Odd man out: a graphical approach to meta-analysis

Heterogeneity in meta-analysis: a comprehensive overview

In recent years, meta-analysis has evolved to a critically important field of Statistics, and has significant applications in Medicine and Health Sciences. In this work we briefly present existing methodologies to conduct meta-analysis along with any discussion and recent developments accompanying them. Undoubtedly, studies brought together in a systematic review will differ in one way or another. This yields a considerable amount of variability, any kind of which may be termed heterogeneity. To this end, reports of meta-analyses commonly present a statistical test of heterogeneity when attempting to establish whether the included studies are indeed similar in terms of the reported output or not. We intend to provide an overview of the topic, discuss the potential sources of heterogeneity commonly met in the literature and provide useful guidelines on how to address this issue and to detect heterogeneity. Moreover, we review the recent developments in the Bayesian approach along with the various graphical tools and statistical software that are currently available to the analyst. In addition, we discuss sensitivity analysis issues and other approaches of understanding the causes of heterogeneity. Finally, we explore heterogeneity in meta-analysis for time to event data in a nutshell, pointing out its unique characteristics.

Partial breast irradiation versus whole breast radiotherapy for early breast cancer

BACKGROUND

Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane Review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)).

OBJECTIVES

To determine whether PBI/APBI is equivalent to or better than conventional or hypofractionated WBRT after breast-conserving therapy for early-stage breast cancer.

SEARCH METHODS

On 27 August 2020, we searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and three trial databases. We searched for grey literature: OpenGrey (September 2020), reference lists of articles, conference proceedings and published abstracts, and applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors (BH and ML) performed data extraction, used Cochrane's risk of bias tool and resolved any disagreements through discussion, and assessed the certainty of the evidence for main outcomes using GRADE. Main outcomes were local recurrence-free survival, cosmesis, overall survival, toxicity (subcutaneous fibrosis), cause-specific survival, distant metastasis-free survival and subsequent mastectomy. We entered data into Review Manager 5 for analysis.

MAIN RESULTS

We included nine RCTs that enrolled 15,187 women who had invasive breast cancer or ductal carcinoma in-situ (6.3%) with T1-2N0-1M0 Grade I or II unifocal tumours (less than 2 cm or 3 cm or less) treated with breast-conserving therapy with negative margins. This is the second update of the review and includes two new studies and 4432 more participants. Local recurrence-free survival is probably slightly reduced (by 3/1000, 95% CI 6 fewer to 0 fewer) with the use of PBI/APBI compared to WBRT (hazard ratio (HR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 8 studies, 13,168 participants; moderate-certainty evidence). Cosmesis (physician/nurse-reported) is probably worse (by 63/1000, 95% CI 35 more to 92 more) with the use of PBI/APBI (odds ratio (OR) 1.57, 95% CI 1.31 to 1.87; 6 studies, 3652 participants; moderate-certainty evidence). Overall survival is similar (0/1000 fewer, 95% CI 6 fewer to 6 more) with PBI/APBI and WBRT (HR 0.99, 95% CI 0.88 to 1.12; 8 studies, 13,175 participants; high-certainty evidence). Late radiation toxicity (subcutaneous fibrosis) is probably increased (by 14/1000 more, 95% CI 102 more to 188 more) with PBI/APBI (OR 5.07, 95% CI 3.81 to 6.74; 2 studies, 3011 participants; moderate-certainty evidence). The use of PBI/APBI probably makes little difference (1/1000 less, 95% CI 6 fewer to 3 more) to cause-specific survival (HR 1.06, 95% CI 0.83 to 1.36; 7 studies, 9865 participants; moderate-certainty evidence). We found the use of PBI/APBI compared with WBRT probably makes little or no difference (1/1000 fewer (95% CI 4 fewer to 6 more)) to distant metastasis-free survival (HR 0.95, 95% CI 0.80 to 1.13; 7 studies, 11,033 participants; moderate-certainty evidence). We found the use of PBI/APBI in comparison with WBRT makes little or no difference (2/1000 fewer, 95% CI 20 fewer to 20 more) to mastectomy rates (OR 0.98, 95% CI 0.78 to 1.23; 3 studies, 3740 participants, high-certainty evidence).

AUTHORS' CONCLUSIONS

It appeared that local recurrence-free survival is probably worse with PBI/APBI; however, the difference was small and nearly all women remain free of local recurrence. Overall survival is similar with PBI/APBI and WBRT, and we found little to no difference in other oncological outcomes. Some late effects (subcutaneous fibrosis) may be worse with PBI/APBI and its use is probably associated with worse cosmetic outcomes. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver PBI/APBI. We await completion of ongoing trials.

Charting the landscape of graphical displays for meta-analysis and systematic reviews: a comprehensive review, taxonomy, and feature analysis

BACKGROUND

Data-visualization methods are essential to explore and communicate meta-analytic data and results. With a large number of novel graphs proposed quite recently, a comprehensive, up-to-date overview of available graphing options for meta-analysis is unavailable.

METHODS

We applied a multi-tiered search strategy to find the meta-analytic graphs proposed and introduced so far. We checked more than 150 retrievable textbooks on research synthesis methodology cover to cover, six different software programs regularly used for meta-analysis, and the entire content of two leading journals on research synthesis. In addition, we conducted Google Scholar and Google image searches and cited-reference searches of prior reviews of the topic. Retrieved graphs were categorized into a taxonomy encompassing 11 main classes, evaluated according to 24 graph-functionality features, and individually presented and described with explanatory vignettes.

RESULTS

We ascertained more than 200 different graphs and graph variants used to visualize meta-analytic data. One half of these have accrued within the past 10 years alone. The most prevalent classes were graphs for network meta-analysis (45 displays), graphs showing combined effect(s) only (26), funnel plot-like displays (24), displays showing more than one outcome per study (19), robustness, outlier and influence diagnostics (15), study selection and p-value based displays (15), and forest plot-like displays (14). The majority of graphs (130, 62.5%) possessed a unique combination of graph features.

CONCLUSIONS

The rich and diverse set of available meta-analytic graphs offers a variety of options to display many different aspects of meta-analyses. This comprehensive overview of available graphs allows researchers to make better-informed decisions on which graphs suit their needs and therefore facilitates using the meta-analytic tool kit of graphs to its full potential. It also constitutes a roadmap for a goal-driven development of further graphical displays for research synthesis.

Follow-up strategies for patients treated for non-metastatic colorectal cancer

BACKGROUND

This is the fourth update of a Cochrane Review first published in 2002 and last updated in 2016.It is common clinical practice to follow patients with colorectal cancer for several years following their curative surgery or adjuvant therapy, or both. Despite this widespread practice, there is considerable controversy about how often patients should be seen, what tests should be performed, and whether these varying strategies have any significant impact on patient outcomes.

OBJECTIVES

To assess the effect of follow-up programmes (follow-up versus no follow-up, follow-up strategies of varying intensity, and follow-up in different healthcare settings) on overall survival for patients with colorectal cancer treated with curative intent. Secondary objectives are to assess relapse-free survival, salvage surgery, interval recurrences, quality of life, and the harms and costs of surveillance and investigations.

SEARCH METHODS

For this update, on 5 April 2109 we searched CENTRAL, MEDLINE, Embase, CINAHL, and Science Citation Index. We also searched reference lists of articles, and handsearched the Proceedings of the American Society for Radiation Oncology. In addition, we searched the following trials registries: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We contacted study authors. We applied no language or publication restrictions to the search strategies.

SELECTION CRITERIA

We included only randomised controlled trials comparing different follow-up strategies for participants with non-metastatic colorectal cancer treated with curative intent.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently determined study eligibility, performed data extraction, and assessed risk of bias and methodological quality. We used GRADE to assess evidence quality.

