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A meta-analysis on the anxiety-reducing effects of acute and chronic exercise. Outcomes and mechanisms.

The relationship between exercise and anxiety has been extensively examined over the last 15 years. Three separate meta-analysis were conducted to quantitatively review the exercise-anxiety literature for state anxiety, trait anxiety and psychophysiological correlates of anxiety. Such a procedure allows tendencies of the research to be characterised. The results substantiate the claim that exercise is associated with reductions in anxiety, but only for aerobic forms of exercise. These effects were generally independent of both subject (i.e. age and health status) and descriptive characteristics. Numerous design characteristics were different, but these differences were not uniform across the 3 meta-analyses. For state anxiety, exercise was associated with reduced anxiety, but had effects similar to other known anxiety-reducing treatments (e.g. relaxation). The trait anxiety meta-analysis revealed that random assignment was important for achieving larger effects when compared to the use of intact groups. Training programmes also need to exceed 10 weeks before significant changes in trait anxiety occur. For psychophysiological correlates, cardiovascular measures of anxiety (e.g. blood pressure, heart rate) yielded significantly smaller effects than did other measures (e.g. EMG, EEG). The only variable that was significant across all 3 meta-analyses was exercise duration. Exercise of at least 21 minutes seems necessary to achieve reductions in state and trait anxiety, but there were variables confounding this relationship. As such, it remains to be seen what the minimum duration is necessary for anxiety reduction. Although exercise offers therapeutic benefits for reducing anxiety without the dangers or costs of drug therapy or psychotherapy, it remains to be determined precisely why exercise is associated with reductions in anxiety. Since several mechanisms may be operating simultaneously, future research should be designed with the idea of testing interactions between these mechanisms.

Acute Disease↗

Heparin-induced thrombocytopenia with thromboembolic complications: meta-analysis of 2 prospective trials to assess the value of parenteral treatment with lepirudin and its therapeutic aPTT range.

This meta-analysis focuses on 2 prospective studies in patients with heparin-induced thrombocytopenia (HIT) and thromboembolic complication (TEC) who were treated with lepirudin (n = 113). Data were compared with those of a historical control group (n = 91). The primary endpoint (combined incidence of death, new TEC, and limb amputation) occurred in 25 lepirudin-treated patients (22.1%; 95% CI, 14.5%-29.8%): 11 died (9.7%; 95% CI, 4.9%-16.8%), 7 underwent limb amputation (6.2%; 95% CI, 2.5%-12.3%), and 12 experienced new TEC (10.6%; 95% CI, 5.8%-18.3%). The risk was highest in the period between diagnosis of HIT and the start of lepirudin therapy (combined event rate per patient day 6.1%). It markedly decreased to 1.3% during lepirudin treatment and to 0.7% in the posttreatment period. From the start of lepirudin therapy to the end of follow-up, lepirudin-treated patients had consistently lower incidences of the combined endpoint than the historical control group (P =.004, log-rank test), primarily because of a reduced risk for new TEC (P =. 005). Thrombin-antithrombin levels in the pretreatment period (median, 43.9 microg/L) decreased after the initiation of lepirudin (at 24 hours +/- 6 hours; median, 9.18 microg/L.) During treatment with lepirudin, aPTT ratios of 1.5 to 2.5 produced optimal clinical efficacy with a moderate risk for bleeding, aPTT ratios lower than 1. 5 were subtherapeutic, and aPTT levels greater than 2.5 were associated with high bleeding risk. Bleeding events requiring transfusion were significantly more frequent in patients taking lepirudin than in historical control patients (P =.02). In conclusion, this meta-analysis provides further evidence that lepirudin is an effective and acceptably safe treatment for patients with HIT.

Aged↗

Personality disorder and the outcome of depression: meta-analysis of published studies.

