Tip:
Highlight text to annotate it
X
bjbjz In part two of the eLearning Module, we'll look at a case and use the literature
to find information to support a clinical decision. As you go through your pre-clinical
courses, you'll learn and practice the problem-oriented approach to diagnosis. We will go through
an overview of this process for this case, but we'll begin our literature search from
the point of having a diagnosis, but needing information about treatment options. Dolly
is a 2-year-old female spayed Springer Spaniel. The owners are finding urine on the couch
and kitchen floor when they come home from work. In addition, Dolly s dog bed smalls
like urine. The owners have had Dolly for about 6 months. They obtained her from an
elderly relative who moved to a long-term care facility. Dolly has adjusted pretty well
into the household but she and the owners cat do not get along. She is eating well and
has actually gained some weight since arriving at the new home. She is active and has lots
of energy. She is vaccinated and on heartworm and flea preventive. During a physical exam,
you find that Dolly is Bright, Alert, Responsive and is well-hydrated. She weighs 29 kg and
has a Body Condition Score of 4/5. Her temperature is 101.6 , pulse is 120 BPM, and respirations
are 30/min. She has normal heart and lung sounds, and her abdomen palpates normally
(though it's hard to get a good feel since she's a bit chunky.) Her bladder is small.
Peripheral lymph nodes are normal, coat is clean and skin looks healthy. Eyes, ears,
nose, throat (EENT) are normal. She has normal vulvar conformation, and there is some reddish
staining of the hair around her ***. Normal *** palpation, urethra feels smooth and
flat. Brief orthopedic and neurologic examinations are normal. Based on this information, you
develop a problem list, and work with the urine found in the house as a pivot problem.
That gives you a differential diagnosis of: Urinary Sphincter Mechanism Incompetence (USMI),
ectopic ureters, loss of housetraining (behavioral), PU/PD related problems, pollakiuria and possible
urinary tract infection (UTI) and Overactive Bladder. You conduct several diagnostic tests
to rule out diagnoses, including observing Dolly s urinations, urinalysis, urine culture,
and blood pressure. The owners decline CBC and serum chemistry. Your interpretation of
these results is that there is no evidence of UTI or polyuria because of high USG. There
is no evidence of systemic disease. That narrows it down to a behavioral problem, urinary sphincter
mechanism incompetence (USMI), ectopic ureters, or overactive bladder After additional testing,
you believe Dolly s problem is USMI. ll use the literature to help make a treatment decision.
Your textbooks and professors offer several treatment options for USMI: Phenylpropanolamine,
DES, and Premarin. Which is the best treatment option for Dolly? We can use the PICO model
to help define our clinical question and break it into search terms. We can define our Patient/problem
as a 2-year-old female spayed Springer Spaniel with urinary incontinence due to urinary sphincter
mechanism incompetence. Our Intervention would be Phenylpropanolamine. Our Comparison interventions
would be DES (diethylstilbestrol) and Premarin. And our Outcome would be the resolution or
management of symptoms of urinary incontinence with minimal side effects. Breaking out our
search terms using the PICO model, our clinical question, then, would be: In a 2-year-old
FS Springer spaniel with urinary incontinence due to USMI, should we treat with phenylpropanolamine,
DES or Premarin to provide the best resolution of symptoms with minimal side effects? We
can take these concepts and break them into terms and synonyms that we can use in our
search. Chances are that we don t need to use all of these terms. We usually don t include
Outcome terms in searches: remember, they are useful for assessing the relevance of
search results, performing a critical appraisal, and implementing a decision. Terms from the
signalment, like a dog s breed and whether it has been spayed are often useful when developing
a diagnosis. (In this case, knowing that Dolly was spayed probably helped you with your diagnosis
of USMI.) However, we would probably leave these terms out when we re looking for information
about treatment. Next, we can convert the terms we select into a format a database will
understand, and this gives us the search string at the bottom. Note that you don t have to
search for all of these terms at once. You might find it easier, for example, to make
a comparison if you run three separate searches looking for information on each of the interventions
separately. Because we re looking for current clinical studies suggesting a treatment for
USMI, we should search for research articles published recently. If possible, we d like
to find study types from the top of the evidence pyramid. Research databases like PubMed or
CAB Abstracts would be good choices in this case. We can begin at the Veterinary Medicine
Library s website to get to these databases and conduct our searches. From the Vet Med
Library's homepage, we can scroll down to access PubMed. When you enter terms in the
PubMed search box, it will search for your terms in all fields title, abstract, Medical
Subject Headings (MeSH terms), etc. It will also convert your terms into MeSH terms, which
lets the database find articles that use different terms for the concepts you re searching for.
You can see what PubMed did by clicking See More under Search Details on the results screen.
You can edit the search if necessary for instance, we might not want it to search urinary and
incontinence as separate terms, and we can delete those terms and run the search again.
