Key messages

• In people with stomach cancer, there may be little to no difference in survival and the chance of the cancer coming back whether the spleen is removed or kept during surgery to remove the stomach. We are unsure about the effects of removing or keeping the spleen on death shortly after surgery.

• Removing the stomach and the spleen probably leads to more people having complications after the operation. However, we are very uncertain whether removing the spleen changes the chance of needing another operation, or the length of hospital stay. We found no evidence about quality of life.

• Future studies should investigate people with tumors in different locations and at different stages of severity. They should look at quality of life and unwanted effects.

What is stomach cancer?

Stomach cancer is a disease in which the cells forming the inner lining of the stomach become abnormal and start to divide uncontrollably, forming a mass called a tumor.

How is stomach cancer managed?

Stomach cancer in the upper third of the stomach is often treated by performing an operation to remove the stomach (total gastrectomy). Removing the spleen at the same time as the stomach also removes the lymph nodes near the spleen. The more lymph nodes that can be removed, the more accurately doctors can judge what stage a cancer has reached, which can indirectly improve survival by identifying people who can benefit from additional therapies. The routine surgical removal of the spleen during total gastrectomy is controversial: it may potentially benefit people in terms of survival; conversely, it is also possible that it may have no benefits and may be associated with unwanted effects.

What did we want to find out?

We wanted to find out if removing the spleen during surgery for stomach cancer is better or worse than leaving it in place. We looked at the effects on survival, chance of cancer coming back, death shortly after surgery, complications after surgery, need for another operation, length of hospital stay, and quality of life.

What did we do?

We searched for studies that compared removing the spleen versus keeping the spleen during total gastrectomy. Studies could take place anywhere, and be published at any time and in any language. We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and study sizes.

What did we find?

We found five studies with 1002 adults undergoing surgery for stomach cancer. The studies were conducted in Asia and South America and were published between 1985 and 2017. On average, the proportion of women in the studies was between 20% and 30%. Four studies with 908 participants reported the tumor stage. Three studies with 736 participants reported the tumor depth and type. The studies reported the following outcomes: survival, chance of cancer coming back, death shortly after surgery, complications after surgery, need for another operation, and length of hospital stay.

Main results

Compared with keeping the spleen, removing the spleen during surgery for stomach cancer probably leads to more people having complications after surgery. It is unclear if removing the spleen has an effect on death shortly after surgery, the chance of needing another operation, or the length of hospital stay. Removing the spleen may make little to no difference to survival and the chance of cancer coming back. None of the studies reported quality of life.

What are the limitations of the evidence?

We are not confident in the evidence because it is possible that people in the studies were aware of what treatment they were getting, and not all the studies provided data about everything that we were interested in. In addition, some studies did not clearly report how they were conducted, and there are not enough studies to be certain about the results of our outcomes.

How up to date is this evidence?

The evidence is current to February 2025.

Key messages

• Choosing to fix the patch with glue or a self-sticking patch compared to using stitches, tacks, or staples may make little to no difference to the risk of long-term pain and the hernia coming back.

• Fixing the patch with glue or a self-sticking patch may reduce the risk of blood collecting under the skin compared with using stitches, tacks, or staples.

• We generally have little or very little confidence in the results, meaning the results should be interpreted carefully.

What is a groin hernia?

A groin hernia happens when abdominal content, like part of the intestine or fat, pushes through a weak spot in the groin. A hernia causes a bulge and sometimes pain. Groin hernias are common and typically require surgery as they do not go away without surgery.

How is a groin hernia treated?

A groin hernia can be treated by a keyhole operation where surgeons make small cuts in the abdomen and use special tools to fix the groin hernia from inside the abdomen. Surgeons place a patch over the weak area in the groin to support it. The patch can be attached using glue or special self-sticking patches (named ‘non-penetrating patch fixation’ in this review) or using sharp tools like stitches, tacks, or staples (named ‘penetrating patch fixation’ in this review).

What did we want to find out?

We wanted to find out whether non-penetrating or penetrating patch fixation was more effective in reducing pain, preventing the hernia from coming back, and avoiding other problems during and after surgery.

What did we do?

We looked for studies where adults with groin hernias were randomly assigned to non-penetrating or penetrating patch fixation during keyhole surgery. We combined the results of these studies and assessed how trustworthy the evidence was.

What did we find?

