Meta分析

Accuracy of MRI, MRArthrography, and Ultrasoundin the Diagnosis of RotatorCuff Tears: A Meta-Analysis,MRI、MR关节造影、超声诊断肩袖撕裂的准确性：Meta分析,OBJECTIVE. The purpose of this study was to compare the diagnostic accuracy of MRI,MR arthrography, and ultrasound for the diagnosis of rotator cuff tears through a meta-analysis of the studies in the literature.,目的：通过学习文献进行一个meta分析，来比较MRI、MR关节造影和超声在诊断肩袖撕裂的准确性。,MATERIALS AND METHODS. Articles reporting the sensitivities and specificities of MRI, MR arthrography, or ultrasound for the diagnosis of rotator cuff tears were identified. Surgical(open and arthroscopic) reference standard was an inclusion criterion. Summary statistics were generated using pooled data. Scatterplots of the data sets were plotted on a graph of sensitivity versus (1 specificity). Receiver operating characteristic (ROC) curves were generated.,材料与方法：文献报道，MRI、MR关节造影和超声在诊断肩袖撕裂的敏感性和特异性是确定的。外科手术（切开和关节镜）的证明标准是一种收入标准，通过对汇总数据的总结形成统计数字、数据设置的散点绘图，在一张敏感性对（1-特异性）的图上进行标绘，就形成Receiver operating characteristic（ROC）曲线。,RESULTS.Sixty-five articles met the inclusion criteria for this meta-analysis. In diagnosing a full-thickness tear or a partial-thickness rotator cuff tear, MR arthrography is more sensitive and specific than either MRI or ultrasound (p 0.05).,结果：65篇文章符合这个meta分析的收入标准。在诊断一个完全或部分的肩袖撕裂时，MR关节造影比MRI或超声更敏感和专业（p0.05）。,Summary ROC curves for MR arthrography,MRI, and ultrasound for all tears show the area under the ROC curve is greatest for MR arthrography (0.935), followed by ultrasound (0.889) and then MRI (0.878); however,pairwise comparisons of these curves show no significant differences between MRI and ultrasound(p 0.05).,MR关节造影、MRI、超声在概括ROC曲线上，对所有撕裂，MR关节造影的ROC曲线最棒（0.935），超声次之（0.889），MRI（0，878），但是，成对比较这些曲线，MRI和超声没有显著区别（p0.05）。,CONCLUSION. MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears. Ultrasound and MRI are comparable in both sensitivity and specificity.,结论：在诊断完全和部分撕裂时，MR关节造影是最敏感和最特异的，超声和MRI在敏感和特异方面差不多。,In the workup of patients with shoulder pain, the role of imaging is to guide treatment decisions 1,2. The diagnosis of a rotator cuff tear and its extent, full or partial thickness, can determine whether the patient will be managed conservatively or will need surgery 3, 4.Furthermore,the surgical approach, open versus arthroscopic, can be chosen once the correct diagnosis is made 3, 5.,在研究肩关节疼痛的病人时，成像技术扮演的角色是指导治疗措施（1，2），诊断肩袖撕裂的程度，包括完整或部分厚度来决定患者是否将保守治疗或进行外科手术（3，4），而且，一旦有了正确的诊断，就可以选择外科手术的方法，切开或关节镜（3，5）。,Of the various imaging tests that have been used to evaluate the painful shoulder, unenhanced MRI, indirect and direct MR arthrography, and ultrasound have become the standards by which a rotator cuff tear is diagnosed.,多种成像检测已经经常用于衡量疼痛的肩关节：非增强MRI、间接或直接MR关节造影、超声，在诊断肩袖撕裂时已成为标准。,Materials and MethodsA comprehensive literature search of the MEDLINE database was performed using the following keywords: rotator cuff and rotator cuff tear; magnetic resonance imaging, magnetic resonance, MRI, and MR; magnetic resonance arthrography and MR arthrography; ultrasound,ultrasonography, sonography, and US.,材料和方法在操作一个广泛的MEDLINE数据库信息资源和文献搜索时我们用了以下几个关键词：肩袖和肩袖撕裂，核磁共振成像，核磁共振，MRI和MR，核磁关节造影和MR关节造影，超声，超声成像，超声学和US。,Articles published from 1966 to September 2007 were searched and included publications in all languages and involving human and animal subjects.,已发表的文献从1966年到2007年9月，包括所有语言和人类及动物课题。