PUBH6005 Interventions In Children With Severe Dengue: Critical Appraisal Assessment 3 Answer

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Question :

ASSESSMENT BRIEF
Subject Code and TitlePUBH6005: Epidemiology
AssessmentAssessment 3: Critical Appraisal
Individual/GroupIndividual
Learning OutcomesThis assessment addresses the following learning outcomes:
  1. Assess levels of evidence and make recommendations
  2. Interpret data arising from surveillance and research studies, including rates and ratios
  3. Understand the difference between association and causation, statistical and public health significance
  4. Critically evaluate epidemiological studies, including potential for bias, confounding and chance errors

Context:

This assessment requires you to apply the knowledge and skills gained in all the modules to undertake a critical appraisal. You will need to appraise 3 articles of a topic and research question given to you by your facilitator.

  1. Search the library database to find three studies that answer your research question. All three studies must be of different study designs. For instance, you could include case control, cohort and RCTs. These studies do not have to prove their hypothesis or agree with each other. Please note that marks will be deducted if all identified papers are of similar study.
  2. Critically appraise all three articles you found. Your answers are to be written in the tables provided to you which was based on CASP checklist and other types of checklist.
  3. In the table, you are required to answer either “Yes”, “No”, “Unclear”.
  4. For each of the answer of “Yes”, “No” or “Unclear”, you will need to provide the “Evidence” that you found in the article to support your answers.
  5. For each of the “Evidence”, you will need to critically appraise stating your justification, compare and contrasting or/and providing solution. Please see table for an example of how “evidence” is written.

References: The quality of references used is important. “high quality

reference” is defined as articles which are peer-reviewed and published in notable international and national journals. Articles such as newspaper, websites, social media statements, unsolicited articles and non-peer reviewed articles are not of “high quality reference”. You shall Include all the sources you have used within your text and organize them in alphabetical order according to APA 6th edition style. Please see example of the quality and the style of referencing.

Table 3 Cohort study: The predictive and diagnostic accuracy of vascular endothelial
growth factor and pentraxin-3 in severe dengue (Low et al., 2018)
Critical appraisal questionsUnderline your answer
Did the study address a clearly focused issue?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The objective of this study was to evaluate VEGF and PTX-3 as predictive and diagnostic markers in differentiating severe dengue from non-severe dengue. The
objective is specific to evaluating the two biomarkers among so many markers mentioned in the pilot study that was conducted before this study. (Low, Gan, & Ho, 2015) The dengue classification (severe and non-severe) was validated, specific and measureable. It was derived from the World Health Organisation dengue guideline. (World Health Organization, 2009) The study also specifically evaluated the predictive and diagnostic
accuracy of the two markers.
Critical appraisal questionsUnderline your answer
Was the cohort recruited in an acceptable
way?
Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The participants were recruited prospectively based on the eligibility criteria. All participants who are 15 years or older, presented only in the first 3 days of illness and a positive NS1 Ag test. However, it was unclear of the definition of the “illness” as it can represent a specific onset of a symptoms or whether it is due to fever. Majority of the existing studies defined the illness begin when patient developed fever. (Ahmed, 2010; Kumar, Gittens-St Hilaire, & Nielsen, 2013; Mahboob et al., 2010) Based on Table 1, we can assume that all patients were recruited based on the fever presented within the first 3 days of illness. Suggestion to the author is to clearly define what is “illness”.

