mkdu ebm july 2015-dr. anang-asking answerable question
TRANSCRIPT
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Asking AnswerableQuestion
Anang Endaryanto
Division of Allergy Immunology, Child Health DepartmentShool of !ediine "niversity of Airlangga # Dr Soetomo Hospital
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LearningObjectiveSetelah mengikuti perkuliahan inimahasiswa diharapkan mampumemformulasikan pertanyaan
klinis $ menyusun pertanyaanklinis tersebut dalam answerable
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Patient /Problem /Population
Intervention Comparison Outcome
In a child withfrequent febrileseizures
wouldanticonvulsanttherapy
compared to notreatment
result in seizurereduction?
4
&'()* !ampu !enyusun +ertanyaanlinis
(PICO untuk Track-down)
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&'(-% !ampu melakukan penarianpustaka dengan struktur umum
PICO untuk Track-down
# (Population OR snon!" OR snon!#$) %&'
# (Intervention OR snon!" OR snon!#$) %&'
# (Co!parator OR snon!" OR snon!#$) %&'# (Outco!e OR snon!" OR snon!#$)
5
earc* (+ealt Cild OR Cild OR Cildren)%&' (Probiotics OR Lactobacillus OR
,idobacteriu!) %&' (Placebo) %&' (In.uen/aOR Cold OR Co!!on Cold OR In.uen/a-like)
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. Population0Proble!dari penelitian yang dilaporkan di /urnaltersebutadalah%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. Intervension0Indicator0Inde1dari penelitian yang dilaporkan di/urnal tersebutadalah%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. Controldari penelitian yang dilaporkan di /urnal tersebutadalah%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. Outco!edari penelitian yang dilaporkan di /urnal tersebutadalah%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&'(0 * !ampu !enyebutkanPICO dari 2urnal untuk Critical
%ppraisal
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&'(1* !ampu menyebutkan Disain,2okus dari 2urnal $ 3orksheet yangdigunakan untuk telaah kritis dari
2urnal ang diperole%Disain dari penelitian yang dilaporkan di /urnal tersebutadalah*A4% Cross sectional%54% Case control3C4% Coort3D4% Eksperimental%
E4% uasi Eksperimental%
2okus dari penelitian tersebut adalah*A4% !anifestasi klinik%54% Causation3C4% +rognosis%D4% Diagnosis%E4% 6erapi%
4orkseetyang paling tepat untuk digunakan untuktelaah kritis laporan penelitian dalam /urnal tersebutadalah workseet*A4% !anifestasi klinik%54% Systemati 7eview8!etaanalysis%C4% +rognosis%
D4% Diagnosis%E4% 6erapi%
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. Apakah penelitian yang dilaporkandalam /urnal tersebut 9A&ID:
. Apakah I!+'76A;C< dalam penelitiantersebut tergambar dalam /urnaltersebut:
. Apakah hasil penelitian yang dilaporkandalam /urnal tersebut bersifatA++&ICA5&E untuk pasien kita:
&'(=* !ampu melakukan telaah kritis>9IA4
(Critical %ppraisal)
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Contoh kasus:
+ertanyaan orang tua pasien kepada dokter* Apayang seharusnya saya lakukan untuk mencegah
anak saya terserang sakit fu?%
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&angkah pertama>menyusun pertanyaan klinis4
. Sebelum melangkah ke kegiatan penelusuran pustaka u/iklinis, yang harus dilakukan adalah menentukan masalahapa yang sebenarnya dihadapi oleh pasien yangmemerlukan solusi.
