NARRATIVE REVIEW Stem cells on YouTube: National vs international content

YouTube is one of the most popular video-based social media sites across the globe. The role of stem cell transplant has not been deeply explored on YouTube. The current narrative review was planned to assess the viewership of content available on YouTube related to stem cells. The videos were classified based on type of content, duration, number of views, comments and number of likes. A total of 40 videos were downloaded under the search terms “stem cells in Pakistan” and “stem cells”. Of them, 6(15%) were repeat videos, and 34(85%) were unique. The findings revealed that in 10(25%) most viewed videos from Pakistan, 6(60%) contained opinions from non-expert physicians. Among the 10(25%) most viewed international videos, the information providers were science educators in 4(40%) videos and researchers in 2 (20%). Notably, no content from Pakistan was present among the top relevant international videos. Over 27 million views were included in the total number of videos that were analysed. YouTube is a powerful tool to spread knowledge and support public health decision-making. However, misleading information regarding stem cell can lead to adverse outcomes.


Introduction
The internet is a vital source of health information.Studies [1][2][3][4] have recently shown that users frequently look for specific information related to health issues that they may have themselves or others known to them.Users can self-diagnose, learn more about certain diseases, and search for treatment alternatives using the internet. 3Trends show that the majority of internet searches for healthrelated information take place on search engines, which then route users to a variety of social media platforms. 4e such platform with video-based social media that is widely used globally is the YouTube. 5With billions of daily views and more than 1 billion registered users, it is the second most visited webpage worldwide.There are almost 30 million health-related videos on YouTube, posted by various individuals and institutions.It has been demonstrated that watching YouTube videos significantly impact people's knowledge and beliefs, leading to better patient care. 6With so many treatments available, many patients struggle to choose the best course of action and, therefore, are increasingly using YouTube for treatmentrelated information.Hundreds of millions of people have viewed videos on patients' stories and information about available treatments and outcomes. 7wever, because YouTube is accessible to all users, anyone can post videos that may contain unreliable and erroneous information. 6,7Viewers should exercise caution regarding the accuracy and dependability of the health-related information presented in such videos.The quality of the information typically depends on the user who posted it.Since YouTube videos are not ranked by the quality of the information they contain, highly valid videos may end up on the last pages of the site's watch-list.Consequently, people searching for health-related information on YouTube often view the most watched videos rather than those with the most supporting evidence.Furthermore, the lack of an upload criterion leads to varying video quality. 8e current narrative review was planned to assess the types of video content available on YouTube regarding stem cells.To the best of our knowledge, no previous study has analysed the video content available for stem cells on YouTube.

Materials and Methods
Data from YouTube was collected from February 14, 2005, the day of its launch, till September 25, 2022.The search terms used for the purpose of analysing video content were "stem cells in Pakistan" and "stem cells".These terms were selected after extensive literature review 1,2,5,6 and discussion to ensure that the most relevant content was captured.These terms covered all general videos on topics related to stem cells.The selected search terms were used on YouTube through a separate search query with the default settings to return the "most relevant" and the "most viewed" results on the top, using the YouTube search filter.

Stem cells on YouTube: National vs international content
Fizzah Arif 1 , Mohammad Fazlur Rahman 2 , Mohammad Khozema Safri  Physicians and patients present in the videos associated with or uploaded by any medical centre were placed in the "medical centres" category.Data was collected and analysed using Microsoft Excel 2021.Frequencies and percentages of the type of videos in each list of most relevant and most viewed videos were calculated by dividing the number of each type of video with the total number of videos in each list, which was 10.Duration of video, number of views, comments and the number of likes were recorded directly from YouTube for every video.
Pie charts were used to display the distribution of the videos with respect to the type from the total unique videos derived from each of the two search terms.

Results
A total of 40 videos were reviewed under the search terms "stem cells in Pakistan" and "stem cells".Of them, 6(15%) were repeat videos, and 34(85%) were unique; 16(47%) from Pakistan and 18(53%) from around the world.There were more than 27 million views overall.
Among the 10(25%) most relevant videos from Pakistan, 3(30%) were live TV talk shows uploaded after having been aired already, and 2(20%) were promotional videos about medical centres providing stem cell therapy to patients for different indications.No research centre was identified, while 2(20%) videos each were classified under 'educational' and 'Vlog' categories, and 1(10%) was a patient review about the stem cell treatment she had received.
Among the information providers, 5(50%) were physicians, but none of them had expertise in stem cells, while 4(40%) videos were uploaded by different medical centres, and F. Arif, M.Fazlur Rahman, M.K. Safri 1(10%) was uploaded by a non-physician person, a filmmaker.The lengthiest video in this list was a recorded TV talk show with running time of 01:04:46 hours (Table 1).
The most viewed video with the search term "stem cells in Pakistan" was about knee pain treatment by stem cells in Karachi.The length of this video was 02:22 minutes and there were 195,070 views.The second most viewed video   Video Title was about "hopeless infertile males and females", and had a duration of 26:21 minutes.This video had the highest number of likes (2.4K) and comments (676), and was about a medical centre in which a physician explained that stem cells can be used for the infertility issues (Table 2).
When only the term "stem cells" was searched, no Pakistani content was found either in the most relevant or the most viewed categories.All international videos were in the English language.All the 10(25%) most relevant videos about stem cells were for medical education, like lectures, animation etc., and the information providers were science educators in all the 10(100%) videos.Of them, 8(80%) videos were animated explainer educational videos, and 2(20%) were academic lectures.The lengthiest video was a biology lecture, with a running time of 46:19 minutes.An animated video had the highest number of likes (18K) (Table 3).
Among the 10(25%) most viewed videos from around the world, 4(40%) were animated explainer educational videos, 2(20%) each were documentaries and entertainment videos, like drama and music, and 1(10%) each was a recorded conference talk and patient testimonial.Among the most viewed international videos, science educators were the information providers in 4(40%), non-physicians in 3(30%) and 1(10%) video was a recorded conference talk uploaded by a medical centre.In 2(20%) videos, researchers provided insight to new developments in stem cell research.
An animated video about 'cure for aging' was the most viewed, with a length of 07:21 minutes.It had over 7.4 million views and the greatest number of comments (14,077).A video about how the body heals itself had no likes despite being among the three most viewed videos in the category.It was uploaded by a non-profit medical organisation and was the only video in which the comment section had been turned off (Table 4).
Among the total 18(53%) unique international videos, the lengthiest one was basically an audio about staying young, with a total duration of 12 hours.Overall, 10(56%) such 2050

