At 88, doctor pursues a long-ignored treatment for strokes, heart attacks
statnews.com
statnews.com
Once a clot has matured they tend to be useless, which is part of why there’s a solid upper cap on time to administration. You cross a line where any clot they’re likely to bust isn’t one you want to bust. So, a window of a couple of hours. Urokinase doesn’t change that, to my knowledge.
Surgical removal of the clot, on the other hand, has recently been shown to offer enormous benefit to at-risk tissue (tissue not yet dead but in the watershed area) 24 hours later, without risk of hitting the wrong clot. It’s no miracle either, but evidence is piling up that it’s got more Pros and fewer Cons.
Thus, no one really following armchair hypotheses (one old non RCT trial not withstanding) about combining two increasingly undesirable drugs.
I respect the guy’s thought and effort, and have to admit he might be right about their combined effectiveness, but this article leaves out a lot of the context as to -why- this isn’t getting attention. Writing a hagiography-by-omission is below what I’ve come to expect from statnews.
Our ambulances are equipped with r-tPA or similar (there is a tendency to avoid streptokinase as rural/indigenous populations have high exposure to streptococcus/hx rheumatic fever and therefore high risk of added complications) and in the event of STEMIs can be administered en route to ED. Similarly many peripheral sites will administer tenecteplase or similar in Emergency Departments as there are almost no sites that are set up to perform out-of-hours angioplasty once you are out of the major cities; even less chance for neuro-radiological intervention, I think there are only 6 or 7 sites in the country and they are all in major cities.
If his research does bear fruit, I could see it immediately becoming the standard of care in Australia outside of major centres
I worked with stroke centers, doctors, etc in building stroke access systems, and that doesn't fly with reality.
Number 1, is that its hard for patients to recognize they are having a stroke. so "If called promptly" is a bit of unrealistic idealism.
Although they say 4 hours, tPA administered after 1 hour has lost most of its benefit, and places that can do thrombectomy 24/7 (in US dedicated stroke centers) is not numerous. You are losing a lot of that hour just for time for the helicopter to warm up, find a spot, and land + your ambulance time getting to /stabilizing the patient.
I'm sure the patients on your beat had suitable access, but that's a bit of selectivity bias no? In the US, although the majority of the population is within the golden hour, there are still a ton of population that does not have access to a stroke center. I find it extremely hard to believe that this is not the case in Australia - where I have heard stories of people getting a finger cut off and having to drive 3 hours to the nearest hospital.
Unfortunately I don't quite know what to make of the recurring phrase "mismatch between clinical deficit and infarct". Could anyone enlighten me, please?
When you look at the area of brain that should be downstream of a clot and therefore nonfunctional, that’s the “infarct volume”. It’s the volume of brain that we believe is infarcted.
The “mismatch” is when we do a CT, find that, say, the chunk of your brain that moves your right hand is downstream from the infarct, but your right hand is still working. This suggests that that part of your brain has enough blood coming to it from other, less salient, arteries that it’s dying slowly instead of fast.
That “mismatch” area is the one that, if we can go in and surgically pull out the clot, we can save.
>>> "At 88, doctor pursues clot-busting medication combination to aid in treatment of heart attacks and strokes"
I'm a NIR and most of us are not paid per surgery/intervention. Also these interventions tend to be loss leaders in terms of hospital reimbursements. Funding for stroke centres can be profitable but that's a very long discussion.
In addition, at least 7 randomized clinical trials have shown the benefit of thrombectomy in acute stroke (actually something of a modern medical technological miracle).
Private practice can be another story, and perhaps there your argument would be more compelling. But many physicians, surgeons, specialist go into private practice to get out of bureaucracy, or, increasingly nowadays with providers who do not take insurance, to avoid the endless paperwork and hassling of insurance.
Most people get into medicine for the right reasons; to help other people.
Why do you presume that our intentions are nefarious when you have no idea what you're talking about?
I do know that doctors like to keep it moving. Surgeons like to start early and finish early. Nobody wants to get bogged down in a specific procedure. As far as profitability (or cost recovery, whatever euphemism) is concerned, doing several short procedures beats one longer procedure, even when surgery time is billed by the minute.
You ignore the fact that many doctors leave the strict employ of the hospital for a private practice that still bills through the hospital. While they are still salaried, they also get a profit share, usually divvied out on productivity. There is no one model. But you're right, I have no idea how it's typically done in IR, NIR, IC etc.
It's rarely up to the interventionalist if and when they will treat a stroke. There are clear guidelines on treating these patients (which mostly take place at comprehensive stroke centres), mostly defined by the neurology service, which functions somewhat independently. These guidelines have been expanding as newer evidence has shown a role in wider time windows but this point remains the same. There is very little opportunity for an individual interventionalist to increase his patient volume independently (at least for ischemic stroke).
I agree in principle with most of the points you make, although I think perverse incentives are largely a function of the US healthcare system in general rather than the domain of any particular specialty.
In specific relation to the original article, I'm extremely doubtful that combing two anti-thrombotic agents would be a miraculous therapeutic regime for treating stroke but I'd be happy to be proved wrong by a legitimate trial. However, I'd worry that we'd be sacrificing patients that could otherwise be treated if we assigned them to an arm of a trial that precludes established therapy.
He might be right, but I’d hesitate to lean too hard on the lone genius angle.
A strong sense of purpose seems to be a factor in health and longevity. Is it just good fortune that allows some people to develop that sense of purpose, or can it be consciously and effectively nurtured?
On average a passenger mile on a modern jet uses significantly less fuel than driving that same mile.
747 burns approximately 5 gallons of fuel per mile and holds 568 people. They are over 70% full on average which works out to:
568 x .7+ / 5 ~= 80+ MPG. At the equator the world is 24,901 miles ~= 300 gallons at worst though most most people consider around the world to be US > EU > Asia > US which is shorter than that.
Edit: US average is 75mpg per passenger in 2014 though longer trips are above that. https://en.wikipedia.org/wiki/Fuel_economy_in_aircraft
On the other hand at 3 gallons (which is far from extreme) / day x 48 x 5 = 720 gallons ignoring all other driving.
PS: On top of that for longer trips aircraft tend to take more direct routes. You can't just drive from NY to LA on a strait line which significantly reduces cars effective MPG.
[0] http://spreadsheets.google.com/ccc?key=0Agol553XfuDZdHlWSmRR...
Average fuel consumption in 2014 was 75 mpg‑US per passenger https://en.wikipedia.org/wiki/Fuel_economy_in_aircraft
I hope he saves more people and lives to 120, but yeah, summary... or at least slightly better writing.
No comment on the underlying science, but I will express my continued frustration with popsci writers and their counterproductive analogies. It's especially unhelpful when it's wrong on the dumbed-down end. A starter motor does not run on gasoline. It's an electric motor that runs off the battery.
> When a clot forms, tPA in the bloodstream is quickly recruited to the site to begin dissolving it. But too much of a clot-buster could lead to bleeds, so once the process is sparked, the body rapidly clears out tPA. Urokinase comes along, carried on the surface of platelets and certain white blood cells, to finish the job.
tPA kicks off the process, and once it's started, urokinase does the rest. I don't know the biochemistry in enough detail to say whether this is a really good metaphor (can urokinase only be activated if tPA has acted? is urokinase consumed by this process?), but the author is not suggesting that a starter motor runs off gasoline.