NS1 Ag is a standard diagnostic test but again, most other studies used Dengue IgM as confirmatory method. (Mahboob et al., 2010; Tang et al., 2015; Thein et al., 2014) However, the author justified that Dengue IgM and a more highly accurate RT-PCR was
used to double confirm the NS1 Ag positive cases.
Critical appraisal questionsUnderline your answer
Was the exposure accurately measured to
minimise bias?
Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
This study did not measure any exposure (environmental, social determinants, etc). Perhaps, the exposure in this study was not the objective in assessing the biomarkers. The “exposure” here for this cohort study should be defined as the biomarkers itself. Thus, the “exposure” is considered accurately measured by the laboratory technique called as
ELISA. (Dussart et al., 2008)
Critical appraisal questionsUnderline your answer
Was the outcome accurately measured to
minimise bias?
Yes/No/Unclear




Evidence: justification, compare and contrasting or/and providing solution
The outcome was the use of clinical dengue classification (World Health Organization, 2012). It was used by the clinician/treating physician to diagnose the patients recruited. The accuracy of the WHO clinical classification is well documented in other study citing that the “severe dengue” category has good sensitivity and specificity. (Alexander et al.,
2011)
Critical appraisal questionsUnderline your answer
Have the authors identified all important
confounding factors?
Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
Confounding factors such as age, sex and ethnicity have been identified. There were other confounding factors such pregnancy; patient with autoimmune disorder, haematological disorder, cancer, cardiovascular disease or on long term warfarin and aspirin. These were identified and it was excluded from the analysis. The different days of illness could also affect the biomarker results and thus, this confounding factor has been included into the
statistical analysis.
Critical appraisal questionsUnderline your answer
Have they taken account of the confounding
factors in the design and/or analysis?
Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
Confounding factors have been controlled for by exclusion (restricted analysis) and included into the multivariate regression analysis.
However, possible confounding factor that the author has not taken into account was the treatment effect. No analysis on the treatment in regards to the biomarker prediction.
Perhaps, future study to evaluate these biomarkers must include the types of treatment. Treatment for dengue are mainly fluid resuscitation and it should be noted down on the different commonly used fluids for resuscitation in dengue. (World Health Organization,
2012)
Critical appraisal questionsUnderline your answer
Was the follow up of subjects complete
enough?
Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The follow up of the subjects were up to the day of discharge from the hospital or health care facility. This should suffice as the patient recovered and free of the symptoms or complication of the disease. Other studies did not have long follow-up, instead they used cross-sectional study as their study design. This could possibly due to the availability of resources to support the long term follow-up. (Colbert et al., 2007; Mairuhu et al., 2005;
Thein et al., 2014)
Critical appraisal questionsUnderline your answer
Was the follow up of subjects long enough?Yes/No/Unclear

Evidence: justification, compare and contrasting or/and providing solution

The follow up of the subjects were up to the day of discharge from the hospital or health care facility. It was the maximum duration of the patients can be follow-up. Though some patients might develop another episode of dengue known as secondary dengue, this study has addressed their objective. It will be interesting to have future study that also follow-up even longer period of time to identify sequelae and secondary which is more common in dengue endemic countries/ tropical countries. (Guzmán et al., 2002; Ludolfs, Schilling, Altenschmidt, & Schmitz, 2002) However, this depends on the resources available to conduct such long-term study.

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Answer :

