Summary

A Systematic Review

[Posted 5/Nov/2024]

AUDIENCE: Family Medicine

KEY FINDINGS: Different anticoagulation-related perioperative management strategies achieve different outcomes following elective arthroplasty in patients with therapeutic chronic anticoagulation. There is contradictory evidence regarding the need for the discontinuation of therapeutic warfarin. Retrospective data showed that individual risk stratification with multi-modal prophylaxis resulted in minimal complications.

BACKGROUND: There are currently different management guidelines for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) that are on long-term anticoagulation. The timing of discontinuation and restarting the anticoagulation is challenging during the postoperative care, which often involves general practitioners and physiotherapists.

DETAILS: The systematic review followed the PRISMA guidelines and included 3 databases: PubMed/MEDLINE, EMBASE, and Web of Science Core Collection. The risk of bias assessment was performed using the Methodological index for non-randomized studies (MINORS) criteria. Six retrospective studies involving 727 patients with therapeutic anticoagulation (1,540 controls) for elective THA, TKA and revision arthroplasty have been included. The follow-up ranged from 30 days to 1 year postoperatively. All studies evaluated outcomes of warfarin therapeutic anticoagulation versus prophylactic dosages of one or more of the following: warfarin, aspirin, low-molecular-weight heparin (LMWH) and unfractionated low-dose heparin (UFH). One study did not discontinue therapeutic anticoagulation. Two studies reported no significant differences in complications between groups, whilst 3 studies had significantly higher rates of superficial wound infections, revision surgeries, postoperative haematomas, and prosthetic joint infections (PJI).

Copyright © Oxford University Press. All rights reserved.

Source: Andronic, D., Andronic, O., Ammann, E., et al. (2024). Outcomes of Different Perioperative Management Strategies of Patients on Chronic Anticoagulation in Elective Total Hip and Knee Arthroplasty: A Systematic Review. Family Practice. 2024; 41(5): 629–637. Published: October, 2024. DOI: 10.1093/fampra/cmae020.

Summary

A Systematic Review and Meta-Analysis of Randomised Controlled Studies

[Posted 14/Jul/2025]

AUDIENCE: Nursing

KEY FINDINGS: This review indicated that NLC was not inferior to other types of care, and even had a better positive impact on disease activity, fatigue, and satisfaction for patients with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis is a chronic autoimmune disease, which may not respond to insufficient rheumatology care capacity and workforce shortage. NLC is a care delivery model that can help address this shortage and improve disease management. Purpose of this study is to evaluate the effectiveness of nurse-led care (NLC) in patients with rheumatoid arthritis on disease activity, physical function, fatigue, satisfaction, pain, and quality of life.

DETAILS: Nine databases were independently searched by two reviewers for eligible studies. Randomised controlled studies evaluating the effects of NLC on disease activity, physical function, fatigue, satisfaction, and other outcomes were included. The cochrane risk of bias tool was used to assess the risk of bias. A total of nine studies involving 1447 participants were included. The pooled results indicated that no significant difference in disease activity was found at 0.5 years of follow-up (SMD: -0.33, 95% CI [-0.70, 0.04]), and a significant difference was seen in favour of NLC at 1 year (SMD: -0.35, 95% CI [-0.48, -0.10]), and 2 years (SMD: -0.29, 95% CI [-0.48, -0.10]). Moreover, no significant difference was found in fatigue and satisfaction at 0.5 years of follow-up, whereas differences in favour of NLC were seen at 1 year. In addition, no significant difference was found in physical function, pain, and quality of life.

Copyright © John Wiley & Sons Ltd. All rights reserved.

Source: Yang, Z., Pei, J., Guo, X., et al. The Effectiveness of Nurse-Led Care in Patients With Rheumatoid Arthritis: A Systematic Review and Meta-Analysis of Randomised Controlled Studies. Journal of Clinical Nursing. 2025; 34(7): 2548-2563. Published: July, 2025. DOI: 10.1111/jocn.17687.

