LEMBAR JAWABAN

SKILLAB EVIDENCE BASED MEDICINE (EBM)

Nama : Ratri Prasetya Ningrum

NIM : 04032771822002

1. TABEL ABNORMALITAS

Parameter Rerata SD Rerata ± 2 SD Nilai Abnormalitas

SGOT/SGPT 26,29 13,923 26,29+2(13,923) = 54,13 54,13+0,05 = 54,18
Abnormal : >54,18
Hemoglobin 12,472 0,3238 12,242-2(0,3238) = 11,83 11,83 + 0,05 = 11,78
Abnormal : <11,78
Trigliserida 115,30 20,047 115,30 + 2 (20,047) = 155,394 155,394 + 0,05 = 155,444
Abnormal : >155,444
Total Kolesterol 137,23 32,405 137,23 + 2 (32,405) = 202,04 202,04 + 0,05 = 202,09
Abnormal : >202,09
HDL 89,44 17,119 89,44 + 2 (17,119) = 55,202 55,202 + 0,05 = 55,152
Abnormal :>55,152
LDL 74,64 13,634 74,64 + 2 (13,634) = 101,908 101,98 + 0,05 = 101,958
Abnormal : >101,958

2.a. Tabel P.I.C.O

P Older adult with early sign/symptom of cognitive impairment

I Mini-cog
C MMSE
O Accurate diagnosis of dementia or Alzheimer’s disease

2.b. Buatlah Clinical Question

In adult with early sign of cognitive impairment, is the Mini-cog as accurate as

MMSE in diagnosis of dementia or Alzheimer’s disease.

2.c.Buatlah search term/search/key word

(Mini-cog OR Minicog) AND (MMSE OR SMMSE OR Mini Mental Stae

Examination) AND (Dementia OR Alzheimer’s disease).
 2.d. Lakukan searching :

https://www.ncbi.nlm.nih.gov/pubmed
Website lain yang dapat digunakan :
 www.tripdatabase.com
 www.evidence.nhs.uk
 www.medicine.ox.ax.uk/bandolier/knowledge.html
 www.intute.ac.uk
 Bestpractice.bmj.com
 www.clinicalevidence.bmj.com

2.e. Pastekan abstract artikel yang didapat pada lembar jawaban

 2.e. Lakukan Critical Appraisal dari Artikel dengan critical appraisal
worksheet

VALIDITY ?
Are the results of this diagnostic study valid ?
Was there an independent, blind No, the reference standard and the index
comparison with a reference (“gold”) test that being assessed to each patient not
standard of diagnosis ? independently and blindly applied.
Was the diagnostic test evaluated in an Yes, the diagnostic test was evaluated in
appropriate spectrum of patients (like an appropriate spectrum of patients. All
those in whom it would be used in of the patient has fulfilled diagnostic
practice?) standards MCI. The Mini-Cog was
composed of the Three Objects Recall
and Clock Drawing Test (CDT) from the
Cognitive Abilities Screening Instrument
(CASI). Patients with condition that
could interfere the test, such as hearing
and visual dysfunction and mental
disease, is not included in the test, that’s
why the spectrum of patients were
appropriate.

Was the reference standard applied Yes, both the index and the references
regardless of the diagnostic test result? standard carried out on all patients in the
study. In this study, the references
standard applied was Petersen’s Criteria
supplemented by objective indexes such
as clinical dementia rating (CDR) and
Mini-Mental State Examination (MMSE).

Was the test (or cluster of tests) validated It is not stated whether the tests were
in a second independent group of validated in a second independent group
patients? of patients or not.

Kesimpulan Jurnal ini valid karena dilakukan blinding

pada saat pengumpulan data.
IMPORTANCE
Are the valid results of this diagnostic study important?
Table 1. Comparison of Mini-cog for the identification of patients with MCI.

MCI Totals

Positive Negative
Diagnostic Mini-cog 90 15 105
Test Positive
Results Mini-cog 21 18 102
Negative
Totals 111 96 207

 Sensitivity : a/(a+c) = 90/111 = 81,1 %

 Specificity : d/(b+d) = 81/96 = 84,3 %
 Likelihood ratio for a : LR+ = Sn/(1-Sp) = 81,1%/15,7% = 5,16
positive test results
 Likelihood ratio for a : LR- = (1-Sn)/Sp = 18,9%/84,3% = 0,22
Negative test results
 Positive predictive value : a/(a+b) = 90/105 = 85,7 %
 Positive predictive value : d/(c+d) = 81/102 = 79,4 %
 Pre-test probability : (a+c)/(a+b+c+d) = 111/207 = 53,6 %
(Prevalence)
 Pre-test odds : Prevalence/(1-Prevalence) = 53,6%/46,4% = 1,1
 Post-test odds : Pre-test odds x LR = 1,1 x 5,16 = 5,7
 Post-test probability : Post-test odds/(Post-test odds+1)
5,7/5,7+1 = 5,7/6,7 = 85,1%

Table 2. Comparison of MMSE for the identification of patients with MCI.

