Taller imss 6 apendicitis subido slide
Transcript of Taller imss 6 apendicitis subido slide
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Sesión 6
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Taller Básico Diagnóstico
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Likelihood RatioDiagnósti
coProbabilid
ad
Inespecífico 43%
Apendicitis 4-20%
Colecistitis 3-9%
Obstrucción intestino delgado
4%
Urolitiasis 4%
Probabilidad diagnóstica en pacientes con dolor
abdominal
McGee, S. Evidence-Based Physical Diagnosis, 2nd Ed. Philadelphia: Saunders, 2007Brewer BJ, Golden GT, Hitch DC, et al. Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. Am J Surg. 1976 Feb;131(2):219-23.
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LR + 1.83LR – 0.26
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General > 7 puntos:Sensibilidad 82%, Especificidad 81%
LR + 4.32LR – 0.22
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LR + 2.91LR – 0.15
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Likelihood RatioSigno LR (+) LR (-)
Dolor cuadrante inferior derecho
1.8 0.3
McBurney 3.4 0.4Rovsing 2.3 0.8Psoas 2.0 NS (no
significativo)Obturador NS NSAlvarado >7 puntos
3.1 NS
Alvarado 5-6 puntos
NS NS
Alvarado <4 puntos
0.1 NS
Apendicitis
McGee, S. Evidence-Based Physical Diagnosis, 2nd Ed. Philadelphia: Saunders, 2007
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Likelihood Ratio
USG LR (+) LR (-)
USG abdominal 1.6 17.4
TAC abdominal 3.4 0.14
Apendicitis
Old JL1, Dusing RW, Yap W, Imaging for suspected appendicitis. Am Fam Physician. 2005 Jan 1;71(1):71-8.
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Artículo
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Antecedentes
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Antecedentes
Factor de impacto 17.4Quinta revista médica
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IgNobel
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Abrahams, M. , 2010. Improbable Research, [Internet] Disponible en:<http://improbable.com/> [Acceso 10 Diciembre 2015].
IgNobel
•“No pueden o no deben ser reproducidos”•“Primero hacen reír a las personas, después las hacen pensar”
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Abrahams, M. , 2010. Improbable Research, [Internet] Disponible en:<http://improbable.com/> [Acceso 10 Diciembre 2015].
IgNobel
•Teatro Sanders de la Universidad de Harvard•Annals of Improbable Research
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Taller Básico Diagnóstico
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VIA
alidez.mportancia.plicabilidad.
Análisis crítico de la evidencia
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VIA
alidez.mportancia.plicabilidad.
Análisis crítico de la evidencia
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VIA
alidez.mportancia.plicabilidad.
Análisis crítico de la evidencia
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Descripción
Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone, 2000.
MétodosSensibilida
dEspecificid
ad
VPP
VPN
Enfermedad
Sí (+) No(-)
Resultado de la
prueba+ VP FP- FN VNSP
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Descripción
Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone, 2000.
Métodos Apendicitis
Sí (+) No(-)
Dolor con topes + 33 21
- 1 9
Sensibilidad
Especificidad
VPP
VPN
LR+,LR-
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Sensibilidad=VP/ (FN+VP) Especificidad= VN/(VN+FP) VPP= VP/(VP+ FP) VPN= VN/(VN+FN) LR (+)= Sensibilidad/ (1-Especificidad) LR (-) = 1-Sensibilidad/Especificidad
Valores
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Sensibilidad=33/ (1+33) Especificidad= 9/(9+21) VPP= 33/(33+ 21) VPN= 9/(9+1) LR (+)= Sensibilidad/ (1-Especificidad) LR (-) = 1-Sensibilidad/Especificidad
Valores
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Sensibilidad=0.9705 Especificidad= 0.3 VPP= 0.6111 VPN= 0.9 LR (+)= 0.9705/ (1-0.3)= 0.9705/ (0.7) LR (-) = (1-0.9705)/0.3= (0.0295)/0.3
Valores
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Sensibilidad=0.9705 Especificidad= 0.3 VPP= 0.6111 VPN= 0.9 LR (+)= 1.3864 LR (-) = 0.0833
Valores
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Signo LR (+)
LR (-)
Dolor cuadrante inferior derecho
1.8 0.3
McBurney 3.4 0.4
Rovsing 2.3 0.8
Psoas 2.0 NS (no significativo)
Obturador NS NS
Alvarado >7 puntos
3.1 NS
Alvarado 5-6 puntos
NS NS
Alvarado <4 puntos
0.1 NSMcGee, S. Evidence-Based Physical Diagnosis, 2nd Ed. Philadelphia: Saunders, 2007
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VIA
alidez.mportancia.plicabilidad.
