苓桂术甘汤及其加味辅助治疗慢性心力衰竭的Meta分析

目的:系统评价西药常规治疗加苓桂术甘汤或加味方与单纯西药常规治疗心力衰竭的临床疗效.方法:电子检索中国期刊全文数据库(CNKI)、中文科技期刊全文数据库(VIP)、万方数据库,中国生物医学文献数据库(CBM)、PubMed、Embase和The Cochrane Library.手工检索相关杂志,搜集单纯西药常规与西药常规加苓桂术甘汤及其加味方治疗慢性心力衰竭的随机对照试验,按照相关方法评价纳入文献质量和提取有效数据进行Meta分析.结果:共纳入人4个RCTs,总计280例患者.Meta分析显示:西药常规加用苓桂术甘汤或其加味方可提高心力衰竭治疗的总有效率[OR=2.79,95% CI(1.43,5.46),P=0.003];可提高心脏的左室射血分数,单纯苓桂术甘汤亚组[WMD=4.77,95% CI(2.04,7.50),P=0.006],苓桂术甘加味方亚组[WMD=11.50,95% CI(6.39,16.61),P<0.001];此外,分别有1项研究显示苓桂术甘汤及其加味方可减少血浆(BNP),(ANP)浓度.结论:西药常规加用苓桂术甘汤及其加味方较单纯西药常规治疗可进一步提高心力衰竭的临床疗效.

Objective To perform a systematic review and meta-analysis of the predictive abilities of CHADS2 and CHA2DS2-VASc in stroke and thromboembolism risk stratification of atrial fibrillation (AF) patients. Methods We searched PubMed and EMBASE for Eng-lish-language literature on comparisons of the diagnostic performance between CHADS2 and CHA2DS2-VASc in predicting stroke, or sys-temic embolism, in AF. We then assessed the quality of the included studies and pooled the C-statistics and 95%confidence intervals (95%CI). Results Eight studies were included. It was unsuitable to perform a direct meta-analysis because of high heterogeneity. When analyzed as a continuous variable, the C-statistic ranged from 0.60 to 0.80 (median 0.683) for CHADS2 and 0.64-0.79 (median 0.673) for CHA2DS2-VASc. When analyzed as a continuous variable in anticoagulation patients, the subgroup analysis showed that the pooled C-statistic (95%CI) was 0.660 (0.655-0.665) for CHADS2 and 0.667 (0.651-0.683) for CHA2DS2-VASc (no significant difference). For non-anticoagulation patients, the pooled C-statistic (95%CI) was 0.685 (0.666-0.705) for CHADS2 and 0.675 (0.656-0.694) for CHA2DS2-VASc (no significant differ-ence). The average ratio of endpoint events in the low-risk group of CHA2DS2-VASc was less than CHADS2 (0.41%vs. 0.94%, P<0.05). The average proportion of the moderate-risk group of CHA2DS2-VASc was lower than CHADS2 (11.12%vs. 30.75%, P<0.05). Conclu-sions The C-statistic suggests a similar clinical utility of the CHADS2 and CHA2DS2-VASc scores in predicting stroke and thromboem-bolism, but CHA2DS2-VASc has the important advantage of identifying extremely low-risk patients with atrial fibrillation, as well as classi-fying a lower proportion of patients as moderate risk.

Meta分析系列之二:Meta分析的软件

随着循证医学的发展,Meta分析(Meta-analysis)已被公认为客观评价和合成针对某一特定问题研究证据的佳手段,被视为高级别的证据,成为循证决策的良好依据[1].上一篇文章我们对Meta分析的类型进行了介绍[2],为了适应不同类型的需要,多种Meta分析软件被开发出来了.这些软件中有的软件可以进行各种Meta分析,有的仅仅是针对某一种类型的Meta分析开发的;基于的操作系统有Windows、DOS、Linux和Mac;按照是否需要编程又分为编程软件和非编程软件(表1).这些软件为行Meta分析提供了很好的支持,但也为评价者的选择带来了疑惑.鉴于此,本文拟对当前常用的Meta分析的软件进行简介,以期为使用者提供参考.

