Bassat Quique, Castillo Paola, Martínez Miguel J, Jordao Dercio, Lovane Lucilia, Hurtado Juan Carlos, Nhampossa Tacilta, Santos Ritchie Paula, Bandeira Sónia, Sambo Calvino, Chicamba Valeria, Ismail Mamudo R, Carrilho Carla, Lorenzoni Cesaltina, Fernandes Fabiola, Cisteró Pau, Mayor Alfredo, Cossa Anelsio, Mandomando Inacio, Navarro Mireia, Casas Isaac, Vila Jordi, Munguambe Khátia, Maixenchs Maria, Sanz Ariadna, Quintó Llorenç, Macete Eusebio, Alonso Pedro, Menéndez Clara, Ordi Jaume
ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain.
Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.
PLoS Med. 2017 Jun 20;14(6):e1002317. doi: 10.1371/journal.pmed.1002317. eCollection 2017 Jun.
In recent decades, the world has witnessed unprecedented progress in child survival. However, our knowledge of what is killing nearly 6 million children annually in low- and middle-income countries remains poor, partly because of the inadequacy and reduced precision of the methods currently utilized in these settings to investigate causes of death (CoDs). The study objective was to validate the use of a minimally invasive autopsy (MIA) approach as an adequate and more acceptable substitute for the complete diagnostic autopsy (CDA) for pediatric CoD investigation in a poor setting.
In this observational study, the validity of the MIA approach in determining the CoD was assessed in 54 post-neonatal pediatric deaths (age range: ≥1 mo to 15 y) in a referral hospital of Mozambique by comparing the results of the MIA with those of the CDA. Concordance in the category of disease obtained by the two methods was evaluated by the Kappa statistic, and the sensitivity, specificity, and positive and negative predictive values of the MIA diagnoses were calculated. A CoD was identified in all cases in the CDA and in 52/54 (96%) of the cases in the MIA, with infections and malignant tumors accounting for the majority of diagnoses. The MIA categorization of disease showed a substantial concordance with the CDA categorization (Kappa = 0.70, 95% CI 0.49-0.92), and sensitivity, specificity, and overall accuracy were high. The ICD-10 diagnoses were coincident in up to 75% (36/48) of the cases. The MIA allowed the identification of the specific pathogen deemed responsible for the death in two-thirds (21/32; 66%) of all deaths of infectious origin. Discrepancies between the MIA and the CDA in individual diagnoses could be minimized with the addition of some basic clinical information such as those ascertainable through a verbal autopsy or clinical record. The main limitation of the analysis is that both the MIA and the CDA include some degree of expert subjective interpretation.
The MIA showed substantial concordance with CDA for CoD identification in this series of pediatric deaths in Mozambique. This minimally invasive approach, simpler and more readily acceptable than the more invasive CDA, could provide robust data for CoD surveillance, especially in resource-limited settings, which could be helpful for guiding child survival strategies in the future.
近几十年来，全球儿童生存状况取得了前所未有的进展。然而，我们对每年在低收入和中等收入国家导致近600万儿童死亡的原因仍知之甚少，部分原因是这些地区目前用于调查死因的方法不够充分且精度降低。本研究的目的是验证在资源匮乏地区，微创尸检（MIA）方法作为小儿死因调查中完整诊断性尸检（CDA）的一种充分且更易接受的替代方法的有效性。
在这项观察性研究中，通过比较莫桑比克一家转诊医院54例新生儿期后儿科死亡病例（年龄范围：≥1个月至15岁）的MIA结果与CDA结果，评估了MIA方法在确定死因方面的有效性。采用Kappa统计量评估两种方法在疾病类别上的一致性，并计算MIA诊断的敏感性、特异性以及阳性和阴性预测值。CDA在所有病例中均确定了死因，MIA在54例病例中的52例（96%）中确定了死因，感染和恶性肿瘤占诊断的大多数。MIA对疾病的分类与CDA分类显示出高度一致性（Kappa = 0.70，95% CI 0.49 - 0.92），敏感性、特异性和总体准确性都很高。国际疾病分类第十版（ICD - 10）诊断在高达75%（36/48）的病例中是一致的。MIA在所有感染性起源死亡病例的三分之二（21/32；66%）中确定了被认为是导致死亡的特定病原体。通过添加一些基本临床信息（如通过口头尸检或临床记录可确定的信息），可以将MIA和CDA在个体诊断上的差异降至最低。分析的主要局限性在于MIA和CDA都包含一定程度的专家主观解读。
在莫桑比克的这一系列儿科死亡病例中，MIA在死因鉴定方面与CDA显示出高度一致性。这种微创方法比更具侵入性的CDA更简单且更容易接受，可为死因监测提供可靠数据，尤其是在资源有限的环境中，这可能有助于指导未来的儿童生存策略。