Análisis crítico de la evidencia
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Tope: Signo presente
Caso clínico
Ausencia datos de alarma
LR + 1.4 PP: 16%
Cáncer de colon
Dolor con topes
Pre test: 12%
Apendicitis
Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review.Am J Gastroenterol. 2002 Nov;97(11):2812-9.
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Tope: Signo ausente
Caso clínico
Ausencia datos de alarma
LR - 0.1 PP: 1.3%
Cáncer de colon
Sin dolor con topes
Pre test: 12%
Apendicitis
Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review.Am J Gastroenterol. 2002 Nov;97(11):2812-9.
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McBurney: Signo presente
Caso clínico
Ausencia datos de alarma
LR + 3.4 PP: 31.7%
Cáncer de colon
McBurney +
Pre test: 12%
Apendicitis
Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review.Am J Gastroenterol. 2002 Nov;97(11):2812-9.
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McBurney: Signo ausente
Caso clínico
Ausencia datos de alarma
LR -0.4 PP: 5.2%
Cáncer de colon
McBurney -
Pre test: 12%
Apendicitis
Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review.Am J Gastroenterol. 2002 Nov;97(11):2812-9.
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Tope: Signo presente
Paciente de 34 años con dolor abdominal, sospecha apendicitis, acude a su hospital pasando por la calle presenta: Dolor con topes (LR + 1.4) Alvarado 8 puntos (LR + 3.1)
¿Cuál es la probabilidad posprueba de apendicitis?
Preprueba: 12%
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12% 16% 16% 3.9%
ApendicitisTope
LR+ 1.4Alvarado LR + 3.1
1. McGee, S. (2007). Evidence based physical diagnosis (2nd ed.). Philadelphia: Saunders.2. Naugle AL, Shulaw WP, Saville WJ, et al. Calculation method for likelihood ratios dictates interpretation. Clin Diagn Lab Immunol. 2003
Jul;10(4):729.
Probabilidad posprueba
37.1%
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Tope: Signo ausente
Paciente de 34 años con dolor abdominal, sospecha apendicitis, acude a su hospital pasando por la calle presenta: Ausencia de dolor con topes (LR +
1.4) Alvarado 8 puntos (LR + 3.1)
¿Cuál es la probabilidad posprueba de apendicitis?
Preprueba: 12%
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12% 1.3% 1.3% 3.9%
ApendicitisTope
LR- 0.1Alvarado LR + 3.1
1. McGee, S. (2007). Evidence based physical diagnosis (2nd ed.). Philadelphia: Saunders.2. Naugle AL, Shulaw WP, Saville WJ, et al. Calculation method for likelihood ratios dictates interpretation. Clin Diagn Lab Immunol. 2003
Jul;10(4):729.
Probabilidad posprueba
3.9%
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Complemento
La paciente sigue con dolor y tengo dudas. Tengo disponibilidad de TAC. La cuál solicito…
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Complemento
TAC positiva a ApendicitisLR + 17.4
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12% 1.3% 1.3% 3.9%
ComplementoTope
LR- 0.1Alvarado LR + 3.1
1. McGee, S. (2007). Evidence based physical diagnosis (2nd ed.). Philadelphia: Saunders.2. Naugle AL, Shulaw WP, Saville WJ, et al. Calculation method for likelihood ratios dictates interpretation. Clin Diagn Lab Immunol. 2003
Jul;10(4):729.
3.9% 41.4%
TAC +LR + 17.4
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Complemento
TAC negativa a ApendicitisLR – 0.14
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12% 1.3% 1.3% 3.9%
ComplementoTope
LR- 0.1Alvarado LR + 3.1
1. McGee, S. (2007). Evidence based physical diagnosis (2nd ed.). Philadelphia: Saunders.2. Naugle AL, Shulaw WP, Saville WJ, et al. Calculation method for likelihood ratios dictates interpretation. Clin Diagn Lab Immunol. 2003
Jul;10(4):729.
3.9% 0.6%
TAC -LR -0.14
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Apendicitis
¿Lo opero?
¿Modifica mi conocimiento este artículo?
¿Modifica mi conducta terapéutica?
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Siguientes sesiones…
Artículos de
tratamiento
•2 sesiones teoría
•1 sesión taller
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Preguntas y comentarios