picot (sarcoidosis)
Week 5: Research Summary Assignment
Due Jun 5 by 11:59pm Points 200 Submitting a file upload
Purpose
This assignment provides the opportunity for the student to find and appraise resources related to the PICOT question from Week 2. The focus of this assignment is to evaluate pertinent literature that supports the practice change intervention.
Note: You are to locate original studies with research conducted and published by the primary investigator. You may also use quantitative, qualitative, mixed methods studies, meta-analyses or Clinical Practice Guidelines (CPGs).
Course Outcomes
This assignment enables the student to meet the following course outcomes:
CO1: Integrate evidence-based and research to support advancement of holistic nursing care in diverse healthcare settings. (PO 1,4)
CO2: Integrate knowledge related to evidence-based practice and person-centered care to improve health outcome. (PO 1, 2)
CO4: Develop knowledge related to research and evidence-based practice as a basis for designing and critiquing research studies. (PO 1, 5)
CO5: Analyze research findings and evidence-based practice to advance holistic care initiatives that promote positive healthcare outcomes. (PO 1, 2, 5)
Due Date: Sunday 11:59 PM MT at the end of Week 5
Total Points Possible: 200 Points
Requirements
Find and review ten (10) scholarly, peer-reviewed research articles, meta-analyses, or CPGs in support of the practice change intervention. Complete the appropriate section in the worksheet for each article.
State the PICOT question
For each article, supply the information for each of the seven headings for the appropriate article type.
Preparing the Assignment:
Use the designated Research Summary Table Worksheet (Links to an external site.) to supply the required information.
All scholarly, peer-reviewed research articles must be current within a 5-year time frame unless a valid rationale is provided, and the instructor has approved the use of an older reference.
Use APA 7th edition formatting for references.
Directions and Assignment Criteria
Assignment Criteria
Points
%
Description
PICOT question
20
10%
PICOT question provided in sentence format
Articles 1-10
15/article
150 total
7.5% / article
75% total
For each article:
Scholarly article: US based peer reviewed journal focused for clinicians
Publication date is current within 5 years
Correctly categorizes article type
Completes all seven areas of article analysis
Explains relevance to PICOT question and implications for advanced nursing practice
APA
20
10%
Use of worksheet template
Correct APA 7th edition format for the following:
Font style and size
Citing and referencing sources
Mechanics of style (abbreviations, capitalization, italics, numbers)
Graduate-level writing style
10
5%
Correct use of spelling, grammar, punctuation, and sentence structure
Clarity, organization, and logical flow of ideas within writing
Synthesis of information is present with no direct quotes
Correct APA 7th edition format for the following:
Font style and size
Citing and referencing sources
Mechanics of style (abbreviations, capitalization, italics, numbers)
Use of template
Total
200
100 %
Rubric
NR505NP Week 5 Research Summary Assignment Rubric
NR505NP Week 5 Research Summary Assignment Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomePICOT Question
20 pts
Exceptional
PICOT question provided in sentence format and all five attributes are listed. (Six critical elements.)
18 pts
Exceeds
PICOT question provided in sentence format, but one attribute is not defined. (Five critical elements.)
16 pts
Meets
PICOT question provided in sentence format, but two attributes are not defined. (Four critical elements.)
8 pts
Needs Improvement
PICOT question is not in sentence format and/or three or more attributes are not defined.
0 pts
Developing
PICOT question not supplied.
20 pts
This criterion is linked to a Learning OutcomeArticle 1
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements.
0 pts
Developing
Presentation missing four or more of the seven critical elements.
15 pts
This criterion is linked to a Learning OutcomeArticle 2
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements
0 pts
Developing
Presentation missing four or more of the seven critical elements.
15 pts
This criterion is linked to a Learning OutcomeArticle 3
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements.
0 pts
Developing
Presentation missing four or more of the seven critical elements.
15 pts
This criterion is linked to a Learning OutcomeArticle 4
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements.
0 pts
Developing
Presentation missing four or more of the seven critical elements.
15 pts
This criterion is linked to a Learning OutcomeArticle 5
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements
0 pts
Developing
Presentation missing four or more of the seven critical elements.
15 pts
This criterion is linked to a Learning OutcomeArticle 6
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements.
0 pts
Developing
Presentation missing four or more of the seven critical elements.
15 pts
This criterion is linked to a Learning OutcomeArticle 7
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements.
