Trip Database Blog

In the previous post (Turning Research Into Practice – Except When the Research Isn’t There), we showed that nearly half of real clinical questions asked through AskTrip sit in areas with only moderate or limited evidence. These are not marginal issues – they are everyday decisions affecting millions of patients.

If we take those questions seriously, the obvious next step is to ask:

What should we actually research next?

Rather than starting from theory, funding trends, or academic fashion, we start from real clinical uncertainty. In other words, from the questions clinicians are already asking, repeatedly, because existing evidence does not give them confident answers.

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How we selected the research priorities

For this exercise, we prioritised questions using two simple criteria:

• Impact – disease burden, severity, mortality, long-term disability, and healthcare cost.
• Scope – the number of people affected, and whether answers would apply broadly.

We assume, following standard health policy principles, that:

• High-impact conditions (major disability, mortality, or healthcare cost) merit priority.
• Interventions that could improve outcomes for large numbers of people have added value.
• Questions that fill persistent, well-recognised evidence gaps are especially important.

Using those assumptions, a small number of clear research priorities emerge directly from the AskTrip data.

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A caveat is important: we have not independently verified the full evidence base for each question. Some may already have better answers than are reflected here. This represents an initial, data-driven approach to research prioritisation based on clinical uncertainty, which we intend to refine through ongoing evidence review.

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1. Diabetes in Critical Illness (GLP-1 agonists in ICU)

Research question:
In critically ill adult patients, do GLP-1 receptor agonists improve glycaemic control and clinical outcomes compared with standard insulin-based management?

Why this matters:
If new evidence shows GLP-1 drugs improve ICU glycaemic control or outcomes, this could significantly benefit many hospitalised diabetics (high incidence, high severity). ICU patients with uncontrolled diabetes face organ damage risks, so a positive finding would be high impact per patient.

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2. COPD and Pneumonia Prevention

Research question:
In patients with COPD, does pulmonary rehabilitation reduce the incidence of recurrent pneumonia compared with usual care?

Why this matters:
COPD is a prevalent chronic disease. Demonstrating that pulmonary rehabilitation (or other intervention) lowers pneumonia risk could reduce hospitalisations and mortality in a large population. Even a moderate reduction in pneumonia incidence would scale to many lives saved, given COPD’s prevalence. This combines moderate per-person effect with large population benefit.

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3. Pain Management (Opioid Side-Effects)

Research question:
Among patients requiring opioid analgesia, which opioid is associated with the lowest incidence of clinically significant constipation and treatment discontinuation?

Why this matters:
Opioids are widely used across many conditions. Identifying the least constipating (or safest) opioid could improve quality of life for countless patients. We assume this is important as opioid-induced constipation is a common, burdensome side effect.

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4. Autonomic Disorders (Gabapentin for POTS)

Research question:
In patients with postural orthostatic tachycardia syndrome (POTS), does gabapentin improve symptoms and functional outcomes compared with placebo or standard management?

Why this matters:
POTS is relatively rare but can be severely disabling. Proving efficacy (or not) of gabapentin would directly change care for those patients (high individual impact), even if the population is smaller.

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5. Fall Prevention (Decaffeinated Drinks and Other Interventions)

Research question:
In older adults, do simple behavioural or environmental interventions (such as caffeine reduction) reduce the incidence of falls compared with usual care?

Why this matters:
Falls in older adults cause major morbidity. If simple interventions can reduce falls, small individual benefits could prevent serious injuries at the population level. This merits research given the high burden of falls, even if any single intervention has a modest effect.

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6. Neonatal and Paediatric Best Practice

Research questions:
In preterm infants, what is the optimal timing for feeding tube placement to maximise growth and minimise complications?
In infants, does early introduction of allergenic foods reduce the long-term risk of food allergy compared with delayed introduction?

Why this matters:
These address early-life interventions with potentially lifelong consequences. Even small nutritional or developmental improvements can drastically affect a child’s trajectory, making these high impact for individuals despite smaller population sizes.

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7. Mental Health Interventions

Research questions:
In veterans with PTSD, which psychological therapies produce sustained functional improvement?
In autistic individuals, which interventions improve long-term quality of life and independence?

Why this matters:
Mental health conditions account for large disability burdens. Better evidence here could be transformative for patients and families.

