This document summarizes a study that assessed outcomes for 588 patients with acute ischemic stroke due to large vessel occlusion who were treated with tenecteplase followed by mechanical thrombectomy. Key findings include:
- 47.2% of patients achieved functional independence at 3 months.
- Factors associated with functional independence included younger age, lower baseline stroke severity, and shorter time from onset to intravenous thrombolysis (under 160 minutes).
- Tenecteplase achieved recanalization prior to thrombectomy in some patients and was generally well-tolerated with low rates of hemorrhage.
Experience of Vascular Interventional Procedures of Adana Numune Research and...ijtsrd
Objective The aim of this study was to analyze our experiences of interventional procedures for diagnosis and treatment. Methods This study was performed retrospective between January 2016 and June 2016. 38 patients were included in this study in Neurology clinic of Adana Numune Research and Training Hospital. Results The mean age of the patients was 58.6. A number of males were 19. A number of females were 19. 21 55.3 of the patients underwent diagnostic angiography, 6 15.8 underwent stenting and 11 28.9 underwent thrombectomy or endovascular coiling operation. Conclusions The use of interventional neurological procedures is increasing. Interventional neurological procedures are very risky. But diagnosis and treatment options are very beneficial for well-selected patient groups. Experienced experts are needed. Investments should be made for the progression of neuro endovascular therapies in our country. Abdurrahman Sönmezler | Semih Giray "Experience of Vascular Interventional Procedures of Adana Numune Research and Training Hospital" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-2 , February 2019, URL: https://www.ijtsrd.com/papers/ijtsrd21597.pdf
Paper URL: https://www.ijtsrd.com/medicine/other/21597/experience-of-vascular-interventional-procedures-of-adana-numune-research-and-training-hospital/abdurrahman-s%C3%B6nmezler
Supratentorial intracerebral hemorrhage volume and other CT variables predict...NeurOptics, Inc.
However, it is not practical to obtain repeated serial CT scans in ICH patients to assess for these factors. A noninvasive indicator method of assessing the aforementioned factors would be very useful and could serve as a trigger for repeating a CT scan in a patient with ICH.
Experience of Vascular Interventional Procedures of Adana Numune Research and...ijtsrd
Objective The aim of this study was to analyze our experiences of interventional procedures for diagnosis and treatment. Methods This study was performed retrospective between January 2016 and June 2016. 38 patients were included in this study in Neurology clinic of Adana Numune Research and Training Hospital. Results The mean age of the patients was 58.6. A number of males were 19. A number of females were 19. 21 55.3 of the patients underwent diagnostic angiography, 6 15.8 underwent stenting and 11 28.9 underwent thrombectomy or endovascular coiling operation. Conclusions The use of interventional neurological procedures is increasing. Interventional neurological procedures are very risky. But diagnosis and treatment options are very beneficial for well-selected patient groups. Experienced experts are needed. Investments should be made for the progression of neuro endovascular therapies in our country. Abdurrahman Sönmezler | Semih Giray "Experience of Vascular Interventional Procedures of Adana Numune Research and Training Hospital" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-2 , February 2019, URL: https://www.ijtsrd.com/papers/ijtsrd21597.pdf
Paper URL: https://www.ijtsrd.com/medicine/other/21597/experience-of-vascular-interventional-procedures-of-adana-numune-research-and-training-hospital/abdurrahman-s%C3%B6nmezler
Supratentorial intracerebral hemorrhage volume and other CT variables predict...NeurOptics, Inc.
However, it is not practical to obtain repeated serial CT scans in ICH patients to assess for these factors. A noninvasive indicator method of assessing the aforementioned factors would be very useful and could serve as a trigger for repeating a CT scan in a patient with ICH.
Reperfusion strategy in patients with ST-Segment Elevation Myocardial Infarct...Premier Publishers
Reperfusion therapy is the cornerstone in management of STEMI. This study was designed to evaluate both In-hospital and 30 days outcome in patients with STEMI treated with primary percutaneous coronary intervention (PPCI) versus fibrinolysis. This prospective, controlled, study included 140 patients with STEMI who were eligible for reperfusion therapy. In hospital and 30 days major adverse cardiovascular events (MACE) were reported and head to head comparison was done between PPCI versus fibrinolysis. All-cause mortality was reported in 5% of patients (10% versus 0% in fibrinolysis and PPCI respectively, p=0.07), recurrence of ischemic symptoms was reported in 18% of patients (30% versus 7% in fibrinolysis and PPCI respectively, P =0.02), heart failure was evident in 22% of patients (33% versus 10% in fibrinolysis and PPCI respectively, P =0.02). PPCI is safe and effective treatment option for patients with STEMI
Bleeding avoidance strategies, such as a transradial approach (TRA), should be considered especially for patients with high bleeding risk.3) However, PCI operators hesitate to choose conventional TRA for patients on dialysis because of the increased risk of radial artery occlusion (RAO) and general tendency to preserve possible hemodialysis access points for the future.
