Good evening and welcome to tonight's platinum webinar with the webinar vet. I'm Rich Daley, head of sales for the webinar vet, and I'm pleased to be chair in tonight's session. Firstly, the housekeeping.
First of all, we have, I'm joined this evening by my colleague Lewis. Lewis is on hand to answer any of your technical queries. You can, contact Lewis either by putting a message in the chat box, which you can find at the bottom of the screen, or alternatively, if you send an email to office at the webinar vet.com, and Lewis will answer your query there as well.
As always with our platinum webinars, as we're going throughout through the presentation, if any questions do pop into your head, please do pop them in the Q&A box, which you can also find at the bottom of the screen. It really does help to Develop the presentation, really helps the engagement with the presenters as well. And also I'm sure that if you're thinking a certain question, there'll be other people also watching thinking the same question, so, and they'll be glad that you've put that in there.
So please do engage and put any questions in the quick Q&A box. Throughout tonight's presentation, there will be a number of poll questions. Once again, these are just to help engage with with yourselves to understand your get your greater understanding of your knowledge of the er topic we're discussing tonight and to help with the discussion.
All you need to do with the poll questions is when I launch it, you just click the box at the relevant answer, and then we'll feed back the results shortly after you've answered. So please do, there's no right or wrong, you don't get your CPD taken away from you, if you don't get the answer right, but I don't believe there are any right or wrong answers tonight, it's just understanding what your opinion is and what your knowledge is of this area. So, 01 more thing, I'm sure you have been like myself inundated in your email inbox with we'd love to keep in touch with you.
Please don't say this is the end. Don't say goodbye, we want to see more of you, etc. GDPR is coming into effect tomorrow.
If you haven't already, we, once it's like all the businesses have been sending out emails along those lines, and we do want to keep in touch with you, so you're kept aware of all these fantastic webinars we've got coming up. So if you haven't yet, please, please do dig out one of those emails. And we will and select that you want to be kept in touch by ourselves by opting in.
If you haven't received an email, please do put in the either the Q&A or actually put in the chat box to Lewis your name, and Lewis will make sure that, an email is sent to you tomorrow to give you the option to opt in. Right, that's the housekeeping done onto tonight's webinar. So I'm delighted that tonight we have a 2 for 1.
We're joined by two absolutely fantastic speakers. We are joined by. Zoe Belshaw and Marnie Brennan.
Both are from the Nottingham vet school. Er Zoe is a European and RCVS recognised specialist in small animal internal medicine. She was initially a clinical lecturer, then as a PhD student and postdoctoral researcher within the centre for Evidence Based Veterinary Medicine.
And then we also have Mary. Mary is also a European and RCVS recognised specialist, but this time in veterinary epidemiology. She is a persistant professor in epidemiology at the School of Veterinary Medicine, at the University of Nottingham and is a Deputy Director of the centre for Evidence Based Veterinary Medicine.
They're both here tonight to talk to you. About the creation of best bets for vets, a free online resource containing simple reviews of the best evidence available on specific clinical topics. So without further ado, I'd like to hand over to Zoe and Marie all over to you ladies.
Thanks very much, Rich. Thank you. We are absolutely overjoyed with joining everybody tonight to talk to you about Best Bets for vets.
So thank you very much for joining us instead of being outside in the sunshine and with a glass of wine or something else. So we're hoping that tonight's session is informative, but also very discussive between Zoe and I about various aspects of the Best Bets website and also a couple of bets in particular that we've gone into in a bit of detail. So, yeah, hopefully informal and chatty and not too hard for this with a bit of luck.
So as with we think it's good to do, in terms of the sort of work we do anyway, it's always good to put up . The sorts of organisations that we work with and sponsor our work because it's good to be transparent about these things. So that's my list there and just thanks very much to the centre team, all of the people that we work with in terms of our research and also the supporters of our research.
We certainly couldn't do a lot of this, without, without those people. And then, yeah, same for me, very grateful to everybody we work with. I've done some consultancies for some of the companies who produce, some of the drugs that we'll be talking about this evening, so just useful to note that, not that it's in any way influenced what we're talking about, but just to be completely transparent.
Brilliant. OK, so briefly, what we're going to cover about, I think all good presentations need a bit of a plan to start with. So essentially, I'll spend a bit of time talking about the backgrounds for Best Bets, so that's the website that we have, a little bit about the context of, of of evidence-based medicine, why we decided to do this, actually, how the process works, and then hopefully for you, some questions that you can help us to try and, I guess, .
Make the website as good as it can be and absolutely fit for purpose for you, because ultimately, the website is for for people out there to use. We've got a couple of best bets that we're going to go into discuss in a bit more detail, and they were chosen by the webinar that audience a week or two ago. So hopefully, if you voted, your favourite ones are there.
We're going to look at Rona Coxin versus other non-steroidals in terms of acute MSK pain in cats, and then Also, the use of antibiotics in dogs with acute hemorrhagic gastroenteritis and then we'll sum up at the end. So hopefully again, not too taxing for people. OK, so a bit of background about the, the website itself.
So I think it's worth starting with what evidence-based medicine is, and you might be wondering why I have a picture of the Fab 4 on the front of this. Well, I said, essentially, it's, it's about the four components that go into evidence-based vet medicine. And a lot of people think maybe that EVM, as I'm going to, to kind of shorten it to, is about reading the evidence.
And saying, well, that's what we have to do in our practise when we're decision making about patients. But actually, it's more complicated than that, as you all very well know, you know, there's lots of factors that have to come into play and we need to consider. So specifics about the animal in front of us, maybe the owners got their own ideas about what things should happen, and then also you as the vet or the nurse making decisions about.
That that patient, for example. So all of those four things have to work together in order to make really good evidence-based decisions. And I just to clarify here, I guess if we're talking traditionally about what evidence-based veterinary medicine is, then people normally talk about evidence in, in a peer reviewed evidence kind of way.
And that means evidence that's come from scientific journals where there's been some kind of quality assessment of that particular study before it's been published in the journal. So that's, that's a traditionally what we mean by evidence. We can talk a little bit more about that in a minute though.
So that's kind of what I'm going to keep coming back to. So some of the key elements in practising evidence-based veteran medicine, so starts with a clinical question, which has to come from practise, because that's the environment where all of these things start. So it's important to, to get practitioners involved in this process.
So what do I want to know? Maybe I've picked something up from a case I've seen that I'm really not sure about, or I'm wanting to, you know, keep myself up to date in a particular area, because I haven't done any CPD in that area for a while. It's about saying, OK, well, if I want to find some information.
Now where are the best sources to go to? How do I do that? What's the process?
