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Sanchez-Pinto LN, Del Pilar Arias López M, Scott H, Gibbons K, Moor M, Watson RS, Wiens MO, Schlapbach LJ, Bennett TD. Digital solutions in paediatric sepsis: current state, challenges, and opportunities to improve care around the world. Lancet Digit Health 2024; 6:e651-e661. [PMID: 39138095 PMCID: PMC11371309 DOI: 10.1016/s2589-7500(24)00141-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 05/17/2024] [Accepted: 06/14/2024] [Indexed: 08/15/2024]
Abstract
The digitisation of health care is offering the promise of transforming the management of paediatric sepsis, which is a major source of morbidity and mortality in children worldwide. Digital technology is already making an impact in paediatric sepsis, but is almost exclusively benefiting patients in high-resource health-care settings. However, digital tools can be highly scalable and cost-effective, and-with the right planning-have the potential to reduce global health disparities. Novel digital solutions, from wearable devices and mobile apps, to electronic health record-embedded decision support tools, have an unprecedented opportunity to transform paediatric sepsis research and care. In this Series paper, we describe the current state of digital solutions in paediatric sepsis around the world, the advances in digital technology that are enabling the development of novel applications, and the potential effect of advances in artificial intelligence in paediatric sepsis research and clinical care.
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Affiliation(s)
- L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | | | - Halden Scott
- Department of Pediatrics, University of Colorado-Denver and Children's Hospital Colorado, Aurora, CO, USA
| | - Kristen Gibbons
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Michael Moor
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - R Scott Watson
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Matthew O Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; World Alliance for Lung and Intensive Care Medicine in Uganda, Kampala, Uganda
| | - Luregn J Schlapbach
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care and Neonatology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tellen D Bennett
- Department of Pediatrics, University of Colorado-Denver and Children's Hospital Colorado, Aurora, CO, USA
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Watson RS, Carrol ED, Carter MJ, Kissoon N, Ranjit S, Schlapbach LJ. The burden and contemporary epidemiology of sepsis in children. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:670-681. [PMID: 39142741 DOI: 10.1016/s2352-4642(24)00140-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 05/27/2024] [Accepted: 06/04/2024] [Indexed: 08/16/2024]
Abstract
Sepsis is a dysregulated host response to infection that leads to life-threatening organ dysfunction. Half of the 50 million people affected by sepsis globally every year are neonates and children younger than 19 years. This burden on the paediatric population translates into a disproportionate impact on global child health in terms of years of life lost, morbidity, and lost opportunities for children to reach their developmental potential. This Series on paediatric sepsis presents the current state of diagnosis and treatment of sepsis in children, and maps the challenges in alleviating the burden on children, their families, and society. Drawing on diverse experience and multidisciplinary expertise, we offer a roadmap to improving outcomes for children with sepsis. This first paper of the Series is a narrative review of the burden of paediatric sepsis from low-income to high-income settings. Advances towards improved operationalisation of paediatric sepsis across all age groups have facilitated more standardised assessment of the Global Burden of Disease estimates of the impact of sepsis on child health, and these estimates are expected to gain further precision with the roll out of the new Phoenix criteria for sepsis. Sepsis remains one of the leading causes of childhood morbidity and mortality, with immense direct and indirect societal costs. Although substantial regional differences persist in relation to incidence, microbiological epidemiology, and outcomes, these cannot be explained by differences in income level alone. Recent insights into post-discharge sequelae after paediatric sepsis, ranging from late mortality and persistent neurodevelopmental impairment to reduced health-related quality of life, show how common post-sepsis syndrome is in children. Targeting sepsis as a key contributor to poor health outcomes in children is therefore an essential component of efforts to meet the Sustainable Development Goals.
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Affiliation(s)
- R Scott Watson
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
| | - Michael J Carter
- Centre for Human Genetics, University of Oxford, Oxford, UK; Paediatric Intensive Care unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Niranjan Kissoon
- Global Child Health Department of Pediatrics and Emergency Medicine, British Columbia Women and Children's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | | | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.