. 5ila pertanyaan orangtua* Apa yang seharusnya saya
lakukan untuk mencegah anak saya terserang sakitfu?, maka pertanyaan tersebut sulit diarikan /awabannyadari penarian pustaka dalam u/i klinis%
. Agar pertanyaan klinis dapat di/awab, maka pertanyaan klinistersebut harus memiliki iri(iri pertanyaan yang baik, yaitu*
#+ertanyaan klinis harus relevan dengan masalah yangdihadapi%
# +ertanyaan klinis disusun dalam frasa yang dapatditerapkan untuk penelusuran pustaka
# +ertanyaan klinis harus fokus pada masalah danterartikulasi dengan baik%
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+erbaikan pertanyaan klinis
Harus diper/elas*
.arakteristik Subyek# Subyeknya siapa:
. 5ayi, anak, rema/a, atau orang dewasa%# 5agaimana kondisi Subyek:
. Sehat,menderita penyakit tertentu, atau sehat
dengan risiko tertentu%
.Intervensi# Intervensi apa yang ingin dilakukan:%
. 'bat(obatan, vaksinasi, nutrisi, atau edukasi%
.!anfaat# !anfaat apa yang kita harapkan: >menegah,
meredakan atau menyembuhkan ge/ala4%# 5ila manfaat yang dipikirkan adalah menegah,
bagaimana ara mengukurnya: >kriteria klinis atau
laboratoris4
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!enyusun pertanyaan5ila klinisi tertarik untuk menelaah penegahan sakit ?u
dengan probiotik, maka kalimat pertanyaanApa yang seharusnya saya lakukan untukmencegah anak saya terserang sakit fu?
harus diperbaiki men/adi pertanyaan yang yang bisadi/awab, ontoh* Pada anak sehat apakah X
dapat mencegah sakit fu.
.Sehingga dari pertanyaan tersebut kita dapat membuatsusunan pertanyaan sebagai berikut*
# P (population/problem) : anak sehat
# I (intervention) : probiotik
# C (comparator/control) : tanpa probiotik
# (outcome) : sakit fu
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!angkah kedua"mencari bukti terbaik#
. Setelah /elas susunan pertanyaan yang menerminkan !asala pasiendengan karakteristik tertentu (P)dengan renana penyelesaian masalahdengan !enggunakan intervensi tertentu (I)dengan indikatorkeberasilan tertentu (O)5 maka kita bisa melakukan penarian pustakadengan struktur umum untuk pertanyaan klinis*
# (Population OR synonym1 OR synonym2) AND# (Intervention OR synonym1 OR synonym2) AND
# (Comparator OR synonym1 OR synonym2) AND
# (Outcome OR synonym1 OR synonym2)
. earc# 1! Probiotics OR "actobacillus OR #i$%obacterium
# 2! &ealt'y C'il% OR C'il% OR C'il%ren
# ! Placebo
# ! In*uen+a OR Col% OR Common Col% OR In*ien+a,li-e
. earc* (Probiotics OR Lactobacillus OR ,idobacteriu!) %&' (+ealtCild OR Cild OR Cildren) %&' (Placebo) %&' (In.uen/a OR Cold OR
Co!!on Cold OR In.ien/a-like)
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!angkah kedua"mencari bukti terbaik#
earcing*
(Probiotics OR Lactobacillus OR,idobacteriu!) %&' (+ealt
Cild OR Cild OR Cildren) %&'
(Placebo) %&' (In.uen/a OR ColdOR Co!!on Cold OR In.ien/a-like)
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Asking AnswerableQuestion
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re0uency o uestions
Brassey et al. BMJ2001;322:529-530.
http://www.bmj.com/content/vol322/issue7285/images/large/braj1680.f1.jpeg -
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$o%accurateadiagnostictes
tis
invariouspatientgroupsandin
omparison%ithothera&ailabletests.!easuresoftestaurayinludeits3n43p4"&4PP54N
P56
6uestion*@2or women with abdominal pain, isultrasono7rap'yas aurate >ie
with eual or better sensitivity andspeiBity4 as 8RIfor %ia7nosin7appen%icitis:
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. An answerable questions
. 2ormulate researc questions
. 5reaks down the uestion into 7 keele!ents
8enyusun pertanyaanpenelitian9
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:oo% clinical 0uestion!PICO
.6he Patient or Problem
.6he Intervention 8 Indiator 8Inde test
. Comparative intervention >if relevant4
.6he utome
'e brie( andspeci)c.....
