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Caro-Cañizares I, López Carpintero N, Carmona-Camacho R. The Elephant in the Room: A Systematic Review of the Application and Effects of Psychological Treatments for Pregnant Women with Dual Pathology (Mental Health and Substance-Related Disorders). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:392. [PMID: 38673305 PMCID: PMC11050033 DOI: 10.3390/ijerph21040392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/14/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
PURPOSE Maternal mental health and substance use, referred to as dual pathology, represent significant concerns associated with adverse pregnancy and birth outcomes, a prevalence higher than commonly anticipated. Nonetheless, a notable dearth exists ofevidence-based treatment protocols tailored for pregnant women with dual pathology. METHODS A systematic review, adhering to the PRISMA methodology, was conducted. RESULTS Out of the 57 identified papers deemed potentially relevant, only 2were ultimately included. Given the limited number of studies assessing the efficacy of psychological interventions utilizing randomized controlled trials (RCTs) for both mental health and substance misuse, and considering the diverse objectives and measures employed, definitive conclusions regarding the effectiveness of psychological interventions in this domain prove challenging. CONCLUSIONS Maternal mental health appears to be the proverbial "elephant in the room". The development of specialized and integrated interventions stands as an imperative to effectively address this pressing issue. As elucidated in the present review, these interventions ought to be grounded in empirical evidence. Furthermore, it is essential that such interventions undergo rigorous evaluation through RCTs to ascertain their efficacy levels. Ultimately, the provision of these interventions by psychology/psychiatric professionals, both within clinical practice and the RCTs themselves, is recommended to facilitate the generalizability of the results to specialized settings.
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Affiliation(s)
- Irene Caro-Cañizares
- Facultad de Ciencias de la Salud y la Educación, Universidad a Distancia de Madrid, UDIMA, 28400 Collado Villalba, Spain
| | - Nayara López Carpintero
- Departamento de Obstetricia y Ginecología, Hospital Universitario del Tajo, 28300 Aranjuez, Spain
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LIU T, LIU T, LIU M. Effectiveness and safety of acupuncture in treatment of pregnancy-related symptoms: a systematic review and Meta-analysis. J TRADIT CHIN MED 2024; 44:16-26. [PMID: 38213235 PMCID: PMC10774725 DOI: 10.19852/j.cnki.jtcm.20231204.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/28/2022] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To systematically evaluate the efficacy and safety of acupuncture (AM) in the treatment of pregnancy-related symptoms such as acute vomiting during pregnancy. METHODS We comprehensively searched the available literature up to November 2021, including PubMed, Embase, Cochrane Library, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure Database, for randomized controlled trials (RCTs) on AM for the treatment of severe vomiting, insomnia, pharyngeal and pelvic pain, mood abnormalities, and dyspepsia during pregnancy. RESULTS Sixteen RCTs with a cumulative sample size of 1178 cases were included. Of these, 964 patients were included in the Meta-analysis. The Meta-analysis results showed that AM was more efficient than Western medicine in treating discomfort during pregnancy [odds ratio (OR) = 1.19, 95% confidence interval (CI) (1.11, 1.28), P < 0.01]. AM was better than the control group in improving the visual analog scale scores [standard mean difference (SMD) = 0.62, 95% CI(0.53, 0.71), P < 0.01]. AM was superior to the control group in improving Numerical Rating Scale (NRS) symptom scores [OR = 7.31, 95% CI(3.36, 15.94), P < 0.01]. There was no significant difference in adverse effects between the AM and sham-AM groups and the analgesic drug group [OR = 0.70, 95% CI(0.39, 1.28), P = 0.25], but the treatment and control groups had mild adverse effects with a low incidence. CONCLUSIONS AM is more effective than other treatments or pharmacotherapy alone in the treatment of pregnancy-related symptoms, and is relatively safe. However, the quality of the included trials was rather poor, and high-quality studies are required to confirm our findings.
