort required has all the characteristics of a "job": long hours, responsibility for meeting goals, considerable monotonous routine only occasionally interspersed with a pleasant-in this case intellectual-experience, and only rare rewards for work well done. Hence, older professionals, particularly those about to or actually retired, will usually not be good candidates for this sort of work. It should also be pointed out that professionals who seek this sort of work because they believe they will learn a lot of clinical neuroscience will be in for a disappointment. The amount and scope of the literature that is worked with prevents much retention; most of what is read goes in one eye and out the other ear. FORMAT OF CCNR
The material is first divided into categories. The three main sections are "Basic science," "Clinical science," and "Miscellaneous." The "Basic science" section is clearly identified by being Bull. Med. Libr. Assoc. 66(3)July 1978
printed on pink sheets, whereas the "Clinical science" section is on white paper. In this way, a reader not interested in basic science can easily skip to the clinical material or vice versa. These three sections are, in turn, divided into subsections which are the same from one issue to another, whether or not there is anything included within these subsections in a particular issue. For example, the "Basic science" section always includes the subsections Neuroanatomy, Neurochemistry, Neuropathology, Neuropharmacology, Neurophysiology, and Neuropsychology. The first four of the thirty-one subsections of the "Clinical science" section are Aging, Basal ganglion disorders, Behavioral disorders, and Cerebrospinal fluid. The third section, "Miscellaneous," is usually quite small; it consists of two subsections: Death and Other. The latter subsection includes things that we believe are pertinent but cannot be placed elsewhere (for example, neurology manpower or education) or an occasional article unrelated to clinical neuroscience, but which seems to be particularly interesting or unusual. These subsections are listed alphabetically. The cover of each issue contains a table of contents which lists the subsections and their paginations within that issue of CCNR. Under each subsection are numerous subsubsections. A subsubsection will be included in a particular issue only if there are references to this topic in that particular issue. For example, under the subsection Epilepsy there may be the subsubsections, again in alphabetical sequence: Adult onset; Biochemistry; Convulsants; Treatment, hydantoins; and Type, psychomotor; or under Tumors there may be: Experimental; Glioma; and Treatment, medical. The titles of the subsubsections are those that are used in the index that appears at the end of each issue and in the cumulative index, which appears at the end of each volume of thirteen issues. The various references are cross-indexed so that, if there is a variety of material in an article or if readers might look for it under several different terms, the reference can be easily located. Some consistency of the terms used in the subsubsections is of value, so that the reader will become accustomed to looking for particular information in particular areas; this consistency is also, of course, a necessity for indexing. We have developed our own thesaurus of 1,879 terms. This is a dynamic list to which we add new terms or modified terms as new knowledge is developed. Because we have a very small number of professionals reading the literature and indexing
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what they read, and because the index is not designed for long-term retrospective retrieval (which necessitates a long-term consistency), we are not tied down to a rigid system which moves almost imperceptibly, such as MeSH. Under each subsubsection, the terse conclusions appear first. These are presented one sentence after another, with all the abstracted material under a single subsubsection making up one paragraph. When several papers can be abstracted in the same sentence, this is done. For example, there may be several references in the same journal or in different journals, to be included in one particular issue of CCNR, on the use of drug X against meningococcic meningitis that can be summarized in a single sentence; the information to be gained from one paper that states that drug X worked in 8/12 patients and from another that states that it worked in 10/15 patients is that drug X worked in 18/27 patients. We feel it is particularly useful that the only distraction between sentences is the number of the complete reference, each of which is listed at the back of each issue. The advantage of this method of presentation is that it offers first to the reader what he is primarily interested in-educational information-without the distraction of "noise" from listing the authors, the journal, pagination, and so on. We feel, too, that presenting the educational information in the format described above (rather than in sequential paragraphs for each reference, as is frequently done by other information services-for example, Excerpta Medica, Biological A bstracts, or Chemical Abstracts), allows the reader to scan the material and to cope with it more efficiently. We have avoided what is commonly done by a number of abstracting services that list their abstracts sequentially in paragraphs headed by titles, authors, and so forth printed in more-prominent print than the abstract, thus diminishing the importance of the abstract. This sort of presentation seems more applicable to an instructional information source than to an educational information source. Immediately below each paragraph those papers that properly belong under a particular subsection, but where the reference only is given, are listed sequentially. Each of these references is marked by a code to indicate what type of paper it is: CR for a case report, DA for a paper that is a descriptive analysis beyond just a case report, R for a review, and M for a paper that describes only a method or instrument. How do we decide to abstract some papers and 312
to give only the references for others? Essentially, all articles are abstracted except if: 1. The article does not offer itself to the simple summarization of a terse conclusion; this applies particularly to review papers. 2. The title of the article is itself an adequate summary; this applies particularly to case reports. 3. The content of the paper seems to be at a considerable distance from clinical use but is included, almost invariably in the "Basic science" section, for the sake of completion. 4. The article is one that is evidently within our scope but contains material beyond the ken of our limited number of reviewers, and a reliable summary is in jeopardy. There are several areas that we have decided to include in our purview that on the surface may seem beyond the range of a specialized neurology information center. For example, under the subsection "Vascular" we will include some articles dealing with hematology, hyperlipidemia, arteriosclerosis, or hypertension, even though these particular articles make no direct reference to neurological disorders. We do this because we recognize that establishing neurology as something unique unto itself is an arbitrary decision made by specialists for their own convenience. Although neurologists would like to believe that all other bodily systems are there only as slaves to maintain nervous functions, the fact is that there are other systems which cannot be neatly dissected away from the nervous system and thus ignored. Platelets aggregate wherever there is blood and form thromboses and emboli which can cause strokes; one of the commonest causes of death from hypertension is a cerebrovascular accident; and the mechanism for arteriosclerosis in the abdominal aorta may well be the same as that which causes arteriosclerosis in the carotid artery. Obviously some selection has to be made as to which nonneurological articles are to be included in our review, or we would have, in addition to a neurology information service, a cardiovascular information center, a hematological information center, or even a general medical information center. Here again, the importance of having experienced, mature neurological professionals doing our work is evident. Another area where a neurological professional is needed is in decision making concerning what material in an ostensibly nonneurological article would be of interest to clinical neuroscientists. An example of this is a paper in the Archives of Bull. Med. Libr. Assoc. 66(3) July 1978
THE CLINICAL NEUROLOGY INFORMATION CENTER
Diseases of Childhood, recently abstracted and entitled "Role of infection in the death of children with acute lymphoblastic leukemia." The title, the summary of the article, and the bulk of the paper made no reference to neurology. However, one of the tables contained pertinent information, and from this the following terse conclusion was composed: There was a neurological cause of death in at least 7/24 (29%) children who died with acute lymphoblastic leukemia; all 7 had an infection (E. coli meningitis-2, Staph. aureus meningitis-1, who also had a cerebral hemorrhage, mucor meningitis-1, mumps encephalitis-1, and measles encephalitis-2).