Table 1 Cross-sectional study:Targeted Interventions in Critically Ill Children with Severe Dengue
Critical appraisal questionsUnderline your answer
Were the criteria for inclusion in the sample clearly defined?Yes/No/Unclear
Evidence: The article clearly defines the inclusion criteria, and the sample has been chosen carefully depending on the conditions of the patients who are suffering from an acute case of dengue. The description shows that the addition of standard therapy with the introduction of intensive care units for the treatment procedure for dengue patients. The need for the sample and the study being conducted on the sample has been chosen so that the effects of the treatment procedures can be studied carefully in the sample. The sample selection process has also been determined through the analysis of the bias, and the inclusion criteria have been decided after the most recurrent trends of the bias and eliminated accordingly. 
Critical appraisal questionsUnderline your answer
Were the study subjects and the setting described in detail?Yes/No/Unclear
Evidence: The details of the procedures and the methods for the study of the sample has also been included in the article as the analysis is subjected to the sample and the definition of the setting for the study has been considered after the aims and objectives of the study. The study subjects have been chosen so that the reflection necessary for the effects and the treatment and interventions used for the study of dengue has been done and the sample has been chosen accordingly. The basis for the choice of the sample for the purpose of the study is also considered keeping in mind the cross-sectional study of the topic. 
Critical appraisal questionsUnderline your answer
Was the exposure measured in a valid and reliable way?Yes/No/Unclear
Evidence: The exposure of the sample to the necessary conditions of the measurements has not been satisfactorily described in the article. The setting of the study, although has been considered and the conditions of the study have been mentioned and yet there is no clear indication that the necessary exposure of the sample has been considered in the process. Although the sample has already been described as the patients suffering from dengue and yet the exposure and the [particulars of the dengue and the patient condition has not been included in the article. Thus, the validity and the reliability of the study cannot be explained properly as there is no explicit evidence which can claim the same in the article.  
Critical appraisal questionsUnderline your answer
Were objective, standard criteria used for measurement of the condition?Yes/No/Unclear
Evidence: The article has a predefined methodology which the researcher intends to follow, and the aims and objectives of the project have been clearly defined at the start of the article. The aims and objectives have been determined so that it helps in attaining the conclusive evidence for the worsening conditions of the dengue patients and the use of the ICU as additional alternatives to the standard therapy which can provide the necessary improvements to the conditions of the patients. The identified objectives and measurement condition sufficiently describe the condition. The measurement of the sample conditions also poses potent possibilities which can be used for the identification of the conditions of the patients in the dengue prone people. 
Critical appraisal questionsUnderline your answer
Were confounding factors identified?Yes/No/Unclear
Evidence: The confounding factors have not been identified as far as I can understand by the analysis and the understanding of the article is that the factors have not been identified in the case. He factors, however, which have been included are sufficient to describe and detail the conditions of the patients suffering from dengue. The conditions worsened, and the patients have been provided with the ICU care for their improvement and the removal of the waterlogged in the arterial space of the patients. The factors have been carefully screened to understand the impacts of ICU care on the patients and help them recover from dengue by controlling oedema and fluid accumulation. 
Critical appraisal questionsUnderline your answer
Were strategies to deal with confounding factors stated?Yes/No/Unclear
Evidence: The factors have not been identified properly in the article, and the inclusion of the confounding factors cannot be stated and found in the article. The need for the inclusion of the strategies is thus redundant as the confounding factors cannot be identified in the article. Hence there are no clearly defined strategies to deal with the confounding factors stated. Oedema and the fluid accumulation in the dengue patients have not been minimized through the use of ICU care. 
Critical appraisal questionsUnderline your answer
Were the outcomes measured in a valid and reliable way?Yes/No/Unclear
Evidence: The outcomes of the project and the article which has been described by the researcher cannot sufficiently substantiate the corroborated conclusions of the study. Although the outcomes have been measured in a reliable way and valid. The conclusions of the study can be applied in the broader aspect of dengue patients. Hence it can be said that the study and the conclusions of the study have been measured in a valid and reliable way.  
Critical appraisal questionsUnderline your answer
Was an appropriate statistical analysis used? Yes/No/Unclear
Evidence: The article does not provide enough statistical analysis for backing up the data and claims which have been made in the article. Although the article has made use of the statistics regarding the number of the sample which has been studied. The analysis is not backed by the statistics.
Table 2 Case control study: Recent advances in dengue pathogenesis and clinical management
Critical appraisal questionsUnderline your answer
Did the study address a clearly focused issue?Yes/No/Unclear
