Moxon Christopher A, Zhao Lei, Li Chenxi, Seydel Karl B, MacCormick Ian J, Diggle Peter J, Mallewa Macpherson, Solomon Tom, Beare Nicholas A, Glover Simon J, Harding Simon P, Lewallen Susan, Kampondeni Sam, Potchen Michael J, Taylor Terrie E, Postels Douglas G
From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
Neurology. 2016 Nov 29;87(22):2355-2362. doi: 10.1212/WNL.0000000000003372. Epub 2016 Oct 28.
We assessed the independent association of lumbar puncture (LP) and death in Malawian children admitted to the hospital with the clinical features of cerebral malaria (CM).
This was a retrospective cohort study in Malawian children with clinical features of CM. Allocation to LP was nonrandom and was associated with severity of illness. Propensity score-based analyses were used to adjust for this bias and assess the independent association between LP and mortality.
Data were available for 1,075 children: 866 (80.6%) underwent LP and 209 (19.4%) did not. Unadjusted mortality rates were lower in children who underwent LP (15.3% vs 26.7% in the no-LP group) but differences in covariates between the 2 groups suggested bias in LP allocation. After propensity score matching, all covariates were balanced. Propensity score-based analyses showed no change in mortality rate associated with LP: by inverse probability weighting, the average risk reduction was 2.0% at 12 hours (95% confidence interval -1.5% to 5.5%, p = 0.27) and 1.7% during hospital admission (95% confidence interval -4.5% to 7.9%, p = 0.60). Undergoing LP did not change the risk of mortality in subanalyses of children with severe brain swelling on MRI or in those with papilledema.
In comatose children with suspected CM who were clinically stable, we found no evidence that LP increases mortality, even in children with objective signs of raised intracranial pressure.
我们评估了在马拉维因脑型疟疾（CM）临床特征入院的儿童中，腰椎穿刺（LP）与死亡之间的独立关联。
这是一项针对有CM临床特征的马拉维儿童的回顾性队列研究。LP的分配并非随机，且与疾病严重程度相关。基于倾向评分的分析用于校正这种偏倚，并评估LP与死亡率之间的独立关联。
1075名儿童的数据可用：866名（80.6%）接受了LP，209名（19.4%）未接受。接受LP的儿童未调整的死亡率较低（LP组为15.3%，未接受LP组为26.7%），但两组之间协变量的差异表明LP分配存在偏倚。倾向评分匹配后，所有协变量均达到平衡。基于倾向评分的分析显示与LP相关的死亡率没有变化：通过逆概率加权法，12小时时平均风险降低2.0%（95%置信区间-1.5%至5.5%，p=0.27）；住院期间为1.7%（95%置信区间-4.5%至7.9%，p=0.60）。在MRI显示有严重脑肿胀的儿童或有视乳头水肿的儿童的亚分析中，接受LP并未改变死亡风险。
在临床上稳定的疑似CM昏迷儿童中我们发现，没有证据表明LP会增加死亡率，即使在有颅内压升高客观体征的儿童中也是如此。
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