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Evidence Based Medicine Clinical Management of Pulmonary Tuberculosis

Section C Maranion – Mendoza. Evidence Based Medicine Clinical Management of Pulmonary Tuberculosis. Case:. Salient features. 28 y/o female Chronic cough & Hemoptysis Cough = productive of scanty whitish to yellowish sputum Intermittent low grade fever, malaise and night sweats

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Evidence Based Medicine Clinical Management of Pulmonary Tuberculosis

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  1. Section C Maranion – Mendoza Evidence Based MedicineClinical Management of Pulmonary Tuberculosis

  2. Case:

  3. Salient features • 28 y/o female • Chronic cough & Hemoptysis • Cough = productive of scanty whitish to yellowish sputum • Intermittent low grade fever, malaise and night sweats • back pains • No weight change

  4. Evidence Based Approach Clinical impression Most probable diagnosis Critical appraisal of an article about a diagnostic test

  5. DIAGNOSIS Karmi Margaret Marcial Michelle Matematico Evangelyn Grace Matias MarienelleMaulion

  6. Clinical Impression • Bronchiectasis • Lung Cancer • Tuberculosis Chief complaint: Hemoptysis Page _______ Diagnosis - 1

  7. Differential Diagnosis

  8. Testing Thresholds and Pre-Test Probabilities Most Probable Diagnosis: 10% 80% 10% 90% 60%TB 30%Lung CA 10% 80% 60%TB 10% 80% 50%Bronchiectasis 0% 100%

  9. Script page • In this scenario, we consider the probability the probability of ____% that the patient has TB. • We also consider institutional care for these patients if the probability is _______% • Maybe home intervention if probability is _____%

  10. Assessment of Clinical Scenario

  11. Diagnostic options for TB

  12. Diagnostic techniques Page _______

  13. Search

  14. Candidate Journals

  15. Clinical scenario or question • What is the accuracy of HRCT or CXR in diagnosis of pulmonary tuberculosis?

  16. The Article ***

  17. Critical Appraisal Validity • Was there an independent, blind comparison with a reference standard? • Yes. The pulmonologist and radiologist who independently interpreted the HRCTs were unaware of the patients’ clinical condition.

  18. Critical Appraisal Validity • Was the diagnostic test evaluated in an appropriate spectrum of patients (like those in whom we would use it in practice?) • Yes. In a 2500-bed medical center in Southern Taiwan, the study group of 157 with suggestive CXR consisted of 33 women and 124 men with an age range of 20 to 83 years.

  19. Critical Appraisal Validity • Was the reference standard applied regardless of the diagnostic test result? • Yes. Sputum culture and AFB smear microscopy were performed in diagnosing active PTB prior to subjecting the patients to HRCT.

  20. Critical Appraisal Validity • Was the test validated in a second, independent group of patients? • No. Chest X-ray and HRCT were performed on the same set patients.

  21. Critical Appraisal Clinical Importance • What is the sensitivity? • CXR: 57% • HRCT: 89% • What is the specificity? • CXR: 28% • HRCT:85% • Can you calculate a likelihood ratio, or is there one already calculated? • Yes. It can be calculated in CXR and HRCT

  22. Clinical Importance: Xray Page _______

  23. Clinical Importance: Xray • Sensitivity = 57% • Specificity = 28% • LR+ = 0.80 • LR- = 1.52

  24. Clinical Importance: Xray

  25. Testing Thresholds: X-ray • Positive Post-Test Probability = 55% • Negative Post-Test Probability = 70% 55% 70% 10% 80% 60%TB

  26. Clinical Importance: HRCT Page _______

  27. Clinical Importance: HRCT • Sensitivity = 89% • Specificity = 85% • LR+ = 5.81 • LR- = 0.13

  28. Clinical Importance: HRCT

  29. Testing Thresholds: HRCT • Positive Post-Test Probability = 90% • Negative Post-Test Probability = 16% Xray HRCT 55% (+) 70% (-) 10% 80% 19% (+) 90% (+) 60%TB

  30. Critical Appraisal Applicability • In our practice, is the test: • Available? Yes. It is available in USTH. • Affordable? No. HRCT plain costs P 8000; with contrast P15,275. • Accurate? Yes. The accuracy of the test based on the pulmonologist’s interpretation is 86% and radiologist’s interpretation is 90%. • Precise? Yes.

  31. Critical Appraisal Applicability • Can we generate a reasonable pre-test probability in our clinical scenario? • Yes. The pre-test probability was generated based on the manifestation of the patient. • Are the study patients similar to our own? • Yes. The study patients are similar on our own, using the patient’s age and gender as the basis. • Has anything changed since the study was published? • None.

  32. Critical Appraisal Applicability • Will the resultant post-test probabilities change our management? • Yes. It will lead the physician decide to give the treatment or not.

  33. TREATMENT JhudielleMedenilla Kristianne Rachelle Medina Carmelou Mae Mejino

  34. HARM Ivy Melgarejo Alvin Mendoza Donne Paolo Mendoza

  35. PROGNOSIS Ma. Cristina Maranion Eric John Marayag Pamela Marcelo

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