Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke.

BACKGROUND: Intravenous infusion of alteplase is used for thrombolysis before endovascular thrombectomy for ischemic stroke. Tenecteplase, which is more fibrin-specific and has longer activity than alteplase, is given as a bolus and may increase the incidence of vascular reperfusion. METHODS: We randomly assigned patients with ischemic stroke who had occlusion of the internal carotid, basilar, or middle cerebral artery and who were eligible to undergo thrombectomy to receive tenecteplase (at a dose of 0.25 mg per kilogram of body weight; maximum dose, 25 mg) or alteplase (at a dose of 0.9 mg per kilogram; maximum dose, 90 mg) within 4.5 hours after symptom onset. The primary outcome was reperfusion of greater than 50% of the involved ischemic territory or an absence of retrievable thrombus at the time of the initial angiographic assessment. Noninferiority of tenecteplase was tested, followed by superiority. Secondary outcomes included the modified Rankin scale score (on a scale from 0 [no neurologic deficit] to 6 [death]) at 90 days. Safety outcomes were death and symptomatic intracerebral hemorrhage. RESULTS: Of 202 patients enrolled, 101 were assigned to receive tenecteplase and 101 to receive alteplase. The primary outcome occurred in 22% of the patients treated with tenecteplase versus 10% of those treated with alteplase (incidence difference, 12 percentage points; 95% confidence interval [CI], 2 to 21; incidence ratio, 2.2; 95% CI, 1.1 to 4.4; P=0.002 for noninferiority; P=0.03 for superiority). Tenecteplase resulted in a better 90-day functional outcome than alteplase (median modified Rankin scale score, 2 vs. 3; common odds ratio, 1.7; 95% CI, 1.0 to 2.8; P=0.04). Symptomatic intracerebral hemorrhage occurred in 1% of the patients in each group. CONCLUSIONS: Tenecteplase before thrombectomy was associated with a higher incidence of reperfusion and better functional outcome than alteplase among patients with ischemic stroke treated within 4.5 hours after symptom onset. (Funded by the National Health and Medical Research Council of Australia and others; EXTEND-IA TNK ClinicalTrials.gov number, NCT02388061 .).

Current State of Advanced Practice Providers in Urological Practice.

INTRODUCTION: This document provides an update to the 2015 consensus statement with new content on inpatient utilization, procedural data, and compensation. The full document is available on the American Urological Association (AUA) website (https://www.auanet.org/guidelines/guidelines/current-state-of-advanced-practice-providers-in-urologic-practice). This document was created by an ad-hoc group of urological providers formed by the AUA board of directors. METHODS: A workforce shortage of 65,000 physicians is projected by the year 2025. In 2018, there were 3.89 urologists per capita, which is amongst the most severe specialty shortages. Urology has the second oldest surgical subspecialty workforce with an average age of 52.5 years. According to the 2018 census, 72.5% of urologists used an advanced practice provider (APP) in their practice, and APPs accounted for 41% of a medical doctor/doctor of osteopathy full-time equivalent. The AUA endorses the use of APPs in the care of patients through a formally defined, supervised role with a board certified urologist under the auspices of applicable state law. This physician-led, team-based approach provides the highest quality urological care. RESULTS: Urologists work with APPs frequently, but many may not know the most efficient way to incorporate them into their practice. This document examines APP integration from a regulatory and practice management approach, as well as provides information on inpatient utilization, procedural data, and compensation. CONCLUSIONS: This document supports the AUA's policy statement that in a team-based approach with a board certified urologist in a supervisory role, APPs contribute to the care of the patient with genitourinary disease and, therefore, encourages the proper use of APPs.

Safety and efficacy of oral DMSA therapy for children with autism spectrum disorders: Part A--medical results.

BACKGROUND: This study investigated the effect of oral dimercapto succinic acid (DMSA) therapy for children with autism spectrum disorders ages 3-8 years. METHODS: Phase 1 involved 65 children who received one round of DMSA (3 days). Participants who had high urinary excretion of toxic metals were selected to continue on to phase 2. In phase 2, 49 participants were randomly assigned in a double-blind design to receive an additional 6 rounds of either DMSA or placebo. RESULTS: DMSA greatly increased the excretion of lead, substantially increased excretion of tin and bismuth, and somewhat increased the excretion of thallium, mercury, antimony, and tungsten. There was some increase in urinary excretion of essential minerals, especially potassium and chromium. The Phase 1 single round of DMSA led to a dramatic normalization of RBC glutathione in almost all cases, and greatly improved abnormal platelet counts, suggesting a significant decrease in inflammation. CONCLUSION: Overall, DMSA therapy seems to be reasonably safe, effective in removing several toxic metals (especially lead), dramatically effective in normalizing RBC glutathione, and effective in normalizing platelet counts. Only 1 round (3 days) was sufficient to improve glutathione and platelets. Additional rounds increased excretion of toxic metals.

Safety and efficacy of oral DMSA therapy for children with autism spectrum disorders: part B - behavioral results.

