ebm prognostic ujian
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R . P R I N D J A T I P R A K A S AH 2 A 0 1 0 0 4 2
EBM prognostic
DHF
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Skenario klinis
Seorang anak 15 tahun datang ke dokter denganmimisan. Dari anamnesis didapatkan riwayat trauma (-),demam 3 hari, mual muntah (+), hepatomegali, tesptekie (+). Dokter mencurigai pasien menderita DBD.
Dokter menyarankan pasien untuk pemeriksaan serologiuntuk memastikan penyebab penyakitnya dan darahrutin untuk memberi keputusan rawat inap.
Setelah dilakukan pemeriksaan pasien (+) DBD danditemukan trombositopenia.
Pasien disarankan rawat inap dan Dokter ingin tahu apakah profil transfusi (menerima
transfusi trombosit) dan manifestasi klinis DBDmenghasilkan karakteristik klinik dan laborat yang baik?
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Practice of EBM
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Step 1: Converting the need for information (aboutprevention, diagnosis, prognosis, therapy, causation, etc.)into an answerable question
Step 2: Tracking down the best evidence with which toanswer that question
Step 3: Critically appraise that evidence for the validity(closeness to the truth), impact (size of the effect), andapplicability (usefulness in our clinical practice)
Step 4: Integrating the critical appraisal with our clinical
expertise and with our patients unique biology, values,and circumstances
Step 5: Evaluating our effectiveness and efficiency inexecuting steps 1-4 and seeking ways to improve themboth for next time
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Clinical question about prognosis
Patient or
Problem
Intervention Comparison Outcomes
Pasien
anak 15
tahun
Manifestasi
klinik DBD &
profil
transfusi
(menerimatransfusitrombosit)
- karakteristikklinik danhasillaboratorium
yang baik
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Pertanyaan klinis
Apakah manifestasi klinik DBD & profil transfusi(menerima transfusi trombosit) pada pasien anak15 tahun dapat menghasilkan karakteristik klinik
dan hasil laboratorium yang baik?
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Practice of EBM
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Step 1: Converting the need for information (aboutprevention, diagnosis, prognosis, therapy, causation, etc.)into an answerable question
Step 2: Tracking down the best evidence with which toanswer that question
Step 3: Critically appraise that evidence for the validity(closeness to the truth), impact (size of the effect), andapplicability (usefulness in our clinical practice)
Step 4: Integrating the critical appraisal with our clinical
expertise and with our patients unique biology, values,and circumstances
Step 5: Evaluating our effectiveness and efficiency inexecuting steps 1-4 and seeking ways to improve themboth for next time
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Search Strategy
Medline database:
http://www.ncbi.nlm.nih.gov/pubmed/
Using the Clinical Queries function of PubMed:
Key words: dengue hemorragic
Clinical Study Categories: prognosis
Scope: Narrow
http://www.ncbi.nlm.nih.gov/pubmed/http://www.ncbi.nlm.nih.gov/pubmed/ -
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Searching the Evidence8
Clinical and laboratory characteristics ofpatients with dengue hemorrhagic fevermanifestations and their transfusion profile
Fujimoto, D. E., Koifman S. Rev Bras Hematol Hemoter. 2014: 36(2):115-
120
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Practice of EBM
9 Step 1: Converting the need for information (about
prevention, diagnosis, prognosis, therapy, causation, etc.)into an answerable question
Step 2: Tracking down the best evidence with which toanswer that question
Step 3: Critically appraise that evidence for the validity(closeness to the truth), impact (size of the effect), andapplicability (usefulness in our clinical practice)
Step 4: Integrating the critical appraisal with our clinicalexpertise and with our patients unique biology, values,
and circumstances Step 5: Evaluating our effectiveness and efficiency in
executing steps 1-4 and seeking ways to improve themboth for next time
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Is this evidence about prognosis valid?10
1. Was a defined, representative sample of patients assembled at acommon point in the course of their disease?
Penelitian ini menggunakan metode studi deskriptifretrospektif
Sample penelitian ini diambil dari satu tempat yaitu di
daerah Rio Branco
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Is this evidence about prognosis valid?11
2. Was follow-up of study patients sufficiently long and complete?
Dari 90.553 kasus dengue, follow-upterhadap 14.985 pasien (pemeriksaanserologi dilakukan) yang diambil dari3 Januari 2007 14 Juni 2011
dengan kematian pasien sebanyak 14orang
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Is this evidence about prognosis valid?12
2. Was follow-up of study patients sufficiently long andcomplete? (contd) Pada akhir pengamatan penelitian ini jumlah sampel semuanya
utuh karena pengambilan data menggunakan metode
retrospektif dimana menggunakan rekam medis
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Is this evidence about prognosis valid?13
3. Were objective outcome criteria applied in a blindfashion? Pada penelitian ini ,
total akhir dari
karakteristik klinik danlaborat tidak dijelaskansecara rinci.
Penyebab karakteristik
klinik dan laboratdilihat melalui rekammedis dari pelayanankesehatan
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Is this evidence about prognosis valid?14
3. Were objective outcome criteria applied in ablind fashion?
Pada penelitian ini , karakteristik klinik dijelaskan
sebagian kecil sedanagkan karakteristik laboratdijelaskan secara detail
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Is this evidence about prognosis valid?15
4. If subgroups with different prognoses are identified: Was there adjustment for important prognostic factors?
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Was there validation in an independent group oftest-set patients?
Tidak ada test-set pasien dalam penelitian ini
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Is this valid evidence about prognosisimportant?
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1. How likely are the outcomes over time?
2. How precise are the prognostic estimates? Dari kasus ini, ditemukan bahwa follow up dilakukanselama 3 Januari 2007 14 Juni 2011 dengan ditemukankasus sebanyak 90.553. dan kematian sebesar 7,3%
Dari 90.553 kasus DBD, dibagi 2 kelompok yaitu dengan
tes serologi dan tanpa tes serologi. Pasien dengan tesserologi dikelompokkan kembali menjadi positif, negatifdan tak tergolongkan. Dari pasien serologi (+)didapatkan 267 pasien dengan DBD dimana mereka yangakan dijadikan sampel penelitan
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Can we apply this valid, important evidence aboutprognosis to our patient?
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1. Is our patient so different from those in the studythat its results cannot apply?
Ya, karena dari kesimpulan penelitan ini tidak adahubungan antara pemberian transfusi dengankarakteristik klinik dan hasil laboratorium
2. Will this evidence make a clinically importantimpact on our conclusions about what to offer ortell our patient?
tidak
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Practice of EBM
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Step 1: Converting the need for information (aboutprevention, diagnosis, prognosis, therapy, causation, etc.)into an answerable question
Step 2: Tracking down the best evidence with which to
answer that question Step 3: Critically appraise that evidence for the validity
(closeness to the truth), impact (size of the effect), andapplicability (usefulness in our clinical practice)
Step 4: Integrating the critical appraisal with our clinical
expertise and with our patients unique biology, values,and circumstances
Step 5: Evaluating our effectiveness and efficiency inexecuting steps 1-4 and seeking ways to improve themboth for next time
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Resolution of the Case21
Pasien anak usia 15 tahun yang terdiagnosa DBD yangdiberikan transfusi trombosit tidak menurunkan risikodari karakteristik klinik maupun hasil laboratoriumyang mengakibatkan kematian