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Hama Diallo A, Shahid ASMSB, Khan AF, Saleem AF, Singa BO, Gnoumou BS, Tigoi C, Achieng C, Bourdon C, Oduol C, Lancioni CL, Manyasi C, McGrath CJ, Maronga C, Lwanga C, Brals D, Ahmed D, Mondal D, Denno DM, Mangale DI, Chimezi E, Mbale E, Mupere E, Salauddin Mamun GM, Ouédraogo I, Berkley JA, Njirammadzi J, Mukisa J, Thitiri J, Walson JL, Jemutai J, Tickell KD, Shahrin L, Mallewa M, Hossain MI, Chisti MJ, Timbwa M, Mburu M, Ngari MM, Ngao N, Aber P, Harawa PP, Sukhtankar P, Bandsma RH, Bamouni RM, Molyneux S, Mwaringa S, Shaima SN, Ali SA, Afsana SM, Banu S, Ahmed T, Voskuijl WP, Kazi Z. Hospital readmission following acute illness among children 2-23 months old in sub-Saharan Africa and South Asia: a secondary analysis of CHAIN cohort. EClinicalMedicine 2024; 73:102676. [PMID: 38933099 PMCID: PMC11200276 DOI: 10.1016/j.eclinm.2024.102676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
Background Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young children admitted to nine hospitals in sub-Saharan Africa and South Asia. Methods This was a secondary analysis of the CHAIN Network prospective cohort enrolled between 20th November 2016 and 31st January 2019. Children aged 2-23 months were eligible for enrolment, if admitted for an acute illness to one of the study hospitals. Exclusions were requiring immediate resuscitation, inability to tolerate oral feeds in their normal state of health, had suspected terminal illness, suspected chromosomal abnormality, trauma, admission for surgery, or their parent/caregiver was unwilling to participate and attend follow-up visits. Data from children discharged alive from the index admission were analysed for hospital readmission within 180-days from discharge. We examined ratios of readmission to post-discharge mortality rates. Using models with death as the competing event, we evaluated demographic, nutritional, clinical, and socioeconomic associations with readmission. Findings Of 2874 children (1239 (43%) girls, median (IQR) age 10.8 (6.8-15.6) months), 655 readmission episodes occurred among 506 (18%) children (198 (39%) girls): 391 (14%) with one, and 115 (4%) with multiple readmissions, with a rate of: 41.0 (95% CI 38.0-44.3) readmissions/1000 child-months. Median time to readmission was 42 (IQR 15-93) days. 460/655 (70%) and 195/655 (30%) readmissions occurred at index study hospital and non-study hospitals respectively. One-third (N = 213/655, 33%) of readmissions occurred within 30 days of index discharge. Sites with fewest readmissions had the highest post-discharge mortality. Most readmissions to study hospitals (371/450, 81%) were for the same illness as the index admission. Age, prior hospitalisation, chronic conditions, illness severity, and maternal mental health score, but not sex, nutritional status, or physical access to healthcare, were associated with readmission. Interpretation Readmissions may be appropriate and necessary to reduce post-discharge mortality in high mortality settings. Social and financial support, training on recognition of serious illness for caregivers, and improving discharge procedures, continuity of care and facilitation of readmission need to be tested in intervention studies. We propose the ratio of readmission to post-discharge mortality rates as a marker of overall post-discharge access and care. Funding The Bill & Melinda Gates Foundation (OPP1131320).
