LEMBAR JAWABAN

SKILLAB EVIDENCE BASED MEDICINE (EBM)

Nama : Rafika Triasa

NIM : 040427223270003

1. Nilai abnormalitas
Dalam file excel tersedia DATA abnormalitas. Data abnormallitas tersebut terdiri dari
variabel SGOT/SGPT, hemoglobin, trigliceyde, total kolesterol, HDL dan LDL pada
laki-laki. Hitunglah nilai abnormalitas dari data yang tersedia.
1.1. Hitunglah harga rerata
1.2 Hitunglah standar deviasi
1.3.Nilai abnormalitas adalah : > rerata+2x SD, kecuali Hb & HDL < rerata -2SD

Jawaban:
Statistics
SGOT/SGPT Total
Laki-laki Hemoglobin Trigliserid Kolestrol HDL LDL
N Valid 200 200 200 200 200 200
Missin 0 0 0 0 0 0
g
Mean 26,29 12,472 115,31 137,24 89,44 74,64
Median 27,00 12,500 116,50 137,50 89,00 74,00
Std. Deviation 13,923 ,3238 20,047 32,405 17,119 13,634

PARAMETER RERATA SD RERATA+2SD NILAI

ABNORMALITAS
1. SGOT/SGPT 26,29 13,923 26,29 + 54,13 + 0.05 = 54,18
2(13,923) = Abnormal ≥54,18
54,13
2. Hemoglobin 12,472 0,3238 12,47 - 2(0,324) 11,83 – 0.05 = 11,78
= 11,83 Abnormal ≤11,78
3. Trigliserid 115,31 20,047 115,31 + 155,39 + 0.05 =
2(20,047) = 155,44
155,39 Abnormal ≥155,44
4. Total Kolesterol 137,24 32,405 137,24 + 202,05 + 0,05 =
2(32,405) = 202,1
202,05 Abnormal ≥ 202,1
5. HDL 89,44 17,119 89,44 – 2(17,11) 55,22 – 0.05 = 55,17
 = 55,22 Abnormal ≤ 55,17
6. LDL 74,64 13,634 74,64 + 2 101,91 + 0,05 =
(13,634) = 101,96
101,91 Abnormal ≥101,96
Keterangan: Nilai abnormalitas harus ditambahkan batas toleransi 5% (0,05), maka dari itu
nilai + akan +0,05 dan nilai – akan -0,05 dari nilai abnormalitas. BIASANYA digunakan 5%.

2. EBM DIAGNOSIS
2.1. TABEL PICO
P Infant under 2 months with acute respiratory infection
I Tachypneu
C Pulse oxymeter
O Predict of hypoxia

2.2. Clinical question: In infant with rapid breathing, is tachypneu as accurate as oxymeter?

2.3. Key word (Search Strategy): [HYPOXIA] and [PNEUMONIA] and [OXIMETRY] and
[INFANT]

2.4. Searching
Di web: https://pubmed.ncbi.nlm.nih.gov/10630912/#:~:text=Conclusion%3A%20These
%20results%20indicates%20that,(s)%20of%20acute%20illness.

2.5. Download Abstrak dan Full text

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1718185/pdf/v082p00046.pdf

2.6. Telaah Kiritis (VIA) Gunakan di worksheet

VALIDITY: Are the results of this diagnostic study valid?

Was there an independent, blind comparison Blind comparison is not stated. In the method the
with a reference (“gold”) standard of authors explain that hypoxia was measured with
diagnosis? pulse oxymeter.
Was the diagnostic test evaluated in an Two hundred infants under 2 months of age who
appropriate spectrum of patients (like those were brought with symptom(s) of any acute illness
in whom it would be used in practice)? to the paediatric emergency serviceof Nehru
Hospital, Postgraduate Institute of Medical
Education and Research, Chandigarh were
included in the study. One 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.
Was the reference standard applied Yes, pulse oxymeter is gold standard in this study
regardless of the diagnostic test result?
Was the test (or cluster of tests) validated in Unmentioned in the article
a second, independent group of patients?

IMPORTANCY: Are the valid results of this diagnostic study important?