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8. Vaccination and Screening Strategies

Research questions:
Which asymptomatic populations benefit from routine screening, and at what intervals?
What vaccination schedules maximise population-level benefit while minimising harm and resource use?

Why this matters:
These questions shape national guidelines and affect very large populations. Even minor changes in evidence can influence millions of clinical decisions.

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Systems like AskTrip do not just answer questions – they reveal where the research system itself is failing.

In the end, the most important research questions are not the ones that sound exciting, but the ones clinicians keep asking because no one has ever given them a reliable answer.

This is a follow-up post to What 10,000 Clinical Questions Tell Us About Evidence, Practice, and Uncertainty. Evidence-based medicine promises that clinical decisions should be grounded in high-quality research. Over the past three decades, enormous effort has gone into building guidelines, systematic reviews, and trial infrastructures to make this possible.

But what does the landscape of evidence actually look like when you step away from theory and look at the questions clinicians really ask?

We recently analysed 10,000 real clinical questions submitted to AskTrip and filtered those rated as having only moderate or limited evidence. These are not obscure or academic questions – they are everyday problems arising in routine practice.

Nearly half of all questions fell into this category.

What emerged was not random noise, but a remarkably coherent map of where medical evidence runs thin.

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Not ignorance – but structural uncertainty

These questions are not poorly formed. They are not “bad questions”. They are often precisely the right questions to ask.

The problem is that they sit in parts of medicine where strong evidence is structurally hard to generate.

This is not a failure of individual clinicians. It is a feature of how medical knowledge is produced.

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The main themes of weak evidence

1. Chronic disease management

One of the largest clusters involves long-term conditions:

• Diabetes
• Heart disease
• COPD
• Chronic kidney disease
• Arthritis

Typical questions are not about whether treatments work in principle, but about how best to use them in real people:

• What is the optimal combination?
• When should treatment be escalated or de-escalated?
• How do we manage multiple conditions at once?

These are exactly the questions that RCTs are worst at answering. Trials usually study single diseases in isolation. Real patients rarely oblige.

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2. Infection, prevention, and everyday risk

Another strong theme is prevention:

• Recurrent infections
• Aspiration risk
• Falls
• Pressure ulcers
• Catheter care

These questions often involve modest interventions with potentially large population effects.

For example:

• Does pulmonary rehabilitation reduce pneumonia recurrence?
• Do certain dietary changes prevent aspiration?
• Can simple environmental interventions reduce falls?

These are difficult to study, context-dependent, and rarely funded at scale – yet they shape huge amounts of morbidity.

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3. Mental health and neurology

Mental health and neurological conditions form a disproportionate share of weak-evidence questions:

• ADHD
• PTSD
• Functional neurological disorders
• Chronic fatigue
• Autism spectrum conditions

These areas are methodologically hard:

• Outcomes are subjective
• Diagnoses are heterogeneous
• Interventions are complex and multi-component

The result is that clinicians repeatedly ask questions where guidance exists, but confidence does not.

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4. Vulnerable populations

Another dominant pattern is questions about people who are routinely excluded from trials:

• Children
• Older adults
• Pregnant patients
• People with multiple comorbidities

These questions matter because they involve:

• High uncertainty
• High ethical stakes
• High potential for harm

They are also exactly the patients for whom evidence is most limited.

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5. Systems, not diseases

Some of the most revealing questions are not about diseases at all, but about systems:

• When should we screen?
• When should we stop investigating?
• How should follow-up be structured?
• What is worth doing routinely?

These questions expose a deeper problem: much of modern medicine is built on historical practice, professional culture, and institutional inertia rather than direct evidence of benefit.

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Duplication: the sound of collective uncertainty

We also found many near-identical questions asked by different clinicians.

Not because the questions were trivial – but because the same uncertainties arise independently across contexts.

This is important.

Duplication is not redundancy. It is a signal.

It is the clinical equivalent of multiple sensors all detecting the same fault line.

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A new way to think about research priorities

If you take this dataset seriously, it suggests a very different research agenda.

Not driven by:

• The latest technology
• The most fundable molecular target
• The easiest trial design

But by:

• Where clinicians repeatedly lack confidence
• Where decisions carry high risk
• Where patients experience the greatest burden

In other words: research priorities defined by real uncertainty, not academic fashion.