Remember that, if you click on the name of an article, you can see more information about
it. This includes MeSH terms, which you can use to revise your search, and the abstract,
which can help you decide if you want to spend time reading an article. As long as you got
to PubMed via the OSU Libraries website, you ll also see links to the full text, either
in the form of links to the publisher s website or as Find It! links to the Libraries full
text holdings. This search returned 33 results. That s a reasonable number of articles to
look through and work with. Many times, you ll get more results than that and want to
narrow down what you see. You can use PubMed s filters to do this. The filters that display
by default are not necessarily the ones that are most useful for finding clinical veterinary
studies. ll talk about the Article types filter later. The set of filters, Text Availability,
doesn t apply to us at OSU, because we have much more full text available than PubMed
knows about. Publication Dates may be useful if you re specifically looking for recent
information. The Species filters list one species humans and the rest of the animal
kingdom, which is especially unhelpful in veterinary medicine! An alternative can be
found under the Show additional filters link, under Subjects. If you click that link then
select Subjects, you ll see a new set of filters, which by default shows only cancer, AIDS,
and Systematic Reviews. If you click the more link below these filters, you ll get the option
to select Veterinary Science, which will then display as a filter option (you haven t actually
applied the filter to your search at this point). You can check this box to limit your
results to studies of animals as veterinary patients, as opposed to model animals of human
disease. Note that you might not want to do this if you re looking for research in oncology,
where the emphasis on translational medicine makes human studies useful to veterinary practitioners,
as well. As with the Subjects filter, there are many more options under Article types
than are displayed by default. Clicking the more link will give you the option to display
additional article type filters, such as Meta-Analysis and Systematic Reviews. If we wanted to limit
our search to meta-analyses, systematic reviews, and randomized controlled trials, we could
display then select each of those article types. There are four randomized controlled
trials that meet our search criteria, and you might want to emphasize these top-tier
articles in your critical appraisal. If your keyword search returns too many results, you
can try searching in the MeSH terms directly. This has the advantage of only finding those
articles that are about your topic, not just those that use your terms somewhere, and you
ll retrieve fewer, more relevant results. If you re doing this following another search,
you may want to clear your filters first. When I type in dogs into a MeSH search, instead
of returning articles, it returns related subject headings. We would want the first
result, simply Dogs, which refers to domestic dogs. We can check the box next to Dogs and
then click Add to search builder on the right side of the screen to save this MeSH term
while we search for others. Next, we can type urinary incontinence into the MeSH search
box at the top of the page. If we click the first result (Urinary incontinence), we can
view subheadings and related terms. In this case, we might want to select the drug therapy
subheading, and add that to our search with AND (to search both dogs and Urinary incontinence/drug
therapy). There is also a veterinary subheading, which we can add to our search with AND. We
can continue adding MeSH terms, or we can stop here and click Search PubMed A quick
way to limit your search to articles that are clinically relevant is to use PubMed s
Clinical Queries tool. If you click on the PubMed.gov icon in the upper left part of
the screen, you ll return to PubMed s home page, which includes several links. Under
PubMed Tools, the fifth link is Clinical Queries. If we plug our original search into the Clinical
Queries search box, the tool searches PubMed and automatically filters the results to match
the clinical study categories of Etiology, Diagnosis, Therapy, Prognosis, and Clinical
Prediction Guides. It also displays any systematic reviews that meet the search criteria, as
well as medical genetics articles. In this case, we see 25 results under Therapy. If
you see more results than you can work with, you can narrow the scope of the search using
the Scope drop-down menu. PubMed doesn t index everything, and because its emphasis is on
human medicine, it may omit useful articles in veterinary medicine. s usually a good idea
to look for information using more than one source. CAB Abstracts is a good choice because
it is part of their mission to be comprehensive in veterinary medicine you will almost always
find articles in CAB that weren t indexed in PubMed, and vice versa. VetMed Resource
is an interface for CAB Abstracts that s designed for veterinary practitioners. It includes
all of the content that you d get from a CAB Abstracts search, but also includes news articles,
reviews, and data sheets. You will have access to VetMed Resource via OSU s Veterinary Medicine
Library at no cost for at least 2 years after you graduate. Searching in the CAB Abstracts
and VetMed Resource interfaces works the same way. We can plug our search into VetMed Resource,
but we should make a few small changes: unlike PubMed, most databases (including CAB) don
t automatically translate search terms into subject headings, so they ll take what you
enter more literally. Since that s the case, we want to put quotation marks around our
phrases. That search in VetMed Resource results in 5 data sheets (which look to be irrelevant,
but picked up the term 13 full text articles (again, OSU has many more full text articles
available than CAB knows about, but you'll be able to access these when you're in practice);
and 64 total articles under Abstracts That s double the number we found in PubMed, so
it s likely we ve found some additional relevant articles. We can do advanced searching including
limits by article type and language by clicking through to the CAB Direct and repeating our
search, which will help us narrow down the articles to those we want to read and critically
appraise. This is the end of the eLearning Module. I want to remind you that you can
always reach me with questions by email or by phone, or by stopping by my office in the
Veterinary Medicine Library. Page PAGE of NUMPAGES kdI kdN! kdS" kdX# kd]$ kdb% kdg&
kdl' [Content_Types].xml _rels/.rels theme/theme/themeManager.xml sQ}# theme/theme/theme1.xml w toc'v )I`n 3Vq%'#q
:\TZaG L+M2 e\O* $*c? Qg20pp \}DU4 hsF+ ,)''K K4'+ vt]K O@%\w S; Z |s*Y 0X4D) ?*|f -45x
/Y|t theme/theme/_rels/themeManager.xml.rels 6?$Q K(M&$R(.1 [Content_Types].xmlPK _rels/.relsPK
theme/theme/themeManager.xmlPK theme/theme/theme1.xmlPK theme/theme/_rels/themeManager.xml.relsPK
!&kj 0&kj un