Sample Calculations
Target disorder
(Hypoxia)
Totals
Present Absent
Positive 62 39 101
Diagnostic (RR≥60x/menit) a b a+b
test result
(Respiratory 15 84 99
Rate) Negative c d c+d
(RR<60x/menit)
77 123 200
Totals a+c b+d a+b+c+d

Sensitivity = a/(a+c) = 62/77 = 80.5%

Specificity = d/(b+d) = 84/123 = 68.3%
Likelihood ratio for a positive test result = LR+ = sens/(1-spec) = 80.5%/31.7% = 2.5
Likelihood ratio for a negative test result = LR - = (1-sens)/spec = 19.5%/68.3% = 0.28
Positive Predictive Value = a/(a+b) = 62/101 = 61%
Negative Predictive Value = d/(c+d) = 84/99 = 84.8%
Pre-test probability (prevalence) = (a+c)/(a+b+c+d) = 77/200 = 32%
Pre-test odds = prevalence/(1-prevalence)= 32%/68% = 0.47
Post-test odds = pre-test odds  LR+ = 0.14 x 2.5= 0.35
Post-test probability = post-test odds/(post-test odds +1)= 0.35/1.35=0.25

APPLICABILITY: Will the results help me in caring for my patient?

Is my patient so different to those in the No, The result from the study applicable to
study that the result cannot apply? the patients according to the result
Is the treatment feasible in my setting? Yes, the feasible for the setting to improve
Will the potential benefits of treatment Yes, the bariatric surgery have more benefit
outweigh the potential harms of treatment thanthe potential harms.
for my patient?

3. EBM THERAPY .

a. Tabel PICO
P Obese, diabetes type II
 I Stomach stapling (gastric bypass surgery, bariatric surgery)
C Standard medical therapy
O Remission of diabetes, weight loss, mortality

b. Clinical question: Is bariatric surgery superior to conventional medical therapy

for obese patients with diabetes type II?

c. Search term/search/key word: [Obesity] AND [diabetes type 2] AND [bariatric

surgery]

d. Searching: https://pubmed.ncbi.nlm.nih.gov/22449317/

e. Download dan Copy paste abstract dan Full text Bariatric Surgery versus Conventional
Medical Therapy for Type 2 Diabetes :
https://www.nejm.org/doi/pdf/10.1056/NEJMoa1200111?articleTools=true

f. Critical Appraisal VIA (Worksheet)

VALIDITY:Are the results of the trial valid? (Internal Validity)
1a. R- Was the assignment of patients to Yes, the study was single-center, nonblinded,
treatments randomized? randomized, controlled trial. The patients were
assigned to one of three study groups (gastric
bypass, biliopancreatic diversion, or medical
therapy) by simple randomization in a 1:1:1 ratio
with the use of a computerized system for generating
random numbers.
1b. R- Were the groups similar at the start The groups were 60 patients between the ages of 30
of the trial? and 60 years with a body-mass index (BMI, the
weight in kilograms divided by the square of the
height in meters) of 35 or more, a history of at least
5 years of diabetes, and a glycated hemoglobin level
of 7.0% or more were randomly assigned to receive
conventional medical therapy or undergo either
gastric bypass or biliopancreatic diversion.
2a. A – Aside from the allocated treatment, The 3 of groups treated equally were evaluated by a
were groups treated equally? multidisciplinary team (including a diabetologist, a
dietitian, and a nurse) at baseline and at 1, 3, 6, 9,
12, and 24 months after surgery.
Medical therapy was adjusted according to the
seven-point glycemic profile during the first 3
months and according to glycated hemoglobin levels
thereafter.
The primary end point is measured by remission of
diabetes from fasting plasma glucose level of less than
100 mg per deciliter (5.6 mmol per liter) and a glycated
hemoglobin level of less than 6.5% for at least 1 year
without active pharmacologic therapy.
2b. A – Were all patients who entered the The patients who entered the trial were15 patients
trial accounted for? – and were they who would receive medical therapy, 15 who would
analysed in the groups to which they were undergo gastric bypass, and 11 who would undergo
randomised? biliopancreatic diversion. However, assuming an
 attrition rate of 25% over the course of the study, the
study determined that enroll 60 patients (20 per
study group).
The result analaysed of a single-center, nonblinded,
randomized, controlled trial comparing the efficacy
of two types of bariatric surgery (gastric bypass and
biliopancreatic diversion) with conventional medical
therapy in severely obese patients with type 2
diabetes.
3. M - Were measures objective or were the Each group knows about treatment they get in the study
patients and clinicians kept “blind” to after they classified with simple randomization in a 1:1:1
which treatment was being received? ratio with the use of a computerized system for generating
random numbers.
In the first group (medical therapy), Patients in the
medical-therapy group were assessed and treated by a
multidisciplinary team, get oral hypoglycemic agents and
insulin doses, programs for diet and lifestyle modification,
and increased physical exercise.
Other group who were assigned and explained to undergo
either gastric bypass or biliopancreatic diversion.
IMPORTANCY (What were the results?)