Everolimus eluting stents or bypass surgery finalGOPAL GHOSH
Trials and registry studies have shown lower long-term mortality after CABG than after PCI among patients with multivessel disease.These previous analyses did not evaluate PCI with second-generation drug-eluting stents
Aim: To study the value of BNP as a screening tool to identify silent ischemia and diastolic dysfunction in asymptomatic type II
diabetic patients.
Objectives: The objective of the study is how far BNP value will be useful in early detection of LV dysfunction and ischemia without subjecting the patient to treadmill test and ECHO, as both are even though specific but not sensitive. Our effort is to identify a simple blood test which is highly sensitive in identifying them.
journal club and critical appraisal checklist
intensive recruitment versus moderate recruitment strategy in postop cardiac surgery patients to avaoid postop pulmonary complications
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
Compliance of pharmacological treatment for non-ST-elevation acute coronary syndromes with contemporary guidelines: influence on outcomes
Authors: Hélder Dores, Carlos Aguiar, Jorge Ferreira, Jorge Mimoso, Sílvia Monteiro, Filipe Seixo, José Ferreira Santos, On behalf of Portuguese Registry on Acute Coronary Syndromes (ProACS) Investigators
Intraoperative aortic dissection during cardiac surgery is infrequent, complicating surgical intervention in 0.04 - 1% of cases. Dissections can occur anywhere, most often as a result of direct mechanical damage at the location of the side clamp, site of cannulation of the aorta, or at the site of proximal anastomosis and may manifest as hematoma, bleeding at the cannulation site or bleeding from the proximal anastomoses or aortic suture lines. Delayed diagnosis and treatment can lead to extremely (23-41%) high mortality rate.
Risk stratification remains central to implement appropriate therapeutic measures for patients with NSTEMI.
The ECG provides rapid risk assessment for patients presenting with chest pain that permits their allocation to appropriate management algorithms to improve the outcomes
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results.
Reperfusion strategy in patients with ST-Segment Elevation Myocardial Infarct...Premier Publishers
Reperfusion therapy is the cornerstone in management of STEMI. This study was designed to evaluate both In-hospital and 30 days outcome in patients with STEMI treated with primary percutaneous coronary intervention (PPCI) versus fibrinolysis. This prospective, controlled, study included 140 patients with STEMI who were eligible for reperfusion therapy. In hospital and 30 days major adverse cardiovascular events (MACE) were reported and head to head comparison was done between PPCI versus fibrinolysis. All-cause mortality was reported in 5% of patients (10% versus 0% in fibrinolysis and PPCI respectively, p=0.07), recurrence of ischemic symptoms was reported in 18% of patients (30% versus 7% in fibrinolysis and PPCI respectively, P =0.02), heart failure was evident in 22% of patients (33% versus 10% in fibrinolysis and PPCI respectively, P =0.02). PPCI is safe and effective treatment option for patients with STEMI
Bleeding avoidance strategies, such as a transradial approach (TRA), should be considered especially for patients with high bleeding risk.3) However, PCI operators hesitate to choose conventional TRA for patients on dialysis because of the increased risk of radial artery occlusion (RAO) and general tendency to preserve possible hemodialysis access points for the future.
Everolimus eluting stents or bypass surgery finalGOPAL GHOSH
Trials and registry studies have shown lower long-term mortality after CABG than after PCI among patients with multivessel disease.These previous analyses did not evaluate PCI with second-generation drug-eluting stents
Aim: To study the value of BNP as a screening tool to identify silent ischemia and diastolic dysfunction in asymptomatic type II
diabetic patients.
Objectives: The objective of the study is how far BNP value will be useful in early detection of LV dysfunction and ischemia without subjecting the patient to treadmill test and ECHO, as both are even though specific but not sensitive. Our effort is to identify a simple blood test which is highly sensitive in identifying them.
journal club and critical appraisal checklist
intensive recruitment versus moderate recruitment strategy in postop cardiac surgery patients to avaoid postop pulmonary complications
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
Compliance of pharmacological treatment for non-ST-elevation acute coronary syndromes with contemporary guidelines: influence on outcomes
Authors: Hélder Dores, Carlos Aguiar, Jorge Ferreira, Jorge Mimoso, Sílvia Monteiro, Filipe Seixo, José Ferreira Santos, On behalf of Portuguese Registry on Acute Coronary Syndromes (ProACS) Investigators
Intraoperative aortic dissection during cardiac surgery is infrequent, complicating surgical intervention in 0.04 - 1% of cases. Dissections can occur anywhere, most often as a result of direct mechanical damage at the location of the side clamp, site of cannulation of the aorta, or at the site of proximal anastomosis and may manifest as hematoma, bleeding at the cannulation site or bleeding from the proximal anastomoses or aortic suture lines. Delayed diagnosis and treatment can lead to extremely (23-41%) high mortality rate.
