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.

Polarized human cholangiocytes release distinct populations of apical and basolateral small extracellular vesicles.

Intercellular communication is critical for organismal homeostasis, and defects can contribute to human disease states. Polarized epithelial cells execute distinct signaling agendas via apical and basolateral surfaces to communicate with different cell types. Small extracellular vesicles (sEVs), including exosomes and small microvesicles, represent an understudied form of intercellular communication in polarized cells. Human cholangiocytes, epithelial cells lining bile ducts, were cultured as polarized epithelia in a Transwell system as a model with which to study polarized sEV communication. Characterization of isolated apically and basolaterally released EVs revealed enrichment in sEVs. However, differences in apical and basolateral sEV composition and numbers were observed. Genetic or pharmacological perturbation of cellular machinery involved in the biogenesis of intralumenal vesicles at endosomes (the source of exosomes) revealed general and domain-specific effects on sEV biogenesis/release. Additionally, analyses of signaling revealed distinct profiles of activation depending on sEV population, target cell, and the function of the endosomal sorting complex required for transport (ESCRT)-associated factor ALG-2-interacting protein X (ALIX) within the donor cells. These results support the conclusion that polarized cholangiocytes release distinct sEV pools to mediate communication via their apical and basolateral domains and suggest that defective ESCRT function may contribute to disease states through altered sEV signaling.

ILIAC CREST HEIGHT DIFFERENCE AND OTHER RUNNING-RELATED VARIABLES' RELATIONSHIP WITH RUNNING INJURY.

BACKGROUND: Leg-length inequality (LLI) is a common condition that may contribute to various spinal, pelvic, and lower extremity dysfunctions. Iliac crest height difference (ICHD) has been demonstrated to be a good estimate for LLI and may be a useful measure for identifying individuals who are at risk for injury. PURPOSE: To investigate the relationship between ICHD and other running-related variables with running injury. METHODS: An observational retrospective case-control design was used. Data were collected via questionnaire and physical examination from a purposive sample of 100 runners and were analyzed using chi-squared tests of independence. RESULTS: The prevalence of ICHD ≥ 5mm reported by subjects via questionnaire was ∼40%. There was no difference in report of injury between subjects with ICHD >5mm and those with ICHD <5mm (χ2 = 0.02, p = 0.88); however, lifetime history of injury (χ2 = 15.68, p = 0.00) and the number of running events participated (χ2 = 3.09, p = 0.04) were significant factors associated with injury; although not significant, there was a trend towards relationship with gender (χ2 = 3.2, = 0.07). CONCLUSION: Small ICHD is not associated with running injury among recreational runners. There appears to be an increased risk of running injury among runners who participate in more than one running event annually and those that have had a past history of running injury. Also, males may be at slightly greater risk of sustaining a running injury compared to females. LEVEL OF EVIDENCE: Therapy, level 3b.

PAIN AND PHYSICAL PERFORMANCE AMONG RECREATIONAL RUNNERS WHO RECEIVE A CORRECTION FOR AN ILIAC CREST HEIGHT DIFFERENCE: A CASE SERIES.

BACKGROUND: Leg-length inequality (LLI) is a musculoskeletal condition where one lower extremity is longer than the other. There is conflicting evidence on the relevance of LLI and conservative treatment options. Iliac crest height difference (ICHD) is a good estimate of LLI. OBJECTIVE: To observe changes in pain and performance among recreational runners with running-induced lower extremity pain who received ICHD correction. METHODS: A 12-week case series with multiple baseline and intervention (A-B-A-B) phases was used to observe the effects of ICHD correction on pain and performance among three symptomatic recreational runners. Primary outcome measures included the Lower Extremity Functional Scale (LEFS), the Visual Analog Scale -Worst Pain (VAS-W), symptom-free running distance, and average running speed. A standardized procedure for fabricating an in-shoe shim was utilized for ICHD correction. RESULTS: There were no clinically important differences in functional capacity for any subject between any phases. Also, two subjects demonstrated trends towards increased pain over the 12-week experimental period, whereas one subject demonstrated a decrease. One subject demonstrated a statistically significant increase in running distance during intervention phases, but the others demonstrated reductions. All subjects demonstrated trends towards increased running speed, but none were statistically significant. CONCLUSION: The correction of small ICHD < 9mm did not improve pain or performance among recreational runners. Individuals with small ICHD may be able to effectively compensate for lower extremity asymmetries; therefore, correction seems to be unnecessary and potentially harmful in short-term. LEVEL OF EVIDENCE: Therapy, level 4.