MAIN RESULTS

We identified 19 studies, which enrolled 13,216 participants (we included four new studies in this second update). Sixteen out of the 19 studies were eligible for quantitative synthesis. Although the studies varied in setting (general practitioner (GP)-led, nurse-led, or surgeon-led) and 'intensity' of follow-up, there was very little inconsistency in the results.Overall survival: we found intensive follow-up made little or no difference (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.80 to 1.04: I² = 18%; high-quality evidence). There were 1453 deaths among 12,528 participants in 15 studies. In absolute terms, the average effect of intensive follow-up on overall survival was 24 fewer deaths per 1000 patients, but the true effect could lie between 60 fewer to 9 more per 1000 patients.Colorectal cancer-specific survival: we found intensive follow-up probably made little or no difference (HR 0.93, 95% CI 0.81 to 1.07: I² = 0%; moderate-quality evidence). There were 925 colorectal cancer deaths among 11,771 participants enrolled in 11 studies. In absolute terms, the average effect of intensive follow-up on colorectal cancer-specific survival was 15 fewer colorectal cancer-specific survival deaths per 1000 patients, but the true effect could lie between 47 fewer to 12 more per 1000 patients.Relapse-free survival: we found intensive follow-up made little or no difference (HR 1.05, 95% CI 0.92 to 1.21; I² = 41%; high-quality evidence). There were 2254 relapses among 8047 participants enrolled in 16 studies. The average effect of intensive follow-up on relapse-free survival was 17 more relapses per 1000 patients, but the true effect could lie between 30 fewer and 66 more per 1000 patients.Salvage surgery with curative intent: this was more frequent with intensive follow-up (risk ratio (RR) 1.98, 95% CI 1.53 to 2.56; I² = 31%; high-quality evidence). There were 457 episodes of salvage surgery in 5157 participants enrolled in 13 studies. In absolute terms, the effect of intensive follow-up on salvage surgery was 60 more episodes of salvage surgery per 1000 patients, but the true effect could lie between 33 to 96 more episodes per 1000 patients.Interval (symptomatic) recurrences: these were less frequent with intensive follow-up (RR 0.59, 95% CI 0.41 to 0.86; I² = 66%; moderate-quality evidence). There were 376 interval recurrences reported in 3933 participants enrolled in seven studies. Intensive follow-up was associated with fewer interval recurrences (52 fewer per 1000 patients); the true effect is between 18 and 75 fewer per 1000 patients.Intensive follow-up probably makes little or no difference to quality of life, anxiety, or depression (reported in 7 studies; moderate-quality evidence). The data were not available in a form that allowed analysis.Intensive follow-up may increase the complications (perforation or haemorrhage) from colonoscopies (OR 7.30, 95% CI 0.75 to 70.69; 1 study, 326 participants; very low-quality evidence). Two studies reported seven colonoscopic complications in 2292 colonoscopies, three perforations and four gastrointestinal haemorrhages requiring transfusion. We could not combine the data, as they were not reported by study arm in one study.The limited data on costs suggests that the cost of more intensive follow-up may be increased in comparison with less intense follow-up (low-quality evidence). The data were not available in a form that allowed analysis.

AUTHORS' CONCLUSIONS

The results of our review suggest that there is no overall survival benefit for intensifying the follow-up of patients after curative surgery for colorectal cancer. Although more participants were treated with salvage surgery with curative intent in the intensive follow-up groups, this was not associated with improved survival. Harms related to intensive follow-up and salvage therapy were not well reported.

Practice Environment Scale of the Nursing Work Index: A Reliability Generalization Meta-Analysis

A healthy work environment is a critical factor in nurse satisfaction, retention, and patient outcomes. The Practice Environment Scale of the Nursing Work Index (PES-NWI) is the most commonly used instrument to measure the nursing practice environment. This study uses meta-analysis to examine the reliability generalization of the PES-NWI. A meta-analysis of 51 studies representing a total of 80,563 subjects was conducted. The mean score reliability for the PES-NWI based on 38 studies ( n = 68,278) was .922 ( p < .05). The Mean Weighted Effect Size was stronger for studies conducted in the United States versus non-U.S. (.946 vs. .907). For studies rated high and moderate quality, the mean score reliability was .911 and .946, respectively. Scores on the PES-NWI are reliable for measuring the nursing practice environment across samples in the United States and non-U.S. countries.

Follow-up strategies for patients treated for non-metastatic colorectal cancer

BACKGROUND

It is common clinical practice to follow patients with colorectal cancer (CRC) for several years following their curative surgery or adjuvant therapy, or both. Despite this widespread practice, there is considerable controversy about how often patients should be seen, what tests should be performed, and whether these varying strategies have any significant impact on patient outcomes. This is the second update of a Cochrane Review first published in 2002 and first updated in 2007.

OBJECTIVES

To assess the effects of intensive follow-up for patients with non-metastatic colorectal cancer treated with curative intent.

SEARCH METHODS

For this update, we searched CENTRAL (2016, Issue 3), MEDLINE (1950 to May 20th, 2016), Embase (1974 to May 20th, 2016), CINAHL (1981 to May 20th, 2016), and Science Citation Index (1900 to May 20th, 2016). We also searched reference lists of articles, and handsearched the Proceedings of the American Society for Radiation Oncology (2011 to 2014). In addition, we searched the following trials registries (May 20th, 2016): ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We further contacted study authors. No language or publication restrictions were applied to the search strategies.

SELECTION CRITERIA

We included only randomised controlled trials comparing different follow-up strategies for participants with non-metastatic CRC treated with curative intent.

DATA COLLECTION AND ANALYSIS

Two authors independently determined trial eligibility, performed data extraction, and assessed methodological quality.

MAIN RESULTS

We studied 5403 participants enrolled in 15 studies. (We included two new studies in this second update.) Although the studies varied in setting (general practitioner (GP)-led, nurse-led, or surgeon-led) and "intensity" of follow-up, there was very little inconsistency in the results.Overall survival: we found no evidence of a statistical effect with intensive follow-up (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.78 to 1.02; I² = 4%; P = 0.41; high-quality evidence). There were 1098 deaths among 4786 participants enrolled in 12 studies.Colorectal cancer-specific survival: this did not differ with intensive follow-up (HR 0.93, 95% CI 0.78 to 1.12; I² = 0%; P = 0.45; moderate-quality evidence). There were 432 colorectal cancer deaths among 3769 participants enrolled in seven studies.Relapse-free survival: we found no statistical evidence of effect with intensive follow-up (HR 1.03, 95% CI 0.90 to 1.18; I² = 5%; P = 0.39; moderate-quality evidence). There were 1416 relapses among 5253 participants enrolled in 14 studies.Salvage surgery with curative intent: this was more frequent with intensive follow-up (risk ratio (RR) 1.98, 95% CI 1.53 to 2.56; I² = 31%; P = 0.14; high-quality evidence). There were 457 episodes of salvage surgery in 5157 participants enrolled in 13 studies.Interval (symptomatic) recurrences: these were less frequent with intensive follow-up (RR 0.59, 95% CI 0.41 to 0.86; I² = 66%; P = 0.007; moderate-quality evidence). Three hundred and seventy-six interval recurrences were reported in 3933 participants enrolled in seven studies.Intensive follow-up did not appear to affect quality of life, anxiety, nor depression (reported in three studies).Harms from colonoscopies did not differ with intensive follow-up (RR 2.08, 95% CI 0.11 to 40.17; moderate-quality evidence). In two studies, there were seven colonoscopic complications in 2112 colonoscopies.

AUTHORS' CONCLUSIONS

The results of our review suggest that there is no overall survival benefit for intensifying the follow-up of patients after curative surgery for colorectal cancer. Although more participants were treated with salvage surgery with curative intent in the intensive follow-up group, this was not associated with improved survival. Harms related to intensive follow-up and salvage therapy were not well reported.

Partial breast irradiation for early breast cancer

BACKGROUND

Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). RT is given to sterilize tumour cells that may remain after surgery to decrease the risk of local tumour recurrence. Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)).

OBJECTIVES

To determine whether PBI/APBI is equivalent to or better than conventional or hypo-fractionated WBRT after breast-conserving therapy for early-stage breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialized Register (4 May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 5), MEDLINE (January 1966 to 4 May 2015), EMBASE (1980 to 4 May 2015), CINAHL (4 May 2015) and Current Contents (4 May 2015). We searched the International Standard Randomised Controlled Trial Number Register (5 May 2015), the World Health Organization's International Clinical Trials Registry Platform (4 May 2015) and ClinicalTrials.gov (17 June 2015). We searched for grey literature: OpenGrey (17 June 2015), reference lists of articles, several conference proceedings and published abstracts, and applied no language restrictions.

SELECTION CRITERIA

Randomized controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors (BH and ML) performed data extraction and used Cochrane's 'Risk of bias' tool, and resolved any disagreements through discussion. We entered data into Review Manager 5 for analysis.