We found 35 studies involving 4329 adults. About half of the participants had non-penetrating patch fixation, and the other half had penetrating patch fixation. Most participants were men aged between 37 and 66 years. The most common type of hernia was a first-time-occurring hernia on one side of the groin. Most studies compared fixing the patch with glue compared to using staples or tacks. The studies were of varying size, with between 30 and 600 people each, and follow-up time varied from a few days up to 56 months after surgery. Most of the included studies were from Asia or Europe.

What are the main results?

Non-penetrating patch fixation may make little to no difference to the risk of long-term pain and the hernia coming back after surgery. Non-penetrating patch fixation may reduce the risk of blood collecting under the skin in the groin compared with penetrating patch fixation, but we are not confident in this evidence. We do not know if the type of patch fixation has an effect on short-term pain, infections of the patch, how long the surgery takes, or if it prolongs how quickly people return to normal activities.

What are the limitations of the evidence?

A limitation is that we have little confidence in the evidence. This is mainly due to studies not reporting all relevant information or because there are not enough studies to be certain about the results of the outcomes.

How up to date is this evidence?

The evidence is up to date to 14 November 2024.

Key messages

• Blue light-supported resection (surgical removal) of the bladder may have little to no effect on the chance of cancer returning in people at low risk (risk for cancer returning), but may reduce the chance for those at medium and high risk.

• Blue light-supported resection of the bladder probably has little to no effect on the chance of cancer getting worse in people at low risk (for cancer getting worse) or medium risk, but may reduce the chance for those at high risk.

Why is a special visualization method (blue light) used during resection of the bladder?

In people who might have bladder cancer, the possible tumor is cut from the inner bladder wall using a special instrument inserted through the tube that carries urine from the bladder to outside the body (the urethra) into the bladder. However, it is sometimes difficult to tell what is normal bladder tissue and what is cancer. In order to see the tumor better and remove it completely, a liquid (contrast agent) is put into the bladder through a thin tube (catheter). During surgery, a special light is used to make the cancer cells light up red.

What did we want to find out?

We wanted to find out if using blue light-enhanced resection of the bladder is better than using white light during bladder surgery for people with non-muscle (superficial) invasive bladder cancer. We looked at whether it affects:

• the time it takes for cancer to return (recurrence);

• the time it takes for cancer to get worse (progression);

• whether people lived for longer;

• serious complications during surgery;

• mild complications during surgery;

• and if it had any unwanted effects.

What did we do?

We searched for studies which randomly assigned people with bladder cancer to have either blue light-enhanced resection of the bladder or white light-based resection of the bladder. We compared and summarized the results of these studies and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We identified 17 studies comparing the use of blue light-enhanced resection of the bladder to white light-based resection of the bladder. These studies involved a total of 4890 participants in the review. Blue light-enhanced resection of the bladder may have little to no effect on the risk of recurrence in people at low risk, but may reduce the risk of recurrence in those at medium and high risk. Blue light supported resection of the bladder probably has little to no effect on the risk of progression in people at low risk, may have little or no effect on the risk of progression in people at medium risk, but may reduce the risk of progression in those at high risk. We also found that blue light may have little to no effect on the number of mild or serious surgical complications, the risk of death from bladder cancer over time, any unwanted effects and mild surgical complications.

What are the limitations of the evidence?

The most significant limitations of the evidence considered in this review stem from the quality of the included studies. In some studies, the treatments were not delivered exactly as planned, making it harder to compare the groups fairly. Other studies had missing information, and the amount or reasons for missing data differed between treatment groups, which could affect the results. In addition, some studies may have reported only selected outcomes while leaving out others, creating a risk that the findings do not provide a complete picture of the intervention's effects.

How up to date is this evidence?

This review updates our previous review. The evidence is up to date to March 2026.

Key messages

• Telepharmacy may help people take their medicines as prescribed, and may reduce both systolic blood pressure (the pressure in your arteries when your heart beats) and diastolic blood pressure (the pressure between heartbeats). It probably makes little or no difference to blood sugar control (HbA1c).

• We are very uncertain about its effects on patients’ satisfaction with care. Telepharmacy may affect medicine‐related problems (such as side effects or interactions), but findings varied because some interventions aimed to detect more problems while others aimed to reduce harms from medicines. No studies reported the number of deaths or unwanted effects from telepharmacy, so potential harms remain uncertain.

• Studies did not show consistent effects on quality of life, hospital admissions, hospital emergency department visits, or healthcare costs. Most studies involved only a few people or had limitations, and the studies varied in delivery and content.

What is telepharmacy?

Telepharmacy is the use of phone calls, video calls, mobile apps, or other electronic communication to provide pharmacy services without meeting in person. It can include advice about medicines, help with taking medicines as prescribed, and monitoring of health. Telepharmacy can make it easier for people to get support from a pharmacist, especially if they live far from a clinic or have difficulty travelling. It may also help pharmacists detect medicine‐related problems and adjust treatments when needed.

