ABSTRACT
Background: Convalescent plasma therapy (CPT) has been issued emergency use authorization for the treatment of SARS-CoV-2 (COVID-19) by the United States Food and Drug Administration. The presence of coagulation factors in CPT in combination with the pro-thrombotic state COVID-19 patients are in may potentiate their risk of thrombotic events. Aim(s): To assess the risk of venous thromboembolisms (VTE) and arterial thromboembolisms (ATE) in COVID-19 patients undergoing CPT. Method(s): MEDLINE, Embase, and Cochrane CENTRAL were searched for randomized controlled trials that investigated the safety and efficacy of CPT and standard of care (SOC) against placebo or SOC alone in adult COVID-19 patients. Study selection and data extraction were done in duplicate. The primary outcome was the development of VTE and ATE. The secondary outcomes were 30-day mortality, clinical improvement, length of hospitalization (LOH), sepsis/fever, and major adverse cardiovascular events (MACE). Meta-analysis was conducted using the Mantel-Haenszel random effects model. Binary endpoints and continuous endpoints were synthesized using odd ratios (OR) and mean differences respectively with 95% confidence intervals (CI). Result(s): 17 randomized controlled trials including 18566 patients were included (Table 1). The risk of VTE and ATE did not differ between the CPT and the control group. There were also no significant differences in 30-day mortality, clinical improvement, LOH, risk of sepsis/fever, and MACE. A summary of outcomes is illustrated in Table 2. Conclusion(s): Treatment of COVID-19 with CPT does not appear to be associated with an increased risk of VTE, ATE, or adverse events but also does not appear to provide mortality or clinical benefit.
ABSTRACT
INTRODUCTION Convalescent plasma therapy (CPT) has been proposed as a mechanism of passive immunization against COVID-19. Current guidelines on the efficacy of its use is not well delineated with limited studies analyzing the risk of thromboembolic events during treatment. The goal of this systematic review and meta-analysis was to assess the risk of arterial and venous thromboembolisms from CPT in patients with COVID-19. METHODS We conducted a comprehensive literature review of Ovid MEDLINE, Cochrane Central Registry of Controlled Trials (CENTRAL), and EMBASE from inception to June 2021. Title and screening and full-text screening was done in duplicate by two independent reviewers. All randomized controlled trials and cohort studies that analyzed adult COVID-19 patients undergoing CPT were included for analysis. Editorials, conference s, narrative reviews, case series, containing less than 100 patients were excluded. The primary outcome analyzed was the risk of thrombotic events in CPT + standard therapy vs standard therapy alone. Meta-analysis was done using a random-effects model using the Revman 5 software. RESULTS Of 1774 studies identified from our search, three randomized (n= 660 patients), and one non-randomized matched cohort study) (n = 96 patients) were included for analysis. The risk ratio for thrombotic events was 2.33, favoring the CPT group (95% CI, [0.70, 7.72], P = 0.17, I2 = 29%). Subgroup analyses showed that CPT + standard therapy was associated with a decreased risk of in-hospital mortality (RR = 0.70 [0.49, 0.98], P = 0.04, I2 = 0%). No significant difference in cardiovascular events (RR = 0.90 [0.67, 1.20], P = 0.48, I2 = 0%), hypertension (RR = 1.67 [0.56, 4.98], P = 0.35, I2 = 0%), and septic shock (RR = 0.97 [0.40, 2.35], P = 0.94, I2 = 41%) was found between CPT + standard therapy and standard therapy alone. CONCLUSION We found treatment of COVID-19 with standard therapy + CPT was not associated with an increase in the risk of thromboembolic events. CPT was associated with a decreased risk of in-hospital mortality but not of MACE, hypertension, or septic shock. Disclosures: Crowther: Hemostasis reference laboratories: Honoraria;Bayer: Speakers Bureau;CSL Behring: Speakers Bureau;Precision Biologicals: Honoraria;Pfizer: Speakers Bureau;Syneos Health: Honoraria.
