摘要
粒细胞巨噬细胞集落刺激因子(granulocyte-macrophage colony-stimulating factor, GM-CSF)是一种作用广泛的细胞因子,由Burgess等在肺条件培养液中首次发现,因能刺激粒细胞巨噬细胞集落形成而得名。随着对GM-CSF基础和临床研究的不断深入,重组人GM-CSF (recombinant human GM-CSF, rhGM-CSF)已经广泛应用于临床治疗的各个领域。作为近十年来研究的热门细胞因子,其用于创面的治疗是近年来人们一直关注的问题。
GM-CSF具有多种生物学活性,能刺激骨髓造血前体细胞增殖、分化以及成髓细胞向中性粒细胞、嗜酸粒细胞和巨噬细胞的转化。GM-CSF局部外用于创面时可以启动创伤修复的连锁反应,调节在创伤修复过程中发挥重要作用的成熟的巨噬细胞、中性粒细胞、内皮细胞、上皮细胞以及成纤维细胞的增殖和活化,诱导炎性细胞和内皮细胞迁移,阻止其从伤口逃逸,诱导角质细胞增殖和分化,并使朗格罕氏细胞进入真皮,从而促进伤口的修复。
动物实验表明,局部应用GM-CSF可促进糖尿病小鼠、免疫抑制或阿霉素处理大鼠创面的愈合,并在多种原因造成的创面或创口(如烧伤创面、全层皮肤缺损、慢性肉芽创面、阿霉素所致的组织坏死、放创复合伤创面及外科切口等)均取得了良好的疗效。临床上已有多篇报道证实,局部应用rhGM-CSF可有效、安全地治疗多种原因导致的急、慢性创面(如静脉性溃疡、糖尿病性溃疡、压力性溃疡、镰刀性贫血患者下肢溃疡、羟基脲所致溃疡、血红蛋白病相关性溃疡等),促进创面的愈合。
rhGM-CSF应用于烧伤创面的临床研究局限于促进深Ⅱ度早期创面的愈合。其是否能促进烧伤后残余创面的愈合目前尚不清楚。而烧伤后残余创面不同于烧伤后早期创面,有着特殊的形成原因和发生机制,本质上属于难愈性慢性创面,因此rhGM-CSF治疗烧伤后残余创面是否也可以取得良好的疗效,需要通过临床试验进行证实。
尽管有很多动物实验及临床研究报造了GM-CSF应用于创面的有效性和安全性,但也有一些研究显示出不一致的结果。一项随机、双盲、安慰剂对照研究结果显示GM-CSF不能促进小鼠切割伤口的愈合。另一项动物实验也发现GM-CSF并不能降低大鼠外科手术后切口疝的发生率。体内及体外实验均发现局部应用GM-CSF能抑制胶原的沉积,并呈剂量依赖性,可能减缓外科伤口的组织修复进程。不仅如此,临床研究还显示rhGM-CSF不能影响健康受试者表浅创面的愈合；如果没有联合应用其它生长因子,对于压力性溃疡也无明显疗效。
由于存在以上矛盾的研究观点,因此有必要对rhGM-CSF局部应用于创面的随机对照试验(randomized control trial, RCT)进行系统评价,以准确地了解rhGM-CSF局部应用于创面的有效性和安全性。有关的第一篇系统评价文献检索截止于2010年1月,其中关于rhGM-CSF局部应用于烧伤创面的Meta分析是不正确的。时隔一年之后,我们获得了rhGM-CSF局部应用于烧伤后残余创面的RCT数据,显然有必要对rhGM-CSF局部应用于烧伤创面的RCT重新进行系统评价,以准确地了解rhGM-CSF局部应用于烧伤创面的有效性和安全性。
基于上述的两个研究目的,本研究主要包括两个部分：第一部分为rhGM-CSF凝胶治疗烧伤后残余创面的临床试验研究；第二部分为rhGM-CSF凝胶治疗烧伤创面的有效性和安全性的系统评价。另外,本文还对GM-CSF促进创面愈合的相关研究进行了综述(第三部分),以供参考。
第一部分：rhGM-CSF凝胶治疗烧伤后残余创面的临床试验研究
目的：评估局部应用rhGM-CSF凝胶治疗烧伤后残余创面的有效性和安全性,并对其作用机制进行初步探讨,以期为治疗烧伤后残余创面提供新的治疗药物,并为新药开发进一步提供实验依据。
方法：采用随机、双盲、安慰剂同体对照的研究方法,将138处烧伤后残余创面随机分为试验组(n=69)和对照组(n=69)。试验组采用rhGM-CSF凝胶[国药准字S20080003]治疗,对照组采用空白基质安慰剂治疗,试验周期为21 d。观察用药后局部不良反应和创面愈合时间,以及用药7、14 d的创面愈合率、总有效率。并于用药前及用药后7、14 d留取创缘组织标本(n=6),经HE染色,光学显微镜下观察各组创面肉芽组织中毛细血管和成纤维细胞的数量；免疫组化检测(EliVisionTM plus法)创面增殖细胞核抗原(PCNA)、转化生长因子-β1(TGF-β1)和血管内皮生长因子(VEGF)的表达。数据处理采用SPSS 13.0统计学软件,并进行意向性(intention-to-treat, ITT)分析。P<0.05表明有统计学意义。