BACKGROUND: There is conflicting evidence about the influence of personality disorder on outcome in depressive disorders. AIMS: Meta-analysis of studies in which a categorical assessment of personality disorder or no personality disorder was made in people with depressive disorders, and categorical outcome (recovered/not recovered) also determined. METHOD: Systematic electronic search of the literature for relevant publications. Hand searches of Journal of Affective Disorders and recent reviews, with subsequent meta-analysis of selected studies. RESULTS: Comorbid personality disorder with depression was associated with a doubling of the risk of a poor outcome for depression compared with no personality disorder (random effects model OR=2.18, 95% CI 1.70-2.80), a robust finding maintained with only Hamilton-type depression criteria at outcome (OR=2.20, 95% CI 1.61-3.01). All treatments apart from electroconvulsive therapy (ECT) showed this poor outcome, and the ECT group was small. CONCLUSIONS: Combined depression and personality disorder is associated with a poorer outcome than depression alone.

Antidepressive Agents↗

Efficacy of adjuvant immunochemotherapy with polysaccharide K for patients with curatively resected colorectal cancer: a meta-analysis of centrally randomized controlled clinical trials.

The benefits of immunochemotherapy employing the biological response modifier polysaccharide K (PSK) for patients with curatively resected colorectal cancer was reassessed by means of a meta-analysis of data with center randomization from 1,094 patients enrolled in three clinical trials. In all three trials, patients were followed up for at least 5 years after surgery and enrollment of the last patient and outcomes for standard chemotherapy were compared with those for chemotherapy plus PSK. The endpoints were overall survival and disease-free survival; and intent-to-treat analysis was performed without patient exclusion. Data were analyzed using the weighted average of the individual log hazard ratios. The overall survival risk ratio for all eligible patients was 0.71 (95% confidence interval (CI) : 0.55-0.90; P=0.006), and the disease-free survival risk ratio was 0.72 (95% CI: 0.58-0.90; P=0.003). The results of this meta-analysis suggest that adjuvant immunochemotherapy with PSK can improve both survival and disease-free survival of patients with curatively resected colorectal cancer.

Antineoplastic Combined Chemotherapy Protocols↗

Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis.

OBJECTIVE: To evaluate efficacy of probiotics in prevention and treatment of diarrhoea associated with the use of antibiotics. DESIGN: Meta-analysis; outcome data (proportion of patients not getting diarrhoea) were analysed, pooled, and compared to determine odds ratios in treated and control groups. IDENTIFICATION: Studies identified by searching Medline between 1966 and 2000 and the Cochrane Library. Studies reviewed Nine randomised, double blind, placebo controlled trials of probiotics. RESULTS: Two of the nine studies investigated the effects of probiotics in children. Four trials used a yeast (Saccharomyces boulardii), four used lactobacilli, and one used a strain of enterococcus that produced lactic acid. Three trials used a combination of probiotic strains of bacteria. In all nine trials, the probiotics were given in combination with antibiotics and the control groups received placebo and antibiotics. The odds ratio in favour of active treatment over placebo in preventing diarrhoea associated with antibiotics was 0.39 (95% confidence interval 0.25 to 0.62; P<0.001) for the yeast and 0.34 (0.19 to 0.61; P<0.01 for lactobacilli. The combined odds ratio was 0.37 (0.26 to 0.53; P<0.001) in favour of active treatment over placebo. CONCLUSIONS: The meta-analysis suggests that probiotics can be used to prevent antibiotic associated diarrhoea and that S boulardii and lactobacilli have the potential to be used in this situation. The efficacy of probiotics in treating antibiotic associated diarrhoea remains to be proved. A further large trial in which probiotics are used as preventive agents should look at the costs of and need for routine use of these agents.

Anti-Bacterial Agents↗

Angiotensinogen gene and essential hypertension in the Japanese: extensive association study and meta-analysis on six reported studies.

