The relationship of publication language, study population, risk of bias, and treatment effects in acupuncture related systematic reviews: a meta-epidemiologic study.

BACKGROUND: There are debates in acupuncture related systematic reviews and meta-analyses on whether searching Chinese databases to get more Chinese-language studies may increase the risk of bias and overestimate the effect size, and whether the treatment effects of acupuncture differ between Chinese and non-Chinese populations. METHODS: In this meta-epidemiological study, we searched the Cochrane library from its inception until December 2021, and identified systematic reviews and meta-analyses with acupuncture as one of the interventions. Paired reviewers independently screened the reviews and extracted the information. We repeated the meta-analysis of the selected outcomes to separately pool the results of Chinese- and non-Chinese-language acupuncture studies and presented the pooled estimates as odds ratios (OR) with 95% confidence interval (CI). We calculated the Ratio of ORs (ROR) by dividing the OR of the Chinese-language trials by the OR of the non-Chinese-language trials, and the ROR by dividing the OR of trials addressing Chinese population by the OR of trials addressing non-Chinese population. We explored whether the impact of a high risk of bias on the effect size differed between studies published in Chinese- and in non-Chinese-language, and whether the treatment effects of acupuncture differed between Chinese and non-Chinese population. RESULTS: We identified 84 Cochrane acupuncture reviews involving 33 Cochrane groups, of which 31 reviews (37%) searched Chinese databases. Searching versus not searching Chinese databases significantly increased the contribution of Chinese-language literature both to the total number of included trials (54% vs. 15%) and the sample size (40% vs. 15%). When compared with non-Chinese-language trials, Chinese-language trials were associated with a larger effect size (pooled ROR 0.51, 95% CI 0.29 to 0.91). We also observed a higher risk of bias in Chinese-language trials in blinding of participants and personnel (97% vs. 51%) and blinding of outcome assessment (93% vs. 47%). The higher risk of bias was associated with a larger effect estimate in both Chinese-language (allocation concealment: high/unclear risk vs. low risk, ROR 0.43, 95% CI 0.21 to 0.87) and non-Chinese-language studies (blinding of participants and personnel: high/unclear risk vs. low risk, ROR 0.41, 95% CI 0.23 to 0.74). However, we found no evidence that the higher risk of bias would increase the effect size of acupuncture in Chinese-language studies more often than in non-Chinese-language studies (the confidence intervals of all ROR in the high-risk group included 1, Table 3). We further found acupuncture appeared to be more effective in Chinese than in non-Chinese population (Table 4). CONCLUSIONS: The findings of this study suggest the higher risk of bias may lead to an overestimation of the treatment effects of acupuncture but would not increase the treatment effects in Chinese-language studies more often than in other language studies. The difference in treatment effects of acupuncture was probably associated with differences in population characteristics. TRIAL REGISTRATION: We registered our protocol on the Open Science Framework (OSF) ( https://doi.org/10.17605/OSF.IO/PZ6XR ).

Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of deep vein thrombosis.

