CRITICAL APPRAISAL

Disusun oleh: KELOMPOK 1

What question (PICO) did the systematic review address? What is best? Where do I find the information? The main question being addressed should The Title, Abstract or final paragraph of the be clearly stated. The exposure, such as a Introduction should clearly state the question. therapy or diagnostic test, and the If you still cannot ascertain what the focused outcome(s) of interest will often be question is after reading these sections, search expressed in terms of a simple relationship. for another paper! This paper: Yes No Unclear Comment: Judul : Advances in the Diagnosis of Etiologic Subtypes of Ischemic Stroke Abstract : A fundamental goal of etiologic stroke classification is to generate subgroups with discrete phenotypic, therapeutic, and prognostic features. Accurate stroke classification requires integration of multiple aspects of diagnostic stroke evaluation in a standardized manner. Diagnostic test findings can be simply organized into major etiologic groups to create a phenotypic subtype, or they can be reduced to a single causative subtype through a decisionmaking process. It is essential for a classification system to provide consistent results across different raters in different clinical settings. Comparability of subtype assignments is the key to valid communication of research results across the field. This article highlights important theoretical aspects of etiologic stroke classification and reviews major etiologic classification systems that have benefited from recent advances in etiologic stroke evaluation.

Introduction : The etiologic architecture of stroke constitutes a hierarchic structure, with frequent but less potent etiologies at the bottom and less frequent but more potent causes close to the top. The pyramid is composed of at least 100 different cardiac, arterial, hemodynamic, rheologic, and other systemic abnormalities. Assortment of patients into classes congruent with the pathophysiology is the key to understanding stroke. A functional classification system is indispensible for selecting patients for clinical trials, phenotyping in genetic and epidemiologic studies, assessing treatment response and prognosis, and interpreting research findings in simultaneous context with other parameters. Obviously, separating patients into various classes may result in the ignoring of some important qualities that characterize individuals. Nevertheless, assembling stroke features to create categories based on similarities compensates for the loss of information on an individual basis by enhancing statistical power in research studies. Several etiologic stroke classification systems, such as the Harvard Stroke Registry [1], the Stroke Data Bank [2], the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) system [3], and the BaltimoreWashington system [4], have been described, but none has demonstrated high reliability and validity. An ideal classification system would provide a common language in the field to ensure unity among physicians and comparability among studies. The ideal system must be simple and logical. Additionally, the system should rely on the pathophysiology, use rules and criteria based on evidence rather than ideas, be flexible enough to accommodate new information as it emerges, and allow categorization of patients into the fewest possible subtypes with discrete phenotypic, therapeutic, and prognostic features. Finally, the ideal system should have proven utility in diverse clinical settings and allow categorization of individual elements of stroke in different ways according to the needs of specific research projects. The purpose of this article is to review etiologic stroke classification systems, with a particular focus on those that have incorporated the latest advances in diagnostic stroke evaluation.

F - Is it unlikely that important, relevant studies were missed? What is best? Where do I find the information?

The starting point for comprehensive search for all relevant studies is the major bibliographic databases (e.g., Medline, Cochrane, EMBASE, etc) but should also include a search of reference lists from relevant studies, and contact with experts, particularly to inquire about unpublished studies. The search should not be limited to English language only. The search strategy should include both MESH terms and text words. This paper: Yes No Unclear
Comment:

The Methods section should describe the search strategy, including the terms used, in some detail. The Results section will outline the number of titles and abstracts reviewed, the number of full-text studies retrieved, and the number of studies excluded together with the reasons for exclusion. This information may be presented in a figure or flow chart.

Dalam jurnal ini tidak tercantum metode yang digunakan secara spesifik. Dalam jurnal ini hanya mengungkapkan perbedaan validitas dan reliabilitas sistem untuk mengklasifikasikan etiologi stroke. Hasil penelitian tidak ditampilkan dalam bentuk tabel maupun flowchart, hanya berupa penjelasan secara deskriptif

A - Were the criteria used to select articles for inclusion appropriate? What is best? Where do I find the information?

The inclusion or exclusion of studies in a The Methods section should describe in systematic review should be clearly defined a detail the inclusion and exclusion criteria. priori. The eligibility criteria used should Normally, this will include the study design. specify the patients, interventions or exposures and outcomes of interest. In many cases the type of study design will also be a key component of the eligibility criteria.

This paper: Yes Comment:

No

Unclear

Dalam jurnal ini tidak terdapat sub bab mengenai metode penelitian, hanya dibahas secara terpisah mengenai sistem untuk mengklasifikasikan etiologi stroke.

A - Were the included studies sufficiently valid for the type of question asked? What is best? The article should describe how the quality of each study was assessed using predetermined quality criteria appropriate to the type of clinical question (e.g., randomization, blinding and completeness of follow-up) Where do I find the information? The Methods section should describe the assessment of quality and the criteria used. The Results section should provide information on the quality of the individual studies.

This paper: Yes Comment:

No

Unclear

Dalam jurnal ini tidak terdapat sub bab mengenai metode dan result

T - Were the results similar from study to study? What is best? Ideally, the results of the different studies should be similar or homogeneous. If heterogeneity exists the authors may estimate whether the differences are significant (chi-square test). Possible reasons for the heterogeneity should be explored. Where do I find the information? The Results section should state whether the results are heterogeneous and discuss possible reasons. The forest plot should show the results of the chi-square test for heterogeneity and if discuss reasons for heterogeneity, if present.

This paper: Yes Comment:

No

Unclear

Dalam jurnal ini tidak terdapat sub bab result, namun di bagian conclusion hanya dijelaskan mengenai reliabilitas tertinggi dari sistem saja.

What were the results?

How are the results presented? Dalam jurnal ini tidak tercantum sub bab pembahasan secara spesifik, hanya membahas mengenai masing-masing sistem saja, kemudian dilanjutkan dengan kesimpulan. Tidak ada hasil perbandingan sistem yang dicantumkan secara sistematis. Conclusions Etiologic classification systems retain important information toward understanding the etiopathogenetic framework of stroke. The TOAST system has been a reflection of the wayneurologists have thought about recognizing and understanding stroke for almost two decades. Nevertheless, it suffers from moderate reliability. The automated CCS carries on the TOAST tradition. It is a more complex system, but it provides causative subtype assignments with higher reliability. The CCS and ASCO system allow stratification of stroke patients based on their phenotypic characteristics, promising utility in large epidemiologic studies. Further studies are needed to assess the utility of stroke subtypes in the clinical management of stroke, including their ability to aid in treatment decisions. Further evaluation of available systemsalso is necessary to characterize their reliability in different clinical settings so that they can be used interchangeably by different investigators from different geographic and professional backgrounds.

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