 MCI Totals

Positive Negative
Diagnostic MMSE Positive 68 37 105
Test
Results MMSE Negative 29 73 102
Totals 97 110 207

 Sensitivity : a/(a+c) = 68/97 = 70,1 %

 Specificity : d/(b+d) = 73/110 = 66,4 %
 Likelihood ratio for a : LR+ = Sn/(1-Sp) = 70,1%/33,6% = 2,08
positive test results
 Likelihood ratio for a : LR- = (1-Sn)/Sp = 29,9%/66,4% = 0,45
Negative test results
 Positive predictive value : a/(a+b) = 68/105 = 64,8 %
 Positive predictive value : d/(c+d) = 73/102 = 79,4 %
 Pre-test probability : (a+c)/(a+b+c+d) = 97/207 = 46,8 %
(Prevalence)
 Pre-test odds : Prevalence/(1-Prevalence) = 46,8%/53,2 = 0,87
 Post-test odds : Pre-test odds x LR = 0,87x2,08 = 1,8
 Post-test probability : Post-test odds/(Post-test odds+1)
1,8/1,8+1 = 1,8/2,8 = 64,3 %

Kesimpulan  karena sensitivitas dan sensifitas Mini-cog tinggi dalam mendeteksi

penyakit dimensia dibandingkan dengan MMSE.

APPLICABILITY
Can you apply this valid, important evidence about a diagnostic test in
caring for your patient?
Is the diagnostic test available, Yes. Mini-Cog examination is
affordable, accurate, and precise in affordable and available in RSMH and
your setting? the test can be done by neurologist so
the results will be accurate and precise
Can you generate a clinically
sensible estimate of your patient’s
pre-test probability (from personal
experience, prevalence statistics,
practice databases, or primary
studies)?
 Are the study patients similar to  Yes, the study patients are similar
your own? with ours.
 Is it unlikely that the disease  It is possible that the disease
possibilities or probabilities possibilities or probabilities have
have changed since the changed since the evidence was
evidence was gathered.
gathered?
Will the resulting post-test
probabilities affect your
management and help your patient?
 Could it move you across a  Yes, it can move us across a test-
test- treatment threshold? treatment threshold.
 Would your patient be a willing  Yes, in our opinion, our patients
partner in carrying it out? would be a willing partner in
carrying it out.
 Would the consequences of the test Yes, the test will help our patients in
help your patient? screening of mild cognitive
impairment.

3.a. Grafik Titik Potong Diagnostik

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

3.b Perkiraan titik potong visual kreatinin kinase untuk diagnostic MCI
adalaha 70 IU

3.c Nilai Diagnostik

Medcalc

Kreatinin Kinase
100
Sensitivity: 100,0
Specificity: 92,0
Criterion : >69,1098
80
Sensitivity

60

40

20

0
0 20 40 60 80 100
100-Specificity
ROC curve

Variable Kreatinin_kinase
Kreatinin Kinase
Classification variable MCI
MCI

Sample size 100

Positive group : MCI = 1 13
Negative group : MCI = 0 87

Disease prevalence (%) unknown

Area under the ROC curve (AUC)

Area under the ROC curve (AUC) 0,973

Standard Errora 0,0140
95% Confidence intervalb 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

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
CatMaker

Epicalc

Tables - 2-by-2 unstratified (11:36:32, 17/09/2018)

+ - Total
+ 12 6 18
- 1 81 82
Total 13 87 100

Tests of significance
Fisher exact test (one tailed) : 0,000000
Fisher exact test (two tailed) : 0,000000
Uncorrected chi-square : 55,90
p-value : 0,000001
Yates corrected Chi-square : 50,26
p-value : 0,000001

Measures of exposure effect [95% CI]

Risk ratio : 54,67 [7,58; 394,05]
Odds ratio : 162,00 [17,91; 1465,19]
Risk difference : 0,65 [0,44; 0,87]
Proportional attributable risk : 0,98 [0,87; 1,00]
Population proportional attr. risk : 0,91 [0,54; 0,99]

Vaccine efficacy [95% CI]

Vaccine efficacy : -53,67 [-393,05; -6,58]

Screening [95% CI]

Prevalence : 0,13 [0,07; 0,22]
Sensitivity : 0,92 [0,62; 1,00]
Specificity : 0,93 [0,85; 0,97]
Accuracy : 0,93 [0,86; 0,97]
Predictive value of +ve result : 0,67 [0,41; 0,86]
Predictive value of -ve result : 0,99 [0,92; 1,00]

Matched data
Z : 1,51
One-sided p-value : 0,065285
Two-sided p-value : 0,130570
McNemar Chi-square : 2,29
p-value : 0,130570
McNemar odds ratio [95% CI] : 6,00 [0,72; 132,29]
Difference in proportions [95% CI] : 0,05 [-0,00; 0,10]

StatCalc

3.d. Kesimpulan
Kreatinin kinase sensitif dan spesifik dlam mendeteksi MCI. Selain itu, hasil
dari penelitian ini penting karena LR+ 13,38 (LR+>10) dan LR-0,08 (LR-
<0,1). Hasil penelitian RRR=53,67 berarti bahwa penelitian ini sangat
bermakna secara klinis. Hasil AUC=0,973 menunjukkan bahwa akurasi
excellent (sangat baik).
4.a. Nilai Importance Therapy Bad Outcome

4.b. Kesimpulan
Sangat bermakna secara klinis, namun secara statistic tidak bermakna.

5.a Nilai Importance Therapy Effectiveness