腔内修复破裂的腹主动脉瘤手术死亡率:一个系统评价和Meta分析

尽管现代外科取得了一些进展,但通过开放手术治疗破裂的腹主动脉瘤(ruptured abdominal aortic aneurysms,RAAAs)其死亡率仍高达50%左右.由于来到医院的患者存活率不到一半,由RAAAs所导致的死亡率更高,为80%～90%.

正确使用和合理解读Meta分析

随着循证医学的兴起,如何系统地总结既往研究成果,为循证决策提供高质量的证据日益受到重视,系统综述(systematic review)和Meta分析(Meta-analysis)已被公认为客观评价和合成针对某一特定问题的研究证据的佳手段,通常被视为高级别的证据.

Is it necessary to do axillary dissection in old women with breast cancer?A meta-analysis of randomized clinical trials

保留乳房切除术后放射治疗对乳腺癌10年复发率和15年病死率的影响:17项随机对照试验10801例患者的meta分析

乳腺癌患者保留乳房切除术后放射治疗能降低乳腺癌的复发和死亡,但这可能只对某些特定的乳腺癌患者有效.早期乳腺癌临床试验协作组(Early Breast Cancer Trialists' Collaborative Group,EBCTCG)在2011年12卷第378期上发表一篇题名为"Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10 801 women in 17 randomised trials"的荟萃分析.

OBJECTIVE: To evaluate the association of X-ray cross-complementing group 1 (XRCC1) Arg399Gln, Arg194Trp and Arg280His polymorphisms with the risk of glioma. DATA SOURCES:A systematic literature search of papers published from January 2000 to August 2012 in PubMed, Embase, China National Knowledge Infrastructure database, and Wanfang da-tabase was performed. The key words used were“glioma”,“polymorphism”, and“XRCC1 or X-ray repair cross-complementing group 1”. References cited in the retrieved articles were screened manual y to identify additional eligible studies. STUDY SELECTION: Studies were identified according to the fol owing inclusion criteria:case-control design was based on unrelated individuals;and genotype frequency was available to estimate an odds ratio (OR) and 95%confidence interval (CI). Meta-analysis was performed for the selected studies after strict screening. Dominant and recessive genetic models were used and the relationship between homozygous mutant genotype frequencies and mutant gene frequency and glioma incidence was investigated. We chose the fixed or random effect model according to the heterogeneity to calculate OR and 95%CI, and sensitivity analyses were conducted. Publication bias was examined using the inverted funnel plot and the Egger’s test using Stata 12.0 software. MAIN OUTCOME MEASURES: Association of XRCC1 Arg399Gln, Arg194Trp, and Arg280His polymorphisms with the risk of glioma, and subgroup analyses were performed according to differ-ent ethnicities of the subjects.
RESULTS:Twelve articles were included in the meta-analysis. Eleven of the articles were concerned with the Arg399Gln polymorphism and glioma onset risk. Significantly increased glioma risks were found only in the dominant model (Gln/Gln+Gln/Arg versus Arg/Arg:OR=1.26, 95%CI=1.03-1.54, P=0.02). In the subgroup analysis by ethnicity, significantly increased risk was found in Asian subjects in the recessive (OR = 1.46, 95%CI = 1.04-2.45, P = 0.03) and dominant models (OR = 1.40, 95%CI = 1.10-1.78, P =0.007), and homozygote contrast (OR=1.69, 95%CI=1.17-2.45, P=0.005), but not in Caucasian sub-jects. For association of the Arg194Trp (eight studies) and Arg280His (four studies) polymorphisms with glioma risk, the meta-analysis did not reveal a significant effect in the al ele contrast, the recessive genetic model, the dominant genetic model, or homozygote contrast. CONCLUSION: The XRCC1 Arg399Gln polymorphism may be a biomarker of glioma susceptibility, es-pecial y in Asian populations. The Arg194Trp and Arg280His polymorphisms were not associated with overal glioma risk.

