NSG 6999 Week 6 Project Complete Solution
Evidence Table Worksheet
I. PICOT Question:
In herpes zoster (HZ), is combination medication therapy, con... [Show More] sisting of an antiviral, a steroid, and a nerve pain medication, more effective than use of an antiviral alone in the treatment of HZ, and associated herpetic neuralgia, over the course of the outbreak and resolution of herpetic neuralgia.
plus
1. Will you have a comparison group or will subjects be their own controls?
There will be comparison groups with a control group. Three groups of about 100 in each would be ideal for the best results.
2. Is a ‘time’ appropriate with your question—why or why not?
Time is appropriate for this as treatment much be initiated within the first 72 hours of symptom onset and the patient will need to be followed until resolution of post herpetic neuralgia.
II. Evidence Synthesis
(database) ex:
Cochran Study #1
Choudhary, S., Dhande, S., Kharat, S., & Singh, A. L. (2018)
Study #2
Cui, J. Z., Zhang, X. B., Zhu, P., Zhao, Z. B., Geng, Z. S., Zhang, Y. H., ... & Feng, J. Y. (2017) Study #3
Koshy, E., Mengting, L., Kumar, H., & Jianbo, W. (2018) Study #4
Johnson, B.H., Palmer, L., Gatwood, J., Lenhart, G., Kawai, K., & Acosta, C.J., (2015) Study #5
Makharita, M. Y., Amr, Y. M., & El‐Bayoumy, Y. (2015) Synthesis
A wide variety of authors and with the most recent studies.
(p) Population 45 participants ages 18-70 96 participant ages 50-80 All ages; primarily those 50-80; 2 pregnant; 4 infants 4-11 months Immuno-competent adults enrolled in the Truven Health MarketScan Research database 138 participants over the age of 50 A large population pool, even though a couple of the articles had small pools, and a wide range of ages.
(i)
Intervention Group A: valacyclovir alone
Group B: Valacyclovir and pregabalin
Group C: Valacyclovir, pregabalin, and Solu-Medral Control group: acyclovir and tramadol
Injection group: ropivacaine and Solu-Medral added Review of +170 articles looking at a wide variety of treatments Instances of herpes zoster in 2011 in immuno-competent individuals and those that had not had an outbreak or the vaccine within 90 days of the study range. A paravertebral injection of bupivacaine and decadron was performed to assist with decreasing the pain associated with herpes zoster outbreaks. The introduction of a steroid in uncomplicated herpes zoster outbreak treatment is a hot topic when looking at treatment regimens for herpes zoster
(c)
Comparison The difference treatment courses Adding a steroid injection to the site of lesions/rash vs standard treatment Age, gender, seasonal and regional distribution, immuno-compromised, host herpetic neuralgia, pregnancy, children, complications, management, and prevention Age and gender with a herpes zoster outbreak in those that had not had the vaccine Paravertebral block vs saline block in the treatment of the pain associated with a herpes zoster outbreak. A wide variety of comparisons was used including age, sex, intervention, and route of treatment.
(o) Outcome Group C had the best outcome and cure rate compared to groups A and B The injection group had improved outcomes treating the pain associated with herpes zoster than the control group Herpes zoster can affect anyone of any age that has previously been exposed to VZV but has a higher incidence in elderly and immuno-compromised individuals. Treatment should start in first 72 hours. Valacyclovir and famciclovir are better than acyclovir but pregnant women, children, and immuno-compromised individuals respond better to acyclovir. Other, non-traditional methods have been more effective in treating post herpetic neuralgia. Treatment still remains a challenge despite several treatment modalities. Incidences of herpes zoster was more common in women than men throughout the age groups. The mean age was 52 with the majority of cases being over the age of 50. Over a third of the cases were found in southern states. 4.47 per 1000 people had a herpes zoster outbreak in the year reviewed. The paravertebral block was more successful in treating the pain associated with a herpes zoster outbreak than the placebo group. It was also found to have a reduction in the incidence of post herpetic neuralgia and length of time the skin eruption was present. It appears that the introduction of a steroid in the treatment of herpes zoster increased quality of life, and decreased adverse effects of an outbreak.