Some decisions have had to be made about what articles to exclude. A number of these have been formulated into more-or-less standard policies. Some of these are: 1. Most review articles or editorials are excluded unless they have at least six references. The number six was arrived at arbitrarily. 2. No "Letters to the editor" are included unless they are bona fide case reports or reviews as I have defined these. 3. Abstracts of papers presented at meetings are almost always excluded, as are "news items"; if the material is noteworthy it is likely to be published eventually. The value of abstracted abstracts is open to question. 4. Papers concerning psychopharmacology are included only if they deal with CNS action; in other words, a paper concerned with the clinical effect of a drug in 100 schizophrenics would be excluded, whereas a paper dealing with the action of that same drug on the hippocampus would be included. Most of the journals that we review publish their articles in English. Articles in a foreign language are included only if they contain a meaningful summary in English. At present, we are examining a number of German, French, Italian, Spanish, South American, and Japanese journals. We have plans to use some Russian journals in the near future. Each issue of CCNR contains a list of the addresses of the authors in order that reprints may be requested. We hope that this format, with its sections, subsections, and numerous subsubsections and its prose presentation of terse conclusions, allows our readers to quickly and efficiently scan a large amount of material and to be educated in those Bull. Med. Libr. Assoc. 66(3)July 1978
topics that are of special interest and pertinence to him. How do we find the material to include in CCNR? As I noted, we review 855 medical periodicals. Some of these, of course, are weeklies, others monthlies or quarterlies. At present, we are looking at only one annual, the Proceedings of the Australian Association of Neurologists. We do not look at books or separately issued annual reviews. Sixty-nine journals (about 8% of all the journals we examine) are subscribed to by CNIC. These journals were selected primarily because they contain the majority-perhaps 65%-of the references that we use. Every article in these journals is scanned. We make an effort-and this has been largely successful-to include the terse conclusions or references from these journals in the issue of CCNR that will be mailed from our office within four to six weeks from the time we receive the journal in our office. This means that most of each issue of CCNR has current-four-
to-six-week-old-material. The "Life science" section and the "Social and behavioral sciences" section of Current Contents are reviewed. Any title listed that appears in any of the 703 journals (82% of all the journals we scan) subscribed to by the University of Nebraska Medical Center library, other than the ones that CNIC subscribes to, and that seems likely to be of interest is checked. The journals with these articles are pulled, the article is scanned, and those that are appropriate are included in CCNR. We obtain about 20% of our terse conclusions and references from these journals. The remaining eighty-three journals (10% of all the journals we scan) are not subscribed to by CNIC and are not listed in Current Contents. These are journals in the University of Nebraska Medical Center's library that, based on experience, have a fair possibility of containing usable articles. These journals are periodically pulled from the library, their table of contents examined, and pertinent articles scanned. We obtain about 15% of our articles from thesejournals. We are aware that the use of the last two sources of journals places a considerable burden on the Medical Center's library. These are relatively current journals and from the time we pull them until we return them to general library use two to six weeks may pass. The library is informed of each journal that is pulled and if any are needed again by the library, while in use by CNIC, they are immediately returned. However, there is no 313
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doubt that CNIC represents a logistic problem to the library. Without the very close cooperation of a large medical library this, or a similar information service, would be difficult. Because of federal regulations, printing and distributing our publication cannot be done at government expense. Hence, a charge is made to our subscribers, numbering over fourteen hundred, which covers these items. We estimate that CCNR is seen by about forty-two hundred to fifty-six hundred clinical neuroscientists, students, house-officers, and other professionals.
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I believe our information center is successful, although both NINCDS and CCNR have given considerable thought to how we can determine how useful we really are. This is a common problem for information services, and as far as I know no really good measuring devices have been invented. We are continuing largely in the belief that, utilizing the methods I have described, we should be useful.
Received January 27, 1978; accepted March 13, 1978.
Bull. Med. Libr. Assoc. 66(3) July 1978