The effect of cushioning insoles on back and lower extremity pain in an industrial setting.

The purpose of this study was to examine the relationship between low back pain and lower extremity pain in a group of factory workers and determine the effect of cushioning insoles on low back pain and lower extremity pain. Data were gathered via questionnaire from 306 employees of an aircraft engine assembly factory. A subset of 40 workers who had reported significant levels of back or lower extremity pain were sampled for four consecutive 12-hour shifts wearing their normal footwear and then a week later for four consecutive shifts wearing cushioning insoles. High levels of low back pain and lower extremity pain were reported by workers on the plant floor, but low back pain was poorly correlated to lower extremity pain (r = 0.371). The effect of insoles on the subset of 40 workers was to lower low back pain by 38%, foot pain by 37%, and knee pain by 38% (p < .001). The reduction in low back pain, however, was not correlated to the reduction in lower extremity pain; workers reporting a decrease in low back pain differed from those reporting less lower extremity pain.

Effect of sterol carrier protein-2 expression on sphingolipid distribution in plasma membrane lipid rafts/caveolae.

Although sphingolipids are highly important signaling molecules enriched in lipid rafts/caveolae, relatively little is known regarding factors such as sphingolipid binding proteins that may regulate the distribution of sphingolipids to lipid rafts/caveolae of living cells. Since early work demonstrated that sterol carrier protein-2 (SCP-2) enhanced glycosphingolipid transfer from membranes in vitro, the effect of SCP-2 expression on sphingolipid distribution to lipid rafts/caveolae in living cells was examined. Using a non-detergent affinity chromatography method to isolate lipid rafts/caveolae and non-rafts from purified L-cell plasma membranes, it was shown that lipid rafts/caveolae were highly enriched in multiple sphingolipid species including ceramides, acidic glycosphingolipids (ganglioside GM1); neutral glycosphingolipids (monohexosides, dihexosides, globosides), and sphingomyelin as compared to non-raft domains. SCP-2 overexpression further enriched the content of total sphingolipids and select sphingolipid species in the lipid rafts/caveolae domains. Analysis of fluorescence binding and displacement data revealed that purified human recombinant SCP-2 exhibited high binding affinity (nanomolar range) for all sphingolipid classes tested. The binding affinity decreased in the following order: ceramides > acidic glycosphingolipid (ganglioside GM1) > neutral glycosphingolipid (monohexosides, hexosides, globosides) > sphingomyelin. Enrichment of individual sphingolipid classes to lipid rafts/caveolae versus non-rafts in SCP-2 expressing plasma membranes followed closely with those classes most strongly bound to SCP-2 (ceramides, GM1 > the neutral glycosphingolipids (monohexosides, dihexosides, and globosides) > sphingomyelin). Taken together these data suggested that SCP-2 acts to selectively regulate sphingolipid distribution to lipid rafts/caveolae in living cells.

Sterol carrier protein-2: new roles in regulating lipid rafts and signaling.