BACKGROUND: Deep vein thrombosis (DVT) is a condition in which a clot forms in the deep veins, most commonly of the leg. It occurs in approximately one in 1000 people. If left untreated, the clot can travel up to the lungs and cause a potentially life-threatening pulmonary embolism (PE). Previously, a DVT was treated with the anticoagulants heparin and vitamin K antagonists. However, two forms of direct oral anticoagulants (DOACs) have been developed: oral direct thrombin inhibitors (DTIs) and oral factor Xa inhibitors, which have characteristics that may be favourable compared to conventional treatment, including oral administration, a predictable effect, lack of frequent monitoring or dose adjustment and few known drug interactions. DOACs are now commonly being used for treating DVT: recent guidelines recommended DOACs over conventional anticoagulants for both DVT and PE treatment. This Cochrane Review was first published in 2015. It was the first systematic review to measure the effectiveness and safety of these drugs in the treatment of DVT. This is an update of the 2015 review.  OBJECTIVES: To assess the effectiveness and safety of oral DTIs and oral factor Xa inhibitors versus conventional anticoagulants for the long-term treatment of DVT. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 March 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which people with a DVT, confirmed by standard imaging techniques, were allocated to receive an oral DTI or an oral factor Xa inhibitor compared with conventional anticoagulation or compared with each other for the treatment of DVT.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were recurrent venous thromboembolism (VTE), recurrent DVT and PE. Secondary outcomes included all-cause mortality, major bleeding, post-thrombotic syndrome (PTS) and quality of life (QoL). We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We identified 10 new studies with 2950 participants for this update. In total, we included 21 RCTs involving 30,895 participants. Three studies investigated oral DTIs (two dabigatran and one ximelagatran), 17 investigated oral factor Xa inhibitors (eight rivaroxaban, five apixaban and four edoxaban) and one three-arm trial investigated both a DTI (dabigatran) and factor Xa inhibitor (rivaroxaban). Overall, the studies were of good methodological quality. Meta-analysis comparing DTIs to conventional anticoagulation showed no clear difference in the rate of recurrent VTE (odds ratio (OR) 1.17, 95% confidence interval (CI) 0.83 to 1.65; 3 studies, 5994 participants; moderate-certainty evidence), recurrent DVT (OR 1.11, 95% CI 0.74 to 1.66; 3 studies, 5994 participants; moderate-certainty evidence), fatal PE (OR 1.32, 95% CI 0.29 to 6.02; 3 studies, 5994 participants; moderate-certainty evidence), non-fatal PE (OR 1.29, 95% CI 0.64 to 2.59; 3 studies, 5994 participants; moderate-certainty evidence) or all-cause mortality (OR 0.66, 95% CI 0.41 to 1.08; 1 study, 2489 participants; moderate-certainty evidence). DTIs reduced the rate of major bleeding (OR 0.58, 95% CI 0.38 to 0.89; 3 studies, 5994 participants; high-certainty evidence).   For oral factor Xa inhibitors compared with conventional anticoagulation, meta-analysis demonstrated no clear difference in recurrent VTE (OR 0.85, 95% CI 0.71 to 1.01; 13 studies, 17,505 participants; moderate-certainty evidence), recurrent DVT (OR 0.70, 95% CI 0.49 to 1.01; 9 studies, 16,439 participants; moderate-certainty evidence), fatal PE (OR 1.18, 95% CI 0.69 to 2.02; 6 studies, 15,082 participants; moderate-certainty evidence), non-fatal PE (OR 0.93, 95% CI 0.68 to 1.27; 7 studies, 15,166 participants; moderate-certainty evidence) or all-cause mortality (OR 0.87, 95% CI 0.67 to 1.14; 9 studies, 10,770 participants; moderate-certainty evidence). Meta-analysis showed a reduced rate of major bleeding with oral factor Xa inhibitors compared with conventional anticoagulation (OR 0.63, 95% CI 0.45 to 0.89; 17 studies, 18,066 participants; high-certainty evidence).  AUTHORS' CONCLUSIONS: The current review suggests that DOACs may be superior to conventional therapy in terms of safety (major bleeding), and are probably equivalent in terms of efficacy. There is probably little or no difference between DOACs and conventional anticoagulation in the prevention of recurrent VTE, recurrent DVT, pulmonary embolism and all-cause mortality. DOACs reduced the rate of major bleeding compared to conventional anticoagulation. The certainty of evidence was moderate or high.

Systematic review and meta-analysis of vitamin D deficiency in different pregnancy on preterm birth: Deficiency in middle pregnancy might be at risk.