If I find some evidence, how do I work out if it's any good? Do I like the quality of it enough to actually decide to, to make decisions with it, which is the next step. So is it relevant to the practise that I do?
So maybe the trial, there's a trial that you're reading that's been done in Canada, for example, and maybe the patient group that's involved is very different to the one that you see. So, you know, you might choose perhaps not to use that evidence if it's not appropriate. And then I guess if you've made a change in practise, it's about saying, well, how did I do?
Have we actually made a difference to the outcomes that we're expecting from for our patients? And that's a really important step, I think that that sometimes doesn't necessarily be, is not necessarily considered. And then I guess we've got a little bit of an outpouching there that what happens if there isn't any evidence and, and hopefully, you know, there's lots of people out there working on trying to fill some of those gaps as we go.
. If you want to recap about these sorts of things, then there's a really great tutorial called EBVM Learning, which I've got the link there for if you wanted to know a bit more detail about this process, but I'm not going to touch on this for too much longer. So, how does it fit into practise? Well, I was thinking about a schematic in terms of how, how do we use information to make decisions about our patient.
And if we think about all the different types of places that we could potentially get information from, it's quite complicated. We've got colleagues that we talked to about cases, we learn stuff that our CPD courses that we go to, we might have industry reps visiting us at our practises. Talking to us about new products, perhaps.
So we're getting lots of information from all of those sources all the time. And I guess everybody is going to be different. You're going to hear from different people and perhaps get different evidence from those different sources.
And I guess that makes it really hard if we're talking about using a combined approach. So everyone's doing similar things because we believe it's the best way. So, you know, that's quite complicated and I guess it makes it difficult if we're not using the same evidence sources to make decisions about cases, particularly when there is really good peer reviewed evidence to make decisions, then we could be having lots of different outcomes, which means it's going to be quite variable for our patients, which I guess is not really what we want.
And I guess there's a really great book actually called Evidence Based Medicine and Sherlock Holmes's Footsteps. It's amazing how many quotes actually from Sherlock Holmes. Books actually fit very nicely with evidence-based medicine.
And I guess it's about saying, you know, the evidence that we come across every day, may look very different depending on the case that you have in front of you. And the only way really to know about whether we've got good evidence or not. Is by trying to use the places or go to the places where we think the evidence is going to be the least biassed as possible.
So that really requires us to think carefully about reading peer reviewed papers if there are something, some on our particular topic, I guess. So ideally, in a realistic world, everybody would get out there, we would all read journal journal papers and make a decision about their quality and then use the evidence in our practise and our clinical decision making. And I guess when I'm saying reading it, we're not just talking about abstracts, we're talking about more than that, because abstracts can be misleading sometimes in terms of, does that actually capture what that study, or what happened in that study, for example, because they don't necessarily.
And there's been research done in the medical field that says abstracts sometimes don't really represent what's going on in the paper. The, the bit in italics I've got, there's just a quote we had from a server we did a few years ago saying, actually, we really have to be careful with what we read and what we use in our decision making, because, you know, we can, there's a lot of bias out there and we have to be careful with, with what we're using. But obviously, you know, you're busy people, it's very difficult to say, yeah, I'm going to read all these journal papers about these particular topics.
It's hard to build that into your time, particularly when you're, you're short of time and when you're not working, what you want to be doing is out there enjoying yourself. So there's, there's lots of difficulties there. And again, there's another quote saying, this is, this makes it difficult for us in terms of the time and also the skills to be able to look very effectively for the information we want, and also to be able to interpret it.
So there's lots of barriers. So I guess ideally what we'd be doing is everyone would be doing it, but actually if we can't do that because it's physically not possible all the time. Then maybe another way is to have other people doing some summaries of what that evidence base tells us and us to be using those summaries.
So there's a balance between doing it yourself and getting those skills, but then also using other people's work that they've done. So I guess there's there's what we're saying is there's really a role here for a resource that has these summaries on them that people can pick up and use straight away while they're getting to grips with maybe the process of doing it themselves. So when we began the centre in 2009, there was very few kind of applied evidence summaries available out there.
There was an organisation called Banfield in the US who used to do some critically appraised topics. I don't think they've done any for a while now. There's a link there to to their resource anyway.
And there was also a where's the evidence series which is published in Jama, which again, they're not, they're not doing anymore, but that was really it at the time. So what we did was we decided that we needed something and we wanted to try and pick the best thing possible to use in a veterinary framework. So we did a lot of looking at what the medical field does in terms of these evidence summaries and, and what might work best for what we had.
And we came across best bets, so there's an, there's a human best bets, . At the, and this is originated from the emergency medics at the Manchester Royal Infirmary. They got a bit bored with the journal clubs that they were running in the, in the hospital, and they decided that they needed to do something a little bit more detailed.
So just looking at one paper at a time really wasn't enough, and they needed to do summaries of these to really get to grips with what was going on. So they developed this system, and we thought, brilliant, we can, we can take that and use that format for, for the stuff that we have in the veterinary literature. So we developed Best Bets for Vets in September 2013, we launched it.
And the idea was for it to be containing simple reviews of the current best evidence to answer specific clinical questions. That's really what we set out to do. It's worth having a look at the, the medical best bets.
Some interesting things in there about do people need antibiotics for dog bites and things like that. So, so quite interesting. And also, if you're in the unfortunate position to find yourself in the emergency room, so where maybe you can have a look to see what the evidence says about different treatments for you.
. Yeah, so the idea is with these things, they're quite narrow and very specific questions. So one of the disadvantages is that, you know, there's lots of different options and treatments maybe we might be looking at for a particular condition. But actually, what it does mean is that it means you can answer your question if you just look at one specific thing, and it doesn't stop you from doing lots of different questions.
It just means that you can get an answer relatively quickly. That's, that's how it's supposed to work. So, whenever this little picture turns up, that means that we, we've got a question that we want to want you guys to answer for us.
So this is our poll question one. So prior to this presentation, had you heard of Best Bets for Vets previously? It be really interesting to know whether people had heard of, heard of this before, I think, for us anyway.
OK, so I've launched the polling, so nice easy one to get you going, just a yes or no. Don't worry, you won't be beaten by a stick if it isn't an end of no. But we'll be asking you again in 2 days' time, you better make sure you have looked at it by then.
OK, come on, there's a few more of you haven't voted yet, so, I can see the numbers, so I know who you are. No, I can't, don't know who you are, but I can see there's a couple more left to vote, so, 5 more seconds and then I'll close the polling. OK, I think that's it.
So let's have a look at the answers. So we've had, it's quite even, we've had 43% of people said yes, they have heard of you before, and 57% have said no. Cool.
OK, good. It's great. It gives us a bit of an idea about what, what we've got, what we're working with here.
