循证临床实践00课件

1、循证临床实践Evidence based Practice福建医科大学附属第一医院 陈君敏(drjunminchen)1课程介绍 循证临床实践重点介绍临床循证实践的技能和方法如何针对临床遇到的疑难问题查找回答问题的临床研究文献如何分析解读临床研究文献报告的结果如何将这些研究结果应用于临床实践如何开展证据研究课程旨在帮助临床医生应用当前最佳的研究证据提高诊疗水平。2概 论循证医学的概念循证医学的起源循证医学的概念循证临床实践3随着医学科学的迅速发展，临床医学的研究也非常活跃，每天都有许多医学论文发表，有新的科学证据产生。这些新的成果只有及时被临床医生了解和应用，病人才能得到最好的治疗。医学研究临

2、床应用4临床应用严重滞后于医学研究有充分证据证明有效的治疗方法长期未被使用如心肌梗死的溶栓疗法在20世纪70年代已有多篇文献证实，在80年代末才得以广泛应用研究证明无效，甚至有害的治疗方法却长期应用如利多卡因预防心肌梗死后的心律失常57循证医学的提出我们生活在知识爆炸的时代，医学研究的信息呈指数增长。医生要保持自己的知识更新非常困难，而且越来越困难。 医疗资源有限，合理使用有限的医疗资源是各国的普遍要求 8什么是循证医学？Evidence based practice is the conscientious, explicit and judicious use of current bes

3、t evidence in making decisions about the care of individual patients.慎重、准确和明智地应用当前所能获得的最好研究依据制定出病人的治疗措施 David Sackett 1011传统医学：以经验医学为主，即根据医师的经验直觉来处理病人，这些经验可能来源于：个人的临床实践积累专业培训老师传授大多数同行的诊疗方法 教科书专家意见遵循证据是EBM的核心思想什么是证据？12Patient preferenceResearch evidence14循证医学概论概念（小结）EBM起源概念（慎重、准确和明智地应用当前所能获得的最好研究依据制定

4、出病人的治疗措施 ）核心思想（遵循证据）循证临床实践（EBCP）和广义的EBMEBCP三要素 （临床经验、临床证据、患者意愿）15医学证据医疗决策的依据依据的优劣决定决策的成败17医疗决策 怀疑病人患某种疾病，医生要决定让病人做某项检查以确诊或排除这种疾病 采用这种检查而不用另一种检查 ？病人出现某种临床问题，医生要为病人选择某种治疗措施 采用这种治疗而不用另一种治疗？18医学证据这种检查比另一种检查更准确、对病人伤害小、价格便宜，等等 何以证明？这种治疗措施比另外一种效果更好、副作用较小、以及花费少 何以证明？19能证明吗？医生的经验直觉 医学理论（比如中医的某种学说）推理 科学实验（比如动

5、物实验和体外实验）？教科书？专家意见 20临床研究作为医学证据（按研究内容分类）关于病因的临床研究关于诊断或筛查的临床研究关于治疗或干预的临床研究关于预后的临床研究21证据的分类原始研究证据观察性研究：队列研究，病例-对照研究，横断面调查，描述性研究，病例系列，个案报告试验性研究：随机对照试验（RCT），非随机同期对照试验，交叉试验，前后对照试验二次研究证据：系统评价（SR），临床实践指南，临床决策分析，卫生技术评估，卫生经济学研究2224251.Clinical study of recombinant adenovirus-p53 combined with fractionated st

6、ereotactic radiotherapy for hepatocellular carcinoma.Yang ZX, Wang D, Wang G, Zhang QH, Liu JM, Peng P, Liu XH.J Cancer Res Clin Oncol. 2010 Apr;136(4):625-30. Epub 2009 Oct 31.PMID: 19882171 PubMed - indexed for MEDLINERelated citations2.An update on gene therapy in China.Shi J, Zheng D.Curr Opin M

7、ol Ther. 2009 Oct;11(5):547-53. Review.PMID: 19806503 PubMed - indexed for MEDLINERelated citations3.Phase I study of repeated intraepithelial delivery of adenoviral p53 in patients with dysplastic oral leukoplakia.Zhang S, Li Y, Li L, Zhang Y, Gao N, Zhang Z, Zhao H.J Oral Maxillofac Surg. 2009 May

8、;67(5):1074-82.PMID: 19375021 PubMed - indexed for MEDLINERelated citations4.A patient with huge hepatocellular carcinoma who had a complete clinical response to p53 gene combined with chemotherapy and transcatheter arterial chemoembolization.Tian G, Liu J, Sui J.Anticancer Drugs. 2009 Jun;20(5):403