,Study SelectionOur query of the MEDLINE database returned 1,195 hits. The articles were analyzed for concordance with the inclusion criteria. These criteria are English language; absolute (raw) data on rotator cuff tears (full or partial thickness or both) in the form of true-positives(TPs), truenegatives(TNs), false-positives (FPs), and falsenegatives(FNs) either provided or extractable;surgical reference standard (arthroscopy or open surgery); and diagnostic imaging studies interpreted by radiologists.,研究选择在MEDLINE数据库，我们检索到1，195个目标。为了得到一致性包含标准，我们对文章进行了分析。这些标准为英语；关于肩袖撕裂绝对的（新录）数据（完整或部分撕裂或两者兼有）；以任何一个提供的或提取的正阳性（TPs）、正阴性（TNs）、假阳性（FPs）和假阴性（FNs）为形式；外科收入标准（关节镜或切开手术）；研究由放射学学者解释诊断成像结果。,In addition, data must not have been published in a prior study. To prevent this possibility, we included only the article with the earlier publication date if two articles with common authors or from the same institution had overlapping dates of subject inclusion.,另外，在先前的研究中，数据不能已发表。为了避免这种可能性，如果两篇文章有相同作者或结论有重叠且来自同一研究机构，我们仅选录发表时间较早的文章。,Non-English-language (n = 160) and animal (n =1) studies were excluded. The abstracts of the remaining studies were evaluated for relevance to our study.Of these, 270 relevant articles were retrieved. One hundred sixty-two of the 270 were excluded because either raw data were not provided or the data could not be extracted into discrete TPs, TNs, FPs, and FNs.,没有英语的文章（n=160）和动物课题（n=1）等研究被排除，剩余已评估的研究摘要与我们研究相关。在这些文章里，270篇文章被检查，270篇里162篇被排除，因为要么没有提供最新的技术，要么数据不能被提取成的TPs、TNs、FPs和FNs。,Of the remaining 108 articles with data, 43 were excluded for the following reasons: 18 studies had a nonsurgical standard of reference, 15 had ultrasound read by nonradiologists, one had MRI read by nonradiologists,and nine had overlapping dates of subject inclusion with other studies by common authors from the same institution.,在剩下的108篇文章数据中，42篇因为以下的原因被排除：18篇研究有一个非外科引用标准，15篇由非超声医生进行超声诊断，1篇由非放射科医生对MRI进行阅片，9篇因为与来自同一研究机构的其他研究的一般作者的研究结论有重叠数据。,Therefore, 65 of 270 (24.1%) of the English-language articles met the inclusion criteria 771. Twenty-five studies analyzed MRI only; five, MRI and MR arthrography;nine, MR arthrography only; five, MRI and ultrasound; one, MR arthrography and ultrasound; and 20, ultrasound only.,所以，65篇（约占24.1%）英语文章符合收入标准（7-71），25篇仅分析MRI，5篇分析MRI和MR关节造影，9篇仅分析MR关节造影，5篇关于MRI和超声，1篇关节造影和超声，20篇仅超声。,From the 65 articles that fulfilled the inclusion criteria, we retrieved a total of 140 data sets: 48 ultrasound, 67 MRI, and 25 MR arthrography. The breakdown of the data sets by diagnostic end point was as follows: 56 evaluated for the presence of a rotator cuff tear (including full or partial thickness) versus no tear; 49 evaluated full-thickness tear versus non-full-thickness tear (including partial thickness tear or no tear); and 35 evaluated partial-thickness tear versus nonpartial-thickness tear (including full-thickness tear or no tear).,从满足收入标准的65篇文章中，我们一共获得了140个信息点：48个超声，67个MRI和25个MR关节造影，划分数据点的最终诊断要点是：56例衡量肩袖损伤的表现（包括完全或部分撕裂）对比没有撕裂；49个衡量完全撕裂对比非完全撕裂（包括部分撕裂和没有撕裂）；35个衡量部分撕裂和没有部分撕裂（包括完全撕裂和没有撕裂）。,In one article 16 that assessed partialthickness tears, three full-thickness tears were identified as partial-thickness tears; however,because a tear was identified, we considered those studies to be TPs.,在1篇文章中（16），测量部分肩袖撕裂、3个完整撕裂被鉴定为部分撕裂，可是，因为1个撕裂已经被鉴别，我们把哪些研究认为是TPs（真阳性）。,Another article 21 evaluated the sensitivity and specificity of six MRI findings in detecting a full-thickness rotator cuff tear; TPs, TNs, FPs, and FNs were recorded for each finding. Because we were concerned with techniques and not with specific findings, we picked one finding to represent MRI.,另一篇文章（21），探查肩袖完全撕裂时，衡量6个MRI发现结果的敏感性和特异性；在每个发现中记录TPs、TNs、FPs和FNs。