CRITICAL APPRAISAL

JURNAL DENGAN JUDUL

“Performance of conventional histopathology and GeneXpert MTB/RIF in the diagnosis of
spinal tuberculosis from bone specimens: A prospective clinical study”

Oleh:
dr. Raditya Rachman Landapa

Dosen Pembimbing:
dr. Ilsa Hunaifi, Sp.N (K)

Peserta Pendidikan Dokter Spesialis Neurologi

Fakultas Kedokteran dan Ilmu Kesehatan Universitas Mataram
2024
 BAGIAN I
PENDAHULUAN

Dengan semakin diterapkannya ilmu/praktek kedokteran berbasis bukti, atau yang

biasa disebut sebagai Evidence Based Medicine/Practice (1), maka sudah menjadi
kewajiban kita sebagai klinisi untuk mampu melakukan critical appraisal terhadap
sumber-sumber ilmu terutama yang berbentuk studi/penelitian (2). Critical appraisal ini
adalah instrumen penting bagi para peneliti dan praktisi, dan akan menjadi dasar
penentuan kebijakan kita mengenai apakah hasil penelitian/studi yang kita pelajari bisa
diterapkan dalam praktek klinis kedokteran yang kita lakukan sehari-hari. (1,3) Selain itu,
akan berguna juga dalam menjaga agar klinisi tetap update terhadap perkembangan terkini
di bidangnya, untuk meningkatkan kualitas pelayanan terhadap pasien(1,4)
Critical appraisal sendiri adalah sebuah evaluasi secara cermat dan sistematis
terhadap sebuah jurnal/studi/penelitian yang nantinya dapat menilai keandalan, kekuatan,
nilai, serta relevansi dari studi tersebut untuk dijadikan referensi dalam pengambilan
keputusan klinis(1,2,5). Critical appraisal dilakukan dengan menggunakan pertanyaan
terstruktur atau checklist. Praktisi juga harus mampu menentukan tools mana yang sesuai
untuk digunakan, agar meningkatkan kualitas dari critical appraisal itu sendiri.(4)
Dalam critical appraisal ini, tools yang digunakan adalah PICO dan CASP
Checklist. Dimana pemilihan tools tersebut diharapkan bisa sesuai dengan jenis dan desain
studi yang akan dinilai.(6–9)
 BAGIAN II
PERSETUJUAN PEMBIMBING

Lembar Pengesahan

Lembar Pengesahan Critical Appraisal Jurnal dengan Judul : Performance of conventional

histopathology and GeneXpert MTB/RIF in the diagnosis of spinal tuberculosis from bone
specimens: A prospective clinical study

Telah disetujui dan disahkan pada:

Hari :
Tanggal :

Pembimbing

dr. Ilsa Hunaifi, Sp.N (K)

 BAGIAN III
CRITICAL APPRAISAL

3.1 PICO

Judul Journal: Performance of conventional histopathology and GeneXpert MTB/RIF in

the diagnosis of spinal tuberculosis from bone specimens: A prospective clinical study
(10)
Patient/Problem: Pasien dengan kecurigaan Spinal Tuberculosis (STB) sebanyak 128
orang
Intervention/approach: Diagnosa STB dengan pemeriksaan Xpert MTB/RIF pada sampel
tulang
Comparrisson: Diagnosa STB dengan Histopatologi Konvensional
Outcome: Mengetahui tingkat sensitivitas dan akurasi penegakan diagnosis STB dengan
pemeriksaan Xpert MTB/RIF pada sampel tulang dan apakah bisa menggantikan
pemeriksaan konvensional (histopatologi) sebagai metode diagnosis.
3.2 CASP Checklist for Diagnostic Study
Paper for appraisal and reference: Performance of conventional histopathology and GeneXpert
MTB/RIF in the diagnosis of spinal tuberculosis from bone specimens: A prospective clinical
study
Section A: Are the results of the trial valid?

1. Was there a clear question Yes HINT: A question should include

for the study to address?
√ information about
Can’t Tell • the population
• the test
No
• the setting
• the outcomes

Comments:
Dalam jurnal,walaupun tidak murni berbentuk pertanyaan, tapi sudah disebutkan hal apa yang ingin
didapatkan dari studi tersebut, termasuk populasi yang dinilai, test yang dilakukan, setting penelitian
dan outcome yang ingin diketahui

“….however, there is insufficient data on its utility for bone samples. This study aimed to assess the
accuracy of Xpert MTB/RIF compared with conventional histopathology in diagnosing spinal
tuberculosis (STB) based on bone specimens….”

