scholarly journals Effectiveness of web-based feedback interventions for people with overweight and obesity: systematic review and network meta-analysis of randomized controlled trials

2021 ◽  
Vol 9 (1) ◽  
Author(s):  
Carmen Varela ◽  
Camila Oda-Montecinos ◽  
Ana Andrés ◽  
Carmina Saldaña
Keyword(s):  
Systematic Review ◽  
Confidence Interval ◽  
Weight Control ◽  
Meta Analysis ◽  
Treatment Options ◽  
Overweight And Obesity ◽  
Mean Difference ◽  
Effective Treatment Option ◽  
Web Based ◽  
Self Help

Abstract Background Web-based delivered interventions have become an innovative option to treat health problems, like obesity. The aim of this systematic review and network meta-analysis was to analyze the effectiveness of web-based behavioral treatments for adults with overweight and obesity. Web-based interventions and comparison interventions (traditional weight control programs) were classified according to the following feedback characteristics: frequency, personalization, and provider (human versus machine). Method From the initial 1789 studies, 15 were included in this review. A network meta-analysis was conducted to analyze the efficacy of web-based programs with traditional interventions, considering direct and indirect comparisons. The main outcome was the weight loss mean difference (kg) between baseline and post-treatment. Heterogeneity and consistency assumptions were validated to conduct the network meta-analysis. Results Network meta-analysis showed comparisons between different treatment options. The main results were that Intensive Contact Web-based programs were more effective than wait-list (Mean Difference − 1.86 kg; 95% Confidence Interval: − 3.61, − 0.12). Moreover, Intensive Contact Web-based programs were more effective than the other web-based options and self-help traditional interventions. However, the only significant comparison was Intensive Contact Web-based programs versus Guided Self-Help Web-based programs (Mean Difference − 4.31 kg; 95% Confidence Interval: − 5,22, − 3,41). Intensive Contact Web-based programs were the most effective treatment option according the obtained results, achieving the first place in the ranking provided by the network meta-analysis with 98.5% of probabilities. Conclusions Intensive Contact Web-based interventions have obtained the first position in the ranking, proving the relevance of frequent, personalized, and professional feedback and their association with a better prognosis for people with overweight and obesity. These results provide relevant information to design more effective treatments for people with overweight and obesity, in a new format especially appropriate for the current situation.

Lee Silverman Voice Treatment (LSVT)-BIG to improve motor function in people with Parkinson’s disease: a systematic review and meta-analysis

2017 ◽  
Vol 32 (5) ◽  
pp. 607-618 ◽  
Author(s):  
Michelle N McDonnell ◽  
Briony Rischbieth ◽  
Tenille T Schammer ◽  
Chantel Seaforth ◽  
Alex J Shaw ◽  
...  
Keyword(s):  
Systematic Review ◽  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Confidence Interval ◽  
Motor Function ◽  
Randomized Trials ◽  
Meta Analysis ◽  
Mean Difference ◽  
Lee Silverman Voice Treatment ◽  
Voice Treatment

Objective: The technique called Lee Silverman Voice Treatment (LSVT)-LOUD has previously been used to improve voice quality in people with Parkinson’s disease. The objective of this study was to assess the effectiveness of an alternate intervention, LSVT-BIG (signifying big movements), to improve functional mobility. Design: Systematic review with meta-analysis of randomized trials. Data sources: Medline, Embase, CINAHL, AgeLine, Scopus and Cochrane Library were searched from inception to September 2017 using multiple search terms related to Parkinson’s disease and LSVT-BIG. Review method: Two researchers searched the literature for studies of the LSVT-BIG intervention of 16 sessions, delivered by a certified instructor over four weeks, to any other intervention. Outcomes related to functional ability were included. Study quality was appraised using the Cochrane Risk of Bias tool. Results: Four studies were included, reporting on three randomized trials of 84 participants with mild Parkinson’s disease. Compared to physiotherapy exercises, or a shorter training protocol, there was a significant improvement in motor function assessed with the Unified Parkinson’s Disease Rating Scale part III (mean difference = −3.20, 95% confidence interval = −5.18 to −1.23) and a trend towards faster Timed Up and Go performance (mean difference = −0.47, 95% confidence interval = −0.99 to 0.06) and 10-metre walk test (mean difference = −0.53, 95% confidence interval = −1.07 to 0.01). Conclusion: Compared to shorter format LSVT-BIG or general exercise, LSVT-BIG was more effective at improving motor function. This provides preliminary, moderate quality evidence that amplitude-oriented training is effective in reducing motor impairments for people with mild Parkinson’s disease.