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The uncomfortable implication

The most uncomfortable finding is this:

Evidence-based medicine works best in exactly the situations where it is least needed.

It works worst in:

• Complex patients
• Long-term care
• Multimorbidity
• Quality-of-life decisions
• System-level design

These are the situations that dominate real clinical work.

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AskTrip as an uncertainty engine

Systems like AskTrip do something unexpected.

They don’t just answer questions.

They reveal:

• Where the evidence is strong
• Where it is thin
• And where it is largely absent

At scale, this becomes something new:

a live, evolving map of medical uncertainty.

Not a failure of medicine – but a diagnostic tool for the research system itself.

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The real opportunity

If medicine is serious about “turning research into practice”, it also has to confront the inverse problem:

turning practice into research.

The 10,000 questions are not just a product.

They are a dataset that quietly answers one of the hardest questions in healthcare:

What don’t we actually know – and who is paying the price for that ignorance?

And the answer, increasingly, is:

almost everyone.

Just over six months after launch, AskTrip answered its 10,000th clinical question. Beyond being a milestone, this created a rare opportunity: to step back and look at what clinicians actually ask when given the freedom to pose questions in natural language – and what kind of evidence is available to answer them.

This post shares some of the most interesting patterns we found when analysing those first 10,000 questions, focusing on three things:

• What types of questions clinicians ask
• How those question types relate to the strength of available evidence
• How questions differ across professional groups

What emerges is a picture of modern clinical uncertainty – and where evidence serves clinicians well, and where it doesn’t.

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1. Most clinical questions are about “what should I do?”

By a long way, the most common questions asked on AskTrip are about treatment and management.

Roughly one third to one half of all questions fall into this category. These include questions about:

• Drug choice and dosing
• First-line and second-line treatments
• Managing patients with specific comorbidities
• Whether an intervention is appropriate in a particular context

Diagnostic questions are much less common, typically under 10% of all questions. Prognosis questions (life expectancy, disease course, outcomes) are rarer still.

This suggests that AskTrip is primarily being used at the point of action, when a clinician is deciding what to do next, rather than earlier in the diagnostic process or later when thinking about long-term outcomes.

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2. Treatment questions tend to have the strongest evidence

One striking finding is how closely question type aligns with evidence strength.

Treatment and management questions are far more likely to be answered using high-quality evidence – such as clinical guidelines, systematic reviews, or large trials. A substantial proportion of these answers receive a High evidence rating.

This makes sense. Many treatments for common conditions are well studied, frequently updated, and synthesised into guidelines. When clinicians ask “What’s the recommended treatment for X?”, there is often a clear evidence trail to follow.

In contrast, questions about:

• Etiology and risk factors
• Rare or unusual clinical scenarios
• Health system issues and care delivery
• Complex patients with multiple conditions

are much more likely to be answered with moderate or limited evidence.

These are the areas where research is sparse, indirect, or ethically difficult to conduct – and AskTrip’s answers reflect that reality.

Importantly, this isn’t a weakness of the system. It’s a reflection of the evidence landscape clinicians work within every day.

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3. “Thin evidence” clusters in predictable places

When we looked more closely at questions rated as having limited evidence, clear patterns emerged.

Thin evidence tends to cluster around:

• Complex decision-making, such as balancing risks after serious adverse events
• Patients with multiple comorbidities, often excluded from trials
• Rare conditions, where large studies don’t exist
• Care delivery and system questions, which sit outside traditional disease-focused research

These are the situations clinicians typically struggle with most, not because they are uncommon, but because they don’t fit neatly into trial designs.

In other words, the hardest clinical questions are often the ones least well served by research, even though they matter deeply to patients and clinicians alike.

Seeing these gaps at scale helps move the conversation away from “why don’t we have an answer?” toward “why is this so hard to study – and what should we do about it?”

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4. Different professionals ask different kinds of questions

AskTrip is used by a wide range of healthcare professionals, and their question patterns differ in telling ways.

Doctors ask the majority of questions, and their focus is overwhelmingly on treatment decisions. Diagnostic questions appear, but less often. Prognosis questions are rare.