“…. 128 suspected STB participants were enrolled into this study. The bone speci mens were obtained
through puncture or operation for histological and Xpert MTB/RIF analyses, so as to compare their
accuracy in diagnosing STB….”

“This study aimed to confirm the XpertMTB/RIF specificity and sensitivity for the diagnosis of STB
patients using bone samples compared with CRS and histopathological test, which has not been
reported in published literature so far”

2. Was there a comparison Yes HINT: Is this reference test(s) the best
with an appropriate
√ available indicator in the circumstances
reference standard? Can’t Tell

No

Comments:
Dalam jurnal disebutkan bahwa sudah dilakukan perbandingan metode diagnostic yang diteliti dengan
referensi/diagnosis standar yang ada

“….accuracy of Xpert MTB/RIF compared with conventional histopathology in diagnosing spinal

tuberculosis (STB) based on bone specimens….”
“…The bone specimens were obtained through puncture or operation for histological and Xpert
MTB/RIF analyses, so as to compare their accuracy in diagnosing STB by the composite reference
standard (CRS).”

Is it worth continuing?

3. Did all patients get the Yes HINT: Consider

diagnostic test and
√
• were both received regardless of the
reference standard? Can’t Tell
results of the test of interest
No • Check the 2x2 table (verification
bias)

Comments:
Semua pasien/sampel menjalani pemeriksaan diagnostic yang diteliti dan pemeriksaan
pembanding/standar

“…106 patients were enrolled finally, among them, 27 (25.5%) were confirmed with STB, 33 (31.1%)
were clinically diagnosed, and 46 (43.4%) were non-STB cases based on CRS…”

4. Could the results of the test Yes HINT: Consider

have been influenced by the
√
• was there blinding
results of the reference Can’t Tell
• were the tests performed
standard? independently
No
• review bias

Comments:
Hasil test diagnostic tidak dipengaruhi oleh referensi standar karena merupakan pemeriksaan yang
terpisah dan tidak saling mempengaruhi penilaian satu sama lain

5. Is the disease status of the Yes HINT: Consider

tested population clearly
√
• presenting symptoms
described? Can’t Tell
• disease stage of severity
No • co-morbidity
 • differential diagnoses (spectrum
bias)

Comments:
Dalam jurnal disebutkan mengenai status/kondisi penyakit pasien, termasuk kriteria inklusinya.

“Altogether 128 suspected STB cases undergoing CT-guided biopsies or surgical treatments were
enrolled for analysis.”

“The inclusion criteria were shown below, (1) all patients who had local symptoms such as back pain,
joint swelling, tenderness, deformity, limitation of motion (LOM), and systematic symptoms like fever
for >2 weeks, loss of weight/appetite, cough, night sweats; (2) each patient was followed up for at
least 3 months; and (3) patients had definite results for Xpert MTB/RIF test.”

6. Were the methods for Yes √ HINT: Consider

performing the test described in • was a protocol followed
sufficient detail?
Can’t Tell

No

Comments:
Metode dalam melakukan test sudah dijabarkan dengan detail dalam bagian Material and Methods

Section B: What are the results?

7. What are the results? HINT: Consider

• are the sensitivity and
specificity and/or likelihood
ratios presented
• are the results presented in
such a way that we can work
them out
Comments:
Dalam hasil penelitian sudah disebutkan mengenai sensitifitas dan spesifisitas, serta perbandingan
hasil test diagnostic dengan referensi standar

“…106 patients were enrolled finally, among them, 27 (25.5%) were confirmed with STB, 33 (31.1%)
were clinically diagnosed, and 46 (43.4%) were non-STB cases based on CRS…”
“When CRS was used as the reference, histopathological test achieved the specificity, sensitivity, PPV,
NPV, negative likelihood ratio (NLR), positive likelihood ratio (PLR), and area under the curve (AUC) of
100.0% (100.0–100.0%), 50.0% (40.8–56.5%), 100.0% (100.0–100.0%), 65.1%(56.8–73.4%), 0.75
(0.66–0.84), and max 0.5 (0.39–0.61), respectively. Among those 60 STB patients identified according
to CRS, Xpert MTB/RIF assay confirmed 38 definite STB patients, yielding a 63.3% sensitivity (95% CI:
52.4–73.5%), and such f igure markedly elevated compared with that achieved by histopatho logical
test (χ2 = 41.812, P < 0.001). Meanwhile, the specificity, PPV, NPV, PLR, NLR and AUC were 97.8%
(93.4–100.0%), 97.4% (94.3–100.0%), 67.2% (60.7–77.9%), 2.9 (2.1–3.8), 0.37 (0.26–0.52), and 0.81
(0.72–0.89) (Table 3), respectively.”