scholarly journals Ketamine for suicidal ideation in adults with psychiatric disorders: A systematic review and meta-analysis of treatment trials

2019 ◽  
Vol 54 (1) ◽  
pp. 29-45 ◽  
Author(s):  
Katrina Witt ◽  
Jennifer Potts ◽  
Anna Hubers ◽  
Michael F Grunebaum ◽  
James W Murrough ◽  
...  
Keyword(s):  
Systematic Review ◽  
Suicidal Ideation ◽  
Confidence Interval ◽  
Meta Analysis ◽  
Mean Difference ◽  
Single Trial ◽  
Evaluation Tool ◽  
Assessment Development ◽  
Post Infusion ◽  
Randomised Controlled

Objective: Ketamine may reduce suicidal ideation in treatment-resistant depression. But it is not known how quickly this occurs and how long it persists. We undertook a systematic review and meta-analysis to determine the short- and long-term effectiveness of ketamine for suicidality. Method: CENTRAL, EMBASE, Medline, and PsycINFO were searched until 12 December 2018. Randomised controlled trials of ketamine or esketamine reporting data on suicidal ideation, self-harm, attempted or completed suicide in adults diagnosed with any psychiatric disorder were included. Two reviewers independently extracted data, and certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. Standardised mean difference was used for continuous outcomes. Results: Twenty-five reports from 15 independent trials, with a total of 572 participants diagnosed with predominately affective disorders, were included. The evidence was rated moderate to low. In most trials, ketamine was administered at 0.5 mg/kg via a single intravenous infusion over a 30- to 45-minute period. Only a single trial of intranasal esketamine was identified. At 4 hours post-infusion, treatment with ketamine was associated with a significant reduction in suicidal ideation scores (standardised mean difference = −0.51, 95% confidence interval = [−1.00, −0.03]), which persisted until 72 hours post-infusion (time points between 12 and 24 hours: standardised mean difference = −0.63, 95% confidence interval = [−0.99, −0.26]; between 24 and 72 hours: standardised mean difference = −0.57, 95% confidence interval = [−0.99, −0.14]), but not thereafter. However, there was marked heterogeneity of results. In a single trial of esketamine, marginal effects on suicidal ideation were observed. In terms of actual suicidal behaviour, there were virtually no data on effects of ketamine or esketamine. Conclusion: A single infusion of ketamine may have a short-term (up to 72 hours) beneficial impact on suicidal thoughts. While confirmation of these results in further trials is needed, they suggest possible use of ketamine to treat acute suicidality. Means of sustaining any anti-suicidal effect need to be found.

Effects of telehealth interventions for adolescent sexual health: A systematic review and meta-analysis of randomized controlled studies

2021 ◽  
pp. 1357633X2110477
Author(s):  
Ita Daryanti Saragih ◽  
Santo Imanuel Tonapa ◽  
Carolyn M. Porta ◽  
Bih-O Lee
Keyword(s):  
Systematic Review ◽  
Confidence Interval ◽  
Sexual Health ◽  
Condom Use ◽  
Self Efficacy ◽  
Meta Analysis ◽  
Mean Difference ◽  
Adolescent Sexual Health ◽  
Randomized Controlled ◽  
Standardized Mean Difference