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Affiliation(s)
- Tingting LIU
- 1 School of Traditional Chinese Medicine Clinical Medicine, Hubei University of Traditional Chinese Medicine, Wuhan 430000, China
| | - Tongou LIU
- 2 First Clinical College of Hubei University of Traditional Chinese Medicine, Wuhan 430000, China
| | - Mingfu LIU
- 3 Department of Acupuncture and Tuina, Affiliated Hospital of Hubei University of Traditional Chinese Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430000, China
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Wu J, Zhao Z. Acupuncture in circadian rhythm sleep-wake disorders and its potential neurochemical mechanisms. Front Neurosci 2024; 18:1346635. [PMID: 38318465 PMCID: PMC10839072 DOI: 10.3389/fnins.2024.1346635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/08/2024] [Indexed: 02/07/2024] Open
Abstract
Circadian rhythm sleep-wake disorders (CRSWDs) are becoming increasingly common in modern societies due to lifestyle changes. The detrimental effects of CRSWDs on sleep and psychological health have attracted considerable attention recently. Alternative remedies for the treatment of CRSWDs have also gained attention in recent years owing to the limitations of medications. Several in vivo and clinical investigations have shown that acupuncture, one of the most important components of traditional Chinese medicine (TCM), has been shown to modulate sleep-related circadian rhythms. Owing to the lack of research on the mechanism and effectiveness of acupuncture in treating CRSWDs, clinical applications of acupuncture have not gained popularity. This paper reviews the acupuncture methods, acupoint selection, and biochemical indicators supplied by in vivo and clinical studies to explore the effectiveness of acupuncture, and summarizes the circadian rhythm mechanisms and the acupuncture characteristics on circadian rhythm. The neurochemical mechanisms linked to acupuncture in treating CRSWDs are also outlined from the perspective of the central and peripheral biological clocks. Lastly, the inadequacy of previous studies on CRSWDs and conflicting results regarding acupuncture are explored and future research directions are envisioned.
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Guo P, Xu M, Pan J, Lin J, Hu T, Wei Y, Chen Y, Guo Y. A Systematic Review and Meta-Analysis Protocol to Establish How Common Clinical Acupoint Stimulation-Related Therapies Should Be Used for Managing Insomnia. J Pain Res 2023; 16:1069-1079. [PMID: 37013154 PMCID: PMC10066717 DOI: 10.2147/jpr.s394328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 03/18/2023] [Indexed: 03/30/2023] Open
Abstract
Background Many studies have now investigated the effects of common clinical acupoint stimulation-related therapies (ASRTs) following the meridian theory of traditional Chinese medicine for the management of insomnia. However, ASRT choice is currently based on personal clinical experience or patient preference. This study will review the common ASRTs reported in clinical trials and analyze their efficacy and safety for managing insomnia with or without co-morbidities. Methods English and Chinese databases will be thoroughly searched, and other potentially eligible trials will be obtained by reviewing reference lists of identified studies and previous reviews. Only randomized controlled trials (RCTs) of common clinical ASRTs to manage insomnia published in peer-reviewed journals will be considered. Sleep quality questionnaires or indices will be considered as the main outcome, while the secondary outcomes will include sleep parameters, daytime dysfunction, quality of life, and adverse effects. Two reviewers will independently investigate eligible RCTs, extract information, analyze their methodological quality, and employ Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria to evaluate the strength of the evidence. The treatment impact of various ASRTs will be calculated using meta-analysis techniques, and the degree of study heterogeneity will be assessed using Cochrane's Q and I-squared statistics. Subgroup and sensitivity analyses will be used to evaluate the reliability of the results. Results Our systematic review and meta-analysis will present up-to-date evidence on: 1) which common clinical ASRTs are beneficial for the management of insomnia; and 2) whether the effects of common clinical ASRTs on insomnia vary depending on clinical, participant, and treatment characteristics. Conclusion The results of our review should help decision-makers make educated choices regarding evidence-based non-pharmacological management options for insomnia. Study Registration The International Platform of Registered Systematic Review and Meta-analysis (INPLASY), record INPLASY2021120137.