APPLICABILITY: Will the results help me in caring for my patient?

(ExternalValidity/Applicability)
Is my patient so different to those in the study No, The result from the study applicable to the
that the result cannot apply? patients according to the result bariatric surgery
was better glucose control than did medical
therapy.
Is the treatment feasible in my setting? Yes, the baiatric surgery feasible for the setting
to improve hyperglicemia in type 2 diabetes.
Will the potenntial benefits of treatment Yes, the bariatric surgery have more benefit
outweigh the potential harms of treatment for thanthe potential harms. There were no
my patient? operative deaths among patients undergoing
either gastric bypass or biliopancreatic
diversion. An incisional hernia requiring
reoperation 9 months after surgery developed in
a patient undergoing biliopancreatic diversion,
and one patient undergoing gastric bypass had
an intestinal obstruction requiring reoperation 6
months after surgery. Two patients who were
receiving medical therapy had persistent
diarrhea associated with metformin, a condition
that resolved when the drug was discontinued
and another oral hypoglycemic agent was
substituted This study was designed to evaluate
medium-term benefits of bariatric surgery
bariatric surgery, specifically gastric bypass and
biliopancreatic diversion more effective than
 conventional medical therapy in controlling
hyperglycemia in severely obese patients with
type 2 diabetes.

4. EBM Diagnosis (Importancy)

Dalam File excell/SPSS ada Data diagnosis td data LDL dan kreatinine kinase
Menghitung nilai Importancy (Diagnosis) dan artinya.
Langkah-langkah:
a. Gunakan SPSS buatlah Nilai AUC dan batas cut of point Kreatinin kinase
berdasarkan nilai sensitivity dan spesificity dan buat tabel 2x2
b. Data tabel 2x2 pindahkan ke Stat Calculator dan MedCalc free calculator
(download di goggle), hasilay copy pastekan di lembar jawaban
c. Hitunglah seluruh nilai diagnostik apa artinya masing masing nilai, buat
kesimpulan

Hasil

Kreatinin Kinase
100
Sensitivity: 100.0
Specificity: 92.0
Criterion : >69.1098
80

60
Sensitivity

40

20

0
0 20 40 60 80 100
100-Specificity

Area Under the Curve

Test Result Variable(s): Kreatinin Kinase
Asymptotic 95% Confidence
Asymptotic Interval
Area Std. Error a
Sig. b
Lower Bound Upper Bound
,973 ,014 ,000 ,945 1,000
The test result variable(s): Kreatinin Kinase has at least one tie between
the positive actual state group and the negative actual state group.
Statistics may be biased.
a. Under the nonparametric assumption
b. Null hypothesis: true area = 0.5

Sensitivitas = 69,637 (cut-off point)

Spesifisitas = 1 – 0,08 = 0,92

CK grup * MCI Crosstabulation

Count
MCI
MCI MCI
Negatif Positif Total
CK grup >= 69,637 7 13 20
< 69,637 80 0 80
Total 87 13 100

KESIMPULAN
Sensitivitas: CK dapat menemukan 100 orang yang sakit dari total 100 orang yang sakit
menurut pemeriksaan gold standard
Spesifisitas: CK dapat menemukan orang yang tidak sakit sebanyak 92 orang dari 100 orang
yang tidak sakit menurut pemeriksaan gold standard

5, Dalam file excel tersedia data Therapy Bad Outcome

Hasil Randomized clinical trial/ control trial ACE inhibitor
Pengaruh ACE inhibitor terhadap MCI (Meninggal dan sehat)

Berapa Nilai Importancy dan artinya?

 Langkah-langkah:

a. Gunakan SPSS untuk membuat table 2x2 outcome MCI (meninggal dan hidup),
variable independent ACE inhibitor (Ya dan tidak)
Buka file SPSS Therapy Bed Outcome pilih analysepilih descrivtive
statisticpilih cross tabulationpada row pindahkan ACE, pada kolom
pindahkan MCI pilih percentage pilih row (Bila ingin melihat uji hipotesis klik
chi square OK

b. Hasil table 2x2 pindahkan ke stat calc dan epi calc (down load di goggle: free
statistical calculators Medcalc software). Hasil nya scan copy pastekan di lembar
jawaban
c. Hitunglah nilai—nilai Importancy, Buat kesimpulan

Hasil

Kelompok * Outcome Crosstabulation

Count
Outcome
Hidup Meninggal Total
Kelompok Ace 6 44 50
Inhibitor
Placebo 13 37 50
Total 19 81 100