MAIN RESULTS

We included seven RCTs and studied 7586 women of the 8955 enrolled.Local recurrence-free survival appeared worse for women receiving PBI/APBI compared to WBRT (hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.11 to 2.35; six studies, 6820 participants, low-quality evidence). Cosmesis (physician-reported) appeared worse with PBI/APBI (odds ratio (OR) 1.51, 95% CI 1.17 to 1.95, five studies, 1720 participants, low-quality evidence). Overall survival did not differ with PBI/APBI (HR 0.90, 95% CI 0.74 to 1.09, five studies, 6718 participants, high-quality evidence).Late radiation toxicity (subcutaneous fibrosis) appeared worse with PBI/APBI (OR 6.58, 95% CI 3.08 to 14.06, one study, 766 participants, moderate-quality evidence). Acute skin toxicity appeared reduced with PBI/APBI (OR 0.04, 95% CI 0.02 to 0.09, two studies, 608 participants). Telangiectasia (OR 26.56, 95% CI 3.59 to 196.51, 1 study, 766 participants) and radiological fat necrosis (OR 1.58, 95% CI 1.02 to 2.43, three studies, 1319 participants) appeared worse with PBI/APBI. Late skin toxicity (OR 0.21, 95% CI 0.01 to 4.39, two studies, 608 participants) and breast pain (OR 2.17, 95% CI 0.56 to 8.44, one study, 766 participants) appeared not to differ with PBI/APBI.'Elsewhere primaries' (new primaries in the ipsilateral breast) appeared more frequent with PBI/APBI (OR 3.97, 95% CI 1.51 to 10.41, three studies, 3009 participants).We found no clear evidence of a difference for the comparison of PBI/APBI with WBRT for the outcomes of: cause-specific survival (HR 1.08, 95% CI 0.73 to 1.58, five studies, 6718 participants, moderate-quality evidence), distant metastasis-free survival (HR 0.94, 95% CI 0.65 to 1.37, four studies, 3267 participants, moderate-quality evidence), relapse-free survival (HR 1.36, 95% CI 0.88 to 2.09, three studies, 3811 participants), loco-regional recurrence-free survival (HR 1.80, 95% CI 1.00 to 3.25, two studies, 3553 participants) or mastectomy rates (OR 1.20, 95% CI 0.77 to 1.87, three studies, 4817 participants, low-quality evidence). Compliance was met: more than 90% of the women in all studies received the RT they were assigned to receive. We found no data for the outcomes of costs, quality of life or consumer preference.

AUTHORS' CONCLUSIONS

It appeared that local recurrence and 'elsewhere primaries' (new primaries in the ipsilateral breast) are increased with PBI/APBI (the difference was small), but we found no evidence of detriment to other oncological outcomes. It appeared that cosmetic outcomes and some late effects were worse with PBI/APBI but its use was associated with less acute skin toxicity. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver of PBI/APBI. We await completion of ongoing trials.

Fraction size in radiation therapy for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conserving surgery. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy. This is an update of a Cochrane Review first published in 2008 and updated in 2009.

OBJECTIVES

To assess the effect of altered radiation fraction size for women with early breast cancer who have had breast conserving surgery.

SEARCH METHODS

We searched the Cochrane Breast Cancer Specialised Register (23 May 2015), CENTRAL (The Cochrane Library 2015, Issue 4), MEDLINE (Jan 1996 to May 2015), EMBASE (Jan 1980 to May 2015), the WHO International Clinical Trials Registry Platform (ICTRP) search portal (June 2010 to May 2015) and ClinicalTrials.gov (16 April 2015), reference lists of articles and relevant conference proceedings. No language or publication constraints were applied.

SELECTION CRITERIA

Randomised controlled trials of altered fraction size versus conventional fractionation for radiation therapy in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

Two authors performed data extraction independently, with disagreements resolved by discussion. We sought missing data from trial authors.

MAIN RESULTS

We studied 8228 women in nine studies. Eight out of nine studies were at low or unclear risk of bias. Altered fraction size (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not have a clinically meaningful effect on: local recurrence-free survival (Hazard Ratio (HR) 0.94, 95% CI 0.77 to 1.15, 7095 women, four studies, high-quality evidence), cosmetic outcome (Risk ratio (RR) 0.90, 95% CI 0.81 to 1.01, 2103 women, four studies, high-quality evidence) or overall survival (HR 0.91, 95% CI 0.80 to 1.03, 5685 women, three studies, high-quality evidence). Acute radiation skin toxicity (RR 0.32, 95% CI 0.22 to 0.45, 357 women, two studies) was reduced with altered fraction size. Late radiation subcutaneous toxicity did not differ with altered fraction size (RR 0.93, 95% CI 0.83 to 1.05, 5130 women, four studies, high-quality evidence). Breast cancer-specific survival (HR 0.91, 95% CI 0.78 to 1.06, 5685 women, three studies, high quality evidence) and relapse-free survival (HR 0.93, 95% CI 0.82 to 1.05, 5685 women, three studies, moderate-quality evidence) did not differ with altered fraction size. We found no data for mastectomy rate. Altered fraction size was associated with less patient-reported (P < 0.001) and physician-reported (P = 0.009) fatigue at six months (287 women, one study). We found no difference in the issue of altered fractionation for patient-reported outcomes of: physical well-being (P = 0.46), functional well-being (P = 0.38), emotional well-being (P = 0.58), social well-being (P = 0.32), breast cancer concerns (P = 0.94; 287 women, one study). We found no data with respect to costs.

AUTHORS' CONCLUSIONS

We found that using altered fraction size regimens (greater than 2 Gy per fraction) does not have a clinically meaningful effect on local recurrence, is associated with decreased acute toxicity and does not seem to affect breast appearance, late toxicity or patient-reported quality-of-life measures for selected women treated with breast conserving therapy. These are mostly women with node negative tumours smaller than 3 cm and negative pathological margins.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem which sometimes leads to excess use of medical care. Although many studies have examined the causes of pain in these patients, few clinical trials have evaluated treatment. This is an update of a Cochrane review originally published in 2005 and last updated in 2010. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with non-specific chest pain.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL, Issue 4 of 12, 2014 and DARE Issue 2 of 4, 2014), MEDLINE (OVID, 1966 to April week 4 2014), EMBASE (OVID, 1980 to week 18 2014), CINAHL (EBSCO, 1982 to April 2014), PsycINFO (OVID, 1887 to April week 5 2014) and BIOSIS Previews (Web of Knowledge, 1969 to 2 May 2014). We also searched citation lists and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed quality of studies. We contacted trial authors for further information about the included RCTs.

MAIN RESULTS

We included two new papers, one of which was an update of a previously included study. Therefore, a total of 17 RCTs with 1006 randomised participants met the inclusion criteria, with the one new study contributing an additional 113 participants. There was a significant reduction in reports of chest pain in the first three months following the intervention: random-effects relative risk = 0.70 (95% CI 0.53 to 0.92). This was maintained from three to nine months afterwards: relative risk 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain-free days up to three months following the intervention: mean difference (MD) 3.00 (95% CI 0.23 to 5.77). This was associated with reduced chest pain frequency (random-effects MD -2.26, 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects MD -0.81, 95% CI -2.35 to 0.74). There was no effect on severity (random-effects MD -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Due to the nature of the main interventions of interest, it was impossible to blind the therapists as to whether the participant was in the intervention or control arm. In addition, in three studies the blinding of participants was expressly forbidden by the local ethics committee because of issues in obtaining fully informed consent . For this reason, all studies had a high risk of performance bias. In addition, three studies were thought to have a high risk of outcome bias. In general, there was a low risk of bias in the other domains. However, there was high heterogeneity and caution is required in interpreting these results. The wide variability in secondary outcome measures made it difficult to integrate findings from studies.

AUTHORS' CONCLUSIONS

This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Meta-Analyses of Predictors of Hope in Adolescents

The purposes of this study were to identify predictors of hope in the literature reviewed, to use meta-analysis to determine the mean effect size (ES) across studies between each predictor and hope, and to examine four moderators on each predictor–hope relationship. Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for the literature reviewed, 77 published studies or doctoral dissertations completed between 1990 and 2012 met the inclusion criteria. Eleven predictors of hope were identified and each predictor in relation to hope was subjected to meta-analysis. Five predictors (positive affect, life satisfaction, optimism, self-esteem, and social support) of hope had large mean ESs, 1 predictor (depression) had a medium ES, 4 predictors (negative affect, stress, academic achievement, and violence) had small ESs, and 1 predictor (gender) had a trivial ES. Findings are interpreted for the 11 predictors in relation to hope. Limitations and conclusions are addressed; future studies are recommended.

Partial breast irradiation for early breast cancer

BACKGROUND

Breast conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiation therapy (RT). RT is given to sterilize tumour cells that may remain after surgery to decrease the risk of local tumour recurrence. Most true recurrences occur in the same quadrant as the original tumour. Whole breast RT may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane Review, we investigated the role of delivering radiation to a limited volume of the breast around the tumour bed (partial breast irradiation: PBI) sometimes with a shortened treatment duration (accelerated partial breast irradiation: APBI).

OBJECTIVES

To determine whether PBI/APBI is equivalent to or better than conventional or hypofractionated WBRT after breast conservation therapy for early-stage breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialised Register (07 November 2013), CENTRAL (2014, Issue 3), MEDLINE (January 1966 to 11 April 2014), EMBASE (1980 to 11 April 2014), CINAHL (11 April 2014) and Current Contents (11 April 2014). Also we searched the International Standard Randomised Controlled Trial Number Register, the World Health Organization's International Clinical Trials Registry Platform (07 November 2013) and US clinical trials registry (www.clinicaltrials.gov) (22 April 2014). We searched for grey literature: Open Grey (23 April 2014), reference lists of articles, a number of conference proceedings and published abstracts, and did not apply any language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) without confounding and evaluating conservative surgery plus PBI/APBI versus conservative surgery plus whole breast RT. We included both published and unpublished trials.