0 pts
Developing
Presentation missing four or more of the seven critical elements.
15 pts
This criterion is linked to a Learning OutcomeArticle 8
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements.
0 pts
Developing
Presentation missing four or more of the seven critical elements.
15 pts
This criterion is linked to a Learning OutcomeArticle 9
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements.
0 pts
Developing
Presentation missing four or more of the seven critical elements
15 pts
This criterion is linked to a Learning OutcomeArticle 10
15 pts
Exceptional
Presentation of information was exceptional and included all seven elements required for study type. (Seven critical elements.)
13 pts
Exceeds
Presentation of information was good but was superficial in places and included all of the seven elements required for study type.
12 pts
Meets
Presentation of information included six of the seven critical elements required for study type.
6 pts
Needs Improvement
Presentation missing two or three of the seven critical elements
0 pts
Developing
Presentation missing four or more of the seven critical elements.
15 pts
This criterion is linked to a Learning OutcomeAPA
20 pts
Exceptional
• Correct APA format with 0-1 error for the following: • Font style and size • Citing and referencing sources • Mechanics of style (abbreviations, capitalization, italics, numbers)
18 pts
Exceeds
• APA format with 2-4 errors for the following: o Font style and size o Citing and referencing sources o Mechanics of style (abbreviations, capitalization, italics, numbers)
16 pts
Meets
• APA format with 5-7 errors for the following: o Font style and size o Citing and referencing sources o Mechanics of style (abbreviations, capitalization, italics, numbers)
8 pts
Needs Improvement
• APA format with 8-9 errors for the following: o Font style and size o Citing and referencing sources o Mechanics of style (abbreviations, capitalization, italics, numbers)
0 pts
Developing
• APA format with > 10 errors for the following: o Font style and size o Citing and referencing sources o Mechanics of style (abbreviations, capitalization, italics, numbers)
20 pts
This criterion is linked to a Learning OutcomeScholarly Writing
10 pts
Exceptional
Distinguished graduate-level writing style is evidenced by meeting all of the following criteria with 0-1 errors total: • Correct use of spelling, grammar, punctuation, and sentence structure • Clarity, organization, and logical flow of ideas within writing • Synthesis of information with no direct quotes • Use of template • Articles from scholarly sources: US based peer-reviewed journals geared for clinicians. (5 critical elements)
9 pts
Exceeds
Graduate-level writing style exceeds expectations as evidenced by 2-4 errors total in the five critical elements.
8 pts
Meets
Proficient graduate-level writing style is evidenced by meeting the following criteria with 5-7 errors total in the five critical elements.
4 pts
Needs Improvement
Graduate-level writing style needs improvement as evidenced by meeting the following criteria with 8-9 errors total in the five critical elements.
0 pts
Developing
Graduate-level writing style needs improvement as evidenced by meeting the following criteria with 10 or more errors total in the five critical elements.
10 pts
Total Points: 200
references must be within 5 years.
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Literature Summary Table
PICOT QUESTION:
Among patients aged 25 to 65 years with suspected pulmonary Sarcoidosis in Panama City,
Florida, does mediastinoscopy and EBUS-guided lymph node sampling compared to no
intervention enhance clinical outcomes after six months of interventions?
QUANTITATIVE STUDIES
Author/Title/Year (APA format):
Mai et al. EBUS-TBNA Biopsy for Pulmonary Sarcoidosis Diagnosis. (2019).
Problem related to PICOT: Compared the efficacy of EBUS-TBNA+EBB and Mediastinoscopy with EBUS-TBNA+EBB in diagnosing Sarcoidosis.
Purpose: To evaluate the diagnostic efficacy and safety of EBUS-TBNA for biopsy for pulmonary sarcoidosis.
Sample/Population: Seventy-eight patients with suspected sarcoidosis
Data Collection Method: Retrospective selection of patients with thoracic sarcoidosis in Tianjin Chest Hospital from January 2014 to March 2017. Imaging staging of the participants using chest X-ray and/or CT performance, biopsy procedure.
Major Findings/Conclusions: The positive rate of EBUS-TBNA+EBB and Mediastinoscopy was 100% which was significantly higher than that of EBUS-TBNA and EBB with statistical difference (0.05%). EBUS-TBNA is a safe and accurate biopsy technique. The diagnostic positive rate is similar to the mediastinoscopy with less postoperative complications, and medical costs.