结果：本试验共入组69例,脱落9例。纳入统计分析的为60例。试验组创面直径(3.70±0.69)cm,对照组创面直径(3.63±0.72)cm,两组比较,差异无统计学意义(P>0.05)。ITT分析结果：试验组创面直径(3.76±0.72)cm,对照组创面直径(3.71±0.75)cm,两组比较,差异无统计学意义(P>0.1)。
试验组创面愈合时间的中位数为12 d[95%可信区间(11-13)d],较对照组[18 d,95%可信区间(17-19)d]明显缩短(P<0.001)。用药7、14 d后,试验组创面愈合率分别为(62±13)%、(95±10)%,均显著高于对照组[(46±11)%、(83±12)%,P<0.001]；试验组总有效率(30.00%、96.67%)均显著高于对照组(3.33%、83.33%,P<0.05)；试验组疗效明显优于对照组(P<0.001)。用药后局部不良反应以局部刺激为主,个别患者有轻微的局部红肿、疼痛现象,可自行消退。
ITT分析结果：试验组创面愈合时间的中位数为13d[95%可信区间(12-14)d],较对照组[18d,95%可信区间(17-19)d]明显缩短(P<0.001)。用药7、14 d后,试验组创面愈合率分别为(61±14)%、(94±11)%,均显著高于对照组[(45±11)%、(80±13)%,P<0.001]；试验组总有效率(29.00%、95.65%)均显著高于对照组(2.90%、76.81%,P<0.01)；试验组疗效明显优于对照组(P<0.001)。
用药7、14 d后,试验组创面肉芽组织中毛细血管数分别为10.30±0.58、14.47±0.93,均显著多于对照组[7.23±0.70、10.37±0.77,P<0.001]；试验组创面肉芽组织中成纤维细胞数分别为143.1±10.3、137.8±6.9,均显著多于对照组[110.2±11.7.126.4±7.7, P<0.01]。PCNA的阳性表达主要见于成纤维细胞及血管内皮细胞的胞核中,TGF-β1的阳性表达主要见于成纤维细胞及血管内皮细胞的胞质和细胞表面,VEGF的阳性表达主要见于血管内皮细胞、成纤维细胞及部分炎性细胞的胞质中。用药7、14 d试验组创面组织PCNA、TGF-β1、VEGF的表达均较对照组明显增强。
结论：局部应用rhGM-CSF凝胶能促进烧伤后残余创面的愈合,并且具有较好的安全性。rhGM-CSF凝胶对烧伤后残余创面的促愈合作用,可能与其促进烧伤后残余创面毛细血管生成和成纤维细胞的增殖或迁移以及创面PCNA、TGF-β1、VEGF的表达有关。
第二部分：rhGM-CSF凝胶治疗烧伤创面有效性和安全性的系统评价
目的：评价局部应用rhGM-CSF凝胶治疗烧伤创面的有效性和安全性,以期为临床提供一定的循证医学证据。
方法：根据研究目的,按PICO程式(Participant, Intervention, Comparator, Outcome)制定相应的详细的纳入与排除标准(包括研究特征、干预措施以及结局指标的测量),同时根据拟定的上述标准制定出系统、全面的检索策略。计算机检索PubMed (1950-2011.1)、EMBASE (1966-2011.1)、Cochranel临床试验注册资料库(-2011.1)、“万方数据资源系统”(1982-2011.1)、中国期刊全文数据库(CNKI) (1994-2011.1)、中国生物医学文献数据库(CBM)(1978-2011.1),主要检索词为“烧伤；烫伤；电损伤；化学性烧伤；放射性损伤；粒细胞巨噬细胞集落刺激因子；莫拉司亭；金扶宁”及其相应的英文术语。手工检索与烧伤创面用药相关的10种中文杂志(《中华烧伤杂志》、《中华创伤杂志》、《第三军医大学学报》、《中华外科杂志》、《中国修复重建外科杂志》、《中国实用外科杂志》、《中国新药杂志》、《中国新药与临床杂志》、《中国医院药学杂志》、《中国现代应用药学》)。并用Google等搜索引擎从互联网上查找相关的文献；参阅已纳入研究的参考文献以及应用其它扩展检索方法。由两名评价员独立选择研究、进行文献筛查、质量评价和资料提取并进行核对,如遇意见不一致双方讨论解决或由第三者判断,缺乏的资料尽量与作者联系予以补充。对纳入研究的方法学质量评价主要从随机方法、分配隐藏、盲法、随访四个方面进行。采用Cochrane协作网提供的Revman 5.0.17软件进行统计分析。二分类变量采用比值比(odds ratio, OR)表示；连续性变量采用标准化差值(standardized mean difference, SMD)表示,两者均计算95%的可信区间(confidence interval, CI)。各研究合并前先分析临床异质性,若有则考虑行亚组分析。研究间统计学异质性检验采用卡方检验,以a=0.10作为检验水准。P<0.1及I2>50%时,表明存在统计学异质性。无统计学异质性时采用固定效应模型分析。如存在统计学异质性,分析异质性原因,采用敏感性分析、亚组分析和随机效应模型处理。P<0.05表明有统计学意义。对无法定量合成或极低事件发生率的测量指标,则通过描述进行定性评价。