DATA COLLECTION AND ANALYSIS

Three review authors (ML, DF and BH) performed data extraction and resolved any disagreements through discussion. We entered data into Review Manager for analysis. BH and ML assessed trials, graded the methodological quality using Cochrane's Risk of Bias tool and resolved any disagreements through discussion.

MAIN RESULTS

We included four RCTs that had 2253 women. Two older trials examined RT techniques which do not reflect current practice and one trial had a short follow-up. We downgraded the quality of the evidence for our key outcomes due to risk of bias. Taken together with other GRADE recommendations, the quality of evidence for our outcomes was very low to low. For the comparison of partial breast irradiation/accelerated breast irradiation (PBI/APBI) with whole breast irradiation (WBRT), local recurrence-free survival appeared worse (Hazard Ratio (HR) 1.74, 95% confidence interval (CI) 1.23 to 2.45; three trials, 1140 participants, very low quality evidence). Cosmesis appeared improved with PBI/APBI in a single trial (OR 0.40, 95% CI 0.23 to 0.72; one trial, 241 participants, very low quality evidence), but late toxicity (telangiectasia OR 4.41, 95% CI 3.21 to 6.05; very low quality evidence, 708 participants) and subcutaneous fibrosis (OR 4.27, 95% CI 3.04 to 6.01; one trial, 710 participants, very low quality evidence) appeared increased in another trial. We found no clear evidence of a difference for the comparison of PBI/APBI versus WBRT for the outcomes of: overall survival (HR 0.99, 95% CI 0.83 to 1.18; three trials, 1140 participants, very low quality evidence), cause-specific survival (HR 0.95, 95% CI 0.74 to 1.22; two trials, 966 participants, low evidence quality), distant metastasis-free survival (HR 1.02, 95% CI 0.81 to 1.28; 1140 participants, low quality evidence), subsequent mastectomy rate (OR 0.20, 95% CI 0.01 to 4.21; 258 participants, low quality evidence) and relapse-free survival (HR 0.99, 95% CI 0.53 to 1.85; 258 participants, low quality evidence). We found no data for the outcomes of acute toxicity, new ipsilateral breast primaries, costs, quality of life or consumer preference.

AUTHORS' CONCLUSIONS

The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver of PBI/APBI. We await completion of ongoing trials.

Psychological interventions for depression in adolescent and adult congenital heart disease

BACKGROUND

Adult and adolescent congenital heart disease is increasing in prevalence as better medical care means more children are surviving to adulthood. People with chronic disease often also experience depression. There are several non-pharmacological treatments that might be effective in treating depression and improving quality of life for adults and young adults with congenital heart disease. The aim of this review was to assess the effects of treatments such as psychotherapy, cognitive behavioural therapies and talking therapies for treating depression in this population.

OBJECTIVES

To update the previous review on the effects (both harms and benefits) of psychological interventions for treating depression in young adults and adults with congenital heart disease. Psychological interventions include cognitive behavioural therapy, psychotherapy, or 'talking/counselling' therapy for depression.

SEARCH METHODS

We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 1, 2013), MEDLINE (OVID, 1946 to January week 4 2013), EMBASE (OVID, 1980 to 2013 week 05), PsycINFO (OVID, 1806 to January week 5 2013), the Database of Abstracts of Reviews of Effectiveness (DARE) on The Cochrane Library (Issue 1, 2013), BIOSIS (Thomson Reuters, 1969 to 21 February 2013), and CINAHL (January 1980 to February 2013) on 5 February 2013. We did not search abstracts from national and international cardiology and psychology conferences and dissertation abstracts for this update. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials comparing psychological interventions with no intervention for people over 15 years with depression who have congenital heart disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of studies that were potentially relevant to the review. We rejected studies that were clearly ineligible. Two review authors independently assessed the abstracts or full papers for inclusion criteria. We sought further information from the authors where papers contained insufficient information to make a decision about eligibility.

MAIN RESULTS

We did not identify any randomised controlled trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

Depression is common in people with congenital heart disease and can exacerbate the physical consequences of the illness. There are effective pharmacological and non-pharmacological treatments for depression, but we have not been able to identify any trials showing the effectiveness of non-pharmacological treatments. A well-designed randomised controlled trial is needed to assess the effects of psychological interventions for depression in congenital heart disease.

Sequencing of chemotherapy and radiotherapy for early breast cancer

BACKGROUND

After surgery for localised breast cancer, radiotherapy (RT) improves both local control and breast cancer-specific survival. In patients at risk of harbouring micro-metastatic disease, adjuvant chemotherapy (CT) improves 15-year survival. However, the best sequence of administering these two types of adjuvant therapy for early-stage breast cancer is unclear.

OBJECTIVES

To determine the effects of different sequencing of adjuvant CT and RT for women with early breast cancer.

SEARCH METHODS

An updated search was carried out in the Cochrane Breast Cancer Group's Specialised Register (20 May 2011), MEDLINE (14 December 2011), EMBASE (20 May 2011) and World Health Organization (WHO) International Clinical Trials Registry Platform (20 May 2011). Details of the search strategy and methods of coding for the Specialised Register are described in the Group's module in The Cochrane Library. We extracted studies that had been coded as 'early', 'chemotherapy' and 'radiotherapy'.

SELECTION CRITERIA

We included randomised controlled trials evaluating different sequencing of CT and RT.

DATA COLLECTION AND ANALYSIS

We assessed the eligibility and quality of the identified studies and extracted data from the published reports of the included trials. We derived odds ratios (OR) and hazard ratios (HR) from the available numerical data. Toxicity data were extracted, where reported. We used a fixed-effect model for meta-analysis and conducted analyses on the basis of the method of sequencing of the two treatments.

MAIN RESULTS

Three trials reporting two different sequencing comparisons were identified. There were no significant differences between the various methods of sequencing adjuvant therapy for local recurrence-free survival, overall survival, relapse-free survival and metastasis-free survival based on 1166 randomised women in three trials. Concurrent chemoradiation increased anaemia (OR 1.54; 95% confidence interval (CI) 1.10 to 2.15), telangiectasia (OR 3.85; 95% CI 1.37 to 10.87) and pigmentation (OR 15.96; 95% CI 2.06 to 123.68). Treated women did not report worse cosmesis with concurrent chemoradiation but physician-reported assessments did (OR 1.14; 95% CI 0.42 to 3.07). Other measures of toxicity did not differ between the two types of sequencing. On the basis of one trial (244 women), RT before CT was associated with an increased risk of neutropenic sepsis (OR 2.96; 95% CI 1.26 to 6.98) compared with CT before RT, but other measures of toxicity did not differ.

AUTHORS' CONCLUSIONS

The data included in this review, from three well-conducted randomised trials, suggest that different methods of sequencing CT and RT do not appear to have a major effect on recurrence or survival for women with breast cancer if RT is commenced within seven months after surgery.

Sequencing of chemotherapy and radiotherapy for early breast cancer

BACKGROUND

After surgery for localised breast cancer, radiotherapy (RT) improves both local control and breast cancer-specific survival. In patients at risk of harbouring micro-metastatic disease, adjuvant chemotherapy (CT) improves 15-year survival. However, the best sequence of administering these two types of adjuvant therapy for early-stage breast cancer is unclear.

OBJECTIVES

To determine the effects of different sequencing of adjuvant CT and RT for women with early breast cancer.

SEARCH METHODS

An updated search was carried out in the Cochrane Breast Cancer Group's Specialised Register (20 May 2011), MEDLINE (14 December 2011), EMBASE (20 May 2011) and World Health Organization (WHO) International Clinical Trials Registry Platform (20 May 2011). Details of the search strategy and methods of coding for the Specialised Register are described in the Group's module in The Cochrane Library. We extracted studies that had been coded as 'early', 'chemotherapy' and 'radiotherapy'.

SELECTION CRITERIA

We included randomised controlled trials evaluating different sequencing of CT and RT.

DATA COLLECTION AND ANALYSIS

We assessed the eligibility and quality of the identified studies and extracted data from the published reports of the included trials. We derived odds ratios (OR) and hazard ratios (HR) from the available numerical data. Toxicity data were extracted, where reported. We used a fixed-effect model for meta-analysis and conducted analyses on the basis of the method of sequencing of the two treatments.

MAIN RESULTS

Three trials reporting two different sequencing comparisons were identified. There were no significant differences between the various methods of sequencing adjuvant therapy for local recurrence-free survival, overall survival, relapse-free survival and metastasis-free survival based on 1166 randomised women in three trials. Concurrent chemoradiation increased anaemia (OR 1.54; 95% confidence interval (CI) 1.10 to 2.15), telangiectasia (OR 3.85; 95% CI 1.37 to 10.87) and pigmentation (OR 15.96; 95% CI 2.06 to 123.68). Treated women did not report worse cosmesis with concurrent chemoradiation but physician-reported assessments did (OR 1.14; 95% CI 0.42 to 3.07). Other measures of toxicity did not differ between the two types of sequencing. On the basis of one trial (244 women), RT before CT was associated with an increased risk of neutropenic sepsis (OR 2.96; 95% CI 1.26 to 6.98) compared with CT before RT, but other measures of toxicity did not differ.