Introduction Telehealth interventions to advance adolescent sexual health have evolved and are being used to promote adolescent sexual health knowledge and healthy sexual behaviors. However, as this area of intervention modality expands, there is a need to pause and examine the effects of telehealth interventions on adolescent sexual health outcomes. Addressing this knowledge gap will inform researchers and practitioners on the current state of evidence of telehealth interventions and inform further intervention development and testing. This study aimed to explore the meta-effects of telehealth interventions on self-efficacy of using condoms, condom use practices, and sexually transmitted infection testing behaviors among adolescents. Methods A systematic review and meta-analysis of randomized controlled trials were conducted. Seven databases (Academic Search Complete, CINAHL, EMBASE, MEDLINE, PubMed, OVID (UpToDate), and Web of Science) were searched for relevant full-text articles from the inception to May 2021. The revised Cochrane risk-of-bias tool for randomized trials was used to assess the methodological quality of the included studies. A meta-analysis was performed using a random effects model to calculate the pooled effects of telehealth interventions for adolescents. Stata 16.0 was used for statistical analysis. Results A total of 15 studies ( N = 5499) that used telehealth interventions with adolescents were included in the analysis. Telehealth interventions were found to increase self-efficacy for condom use (standardized mean difference: 0.22; 95% confidence interval: 0.08–0.36), practice for condom use (standardized mean difference: 0.35; 95% confidence interval: 0.23–0.47), and being screened/tested for sexual transmitted infections (standardized mean difference: 0.61; 95% confidence interval: 0.31–0.92). Discussion Telehealth interventions show promise as effective intervention delivery solutions for improving self-efficacy and certain sexual health behaviors among adolescents. These telehealth strategies could be important alternatives to in-person visits to accessing sexual health information or services near where they live. Future research should consider testing telehealth strategies where there is evidence of impact to move the field forward.

Augmentation strategies for clozapine refractory schizophrenia: A systematic review and meta-analysis

2018 ◽  
Vol 52 (8) ◽  
pp. 751-767 ◽  
Author(s):  
Dan J Siskind ◽  
Michael Lee ◽  
Arul Ravindran ◽  
Qichen Zhang ◽  
Evelyn Ma ◽  
...  
Keyword(s):  
Systematic Review ◽  
Confidence Interval ◽  
Negative Symptoms ◽  
Meta Analysis ◽  
Mean Difference ◽  
Augmentation Strategies ◽  
Mixed Treatment ◽  
Treatment Comparisons ◽  
Meta Analyses ◽  
Mixed Treatment Comparisons

Background: Although clozapine is the most effective medication for treatment refractory schizophrenia, only 40% of people will meet response criteria. We therefore undertook a systematic review and meta-analysis of global literature on clozapine augmentation strategies. Methods: We systematically reviewed PubMed, PsycInfo, Embase, Cochrane Database, Chinese Biomedical Literature Service System and China Knowledge Resource Integrated Database for randomised control trials of augmentation strategies for clozapine resistant schizophrenia. We undertook pairwise meta-analyses of within-class interventions and, where possible, frequentist mixed treatment comparisons to differentiate treatment effectiveness Results: We identified 46 studies of 25 interventions. On pairwise meta-analyses, the most effective augmentation agents for total psychosis symptoms were aripiprazole (standardised mean difference: 0.48; 95% confidence interval: −0.89 to −0.07) fluoxetine (standardised mean difference: 0.73; 95% confidence interval: −0.97 to −0.50) and, sodium valproate (standardised mean difference: 2.36 95% confidence interval: −3.96 to −0.75). Memantine was effective for negative symptoms (standardised mean difference: −0.56 95% confidence interval: −0.93 to −0.20). However, many of these results included poor-quality studies. Single studies of certain antipsychotics (penfluridol), antidepressants (paroxetine, duloxetine), lithium and Ginkgo biloba showed potential, while electroconvulsive therapy was highly promising. Mixed treatment comparisons were only possible for antipsychotics, and these gave similar results to the pairwise meta-analyses. Conclusions: On the basis of the limited data available, the best evidence is for the use of aripiprazole, fluoxetine and sodium valproate as augmentation agents for total psychosis symptoms and memantine for negative symptoms. However, these conclusions are tempered by generally short follow-up periods and poor study quality.

Tubeless versus standard percutaneous nephrolithotomy in pediatric patients: a systematic review and meta-analysis

2017 ◽  
Vol 85 (1) ◽  
pp. 3-9 ◽  
Author(s):  
Akbar Nouralizadeh ◽  
Nasser Simforoosh ◽  
Hamidreza Shemshaki ◽  
Mohammad H. Soltani ◽  
Mehdi Sotoudeh ◽  
...  
Keyword(s):  
Systematic Review ◽  
Confidence Interval ◽  
Percutaneous Nephrolithotomy ◽  
Meta Analysis ◽  
Operation Time ◽  
Mean Difference ◽  
Transfusion Rate ◽  
Stone Clearance ◽  
Significant Difference ◽  
Tubeless Pcnl