因为我们关注技术而不是特殊的结果，我们选择一个结果来代表MRI。,In one article 22, some MRI diagnoses by report were equivocal (e.g., partial- versus fullthickness tear). The authors of this study used the more severe diagnosis in the final tally of no disease versus disease with the rationale that a more significant diagnosis is more likely to affect management.,在一篇文章（22），一些报道的MRI诊断是模糊的（比如：部分对比完整撕裂），作者在这个研究的最后用更多的多种诊断手段将没有疾病和疾病进行对比，因为一个更显著的诊断可能影响处理时的合理性。,One article 27 compared the accuracy of two MR pulse sequences. Because we were not interested in individual sequences but more in the actual technique, we omitted one of the sequences. The sequence we omitted was trivial because the authors of that article found no diagnostically significant difference between the two sequences。,在文章（27），作者比较了两个MR振动序列的准确性，因为我们对单个序列并没有兴趣，而更专注于实际技术，我们省略了序列中的一个无价值的，因为文章的作者发现两个序列诊断上没有显著差异。,Another article 28 looked at the accuracy of T2-weighted sequences with and without fat saturation in diagnosing full- and partial-thickness rotator cuff tears. For each of the four sets of data, we took (sensitivity + specificity)/ 2 and omitted the sequence with the lowest value(i.e., the fat-saturated fast spin-echo sequence).,文章28观察T2WI序列的准确度，伴或不伴脂肪浸润，在诊断完全和部分肩袖撕裂四个信息点的每一个，我们计算（敏感性+特异性）/2并且省略了最低价值序列（比如：脂肪浸润快速快捷发射序列）。,In one article 30, the authors divided patients into two groups on the basis of who performed ultrasound: Group 1 patients underwent ultrasound performed by a sonographer with 5 years of experience and group 2, by a radiologist with 10 years of experience. We omitted the data from the group examined by the sonographer.,在文章30，作者以超声下的情况将患者分为两组：1号组由一个5年经验的超声诊断医师进行诊断，2号组由1个10年工作经验的放射科医师诊断，我们省略了由超声诊断师检查的那组信息。,Another study 31 examined the interobserver agreement of five readers, each of whom interpreted MR images twice, first as a blinded review and second with knowledge of the surgical outcome. Sensitivities and specificities were calculated for full- and partial-thickness tears for each reader, generating five sets of data. For our purposes, we averaged the TPs, TNs, FPs, and FNs for full- and partial-thickness tears for both the blinded and retrospective readings.,另外的31研究，检验了五个读片者的观察一致性，每个人双次解释MR片，首先1次盲法回顾，第2次提供外科结果的信息，每一个读片者对完全或部分撕裂的敏感度和特异度进行计算，收集了5组数据，为了满足我们的研究目的，我们对完全或部分撕裂在盲法和回顾性阅读后按比例分配了TPs、TNs、FPs和FNs。,In one study 32, investigators also reported TPs, TNs, FPs, and FNs for two readers and in another study 33, for four readers. In a similar fashion, we took the average TP, average TN, average FP, and average FN and calculated sensitivities and specificities.,在文章32，调查者同样依赖两个读片专家来报道TPs、TNs、FPs和FNs。在另一个研究中，用了4个人读片，用一种相似的方式，我们取了TP、TN、FP、FN的平均值并计算了敏感性和特异性。,One article 36 compared MR arthrography performed on a low-field magnet (0.2-T) and on a high-field magnet (1.5-T); two sets of data were reported. The reported sensitivities and specificities were identical, so we dropped one of the data sets.one study 38 had two sets of data for two independent readers. We averaged the TP, TN, FP, and FN values for those readers.,一篇文章36比较了在低场强（0.2T）和高场强（1.5T）MR关节造影的表现；报道了两组信息，报道的敏感性和特异性完全相同，所以我们放弃了一组数据。38号文章用了两个不相关联的读片者拥有了两组数据。我们为那些读片者平均了TP、TN、FP和FN。,In one article 45, the diagnosis of a rotator cuff tear was established on the basis of findings from transverse, parasagittal, or both transverse and parasagittal MR images of the shoulder. Two radiologists independently evaluated the planar images for each shoulder. We used the reported data for diagnosis based on both the transverse and parasagittal images. As in prior studies, we averaged the data for the two readers.,在文章45中，在横切面、旁矢状面、横切面和旁矢状面双面的肩关节MRI基础上，明确肩袖撕裂的诊断。