AUTHORS' CONCLUSIONS

The data included in this review, from three well-conducted randomised trials, suggest that different methods of sequencing CT and RT do not appear to have a major effect on recurrence or survival for women with breast cancer if RT is commenced within seven months after surgery.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To update the previously published systematic review.

SEARCH METHODS

We searched the Cochrane LIbrary (CENTRAL and DARE) (Issue 3 of 4 2011), MEDLINE (1966 to August Week 5, 2011), CINAHL (1982 to Sept 2011) EMBASE (1980 to Week 35 2011), PsycINFO (1887 to Sept Week 1, 2011), and Biological Abstracts (January 1980 to Sept 2011). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Six new RCTs were located and added to the existing trials, therefore, a total of 15 RCTs (803 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed-effect relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from three to nine months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (random-effects mean difference = -2.26 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects mean difference -0.81 95% CI -2.35, 0.74). There was no effect on severity (random-effects mean difference = -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Overall there was generally a low risk of bias, however, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Fraction size in radiation treatment for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conserving surgery. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy. This is an updated version of the original Cochrane Review published in Issue 3, 2008.

OBJECTIVES

To determine the effect of altered radiation fraction size on outcomes for women with early breast cancer who have undergone breast conserving surgery.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register, MEDLINE, EMBASE and the WHO ICTRP search portal to June 2009, reference lists of articles and relevant conference proceedings. We applied no language constraints.

SELECTION CRITERIA

Randomised controlled trials of unconventional versus conventional fractionation in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

The authors performed data extraction independently, with disagreements resolved by discussion. We sought missing data from trial authors.

MAIN RESULTS

Four trials reported on 7095 women. The women were highly selected: tumours were node negative and 89.8% were smaller than 3 cm. Where the breast size was known, 87% had small or medium breasts. The studies were of low to medium quality. Unconventional fractionation (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not affect: (1) local recurrence risk ratio (RR) 0.97 (95% CI 0.76 to 1.22, P = 0.78), (2) breast appearance RR 1.17 (95% CI 0.98 to 1.39, P = 0.09), (3) survival at five years RR 0.89 (95% CI 0.77 to 1.04, P = 0.16). Acute skin toxicity was decreased with unconventional fractionation: RR 0.21 (95% CI 0.07 to 0.64, P = 0.007).

AUTHORS' CONCLUSIONS

Two new studies have been published since the last version of the review, altering our conclusions. We have evidence from four low to medium quality randomised trials that using unconventional fractionation regimens (greater than 2 Gy per fraction) does not affect local recurrence, is associated with decreased acute toxicity and does not seem to affect breast appearance or late toxicity for selected women treated with breast conserving therapy. These are mostly women with node negative tumours smaller than 3 cm and negative pathological margins. Long-term follow up (> 5 years) is available for a small proportion of the patients randomised. Longer follow up is required for a more complete assessment of the effect of altered fractionation.

A meta-analytic study of predictors of anger in adolescents

BACKGROUND

There is a vast body of empirical work on adolescent anger, but no efforts have been made to summarize findings across nonintervention studies.

OBJECTIVES

The aims of this study were to identify predictors for anger in adolescents through a comprehensive review of the literature, to use quantitative meta-analysis to determine the magnitude of the relationship between each predictor and anger, and to examine the influence of selected moderators on the relationship between each predictor and anger.

METHOD

The literature review included 288 published studies and 87 unpublished doctoral dissertation completed between 1980 and 2007, of which 88 met the inclusion criteria. Twelve prominent predictors for anger were identified in the 88 studies. Each predictor related to anger was subjected to a meta-analysis.

RESULTS

Five predictors (trait anger, anxiety, depression, stress, and exposure to violence) had moderate to substantial average effect sizes, four predictors (victim of violence, hostility, self-esteem, and social support) had low to moderate effect sizes, and three predictors (age, race/ethnicity, and gender) had trivial effect sizes.

DISCUSSION

The findings are interpreted for nine predictors in relation to anger. The contributions and limitations of these meta-analyses are addressed, and future studies are recommended.

Graphical displays for meta-analysis: An overview with suggestions for practice

Meta-analyses are fundamental tools for collating and synthesizing large amounts of information, and graphical displays have become the principal tool for presenting the results of multiple studies of the same research question. We review standard and proposed graphical displays for presentation of meta-analytic data, and offer our recommendations on how they might be presented to provide the most useful and user-friendly illustrations. We concentrate on graphs that specifically aim to present similar sorts of univariate results from multiple studies. We start with forest plots and funnel plots, and proceed to Galbraith (or radial) plots, L'Abbé (and related) plots, further plots useful for investigating heterogeneity, plots useful for model diagnostics and plots for illustrating likelihoods and Bayesian meta-analyses. Copyright © 2010 John Wiley & Sons, Ltd.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2008, Issue 4), MEDLINE (1966 to December 2008), CINAHL (1982 to December 2008) EMBASE (1980 to December 2008), PsycINFO (1887 to December 2008), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to December 2008). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Ten RCTs (484 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (mean difference = -1.73 (95% CI -2.21 to -1.26)) and severity (mean difference = -6.86 (95% CI -10.74 to -2.97)). However, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Fraction size in radiation treatment for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conservation. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy.

OBJECTIVES

To assess the effects of altered fraction size on women with early breast cancer who have undergone breast conserving surgery.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register (June 2006), MEDLINE (November 2006), EMBASE (November 2006), reference lists for articles, and relevant conference proceedings. No language constraints were applied.

SELECTION CRITERIA

Randomised controlled trials of unconventional versus conventional fractionation in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

Data extraction was performed independently by the authors with disagreements resolved by discussion. Missing data was sought by contacting the authors concerned.

MAIN RESULTS

Two trials were included and reported on 2644 women. The women were highly selected with node negative tumours smaller than 5 cm and negative pathological margins; 46% of the women had a cup separation size of less than 25 cm. The studies were of high quality. Data for local recurrence and breast appearance were not available in a form which could be combined. Unconventional fractionation (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not appear to affect: (1) local-recurrence free survival (absolute difference 0.4%, 95% CI -1.5% to 2.4%), (2) breast appearance (risk ratio (RR) 1.01, 95% CI 0.88 to 1.17; P = 0.86), (3) survival at five years (RR 0.97, 95% CI 0.78 to 1.19; P = 0.75), (4) late skin toxicity at five years (RR 0.99, 95% CI 0.44 to 2.22; P = 0.98, or (5) late radiation toxicity in sub-cutaneous tissue (RR 1.0, 95% CI 0.78 to 1.28; P = 0.99).

AUTHORS' CONCLUSIONS

We have evidence from two high quality randomised trials that the use of unconventional fractionation regimes (greater than 2 Gy per fraction) does not affect breast appearance or toxicity and does not seem to affect local recurrence for selected women treated with breast conserving therapy. These are women with node negative tumours smaller than 5 cm and negative pathological margins. Two new trials have been published in March 2008. Their results are consistent with our findings. The results of these trials will be incorporated in the next update of this review.

Meta-analyses in vaccinology

The use of meta-analysis as a method for systematic review of the literature has grown substantially since its appearance in 1988. We obtained and reviewed 134 meta-analyses cited in Current Contents, MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews reporting original meta-analyses in human subjects regarding vaccines directed against infectious diseases and their sequelae. More than a fifth of the meta-analyses concerned influenza vaccines and almost a sixth concerned pneumococcal vaccines. Nearly 80% principally evaluated efficacy, effectiveness, and immunogenicity. We review three prominent meta-analyses to illustrate features of the methods and make several observations. These concern electronic searches, the Cochrane Collaboration, individual study heterogeneity, and individual study quality as well as the utility of meta-analyses despite the limitations and the likelihood of its endurance as a methodologic technique in vaccinology.

A meta-analysis of studies of nurses' job satisfaction

Although several variables have been correlated with nursing job satisfaction, the findings are not uniform across studies. Three commonly noted variables from the nursing literature are: autonomy, job stress, and nurse-physician collaboration. This meta-analysis examined the strength of the relationships between job satisfaction and autonomy, job stress, and nurse-physician collaboration among registered nurses working in staff positions. A meta-analysis of 31 studies representing a total of 14,567 subjects was performed. Job satisfaction was most strongly correlated with job stress (ES = -.43), followed by nurse-physician collaboration (ES = .37), and autonomy (ES = .30). These findings have implications for the importance of improving the work environment to increase nurses' job satisfaction.

