LEMBAR JAWABAN

SKILL LAB EVIDENCE BASED MEDICINE (EBM)

NAMA : dr Adi Cahya Kumara
NIM : 04062722024001

1. Data abnormalitas

Parameter Rerata SD Rerata ±2SD Nilai Abnormalitas

SGOT/SGPT 26,29 13,92 26,29+(2x13.92)= 54,13 + 0,05=54,18
54,13 Abnormal >54,18
HB 12,47 0,32 12,47-(2x0,32)= 11,83 11,83-0,05 = 11,78
Abnormal <11,78
Trigliserida 115,31 20,05 115,3 + (2x20,05) 155,4 +0,05 =
=155,4 155,45
Abnormal >155,4
Total 137,24 32,4 137,24 + 202,4+0,05 = 202,45
Kolestrol (2x32,4)=202,4 Abnormal >202,45
HDL 89,44 17,12 89,44- 55,22-0,05=55,17
(2x17,12)=55,22 Abnormal <55,17
LDL 74,64 13,63 74,64 + (2x13,63) = 101,9+0,05 = 101,95
101,9 Abnormal >101,95

2. EBM DIAGNOSIS
2.1 TABEL PICO
P Two months infant
I Tachypnea
C Oximetry
O hypoxia
2.2 Clinical question
In young infant, is tachypnea as accurate as oximetry to diagnose hypoxia?

