Antiplatelet drugs for secondary prevention in patients with ischemic stroke or transient ischemic attack: a systematic review and network meta-analysis

Background: Antiplatelet drugs may prevent recurrent ischemic events after ischemic stroke but their relative effectiveness and harms still need to be clarified. Within this network meta-analysis we aimed to summarize the current evidence for using antiplatelet drugs for secondary stroke prevention. Methods: We searched MEDLINE, EMBASE and CENTRAL up to September 2020. Randomized controlled trials (RCTs) assessing antiplatelet drugs for secondary stroke prevention were included. We did pairwise meta-analyses and network meta-analyses using random-effects models. Primary outcomes were all strokes (ischemic or hemorrhagic) and all-cause mortality. Results: The review included 57 RCTs, 50 (n = 165,533 participants) provided data for the meta-analyses. Compared to placebo/no treatment, moderate to high-confidence evidence indicated that cilostazol, clopidogrel, dipyridamole + aspirin, ticagrelor, ticlopidine, and aspirin ≤ 150 mg/day significantly reduced the risk of all strokes (odds ratios, ORs and absolute risk difference, ARD): cilostazol 0.51 (95 % confidence interval, CI, 0.37 to 0.71; 3.6 % fewer), clopidogrel 0.63 (95 % CI, 0.49 to 0.79; 2.7 % fewer), dipyridamole + aspirin 0.65 (95 % CI, 0.55 to 0.78; 2.5 % fewer), ticagrelor 0.68 (95 % CI, 0.50 to 0.93; 2.3 % fewer), ticlopidine 0.74 (95 % CI 0.59 to 0.93; 1.9 % fewer), aspirin ≤ 150 mg/day 0.79 (95 % CI, 0.66 to 0.95; 1.5 % fewer). Aspirin > 150 mg/day and the combinations clopidogrel/aspirin, ticagrelor/aspirin, also decrease all strokes but increase the risk of hemorrhagic events. Only aspirin > 150 mg/day significantly reduced all-cause mortality (OR 0.86, 95 % CI 0.76 to 0.97; ARD 0.9 %, 95 %CI 1.5–0.2 % fewer, moderate confidence). Compared to aspirin ≤ 150 mg/day, clopidogrel significantly reduced the risk of all strokes, cardiovascular events, and intracranial hemorrhage outcomes. Cilostazol also appeared to provide advantages but data are limited to the Asian population. Conclusions: Considering the benefits and harms ratio, cilostazol, clopidogrel, dipyridamole + aspirin, ticagrelor, ticlopidine, and aspirin ≤ 150 mg/day appear to be the best choices as antiplatelet drugs for secondary prevention of patients with ischemic stroke or TIA. Systematic review registration: PROSPERO CRD42020159896

Cranial ultrasound screening in term and late preterm neonates born by vacuum-assisted delivery: Is itworthwhile?

Background: Vacuum extraction is the most common choice to assist vaginal delivery, but there are still concerns regarding the neonatal injuries it may cause. This study aimed to evaluate the rate of intracranial injuries assessed by cranial ultrasound (cUS) among infants born by vacuum extraction, and the relationship with maternal and perinatal factors. Methods: This was a single-center retrospective study carried out in a level-3 neonatal unit. A total of 593 term and late preterm infants born by vacuum-assisted delivery were examined with a cUS scan within 3 days after birth. Results: Major head injuries were clinically silent and occurred in 2% of the infants, with a rate of intracranial haemorrhage of 1.7%. Regardless of obstetric factors, the risk of cranial injury was increased in infants requiring resuscitation at birth (p = 0.04, OR 4.1), admitted to NICU (p = 0.01, OR 5.5) or with perinatal asphyxia (p < 0.01, OR 21.3). Maternal age ≥40 years correlated both with adverse perinatal outcomes (p < 0.05) and the occurrence of major injury (p = 0.02, OR 4.6). Conclusion: Overall, vacuum extraction is a safe procedure for neonates. Head injuries are usually mild and asymptomatic, and with spontaneous recovery. However, the rate of major cranial injuries in our cohort warrants further investigation to support a cUS screening, particularly for infants requiring respiratory support at birth. Also, maternal age might be taken into account when evaluating the risk for neonatal complications after vacuum application

Very elderly patients with venous thromboembolism on oral anticoagulation with VKAs or DOACs. results from the prospective multicenter START2-register study

Introduction: Few data are available on the safety of anticoagulation in very elderly patients treated with Vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) for venous thromboembolism (VTE). Methods: We carried out a prospective cohort study on VTE patients aged ≥85 years enrolled in the Survey on anticoagulaTed pAtients RegisTer (START2-Register) on treatment with VKAs or DOACs, with the aim to evaluate mortality, bleeding and thrombotic rates (venous and arterial). Results: We enrolled 272 patients, 58.7% on VKA and 41.3% on DOACs. Baseline characteristics were similar between treatment groups, with a higher prevalence of renal failure in VKAs patients and of a history of bleeding and previous stroke/TIA in DOACs patients. During follow-up of 429 patient-years, 15 major and non-major clinically relevant bleedings were recorded (rate 3.5 × 100 pt-yrs), 5 were major bleeds (rate 1.2 × 100 pt-yrs), 1 in a patient on aspirin (rate 4.3 × 100 pt-yrs). Bleeding rate was higher in patients on DOACs (crude HR 4.7; 95%CI 1.5–15.01). Eight thrombotic events were recorded (rate 1.9 × 100 pt-yrs), 3 recurrent VTE and 5 stroke/TIA. Overall, the incidence of thrombotic events was higher in DOACs patients (crude HR 4.5; 95% CI 1.5; 13.3). The rate of recurrent VTE was similar in the two group. Mortality rate was significantly lower in DOACs patients (crude HR 0.30; 95% CI 0.1;0.9). Conclusion: A higher bleeding risk was found in very elderly VTE patients on DOACs despite the wide use of low-dosages. Similarly a higher thrombotic risk was found while the incidence of recurrent VTE was low and similar between the groups. Mortality rate were significantly lower in DOACs patients

