Just want to give a big thank you to NEJM and Dr G for this whole project. It makes up to date research more accessible and increases awareness of interesting studies. As a layperson, I feel more in touch with medical research, so I can only imagine the clinical benefits this series must be providing for those who will benefit from the awareness
Just an FYI: as a PCP I use a site called UP TO DATE literally every day. It’s the only way to get up to date guidelines on everything from toe fungus to incredibly rare things like alcoholic retinopathy secondary to acute pancreatitis. And yes, knowing this stuff means that rural medicine has more in their arsenal to treat strokes.
Texaco Mike could probably turn his hand to thrombectomy. Hard part is getting the locals to present within a week. You can still drive a tractor with one arm and leg.
@@davidcottee2808 Texaco Mike already on next level "good stuff" - Texplase...it's $15,- a gallon - and will dissolve even the most stubborn clot up to a week after forming. It's cheap because its main ingredients is wiper fluid, and WD40.
My mom was within the 4.5 hour window and got it. Every doctor I spoke with was shocked, since it’s given so infrequently. Her doctor said she probably wouldn’t have survived without it. She still has hemiplegia, but is getting stronger. And she’s here! I can talk with her, and take the grandchildren to visit her (she lives on the other side of the country). Hopefully now that it’s shown to be beneficial more people can access this lifesaving and disability sparing treatment.
I’m so happy to hear she’s doing well! As a prehospital provider, we break our backs (and the ambulance’s transmission) to get patients to therapy on time and red tape has robbed length and quality of life from so many. Two in particular haunt me. A young lady who began to have slurred speech while talking on the phone with her son an hour before arrival, but was refused tenecteplase because she hadn’t been seen in person since the morning before. The second was an older gal with a similar timeframe, but her neurologist at an academic center demanded she be transported 45 minutes to his facility for thrombectomy. She was talking and in good spirits when we left, but by the time we got to the hospital she could only look at me in terror because she could no longer form speech. We were supposed to take her straight to the OR, but there was another thirty minute delay for registration before the neurologist would touch her. All this to say that hopefully we can be a little less uptight about thrombolytics. I would personally choose life threatening bleeding over ischemic stroke any day of the week, and twice on Sundays.
@@ebubechiibegbula5968This got me thinking, is Tenecteplase too dangerous to use in place of Aspirin for a layman suspecting a stroke? How about EMT? Is confirmation that the stroke is caused by large vessel blockage more safe than confirming later?
@@AkaiAzul If it's a hemorragic stroke and you give tenecteplase its the same as shooting the person in the head, and even doctors can't safely diferentiate isquemic from hemorragic stroke without a CT scan. So yeah, extremely dangerous.
@@MalachiGuarnieri "when was your mom's last known well?" me: "20 seconds before I called 911" Also me in case of possible stroke: "give me the TNK!" I'd rather hemorrhage than live as a cripple. - AHA Acute Stroke Life Support certified RN.
In fairness to neurology, they saw the journal article's name had the word "medicine" in it and assumed it would be a 5 hr discussion of hyponatremia during rounds.
Loving the new initiative to use skits to cover recent major trial findings to prompt further review, and in turn promote ongoing evidence based clinical practice so as to optimise patient care outcomes.
Very interesting. Going to have a look at the paper. The 4.5 hour window is often very tight and this is potentially game changing. At my hospital though the stroke calls come direct to the stroke team bypassing the cycle helmets!
One of my favorite things to do so far in pharmacy residency has been mixing and giving teneteplase. When the neurologist gives you the go ahead and you go flush, tnk, flush. It’s just empowering.
My facility recently changed from alteplase to tenectaplase for AIS and from a work flow standpoint we saw massive reductions in door-to-needle time as we can store the tenectaplase in the ED. We did not have mechanical thrombectamy capability there.
Thank you for communicating important new NEJM information through your highly effective method. It would be appreciated if you made more of this same type of content. The Lancet, too?
Though a bit over 1% did get a symptomatic intracranial hemorrhage, with 9% of patients having better outcomes. Seems like a net positive, but it should probably only be used that late in strokes with severe symptoms
As a previous stroke medical registrar, having an increased percentage of better outcome does not mean that the risk of a catastrophic complication from Thrombolysis is lower. The 4.5 hour threshold is an expert opinion of a balanced risk to benefit. Thrombolysis treatment has small benefits after 4.5 hours but the risk of bleed goes way up. The devil is in the details of percentages of risk. Look up stroke visual decision aids.
it looks like the rate of hemorrhage was only 3% vs. 0.8%, with such a low rate, I don't know if I would consider that clinically significant, but I guess that would be a judgement call
You would expect the complications to show up in the functional outcome. If thrombolysis causes a brain bleed, but that doesn't result in more disability or mortality, the brain bleed isn't really a complication, just a cosmetic issue.