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Background: BESS/BOA Patient Care Pathways provide national guidelines for acute management of traumatic anterior shoulder dislocations with respect to emergency reduction and clinic follow-up. COVID-19 posed challenges in terms of analgesia choice for reductions and altered follow-up arrangements. This study aimed to assess variance from the care pathway. Methodology: We performed a retrospective case note analysis of all emergency presentations with acute traumatic anterior shoulder dislocations at the MTC in Bristol. We compared 01 Apr to 31 May in 2019 to the same period in 2020 to analyse the effects of the COVID-19 pandemic on the management of these injuries. Data parameters collated included examinations and imaging pre-and post-reduction, choice of analgesia, follow-up rates, referral to physiotherapy, and further imaging requested. Results: We identified 32 patients in 2019, and 24 in 2020. Use of Entonox fell during the pandemic in favour of Penthrox. Use of conscious sedation (requiring full PPE) remained around 20%. Pre-and post-reduction orthogonal radiographs was near 100% in both cohorts. Referral to follow-up was 88% in 2019 but fell to 38% in 2020. Of those assessed in clinic during COVID-19, fewer were mobilised early or referred to outpatient physiotherapy compared to the previous year. Conclusions: The acute management of anterior shoulder dislocations during the early COVID-19 pandemic faced two main challenges: choice of suitable analgesia whilst minimising AGPs;and limiting access to 'face-to-face' follow-up to minimise hospital attendances. A key concern was a significant decrease in patient follow-up, thus limiting the access to optimal aftercare such as physiotherapy and further imaging.
ABSTRACT
Background: BESS/BOA Patient Care Pathways provide national guidelines for the acute management of traumatic anterior shoulder dislocations with respect to emergency reduction and follow-up assessment. COVID-19 posed increased challenges in terms of analgesia choice and altered follow-up arrangements. This study aimed to assess adherence to the care pathway and improve patient care. Methodology: We retrospectively analysed all acute traumatic anterior shoulder dislocations at the MTC in Bristol. We collected data during 01/04/2019-31/05/2019 and 01/04/2020-31/05/2020 to analyse the quality of their management. Data parameters collated included examinations and imaging performance, choice of analgesia, follow-up rates, and physiotherapy referrals. Results: We identified 32 patients in 2019, and 24 in 2020. Full neurovascular examinations pre-and post-reduction were poorly documented. Peri-reduction imaging utilization was near 100%. Referral to follow-up was 88% in 2019 but 38% in 2020. Of those assessed in clinic during COVID-19, fewer were mobilised early or referred to outpatient physiotherapy. Conclusions: We have created a proforma/prompt to improve the quality of the management of these injuries, and successfully liaised with the Emergency Department for this to be included in their documentation. This proforma improves documentation quality, access to follow up and physiotherapy. During a 'second wave' we encourage patient access to BESS online resources.
ABSTRACT
Since the initial description of the SARS-CoV-2 outbreak and its declaration as a worldwide pandemic, the number of publications on the novel virus has increased rapidly. We studied the trends and quality of evidence in early SARS-CoV-2 publications. A comprehensive search of MEDLINE and EMBASE was performed for papers published between 1 January 2020 and 21 April 2020. Two reviewers independently screened titles and abstracts and subsequently full texts for eligibility in this systematic review. The search yielded 2504 citations published between January and February 2020 or an unspecified date, 109 of which remained for extraction after screening. Data extracted included study design, year of publication, country of basis, journal of publication, impact factor of publishing journal, study sample size, number of citations and topic of investigation. Study design-specific critical appraisal tools were used to evaluate the scientific rigour of all included papers: the Joanna Briggs Institute checklist was used for case series, Scale for the Assessment of Narrative Review Articles scale for narrative reviews, Newcastle-Ottawa scale for cohort studies and AMSTAR 2 for systematic reviews. The overall quality of the literature was low-moderate. Of 541 papers that reported clinical characteristics, 295 were commentaries/expert opinions and 36 were case reports. There were no randomised clinical trials, 45 case series studies, 58 narrative reviews, 1 cohort study and 5 systematic reviews. We encourage clinicians to be attentive to these findings when utilising early SARS-CoV-2 evidence in their practices.