Response #1 to Deana
Weighing the Evidence
Alcohol abuse is a common societal and economic problem in the United States with approximately 8.2 million persons dependent on alcohol (Perry, 2014). It is thought that patients with mild to moderate symptoms of AW can be treated successfully on an outpatient basis. However, hospital admission provides the safest setting for the treatment.
In the study conducted by Ray, Chin, Heydari & Miotto (2011) the objective is to clarify the bio behavioral mechanisms of action of quetiapine for alcoholism, by examining its effects on subjective intoxication and craving. The six main considerations for study design are the question to be answered, the study population, the unit of analysis, the type of study, the measuring technique, and the calculation of sample size (Bernd, du Prel, & Blettner, 2009).
According to Ray, Chin, Heydari & Miotto (2011) the study aims to answer the question related to the significant reduction of alcohol cravings during the administration of quetiapine in patients. The study population was a total of 20 non-treatment seeking alcohol dependent individuals who were randomized to one of two medication conditions: quetiapine (400 mg/day) or matched placebo (2011). Inclusion criteria was age range between 21 and 65 years old and a diagnostic criteria for alcohol dependence. 20 participants were randomized into two groups of ten. Weekly assessments were completed to review medication compliance and assess the side effects of the medications. During the weeks that followed, participants were places on the target dose of the medication, or matched placebo.
Conclusions were made based on the analysis of study participants with medication adherence, weekly reports of alcohol cravings, and the effects of quetiapine versus placebo on sleep, anxiety and depression, and alcohol use. Participants were studied using series of mixed-design repeated-measure analysis of variance (ANOVAs), to test the study hypothesis (Ray, Chin, Heydari & Miotto 2011). Specifically, ANOVAs using the general linear model were used to examine the effects of alcohol which was a two-level within subject factor (quetiapine vs placebo). According to Polit & Beck (2012) meta-analysis is often described as a two-step analytic process (p. 661, 2012).
Whenever a clinical question arises, a first step in finding a quality answer is to review the literature for previous research and ask experts in the field for their opinions (Bernd, du Prel, & Blettner, 2009). The study results are consistent with previous reports of quetiapine induced blunting of alcohol cravings (Ray, Chin, Heydari & Miotto 2011). Findings extend the clinical literature suggesting that quetiapine many be effective for the treatment of alcohol dependence. However, one weakness related to the analysis of this study, is whether quetiapine may be most effective as a monotherapy or as an adjunct therapy.
Additional research studies can be done to examine the effectiveness of treating alcohol dependence with quetiapine in combination with other medications. An alternate conclusion that can be made is the effects of quetiapine on alcohol withdrawal does not provide significant amount of beneficial treatment in the acute stages of treatment. According to Dingle (2011), a fundamental problem is that researchers with direct links to drug companies have the authority to select the most positive studies and ignore the rest - including independent studies not funded by pharmaceutical companies.
Bernd, R., du Prel, J.-B., & Blettner, M. (2009). Study design in medical research: Part 2 of a series on the evaluation of scientific publications. Deutsches Aerzteblatt International, 106(11), 184–189. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695375/pdf/Dtsch_Arztebl_Int-106-0184.pdf
Dingle, P. (2011). Statin statistics: Lies and deception. Positive Health, 180, 1.
Retrieved from the Walden Library databases.
Perry, E. C. (2014). Inpatient management of acute alcohol withdrawal syndrome. CNS Drugs, 28(5), 401-410. doi:10.1007/s40263-014-0163-5
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice(Laureate Education, Inc., custom ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Ray, L. A., Chin, P. F., Heydari, A., & Miotto, K. (2011). A human laboratory study of the effects of quetiapine on subjective intoxication and alcohol craving. Psychopharmacology, 217(3), 341-51.
Response # 2 to Julie
Research Article: Meddings, J., Saint, S., Fowler, K. E., Gaies, E., Hickner, A., Krein, S. L., & Bernstein, S. J. (2015). The Ann Arbor criteria for appropriate urinary catheter use in hospitalized medical patients: Results obtained by using the RAND/UCLA appropriateness method. Annals of Internal Medicine, 162(9_Supplement), S1-S34.doi:10.7326/M14-1304
This study was initiated to examine the appropriate use of urinary catheters. The researchers felt the HICAP list of appropriate use did not consider other appropriate actions lie, urinary incontinence without obstruction or patient comfort and request. (Meddings, Saint, Fowler, Gaies, Hickner, Krein, & Bernstein, 2015).
The studies secondary aim was to design parameters for future catheter use on medical patients. Three type of urinary catheters, indwelling, external and straight cath were evaluated. A 15-member panel comprised of healthcare professionals, experts on infection prevention. In total 299 clinical scenarios were reviewed by the panelists in order to score for appropriate catheter use, inappropriate use or uncertain. Currently, most common reason for catheter use involve, urinary retention, accurate measuring of urine volume and incontinence. The study excluded catheter use in periopertiaitve patients.