(t) time June 2014-May 2015 (1 year); followed for 6 weeks July 2010-June 2013; followed for up to 6 months Varies Jan 1, 2011-Dec 31, 2011 Followed for 6 months after outbreak Follow-up for 6 months appears to have the greatest documentation on the outcomes and there is an adequate population pool when looking at people during a 24 month period.
III. Evaluation Table
Citation Design Sample size: Adequate? Major Variables:
Independent
Dependent Study findings:
Strengths and weaknesses Level of evidence Evidence Synthesis
Choudhary, S., Dhande, S., Kharat, S., & Singh, A. L. (2018) Randomized, single-blind, parallel control study Sample size was small, but adequate for the region the testing was done in. There is still controversy over the use of steroids in the treatment of herpes zoster Strengths: Direct patient contact. Able to follow the patients for an appropriate amount of time.
Weaknesses: Small population pool. Level II This study found that the use of steroids in conjunction with an antiviral yielded better outcomes for patients with a herpes zoster outbreak and post herpetic neuralgia.
Cui, J. Z., Zhang, X. B., Zhu, P., Zhao, Z. B., Geng, Z. S., Zhang, Y. H., ... & Feng, J. Y. (2017) Prospective randomized placebo-controlled clinical trial Sample size was adequate for the area and to reach a conclusion. Injecting a steroid and anesthetic is not common practice considered controversial even though data is supporting the use of steroids in treating herpes zoster Strength: Early introduction of injections and
Weaknesses: Small population pool and was a single-center site. The optimal dose of an anesthetic and steroid have yet to be determined Level II The study showed that the use of steroid injections to the site of the outbreak reduced the time length of an outbreak and prevented post herpetic neuralgia and improved quality of life better than standard treatment alone.
Koshy, E., Mengting, L., Kumar, H., & Jianbo, W. (2018) A systematic review Large, adequate sample size Variables include age, sex, region, season, pregnancy, complications, management, and prevention. Strengths: Large selection of articles reviewed; different search engines used; broad age groups
Weaknesses: A lot of topics included, some with minimal information or background, number of articles included not stated nor inclusion or exclusion criteria. Level V Large compilation of articles reviewed. Concluded that treatment is most effective when started in the first 72 hours from onset of symptoms, regardless of the treatment used. Most patients affected by herpes zoster are over the age of 50. Treatment remains challenging even with the different treatment modalities.
Johnson, B.H., Palmer, L., Gatwood, J., Lenhart, G., Kawai, K., & Acosta, C.J., (2015) Descriptive analysis Large population pool The different age groups and sex of the population affected be herpes zoster Strengths: Large population pool, used Census data to help calculate occurrence rates in the US population
Weaknesses: difficult to read and follow the percentages Level VI Large population study over a single year to provide incidence rates of herpes zoster in the US. All adult age groups were evaluated. It was found that there is still a high incidence rate among the US population of immuno-competent adults despite a vaccine being available.
Makharita, M. Y., Amr, Y. M., & El‐Bayoumy, Y. (2015) Randomized clinical trial Adequate trial pool One group injected with saline (control group), the other injected with bupivacaine and decadron. All received an antiviral, pregabalin, and Tylenol. Strengths: well defined inclusion and exclusion criteria. Exact dose and volume of injection given. Followed for 6 months.
Weaknesses: Only patients over the age of 50 were used. No specific time frame given of when the participants were selected. Level II With an adequate pool of participants, it was found that the group that received the paravertebral block had a better outcome than the control group. Their pain was better managed during the outbreak, the skin lesions resolved sooner, and the number of patients that experienced post herpetic neuralgia was significantly less than the control group.
Exploring the Literature
Picot Question: In herpes zoster, is combination medication therapy, consisting of an antiviral, a steroid, and a nerve pain medication, more effective than use of an antiviral alone in the treatment of herpes zoster and associated post herpetic neuralgia over the course of the outbreak to resolution of post herpetic neuralgia during the first year of an initial outbreak.
