Problem-based Learning & Finding the Evidence: Cite it Right

Expectations when writing learning issues

In writing learning issues and papers, students are expected to:

• Find and use an appropriate mix of sources of information (books, journal articles, Web pages, and expert opinion).
• Routinely cite sources in a way that allows others to easily locate and learn from them.
• Integrate information from the sources with personal ideas to produce a coherent whole.
• In the body of the text, attribute quotes, paraphrases, and concepts to the source(s) from which they were obtained.

 **  Relate what you found and wrote to the current case/patient.

Clearly attribute quotes, paraphrases and ideas to their sources

References are listed at the end of a write-up. However, it is not sufficient to merely list the sources that were used. Students are also expected to make clear which ideas and words in your write-up come from them and which come from others. The words and ideas written without a clear attribution will be presumed to be theirs.

One way to make clear attributions: Put direct quotes in double quotation marks ("), and put paraphrases in single quotation marks ('). Here are some examples:

Direct quote

"Renal artery stenosis should be suspected when hypertension develops in a previously normotensive individual over 50 years of age or in the young (under 30 years) with suggestive features: symptoms of vascular insufficiency to other organs, high-pitched epigastric bruit on physical examination, symptoms of hypokalemia secondary to hyperaldosteronism (muscle weakness, tetany, polyuria), and metabolic alkalosis. If renovascular hypertension is suspected, a positive captopril test, which has a sensitivity and specificity of greater than 95 percent, constitutes an excellent screening procedure to assess the need for more invasive radiographic evaluation. The test relies on the exaggerated increase in plasma renin activity (PRA) following administration of captopril to patients with renovascular hypertension as compared with those with essential hypertension. (1)"

 Paraphrase

'When hypertension develops for the first time in an over 50 patient, you should suspect renal artery stenosis. This is especially true if the patient shows other symptoms of vascular insufficiency, has an epigastric bruit, or has hypokalemia and metabolic alkalosis. The captopril test is an excellent initial screening procedure. (1)

 Idea

Mr. Jones is 65 years old and had normal blood pressure until last year. His blood pressure is now 174/93. He also has a history of coronary artery disease. I would recommend a captopril test (1) to screen for the possibility his hypertension is of renal vascular origin.

1.    K. F. Badr and B. M. Brenner, "Vascular Injury to the Kidney" in Harrison's OnLine,http://www.harrisonsonline.com/server-java/Arknoid/harrisons/1096-7133/Chapters/ch-277?Page=6&Sect=Sect6 (1999)

Each resource should have the following chunks of information:

• Author(s),
• Title of resource (including chapter heading when appropriate),
• Source (insert link if appropriate),
• Date (and journal details, if appropriate)

  **  Cite sources for writeups in ways that allow others to easily locate and learn from them.

Be sure to include the following elements:.

1.   Author

a.   Last name and initials or surname.  If more than two authors, you can list first author, followed by et al.

b.   If author’s name cannot be determined, write Anon. or Anonymous.

c.    If source is unrefereed, indicate something about author’s background, e.g., physician in private practice, or patient or drug company, or background unknown.

2.   Title

a.   Title of journal article, book chapter, web page, etc.

b.   If a chapter in book, cite chapter as well as book’s title.

c.    Publication: State book title, journal name, website name

d.   If book give edition, publisher (and chief editor if applicable). e.   If website, briefly characterize it

 3.   Pages Cited, or Full URL

It’s easy to copy the URL from the browser’s Location window into a learning issue writeup. However: This does not always work, because some URL’s are temporary. The student should check for this and make certain that the URL he/she provides can work for others. Otherwise some other way to help others locate their source must be used.

4.   Date

Author: Fred – Group 11 – PBL 1 – 9/6-9/10                                  Case: A man with a spinal injury

Question: What is the current treatment and associated prognosis for an injured spinal cord?

Spinal cord injury is most commonly caused by trauma. Other causes include infarction, hemorrhage, and acute disc herniation.  Current practices for treating spinal cord injury are generally to prevent further damage to the spinal cord (1, 2).

Treatment includes immobilization of the entire spine for transport of the patient to a medical facility. The patient should be rapidly delivered to the closest spine center as delays increase morbidity. Unstable patients

should simply be taken to the closest hospital. Immobilization reduces the risk of further damage to the spinal cord (2).

An airway is also established depending on the level of the injury as respiratory function may be impaired.