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Affiliation(s)
- Pei Guo
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu City, People’s Republic of China
| | - Mingmin Xu
- School of Traditional Chinese Medicine, Jinan University, Guangzhou City, People’s Republic of China
| | - Jiongwei Pan
- School of Traditional Chinese Medicine, Jinan University, Guangzhou City, People’s Republic of China
| | - Jiayi Lin
- School of Traditional Chinese Medicine, Jinan University, Guangzhou City, People’s Republic of China
| | - Tiannuo Hu
- School of Traditional Chinese Medicine, Jinan University, Guangzhou City, People’s Republic of China
| | - Yulong Wei
- School of Acupuncture–Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing City, People’s Republic of China
| | - Yue Chen
- School of Acupuncture–Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing City, People’s Republic of China
| | - Yu Guo
- School of Traditional Chinese Medicine, Jinan University, Guangzhou City, People’s Republic of China
- Guangzhou Key Laboratory of Formula-Pattern of Traditional Chinese Medicine, School of Traditional Chinese Medicine, Jinan University, Guangzhou City, People’s Republic of China
- Correspondence: Yu Guo, School of Traditional Chinese Medicine, Jinan University, No. 601 Huangpu Road West, Tianhe District, Guangzhou City, People’s Republic of China, Email
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Jiang Y, Lin Y, Tan Y, Shen X, Liao M, Wang H, Lu N, Han F, Xu N, Tang C, Song J, Tao R. Electroacupuncture ameliorates cerebrovascular impairment in Alzheimer's disease mice via melatonin signaling. CNS Neurosci Ther 2022; 29:917-931. [PMID: 36382345 PMCID: PMC9928543 DOI: 10.1111/cns.14027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 10/12/2022] [Accepted: 10/25/2022] [Indexed: 11/18/2022] Open
Abstract
AIMS Cerebrovascular impairment contributes to the pathogenesis of Alzheimer's disease (AD). However, it still lacks effective intervention in clinical practice. Here, we investigated the efficacy of electroacupuncture (EA) in cerebrovascular repair in 3xTg-AD mice and its mechanism. METHODS 3xTg-AD mice were employed to evaluate the protective effect of EA at ST36 acupoint (EAST36). Behavioral tests were performed to assess neurological disorders. Laser speckle contrast imaging, immunostaining, and Western blot were applied to determine EAST36-boosted cerebrovascular repair. The mechanism was explored in 3xTg mice and endothelial cell cultures by melatonin signaling modulation. RESULTS EAST36 at 20/100 Hz effectively alleviated the olfactory impairment and anxiety behavior and boosted cerebrovascular repair in AD mice. EAST36 attenuated cerebral microvascular degeneration in AD mice by modulating endothelial cell viability and injury. Consequently, the Aβ deposits and neural damage in AD mice were reversed after EAST36. Mechanistically, we revealed that EAST36 restored melatonin levels in AD mice. Melatonin supplement mimicked the EAST36 effect on cerebrovascular protection in AD mice and endothelial cell cultures. Importantly, blockage of melatonin signaling by antagonist blunted EAST36-induced cerebrovascular recovery and subsequent neurological improvement. CONCLUSIONS These findings provided strong evidence to support EAST36 as a potential nonpharmacological therapy against cerebrovascular impairment in AD. Further study is necessary to better understand how EAST36 treatment drives melatonin signaling.