What are long-term health conditions?

Long-term health conditions, sometimes called chronic conditions, are health problems that can usually be controlled but not cured. They last for three months or longer, and may get worse over time. People with long-term conditions often require ongoing care. Examples include diabetes, high blood pressure, asthma, and heart disease. These conditions can affect a person’s quality of life and may lead to serious complications if not well managed. People with long‐term conditions often need regular check‐ups, tests, and support to take their medicines correctly.

What did we want to find out?

We wanted to find out whether telepharmacy, compared with usual care, helps people take their medicines as prescribed, and improves patients’ satisfaction with care, medicine‐related problems, asthma control, blood pressure, and blood sugar control (measured using the HbA1c test) in people with long‐term conditions in outpatient settings. We also looked at other possible effects, such as quality of life, admissions to hospital, emergency department visits, and healthcare costs.

What did we do?

We searched for studies that compared pharmacist‐led telepharmacy with usual care for people with long-term conditions in outpatient settings. We included high-quality studies, known as randomised controlled trials. We summarised the results and rated our confidence in the evidence, considering factors such as study design, number of participants, and consistency of results.

What did we find?

We found 21 trials including 5440 people, which were performed in different countries and settings (e.g. pharmacy, hospital). Most trials compared telepharmacy with usual face-to-face care for people with long‐term conditions in outpatient settings. In the included studies, usual care generally referred to standard face-to-face care without additional telepharmacy support. Most studies lasted 12 months or less.

In people with long-term conditions in outpatient settings, compared with usual care:

• telepharmacy may improve how well people take their medicines as prescribed (10 studies, 2978 people), that is, as instructed by their healthcare providers;

• the evidence is very uncertain about whether telepharmacy improves patients’ satisfaction with their care (3 studies, 422 people);

• telepharmacy may affect problems such as medicine side effects or interactions (5 studies, 547 people), but findings varied because some studies aimed to detect more problems while other studies aimed to reduce harms;

• telepharmacy may reduce systolic blood pressure (the pressure in your arteries when your heart beats) and diastolic blood pressure (the pressure between heartbeats) (5 studies, 1254 people); but

• telepharmacy probably makes little or no difference to blood sugar control (HbA1c levels) (5 studies, 1771 people).

No studies reported the number of deaths or unwanted effects from telepharmacy, so potential harms remain uncertain. We have more confidence in some findings (such as blood sugar control) than in others (such as patients' satisfaction with their care). For some outcomes, future research could change what we know.

What are the limitations of the evidence?

Our confidence in the findings was reduced because many studies involved only a few people, had problems with how they were carried out, or produced results that did not always agree. Evidence about problems caused by medicines came only from descriptions given by patients, as we were unable to group and analyse data from different studies. The studies used telepharmacy interventions that varied in their content, and how or how often they were given, which may have influenced the results.

How up to date is this evidence?

The evidence is up to date to December 2025.

Key messages

• Current evidence does not allow firm conclusions regarding the safety of treatment with insulin-like growth factor-1, a protein that helps blood vessels in the retina of the eye grow normally, in premature babies born before term and weighing less than 1500 grams.

• Current evidence does not allow firm conclusions regarding the effect of insulin-like growth factor-1 treatment for prevention of retinopathy of prematurity, a disease in premature babies where blood vessels in the back of the eye do not grow normally.

• So far, studies of insulin-like growth factor-1 in preterm infants may not detect important benefits or side effects.

What are retinopathy of prematurity and insulin-like growth factor-1?

Retinopathy of prematurity is a common disease in babies born prematurely with a birth weight less than 1500 grams. It is caused when blood vessels in the back of the eye do not grow normally. Retinopathy of prematurity can cause vision problems or blindness.

Insulin-like growth factor-1 is a protein that helps blood vessels in the retina of the eye grow normally during pregnancy. When babies are born too early, they may not have enough insulin-like growth factor-1 in their bodies and this may cause blood vessels in the retina to grow abnormally, leading to the development of retinopathy of prematurity.

How is retinopathy of prematurity treated?

Currently, retinopathy of prematurity is treated with lasers that burn the retina in the back of the baby's eye to stop stimulation of the abnormal blood vessels that may damage vision, or with medications that are injected into the eye to temporarily stop the abnormal blood vessels from continuing to grow and damage vision.

What did we want to find out?