BACKGROUND: Current studies suggest that vitamin D deficiency during pregnancy can produce a certain effect for preterm birth (PTB), but there is no research showing whether vitamin D deficiency has a consistent effect in different pregnancies; thus, we conducted a systematic review and meta-analysis of 24 observational studies, grouping them according to the gestational age at the time of serum sampling, to investigate whether vitamin D deficiency in different periods of gestation has different effects on PTB and to provide an evidence-based basis for pregnant women to measure and supplement vitamin D. METHODS: The databases PubMed-Medline, EMBASE, the Cochrane Library, Web of Science, EBSCO, CBM, and CNKI were searched until February 2020. Two researchers independently assessed the eligibility and quality of studies, and STATA 12.0 software was used for meta-analysis. RESULT: Seven cohort studies, 13 case-control studies, and 4 cross-sectional studies were included from 2500 articles by inclusion and exclusion criteria. After adjusting for age, race, and other confounding factors, meta-analysis results showed that vitamin D deficiency in the first trimester, the second trimester, and the third trimester did not increase the risk of PTB (odds ratio (OR) = 1.01, 95% confidence interval (CI) (0.88, 1.16), P = .867; OR = 1.12, 95%CI (0.92, 1.37), P = .249; OR = 1.05, 95%CI (0.87, 1.27), P = .602). However, there was moderate heterogeneity in the study of vitamin D deficiency in the second trimester, and subgroup analysis suggested that vitamin D deficiency in the second trimester may increase the risk of PTB (OR = 1.33, 95%CI (1.15, 1.54), P = .000). A sensitivity analysis of the second trimester showed that excluding any 1 study did not significantly change the results. CONCLUSIONS: Vitamin D deficiency in early and late pregnancy may not be associated with PTB, while vitamin D deficiency in middle pregnancy is likely to have an important effect on PTB. Vitamin D levels should be measured in the second trimester of pregnancy, and vitamin D supplements should be provided if necessary.

Efficacy and safety of phytoestrogens in the treatment of perimenopausal and postmenopausal depressive disorders: A systematic review and meta-analysis.

BACKGROUND: Depression is one of the most common and specific symptoms among menopausal women, leading to significant personal, family, and economic burdens. Some studies have shown that phytoestrogens can help relieve symptoms of depression. OBJECTIVES: This systematic review and meta-analysis aim to assess the efficacy and safety of phytoestrogens in treating depression among menopausal women. METHODS: A comprehensive search for relevant studies published until November 25, 2020, was conducted in PubMed, the Cochrane Library, Chinese Biomedical Literature Database, Web of Science, and EMBASE. Statistical analyses were performed with R 4.0.3.and Review Manager 5.4. RESULTS: 2183 studies were identified and 10 studies with 15 independent reports were included, involving 1248 participants. The quality of the four studies was assessed as high risk, six studies were assessed as unclear. The analyses conducted according random effects model indicated the significant positive effect on depressive symptoms for postmenopausal women compared with the placebo (SMD = -0.62; 95% CI = -1.13 to -0.12; Q = 45.62, df = 14, P < .01; I2  = 79%). The low dose phytoestrogens (25 mg/d ≤ dose ≤ 100 mg/d) have better effectiveness (SMD = -0.52; 95% CI = -0.85 to -0.20; I2  = 79%, P< .01) than high dose (dose > 100 mg/d) and ultralow dose (0 < dose < 25 mg/d), but showed no statistical significance (Q = 0.81 df = 2, P = .67). Isoflavones had better effectiveness (SMD = -0.48; 95% CI = -0.75 to 0.21; I2  = 75%, P < .01) than lignans of phytoestrogens (SMD = -0.22; 95% CI = -0.37 to 0.08; I2  = 0%, P = .96). The duration of intervention affects the efficacy of phytoestrogens (ß = -0.03; 95% CI: [-0.05, 0.00]; P = .045). The effectiveness varies in regions. The adverse reactions frequently reported were gastrointestinal symptoms and cold or upper respiratory tract infection. CONCLUSIONS: Phytoestrogen can relieve depression symptoms among menopausal, especially for postmenopausal women who take low doses(25 mg/d ≤ dose ≤ 100 mg/d) of phytoestrogens for a long-term duration. Although mild adverse reactions have been reported, phytoestrogen could be considered as a complementary treatment for postmenopausal depression.

Electro-acupuncture vs. sham electro-acupuncture for chronic severe functional constipation: A systematic review and meta-analysis.

