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Toh KZX, Koh MY, Loh EDW, Kwok GYR, Teo YH, Teo YN, Goh CXY, Syn NLX, Ho AFW, Sia CH, Brouwer PA, Andersson T, Meyer L, Fiehler J, Bhogal P, Sharma VK, Tan BYQ, Yeo LLL. Distal medium vessel occlusions in acute ischaemic stroke - Stent retriever versus direct aspiration: A systematic review and meta-analysis. Eur Stroke J 2023; 8:434-447. [PMID: 37231692 PMCID: PMC10334182 DOI: 10.1177/23969873231151262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/28/2022] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Acute ischaemic stroke due to distal medium vessel occlusion (AIS-DMVO) causes significant morbidity. Endovascular thrombectomy advancement has made treating AIS-DMVO with stent retrievers (SR) and aspiration catheters (AC) possible, however the optimal technique remains unknown. We performed a systematic review and meta-analysis to investigate the efficacy and safety of SR use compared to purely AC use in patients with AIS-DMVO. METHODS We systematically searched PubMed, Cochrane Library and EMBASE, from inception to 2nd September 2022, for studies comparing SR or primary combined (SR/PC) against AC in AIS-DMVO. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (modified Rankin Scale (mRS) 0-2 at 90 days), first pass effect (modified Thrombolysis in Cerebral Infarction scale (mTICI) 2c-3 or expanded Thrombolysis in Cerebral Infarction scale (eTICI) 2c-3 at first pass), successful final recanalisation (mTICI or eTICI 2b-3), and excellent final recanalisation (mTICI or eTICI 2c-3). Safety outcomes were symptomatic intracranial haemorrhage (sICH) and 90-day mortality. RESULTS 12 cohort studies and 1 randomised-controlled trial were included, involving 1881 patients with 1274 receiving SR/PC and 607 receiving AC only. SR/PC achieved higher odds of functional independence (odds ratio (OR) 1.33, 95% confidence interval (CI) 1.06-1.67) and lower odds of mortality (OR 0.69, 95% CI 0.50-0.94) than AC. Odds of successful/excellent recanalisation and sICH were similar between both groups. Stratified to compare only SR and only AC, the use of only SR, achieved significantly higher odds of successful recanalisation as compared to only AC (OR 1.80, 95% CI 1.17-2.78). CONCLUSION There is potential for efficacy and safety benefits in SR/PC use as compared to AC only in AIS-DMVO. Further trials are necessary to validate the efficacy and safety of SR use in AIS-DMVO.
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Affiliation(s)
- Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ming Yi Koh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Enver De Wei Loh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gabriel Yi Ren Kwok
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Xin Yi Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Li Xun Syn
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Andrew Fu Wah Ho
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Program, Singapore
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Patrick A Brouwer
- Cerenovus (Johnson & Johnson), Galway Neuro Technology Centre, Galway, Ireland
| | | | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin YQ Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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Lee MX, Peng S, Lee ARYB, Tay RYK, Li J, Wong SY, Tariq A, Goh CXY, Tan YK, Tan BKJ, Teo CB, Chan E, Ooi M, Chng WJ, Chee CE, Ho CLF, Walsh RJ, Sethi SK, Tan SSY, Chan YH, Tan KB, Lee SC, Chai LYA, Sundar R. Neutralising antibody titers and COVID outcomes in cancer patients. Pathology 2023. [DOI: 10.1016/j.pathol.2022.12.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Lee MX, Peng S, Lee ARYB, Wong SY, Tay RYK, Li J, Tariq A, Goh CXY, Tan YK, Tan BKJ, Teo CB, Chan E, Ooi M, Chng WJ, Chee CE, Ho CLF, Walsh RJ, Wong M, Su Y, Alexander L, Sethi SK, Tan SSY, Chan YH, Tan KB, Lee SC, Chai LYA, Sundar R. Clinical efficacy and long-term immunogenicity of an early triple dose regimen of SARS-CoV-2 mRNA vaccination in cancer patients. Ann Acad Med Singap 2023. [DOI: 10.47102/annals-acadmedsg.2022302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Introduction: Three doses of SARS-CoV-2 mRNA vaccines have been recommended for cancer patients to reduce the risk of severe disease. Anti-neoplastic treatment, such as chemotherapy, may affect long-term vaccine immunogenicity.