Summary

[Posted 7/Jul/2025]

AUDIENCE: Dermatologists, Gynecologists, Primary Care Physicians, and other healthcare professionals involved in women's health.

KEY FINDINGS:

• Vulvovaginal itching is a common, often under-recognized condition with diverse etiologies, necessitating a comprehensive diagnostic approach.
• Causes span infectious, inflammatory, hormonal, neoplastic, neuropathic, systemic, and genetic factors, often requiring a multidisciplinary assessment.
• Chronic vulvovaginal pruritus significantly impacts patients' physical and emotional quality of life, leading to embarrassment, frustration, and avoidance of care.
• Effective management involves a multimodal strategy, combining lifestyle modifications, topical therapies (e.g., corticosteroids, antifungals, calcineurin inhibitors), systemic treatments (e.g., oral corticosteroids, anticonvulsants, biologics for refractory cases), and non-pharmaceutical interventions.
• There remains a critical need for further research to develop comprehensive, evidence-based guidelines and understand the holistic impact of female-specific pruritus.

BACKGROUND: Vulvovaginal itching is a prevalent yet frequently under-recognized complaint affecting women across all age groups. Despite its commonality, many dermatologists receive limited training in vulvar diseases, contributing to delayed diagnoses and prolonged patient discomfort. Patients often attempt self-treatment with over-the-counter products, which can exacerbate symptoms and complicate accurate diagnosis. The complex nature of vulvovaginal pruritus often demands a multidisciplinary approach for effective diagnosis and treatment, highlighting the need for improved understanding and management strategies.

DETAILS:

Pathophysiology Vulvovaginal itching can arise from various mechanisms, including compromised skin barrier integrity, elevated skin pH activating proteases, and hormonal fluctuations impacting epithelial health and microflora. Psychogenic factors can also initiate or aggravate itch through an itch-scratch cycle.

Causes

• Infectious Common acute causes include fungal (e.g., *Candida albicans*), bacterial (e.g., bacterial vaginosis, Group A β-hemolytic streptococcus), parasitic (e.g., trichomoniasis, pinworms, scabies, pubic lice), and viral infections (e.g., HSV, HPV).
• Inflammatory Dermatological conditions like atopic dermatitis, irritant/allergic contact dermatitis (from hygiene products, fabrics), psoriasis, lichen simplex chronicus, lichen sclerosus, and lichen planus are frequent culprits.
• Neoplastic Though rare, vulvar malignancies (e.g., squamous cell carcinoma, melanoma, extramammary Paget's disease) can present with persistent itching, often as an early symptom. Benign tumors like syringomas can also be pruritic.
• Neuropathic Damage or dysfunction of nerve fibers in the vulvar region (e.g., from burns, scars, radiation, spinal nerve compression, small fiber polyneuropathy, vulvodynia) can lead to abnormal, often intense, sensory experiences.
• Systemic Conditions like diabetes (predisposing to infection and neurogenic itch), HIV, hepatic, and renal diseases can cause generalized or localized vulvar pruritus due to circulating pruritogens or altered immune responses.
• Genetic Rare genodermatoses such as Darier disease and Hailey-Hailey disease can cause itchy lesions in the vulvovaginal area. Genetic predispositions may also increase susceptibility to conditions like atopic dermatitis or recurrent candidiasis.

Evaluation A thorough history (onset, duration, severity, timing, aggravating/relieving factors, environmental exposures, hygiene, sexual history, medications, medical history) and physical examination are crucial. This includes inspecting the vulvovaginal area for lesions, discharge, and tissue changes. Diagnostic tools may include wet mount microscopy, STI testing, pH testing, vulvoscopy, and biopsy for persistent or suspicious lesions.