OBJECTIVES: To assess the efficacy of electro-acupuncture (EA) relative to sham electro-acupuncture (sham EA) in treating chronic severe functional constipation (CSFC). METHODS: A comprehensive search for relevant studies published between January 1, 1951 and May 14, 2020 was conducted in PubMed, the Cochrane Library, Chinese Biomedical Literature Database, Web of Science, and EMbase. Two investigators independently selected studies, extracted data, and assessed the quality of the included studies. The software Endnote X9 was used for screening articles, and the Review Manager 5.3 for analyzing data. RESULTS: The meta-analyses involved 6 studies and 1457 individuals. The pooled results favored the EA group for the increase of complete spontaneous bowel movements (CSBMs) per week in the fourth week (MD = 0.80, P = 0.001) during treatment, and further improved in the eight weeks (MD = 1.25, P < 0.001). During the follow-up period, significant changes in CSBMs per week were seen in the experimental group (MD = 1.38, P = 0.008); the effect decreased in the twelfth week (MD = 0.87, P < 0.001). There was no significant difference in the Bristol stool scale score between the two groups in the fourth week (MD = 0.40, P = 0.08), but significant differences were observed in the eighth week (MD = 0.40, P = 0.03). A significant reduction in patient assessment of constipation quality of life (PAC-QOL) score were observed in the EA group during treatment (SMD = -0.83, P < 0.001). No serious adverse events were reported. CONCLUSIONS: EA had favorable effects on CSFC, and the longer the treatment duration was, the better was the effect, but the effect showed a certain period of validity. However, the results may be influenced by the clinical heterogeneity of acupuncture points, depth of needling, intensity, and frequency of EA.

Agaricus blazei extract (FA-2-b-ß) induces apoptosis in chronic myeloid leukemia cells.

Agaricus blazei Murill (AbM) is a mushroom belonging to the Basidiomycetes family, which is believed to have antitumor and antioxidative activities. Proteoglycans and ergosterol are considered the key compounds of AbM for antitumor properties and so are used in complementary and alternative medicine as an anticancer drug. AbM is used to avoid serious side effects that would inevitably affect patients. Currently, the efficacy of AbM against chronic myeloid leukemia (CML) has not been established. The present study aimed to investigate the antitumor activities of the acidic RNA protein complex, FA-2-b-ß, extracted from wild edible AbM. The CML K562 cells or primary CML bone marrow (BM) cells were treated with FA-2-b-ß at different concentrations and time points. CML cell line proliferation and apoptosis were determined using the CCK-8 assay or Annexin V/propidium iodide (PI) labeling, RT-qPCR and western blotting was performed to determine the involvement of the Wnt/ß-catenin-associated apoptotic pathway. The results of the present study demonstrated that FA-2-b-ß has a high anti-proliferative potency and strong pro-apoptotic effects. Thus, daily intake of mushrooms containing FA-2-b-ß may be an adequate source as an alternative medicine in the management of CML, and may provide useful information for the development of a novel therapeutic target in this area.

Use of AMSTAR-2 in the methodological assessment of systematic reviews: protocol for a methodological study.

BACKGROUND: Systematic reviews (SRs) with or without meta-analyses (MAs) are widely used in resolving questions in various healthcare areas (such as, traditional Chinese medicine, public health and surgery), and they are the cornerstone of evidence-based healthcare. However, the reliability of SRs is typically influenced by their methodological quality. AMSTAR (A Measurement Tool to Assess Systematic Reviews) and AMSTAR-2 tools can assess the methodological quality of SRs, and the use of AMSTAR has been investigated. However, AMSTAR-2 is now widely used to evaluate the methodological quality of SRs, but the use of AMSTAR-2 for determining the methodological quality of SRs has not yet been investigated and assessed thoroughly. Thus, we designed the present study to investigate the use of AMSTAR-2 in studies that assessed the methodological quality of a sample of SRs with the AMSTAR-2 and provide references to potential users of AMSTAR-2 tool. METHODS: Four commonly used electronic databases including PubMed, EmBase, the Cochrane Library, and Web of Science will be searched following a comprehensive search strategy to identify and retrieve studies that have used AMSTAR-2 tool for evaluating the methodological quality of SRs. Two independent authors will retrieve bibliometric information and methodological data, including all author names, time of publication, and journal names, whether a specific score value was given for each item, and whether overall quality assessment was performed. Descriptive statistical analyses will be used to present the study results, e.g., frequencies and percentages, mean and standard deviation (SD) or median and interquartile range (IQR). In addition, subgroup analyses will be performed to identify the methodological differences (e.g., the reporting of study designs included in SRs) between overviews and methodological studies. The risk ratio (RR) with 95% confidence interval (95% CI) will be calculated to measure the methodological differences. Cytoscape 3.7.1 software tool will be used to construct collaboration network maps. Further, Microsoft Office Excel 2016 and Stata 12.0 will be used to manage and analyze data. DISCUSSION: The results of this study will identify any gaps in the use of AMSTAR-2 and important bibliometric features, such as active researchers and journals, provide guidance to researchers in various healthcare areas (such as, traditional Chinese medicine and public health) for using AMSTAR-2 tool and help them in developing cooperation and submitting their manuscripts.