结果：共纳入3个符合要求的RCT,共包括烧伤患者422例,其中试验组260例(采用rhGM-CSF凝胶治疗),对照组162例(采用空白基质安慰剂治疗)。所纳入的研究根据随机方法、分配隐藏、盲法、随访四项指标进行方法学质量评价,结果为B级2个,A级1个。由于存在临床异质性,分别对测量指标行亚组分析(根据创面类型分为两个亚组)。
Meta分析结果：(1) rhGM-CSF凝胶和安慰剂对用药后8d创面愈合率的影响：亚组内分析SMD分别为0.51、1.44,95%C1分别为[0.27,0.75]、[1.04,1.84],P<0.0001。亚组间异质性检验结果为：Chi2=14.89, P=0.0001, I2=93%,表明存在统计学异质性,故采用随机效应模型计算总结果,合并后的SMD为0.96,95%CI为[0.05,1.87],P=0.04。敏感性分析结果显示统计推断结果稳定性良好。(2)rhGM-CSF凝胶和安慰剂对用药后14 d创面愈合率的影响：亚组内分析SMD分别为0.63、1.09,95%C1分别为[0.38,0.87]、[0.70,1.47],P<0.00001。亚组间异质性检验结果为：Chi2=3.95,P=0.05,I2=75%,表明存在统计学异质性,故采用随机效应模型计算总结果,合并后的SMD为0.83,95%CI为[0.38,1.28],P=0.0003。敏感性分析结果显示统计推断结果稳定性良好。(3)rhGM-CSF凝胶和安慰剂对创面愈合时间的影响：亚组间异质性检验结果为：Chi2=83.36,P< 0.00001,I2=99%,表明统计学异质性过大,故放弃进行效应量合并。亚组内分析SMD分别为-7.79、-1.44,95%C1分别为[-9.09,-6.50]、[-1.86,-1.03],P<0.00001。(4)rhGM-CSF凝胶和安慰剂对用药后8d,总有效率的影响：亚组内分析OR分别为2.55、11.81,95%C1分别为[1.55,4.19]、[3.31,42.15],P<0.001。亚组间异质性检验结果为：Chi2=4.93,P=0.03,I2=80%,表明存在统计学异质性,故采用随机效应模型计算总结果,合并后的OR为4.89,95%CI为[1.09,21.91],P=0.04。敏感性分析结果显示统计推断结果稳定性良好。(5)rhGM-CSF凝胶和安慰剂对用药后14d总有效率的影响：亚组内分析OR分别为3.01、5.80,95%C1分别为[1.47,6.17]、[1.21,27.73],P<0.05。亚组间异质性检验结果为：Chi2=0.57, P=0.45,I2=0%,表明满足统计学同质性,故采用固定效应模型计算总结果,合并后的OR为3.48,95%CI为[1.82,6.65],P=0.0002。敏感性分析结果显示统计推断结果稳定性良好。
安全性评价结果显示局部应用rhGM-CSF凝胶治疗烧伤创面的不良反应以局部刺激为主,个别患者有轻微的局部红肿、疼痛现象,可自行消退,未见与rhGM-CSF有关的全身不良反应。
结论：局部应用rhGM-CSF凝胶治疗烧伤创面具有良好的疗效和安全性。由于存在发表偏倚等局限性,可能对本研究结果的证据强度会产生一定的影响。期待进行更多高质量的随机双盲对照试验,以提供坚实、可靠的证据。
Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a cytokine with pleiotropic functions. Found in lung-conditioned medium by Burgess et al., it was named for its ability to stimulate the formation of a granulocyte and macrophage colony. With progress in the basic and clinical research of GM-CSF, recombinant human GM-CSF (rhGM-CSF) has been widely used in the clinical treatment of many conditions. As the most attractive cytokine of research in the last 10 years, the application of rhGM-CSF in the treatment of wounds has become popular increasingly.