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Patient4 Population4(clinical) Problem
. +atient or patient group >gender, rae,age4
. Disease or ondition
. Stage of the illness
. Care setting
Penting
untukgeneralisasiasil
enelitian
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Intervention4 In%icator4In%e; drug, proedure, therapy4
. Intervention level>dosage, freueny4
. tageof intervention >preventative, early,advaned4
. 'eliver>who delivers the intervention: where:4
I*/ICA+-
. 81posure
. 2ators that a9ect a ealt outco!e
I*/,X +,0+* a Diagnosti test
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Comparison
. Alternative interventions >standardtreatment, plaebo, anotherintervention4, indiators or diagnosti
test
.6here may not always be aomparison
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Outcome
6he outome or eets you >and8orpatients4
.I!prove!ent of symptoms, healing
.ide e9ects
.Improved qualit o: li:e
.Cost e9ectiveness and benetsfor theprovider
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Patient 1Problem 1Population
Inter&ention Comparison utcome
+ada
penderitadengansindromsyokdenguepadaresusitasiinisial
apakah
pemberianairankoloid
dibandingka
n kristaloidisotonis
akan
memberikan responsterapi yanglebih baik
8enyusun pertanyaan-linis9
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6reatment
Patient 1Problem 1
Population
Inter&ention Comparison utcome
In a hildwithfreuentfebrileseiFures
wouldantionvulsant therapy
omparedto notreatment
result inseiFureredution:
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Diagnosis
Patient 1Problem 1
Population
Inter&ention Comparison utcome
In anotherwisehealthy G(year(oldboy withsore throat
how doesthe linialeam
ompare tothroatulture
indiagnosing;roup-%treptococcal infetion:
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+rognosis
Patient 1Problem 1
Population
Inter&ention Comparison utcome
In hildrenwith Downsyndrome,
is IQ animportantprognostifator
( inpreditingAlFheimerslater in life:
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Etiology 8 Harm
Patient 1Problem 1
Population
Inter&ention Comparison utcome
ontrollingforonfounding fators,dootherwisehealthyhildren
eposed inutero tooaine,
omparedto hildrennot eposed
haveinreasedinidene oflearningdisabilitiesat age siyears:
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7elevane* +'Es and D'Es
. D'E 'isease orientedevidene# 'logiesJ >path(, etiol(, pathophys(4
# ie !ed shool
. +'E Patient oriented evidene
# !orbidity, mortality or uality of life# Something a patient would areabout without eplanation
# Highest uality evidene
Focused
Onpatient need
Focused
Ondisease
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Comparing D'Es and+'E!s
+rostatesreening
+SA sreeningdetets prostate
Ca% early
: whether +SAsreening mortality
D'E eists, but+'E! unknown
Antiarrhythmi6herapy
Antihypertens%
6herapy
Drug A +9C'n ECK
Drug L 5+Drug L mortality
Drug A Mmortality
D'E $ +'E!
ontradits
+'E! agrees3ith D'E
Eample D'E +'E! Comment
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+'E!s
. +atient 'riented Evidene that!atters
. !atters beause if it is true,it reuires you to hange yourpratie
. >Also a review of an artile writtenand published in a speiBed format seondary literature4
PICO i
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+itle
'ackground"Clinical 2uestion#
'ackground"b3ecti&e#
4ethod
-esult
Conclusion
P5 I5 "C#5
0e3auh ini pengaruh I untuk ter3adi pada P "dibanding C# belum 3el
4engetahui e(ek I dalam hal pada P
P677I6 777 C67.
677.
677
Pada P5 I berpengaruh padater3adinya
PICO inResearc
'
PIC.8here?
ili' %i i li i
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Hierarhy of study designs 5IAS vs
7ISRandomised controlled trialRandomised controlled trial
Cohort studiesCohort studies
Case-control studiesCase-control studies
Cross-sectional studiesCross-sectional studies(Clinical observation (Case(Clinical observation (Case
reportcase-series!reportcase-series!
"nalytical
#escriptive
$%periment
al
&bserv
ational
'east biased
ost biased
ost ris)
'east ris)
Pemili'an %isain penelitian
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. 7A;D'!ISA6I';# Alloate sub/ets among study groups randomly >by
hange4
. S67A6I2ICA6I';8!"&6I9A7IA6E A;A&ase(ontrol4
. 7ES67IC6I';
# admit only those who fall into speiBed atagories of
eah variable of interest >inlusion8elusion riteria4
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9...9n6 X. X;. X. X. [email protected]
9 >'4utome
9 host
9 agent
9 environment
9 time
9 plae
9 et%
Con(ounder
9 >I4ntervention, indiator, inde
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ResearcherInvolvement
Longitudinal
Cross-sectional
ResearchGoal
ResearchApproach
Controlled?Randomized?
