Helicopter "Drip and Ship" Flights Do Not Alter the Pharmacological Integrity of rtPA

Stability of alteplase for ultrasound-facilitated catheter-directed thrombolysis

Alteplase solutions degrade steadily over time during simulated ultrasound-facilitated catheter-directed administration.

Remaining nondegraded alteplase proteins retained functional activity.

Ultrasound-facilitated catheter-directed thrombolysis is used with low-dose alteplase to treat pulmonary embolism. This reduces the risk of bleeding that accompanies systemic administration of higher alteplase doses. Some studies suggest that alteplase given over 2 to 6 hours is safe and effective, but there are few data to support the stability of alteplase under these conditions. Therefore, we undertook this in vitro study to determine the duration of alteplase stability. Alteplase was prepared in solutions of 8 mg in 100 mL, 6 mg in 150 mL, and 8 mg in 200 mL. Solutions were administered through the EkoSonic Endovascular System (with and without ultrasound) to simulate administration over 2, 4, and 6 hours. Alteplase was assessed with reversed-phase high-performance liquid chromatography (RP-HPLC). Assays were performed at time 0 and at 30-minute intervals during simulated infusion. An enzyme-linked immunosorbent assay was used to measure alteplase concentrations at time 0 and at 15-minute intervals during simulated infusion. By using RP-HPLC in the absence of ultrasound, the alteplase concentration remained within 1% of the original concentration through 120, 240, and 360 minutes of infusion. By using RP-HPLC for measurement, alteplase in the presence of ultrasound degraded steadily over time to ∼90% of its original amount in 120 minutes, ∼80% in 240 minutes, and ∼70% in 360 minutes. The remaining alteplase was available for enzymatic activity. Alteplase solutions of 0.04 and 0.08 mg/mL degraded steadily over time during simulated ultrasound-facilitated catheter-directed administration. Alteplase that did not degrade remained available for enzymatic activity.

Possible Mechanisms for the Effects of Sound Vibration on Human Health

This paper presents a narrative review of research literature to “map the landscape” of the mechanisms of the effect of sound vibration on humans including the physiological, neurological, and biochemical. It begins by narrowing music to sound and sound to vibration. The focus is on low frequency sound (up to 250 Hz) including infrasound (1–16 Hz). Types of application are described and include whole body vibration, vibroacoustics, and focal applications of vibration. Literature on mechanisms of response to vibration is categorized into hemodynamic, neurological, and musculoskeletal. Basic mechanisms of hemodynamic effects including stimulation of endothelial cells and vibropercussion; of neurological effects including protein kinases activation, nerve stimulation with a specific look at vibratory analgesia, and oscillatory coherence; of musculoskeletal effects including muscle stretch reflex, bone cell progenitor fate, vibration effects on bone ossification and resorption, and anabolic effects on spine and intervertebral discs. In every category research on clinical applications are described. The conclusion points to the complexity of the field of vibrational medicine and calls for specific comparative research on type of vibration delivery, amount of body or surface being stimulated, effect of specific frequencies and intensities to specific mechanisms, and to greater interdisciplinary cooperation and focus.

Pharmakologische Eigenschaften von Notfallmedikamenten unter Extrembedingungen

Notfallmedikamente kommen an nahezu allen Orten dieser Erde zum Einsatz. Damit werden sie unterschiedlichsten Umweltbedingungen (Kälte, Hitze, direkte Sonneneinstrahlung) ausgesetzt. Sämtliche Daten zur Pharmakokinetik, Pharmakodynamik, Medikamentensicherheit und -haltbarkeit werden jedoch unter standardisierten Bedingungen erhoben, die sich von den Anwendungsbedingungen in der Notfallmedizin erheblich unterscheiden können. Durch die Kälte bei Wintereinsätzen im Gebirge können ebenso wie bei Einsätzen in großer Hitze und bei direkter Sonnenexposition chemische Reaktionen entstehen, welche die Eigenschaften der Medikamente bis hin zur kompletten Wirkungslosigkeit verändern können. Zusätzlich können Unterkühlung oder Überhitzung des Patienten zu einer Zentralisation bzw. Vasodilatation führen und damit das pharmakologische Verteilungsvolumen erheblich verändern, woraus Unter- bzw. Überdosierungen resultieren können. Gleichzeitig kann durch einen temperaturbedingt veränderten Metabolismus die Konjugation und Elimination von Medikamenten beeinflusst sein und zu einer unvorhersehbaren Verlängerung der Medikamentenwirkung führen. Trotz der erheblichen klinischen Relevanz dieser Thematik existieren bisher kaum Daten zu den konkreten Effekten extremer Umweltbedingungen auf die pharmakologischen Eigenschaften von Notfallmedikamenten. Diese Übersicht soll dazu dienen, den aktuellen Kenntnisstand der notfallmedizinischen Pharmakotherapie unter Extrembedingungen darzustellen.

Low-Frequency Vibrations Enhance Thrombolytic Therapy and Improve Stroke Outcomes