Evidence: The study has clearly defined the pathogenesis and the clinical processes which have been applied for the identification and treatment of dengue. The advances made in this sector has been clearly identified and pointed out in the article. It is considered a clearly focused issue for the articulation of the advances which have been made in the dengue pathogenesis and clinical management. The aim of the study has been clearly defining and all the processes and methodologies adopted have been chosen to fulfil that aim.
Critical appraisal questionsUnderline your answer
Did the authors use an appropriate method to answer their question?Yes/No/Unclear
Evidence: The methods which have been applied in the article to answer the questions formulated the beginning of the research has been critically analysing the chosen carefully so that its alliance with the questions and also offers conclusive evidence regarding the aims and objectives of the study. The method is appropriate and sufficiently explains the background of the chosen methodologies. It offers associative backup through the data and statistical analysis undertaken by the researcher for conclusions drawn to the research. However, the sample size if the increase would have also corroborated a much wider aspect of the research analysis and provided better applicability of the conclusions in understanding the advances for the identification and prevention of dengue. 
Critical appraisal questionsUnderline your answer
Were the cases recruited in an acceptable way?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing a solution 
The cases which have been recruited for the conclusions to be drawn through the research were considered, and comprehensive research was also undertaken in this regard. It was done carefully to find out the articles and cases which would contribute to achieving the aims and objectives of the research and would sufficiently answer the questions which have been formulated the beginning of the study. The cases recruited is acceptable as most of the data included in the research are from peer-reviewed articles which are widely accepted in the research community as a benchmark for conclusive evidence and applicability and viability of the results. The design of the research was also hierarchical and unidirectional, which provided a parallel flow of proving the points for the purpose of the research. 
Critical appraisal questionsUnderline your answer
Was the exposure accurately measured to minimise bias?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing a solution 
The exposure to the study sufficiently measured to the inclusion of such dengue patients which shows positive science for the innovative interventions which have been used for the treatment. It proves that the advances for the dengue pathogenesis and clinical management is advancing in the right direction and can be applied on a wider basis so that more people suffering from dengue can benefit from it. The metric for the exposure being measured should be on the actual application of the interventions, and the reactions and response of the patient should be recorded accordingly to reflect that the interventions are inducing some positive reactions and improving the conditions of the patients for the without having any side effects. 
Critical appraisal questionsUnderline your answer
Aside from the experimental intervention, were the groups treated equally?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing a solution 
The experimental interventions which have been applied for experimenting on the effects of improving the dengue pathogenesis and the management of the patients in a much more efficient way prove that the interventions can be broadened in its application. The group for this study was also treated equally, and no bias was introduced on the part of the researcher who has been very careful and ethical about the selection and analysis of the data.
Critical appraisal questionsUnderline your answer
Have the authors taken account of the potential confounding factors in the design and/or in their analysis?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing a solution 
The confounding factors in the analysis and the design have not been clearly considered by the authors as the subjective analysis of the factors has only included the contributing factors in their research. Although the side effects of the advances and interventions introduced in the dengue patients have been considered for the conclusions of the study and yet the confounding factors have not been determined and expressed significantly in the study. 
Table 3 Cohort study: Clinical Review of Dengue Fever
Critical appraisal questionsUnderline your answer
Did the study address a clearly focused issue?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing a solution 
The main focus of this study has understood the associated factors of dengue fever. The study has maintained a definite purpose and the aims of this study is clearly focused on analysing the factors which causes dengue and after effects fever which is largely observed in patients suffering from dengue. The study has concluded the possible reasons which cause Dengue and also the most recurrent demographics of the patient as is seen. The article has also considered the possible interventions and management strategies which can be used for the prevention and treatment of patients suffering from dengue.  
Critical appraisal questionsUnderline your answer
Was the cohort recruited in an acceptable way?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The cohort for the purpose of the study has been recruited in an acceptable fashion as the sample has been divided into multiple categories depending on the significant features and commonalities. This helps the researcher in analysing the patterns and also associated a greater degree of contextual evidence behind the conclusions drawn from each group. The differentiation of the cohort has been successful as a variety of symptoms and reactions are noted in people suffering from dengue.
Critical appraisal questionsUnderline your answer