Pharmacists ask fewer questions overall, but theirs are the most tightly focused. The vast majority are about medications – dosing, interactions, safety, and comparative effectiveness. Diagnostic and prognostic questions are almost absent.

Nurses ask fewer “classic” clinical questions and more queries that sit outside neat categories —- for example:

• Practical aspects of care
• Clinical measurements and interpretation
• Protocols, safeguarding, and service delivery

As a result, a higher proportion of nursing questions fall into “other” categories and are more likely to involve moderate or limited evidence.

Information specialists and librarians ask a distinct set of questions on AskTrip. Their queries often focus less on a single clinical decision and more on understanding the shape and strength of the evidence – for example, whether high-quality studies or guidelines exist on a topic, or where evidence is thin or conflicting. In this sense, AskTrip appears to function as a rapid evidence-triage tool, helping information specialists quickly gauge what is known before undertaking deeper searches, synthesis work, or supporting clinicians’ decision-making.

This isn’t accidental. It reflects professional roles and responsibilities. Each group uses AskTrip to fill different kinds of gaps – and that diversity of use is one of the platform’s strengths.

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5. What this tells us about evidence-based medicine

Looking across 10,000 questions, a few broader lessons stand out.

First, evidence-based medicine is working well where research, guidelines, and synthesis are mature – particularly for treatment decisions in common conditions.

Second, uncertainty hasn’t gone away. It has simply moved into more complex, contextual, and system-level spaces where traditional research struggles.

Third, clinicians are not just asking “What does the evidence say?” – they are asking:

• “Does evidence exist for this situation?”
• “How confident should I be?”
• “What do we do when evidence is thin?”

Finally, surfacing where evidence is limited is not a failure. It’s a necessary step toward more honest decision-making – and toward identifying priorities for future research.

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Closing thought

AskTrip was built to lower the barriers to high-quality evidence. But these 10,000 questions show something equally important: they map the boundaries of our knowledge.

They show us where evidence is strong, where it’s weak, and where clinicians are navigating uncertainty every day.

That, in itself, is evidence worth paying attention to.

A user asked if we could bring Trip’s evidence lozenges into AskTrip references, so evidence levels are easier to spot at a glance. You asked, we delivered.

Just over six months ago, we quietly launched AskTrip with a simple aim: to help clinicians get clearer, evidence-based answers to real clinical questions. Yesterday, AskTrip answered its 10,000th question – a milestone that genuinely makes us pause. The 10,000th Q&A was What are the legal obligations of healthcare institutions when allegations of abuse arise concerning safeguarding vulnerable individuals? Not a typical clinical question but it still a small moment that represents thousands of clinical uncertainties explored, clarified, and shared.

For me personally, this marks a much longer journey. Trip originally began with ATTRACT, a manual Q&A service started in Gwent, Wales in 1997 alongside Chris (my business partner at Trip), with the simple aim of helping clinicians get evidence-based answers to real clinical questions. AskTrip feels like a natural continuation of that mission: lowering the barriers to high-quality evidence and making it easier to disseminate trustworthy answers at scale.

We’re already looking ahead. The next 2–3 months will bring significant changes and improvements as AskTrip enters its next phase. But before ploughing on, it feels right to pause, reflect, and briefly bask in this milestone. Ten thousand questions answered – and many more to come.

At the end of last year we rolled out a fresh new look to our bookmarks and search history in Trip. We have followed on with this by extending the bookmarking to AskTrip.

You can see the bookmark icons on the results pages for search and also, as shown below, Past Questions. The red arrow indicating the icon:

And, on individual answers:

And, to view them, I go to Bookmarked (via My Account) and you see this:

Simple and powerful.

This year-in-review reflects on what Trip achieved during 2025 and looks ahead to our plans for 2026. A major milestone this year was the launch of AskTrip, which has rapidly become a core part of Trip’s mission to support clinical decision-making. Alongside continued development of the main Trip platform, 2025 was a year of meaningful progress in how clinicians and information specialists access, explore, and use trustworthy evidence.

Trip

1) Impact

Over the past year, Trip experienced substantial growth, with a 60% increase in unique users and a 43% year-on-year rise in page views generated by clinicians and information specialists worldwide.