Cool. OK, so our best bets website looks like this, if you go onto it, so it's www.bestbetsfort.
Dot org, and this is a screen you're met with, so there's a number of ways to navigate it. You could click on one of those species icons at the bottom, if you're interested in dogs, for example, you click on the dog icon, or you can just plug your search terms into that search box and find various things. Then you can see the, the most recent bets that we've published appear under that latest bets area in the top.
Then if we click onto our browser bets tab, you can actually get a big long list of all of the bets that we've published so far, and you can use the menu on the left-hand side to search by species if you want to, or topic area, and the bit you can't see right down the bottom is the intervention. So you can, you can do these searches in a number of ways to find the various questions that we've got there. So the process of how we go about this, I think is quite important for for people to understand because it's, it's, it's I like to think it's fairly rigorous in, in, in, in its design.
So we always use questions that have come from clinicians or nurses or our veterinary students actually that they've seen when they've been out on practise, because again, it's got to be useful for everyone, and generally what we find is certain questions come up quite a lot. So they're the ones that we tend to try and put on to our website if we can. We do searches in two different literature databases, and we do a quite a structured search, and that's done repeated by two different people, just to make sure that we've got everything as spot on as it can be.
We then have a look at whatever papers come back and make an an assessment of the quality of them. So we go through what's called a critical appraisal process. This is where we have a list of questions that we put to each paper, I guess.
So for a randomised control trial, there's specific questions that need answering for for randomised control trials. And that's done by two different people again, just to make sure that we've got the same, we've read the same things and we're happy we've got the same answer. Then we come up with a summary, and a clinical bottom line it's called, this is where we answer the question about that.
And again, we've got two authors that agree on, on that bottom line. And then we published on our website, like I said, as you can see, we're, we're doing one a month at the moment, so, so it's slow progress, but we're getting there, which is good. Some of those go on to be published also on the vet records, so they come directly from the website, that's every couple of months.
We put some on our Facebook site, and we have a blog shop system where we do a very discreet summary of each one of these bets, which you'll get to see an example of a bit later on. And then what we do is every 2 years we get an alert to say these things need to be updated, because clearly, you know, there's more papers that are published all the time, so it's good to make sure that we're keeping them up to date. But the idea of this whole process is that it's quite structured and transparent, and everybody can see where we're at.
So this is an example of a bet, if you click into it, you'll see, it's got a clinical scenario, we've got our three part question there, which, which is the question that's been posed, and then our bottom line at the bottom. And if you're really interested to know more of the detail, you can click into the search strategy, read these sections box there. And you'll get to know all of our search terms we've used, what the outcome from our searches have been in terms of these two different databases, what the different papers have told us in terms of what kind of outcomes they've measured, what the key results were, and then anything we thought probably should be in there that wasn't reported in our study weaknesses box.
And then you can get down to the bottom line again to say, well, these are the contextual things in the comments box, but actually this is what the outcome of the thing is. So if you want to post a question to us, or can you subscribe, you know, you can say, I'm really interested in horses. So if I, if I put my email address in there and I click horses, that means every time we publish a bet on horses, you'll get an alert sent to you in your inbox, which is is a good system and it seems to work quite well for people.
Again, you submit your question there with your email so we can tell you when we've answered it. And then again, you can also join our mailing list if you'd like to. We do put our vlog shots on a newsletter that we send around every 3 months to people, so you can keep up to date that way as well.
So that's a bit of a whistle stop tour through the best bets process. Again, some questions here for you. .
For people, so the 45% it was or something of people that have seen best bets before, it would be really interesting to know whether anybody's ever used the best bet to kind of help them make decisions about patients, or perhaps create a practise protocol or guideline with one of them, or even if you've used them in a journal club session, for example. Again, we've had people tell us that they've used some of these bets as a bit of a basis for that. So yeah, it would be great to know whether you guys have had that as well, I guess.
So I've just launched the first poll question, which is for those that are familiar with the Best Bets for Vett's website, have you ever used a Best Bet to help inform a clinical decision you've made about a patient? OK, come on, just a few more of you to vote, and then I'll move on to the next one. Well we can't leave it there, because if we leave it there, they'll think I'm making up these results because it's the same as the last poll.
OK, so, and the polling there for that one. So 43% have said that they have, used Best Bet to help inform a clinical decision about a patient and 57% have said no. I'll then move on to the next one.
So this one is. For those that are familiar with the Best Bets for Vets website, have you ever used a Best Bet to help create a practise protocol or guideline? Launch that now.
So just give you 15 seconds to answer that. So once again, for those that are familiar with Best Bets for Vets website, have you ever used a Best Bet to help create a practise protocol or guideline? OK, I'll in the pole in there.
Right, so 100% have said no, they have not used one yet to create a practise protocol or guidelines, so plenty of opportunities there for you. And then finally, poll question 4. For those that are familiar with the Best Bets for Vets website, have you ever used a Best Bet as the basis for a journal club session or practise meeting?
Just launched that, this is the last one for a period, it's your little period. So have you used a best bet as the basis for a journal club or session practise meeting? Just a few more seconds.
OK, and we'll end it there. So once again, 100% of people said no, they haven't, they are yet to use a best bet as a basis for a journal club session or practise meeting meeting. So they are, that's some hopefully some useful insight there for yourselves, Zoe and Marnie.
Absolutely, that's brilliant. Thank you very much, Rich. I think that really helps us to, to know about where we put our resources and and what happens next for us.
So thank you very much, everybody. OK, so, . Just to update you, I suppose, I talked about when the centre started in 2009.
The good news is for everyone out there, that there's some, some great other things out there now that that are available freely to people. So, equine Veterinary Education journal do critically appraised topics. They started this in March 2015, and that's free to anybody, even if you don't aren't a beaver member, for example.
So you can access those, there's a link there. RCVS Knowledge also has their veterinary evidence journal. Again, they began in October 2015, and that's free also to anybody who would like to have a look at that.
So there's loads of opportunities here for us to be using some of these things in our practise. And one of the questions we get often is, is why don't we all work on the same platform? Why is everyone doing their own thing?
Well, I think the question or the comment to say there is, I think the more evidence summaries there are out there, the better. You know, we're all working on lots of different questions. So I think, you know, we can definitely move the area forward if more of us are doing it.
And also, the medical field have lots of different. That they use when they're decision making about things. So, so, you know, hopefully that that means that it means that the more the stuff that's out there, it means it's more accessible.
And the methodologies are slightly different, but that's OK. It's about, about being aware that these things are important and also, you know, making sure that people use them. So there's really good, you know, as I said, if I think back to 2009, we're in a really great place now for these things.
So, getting down to business, these are the best chosen by you. So this is our first one we're going to go through in a bit more detail tonight. So Rubena Coxi for acute musculoskeletal pain control in cats.
