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Practice Cases

This is a self-correcting exercise. Click on the letter (A, B, or C) or "Quiz Yourself" for a pop-up box with the response.

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ASSESS the patient


Start with the patient -- a clinical problem or question arises from the care of the patient

 

Ms. MP is an 86 year old highly-functional resident of Croasdaile who presents to the emergency room after a fall in her home.  Workup identifies a right femur fracture.  The orthopaedic surgeon recommends urgent repair and perioperative antibiotics.  Ms. MP, who with her husband operated a health food store for 40 years, has spent her life avoiding medications and using natural remedies.  Her husband mentions concern over the possibility of diarrhea as a side effect of the antibiotics and asks if using fermented milk with lactobacillus or some other probiotic product would prevent this side effect. Should she start taking a form of probiotic to prevent this problem?

  
ASK the question

Choose the BEST clinical question:

What is the best treatment for diarrhea?

In patients taking antibiotics, are probiotics helpful in preventing diarrhea?

Do probiotics prevent diarrhea in the elderly hospitalized patient?

 

ACQUIRE the evidence

Choose the best PubMed search strategy to address the clinical question.

Search: diarrhea AND best treatment Limited to Free Full Text

Search: diarrhea AND probiotics AND elderly AND female AND adult  Limited to English 

Search: antibiotics AND diarrhea AND probiotics   Limited to randomized controlled trial

 

APPRAISE the evidence

Read the following article and determine if it meets the validity criteria.  (Click on title to access free full text)

Beausoleil M. Effect of a fermented milk combining Lactobacillus acidophilus Cl1285 and Lactobacillus casei in the prevention of antibiotic-associated diarrhea: a randomized, double-blind, placebo-controlled trial. Can J Gastroenterol. 2007 Nov;21(11):732-6. PMCID: PMC2658588 PMID: 18026577

ABSTRACT:

BACKGROUND: Antibiotic-associated diarrhea is an important problem in hospitalized patients. The use of probiotics is gaining interest in the scientific community as a potential measure to prevent this complication. The main objective of the present study was to assess the efficacy and safety of a fermented milk combining Lactobacillus acidophilus and Lactobacillus casei that is widely available in Canada, in the prevention of antibiotic-associated diarrhea. METHODS: In this double-blind, randomized study, hospitalized patients were randomly assigned to receive either a lactobacilli-fermented milk or a placebo on a daily basis.
RESULTS: Among 89 randomized patients, antibiotic-associated diarrhea occurred in seven of 44 patients (15.9%) in the lactobacilli group and in 16 of 45 patients (35.6%) in the placebo group (OR 0.34, 95% CI 0.125 to 0.944; P=0.05). The median hospitalization duration was eight days in the lactobacilli group, compared with 10 days in the placebo group (P=0.09). Overall, the lactobacilli-fermented milk was well tolerated. CONCLUSION: The daily administration of a lactobacilli-fermented milk was safe and effective in the prevention of antibiotic-associated diarrhea in hospitalized patients.

Are the results valid?

You will need to read the methodology section of the article to address the validity questions. Evaluating the medical literature is a complex undertaking. You will find that the answers to the questions of validity may not always be clearly stated in the article and that you may have to use your own judgment about the importance and significance of each question.

Randomization: Were patients randomized?

Concealed allocation: Was group allocation concealed?

Baseline characteristics: Were patients in the study groups similar with respect to known prognostic variables?

Blinding: To what extent was the study blinded?

Follow-up: Was follow-up complete?

Intention to Treat: Were patients analyzed in the groups to which they were first allocated?

Equal treatment: Aside from the experimental intervention, were the groups treated equally?

What are the results & how can I apply them to patient care?

Results:  Among 89 randomized patients, antibiotic-associated diarrhea occurred in seven of 44 patients (15.9%) in the lactobacilli group and in 16 of 45 patients (35.6%) in the placebo group (OR 0.34, 95% CI 0.125 to 0.944; P=0.05). The median hospitalization duration was eight days in the lactobacilli group, compared with 10 days in the placebo group (P=0.09). Overall, the lactobacilli-fermented milk was well tolerated.