Contribution to Review of the Literature:
The study confirms that EBUS-TBNA, which is safe, real-time, accurate, minimally invasive diagnostic technology that can accurately diagnose Sarcoidosis and help in adopting the right care.
Author/Title/Year (APA format)
Onat et al. The Role of Mediastinoscopy in the Diagnosis of Non-Lung Cancer Diseases. (2017).
Problem related to PICOT: Examines the role of mediastinoscopy in diagnosis of granulomatous disease such as sarcoidosis or tuberculosis.
Purpose: To determine the current role of mediastinoscopy in the investigation of non-lung cancer patients with mediastinal lymphadenopathy.
Sample/Population: Two-hundred twenty-nine patients without lung cancer.
Data Collection Method: Retrospective review of clinical parameters of all patients without lung cancer who consecutively underwent mediastinoscopy in Hospital of Faculty of Medicine of Dicle University between June 2003 and December 2016.
Major Findings/Conclusions: Despite the increased use of newer diagnostic modalities to diagnose mediastinal diseases, mediastinoscopy continues to be a reliable method for the investigation of mediastinal lesions.
Contribution to Review of the Literature:
Assert the usefulness of mediastinoscopy in evaluating and diagnosing sarcoidosis. Recommends prospective studies that directly compare mediastinoscopy with new diagnostic methods such as EBUS and TBNA to diagnose noncancerous mediastinal adenopathy.
QUALITATIVE STUDIES
Author/Title/Year (APA format):
Madan et al. A Survey of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) practices in India. (2022).
Problem related to PICOT: Looks at endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), a standard of care modality for evaluating mediastinal lymphadenopathy and mediastinal lesions in adults.
Purpose: To study the current practices of EBUS-TBNA in India.
Sample: 134 respondents mostly pulmonologists or physicians.
Data Collection Method: Online questionnaires with survey questions related to demographics, sedation, analgesia and anesthesia, technical aspects, and infection control related to the procedure of EBUS-TBNA.
Key Findings/Themes: There is practice variability in the multiple aspects related technical performance of EBUS-TBNA. Evidence-based guidelines addressing the multiple technical aspects are required to standardize the practice of EBUS-TBNA.
Contribution to Review of the Literature:
EBUS-TBNA has an acceptable diagnostic yield and may avoid the need for invasive biopsy procedures.
Author/Title/Year (APA format):
Rosenblum et al. A Mass That Has No (EBUS) Echo. (2018).
Problem related to PICOT: Use of Endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) for diagnostic purposes after an abnormal chest CT
Purpose: To illustrate the importance of the Hounsfield units and ultrasound imaging in correctly diagnosing thin-walled para-tracheal pathologies.
Sample: A 40-year-old obese man with a history of hypertension, methamphetamine use, and heart failure presented to an outside ED with chest discomfort and shortness of breath.
Data Collection Method: Case Report
Key Findings/Themes: EBUS guided TBNA can be a useful tool in the diagnosis and treatment of bronchogenic cysts, particularly in patients that are sub-optimal surgical candidates.
Contribution to Review of the Literature:
The authors report that since undergoing EBUS guided TBNA, the patient reported a good functional outcome with total resolution of his symptoms and greatly improved exercise tolerance. The findings indicate that EBUS improves patient outcomes.
MIXED METHODS STUDIES:
Author/Title/Year (APA format):
Kampstra et al. First Patient-Centred Set of Outcomes for Pulmonary Sarcoidosis: A
Multicentre Initiative. (2019).
Problem related to PICOT: Pulmonary sarcoidosis
Purpose: To develop a standard set of outcome measures for pulmonary sarcoidosis, using the value-based healthcare principles.
Sample: Six expert clinics for interstitial lung diseases in four countries participated in a consensus-driven RAND-modified Delphi study.
Data Collection Method: Mixed method approach
Key Findings/Themes/Conclusions: Patient-centred outcomes have the potential to better
inform patients, healthcare providers and other stakeholders in achieving value-based care for patients with pulmonary sarcoidosis.
Contribution to Review of the Literature:
Routine data collection based on standardized outcome measures creates an opportunity
to improve patient care. A reliable data collection process for patients with pulmonary sarcoidosis enables us to compare outcomes between various clinics/treatments,
which can ultimately help to identify best practices.
Author/Title/Year (APA format):
Sun et al. Endobronchial Ultrasound Elastography for Evaluation of Intrathoracic Lymph Nodes: A Pilot Study. (2017).
