Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis.

BACKGROUND: Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use. METHODS AND RESULTS: A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration. CONCLUSIONS: Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.

Hyperimmunoglobulin therapy for the prevention and treatment of congenital cytomegalovirus: a systematic review and meta-analysis.

Objective: To examine the safety and efficacy of hyeprimmunoglobulin therapy on vertical transmission of congenital cytomegalovirus (CCMV).Method: We searched nine databases for studies investigating the effect of Hyperimmunoglobulin among pregnant women with CMV.Results: Of total eight studies, the pooled prevalence of CCMV was 36.5% (95% confidence intervals (CI): 26-49%). There was no evidence that hyperimmunoglobulin is effective against CCMV [odds ratio (OR) (95% (CI)) = 0.53 (0.20-1.42)]. However, analyzing only studies of pregnant women with confirmed primary infection, a significant reduction in the congenital CCMV rates was observed [OR (95% CI) = 0.33 (0.18-0.59)]. Based on the purpose, CCMV prevention was successful with a reduction of the CCMV rates [OR (95% CI) = 0.33 (0.16-0.68)[, while treatment was not]OR (95% CI) = 0.80 (0.04-15.01)]. The most common adverse pregnancy outcome was prematurity, followed by intrauterine growth retardation (IUGR) and termination of pregnancy (TOP), with no significant impact of antenatal hyperimmunoglobulin usage.Conclusion: Our results showed a promising efficacy of hyperimmunoglobulin therapy among pregnant women with confirmed primary infection, which fades away on including secondary infection. This effectiveness was limited to the prevention, not the treatment, of CCMV. More randomized controlled trials are needed to provide concrete evidence.

Efficacy and safety of lopinavir/ritonavir in the treatment of COVID-19: A systematic review.

Objectives: To systematically review the clinical literature reporting the use of Lopinavir/ritonavir (LPV/r) for the treatment of patients with Cornonavirus disease 19 (COVID-19) to assess the efficacy of LPV/r for the treatment of COVID-19.Methods: The authors systematically searched PubMed and MedRxiv databases for studies describing treatment of COVID-19 patients using LPV/r compared to other therapies. Articles were excluded if they were case reports, opinion editorials, preclinical studies, single-armed studies, not written in English, not relevant to the topic, or published before May 2020. The included outcomes were viral clearance as measured by reverse-transcription polymerase chain reaction (RT-PCR) negativity and/or improvement on chest computed tomography (CT), mortality, and adverse events.Results: Among 858 total studies, 16 studies met the inclusion criteria and were included in the qualitative review. These studies consisted of 3 randomized control trials, 3 open-label trials, and 10 observational studies. Most of these studies did not report positive clinical outcomes with LPV/r treatment.Conclusion: The systematic review revealed insufficient evidence of effectiveness and clinical benefit of LPV/r in the treatment of COVID-19 patients. Specifically, LPV/r does not appear to improve clinical outcome, mortality, time to RT-PCR negativity, or chest CT clearance in patients with COVID-19.

Impact of aneurysm location and endovascular treatment modality on the improvement of headache in patients with unruptured intracranial aneurysms.

INTRODUCTION: The use of endovascular therapy (EVT) in patients with unruptured intracranial aneurysms (UIA) is associated with a significant reduction of headache severity. It is still unclear how the treatment modality and the aneurysm location affect headache in these patients. This systematic review and meta-analysis aimed to compare the improvement of headache rates based on the endovascular treatment modality and aneurysm location. EVIDENCE ACQUISITION: We conducted a complete search through four databases. Original studies that reported the improvement in headache rates in patients that had undergone EVT for UIA based on the treatment modality and location were included in the analysis. Fixed effect meta-analysis was performed to compare them using the odds ratio (OR). EVIDENCE SYNTHESIS: A total of 180 reports were screened for title and abstract, of which six reports were included in this study. There were 199 patients that underwent stent-assisted coiling and 184 patients who had coiling alone. A total of 75 patients with posterior aneurysms were included as compared to 347 with anterior aneurysms. There was no significant difference between the two treatment modalities regarding the improvement in headache rates (OR=0.591, 95% CI: 0.349-1.003, P=0.051). Additionally, no difference was found in headache improvement rates between posterior and anterior UIA (OR=0.738, 95% CI: 0.434-1.254, P=0.262). CONCLUSIONS: There was no clear statistical difference between stent-assisted coiling and coiling alone for the improvement of headache in patients with UIA, as well as between posterior and anterior UIA. Future well-conducted large trials that use headache severity scores are warranted to investigate that further.