Background and Purpose- We aim to determine the potential impact on stroke thrombolysis of drip-and-ship helicopter flights and specifically of their low-frequency vibrations (LFVs). Methods- Mice with a middle cerebral artery autologous thromboembolic occlusion were randomized to receive rtPA (recombinant tissue-type plasminogen activator; or saline) 90 minutes later in 3 different settings: (1) a motion platform simulator that reproduced the LFV signature of the helicopter, (2) a standardized actual helicopter flight, and (3) a ground control. Results- Mice assigned to the LFV simulation while receiving tPA had smaller infarctions (31.6 versus 54.9 mm3; P=0.007) and increased favorable neurological outcomes (86% versus 28%; P=0.0001) when compared with ground controls. Surprisingly, mice receiving tPA in the helicopter did not exhibit smaller infarctions (47.8 versus 54.9 mm3; P=0.58) nor improved neurological outcomes (37% versus 28%; P=0.71). This could be due to a causative effect of the 20- to 30-Hz band, which was inadvertently attenuated during actual flights. Mice using saline showed no differences between the LFV simulator and controls with respect to infarct size (80.9 versus 95.3; P=0.81) or neurological outcomes (25% versus 11%; P=0.24), ruling out an effect of LFV alone. There were no differences in blood-brain barrier permeability between LFV simulator or helicopter, compared with controls (2.45-3.02 versus 4.82 mm3; P=0.14). Conclusions- Vibration in the low-frequency range (0.5-120 Hz) is synergistic with rtPA, significantly improving the effectiveness of thrombolysis without impairing blood-brain barrier permeability. Our findings reveal LFV as a novel, safe, and simple-to-deliver intervention that could improve the outcomes of patients. Visual Overview- An online visual overview is available for this article.

Toward Inter-isolated Island Cooperation for the Drip, Ship, and Retrieve Method in the Sakishima Islands: A Case Report

Objective

Based on the findings of preferable outcomes from recanalization therapy in recent studies, regional partnerships for the endovascular treatment of acute ischemic stroke are being promoted. However, reports of inter-island cooperation between remote islands located far from high-volume centers on the mainland are rare.

Case Presentation

A 63-year-old man experienced an acute ischemic stroke on a small, isolated island in Okinawa, Japan. He was transferred by helicopter to the primary emergency hospital on Ishigaki Island, which was the nearest island on which he could be administered recombinant tissue plasminogen activator (rtPA). After this, he was carried again by helicopter and ambulance to the primary stroke center on Miyako Island using the drip and ship method. Mechanical thrombectomy with a stent retriever achieved recanalization of the occluded major vessels and improved the neurological disturbance. The patient became neurologically independent and could be discharged only 11 days after onset.

Conclusion

Building a local area network that includes hospitals providing mechanical thrombectomy is a meaningful approach to treating acute ischemic stroke occurring on isolated islands. It is necessary to recognize the specific restrictions imposed by helicopter transportation and to make efforts to shorten the time required for key processes to provide faster treatment.

The impact of helicopter emergency medical service on acute ischemic stroke patients: A systematic review

BACKGROUND

Helicopter emergency medical services (HEMS) is commonly elected transport for acute ischemic stroke (AIS) known as a time-critical illness.

AIM

To conduct a systematic review in order to explore the HEMS impact on healthcare status, process and outcome measures for AIS patients.

METHODS

A systematic search was conducted of PubMed, Medline, CINAHL, Cochrane Library and Google Scholar. The gray literature and reference lists of included articles were also searched. Thirty studies met inclusion criteria.

RESULTS

Using Donabedian's framework, two studies focused on the impact on healthcare structure, twenty-three explored the impact on process measures, and five focused on clinical outcomes. HEMS structure implications could not be assessed due to insufficient studies. HEMS showed no significant outcome benefit compared to ground emergency medical services (EMS) and the impact on process measures was ambiguous.

CONCLUSIONS

HEMS necessity varied considerably between studies. More robust studies are needed for detection of the most suitable use of HEMS in AIS.

Efficacy of the Drip and Ship Method in 24-h Helicopter Transportation and Teleradiology for Isolated Islands

Our hospital, located on the mainland, serves as a hub center for nine hospitals on the remote islands of Nagasaki Prefecture, Japan. There are no stroke specialists on these islands. We can transfer emergency patients from these islands to our hospital at any time, using a teleradiology system and three types of helicopter transport. We examined the efficacy of the drip and ship (DS) method for treating patients with acute ischemic stroke (AIS) on these islands, in comparison with patients on the mainland. From 2010 to 2017, we reviewed 98 consecutive patients with AIS who received intravenous recombinant tissue plasminogen activator (IV rt-PA) in our hospital or were transported to our hospital after IV rt-PA. Patients were divided into the Islands group (received IV rt-PA on the islands, DS; 31 cases) and the Mainland group (67 cases). The median transport distance from the islands was 112 km. The rate of patients achieving favorable outcomes was 54.8% in the Islands group and 64.2% in the Mainland group, with no significant differences. Multivariate analysis revealed that patients living on isolated islands did not have increased risks of unfavorable outcomes. Endovascular therapy (EVT), as part of the drip, ship, and retrieve method, was performed in 22.6% of patients in the Islands group and EVT in 38.8% of those in the Mainland group. The DS method seems feasible and safe for patients living on isolated islands with the use of 24-h helicopter transportation and teleradiology.

Stroke Patients' Status Post-Acute Phase of Illness. How Is It and How Ought It to Be: Ain Shams University Experience

BACKGROUND

Stroke is a leading cause of disability worldwide with a great impact on quality of life. Ain Shams University Hospital is a tertiary center for neurology and a pioneer in offering comprehensive stroke service in the region.

METHODS

A cross sectional study in which an 8 domains questionnaire was applied to all cerebrovascular stroke patients who were admitted to the stroke unit of the neurology department of Ain Shams University Hospital in the period from January 2016 till May 2017, with the aim to define pitfalls in post discharge.

RESULTS

From our study show that 20% of all patients discharged from acute stroke unit did not have further follow up with any stroke doctor. Moreover, 60% of patients were not seen by a physiotherapist after discharge, including almost half of patients with moderate or severe disability on discharge who are expected to have ongoing care needs. Patients who developed stroke complications were more likely to seek follow up. As expected, continuous follow up was associated with increased adherence to secondary preventive medications.

CONCLUSIONS

Patient needs should be assessed before patient discharge and patient and care givers should have clear written information on required follow up with stroke doctors, and arrangements made for receiving adequate rehabilitation post discharge.