sarkaidosis

8/10/2019 sarkaidosis

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EBM therapy


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Skenario Klinis

Seorang pasien berusia 4 tahun datang bersama ibunyake tempat praktek pribadi dengan keluhan demam.Gejala demam disertai sakit perut, muntah, dan lemas.Pasien tidak mengalami kejang. Pasien tinggal di

daerah endemis malaria. Hasil pemeriksaan apusandarah didapatkan plasmodium falciparum. Doktermenyarankan untuk mendapatkan pengobatan terkinimenggunakan Artemisinin-based combination therapy(ACT) yang hanya tersedia di puskesmas dan diperoleh

secara cuma-cuma. Namun ibu pasien menolak daningin mendapatkan terapi dari dokter yangbersangkutan .


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Dokter berfikir terdapat sediaan ACT di luar

program pemerintah. Namun dokter belum

begitu yakin efektifitas obat tersebut


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Steps in Practicing EBM

1. Convertthe need for information into ananswerable question.

2. Track down the best evidence with which to

answer that question.3. Critically appraise the evidence for itsvalidity, impact, and applicability.

4. Integrate the evidence with our clinicalexpertise and our patients characteristicsand values.

5. Evaluating our effectiveness and efficiency inexecuting steps 14 and seeking ways toimprove them both for next time.


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Pertanyaan klinis

Patient and the

problem:

Intervention: Comparison: Outcome of

interest:

Pasien dengan

sarkaidosis

kutaneus

CLEAR

(concomitant,

Levofloxacin,

Ethambutol,Azitromisin,

Rifampin)

Placebo Reduksi diameter

lesi sarkaidosis

kutaneus

Components of foreground question (PICO):


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Pertanyaan klinis

Pada pasien dengan sarkaidosis kutaneus,

apakah pemberian CLEAR (concomitnan,

Levofloxasin, Ethambutol, Azitromisin,

Rifampin) sama efektifnya dengan pemberian

placebo dalam mempengaruhi kesembuhan?


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1. Convert the need for information into ananswerable question.






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Search Strategy

Medline database:

http://www.ncbi.nlm.nih.gov/pubmed/

Using the Clinical Queries function ofPubMed:

Key words:

coartemAND

malaria

Clinical Study Categories: Therapy

Scope: Narrow
http://www.ncbi.nlm.nih.gov/pubmed/http://www.ncbi.nlm.nih.gov/pubmed/


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The evidence

Efficacy of artesunate-amodiaquine and artemether-lumefantrine fixed-dose combinations for thetreatment of uncomplicated Plasmodium falciparummalaria among children aged six to 59 months inNimba County, Liberia: an open-label randomized non-

inferiority trial

Schramm B, Valeh P, Baudin E, Mazinda CS, Smith R,Pinoges L, Dhorda M, Boum Y, Sundaygar T, Zolia YM,Jones JJ, Comte E, Houze P, Jullien V, Carn G, Kiechel J,Ashley EA, Guerin PJ.

http://www.malariajournal.com/content/12/1/251


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ARE THE RESULTS OF THIS INDIVIDUAL STUDY

VALID?


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VALID?

1. Was the assignment of patients to treatment

randomized? Lihat di judul

Ya, pada jurnal yang kami temukan di juduldikemukakan bahwa penelitain ini merupakan

Randomizeddan hal tersebut juga dinyatakan dalam

metode.


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2. Was the randomization concealed ?

- Ya


VALID?


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3. Were the groups similiar at the start of the

trial ?

- Ya

pada methodde kalimat berdua, dan kriteria

inklusi eklusi pada paragraf kedua, pada

interventions


VALID?


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VALID?

2. Was the randomization concealed? Bukti

randomizedny mana?

ya


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VALID?

3. Were the groups similar at the start of the trial?carikriteria inklusinya sama (orang, waktu, cara

pengambilan)

Ya + tbel 1


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VALID?4. Was follow-up of patients sufficiently long and complete?

Pada penelitian ini follow-up pasien dilakukan selama 180 hari mulai

dari awal


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VALID?

5. Were all patients analyzed in the groups to which

they were randomized?

Ya, penelitian ini menganalisis masing-masing kelompok


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VALID?

6. Were patients, clinicians, and study personnelkept blind to treatment?

Tidak

Pasien diberikan inform consent sebelumdilakukan penelitian

Clinicians tidak mengetahui tujuan dari penelitian

ini (single blind)


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VALID?