Isn't there a scale or sorta guideline for neurologists to decide which patient is more likely to bleed & thus would be preferable for Endovascular thrombectomy & which cases would be unlikely to bleed or be safer to thrombolyse? Pretty sure there has to be something from all the cases we've treated so far..
@@jonnyblaze8871 yes there is already a comprehensive list of relative and absolute contraindications to thrombolytics that is listed in every thrombolytic protocol
Do one where the neurologist reads the study and points out it's open label and the modified rankin scale, the 1' endpoint, has an element of subjectivity
Savagely brilliant, loving this series! 😆 Just got to remember to request tenecteplase if I have a stroke in the boonies now... 🤔 Or "Brain anti-clot juice, bro" as Ortho would say!
As an aspiring academic, I wish this level of coverage was standard practice. (Un)fortunately, medicine isn't my field, so I forsee no means to wver have a paper to submit for Dr. G to use for script inspiration.
Tenectaplase is TPA. TPA has become an unfortunate shorthand for the medication Alteplase. TPA stands for Tissue Plasminogen Activator. Both Tenectaplase and Alteplase are Tissue Plasminogen Acttivators. The only real difference is that Tenectaplase doesn’t have a label indication for ischemic stroke, and is is a weight based IV push vs. the calculation for push and drip needed for Alteplase.
I'm curious to know how ER neurology dresses. Is it bike outfit with a tie or maybe the normal outfit with a bike helmet, a bike outfit that's printed like his normal outfit.
Please also note there where higher incidence of symptomatic ICH and adverse events in the tNK group. Nuance is important. Please consult with a vascular neurologist before pushing!
I once took care of an inbound life flight from a very rural location who’d been given alteplase for an MI with a trop in the 70s. At that time, I was just 😮😵💫😱 But, in rural medicine, 🤷🏽♀️ The rural docs knew they could not get the patient to a cardiac cath and it was likely to be more than 24 hours, from onset to cath lab so they did whatever they could to save the patient’s life. The patient lived. And while they were mine, strict neuros Q2H, ICU admit, and VERY CLOSE observation. I don’t have an opinion about whether what they did was the right call or not-primarily because I don’t know what it looked like from their end. I agree, we must be cautious. But to give rural medicine another option to save lives, and function, well, that’s darn profound.
At 0:54, Emergency medicine having some fun with the neurologist where the neurologist has "A synapse that ran out of neuro transmitters" or "a congenital absence of long term memory".😀
The Japanese use acupuncture with extremely high effectiveness for certain strokes, if within a certain time frame. They are able to stop the swelling with it. American allopathic medicine should investigate this, and adopt it. Less meds, less cost, and more effective in the long run for some strokes.
Grandpa passed from a stroke around this time last year. He did get the medicine in time and they airlifted him to another hospital for surgery. The scans the next morning showed too much damage. He was 91 and was ready to go home to Jesus. He made his wishes known, so we knew the right thing was to let him go.
Dr Glaukenflacken. Not to be that guy but you don’t mention how that outside window tenecteplase also increases the intracranial bleeding risk significantly which is also mentioned for the paper. Kind of an important detail cuz everyone is going to get the false impression they should be giving TNK at all rural hospitals now
Conversion from an ischemic stroke that you will probably survive with possible deficits, to a hemorrhagic stroke that will probably kill you. That’s the concern.
![Blox Fruits Dragon Rework Update [Full Stream]](http://i.ytimg.com/vi/EqDAp8udhm0/mqdefault.jpg)
Just want to give a big thank you to NEJM and Dr G for this whole project. It makes up to date research more accessible and increases awareness of interesting studies. As a layperson, I feel more in touch with medical research, so I can only imagine the clinical benefits this series must be providing for those who will benefit from the awareness
Just an FYI: as a PCP I use a site called UP TO DATE literally every day. It’s the only way to get up to date guidelines on everything from toe fungus to incredibly rare things like alcoholic retinopathy secondary to acute pancreatitis. And yes, knowing this stuff means that rural medicine has more in their arsenal to treat strokes.
The sheer surprise of "I didn't know you could read". Savage.
This sounds like a game changer for rural medicine
Texaco Mike whips up the best Tenecteplase.