GM-CSF has multifarious biologic effects such as stimulating proliferation and differentiation of hematopoietic progenitor cells in the myeloid and myeloblasts into neutrophils, eosinophils and macrophages. The topical application of GM-CSF on wounds starts a cascade reaction of trauma repair to improve wound healing. GM-CSF promotes the proliferation and activation of mature macrophages, neutrophils, endothelial cells, epithelial cells and fibroblasts, which are important in the reparative process after trauma. The underlying mechanisms of GM-CSF also include attracting inflammatory cells and endothelial cells with subsequent prevention from escaping the wound, inducing the proliferation and differentiation of epidermal keratinocytes, and attracting Langerhans cells into dermal layers.
Locally administered GM-CSF can enhance the wound healing in diabetic mice, immuno-suppressed or adriamycin-treated rats. Other animal experiments also reported beneficial effects including burns, full-thickness wounds, chronic granulating wounds, doxorubicin induced tissue necrosis, radiation-impaired wound, as well as surgical incisions. Clinically, locally applied rhGM-CSF assists wound healing of diverse etiologies including venous ulcers, diabetic ulcers, pressure ulcers, sickle cell leg ulcers, hydroxycarbamide-related leg ulcers, hemoglobinopathy-related ulcers and so on.
The topical application of rhGM-CSF on burn wounds has been only reported for wounds early after deep second-degree burns. Until now, whether rhGM-CSF can accelerate healing of residual burn wounds is not clear. Residual burn wounds are difference from wounds early postburn, which are non-healing chronic wounds with particular forming causation and mechanism. So it is necessary to perform a clinical trial to evaluate the efficacy of rhGM-CSF in the topical treatment of residual burn wounds.