We wanted to find out if giving insulin-like growth factor-1 to premature babies prevents or treats retinopathy of prematurity. We also wanted to find out if giving insulin-like growth factor-1 to premature babies causes any serious side effects or problems, or had an effect on any other medical issues caused by prematurity, like brain bleeding or lung disease of prematurity.

What did we do?

We searched for research studies that compared treatment with insulin-like growth factor-1 either to a placebo (a ‘dummy’ or sham treatment) or to standard care, which is usual neonatal intensive care unit (NICU) care that does not normally include giving insulin-like growth factor-1, in premature babies who were at risk of developing retinopathy of prematurity. We compared and summarized the results of the studies and rated our confidence in the evidence based on study methods and size.

What did we find?

We included two studies with a total of 140 premature babies. The included studies tested insulin-like growth factor-1 treatment in premature babies and followed their outcomes through five to six years of age.

We found that the results of current studies do not allow for a definite conclusion regarding its efficacy for preventing or treating retinopathy of prematurity. The results of current studies also do not allow for a definite conclusion regarding the safety of insulin-like growth factor-1 treatment in premature babies, including harmful effects or death.

What are the limitations of the evidence?

Our confidence in the evidence is very low, and the results of further research could differ from the results of this review. Two main factors reduced our confidence in the evidence. First, we only identified two studies of insulin-like growth factor-1 treatment in premature infants and not many infants participated in them. This means there may not have been enough participants who received treatment to determine whether it actually made a difference. Second, the studies we found had problems with their design or the way they were conducted, which may affect the accuracy of their results.

How up to date is this evidence?

The evidence is up-to-date to March 2025.

Key messages

• In people with mild memory and thinking problems (mild cognitive impairment (MCI)) or mild dementia due to Alzheimer's disease, laboratory-produced medicines (anti-amyloid monoclonal antibodies) that target and remove potentially damaging build-ups of amyloid proteins in the brain, probably result in little to no difference in the decline in memory functioning and thinking ability, or in how severe dementia symptoms are, compared with placebo (sham treatment) 18 months after the start of treatment.

• Anti-amyloid monoclonal antibodies probably cause more brain swelling and tiny (micro) bleeds than placebo. They do not increase other serious unwanted effects or deaths compared with placebo.

• Successful removal of amyloid proteins from the brain does not seem to be associated with clinically meaningful improvements in people with MCI or mild dementia due to Alzheimer’s disease. Future research on disease-modifying treatments for Alzheimer’s disease should focus on other treatments.

What is Alzheimer’s disease?

In Alzheimer’s disease, brain cells die following the build-up of proteins (called amyloid plaques). Alzheimer’s disease affects people’s memory and thinking abilities. Symptoms are usually mild to begin with and do not interfere with everyday life. This is called ‘mild cognitive impairment’ (MCI). Over time, it can progress to mild dementia, where memory and thinking difficulties are serious enough to interfere with everyday activities. About 15% of people with MCI will develop dementia due to Alzheimer’s disease within two years. It is the most common form of dementia among older people.

What are anti-amyloid monoclonal antibodies?

Antibodies are made by the body as a defence against disease. They can also be produced in a laboratory for use as a medical treatment. Anti-amyloid antibodies are designed to target the amyloid proteins that cause plaques due to Alzheimer’s disease, and remove them from the brain. They are ‘monoclonal’ because they only target amyloid proteins. Removing amyloid proteins from the brain may slow the progression of Alzheimer’s disease.

What did we want to find out?

We wanted to know if anti-amyloid monoclonal antibodies are an effective medicine for people with MCI or mild dementia due to Alzheimer’s disease. We evaluated whether they slowed down:

• the decline in memory and thinking;

• the decline in ability to manage everyday activities; and

• the worsening of dementia symptoms.

We also wanted to know if they caused any unwanted effects.

What did we do?

We searched for studies that investigated one or more anti-amyloid monoclonal antibodies to treat people with MCI or mild dementia due to Alzheimer’s disease, compared with placebo (sham treatment that does not contain any medicine but looks identical to the medicine being tested and is delivered in the same way).

We summarised the results of the studies, and rated our confidence in the evidence, considering aspects such as study sizes and methods.

What did we find?

We found 17 studies that were carried out in different countries and involved 20,342 people. The average age across studies was from 70 to 74 years. All studies were funded by companies that produced the anti-amyloid monoclonal antibodies.