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Huxford C, Rafiei A, Nguyen V, Wiens MO, Ansermino JM, Kissoon N, Kumbakumba E, Businge S, Komugisha C, Tayebwa M, Kabakyenga J, Mugisha NK, Kamaleswaran R. The 2024 Pediatric Sepsis Challenge: Predicting In-Hospital Mortality in Children With Suspected Sepsis in Uganda. Pediatr Crit Care Med 2024:00130478-990000000-00356. [PMID: 38904442 DOI: 10.1097/pcc.0000000000003556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
The aim of this "Technical Note" is to inform the pediatric critical care data research community about the "2024 Pediatric Sepsis Data Challenge." This competition aims to facilitate the development of open-source algorithms to predict in-hospital mortality in Ugandan children with sepsis. The challenge is to first develop an algorithm using a synthetic training dataset, which will then be scored according to standard diagnostic testing criteria, and then be evaluated against a nonsynthetic test dataset. The datasets originate from admissions to six hospitals in Uganda (2017-2020) and include 3837 children, 6 to 60 months old, who were confirmed or suspected to have a diagnosis of sepsis. The synthetic dataset was created from a random subset of the original data. The test validation dataset closely resembles the synthetic dataset. The challenge should generate an optimal model for predicting in-hospital mortality. Following external validation, this model could be used to improve the outcomes for children with proven or suspected sepsis in low- and middle-income settings.
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Affiliation(s)
- Charly Huxford
- Institute for Global Health, BC Children's Hospital and BC Women's Hospital + Health Centre, Vancouver, BC, Canada
| | - Alireza Rafiei
- Department of Computer Science and Informatics, Emory University, Atlanta, GA
| | - Vuong Nguyen
- Institute for Global Health, BC Children's Hospital and BC Women's Hospital + Health Centre, Vancouver, BC, Canada
| | - Matthew O Wiens
- Institute for Global Health, BC Children's Hospital and BC Women's Hospital + Health Centre, Vancouver, BC, Canada
- Department of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - J Mark Ansermino
- Institute for Global Health, BC Children's Hospital and BC Women's Hospital + Health Centre, Vancouver, BC, Canada
- Department of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Niranjan Kissoon
- Institute for Global Health, BC Children's Hospital and BC Women's Hospital + Health Centre, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, BC Children's Hospital, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Elias Kumbakumba
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | | | - Jerome Kabakyenga
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
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Wu Y, Wang L, Li Y, Cao Y, Wang M, Deng Z, Kang H. Immunotherapy in the context of sepsis-induced immunological dysregulation. Front Immunol 2024; 15:1391395. [PMID: 38835773 PMCID: PMC11148279 DOI: 10.3389/fimmu.2024.1391395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/06/2024] [Indexed: 06/06/2024] Open
Abstract
Sepsis is a clinical syndrome caused by uncontrollable immune dysregulation triggered by pathogen infection, characterized by high incidence, mortality rates, and disease burden. Current treatments primarily focus on symptomatic relief, lacking specific therapeutic interventions. The core mechanism of sepsis is believed to be an imbalance in the host's immune response, characterized by early excessive inflammation followed by late immune suppression, triggered by pathogen invasion. This suggests that we can develop immunotherapeutic treatment strategies by targeting and modulating the components and immunological functions of the host's innate and adaptive immune systems. Therefore, this paper reviews the mechanisms of immune dysregulation in sepsis and, based on this foundation, discusses the current state of immunotherapy applications in sepsis animal models and clinical trials.