Short-term psychodynamic psychotherapies for common mental disorders

BACKGROUND

Over the past 40 years, short-term psychodynamic psychotherapies (STPP) for a broad range of psychological and somatic disorders have been developed and studied. Four published meta-analyses of STPP, using different methods and samples, have found conflicting results.

OBJECTIVES

This review evaluated the efficacy of STPP relative to minimal treatment and non-treatment controls for adults with common mental disorders.

SEARCH STRATEGY

We searched CCDANCTR-Studies and CCDANCTR-References on 25/4/2005, CENTRAL, MEDLINE, CINAHL, EMBASE, PsycINFO, DARE and Biological Abstracts were also searched. We contacted triallists and checked references from papers retrieved.

SELECTION CRITERIA

All randomised controlled trials (RCT) of adults with common mental disorders, in which a brief psychodynamic therapy lasting less than 40 hours in total, and provided in individual format, were included.

DATA COLLECTION AND ANALYSIS

Three reviewers working in pairs evaluated studies. Studies were selected only if pairs of reviewers agreed they met inclusion criteria. A third reviewer was consulted if two reviewers could not reach consensus. Data were collected and entered into Review Manager. Study quality was assessed and scored by pairs of raters. Publication bias was assessed using a funnel plot. Sensitivity analyses were also conducted.

MAIN RESULTS

23 studies of 1431 randomised patients with common mental disorders were included. These studies evaluated STPP for general, somatic, anxiety, and depressive symptom reduction, as well as social adjustment. Outcomes for most categories of disorder suggested significantly greater improvement in the treatment versus the control groups, which were generally maintained in medium and long term follow-up. However, only a small number of studies contributed data for each category of disorder, there was significant heterogeneity between studies, and results were not always maintained in sensitivity analyses.

AUTHORS' CONCLUSIONS

STPP shows promise, with modest to moderate, often sustained gains for a variety of patients. However, given the limited data and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.

Sequencing of chemotherapy and radiation therapy for early breast cancer

BACKGROUND

After surgery for localised breast cancer, adjuvant radiotherapy improves both local control and breast cancer specific survival. In patients at risk of harbouring micro-metastatic disease, adjuvant chemotherapy improves 15-year survival. However, the best sequence of administering these two types of adjuvant therapy for early stage breast cancer is not clear.

OBJECTIVES

To determine the effects of different sequencing of chemotherapy and radiotherapy for women with early breast cancer.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialized Register (10 March 2005). Details of the search strategy and methods of coding are described in the Group's module in The Cochrane Library. We extracted studies that had been coded as 'early', 'chemotherapy' and 'radiotherapy'.

SELECTION CRITERIA

Randomised controlled trials evaluating different sequencing of chemotherapy and radiotherapy were included.

DATA COLLECTION AND ANALYSIS

We assessed the eligibility and quality of the identified studies and extracted data from the published reports of the included studies. We derived odds ratios (OR) and risk ratios from the available numerical data. Hazard ratios were extracted directly from text. Toxicity data were extracted, where reported. We used a fixed-effect model for meta-analysis and conducted analyses on the basis of the method of sequencing of the two treatments.

MAIN RESULTS

Three trials reporting two different sequencing comparisons were identified. There were no significant differences between the various methods of sequencing adjuvant therapy for survival, distant metastases or local recurrence, based on 853 randomised patients in two trials. One of these two trials (647 women) provided data on toxicity. Haematological toxicity (OR 1.43, confidence interval (CI) 1.01 to 2.03) and oesophageal toxicity (OR 1.44, CI 1.03 to 2.02) were significantly increased with concurrent therapy, and nausea and vomiting were significantly decreased (OR 0.70, CI 0.50 to 0.98). Other measures of toxicity did not differ between the two types of sequencing. On the basis of one trial (244 women), radiotherapy before chemotherapy was associated with a significantly increased risk of neutropenic sepsis (OR 2.96, 95% CI 1.26 to 6.98) compared with chemotherapy before radiotherapy, but other measures of toxicity were not significantly different.

AUTHORS' CONCLUSIONS

The data included in this review, from three well conducted randomised trials, suggest that different methods of sequencing chemotherapy and radiotherapy do not appear to have a major effect on survival or recurrence for women with breast cancer if radiation therapy is commenced within 7 months after surgery.

Intake of selenium in the prevention of prostate cancer: a systematic review and meta-analysis

BACKGROUND

Recent studies have suggested that selenium intake may prevent the risk of developing prostate cancer. Results from some of these studies have given conflicting results. Because of these discrepant results we sought to explore the association between selenium intake and prostate cancer by conducting a systematic review and meta-analysis of the literature.

METHODS

We systematically searched MEDLINE, EMBASE and Cochrane Library between 1966 and May 2005 for articles that examined the association between intake of selenium and the risk of prostate cancer. We abstracted the data from relevant studies. A random effects model was used to estimate pooled relative risks for both cohort and case-control studies. Heterogeneity was assessed graphically using a Funnel Plot.

RESULTS

Sixteen studies (eleven cohort studies and five case-control studies) were included in the final analysis. The pooled relative risk of prostate cancer for any intake of selenium was 0.72 (0.61-0.84) for cohort studies and 0.74 (0.61-1.39) for case-control studies. The pooled relative risk of moderate intake was 0.74 (0.61-0.90) for cohort studies and 0.74 (0.39-1.39) for case-control studies. A dose-response trend was observed when we stratified the studies by disease severity.

CONCLUSION

The results of our systematic review suggest that selenium intake may reduce the risk of prostate cancer. The results confirm the need for large randomized controlled trials, which are ongoing, to answer this question.

Intake of vitamin E, vitamin C, and carotenoids and the risk of Parkinson's disease: a meta-analysis

We studied the effect of vitamin C, vitamin E, and beta carotene intake on the risk of Parkinson's disease (PD). We did a systematic review and meta-analysis of observational studies published between 1966 and March 2005 searching MEDLINE, EMBASE, and the Cochrane Library. Eight studies were identified (six case-control, one cohort, and one cross-sectional). We found that dietary intake of vitamin E protects against PD. This protective influence was seen with both moderate intake (relative risk 0.81, 95% CI 0.67-0.98) and high intake (0.78, 0.57-1.06) of vitamin E, although the possible benefit associated with high intake of vitamin E was not significant. The studies did not suggest any protective effects associated with vitamin C or beta carotene. We conclude that dietary vitamin E may have a neuroprotective effect attenuating the risk of PD. These results require confirmation in randomised controlled trials.

Paraprofessionals for anxiety and depressive disorders

BACKGROUND

The established mental health care system does not have the resources to meet the extensive need for care of those with anxiety and depressive disorders. Paraprofessionals partially replacing professionals may be cost-effective.

OBJECTIVES

To investigate the effectiveness of any kind of psychological treatment for anxiety and depressive disorders performed by paraprofessionals compared with professionals, waiting list or placebo condition. To examine whether the results apply to clinically significant anxiety and depressive disorders of referred patients with a psychiatric history and/or whose illness has lasted two years or more.

SEARCH STRATEGY

CCDANCTR-Studies using the following terms: (paraprofessional* or para-professional* or non-professional* or non-professional* or peer or volunt*); EMBASE (ExerptaMedica), MEDLINE and PsycINFO, all years published, key words: para-/paraprofessional, non-/nonprofessional, rand*, respectively psy*; citation lists of articles reviewing the subject and included studies; correspondence with authors of controlled studies and review reports on the subject.

SELECTION CRITERIA

Randomised controlled trials that used symptom measures, and compared the effects of psychological treatments given by paraprofessionals (mental health care workers, paid or voluntary, unqualified with respect to the psychological treatment) with psychological treatments given by professionals, and with waiting list or placebo condition.

DATA COLLECTION AND ANALYSIS

The standard mean difference was used to pool continuous data from each trial, and odds ratios were used to pool dichotomous data, using a random effects model. The generic inverse variance method was used for combining continuous and dichotomous data. The effect of low quality studies and the use of self-rated versus observer-rated measures were tested, and subgroup analyses were performed for differences between depression and anxiety diagnosis, paraprofessionals with/without professional background, group/individual intervention, length of follow-up and gender (post-hoc subgroup analysis).

MAIN RESULTS

Five studies, all using self-report measures, reported five comparisons of paraprofessionals versus professionals (n=106) and five comparisons of paraprofessionals versus control condition (n=220). No differences were found between paraprofessionals and professionals (SMD=0.09, 95% CI -0.23 to 0.40, p=0.58; no significant heterogeneity). Studies comparing paraprofessionals versus control reported mixed continuous and dichotomous data showed a significant pooled effect in favour of paraprofessionals (OR=0.34, 95% CI 0.13 to 0.88, p=0.03), but heterogeneity was indicated (I(2)=60.9%, Chi(2)= 10.24, df=4, p=0.04). After correction for heterogeneity and removing one study of low quality, the pooling of data from three studies (n=128; mixed gender and women only) indicated no significant difference in effect between paraprofessionals and professionals (SMD=0.13, 95% CI -0.39 to 0.64; p=0.63) and a strongly significant pooled effect for three studies (n=188; women only) favouring paraprofessionals over the control condition (OR=0.30, 95% CI 0.18 to 0.48, p<0.00001), and homogeneity indicated between studies (I(2)=0%, Chi(2)=0.47, df=2, p=0.79).

