Prospective Observational Cohort Study of Tenecteplase Versus Alteplase in Routine Clinical Practice.

BACKGROUND: A 10-hospital regional network transitioned to tenecteplase as the standard of care stroke thrombolytic in September 2019 because of potential workflow advantages and reported noninferior clinical outcomes relative to alteplase in meta-analyses of randomized trials. We assessed whether tenecteplase use in routine clinical practice reduced thrombolytic workflow times with noninferior clinical outcomes. METHODS: We designed a prospective registry-based observational, sequential cohort comparison of tenecteplase- (n=234) to alteplase-treated (n=354) stroke patients. We hypothesized: (1) an increase in the proportion of patients meeting target times for target door-to-needle time and transfer door-in-door-out time, and (2) noninferior favorable (discharge to home with independent ambulation) and unfavorable (symptomatic intracranial hemorrhage, in-hospital mortality or discharge to hospice) in the tenecteplase group. Total hospital cost associated with each treatment was also compared. RESULTS: Target door-to-needle time within 45 minutes for all patients was superior for tenecteplase, 41% versus 29%; adjusted odds ratio, 1.85 (95% CI, 1.27-2.71); P=0.001; 58% versus 41% by Get With The Guidelines criteria. Target door-in-door-out time within 90 minutes was superior for tenecteplase 37% (15/43) versus 14% (9/65); adjusted odds ratio, 3.62 (95% CI, 1.30-10.74); P=0.02. Favorable outcome for tenecteplase fell within the 6.5% noninferiority margin; adjusted odds ratio, 1.26 (95% CI, 0.89-1.80). Unfavorable outcome was less for tenecteplase, 7.3% versus 11.9%, adjusted odds ratio, 0.77 (95% CI, 0.42-1.37) but did not fall within the prespecified 1% noninferior boundary. Net benefit (%favorable-%unfavorable) was greater for the tenecteplase sample: 37% versus 27%. P=0.02. Median cost per hospital encounter was less for tenecteplase cases ($13 382 versus $15 841; P<0.001). CONCLUSIONS: Switching to tenecteplase in routine clinical practice in a 10-hospital network was associated with shorter door-to-needle time and door-in-door-out times, noninferior favorable clinical outcomes at discharge, and reduced hospital costs. Evaluation in larger, multicenter cohorts is recommended to determine if these observations generalize.

Lower extremity predominant stiff-person syndrome and limbic encephalitis with amphiphysin antibodies in breast cancer.

A 54-year-old woman presented with several weeks of psychiatric symptoms, partial-onset seizures, and painful spasms of the lower extremities. On examination, she exhibited severe stiffness and intermittent extensor spasms of the lower extremities. Magnetic resonance imaging of the brain showed T2 hyperintensity in the left temporal lobe with enhancement after gadolinium administration on T1-weighted images. Amphiphysin antibodies were present in the serum. Radiographic screening for malignancy disclosed a metastatic breast cancer. The case is a unique example of amphiphysin autoimmunity, illustrating the possibility of paraneoplastic stiff-person syndrome and limbic encephalitis coexisting in a patient with a "classical" presentation of stiff-person syndrome confined to the lower extremities.

Prognosis of acute compressive radial neuropathy.

INTRODUCTION: Small published case series suggest that compressive radial neuropathy is often a self-limited phenomenon with a favorable prognosis. Due to paucity of data, we sought to clearly define prognosis. METHODS: To define clinical and electrodiagnostic features in this condition, we retrospectively reviewed consecutive cases of compressive radial neuropathy confirmed using electrodiagnostic studies at a large tertiary center over a 10-year period. RESULTS: A total of 51 patients (26 men, 25 women, mean age 46 years ± 15; range, 19-83 years) with compressive radial neuropathy were identified and reviewed. All patients in whom clinical follow-up was available (23 [45%] of the 51 patients identified) experienced complete recovery. Mean duration from onset to resolution of symptoms was 3.4 months. CONCLUSIONS: Our results support a good prognosis in essentially all patients with acute compressive radial neuropathies. This report provides valuable information to assist in counseling patients who may present with profound clinical deficits.

Temporal properties of the mouse cone electroretinogram.

To determine the temporal response characteristics of the mouse cone electroretinogram (ERG), we recorded responses to high contrast sinusoidal stimuli ranging from 2 to 52 Hz. The largest response amplitudes obtained from wild-type (WT) mice occurred at stimulus frequencies below 10 Hz, and cone ERG amplitude declined progressively with increasing stimulus frequency above that level. In comparison, human responses recorded under the same stimulus and recording conditions displayed maximal responses to stimulus frequencies near 4 and 40 Hz, and a pronounced dip at 12 Hz. Responses were also obtained from nob (no b-wave) mice, which lack ERG contributions from depolarizing bipolar cells (DBCs). At low temporal frequencies, nob cone ERGs were smaller than those of WT mice and had a different waveform. As temporal frequency increased, nob and WT responses became more similar and came into register at the highest temporal frequencies. To evaluate the contribution of the DBC pathway to the mouse cone ERG, nob responses were vector-subtracted from those of WT mice. The derived DBC response was maximal at low stimulus frequencies and fell sharply as stimulus frequency increased. These results indicate that the mouse cone ERG is more linear than the primate response and that the temporal response of the mouse outer retina is tuned to much lower frequencies than that of primate.