@@lindiatle- as long as you don't mind the smell! 😆
@lindiatle- Do you think he makes it in his instapot or does he use his green egg smoker?
Texaco Mike could probably turn his hand to thrombectomy. Hard part is getting the locals to present within a week. You can still drive a tractor with one arm and leg.
@@davidcottee2808 Texaco Mike already on next level "good stuff" - Texplase...it's $15,- a gallon - and will dissolve even the most stubborn clot up to a week after forming. It's cheap because its main ingredients is wiper fluid, and WD40.
You should win an award for costume design. Nobody would confuse the different bros.
Ortho, I know that’s you using an alt account.
Not just the costume, but the hair, the expression, it's impressive!
I'm an emergency doc. My brothers are a neurologist and a neurosurgeon. This skit speaks to me.
I can only imagine the conversations during christmas dinner.
Can this be how I receive all my journal updates. Pleeeeaaaasssse
My mom was within the 4.5 hour window and got it. Every doctor I spoke with was shocked, since it’s given so infrequently.
Her doctor said she probably wouldn’t have survived without it. She still has hemiplegia, but is getting stronger. And she’s here! I can talk with her, and take the grandchildren to visit her (she lives on the other side of the country).
Hopefully now that it’s shown to be beneficial more people can access this lifesaving and disability sparing treatment.
In summary Tenecteplase better than Aspirin.... Got it.....
I’m so happy to hear she’s doing well! As a prehospital provider, we break our backs (and the ambulance’s transmission) to get patients to therapy on time and red tape has robbed length and quality of life from so many.
Two in particular haunt me. A young lady who began to have slurred speech while talking on the phone with her son an hour before arrival, but was refused tenecteplase because she hadn’t been seen in person since the morning before. The second was an older gal with a similar timeframe, but her neurologist at an academic center demanded she be transported 45 minutes to his facility for thrombectomy. She was talking and in good spirits when we left, but by the time we got to the hospital she could only look at me in terror because she could no longer form speech. We were supposed to take her straight to the OR, but there was another thirty minute delay for registration before the neurologist would touch her.
All this to say that hopefully we can be a little less uptight about thrombolytics. I would personally choose life threatening bleeding over ischemic stroke any day of the week, and twice on Sundays.
@@ebubechiibegbula5968This got me thinking, is Tenecteplase too dangerous to use in place of Aspirin for a layman suspecting a stroke? How about EMT? Is confirmation that the stroke is caused by large vessel blockage more safe than confirming later?
@@AkaiAzul If it's a hemorragic stroke and you give tenecteplase its the same as shooting the person in the head, and even doctors can't safely diferentiate isquemic from hemorragic stroke without a CT scan. So yeah, extremely dangerous.
@@MalachiGuarnieri "when was your mom's last known well?" me: "20 seconds before I called 911" Also me in case of possible stroke: "give me the TNK!" I'd rather hemorrhage than live as a cripple. - AHA Acute Stroke Life Support certified RN.
In fairness to neurology, they saw the journal article's name had the word "medicine" in it and assumed it would be a 5 hr discussion of hyponatremia during rounds.
Loving the new initiative to use skits to cover recent major trial findings to prompt further review, and in turn promote ongoing evidence based clinical practice so as to optimise patient care outcomes.
This might be a practice changing article, thanks Dr. G, I'll look it up
The Emergency Physician needs to be admitted to the burn unit
🤣🤣
I was just thinking the same thing.
Surely it's neurology getting admitted to the burns unit?
This is the template from which all medical research should be shared.
If I had one CME for each time I've watched ER having this moment, I would have completed this year's requirement.
Best journal club ever.
Very interesting. Going to have a look at the paper. The 4.5 hour window is often very tight and this is potentially game changing. At my hospital though the stroke calls come direct to the stroke team bypassing the cycle helmets!
I’m loving this collaboration with Dr G! 😂
NEJM, now only this mode of teaching could be widening, I would to be more attentive 😂.👍🏼
Neurology actually being Nice when he can share knowledge is kinda nice
As someone who had a stroke last summer 2023 I LOVE this video. I'm also a nurse so this is right up my alley! 😂❤😮😊❤🎉
Not a Dr. and I thoroughly enjoy this content. Makes me smarter and more aware of new treatment.
NEJM is so crazily accessible nowadays 😂❤
One of my favorite things to do so far in pharmacy residency has been mixing and giving teneteplase. When the neurologist gives you the go ahead and you go flush, tnk, flush. It’s just empowering.