2.3 Key word (search strategy)

- A two months infant AND tachypnea AND oximetry AND hypoxia

Yang singkat
Infant 2 month AND tacnypnea AND hypoxia

2.4 Search
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1718185/

2.5 Abstrak artikel

Abstract Objective—To evaluate the respiratory rate as an indicator of hypoxia
in infants < 2 months of age.
Setting—Pediatric emergency unit of an urban teaching hospital. Subjects—200
infants < 2 months, with symptom(s) of any acute illness.
Methods—Respiratory rate (by observation method), and oxygen saturation
(SaO2) by means of a pulse oximeter were recorded at admission. Infants were
categorised by presence or absence of hypoxia (SaO2 < 90%).
Results—The respiratory rate was > 50/ min in 120 (60%), > 60/min in 101
(50.5%), and > 70/min in 58 (29%) infants. Hypoxia (SaO2 < 90%) was seen in
77 (38.5%) infants. Respiratory rate and SaO2 showed a significant negative
correlation (r = −0.39). Respiratory rate > 60/min predicted hypoxia with 80%
sensitivity and 68% specificity.
Conclusion—These results indicates that a respiratory rate > 60/min is a good
predictor of hypoxia in infants under 2 months of age brought to the emergency
service of an urban hospital for any symptom(s) of acute illness. (Arch Dis Child
2000;82:46–49)
 2.6 Critical Appraisal
SCREENING
Does the study question match your
question?
Was the study design appropriate?
VALIDITY
F: Patient Follow-Up
 Were all patients who entered the trial
properly accounted for at its
conclusion? Losses to follow-up
should be less than 20% and reasons
for drop-out given.
 Was follow-up long enough?
R: Randomization
 Were the recruited patients
representative of the target population?
 Was the allocation (assignment) of
patients to treatment randomized and
concealed?
I: Intention to Treat Analysis
 Were patients analyzed in the groups
to which they were randomized?
 Were all randomized patient data
Yes, The Study question does match my
question, because the study also
questioned how to evaluate breathing as
an indicator of hypoxia in infants < 2
months.
Yes, The Study design was appropriate
because The study uses observational
methods.
Yes, all patients who entered the trial
properly accounted for at its conclusion.
explained in the journal section, i.e. Of the
200 infants, 77 (38.5%) had hypoxia
(SaO2 <90%). The respiratory rate was>
40 / min in 152 (76%),> 50 / min in 120
(60%), and> 60 / min in 101 (50.5%)
infants. A significant negative correlation
was seen between the respiratory rate and
SaO2.
In this study there were no samples losses
to follow-up should be less than 20% and
reasons for drop out.
The recruited patients were representative
of the target population. in this journal, the
research subject is Two hundred infants
under 2 months and data collection by
observational methods.
Yes, patients were analyzed in the groups
to which they were randomized and all
randomized patient data were analyzed.
explained in the journal section, i.e. One
 analyzed? If not, was a sensitivity or
“worst case scenario” analysis done?
S: Similar Baseline Characteristics of
Patients
Were groups similar at the start of the
trial?
B: Blinding
 Were patients, health workers, and
study personnel “blind” to treatment?
 If blinding was impossible, were
blinded
raters and/or objective outcome measures
used?
E: Equal Treatment
 Aside from the experimental
intervention, were the groups treated
equally?
Conflict of Interest
 Are the sources of support and other
potential conflicts of interest
acknowledged and addressed?
Summary of Article’s Validity
hundred infants each were enrolled during
winter (October to February) and summer
months (May to September). All the
infants came from the urban or periurban
areas of Chandigarh; most of them were
using the facility as their first medical
contact point. Infants less than 24 hours of
age, those with major congenital
malformations, and those referred after
previous hospitalisaton or active
cardiopulmonary resuscitation were
excluded. Informed parental consent was
obtained. Our study was approved by the
ethics committee of the institute.
Yes, groups were similar at the start of the
trial. explained in the journal section, i.e.
infants < 2 months.
Yes, patients, health workers, and study
personnel were “blind” to treatment.
explained in the journal section, i.e. All
the infants came from the urban or
periurban areas of Chandigarh; most of
them were using the facility as their first
medical contact point. Infants less than 24
hours of age, those with major congenital
malformations, and those referred after
previous hospitalisaton or active
cardiopulmonary resuscitation were
excluded. Informed parental consent was
obtained. Our study was approved by the
ethics committee of the institute.
The study make observasional study.
Yes, the sources of support and other
potential conflicts of interest
acknowledged and addressed. explained in
the journal section, i.e. Informed parental
consent was obtained. Our study was
approved by the ethics committee of the
institute.
The weaknesses of study were The Study
 Notable study strengths or weaknesses do acknowledge that the sensitivity and
or concerns? specificity of the respiratory rate as an
 How serious are the threats to validity indicator of hypoxia might not be the
and in what direction could they bias the same in a community setting, but our
study outcomes? findings should be helpful in planning a
\ nnhhhhhhhh community based study on the subject. In
a large longitudinal study, They found that
the mean respiratory rate of healthy Indian
infants under 2 months of age counted by
the observation method is 42–43 breaths /
min, and less than 9% of these infants had
a respiratory rate> 60 / min.
They conclude that acutely ill infants
under 2 months of age presenting at an
urban paediatric emergency service with a
respiratory rate > 60/min should be
considered hypoxic and treated with
oxygen if the facility to measure SaO2 is
not available. More data might be needed
before recommending the application of
these findings at the primary health care
level and in remote places in developing
countries.
CLINICAL IMPORTANCE

Present of Absent of Hypoxia

Hypoxia
Treated/Exposed 62 39 101
Control (Not 16 83 99
exposed)

