Anticoagulation Versus Antiplatelets in Spontaneous Cervical Artery Dissection: A Systematic Review and Meta-Analysis.

BACKGROUND: It is uncertain whether antiplatelets or anticoagulants are more effective in preventing early recurrent stroke in patients with cervical artery dissection. Following the publication of the observational Antithrombotic for STOP-CAD (Stroke Prevention in Cervical Artery Dissection) study, which has more than doubled available data, we performed an updated systematic review and meta-analysis comparing antiplatelets versus anticoagulation in cervical artery dissection. METHODS: The systematic review was registered in PROSPERO (CRD42023468063). We searched 5 databases using a combination of keywords that encompass different antiplatelets and anticoagulants, as well as cervical artery dissection. We included relevant randomized trials and included observational studies of dissection unrelated to major trauma. Where studies were sufficiently similar, we performed meta-analyses for efficacy (ischemic stroke) and safety (major hemorrhage, symptomatic intracranial hemorrhage, and death) outcomes using relative risks. RESULTS: We identified 11 studies (2 randomized trials and 9 observational studies) that met the inclusion criteria. These included 5039 patients (30% [1512] treated with anticoagulation and 70% [3527]) treated with antiplatelets]. In meta-analysis, anticoagulation was associated with a lower ischemic stroke risk (relative risk, 0.63 [95% CI, 0.43 to 0.94]; P=0.02; I2=0%) but higher major bleeding risk (relative risk, 2.25 [95% CI, 1.07 to 4.72]; P=0.03, I2=0%). The risks of death and symptomatic intracranial hemorrhage were similar between the 2 treatments. Effect sizes were larger in randomized trials. There are insufficient data on the efficacy and safety of dual antiplatelet therapy or direct oral anticoagulants. CONCLUSIONS: In this study of patients with cervical artery dissection, anticoagulation was superior to antiplatelet therapy in reducing ischemic stroke but carried a higher major bleeding risk. This argues for an individualized therapeutic approach incorporating the net clinical benefit of ischemic stroke reduction and bleeding risks. Large randomized clinical trials are required to clarify optimal antithrombotic strategies for management of cervical artery dissection.

Influenza-Associated Outcomes and Healthcare Utilization by Race and Ethnicity in the USA: a Retrospective Cohort Study Using the National Inpatient Sample Database.

BACKGROUND: The influenza virus continues to be a public health concern every season. We aimed to evaluate influenza-associated outcomes and healthcare utilization by race and ethnicity. METHODS: We conducted a retrospective cohort study using the National Inpatient Sample across 2019 and 2020. Influenza pneumonia was selected as the principal diagnosis. Outcomes included mortality, use of respiratory support ventilation, length of stay, and total hospitalization charge. Regression models were adjusted for age, gender, Charlson Comorbidity Index, hospitals' region, bed size, teaching status, insurance status, and median income. RESULTS: We identified 73,098 individuals hospitalized with influenza pneumonia; 39,807 and 33,291 were admitted in 2019 and 2020, respectively. The sample included 49,829 (68%) White, 11,356 (15.5%) Black, 7526 (10%) Hispanic, 1860 (2.5%) Asian/Pacific, and 617 (0.84%) Native American patients. In-hospital mortality rates and respiratory support (non-invasive ventilation and invasive mechanical ventilation) in 2019 and 2020 were not significantly different across all the races. In 2019 and 2020, the adjusted odds ratios of in-patient mortality were not significantly different. Asians had higher odds of receiving NIV in 2019 but not in 2020 compared to White patients (adjusted odds ratio (aOR) 1.67, p value 0.04). The adjusted odds ratios for receiving IMV were not significantly different between the races in 2019 and 2020. CONCLUSIONS: This study contributes valuable insight into influenza-associated outcomes and healthcare utilization patterns among diverse racial and ethnic groups. Disparities in healthcare utilization were observed among younger (< 65 years) individuals of Black and Hispanic ethnicity.