It’s awesome that you have been collaborating with NEJM for these videos. 😊
Loving these collabs! Plz do more of these for those of us who never bother to read the journals
This was a fantastic collaboration, and I'm really enjoying seeing these pop up on my youtube feed.
These med journal videos are fast becoming my favorite!
"Yeah, go ahead, just watch a RUclips video first"... Hilarious throwaway!
Neurology is still speaking Nobel tongue
My facility recently changed from alteplase to tenectaplase for AIS and from a work flow standpoint we saw massive reductions in door-to-needle time as we can store the tenectaplase in the ED. We did not have mechanical thrombectamy capability there.
OMG NEJM AND DR GLAUCOMFLECKEN!!!!!!😊😊😊
This is a wonderful research with easily-comprehensible delivery thank y'all
this is how i want to get all of my medical studies from now on
um...Neurology reads every article, always.
😂
😅
Yeah that’s the only unbelievable thing about this vid.
Thank you for communicating important new NEJM information through your highly effective method. It would be appreciated if you made more of this same type of content. The Lancet, too?
Another gem! (And I really have to stop drinking coffee while I watch these. I don't think my key board can take much more splatter.)
That final line killed me. I wont spoil it for people, but I am dead from laughing now.
Though a bit over 1% did get a symptomatic intracranial hemorrhage, with 9% of patients having better outcomes. Seems like a net positive, but it should probably only be used that late in strokes with severe symptoms
As a previous stroke medical registrar, having an increased percentage of better outcome does not mean that the risk of a catastrophic complication from Thrombolysis is lower. The 4.5 hour threshold is an expert opinion of a balanced risk to benefit. Thrombolysis treatment has small benefits after 4.5 hours but the risk of bleed goes way up. The devil is in the details of percentages of risk. Look up stroke visual decision aids.
it looks like the rate of hemorrhage was only 3% vs. 0.8%, with such a low rate, I don't know if I would consider that clinically significant, but I guess that would be a judgement call
You would expect the complications to show up in the functional outcome. If thrombolysis causes a brain bleed, but that doesn't result in more disability or mortality, the brain bleed isn't really a complication, just a cosmetic issue.
Isn't there a scale or sorta guideline for neurologists to decide which patient is more likely to bleed & thus would be preferable for Endovascular thrombectomy & which cases would be unlikely to bleed or be safer to thrombolyse?
Pretty sure there has to be something from all the cases we've treated so far..
So not a physician....
@@jonnyblaze8871 yes there is already a comprehensive list of relative and absolute contraindications to thrombolytics that is listed in every thrombolytic protocol
Wowww that really does sound interesting!!! And of course the banter comedic parts are always funny!!!! 😆
Omg this is amazing… please keep doing this…
That is an awesome vid, it's like that in every specialty, not just medicine.
Do one where the neurologist reads the study and points out it's open label and the modified rankin scale, the 1' endpoint, has an element of subjectivity
I literally laughed out loud. Of course your comment also evoked nightmares from my thesis defense… so thanks for that
Love this humour - your characters are spot on. Research over my head but interesting-
This is a more effective way of delivering trial results than skimming abstracts.
I didn’t know you could read 🤣🤣
I have to say neurology makes my day
An important article indeed.
It's constantly amazing how different all the characters are.
Please summarise more landmark papers for us Dr G. They are far more palatable in this format 😂.
That last line was great
Informative AND entertaining!!
Savagely brilliant, loving this series! 😆
Just got to remember to request tenecteplase if I have a stroke in the boonies now... 🤔
Or "Brain anti-clot juice, bro" as Ortho would say!
This NEJM thingy seems to be a serious outfit
i literally NEVER want to read a journal again. Please just make Dr Glauc do skits for them all
This is revolutionary. Now sadly tenecteplase is expensive. We need the price to come down asap.
Wowowowow! Sounds awesome...Tenecteplase
As an aspiring academic, I wish this level of coverage was standard practice. (Un)fortunately, medicine isn't my field, so I forsee no means to wver have a paper to submit for Dr. G to use for script inspiration.
The neurologists resting condescending face (RCF) owns me. 😂😂
I’m stealing that. OMG. You just described my senior. SHHHHH …. I don’t think he knows about Glaucomflecken yet….
I love how neurology knew, but just wanted to see if Emergency could fully recall the article 😂
What about the incidence of intracranial hemorrhage? Was the study powered to demonstrate safety?
What about TIMELESS though???
but what is the NNT?
WOW. Just wow.
What if the Cardiologist and Neurologist had an argument over this too? Or another scenario?