Risk stratification remains central to implement appropriate therapeutic measures for patients with NSTEMI.
The ECG provides rapid risk assessment for patients presenting with chest pain that permits their allocation to appropriate management algorithms to improve the outcomes
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results.
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results.
The good news in resuscitation is that there have not been any new advances that mandate a change in practice since the 2016 ANZCOR Guidelines. The bad news is that despite our best intent, the ever-increasing research appears unable to demonstrate improved outcomes with any particular approach. Two of the most exciting areas (eCPR and post-resuscitation care) are being covered in detail at separate talks at this meeting. This presentation will focus on updating the audience on the more continuous approach to evidence evaluation, and the key recent publications that have made us at least re-evaluate our practices in BLS (including ventilation), ALS (including anti-arrhythmics) and peri-resuscitation care.
Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low...Shadab Ahmad
The role of transcatheter aortic valve replacement (TAVR) in the treatment of patients with severe, symptomatic aortic stenosis has evolved on the basis of evidence from clinical trials.
Previous randomized trials of TAVR with both balloon-expandable valves and self-expanding valves showed that, in patients who were at intermediate or high risk for death with surgery, TAVR was either superior or noninferior to standard therapies, including surgical aortic-valve replacement.
However, most patients with severe aortic stenosis are at low surgical risk, and there is insufficient evidence regarding the comparison of TAVR with surgery in such patients.
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practicebgander23
A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
EVOLUTION IN CARDIAC RESYNCHRONIZATION THERAPY
Moving towards Leadless pacing mainly in cases with difficult coronary sinus anatomy, where placing the LV lead is difficult.
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
2. BASIC
Management of acute ischemic stroke with large vessel occlusion (LVO-AIS)- consists of IV
thrombolysis (IVT)-generally with alteplase - administered as a 10% bolus followed by a 1-hour
infusion, combined with mechanical thrombectomy (MT).
The rationale for IVT in patients with LVO-AIS is to achieve timely recanalization, if possible
prior to MT (pre-MT). This applies to patients directly admitted in a comprehensive stroke center
(CSC; “direct admission”) and those admitted in a primary stroke center (PSC) before being
transferred to a CSC to receive MT (“secondary transfer”).
Pre-MT re-canalization rate- maximum 20% - by alteplase but alteplase often yields lower rates of
recanalisation especially in patients directly admitted in a CSC with much shorter IVT to
puncture times.
LVO was defined as an occlusion of the intracranial internal carotid artery (ICA), the first or
second segment of the middle cerebral artery (MCA), or the basilar artery.
3. Tenecteplase - genetically modified more fibrin-specific variant of alteplase with
a longer half-life, allowing a single bolus administration.
Recently,the Tenecteplase vs Alteplase Before Endo-vascular Therapy for
Ischemic Stroke (EXTEND-IA TNK) trial demonstrated that 0.25 mg/kg
(maximum 25 mg) tenecteplase led to a higher incidence of pre-MT
recanalization and better functional outcome than alteplase.
Following these results- tenecteplase was added in stroke guidelines as an
alternative to alteplase for IVT in bridging therapy
4. Aim
1)Our aim was to assess the neurologic and safety outcomes and the pre-MT
recanalization rate of patients admitted for a LVO-AIS who underwent bridging
therapy with 0.25 mg/kg tenecteplase, either directly admitted or secondarily
transferred to a CSC
2)To evaluate the 3-month functional independence rate of patients treated with
tenecteplase within 270 minutes of LVO-AIS (Class IV evidence).
Classification of Evidence
This study provides Class IV evidence that tenecteplase within 270 minutes of
LVO-AIS increases the probability of functional independence.
5. Study Population
The Tenecteplase Treatment in Ischemic Stroke (TETRIS) database is a
multicenter retrospective registry based on the prospective AIS registries of
4 French stroke centers that opted for tenecteplase instead of alteplase for
bridging therapy:
-2 PSCs-Sud Francilien (SFH) and Saint Antoine (StAH) hospitals
-2 CSCs- the Bordeaux University Hospital (BUH) and GHU Paris Psychiatrie et
Neurosciences (GHU).
6. In each center, patients were included once the complete transition to tenecteplase
occurred:
SFH started on May 1, 2015, to use it off-label based on 2 published clinical
trials
Other centers transitioned after the publication of EXTEND-IA TNK16 on
May 28, 2018 (St AH)
July 15,2018 (GHU)
April 16, 2019 (BUH).
Inclusion ended in all centers on December 31, 2019.
7. Inclusion Criteria
Patients who fulfilled the following criteria were included:
1)18 years or older
2)Evidence of LVO-AIS
3)IVT with 0.25 mg/kg tenecteplase (maximum 25 mg) within 4 hours 30
minutes of symptoms onset or in the presence of MRI mismatch between
diffusion- weighted imaging and fluid-attenuated inversion recovery in case of
unknown onset.