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Affiliation(s)
- Yiqi Wu
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Graduate School of The People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Lu Wang
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Graduate School of The People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yun Li
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Graduate School of The People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Yuan Cao
- Department of Emergency Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Min Wang
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- Graduate School of The People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Zihui Deng
- Department of Basic Medicine, Graduate School, Chinese PLA General Hospital, Beijing, China
| | - Hongjun Kang
- Department of Critical Care Medicine, The First Medical Center, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
- National Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
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Wiens MO, Nguyen V, Bone JN, Kumbakumba E, Businge S, Tagoola A, Sherine SO, Byaruhanga E, Ssemwanga E, Barigye C, Nsungwa J, Olaro C, Ansermino JM, Kissoon N, Singer J, Larson CP, Lavoie PM, Dunsmuir D, Moschovis PP, Novakowski S, Komugisha C, Tayebwa M, Mwesigwa D, Knappett M, West N, Mugisha NK, Kabakyenga J. Prediction models for post-discharge mortality among under-five children with suspected sepsis in Uganda: A multicohort analysis. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003050. [PMID: 38683787 PMCID: PMC11057737 DOI: 10.1371/journal.pgph.0003050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Abstract
In many low-income countries, over five percent of hospitalized children die following hospital discharge. The lack of available tools to identify those at risk of post-discharge mortality has limited the ability to make progress towards improving outcomes. We aimed to develop algorithms designed to predict post-discharge mortality among children admitted with suspected sepsis. Four prospective cohort studies of children in two age groups (0-6 and 6-60 months) were conducted between 2012-2021 in six Ugandan hospitals. Prediction models were derived for six-months post-discharge mortality, based on candidate predictors collected at admission, each with a maximum of eight variables, and internally validated using 10-fold cross-validation. 8,810 children were enrolled: 470 (5.3%) died in hospital; 257 (7.7%) and 233 (4.8%) post-discharge deaths occurred in the 0-6-month and 6-60-month age groups, respectively. The primary models had an area under the receiver operating characteristic curve (AUROC) of 0.77 (95%CI 0.74-0.80) for 0-6-month-olds and 0.75 (95%CI 0.72-0.79) for 6-60-month-olds; mean AUROCs among the 10 cross-validation folds were 0.75 and 0.73, respectively. Calibration across risk strata was good: Brier scores were 0.07 and 0.04, respectively. The most important variables included anthropometry and oxygen saturation. Additional variables included: illness duration, jaundice-age interaction, and a bulging fontanelle among 0-6-month-olds; and prior admissions, coma score, temperature, age-respiratory rate interaction, and HIV status among 6-60-month-olds. Simple prediction models at admission with suspected sepsis can identify children at risk of post-discharge mortality. Further external validation is recommended for different contexts. Models can be digitally integrated into existing processes to improve peri-discharge care as children transition from the hospital to the community.
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Affiliation(s)
- Matthew O. Wiens
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- BC Children’s Hospital Research Institute, Vancouver, Canada
- Walimu, Kampala, Uganda
| | - Vuong Nguyen
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
| | - Jeffrey N. Bone
- BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Elias Kumbakumba
- Department of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Abner Tagoola
- Jinja Regional Referral Hospital, Jinja City, Uganda
| | | | | | | | | | - Jesca Nsungwa
- Ministry of Health for the Republic of Uganda, Kampala, Uganda
| | - Charles Olaro
- Ministry of Health for the Republic of Uganda, Kampala, Uganda
| | - J. Mark Ansermino
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
- BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Niranjan Kissoon
- BC Children’s Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Charles P. Larson
- School of Population and Global Health, McGill University, Montréal, Canada
| | - Pascal M. Lavoie
- BC Children’s Hospital Research Institute, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Dustin Dunsmuir
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Peter P. Moschovis
- Division of Global Health, Massachusetts General Hospital, Boston, MA, United States of America
| | - Stefanie Novakowski
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | | | | | | | - Martina Knappett