ResearchFocus Clinical Manifestation / Diagnosis / Causation/Prognosis / Therapy / Review
13 2 4
experim
ental
observasional
Control
(+)
Control(-)
8enetap-an %isainpenelitian
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8enetap-an %isain penelitian
8enetap-an %isain penelitian
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8enetap-an %isain penelitian
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-A*/4I0A+4A+C$I*10+-A+IBICA+I*
4A+C$I*
8en%isain
penelitian
P t liti
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9...9n6 X. X;. X. X. [email protected]
9 >'4utome
9 host
9 agent
9 environment
9 time
9 plae
9 et%
Con(ounder
9 >I4ntervention, indiator, inde
Pertanaan penelitian siFe of the beneBt4
# Appliability
1% Integrate with linial epertise and patient
values=% Evaluate our eetiveness and eOieny
# keep a reordP improve the proess45
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+IC'
&iterature
Searhing42
PICO : T k d
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earc>"* +ealt Cild OR Cild OR Cildren
>#* Probiotics OR Lactobacillus OR ,idobacteriu!
>?* Placebo
>7* In.uen/a OR Cold OR Co!!on Cold OR In.ien/a-like
earc* (+ealt Cild OR Cild OR Cildren) %&'
(Probiotic@ OR Lactobacillus OR ,idobacteriu!) %&'(Placebo) %&' (In.uen/a OR Cold OR Co!!on Cold ORIn.uen/a-like)
43
PICO o: Track down
PICO : T k d
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>infant '7 newborn '7 neonat '7 pediatri '7paediatri4
A;D
>hydrolysed4
A;D
>feed '7 food '7 formula '7 protein '7 milk4
A;D
>asthma '7 atopi dermatitis '7 eFema '7 allergi rhinitis'7 ows milk intolerane '7 soy protein intolerane '7ows milk allergy '7 soy protein allergy '7 food allergy
'7 food intolerane '7 urtiaria '7 anaphylais4
4
PICO o: Track down
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+IC'
Critially appraise
4
+IC' of Critially appraise
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P Population
CComparator
I C
utcomesyes
no
I Indicator
a b
d
0ource
0ub3ects
-eruitR% 3as a deBnedrepresentati&e sample ofpatients assembled at aommon >usually early4point in the ourse of theirdisease:
Ad3ustment > How werepatients treated: Didad/ustment for importantprognosti fators takeplae:
4aintenance 3as theomparable status of thestudy groups maintainedthrough eual managementand ade2uate (ollo%Dup?:
4easure outomes with *blinded sub/ets $ assessors $
or
+IC' of Critially appraise
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=okusPenelitian
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+itle
'ackground"Clinical 2uestion#
'ackground"b3ecti&e#
4ethod
-esult
Conclusion
P5 I5 "C#5
0e3auh ini pengaruh I untuk ter3adi pada P "dibanding C# belum 3el
4engetahui e(ek I dalam hal pada P
P677I6 777 C67.
677.
677
Pada P5 I berpengaruh padater3adinya
+IC' ofCritially
appraise
PIC.8here?
8est C,5 $ammarstrom 4!5 $ernel .
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A redued mirobial load early in life has been suggested to be linked to the
inreasing prevalene of allergi diseases in the industrialiFed world% Somestudies have indiated that probiotis may be eetive in the prevention ofeFema% In vitro studies indiate that probiotis have immunomodulatory eets%
In the present study, we evaluated the eets of feeding &atobaillus 2) duringweaning on the inidene of eFema and 6h)86h- balane%
In a double(blind, plaebo(ontrolled randomiFed intervention trial, infants werefed ereals with >n T4 or without &atobaillus 2) >n U4 from 1 to )0months of age% 3e assessed the umulative inidene of eFema at )0 months ofage% 6he ratio of interferon(gamma >I2;(gamma4 to interleukin 1 >I&14 m7;Aepression levels in polylonally stimulated peripheral blood 6 ells was used as aproy for immune balane% 6otal and speiB IgE serum levels were also assessed%
6he umulative inidene of eFema at )0 months was ))V >1()GV, =V CI4 and--V >)0(0)V, =V CI4 in the probioti and plaebo groups, respetively >p WU%U=4% 6he number needed to treat was >X%=())%=, =V CI4% At )0 months of age,
the I2;(gamma8I&1 m7;A ratio was higher in the probioti ompared with theplaebo group >p W U%U=4% In ontrast, there were no dierenes between groupsin serum onentrations of IgE%
In summary, feeding &atobaillus 2) during weaning ould be an eetive toolin the prevention of early manifestation of allergy, e%g%, eFema% 6he higher6h)86h- ratio in the probioti ompared with the plaebo group suggestsenhaning eets of &atobaillus 2) on the 6 ell(mediated immune response%
8est C,5 $ammarstrom 4!5 $ernel .Probiotics during %eaningreduce the incidence o( ecEema.
