CLINICAL EXPERIENCE WITH THREE COMBINATION REGIMENS FOR THE TREATMENT OF HIGH-RISK FEBRILE NEUTROPENIA - Book Report/Review Example

al Affiliation Using the current best evidence is a key practice of science; therefore, reading research articles critically is a skill to develop to explore research independently. The aim of this essay is to examine critically the article of Serefhanoglu and colleagues (2006) about their clinical experience with three combination regimens to manage high-risk febrile cases of neutropenia. The article has its strengths and weakness, but as the methods were described in detail, this enabled other researchers to replicate the research examining other aspects of the problem. Outline 1. Introduction Using the current best evidence is a key practice of science; therefore, research articles must be read critically. Although it is not a simple process; however, it is an essential skill to develop to explore research results in an independent way. Transmission of best practice is the first step in the process of application evidence of best practice in patient care, bridging the gap between evidenced best practice and reality practice. In addition, critical reading changes attitudes and perceptions of utilizing research (Shankar and Subish, 2007). A structured framework for an article critique is a tool that brings about questions leading to better assessment of the value of a research paper. The primary aim of the structured framework is to question each section of the paper to achieve analysis then better understanding of the content (Branson, 2004). The aim of this essay is to review critically the article of Serefhanoglu and colleagues (2006) about their clinical experience with three combination regimens to manage high-risk febrile cases of neutropenia. 2. Article critique The article of Serefhanoglu and colleagues (2006) is an example of a quantitative research design that produces statistical data from numerical results aiming at generalization of findings (Dawson, 2002). The authors managed 89 febrile episodes (in 62 cancer patients with neutropenia) with ceftazidime and amikacin in 29 episodes, a combination of piperacillin, tazobactem and amikacin in 30 episodes, and meropenem combined with amikacin in further 30 episodes. The authors inferred all three regimens were safe and effective as empirical treatment for high-risk febrile neutropenia patients. 2.1 Title Research articles' titles are either descriptive or conclusive (briefing the authors' inferences); however, in any case, it should be clear enough to pass on the research theory and methods (APA publication manual, 2001). The title of the article at hand is descriptive and explains the objective of the research. 2.2 Authors, date, and key words It is of importance to examine how relevant the authors' institutional affiliation to the subject of the paper as it gives credibility to their experiences (Dawson, 2002). Choosing article key words is not just an author preference, but to further search easier, they must appear in the medical subjects list of the National Library of Medicine at http://www.nlm.nih.gov/mesh/MBrowser.html (Branson, 2004). The institutional affiliation of the article authors is relevant to the subject; besides, the key words selected appear in the medical subjects list. 2.3 Abstract Abstracts became an important part of a research article since electronic databases are a primary method of finding relevant research. Abstracts can be informative composed of a single paragraph describing everything relevant to the article; alternatively, they can be indicative, structurally describing the article contents (Derntl, 2003). The abstract of the article at hand is an indicative, well-structured, content-informative abstract. Thus, the article's abstract is reflecting the experimental design and results of the research. 2.4 Introduction, research problem, and research questions The introduction section is the part of a research article that enlightens the reader with the outline of the subject addressed. Thus, it should have three identifiable parts, a description of the topic, research problem statement, and a background literature review (Fawcett and Garity 2009). A research problem statement differs from the aim or work objectives in that it identifies theory, models, framework and variables (Creswell, 2003). Further, in quantitative research, research problem statement provides a schematic description of the relationship between the variables identified (dependent as response to treatment, and independent as the dose or the antibiotic administered) (Rhadhakarishna et al, 2007). Serefhanoglu and colleagues (2006) did not clarify in the introduction section the need for empirical treatment, why did they choose patients with neutropenia not leucopoenia, or the basis of selecting these antibiotics (theoretical framework). In addition, the authors did not identify or describe the variables they selected for analysis, and provided no background literature review. The main objective of stating research questions is to narrow the research topic from the broader research problem statement to what the researcher (s) will attempt to answer. In quantitative research, the research question (s) addresses the question tag, why, and directed to measuring, comparing or correlating variables (Tashakkori and Creswell, 2007). Serefhanoglu and colleagues (2006) did not clarify their research questions probably because they did identify neither their research problems statement nor the theoretical framework. In summary, the introduction does not clarify the research hypothesis, nor does it analyse the basis of the evaluation of the study results. 2.5 Literature review: In literature review section whether included in the introduction or presented as a separate research paper section, the author provides a detailed comprehensive of relevant literature. The aim is to clarify the research hypothesis statement and present the importance of the present research, in addition to providing a justification to research question (Chapin, 2004). Serefhanoglu and colleagues (2006) did not provide a comprehensive review of literature in their research article. They omitted points like the microbiology of febrile episodes in this category of patients unexplained, which might have justified the use of the antibiotics used in their study. 2.6 Methods 2.6.1 Study design The research study design is the plane to answer the questions how, when and where data are collected and analysed. The aim is to enable the readers to assess the work and repeat it if they need. Therefore, the authors should describe the study design, participants and associated limitations. Description of participants should include total number, number in assigned groups, age and gender distribution and criteria of selection or inclusion in the study. Some authorities consider the demographic characteristics essential to include (Hittleman and Simon, 2006). Comparative studies are used to establish and measure the relationships between two or more variables by observing different groups subjected to different treatments or a treatment and a control group. Comparative studies can be retrospective (looking at results of treatment that have already took place) or prospective that is examining variables in response to treatment for present onwards (Hittleman and Simon, 2006). Serefhanoglu and colleagues (2006) selected a prospective comparative study design to evaluate the results of managing patient at or above 16 years experiencing fever and a reduced neutrophils count. They defined neutropenia as reduced neutrophils count below 5x109 per litre, occurring after 7-10 days of intensive chemotherapy for a haematological malignancy. They defined fever as a single rise in temperature at or above 38.3 degrees or a temperature of 38 degrees persistent for 1 hour; in any case, fever should not relate to blood transfusion or a pyrogenic reaction during transfusion. Subsequent episodes for the same patient should be at least 7 days apart to be included as separate episodes. Other criteria of inclusion included no antibiotic treatment in the previous 48 hours; besides, patients with poor renal and hepatic functions were excluded from the study. The authors included age, gender, disease specifications and infection type in table 1 of their study. 