- Institute for Global Health at BC Children’s and Women’s Hospital, Vancouver, Canada
| | - Nicholas West
- BC Children’s Hospital Research Institute, Vancouver, Canada
| | | | - Jerome Kabakyenga
- Maternal Newborn & Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
- Faculty of Medicine, Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
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Lyimo RE, Said YH, Kivuyo SL, Nkya D, Furia FF. Mortality and associated factors among children admitted to an intensive care unit in muhimbili national hospital, from the time of admission to three months after discharge: a prospective cohort study. BMC Pediatr 2024; 24:170. [PMID: 38459470 PMCID: PMC10921595 DOI: 10.1186/s12887-024-04620-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/04/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Mortality of children admitted to Intensive Care Units (ICU) is higher in low-to-middle-income countries (LMICs) as compared to high-income countries (HICs). There is paucity of information on outcomes following discharge from ICU, especially from sub-Saharan Africa region. This study was conducted to determine mortality and its associated factors among children admitted to Pediatric ICU (PICU) at Muhimbili National Hospital, from admission to three months after discharge. METHODOLOGY This was a hospital-based prospective cohort study conducted between July 2021 and May 2022, among children admitted to PICU who were followed up for 3-month after discharge. Structured questionnaires were used to collect data from their medical charts. Telephone interviews were made after discharge. Medical records and verbal autopsy were used to determine the cause of death after discharge. Cox regression analysis was performed to assess the association between variables. A p-value of < 0.05 was considered statistically significant. Survival after PICU discharge was estimated by Kaplan - Meier curve. RESULTS Of 323 children recruited, 177(54.8%) were male, with a median age of 17 months (1-168). The leading cause of PICU admission was severe sepsis 90/323(27.9%). A total of 161/323 children died, yielding an overall mortality of 49.8%. Of 173 children discharged from PICU, 33(19.1%) died. The leading cause of death among children who died in the general ward or as readmission into PICU was sepsis 4/17(23.5%). Respiratory diseases 4/16(25.0%) were the commonest cause of death among those who died after hospital discharge. Independent predictors of overall mortality included single organ dysfunction with hazard ratio(HR):5.97, 95% confidence interval (CI)(3.05-12.26)] and multiple organ dysfunction [HR:2.77,95%CI(1.03-2.21)]. Chronic illness[HR:8.13,95%CI(2.45-27.02)], thrombocytosis [HR:3.39,95%CI(1.32-8.73)], single[HR:3.57,95%CI(1.42-9.03)] and multiple organ dysfunction[HR:3.11,95%CI(1.01-9.61)] independently predicted post-PICU discharge mortality. CONCLUSION Overall mortality and post- PICU discharge mortality were high and more likely to affect children with organ dysfunction, chronic illness, and thrombocytosis. The leading causes of mortality post- PICU discharge were sepsis and respiratory diseases. There is a need for a focused follow up plan of children post- PICU discharge, further research on the long term survival and strategies to improve it.
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Affiliation(s)
- Rehema E Lyimo
- Department of Pediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Yasser H Said
- Department of Pediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Sokoine L Kivuyo
- Department of Pediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- National Institute for Medical Research, Dar es salaam, Tanzania
| | - Deogratias Nkya
- Department of Pediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Pediatric Cardiology, Jakaya Kikwete Cardiac Institute, Dar es salaam, Tanzania
| | - Francis F Furia
- Department of Pediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Paediatrics and Child Health, Muhimbili National Hospital, Dar es Salaam, Tanzania
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Rees CA, Ideh RC, Kisenge R, Kamara J, Coleman-Nekar YJG, Samma A, Godfrey E, Manji HK, Sudfeld CR, Westbrook AL, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP. Identifying neonates at risk for post-discharge mortality in Dar es Salaam, Tanzania, and Monrovia, Liberia: Derivation and internal validation of a novel risk assessment tool. BMJ Open 2024; 14:e079389. [PMID: 38365298 PMCID: PMC10875550 DOI: 10.1136/bmjopen-2023-079389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION The immediate period after hospital discharge carries a large burden of childhood mortality in sub-Saharan Africa. Our objective was to derive and internally validate a risk assessment tool to identify neonates discharged from the neonatal ward at risk for 60-day post-discharge mortality. METHODS We conducted a prospective observational cohort study of neonates discharged from Muhimbili National Hospital in Dar es Salaam, Tanzania, and