The effectiveness and safety of acupuncture for depression: An overview of meta-analyses.

PURPOSE: To provide an overview of existing meta-analysis (MAs) on the efficacy and safety of acupuncture for depression, and assess the methodological quality and the strength of evidence of the included MAs. METHODS: We searched MAs of randomized trials that have evaluated the effects of acupuncture on depression in three international and three Chinese databases from their inception until August 2019. The methodological quality of included MAs was evaluated with the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2), and the strength of evidence with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). We used the intra-class correlation coefficient (ICC) to assess reviewer agreement in the pre-experiment. RESULTS: We included 31 MAs and 59 RCTs. The results of included MAs were conflicting, our meta-analyses found that acupuncture may confer small benefit in reducing the severity of depression by end of treatment than no treatment/wait list/treatment as usual(SMD -0.74, 95% CI -1.06 to -0.41, eight trials, 624 participants), control acupuncture (invasive, non-invasive sham controls) (SMD 0.27, 95% CI -0.51 to -0.04, 20 trials, 1055 participants), antidepressants(Selective serotonin reuptake inhibitors (SSRI)/ Tetracyclic antidepressants(TCAs)) (SMD -0.28, 95% CI -0.46 to -0.10, 30 trials, 3068 participants), acupuncture plus antidepressants versus antidepressants(SSRI/TCAs) (SMD -0.99, 95% CI -1.37 to -0.61, 17 trials, 1110 participants). Subgroup analyses showed that there was no difference between electro-acupuncture and invasive control (P = 0.37), electro-acupuncture and non-invasive control (P = 0.90), manual acupuncture and Tetracyclic antidepressants (P = 0.57), electro-acupuncture and Tetracyclic antidepressants (P = 0.07). Six MAs concluded that acupuncture reduced the incidence of adverse events compared with antidepressants. The evaluation with AMSTAR-2 showed that the quality of included MAs was low or critically low. The results of the GRADE evaluation showed that the strength of evidence was low to very low for most outcomes. CONCLUSIONS: Although acupuncture appears to be more effective and safer than no treatment, control acupuncture and antidepressants, the quality of the available evidence was very low. Further methodologically rigorous and adequately powered primary studies are needed to confirm the effectiveness of acupuncture for depression.

The effectiveness of music therapy for patients with cancer: A systematic review and meta-analysis.

AIMS: To assess the effectiveness of music therapy on the quality of life, anxiety, depression and pain of patients with cancer. DESIGN: Systematic review. DATA SOURCES: Five electronic databases were searched in September 2018 for randomized controlled trials evaluating music therapy for patients with cancer. REVIEW METHODS: The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane Handbook Version 5.1.0 and the Revman version 5.3 software was used to perform the meta-analysis. The outcomes were overall quality of life, anxiety, depression and pain. RESULTS: A total of 19 trials evaluating 1,548 patients were included in this study, of which 765 were in the control group and 783 in the experimental group. Compared with standard care, music therapy can significantly increase the score of the overall quality of life in patients with cancer. In addition, music therapy was found to be more effective for decreasing the score of anxiety, depression and pain. CONCLUSION: Music therapy can improve the overall quality of life of patients with cancer, with an observed optimal intervention duration of 1-2 months. Meanwhile, anxiety, depression and pain are improved as well. Nevertheless, high-quality trials are still needed to further determine the effects of music intervention in supportive cancer care.