AUTHORS' CONCLUSIONS

The few studies included in the review did not allow conclusions about the effect of paraprofessionals compared to professionals. Pooling data from three studies, involving women only, indicated a significant effect for paraprofessionals (all volunteers) compared to no treatment. The evidence to date may justify the development and evaluation of programs incorporating paraprofessionals in treatment programs for anxiety and depressive disorders.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trails have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2002, Issue 3), MEDLINE (1966 to 2002), CINAHL (1982 to 2002) EMBASE (1980 to 2002), PSYCH Info (1887 to 2002), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to 2002). We also searched citation lists and approached authors.

SELECTION CRITERIA

RCTs with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Eight studies involving 403 randomised participants were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.58 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; the standardized mean difference = 0.85 (95% CI 0.38 to 1.31). However, there was high heterogeneity for this test. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult.

AUTHORS' CONCLUSIONS

Review suggested a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Meta-Analysis of the Reliability and Validity of Part B of the Index of Work Satisfaction Across Studies

Nurses’ job satisfaction is a crucial factor in health care organizations. This study uses meta-analysis for reliability generalization and synthesis of construct validity of Part B of the Index of Work Satisfaction (IWS), a measure of job satisfaction. Meta-analysis was performed including assessments of study quality and descriptive coding of studies. Rater reliability was assessed for all coding and extraction of data. The mean reliability of Part B scores of the IWS based on 14 studies was .78 (df = 13, p < .05). The mean score reliability was .77 for university settings, .73 for community/acute care hospitals, .77 for multi-site studies, and .90 for other settings. For studies rated high and low quality, the mean score reliability was .77 and .83, respectively. Scores on Part B of the IWS correlated −.38 with turnover intent, .60 with organizational commitment, and −.53 with job stress. Scores on Part B of the IWS are reliable for measuring job satisfaction of nurses across samples. Construct validity needs additional testing.

Effect of non-steroidal anti-inflammatory drugs on risk of Alzheimer's disease: systematic review and meta-analysis of observational studies

OBJECTIVES

To quantify the risk of Alzheimer's disease in users of all non-steroidal anti-inflammatory drugs (NSAIDs) and users of aspirin and to determine any influence of duration of use.

DESIGN

Systematic review and meta-analysis of observational studies published between 1966 and October 2002 that examined the role of NSAID use in preventing Alzheimer's disease. Studies identified through Medline, Embase, International Pharmaceutical Abstracts, and the Cochrane Library.

RESULTS

Nine studies looked at all NSAIDs in adults aged > 55 years. Six were cohort studies (total of 13 211 participants), and three were case-control studies (1443 participants). The pooled relative risk of Alzheimer's disease among users of NSAIDs was 0.72 (95% confidence interval 0.56 to 0.94). The risk was 0.95 (0.70 to 1.29) among short term users (< 1 month) and 0.83 (0.65 to 1.06) and 0.27 (0.13 to 0.58) among intermediate term (mostly < 24 months) and long term (mostly > 24 months) users, respectively. The pooled relative risk in the eight studies of aspirin users was 0.87 (0.70 to 1.07).

CONCLUSIONS

NSAIDs offer some protection against the development of Alzheimer's disease. The appropriate dosage and duration of drug use and the ratios of risk to benefit are still unclear.

Estrogens, progestogens and thrombosis

Hundreds of millions of women worldwide use either oral contraceptives or postmenopausal hormone replacement. The use of oral contraceptives leads to an increased risk of venous thrombosis, of myocardial infarction, of stroke and of peripheral artery disease, the risks of which are highest during the first year of use. Women with coagulation abnormalities have a higher risk of venous thrombosis when they use oral contraceptives (or postmenopausal hormones) than women without these abnormalities. The risk of venous thrombosis is also higher for preparations containing desogestrel or gestodene (third-generation progestogens) than for those containing levonorgestrel (second-generation progestogens). A previous thrombosis as well as obesity also increase the risk of oral contraceptive-related thrombosis. Hormone replacement therapy increases the risk of venous thrombosis, and has no beneficial, and possibly even a detrimental, effect on the risk of arterial disease. The risk of arterial disease in oral contraceptive users and users of hormone replacement therapy is at most weakly affected by the presence of prothrombotic abnormalities.

Breathing retraining for asthma

Breathing retraining is used increasingly throughout the world by many patients with asthma in addition to their usual medical care. We undertook a systematic review of the literature in order to determine the effectiveness of breathing retraining in the management of asthma. Six randomised-controlled trials were identified that involved breathing retraining in asthma. Due to the variation in reported trial outcomes, limited reporting of study data and small number of included trials it was not possible to draw any firm conclusions as to its effectiveness. However, outcomes that were reported from individual trials do show that breathing retraining may have a role in the treatment and management of asthma. Further large-scale trials using breathing retraining techniques in asthma are required to address this important issue.

History of depression as a risk factor for dementia: an updated review

OBJECTIVE

This review updates an earlier meta-analysis of the data on history of depression as a risk factor for dementia. It also considers the available evidence on the hypotheses proposed to explain the association between history of depression and dementia.

METHOD

A meta-analysis was carried out on results from seven case-control and six prospective studies. A qualitative review was carried out on the evidence related to the hypotheses to explain the association.

RESULTS

The meta-analysis found evidence to support an association from both case-control studies (estimated relative risk 2.01; 95% CI 1.16-3.50) and prospective studies (estimated relative risk 1.87; 95% CI 1.09-3.20). However, the evidence did not clearly support any one hypothesis explaining the association. The most likely contenders are: (i) depression can be an early prodrome of dementia, (ii) depression brings forward the clinical manifestation of dementing diseases, and (iii) depression leads to damage to the hippocampus through a glucocorticoid cascade.

CONCLUSIONS

The possibility that history of depression is a risk factor for dementia needs to be taken seriously and explanations of the association need to be further researched.

HEpiMA: software for the identification of heterogeneity in meta-analysis

Meta-analysis is a quantitative method available to epidemiologists, psychologists, social scientists and others who wish to produce a summary measure of the effect of exposure on disease, based on results from published studies along with a summary measure of uncertainty. The magnitude of the effect vary from study to study because of differences in the features of these studies (design, population, control of confounding variables etc.). From the various studies an estimator is formed by pooling the results found in each study in one summary measure. This summary (or pooled) measure is meaningful only if the magnitude of heterogeneity between study effects is small and can be explained by sampling variation. In this paper, we present HEpiMA, a new comprehensive and user-friendly software program for epidemiologic meta-analysis. HEpiMA has new features that are not available in other programs. The program carries out a complete study of heterogeneity of study effects with 11 hypothesis test results. In addition to model-based methods, the program also implements bootstrap methodology. New useful estimators of heterogeneity, Ri and CV(B), developed by the authors are given in the output. In addition to these unique features, the major advantage of this software is the option for direct entry of adjusted relative risk estimates of individual studies, the most common form of presentation of results in the epidemiologic literature. This program may also be useful for meta-analysts of clinical trials, in which the relative risk is the parameter of interest as it also allows the entry of crude data under the form of 2x2 tables.

The effect of inhaled steroids on the linear growth of children with asthma: a meta-analysis

OBJECTIVE

To determine whether inhaled steroid therapy causes delayed linear growth in children with asthma.

DATA SOURCES

Medline (1966-1998), Embase (1980-1998), and Cinahl (1982-1998) databases and bibliographies of included studies were searched for randomized, controlled trials of inhaled steroid therapy in children with asthma that evaluated linear growth.

STUDY SELECTION

Studies were included if they met the following criteria: subjects 0 to 18 years of age with the clinical diagnosis of asthma; subjects randomized to inhaled beclomethasone, budesonide, flunisolide, fluticasone, or triamcinolone versus a nonsteroidal inhaled control for a minimum of 3 months; single- or double-blind; and outcome convertible to linear growth velocity. English- and non-English-language trials were included.

DATA EXTRACTION

Data were extracted using a priori guidelines. Methodologic quality was assessed independently by both authors. Outcome was extracted as linear growth velocity.

RESULTS

Included trials were subgrouped by inhaled steroid. The beclomethasone subgroup, with 4 studies and 450 subjects, showed a decrease in linear growth velocity of 1.51 cm/year (95% confidence interval: 1.15,1.87). The fluticasone subgroup, with 1 study and 183 subjects, showed a decrease in linear growth velocity of.43 cm/year (95% confidence interval:.01,.85). Sensitivity analysis in the beclomethasone subgroup, which evaluated study quality, mode of medication delivery, control medication, and statistical model, showed similar results.