Background: This systematic review and meta-analysis was designed to evaluate the post-operative outcomes between tubeless and standard percutaneous nephrolithotomy (PCNL) among children. Methods: Literature searches were performed following the Cochrane guidelines. We conducted a systematic review and meta-analysis that included three trials investigating the outcomes including the length of hospital stay, operation time, hemoglobin decrease, blood transfusion rate, perirenal fluid presence, post-operative fever, stone clearance rate, and the need for a second operation. Results: The patients who underwent tubeless PCNL had shorter length of hospitalization compared to standard PCNLs (mean difference -1.57, 95% confidence interval -3.2 to 0.07, p = 0.06). No significant decrease was detected in hemoglobin after tubeless PCNL compared to standard PCNL (mean difference 0.05, 95% confidence interval -0.03 to 0.13, p = 0.21). There were no significant differences in operation time (p = 0.7), perirenal fluid presence (p = 0.15), post-operative fever (p = 0.72), stone clearance (p = 0.68), and the need for a second operation (p = 0.90). Conclusions: This study showed no significant difference between tubeless and standard PCNLs in children. However, due to the lack of data, the results should be mentioned prudently. Future randomized trials with more sample sizes and longer follow-ups are warranted.

On-clamp versus off-clamp robotic partial nephrectomy: A systematic review and meta-analysis

2019 ◽  
Vol 86 (2) ◽  
pp. 52-62 ◽  
Author(s):  
Alessandro Antonelli ◽  
Alessandro Veccia ◽  
Simone Francavilla ◽  
Riccardo Bertolo ◽  
Pierluigi Bove ◽  
...  
Keyword(s):  
Systematic Review ◽  
Confidence Interval ◽  
Partial Nephrectomy ◽  
Weighted Mean Difference ◽  
Meta Analysis ◽  
Mean Difference ◽  
Robotic Partial Nephrectomy ◽  
Weighted Mean ◽  
Robot Assisted ◽  
Significant Difference

Background: The debate on the pros and cons of robot-assisted partial nephrectomy performed with (on-clamp) or without (off-clamp) renal artery clamping is ongoing. The aim of this meta-analysis is to summarize the available evidence on the comparative studies assessing the outcomes of these two approaches. Material and methods: A systematic review of the literature on PubMed, ScienceDirect®, and Embase® was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA). Only comparative and case-control studies were submitted to full-text assessment and meta-analysis. RevMan 5.3 software was used. Results: From the initial retrieval of 1937 studies, 15 fulfilling inclusion criteria were selected and provided 2075 patients for analysis (702 off-clamp, 1373 on-clamp). Baseline tumor’s features showed a significant difference in size (weighted mean difference: –0.58 cm; 95% confidence interval: [–1.06, –0.10]; p = 0.02) and R.E.N.A.L. score (weighted mean difference: –0.53; 95% confidence interval: [–0.81, –0.25]; p = 0.0002), but not in the exophytic property, the location, and the PADUA score. Pooled analysis revealed shorter operative time (p = 0.02) and higher estimated blood loss (p = 0.0002) for the off-clamp group. Overall complication and transfusion rates were similar, while higher major complication rate was observed in the on-clamp approach (5.6% vs 1.9%, p = 0.03). No differences in oncological outcomes were found. Finally, functional outcomes (assessed by estimated glomerular filtration rate at early postoperative, 3 month, 6 month, and last available follow-up) were not statistically different. Conclusion: This meta-analysis shows that off-clamp robot-assisted partial nephrectomy is reserved to smaller renal masses. Under such conditions, no differences with the on-clamp approach emerged.