 

Outcome Present

ADD occurrence

Outcome NOT present

ADD no occurrence
lactobacilli group 7 37
placebo group 16 29

Experimental (lactobacilli)  Event Rate = 7 / 44 = 15.9%

Control (placebo) Event Rate = 16 / 45 =  35.5%

Absolute Risk Reduction = 35.5% - 15.9% = 19.6%

Relative Risk reduction = 19.6% / 35.5% = 53.5%

Number Needed-to-Treat = 1/ 19.6% = 5

The results of Beausoleil and colleagues are consistent with those of a recent systematic review showing that probiotics reduce the frequency of antibiotic-associated diarrhea and accelerate resolution of C. difficile–associated colitis. The study was underpowered to demonstrate an effect on more clinically important outcomes. The intervention is simple, rational, and presumably relatively inexpensive. Thus, it could be reasoned that it should be implemented more widely without further study. On the other hand, there have been isolated reports of systemic infection with organisms used as probiotics. Moreover, in light of the potential importance of minimizing the adverse effects of systemic antibiotics in hospitalized patients, further studies should be powered to probe the effects of probiotics on rates of acquisition of nosocomial infections (with both typical nosocomial pathogens and the probiotic itself) and on clinically important outcomes, such as length of stay and nutritional status. In addition, further work to determine which microbial species exert optimal probiotic effects will aid in defining a role for probiotics in routine clinical practice.  [ACP Journal Club 15 July 2008 - Volume 149, Number 1)

 

Questions to consider before applying the results of a study to your patient:

  • Were the study patients similar to my population of interest?
  • Does your patient match the study inclusion criteria? If not, are there compelling reasons why the results should not apply to your patient?
  • Were all clinically important outcomes considered?
  • Are the likely treatment benefits worth the potential harm and costs?


APPLY: talk with the patient

Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice

 

Think about your patient, her goals, your treatment recommendation for her, the cost and adverse effects of probiotics, and help her decide whether to start taking the probiotics.

 

 

 

This is a self-correcting exercise. Click on the letter (A, B, or C) or "Quiz Yourself" for a pop-up box with the response.

Note: If you do not see a pop-up box, check your pop-up blocker settings in your browser. If that is not the problem, try closing the previous pop-up box or check to see if the pop-up box is behind your browser window. If you still do not see the pop-up box, you may need to update your browser.

ASSESS the patient
Start with the patient -- a clinical problem or question arises from the care of the patient

You are working in an out-patient Physical Therapy Department in a rural community in North Carolina.  Your regular patient, Ms. Baxter is here for her monthly visit for physical therapy related to osteoarthritis of the hip.  She is 65 years old, recently retired and has no other serious medical problems.  She shows up wearing a new magnetic bracelet which her daughter sent her.  Her daughter swears that this will help the hip pain.  Ms. Baxter is very skeptical and asks you if you would recommend the bracelet for pain control.  You don't know if there is any good evidence to demonstrate the effectiveness of the magnetic bracelets but promise to look into it before her next visit.  Will this bracelet help her hip pain?

 
 
ASK the question

Choose the BEST clinical question:

 Do magnets help control pain in elderly patients?

 Do magnetic bracelets help control pain in patients with osteoarthritis?

Do magnetics help control pain in patients with osteoarthritis of the hip?

 

ACQUIRE the evidence

Choose the best PubMed search strategy to address the clinical question.

Search: magnets AND pain AND elderly     Limited to English

Search: magnetics AND osteoarthritis AND hip      Limited to randomized controlled trial

Search: magnetics AND pain     Limited to randomized controlled trial

 

APPRAISE the evidence

This are a couple of randomized controlled trials found in PubMed for this topic.  This one is Free in PubMed Central: Harlow T. Randomised controlled trial of magnetic bracelets for relieving pain in osteoarthritis of the hip and knee. BMJ. 2004 Dec 18;329(7480):1450-4. PubMed PMID: 15604181; PubMed Central PMCID: PMC535975.

