Tenecteplase or Alteplase: What Is the Thrombolytic Agent of the Future?

Purpose of review: Alteplase has been the thrombolytic of choice for acute ischaemic stroke for more than two decades. A thrombolytic which is easier to administer and with improved or comparable safety and efficacy is desirable. Tenecteplase has emerged as a potential successor, and its off-license use in acute ischaemic stroke has increased in recent years. We aimed to examine the evidence base for each drug and discuss their use in varying patient populations in acute ischaemic stroke. Recent findings: Several trials comparing tenecteplase and alteplase have reported very recently with the results of the ACT trial strengthening the argument in favour of non-inferiority of tenecteplase to alteplase. Ongoing trials such as ATTEST-2 are of interest, and trials such as TASTE and TEMPO-2 will shed further light on use of tenecteplase in specific populations. Summary: A single thrombolytic agent for all indications for thrombolysis in acute ischaemic stroke is desirable in streamlining workflows. Based on recent and upcoming trials, guidelines may soon recommend tenecteplase as a suitable alternative to alteplase. The use of tenecteplase in specific subgroups will depend on further recruitment to ongoing clinical trials.

Stimulating effect of hydrostatic pressure on ultrasonic sewage sludge treatment for COD solubilization and methane production.

The performance of ultrasonic treatment was assessed under different hydrostatic pressures for two different waste activated sludges. The impact of pressurized sonication was evaluated based on the degree of disintegration (DDCOD) and the specific methane yield (SMY). An enhancement of DDCOD was observed at an intermediate pressure level (max. 53% at 1.0 bar), but at higher pressure levels (up to 3.5 bar), the enhancement was not as pronounced as for the intermediate ranges (max. 11%). In contrast to DDCOD, SMY increased with increasing pressure for both sludge samples tested (max 17% at 3.5 bar) so that SMY did not show a notable correlation with DDCOD. A positive energy balance (max. 167%) considering the energy input for ultrasonication and the additional methane generated was only achieved in samples treated under elevated hydrostatic pressure. Since this can be achieved with negligible effort, the enhancement can be considered as "methane for free".

Normobaric Oxygen Therapy in Acute Stroke: A Systematic Review and Meta-Analysis.

PURPOSE: Normobaric oxygen (NBO) is potentially a readily accessible neuroprotective therapy. We undertook a systematic review to assess NBO in acute stroke. METHODS: MEDLINE, EMBASE, and CENTRAL databases were searched to December 2020. Randomized controlled trials of NBO administered <7 days after stroke to normoxic patients with no other indication for oxygen were identified. Data on early neurological recovery; functional outcome; mortality; oxygen saturation, and imaging markers were collected. FINDINGS: Fifteen publications involving 12 cohorts and 9,255 participants were identified. One study with 8,003 participants had low risk of bias, but the designs of smaller trials had limitations. Ninety-seven per cent of participants were in studies of low-flow oxygen (≤4 L/min). 82.8% had ischaemic stroke. Median time to treatment was 19.3 h. Meta-analysis demonstrated no significant effect on: reduction in National Institutes of Health Stroke Scale at 7 days in all stroke or ischaemic stroke only (mean difference -0.16 [-1.11 to 0.80] and -0.73 [-3.54 to 2.08], respectively); modified Rankin scale at 3-6 months of follow-up (combined standardized mean difference [SMD] -0.08 [-0.38 to 0.22]; 3 months SMD -0.01 [-0.03 to 0.029]; 6-month SMD -0.20 [-1.49 to 1.09]), or mortality (odds ratio 1.15 [0.87-1.53]). DISCUSSION: The majority of patients were administered low-flow oxygen in the sub-acute phase. Intervention strategies targeted at modification of early tissue survival (higher oxygen delivery and administration at early time points when significant volumes of viable tissue persist) have not been tested adequately. CONCLUSION: Studies of NBO have shown no significant effect on early neurological recovery, functional outcome, or mortality in acute stroke. Oxygen has been predominantly low-flow and commenced in the sub-acute phase.

Managing epilepsy in Ramadan: Guidance for healthcare providers and patients.

Ramadan is a regularly recurring period of fasting that takes place in the ninth month of the Islamic calendar. For this period, adult Muslims refrain from eating and drinking between dawn and sunset. The variation in summer daylight hours means that at temperate latitudes, fasting can last up to 20 h. It is already recognized that epilepsy control can deteriorate during Ramadan, and this may be explained by fasting-related changes to adherence to antiseizure drug regimes. This article provides specific advice to help Muslim patients prepare for Ramadan and reduce chances of exacerbation in epilepsy. In addition to advice around sleep hygiene, it explores the use of drugs or preparations of drugs that will demonstrate reduced variation during periods of fasting.

The management of patients with aortic regurgitation and severe left ventricular dysfunction: a systematic review.

A systematic search of Medline, EMBASE and CINAHL electronic databases was performed. Original research articles reporting all-cause mortality following surgery in patients with aortic regurgitation and severe left ventricular systolic dysfunction (LVSD) were identified. Nine of the 10 eligible studies were observational, single-center, retrospective analyses. Survival ranged from 86 to 100% at 30 days; 81 to 100% at 1 year and 68 to 84% at 5 years. Three studies described an improvement in mean left ventricular ejection fraction (LVEF) following aortic valve replacement (AVR) of 5-14%; a fourth study reported an increase in mean left ventricular ejection fraction (LVEF) of 9% in patients undergoing isolated AVR but not when AVR was combined with coronary artery bypass graft and/or mitral valve surgery. Three studies demonstrated improvements in functional New York Heart Association (NYHA) class following AVR. Additional studies are needed to clarify the benefits of AVR in patients with more extreme degrees of left ventricular systolic dysfunction (LVSD) and the potential roles of cardiac transplantation and transaortic valve implantation.