9、-7.PMID: 19318914 PubMed - indexed for MEDLINERelated citations5.The application of gene therapy in China.Peng Z, Yu Q, Bao L.IDrugs. 2008 May;11(5):346-50. Review.PMID: 18465676 PubMed - indexed for MEDLINERelated citations6.Recombinant adenovirus-p53 gene therapy combined with radiotherapy for hea

10、d and neck squamous-cell carcinomaZhang SW, Xiao SW, Liu CQ, Sun Y, Su X, Li DM, Xu G, Zhu GY, Xu B.Zhonghua Zhong Liu Za Zhi. 2005 Jul;27(7):426-8. Chinese. PMID: 16188130 PubMed - indexed for MEDLINERelated citations7.Current status of gendicine in China: recombinant human Ad-p53 agent for treatme

11、nt of cancers.Peng Z.Hum Gene Ther. 2005 Sep;16(9):1016-27. Review. No abstract available. PMID: 16149900 PubMed - indexed for MEDLINERelated citations8.Gendicine: the first commercial gene therapy product.Wilson JM.Hum Gene Ther. 2005 Sep;16(9):1014-5. Chinese, English. No abstract available. PMID:

12、 16149899 PubMed - indexed for MEDLINERelated citations9.DNA-based therapeutics and DNA delivery systems: a comprehensive review.Patil SD, Rhodes DG, Burgess DJ.AAPS J. 2005 Apr 8;7(1):E61-77. Review.PMID: 16146351 PubMed - indexed for MEDLINEFree PMC ArticleFree textRelated citations27当前最佳证据表1-3评价的

13、基础上应用28研究设计（依证据级别）治疗诊断病因预后系统评价随机对照试验非随机的对照试验队列研究（观察）无对照的病例系列个案报告系统评价队列研究系统评价随机对照试验队列研究病例-对照研究系统评价队列研究病例-对照研究29系统评价 Systematic Review选题：要回答的临床问题拟定纳入标准和排除标准检索：检索策略和数据库确定纳入的试验评价纳入试验的方法学质量抽取试验的结果数据汇总分析讨论总结： 回答问题查找证据 分析证据 最高级别的证据30/3132常用统计学指标二分变量（dichotomous)比值比（Odds Ratio, OR）危险比（Risk Ratio, RR），或称相对危险

14、度（Relative Risk, RR）危险差（Risk Reduction, RD），或称绝对危险减少（Absolute Risk Reduction, ARR）需要治疗的病人数（Number Needed to Treat, NNT）连续变量（Continuous）均数差（Mean Difference, MD）33Risk=发生某事件的人数观察的总人数 -实际上指某事件的发生率odds=发生某事件的人数未发生某事件人数比如24人沿一斜坡滑雪，6人滑倒Risk=624=0.25Odd=6(24-6)=0.33在事件发生率很低情况下，risk和odds接近。 Risk and Odds34O

15、RRR干预组odds / 对照组odds 干预组risk / 对照组risk=1，干预组和对照组的事件发生频率一致1，干预使事件发生频率增高1，干预使事件发生频率降低离1越近，效应值越小，离1越远，效应值越大。95% CI 如果包括1，说明差异无统计学意义（P0.05），否则差异有统计学意义（P0.05）。 OR和RR 反映治疗组和对照组事件发生频率对比35可信区间 （Confidence Interval，CI） 一个试验的结果效应值点估计同一试验重复多次，结果不一致效应值范围可信区间是指真实的效应值所分布的范围，范围越小，说明对真实效应值的估计越精确 95% CI 指对每一项研究估计的效应

16、值的分布范围，人们有95%的把握认为效应真值是在此区间之内 如果OR或RR的95% CI 不包括1，说明干预组和对照组比较，危险（或比值）的差异有统计学意义，P0.05。否则无统计学意义，P0.05。 36双膦酸盐的疗效比较（vs安慰剂）观察项目 （研究数目）双膦酸盐对比安慰剂 (病例数) Odds Ratio（95可信区间）p值评估病例数结果Mortality (10) 1,079 vs 1,048 557 vs 549 0.99 (0.88 to 1.12) 0.9Vertebral fractures (7) 575 vs 541 141 vs 188 0.59 (0.45 to 0.7