CER *Control event rate)=c/(c+d) 84%

EER (experimenal event rate) =a/(a+b) 38%
RR (Relative Risik)=(a+b)/(c+d) 1.02
RRR (relative Risi reduction)/RBI (relative 54%
Benefit Increase)=(CER-EER)/CER
ARI (Atributable Riskk Reduction)/ABI 0.46
(Absolut Benefit Increase)-CER-EER
NNT (Bnmber Needed tto Treat) 1/RRR 2.17
Results OF IMPORTANCY Pada RRR 54%, maka secara klinis sangat
bermakna respiratory rate sebagai
indikator hipoksia pada bayi berusia 2
bulan
APPLICAbILITY
`
Similar patient
1. Are your patients similar to those in the
study?
2. Are they so different that the results
can’t help you
3. How much of the study effect can you
expect for your patients
Apakah pasin dan keluarga dapat
menerima pemberian obat/pengobatan atas
dasar nilai nilai sosial, budaya dan agama?
Realistic Interventions
4. Is the intervention realistic in your
setting?
5. Does the comparison intervention reflect
your current practice?
6. What alternatives are available
Right Outcomes
7. Have all the right outcomes been
considered?
Yes, My patients is similar to those in the
study. Because to find out hypoxia in
infants less than 2 mounths by measuring
the respiratory rate.
No, They are not different that the results.
Because These results indicates that a
respiratory rate > 60/min is a good
predictor of hypoxia in infants under 2
months of age brought to the emergency
service of an urban hospital for any
symptom(s) of acute illness.
Very much of the study effect can I expect
for my patients.
Yes, The intervention is realistic in my
setting. Because in the study using simple
algorithm to calculate the respiratory rate.
Yes, The comparison intervention is
reflect my current practice.
alternatives to the situation of infarnt less
than 2 months with hypoxia can be
measured use SpO2.
Yes, all the right outcomes have been
considered. By studying patients who
were brought to hospital for assessment of
illness we might have been looking at a
population skewed in favour of serious
illness. Nonetheless, our investigation has
met the objective to evaluate the
respiratory rate as an indicator of hypoxia
in the infants who are brought to a health
care facility and by implication were
considered unwell by their parents. We do
acknowledge that the sensitivity and
specificity of the respiratory rate as an
indicator of hypoxia might not be same in
a community setting, but our findings
should be helpful in planning a
community based study on the subject. In
 a large longitudinal study, we found that
the mean respiratory rate of healthy Indian
infants under 2 months of age counted by
the observation method is 42–43
breaths/min, and less than 9% of these
infants had a respiratory rate > 60/min.
We conclude that acutely ill infants under
2 months of age presenting at an urban
paediatric emergency service with a
respiratory rate > 60/min should be
considered hypoxic and treated with
oxygen if the facility to measure SaO2 is
not available. More data might be needed
before recommending the application of
these findings at the primary health care
level and in remote places in developing
countries.
8. Are the outcomes appropriate to your Yes, the outcomes is appropriate to my
patient? patient
9. Does the intervention meet their values Yes, the intervention meet their values and
and preferences? preferences. Because im the result, The
respiratory rate was > 50/ min in 120
(60%), > 60/min in 101 (50.5%), and >
70/min in 58 (29%) infants. Hypoxia
(SaO2 < 90%) was seen in 77 (38.5%)
infants. Respiratory rate and SaO2 showed
a significant negative correlation (r =
−0.39). Respiratory rate > 60/min
predicted hypoxia with 80% sensitivity
and 68% specificity.
Overall conclusion This study is valid, importance, and
applicable
3. EBM TERAPI PENILAIAN IMPORTANCY: BAD OUT COME

3.1 Nilai Importancy

Secara klinis:
EER : 0,12 artinya kejadian kematian pada penggunaan ACE inhibitor sebesar 12%
CER : 0,26 artinya kejadian kematian pada kelompok placebo sebesar 26%
RR : 0,46 artinya ACE inhibitor merupakan factor proteksi terjadinya kematian.
 ARR : 0,14 artinya peluang kematian penggunaan ACE inhibitor dapat mengurangi
kematian sebesar 14%
RRR : 0,538 artinya pengurangan kematian pada penggunaan ACE inhibitor sebesar
53,8% dibandingkan placebo.
NNT : 7,14 artinya diperlukan pengobatan dengan ACE inhibitor sebesar 7-8 orang
untuk mencegah satu kematian.

Bermakna secara klinis bila RRR =>25%, sangat bermakna (pasti bermakna) =>50%

Secara statistic: Pada uji Chi Square nilai p = 0,126 > 0,05 artinya perbedaan persentase
kematian antara penggunaan ACE inhibitor dan placebo tidak bermakna.

3.2.kesimpulan
Hasil penelitian penting secara klinis sebab nilai RRR > 50%, hasil penelitian tidak
bermakna secara statistik.