Yeah, so this is the question, which was posed by, which we published in October 2016, sorry, and the origin of this was our final year undergraduate veterinary students. So, you know, we, we use this system in our teaching with the students. So hopefully, when they graduate from here.
They've got the skills to be able to search for and appraise these, these evidence sources. So this is one of them, came up with this question after, as I said, doing lots of EMS placements and looking at what people are doing, saying, well, is there one that's better than the other in terms of these sorts of things, particularly around Rabena Cox, I guess. So the question is obviously designed to look at rubenacoccib versus all non-steroidals, .
So what is it about rubenacocci really that we, we think might be a little bit interesting, Zoe, to, to maybe have a look at? I don't know. So, yeah, just to go a little bit into the pharmacology of of rubenacoccib.
So it's it's, licences on tour in the UK by Elanco. And it's licenced for use in acute pain and inflammation associated with musculoskeletal disease in cats and It's, it's a COX 2 selective NSAID, which should theoretically, and I'll emphasise it theoretically have patient safety benefits over a, a COX non-specific or a COX 1 selective, treatment. And it's one of the very few, NSAIDs that has this indication.
There are very few NSAIDs licenced in cats around musculoskeletal pain at all. So it was quite a new, relatively novel indication when this one came out. Just gonna put some extra stuff in there.
We have, we have a question that we would like you to, to maybe type some answers into the Q&A box for us actually, in terms of what aspects of this particular bet where you're interested in when, when, if the people who are listening tonight are the ones that voted for it, it would be really interesting to know what aspects of this bet particularly interested you and while we're doing, while you're doing that, we'll, we'll continue on with our discussion about these, these various bits and pieces. Yeah. So, .
And ketorofen specifically, I guess, again, that was the only comparator that we had at the time when we did the search, . In terms of publications that that had any non-steroidals in them. So, so yeah, anything to say sorry about kerofen.
So ketorofen is, obviously quite an old drug. It's licenced, for use again, for acute muscular pain for up to 5 days. It's not COX selective COX 1 selective.
And the, I guess the important thing to emphasise when we're talking about these comparisons we've made is that the papers that we're looking for to fulfil these search criteria have to compare Rabena coxi with another NSAID within the same paper. There's lots of papers out there extolling the virtues of all sorts of different NSAIDs compared to nothing, specifically to answer this question had to be within that paper, that comparison, we can't take a paper that looked at Rubena Coxib and compare that with a paper that just looked at meloxicam, for example. So although that we did a search that covered all of these, all of the NSAIDs available, the only comparator within a single paper that was available at that time was ketorofen.
So that's, that is why we've gone into that specifically in, in, in this bed. And I guess the other thing to talk about is, is obviously the bet was targeted very much at acute musculoskeletal pain of unknown origin, and we I had a bit of a chat about that actually, that could, that's quite broad and could mean lots of things actually. And then, you know, you say, OK, well, how does this relate to other types of pain maybe for other conditions and whether it's, it's, it's relevant for that as well.
Again, I guess we could create other questions asking about other types of pain as well, just to see what's out there. So yeah, I don't know how we're going with the poll question, but yeah, whether we've got any any specific areas that People are interested in to know more about in terms of this particular bet. We've got a very quiet audience at the moment.
We haven't had anyone pop anything in there yet into the Q&A, so, that's good to know. We'll keep pressing on. We've certainly got some things to say about it.
So hopefully it's what other people are thinking as well as we go. OK, so We might just skip over that searching process one, So I was thinking in terms of before we go right down in the detail of these individual papers, there's two papers that came back with our search, and I thought it might be worth looking at the similarities across both publications, actually, just as a starting point. So one of the things to note is that these are non-inferiority trials, .
Which I think is a bit different to maybe majority of trials that we we find out there in the veterinary literature, which are considered superiority trials. So non-inferiority trials are considered the ones where you're looking at products that are no worse than or not inferior to the other treatments. So for example, rubenacoccib is no worse than ketoprofen.
And that's different to the majority trials out there, which is this treatment is better than that one. And it's a slight difference and it's very subtle, but actually it is quite important, I think in terms of, of how these studies are done. And in terms of maybe the reasons why these sorts of trials are employed instead of a superiority trial, there's lots of reasons.
You know, maybe if it's not ethical to use a placebo, for example, as a comparison, or, you know, maybe the new treatment is not really expected to be any better in terms of the primary endpoint. So that's the primary outcome that people are interested in and are measuring in their study. But there could be other benefits like maybe it's got fewer side effects, maybe it's going to lead to a better quality of life, maybe it's cheaper or easier to administer, etc.
So there's lots of reasons why you might be using one of these non non-inferiority trials. I'd also add to that list that . You wouldn't necessarily want to go head to head with your rival competitive product and be found to be less good.
So there's a massive amount of risk associated with doing a superiority trial that many of the pharmaceutical companies would be quite keen to steer away from if ever possible. It would be pretty suicidal if you, decided that you, when we're gonna go head to head with your competitor and came out worse. So that's, that's another less clearly spoken, but definitely on a reason that, that people don't necessarily go for superiority trials.
So, if we think about interpretation of the results of non-inferiority trials, I guess they're slightly different in terms of what the sorts of things are that we look for. And I guess we're looking specifically at confidence intervals. So often when you're looking at statistics, you're looking for a P value.
I think most people will know what in terms of, they know that they need to look for P value, and most of the time for those P values, it's less than 0.05 is the cutoff people are looking for. So that means there's a significant difference between our groups, if that's what you're looking for.
In these types of trials, actually, the confidence intervals are the the things that are really important. And confidence intervals are things that kind of show the range within which the true treatment effect is likely to lie. So it gives you an indication of how certain you are about how good that P-value is, for example, or how accurate that P-value is.
And I suppose particularly with the non-inferiority trials, it's the lower bound because these things come in a range, so you get a lower lower level and an upper level. And we're interested in the lower one, that's the one that we're particularly interested in, because it tells us, again, we're just looking at how this thing performs against the current thing that's already out there, that that's pretty much what that's about. So in terms of the formulation of the tablets, they, they, they both use tablet formats.
Obviously these products also come in injectable formats, but in these particular studies they were looking at the use of tablets. Blinding, so in terms of blinding, I guess what we're saying is when these treatments are being administered or perhaps the outcomes of using particular treatments are being measured, then the idea is that people shouldn't know about which treatment this animals on because they could be subconsciously biassed towards one or the other. And in this case, for both trials actually, the person dispensing and administering the Particular products, so ketuprofen or rubenacoccib, were not blinded.
So that's a bit of an issue, I guess. But the person measuring the outcomes for the study was blinded. So, so I guess the implications are there that that there could have been some bias creep in here.