17、8) 0.0001Non-vertebral fractures (6) 708 vs 681 102 vs 93 1.05 (0.77 to 1.44) 0.7Hypercalcemia (8) 1,044 vs 1,002 84 vs 101 0.76 (0.56 to 1.03) 0.07Pain (8) 657 vs 624 276 vs 318 0.59 (0.46 to 0.76) 0.00005Gastrointestinal symptomsd (6) 853 vs 836 110 vs 86 1.28 (0.95 to 1.74) 0.11373839Odds ratio (

18、OR) for vascular events40疾病疾病暴露41RD干预组risk 对照组risk =0，干预组和对照组的事件发生频率一致0，干预使事件发生频率增高0，干预使事件发生频率降低离0越近，效应值越小，离0越远，效应值越大。95% CI 如果包括0，说明差异无统计学意义（P0.05），否则差异有统计学意义（P0.05）。 RD 反映治疗组和对照组事件发生频率差别42伏立康唑与二性霉素治疗侵袭性曲霉菌治疗成功的危险差（RD）43NNT 指获得（或避免）1个事件需要治疗的病人数。NNT越大，效应值越小 例子：6328人用戒烟口香糖，1149人戒烟成功对照组8380人，893人戒烟成功口

19、香糖组成功率：1149/6328=18.2%对照组成功率： 893/8389=10.6%RD=18.2%-10.6%=7.6%NNT=1/RD=1 / 7.6%=13.244RR 对每个人而言，“临床疗效”是一样的，但NNT不同。（表4-3）例子: 某种药物降低心梗死亡率40%，即 RR=0.60如果治疗的对象人群死于心脏事件的年死亡率1/10，NNT=25如果治疗的对象人群死于心脏事件的年死亡率1/100，NNT=250其他例子（表4-345MD干预组mean 对照组mean =0，干预组和对照组的测量值一致0，干预组测量值高于对照组 0，干预组测量值低于对照组 离0越近，效应值越小，离0越

20、远，效应值越大。95% CI 如果包括0，说明差异无统计学意义（P0.05），否则差异有统计学意义（P0.05）。 MD 反映治疗组和对照组测量值差别4647诊断研究：Sen/Spe/Acc/+PV/-PV诊断试验金标准合计有病无病是ABA+B否CDC+D合计A+CB+DA+B+C+D敏感度：真阳性率，A/(A+C)特异度：真阴性率，D/(B+D)准确度：(A+D)/(A+B+C+D)阳性预测值：全部阳性中真阳性的比例， A/(A+B)阴性预测值：全部阴性中真阴性的比例， D/(C+D)受患者集中程度影响：大医院都是阳性的48诊断研究：似然比(LR)诊断试验金标准合计有病无病是ABA+B否CD

21、C+D合计A+CB+DA+B+C+D阳性似然比(+LR):真阳性率/假阳性率,阳性时患病与不患病机会之比阴性似然比(-LR):假阴性率/真阴性率,阴性时患病与不患病机会之比49预后研究发病率:一定期间人群新发病例频率患病率:特定时间内新旧病例数/同期平均人口中位生存时间:50%随访者死亡所需随访时间生存率:一段时间后存活的病例数/总例数生存曲线:预后随时间变化的情况50循证临床实践的步骤方法 提出临床问题查询有关的研究资料（证据）评价证据的质量（可靠性），了解证据结果是什么（效应值及其精确度）？这些证据是否适合于您的病人将这些证据结合专业知识和病人的要求进行医疗决策评价在临床实践中应用证据的效

22、果51Essential steps of EBM -David SackettTo convert our information needs into answerable question (that is, to formulate the problem)To track down, with maximum efficiency, the best evidence with which to answer these questions.To appraise the evidence critically (that is, to weigh it up) to assess

23、its validity (closeness to the truth) and usefulness (clinical applicability)To implement the results of this appraisal in our clinical practiceTo evaluate our performance52构建临床问题问题的类型问题的来源问题的构建（PICO） 53问题类型治疗问题诊断问题病因问题预后问题54Aetiology or Causation: What is the risk that this exposure will cause a gi

24、ven disease?什么是风险,这些资讯会将导致一个给定的疾病吗?Diagnosis: what test should I use to investigate this patients pathology and how accurate is that test?诊断:我要用什么测试研究这个病人的病理学和精确性如何这个测试吗?Treatment and Prevention: Does this intervention improve this condition in patients such as this one?防治:这是不是干预患者改善这一状况,例如有吗? Progn