两位放射科医师各自对每一个肩部平面片进行衡量，我们用已报道的在横切面和旁矢状面成像信息来诊断。如先前的研究方法一样，我们平均了阅片者获得的信息。,Another article 46 compared T2-weighted fast spin-echo with and without fat suppression. Of the data for the two sequences, we retained the data set with the higher sensitivity and spe cificity.One study 49 compared the results of MR arthrography performed using three different solutions for intraarticular injection: Ringer solution and two different concentrations of gadoteridol. Two independent readers evaluated all the studies,and interobserver agreement was calculated as akappa value for each of the three solutions.,文章46比较了T2加权快速平扫伴或不伴脂肪抑制，对两组序列的结果，我们保留了高敏感和高特异的那组数据。文章49用3种不同浓度关节内注射液的方法比较了MR关节造影表现的结果，林格氏液和两种不同浓度的軋特醇。两个独立的阅片者衡量了所有的研究并计算了三种浓度每一种的Kappa值（kappa值：实际符合率与最大可能率之比）我们用最高特异度的对比浓度来获得信息并平均两位阅片者获得的信息。,In one article 52 that looked at ultrasound of the rotator cuff, the authors established the diagnosis of a tear using published diagnostic criteria and again using a subset of the published criteria. We used the data set that yielded the higher accuracynamely, the one generated from the more restricted subset of the published criteria.,在文章52中，观察肩袖的超声结果，该文作者用已发表的诊断标准和标准子集来确定一个撕裂，我们选用更严格的子集标准的那一组准确性更高的数据。,In references 4551, multiple reference standards were used in each study. For each article, we used only the data sets with surgically proven findingsthat is, either open surgery or arthroscopy.,在参考文献45-51中，研究使用了多种参考标准，每一个文章，我们仅使用了经过外科（切开或关节镜）证实的数据。,Meister et al. 61 reported nine full-thickness tears, 28 partial-thickness tears, and 39 intact tendons by arthroscopy. The authors reported a specificity of 96% (43/45), which appears instead to correspond to the negative predictive value. Specificity should actually be 90% (43/48) if the nine full-thickness tears are counted as TNs.,Meister(61)报道了关节镜下9例完全撕脱，28例部分撕脱和39例未受损伤肌腱。作者报道了96%的特异性（43/45），看起来与预期的负价值一致，如果9个完全撕裂作为TNs(真阴性)计算的话，事实上应该是90%（43/48）。,In their study, Milosavljevic et al. 64stated “ultrasound identified a full-thickness tear instead of a partial-thickness tear. Because a tear was identified, these studies were considered to be true-positive.” For the purpose of calculating sensitivity for partial-thickness tears in this metaanalysis, we counted only the 17 partial-thickness tears as TPs.,在Milosavljevic(64)阐述超声将一个部分撕裂鉴别为完全撕裂，因为鉴别一个撕裂即认为是一个真阳性”为了Meta分析诊断部分撕裂的敏感性，我们仅计算了17个部分撕裂作为TPs。,Herold et al. 65 recorded data for two readers. These data were averaged in the aforementioned fashion. Additionally the authors noted that each patient underwent MR arthrography twice: once with the patients shoulder in a neutral position and a second time with it abducted and externally rotated (ABER). Sensitivity, specificity, and accuracy were compared. As done previously, we calculated (sensitivity + specificity) / 2 and took the data set with the higher values, which turned out to be the ABER data set.,Herold（65）记录了以上述方式平均后两个读片人读片的信息，作者指出每个患者进行了两次MR关节造影，一次在中立位，一次在外展外旋位，比较了敏感性、特异性、准确性，正如先前做的一样，我们计算了（敏感性+特异性）/2并取用了价值最高的信息，就是外展外旋位的信息。,Fritz et al. 67 evaluated the association of cystic changes at tendon insertion sites with rotator cuff disorders. Overall performance for tears was reported. Data for full- or partial-thickness tears could not be gleaned.,Frit（67）衡量了肩袖失稳时肌腱插入位置与关节囊改变的联系，肩袖完全撕裂与部分撕裂的信息不能被收集。