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DIAGNOSTIK & SKRINING

Iwan Dwiprahasto
CE&BU
Fakultas Kedokteran UGM

(a) patients who underwent presurgical US and in
(b) patients who underwent appendectomy without prior US.
Puig et al, Radiology January 2003

Natural History of Disease

Preclinical Clinical Outcome

A B C D E F
A. Biologic onset of the condition
B. Pathologic evidence of disease detectable by screening
C. Signs and symptoms of disease
D. Health care sought
E. Diagnosis of disease
F. Treatment of disease

Issues in Screening Definition Early detection of preclinical disease in asymptomatic persons Purpose of screening Improve outcomes of illness • Improve morbidity: example • Improve mortality: example .

. diet & pengendalian BB untuk mencegah Type II diabetes pada pasien early-stage impaired glucose tolerance.g. Types of Screening Primary prevention Target: identifikasi faktor risiko pada individu yang asymptomatik untuk mencegah perlangsungan penyakit lebih lanjut. E..

Types of Screening Secondary prevention Target: mencegah proses penyakit untuk memperbaiki prognosis Menemukan pasien DM dg kadar gula tidak terkontrol untuk mencegah komplikasi penyakit microvascular (retinopathy dan nefropathy). .

Tertiary prevention: Target: individu yang telah mengalami komplikasi. untuk memperbaiki prognosis Pada penderita retinopati diabetikum. untuk mencegah perdarahan retina dan kebutaan .

hypertension.g. phenylketonuria (PKU). breast cancer. prostate cancer? • High prevalence of preclinical disease • E. lung cancer? • Effective preclinical treatment available • E. lung cancer. gallstones? • Effective test available • E... Diseases Appropriate for Screening • Serious consequences from disease – Reduce morbidity and/or mortality • E.. bladder cancer. breast cancer.g.g..g. uterine cancer. PKU. hypertension. CVD? .

Screening Recommended: .

MENGAPA TEST DIAGNOSTIK DIPERLUKAN? Rumit Mahal Invasif Spesialistik Interpretasi sulit Test canggih Hasil test negatif Aksesibilitas rendah .

Diagnostic/screening Highly sensitive/specific False positive/negative Diagnostic/screening Misleading Accurate Best diagnostic tools .

PROSEDUR UJI DIAGNOSTIK GOLD STANDARD Pneumonia Pneumonia No Pneumonia Pneumonia Respiratory No rate Pneumonia No Pneumonia .

FOTO RONTGEN No Pneumonia Pneumonia Pneumonia a b RESPIRA SI No Pneumonia c d Sensitivit Specificit y= y= a / (a+c) d / (b+d) .

DEFINISI Sensitivity: Proporsi penderita yang sakit dan memberikan hasil test positif Spesificity Proporsi orang tanpa penyakit dan memberikan hasil test negatif .

PV = I RASI No Pneumonia c d d/ (c+d) . FOTO RONTGEN No Pneumonia Pneumonia + PV = Pneumonia a b a/ (a+b) RESP .

DEFINISI Positive Predictive Value probabilitas adanya penyakit pada penderita dengan hasil test positif Negative Predictive Value probabilitas seseorang bebas dari penyakit karena hasil test negatif .

10 77 87 37 112 149 Se = 27/37 = Sp = 77/112 = 69% 73% +PV= 27/62 = 43% -PV= 77/87 = 88% . streptococcus + - + 27 35 62 Dx klinis .

FOTO RONTGEN No Pneumonia Pneumonia Pneumonia a b RESPIRA SI No Pneumonia c d Accuracy = (a+d) / N Prevalence = (a+c) / N .

LR . FOTO RONTGEN No Pneumonia Pneumonia Pneumonia a b RESPIRA SI No Pneumonia c d a/a + c c/a + c LR + = ---------.= ---------- b/b + d d/b + d .

Likelihood ratio positif: probabilitas suatu hasil test positif pada penderita yang sakit Likelihood ratio negatif: probabilitas suatu hasil test negatif pada orang yang tidak sakit .

10 77 87 37 112 149 27/37 10/37 LR+ = --------.3 LR.= ------.= 0.39 35/112 77/112 .= 2. streptococcus + - + 27 35 62 Dx klinis .