Method: Patients with solid or haematological cancer were recruited from 2 hospitals between July 2021 and March 2022. Humoral response was evaluated using GenScript cPASS surrogate virus neutralisation assays. Clinical outcomes were obtained from medical records and national mandatory-reporting databases.
Results: A total of 273 patients were recruited, with 40 having haematological malignancies and the rest solid tumours. Among the participants, 204 (74.7%) were receiving active cancer therapy, including 98 (35.9%) undergoing systemic chemotherapy and the rest targeted therapy or immunotherapy. All patients were seronegative at baseline. Seroconversion rates after receiving 1, 2 and 3 doses of SARS-CoV-2 mRNA vaccination were 35.2%, 79.4% and 92.4%, respectively. After 3 doses, patients on active treatment for haematological malignancies had lower antibodies (57.3%±46.2) when compared to patients on immunotherapy (94.1%±9.56, P<0.05) and chemotherapy (92.8%±18.1, P<0.05). SARS-CoV-2 infection was reported in 77 (28.2%) patients, of which 18 were severe. No patient receiving a third dose within 90 days of the second dose experienced severe infection.
Conclusion: This study demonstrates the benefit of early administration of the third dose among cancer patients.
Keywords: Cancer, oncology, SARS-CoV-2, third dose, vaccination
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Affiliation(s)
| | - Siyu Peng
- National University Hospital, Singapore
| | | | - Shi Yin Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ryan Yong Kiat Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jiaqi Li
- School of Clinical Medicine, University of Cambridge, United Kingdom
| | - Areeba Tariq
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Xin Yi Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ying Kiat Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Chong Boon Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Esther Chan
- National University Cancer Institute, Singapore, Singapore
| | - Melissa Ooi
- National University Cancer Institute, Singapore, Singapore
| | - Wee Joo Chng
- National University Cancer Institute, Singapore, Singapore
| | - Cheng Ean Chee
- National University Cancer Institute, Singapore, Singapore
| | - Carol LF Ho
- National University Cancer Institute, Singapore, Singapore
| | | | - Maggie Wong
- National University Cancer Institute, Singapore, Singapore
| | - Yan Su
- Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore
| | - Lezhava Alexander
- Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore
| | | | | | - Yiong Huak Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Soo-Chin Lee
- National University Cancer Institute, Singapore, Singapore
| | | | - Raghav Sundar
- National University Cancer Institute, Singapore, Singapore
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Lee MX, Peng S, Lee ARYB, Wong SY, Tay RYK, Li J, Tariq A, Goh CXY, Tan YK, Tan BKJ, Teo CB, Chan E, Ooi M, Chng WJ, Chee CE, Ho CLF, Walsh RJ, Wong M, Su Y, Alexander L, Sethi SK, Tan SSY, Chan YH, Tan KB, Lee SC, Chai LYA, Sundar R. Clinical efficacy and long-term immunogenicity of an early triple dose regimen of SARS-CoV-2 mRNA vaccination in cancer patients. Ann Acad Med Singap 2023; 52:8-16. [PMID: 36730801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Three doses of SARS-CoV-2 mRNA vaccines have been recommended for cancer patients to reduce the risk of severe disease. Anti-neoplastic treatment, such as chemotherapy, may affect long-term vaccine immunogenicity. METHOD Patients with solid or haematological cancer were recruited from 2 hospitals between July 2021 and March 2022. Humoral response was evaluated using GenScript cPASS surrogate virus neutralisation assays. Clinical outcomes were obtained from medical records and national mandatory-reporting databases. RESULTS A total of 273 patients were recruited, with 40 having haematological malignancies and the rest solid tumours. Among the participants, 204 (74.7%) were receiving active cancer therapy, including 98 (35.9%) undergoing systemic chemotherapy and the rest targeted therapy or immunotherapy. All patients were seronegative at baseline. Seroconversion rates after receiving 1, 2 and 3 doses of SARS-CoV-2 mRNA vaccination were 35.2%, 79.4% and 92.4%, respectively. After 3 doses, patients on active treatment for haematological malignancies had lower antibodies (57.3%±46.2) when compared to patients on immunotherapy (94.1%±9.56, P<0.05) and chemotherapy (92.8%±18.1, P<0.05). SARS-CoV-2 infection was reported in 77 (28.2%) patients, of which 18 were severe. No patient receiving a third dose within 90 days of the second dose experienced severe infection. CONCLUSION This study demonstrates the benefit of early administration of the third dose among cancer patients.