Video Title
Stem cells on YouTube: National vs international content uploads were animated educational videos, 2(11%) each were academic lectures, documentaries and entertainment-based, and 1(5.5%) each was patient testimonial and recorded conference talk (Figure 2).

Discussion
YouTube is the most common video-based social media used around the world, second only to Facebook.Every day, millions of people view countless videos on various topics.YouTube provides a platform to the general population to access information about diverse medicalrelated content.However, the reliability for the information remains questionable, as not all information providers are physicians or related to the medical field.[11] Numerous studies have been conducted to analyse the quality of information uploaded to YouTube, covering medical topics, such as plastic surgery, 5 fibromyalgia, 12 food poisoning, 13 urinary incontinence, 14 anakinra self-injection 15 and the coronavirus disease-2019 (COVID-19) pandemic etc. 16 The current findings suggest people globally are interested in knowing any scientific measures that can help combat aging.
In Pakistan, 40% of the most viewed videos about stem cells were about treating infertility.The video with the most likes in Pakistan was also regarding the treatment of infertility using stem cells.In contrast, most globally viewed videos were related to medical education, like lectures, tutorials, animations or documentaries based on the recent advances about the use of stem cells in aging, burns and diabetes.
Among the 34 videos analysed, the second most-viewed video overall was the documentary, having 5.1 million views.This video was published nearly 11 years ago, introducing a new technique of isolating stem cells from healthy skin of a burns victim and spraying it on burned skin wounds.Interestingly, till date this practice has not 2051 Open Access J Pak Med Assoc The information in the form of paid content by medical professionals is problematic due to its ability to influence the patients' trust and compliance with their primary physician.YouTube has now become a platform for promoting businesses, and various medical centres and affiliated physicians have uploaded videos advocating the usefulness of stem cells.Patients are turning to YouTube to seek information about any intervention of interest.This leads to an ethical dilemma due to a disconnect between the physicians and patients on the use of YouTube.
Overall, the correct and unbiased information about the practical and clinical use of stem cells for numerous pathologies is lacking on YouTube.Many videos falsely depict stem cells as "magical" and capable of healing every condition, with deceiving information on the video thumbnails, such as in the case of Pakistan's video, claiming to 'get any organ (liver, kidney and heart etc.) made to order from stem cells' .Such thumbnails mislead the population in the absence of any authentication, although in the said video, general information about stem cells is provided by a physician with no expertise in stem cells.
Ideally, every patient who is considering stem cell treatment for any pathology should discuss it with a medical professional to obtain high-quality knowledge about the use of the stem cells in that particular disease 17 and its associated risks.It is important to note that the Food and Drug Administration (FDA) has approved the use of only blood-forming stem cells for haematopoietic 2052

6.
*What are stem cells?-Craig A. Kohn disorders.The unproven use of stem cell therapy is associated with multiple safety concerns, such as local administration site reactions, tumour growth due to uncontrolled and inappropriate cell growth and failure to gain expected results. 18e current review has limitations associated with the complexity of the YouTube search algorithm, which can be influenced by various factors, such as the number of previous views and browsing history. 19The algorithm adjusts itself and displays different videos for a specific search term on various browsers, resulting in the possibility that the videos shown in accordance with their relevance may not appear in the same order for everyone.

Conclusion
YouTube's potential for sharing information with the public is incomparable to other social media applications.YouTube videos can be a powerful tool to spread knowledge and support public health decision-making, and vice versa.Misleading and wrong information about unauthorised use of stem cells can lead to local and systemic reaction with unpredictable outcomes.
Disclaimer: An earlier version of the text was presented as a poster presentation at the 8th Aga Khan University (AKU) Annual Surgical Conference, 2023, where it was awarded the third prize in the moderated poster session.

Figure- 1 :
Figure-1: Various formats of videos on YouTube from Pakistan.Figure-2: Carious formats of videos on YouTube from around the world.

Figure- 2 :
Figure-1: Various formats of videos on YouTube from Pakistan.Figure-2: Carious formats of videos on YouTube from around the world. 3

Table - 1
: Top 10 most relevant Pakistani videos about stem cells on YouTube.
R3 Stem cell: Name of a medical centre, PRP: Platelet rich plasma

Table - 2
: Top 10 most viewed Pakistani videos about stem cells on YouTube.
* Indicates videos also present in most relevant videos list; PRP: Platelet rich plasma

Table - 3
: Top 10 most relevant international videos about stem cells on YouTube.

Table - 4
: Top 10 most viewed international videos about stem cells on YouTube.