Main results

After 18 months of treatment, anti-amyloid monoclonal antibodies:

• may make little to no difference to how bad people’s dementia symptoms are (9 studies, 8053 people);

• probably make little to no difference in the decline in memory and thinking ability (13 studies, 9895 people) or the ability to manage everyday activities (3 studies, 3478 people);

• may result in a small improvement in more complex everyday tasks, such as shopping, managing finances, taking medication, and using transportation (1 study, 1252 people);

• probably result in a small increase in the occurrence of brain swelling. For every 1000 people using monoclonal antibodies, 119 developed brain swelling compared with only 12 of 1000 people using placebo (11 studies, 13,595 people);

• may result in a small increase in microbleeds in the brain (3 studies, 4308 people);

• do not increase other serious unwanted effects as defined by the study authors (9 studies, 11,904 people); and

• do not increase deaths from any cause (7 studies, 9733 people).

What are the limitations of the evidence?

Our confidence in the evidence is limited for two reasons. Firstly, people who received monoclonal antibodies had more brain swelling and microbleeds than people receiving placebo. However, most studies did not separate people with symptoms of brain swelling and microbleeds from those in whom these effects were only visible with a scan. This reporting gap leaves patients without the information they need to understand the seriousness of potential unwanted effects. Secondly, the results came from studies that did not last very long. These are important limitations in the evidence for people with Alzheimer’s disease, who need to know the longer-term benefits and unwanted effects of medicines.

We found six ongoing studies. The review's conclusions may change as new results become available.

How up to date is this evidence?

The evidence is current to 7 August 2025.

Key messages

• Children with low language proficiency (LLP) (difficulties) may meet problems with speaking, understanding language, and literacy (ability to read) as they grow older. They also have psychological and social difficulties later in life, but the evidence is less certain for these outcomes than for learning outcomes.

• It is unclear whether early language skills affect later independence and participation in everyday life, as the evidence is very limited and uncertain.

• We need more long-term, high-quality studies with large samples and comparison groups to understand which children are most affected and how early language difficulties affect later outcomes, particularly independence and participation in daily life, where current evidence is limited.

Low language proficiency in children

Children with LLP have difficulties with speaking, understanding, or using language in early childhood. These difficulties can affect how children learn to read, communicate with others, and take part in everyday activities at school and at home. For some children, early language difficulties improve over time. For others, they continue as children grow older and may affect later learning, social relationships, and independence.

What did we want to find out?
We wanted to see whether children with low language skills at ages four to eight years old continue to have problems with language, reading, and quality of life as they grow up.

What did we do?
We searched for studies of children between the ages of four and eight years who were identified as having LLP. These children either scored below average on language tests or had a clinical diagnosis. We analysed outcomes related to language and reading, as well as five areas of quality of life:

• psychological well-being (mental health)

• physical health

• independence

• social relationships (making friends)

• participation in everyday life such as work and community life

We combined the results of the studies using statistical methods (meta-analysis) and took into account that some outcomes were related to each other.

What did we find?

We found 80 studies (that took place in North America or Europe) which followed children with LLP into adolescence or adulthood and reported outcomes from 15 different groups of children (cohorts), with about 28,800 children in total.

Children with LLP are likely to continue:

• having difficulties with language and reading into adolescence and adulthood.

These difficulties were noticeable and consistent across studies. Children with LLP may also be at higher risk of:

• mental health problems, such as depression or anxiety

• difficulties with making friends

• less independence in daily life

We do not have enough evidence to know whether they have problems with physical health.

What are the limitations of the evidence?

Some studies in this review had limitations that affect how confident we can be in the results.

• We are highly confident that children with LLP have difficulties with literacy (ability to read) when growing up.

• We are moderately confident that children with LLP have difficulties with language when growing up, because some of the children in the studies dropped out. However, our results were generally consistent.

• We are moderately confident that children with LLP experience more mental health problems (e.g. problems with making friends) and a lack of participation in everyday life when growing up. Our confidence is only moderate because of small studies (for participation) or variation between studies. Generally, patterns were consistent but further evidence may change our results.

• We have low confidence that children with LLP have difficulties with becoming independent when growing up, because of very few studies. Further evidence is likely to change our results.

• We are not confident that children with LLP have difficulties with physical health when growing up. The evidence is very uncertain.

The way low language proficiency was described and measured sometimes varied between studies. Some outcomes — especially physical health, independence, and participation in daily life — were only reported in a few studies. Some studies were small or included only certain groups of children. Important factors, such as non-verbal IQ or other health conditions, were not always reported. The results also varied between studies, which means that not all children with LLP are affected in the same way. Overall patterns are consistent, but some findings should be interpreted carefully.

How up to date is this evidence?

The evidence is up-to-date to March 2025.

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