In terms of the outcomes that are measured, they used a specific scoring systems that they actually developed themselves, and we're going to talk about that in a bit more detail in terms of the results when we get to them. So yeah, it's, it's, there's lots of things to discuss, I think, in terms of, of these studies. So if we move on to our first paper, which is the Giroel paper, so this is an international study that was done in France, and the UK.
They use both types of practises, or both countries to, to recruit, and so there's 29 practises altogether, and this is, . The information I guess we don't get is that they didn't actually tell us how many animals came from each of those clinics, for example. So we started with 156 cats, and we needed to exclude a number of them actually, because for lots of different reasons, they, they didn't meet the criteria that was set at the beginning, and they split these cats into three different groups.
So one that had rubena coccib every 24 hours, one that had rubena coccib every 12 hours, and then and the key to profen group, which they administer. Every 24 hours, for example. So yeah, I think they, they described their methods pretty well, and they randomly assigned or their cats into the different groups, which is again, a way of saying we're not going to be influenced by putting all the really sick cats in the menococcy group.
We're going to do that randomly to make sure we're being as unbiased as we possibly could be. So yeah, the, the, assessment scores, so they used what's called a global assessment score for the vet assessment. So this is where they had 3 different scales that they use to measure the outcomes for the patients.
So signs of pain and palpation was one of them, inflammation intensity was the other, and mobility was the third one. And they, they summed all of those scores up to make this global assessment score, which was assessed by a vet. And then they also had a global assessment score for the owner, and again, same thing, 4 different scales that they kind of added up.
So level of activity was one of them behaviour, second one, appetite, and interaction or sociability. So that's really the, the sorts of things that they were looking at. And they decided that these things would be considered non-inferior if the lower bound of that confidence inter was greater than 0.8, and this applied to both the vet and the owner scoring.
So for our results. So we can see here, so the primary outcome of interest, so every time someone does a trial, they should have something that they're primarily interested in, and they should state that. So for us, this was this global assessment score, and they were saying that they demonstrated non-inferiority for both.
Be a coxy groups, so the vet and the owner assessments, because the lower estimate was greater than 0.8. So if you have a look at the table one here, you can see all of those values that have been circled are greater than 0.8.
So that means that we can say Rabena coxi is demonstrating no inferiority. So that's, that's for the That one. So, so for the other outcomes of interest, the other things they were looking at, again, they demonstrated non-inferiority for veteran owner assessments, because this lower estimate was, was greater than 0.8%, the same thing.
So in table one, there's, there's some secondary other things they're interested in. And then again, for the owner related things down the bottom there that, that again, we can see that's greater than 0.8, so we're pretty happy that non-inferiority was demonstrated in terms of, of this.
There was no significant difference in terms of adverse events between these different groups. So if we move on to to paper two, I guess our population of interest was Cats based in veterinary practises in Japan, which is a bit of a comparison. And I guess we didn't really find out again which animals came from, how many animals came from each clinic.
And again, we had, we started off with a number of cats, and we needed to exclude them as time went on. And these were split just into two different groups. So we We have a coxi dosed it once every 24 hours and ketuprofen at once every 24 hours.
Again, they randomly allocated these into the different groups and the methods were described pretty well. And again, if we just have a look at the clinician score, so, . Again, they've done this sort of summed score.
They had 3 different scales. So pain on palpation, inflammation, intensity, and mobility for the vet assessment and then owner assessment was measured level activity, behaviour and appetite. There's not a lot of detail actually in the methods that describe how these things put together.
It is a bit unusual. Normally they tell you about how these things are added up together, what they should do at least. Yeah.
And we just have to assume that that's what they've done in terms of this sort of overarching score for these various bits and pieces, I think. And again, same thing with the non-inferiority, so this time instead of 0.8, the lower boundary they're looking for was greater than 0.75 and that was for both of them.
So again, if we have a look at our results, so we've got our non-inferiority demonstrated for rubena coccyd for the primary outcome of interest. This is for the vet assessment, because again, our lower estimate was greater than 0.75.
And you can see here, again, we're just talking about our primary outcome of interest here, which is the total clinician score, which is the first one there. And if we have a look at our other outcomes of interest, you can see that non-inferiority was demonstrated for some of the variables, but not all of them. So for example, behaviour and appetite was very much less than 0.75, so we can say maybe for those variables, non-inferiority wasn't really demonstrated.
So it's a, yeah, so for this particular one, for example, it means that there are, things that that perhaps didn't quite happen the same, and I guess if we're having a look at total owner score, for example, you can see probably that that we've got activity and human animal relationship there. If those things are are are put together with behaviour and appetite, then probably overall we've got a pretty good score. But actually when you dig down in the detail of that, then actually there's individual things like activity and human animal relationship that very much tick the box and the other two don't.
So again, it's a bit weird to put them all together and say that's what we're interested in because it doesn't necessarily represent the results that we got, I don't think. So this is our clinical bottom line. So this is an example of our blog shot that we put up on our Facebook page and also put into our newsletter, just, it's a very distilled summary of, of the things that have happened in that best bet.
And the authors of this bet have concluded that Rubena Coxi has non-inferior efficacy compared to ketorofen in controlling acute musculoskeletal pain. And that's after these two things have been kind of summed together, . So I guess if we, if we try and put this into context then, then .
Again, as we said at the beginning, we're focused on just acute pain, aren't we? Yeah, and it's super interesting actually if you look at the population of cats that were actually included in these studies, the majority of them in both studies actually were cats that had suffered, cat bite abscesses or bites or scratches, which kind of gets you into an interesting situation of actually how do you define musculoskeletal pain really and. Some of the other populations within both of these studies included severities up to, you know, limb dislocation, or ruptured ligaments in the limbs.
So there's a massive wide range, and it's very untransparent, really, as to, you get the percentages of cats that were scratched versus had a cat by abscess versus had a dislocated limb. But it's quite difficult to then to. Determine the severity of the scratch, the abscess, etc.
To really understand quite what they mean when they're talking about acute pain and musculoskeletal disorders, which may be an interesting way to, well, it's hard to know quite why that was. It may be that that's how they decided to define musculoskeletal disorders. I'm not sure that I would necessarily have.
Myself thought about cat like abscess as a musculoskeletal disorder, but it's quite interesting, to then to look at that, because it, it may be that these cats were so wide ranging in the severity that actually these trials really don't tell us very much at all about the majority of cats that maybe we would think about having musculoskeletal pain in terms of, you know, primary orthopaedic injuries, really. Yeah, for sure. .