BACKGROUND: Accumulating evidence has supported the pathophysiological role of angiotensinogen in essential hypertension. However, some studies of molecular genetics have implicated that there may be an ethnic variation concerning the disease susceptibility of the AGT gene. OBJECTIVES AND METHODS: To evaluate the importance of this candidate gene for hypertension, we undertook an extensive association study in the Japanese. This case-control study was conducted in a total of 1232 individuals consecutively enrolled in a single institution, divided into two subgroups: one subgroup comprised 254 hypertensive and 224 normotensive subjects and the other comprised 463 hypertensive and 291 normotensive subjects. A meta-analysis was subsequently performed on six Japanese studies including the present study. RESULTS: No significant association was observed between a molecular variant of AGT, Thr235, and hypertension status in our case-control study. Moreover, this finding was extendible to another AGT polymorphism, G-6A, one of the potential functional polymorphisms in the promoter region, because these two polymorphisms proved to be in complete linkage disequilibrium in the studied population. The meta-analysis revealed that the pooled estimate of the odds ratio across the studies was 1.22 (95% CI 1.05-1.42), and that there was significant evidence against homogeneity of the odds ratios among the studies included (phi2 = 19.8, df = 5, P = 0.0014). In particular, a large range of variation (60-83%) was found for the allele frequency of Thr235 among control subjects of the six Japanese case-control studies. CONCLUSIONS: Although the meta-analysis appears in favour of association between the AGT variant and essential hypertension in the Japanese, there is considerable heterogeneity among the studies and the evidence is also rather borderline. Further comprehensive approaches are needed to resolve this debatable issue.

Adult↗

Reference values for ambulatory blood pressure: a meta-analysis.

The aim of the present study was to perform a meta-analysis of published studies in an attempt to determine the mean and range of normal ambulatory blood pressure. Twenty-two studies, including a total of 2638 subjects, were reviewed. Most studies were compatible with a mean 24-h ambulatory pressure in the range of 115/70-120/75 mmHg, a mean daytime pressure of 120/75-125/80 mmHg and a mean night-time pressure of 105/60-110/65 mmHg. With weighting for the number of subjects included in the individual studies, the 24-h ambulatory pressure averaged 117/72 mmHg, the daytime pressure 122/77 mmHg and the night-time pressure 106/64 mmHg. The night:day pressure ratio averaged 0.87 for systolic and 0.83 for diastolic pressure, ranging from 0.79 to 0.92 and from 0.75 to 0.90, respectively, across the individual studies. With the mean +/- 2 standard deviation intervals in the various studies taken as normal, the range of normality averaged 97/57-137/87 mmHg over 24 h, 101/62-143/91 mmHg for the daytime pressure and 86/48-127/79 mmHg for the night-time pressure. Until the results of prospective studies on the relationship between ambulatory blood pressure and the incidence of cardiovascular morbidity and mortality become available, these estimates of normal ambulatory pressure could be applied as reference values in clinical practice.

Adolescent↗

Does acupuncture improve motor recovery after stroke? A meta-analysis of randomized controlled trials.

BACKGROUND AND PURPOSE: Acupuncture may be a promising treatment for poststroke paralysis. We conducted a meta-analysis, assessing the efficacy of acupuncture with and without stroke rehabilitation. METHODS: We identified randomized trials comparing acupuncture with no acupuncture within 6 months of stroke by searching MEDLINE, CINAHL, EMBASE, Cochrane Library, and Chinese medical literature databases. Two reviewers independently extracted data on study characteristics, patient characteristics, and impairment and disability outcomes. The outcome measures were internationally recognized or nationally approved. The fixed- and random-effects models were used to combine effect size and odds ratio across studies. RESULTS: Fourteen trials with 1213 patients met all the inclusion criteria. For the comparison of acupuncture with no acupuncture in addition to stroke rehabilitation, the pooled random-effects estimates of the change in motor impairment and disability were 0.06 (95% CI, -0.12 to 0.24) and 0.49 (95% CI, 0.03 to 0.96), respectively, with heterogeneity in disability measures (P=0.05, chi(2) test). For the comparison of real with sham acupuncture, the pooled random-effects estimate of the change in disability was 0.07 (95% CI, -0.34 to 0.48). For the comparison of acupuncture with no acupuncture without stroke rehabilitation, the pooled random-effects estimate of the change in motor impairment was 0.46 (95% CI, -0.20 to 1.12), and the pooled random-effects odds ratio for disability was 12.5 (95% CI, 4.3 to 36.2), with no statistically significant heterogeneity (P=0.97 and P=0.12, respectively, chi(2) test), but the study quality was poor. CONCLUSIONS: This meta-analysis suggests that with stroke rehabilitation, acupuncture has no additional effect on motor recovery but has a small positive effect on disability, which may be due to a true placebo effect and varied study quality. The efficacy of acupuncture without stroke rehabilitation remains uncertain, mainly because of the poor quality of such studies.

