如何写好系统综述.ppt

首都医科大学附属北京安贞医院北京市心肺血管疾病研究所赵冬,1,如何写一份好的综述,2,写综述？,写综述？,3,综述的类型和特点,综述包括普通综述、系统综述和Meta分析：传统综述是常见的综述形式，为某一主题的文献结果的总结，但有逐渐被系统综述取代的可能性。系统综述是根据一定的入选标准,系统地整理所有相关的观察或实验研究的证据,以回答一个特定的研究问题。特点为（1）目标明确，方法学清晰且可复制；（2）进行了系统化的文献检索，包括符合入选标准的所有文献；（3）对文献可靠性进行了评价；（4）综合包括的文献的特征和研究结果并给予系统的陈述。Meta分析采用统计学的方法整合和总结所研究的文献的结果。系统综述可以包括Meta分析，也可以不包括。Meta分析与一般的系统综述相比，可以对干预效果进行更加准确的估计。,(CochraneCollaboration的定义),AbstractC-reactiveprotein(CRP)isamarkerofsystemicinflammation,andithasbeenimplicatedinthepathogenesisofmanychronicdiseases,includingcardiovascular(CV)diseases.WithhighlysensitiveCRPassays,serumCRPcanaddconsiderablytostandardcoronaryheartdiseaseriskfactorsandinthepredictionofsubsequentmajorCVrisk.WereviewevidencesupportingtheassessmentofhighlysensitiveCRPbothinpatientswithestablishedCVdiseasesandinthosewithoutknowndiseaseaswellasevidencesupportingCRPasatargetoftherapy.Wealsoreviewvariouspharmacologic(especiallyintensivestatintherapy)andnonpharmacologictherapiestoreducelevelsofCRP.,AmJMedSci2009338:486-92,4,C-reactiveproteinandcardiovasculardiseases-isitreadyforprimetime?,AbstractOBJECTIVES:Thegoalofthissystematicreviewistoassessthecross-sectionalrelationshipofinflammatorymarkerswiththepresenceandextentofcoronaryarterycalcium(CAC)toidentifyasymptomaticindividualswithahigherriskofcoronaryheartdisease(CHD).BACKGROUND:Markersofsubclinicalinflammationandsubclinicalatherosclerosishavebothbeenusedtoimprovedetectionofindividualsathighriskofdevelopingcardiovasculardisease.CAChasemergedasasurrogatemakerforunderlyingcoronaryatherosclerosis,andhasbeenshowntopredictfutureCHDevents.Althoughinflammationisintimatelyassociatedwithatherosclerosis,andlevelsofinflammatorymarkerspredictcardiovascularrisk,therelationshipofsubclinicalinflammatorymarkerswiththeburdenofcoronaryatherosclerosisisnotclear.METHODS:MedlineandPubMeddatabasesweresearchedforallstudiesassessingtherelationshipofinflammatorymarkerswithCACpublishedtillJuly2007.RESULTS:Wefound12studiesthatmetourcriteria.CRP,fibrinogen,metallicmetalloproteinase-9(MMP-9),monocytechemotacticprotein1(MCP-1),resistin,lipoprotein-associatedphospholipaseA(2)(Lp-PLA(2),IL-6,tumornecrosisfactoralpha(TNF-alpha)andbeta-fibroblastgrowthfactor(bFGF)wereusedasinflammatorymarkers.Therewasawidevariationamongstudieswithregardstopopulationsize,inclusioncriterias,agerangeandtechniques.ItwasobservedthatinalmostallstudiestherelationshipbetweeninflammatorymarkersandCACwasweak,andwasmostlyfounduponunivariateanalysisinwomen.However,thisassociationwaslostaftercorrectionforobesityandBMI.ThedataontherelationshipofinflammationandCACwithprogressionofatherosclerosisisscarceanddidnotshowanypredictivebenefitsforfutureCHD.CONCLUSION:VariableassociationsbetweenCACandinflammatorymarkerswereidentified.Inmoststudieswhereapositiverelationshipwasfound,thisrelationshipdisappearedafterappropriatecorrectionforthepresenceoftraditionalriskfactors.OurdatasuggeststhatanapproachinwhichinflammatorymarkersareusedtofurthercharacterizeriskinindividualswithanestablishedcoronaryarterydiseaseburdenismorewarrantedthanusingbiomarkersassoleriskpredictorsoffutureCHDevents.Large,well-plannedcomprehensivestudiesarerequiredtoidentifythecombinedroleofmeasuringinflammatorymarkersinassessmentofatheroscleroticdisease.,Atherosclerosis2008201:1-7,5,Markersofinflammationandcoronaryarterycalcification:asystematicreview.,AbstractBACKGROUND:Traditionalriskfactorsdonotexplainalloftheriskforincidentcoronaryheartdisease(CHD)events.VariousneworemergingriskfactorshavethepotentialtoimproveglobalriskassessmentforCHD.PURPOSE:Tosummarizetheresultsof9systematicreviewsofnovelriskfactorstohelptheU.S.PreventiveServicesTaskForce(USPSTF)evaluatethefactorsclinicalusefulness.DATASOURCES:ResultsfromaMEDLINEsearchforEnglish-languagearticlespublishedfrom1966toSeptember2008,usingtheMedicalSubjectHeadingtermscohortstudiesandcardiovasculardiseasesincombinationwithtermsforeachriskfactor.STUDYSELECTION:Studieswereincludediftheparticipantshadnobaselinecardiovasculardiseaseandtheinvestigatorsadjustedforatleast6Framinghamriskfactors.DATAEXTRACTION:StudyqualitywasevaluatedbyusingUSPSTFcriteriaandoverallqualityofevidenceforeachriskfactorbyusingamodifiedversionoftheGradingofRecommendations,Assessment,Development,andEvaluationframework.Eachfactorspotentialclinicalvaluewasevaluatedbyusingasetofcriteriathatemphasizedtheimportanceoftheeffectofthatfactoronthereclassificationofintermediate-riskpersons.DATASYNTHESIS:9systematicreviewswereconducted.C-reactiveprotein(CRP)wasthebestcandidateforuseinscreeningandthemostrigorouslystudied,butevidencethatchangesinCRPlevelleadtoprimarypreventionofCHDeventsisinconclusive.Theotherevaluatedriskfactorswerecoronaryarterycalciumscoreasmeasuredbyelectron-beamcomputedtomography,lipoprotein(a)level,homocysteinelevel,leukocytecount,fastingbloodglucose,periodontaldisease,ankle-brachialindex,andcarotidintima-mediathickness.Theavailabilityandvalidityoftheevidencevariedconsiderablyacrosstheriskfactorsintermsofaggregatequality,consistencyoffindings,andapplicabilitytointermediate-riskpersonsinthegeneralpopulation.Formostriskfactors,nostudiesassessedtheirusefulnessforreclassifyingintermediate-riskpersons.LIMITATIONS:Becauseoflackofaccesstooriginaldata,nofirmconclusionscouldbedrawnaboutdifferencesinriskpredictionamongracialandethnicgroups.Thereviewdidnotemphasizewithin-cohortcomparisonsofmultipleriskfactors.CONCLUSION:Thecurrentevidencedoesnotsupporttheroutineuseofanyofthe9riskfactorsforfurtherriskstratificationofintermediate-riskpersons.,6,Emergingriskfactorsforcoronaryheartdisease:asummaryofsystematicreviewsconductedfortheU.S.PreventiveServicesTaskForce.,7,AbstractOBJECTIVE:Toassesstheoveralleffectsbyameta-analysis.DATASOURCES:ElectronicsearchesonPubMedandOvidMedlinefromtheirstarttoOctober2009werecarriedout.ObjectiveCohortstudiesandsecondaryanalysisofrandomisedcontrolledtrialsreportingtherelativerisk(RR)ofrecurrentcardiovasculareventsordeathassociatedwithC-reactiveprotein(CRP)obtainedwithin72hfromacutecoronarysyndromes(ACS)onset.DATAEXTRACTION:Twoepidemiologistsindependentlyabstractedinformationonstudydesign,studyandparticipantcharacteristics,levelofCRP,outcomes,controlforpotentialconfoundingfactorsandriskestimatesusingastandardisedform.RESULTS:Ageneralvariance-basedmethodwasusedtopooltheestimatesofrisk.Thirteenstudiescontaining1364newcasesidentifiedfrom9787patientsduringthefollow-upperiodsreportedtheriskestimatesbyCRPcategories.ComparedwiththebottomCRPcategory(10mg/l)categoryofCRPvalueswitharandom-effectsmodel,respectively.AnotherfourandthreestudiesreportedtheriskbyunitofCRPorlogarithmicallytransformedCRP.ThepooledRRs(95%CI)were1.49(1.06to2.08)per5mg/land1.26(0.95to1.69)pernaturallogarithmofCRP(mg/l),respectively.CONCLUSIONS:GreaterearlybloodCRPmoderatelyincreaseslong-termriskofrecurrentcardiovasculareventsordeath,andmaybeavaluableprognosticpredictorinpatientsafterACS.,Heart201095:339-410,8,EarlyC-reactiveproteininthepredictionoflong-termoutcomesafteracutecoronarysyndromes:ameta-analysisoflongitudinalstudies.,AbstractBACKGROUND:AssociationsofC-reactiveprotein(CRP)concentrationwithriskofmajordiseasescanbestbeassessedbylong-termprospectivefollow-upoflargenumbersofpeople.WeassessedtheassociationsofCRPconcentrationwithriskofvascularandnon-vascularoutcomesunderdifferentcircumstances.METHODS:Wemeta-analysedindividualrecordsof160309peoplewithoutahistoryofvasculardisease(ie,1.31millionperson-yearsatrisk,27769fatalornon-fataldiseaseoutcomes)from54long-termprospectivestudies.Within-studyregressionanalyseswereadjustedforwithin-personvariationinriskfactorlevels.RESULTS:Log(e)CRPconcentrationwaslinearlyassociatedwithseveralconventionalriskfactorsandinflammatorymarkers,andnearlylog-linearlywiththeriskofischaemicvasculardiseaseandnon-vascularmortality.Riskratios(RRs)forcoronaryheartdiseaseper1-SDhigherlog(e)CRPconcentration(three-foldhigher)were1.63(95%CI1.51-1.76)wheninitiallyadjustedforageandsexonly,and1.37(1.27-1.48)whenadjustedfurtherforconventionalriskfactors;1.44(1.32-1.57)and1.27(1.15-1.40)forischaemicstroke;1.71(1.53-1.91)and1.55(1.37-1.76)forvascularmortality;and1.55(1.41-1.69)and1.54(1.40-1.68)fornon-vascularmortality.RRswerelargelyunchangedafterexclusionofsmokersorinitialfollow-up.Afterfurtheradjustmentforfibrinogen,thecorrespondingRRswere1.23(1.07-1.42)forcoronaryheartdisease;1.32(1.18-1.49)forischaemicstroke;1.34(1.18-1.52)forvascularmortality;and1.34(1.20-1.50)fornon-vascularmortality.INTERPRETATION:CRPconcentrationhascontinuousassociationswiththeriskofcoronaryheartdisease,ischaemicstroke,vascularmortality,anddeathfromseveralcancersandlungdiseasethatareeachofbroadlysimilarsize.TherelevanceofCRPtosucharangeofdisordersisunclear.Associationswithischaemicvasculardiseasedependconsiderablyonconventionalriskfactorsandothermarkersofinflammation.FUNDING:BritishHeartFoundation,UKMedicalResearchCouncil,BUPAFoundation,andGlaxoSmithKline.Copyright2010ElsevierLtd.Allrightsreserved.,Lancet2010375:132-140,9,C-reactiveproteinconcentrationandriskofcoronaryheartdisease,stroke,andmortality:anindividualparticipantmeta-analysis.,10,不同类型文献的主要区别,传统文献综述的缺陷主观综合缺乏标准化（可重复）的方法注重统计学是否“有意义”等价对待每篇文献，无权重定性而非定量,是准确、可靠总结研究证据的工具，帮助临床医生、研究人员和病人了解最新的研究现状；为政策制定者者判断比较诊断、干预或治疗方法的效果和危险提供依据；临床指南诊治制定的依据；杂志编辑判断投稿创新性的依据。,12,系统综述和Meta分析的功能,13,系统综述和Meta分析流程图,14,好综述的27条标准PRISMA菜单（PreferredReportingItemsforSystematicreviewsandMeta-Analyses),题目:1项标准摘要：1项标准前言：2项标准方法：12项标准结果：7项标准讨论：3项标准经费：1项标准,AlessandroLiberatietalAnnalsofInternalMedicine2009;151:W65-w94,题目中应说明是系统综述或Meta分析举例：1.C-reactiveproteinasariskfactorforcoronaryheartdisease:asystematicreviewandmeta-analysesfortheU.S.PreventiveServicesTaskForce.2.Markersofinflammationandcoronaryarterycalcification:asystematicreview.,15,题目：1项标准,符合如下结构和内容：背景目标资料来源研究入选标准、研究人群和干预措施评价和综合研究结果的方法结果局限性结论和主要结果的意义系统综述的注册号,16,摘要：1项标准,2019/12/13,17,可编辑,已现有知识为背景，说明了为什么要写本篇综述；要综述的研究问题明确（符合PICOS标准）,18,前言：2项标准,P：研究对象（Participants)I:干预措施（Interventions)C:对照（Comparison)O:结局（Outcome)S:研究设计(Studydesign),19,PICOS标准：,提供标准化的综述方案（reviewprotocol)，最好有注册号码*入选标准明确合理说明所有文献来源（文献数据库、其他文献来源）文献检索的策略正确（说明局限性，如不可复制的检索方式）；选择研究的标准合理；有资料收集或摘录的程序（表格、独立性、获得原始数据的方法）收集资料的内容（应列出所有采集的变量和定义）应对个体研究内可能的偏倚进行评价；合并的测量指标（如RR或均数差值）结果合并的方法（统计学方法，如异质性检验、Meta分析的模型）应对研究间的偏倚进行评价（如发表偏倚）附加的分析方法（如敏感度分析、Meta回归分析）,20,方