Although many animal experiments and clinical studies have reported the beneficial efficacy and safety of GM-CSF in the topical treatment of various wounds, there are some studies with negative results. A randomized, double-blind, placebo-controlled study has showed GM-CSF did not significantly accelerate the healing rate in murine excisional wounds model. Another animal experiment also found GM-CSF did not significantly decrease the incidence of incisional hernias in rats. Both in vitro and in vivo study demonstrated GM-CSF treatment suppressed specifically and dose-dependently collagen deposition and may impair tissue repair processes during surgery. Except that, rhGM-CSF was shown to have no effect on the healing of the superficial wounds in healthy volunteers, and have no effect on pressure ulcers if used without other growth factors.
Owing to above inconsistent conclusions, it is necessary to conduct a systematic review of randomized controlled trials (RCT) of locally administered rhGM-CSF on wounds and adequately evaluate its efficacy and safety. The first relevant systematic review searched various databases up to January 2010, of which the Meta analysis about locally administered rhGM-CSF on burn wounds is incorrect. In addition, we have obtained the observation data of locally applied rhGM-CSF on residual burn wounds one year later. It is necessary to conduct a new systematic review of RCT for local rhGM-CSF administration on burn wounds and evaluate its efficacy and safety more adequately.
Based on above-mentioned two aims, this study consists of two parts mainly: PartⅠ:A clinical trial of rhGM-CSF hydrogel for the treatment of residual burn wounds. PartⅡ:Systematic review for efficacy and safety of rhGM-CSF hydrogel for the treatment of burn wounds. In addition, the relevant studies on accelerating wound healing effect of GM-CSF were introduced for reference (PartⅢ).
PartⅠ:A clinical trial of rhGM-CSF hydrogel for the treatment of residual burn wounds
Objective:Aim to evaluate the efficacy and safety of topical rhGM-CSF hydrogel treatment for residual burn wounds and explore the potential mechanisms. Our study will help find a new way for treating residual burn wounds and reveal new pharmacological basis for drug exploiture.
Methods:The study was a randomized, double-blind, placebo-controlled and self-controlled clinical trial. One hundred and thirty-eight residual burn wounds were divided into group A(n= 69, with treatment of rhGM-CSF hydrogel [State Drug Approval Document No:S20080003]) and group C (n= 69, with treatment of placebo), which were treated for 21 days totally. Local adverse reaction, wound healing time and wound healing rate, total effective rate at the 7th and 14th day after treatment were investigated. The wound tissue samples (n=6) around the residual burn wounds at different time points were obtained for taking count of blood capillaries and fibroblasts through optical microscope and evaluating the expression change of proliferating cell nuclear antigen (PCNA), transforming growth factor-β1 (TGF-β1) and vascular endothelial growth factor (VEGF) through EliVisionTM plus method. The statistical analysis was done with SPSS13.0 software. Intention-to-treat (ITT) analysis was performed. A two-sided P<0.05 was considered significant.
Results:Sixty-nine patients with residual burn wounds were enrolled in this study. Nine patients dropped out of the trial. The data of sixty patients were analyzed. The wound diameter in group A was (3.70±0.69) cm, which was (3.63±0.72) cm in group C. There were no differences between two groups (P> 0.05). ITT analysis results:The wound diameter in group A was (3.76±0.72) cm, which was (3.71±0.75) cm in group C. There were no differences between two groups (P>0.1).
The median wound healing time was 12 (95%CI:11-13) days in group A, which was significantly shorter than that in group C [18 (95%CI:17-19) days, P<0.001]. The wound healing rate in group A was (62±13)% and (95±10)% respectively at the 7th and 14th day after remedy, which was significantly higher than that in group C [(46±11)% and (83±12)%, P<0.001]. The total effective rates in group A (30.00% and 96.67%) were also higher than that in group C [3.33% and 83.33%, P<0.05]. The therapeutic efficacy of group A was significantly better than group C(P<0.001). The main adverse event after remedy was local irritating. Local slight red and swollen with mild pain was found in the wound of a few cases, which disappeared without management.