Problem related to PICOT: Use of EBUS-TBNA in Sarcoidosis diagnosis
Purpose: To utilize the feasibility of qualitative and quantitative methods to evaluate the ability of EBUS elastography to differentiate between benign and malignant mediastinal and hilar lymph nodes (LNs) during EBUS-guided transbronchial needle aspiration (EBUS-TBNA).
Sample: Fifty-six patients including 68 LNs (33 benign and 35 malignant nodes) were prospectively enrolled into this study and retrospectively analyzed.
Data Collection Method: Patients with enlarged intrathoracic LNs required for EBUS-TBNA examination at a clinical center for thoracic medicine from January 2014 to April 2014 were prospectively enrolled. EBUS sonographic characteristics on B-mode, vascular patterns and elastography, EBUS-TBNA procedures, pathological findings, and microbiological results were recorded. Further, more elastographic patterns (qualitative method) and the mean gray value inside the region of interest (quantitative method) were analyzed. Both methods were compared with a definitive diagnosis of the involved LNs.
Key Findings/Themes:
EBUS elastography is a promising method that allows for the differentiation of benign and malignant LNs with high sensitivity, specificity, and predictive accuracy, which
may offer important supplementary information in EBUS-TBNA cases
Contribution to Review of the Literature:
The study revealed that EBUS elastography could be useful in predicting malignant LNs with a high sensitivity of 85.71 and 91.43% and a diagnosis accuracy of 83.82 and 82.35%
based on qualitative and quantitative methods.
META-ANALYSIS STUDIES
Author/Title/Year (APA format):
Figueiredo et al. EBUS-TBNA versus surgical mediastinoscopy for mediastinal lymph
node staging in potentially operable non-small cell lung cancer: a systematic review
and meta-analysis. (2020).
Problem related to PICOT: Use of EBUS-TBNA and mediastinoscopy
Purpose: To compare EBUS-TBNA and mediastinoscopy in terms of their effectiveness for mediastinal LN staging in potentially operable non-small cell lung cancer (NSCLC).
Search selection method: Systematic searches were conducted in the MEDLINE,
Cochrane Central Register of Controlled Trials, EMBASE, Elton Bryson Stephens Company (EBSCO), LILACS, Brazilian Virtual Library of Health, and Scopus databases. Absolute numbers were collected directly from the text and separated into true positives, true negatives,
false positives, and false negatives. Five studies were considered for meta-analysis of complications.
Meta-Analysis Model: The Mantel-Haenszel fixed-effect model.
Consistency/Variation of Studies: All the studies were prospective sequential clinical
studies.
Summary of Findings:
EBUS-TBNA and mediastinoscopy achieved similar results for the mediastinal staging of lung cancer. EBUS-TBNA showed a performance and a safety profile that are good enough to replace mediastinoscopy altogether in the mediastinal staging for patients with potentially resectable NSCLC.
Author/Title/Year (APA format):
Kassirian et al. Effect of Needle Size on Diagnosis of Sarcoidosis with Endobronchial Ultrasound-guided Transbronchial Needle Aspiration: Systematic Review and Meta-Analysis. (2021).
Problem related to PICOT: Sarcoidosis diagnosis
Purpose: To evaluate if the use of the larger 19-gauge (G) needle with EBUS-TBNA improves diagnostic sensitivity in sarcoidosis.
Search selection method: Literature search of Embase and Medline and articles evaluated for bias using the QUADAS-2 tool.
Meta-Analysis Model: Binary random-effects model to determine pooled sensitivity
Consistency/Variation of Studies: The studies were relatively consistent.
Summary of Findings: The studies had a pooled sensitivity for diagnosis of sarcoidosis of 83.99%. The use of 19G needles during EBUS-TBNA had the highest diagnostic sensitivity based on available studies.
CLINICAL PRACTICE GUIDELINES
Author/Title/Year (APA format):
Thillai et al. BTS Clinical Statement on Pulmonary Sarcoidosis. (2021).
Problem related to PICOT: Diagnosis, evaluation and management of pulmonary sarcoidosis.
Stakeholders represented: Clinicians expert opinion and accumulated clinical experience.
Systematic review of literature: Reviewed metanalyses studies and randomized control trials.
Strength of recommendations used: Weak
Recommendations have been peer reviewed: Yes
Summary of findings as related to PICOT:
EBUS-TBNA is an appropriate primary diagnostic approach for stage I and II sarcoidosis, variably combined with EBB, TBBx and BAL
Author/Title/Year (APA format):
Crouser et al. Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline. (2020).