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Affiliation(s)
- Yimin Jiang
- South China Research Center for Acupuncture and MoxibustionGuangzhou University of Chinese MedicineGuangzhouChina
| | - Yunshi Lin
- South China Research Center for Acupuncture and MoxibustionGuangzhou University of Chinese MedicineGuangzhouChina
| | - Yuhang Tan
- South China Research Center for Acupuncture and MoxibustionGuangzhou University of Chinese MedicineGuangzhouChina
| | - Xinkai Shen
- South China Research Center for Acupuncture and MoxibustionGuangzhou University of Chinese MedicineGuangzhouChina
| | - Meihua Liao
- South China Research Center for Acupuncture and MoxibustionGuangzhou University of Chinese MedicineGuangzhouChina
| | - Huan Wang
- College of Life Science and TechnologyDalian UniversityDalianChina
| | - Nannan Lu
- Department of Neurology and Neurological SciencesStanford University School of MedicineStanfordCaliforniaUSA
| | - Feng Han
- Key Laboratory of Cardiovascular and Cerebrovascular Medicine, School of PharmacyNanjing Medical UniversityNanjingChina
| | - Nenggui Xu
- South China Research Center for Acupuncture and MoxibustionGuangzhou University of Chinese MedicineGuangzhouChina
| | - Chunzhi Tang
- South China Research Center for Acupuncture and MoxibustionGuangzhou University of Chinese MedicineGuangzhouChina
| | - Juxian Song
- South China Research Center for Acupuncture and MoxibustionGuangzhou University of Chinese MedicineGuangzhouChina
| | - Rongrong Tao
- South China Research Center for Acupuncture and MoxibustionGuangzhou University of Chinese MedicineGuangzhouChina
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Kellner S, Richter K. Insomnie in der Schwangerschaft – eine systematische Übersichtsarbeit. SOMNOLOGIE 2022. [DOI: 10.1007/s11818-022-00342-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wang C, Xu WL, Li GW, Fu C, Li JJ, Wang J, Chen XY, Liu Z, Chen YF. Impact of Acupuncture on Sleep and Comorbid Symptoms for Chronic Insomnia: A Randomized Clinical Trial. Nat Sci Sleep 2021; 13:1807-1822. [PMID: 34675728 PMCID: PMC8519353 DOI: 10.2147/nss.s326762] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 09/20/2021] [Indexed: 11/23/2022] Open
Abstract
STUDY OBJECTIVES To evaluate the efficacy and safety of acupuncture at HT 7 (Shenmen) and KI 7 (Fuliu) on sleep and comorbid symptoms for chronic insomnia. METHODS AND DESIGN A randomized, single-blind, parallel and sham-controlled trial consisted of an acupuncture group (n = 41) and a sham acupuncture group (n = 41). Setting: a tertiary hospital of integrated Chinese and Western medicine. Participants: 82 subjects with chronic insomnia based on the International Classification of Sleep Disorders, Third Edition (ICSD-3). Interventions: a 10-session acupuncture treatment at bilateral HT 7 and KI 7 or sham acupoints with shallow needling was performed over 3 weeks. Measurements: the Pittsburgh sleep quality index (PSQI) and insomnia severity index (ISI) were evaluated at baseline, posttreatment, and at two follow-ups as the primary outcome measures. Polysomnography (PSG) on two consecutive nights, the Beck anxiety inventory (BAI), the Beck depression inventory (BDI) fatigue severity scale (FSS) and the Epworth sleepiness scale (ESS) were evaluated at baseline and posttreatment as the secondary outcome measures. RESULTS After the treatments, PSQI scores decreased by 5.04 in the acupuncture group and 2.92 in the sham acupuncture group. ISI scores decreased by 7.65 in the acupuncture group and 5.05 in the sham acupuncture group. The between-group differences in the primary outcome measures posttreatment were statistically significant. However, no differences were found between the two groups during the two follow-ups. Regarding the PSG data, there were significantly lower levels of sleep onset latency (SOL), a lower percentage of sleep stage N1 and a higher percentage of sleep stage N3 in the acupuncture group than in the sham acupuncture group. After treatment, there were lower levels of comorbid symptoms (BAI, BDI, FSS and ESS) in both groups. However, no significant differences were observed between the groups. CONCLUSION Acupuncture at HT 7 and KI 7 is an effective and safe nonpharmacologic intervention option for chronic insomnia. CLINICAL TRIAL REGISTRATION The study was registered at the Chinese Clinical Trial Registry, registration ID: ChiCTR1900023787, China.
