Evidence surveillance for a living clinical guideline: Case study of the Australian stroke guidelines.

BACKGROUND: Continual evidence surveillance is an integral feature of living guidelines. The Australian Stroke Guidelines include recommendations on 100 clinical topics and have been 'living' since 2018. OBJECTIVES: To describe the approach for establishing and evaluating an evidence surveillance system for the living Australian Stroke Guidelines. METHODS: We developed a pragmatic surveillance system based on an analysis of the searches for the 2017 Stroke Guidelines and evaluated its reliability by assessing the potential impact on guideline recommendations. Search retrieval and screening workload are monitored monthly, together with the frequency of changes to the guideline recommendations. RESULTS: Evidence surveillance was guided by practical considerations of efficiency and sustainability. A single PubMed search covering all guideline topics, limited to systematic reviews and randomised trials, is run monthly. The search retrieves about 400 records a month of which a sixth are triaged to the guideline panels for further consideration. Evaluations with Epistemonikos and the Cochrane Stroke Trials Register demonstrated the robustness of adopting this more restrictive approach. Collaborating with the guideline team in designing, implementing and evaluating the surveillance is essential for optimising the approach. CONCLUSION: Monthly evidence surveillance for a large living guideline is feasible and sustainable when applying a pragmatic approach.

Imiquimod-induced bullous pemphigoid: A case report.

A 72-year-old man treated with 3.5% imiquimod cream for scalp actinic keratoses developed the usual crusted and erosive reaction but developed bullae on the scalp, as well as the limbs and torso after several weeks into treatment. Biopsy confirmed bullous pemphigoid. He was treated with clobetasol ointment, prednisone and methotrexate, with eventual disease control. He had a severe disease course. Bullous pemphigoid is usually idiopathic, but can be induced by skin trauma, as well as by several medications; this is the first report of imiquimod as a trigger. Imiquimod is a toll-like receptor 7 agonist that induces cellular apoptosis and recruits pro-inflammatory cytokines including tumour necrosis factor-alpha and interferon-alpha, which have been implicated in autoimmunity. This case highlights an unusual but severe adverse effect from topical imiquimod.

New mycosis fungoides-like lymphomatoid reaction following COVID-19 vaccination: A case report.

Numerous cutaneous side effects arising from COVID-19 vaccination have been reported. Mycosis fungoides (MF) is a rare indolent form of cutaneous t-cell lymphoma. While the pathogenesis of MF is not well understood, it is thought to involve immune dysregulation. There have been reports of COVID-19 vaccination induced flares and recurrences of cutaneous lymphomas and lymphomatoid reactions. We present the first reported case of COVID-19 vaccine induced MF-like lymphomatoid reaction.

YouTube as a source of misinformation on COVID-19 vaccination: a systematic analysis.

INTRODUCTION: Vaccines for SARS-CoV-2 have been accessible to the public since December 2020. However, only 58.3% of Americans are fully vaccinated as of 5 November 2021. Numerous studies have supported YouTube as a source of both reliable and misleading information during the COVID-19 pandemic. Misinformation regarding the safety and efficacy of COVID-19 vaccines has negatively impacted vaccination intent. To date, the literature lacks a systematic evaluation of YouTube's content on COVID-19 vaccination using validated scoring tools. The objective of this study was to evaluate the accuracy, usability and quality of the most widely viewed YouTube videos on COVID-19 vaccination. METHODS: A search on YouTube was performed on 21 July 2021, using keywords 'COVID-19 vaccine' on a cleared-cache web browser. Search results were sorted by 'views', and the top 150 most-viewed videos were collected and analysed. Duplicate, non-English, non-audiovisual, exceeding 1-hour duration, or videos unrelated to COVID-19 vaccine were excluded. The primary outcome was usability and reliability of videos, analysed using the modified DISCERN (mDISCERN) score, the modified Journal of the American Medical Association (mJAMA) score and the COVID-19 Vaccine Score (CVS). RESULTS: CONCLUSION: As the COVID-19 pandemic evolves, widespread adoption of vaccination is essential in reducing morbidity, mortality, and returning to some semblance of normalcy. Providing high-quality and engaging health information from reputable sources is essential in addressing vaccine hesitancy.

Early Warning of Infection in Patients Undergoing Hematopoietic Stem Cell Transplantation Using Heart Rate Variability and Serum Biomarkers.

Early warning of infection is critical to reduce the risk of deterioration and mortality, especially in neutropenic patients following hematopoietic stem cell transplantation (HCT). Given that heart rate variability (HRV) is a sensitive and early marker for infection, and that serum inflammatory biomarkers can have high specificity for infection, we hypothesized their combination may be useful for accurate early warning of infection. In this study, we developed and evaluated a composite predictive model using continuous HRV with daily serum biomarker measurements to provide risk stratification of future deterioration in HCT recipients. A total of 116 ambulatory outpatients about to undergo HCT consented to collection of prospective demographic, clinical (daily vital signs), HRV (continuous electrocardiography [ECG] monitoring, laboratory [daily serum samples frozen at -80 °C]), and infection outcome variables (defined as the time of escalation of antibiotics), all from 24 hours pre-HCT to the onset of infection or 14 days post-HCT. Indications for antibiotic escalation were adjudicated as "true infection" or not by 2 blinded HCT clinicians. A composite time series of 8 HRV metrics was created for each patient, and the probability of deterioration within the next 72 hours was estimated using logistic regression modeling of composite HRV and serum biomarkers using a rule-based naïve Bayes model if the HRV-based probability exceeded a median threshold. Thirty-five patients (30%) withdrew within <24 hours owing to intolerability of ECG monitoring, leaving 81 patients, of whom 48 (59%) had antibiotic escalation adjudicated as true infection. The combined HRV and biomarker (TNF-α, IL-6, and IL-7) predictive model began increasing at ~48 hours on average before the diagnosis of infection, could distinguish between high risk of impending infection (>90% incidence of subsequent infection within 72 hours), average risk (~50%), and low risk (<10%), with an area under the receiver operating characteristic curve of 0.87. However, given that prophylactic predictive ECG monitoring and daily serum collection proved challenging for many patients, further refinement in measurement is necessary for further study.