A Unique Presentation of an Infected Renal Cyst: A Case Report and Literature Review.

Renal cysts are prevalent conditions and are often diagnosed incidentally. The infection of renal cysts is an uncommon presentation. It is even more rare in solitary simple cysts than in autosomal dominant polycystic kidney disease (ADPKD). Patients with infected renal cysts can have variable presenting symptoms; however, almost universally, they have flank pain. Here, we report a case of a solitary renal cyst infection in the absence of flank pain, a relatively rare condition. A 60-year-old male patient presented to our emergency department (ED) for ongoing periumbilical/lower abdominal pain, chills, and high-grade fever. He was initially seen in urgent care and thought to have a urinary tract infection (UTI). He was discharged on trimethoprim-sulfamethoxazole (TMP-SMX). He was hemodynamically stable in the ED and did not have flank pain. Urine culture showed Escherichia coli. Computed tomography (CT) showed changes concerning for possible early pyelonephritis of the right kidney area and an enlarged right upper pole renal cyst compared to previous imaging. The urology team was consulted, and the enlarging cyst was considered secondary to hemorrhage. The patient continued to have high-grade fevers and worsening abdominal pain during his stay despite being on culture-directed intravenous antibiotics. Consequently, the cyst was aspirated, and cultures grew E. coli with a similar antimicrobial susceptibility pattern as the one found in the urine. After the procedure, the fever and abdominal pain significantly improved. This case report describes a patient with an infected solitary renal cyst with a unique presentation. Imaging modalities can be misleading and delay the diagnosis. Appropriate source control via cyst aspiration and/or drain insertion is crucial for successful treatment.

Lebanese medical students' knowledge on and attitude toward xenotransplantation and its ethical issues: A cross-sectional study.

INTRODUCTION: Xenotransplantation is the transplantation of animal parts into humans. This study's aim is to assess the Lebanese medical students' attitude toward xenotransplantation and their knowledge of its related ethical issues. METHODS: A questionnaire was answered by 120 Lebanese medical students. Statistical analysis and ethical reflections were performed on the results. RESULTS: Out of the 120 participants, 100 already knew about xenotransplantation, and 61.7% of the students believe that it is applied clinically. Only 25% trust that the animals need to be genetically modified for the organs to be eligible for transplantation. About 25.8% and 46.7% of the students, respectively, strongly agree that the patients' and physicians' beliefs play an important role in agreeing to the procedure. Students were likely to accept the animal organ for transplantation if the transplant could completely cure or improve the course of an untreatable disease (86.6% and 75.0%) or if the outcomes and risks were the same as with a human transplant with a shorter waiting period (71.7%). Students who agreed that animal rights and welfare/wellbeing should be respected tended to disagree with the statement that it is acceptable to use animals for human ends (p = .026). CONCLUSION: Medical students proved to be knowledgeable on the ethical dilemmas related to xenotransplantation and showed a favorable attitude toward this procedure, which is crucial in its establishment as an absolute clinical reality in the near future and in the development and strengthening of research in this field.

City planning policies to support health and sustainability: an international comparison of policy indicators for 25 cities.

City planning policies influence urban lifestyles, health, and sustainability. We assessed policy frameworks for city planning for 25 cities across 19 lower-middle-income countries, upper-middle-income countries, and high-income countries to identify whether these policies supported the creation of healthy and sustainable cities. We systematically collected policy data for evidence-informed indicators related to integrated city planning, air pollution, destination accessibility, distribution of employment, demand management, design, density, distance to public transport, and transport infrastructure investment. Content analysis identified strengths, limitations, and gaps in policies, allowing us to draw comparisons between cities. We found that despite common policy rhetoric endorsing healthy and sustainable cities, there was a paucity of measurable policy targets in place to achieve these aspirations. Some policies were inconsistent with public health evidence, which sets up barriers to achieving healthy and sustainable urban environments. There is an urgent need to build capacity for health-enhancing city planning policy and governance, particularly in low-income and middle-income countries.