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Certainty assessment Grading of recommendations, assessment, development, and evaluations (GRADE) methodology was employed to evaluate the certainty of evidence for the primary outcome, which categorizes the quality of evidence as high, moderate, low, or very low, based on five essential domains (study limitations, directness, consistency, precision, and reporting bias) as well as three supplementary domains (dose-response relationship, plausible confounding factors that could decrease the observed effect, and strength of association) 17,18

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