BackgroundSepsis is a potential life threatening dysregulated immune response to an infection, which can result in multi-organ failure and death. Unfortunately, good prognostic markers are lacking in patients with suspected infection to identify those at risk. Red blood cell distribution width (RDW) is a common and inexpensive hematologic laboratory measurement associated with adverse prognosis in multiple diseases. The aim of this study was to determine the prognostic value of RDW for mortality and early clinical deterioration in patients with a suspected infection in the emergency department.MethodsIn this single center prospective observational cohort study, consecutive patients with suspected infection presenting for internal medicine in the emergency department between September 2016 and March 2018 were included. For prognostic validation of bedside sepsis scores and RDW receiver operating characteristics were generated. Association between RDW and mortality and ICU admission was analyzed univariate and in a multivariate logistic regression model.Results1046 patients were included. In multivariate analyses, RDW was significantly associated with 30-day mortality (OR 1.15, 95% CI: 1.04–1.28) and early clinical deterioration (OR 1.09, 95% CI: 1.00–1.18). For 30-day mortality RDW had an AUROC of 0.66 (95% CI 0.59–0.72). Optimal cut-off value for RDW 2 was 12.95%. For early clinical deterioration RDW had an AUROC of 0.59 (95% CI 0.54–0.63) with an optimal cut-off value of 14.48%.ConclusionsRDW was found to be a significant independent prognostic factor of 30-day mortality and early clinical deterioration in patients with suspected infection.. Therefore it can be a used as an extra marker besides bedside sepsis scores in identifying patients at risk for worse outcome in patients with suspected infection.
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Infection with the human immunodeficiency virus (HIV) is characterized by progressive depletion of CD4+ lymphocytes cells as a result of chronic immune activation. Next to the decreases in the number of CD4+ cells which leads to opportunistic infections, HIV-related immune activation is associated with several prevalent comorbidities in the HIV-positive population such as cardiovascular and bone disease. Traditionally, combination antiretroviral therapy (cART) consists of three drugs with activity against HIV and is highly effective in diminishing the degree of immune activation. Over the years, questions were raised whether virological suppression could also be achieved with fewer antiretroviral drugs, i.e., dual- or even monotherapy. This is an intriguing question considering the fact that antiretroviral drugs should be used lifelong and their use could also induce cardiovascular and bone disease. Therefore, the equilibrium between drug-induced toxicity and immune activation related comorbidity is delicate. Recently, two large clinical trials evaluating two-drug cART showed non-inferiority with respect to virological outcomes when compared to triple-drug regimens. This led to adoption of dual antiretroviral therapy in current HIV treatment guidelines. However, it is largely unknown whether dual therapy is also able to suppress immune activation to the same degree as triple therapy. This poses a risk for an imbalance in the delicate equilibrium. This mini review gives an overview of the current available evidence concerning immune activation in the setting of cART with less than three antiretroviral drugs.
Objective: To assess the impact of past Pneumocystis jirovecii pneumonia (PJP) on the pulmonary diffusion capacity in people with HIV (PWH) with a history of advanced immunodeficiency.Design: Prospective cross-sectional study.Methods: Adult PWH with past PJP >1 year ago were included as the study group. The control group consisted of PWH with a nadir CD4 þ lymphocyte count <200 cells/mm 3 , matched by age, sex, smoking status and time since HIV diagnosis. All PWH completed a pulmonary function test (PFT) consisting of pre-bronchodilation spirometry, body plethysmography and single-breath carbon monoxide transfer factor (TLCO) measurement. TLCO, diffusion impairment (defined as a TLCO Z-score <À1.645), total lung capacity (TLC) and forced expiratory volume in one second/forced vital capacity (FEV1/ FVC) Z-scores were assessed. Multivariable regression analyses were conducted with Zscores and odds of diffusion impairment as outcomes.Results: PFTs of 102 participants were analyzed, 51 of whom had past PJP with a median of 10 years since PJP. Mean TLCO Z-score and diffusion impairment rate did not differ significantly between groups (P ¼ 0.790; P ¼ 0.650). Past PJP was not independently associated with TLCO Z-score [b ¼ 0.14; 95% confidence interval (CI) À0.30-0.57], diffusion impairment (odds ratio 1.00; 95% CI 0.36-2.75) nor TLC or FEV1/FVC Z-scores, whereas current (vs. never) smoking was associated with more diffusion impairment and lower TLCO Z-scores. Conclusion:In our study, past PJP was not associated with long-term diffusion impairment. Our findings suggest that smoking plays a more important role in persistent pulmonary function impairment whereas PJP-related changes seem to be reversible.
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