OBJECTIVE: To examine the efficacy and safety of short-term and long-term use of antidepres-sants in the treatment of bipolar disorder.
DATA SOURCES:A literature search of randomized, double-blind, control ed trials published until December 2012 was performed using the PubMed, ISI Web of Science, Medline and Cochrane Central Register of Control ed Trials databases. The keywords“bipolar disorder, bipolar I disorder, bipolar II disorder, bipolar mania, bipolar depression, cyclothymia, mixed mania and depression, rapid cycling and bipolar disorder”, AND “antidepressant agent, antidepressive agents second-generation, antidepressive agents tricyclic, monoamine oxidase inhibitor, noradrenaline uptake in-hibitor, serotonin uptake inhibitor, and tricyclic antidepressant agent” were used. The studies that were listed in the reference list of the published papers but were not retrieved in the above-mentioned databases were supplemented.
STUDY SELECTION: Studies selected were double-blind randomized control ed trials assessing the efficacy and safety of antidepressants in patients with bipolar disorder. Al participants were aged 18 years or older, and were diagnosed as having primary bipolar disorder. Antidepressants or antidepressants combined with mood stabilizers were used in experimental interventions. Placebos, mood stabilizers, antipsychotics and other antide pressants were used in the control interventions. Studies that were quasi-randomized studies, or used antidepressants in combination with antipsy-chotics in the experimental group were excluded. Al analyses were conducted using Review Man-ager 5.1 provided by the Cochrane Col aboration.
MAIN OUTCOME MEASURES:The primary outcome was the response and switching to mania. The secondary outcomes included remission, discontinuation rate, and suicidality.
RESULTS: Among 5 001 treatment studies published, 14 double-blind randomized control ed trials involving 1 244 patients were included in the meta-analysis. Eleven short-term studies and three maintenance studies were included. Studies suggested that pa-tients treated with antidepressants were not significantly more likely to achieve higher response and remission rates in the short-term or long-term treatment than patients treated with placebo and other medications. Antidepressants were not associated with an in-creased risk of discontinuation, relapse or suicidality. When one antidepressant was compared with another, no significant difference in efficacy and tolerability was found.
CONCLUSION:Existing evidence of efficacy does not support the short-term or long-term application of antidepressant therapy in patients with bipolar disorder, although the tolerability and safety of antidepressants have been general y acknowledged. There is a need for large-sample, double-blind, randomized control ed trials to elucidate the role of antidepressants in patients with different subcategories of bipolar disorder.

Objective To investigate the preventive effect of probiotics on pediatric food allergy.
Methods From MEDLINE bibliographical database, we searched and reviewed all randomized controlled trials on the preventive effects of probiotics on pediatric food allergies up to September 2013 and excluded the studies that do not meet inclusion criteria and extracted the data. Meta-analysis for the results of homogenous studies was performed using RevMan 5.0 and the co-effect was pooled by using fixed-effects model of relative risk (RR) ratios.
Results Ten trials published between 2007 and 2012 including 2701 cases were included. Meta-analysis based on included data showed that the preventive effect of prenatal and postnatal probiotic supplementation on food allergies was not significant with the RR=0.88 (95%CI:0.76-1.03).
Conclusion Present evidences cannot show in unequivocal terms that prenatal and postnatal probiotic supplementation will prevent food allergic diseases.

Objective To evaluate the efficacy and safety of ustekinumab in the therapy of plaque psoriasis.
Methods Literatures published up to November 2013 were collected from Cochrane library, MEDLINE, and PubMed which were related with ustekinumab for plaque psoriasis. The efficacy was estimated using relative risk of Psoriasis Area and Severity Index (PASI) 75 response rate at the week 12 endpoint in clinical trials, and adverse effects were also analyzed. Meta-analysis was carried out by using Review Manager 5.1.
Results Six randomized control trials consistent with the inclusion criteria were selected and reviewed. Ustekinumab 45 mg group and 90 mg group could get better therapeutic effect compared with the placebo group (all P<0.00001). Furthermore, ustekinumab 90 mg group was more effective than ustekinumab 45 mg group (P=0.01). Adverse effects in the 6 trials were mentioned including headache, upper respiratory tract infection, nasopharyngtis, infection, serious infection, cardiovascular events, and malignant tumors. There were no statistically significant differences of these adverse effects among three groups (all P>0.05), except that infection rate in ustekinumab 45 mg group was higher than the placebo group (P=0.02).
Conclusions Ustekinumab is an effective and safe therapeutic method for plaque psoriasis. However, further longer time analysis of safety is needed.