Abstract

OBJECTIVE: To determine the effectiveness of commercially available magnetic bracelets for pain control in osteoarthritis of the hip and knee. DESIGN: Randomised, placebo controlled trial with three parallel groups. SETTING: Five rural general practices. PARTICIPANTS: 194 men and women aged 45-80 years with osteoarthritis of the hip or knee. INTERVENTION: Wearing a standard strength static bipolar magnetic bracelet, a weak magnetic bracelet, or a non-magnetic (dummy) bracelet for 12 weeks. MAIN OUTCOME MEASURES: Change in the Western Ontario and McMaster Universities osteoarthritis lower limb pain scale (WOMAC A) after 12 weeks, with the primary comparison between the standard and dummy groups. Secondary outcomes included changes in WOMAC B and C scales and a visual analogue scale for pain. RESULTS: Mean pain scores were reduced more in the standard magnet group than in the dummy group (mean difference 1.3 points, 95% confidence interval 0.05 to 2.55). Self reported blinding status did not affect the results. The scores for secondary outcome measures were consistent with the WOMAC A scores. CONCLUSION: Pain from osteoarthritis of the hip and knee decreases when wearing magnetic bracelets. It is uncertain whether this response is due to specific or non-specific (placebo) effects.

Are the results valid?

You will need to read the full article to address the validity questions. Click on the link above to get a free copy of the article. Evaluating the medical literature is a complex undertaking. You will find that the answers to the questions of validity may not always be clearly stated in the article and that you may have to use your own judgment about the importance and significance of each question.

Randomization: Were patients randomized?

Concealed allocation: Was group allocation concealed?

Baseline characteristics: Were patients in the study groups similar with respect to known prognostic variables?

Blinding: To what extent was the study blinded?

Follow-up: Was follow-up complete?

Intention to Treat: Were patients analyzed in the groups to which they were first allocated?

Equal treatment: Aside from the experimental intervention, were the groups treated equally?

What are the results & how can I apply them to patient care?

Results:  Mean pain scores were reduced more in the standard magnet group than in the dummy group (mean difference 1.3 points, 95% confidence interval 0.05 to 2.55). Self reported blinding status did not affect the results. The scores for secondary outcome measures were consistent with the WOMAC A scores.  Conclusion: Pain from osteoarthritis of the hip and knee decreases when wearing magnetic bracelets. It is uncertain whether this response is due to specific or non-specific (placebo) effects.

The results are reported as a continuous variable (change in scores).  This does not allow for calculations of Absolute and Relative differences or Number-Needed-to-Treat.

Questions to consider before applying the results of a study to your patient:

 

  • Were the study patients similar to my population of interest?
  • Does your patient match the study inclusion criteria? If not, are there compelling reasons why the results should not apply to your patient?
  • Were all clinically important outcomes considered?
  • Are the likely treatment benefits worth the potential harm and costs?

 

APPLY: talk with the patient

Return to the patient -- integrate that evidence from the study with clinical expertise, patient preferences and apply it to practice

Think about your patient, her goals, the evidence you found,  the adverse effects of the magentic bracelet and what you would discuss with her at your next visit.

 

This is a self-correcting exercise. Click on the letter (A, B, or C) or "Quiz Yourself" for a pop-up box with the response.

Note: If you do not see a pop-up box, check your pop-up blocker settings in your browser. If that is not the problem, try closing the previous pop-up box or check to see if the pop-up box is behind your browser window. If you still do not see the pop-up box, you may need to update your browser.

ASSESS the Problem
Start with the problem -- a clinical problem or question arises from the care of the patients

Peripheral IV catheter insertion is a common nursing procedure often required for the administration of chemotherapy, antibiotics, blood products, fluids, and other medical therapies in hematologic patients with cancer. Although necessary and usually brief, IV insertion often is a source of patient anxiety and discomfort and can be extremely difficult to achieve, particularly in individuals receiving repeated courses of chemotherapy. Unfortunately, not all IV insertions are successful on the first attempt; multiple attempts may occur, which may cause patient distress and anxiety and increase costs as a result of additional supplies and nursing time. Nurses currently use various techniques, including heat, to improve the success rates of IV insertion; however, few are based on evidence. (Fink RM, 2009)  In an effort to improve the patient experience you are asked by the Nursing Council to look at the evidence for using dry versus moist heat for IV catheterization.