The efficacy and safety of intravaginal oxytocin on vaginal atrophy: A systematic review

2020 ◽  
pp. 205336912094664
Author(s):  
Zahra Ghorbani ◽  
Mojgan Mirghafourvand
Keyword(s):  
Systematic Review ◽  
Confidence Interval ◽  
Fixed Effects ◽  
Meta Analysis ◽  
Mean Difference ◽  
Cochrane Library ◽  
Vaginal Atrophy ◽  
Suitable Alternative ◽  
Statistical Heterogeneity ◽  
Standardized Mean Difference

Genitourinary syndrome of menopause is a major issue in menopausal health. Because unlike vasomotor symptoms, it has a progressive trend. In this regard we conducted a systematic review to evaluate the efficacy of intravaginal oxytocin on postmenopausal vaginal atrophy. A search was performed for published studies in Cochrane Library, MEDLINE, Web of Science, Embase, Scopus, ProQuest, Google Scholar and Persian databases without time and language limitations. Only randomized controlled trials that compared intravaginal oxytocin with placebos were included. The outcome measures were objective and subjective assessed symptoms of vaginal atrophy. Statistical heterogeneity was evaluated using the I2. The standardized mean differences were pooled the fixed effects model. Of the five included studies, four studies meta-analysed. The meta-analysis in terms of the cytological analysis (standardized mean difference: 35.13, 95% confidence interval: 32.59–37.67, n = 218, I2 = 96%) was statistically significant. In terms of histological assessments (standardized mean difference: −0.38, 95% confidence interval: −0.94 to 0.17, n = 38, I2 = 0%) and endometrial thickness (standardized mean difference: 0.05, 95% confidence interval: −0.20 to −0.31, n = 95, I2 = 0%), there were no statistically significant differences between the groups. Three studies reported a statistically significant improvement in the subjective symptoms; however, we were unable to perform a meta-analysis. Four of the included studies assessed side effects, but only two studies reported them. Oxytocin as a nonestrogenic compound can be a suitable alternative for the treatment of vaginal atrophy, especially in women with contraindications for using estrogenic compounds. Further good quality clinical trials with long-term follow-ups are recommended to demonstrate the effects of intravaginal gel in the treatment of vaginal atrophy.

scholarly journals Effectiveness of caregiver interventions for people with cancer and non-cancer-related chronic pain: a systematic review and meta-analysis

2021 ◽  
pp. 204946372110227
Author(s):  
Toby O. Smith ◽  
Matthew Pearson ◽  
Matthew J Smith ◽  
Jessica Fletcher ◽  
Lisa Irving ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Systematic Review ◽  
Chronic Pain ◽  
Confidence Interval ◽  
Meta Analysis ◽  
Informal Caregivers ◽  
Mean Difference ◽  
Caregiver Interventions ◽  
Quality Evidence

Background: People with chronic pain frequently have difficulties in completing everyday tasks to maintain independence and quality of life. Informal caregivers may provide support to these individuals. However, the effectiveness of interventions to train and support these individuals in caregiving remains unclear. The purpose of this study was to systematically review the evidence to determine the effectiveness of caregiver interventions to support informal caregivers of people with chronic pain. Methods: A systematic review of published and unpublished literature databases was undertaken (9 April 2021). Trials reporting clinical outcomes of caregiver interventions to train informal caregivers to support community-dwelling people with chronic pain were included. Meta-analysis was undertaken and each outcome was assessed using Grading of Recommendations, Assessment, Development and Evaluation. Results: Twenty-seven studies were eligible (N = 3427 patients). Twenty-four studies assessed patients with cancer pain and three with musculoskeletal pain. No other patient groups were identified. There was very low-quality evidence that caregiver interventions were beneficial for caregiver health-related quality of life (standardised mean difference = 0.26, 95% confidence interval = 0.01 to 0.52; N = 231). There was moderate-quality evidence that caregiving interventions were effective in reducing pain in the short-term (standardised mean difference = 0.16, 95% confidence interval = −0.29 to −0.03). There was low-quality evidence that caregiving interventions had no beneficial effect over usual care for psychological outcomes, fatigue, coping or physical function in the long-term. Conclusion: Caregiving interventions may be effective for patients and caregivers but only in the shorter-term and for a limited number of outcomes. There is insufficient evidence examining the effectiveness of caregiver interventions for people with non-cancer-related pain.

scholarly journals The effect of grape products containing polyphenols on oxidative stress: a systematic review and meta-analysis of randomized clinical trials

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Sahar Sarkhosh-Khorasani ◽  
Zohreh Sadat Sangsefidi ◽  
Mahdieh Hosseinzadeh
Keyword(s):  
Oxidative Stress ◽  
Systematic Review ◽  
Confidence Interval ◽  
Randomized Clinical Trials ◽  
Weighted Mean Difference ◽  
Meta Analysis ◽  
Mean Difference ◽  
Weighted Mean ◽  
Stress Markers ◽  
Total Antioxidant