7. Were groups treated equally, apart from the

experimental therapy?Apakah kelompok

pasien yang diteliti dipilih secara acak,

terlepas dari riwayat terapiny?

Ya, sampel penelitian diacak menggunakan

random sampling dengan perbandingan 1:1


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ARE THE VALID RESULTS OF THIS INDIVIDUAL

STUDY IMPORTANT?


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1. What is the magnitude of the treatment

effect? Cari ditabel ttg perlakuan

event Time to

event

Kel. Control

Total pasien : 150Total yg dianalisis: 149

Kel. perlakuan

Total pasien : 150Total yg dianalisis: 150

cure 28 days Number of

event

CER

99

0.66

Number of

event

EER

108

0.720

cure 42 days Number of

event

CER

75

0.50

Number of

event

EER

71

0.473


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2. How precise is this estimate of the

treatment effect?Cari ditabel juga ttg

besarnya pengaruh obat trhp lesi

CER EER RRR

|CER-EER|/CER

ARR

|CER-EER|

NNT

1/ARR

Cure 28 days 66 72 -9%-25%-7%

0.06-0.164-0.044

17NNT: 22 to INF

NNH: 6 to INF

Cure 42 days 50 47.3 5%

-17%-28%

0.027

-0.086-0.14

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NNT: 7 to INF

NNH: 12 to INF


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ARE THE VALID, IMPORTANT RESULTS OF THIS INDIVIDUAL STUDY

APPLICABLE TO OUR PATIENT?


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1. Is our patient so different from those in the

study that its results cannot apply?

Tidak, pasien sesuai kriteria inklusi penelitian,

namun menurut American Lung Association Stateof Lung Disease in Diverse Communities (2010)

menyebutkan bahwa Indonesia bahwa penyakit

sarkaidosis jarang terjadi di Asia Selatan (Korea,

Cina dan Indonesia)


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2. Is the treatment feasible in our setting?

(harga, ready stok)

Tidak

Untuk metode CLEAR (concominant, levofloxacin,

ethambutol, azitromycin dan rifampin),

concominanttidak tersedia di Indonesia

Sedangkan rifampin biasa dikenal di Indonesiadengan sebutan rifampicin

(ISO Indonesia, 2010)


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3. What are our patients potential benefits and harmsfrom the therapy?Bukti bahwa potensi kesembuhan dankesakitan dari terapi?

Penelitian ini melaporkan nilai NNT pada akhir pengamatan: 37,

artinya kita membutuhkan 37 pasien yang mendapatkan terapicoartem selama 42 hari untuk mendapatkan hasil tambahan 1orang yang sembuh dari malaria

Pasien ini tidak memerlukan analog peningkatan risiko karenapasien tinggal di daerah endemis ( sesuai dengan setting

penelitian) Dengan ACT Program biaya yang dikeluarkan lebih sedikit,

bahkan bisa diperoleh secara gratis, sedangkan untuk AL biayayang diperlukan lebih besar/mahal


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4. What are our patients values and expectationsfor both the outcome we are trying to preventand the treatment we are offering?Bagaimanaekspektasi dari pasien kita thdp terapi yang kitaanjurkan?

Penggunaan ACT maupun coartem memilikikesamaan efektifitas dalam kesembuhan pasien

Jadi ada kesesuaian antarapatients values andexpectationsdengan pengobatan yang akandiberikan berdasarkan evidence tersebut


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2. Track down the best evidence with which toanswer that question.

3. Critically appraise the evidence for itsvalidity, impact, and applicability.

4. Integrate the evidence with our clinicalexpertise and our patients characteristics

and values.5. Evaluating our effectiveness and efficiency in

executing steps 14 and seeking ways toimprove them both for next time.


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Resolution of The Case Scenario

Dokter bisa menggunakan coartem sebagai

terapi alternatif pada pengobatan malaria


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2. Track down the best evidence with which toanswer that question.

3. Critically appraise the evidence for itsvalidity, impact, and applicability.

4. Integrate the evidence with our clinicalexpertise and our patients characteristics

and values.5. Evaluating our effectiveness and efficiency in

executing steps 14 and seeking ways toimprove them both for next time.


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Terimakasih

Alhamdulillah

sarkaidosis

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