+ediatr Allergy Immunol% -UU AugP-U>=4*10U(G
8est C,5 $ammarstrom 4!5 $ernel .
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/esign:Double(blind, plaebo(ontrolled randomiFed intervention trial
PopulationInfant >=ed cereals)Inter&ention&atobaillus 2) >n T4 from 1 to )0 months of age%Control+laebo >or without &atobaillus 2)4 >n U4utcome F -esult
.6he ratio of interferon(gamma >I2;(gamma4 to interleukin 1 >I&14 m7;Aepression levels in polylonally stimulated peripheral blood 6 ells wasused as a proy for immune balane%
.6he umulative inidene of eFema at )0 months was ))V >1()GV, =VCI4 and --V >)0(0)V, =V CI4 in the probioti and plaebo groups,respetively >p W U%U=4%
.6he nu!ber needed to treat was >X%=())%=, =V CI4%
.At )0 months of age, the I2;(gamma8I&1 m7;A ratio was higher in theprobioti ompared with the plaebo group >p W U%U=4%
.6here were no dierenes between groups in serum onentrations of IgE%Conclusions. 2eeding &atobaillus 2) during weaning ould be an eetive tool in the
prevention of early manifestation of allergy, e%g%, eFema%.6he higher 6h)86h- ratio in the probioti ompared with the plaebo group
suggests enhaning eets of &atobaillus 2) on the 6 ell(mediated
immune response%
5 5Probiotics during %eaning reduce the incidence o( ecEema.
+ediatr Allergy Immunol% -UU AugP-U>=4*10U(G
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oal Djian
%kir 8,A
0oa t pe p an
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0oa t pe p anberganda
Petunjuk* pilila " jawaban ang
paling benar*Disain dari penelitian yang dilaporkan di /urnal tersebutadalah*A4% Cross sectional%54% Case control3C4% Coort3D4% Eksperimental%E4% uasi Eksperimental%
2okus dari penelitian tersebut adalah*A4% !anifestasi klinik%54% Causation3C4% +rognosis%D4% Diagnosis%E4% 6erapi%
4orkseetyang paling tepat untuk digunakan untuktelaah kritis laporan penelitian dalam /urnal tersebutadalah workseet*A4% !anifestasi klinik%54% Systemati 7eview8!etaanalysis%C4% +rognosis%D4% Diagnosis%
E4% 6erapi%
0oal tipe 3a%aban
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0oal tipe 3a%abansingkat:
Petunjuk* 2awabla dengan " kali!at
saja. Population0Proble!dari penelitian yang dilaporkan di /urnaltersebutadalah%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. Intervension0Indicator0Inde1dari penelitian yang dilaporkan di/urnal tersebutadalah%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. Controldari penelitian yang dilaporkan di /urnal tersebutadalah%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
. Outco!edari penelitian yang dilaporkan di /urnal tersebutadalah%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
0 l , i i
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0oal ,sei uraianterbatas.
Petunjuk* 2awabla dengan sala satu dari ? pilian(EFaG5 ETidakG5 atau ETidak jelasG)5 ang diikutidengan alasan jawaban !aksi!al " paragra:
dengan isi !aksi!al H kali!at0paragra:)
. Apakah penelitian yang dilaporkan
dalam /urnal tersebut 9A&ID:. Apakah I!+'76A;C< dalam penelitian
tersebut tergambar dalam /urnaltersebut:
. Apakah hasil penelitian yang dilaporkandalam /urnal tersebut bersifatA++&ICA5&E untuk pasien kita:
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