Sypniewska Paulina, Duda Jose F, Locatelli Isabella, Althaus Clotilde Rambaud, Althaus Fabrice, Genton Blaise
Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
RWTH Aachen University, Aachen, Germany.
BMC Med. 2017 Aug 3;15(1):147. doi: 10.1186/s12916-017-0906-5.
The criteria for defining severe malaria have evolved over the last 20 years. We aimed to assess the strength of association of death with features currently characterizing severe malaria through a systematic review and meta-analysis.
Electronic databases (Medline, Embase, Cochrane Database of Systematic Reviews, Thomson Reuters Web of Knowledge) were searched to identify publications including African children with severe malaria. PRISMA guidelines were followed. Selection was based on design (epidemiological, clinical and treatment studies), setting (Africa), participants (children < 15 years old with severe malaria), outcome (survival/death rate), and prognostic indicators (clinical and laboratory features). Quality assessment was performed following the criteria of the 2011 Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). Odds ratios (ORs) were calculated for each study and prognostic indicator, and, when a test was assessed in at least two studies, pooled estimates of ORs were computed using fixed- or random-effects meta-analysis.
A total of 601 articles were identified and screened and 30 publications were retained. Features with the highest pooled ORs were renal failure (5.96, 95% CI 2.93-12.11), coma score (4.83, 95% CI 3.11-7.5), hypoglycemia (4.59, 95% CI 2.68-7.89), shock (4.31, 95% CI 2.15-8.64), and deep breathing (3.8, 95% CI 3.29-4.39). Only half of the criteria had an OR > 2. Features with the lowest pooled ORs were impaired consciousness (0.58, 95% CI 0.25-1.37), severe anemia (0.76, 95% CI 0.5- 1.13), and prostration (1.12, 95% CI 0.45-2.82).
The findings of this meta-analysis show that the strength of association between the criteria defining severe malaria and death is quite variable for each clinical and/or laboratory feature (OR ranging from 0.58 to 5.96). This ranking allowed the identification of features weakly associated with death, such as impaired consciousness and prostration, which could assist to improve case definition, and thus optimize antimalarial treatment.
过去20年里，定义重症疟疾的标准不断演变。我们旨在通过系统评价和荟萃分析，评估目前用于表征重症疟疾的特征与死亡之间的关联强度。
检索电子数据库（Medline、Embase、Cochrane系统评价数据库、汤森路透知识网），以识别包含患有重症疟疾的非洲儿童的出版物。遵循PRISMA指南。选择基于设计（流行病学、临床和治疗研究）、研究背景（非洲）、参与者（年龄小于15岁的重症疟疾儿童）、结局（生存率/死亡率）和预后指标（临床和实验室特征）。按照2011年诊断准确性研究质量评估（QUADAS-2）的标准进行质量评估。计算每项研究和预后指标的比值比（OR），当一项检测在至少两项研究中被评估时，使用固定效应或随机效应荟萃分析计算OR的合并估计值。
共识别并筛选了601篇文章，保留了30篇出版物。合并OR最高的特征是肾衰竭（5.96，95%可信区间2.93 - 12.11）、昏迷评分（4.83，95%可信区间3.11 - 7.5）、低血糖（4.59，95%可信区间2.68 - 7.89）、休克（4.31，95%可信区间2.15 - 8.64）和深呼吸（3.8，95%可信区间3.29 - 4.39）。只有一半的标准OR大于2。合并OR最低的特征是意识障碍（0.58，95%可信区间0.25 - 1.37）、严重贫血（0.76，95%可信区间0.5 - 1.13）和极度衰弱（1.12，95%可信区间0.45 - 2.82）。
这项荟萃分析的结果表明，对于每个临床和/或实验室特征，定义重症疟疾的标准与死亡之间的关联强度差异很大（OR范围为0.58至5.96）。这种排序有助于识别与死亡关联较弱的特征，如意识障碍和极度衰弱，这有助于改进病例定义，从而优化抗疟治疗。
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