8. Data Collection
The following data were extracted from the registry, reviewing medical records:
1)Age
2)Sex
3)Vascular risk factors (smoking, hypertension, diabetes mellitus, dyslipidemia, history of myocardial
infarction or stroke)
4)Prestroke medication (statin, antiplatelet, anticoagulant)
5)Stroke onset (time, if known, or unknown)
6)Neurologic severity measured with the NIH Stroke Scale (NIHSS)
7)Ttime points (IVT, groin puncture and recanalization)
8)Final determined cause of stroke at the 3-month consultation according to the Trial of Org 10172 in Acute
Stroke Treatment (TOAST) classification (large-artery atherosclerosis, cardioembolism, small vessel
occlusion, undetermined, or other cause).
9. Data collection
-Neurologic outcome assessed with the 24-hour NIHSS and 3-month modified
Rankin Scale (mRS) scores.
-The main outcome was functional independence (mRS ≤2) 3 months after
stroke.
Secondary outcomes were substantial recanalization (revised Treatment in
Cerebral Ischemia [rTICI] score 2b-3) before (pre-MT) and after MT (post-MT)
Early neurologic improvement (ENI) defined as a reduction of 8 points or more
on the NIHSS or a score of 0 or 1 after 24 hours.
10. Data collection
Safety outcomes- were 1)symptomatic intracranial hemorrhage (sICH)
2)major systemic bleeding (hemoglobin decline of at least 2 g/dL).
Safe Implementation of Thrombolysis in Stroke-Monitoring (SITS-MOST) study
was used.
Definition sICH -local or remote type 2 parenchymal hemorrhage associated
with an increase of at least 4 points in the NIHSS score within 36 hours of IVT.
11. Brain Imaging Analysis
Patients underwent either brain MRI or CT angiography (CTA) on admission and
24 hours after IVT.
The following variables were collected from the first brain imaging:
1) Occlusion site on time-of-flight magnetic resonance angiography or CTA,
2) Presence and length of thrombus susceptibility vessel sign on gradient echo
sequences for intracranial occlusions.
3) Diffusion-weighted imaging Alberta Stroke Program Early Computed
Tomography Score (DWI-ASPECTS) for patients with an anterior circulation
occlusion.
Occlusion sites were categorized as extracranial ICA , intracranial ICA, M1
MCA, M2 MCA, and basilar artery.
12. Brain Imaging Analysis
-According European Cooperative Acute Stroke Study radiologic classification
24-hour brain imaging- used to assess ICH transformation.
-The use of brain MRI or CT was considered to be comparable as they have
similar sensitivities to detect post-IVT type 2 parenchymal hemorrhages (PH).
-When available, 24-hour recanalization was also retrieved.
-Brain DSAs were reevaluated for the initial and final rTICI score.
13. Statistical Analysis:
-Quantitative variables were described as median (interquartile range [IQR]) and
qualitative parameters as counts and percentages.
-Categorical variables were compared with χ2 or Fisher exact test and continuous
variables with Wilcoxon row sum or Kruskal-Wallis test.
-To identify associations between baseline characteristics and the main outcome
(3-month mRS ≤2),univariable and multivariable logistic regression analysis
across the whole cohort was used.
14. -The results of analysis of each dataset were aggregated into a final result using
Rubin rules.
-The Hosmer-Lemeshow goodness-of-fit test and area under the receiver
operating characteristic curve were computed for the final model.
- Associations between variables and the main outcome are reported as odds
ratios (ORs) with their 95% confidence intervals (CIs).
- The direct admission and secondary transfer sub- group analysis was carried
out as a secondary analysis.
- All tests were 2-sided and p values <0.05 were considered significant.
- Analyses were performed using R statistical software version 4.0.5.
15. Standard Protocol Approvals,
Registrations, and Patient Consents
-As per current French law regarding retrospective studies of anonymized
standard care data, patients were informed of their participation in this research
and offered the possibility to withdraw.
-No written consent to participate in this research and no internal review board
approval were required.
16. Results
Patient Characteristics:
Over the study period, 2,625 patients were hospitalized in the participating
centers for an AIS eligible for reperfusion therapy:
217 were treated with MT alone because of contraindications to IVT
1748 were treated with IVT alone
660 were treated with IVT followed by MT.
Of these 660 patients, 72 were excluded: -32 received 0.9 mg/kg alteplase
- 2 were treated with 0.5 mg/kg tenecteplase
- 27 received IVT after 270 minutes
- 9 had only a P1 posterior cerebral artery occlusion
- 2 had a cervical-only carotid artery occlusion.
17. -The resulting 588 patients were therefore included in the main analysis.