Coccidioidomycosis in Chicken Pullets in Jos, Plateau State, Nigeria: A Case Report

No Abstract

Brucellosis as an Emerging Threat in Developing Economies:Lessons from Nigeria

Nigeria is the most populous country in Africa, has a large proportion of the world's poor livestock keepers, and is a hotspot for neglected zoonoses. A review of the 127 accessible publications on brucellosis in Nigeria reveals only scant and fragmented evidence on its spatial and temporal distribution in different epidemiological contexts. The few bacteriological studies conducted demonstrate the existence of Brucella abortus in cattle and sheep, but evidence for B. melitensis in small ruminants is dated and unclear. The bulk of the evidence consists of seroprevalence studies, but test standardization and validation are not always adequately described, and misinterpretations exist with regard to sensitivity and/or specificity and ability to identify the infecting Brucella species. Despite this, early studies suggest that although brucellosis was endemic in extensive nomadic systems, seroprevalence was low, and brucellosis was not perceived as a real burden; recent studies, however, may reflect a changing trend. Concerning human brucellosis, no studies have identified the Brucella species and most reports provide only serological evidence of contact with Brucella in the classical risk groups; some suggest brucellosis misdiagnoses as malaria or other febrile conditions. The investigation of a severe outbreak that occurred in the late 1970s describes the emergence of animal and human disease caused by the settling of previously nomadic populations during the Sahelian drought. There appears to be an increasing risk of re-emergence of brucellosis in sub-Saharan Africa, as a result of the co-existence of pastoralist movements and the increase of intensive management resulting from growing urbanization and food demand. Highly contagious zoonoses like brucellosis pose a threat with far-reaching social and political consequences

Wealth, household heterogeneity and livelihood diversification of Fulani pastoralists in the Kachia Grazing Reserve, northern Nigeria, during a period of social transition

A mixed methods study was undertaken in the Kachia Grazing Reserve of northern Nigeria. Surveys in March, June and October 2011 included focus group discussions, key informant and in-depth household interviews, concerning livelihood practices, animal health, ownership, and productivity. In May 2011, 249 Fulani families fleeing post-election violence entered the reserve with their livestock, increasing the number of households by one third.Despite being settled within a grazing reserve, over half of households sent all their cattle away on seasonal transhumance and another third sent some away. Cattle accounted for 96% of total tropical livestock units (TLU), of which 26% were cattle kept permanently outside the reserve. While all households cited livestock as their main source of income, 90% grew crops and 55% derived income from off-farm activities. A multiple correspondence analysis showed that for each extra member of a household its TLU value increased by 2.0 [95% CI, 1.4-2.7], while for each additional marriage its TLU increased by 15.7 [95% CI, 7.1-24.3]. A strong association was also observed between small herds, small households with only one wife, alongside marked geographical wealth differences within the reserve. New immigrant families had larger household sizes (33) and livestock holdings (122 TLU) than old settlers (22 people and 67 TLU). Prior to the mass immigration, the distribution of TLU per person was unimodal: 41% of households were classified as 'poor' and 27% as 'medium', whereas post-immigration it was bi-modal, with 26% classified as 'very poor' and 28% as 'medium'.While cattle remain the principal source of Fulani income and wealth, the inhabitants of Kachia Grazing Reserve have diversified their livelihood strategies to respond to changing circumstances and stress, especially the limited availability of grazing within the reserve and political insecurity outside, resulting in continued transhumance, the maintenance of smaller livestock holdings and pushing households into poverty

Is musculoskeletal pain a consequence or a cause of occupational stress? A longitudinal study

Objectives: longitudinal studies have linked stress at work with a higher incidence of musculoskeletal pain. We aimed to explore the extent to which musculoskeletal pain is a cause as opposed to a consequence of perceived occupational stress.Methods: as part of the international cultural and psychosocial influences on disability study, we collected information from 305 Italian nurses, at baseline and again after 12 months, about pain during the past month in the low-back and neck/shoulder, and about effort–reward imbalance (ERI) (assessed by Siegrist’s ERI questionnaire). Poisson regression was used to assess the RR of ERI &gt;1 at follow-up according to the report of pain and of ERI &gt;1 at baseline.Results: among nurses with ERI ?1 at baseline, ERI &gt;1 at follow-up was associated with baseline report of pain in the low-back (RR 2.7, 95 % CI 1.4–5.0) and neck/shoulder (RR 2.6, 95 % CI 1.3–5.1). However, there was no corresponding association with persistence of ERI in nurses who already had ERI &gt;1 at baseline. Associations of ERI at baseline with pain at follow-up were weak.Conclusion: our results suggest that the well-documented association between job stress and musculoskeletal pain is not explained entirely by an effect of stress on reporting of pain. It appears also that workers who report musculoskeletal pain are more likely to develop subsequent perceptions of stress. This may be because pain renders people less tolerant of the psychological demands of work. Another possibility is that reports of pain and stress are both manifestations of a general tendency to be aware of and complain about symptoms and difficulties<br/