Abstract Background The literature showed that Grape Products Containing Polyphenols (GPCP) had anti-oxidant activity. However, the effects of GPCP on different biomarkers of oxidative stress are still controversial. In this regard, this systematic review and meta-analysis aimed to evaluate the effect of Grape Products Containing Polyphenols (GPCP) intake on oxidative stress markers. Methods PubMed, Scopus, Web of Science, and Google Scholar data bases were searched up to August 20, 2020. A random-effects model, weighted mean difference (WMD), and 95% confidence interval (CI) were applied for data analysis. Meta-analysis was conducted over 17 eligible RCTs with a total of 633 participants. The study registration number is CRD42019116696. Results A significant increase was observed in Total Antioxidant Capacity (TAC) (weighted mean difference (WMD) = 1.524 mmol/L, 95% confidence interval (CI): 0.83, 2.21). Intake of GPCP enhanced Superoxide Dismutase (SOD) (WMD = 0.450 mmol/L, 95% CI: 0.23, 0.66), TAC (WMD = 2.829 mmol/L, 95% CI: 0.13, 5.52), and Oxygen Radical Absorbance Capacity (ORAC) (WMD = 0.524 μmol/L, 95% CI: 0.42, 0.62) among healthy participants. Higher GPCP doses increased SOD (WMD = 0.539 U/mgHb, 95% CI: 0.24, 0.82) and ORAC (WMD = 0.377 μmol/L, 95% CI: 0.08, 0.67), whereas longer intervention periods enhanced ORAC (WMD = 0.543 μmol/L, 95% CI: 0.43, 0.64). Conclusion GPCP intake may partly improve status of oxidative stress, but further well-designed trials are required to confirm these results.

scholarly journals Impact of anesthetic agents on the amount of bleeding during dilatation and evacuation: A systematic review and meta-analysis

PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0261494
Author(s):  
Hyun Ah Lee ◽  
Hiromasa Kawakami ◽  
Takahiro Mihara ◽  
Hitoshi Sato ◽  
Takahisa Goto
Keyword(s):  
Systematic Review ◽  
Confidence Interval ◽  
Meta Analysis ◽  
Volatile Anesthetic ◽  
Volatile Anesthetics ◽  
Risk Of Bias ◽  
Mean Difference ◽  
Trial Registration ◽  
Controlled Trials

Purpose Patients undergo dilatation and evacuation for abortion or miscarriage. However, bleeding is sometimes problematic. Despite reports on the association between volatile anesthetics and increased bleeding during the procedure, firm evidence is lacking. Therefore, we conducted a systematic review and meta-analysis to compare the effects of volatile anesthetics and propofol on the amount of bleeding in patients undergoing dilatation and evacuation. Methods We conducted a systematic search of four databases, namely PubMed, Embase, Cochrane Central Register of Controlled Trials databases, and Web of Science (Clarivate Analytics), from their respective inception to April 2021. Moreover, we searched two trial registration sites. The inclusion criterion was randomized controlled trials of patients who underwent dilatation and evacuation under general anesthesia using volatile anesthetics or propofol. The primary outcome was the amount of perioperative bleeding. The mean difference of the bleeding was combined using a random-effects model. The I2 statistic was used to assess heterogeneity. We assessed risk of bias with Cochrane domains. We controlled type I and II errors due to sparse data and repetitive testing with Trial Sequential Analysis. We assessed the quality of evidence with GRADE. Results Five studies were included in the systematic review. The amount of bleeding was compared in four studies and was higher in the volatile anesthetic group, with a mean difference of 164.7 ml (95% confidence interval, 43.6 to 285.7; p = 0.04). Heterogeneity was considerable, with an I2 value of 97%. Two studies evaluated the incidence of significant bleeding, which was significantly higher in the volatile anesthetic group (RR, 2.42; 95% confidence interval, 1.04–5.63; p = 0.04). Conclusion Choosing propofol over volatile anesthetics during dilatation and evacuation might reduce bleeding and the incidence of excessive bleeding. However, the quality of the evidence was very low. This necessitates further trials with a low risk of bias. Trial registration PROSPERO (CRD42019120873).

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