Wen Bijun, Brals Daniella, Bourdon Celine, Erdman Lauren, Ngari Moses, Chimwezi Emmanuel, Potani Isabel, Thitiri Johnstone, Mwalekwa Laura, Berkley James A, Bandsma Robert H J, Voskuijl Wieger
Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.
Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada.
BMC Med. 2021 Sep 20;19(1):222. doi: 10.1186/s12916-021-02074-6.
Despite adherence to WHO guidelines, inpatient mortality among sick children admitted to hospital with complicated severe acute malnutrition (SAM) remains unacceptably high. Several studies have examined risk factors present at admission for mortality. However, risks may evolve during admission with medical and nutritional treatment or deterioration. Currently, no specific guidance exists for assessing daily treatment response. This study aimed to determine the prognostic value of monitoring clinical signs on a daily basis for assessing mortality risk during hospitalization in children with SAM.
This is a secondary analysis of data from a randomized trial (NCT02246296) among 843 hospitalized children with SAM. Daily clinical signs were prospectively collected during ward rounds. Multivariable extended Cox regression using backward feature selection was performed to identify daily clinical warning signs (CWS) associated with time to death within the first 21 days of hospitalization. Predictive models were subsequently developed, and their prognostic performance evaluated using Harrell's concordance index (C-index) and time-dependent area under the curve (tAUC).
Inpatient case fatality ratio was 16.3% (n=127). The presence of the following CWS during daily assessment were found to be independent predictors of inpatient mortality: symptomatic hypoglycemia, reduced consciousness, chest indrawing, not able to complete feeds, nutritional edema, diarrhea, and fever. Daily risk scores computed using these 7 CWS together with MUAC<10.5cm at admission as additional CWS predict survival outcome of children with SAM with a C-index of 0.81 (95% CI 0.77-0.86). Moreover, counting signs among the top 5 CWS (reduced consciousness, symptomatic hypoglycemia, chest indrawing, not able to complete foods, and MUAC<10.5cm) provided a simpler tool with similar prognostic performance (C-index of 0.79; 95% CI 0.74-0.84). Having 1 or 2 of these CWS on any day during hospitalization was associated with a 3 or 11-fold increased mortality risk compared with no signs, respectively.
This study provides evidence for structured monitoring of daily CWS as recommended clinical practice as it improves prediction of inpatient mortality among sick children with complicated SAM. We propose a simple counting-tool to guide healthcare workers to assess treatment response for these children.
NCT02246296.
尽管遵循了世界卫生组织的指南，但因复杂的重度急性营养不良（SAM）入院的患病儿童的住院死亡率仍然高得令人无法接受。多项研究调查了入院时存在的死亡风险因素。然而，风险可能会在住院期间随着医疗和营养治疗或病情恶化而演变。目前，对于评估每日治疗反应尚无具体指导。本研究旨在确定每日监测临床体征对评估SAM患儿住院期间死亡风险的预后价值。
这是一项对843名住院的SAM患儿进行的随机试验（NCT02246296）数据的二次分析。在查房期间前瞻性收集每日临床体征。使用向后特征选择进行多变量扩展Cox回归，以识别与住院后21天内死亡时间相关的每日临床警示体征（CWS）。随后建立预测模型，并使用Harrell一致性指数（C指数）和时间依赖性曲线下面积（tAUC）评估其预后性能。
住院病死率为16.3%（n = 127）。每日评估中出现以下CWS被发现是住院死亡的独立预测因素：症状性低血糖、意识减退、吸气性凹陷、无法完成喂养、营养性水肿、腹泻和发热。使用这7种CWS以及入院时MUAC<10.5cm作为额外的CWS共同计算的每日风险评分预测SAM患儿的生存结局，C指数为0.81（95%CI 0.77 - 0.86）。此外，计算前5种CWS（意识减退、症状性低血糖、吸气性凹陷、无法完成进食和MUAC<10.5cm）中的体征提供了一种具有相似预后性能的更简单工具（C指数为0.79；95%CI 0.74 - 0.84）。住院期间任何一天出现1种或2种这些CWS与无体征相比，死亡风险分别增加3倍或11倍。
本研究为按结构化方式每日监测CWS提供了证据，作为推荐的临床实践，因为它改善了对患有复杂SAM的患病儿童住院死亡率的预测。我们提出一种简单的计数工具，以指导医护人员评估这些儿童的治疗反应。
NCT02246296。