When viewed alongside our previously published impact evaluations – which showed that 40.77% of searches led directly to improvements in patient care – these usage figures suggest that Trip continues to play a meaningful and growing role in clinical decision-making and patient care globally.
(See: The impact of Trip parts 1 and 2)

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2) New features

Systematic Review and RCT scores launched
We introduced scores for systematic reviews and randomised controlled trials, accompanied by a published critique of their strengths and limitations. This reflects Trip’s ongoing commitment to transparency, methodological rigour, and responsible use of evidence indicators.

Improved mobile interface
A redesigned mobile experience now makes Trip much easier to use on the go, supporting faster access to evidence at the point of care.

Expanded journal coverage
We added new journals to Trip, broadening coverage and strengthening the depth and breadth of evidence available to users.

Linking trials across the evidence ecosystem
Randomised Controlled Trials are now directly linked to their trial registrations and to relevant systematic reviews, allowing users to verify trial details easily and see how individual studies fit into the wider evidence base.

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3) Blog activity and readership

Our blog activity increased markedly in 2025, with 91 posts published, compared with 34 in 2024, a 168% increase, driven in large part by the growing number of AskTrip-related posts.

This increase in output was matched by strong audience growth. The blog attracted 40,000 views from 23,700 visitors in 2025, representing a 44% increase in views (from 27,700) and a 57% increase in visitors (from 15,100) compared with 2024. Together, these figures point to both sustained publishing momentum and a steadily expanding readership for Trip’s writing on evidence, search, and clinical decision-making.

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AskTrip

AskTrip launched on 25 June 2025, and it quickly became clear that it was meeting a real need. As we approach 10,000 clinical Q&As (a milestone we expect to reach by mid-January) AskTrip has significantly strengthened one of Trip’s core purposes: connecting clinical decision-makers with the best available evidence.

Since launch, we have learned a great deal and made numerous improvements to the service, with further substantial enhancements already planned for early 2026.

The AskTrip sub-site has been viewed nearly 100,000 times by almost 20,000 unique users, demonstrating that this growing repository of clinical questions is not only heavily used, but also valued as a distinctive resource in its own right.

Stepping back, it is hard not to feel a sense of excitement about what this represents. Trip was originally created in 1997 to support the ATTRACT clinical Q&A service, helping answer questions manually using the best available evidence at the time. Nearly three decades later, returning so strongly to clinical Q&A – now at scale, powered by a vastly richer evidence base and modern technology – feels like coming full circle. It is a powerful reminder of why Trip exists: to help clinicians ask better questions, find better answers, and ultimately improve patient care worldwide.

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Looking ahead to 2026

Looking ahead, we already have a full and ambitious programme of work planned for 2026. A major focus will be on improving search, including the use of document chunking and a hybrid lexical–vector search approach. These techniques will enhance both core Trip search results and AskTrip answers by improving relevance, recall, and precision.

For the main Trip platform, we plan to significantly expand the number of indexed clinical guidelines and to explore indexing full-text journal articles, moving beyond abstracts to provide deeper access to the underlying evidence.

AskTrip will continue to evolve rapidly in early 2026, with several major enhancements already in progress:

• Longer, more detailed answers
  Feedback from our user survey showed that around one third of users want deeper, more comprehensive responses. We are developing a system that allows AskTrip to deliver this when needed.
• Support for follow-up questions
  Clinical questions rarely end with a single answer. We are adding functionality that allows users to ask follow-up questions or seek clarification, helping them continue their knowledge journey without starting from scratch.
• Enhanced Beyond Trip searching using PubMed Central
  We plan to incorporate Google’s BigQuery vector search of PubMed Central into Beyond Trip. While this content overlaps with OpenAlex and Google Scholar, vector search will surface new, semantically relevant articles and improve how external evidence is incorporated into AskTrip answers.

Looking further ahead, there remain areas where we know we can do better, particularly for certain types of clinical questions. These include country-specific questions, where the academic literature does not always align neatly with national practice or policy, and recency-focused questions such as “What is the latest evidence for…?”, which place additional demands on how evidence is identified and prioritised. We have clear ideas about how to address these challenges, and they will become a focus once the current development programme is complete.