ITT analysis results:The median wound healing time was 13 (95%CI:12-14) days in group A, which was significantly shorter than that in group C [18 (95%CI: 17-19) days, P<0.001]. The wound healing rate in group A was (61±14)% and (94±11)% respectively at the 7th and 14th day after remedy, which was significantly higher than that in group C [(45±11)% and (80±13)%, P<0.001]. The total effective rates in group A (29.00% and 95.65%) were also higher than that in group C [2.90% and 76.81%, P< 0.01]. The therapeutic efficacy of group A was significantly better than group C(P< 0.001).
At the 7th and 14th day after remedy, histopathology showed the number of blood capillaries (10.30±0.58 and 14.47±0.93 respectively) and fibroblasts (143.1±10.3 and 137.8±6.9 respectively) in group A was significantly increased compared with group C (blood capillaries:7.23±0.70 and 10.37±0.77; fibroblasts 110.2±11.7 and 126.4±7.7) respectively (P<0.01 in all). It was found the positive expression of PCNA in the cell nucleus of fibroblasts and endothelial cells, TGF-β1 in the cytoplasm and surface of fibroblasts and endothelial cells, VEGF in the cytoplasm of endothelial cells, fibroblasts and some inflammatory cells. The expression intensity of PCNA, TGF-β1 and VEGF in wound tissue of group A was also significantly higher than that in group C at the 7th and 14th day after remedy.
Conclusions:Topical rhGM-CSF hydrogel treatment can accelerate healing of residual burn wounds with superior safety. Its mechanism may be in association with promoting blood capillaries formation, inducing the proliferation or transferring of fibroblasts and increasing expression intensity of PCNA, TGF-β1 and VEGF in wound tissue.
Part II:Systematic review for efficacy and safety of rhGM-CSF hydrogel for the treatment of burn wounds
Objective:To systematic evaluate the efficacy and safety of topical rhGM-CSF hydrogel treatment of burn wounds and provide evidence-based medicine study information for clinical practice.
Methods:According to research purposes, the appropriate detailed inclusion and exclusion criteria (including study characteristics, interventions and measurement of outcome) were constituted by PICO program (Participant, Intervention, Comparator, Outcome) and a systematic and comprehensive search strategy was formulated according to above-mentioned standards. We searched PubMed (1950 through Jan.2011.); EMBASE (1966 through Jan.2011.); Cochrane Central Register of Controlled Trials (up to Jan.2011.); WANFANG Database (1982 through Jan. 2011.); The Chinese Journal Full-text databases (1994 through Jan.2011.); The Chinese Biomedical Database (CBM)(1978 through Jan.2011.). The review used a subject and text word strategy with "burns; scald; electric injuries; chemical injuries; radiation injuries; granulocyte-macrophage colony-stimulating factor; molgramostim; leucomax; mielogen" and relevant Chinese terms as the primary search terms, handsearched 10 Chinese journals related to drugs for external use in burn wounds (Zhonghua Shao Shang Za Zhi, Chinese Journal of Trauma, Acta Academiae Medicinae Militaris Tertiae, Chinese Journal of Surgery, Chinese Journal of Reparative and Reconstructive Surgery, Chinese Journal of Practical Surgery, Chinese Journal of New Drugs, Chinese Journal of New Drugs and Clinical Remedies, Chinese Journal of Hospital Pharmacy, Chinese Journal of Modern Applied Pharmacy) and searched correlative websites, such as "google". The studies covered the references of eligible studies were additionally searched. Some other expand search methods were also used. At least two reviewers independently screen the studies for eligibility, evaluated the quality and extracted the data from the eligible studies, with confirmation of cross-check. Different opinions would be solved by the third party. The methodological quality of included studies such as randomization, allocation concealment, blinding and attrition was evaluated. The lacking data was obtained through contacting with author at full steam. Meta-analyses were conducted using Revman Analyses software (Revman 5.0.17) of the Cochrane Collaboration. We would use odds ratio (OR) for binary data, standardized mean difference (SMD) for continuous data with 95% confidence intervals (CI). The clinical heterogeneity would be analyzed before pooling data. Subgroup analysis would be performed if there was clinical heterogeneity. We would use Chi-square test to evaluate heterogeneity among various study with the test level of a=0.10. Heterogeneity was tested using the I2-statistic with values>50% and Chi-square test with P<0.1 indicating strong heterogeneity. Data without heterogeneity could be pooled using fixed effect model, and those with heterogeneity could be solved by sensitivity analysis, subgroup analysis or randomized effect model. A two-sided P<0.05 was considered significant. We will use non-quantitative synthesis for outcome that cannot be pooled or with a very low incidence.