BACKGROUND: This study investigated the effects of oral dimercapto succinic acid (DMSA) therapy on the behavioural symptoms of children with autism spectrum disorders (ASD) ages 3-8 years. METHODS: Phase 1 involved 65 children with ASD who received one round of DMSA (3 days). Participants who had high urinary excretion of toxic metals were selected to continue on to phase 2. In phase 2, 49 participants were randomly assigned in a double-blind design to receive an additional 6 rounds of either DMSA or placebo. RESULTS: The groups receiving one round and seven rounds of DMSA had significant improvements on all the assessment measures. For the seven round group, the degree of improvement on the assessment measures could be partially explained by a regression analysis based on excretion of toxic metals and changes in glutathione (adjusted R2 of 0.28-0.75, p < 0.02 in all cases). One round of DMSA had nearly the same benefit as seven rounds. The assessment measures correlated reasonably with one another at the beginning of the study (r = 0.60-0.87) and even better at the end of the study (r = 0.63-0.94). CONCLUSION: Overall, both one and seven rounds of DMSA therapy seems to be reasonably safe in children with ASD who have high urinary excretion of toxic metals, and possibly helpful in reducing some of the symptoms of autism in those children.

A Right Intercosto-Bronchial Artery Derived from the Thyrocervical Trunk: An Unusual Cause of Type II Endoleak Post Thoracic Aortic Stenting.

The aetiology, incidence and management of type II endoleaks in standard infrarenal endovascular aortic aneurysm repair is well described. Far less data is available for thoracic stent grafting. We present a rare and interesting case of a type II endoleak post thoracic aortic stenting and highlight the aberrant anatomy that can cause this phenomenon in such cases.

Comparison of vehicle exhaust emissions from modified diesel fuels.

Three diesel fuels, one oil sand-derived (OSD) diesel serving as base fuel, one cetane-enhanced base fuel, and one oxygenate [diethylene glycol dimethyl ether (DEDM)]-blended base fuel, were tested for their emission characterizations in vehicle exhaust on a light-duty diesel truck that reflects the engine technology of the 1994 North American standard. Both the cetane-enhanced and the oxygenate-blended fuels were able to reduce regulated [CO, particulate matter (PM), total hydrocarbon (THC)] and nonregulated [polyaromatic hydrocarbons (PAHs), carbonyls, and other volatile organic chemicals] emissions, except for nitrogen oxides (NO(x)), compared with the base fuel. Although burning a fuel that contains oxygen could conceivably yield more oxygenated compounds in emissions, the oxygenate-blended diesel fuel resulted in reduced emissions of formaldehyde along with hydrocarbons such as benzene, 1,3-butadiene, and PAHs. Reductions in nitro-PAH emissions have been observed in both the cetane-enhanced and oxygenated fuels. This further demonstrates the benefits of using a cetane enhancer and the oxygenated fuel component.

Vertebrobasilar dissections: case series comparing patients with and without dissecting aneurysms.

Vertebrobasilar dissections are being increasingly diagnosed due to better awareness and increased availability of modern imaging techniques of the intracranial and extracranial arteries. The clinical presentation and outcome in patients with vertebrobasilar dissections may be complicated by dissecting aneurysms. The aim of this retrospective study was to compare the clinical profile of patients with vertebrobasilar dissections with and without dissecting aneurysms, and to determine predisposing factors to the development of aneurysms. Thirty patients (19 [63%] male; median age 44.5 years) were identified. The patients were divided into two groups, an aneurysmal dissection group with seven patients and a non-aneurysmal dissection group with 23 patients. Eight (27%) patients presented with dissection after trivial trauma, three (10%) following high-speed vehicular trauma, two (7%) were associated with infection, but most (57%) were apparently spontaneous. Migraine with aura (p=0.008) and female sex (p=0.03) were observed more frequently in the aneurysmal dissection group. Though vascular risk factors other than hypertension and atrial fibrillation were seen in a greater percentage of patients in the non-aneurysmal dissection group, this was not statistically significant. Patients were treated with antiplatelet agents (n=8) or warfarin (n=13) or underwent an endovascular intervention (n=6). Post-discharge data were available in 19 patients, of whom 14 (74%) were independent at a median follow-up of 4 months. Female sex and migraine with aura may predispose to the formation of acute dissecting aneurysms and this requires further research. Larger, prospective studies are required to ascertain epidemiologic and etiologic factors predisposing patients to the development of both intracranial and extracranial dissecting aneurysms in the vertebrobasilar circulation.

Intraorbital ophthalmic artery aneurysms.

Angiographically documented aneurysms of the intraorbital ophthalmic artery are extremely rare. Two cases are presented of intra-orbital ophthalmic artery aneurysms, both associated with arteriovenous malformation (AVM). There have only been isolated reports documenting this combination of vascular anomalies. In the first case, the aneurysm was treated conservatively and in the second case, after staging angiography and interventional embolization, the aneurysm was removed along with the associated AVM. The clinical presentation, pathogenesis and management of this rare combination of vascular anomalies is briefly discussed.

More than one dilemma.

We present an unusual case that highlights a number of management dilemmas: the cause, investigation and treatment of subarachnoid hemmorrhage in patients iwth vascular connective tissue diseases; the further investigation of small aneurysms identified on CT angiography; and the difficulties associated with anticoagulation, mechanical cardiac valves and cerebral hemorrhage.

Regions of strong coupling between soil moisture and precipitation.

Previous estimates of land-atmosphere interaction (the impact of soil moisture on precipitation) have been limited by a lack of observational data and by the model dependence of computational estimates. To counter the second limitation, a dozen climate-modeling groups have recently performed the same highly controlled numerical experiment as part of a coordinated comparison project. This allows a multimodel estimation of the regions on Earth where precipitation is affected by soil moisture anomalies during Northern Hemisphere summer. Potential benefits of this estimation may include improved seasonal rainfall forecasts.