RESUMEN
The monocyte distribution width (MDW) has emerged as a promising biomarker for accurate and early identification of patients with potentially life-threatening infections. Here we tested the diagnostic performance of MDW in adult patients requiring hospital admission for community-acquired infections and sepsis, evaluated sources of heterogeneity in the estimates of diagnostic accuracy, and assessed the meaning of MDW in a patient population presenting to the emergency department (ED) for acute non-infectious conditions. 1925 consecutive patients were categorized into three groups: non-infection (n = 1507), infection (n = 316), and sepsis/septic shock (n = 102). Diagnostic performance for infection or sepsis of MDW alone or in combination with components of SOFA was tested using AUC of ROC curves, sensitivity, and specificity. The relationship between MDW and different pathogens as well as the impact of non-infectious conditions on MDW values were explored. For the prediction of infection, the AUC/ROC of MDW (0.84) was nearly overlapping that of procalcitonin (0.83), and C-reactive protein (0.89). Statistical optimal cut-off value for MDW was 21 for predicting infection (sensitivity 73%, specificity 82%) and 22 for predicting sepsis (sensitivity 79%, specificity 83%). The best threshold to rule out infection was MDW ≤ 17 (NPV 96.9, 95% CI 88.3-100.0), and ≤ 18 (NPV 99.5, 95% CI 98.3-100.0) to rule out sepsis. The combination of MDW with markers of organ dysfunction (creatinine, bilirubin, platelets) substantially improved the AUC (0.96 (95% CI 0.94-0.97); specificity and sensitivity of 88% and 94%, respectively). In conclusion, MDW has a good diagnostic performance in diagnosing infection and sepsis in patients presenting in ED. Its use as an infection marker even increases when combined with other markers of organ dysfunction. Understanding the impact of interactions of non-infectious conditions and comorbidities on MDW and its diagnostic accuracy requires further elucidation.
Asunto(s)
Biomarcadores , Servicio de Urgencia en Hospital , Monocitos , Sepsis , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Prospectivos , Anciano , Sepsis/diagnóstico , Sepsis/sangre , Monocitos/metabolismo , Biomarcadores/sangre , Adulto , Curva ROC , Enfermedad Aguda , Anciano de 80 o más Años , Infecciones Comunitarias Adquiridas/diagnóstico , Sensibilidad y EspecificidadRESUMEN
Idarucizumab is designed to reverse the anticoagulant effect of dabigatran. This case report describes the administration of three independent doses of idarucizumab to a 76-year-old man suffering from atrial flutter being treated with dabigatran to prevent ischaemic stroke. The last dose of dabigatran was administered in the morning of the same day the patient was transferred to hospital because of the need for urgent pericardium puncture. Baseline dTT (dilute thrombin time) reached 700 ng/mL as glomerular filtration (GF) dropped to 0.19 mL/s. The first dose of idarucizumab was administered prior to puncture and the clinical state was stabilized for the next 24 hours although dTT climbed to 400 ng/mL. The need for cannulation before dialysis required a second dose of antidote and a third dose was given prior to removal of the pericardium drain. Monitoring of dabigatran recovery showed that the reverse effect of idarucizumab lasted 12 hours, which is sufficiently long and reliable for urgent situations. Idarucizumab administration is not limited by age and/or renal impairment. We recommend repeated dTT examinations when the dabigatran baseline level exceeds 200 ng/mL and the antidote has been administered.
Asunto(s)
Anticuerpos Monoclonales Humanizados/administración & dosificación , Aleteo Atrial/tratamiento farmacológico , Infarto Cerebral/prevención & control , Dabigatrán/efectos adversos , Sobredosis de Droga/tratamiento farmacológico , Anciano , Infarto Cerebral/inducido químicamente , Dabigatrán/administración & dosificación , Esquema de Medicación , Sobredosis de Droga/sangre , Servicios Médicos de Urgencia , Tasa de Filtración Glomerular/efectos de los fármacos , Humanos , Masculino , Pericardiectomía , Diálisis Renal , Retratamiento , Tiempo de TrombinaRESUMEN
Dabigatran (Pradaxa, Boehringer Ingelheim) is the first direct oral thrombin (FIIa) inhibitor. It is indicated for thromboprophylaxis in patients undergoing elective total replacement hip or knee joint surgery or for the primary or secondary prophylaxis of elderly patients with non-valvular atrial fibrillation or for deep vein thrombosis and pulmonary embolism treatment and prophylaxis. Idarucizumab (Praxbind, Boehringer Ingelheim) is a specific monoclonal antibody fragment indicated in patients treated with dabigatran. It is recommended when reversal of anticoagulant effect of dabigatran is needed especially in cases of life-threatening bleeding, for emergency surgery or urgent procedures purposes. In this article, there is a summary of our clinical and laboratory experience with reversal effect of idarucizumab in our five patients.