Acupuncture Therapy↗

Meta-analysis of benzodiazepine use in the treatment of acute alcohol withdrawal.

OBJECTIVE: To analyse the evidence for the efficacy and potential harmful effects of benzodiazepines compared with other therapies in the treatment of acute alcohol withdrawal. DATA SOURCES: MEDLINE and the Cochrane Controlled Trials Registry were searched for English-language articles published from 1966 to December 1997 that described randomized controlled trials (RCTs) of benzodiazepines in the treatment of acute alcohol withdrawal. Key words included "benzodiazepines" (exploded) and "randomized controlled trial." Bibliographies of relevant articles were reviewed for additional RCTs, and manufacturers of benzodiazepines were asked to submit additional RCT reports not in the literature. STUDY SELECTION: Articles were considered for the meta-analysis if they were RCTs involving patients experiencing acute alcohol withdrawal and comparing a benzodiazepine available in Canada with placebo or an active control drug. Of the original 23 trials identified, 11 met these criteria, representing a total of 1286 patients. DATA EXTRACTION: Data were extracted regarding the participants, the setting, details of the intervention, the outcomes (including adverse effects) and the methodologic quality of the studies. DATA SYNTHESIS: The meta-analysis of benefit (therapeutic success within 2 days) showed that benzodiazepines were superior to placebo (common odds ratio [OR] 3.28, 95% confidence interval [CI] 1.30-8.28). Data on comparisons between benzodiazepines and other drugs, including beta-blockers, carbamazepine and clonidine, could not be pooled, but none of the alternative drugs was found to be clearly more beneficial than the benzodiazepines. The meta-analysis of harm revealed no significant difference between benzodiazepines and alternative drugs in terms of adverse events (common OR 0.67, 95% CI 0.34-1.32) or dropout rates (common OR 0.68, 95% CI 0.47-0.97). INTERPRETATION: Benzodiazepines should remain the drugs of choice for the treatment of acute alcohol withdrawal.

Acute Disease↗

Disparities in HbA1c levels between African-American and non-Hispanic white adults with diabetes: a meta-analysis.

OBJECTIVE: Among individuals with diabetes, a comparison of HbA(1c) (A1C) levels between African Americans and non-Hispanic whites was evaluated. Data sources included PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health, the Cochrane Library, the Combined Health Information Database, and the Education Resources Information Center. RESEARCH DESIGN AND METHODS: We executed a search for articles published between 1993 and 2005. Data on sample size, age, sex, A1C, geographical location, and study design were extracted. Cross-sectional data and baseline data from clinical trials and cohort studies for African Americans and non-Hispanic whites with diabetes were included. Diabetic subjects aged <18 years and those with pre-diabetes or gestational diabetes were excluded. We conducted a meta-analysis to estimate the difference in the mean values of A1C for African Americans and non-Hispanic whites. RESULTS: A total of 391 studies were reviewed, of which 78 contained A1C data. Eleven had data on A1C for African Americans and non-Hispanic whites and met selection criteria. A meta-analysis revealed the standard effect to be 0.31 (95% CI 0.39-0.25). This standard effect correlates to an A1C difference between groups of approximately 0.65%, indicating a higher A1C across studies for African Americans. Grouping studies by study type (cross-sectional or cohort), method of data collection for A1C (chart review or blood draw), and insurance status (managed care or nonmanaged care) showed similar results. CONCLUSIONS: The higher A1C observed in this meta-analysis among African Americans compared with non-Hispanic whites may contribute to disparity in diabetes morbidity and mortality in this population.