25、osis: Given this patients demographic factors, what is the natural history of this condition?预后:考虑到患者的人口因素,什么是自然历史的情况吗?55背景问题前景问题56诊断下肢深静脉血栓的方法小腿肿鉴别诊断DVT蜂窝织炎 B超阴性能排除是DVT吗？D-Dimer阴性能排除DVT吗？静脉造影B超D-Dimer57知识更新的方式基于主题的学习系统以教材为中心效率低下缺乏目的性基于问题的学习零散以学习者为中心印象深刻针对性强58治疗问题某种疾病“最好”的治疗是什么？什么样的治疗措施“起效最快”、“效果最好”

26、、“副作用最少”？ 59PICO形式Patients or PopulationInterventionComparisonOutcomes60PICO的目的搞清楚问的问题是什么？明白要回答这个问题需要什么样的信息？可以根据问题选择合适的检索词。可以拟订和修改检索策略。 61A question about selecting therapy一个关于选择的治疗方法In coronary patients who develop heart failure on ibuprofen, would simple drug withdrawal plus diuretics suffice or s

27、hould they be offered an angiotensin-converting enzyme (ACE) inhibitor, in order to alleviate the heart failure?在冠状动脉患者在布洛芬发展为心衰,简单的药物戒断加上利尿剂够或应提供了血管紧张素酶(ACE)抑制剂,为了缓解心脏的失败?PIC O62A question of selecting a diagnosis test选择的问题诊断测试In patients with heart failure, how accurate is the bed-side test for po

28、st-Valsalva systolic overshoot in predicting left ventricular function?P: Participants(对象), pts with heart failureI: Indicator(指标), C: ComparisonO: Outcome63A question about predicting prognosis关于判断预后的问题In an elderly woman with coronary heart disease, by how much does the appearance of heart failure

29、 shorten her life? P: ParticipantsI: Prognostic indicatorC: ComparisonO: Outcome64A question of determining etiology确定集合的问题In an elderly woman with preexisting coronary heart disease, can ibuprofen precipitate heart failure? P: ParticipantsI: ExposureC: ComparisonO: Outcome65PICO治疗急性心梗病人早期他汀治疗安慰剂死亡诊

30、断怀疑冠心病人ECT心肌显影冠脉造影敏感度、特异度病因（不良反应）绝经期妇女激素替代治疗无激素替代乳腺癌发生预后充血性心力衰竭年龄70年龄10或0.1，验前概率到验后概率起决定性变化，基本可以确定和排除诊断。122诊断研究的临界点取值表6-3受试者工作特性曲线（Receiver operator characteristic curve, ROC)123Sen1-Spe124诊断研究的评价结果是否可靠？结果是什么？结果适合于当前病人吗？125Appraisal of Articles about Diagnostic Tests Adapted from Duke University Evi

31、dence-based Medicine Website126Are the results valid?Was there an independent blind comparison with a reference standard? 独立盲法Were patients from an appropriate spectrum for whom the test will be applied in clinical practice?疾病谱 Was the reference standard performed in all cases or did the results of

32、the test being evaluated influence the decision to perform the reference standard? 是否全部病例均接受标准检查Were methods of the test described in sufficient detail to permit replication? 采用的筛查方法是否详述127What are the results?What is the strength of the outcome? What were the likelihood ratios? Sen (95% CI)Spe (95%

33、 CI)Positive predictive value (95% CI)Negative predictive value (95% CI)Likelihood ratios128Were the results help me in caring my patients?Will the reproducibility of the test result and its interpretation be satisfactory in my setting? 129预后研究预后：关于预测疾病可能结局及其发生的可能性大小的估计。预后因素：与病因因素不同。预后因素包括预后研究的设计类型（

34、表7-3）预后研究的评价（表7-1）130Prognostic factorsPrognostic factors are characteristics of a patient that may be used to more accurately predict that patients outcome. These characteristics may be demographic（人口统计学）, disease specific（疾病相关性）, or co-morbid（并发病）. Unlike aetiological or causative factors, prognos

35、tic factors need not be causal, just strongly associated with the outcome and thus, an accurate predictor of how an individual may progress through a disease process. 131Prognostic factors are investigated and established via the following types of study:Cohort studies: Participants are selected acc

36、ording to exposure to prognostic factor. They can be studied either prospectively or retrospectively. Case-control studies: Participants are selected by outcome, with the investigator looking back to see if they have the prognostic factor, as compared to a similar control group without the outcome.