我国居民吸烟与脑卒中关系的Meta-analysis

应用随机效应模型(法)对国内16篇吸烟与脑卒中关系的流行病学研究文献进行综合定量分析,结果表明吸烟与脑卒中有关,总合并OR(95%CI)为1. 54(1.26～1.88).按脑卒中类型分层合并分析,结果吸烟与缺血型脑卒中、出血型脑卒中和脑卒中(未分型)联系的OR分别为1.70(1.19～2.43)、1.34(0.91～1.78)和1.7 5(1.32～2.33).并且还表明吸烟与脑卒中之间存在剂量效应关系.研究认为吸烟是我国居民脑卒中及其亚型的危险因素,控制吸烟是脑卒中病因预防的一项重要措施.

Meta-analysis方法的研究进展

Meta-analysis方法近年国内已逐渐开展应用,本文就其基本概念、应用范围、操作步骤及常用的统计学方法作一综述.

乳腺癌危险因素的Meta-analysis

目的:为了评价女性乳腺癌危险因素的作用,为乳腺癌的病因学研究和预防提供依据.方法:应用Meta-analysis分析方法对我国1990年～2000年间公开发表的十篇有关乳腺癌病例对照研究的资料进行了综合分析.结果:危险因素为乳腺炎史、乳癌家族史、初产年龄晚、初潮年龄早及服用避孕药史,它们与乳腺癌OR分别为4.31(3.21～5.76)、4.36(2.46～7.75)、1.50(1.24～1.81)、1.50(1.05～2.16)、1.51(1.07～2.13).哺乳为保护因子OR为0.64(0.50～0.83).结论:乳腺癌与乳腺炎、乳癌家族史、初产年龄初潮年龄有密切联系,哺乳对乳腺癌有预防作用.

在stata软件中实现Contour-enhanced meta-analysis funnel plots绘制

Contour-enhanced meta-analysis funnel plots产生的背景漏斗图是做meta分析时常会用到的一种方法.我们可以很直观的从图上看出散点图的分布是否对称,来评估meta分析结果的稳定性和真实性.这种方法虽然直观,简便,但却不能定量的评估出漏斗图的偏倚.常用的定量评估漏斗图对不对称的方法有Beggand Mazumdar'S等级相关检验[1],Egger's回归分析[2],失安全系数的计算[3]和剪补法[4].通常我们把漏斗图不对称的原因归结到发表偏倚上,但事实上,引起漏斗图不对称的原因有很多,比如那些样本量小,设计简单的研究往往会影响到到漏斗图顶部的那些样本量大,设计严谨的研究效应,也会导致不对称的漏斗图出现[5].J.L.Peters在2008年提出了一种新的方法——Contour-enhanced meta-analysis funnel plots,用来帮助我们识别漏斗图不对称的原因[6].

口服避孕药与乳腺癌关系的Meta-analysis

目的评价口服避孕药对乳腺癌发生的影响,为指导正确使用避孕药和维护使用者的身心健康上提供理论依据.方法应用Meta-analysis分析方法对我国1979～2004年间公开发表的11篇有关口服避孕药与乳腺癌病例对照研究的资料进行综合分析.结果对11篇文章的13个统计量(OR)行统计分析,口服避孕药与乳腺癌OR=1.589 8,95%CI:(1.155～2.011),P＜0.05.结论可以认为口服避孕药是乳腺癌发生的危险因素之一.

去氢表雄酮对肾上腺皮质功能减退妇女生活质量的影响——一项随机安慰剂对照试验的系统综述和meta分析

与普通人群相比,肾上腺皮质功能减退患者虽然接受了充分的糖皮质激素替代治疗,其生活质量仍然下降.这促使人们去寻找进一步改善患者健康状况的方法.去氢表雄酮(DHEA)和去氢表雄酮硫酸盐(DHEAS)是主要来源于肾上腺的雄激素,DHEA在外周组织中转化为作用更强的雄激素和雌激素.由于肾上腺皮质功能减退妇女的DHEA水平明显降低或缺如,因而有人研究能否将之作为常规糖皮质激素替代治疗的辅助药物.但是,DHEA的确切生理作用尚未阐明,对于肾上腺皮质功能减退患者是否应常规使用DHEA治疗也仍有争议.