Having "Tenecteplase please" inscribed on my medical bracelet....
I like this idea
or a tattoo on the inside of your elbow. "Insert TNK here"
Can i claim watching this as cme credit ?😅😅😅
It was just pointed out to me that in the Emergency Department's glasses, you can see the reflection of him holding his phone.
What’s the difference between Tenecteplase and TPA?
Tenectaplase is TPA. TPA has become an unfortunate shorthand for the medication Alteplase.
TPA stands for Tissue Plasminogen Activator. Both Tenectaplase and Alteplase are Tissue Plasminogen Acttivators.
The only real difference is that Tenectaplase doesn’t have a label indication for ischemic stroke, and is is a weight based IV push vs. the calculation for push and drip needed for Alteplase.
@@phenethylamines if I’m not mistaken, isn’t alteplase also a bit less stable for storage than tenectaplase?
I'm curious to know how ER neurology dresses. Is it bike outfit with a tie or maybe the normal outfit with a bike helmet, a bike outfit that's printed like his normal outfit.
Well that was interesting.
soooo I can TPA post 6 hours is what you're saying?
Please also note there where higher incidence of symptomatic ICH and adverse events in the tNK group. Nuance is important. Please consult with a vascular neurologist before pushing!
I once took care of an inbound life flight from a very rural location who’d been given alteplase for an MI with a trop in the 70s. At that time, I was just 😮😵💫😱 But, in rural medicine, 🤷🏽♀️ The rural docs knew they could not get the patient to a cardiac cath and it was likely to be more than 24 hours, from onset to cath lab so they did whatever they could to save the patient’s life. The patient lived. And while they were mine, strict neuros Q2H, ICU admit, and VERY CLOSE observation. I don’t have an opinion about whether what they did was the right call or not-primarily because I don’t know what it looked like from their end. I agree, we must be cautious. But to give rural medicine another option to save lives, and function, well, that’s darn profound.
At 0:54, Emergency medicine having some fun with the neurologist where the neurologist has "A synapse that ran out of neuro transmitters" or "a congenital absence of long term memory".😀
"I didn't know you could read" - I'm dying of laughter here, you broke your hippocratic oath for a joke! (you hilarious monster!)
Well this is one way to advertise a journal drop
The Japanese use acupuncture with extremely high effectiveness for certain strokes, if within a certain time frame. They are able to stop the swelling with it. American allopathic medicine should investigate this, and adopt it. Less meds, less cost, and more effective in the long run for some strokes.
I wonder if that could have saved my grandfather from hemiplegia.
Brutal.
Damn! That was quite the burn from Neuro to ER!! 🤣😂🤣😂🤣😂
Tenecteplase is the new t-PA with less risk and cost!
I didn't understand any of that. Great video as always! I feel like an idiot.
Amazing
I gained knowledge and I have a smile on my face.
Thank you!
that last exchange!!!!! LMFAOOOOOOOOOO. but also great news for stroke patients.
Oh how snarky Neurology is towards the ED doc 😂sooo good !!!
A sign of a lost argument is when one side resorts to ad hominems. Good job EM!
While this does sound incredible, it also feels somewhat like an advertisement rather then purely educational
Still can't tell if this is a "turbo encabulator" type of vid
Grandpa passed from a stroke around this time last year. He did get the medicine in time and they airlifted him to another hospital for surgery. The scans the next morning showed too much damage. He was 91 and was ready to go home to Jesus. He made his wishes known, so we knew the right thing was to let him go.
Love the Phi Beta Kappa tie
Saw the recording reflection in your goggles
Dr Glaukenflacken. Not to be that guy but you don’t mention how that outside window tenecteplase also increases the intracranial bleeding risk significantly which is also mentioned for the paper. Kind of an important detail cuz everyone is going to get the false impression they should be giving TNK at all rural hospitals now
Also most of our rural hospitals here don’t have access to an on site CT to rule out hemmoragic stroke so it doesn’t change much for them regardless
1st Lol
2nd will be considered
"I didn't know you could read!" 💀
This is how Gen z going to keep up with latest research
I subscribe to his channel. He's hilarious. It's doctorglacomaflecken or something like that.
The Phi Beta Kappa tie!
it’s also over $10k a dose
Funny, thanks.
I'm just going to sit here and pretend to be a doctor for a minute.
I don't understand the tendency toward such conservative treatment when the known consequences are so catastrophic.
Conversion from an ischemic stroke that you will probably survive with possible deficits, to a hemorrhagic stroke that will probably kill you.
That’s the concern.