Background Cytokine release syndrome (CRS) plays a pivotal role in the pathophysiology and progression of Coronavirus disease-2019 (COVID-19). Therapeutic plasma exchange (TPE) by removing the pathogenic cytokines is hypothesized to dampen CRS. Objective To evaluate the outcomes of the patients with COVID-19 having CRS being treated with TPE compared to controls on the standard of care. Methodology Retrospective propensity score-matched analysis in a single centre from 1st April to 31st July 2020. We retrospectively analyzed data of 280 hospitalized patients developing CRS initially. PSM was used to minimize bias from non-randomized treatment assignment. Using PSM 1:1, 90 patients were selected and assigned to 2 equal groups. Forced matching was done for disease severity, routine standard care and advanced supportive care. Many other Co-variates were matched. Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of viral clearance on Polymerase chain reaction testing. Results After PS-matching, the selected cohort had a median age of 60 years (range 32–73 in TPE, 37–75 in controls), p = 0.325 and all were males. Median symptoms duration was 7 days (range 3–22 days’ TPE and 3–20 days controls), p = 0.266. Disease severity in both groups was 6 (6.6%) moderate, 40 (44.4%) severe and 44 (49%) critical. Overall, 28-day survival was significantly superior in the TPE group (91.1%), 95% CI 78.33–97.76; as compared to PS-matched controls (61.5%), 95% CI 51.29–78.76 (log rank 0.002), p<0.001. Median duration of hospitalization was significantly reduced in the TPE treated group (10 days vs 15 days) (p< 0.01). CRS resolution time was also significantly reduced in the TPE group (6 days vs. 12 days) (p< 0.001). In 71 patients who underwent TPE, the mortality was 0 (n = 43) if TPE was done within the first 12 days of illness while it was 17.9% (deaths 5, n = 28 who received it after 12th day (p = 0.0045). Conclusion An earlier use of TPE was associated with improved overall survival, early CRS resolution and time to discharge compared to SOC for COVID-19 triggered CRS in this selected cohort of PS-matched male patients from one major hospital in Pakistan.
Objective: To present guidance for clinicians caring for adult patients with acuteischemic stroke with confirmed or suspected COVID-19 infection. Methods: The summary was prepared after review of systematic literature reviews,reference to previously published stroke guidelines, personal files, and expert opinionby members from 18 countries. Results: The document includes practice implications for evaluation of stroke patientswith caution for stroke team members to avoid COVID-19 exposure, during clinicalevaluation and conduction of imaging and laboratory procedures with specialconsiderations of intravenous thrombolysis and mechanical thrombectomy in strokepatients with suspected or confirmed COVID-19 infection. Results: Conclusions-The summary is expected to guide clinicians caring for adult patientswith acute ischemic stroke who are suspected of, or confirmed, with
BACKGROUND A better understanding of differences in outcomes of mechanical thrombectomy performed within and outside clinical trials will assist in optimal implementation of the procedure for acute ischemic stroke patients in general practice. OBJECTIVE To identify differences in demographic and clinical characteristics and outcomes related to mechanical thrombectomy in patients treated within clinical trials and those treated outside clinical trials in a large national cohort. METHODS We compared the patient characteristics and associated in-hospital outcomes of mechanical thrombectomy in acute ischemic stroke patients performed within and outside clinical trials using the Nationwide Inpatient Sample from 2013 to 2015. We analyzed in-hospital mortality (primary outcome) and moderate to severe disability (secondary outcome) based on discharge disposition after adjusting for potential confounders. RESULTS Of 23 375 patients who underwent mechanical thrombectomy, 430 (1.8%) underwent the procedure as part of a clinical trial. After adjusting for age, gender, and the teaching status of the hospital, patients treated within a clinical trial had lower rates of in-hospital mortality (odds ratio [OR] 0.14; 95% CI .03 to .71; P < .001). Among patients discharged alive, the rate of moderate to severe disability (OR .43; 95% CI .26 to .71; P < .001) was lower among those patients treated within a clinical trial. There was no difference in odds of post-thrombectomy intracerebral or subarachnoid hemorrhage between the two groups. CONCLUSION Mechanical thrombectomy performed as part of clinical trials was associated with lower rates of in-hospital mortality and lower rates of moderate to severe disability compared with those performed outside clinical trials.
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