2 pre. and often >10 or < 0. MAKNA LIKELIHOOD RATIO generate large.to post-test probability generate moderate shifts in 5-10 and 0.2 important) changes in probability alter probability to a small (and 1-2 and 0.5-1 rarely important) degree .5-0.1 conclusive changes from pre.to post-test probability generate small (but sometimes 2-5 and 0.1-0.

39 .3 LR (-) = 0.LIKELIHOOD RATIO • Probabilitas suatu hasil test pada seorang penderita dibandingkan dengan probabilitas hasil test pada individu tanpa penyakit Apa arti? LR (+) = 12.

.Figure 1. pelvic inflammatory disease. acute sinusitis. and non-infectious processes. Physicians’ diagnosis of low-risk infective sites included acute pharyngitis. acute otitis media. Classification algorithm for predicting bacteraemia in patients with acute febrile illness (temperature 538C) in the first scenario (without use of laboratory data). acute diarrhoea. acute bronchitis. acute viral syndrome.

and non-infectious processes. acute diarrhoea. acute sinusitis. Physicians’ diagnosis of low-risk infective sites included acute pharyngitis. pelvic inflammatory disease. C-reactive protein. acute bronchitis.Figure 2. acute viral syndrome. Classification algorithm for predicting bacteraemia in patients with acute febrile illness (temperature 538C) in the second scenario (with use of laboratory data). CRP. acute otitis media. .

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Keuntungan likelihood ratio • Mudah mengklasifikasikan hasil test sebagai normal & abnormal • Mengemas informasi yang terkandung dalam hasil test pada derajat yang berbeda-beda • Pengambilan keputusan klinik untuk menentukan perlu/tidaknya dilakukan test • Menggambarkan “test performance” • > bermakna untuk klinisi dibanding dengan sensitivitas/spesifisitas: hanya 1 hasil. yaitu LR (+) .

blind comparison with a reference (“gold”) standard of diagnosis? 2. Was the reference standard applied regardless of the diagnostic test result? 4. independent group of patients? .Is this evidence about a diagnostic test valid? 1. Was the test (or cluster of tests) validated in a second. Was there an independent. Was the diagnostic test evaluated in an appropriate spectrum of patients (like those in whom we would use it in practice)? 3.

Was there an independent. 1. blind comparison with a reference (“gold”) standard of diagnosis? diagnostic test in question “gold” standard • history or • autopsy or • physical examination. • biopsy • a blood test BLINDING .

independent group of patients? .Is this evidence about a diagnostic test valid? 1. Was the diagnostic test evaluated in an appropriate spectrum of patients (like those in whom we would use it in practice)? 3. Was the test (or cluster of tests) validated in a second. blind comparison with a reference (“gold”) standard of diagnosis? 2. Was there an independent. Was the reference standard applied regardless of the diagnostic test result? 4.

36 Ca colon/rectum 35 lanjut positif Carcino Embryonic Antigen (CEA) Ca colon/rectum Derajat ringan Akurasi buruk Ca gastrointes- tinal lain high medium low clinical suspicion .

Was the reference standard applied regardless of the diagnostic test result? 4. Was the diagnostic test evaluated in an appropriate spectrum of patients (like those in whom we would use it in practice)? 3. Was there an independent.Is this evidence about a diagnostic test valid? 1. Was the test (or cluster of tests) validated in a second. independent group of patients? . blind comparison with a reference (“gold”) standard of diagnosis? 2.

Was the reference standard applied regardless of the diagnostic test result? Standard Invasif Do more harm NEGATIF Standard Non invasif Do more good .

Was the test (or cluster of tests) validated in a second. independent group of patients? Disease (+) Study Patiens Disease (-) Disease (+) Independent Group Disease (-) .

affordable. Is the dx test available. accurate. and precise in our setting? Tersedia Terjangkau Akurasi EXPERT???? Presisi .1.

prevalence statistics. practice databases. Can we generate a clinically sensible estimate of our patient’s pre-test probability? • From personal experience. or primary studies “pre-test” probability (apa yang kita pikirkan/duga sebelum test) “post-test” probability (apa yang kita pikirkan/duga setelah test) Diagnostic tests that produce big changes from pretest to post-test probabilities are important and likely to be useful to us in our practice .2.

USG Hipertensi Kriteria hipertensi?? .2. Can we generate a clinically sensible estimate of our patient’s pre-test probability? • Are the study patients similar to our own? • Is it unlikely that the disease possibilities or probabilities have changed since this evidence was gathered? Widal Typhoid??? Appendisitis Mc Burney vs.