Crowd-sourcing and automation facilitated the identification and classification of randomized controlled trials in a living review.

OBJECTIVES: To evaluate an approach using automation and crowdsourcing to identify and classify randomized controlled trials (RCTs) for rheumatoid arthritis (RA) in a living systematic review (LSR). METHODS: Records from a database search for RCTs in RA were screened first by machine learning and Cochrane Crowd to exclude non-RCTs, then by trainee reviewers using a Population, Intervention, Comparison, and Outcome (PICO) annotator platform to assess eligibility and classify the trial to the appropriate review. Disagreements were resolved by experts using a custom online tool. We evaluated the efficiency gains, sensitivity, accuracy, and interrater agreement (kappa scores) between reviewers. RESULTS: From 42,452 records, machine learning and Cochrane Crowd excluded 28,777 (68%), trainee reviewers excluded 4,529 (11%), and experts excluded 7,200 (17%). The 1,946 records eligible for our LSR represented 220 RCTs and included 148/149 (99.3%) of known eligible trials from prior reviews. Although excluded from our LSRs, 6,420 records were classified as other RCTs in RA to inform future reviews. False negative rates among trainees were highest for the RCT domain (12%), although only 1.1% of these were for the primary record. Kappa scores for two reviewers ranged from moderate to substantial agreement (0.40-0.69). CONCLUSION: A screening approach combining machine learning, crowdsourcing, and trainee participation substantially reduced the screening burden for expert reviewers and was highly sensitive.

Prioritization of clinical questions for the Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis.

AIM: Living guidelines aim to reduce delays in translating new knowledge into practice by updating individual recommendations as soon as relevant new evidence emerges. We surveyed members of the Australian Rheumatology Association (ARA) to develop a list of priority questions for the Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis (ALG) and to explore clinicians' use of clinical practice guidelines. METHODS: An electronic survey of ARA members was performed in two phases. The first survey contained questions about current guideline use and beliefs and invited participants to submit at least three questions relevant to the management of rheumatoid arthritis (RA). In the second round, participants selected 10 questions they considered to be the highest priority from the collated list and ranked them in priority order. The sum of ranks was used to generate a final priority list. RESULTS: There were 115 (21%) and 78 (14%) responses to the first and second survey rounds respectively. 87% of respondents use existing rheumatology guidelines in their usual practice, primarily EULAR guidelines. Most respondents favored the development of Australian rheumatology guidelines. In total, 34 potential recommendation topics were identified and ranked in order of priority. CONCLUSION: A list of 34 clinical questions about RA management, ranked in order of importance by clinicians, has informed the development of the ALG. Similar prioritization exercises in other contexts may permit guidelines to be tailored to the needs of guideline users in their specific context, which may facilitate international collaboration and promote efficient translation of evidence to practice.

Australian recommendations on perioperative use of disease-modifying anti-rheumatic drugs in people with inflammatory arthritis undergoing elective surgery.

Disease-modifying anti-rheumatic drugs (DMARDs) are effective treatments for inflammatory arthritis but carry an increased risk of infection. For patients undergoing surgery, there is a need to consider the trade-off between a theoretical increased risk of infection with continuation of DMARDs perioperatively versus an increased risk of disease flare if they are temporarily withheld. We used the Grading of Recommendations Assessment, Development and Evaluation methodology to develop recommendations for perioperative use of DMARDs for people with inflammatory arthritis undergoing elective surgery. The recommendations form part of the National Health and Medical Research Council-endorsed Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis. Conditional recommendations were made against routinely discontinuing conventional synthetic and biologic (b) DMARDs in the perioperative period but to consider temporary discontinuation of bDMARDs in individuals with a high risk of infection or where the impact of infection would be severe. A conditional recommendation was made in favour of temporary discontinuation of targeted synthetic DMARDs in the perioperative period.

Australian recommendations on tapering of biologic and targeted synthetic disease-modifying anti-rheumatic drugs in inflammatory arthritis.

Biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARD) have been an important advance in the management of inflammatory arthritis, but are expensive medications, carry a risk of infection and other adverse effects, and are often perceived as a burden by patients. We used GRADE methodology to develop recommendations for dose reduction and discontinuation of b/tsDMARD in people with rheumatoid arthritis (RA), axial spondyloarthritis (AxSpA) and psoriatic arthritis (PsA) who have achieved a low disease activity state or remission. The recommendations form part of the Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis, an NHMRC-endorsed 'living' guideline, in which recommendations are updated in near real-time as new evidence emerges. Conditional recommendations were made in favour of dose reduction in RA and AxSpA but not in PsA. Abrupt discontinuation of b/tsDMARD is not recommended in any of the three diseases.