Black or African American↗

A meta-analysis of the effects of various interventions in preventing endotracheal suction-induced hypoxemia.

The purpose of this study was to clarify the effects of interventions that were applied to prevent endotracheal suction-induced hypoxia by meta-analysis. To obtain a sample for this meta-analysis, a computerized search was performed through MEDLINE in addition to tracking down additional references cited in bibliographies of past reports. Finally thirty research reports were examined. In terms of the application time of oxygenation, insufflation and preoxygenation were the most prevalently used in the studies. Regarding the methods of oxygenation, the most prevalent technique for oxygenation was hyperoxygenation in combination with hyperinflation. Hyperoxygenation and hyperinflation were most frequently induced by FiO2 of 1 and a 150% tidal volume of three to six breaths, respectively. Suctioning was commonly sustained for <15 seconds using pressures of -80 to -120 mmHg and with size 14 French catheters. Insufflation was less effective than the other methods examined in the present study. From this study, it can be concluded that the interventions that were applied to prevent endotracheal suction-induced hypoxia, regardless of their application times or methods, reduced suction-induced hypoxia significantly.

Adult↗

Is suction drainage an effective means of preventing hematoma in thyroid surgery? A meta-analysis.

OBJECTIVE: To evaluate the efficacy of suction drainage in preventing postoperative hematoma formation in thyroid surgery. METHODS: We conducted a meta-analysis using only randomized controlled trials in which the incidence of post-thyroidectomy hematoma was compared directly in patients with and without suction drains (eight studies since 1980; N = 944). The odds ratio (OR) with respective confidence intervals (CIs) using the fixed effects model was reported. We used an OR < 1.0 as being in favour of treatment (ie, the use of suction drains). RESULTS: In our meta-analysis, there was no statistically significant difference between the rates of post-thyroidectomy hematoma whether or not suction drains were used when the results were combined using a fixed effects model (OR 1.04, 95% CI-1.93), with p = .90. In this comparison, a fixed effects model was used rather than a random effects model because there was no statistically significant heterogeneity (chi2 = 6.26, p = .28). CONCLUSIONS: We conclude that the use of suction drains in thyroid surgery to prevent postoperative hematoma is not evidence based.

Chi-Square Distribution↗

Metformin in polycystic ovary syndrome: systematic review and meta-analysis.

OBJECTIVE: To assess the effectiveness of metformin in improving clinical and biochemical features of polycystic ovary syndrome. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Randomised controlled trials that investigated the effect of metformin compared with either placebo or no treatment, or compared with an ovulation induction agent. SELECTION OF STUDIES: 13 trials were included for analysis, including 543 women with polycystic ovary syndrome that was defined by using biochemical or ultrasound evidence. MAIN OUTCOME MEASURE: Pregnancy and ovulation rates. Secondary outcomes of clinical and biochemical features of polycystic ovary syndrome. RESULTS: Meta-analysis showed that metformin is effective in achieving ovulation in women with polycystic ovary syndrome, with odds ratios of 3.88 (95% confidence interval 2.25 to 6.69) for metformin compared with placebo and 4.41 (2.37 to 8.22) for metformin and clomifene compared with clomifene alone. An analysis of pregnancy rates shows a significant treatment effect for metformin and clomifene (odds ratio 4.40, 1.96 to 9.85). Metformin has an effect in reducing fasting insulin concentrations, blood pressure, and low density lipoprotein cholesterol. We found no evidence of any effect on body mass index or waist:hip ratio. Metformin was associated with a higher incidence of nausea, vomiting, and other gastrointestinal disturbance. CONCLUSIONS: Metformin is an effective treatment for anovulation in women with polycystic ovary syndrome. Its choice as a first line agent seems justified, and there is some evidence of benefit on variables of the metabolic syndrome. No data are available regarding the safety of metformin in long term use in young women and only limited data on its safety in early pregnancy. It should be used as an adjuvant to general lifestyle improvements and not as a replacement for increased exercise and improved diet.