Researchers evaluated several studies to observe for the appropriate indication of use in indwelling Foley catheters for the inpatient population. Several rounds of data collection involving 299 scenarios contributed to the findings. Urinary catheter types (internal, external and straight cath) were evaluated in 97 clinical scenarios. Evaluation for appropriateness included patient preference to have a Foley in some of the studies.
Data and Statistics
In order to remove errors and check for inconsistencies researchers utilized Microsoft Access Database in duplicate. Data from every round was entered into the program. Researches used descriptive statistics to calculate all variables. Frequency of responses, median response and panelist response were summarized and classified. Analysis utilized SAS software version 9.3. RAND / UCLA Appropriateness Method was applied to evaluate median scores and levels of disagreement. (Meddings et al., 2015).
Researchers evaluated several studies to observe for the medically appropriate indication of use in indwelling Foley catheters for the inpatient population. Several rounds of data collection involving 299 scenarios contributed to the findings. Urinary catheter types (internal, external and straight cath) were evaluated in 97 clinical scenarios. Evaluation for appropriateness included patient preference to have a Foley in some of the studies. Only 88 of the 299 patient scenarios were deemed appropriate catheter use. 165 were inappropriate and 46 were rate uncertain by the panelist. Additionally, 105 clinical scenarios were evaluated for appropriate indwelling Foley use, panelist found 43 were rated as appropriate, 48 were rated as inappropriate, and 14 were rated as uncertain due disagreement. Other clinical scenarios were considered as well. This information help the researchers to design a more refined appropriate use of Foley catheter in hospitalized patients. New guidelines could be adopted to that further clarify appropriate catheter use. These inclusions are accurate measuring of urinary output when there is no other method to do so. Currently this practice is only accepted in ICU patients. In addition, there are indications where incontinence in medical patients should warrant the use of urinary catheter.
The placement avoidance and prompt removal of unnecessary catheters will contribute to a decreased incidence of CAUTI in the inpatient population. Additional criteria outlined by the researchers can contribute to the decrease in CAUTI. The researcher highlight the problem of patient specific challenges as a weakness in the study, like age, pre exiting conditions of skin and other disease process. The application of Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients can educate healthcare facilities devise interventions to evaluate Foley placement and ensure prompt removal of unnecessary indwelling or external urinary catheter.
Alternate Interpretation of Data and Additional Weakness
The study evaluates for appropriate use however, challenges remain in the area of increased infection rates for those receiving urinary catheters.
The inclusion of external catheters and condom catheter can influence CAUTI results. Indwelling catheters are attributed to higher infection rates. Additionally, patients who straight cath due to disease process have a medically appropriate reason for catheter use and have higher incidence of catheter associated infection. Their inclusion in the study could influence the results. Perhaps considering acute over chronic patient scenarios would have been a better option. If the researchers are trying to develop appropriate urinary catheter protocols excluding those who have clear, medical necessity should not be included. The researchers were trying to rectify gaps in the HIPAC guidelines for catheter use Meddings et al., 2015). Rate of infection for men and women may vary due to anatomy. Disease process such as prostate problems or diabetes can affect appropriate use and CAUTI incidence.
The authors focused on size of catheter and duration of time of Foley indwelling. In other studies, the impact of pericare has come into question.
Panelist experience may affect the study. These panelist were experts on infection not Foley catheter use. Use of indwelling Foley catheter for bladder retention is sometimes used. Some panelist did not recognize that external catheters would not rectify this problem. This could have led to errors in the appropriate use category. Clinical experience of panelist could sway the data regarding personal opinion on appropriateness.
Additional Research Study
A possible study could be done to consider the morbidly obese population or those patients with limited mobility. The tradition appropriateness for catheter use may exclude this population although there may be instances were catheter use is warranted for this population due to increased risk of skin breakdown. Perhaps guidelines that are more stringent that consider challenging anatomy and the difficult inspection of urinary meatus should be considered for this population (Meddings et al, 2015).
The results for indication of use varies on medical floors medical floors. Therefore, the authors assert limits to the findings regarding perioperative patients (Meddings et al, 2015).An additional study that may be appropriate would consider use of pre op and perioperative patients. More quantitative studies could help to evaluate the effectiveness of using stricter urinary catheter guidelines.
Quality appraisal appears sufficient as panelist reviewed over 299 examples. However, clinical expertise and opinion of the panelists significantly affect the study results. Polit and Beck (2012) reiterate that in systemic reviews the quality of the study will contribute to strength or weakness this includes instruments of the study as well. Tools and instrument of measure will have effects on study quality. How much the panelist influenced the results is uncertain as well as their level of expertise on urinary catheters and appropriates use.
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (Laureate Education, Inc., custom ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Meddings, J., Saint, S., Fowler, K. E., Gaies, E., Hickner, A., Krein, S. L., & Bernstein, S. J. (2015). The Ann Arbor criteria for appropriate urinary catheter use in hospitalized medical patients: Results obtained by using the RAND/UCLA appropriateness method. Annals of Internal Medicine, 162(9_Supplement), S1-S34.doi:10.7326/M14-1304
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