Results:Three studies (422 Patients with burn wounds) were included. There were 260 cases in the treatment group (with treatment of rhGM-CSF hydrogel) and 162 cases in the control group (with treatment of placebo). All included studies were graded in term of randomization, allocation concealment, blinding and attrition. Two studies were graded B and the other one was graded A. Subgroup analyses (two subgroups according to wound category) were performed because of the existed clinical heterogeneity.
Meta analysis results:(1) Effects on the 8th day wound healing rate of rhGM-CSF hydrogel vs. placebo:Meta analysis within subgroups showed that SMD of the two subgroups were 0.51 (95%CI:0.27-0.75) and 1.44 (95%CI:1.04-1.84), P< 0.0001. Heterogeneity existed between subgroups (Chi2=14.89, P=0.0001, I2= 93%) and the random effect model was selected for pooling the effects. The pooled SMD was 0.96 (95%CI:0.05-1.87), P=0.04. Sensitivity analysis results indicated that the stability of statistical inference was good. (2) Effects on the 14th day wound healing rate of rhGM-CSF hydrogel vs. placebo:Meta analysis within subgroups showed that SMD of the two subgroups were 0.63 (95%CI:0.38-0.87) and 1.09 (95%CI:0.70-1.47), P<0.00001. Heterogeneity existed between subgroups (Chi2= 3.95, P=0.05, I2=75%) and the random effect model was selected for pooling the effects. The pooled SMD was 0.83 (95%CI:0.38-1.28), P=0.0003. Sensitivity analysis results indicated that the stability of statistical inference was good. (3) Effects on the wound healing time of rhGM-CSF hydrogel vs. placebo:Heterogeneity between subgroups (Chi2=83.36, P<0.00001,I2=99%) was too strong and pooling the effects was given up. Meta analysis within subgroups showed that SMD of the two subgroups were-7.79 (95%CI:-9.09--6.50) and-1.44 (95%CI:-1.86-1.03), P< 0.00001. (4) Effects on the 8th day total effective rate of rhGM-CSF hydrogel vs. placebo:Meta analysis within subgroups showed that OR of the two subgroups were 2.55 (95%CI:1.55-4.19) and 11.81 (95%CI:3.31-42.15), P<0.001. Heterogeneity existed between subgroups (Chi2=4.93, P=0.03,I2=80%) and the random effect model was selected for pooling the effects. The pooled OR was 4.89 (95%CI: 1.09-21.91), P=0.04. Sensitivity analysis results indicated that the stability of statistical inference was good. (5) Effects on the 14th day total effective rate of rhGM-CSF hydrogel vs. placebo:Meta analysis within subgroups showed that OR of the two subgroups were 3.01 (95%CI:1.47-6.17) and 5.80 (95%CI:1.21-27.73), P< 0.05. Homogeneity existed between subgroups (Chi2=0.57, P=0.45,I2=0%) and the fixed effect model was selected for pooling the effects. The pooled OR was 3.48 (95%CI:1.82-6.65), P=0.0002. Sensitivity analysis results indicated that the stability of statistical inference was good.
Evaluation results of safety:The main adverse event of locally administered rhGM-CSF on burn wounds was local irritating. Local slight red and swollen with mild pain was found in the wound of a few cases, which disappeared without management. Any systemic adverse reaction related to rhGM-CSF hydrogel was not observed.
Conclusions:Locally applied rhGM-CSF hydrogel has a positive effect on burn wounds with certain safety. Owing to possibility of selection bias in included studies, there may be a negative impact on evidence intensity of our results. We expect that future systematic review could involve more high quality evidences provided by high quality double-blind randomized control trials.
引文
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