Research Tool Search Tips Search Terms & Limits Findings Features
CINAHL
CINAHL is an SU subscription-only resource that offers full text access to 336 scholarly journals and indexes over 3,000 journals from the fields of nursing and allied health. Indexed journals do not provide access to full-text. Just because it is indexed in does not mean the library has full-text access to the journal. SU can always request articles for students via Interlibrary Loan, but the service is not instantaneous Look at the Major Subject Heading in the Full Record
Use the Limits Feature:
Date range 2016-2020
Academic, peer-review, and evidence-based journals/articles
Language: English
Full text
Try the CINAHL Heading search:
While this gave more possible options under the subheadings, I found it a little more difficult to use. This is probably due to my unfamiliarity with this specific search option. Keyword search: Herpes zoster treatments AND post-herpetic neuralgia
Limits:
Date range 2016-2020
Academic, peer-review, and evidence-based journals/articles
Language: English
Full text
CINAHL Heading search: Herpes zoster treatments
Limits: Subheadings
Complications
Therapy
Prognosis
Education 8 articles
108 articles All articles were related to herpes zoster; some had treatment options in the title; all were within the date range; all were full text; 7 articles from Academic Journals, 1 from a magazine
78 from Academic Journals; most full text within date range; wider topic range, some better but some worse
PubMed
PubMed is a free health science citation & abstracts index from the National Center for Biotechnology Information at the U.S. National Library of Medicine.
Look at MeSH Terms in Full Record
Use the Limits Feature:
5 year date range
Full free text
Clinical study, Clinical trial, Comparative Study, Meta-analysis, Review
Humans
Look for the open access Free articles!
Keyword search:
Herpes zoster treatments AND post-herpetic neuralgia
Limits:
5 year date range
Full free text
Clinical study, Clinical trial, Comparative Study, Meta-analysis, Review
Humans
MESH search: (Herpes zoster treatments) AND post-herpetic neuralgia
Limits: see above
54 articles
No results found Search yielded a larger article pool than previous search engine, many of the previous articles were present in this search, was a little easier to find treatment option articles based on titles.
Cochrane Library
Cochrane Library provides access to the Cochrane Library of Systematic Reviews. Full text of reviews are subscription only. Index summaries are a public resource. Indexed journals do not provide access to full-text. Just because it is indexed in does not mean the library has full-text access to the journal. SU can always request articles for students via Interlibrary Loan, but the service is not instantaneous Use the Simple Search and the Advance Search Features
Allows you to search with MeSH Terms
Check out the New Reviews
Browse reviews by topic Keyword search:
Herpes zoster treatments
Limits:
Date range starting Jan 2016
MESH search: Herpes zoster treatments
Limits:
8 Cochrane Reviews; 19 when date range removed
Number of articles varied depending upon what was selected in Thesaurus Matches All articles were related to herpes zoster and all were within the date range; the date range was not intuitive and needed to have month, day, and year selected.
Thesaurus Matches was a nice feature, but it gave a lot of possibilities without an easy way to narrow the search; having the dropdown on the MeSH tree was a bonus to save me from going back and forth with the different trees per topic
Dynamed
• Use the Simple Search and the Advance Search Features
• Allows you to search with MeSH Terms
• Check out the New Reviews
Browse reviews by topic Keyword search:
Herpes zoster treatments
Also browse by:
Topic, Immunology; Herpes zoster; Acyclovir; Trigeminal Neuralgia 287 topics and 15 images Not a great search engine as there is no way to refine the search
TRIP Database
TRIP is a clinical search engine to locate publicly available clinical evidence.
Limit to:
Systematic Reviews
Guidelines-US Keyword search: Herpes zoster treatments
Limits:
Systematic Review
Since 2016
Evidence-based synopses
30 systematic reviews;
18 evidence-based synopses Not a lot of filters, lists literature that the articles are published in but not the authors at a glance of the ‘Snippets’. Lists year but not month.
SU Library Search • Library Search is setup just like an EBSCO
• The Library even has a specialized PICOT search setup in Library Search—must go to Advance search to get to PICOT option Herpes zoster treatments
Full text
Last 5 years
Peer reviewed (scholarly)
Academic Journals
English 185 articles Easy to use, good feature with a quick search option that can be refined easily, yields a large pool of articles so narrowing down the search is important, search options are very similar to CINAHL [Show Less]
