Background High blood pressure is common in acute stroke and is a predictor of poor outcome; however, large trials of lowering blood pressure have given variable results, and the management of high blood pressure in ultra-acute stroke remains unclear. We investigated whether transdermal glyceryl trinitrate (GTN; also known as nitroglycerin), a nitric oxide donor, might improve outcome when administered very early after stroke onset. Methods We did a multicentre, paramedic-delivered, ambulance-based, prospective, randomised, sham-controlled, blinded-endpoint, phase 3 trial in adults with presumed stroke within 4 h of onset, face-arm-speech-time score of 2 or 3, and systolic blood pressure 120 mm Hg or higher. Participants were randomly assigned (1:1) to receive transdermal GTN (5 mg once daily for 4 days; the GTN group) or a similar sham dressing (the sham group) in UKbased ambulances by paramedics, with treatment continued in hospital. Paramedics were unmasked to treatment, whereas participants were masked. The primary outcome was the 7-level modified Rankin Scale (mRS; a measure of functional outcome) at 90 days, assessed by central telephone follow-up with masking to treatment. Analysis was hierarchical, first in participants with a confirmed stroke or transient ischaemic attack (cohort 1), and then in all participants who were randomly assigned (intention to treat, cohort 2) according to the statistical analysis plan. This trial is registered with ISRCTN, number ISRCTN26986053.

An intramedullary fixation device was devised by the senior author (K.A.J.) to use in conjunction with a previously described method for tibiotalocalcaneal arthrodesis. Satisfactory results were obtained in approximately 87% of the initial 30 patients; union was radiographically or clinically evident in all but two patients. Many of these patients had been offered or were considering below the knee amputation; only two ultimately chose this reconstructive option at a follow-up that ranged from 4 to 27 months.

Introduction: Diabetes mellitus is a major public health problem and its burden is expected to increase in developing countries such as Nigeria. One of the most frequent complications of type II diabetes is diabetic retinopathy, and a major cause of blindness worldwide especially among adults. Objective: To determine the awareness of diabetes-related eye health risks and complications among type II diabetics in Lagos, Nigeria. Method: The study was carried out in Rhowil Medical Centre in Lagos, Nigeria and adopted qualitative methodology. Data was collected via semi-structured interviews. Interviews were carried out on nine type II diabetes patients above the age of eighteen via purposive sampling. The interviews were analyzed based on Kvale's framework for the qualitative data analysis. Results: Knowledge of diabetes, sources of information, cultural health beliefs and practices, and communication were themes that emerged from the thematic analysis. The data revealed significant gaps in awareness of diabetesrelated eye complications amongst type II diabetics. Data showed poor knowledge of diabetes-related eye diseases and of inadequate awareness of the connection between diabetes and ocular complications. Also, education, health literacy and communication barrier problems between health professionals and diabetic patients were also evident. In addition, sources of information on diabetes and eye care, as well as health beliefs influenced awareness. Conclusion: Findings from this study can inform strategic plans of public health authorities in addressing the growing diabetes epidemic by developing effective health education programs with the aim to increase awareness amongst people living with diabetes in the region.Keywords: Diabetes Mellitus; Diabetic Retinopathy; awareness; eye health. (Source: DeCS BIREME) ResumenAntecedentes: La diabetes mellitus es uno de los mayores problemas de salud pública y se espera que su carga incremente en países en desarrollo como Nigeria. Uno de las más frecuentes complicaciones de la diabetes tipo II es la retinopatía diabética, y la mayor causa de ceguera en el mundo especialmente en adultos. Objetivo: Determinar el conocimiento sobre la diabetes -riesgos de salud visual relacionados y complicaciones entre diabéticos tipo II en Lagos, Nigeria. Métodos: El estudio fue realizado en el Centro Médico Rhowil en Lagos, Nigeria and adoptó una metodología cualitativa. Los datos fueron recolectados mediante entrevistas semi-estructuradas. Las entrevistas se realizaron en nueve personas con diabetes tipo II mayores de 18 años seleccionados por muestreo intencional. Las entrevistas fueron analizadas basadas en el marco teórico de Kvale para el análisis cualitativo de los datos. Resultados: El conocimiento de la diabetes, las fuentes de información, las creencias y las prácticas culturales de salud, y la comunicación fueron temas que surgieron del análisis temático. Los datos revelaron significativos vacíos sobre el conocimiento de las complicaciones oculares relacionadas con la d...

Summary Background Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention. Funding British Heart Foundation.

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