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Affiliation(s)
- Matilda Xinwei Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
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Tan YK, Han MX, Tan BYQ, Sia CH, Goh CXY, Leow AST, Hausenloy DJ, Chan ESY, Ong MEH, Ho AFW. The role of head-up cardiopulmonary resuscitation in sudden cardiac arrest: a systematic review and meta-analysis. Ann Transl Med 2022; 10:515. [PMID: 35928751 PMCID: PMC9347036 DOI: 10.21037/atm-21-4984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/08/2022] [Indexed: 11/25/2022]
Abstract
Background Head-up cardiopulmonary resuscitation (HU-CPR) is an experimental treatment for sudden cardiac arrest (SCA), where cardiopulmonary resuscitation (CPR) is performed in a ramped position. We evaluated whether HU-CPR improved survival and surrogate outcomes as compared to standard CPR (S-CPR). Methods Studies reporting on HU-CPR in SCA were searched for in PubMed, Embase and Cochrane Library from inception to May 1st 2021. Outcomes included neurologically-intact survival, 24-hour-survival, intracranial pressure (ICP), cerebral perfusion pressure (CerPP) and brain blood flow (BBF). Risk of bias was assessed using the GRADE assessment tool and Newcastle Ottawa Scale. Fixed- and random-effects models were used to estimate the pooled effects of HU-CPR at 30 degrees. Results Thirteen articles met the criteria for inclusion (11 animal-only studies, one before-and-after human-only study, one study that utilized human- and animal-cadavers). Among animal studies, the most common implementation of HU-CPR was a 30-degree upward tilt of the head and thorax (n=7), while four studies investigated controlled sequential elevation (CSE). Two animal studies reported improved cerebral performance category (CPC) scores at 24-hour. The pooled effect on 24-hour survival was not statistically significant (P=0.37). The lone human study reported doubled return of spontaneous circulation (ROSC) (17.9% versus 34.2%, P<0.0001). The pooled effect on ROSC in three porcine studies was OR =3.63 (95% CI: 0.72–18.39). Pooled effects for surrogate physiological outcomes of intracranial cranial pressure (MD −14.08, 95% CI: −23.21 to −4.95, P=0.003), CerPP (MD 14.39, 95% CI: 3.07–25.72, P=0.01) and BBF (MD 0.14, 95% CI: 0.02–0.27, P=0.03), showed statistically significant benefit. Discussion Overall, HU-CPR improved neurologically-intact survival at 24-hour, ROSC and physiological surrogate outcomes in animal models. Despite promising preclinical data, and one human observational study, clinical equipoise remains surrounding the role of HU-CPR in SCA, necessitating clarification with future randomized human trials.
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Affiliation(s)
- Ying Kiat Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ming Xuan Han
- Emergency Medical Services Department, Singapore Civil Defence Force, Ministry of Home Affairs, Singapore, Singapore
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Claire Xin Yi Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Derek J. Hausenloy
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore
- Cardiovascular & Metabolic Disorders, Duke-NUS Medical School, Singapore, Singapore
- The Hatter Cardiovascular Institute, University College London, London, UK
- Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taichung
| | | | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
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