Comparative phylogeography reveals host generalists, specialists and cryptic diversity: Hexabothriid, microbothriid and monocotylid monogeneans from rhinobatid rays in southern Australia.

The phylogeography and host specificity of three monogenean species infecting different sites on the southern fiddler ray, Trygonorrhina fasciata (Rhinobatidae) in South Australia (SA) were studied: Branchotenthes octohamatus (Hexabothriidae: gills), Calicotyle australis (Monocotylidae: cloaca) and Pseudoleptobothrium aptychotremae (Microbothriidae: skin). Five rhinobatid species (Aptychotrema vincentiana, T. fasciata, Trygonorrhina sp. A, Aptychotrema rostrata and Rhinobatos typus) with distributions spanning west, south and east Australian coastal waters, were surveyed for monogeneans resembling the three species documented from T. fasciata in SA. The identities of hosts and parasites collected were investigated using the mitochondrial genes ND4 and Cytochrome b (cytb), respectively, in addition to the nuclear marker, Elongation factor 1-alpha (EF1a) for Pseudoleptobothrium. Genetic analyses confirmed that B. octohamatus is geographically widespread and displays little genetic structure, suggesting high levels of gene flow. It was collected from four rhinobatid species throughout its distribution and is not, therefore, host specific. For C. australis, genetic analyses revealed two discrete populations with a genetic divergence of ∼4%, one population occurring west of Bass Strait on two sympatric host species and the other population on the east coast, also occurring on sympatric host species. Similarly, for Pseudoleptobothrium, specimens collected west of Bass Strait were genetically distinct (∼3.5%) from those collected to the east. However, on the east coast, a third Pseudoleptobothrium population was revealed, separated by a genetic distance of >11%, indicating a morphologically cryptic species. Host preferences were indicated for each Pseudoleptobothrium lineage. These genetic discoveries are discussed in relation to life history characteristics of each monogenean species, highlighting the value of phylogeographic analyses to understand the parasite-host relationship.

A redescription of Calicotyle australis Johnston, 1934 (Monogenea: Monocotylidae) from the type-host Trygonorrhina fasciata (Rhinobatidae) off Adelaide, South Australia, including descriptions of live and silver stained larvae.

Calicotyle australis Johnston, 1934 (Monogenea Monxocotylidae) is redescribed from the cloaca of the type-host, the southern fiddler ray Trygonorrhina fasciata (Rhinobatidae) off Adelaide, South Australia. Lobed glands joining the oötype are reported for the first time and may be characteristic of the genus. The presence of an appendix associated with the seminal vesicle in C. australis, previously reported as absent, is confirmed. The anatomy of the oncomiracidium of C. australis is described from observations of live larvae, and the number and distribution of ciliated epidermal cells and sensilla, revealed by silver staining larvae, is also described. Use of larval characters to distinguish between species of Calicotyle Diesing, 1850 and other closely related monocotylids is discussed.

Branchotenthes octohamatus sp. n. (Monogenea: Hexabothriidae) from the gills of the southern fiddler ray, Trygonorrhina fasciata (Rhinobatidae) in South Australia: description of adult and larva.

Branchotenthes octohamatus sp. n. (Monogenea: Hexabothriidae) is described from the gills of the southern fiddler ray, Trygonorrhina fasciata Müller et Henle (Elasmobranchii: Rhinobatidae), off Adelaide, South Australia. It is distinguished from the type species, Branchotenthes robinoverstreeti Bullard et Dippenaar, 2003, by producing eggs that are joined end to end forming a chain, in the morphology of the male copulatory organ that has a pronounced constriction in duct diameter between proximal and distal regions, the possession of a thin muscular layer surrounding the proximal part of the male copulatory organ and distal region of the vaginae, and by the absence of a raised process on the shaft of the hamulus. An amended generic diagnosis is provided and the reliability of sperm duct number as a generic character is discussed. The oncomiracidium of B. octohamatus is also described and is the first monogenean to be described with only eight hooklets in the larval haptor. This discovery of eight hooklets may be important for higher-level monogenean evolutionary hypotheses.