Blood Pressure↗

The Association Between Child Maltreatment and Quality of Life: A Systematic Review and Meta-Analysis.

The association between child maltreatment (CM) and quality of life (QoL) has been widely examined in the past decade. In this study, we estimated the association between CM and QoL using a systematic review and meta-analysis. Articles were searched up to May 15, 2024, in both English databases (Web of Science, EMBASE, CINAHL, PsycINFO & PsycArticles, MEDLINE, Cochrane Library, PubMed, and Scopus) and Chinese databases (CNKI, Weipu, and Wanfang). The meta-analysis was performed by a random-effects model, using 43 studies comprising 130,884 participants. This study demonstrated that general CM had an adverse impact on QoL and its sub-dimensions, including physical, mental, psychosocial, and environmental QoL. Further analysis showed that the subtypes of CM also had negative impacts on the dimensions of QoL, except for mental QoL. Emotional maltreatment had stronger negative associations with QoL than other subtypes of CM, while neglect received relatively less attention. In addition, the association between CM and QoL was moderated by region, gender ratio, and measurement methods. The findings of this study suggest that CM is negatively associated with QoL. Future studies need to investigate the impact of neglect on QoL and develop tailored programs to improve the QoL of people who have suffered from CM.

Humans↗

Meta-analysis of value of propranolol in prevention of variceal haemorrhage.

A meta-analysis of all controlled clinical trials of beta-adrenoceptor blocking drugs, principally propranolol, in the prevention of primary or secondary variceal bleeding has shown that beta-blockade significantly reduced the occurrence of variceal bleeding, deaths from variceal bleeding, and overall mortality. There was some heterogeneity between trials in the effect of beta blockade on secondary prevention. When only fully reported, randomised, placebo-controlled studies were included the heterogeneity disappeared, and the reductions in bleeding episodes and mortality became more striking. Separate analyses of primary and secondary prevention studies also showed clear reductions in occurrence of variceal bleeding and deaths. These results seem to indicate the value of beta-adrenoreceptor blocking drugs for the primary prevention of haemorrhage from large oesophageal varices. However, there is still a need for large multicentre trials of beta-blockade for primary prevention of variceal bleeding in patients without large varices and of comparisons between beta-blocker therapy with other treatments in secondary prevention.

Adrenergic beta-Antagonists↗

A meta-analysis of the efficacy and toxicity of combining disease-modifying anti-rheumatic drugs in rheumatoid arthritis based on patient withdrawal.