Again, I think in terms of the studies generally, it's really hard to unpick from these where the cases would come from, particularly when you've got, you know, multiple countries that are involved. So it's, it's hard to, to say actually, and with all of these things we're saying, can we extrapolate back to our UK population, as I said at the beginning, if a study is done in a different country, can we be confident that the way that practise works here is the same as the way that practise works in other countries. So that's definitely has to be consideration, I think.
And, and as I said, I think sometimes if you believe that it doesn't, it's not comparable with the type of practise you do, then it's absolutely fine to go, well, I'm just gonna not use that bit of evidence because I really don't think it's going to make any difference, to be fair. . Yeah, so I guess, again, our bet question was more generic than the papers that we actually found.
And again, this search was done a couple of years ago. We'll be updating the search later on this year. So it's quite possible there's other evidence out there that we could add into this question.
Yeah, which will be really interesting. Wouldn't it? Yeah, it'll be really cool if Benaco it has now been compared to something that isn't just ketorofen to see whether or not there's any, any evidence of any any differences really would be quite cool to see of any outcome.
Absolutely. And again, I think, you know, non-inferiority was demonstrated, but actually, you know, if you're using ketuprofen, and, and, you know, this is saying, well, it's equivalent to urbanooxxi is equivalent to ketuprofen, I think maybe people would be saying, well, there's got to be lots of other reasons why I might be choosing this new drug, maybe, over this, this old one, because if I've got something that works equivalently, then maybe I don't need to worry about investing in something new. And other things, so cost comes into it, and other factors that might Mean that you're gonna choose to decide to change what you do, or maybe you decide to stick with what you've got, which is, which is quite fine with this sort of stuff.
Yeah, there were a few comments in the papers around palatability, for example, that the owners had just said back potentially that Robenaox it was maybe a bit more palatable than ketorofen. So there's lots of other reasons, obviously, why you might the COX 2 selectivity may be a factor in it, for example, and this is looked at obviously just one very specific outcome for that inferiority. So yeah, it's interesting.
And as I said, again a bit earlier, it's about, it's about, you know, owner and patient factors may be coming into play here. And again, going back to that final step, you know, feasibility of treatments, or maybe, you know, if, if an owner has real troubles tableting a cat, for example, then, then maybe these treatments aren't going to be the most appropriate ones for that person to be giving their animals. So, you know, we might need to think about other alternatives and other administration routes.
So again, it's got to be, it's got to be applied back to the situation you have in front of you. Brilliant. Cool.
Enough of the orthopaedics. Time for some good old internal medicine. So that too that was chosen by, the webinar vet respondents was this one around the use of antibiotics in dogs with aseptic hemorrhagic gastroenteritis.
And so the PIO question that we asked was in clinically well dogs with Hemorrhagic gastroenteritis, the systemic antibiotics compared to no antibiotics, decrease the time to resolution of clinical signs. And this was a bet that we, we published in March 2017 that came from a BSAVA regional workshop and evidence-based veterinary medicine. So it's a really, really nice question.
And again, similar to the, the ketorofen example in the previous be, . Actually, we looked for, you know, any systemic antibiotics, you'll see that we only found one paper that compared one type of antibiotic. That wasn't the choice, we didn't decide to just look for amoxicillin clafeic acid, that was literally just the the the one antibiotic that we found that fitted the bill.
I think probably important to say that . Probably we wouldn't use the term, well, we might not necessarily use the term hemorrhagic gastroenteritis now when we're describing the population of animals that are included in this paper, we're probably much more likely to actually talk about, acute hemorrhagic diarrhoea syndrome. And I'll dig into that a little bit more in a second, actually, in terms of why that's important.
But we've got a question, that's a box question again there for you that we can just keep ticking along as we go. If any of you are listening that did vote for the question and there was something specific you'd like us to dig into, then do pop that in the, in the box. We'll keep going for now, but then if you just wanna type it in there, then then go for it.
So in terms of the searching process, as with the previous vet vet, as I've just said, we did look for any antibiotic, it wasn't specifically targeted for amoxicillin clabulanate, and we also use much broader terms than just hemorrhagic gastroenteritis. And the context in which this question sits, I think is probably really around the concerns that many of us have. Around antibiotic overuse in clinical practise and small animal medicine.
So, do we really need to be, to be giving antibiotics for some of the cases that we're using them for and certainly routinely did use them for? And there's lots of focus groups, really now putting pressure on us, I would say, as vets to really be responsible with how we use our antimicrobials in practise. And so there's a few reasons why, why this question might have been posed.
Really based on do I need to be giving the treatment. And I think it's important also to realise that a lot of us have a fear of not doing anything because what if it goes wrong if we don't do anything? Maybe we get sued by the clients, maybe we get criticised by our colleagues, and I think that's one of the motivators that we do sometimes think, well, actually, I'd better be safe than sorry, really.
And so this is quite a useful bet to dig into that and what's probably quite a common question, actually, common clinical scenario. So the paper that we found was by Stefan Unterer and colleagues who's somebody who's really done quite a lot of research in this field and continues to publish even last month, had another publication out actually about this acute hemorrhagic diarrhoea syndrome. This was a study that was performed in Germany at a single small animal clinic in the University of Munich.
And, what they did is over a two year period, they identified 60 cases of what was then called hemorrhagic gastroenteritis, . Just to dig into that a little bit more as to why it's changed its its name and it's predominantly actually due to the work of this group, when they've done further work looking at necropsy and the biopsies in these dogs, they found actually that the stomach region doesn't particularly seem to be affected at all. So that's why the gastro bit's gone out of it.
And it's also had the name syndrome added on to the end, so it's acute hemorrhagic diarrhoea syndrome. And syndrome is, is a really great way that we internal medics and other disciplines, would use to describe something that we just don't really know what's going on actually. And that's really important to be aware of when we're thinking about the context of this death.
So there's several etiologic agents that have been proposed, the UNT group are particularly interested in a specific type of Clostridium has been the causative agent in this syndrome, other. A proposed circa virus. And there's also quite an interesting, channel of thought around whether this is actually dysbiosis.
So whether it's a change in the normal gut flora that leads to an increase in virulence in something that would have previously not have been virulent, and that might fit into the into the into the clostridial pocket. But really important that we, we really don't actually know what we're treating here. This is a syndrome.
And these, this group, when they were setting up this study, put in exclusions to try and rule out the common things that we would recognise. So they said that, you know, we can't have septic dogs, it can't be adverse events. We've got rid of the Campylobacters, salmonellas, we screened for all of those.
So they've tried to keep it quite a pure focus on these quite idiopathic dogs, really, where we don't quite know what the underlying cause is. And they randomly allocated these dogs into two groups. They either received amoxicillin, clabulaic acid for 7 days or placebo for 7 days, along with supportive therapy, which consisted of intravenous fluids and gastroprotectants.