2.6.2 Instruments, measures and variables In addition to study design, methods section of a research article should also include description of research instrument used and how variables are measured, which relate to validity and reliability of research. A research instrument is the tool used to measure variables, while measurement is the assignment of numbers to represent the amount of the variable or the change in its value. Reliability is an expression of the accuracy of a variable; thus, the less variation in measurement by the research instrument, the more reliable and more consistent the results are. Validity is the extent of the instrument to measure a variable and reflect the degree of change (Hittleman and Simon, 2006). Reliability and validity are inherent linked qualities to research instrument; therefore, an instrument cannot be valid but unreliable, and an unreliable instrument is the one that produces errors frequently to consider it valid (Smith, 2005). Serefhanoglu and colleagues (2006) used objective standard research instruments like tools for general examination, chest radiographs, urinalysis, standard microbiological examination, antibiotic susceptibility testing, and biochemical tests. They used standard culture techniques including blood culture to all patients included in the study. Antibiotic treatment in the study of Serefhanoglu and colleagues (2006) is the categorical variable, which is a variable that gives the pertinent tag of an observation after allotment to one of several possible categories (Everitt, 2006). The authors adequately described the combinations administered, dose of each drug, method of administration, period separating administration of each drug in a combination. They also suggested the indications of changing the regimen of antibiotic therapy and the duration of the treatment. The criterion variable, which is the variable predicted from the categorical variable in this study is the patients' response (Everitt, 2006). The authors further classified it into three groups, first is successful treatment with modification of the regimen. Second is success with modification and third is failure of treatment. In all cases, criteria for success were disappearance of fever and the pre treatment clinical features, besides, eradication of the microorganism isolated. 2.6.3 Statistical analysis The authors used Chi-Square test for data analysis, which is in addition to t-test and z-test are the commonest statistical tests used to address generalizability of the relationships between variables. The Chi-Square test is used to analyse data in a contingency table (a table of the number of individuals who fall in each category). The test reports the statistically significant differences between variables or subgroups. Chi-Square test compares the differences between the expected and observed number of individuals of two or more groups (successful treatment, treatment failure, or successful with modification) that fall in two or more categories (regimen 1, 2, or 3). Therefore, the estimated relative proportions in each category for each group should assess the sample size in each group of categorical variables (Sheskin, 2003). To summarize the above discussion, in the materials and methods section the authors provided enough material for a reader to repeat their work in the future. However, the authors did not provide enough explanation of data analysis as either a statistical test or a hypothesis. 2.7 Results Since the study of Serefhanoglu and colleagues, (2006) design was a comparative prospective research, there was no control group. According to Branson (2004), the authors stated their finding with neither interpretation nor bias and are described orderly similar to the order of methods description. Since there is no specific construct to the results section (Branson, 2004), the authors have included tables in the results section, table 1 added the missing text information about the study participants about age, gender, diagnosis and neutrophils count. Table 2 added information about the organisms isolated; however, table 3 about clinical outcome of the febrile episodes repeated a clinical outcome paragraph in the text. According to Chatburn (2002, mentioned in Branson, 2004), the authors should not prove or refute previous work in the results section, but can only prove or refute a hypothesis. The findings of the study are additions to information on a problem that can collectively add evidence to prove or refute a certain interpretation. Serefhanoglu and colleagues, (2006) in their results section followed this rule; however, they have fallen in a major stagger that is they did not mention the significance results of using the Chi-square test mentioned in their methods section. Not only that, they did not comment on using the statistical test for measuring the relationship between two or more of the study variables (Chi-square test for independence) (Sheskin, 2003). In summary, the authors presented results of the study in a logical ordered format, and were described appropriately. However, the authors did not clarify the statistical significance or correlations between variables as emerged from using the Chi-square test. 2.8 Discussion The discussion part of a research paper is where the authors interpret their results and use the statistical results to make conclusions on the research question. The authors started their discussion by stating the aim of their work, reviewed the literature on the antibiotics regimens they used. The authors also reviewed the risk factors contributed to increased incidence of gram-positive bacterial infection in this particular group of patients. Thus, the results of Serefhanoglu and colleagues, (2006) support their inferences; the references they used are well interpreted and well placed in the discussion. 3. Conclusion Serefhanoglu and colleagues, (2006) designed a comparative prospective study to examine the efficacy and safety of three antibiotics combination regimens to manage febrile episodes in high-risk patients with neutropenia. Despite the defect in research explained, their study was the first to explore the efficacy of these combinations. The main advantage of this article is the proper description of methods, which enable reader to repeat the study. An example is the article of Hamidah et al (2008), who examined one of the regimens suggested in this article to manage febrile neutropenia episodes in patients of paediatric population. References American Psychological Association (APA), 2001. Publication manual of the American Psychological Association (fourth edition). 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