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Affiliation(s)
- Cong Wang
- Department of Acupuncture and Moxibustion, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Wen-lin Xu
- Department of Acupuncture and Moxibustion, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Guan-wu Li
- Department of Radiology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Cong Fu
- Department of Acupuncture and Moxibustion, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Jin-jin Li
- Department of Acupuncture and Moxibustion, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Jing Wang
- Department of Acupuncture and Moxibustion, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Xin-yu Chen
- Acupuncture and Tuina Academy, Beijing University of Chinese Medicine Dongfang College, Hebei, People’s Republic of China
| | - Zhen Liu
- Department of Acupuncture and Moxibustion, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Yun-fei Chen
- Department of Acupuncture and Moxibustion, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
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Guo Y, Chen Y, Yang Q, Hou F, Liu X, Ma Y. Multi-Scale Permutation Entropy: A Potential Measure for the Impact of Sleep Medication on Brain Dynamics of Patients with Insomnia. ENTROPY (BASEL, SWITZERLAND) 2021; 23:1101. [PMID: 34573726 PMCID: PMC8472826 DOI: 10.3390/e23091101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/21/2021] [Accepted: 08/22/2021] [Indexed: 11/23/2022]
Abstract
Insomnia is a common sleep disorder that is closely associated with the occurrence and deterioration of cardiovascular disease, depression and other diseases. The evaluation of pharmacological treatments for insomnia brings significant clinical implications. In this study, a total of 20 patients with mild insomnia and 75 healthy subjects as controls (HC) were included to explore alterations of electroencephalogram (EEG) complexity associated with insomnia and its pharmacological treatment by using multi-scale permutation entropy (MPE). All participants were recorded for two nights of polysomnography (PSG). The patients with mild insomnia received a placebo on the first night (Placebo) and temazepam on the second night (Temazepam), while the HCs had no sleep-related medication intake for either night. EEG recordings from each night were extracted and analyzed using MPE. The results showed that MPE decreased significantly from pre-lights-off to the period during sleep transition and then to the period after sleep onset, and also during the deepening of sleep stage in the HC group. Furthermore, results from the insomnia subjects showed that MPE values were significantly lower for the Temazepam night compared to MPE values for the Placebo night. Moreover, MPE values for the Temazepam night showed no correlation with age or gender. Our results indicated that EEG complexity, measured by MPE, may be utilized as an alternative approach to measure the impact of sleep medication on brain dynamics.
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Affiliation(s)
- Yanping Guo
- School of Electrical & Mechanical Engineering and Automation, Nanhang Jincheng College, Nanjing 211156, China;
| | - Yingying Chen
- School of Science, China Pharmaceutical University, Nanjing 210009, China; (Y.C.); (Q.Y.); (F.H.)
- School of Software, Nanjing University of Science and Technology, Nanjing 210094, China
| | - Qianru Yang
- School of Science, China Pharmaceutical University, Nanjing 210009, China; (Y.C.); (Q.Y.); (F.H.)
| | - Fengzhen Hou
- School of Science, China Pharmaceutical University, Nanjing 210009, China; (Y.C.); (Q.Y.); (F.H.)
| | - Xinyu Liu
- School of Science, China Pharmaceutical University, Nanjing 210009, China; (Y.C.); (Q.Y.); (F.H.)
| | - Yan Ma
- Osher Center for Integrative Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02215, USA;
- Beth Israel Deaconess Medical Center, Division of Interdisciplinary Medicine and Biotechnology, Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
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Xia Q, Gao H, Xian J, Yan X, Zhou Y, Lu Y, Ma Y. Efficacy and safety of acupuncture for elderly patients with coronavirus disease 2019 (COVID-19): A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24515. [PMID: 33592905 PMCID: PMC7870192 DOI: 10.1097/md.0000000000024515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The study aims to evaluate the effectiveness and safety of acupuncture therapy for elderly patients with coronavirus disease 2019 (COVID-19). METHODS Relevant articles from December 2019 to December 2020 will be searched in the following electronic databases: Medline, PubMed, EMBASE, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), and China Scientific Journals Database. All published randomized controlled trials (RCTs) and credible clinical observations about this topic will be included. Two independent researchers will operate article retrieval, duplication removing, screening and data analysis by EndNote X9.0 and Stata 15.0. We will use the Cochrane risk of bias tool for randomized trials to assess the risk of bias of included studies. Meta-analysis, subgroup analysis, and/or descriptive analysis will be performed according to the data conditions included. RESULTS High-quality synthesis and/or descriptive analysis of current evidence will be provided from mortality rate, cure rate, C-reactive protein (CRP), creatine, troponin, aspartate aminotransferase, alanine aminotransferase, and improvements in chest CT scans, clinical symptoms (including fever, fatigue, cough, nausea, vomiting and diarrhea) and the side effects of acupuncture. CONCLUSION This study will provide evidence of whether acupuncture is an effective and safe intervention for the elderly with COVID-19. PROSPERO REGISTRATION NUMBER CRD42020225245.
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