The more superior the injury, the greater is the indication for airway intervention. Any patient with an injury superior to C5 should be intubated. In general, an orotracheal intubation is performed. Nasal intubation, although not preferred, can be performed on patients with spinal immobilization. Virtually all patients with cervical spine trauma require sedation for proper nasal intubation (2).

Injury of the spinal cord often leads to sympathetic denervation. There is a loss of alpha-1 activity causing dilation of arteries, and a loss of beta-1 activity causing bradycardia and reduced cardiac contractile strength.

This ultimately leads to hypotension. This is treated with fluid replacement. It is important to note that after

a traumatic event, hemorrhage should come before spinal cord damage on the differential for the hypotension (2).

Steroids are also used to treat spinal cord injury. Treatment should begin within 8 hours of the injury. Initially a 30 mg/kg bolus of methylprednisolone is administered IV over 15 minutes followed by a

45 minute pause. This is, in turn, followed by continued application via IV of methylprednisolone at 5.4

mg/kg for an additional 23 hours. This has been shown to improve motor and sensory function in patients after blunt trauma. Methylprednisolone is believed to work by inhibiting free radical-mediated neuron membrane damage. Other beneficial mechanisms include increased spinal cord blood flow, increased extracellular calcium, and reduced potassium loss from the damaged nerves (2, 3).

Surgery can also be used to treat spinal cord injuries. In some cases, realignment of the spine may be necessary through surgical manipulation. Also, in cases such as gun shot wounds, surgery may be needed to

remove pieces of bone or other foreign bodies such as shrapnel. This is indicated if the foreign body is in the

spinal canal or causes a hematoma which leads to a progressive decline in function. If the spine is unstable, surgery may be performed to stabilize the vertebrae by spinal fusion with metal plates, rods, and/or screws (2, 4).

Within 72 hours to 1 month after a spinal cord injury, it is possible to reasonably predict the recovery of a patient. A comprehensive physical examination, and the initial location and severity of the

injury are the most accurate measures of ultimate functional capability. MRI can also be helpful. Acutely,

20% of traumatic spinal cord injuries are fatal. Patients with complete motor and sensory loss at 72 hours are very unlikely to recover function beyond one root below initial site of injury. 90% of patients with

incomplete transections of the spinal cord can ambulate a year after the injury. The ultimate extent of the loss of function after spinal cord injury is highly variable (4, 5, 6).

Relevance to Case-

After the jump, Bill has lost sensation at his torso (1-2 inches below his collar bone), chest, back, abdomen, legs, and the medial aspect of his arm to his elbows. This represents a loss of sensation from dermatomes T1 and below. Bill also notes that his thumbs and fingers are weak. His digits relate to

dermatomes C6-C8. This information indicates that his spinal cord is severely damaged at somewhere above

T1 and also is affected at the C6-8 segments.

Bill was immobilized to reduce the chance of further spinal cord injury. He was not intubated as he had proper respiratory function, although his spinal cord may be damaged at the cervical level. He seemed to

be still very active, and so is probably not very hypotensive. Methylprednisolone was administered in an

appropriate manner to increase the chances of recovery functional recovery. He was immediately evacuated to a medical center to increase his likelihood of recovery and survival. Surgery may be indicated if he has an unstable spine, or loose bone fragments from the fall.

References-

1.   Jason E Decker, MD, Albert C Hergenroeder, MD; Overview of cervical spinal cord and cervical peripheral nerve injuries in the young athlete; ©2006 UpToDate

2.   Judith E. Tintinalli, MD, MS, et al; EMERGENCY MEDICINE: A Comprehensive Study Guide; Chapter 256. Spinal Cord Injuries; Copyright © 2004

3.   Nesathurai S.; Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials.; J Trauma. 1998 Dec;45(6):1088-93.

4.   Gerard M. Doherty, Lawrence W. Way; Current Surgical Diagnosis and Treatment, 12th Edition; Chapter 37. Neurosurgery & Surgery of the Pituitary; Copyright © 2006

5.   Burns AS, Ditunno JF.; Establishing prognosis and maximizing functional outcomes after spinal cord injury: a review of current and future directions in rehabilitation management. Spine. 2001 Dec 15;26(24 Suppl):S137-45.

6.   Kirshblum SC, O'Connor KC.; Predicting neurologic recovery in traumatic cervical spinal cord injury.; Arch Phys Med Rehabil. 1998 Nov;79(11):1456-66.