MSC-Derived Extracellular Vesicles to Heal Diabetic Wounds: a Systematic Review and Meta-Analysis of Preclinical Animal Studies.

INTRODUCTION: Extracellular vesicles from mesenchymal stromal cells (MSC-EVs) have shown promise in wound healing. Their use in diabetic wounds specifically, however, remains pre-clinical and their efficacy remains uncertain less clear. A systematic review of preclinical studies is needed to determine the efficacy of MSC-EVs in the treatment of diabetic wounds to accelerate the clinical translation of this cell-based therapy. METHODS: PubMed and Embase were searched (to June 23, 2020). All English-language, full-text, controlled interventional studies comparing MSC-EVs to placebo or a "no treatment" arm in animal models of diabetic wounds were included. Study outcomes, including wound closure (primary outcome), scar width, blood vessel number and density, and re-epithelialisation were pooled using a random effects meta-analysis. Risk of bias (ROB) was assessed using the SYRCLE tool for pre-clinical animal studies. RESULTS: A total of 313 unique records were identified from our search, with 10 full text articles satisfying inclusion criteria (n = 136 animals). The administration of MSC-EVs improved closure of diabetic wounds compared to controls with a large observed effect (Standardized Mean Difference (SMD) 5.48, 95% Confidence Interval (CI) 3.55-8.13). Healing was further enhanced using MSC-EVs enriched in non-coding RNAs or microRNAs compared to controls (SMD 9.89, 95%CI 7.32-12.46). Other outcomes, such as blood vessel density and number, scar width, and re-epithelialisation were improved with the administration of MSC-EVs, with a large effect. ROB across studies was unclear. CONCLUSION: MSC-EVs, particularly following enrichment for specific RNAs, are a promising treatment for diabetic wounds in pre-clinical studies and translation to the clinical domain appears warranted. REGISTRATION: PROSPERO #CRD42020199327 [248]. Forest plot demonstrating increased wound closure rates of diabetic wounds receiving genetically modified MSC-EVs that were enriched for specific RNAs. DFO = deferoxamine. Control groups were inactive (no treatment or saline) except for 3 studies which used hydrogels without MSC-EVs as control (Li M 2016; Shi 2017; Tao 2016).

Microneedling as an adjuvant to topical therapies for melasma: A systematic review and meta-analysis.

BACKGROUND: Microneedling as an adjuvant to topical medications has shown promising but variable results in the treatment of melasma. OBJECTIVE: To conduct a systematic review and meta-analysis on the efficacy of microneedling as an adjuvant to topical therapies for the treatment of melasma. METHODS: This study followed PRISMA guidelines. All comparative, prospective studies on the use of topical interventions with microneedling for the treatment of melasma were included. Studies involving radiofrequency microneedling were excluded. RESULTS: Twelve eligible studies comprising 459 patients from 7 different countries were included. Topical therapies included topical tranexamic acid, vitamin C, platelet-rich plasma, non-hydroquinone-based depigmentation serums, and hydroquinone-based depigmenting agents. Topical therapy with microneedling improved melasma severity with a large effect (standardized mean difference >0.8) beyond 8 weeks, with best results seen at 12 weeks. Compared to topical therapy alone, topical therapy with microneedling resulted in an additional improvement in melasma severity with a moderate effect at 8 weeks and a large effect at 12-16 weeks. Microneedling was well tolerated across studies, with no serious adverse events reported. LIMITATIONS: Heterogeneity in study designs did not allow for a comparison of the efficacy of various topical therapies with microneedling. CONCLUSION: Microneedling is useful adjuvant to topical therapies for the treatment of melasma.

Preventing postpartum weight retention following antenatal lifestyle intervention: One year postpartum follow up of the Healthy Lifestyles in Pregnancy (HeLP-her) randomised controlled trial.

Antenatal lifestyle interventions optimise gestational weight gain, yet longer-term efficacy on postpartum weight retention is unclear. Overall, 228 pregnant women <15 weeks gestation were randomised to intervention (four behavioural self-management sessions) or control (generic health information). Median weight retention at 12 months postpartum was significantly reduced in the intervention with a between group difference of -2.3 (-2.8 (-5.9 to 0.35) vs -0.5 (-2.6 to 2.1) kg, respectively P < 0.05, (n = 75) ± 6.3 kg vs -0.5 ± 4.7 kg, respectively, P < 0.05) and associated increased self-weighing behaviours, compared with the control group (regular weighing: 68% vs 43%, P < 0.01). Results demonstrate the efficacy of a low-intensity, behavioural lifestyle intervention in limiting postpartum weight retention.