-Median age was 75 years (IQR, 61–84 years) and 315 (53.6%) patients were
women .
-The leading documented cause of stroke were-
1) cardioembolism (n = 321 [54.6%])
2) large-artery atherosclerosis (n = 69 [11.7%]).
3)Twenty-five (4.3%) patients had a cervical artery dissection.
-No stroke etiology was identified in 153 (26.0%) patients
18. ICA = internal carotid artery; IVT = IV thrombolysis; PCA = posterior cerebral artery.
Flow Diagram of Study Inclusion and Exclusion
20. Abbreviations: CE = cardioembolism
DWI-ASPECTS = diffusion-weighted imaging Alberta Stroke Program Early CT Score
FLAIR = fluid-attenuated inversion recovery
ICA = internal carotid artery;
IVT = IV thrombolysis
LAA = large-artery atherosclerosis
MCA = middle cerebral artery
mRS = modified Rankin Scale
NIHSS = National Institutes of Health Stroke Scale
ODE = other determined etiology
SVS = susceptibility vessel sign
TOAST = Trial of Org 10172 in Acute Stroke Treatment
UDE = undetermined etiology.
21. Stroke Characteristics
-A total of 528 (89.8%) patients underwent brain MRI as first-line imaging.
Median baseline NIHSS score and DWI- ASPECTS were 16 (IQR, 10–20)
and 7 (IQR, 6–8), respectively.
The most frequent occlusion sites were M1 MCA (n = 364 [61.9%])>ICA (n =
128 [21.8%])>M2 MCA (n =73 [12.4%]).
Fifty-nine (10.1%) patients also had an extra- cranial (tandem) ICA occlusion.
Basilar artery occlusions accounted for 23 (3.9%) patients. All patients
underwent DSA.
22. Median process times (IQR) in minutes were the following:
1) Onset to IVT 148 (121–180)
2) IVT to puncture 82 (65–106)
3) onset to recanalization 290 (249–340---for those who still required MT after
IVT).
4)MT was started (groin puncture) after 360 minutes in 21 patients (3.6%).
23. Main and Secondary Outcomes
-Three-month mRS scores were available for 570 (96.9%) patients of whom 269
(47.2%; 95% CI 43.0–51.4) achieved functional independence. .
-The variables independently associated with the main outcome
1) age (OR 0.95; 95% CI 0.94–0.97)
2) baseline NIHSS score (OR 0.86; 95% CI 0.83–0.9)
3) onset to IVT time ≥160 minutes (OR 0.58; 95% CI 0.35–0.95),
4) unknown stroke onset (OR 0.53; 95% CI 0.29–0.95)
5) no recanalization (OR 0.42; 95% CI 0.21–0.82).
In a sensitivity analysis, un- known onset was independently associated with a
poor outcome (OR 0.48; 0.3–0.77; p < 0.01).
24. A total of 492 patients (83.7%; 80.4–86.6) had a substantial recanalization.
120 patients (20.4%; 17.2–23.9) it was identified on the first angiographic run -Among them,
44 patients (36.7%) with a 2b and 4 patients (3.3%) with a 2c rTICI score still underwent
The global pre-MT recanalization rate did not increase with the IVT to puncture time,
remaining stable around 20% (Figures 3 and 4A), with a similar trend for M1 and M2
occlusions (data not shown).
Twenty-four hour NIHSS score was available for 561 (95.4%) patients, with a median of 8
(IQR, 3–17).
ENI occurred in 40.8% (n = 232/568; 36.8–45.0) of patients .
On follow-up brain imaging, 43 (7.5%), 25 (4.4%), and 4 (0.7%) patients had a type 1, type
2, and remote PH, respectively (Table 2). Fourteen (2.5%; 1.4–4.1) patients had sICH.
Four (0.7%) patients had a major systemic bleeding—gastrointestinal (n = 2),
hematuria (n = 1), and groin puncture hematoma (n = 1)—none of which was fatal.
25. TETRIS cohort
Characteristic All patients (n = 588) Secondary transfer (n = 520) Direct admission (n = 68) pValue
Clinical outcomes
Pre-MT recanalization 120/588 (20.4) 106/520 (20.4) 14/68 (20.6) >0.99
Post-MT recanalization 492/588 (83.7) 432/520 (83.1) 60/68 (88.2) 0.38
24-hour recanalization 378/436 (86.7) 327/375 (87.2) 51/61 (83.6) 0.42
24-hour NIHSS, n = 561 8 (3–17) 8 (3–17) 7 (2–15) 0.23
Early neurologic improvement 232/568 (40.8) 198/501 (39.5) 34/67 (50.7) 0.09
3-month mRS ≤2 269/570 (47.2) 227/502 (45.2) 42/68 (61.8) 0.01
3-month mRS, n = 570 3 (1–5) 3 (1–5) 2 (0–4) <0.01
Safety outcomes
sICH 14/567 (2.5) 12/500 (2.4) 2/67 (3.0) 0.68
Hemorrhagic transformation 0.48
PH-1 43/570 (7.5) 40/503 (8.0) 3/67 (4.5)
PH-2 25/570 (4.4) 23/503 (4.6) 2/67 (3.0)
Remote PH 4/570 (0.7) 3/503 (0.6) 1/67 (1.5)
Major systemic bleeding 4/572 (0.7) 3/505 (0.6) 1/67 (1.5) 0.39
Clinical and Safety Outcomes
Abbreviations: mRS = modified Rankin Scale; MT = mechanical thrombectomy; NIHSS = National Institutes of Health
Stroke Scale; PH = parenchymal hemorrhage; sICH = symptomatic intracranial hemorrhage.
