Chinese Journal of Tissue Engineering Research ›› 2020, Vol. 24 ›› Issue (23): 3756-3763.doi: 10.3969/j.issn.2095-4344.2729
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Shi Yuling1, Li Guangyao2, Liang Zujian3
Received:
2019-12-02
Revised:
2019-12-04
Accepted:
2020-01-10
Online:
2020-08-18
Published:
2020-07-30
Contact:
Liang Zujian, MD, Chief physician, Orthopedics Hospital, Guangzhou University of Chinese Medicine, Guangzhou 510240, Guangdong Province, China
About author:
Shi Yuling, Master candidate, Third Clinical School, Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China
Supported by:
CLC Number:
Shi Yuling, Li Guangyao, Liang Zujian. Various acupuncture therapies for lateral epicondylitis: a Bayesian network meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2020, 24(23): 3756-3763.
2.2 所纳文献质量评价结果 纳入的32篇文献中有2篇质量较高,其余文献质量一般,其评估的依据主要体现在:①10篇文献在文中详细提及研究时所开展的随机法,但有15篇仅提及了随机字样,7篇按就诊顺序随机;②由于针刺器具及治疗方式的特殊性,故在施术时无法施盲于医患,但由于两方事先了解治疗过程,按循证医学施盲法则的判断,当医患双方在知情的情况下,未做设盲处理时可认为其对治疗结果影响较小[49],但所纳文献均未明确提及结局统计方面是否施盲,这将在一定程度上对结果的公认性有部分影响;③所纳文章均未明确提及分配隐藏与否;④有1篇文章存在人员脱落[37],且文中说明来源于何组别及具体缘由;⑤有3篇文献在随访及复发方面有记录[34,43,48],随访的时间分别为4周、1个月、3个月,且时实记录了详情;⑥有1篇文献提及在所涉的干预措施中治愈网球肘需要的具体疗程[19];⑦1篇文章只提及了治疗频次,无具体疗程[28]。结果详见表1,图2。 "
2.3 结果分析 2.3.1 直接比较Meta分析结果 (1)对所纳以有效率为主要指标里两两比较的文献进行Meta分析:结果示浮针优于电针[OR=0.88,95%CI (0.81,0.97)],温针优于毫针刺[OR=0.27,95%CI(0.15,0.48)],温针优于电针[OR =0.24,95%CI(0.08,0.76)],火针+毫针刺优于毫针刺[OR =0.22,95%CI(0.07,0.74)],火针优于毫针刺[OR=0.15,95%CI(0.07,0.36)],火针优于温针[OR= 0.13,95%CI(0.03,0.61)],火针优于电针[OR=0.24,95%CI (0.06,0.95)],剩余浮针与温针的两两比较结果无统计学差异。 (2)对所纳目测类比评分(VAS)为次要结局指标的文献进行分析:结果示浮针优于温针[MD=0.65,95%CI(0.02,1.28)],温针优于毫针刺[MD=1.33,95%CI(1.03,1.63)],温针优于电针[MD=1.60,95%CI(0.95,2.25)],火针+毫针刺优于毫针刺[MD=1.37,95%CI(0.41,2.33)],火针优于毫针刺[MD=0.96,95%CI(0.73,1.18)],火针亦优于电针[MD=1.61,95%CI(0.76,2.46)],纳入文献中目测类比评分作为次要指标的统计学均显示出差异。见表2。 "
2.3.4 一致性模型下的网状Meta分析及疗效排序 此次所纳32篇文章,共涉及2 318例患者,将此32篇文献的数据基于贝叶斯理论进行数据的拟合并分析[6,18-48],其马尔科夫链-蒙特卡罗(MarkovChain Monte Carlo,MCMC)的参数采用软件预设,其有效率结果见表3所示,结果释为温针优于电针[OR=2.68,95%CI(1.28,6.54)],温针优于毫针刺[OR=4.43,95%CI(2.44,8.71)],火针优于温针[OR=2.32,95%CI(1.04,4.79)],火针优于电针[OR=6.14,95%CI(2.41,15.18)],火针优于毫针刺[OR=10.23,95%CI(4.90,23.05)],浮针优于电针[OR=6.86,95%CI(2.80,19.72)],浮针优于毫针刺[OR=11.86,95%CI(3.58,37.71)],火针+毫针刺优于毫针刺[OR=6.65,95%CI(1.93,30.78)],其余比较均无统计学差异。依据一致性模型下的统计结果,查看疗效排序的概率,具体见图5a,通过直观评估来判断疗效排序,其结果从优到劣依次为:浮针>火针>火针+毫针刺>温针>电针>毫针刺。所纳32篇文章中有12篇文章以目测类比评分作为次要指标,结果见表4,对其进行统计,结果为温针优于电针[MD=-1.88,95%CI(-2.76,-0.96)],温针优于毫针刺[MD=-1.34,95%CI(-1.99,-0.82)],火针优于电针[MD=-1.60,95%CI (-2.20,-0.85)],火针优于毫针刺[MD=-1.06,95%CI (-1.82,-0.36)],浮针优于电针[MD=-2.54,95%CI(-4.08,-0.90)]浮针优于毫针刺 [MD=-2.00,95%CI(-3.46,-0.62)],火针+毫针刺优于电针[MD=-1.90,95%CI(-3.56,-0.09)],其余比较均无明显统计学差异。查看疗效排序的概率,具体见图5b,通过直观评估来判断疗效排序,其结果从优到劣依次为:浮针>火针+毫针刺>火针>温针>毫针刺>电针。 "
2.3.5 非一致性模型检验 当在一致性模型下行结果的统计和分析时,需另行非一致性模型运算以鉴别所得结果稳定与否。首先对有效率的非一致性模型下产生的3个非一致性模型因子进行核对,分别为0.88(-0.39,3.12)、0.11(-1.40,2.02)、0.46(-0.64,2.38),再核对非一致性模型标准差,其为1.07(0.05,2.78)。根据结果其非一致性模型因子95%置信度区间包含0,非一致性模型标准差95%置信度区间包含1,表示一致性模型下的有效率结果稳定且可靠。 其次核对目测类比评分的非一致性模型因子,其为-0.16(-1.52,0.09),再核对非一致性模型标准差,其为0.88(0.04,2.20)。根据结果其非一致性模型因子95%置信度区间包含0,非一致性模型标准差95%置信度区间包含1,表示一致性模型下的目测类比评分结果稳定且可靠。 2.4 发表偏倚分析 用STATA呈现此次网状Meta的漏斗图,以便探析在本研究中的发表偏倚的情况。由图6a示有效率的漏斗图,该图大致对称,但有1项研究在倒置的三角形外,说明存在小样本效应及发表偏倚,据敏感性分析可知该偏倚来源于龙翔等[38]的文章,文章作者认为电针与火针之间无明显差异。图6b示目测类比评分的漏斗图,该图有2点存在三角形外,发现其点为温针vs毫针刺及火针vs电针的文献[26,38],说明存在发表偏倚,仔细分析数据后发现该偏倚不属临床方法及统计学问题造成,且这些文章皆符合文献纳入标准,不应剔除,故应继续纳入并行统计分析。 "
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