Chi-Square Tests
Asymp. Sig. (2- Exact Sig. (2- Exact Sig. (1-
Value df sided) sided) sided)

Pearson Chi-Square 3.184 a

1 .074
Continuity Correction b
2.339 1 .126
Likelihood Ratio 3.246 1 .072
Fisher's Exact Test .125 .062
Linear-by-Linear Association 3.152 1 .076
N of Valid Cases 100

a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 9.50.
b. Computed only for a 2x2 table

Secara statistik:
Pada uji Chi-square p = 0,126 > 0,05 artinya perbedaan kematian antara penggunaan ACE-I
dan placebo tidak bermakna.
STATS Calculator

Nilai-nilai Importancy
Secara klinis:
 EER = 0,12 artinya kejadian kematian 12 % pada penggunaan ACE-Inhibitor
 CER = 0,26 artinya kejadian kematian pada kelompok penggunaan placebo sebesar 26%
 RR =0,46 artinya ACE inhibitor merupakan factor proteksi terjadinya kematian
 ARR = 0,14 artinya perbedaan proporsi kematian MCI antara pemberian ACEI dan
placebo adalah sebesar 14%
 RRR = 0,538 artinya pengurangan kematian pada penggunaan ACE Inhibitor sebesar
53,8% di bandingkan Placebo (ACEI dapat mencegah kematian hingga 53.8%).
Bermakna secara klinis bila RRR≥25%, sangat bermakna jika lebih dari 50%.
 NNT = 7,14 artinya diperlukan pengobatan dengan ACE-i sebesar 7-8 orang untuk
mencegah kematian 1 orang

Kesimpulan:
Hasil penelitian penting dan sangat bermakna secara klinis, karena RRR>50%, yaitu 53,8%.
Namun, secara statistik tidak bermakna penggunaan ACE untuk menurunkan kematian (table
2x2 dengan chi-square pakai continuity correction untuk penentuan kemaknaan klinis secara
statistik)

6. Dalam file excel tersedia Data Therapy Effectiveness

RCT Efek obat dan control terhadap MCI (sembuh, tidak sembuh)

5.1. Hitunglah nilai—nilai Importancy

5.2. Buat kesimpulan
Berapa Nilai Importancy dan artinya?

Langkah-langkah

a. Gunakan SPSS untuk membuat table 2x2 outcome MCI (meninggal dan hidup),
variable independent ACE inhibitor (Ya dan tidak)
Buka file SPSS Therapy Effectivenes  pilih analysepilih descriptive
statisticpilih cross tabulationpada row pindahkan kelompok, pada kolom
pindahkan sembuh pilih percentage pilih row (Bila ingin melihat uji hipotesis
klik chi square OK
b. Hasil table 2x2 pindahkan ke stat calc dan epi calc ( download free statistical
calculators Medcalc software) calculator, hasilnya scan di copy paste kan di
lembar jawaban.
c. Hitunglah nilai—nilai Importancy, Buat kesimpulan

Hasil

Kelompok * Outcome Crosstabulation

Count
Outcome
Tidak
Sembuh Sembuh Total
Kelompok Enalapril + ASA 26 24 50
Isossorbid Prodiprogrel 9 41 50
+ Deuretik
Total 35 65 100

Chi-Square Tests
Asymp. Sig. Exact Sig. (2- Exact Sig. (1-
Value df (2-sided) sided) sided)
Pearson Chi-Square 12.703a 1 .000
Continuity Correctionb 11.253 1 .001
Likelihood Ratio 13.115 1 .000
Fisher's Exact Test .001 .000
Linear-by-Linear
12.576 1 .000
Association
N of Valid Cases 100
a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 17.50.
b. Computed only for a 2x2 table
STATS Calculator

Nilai-nilai Importancy:
 CER = 0.18  kejadian hidup pada MCI pada kelompok ISDN adalah sebesar 18%
 EER = 0.52  kejadian hidup pada MCI di kelompok enalapril + ASA adalah 52%
 NNT = Diperlukan 2-3 orang yang diterapi dengan Enalapril + ASA untuk sembuh dari 1
orang akibat MCI
 RRR = 188%  enalapril + ASA dapat menurunkan kejadian MCI 188% dibandingkan
ISDN + diuretic

Karena nilai RRR <50%, dapat dikatakan bahwa Enalapril + ASA bermakna secara klinis.

Kesimpulan:
Nilai Enalapril + ASA (p <0.05  0.001) bermakna secara statistik, efektif untuk
kesembuhan pasien dari MCI.