Treatment Strategies

• Lifestyle & Environment Wearing breathable cotton underwear, avoiding irritants (scented products, harsh soaps), gentle hygiene, proper toilet habits, and addressing psychological factors (stress, anxiety) are fundamental.
• Topical Therapies Corticosteroids (mid- to high-potency for acute inflammation, lower for maintenance), calcineurin inhibitors (tacrolimus, pimecrolimus) for chronic management, local estrogen for atrophy, antifungals for fungal infections, lactic acid products for pH balance, emollients for barrier support, and topical anesthetics (lidocaine, pramoxine) for symptomatic relief, especially in neuropathic itch. Novel topical agents like tofacitinib are emerging for inflammatory conditions.
• Systemic Treatments Oral corticosteroids for severe inflammation, anticonvulsants (gabapentin, pregabalin) and antidepressants (TCAs, SSRIs, SNRIs) for neuropathic/psychogenic itch, opiate receptor antagonists (naltrexone) for some cases, and systemic immunotherapies (methotrexate, mycophenolate mofetil) for refractory inflammatory conditions. Biologics (ixekizumab, dupilumab, tralokinumab) show promise for specific inflammatory and autoimmune causes. Antibiotics are used for bacterial infections.
• Non-pharmaceutical Sitz baths, cold compresses, Transcutaneous Electrical Nerve Stimulation (TENS), acupuncture, and physical therapy can offer symptomatic relief.

Copyright © [Your Name/Institution, if applicable]. All rights reserved.

Source: Mashoudy, K. D., Tomlinson, A.F., Kim, S. et al. Scratching the Surface: A Comprehensive Guide to Understanding and Managing Vulvovaginal Itching. Am J Clin Dermatol. 26: 361-378 (2025); Published: March 25, 2025. DOI: 10.1007/s40257-025-00939-7.

Summary

Immunogenicity, Safety, and Efficacy of the Vaccine H56:IC31 In Reducing the Rate of Tuberculosis Disease Recurrence In HIV-negative Adults Successfully Treated for Drug-Susceptible Pulmonary Tuberculosis: A Double-Blind, Randomised, Placebo-Controlled, Phase 2b Trial

[Posted 2/Jul/2025]

AUDIENCE: Infectious Disease, Family Medicine

KEY FINDINGS: Vaccination with H56:IC31 at treatment completion for pulmonary tuberculosis did not reduce the risk of recurrent disease. H56:IC31 was well tolerated and immunogenic but might have increased the risk of relapses by endogenous strains.

BACKGROUND: People with tuberculosis who complete treatment remain at risk of recurrent disease. The vaccine H56:IC31 has been shown to be safe and immunogenic in phase 1 and 2 studies, but whether it can reduce the risk of tuberculosis recurrence is unknown.