Recanalization is defined as a revised Treatment in Cerebral Ischemia score ≥2B.
Early neurologic improvement is defined as a reduction of 8 points or more on the NIHSS or a score of 0 or 1 after 24 hours;
sICH is defined as a local or remote type 2 PH associated with an increase of 4 points or more in the NIHSS score.
26. Functional Independence (modified Rankin Scale) at 3 Months
Data are proportion of patients. The first and third rows represent the result of the bridging therapy groups in the HERMES meta-analysis of 5 trials, which used
alteplase for IVT
, and the pooled analysis of the EXTEND-IA TNK trials, which used tenecteplase for IVT. EXTEND-IA TNK = Tenecteplase vs Alteplase Before
Endovascular Therapy for Ischemic Stroke
HERMES = Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials; IVT = IV thrombolysis; TETRIS = Tenecteplase Treatment in Ischemic Stroke.
27. Univariable Multivariable
Characteristic OR 95% CI pValue OR 95% CI pValue
Age, y 0.95 0.94–0.96 <0.001 0.95 0.94–0.97 <0.001
Female sex 0.68 0.49–0.95 0.02 0.9 0.56–1.43 0.65
Vascular risk factors
Hypertension 0.53 0.37–0.74 <0.001 1.13 0.68–1.86 0.64
Diabetes mellitus 0.53 0.34–0.83 <0.01 0.75 0.41–1.36 0.34
Smoking 1.97 1.31–2.98 <0.01 1.24 0.7–2.2 0.46
History of stroke 0.56 0.33–0.97 0.04 1.20 0.57–2.55 0.63
History of myocardial infarction 0.79 0.47–1.34 0.38
Prestroke treatment
Antiplatelet 0.82 0.57–1.18 0.29
Anticoagulant 0.62 0.36–1.07 0.09 0.86 0.42–1.77 0.69
Statin 1.15 0.8–1.64 0.46
TOAST classification <0.001 0.16
CE 1 1
LAA 2.12 1.25–3.61 2.33 1.11–4.91
ODE 4.05 2–8.17 1.16 0.45–3.01
UDE 1.52 1.03–2.26 1.35 0.79–2.33
Baseline NIHSS, n = 604 0.89 0.87–0.92 <0.001 0.86 0.83–0.9 <0.001
Intracranial occlusion 0.01 0.02
M1 MCA 1 1
M2 MCA 0.90 0.54–1.5 0.62 0.31–1.25
ICA/carotid terminus 0.50 0.33–0.77 0.53 0.3–0.92
Basilar artery 0.65 0.27–1.58 0.26 0.09–0.81
Extracranial ICA occlusion 1.16 0.67–2 0.59
Secondary transfer to a CSC 0.50 0.3–0.85 0.01 0.73 0.31–1.71 0.46
Onset to IVT time, min, n = 606 <0.001 0.04
<160 1 1
≥160 0.67 0.46–0.97 0.58 0.35–0.95
Unclear onset 0.42 0.27–0.65 0.53 0.29–0.95
IVT to puncture time, min, n = 578 <0.01 0.34
60–120 1 1
<60 1.82 1.16–2.86 1.48 0.71–3.09
≥120 0.72 0.45–1.15 0.76 0.41–1.41
Recanalization status <0.001 0.02
Post-MT recanalization 1 1
Pre-MT recanalization 1.21 0.8–1.84 1.28 0.72–2.28
None 0.32 0.19–0.54 0.42 0.21–0.82
Continued
Table 3 Factors Associated With 3-Month Functional Independence (mRS ≤2)
28. Univariable Multivariable
Characteristic OR 95% CI p Value OR 95% CI p Value
Early neurologic improvement 5.80 4.01–8.37 <0.001 6.86 4.13–11.41 <0.001
Parenchymal hemorrhage 0.28 0.16–0.49 <0.001 0.55 0.27–1.13 0.11
Factors Associated With 3-Month Functional Independence (mRS ≤2) (continued)
Abbreviations: CE = cardioembolism; CI = confidence interval; ICA = internal carotid artery; IVT = IV thrombolysis; LAA = large-artery
atherosclerosis; MCA = middle cerebral artery; MT = mechanical thrombectomy; NIHSS = National Institutes of Health Stroke Scale;
ODE = other determined etiology; OR = odds ratio; SVS = susceptibility vessel sign; TOAST = Trial of Org 10172 in Acute Stroke Treatment
; UDE = undetermined etiology.