,Ferrari et al. 71 classified full-thickness supraspinatus tears as focal, subtotal, or total and classified partial-thickness tears as intratendinous, articular, or bursal-sided. For the meta-analysis, these subcategories of full- and partial-thickness tears were not considered separately.,Ferrari（71）将完全冈上肌撕裂分类为局限撕裂、接近完全和完全撕裂，并将部分撕裂分类为腱内的、关节内的、囊内的。在Meta分析，完全或部分撕裂的次种类没有被分开考虑。,Statistical AnalysisTwo common approaches appear in the metaanalysis literature for the analysis of diagnostic tests. One approach is to pool data from a number of studies to obtain overall sensitivities and specificities and compare them using the chisquare test.,统计学分析在进行诊断方式分析时，我们用Meta分析文献时用了两种方式，一种是将大量的研究数据汇总，从而获得全部的敏感性和特异性，并用卡方检验进行比较。,A second approach involves using regression to construct summary ROC curves for each technique and then computing a z test to compare the Q* points of the curvethat is, the points on an ROC curve where sensitivity equals specificity 72.,另一方法是包括统计回归到作图总结ROC曲线，然后计算一个z检验来比较曲线Q点就是代表ROC曲线上敏感性和特异性相等。,结果图1表示完全撕裂、完全或部分撕裂和部分撕裂分布在散点图上显示敏感性和（1-特异性），各自在y轴和x轴。图上的每一个点表示一篇发表的研究，一个理想的影像技术的Meta分析，就是拥有高敏感的同时有低FP（假阳性）率可以在图的左上方区域描绘一群信息点。,Plots show data for detection of full-thickness tears (A), full- and partialthicknesstears (B), and partial-thickness tears (C).MR arthrography (O), MRI (), and ultrasound (),在MRI和超声信息点分布时，在完全撕裂的图上可能存在重叠（Fig.1A），MRI和超声在左上方有一组信息点。,For full-thickness tears, chi-square analysis shows no significant difference in sensitivity among the three techniques. Furthermore, ultrasound and MRI are not significantly different in sensitivity or specificity. MR arthrography is more specific than either MRI or ultrasound (specificity vs MRI, 2 = 40.142, p 0.0001; specificity vs ultrasound, 2 = 25.836, p 0.0001).,在完全撕裂方面，卡方检验三种技术，敏感性没有显著差异。接着，超声和MRI在敏感性和特异性上没有显著差异。MR关节造影比MRI或超声更加专业（特异性vsMRI，x2=40.142，p0.001,特异性vs超声，x2=25.836，p0.0001）。,在完全和部分撕裂的图上（Fig.1B），MRI和超声有一些点松散分布在图表的上半部分，类似于高敏感性和变化的FP率，这几个指标都有突出的轮廓。,For the diagnosis of full- or partial-thickness tears, MR arthrography is more sensitive and more specific than either MRI or ultrasound (sensitivity and specificity of MR arthrography vs MRI: 2 = 8.130 and 54.990, p 0.0004 and 0.0001, respectively; vs ultrasound: 2 = 14.843 and 28.073, p 0.05).,在完全或部分撕裂的诊断方面，MR关节造影比MRI或超声更具敏感性和特异性（MR关节造影敏感性和特异性vsMRI：x2=8.130和54.990，p0.0004和0.0001，各自地；vs超声：x2=14.843和28.073.p0.05）。,在部分撕裂的图表上（Fig.1C），MRI和超声有一个较低的FP率，但在敏感性方面有较大范围的改变，信息点松散地分布在图标的左1/3。同样，都有突出的轮廓。,For partial-thickness tears, MR arthrography is more sensitive and more specific than either MRI or ultrasound (sensitivity and specificity of MR arthrography vs MRI: 2 = 27.358 and 14.134, p 0.0001 and 0.0002, respectively; vs ultrasound: 2 = 21.635 and 5.111, p 0.0001 and 0.02). Although there is no statistically significant difference between MRI and ultrasound for the diagnosis of partial-thickness tears, ultrasound tends to be more sensitive and more specific (sensitivity: 2 = 2.057, p = 0.15; specificity: 2 = 3.347, p = 0.067).,在部分撕裂方面，MR关节造影比MRI或超声更具敏感性和特异性（关节造影敏感性和特异性vsMRI：x2=27.358；vs超声x2=21.635和5.111，p0.05），MRI0.86和0.032，超声0.86和0.049。z检验的结果显示广泛的比较没有显著差异。,For the patient with shoulder pain, a host of therapeutic options, ranging from medical management to physiotherapy to open surgery, are available 6, 74. The role of diagnostic imaging is to help guide surgical or nonsurgical management. The ideal imaging technique should have a high rate of TPs and an acceptable rate of FPs to limit unnecessary surgical intervention.,讨论对肩部疼痛的病人，从药物治疗到物理治疗到外科切开手术，治疗的主动选择是有效的（6，74），影像诊断的角色是帮助指导手术或非手术的治疗方式。理想的影像技术必须有一个高的TPs率和可接受的FPs率来减少不必要的