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Trip delivered an extraordinary amount in 2025 – made all the more remarkable by the size of our team. What we have achieved this year is a testament not to scale, but to focus, commitment, and a shared belief in the value of trustworthy clinical evidence.

Huge applause goes to Phil, Abrar, AD, and Chris for their outstanding work throughout 2025. None are employees of Trip; all are contractors working part-time – and in some cases very part-time – making their collective contribution even more impressive. Their expertise, care, and persistence underpin much of what Trip and AskTrip have become.

We are also deeply grateful to our users and user group members, whose feedback, questions, and challenges continue to shape everything we do. Trip has always been built with its users, not just for them.

Finally, we have never been the loudest voice in healthcare – but we are quietly committed to helping clinicians make better decisions, every single day.

Inspired by the work of Google (see our post A great example of the power of vector search), we’ve developed a test system based on a subset of Trip documents covering GLP-1 receptor agonists. Rather than relying on a single search method, the system effectively runs two searches at the same time – one keyword-based and one vector-based – and combines what each finds.

Here’s an illustration based on a search for “GLP-1 and neurological disorders”:

The top result appears in both the vector (Vec) and lexical (Lex) searches. Results #2 and #4 appear only in the lexical search, while #3, #5, and #6 appear only in the vector search.

The vector-only results do not contain the exact term “neurological disorders”. As a result, a traditional keyword-based search would have missed them unless extensive term expansion or synonymisation had been applied. This illustrates how vector search can surface conceptually related evidence that would otherwise be invisible to purely keyword-based approaches.

Another example comes from a search for “GLP-1 and anxiety”. The top results break down as follows:

Appeared in both vector (Vec) and lexical (Lex) searches

• Association of GLP-1 receptor agonist use with psychiatric outcomes in adults with type 2 diabetes: a target trial emulation
  → Top-ranked result in both searches

Vector (Vec) only — no explicit mention of anxiety

• GLP-1 medicines for weight loss and diabetes: what you need to know (section: GLP-1 medicines and mental health)
• GLP-1 agonists: depression, suicidal thoughts or behaviour? (GLP-1 agonists review)

Lexical (Lex) only

• GLP-1 receptor agonist use and risk of suicide death
• Anti-obesity medication guideline

The vector-only results are closely related to anxiety through overlapping concepts such as depression and suicidality, despite the term itself not appearing. This illustrates both the strength of semantic search and the potential for ambiguity in how relevance is interpreted.

Final thoughts

These examples highlight both the potential and the challenges of vector-based and hybrid search. The ability to surface conceptually related evidence that would be missed by traditional keyword search is powerful, while also raising important questions around relevance, explainability, and user trust – particularly in a clinical context.

We will continue to develop and refine this technology, with the intention of rolling it out across Trip and AskTrip in the near future. Our focus is on striking the right balance between precision and discovery, and ensuring that any changes meaningfully improve the search experience for clinicians and information specialists. This represents a significant evolution in how Trip works.

Crucially, this will remain a user choice. Users will be able to opt in to – or opt out of – vector-based and hybrid search, retaining full control over how their searches are performed.

This is an exciting new addition to AskTrip: you can now browse Q&As by most viewed.

Ever wondered which clinical questions other users are spending time on? This feature lets you see, at a glance, what’s capturing the most attention across AskTrip.

How to explore the most viewed Q&As

First, navigate to Past Questions:

Next, open the Order drop-down menu and select Most viewed:

The Q&As will then automatically rearrange based on popularity:

What’s popular right now?

At the moment, the most viewed Q&As are all focused on sarcopenia, highlighting strong interest in muscle health and ageing. The top questions include:

• What are the primary exercises recommended for managing sarcopenia in older adults according to the evidence-based guidelines?
• What are the risk factors associated with developing sarcopenia in middle-aged individuals?
• How does sarcopenia affect the overall health and mobility of elderly patients?

This kind of insight offers a fascinating snapshot of what clinicians are actively looking for – and may even prompt ideas for learning, teaching, or service development.

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NOTE:

• We only started collecting view data at the end of last week, so these rankings are based on relatively small numbers for now. In the New Year, we’ll add options to view All time and Last 30 days.
• Views are counted only from authenticated users. This includes users logged into their accounts, as well as those accessing AskTrip Pro via IP authentication or OpenAthens.