DETAILS: In a double-blind, randomised, placebo-controlled, phase 2b trial in South Africa (five clinical trial sites) and Tanzania (one clinical trial site), we enrolled participants aged 18-60 years, without HIV, who had completed more than 5 months (22 weeks) of treatment for drug-susceptible pulmonary tuberculosis. During trial screening (<=7 days after starting treatment), two sputum samples were obtained and frozen for later comparison to recurrent isolates by whole-genome sequencing (WGS). Eligible participants were randomly assigned (1:1; block size of four) to receive two intramuscular doses in the deltoid, 56 days apart, of H56:IC31 or placebo. After the first dose of H56:IC31 or placebo, participants were followed up until study day 421 (1 year after the second dose) and checked at each visit for tuberculosis signs and symptoms. If tuberculosis was suspected, two sputum samples were obtained: one sample was tested by automated molecular test (Xpert MTB/RIF Ultra) and sent for liquid culture; and the other sample was stored frozen for later analysis by whole-genome sequencing (WGS). At the last visit (day 421), two sputum samples were obtained from all sputum-productive participants, regardless of symptoms, to detect cases of asymptomatic tuberculosis. The primary endpoint was culture-confirmed recurrent pulmonary tuberculosis (due to relapse with the same strain, reinfection by a different strain, or indeterminate) occuring during the period starting at day 70 (14 days after the second dose) and ending on day 421 (1 year after the second dose). Vaccine efficacy against recurrent tuberculosis was derived from Cox proportional hazards models. Secondary endpoints included vaccine efficacy to prevent tuberculosis relapse or reinfection independently, as differentiated by WGS, and safety and immunogenicity outcomes (H56-specific CD4 T-cell responses and humoral anti-H56 IgG responses). Primary analysis of vaccine efficacy was based on modified intention-to-treat (mITT), in all randomly assigned participants except those with tuberculosis disease recurrence or who withdrew before day 70 (or 14 days after the second dose for those who received both doses). Safety was assessed in all randomly assigned participants who received at least one dose of vaccine or placebo. The trial was registered with ClinicalTrials.gov, NCT03512249, and is complete. 831 participants (mean age 34.7 years [SD 11.1]; 229 [28%] female and 602 [72%] male; 549 [66%] Black) were enrolled from Jan 31, 2019, to Jan 20, 2022; 415 participants were randomly assigned to receive H56:IC31 and 416 to receive placebo. Follow-up was completed by March 20, 2023 (mean follow-up duration 410.1 days [SD 82.8]). In the primary mITT analysis, recurrent tuberculosis occurred in 23 of 400 participants in the H56:IC31 group (12 relapses, eight reinfections, and three indeterminate); and in 14 of 406 in the placebo group (six relapses, seven reinfections, and one indeterminate). Vaccine efficacy for prevention of recurrence was -73.8% (95% CI -246.9 to 9.8; p=0.10). Vaccine efficacy for prevention of relapse was -116.1% (-522.2 to 16.3; p=0.11) and for prevention of reinfection was -21.1% (-245.3 to 56.5; p=0.71). 2 weeks after the planned second dose, H56:IC31 had significantly increased the frequencies of H56-specific CD4 T cells expressing interferon-γ, tumour necrosis factor, interleukin (IL)-2, or IL-17 in vaccinees (median percentage of CD4 T cells, 0.35% [IQR 0.19 to 0.57]) compared with placebo (0.11% [0.09 to 0.23]; p < 0.0001). H56-specific IgG responses were significantly higher in H56:IC31 recipients (median arbitrary units per mL, 6.84 [IQR 1.64 to 32.8]) than in placebo recipients (1.94 [1.05 to 3.86]; p < 0.0001). A greater proportion of H56:IC31 recipients had mild-to-moderate injection site reactions than placebo recipients (165 [40%] of 415 vs 78 [19%] of 416). No treatment-related serious adverse events were reported. Two participants who received H56:IC31 and six who received placebo died.

Copyright © Elsevier Ltd. All rights reserved.

Source: Borges, A. H., Russell, M., Tait, D., et al. Immunogenicity, Safety, and Efficacy of the Vaccine H56:IC31 In Reducing the Rate of Tuberculosis Disease Recurrence In HIV-negative Adults Successfully Treated for Drug-Susceptible Pulmonary Tuberculosis: A Double-Blind, Randomised, Placebo-Controlled, Phase 2b Trial. The Lancet Infectious Diseases. 2025; 25(7): 751-763. Published: July, 2025. DOI: 10.1016/S1473-3099(24)00814-4.

Summary

[Posted 1/Jul/2025]

AUDIENCE: Neurology, Internal Medicine, Ob/Gyn

KEY FINDINGS: This population-based study on dementia biomarkers found that P-tau181 was dependent on age and APOEe4; NfL on age and sex; and GFAP on age, sex, APOEe4, and menopause status. GFAP levels and rate of increase were higher in women, especially in premenopausal participants. Future research should confirm these findings and further explore the role of menopause in dementia pathogenesis among women.