INTRODUCTION: Combinations of disease-modifying anti-rheumatic drugs (DMARDs) are increasingly used to treat rheumatoid arthritis (RA). Early trials showed their toxicity while recent trials suggest superior efficacy. Trials of DMARD combinations have enrolled different types of patient (early or established RA), used different designs (step-up, parallel or step-down) and utilized a range of outcome measures. We undertook a systematic review of combination DMARD therapy for RA and carried out a meta-analysis to evaluate the evidence for efficacy and toxicity. METHOD: Medline, PubMed and EmBase were searched using MESH headlines 'arthritis, rheumatoid', 'drug therapy, combination' and 'randomized controlled trial' (RCT) for papers published from 1975 to April 2004. References from published articles were also searched. Three independent assessors evaluated abstracts and selected trials for detailed examination. Trials were excluded if their quality was poor, were not published in English or studied DMARDs not licensed to treat RA. Two independent assessors extracted data. Efficacy was assessed by the numbers of patients withdrawn due to lack of efficacy. Toxicity was assessed by the numbers of patients withdrawn due to adverse events. Risk ratios (RR) with 95% confidence intervals (CI) were calculated and meta-analysis was carried out based on a random effects model. Sensitivity analyses evaluated different treatment combinations, trial designs, study populations and outcome measures. RESULTS: Fifty-three potentially relevant RCTs were identified. Twelve were excluded due to: using unlicensed DMARDs (n = 3); reporting in journal supplements of RCTs already included (n = 2); follow-up of an earlier RCT, report of biological outcomes or pharmacokinetics (n = 5); and non-English language publications (n = 2). Forty-one RCTs were evaluated in detail and another five excluded (three open-labelled studies and two with high patient attrition); 36 studies were included in the meta-analysis. These comprised 13 step-up, 16 parallel and 7 step-down trials. Nine assessed early RA and 27 established RA. Seven added steroids to DMARD monotherapy and one study added steroids to DMARD combinations. Six assessed methotrexate (MTX) plus tumour necrosis factor (TNF) inhibitors. Overall, combination DMARD therapy was more effective than monotherapy (RR 0.35; 95% CI 0.28, 0.45) although the risk of toxicity was also slightly higher (RR 1.37; 95% CI 1.16, 1.62). Combinations of MTX with TNF inhibitors and MTX with sulphasalazine or anti-malarials showed good efficacy/toxicity ratios. CONCLUSIONS: DMARD combinations vary in their efficacy/toxicity ratio. MTX plus sulphasalazine and/or anti-malarials and MTX plus TNF inhibitors have particularly favourable benefit/risk ratios.

Antirheumatic Agents↗

DST studies in psychotic depression: a meta-analysis.

OBJECTIVE: Although hypersecretion of cortisol has frequently been reported in psychotic depression, the findings have been mixed. The authors performed a meta-analysis of the existing studies to determine the significance of differences in nonsuppression of cortisol across studies. METHOD: Fourteen studies that compared dexamethasone suppression test (DST) results in psychotic and nonpsychotic patients were examined, and a Mantel-Haenszel meta-analysis was performed. For comparison purposes, 19 studies of the DST with respect to melancholic/nonmelancholic and inpatient/outpatient distinctions were similarly reviewed. RESULTS: This analysis indicated a highly significant probability that a greater rate of cortisol nonsuppression occurs in psychotic depression. The nonsuppression rate was substantially higher in patients with psychotic depression (64%) than in nonpsychotic patients (41%). In the 19 studies of melancholia, nonsuppression was less frequent (36%), and when inpatient/outpatient status was controlled, melancholic depression was not significantly associated with nonsuppression. In nonmelancholic outpatients with major depression, the nonsuppression rate was low (12%). CONCLUSIONS: Among patients with major depression, psychotic depression is the subtype that is most closely associated with nonsuppression of cortisol on the DST. Hypercortisolemia is usually present in psychotic depression and may be important in understanding the pathophysiology of this syndrome.

Ambulatory Care↗

A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes.

OBJECTIVES: We performed a meta-analysis of randomized trials comparing coronary artery bypass graft surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) for the treatment of coronary artery disease, incorporating new trials and examining long-term outcomes. BACKGROUND: Previous meta-analyses of trials comparing CABG with PTCA have reported short- and intermediate-term outcomes, but since then longer term follow-up and newer trials have been published. METHODS: We performed a meta-analysis of 13 randomized trials on 7,964 patients comparing PTCA with CABG. RESULTS: We found a 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p < 0.02), but no significant advantage at one, three, or eight years. In subgroup analysis of multivessel disease, CABG provided significant survival advantage at both five and eight years. Patients randomized to PTCA had more repeat revascularizations at all time points (risk difference [RD] 24% to 38%, p < 0.001); with stents, this RD was reduced to 15% at one and three years. Stents also resulted in a significant decrease in nonfatal myocardial infarction at three years when compared with CABG. For diabetic patients, CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years. CONCLUSIONS: Our results suggest that, when compared with PTCA, CABG is associated with a lower five-year mortality, less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat revascularization by about half.

Angioplasty, Balloon, Coronary↗