Problem related to PICOT: Guidelines on diagnosis and detection of Sarcoidosis
Stakeholders represented: Clinicians, patients, and payers.
Systematic review of literature: EBUS-guided lymph node sampling had a diagnostic yield of 87% while mediastinoscopy had a diagnostic yield of 98%.
Strength of recommendations used: Derived from nonrandomized studies thus very low-quality evidence.
Recommendations have been peer reviewed: Yes.
Summary of findings as related to PICOT:
For patients with suspected sarcoidosis and mediastinal and/or hilar lymphadenopathy for whom it has been determined that tissue sampling is necessary, the authors suggested EBUS-guided lymph node sampling, rather than mediastinoscopy, as the initial mediastinal and/or hilar lymph node sampling procedure (conditional recommendation, very low-quality evidence)
References
Crouser, E. D., Maier, L. A., Wilson, K. C., Bonham, C. A., Morgenthau, A. S., Patterson, K. C., … & Baughman, R. P. (2020). Diagnosis and detection of sarcoidosis. An official American Thoracic Society clinical practice guideline. American journal of respiratory and critical care medicine, 201(8), e26-e51. https://doi.org/10.1164/rccm.202002-0251ST
Figueiredo, V. R., Cardoso, P. F. G., Jacomelli, M., Santos, L. M., Minata, M., & Terra, R. M. (2020). EBUS-TBNA versus surgical mediastinoscopy for mediastinal lymph node staging in potentially operable non-small cell lung cancer: a systematic review and meta-analysis. Jornal Brasileiro de Pneumologia, 46. https://doi.org/10.36416/1806-3713/e20190221
Kampstra, N. A., Grutters, J. C., van Beek, F. T., Culver, D. A., Baughman, R. P., Renzoni, E. A., … & van der Nat, P. B. (2019). First patient-centred set of outcomes for pulmonary sarcoidosis: a multicentre initiative. BMJ open respiratory research, 6(1), e000394. http://dx.doi.org/10.1136/bmjresp-2018-000394
Kassirian, S., Hinton, S. N., Iansavitchene, A., Amjadi, K., Chee, A., Dhaliwal, I., & Mitchell, M. A. (2022). Effect of Needle Size on Diagnosis of Sarcoidosis with Endobronchial Ultrasound-guided Transbronchial Needle Aspiration: Systematic Review and Meta-Analysis. Annals of the American Thoracic Society, 19(2), 279-290. https://doi.org/10.1513/AnnalsATS.202103-366OC
Madan, K., Mittal, S., Tiwari, P., Hadda, V., Mohan, A., & Guleria, R. (2022). A Survey of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) practices in India. Lung India, 39(3), 234-241. https://doi.org/10.4103/lungindia.lungindia_497_21
Mai, H., Zhango, Y., Jias, W., & Li, Y. (2019). EBUS-TBNA Biopsy for Pulmonary Sarcoidosis Diagnosis. Biomedical Research, 30(6), 0970-938X. https://1stdirectory.co.uk/_assets/files_comp/908665e5-a57f-464a-b960-47d9f8ce5ef9.pdf
Onat, S., Ates, G., Avcı, A., Yıldız, T., Birak, A., Ozmen, C. A., & Ulku, R. (2017). The role of mediastinoscopy in the diagnosis of non-lung cancer diseases. Therapeutics and clinical risk management, 13, 939. https://doi.org/10.2147/TCRM.S144393
Rosenblum, M. K., Wang, S. X., & Seeley, E. J. (2018). A mass that has no (EBUS) echo. Respiratory medicine case reports, 23, 18-20. https://doi.org/10.1016/j.rmcr.2017.11.001
Sun, J., Zheng, X., Mao, X., Wang, L., Xiong, H., Herth, F. J., & Han, B. (2017). Endobronchial ultrasound elastography for evaluation of intrathoracic lymph nodes: A pilot study. Respiration, 93(5), 327-338. https://doi.org/10.1159/000464253
Thillai, M., Atkins, C. P., Crawshaw, A., Hart, S. P., Ho, L. P., Kouranos, V., … & Wells, A. U. (2021). BTS Clinical Statement on pulmonary sarcoidosis. Thorax, 76(1), 4-20. https://doi.org/10.1136/thoraxjnl-2019-214348