Acupoint injection treatment for primary osteoporosis: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Acupoint injection has currently received increasing attention as a treatment for primary osteoporosis (POP), This study aimed to evaluate the efficacy and safety of acupoint injection as a clinical treatment for POP. METHODS: Randomized controlled trials (RCTs) of acupoint injection compared with conventional non-acupoint injection for POP were identified in searches of seven databases from their inception to March 2019. All data were assessed and extracted by two authors independently. The risk of bias assessment recommended by the Cochrane Collaboration was used to assess the quality of the selected studies. RevMan 5.3 was used to conduct meta-analysis for the efficacy and safety of acupoint injection. RESULTS: Five trials with 337 patients (aged 45-86 years) with bone mineral density (BMD) ≤2 SD were included in our meta-analysis. The results showed that, compared with conventional intramuscular injection, acupoint injection significantly increased the BMD [mean difference (MD) =0.02; 95% CI, 0.01 to 0.03, P<0.00001]. Subgroup analysis indicated that acupoint injection significantly improved lumbar BMD (MD =0.02; 95% CI, 0.01 to 0.03, P<0.00001) but did not reduce the pain score (SMD =-2.29, 95% CI, -6.81 to 2.23, P>0.05). Individuals results showed that acupoint injection improved biochemical indicators, such as NBAP, IGF-I and reduced CTX and leptin levels. While the risk of bias was high in all five trials. CONCLUSIONS: This meta-analysis and systematic review suggests that acupoint injection improves BMD and some biochemical indicators in POP patients compared with the effects of conventional intramuscular injection. However, due to the high risk of bias in all the trials reviewed, the evidence remains inconclusive and future research will be required with improved methodological quality.

The association between calcium supplement and preeclampsia and gestational hypertension: a systematic review and meta-analysis of randomized trials.

OBJECTIVES: The purpose of this study is to investigate whether calcium supplement with or without other drugs could reduce the risk of preeclampsia and gestational hypertension based on existed evidence, and to clarify whether there is discrepant effect among different population and using different dose. METHODS: PubMed, Cochrane library, and EMBASE database were searched. Two authors independently screened all records and extracted data. The meta-analysis was performed to calculate risk ratios and 95% CIs using random-effects models. RESULTS: 27 studies, with 28 492 pregnant women were included. The results showed calcium supplement was associated with lower incidence of preeclampsia (RR 0.51, 95% CI: 0.40 to 0.64) and gestational hypertension (RR 0.70, 95% CI: 0.60 to 0.82). Sub-analyses revealed high-dose (1.2-2 g/day), moderate-dose (0.6-1.2 g/day), and low-dose (<0.6 g/day) of calcium supplement could reduce the risk of preeclampsia. For gestational hypertension, only high dose and moderate dose groups were associated with reducing the risk of gestational hypertension. However, we could draw a conclusion which does group was the most protective, as we were unable to directly compare the effects of different doses. CONCLUSIONS: This study indicated calcium supplementation might decrease the risk of preeclampsia and gestational hypertension. And results of subgroups analyses enhanced our confidence to the protective effect of calcium supplementation. However, further studies with direct comparison of different dose of calcium supplementation are needed to explore the ideal dose of calcium supplementation to prevent preeclampsia and gestational hypertension.

Acupuncture for treatment of anxiety, an overview of systematic reviews.

PURPOSE: To evaluate the methodological quality and summarize evidence of important outcomes of systematic reviews (SRs)/Meta analyses (MAs) of acupuncture for anxiety. METHODS: We conducted a comprehensive literature search for SRs/MAs in PubMed, EMBASE, Cochrane library, Chinese Biomedical Databases (CBM), Wanfang database and China National Knowledge Infrastructure (CNKI) until November 30, 2018. Three reviewers independently extracted data and assessed the methodological quality of the reviews according to the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2), the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to rate the quality of evidence. In the pre-experiment, we used the intra-class correlation coefficient (ICC) to assess reviewer agreement, the ICC value for overall score was 0.978. RESULTS: Ten reviews were included. The assessment results of AMSTAR-2 showed that the methodological quality of all included studies was critically low. The lowest score were item "provide a list of excluded studies and justify the exclusions" and item "report sources of funding for the included studies", none of studies provided information about the above two items, followed by the "providing a priori design" item with only two (20%) studies conforming to this item. For GRADE, of the 7 outcomes, high quality evidence was provided in only 1 (14.3%), moderate in 2 (28.6.7%), and low in 4 (57.1%). CONCLUSION: Although most of the included reviews indicated that acupuncture group was more effective than control group in the treatment of anxiety, more importantly, the methodological quality of the included reviews and the quality of evidence were low. More high-quality evidence is needed to determine whether acupuncture is more effective than other treatments.