 
ASK the question

Choose the BEST clinical question:

 Is dry or moist heat more effective at reducing pain and anxiety?

 Does heat help improve the time to insertion of an IV catheter?

 Is dry or moist heat helpful in reducing pain and time of IV catheter insertion in patients undergoing chemotherapy?

 

ACQUIRE the evidence

Choose the best PubMed search strategy to address the clinical question.

Search: heat AND chemotherapy   Limited to randomized controlled trial

Search: hyperthermia AND catheterization  Limited to randomized controlled trial

Search: heat AND IV catheter  Limited to Human and English and last 5 years

 

APPRAISE the evidence

Fink RM. The impact of dry versus moist heat on peripheral IV catheter insertion in a hematology-oncology outpatient 
population.  Oncol Nurs Forum. 2009 Jul;36(4):E198-204. doi: 10.1188/09.ONF.E198-E204. PubMed PMID: 19581223.

Abstract

PURPOSE/OBJECTIVES: To determine whether dry versus moist heat application to the upper extremity improves IV 
insertion rates. DESIGN: Two-group, randomized, controlled clinical design. SETTING: An academic cancer infusion center in the western United States. Sample: 136 hematologic outpatients with cancer or other malignancies. METHODS: 
Participants were randomly assigned to dry or moist heat with warmed towels wrapped around each patient's arm for 
seven minutes prior to IV insertion. Skin and room temperatures were monitored pre- and postwarming. Two experienced 
chemotherapy infusion nurses performed the venipunctures according to protocol. Outcomes were examined using varianceanalysis, with 34 patients for each combination of nurse and heat type. MAIN RESEARCH VARIABLES: Number of IV 
insertion attempts, time to achieve IV insertion postheating, patient anxiety levels pre- and postheating, and patient 
comfort.Findings: Dry heat was 2.7 times more likely than moist heat to result in successful IV insertion on the first 
attempt, had significantly lower insertion times, and was more comfortable. Heat type had no effect on patient anxiety. 
CONCLUSIONS: Dry heat application decreases the likelihood of multiple IV insertion attempts and procedure time and is 
comfortable, safe, and economical to use in an outpatient oncology setting.

You will need to read the full article to address the validity questions. Click on the link above to get a free copy of the article. Evaluating the medical literature is a complex undertaking. You will find that the answers to the questions of validity may not always be clearly stated in the article and that you may have to use your own judgment about the importance and significance of each question.

Randomization: Were patients randomized?

Concealed allocation: Was group allocation concealed?

Baseline characteristics: Were patients in the study groups similar with respect to known prognostic variables?

Blinding: To what extent was the study blinded?

Follow-up: Was follow-up complete?

Intention to Treat: Were patients analyzed in the groups to which they were first allocated?

Equal treatment: Aside from the experimental intervention, were the groups treated equally?

What are the results & how can I apply them to patient care?

Results: Controlling for prewarming vein status, dry heat was 2.7 times more likely to result in successful IV insertion. After controlling for preinsertion anxiety, vein status, and the participants’ number of venipunctures in the prior year, dry heat resulted in significantly lower insertion times than moist heat. No significant difference was found between the heat modalities or between nurses on postinsertion patient reported anxiety scores.  Dry heat was associated with significantly higher participant self-reported comfort after controlling for preinsertion anxiety and vein status and the participants’ numbers of venipunctures in the prior year.

 

The results are reported as a continuous variable (change in scores).  This does not allow for calculations of Absolute and relative differences or number -needed-to-treat.

Questions to consider before applying the results of a study to your patient:

  • Were the study patients similar to my population of interest?
  • Does your patient match the study inclusion criteria? If not, are there compelling reasons why the results should not apply to your patient?
  • Were all clinically important outcomes considered?
  • Are the likely treatment benefits worth the potential harm and costs?

 

APPLY: talk with the patient

Return to the Nursing Council -- integrate that evidence with clinical expertise, patient preferences and apply it to practice

 

You bring this article to the Nursing Council and any other studies that you found to address this issue.  The Nursing Council needs to consider the results of thess studies, the benefits, the adverse effects, the cost and the training involved in changing clinical procedures. All of these factors need to be factored into a decision.

 

 

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