Sterol carrier protein-2 (SCP-2) was independently discovered as a soluble protein that binds and transfers cholesterol as well as phospholipids (nonspecific lipid transfer protein, nsLTP) in vitro. Physiological functions of this protein are only now beginning to be resolved. The gene encoding SCP-2 also encodes sterol carrier protein-x (SCP-x) arising from an alternate transcription site. In vitro and in vivo SCP-x serves as a peroxisomal 3-ketoacyl-CoA thiolase in oxidation of branched-chain lipids (cholesterol to form bile acids; branched-chain fatty acid for detoxification). While peroxisomal SCP-2 facilitates branched-chain lipid oxidation, the role(s) of extraperoxisomal (up to 50% of total) are less clear. Studies using transfected fibroblasts overexpressing SCP-2 and hepatocytes from SCP-2/SCP-x gene-ablated mice reveal that SCP-2 selectively remodels the lipid composition, structure, and function of lipid rafts/caveolae. Studies of purified SCP-2 and in cells show that SCP-2 has high affinity for and selectively transfers many lipid species involved in intracellular signaling: fatty acids, fatty acyl CoAs, lysophosphatidic acid, phosphatidylinositols, and sphingolipids (sphingomyelin, ceramide, mono-di-and multi-hexosylceramides, gangliosides). SCP-2 selectively redistributes these signaling lipids between lipid rafts/caveolae and intracellular sites. These findings suggest SCP-2 serves not only in cholesterol and phospholipid transfer, but also in regulating multiple lipid signaling pathways in lipid raft/caveolae microdomains of the plasma membrane.

Sterol carrier protein-2 expression alters sphingolipid metabolism in transfected mouse L-cell fibroblasts.

The influence of sterol carrier protein-2 (SCP-2) on the cellular metabolism of sphingolipids was examined in control mouse L-cells and stably transfected clones expressing the protein SCP-2. Three approaches were used to examine for differences; (1) compositional analysis of endogenous sphingolipid classes, (2) metabolism of NBD-ceramide, and (3) live cell labelling via endocytic uptake of BODIPY-sphingomyelin. SCP-2 over expression significantly altered the endogenous levels of both neutral and acidic sphingolipid classes. Among the neutral sphingolipids, expression of SCP-2 induced a 1.7-fold increase in the level of lactosylceramide (LacCer, p < 0.05) and a similar fold decrease in the level of the higher-order neutral glycosylceramides (p < 0.05). Among the acidic sphingolipids, SCP-2 resulted in a 5.2-fold decrease in the endogenous plasma membrane level of ganglioside GM1 (p < 0.03). Incubation of both control and transfected cell lines with NBD-ceramide resulted in the rapid establishment of a steady-state distribution of NBD-labelled sphingomyelin (NBD-SM) and glucosylceramide (NBD-GlcCer). In the SCP-2 expressing clones the conversion of NBD-Cer to NBD-GlcCer was 30% lower during incubation periods between 5 and 30 min (p < 0.025). Inspection of the cells by fluorescence microscopy after incubation with BODIPY labelled sphingomyelin (BODIPY-SM) revealed similar punctuated patterns with no distinguishable differences between the cell types. These results imply that SCP-2 plays a role in modulating enzymatic steps involved in metabolism of sphingolipid homeostasis.

Sphingolipid storage induces accumulation of intracellular cholesterol by stimulating SREBP-1 cleavage.

We showed previously that the intracellular transport of sphingolipids (SLs) is altered in SL storage disease fibroblasts, due in part to the secondary accumulation of free cholesterol. In the present study we examined the mechanism of cholesterol elevation in normal human skin fibroblasts induced by treatment with SLs. When cells were incubated with various natural SLs for 44 h, cholesterol levels increased 25-35%, and cholesterol esterification was reduced. Catabolism of the exogenous SLs was not required for elevation of cholesterol because (i) a non-hydrolyzable and a degradable SL analog elevated cellular cholesterol to similar extents, and (ii) incubation of cells with various SL catabolites, including ceramide, had no effect on cholesterol levels. Elevated cholesterol was derived primarily from low density lipoproteins (LDL) and resulted from up-regulation of LDL receptors induced by cleavage of the sterol regulatory element-binding protein-1. Upon SL treatment, cholesterol accumulated with exogenous SLs in late endosomes and lysosomes. These results suggest a model in which excess SLs present in endocytic compartments serve as a "molecular trap" for cholesterol, leading to a reduction in cholesterol at the endoplasmic reticulum, induction of sterol regulatory element-binding protein-1 cleavage, and up-regulation of LDL receptors.