BACKGROUND: Dementia-related blood biomarkers are the future of large-scale dementia risk stratification; however, the extent to which phosphorylated tau (P-tau181), neurofilament light (NfL), and glial fibrillary acidic protein (GFAP) are associated with nonmodifiable risk factors has yet to be confirmed in the community, and the role of menopause has yet to be investigated. Therefore, the aim of this study was to examine the association of age, sex, APOEe4 status, and menopause, with dementia-related blood biomarker levels (P-tau181, NfL, and GFAP) and rate of change over 11 years in longitudinal biomarker measurements in community-dwelling adults.

DETAILS: Within this German population-based Epidemiologische Studie zu Chancen der Verhütung, Früherkennung und optimierten Therapie chronischer Erkrankungen in der älteren Bevölkerung cohort study (n = 9,940), a nested case-control study of 1,026 participants (1:1, without dementia during follow-up: incident dementia during follow-up) aged 50-75 years at baseline followed over 17 years was conducted. Blood biomarker measurements (P-tau181, NfL, and GFAP) were completed in blood from baseline, 8-year, and 11-year follow-ups, and cross-sectional and longitudinal regression analyses were used to assess the association with age, sex, APOEe4, and menopause. The mean age of participants was 64 years, and women accounted for slightly over half (54%) of the sample. Age was cross-sectionally and longitudinally significantly associated with all dementia-related biomarkers (p < 0.001). NfL and GFAP levels more strongly correlated (Spearman R = 0.55 and 0.49) with age at baseline than P-tau181 levels (Spearman R = 0.21). Women experienced significantly higher levels and rates of increase in GFAP (p < 0.001) while men experienced higher levels of NfL after adjusting for age and APOEe4 (p < 0.01). APOEe4 status was significantly associated with baseline and longitudinal levels of P-tau181 (baseline β = 0.30, p < 0.05) and GFAP (baseline β = 15.84, p < 0.001). Of interest, premenopausal status was significantly associated with higher GFAP levels after adjusting for age, sex, and APOEe4 (β = 19.09, p < 0.05).

Copyright © American Academy of Neurology. All Rights Reserved.

Source: Stocker, H., Beyer, L., Trares, K., et al. Association of Nonmodifiable Risk Factors With Alzheimer Disease Blood Biomarkers in Community-Dwelling Adults in the ESTHER Study. American Academy of Neurology. 2025; 104(9): 213500. Published: May 27, 2025. DOI: 10.1212/WNL.000000000021350.

Summary

A Prospective Follow Up Study.

[Posted 28/May/2025]

AUDIENCE: Nursing, Neonatology

KEY FINDINGS: As early of initiation of minimal enteral nutrition has a significant role to shorten the time to reach full enteral feeding and reducing malnutrition in the NICU health care staffs treating LBW neonates should consider nutrition as part of the management and special concerns should be given for those who are very preterm and very LBW. Experts in the area and hospitals should prepare feeding initiation protocol to be used across all hospitals and health care staffs to avoid a variation in time to MEN among different neonatal units.

BACKGROUND: In Ethiopia the proportion of low birth weight infants is thought to be 17.3%. The purpose of this study was to determine the time to minimal enteral nutrition (MEN) and its predictors in LBW neonates admitted to neonatal intensive care unit in selected hospitals of Addis Ababa, Ethiopia.

DETAILS: An institutional based prospective follow up study was conducted. Both primary and secondary data was used by interviewing mothers and prospective medical chart review of neonates. The Cox regression model was used and variables having a p-value less than 0.05 with 95% CIs in a multivariable analysis were declared as statistically significant association with time to minimal enteral nutrition. 79.4% of them were initiated with MEN. The median time to MEN was 37 h. BW, GA, weight for gestational age, hospital acquired infection, respiratory support and NICU location (hospital) were found to have a statistically significant association with time to initiate minimal enteral nutrition.

Copyright © Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

Source: Terefe, A., Tachbele, E., Mislu, E., et al. Time to Start Minimal Enteral Nutrition in Low Birth Weight Infants and Its Predictors: A Prospective Follow Up Study. Journal of Neonatal Nursing. 2025; 31(3): 101648. Published: June, 2025. j.jnn.2025.101648.