CONCLUSIONS

This meta-analysis suggests that moderate doses of beclomethasone and fluticasone in children with mild to moderate asthma cause a decrease in linear growth velocity of 1.51 cm/year and.43 cm/year, respectively. The effects of inhaled steroids when given for >54 weeks, or on final adult height, remain unknown.

Beclomethasone for asthma in children: effects on linear growth

BACKGROUND

Inhaled steroids play a central role in the management of childhood asthma. There is concern about their side effects, especially on growth. However asthma may also cause growth retardation. Growth rates are not stable, so randomised controlled parallel group studies are needed to assess the impact of inhaled steroids on growth. This review is confine to one inhaled steroid, beclomethasone, that is known to have significant levels of systemic absorption.

OBJECTIVES

To determine whether inhaled beclomethasone cause significant delay in the linear growth of children with asthma.

SEARCH STRATEGY

The Cochrane Airways Group asthma register was searched. Bibliographies from included studies, and known reviews were searched for additional citations. Personal contact with colleagues and researchers working in the field of asthma were made to identify potentially relevant trials.

SELECTION CRITERIA

Randomized, controlled trials comparing the effects of beclamethasone to non-steroidal medication (placebo or non-steroidal therapy) on the linear growth of children with asthma.

DATA COLLECTION AND ANALYSIS

Data related to the clinical outcome "change in growth" were extracted by two reviewers working independently

MAIN RESULTS

One hundred and fifty-nine citations were identified by the search strategy and bibliography review. Three studies met the inclusion criteria. All used beclomethasone 200 mcg twice daily delivered by dry powder Diskhaler to treat children with mild-moderate asthma. Study duration was 7-12 months. In all three studies, a significant decrease in linear growth occurred in children treated with beclomethasone compared to those receiving placebo or non-steroidal asthma therapy. The average decrease, calculated through meta-analysis, was -1.54 cm per year (95% CI -1.15, -1.94).

REVIEWER'S CONCLUSIONS

In children with mild-moderate asthma, beclomethasone 200 mcg twice daily caused a decrease in linear growth of -1.54 cm per year. These studies lasted a maximum of 54 weeks, so it remains unclear whether the decrease in growth is sustained or whether it reverses with 'catch up' after therapy is discontinued. We are unable to comment on growth effects of other inhaled steroids that have potentially less systemic effects. If inhaled steroids are required to control a child's asthma, we recommend using the minimum dose that effectively controls the child's asthma and closely following growth.

Effectiveness of condoms in preventing HIV transmission

The consistent use of latex condoms continues to be advocated for primary prevention of HIV infection despite limited quantitative evidence regarding the effectiveness of condoms in blocking the sexual transmission of HIV. Although recent meta-analyses of condom effectiveness suggest that condoms are 60 to 70% effective when used for HIV prophylaxis, these studies do not isolate consistent condom use, and therefore provide only a lower bound on the true effectiveness of correct and consistent condom use. A reexamination of HIV seroconversion studies suggests that condoms are 90 to 95% effective when used consistently, i.e. consistent condom users are 10 to 20 times less likely to become infected when exposed to the virus than are inconsistent or non-users. Similar results are obtained utilizing model-based estimation techniques, which indicate that condoms decrease the per-contact probability of male-to-female transmission of HIV by about 95%. Though imperfect, condoms provide substantial protection against HIV infection. Condom promotion therefore remains an important international priority in the fight against AIDS.

Meta-analysis and prospective meta-analysis in childhood leukemia clinical research

In this paper, we consider the role of meta-analysis and 'prospective meta-analysis' studies in childhood acute lymphocytic leukemia (ALL). In this issue, Valsecchi and Masera [1] give a thoughtful discourse, generally favorable to this approach. This article presents the opposite point of view. The aims of our article are to present the implications in clinical, rather than biostatistical terms, and to provide an extensive literature review of the subject of meta-analysis. We conclude that treatment assessments, resulting from meta-analysis of closed studies (retrospective) should be met with healthy skepticism. Trials requiring international resources should be true intergroup trials with a single coordinating center, rather than prospective meta-analysis, unless it is a question grafted onto each group's own research agenda. For example, each group might ask its own systemic control question, but a CNS protection question is asked collectively.

Meta-analysis: weighing the evidence

Use of meta-analytical (quantitative overview) techniques is now commonplace in a wide range of medical research contexts, with a rapid rise in its frequency of use being particularly apparent in the last decade. The history of meta-analyses in other fields, particularly psychology and educational research, is longer. Many methods have been proposed and used, from crude 'vote counting' of studies showing significant or non-significant results, through methods for combination of effect size estimates based on fixed or random effects models, to general linear mixed models and Bayesian methods. The history of meta-analysis and the advantages and disadvantages of various approaches to it are briefly reviewed in this paper, with reference to pharmaceutical product licence applications, other reviews of clinical trials and epidemiological studies, and health services research.

A meta-analysis of condom effectiveness in reducing sexually transmitted HIV

Before condoms can be considered as a prophylaxis for sexually transmitted human immunodeficiency virus (HIV), their efficacy must be considered. This paper reviews evidence on condom effectiveness in reducing the risk of heterosexually transmitted human HIV. A meta-analysis conducted on data from in vivo studies of HIV discordant sexual partners is used to estimate the protective effect of condoms. Although contraceptive research indicates that condoms are 87% effective in preventing pregnancy, results of HIV transmission studies indicate that condoms may reduce risk of HIV infection by approximately 69%. Thus, efficacy may be much lower than commonly assumed, although results should be viewed tentatively due to design limitations in the original studies.

Urinary tract infections and the uncircumcised state: an update

In a two-part study of the circumcision status of boys with urinary tract infections (UTIs), we reviewed the occurrence of UTIs in 209,399 infants born in US Army hospitals worldwide from 1985 to 1990. During the first year of life, 1,046 (0.5%: 550 girls and 496 boys) were hospitalized for UTIs. Noncircumcised male infants had a 10-fold greater incidence of infection than did circumcised male infants. The frequency rate of circumcision rose significantly, from 70.3% to 80.2%, during the study period. Among uncircumcised boys younger than 3 months with UTIs, 23% had concomitant bacteremia involving the same organism. The second part of the study consisted of a meta-analysis of all nine previous reports on the circumcision status of boys with UTIs. These studies revealed a fivefold to 89-fold increased risk of infection in uncircumcised boys; the combined data yielded a 12-fold increase in UTIs in this population. Parents should be told of the lower risk of UTIs for circumcised boys during informed-consent counseling.

[Meta-analysis in epidemiology (2): quantitative methods]

The main goal of this paper is to offer an introduction to the quantitative methods of meta-analysis used in epidemiology/public health, emphasizing on the most widespread used. We give also a brief reference of the methods to recognize publication bias. The limitations and advantages of the methods commented on are discussed.

Relationship between gestational cocaine use and pregnancy outcome: a meta-analysis

Despite a growing number of studies that have investigated the reproductive effects of maternal cocaine use, a homogeneous pattern of fetal effects has not been established and there is little consensus on the adverse effects of the drug. We used meta-analysis to evaluate the reproductive risks of cocaine. We reviewed the 45 scientific papers published in the English language dealing with effects of cocaine used during pregnancy on pregnancy outcome in humans, and identified 20 papers eligible for meta-analysis (cocaine use in pregnancy, pregnancy/fetal outcome studies, human studies, original work, cohort or case control studies, control group present, English language). Our analysis revealed that very few adverse reproductive effects could be shown to be significantly associated with cocaine use by polydrug users when compared to control groups of polydrug users not using cocaine [genitourinary malformations; odds ratio of 6.08 (95% CI 1.18-31.3); gestation age: Cohen's d 0.37 (CI 0.2-0.55)]. When the control groups consisted of no drug users, the polydrug users abusing cocaine had a higher risk for spontaneous abortions [odds ration 10.50 (CI 11.74-64.1)]. Similarly, comparison of users of cocaine alone or no drug users revealed a higher risk for in utero death, in addition to genitourinary tract malformations. Analysis of continuous variables (head circumference, gestational age, birth weight and length) revealed that the effect size was dependent upon the nature of the comparison. Comparison of cocaine users to no drug users consistently yielded a medium effect size (Cohen's d) between 0.50 and 0.58, while comparison of polydrug/cocaine users to polydrug/no cocaine users provided effect sizes small to non existent (0.06-0.37). These discrepancies suggest that a variety of adverse reproductive effects commonly quoted to be associated with maternal use of cocaine may be caused by confounding factors clustering in cocaine users.

Informing the mammography coverage debate. Results of meta-analysis, computer modeling, and issue analysis

Methods of meta-analysis, computer modeling, and issue analysis are used to answer four key questions related to efficacy, cost, and political feasibility of legislating insurance coverage for mammography. The findings are presented, and the strengths and weaknesses of the combined use of these methods to inform policy debate at the regional level are discussed.