37、132Cohort Studies are preferable, as case-control studies rely on the patient or a family member reporting exposure to a prognostic factor. Case-control studies are, therefore, subject to recall bias (回忆偏倚). In addition, case-control studies have potential for bias when selecting cases and controls;

38、 i.e., in defining whether or not the participant has the outcome.133Worksheet for Appraisal of an Article about PrognosisAdapted from Sackett June 1996134Are the results of this prognosis study valid?Was a defined, representative sample of patients assembled at a common (usually early) point in the

39、 course of their disease? 队列有代表性，起点一致Was patient follow-up sufficiently long and complete? 随访够长，完整Were objective outcome criteria applied in a blind fashion? 结局的判定是客观的，采用盲法If subgroups with different prognoses are identified, was there adjustment for important prognostic factors? 如果分组分析，对重要的预后因素要进行校

40、正135Are the results of this prognosis study important?How likely are the outcomes over time? How precise are the prognostic estimates?136137Kaplan-Meier analysis measures the ratio of surviving subjects (or those without an event) divided by the total number of subjects at risk for the event. 138系统评

41、价Systematic review概念：系统评价，meta分析 意义系统评价的评价（表8-1）139系统评价（systematic review） 指针对某一具体临床问题，系统、全面地收集所有临床研究，采用临床流行病学严格评价文献的原则和方法，筛选出符合质量标准的文献，进行定性或定量合成(Meta-分析），得出综合可靠的结论。其与一般意义的综述不同。一般意义的综述可能只是就关于一个问题的数篇文献进行概括性的描述，可能带有主观性，以支持综述作者的观点。 140Meta-分析 是1976年由Glass提出来的，通过综合多个目的相同且相互独立的研究结果，以提供量化结果来回答根据临床情况提出的研究问

42、题，这是目前进行系统评价的一种研究手段和方法。系统评价有时与Meta分析这个名词通用，但严格意义上说二者是不同的。系统评价可以用、也可以不用meta分析，标以meta分析的文献可能做过系统全面的检索（此时可以说是系统评价），也可能没有。141为什么做系统评价？作为临床医生的决策参考：解决信息多、时间少的问题；对RCT的质量和结果有评价，结论可靠性增加；经过meta分析，有综合的结果。综合多个样本量较小的试验结果，使权重增加。前人工作的总结为进一步的研究提供线索142Human albumin solutionLicensed indications (in UK)hypovolaemic sh

43、ockburnshypoalbuminaemia143Systematic reviewtrials comparing albumin with no albumin for the licensed indicationsfound 32 trials30 trials with data on death144Total (95%CI)Woittiez 1998So 1997Tollofsrud 1995Woods 1993Rackow 1983Grundmann 1982Zetterstrom 1981bZetterstrom 1981aLucas 1980Boutros 1979Vi

44、rgilio 1979Shah 1977Lowe 19770.010.11101001000Albumin better RR Albumin worseAlbumin vs no colloid in hypovolaemiaRR 1.46 (0.97-2.22)Number of deaths- albumin38/256 (14.8%)- control26/278 (9.4%)145Albumin vs. no colloid in burnsGreenhalgh 19950.010.1110100Total (95%CI)Goodwin 1983Jelenko 1978Albumin

45、 better RR Albumin worseRR 2.40 (1.11 to 5.19)Number of deaths- albumin19/81 (23.5%)- control8/82 (9.8%)146Albumin vs. no colloid in hypoalbuminaemia0.1110100Total (95%CI)Rubin 1997Golub 1994 Greenough 1993Kanarek 1992Foley 1990Brown 1988Nilsson 1980Bland 1976Albumin better RR Albumin worseRR 1.69 (

46、1.07 to 2.67)Number of deaths- albumin41/259 (15.8%)- control24/248 (9.7%)147ConclusionThere is no evidence from the available controlled trials that albumin reduces mortality in critically ill patients withhypovolaemic shockburnshypoalbuminaemia148ConclusionThere is a strong suggestion that albumin

47、 increases mortality in critically ill patients withhypovolaemic shockburnshypoalbuminaemia149Appraisal of systematic reviews? A flawed compilation of data is potentially more harmful than a flawed initial study, because people will assume that it is the right answer as it is gold-standard evidence.

