| Objective:By means of network Meta-analysis,the effectiveness of various Traditional Chinese Medicine external treatments for AGA was evaluated by searching the previous Chinese and foreign literature,and a comparison of the efficacy of each treatment was conducted.The quality of evidence for outcome indicators was graded using the quality of GRADE system.To provide an evidence-based medical rationale for the clinical treatment of AGA.Methods:Develop a scientific search strategy based on evidence-based medicine.The literature in China National Knowledge Internet,Vip Database,Chinese Biological Medical Disc,Wanfang Digital Periodical Group,Pub Med,The Cochrane Library,and EMbase were searched respectively.Search for RCT using TCM external therapies alone and in combination.If the full text of some documents was not available in electronic databases,the journal database of Heilongjiang University of Traditional Chinese Medicine Library was searched manually.The time limit of the claim is from the construction of the bank to June 30,2022.Two researchers independently sorted and screened the literature that met the inclusion criteria by Note Express 3.5 software,and did data extraction for the included studies.Referring to the risk of bias assessment method provided in Cochrane Handbook 6.3,a summary plot of the risk of bias was drawn using the official Excl tool sheet.A frequency-based analysis method was chosen for the reticulated Meta-analysis section.STATA17.0 software was used for data integration analysis,inconsistency testing,and publication bias detection.Evidence network diagrams,SUCRA cumulative probability ranking diagrams,inverted triangle diagrams and funnel diagrams were also drawn.Finally,the GRADEprofiler 3.6.1 software was used to rate the quality of the outcome evidence and to create separate quality rating scales based on outcome indicators.Results:1.A total of 8241 documents were retrieved.After checking and screening to exclude irrelevant literature,27 clinical studies were finally included.The 16 types of Traditional Chinese Medicine external treatments involved include general acupuncture,floating needles,electro-acupuncture,fire acupuncture,blood pricking,warm acupuncture,external application of Chinese herbs,moxibustion,and the combined application of the above therapies.The risk of bias assessment of the included studies showed that four studies were evaluated as "high risk" in aggregate,only one study was rated as "low risk",and the remaining 22 studies were rated as "some concerns".In the specific assessment of each entry,2 studies were rated as high risk of bias arising from the randomization process,and the remaining assessment entries were rated as low to moderate risk.The studies under each outcome indicator were predominantly medium risk.2.The results of reticulated Meta-analysis showed that:(1)In terms of clinical efficiency,a total of 23 studies and 15 Traditional Chinese Medicine external therapies were included.The possible optimal ranking is:acupuncture + electro-acupuncture > warm acupuncture + acupuncture >herbal topical application + acupuncture > herbal topical application +conventional acupuncture > acupuncture + conventional acupuncture >acupuncture + moxibustion > fire acupuncture + conventional acupuncture >moxibustion > electro-acupuncture > floating acupuncture > conventional acupuncture + moxibustion > acupuncture > warm acupuncture > herbal topical application > conventional acupuncture.(2)In terms of reducing UA,a total of 14 studies were included.The network diagrams were divided into subgroups covering 11 studies and 9 Traditional Chinese Medicine external treatments1 and those covering 3 studies and 2 Traditional Chinese Medicine external treatments,depending on whether the network diagrams were connected two by two.The possible optimal ranking for subgroup 1 was:acupuncture + electroacupuncture > acupuncture + conventional acupuncture > fire acupuncture + conventional acupuncture >electroacupuncture > herbal topical application + conventional acupuncture >acupuncture + moxibustion > acupuncture + moxibustion > conventional acupuncture;the results for subgroup 2 were: herbal topical application >herbal topical application + moxibustion;the possible optimal ranking for subgroup 2 was: herbal topical application > herbal topical application +moxibustion.(3)In terms of improving Visual Analogue Scale,a total of 9studies and 9 Traditional Chinese Medicine topical treatments were included.The possible optimal ranking is: prick blood method + electro-acupuncture >floating acupuncture > warm acupuncture + prick blood method > prick blood method + conventional acupuncture > prick blood method > moxibustion method > warm acupuncture > electro-acupuncture > conventional acupuncture.3.With regard to the safety evaluation of the above Traditional Chinese Medicine external treatment methods,only 3 out of 27 studies reported a total of 7 cases of adverse reactions.The ratio of the number of adverse reaction cases to the total sample size was 7/2030.Specifically,they included three patients with blood sickness(intervention: blood pricking),three patients with needle sickness(intervention: conventional acupuncture),and one patient with poor healing pain(intervention: conventional acupuncture).4.The GRADE quality of evidence evaluation revealed that:(1)In terms of treatment efficiency,a total of 15 pairs of Traditional Chinese Medicine external treatments had statistically significant two-pair comparisons.Among them,"warm acupuncture + blood pricking vs.warm acupuncture","blood pricking vs.conventional acupuncture",and "blood pricking + conventional acupuncture vs.conventional acupuncture" were rated as low-quality evidence.The remaining 12 items were rated as very low quality evidence.(2)In terms of reducing UA,a total of 9 pairs of Traditional Chinese Medicine external treatments were compared in a statistically significant manner.Only "blood pricking + conventional needling vs.conventional needling" was rated as low quality evidence,and the remaining 8 comparisons were all very low quality evidence.(3)In terms of improving Visual Analogue Scale,there were12 pairs of statistically significant two-by-two comparison results.Evidence for "floating needles vs conventional acupuncture","warm acupuncture +pricking blood method vs warm acupuncture","pricking blood method +conventional acupuncture vs conventional acupuncture",and "pricking blood method vs conventional acupuncture" was rated as low quality.The level of evidence for the remaining eight comparisons was of very low quality.Conclusions:1.The results of the combined mesh Meta-analysis revealed that:(1)In all outcomes,the combination of two Traditional Chinese Medicine external treatment methods is generally better than the treatment method alone.Among them,the prick method + electroacupuncture was optimal in terms of efficiency,reduction of UA,and improvement of VAS scores.(2)For a single Traditional Chinese Medicine external treatment method,moxibustion may be more advantageous in terms of efficiency;electroacupuncture may have a stronger effect in lowering UA;and floating acupuncture may be more beneficial in improving Visual Analogue Scale.2.The literature included in this study was generally at moderate risk of bias.The quality of the studies was generally poor,lacking large sample size studies and a closed loop between two comparisons.The implementation details of some of the interventions(e.g.,blood pricking,topical application of herbs,etc.)are complicated and varied.Also the sites of AGA are often diverse and the degree of resolution of its acute symptoms is dependent on multiple follow-up visits over a short period of time.Follow-up still relies on more high-quality RCT of large size,detailed treatment,and follow-up to provide higher-grade evidence on the comprehensive efficacy ranking of Traditional Chinese Medicine external treatment methods for AGA. |
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