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Gonçalves B, Rynkowski C, Turon R, Charris N, Miranda F, de Caro V, Prazeres M, Santos T, Greer DM, Sharshar T, Guillaume T, Bozza FA, Righy C, Kurtz P. Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country. Neurocrit Care 2023; 38:378-387. [PMID: 36324005 DOI: 10.1007/s12028-022-01629-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/03/2022] [Indexed: 04/13/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality and long-term functional impairment. Data on clinical management and functional outcomes from developing countries are scarce. We aimed to define patient profiles and clinical practices and evaluate long-term outcomes after SAH in a middle-income country. METHODS This was a prospective study including consecutive adult patients admitted with SAH to two reference centers in Brazil from January 2016 to February 2020. The primary outcome was functional status at 6 months using the modified Rankin Scale. Mixed multivariable analysis was performed to determine the relationship between clinical variables and functional outcomes. RESULTS From 471patients analyzed, the median time from symptom onset to arrival at a study center was 4 days (interquartile range 0-9). Median age was 55 years (interquartile range 46-62) and 353 (75%) patients were women. A total of 426 patients (90%) were transferred from nonspecialized general hospitals, initial computed tomography revealed thick hemorrhage in 73% of patients (modified Fisher score of 3 or 4), and 136 (29%) had poor clinical grade (World Federation of Neurological Surgeons score of 4 or 5). A total of 312 (66%) patients underwent surgical clipping, and 119 (25%) underwent endovascular coiling. Only 34 patients (7%) underwent withdrawal or withholding of life-sustaining therapy during their hospital stay, and in-hospital mortality was 24%. A total of 187 (40%) patients had an unfavorable long-term functional outcome (modified Rankin Scale score of 4 to 6). Factors associated with unfavorable outcome were age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.03-1.08), hypertension (adjusted OR 1.81, 95% CI 1.04-3.16), poor clinical grade (adjusted OR 4.92, 95% CI 2.85-8.48), external ventricular drain (adjusted OR 3.8, 95% CI 2.31-6.24), postoperative deterioration (adjusted OR 2.33, 95% CI 1.32-4.13), cerebral infarction (adjusted OR 3.16, 95% CI 1.81-5.52), rebleeding (adjusted OR 2.95, 95% CI 1.13-7.69), and sepsis (adjusted OR 2.68, 95% CI 1.42-5.05). CONCLUSIONS Our study demonstrated that SAH management in a middle-income country diverges significantly from published cohorts and current guidelines, despite comparable clinical profiles on presentation and admission to high-volume referral centers. Earlier aneurysm occlusion and increased use of endovascular therapy could potentially reduce modifiable in-hospital complications and improve functional outcomes in Brazil.
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Affiliation(s)
- Bruno Gonçalves
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Carla Rynkowski
- Department of Intensive Care Medicine, Hospital Cristo Redentor, Porto Alegre, Brazil
| | - Ricardo Turon
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Nestor Charris
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Fabio Miranda
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
| | - Vanessa de Caro
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Marco Prazeres
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Thayana Santos
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Tarek Sharshar
- Department of Neuro-Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris, France
| | - Turc Guillaume
- GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Paris, France
- INSERM, Paris, France
- FHU NeuroVasc, Paris, France
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, CEP 22281-100, Brazil
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
| | - Cassia Righy
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
| | - Pedro Kurtz
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil.
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil.
- D'Or Institute for Research and Education, Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, CEP 22281-100, Brazil.
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Kurtz P, Righy C, Gadelha M, Bozza FA, Bozza PT, Gonçalves B, Bastos LSL, Vale AM, Higa LM, Castilho L, Monteiro FL, Charris N, Fialho F, Turon R, Guterres A, Lyra Miranda R, de Azeredo Lima CH, de Caro V, Prazeres MA, Ventura N, Gaspari C, Miranda F, Jose da Mata P, Pêcego M, Mateos S, Lopes ME, Castilho S, Oliveira Á, Boquimpani C, Rabello A, Lopes J, Neto OC, Ferreira ODC, Tanuri A, Filho PN, Amorim L. Effect of Convalescent Plasma in Critically Ill Patients With COVID-19: An Observational Study. Front Med (Lausanne) 2021; 8:630982. [PMID: 33585529 PMCID: PMC7876445 DOI: 10.3389/fmed.2021.630982] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/04/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Convalescent plasma is a potential therapeutic option for critically ill patients with coronavirus disease 19 (COVID-19), yet its efficacy remains to be determined. The aim was to investigate the effects of convalescent plasma (CP) in critically ill patients with COVID-19. Methods: This was a single-center prospective observational study conducted in Rio de Janeiro, Brazil, from March 17th to May 30th, with final follow-up on June 30th. We included 113 laboratory-confirmed COVID-19 patients with respiratory failure. Primary outcomes were time to clinical improvement and survival within 28 days. Secondary outcomes included behavior of biomarkers and viral loads. Kaplan–Meier analyses and Cox proportional-hazards regression using propensity score with inverse-probability weighing were performed. Results: 41 patients received CP and 72 received standard of care (SOC). Median age was 61 years (IQR 48–68), disease duration was 10 days (IQR 6–13), and 86% were mechanically ventilated. At least 29 out of 41CP-recipients had baseline IgG titers ≥ 1:1,080. Clinical improvement within 28 days occurred in 19 (46%) CP-treated patients, as compared to 23 (32%) in the SOC group [adjusted hazard ratio (aHR) 0.91 (0.49–1.69)]. There was no significant change in 28-day mortality (CP 49% vs. SOC 56%; aHR 0.90 [0.52–1.57]). Biomarker assessment revealed reduced inflammatory activity and increased lymphocyte count after CP. Conclusions: In this study, CP was not associated with clinical improvement or increase in 28-day survival. However, our study may have been underpowered and included patients with high IgG titers and life-threatening disease. Clinical Trial Registration: The study protocol was retrospectively registered at the Brazilian Registry of Clinical Trials (ReBEC) with the identification RBR-4vm3yy (http://www.ensaiosclinicos.gov.br).
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Affiliation(s)
- Pedro Kurtz
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Cassia Righy
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Monica Gadelha
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil.,National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Patricia T Bozza
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Bruno Gonçalves
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Leonardo S L Bastos
- Industrial Engineering Department, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, Brazil
| | - Andre M Vale
- Laboratory of Lymphocyte Biology, Program in Immunobiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Luiza M Higa
- Laboratory of Molecular Virology, Department of Genetics, Institute of Biology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leda Castilho
- Laboratory of Cell Culture Engineering, COPPE, Chemical Engineering Program, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Fabio L Monteiro
- Laboratory of Molecular Virology, Department of Genetics, Institute of Biology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nestor Charris
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Fernanda Fialho
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Ricardo Turon
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | | | | | | | - Vanessa de Caro
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | | | - Nina Ventura
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Clara Gaspari
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Fabio Miranda
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | | | - Margarida Pêcego
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Sheila Mateos
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Maria Esther Lopes
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Shirley Castilho
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Álvaro Oliveira
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Carla Boquimpani
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Andréa Rabello
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Josiane Lopes
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Orlando Conceição Neto
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
| | - Orlando da C Ferreira
- Laboratory of Molecular Virology, Department of Genetics, Institute of Biology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amilcar Tanuri
- Laboratory of Molecular Virology, Department of Genetics, Institute of Biology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Luiz Amorim
- Instituto Estadual de Hematologia Arthur de Siqueira Cavalcanti (HEMORIO), Rio de Janeiro, Brazil
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