8. How sure are we about the results? HINT: Consider

Consequences and cost of alternatives • could they have occurred by chance
performed? • are there confidence limits
• what are they

Comments:

“When these 2 tests were used in combination, the pooled specificity and sensitivity were 97.8% and
95.0%, separately, which outperformed any one of the 2 tests used alone (P = 0.000), yielding a
surprising diagnostic value in STB”

Section C: Will the results help locally?

Consider whether you are primarily interested in the impact on a population or individual level

9. Can the results be applied to Yes HINT: Do you think your

your patients/the population
√ patients/population are so different from
of interest? those in the study that the results cannot
Can’t Tell be applied, such as age, sex, ethnicity and
spectrum bias
No

Comments:
Hasil penelitian secara umum bisa diterapkan pada populasi/pasien di Indonesia khususnya NTB,
karena dari demografi sampel yang digunakan berasal dari etnis yang serupa (Asia) dan kondisi
penyakit yang dievaluasi juga serupa dengan yang ada di populasi.
 10. Can the test be applied to Yes HINT: Consider
your patient or population of
√ • resources and opportunity costs
interest? • level and availability of expertise
Can’t Tell required to interpret the tests
• current practice and availability of
No
services

Comments:
Tes diagnostik STB dengan Xpert MTB/RIF bisa diterapkan karena fasilitas pemeriksaan tersebut sudah
tersedia dan sudah rutin dilakukan untuk pemeriksaan dengan sampel lain, misalnya dahak

11. Were all outcomes Yes HINT: Consider

important to the individual
√ • will the knowledge of the test result
or population considered? improve patient wellbeing
Can’t Tell • will the knowledge of the test result
lead to a change in patient
No management

Comments:
Hasil penelitian akan bermanfaat dalam penegakan diagnosis lebih awal, sehingga pemberian
tatalaksana bisa lebih adekuat.

12. What would be the impact of using this test on your patients/population?

Comments:

Dengan menggunakan metode diagnosis Xpert MTB/RIF yang tidak membutuhkan teknologi atau
keahlian tinggi, diharapkan penegakan diagnose STB bisa lebih mudah diakses dan dilaksanakan,
sehingga meningkatkan kualitas pengobatan dan prognosis pasien.
 BAGIAN IV

KESIMPULAN

Berdasarkan hasil dari critical appraisal menggunakan PICO dan CASP Checklist di atas,
dapat saya simpulkan bahwa jurnal/studi diagnostic ini valid, memiliki efek yang positif
terhadap penerapan penegakan diagnosis penyakit yang diteliti, serta dapat diterapkan di
populasi/pasien yang ada di NTB.
 BAGIAN V

DAFTAR PUSTAKA

1. Abdullah M, Firmansyah MA. Critical Appraisal on Journal of Clinical Trials.

2. A review of the Scottish Intercollegiate Guidelines Network, the Grading of Recommendations

Assessment, Development and Evaluation, the Graphic Appraisal Tool for Epidemiology and the
National Service Framework for.

3. Haile ZT. Critical Appraisal Tools and Reporting Guidelines. Journal of Human Lactation. 2022 Feb
1;38(1):21–7.

4. Buccheri RK, Sharifi C. Critical Appraisal Tools and Reporting Guidelines for Evidence-Based Practice.
Worldviews Evid Based Nurs. 2017 Dec 1;14(6):463–72.

5. Tod D, Booth A, Smith B. Critical appraisal. Int Rev Sport Exerc Psychol. 2022;15(1):52–72.

6. Roever L. PICO: Model for Clinical Questions Evidence Based Medicine and Practice E v id ence B a
s e d Me dic in e. 2018; Available from: http://pubmedhh.nlm.nih.gov/nlmd/pico/piconew.php

7. Long HA, French DP, Brooks JM. Optimising the value of the critical appraisal skills programme
(CASP) tool for quality appraisal in qualitative evidence synthesis. Research Methods in Medicine
& Health Sciences. 2020 Sep;1(1):31–42.

8. Casp UK. CASP Checklist [Internet]. Available from: www.casp-uk.net

9. Schiavenato M, Chu F. PICO: What it is and what it is not. Vol. 56, Nurse Education in Practice.
Elsevier Ltd; 2021.

10. Yu Y, Kong Y, Ye J, Wang A. Performance of conventional histopathology and GeneXpert MTB/RIF in

the diagnosis of spinal tuberculosis from bone specimens: A prospective clinical study. Clin
Biochem. 2020 Nov 1;85:33–7.