48、 150 Important points of a good systematic reviewDid the trial address a clearly focused question with a clearly defined问题是否清楚Is all the relevant evidence either in the review or excluded for a valid reason? 包括所有应该纳入的研究Has there been some assessment of the quality of the included trials/data? 是否做方法学

49、质量评估How convincing are the results (in terms of size of effect, homogeneity of results, precision of effect)? Do the results apply to my patient population? 结果可靠吗结果是什么能用于当前病人吗151152153临床指南（clinical guideline） 最好的研究证据付诸临床实践的桥梁 由官方机构或学术团体组织制作针对某一种常见的疾病或临床问题，通过全面收集并严格评估现有各种诊疗措施的研究证据，提出指导性的建议 在深入研究证据的基础

50、上提出的，因此也称为循证指南（evidence-based guidelines） 需要各方面的专家，工作量大不做证据说明的指南只能算专家意见，可靠性差154BCSH多发性骨髓瘤指南 (2005)对于年龄65岁、体力状态和器官功能良好的初诊病人，HDT加ASCT应该作为一线治疗策略的一部分（A级建议，证据水平b级）。对于体力状态良好、 65岁的病人，可以考虑HDT加ASCT（B级建议，证据水平a级）。建议采用苯丙氨酸氮芥单用、不加TBI的预处理（B级建议，证据水平a级）。通常苯丙氨酸氮芥的剂量为200 mg/m2，年纪大（超过65-70岁）的病人和肾功能衰竭的病人要减少剂量。155a从随机对照

51、试验的Meta分析获得的证据b从至少一项随机对照试验获得的证据a从至少一项设计很好的非随机对照试验获得的证据，包括期临床试验和病例-对照研究b证据来自至少一项其他类型设计很好的准试验研究，即研究中没有安排好的干预措施，包括观察研究证据来自很好设计的非试验的描述性研究证据来自随机对照试验的Meta分析或期临床试验，但这些证据只有文摘的形式发表证据来自专家委员会的报告或意见 和/或 有名望权威的临床经验BCSH 指南: 证据水平 156BCSH 指南: 建议级别A 级建议证据水平a、b建议的依据是：至少一项针对特定问题所做的随机对照试验，试验的质量高，而且结果一致B 级建议证据水平a、b、建议的依

52、据是：针对建议主题做的、完成较好的临床试验，但不是随机对照试验C 级建议证据水平证据来自专家委员会的报告 和/或 有名望权威的临床经验157系统评价的制作过程选题拟定纳入标准和排除标准检索确定纳入的试验评价纳入试验的方法学质量抽取试验的结果数据汇总分析讨论总结 158159BackgroundAlthough non-steroidal anti-inammatory drugs (NSAIDs) have been widely used for the treatment of pain and fever associated with the common cold, there is

53、 no systematic review to assess the effects of NSAIDs in patients with the common cold.ObjectivesTo determine the effects of NSAIDs versus placebo and other treatments on the signs and symptoms of the common cold. To determine any adverse effects of NSAIDs in patients treated with NSAIDs for the com

54、mon cold.Search strategyWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1) which includes the Acute Respiratory Infections (ARI) Groups Specialized Register;MEDLINE (January 1966 to March 2009); EMBASE (January 1980 to March 2009); CINAHL (J

55、anuary 1982 to March 2009); ProQuest Digital Dissertations (January 1938 to March 2009); KoreaMed(January 1958 to March 2009) and KMbase (January 1949 to March 2009).Abstract160Selection criteriaRandomized controlled trials (RCTs) studying treatment of the common cold with NSAIDs in adults or childr

56、en. Data collection and analysis Four review authors extracted data (SYK, YSM, YJC, YWH). We subdivided trials into placebo-controlled RCTs and NSAIDs versus NSAIDs RCTs. We extracted and summarized data on global efcacies: analgesic effects such as reduction of headache and myalgia; non-analgesic e

57、ffects such as reduction of nasal symptoms, cough, sputum and sneezing; and side effects.161Main resultsThis review includes nine RCTs, describing 37 comparisons: six were NSAIDs versus placebo, and three were NSAIDs versus NSAIDs. A total of 1064 patients with the common cold were included. In a po

58、oled analysis, NSAIDs did not signicantly reduce the total symptom score, or duration of colds. However, for outcomes related to the analgesic effects of NSAIDs (headache, ear pain, and muscle and joint pain) NSAIDs produced signicant benets, and malaise showed a borderline benet, although throat ir

59、ritation was not improved. Chills showed mixed results. For respiratory symptoms, cough and nasal discharge scores were not improved, but the sneezing score signicantly improved. We found no evidence of increased frequency of adverse effects in the NSAID treatment groups.Authors conclusionsThe autho

60、rs recommend NSAIDs for relieving discomfort or pain caused by the common cold. Further research is needed to investigate the effect of NSAIDs in relieving respiratory symptoms such as cough and nasal discharge.162Sulfasalazine for ankylosing spondylitis J Chen, C LiuCochrane Library 2005, Issue 3Is