4. NILAI IMPORTANCY EBM TERAPY YG EFECTIVE OUTCOME

4.1 Nilai importancy
Secara klinis
EER : 0,52 artinya kejadian kesembuhan pada penggunaan Enalapril + ASA sebesar
52%
CER : 0.18 artinya kejadian kesembuhan pada penggunaan Isosorbid Prodiprogrel +
Diuretik sebesar 18%
RR : 2,89 artinya penggunaan Enalapril + ASA meningkatkan tingkat kesembuhan
ABI : 1 (100%) artinya peluang sembuh pada pengunaan Enalapril + ASA 100%
dibandingkan dengan penggunaan isosorbid progerol + diuretik
RBI : 0,34 artinya peluang ketidaksembuhan pada penggunaan Enalapril + ASA
sebesar 34%
NNT : 2,94 artinya jumlah pasien yang sembuh menggunakan Enalapril + ASA
memperoleh tambahan 3 orang disbanding bila diobati dengan obat Isosorbid
Prodiprogrel + Diuretik
 Secara statistik chi square nilai p 0,001 < 0,05 artinya perbedaan persentase
kesembuhan pada penggunaan Enalapril + ASA dan Isosorbid Prodiprogrel + Diuretik
bermakna

4.2 Kesimpulan
Penggunaan Enalapril + ASA bermakna secara klinis dan statistik

5. Data LDL dan Kreatinin Kinase

Classification: MCI
100
90
80
70
60
Sensitivity (%)
50
Specificity (%)
40
30
20
10
0
40 50 60 70 80
Kreatinin Kinase

Stat calc

ROC curve

Variable Kreatinin_kinase
Kreatinin Kinase
Classification variable MCI
MCI

Sample size 100

Positive group a 13 (13,00%)
Negative group b 87 (87,00%)
a
MCI = 1
b
MCI = 0

Disease prevalence (%) unknown

Area under the ROC curve (AUC)

Area under the ROC curve (AUC) 0,973

Standard Error a 0,0140
95% Confidence interval b 0,919 to 0,995
z statistic 33,901
Significance level P (Area=0.5) <0,0001
a
DeLong et al., 1988
b
Binomial exact

Youden index

Youden index J 0,9195

Associated criterion >69,1098
Sensitivity 100,00
Specificity 91,95

Criterion values and coordinates of the ROC curve [Hide]

Criterion Sensitivity 95% CI Specificity 95% CI +LR -LR

≥40,0886 100,00 75,3 - 100,0 0,00 0,0 - 4,2 1,00
>69,1098 100,00 75,3 - 100,0 91,95 84,1 - 96,7 12,43 0,00
>70,1641 92,31 64,0 - 99,8 93,10 85,6 - 97,4 13,38 0,083
>72,9038 76,92 46,2 - 95,0 93,10 85,6 - 97,4 11,15 0,25
>73,2495 69,23 38,6 - 90,9 94,25 87,1 - 98,1 12,05 0,33
>75,2407 69,23 38,6 - 90,9 96,55 90,3 - 99,3 20,08 0,32
>76,5148 61,54 31,6 - 86,1 97,70 91,9 - 99,7 26,77 0,39
>76,8872 53,85 25,1 - 80,8 98,85 93,8 - 100,0 46,85 0,47
>77,4574 38,46 13,9 - 68,4 98,85 93,8 - 100,0 33,46 0,62
>77,995 30,77 9,1 - 61,4 100,00 95,8 - 100,0 0,69
>78,6751 0,00 0,0 - 24,7 100,00 95,8 - 100,0 1,00

4.1. Cut off point kreatinin kinase………………..

4.2. AUC 0.973 akurasinya excellen
Screening [95% CI]
Prevalence : 0,13 [0,07; 0,22]
Sensitivity : 1,00 [0,72; 0,99]
Specificity : 0,90 [0,81; 0,95]
Accuracy : 0,91 [0,83; 0,96]
Predictive value of +ve result : 0,59 [0,37; 0,79]
Predictive value of -ve result : 1,00 [0,94; 1,00]

Sensitivity = 100% CI 95% (72-99%)

Specificity = 90% CI 95% (81-95%)
LR – = 0
LR + = 9.66 artinya peluang test positif pada kelompok penyakit sebesar 9.66 kali
LR test = 0
Akurasi = 0.91
PPV = kreatinin kinase dapat memprediksi penyakit sebesar 59%
NPV = probabilitas seseorang dengan hasil uji diagnostik negatif tidak menderita
penyakit sebesar 100 %
4.3. Kesimpulan:
Penggunaan kreatinini kinase sebagai test D MCI sangat akurat (excellent) karena AUC
0.973, tes ini juga dpat menentukan penyakit sebsar 100% (sensitivity) dan menentukan
bukan penyakit 92% (specificity)