They had typically about 3 days in hospital, and then, they were then sent home to continue treatment after that. And their outcome measure of choice was a canine hemorrhagic gastroenteritiss activity index, which was scored by vets, which is quite considerably based on the, the canine inflammatory bowel disease index, which is something that's been around for quite a few years, it's quite commonly used in a lot of papers actually. And it's a cumulative score, and you can just see what was assessed there.
So it's clinician scored, which in itself is quite interesting actually. They'll have used some owner report for when the dogs were at home. But around appetite, vomiting, stool consistency, frequency and dehydration, and that they, they've set some criteria for normal, mild, moderate and severely decreased.
So we've got all of these dogs that are presented with similar clinical signs that are either getting placebo or they're getting amoxicillin clavulanic plus IV fluids and, and gastric protectants. So pretty much when you have a look at the groups, one of the things that's really important for us to have a look at in all of these studies is were these groups comparable prior to the intervention, and they pretty much were, they did quite a lot of stats to have a look at whether or not these dogs were roughly the same and and they were. In terms of blinding, the people who were administering the treatments weren't blinded, so they knew what the dog was getting, but the person that was assessing the outcomes didn't, which is kind of OK, probably, it's interesting to again consider how much over report might have been involved in that seven day outcome measure in terms of having unblinded owners.
We also get very interested in sample size calculations. Marie and I get quite geekily into these stats, I would say. Probably not as interesting to others, but it should be, because actually, if you have got two smaller a number of animals, then you're not necessarily gonna find a positive response, positive answer to your question of interest.
And so what we like to look for is something called a sample size calculation in the materials and methods that says, to show the difference, we wanted to demonstrate we needed this many dogs, and then we. Look at whether or not they actually achieved that. And these guys didn't specifically do that in the materials and methods.
They did something later to have a look at dropouts, but they didn't specifically do a sample size calculation. Again, we also get quite interested in funding sources for these ones. There wasn't any funding stated for this, but it was probably part, we know it was part of the university patient cohort, so it may well have just been internally funded by the hospital.
So the main key finding in this one, really interestingly was that there was really no difference actually in this activity index or the length of hospital stay between these two populations. So the dogs that received labuanttic amoxicillin, did the same really as those that just received a placebo. And interestingly, there was a very rapid improvement in clinical signs in both groups which in the discussion in this paper, the authors really attribute very strongly to the importance of intravenous fluids.
I think it's. Difficult to say, definitely, that that was what did it, because obviously there wasn't a comparison to dogs that received absolutely nothing at all, but there's lots of evidence that these dogs can become quite dehydrated. And so supportive therapy in terms of IV fluids, plus minus gastroprotectants is certainly something that is currently very indicated.
And of 60 animals that went into the study, 53 completed it. There were a couple of deaths, interestingly, in this study from within both of the different arms, showing that this isn't a completely benign, clinical problem, even though, . The majority of dogs did get better very, very quickly.
So that's just a table of results down there really that shows you actually there really wasn't any particular significant interest significant difference at all between those groups on any day actually of that study. So again, here's our blog shot, that's what we put out on our kind of social media to make it easier to share. And our bottom line in this bet was that treatment of dogs with aseptic hemorrhagic gastroenteritis with amoxicillin clavulanic acid doesn't seem to reduce the time to resolution of clinical signs compared to a placebo.
In the second paragraph, we've got a caveat. So really, obviously only one relevant study was found in which one antibiotic was used, so we don't know the efficacy of other antibiotics, in the treatment of this condition in other dogs because there aren't the studies there that directly head to head compare those. But from this study, it, it looks like there was, there was no improvement, in the dogs that did receive the antibiotic.
So again, what are the main take home messages from this one? Well, a good thing about this was that the authors were pretty honest in terms of realising the limitations of the study, which is always something that we'd quite like to see. And as I've said, this group have gone on and continued to do lots and lots of work actually to really try to pin down.
A little bit more what's going on, with this population of dogs. The sample size is something they dug into a little bit there in terms of maybe they just didn't have enough dogs to get, to get a significant result, which is certainly, certainly a definite risk there, actually. They didn't tell us loads about the breed of the dogs, which maybe from our point of view would be quite handy.
And also it's quite, it's. It's tricky to know from this paper really how well these dogs might match the ones that we see in practise in the UK in terms of when they present in the course of the disease. Was it very early on?
Was it quite a long way through? There aren't those details in there, and that's a very common feature actually in most of the, the small animal publications that we see that there isn't loads of patient information data in there at all. So again, no significant difference may be potentially underpowered as the cause for that really.
And yeah, I think we've still got this problem that we're gonna feel probably we should do something. There may be an expectation from colleagues, you know, you've got he magic diarrhoea. We do worry about sepsis, even though in this population, that has been looked at now in several papers, it does seem to be pretty rare, but there is obviously that clear pressure.
But on the basis of this bet, the evidence would suggest that, amoxicillin and clanana is not necessarily the treatment of choice. So again, you know, just going over the same things we've talked about in terms of across both of these best bets, you know, study design issues come up like sample size, you know, wasn't kind of calculated beforehand. We don't really have any validated scoring systems that are used.
So these are just scoring systems people have made up themselves, and we don't really have any idea about how they perform in other populations and obviously blinding is what we've talked about. And then, or maybe it's about reporting, maybe these things actually happened, but it didn't never made it into the publication that actually got got published. So, so again, there's lots of good frameworks that people can use to help report their science, actually, the equator.
Network is a really good place to go if you're ever publishing stuff to say, what do I need to, what's the important information I need to include in my paper when I'm reporting a trial, for example. And again, we've focused very much on peer-reviewed papers in these bits, because that's how we, how we kind of go through the process. But obviously, you know, for questions that don't have any peer-reviewed evidence, for example, so absolutely, other forms of evidence, we can absolutely use like textbooks, conference proceedings, expert opinion, etc.
. So just in summary, very quickly, you know, I think these sorts of resources can really help with decision making. We've had feedback saying it can, so hopefully that's good, without having to spend hours yourself doing these assessments on these papers, and maybe until you get yourself skilled up in how to, how to assess quality of papers, it's a good opportunity to, to use these. And again, as I said before, there's loads of other sources out there to use, so, so, we're in a really good position.
And I think too, you know, these structured critical appraisal questions can really help when you're trying to interpret journal clubs and things. So we know people have used them previously, and context, obviously, when we're applying it back into our practise is really important in terms of what patient we have in front of us and owners as well. So, we might just skip that one, I think, and go to, go to here.
So just to give you a summary, we've just under 70 published online. We've got quite a few page views and lots of users now actually, and most of the countries or people based in countries are from the UK essentially, but we've got a range of other countries that are now dipping into our best bets as well, which is great because it means people are using it out there. .