Hosmer-Lemeshow test: p = 0.13; area under the receiver operating characteristic curve: 0.86; fraction of missing data: 16%.
Logistic regression model after replacement of missing values using the multivariate imputation by chained equations algorithm.
29. Pre-MT Recanalization Rate Depending on the IVT to Puncture Time and Pre- and Post-MT rTICI Scores
Data are proportion of patients. (A) Pre–mechanical thrombectomy (MT) recanalization rate depending on the IV
thrombolysis (IVT) to puncture time. (B) Each panel represents the repartition of the revised Treatment in Cerebral
Ischemia (rTICI) scores at the first angiographic run (pre-MT) and at the end of the procedure (post-MT).
30. Subgroup Analysis
Subgroup analysis comparing patients secondarily transferred (n = 520 [88.4%]) and directly
admitted (n = 68[11.6%]) to a CSC .
-Directly admitted and secondarily transferred patient baseline characteristics were similar in
both groups.
-Median process times were significantly longer in the secondary transfer group:
1)onset to IVT time of 150 minutes (IQR, 124–180) vs 130 minutes (IQR, 106–153; p < 0.01),
2)IVT to puncture time of 86 minutes (IQR, 70–110) vs 38 minutes (IQR, 23–55; p < 0.001),
3)onset to recanalization time of 300 minutes (IQR, 260–347) vs 210 minutes (IQR, 169–255; p
< 0.001).
31. Subgroup Analysis
-Both groups had similar pre-MT recanalization (n = 106 [20.4%] in the
secondary transfer group and n = 14 [20.6%] in the direct admission group; p >
0.99) and post-MT recanalization rates (n = 432 [83.1%] in the secondary
transfer group and n = 60 [88.2%] in the direct admission group; p = 0.38).
-The proportion of patients who achieved functional independence was
significantly higher in the direct admission group at 61.8% (n = 42) vs 45.2%
(n = 227) in the secondary transfer group (p = 0.01).
-Rates of sICH were 2.4% (n = 12/500) in the secondary transfer group and 3.0%
(n = 2/67) in the direct admission group (p = 0.68).
32. Discussion
In this study, we assessed real-life use of 0.25 mg/kg tenecteplase for IVT before
MT in a large population of patients with LVO-AIS.
The proportion of patients who achieved functional independence was 47.2%
(43.0–51.5).
We found that patients treated with tenecteplase had a pre-MT recanalization
rate of 20.4% (17.2–23.9), even with short IVT to puncture times. Finally, with a
sICH rate of 2.5% (1.4–4.1), there was no significant safety concern.
33. Discussion
Pre-MT recanalization is the main expected benefit of IVT prior to MT, as it has
been shown that shorter onset to reperfusion times are associated with lower
degrees of 3-month disability. Even when incomplete, pre-MT recanalization has
been reported to be associated with a better functional outcome.
34. Comparision with other studies
Although the pre-MT recanalization rate can reach up to 20% with alteplase, it is
lower when the IVT to puncture time is shorter and in more proximal occlusions.
In our study, we found an average pre-MT recanalization rate of 20.5% (17.3–
24.0), ranging from 5.4% for ICA to 29.8% for M2 MCA occlusions, similar to
published data from the pooled analysis of the EXTEND-IA TNK trials (20.3%;
15.5–25.8).
Strikingly, the pre-MT recanalization rate remained stable for IVT to puncture
times under 1 hour , indirectly supporting a faster recanalization compared to
alteplase, which has been reported to be under 10% for similar times.
The faster recanalization with tenecteplase, may be explained by its
pharmacokinetic properties, which allow a bolus administration of its full dose,
unlike alteplase, which requires after its bolus a 1-hour infusion.
35. Comparision with other studies
In DIRECT-MT and DEVT, trials that found MT alone to be noninferior to
bridging therapy with alteplase, pre-MT recanalization occurred respectively at a
7% and 2.5% rate with IVT with a median IVT to puncture time around 30
minutes, and a 2.4% and 1.7% rate without it.
This significant efficacy gap between alteplase and tenecteplase in short IVT to
puncture times warrants clinical trials comparing bridging therapy with
tenecteplase and MT alone.