Was the exposure accurately measured to minimise bias? Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The exposure has been accurately measured for reducing the bias in the study as the researcher has included the variety of people suffering from dengue and categorized them into different sections. The exposure have sufficiently concluded an added value to the research to the conclusion of evidence which has been associated with the research through the identification of common characteristics observed in the sample. Thus, any base which could have been inadvertently introduced in the research has been eliminated through a careful and varied selection of the sample.
Critical appraisal questionsUnderline your answer
Was the outcome accurately measured to minimise bias?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The outcome of the research was accurately measured through particular conclusions drawn from the various groups which have been formulated after careful examination of the characteristics exhibited by the samples. The sample has been divided into separate groups depending on it, and hence, the conclusions which have been drawn from the analysis is unbiased and acceptable to the scientific community. The measurement of the outcome to the analysis was also free from any influencing factors as the sample size have been differentiating into several categories and studied independently without the influence of each other.  
Critical appraisal questionsUnderline your answer
Have the authors identified all the important confounding factors? Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The researcher has concluded all the possible factors which could have influenced the outcome of the research and hence, the confounding factors of the study have been clearly mentioned in the research. The identified factors have been included during the analysis, which has increased the applicability of the outcomes and the conclusions drawn from the study. The confounding factors have also been considered during the classification of the groups based on the exhibit characteristics of the patients suffering from dengue. Thus the confounding factors have little to contribute towards the variation of the results, which increases its accuracy. 
Critical appraisal questionsUnderline your answer
Have they taken account of the confounding factors in the design and/or analysis?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The researcher has definitely considered the confounding factors by the differentiation of the samples into various groups depending on their characteristic features as well as the analysis stage of the collected data. The account which has been considered during the analysis has also increased the applicability of the outcomes and have improved the accuracy of the conclusions.
Critical appraisal questionsUnderline your answer
Was the follow up of subjects complete enough?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
Since the researcher has not made any follow-up attempt to corporate the conclusions which have been drawn through the analysis of the collected data during the progress of the research, it cannot be sufficiently concluded that the following subjects were complete enough. However, the analysis of the collected data has included complete and confounding factors to which increases the applicability of the research results. 
Critical appraisal questionsUnderline your answer
Was the follow up of subjects long enough?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
the researcher has definitely considered long and excruciating list of samples to be included within the research area so that the conclusions arrived at from the analysis of the collected data can be applied in real-world which also has provisions for being applied in multiple and varying degrees of dengue patients.  
Table 3 Randomised controlled trial:(The Pathogenesis and Clinical Management of Dengue)
Critical appraisal questionsUnderline your answer
Did the trial address a clearly focused issue?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The study has clearly defined the pathogenesis and the clinical processes which have been applied for the identification and treatment of dengue
The aim of the study has been clearly defining and all the processes and methodologies adopted have been chosen to fulfil that aim. 

Critical appraisal questionsUnderline your answer
Was the assignment of patients to treatments randomised?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The study involved less severe and higher levels of dengue genotyping of 3961 and 2742, respectively. The study has clearly defined the pathogenesis and the clinical processes which have been applied for the identification and treatment of dengue. The advances made in this sector has been clearly identified and pointed out in the article. It is considered a clearly focused issue for the articulation of the advances which have been made in the dengue pathogenesis and clinical management. 
Critical appraisal questionsUnderline your answer
Were all of the patients who entered the trial properly accounted for at its conclusion?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The researchers have considered the human dengue infection model for treating the disease for people suffering from the same around the globe in general.
Critical appraisal questionsUnderline your answer
Were patients, health workers and study personnel ‘blind’ to treatment?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The study involved patients both with less severe and higher levels of dengue.
Critical appraisal questionsUnderline your answer
Were the groups similar at the start of the trial?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The researcher conducted a survey of platelet management in 20 countries 
Critical appraisal questionsUnderline your answer
Aside from the experimental intervention, were the groups treated equally?Yes/No/Unclear
Evidence: justification, compare and contrasting or/and providing solution
The group for this study was also treated equally, and no bias was introduced on the part of the researcher who has been very careful and ethical about the selection and analysis of the data.