So again, resources that we've covered, so if you're interested in knowing more about searching strategies, EBDM learning tutorial is a really good place to start. There's loads of resources out there in terms of these critical appraisal sheets or questions you can use to ask of each paper to determine the quality of it. And there's some references there you can, you can go to or click into.
And again, we're really interested in, in working with people to offer some bets. So please get in touch with us if you'd really like to, to kind of publish them with us. So again, you can post questions via our best bets for Vets website.
You can email us at CBM at Nottingham.ac.uk.
You can get in touch directly with us. I think you've got both of our email details, or you can follow us on Facebook about our best bets blogs shots, . Which the Facebook page is centre and the space medicine, I think, isn't it, if you just look for a centre for evidence-based medicine, we've got nearly 1000 people that follow that now, and there's some interesting discussions when we post these bets, we put one up very recently about cat bite abscesses which generated a tremendous amount of, discussions and, and that's another place also if you want to send us a question, we've had quite a few questions coming directly through the Facebook, direct messaging system.
That's totally cool we can incorporate those into the system. Fabulous. Again, if you're really interested in going into this in a bit more detail, we've got a course that we're running, which goes over a number of months, so it's, it's pretty chunky.
You get 65 hours worth of CPD credits if you decide to come on board. And it's mostly online, with some a couple of days in person here talking about more in this sort of detail in terms of how we go about this process. So, yeah, lots of good things.
If you just go to our training opportunities on our website page, you'll see all of the detail of that. So thank you very much for listening everybody, and hopefully we've got a couple of minutes now for questions. I think there was someone did put something on the Q&A.
I think, yeah, it was, Cameron, I think it was. So thank, firstly, thank you very much. I'll come to Cameron in a second, so that was fantastic.
I think we've missed off a question, to be honest, Zoe and Mai. And I think the question that we, at the end, we should have asked was, following this presentation, how likely are you to now use best bets for vets in clinical practise, both in. Decision making and also in writing your protocols.
So I think that's probably, remiss of us not to include that. But it would be interesting to get you, you, the, people who are listening your thoughts on, and, just to put a quick thing in the Q&A in the chat box to say whether they're off the, for those who said, no, they haven't used it yet, whether they're actually following this presentation, you would now, use it as a tool. So, I could give you 2 minutes to, let us know about that.
That'd be fantastic. When you look on the website, there's loads of really good information on there about some really common clinical questions. So, and it's super easy to access and it's, you get an instant bottom line and the level of rigour that we've discussed just here certainly reflects, you know, these, these things take quite a considerable amount of time for us to do and so the bottom line is really quite well.
Considered, you can, I would say you can trust it, if you can trust us, you can trust the bottom line pretty well. Hopefully, hopefully, like I said, I think the emphasis for us very much on, on making sure that it's as robust as it can possibly be. So yeah.
So, so what Cameron was saying, and I think at the end you did summarise it, but you can just go back, it's on the HGE. about, find out what he was interested in was about the, use of antibiotics, and he finds that even though the research suggests antibiotics are not required, he often finds that those animals treated without antibiotics in some form of anti-inflammatory, it takes longer to recover compared to those treated without antibiotics. Yeah, it's interesting, isn't it?
It's really hard to dig into that because it could be that the, the. It depends whether or not you're choosing to treat them with antibiotics or not, and it may be that certain owners or certain types of animals are maybe more likely to receive those antibiotics. So it may be that certain owner populations decline, and then they give you different feedback or are more likely to present back with the dogs, saying they're not satisfied.
Or it may be that you're absolutely right and that actually, you know, there is a strong suspicion that the etiological agent for this is probably a bacterium. But as we've said, and this is a syndrome, and we just don't know what the causative agent is. So at the moment, we're all kind of working in the dark a bit, because we don't know what, what it is we're trying to fix.
And it may be that ultimately we do find that actually this is something that, or it may be that because it's a syndrome, there's loads of different etiological agents. So it may be that some of the population absolutely do improve with antibiotics and some of them don't, so. Yeah, it's super tricky.
Maybe it's about severity, so maybe you're more likely as a clinician to give antibiotics when you think it's a bit more severe. And so therefore, naturally, because they're a more severe population, they're going to take longer to recover anyway. So you just so it could be, it could be about the treatment that You choose to and which animals choose, you choose to give it to as well.
More research needed as ever with our bottom line with these things really. So yeah, super interesting if you start keeping a note on, start looking at your own case population really and think about how you make those decisions about when you use antibiotics and when you don't, and, see if you've got some biases going on in there about what you treat. I think we all do, to be honest.
And it might be about the animal, it might be about the owner, and, yeah, but definitely we need more data on these, it's tiny, tiny case population at the moment that are being studied by this in a group, so. No, and so if obviously if anyone does have any other questions, after the webinar, they can of course, just go on the, on the website and. Submit a question via the form that you put up on that earlier slide, can't they?
Yeah, which is CEM at Nottingham.ac.uk.
That sounds good. Fantastic, no problem. So, that's another area where you can obviously please do get engaged because I think you're right in saying that the more people that engage with this, .
Platform, then obviously the more powerful it will be and the more useful people will find it as people engage in cross reference, would you say is that, is that what you're trying to, you'd encourage people to do is the more people to get involved in the into that discussion? Totally, yeah, absolutely. Like I said, this is for people to use out there.
So, so, you know, it's got, if we can make it the best it can be for what people want it to be, then that's, that's great. We're ticking that box and we're, we're doing the right thing. So yeah, more, more, any feedback anybody has would be really useful.
And definitely joining the chat on Facebook when we post one of these blog shots, we often put quite a bit of information up there about the clinical context and some of the discussion. And, it's really interesting when we get feedback, when people start to tell us, oh, that fits with what I thought. Oh gosh, that surprises me.
And it can lead to some really interesting discussions actually. Again. Reference the one that the cat might abscesses and whether or not you should give an antibiotic because they, they then always turn into critical appraisals themselves actually about the question that was asked, it's super interesting, so definitely joining.
Fantastic. Well, thank you. Oh I think I haven't had any more questions, so what I'll leave me to is to say thank you to yourselves for that fantastic presentation.
And say, please do. There is a call to action there for everyone who's tuned in tonight to visit the website, take a bit of time, familiarise yourself with it, and start to use it and look at how you can incorporate into your practise. For me here in Chester, it's still a very pleasant evening.
I think it's even still nice enough to sit outside, so I'm sure there's time for you to grab a glass of wine or a G&T and enjoy the rest of the evening. And I, look forward to welcoming you on a webinar shortly. So, good night and thank you very much.
Thanks everyone. Thank you.