36. Comparision with other studies
-Our patients achieved a 3-month functional independence rate of 47.2% (43.0–
51.4), similar to the reported rate in the HERMES meta-analysis of 5 trials with
alteplase (46.0%; 42.0–49.9)
-Our 3-month functional independence rate was lower than the one reported in
the pooled analysis of the EXTEND-IA TNK trials (57.8%; 51.4–64.0)
This difference may be due to:
1) Our patients were older, with a median age of 75 years, compared to 68 in
HERMES and an average age of 72 in the pooled EXTEND-IA TNK trials.
37. Comparision with other studies
2) Our patients had larger ischemic cores with a median DWI- ASPECTS of 7
(IQR, 6–8) compared to a median CT- ASPECTS of 9 (IQR, 7–10) in HERMES
and an estimated median DWI-ASPECTS of 8 in EXTEND IA TNK.
3)In addition, our cohort differed from the EXTEND-IA TNK trials in 2
important ways
A) most of our patients were secondarily transferred (88.5% vs 30.7%), which
resulted in a longer median onset to puncture time (237 vs 168 minutes).
B)Contrary to the EXTEND IA TNK trials, 127 patients (21.7%) had a stroke
with unknown onset, which was independently associated with a poor outcome in
our cohort.
38. Comparision with other studies
Several metanalyses have reported an improved ENI rate with tenecteplase,
Our patients had a rate of 40.8% (36.8–45.0), lower than in HERMES (50.2%;
46.1–54.2) and the EXTEND-IA TNK trials (65.7%; 59.5–71.6).
This result is likely due to the higher age, larger ischemic cores, and longer
treatment times in our cohort. Interestingly, in our direct admission subgroup, we
observed a 3-month functional independence rate of 61.8% , similar to the pooled
EXTEND-IA TNK trials (57.8%), and a higher ENI rate of 50.7%.
Overall, these results are encouraging regarding the efficacy of tenecteplase in
routine clinical care.
39. Comparision with other studies
-This study did not disclose any safety concern with tenecteplase, with a sICH
rate of 2.5% (1.4–4.1), similar to those reported in the pooled EXTEND-IA TNK
trials (1.2%; 0.2–3.5) and HERMES (4.4%; 3.0–6.3)
-Parenchymal hematomas were more frequent in our study (11.2%) than in the
pooled EXTEND-IA TNK trials (4.8%). While it cannot be excluded that MRI
may overestimate type 1 PHs
.
40. Figure 4 Comparison of Pre-MT Recanalization With Tenecteplase and Alteplase
(A) Predicted probabilities for pre–mechanical thrombectomy (MT) recanalization with tenecteplase depending on the IV thrombolysis (IVT) to puncture time based on the TETRIS
cohort (logistic regression). (B) Pre-MT recanalization rates with alteplase compared with the IVT to puncture time in recent clinical trials and registry studies. For better comparison,
we included those in which all patients received IVT with 0.9 mg/kg (maximum 90 mg) alteplase and underwent brain digital subtraction angiography. Shaded area represent the 95%
confidence intervals. DEVT = Direct Endovascular Thrombectomy vs Combined IVT and Endovascular Thrombectomy for Patients With Acute Large Vessel Occlusion in the Anterior
Circulation; DIRECT-MT = Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary
Hospitals: A Multicenter Randomized Clinical Trial; EIA = Extending the Time for Thrombolysis in Emergency Neurologic Deficits–Intra-Arterial; EIA TNK = Tenecteplase vs Alteplase
Before Endovascular Therapy for Ischemic Stroke; ESCAPE = Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to
Recanalization Times; IMS III = Interventional Management of Stroke III; SWIFT PRIME = Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for
Acute Ischemic Stroke; TETRIS = Tenecteplase Treatment in Ischemic Stroke.
41. Strengths of study
1)It is a multicentric study of both PSCs and CSCs from metropolitan and rural
areas with a substantial number of consecutive patients.
2)There were few missing data (≤5%) for baseline NIHSS score evaluation,
recanalization status, 24-hour NIHSS, and 3-month mRS scores, making major
biases on efficacy and safety interpretation unlikely.
3)All initial and follow-up brain images were reviewed by a trained neurologist
and subsequently compared with their initial reports.
42. Limitations
1)Its design was retrospective and without a control group of patients treated with
alteplase.
2)4 stroke centers contributed to the registry, 80% of the inclusions were from 1
center (S.F.H.), and patients secondarily transferred to a CSC represented 88% of
the population, limiting the generalizability of study. Therefore, the
interpretation of our data deserves particular caution and further replication in a
wider range of centers is needed.
3)Finally, assessors for the clinical and radiologic outcome data were unblinded
to the pathway of care, which represents a potential bias.
43. Take home message
This study shows the feasibility, efficacy, and safety of using 0.25 mg/kg
tenecteplase before MT in a large population of patients with LVO-AIS either
directly admitted or secondarily transferred to a CSC. Our ability to replicate a
fast pre-MT recanalization and functional independence rates similar to those
published in clinical trials supports the use of tenecteplase in bridging therapy
for all eligible patients.