John F Kennedy Medical Centre in Monrovia, Liberia. Research staff called caregivers to ascertain vital status up to 60 days after discharge. We conducted multivariable logistic regression analyses with best subset selection to identify socioeconomic, demographic, clinical, and anthropometric factors associated with post-discharge mortality. We used adjusted log coefficients to assign points to each variable and internally validated our tool with bootstrap validation with 500 repetitions. RESULTS There were 2344 neonates discharged and 2310 (98.5%) had post-discharge outcomes available. The median (IQR) age at discharge was 8 (4, 15) days; 1238 (53.6%) were male. In total, 71 (3.1%) died during follow-up (26.8% within 7 days of discharge). Leaving against medical advice (adjusted OR [aOR] 5.62, 95% CI 2.40 to 12.10) and diagnosis of meconium aspiration (aOR 6.98, 95% CI 1.69 to 21.70) conferred the greatest risk for post-discharge mortality. The risk assessment tool included nine variables (total possible score=63) and had an optimism corrected area under the receiver operating characteristic curve of 0.77 (95% CI 0.75 to 0.80). A score of ≥6 was most optimal (sensitivity 68.3% [95% CI 64.8% to 71.5%], specificity 72.1% [95% CI 71.5% to 72.7%]). CONCLUSIONS A small number of factors predicted all-cause, 60-day mortality after discharge from neonatal wards in Tanzania and Liberia. After external validation, this risk assessment tool may facilitate clinical decision making for eligibility for discharge and the direction of resources to follow-up high risk neonates.
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Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Readon C Ideh
- Department of Pediatrics, John F Kennedy Medical Center, Monrovia, Liberia
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Julia Kamara
- Department of Pediatrics, John F Kennedy Medical Center, Monrovia, Liberia
| | | | - Abraham Samma
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Evance Godfrey
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Hussein K Manji
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
- Accident and Emergency Department, The Aga Khan Health Services, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Christopher R Sudfeld
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Boston, USA
| | - Adrianna L Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Claudia R Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Cynthia G Whitney
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Robert F Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher P Duggan
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Boston, USA
- Center for Nutrition, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
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Atreya MR, Banerjee S, Lautz AJ, Alder MN, Varisco BM, Wong HR, Muszynski JA, Hall MW, Sanchez-Pinto LN, Kamaleswaran R. Machine learning-driven identification of the gene-expression signature associated with a persistent multiple organ dysfunction trajectory in critical illness. EBioMedicine 2024; 99:104938. [PMID: 38142638 PMCID: PMC10788426 DOI: 10.1016/j.ebiom.2023.104938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) disproportionately drives morbidity and mortality among critically ill patients. However, we lack a comprehensive understanding of its pathobiology. Identification of genes associated with a persistent MODS trajectory may shed light on underlying biology and allow for accurate prediction of those at-risk. METHODS Secondary analyses of publicly available gene-expression datasets. Supervised machine learning (ML) was used to identify a parsimonious set of genes associated with a persistent MODS trajectory in a training set of pediatric septic shock. We optimized model parameters and tested risk-prediction capabilities in independent validation and test datasets, respectively. We compared model performance relative to an established gene-set predictive of sepsis mortality. FINDINGS Patients with a persistent MODS trajectory had 568 differentially expressed genes and characterized by a dysregulated innate immune response. Supervised ML identified 111 genes associated with the outcome of interest on repeated cross-validation, with an AUROC of 0.87 (95% CI: 0.85-0.88) in the training set. The optimized model, limited to 20 genes, achieved AUROCs ranging from 0.74 to 0.79 in the validation and test sets to predict those with persistent MODS, regardless of host age and cause of organ dysfunction. Our classifier demonstrated reproducibility in identifying those with persistent MODS in comparison with a published gene-set predictive of sepsis mortality. INTERPRETATION We demonstrate the utility of supervised ML driven identification of the genes associated with persistent MODS. Pending validation in enriched cohorts with a high burden of organ dysfunction, such an approach may inform targeted delivery of interventions among at-risk patients. FUNDING H.R.W.'s NIHR35GM126943 award supported the work detailed in this manuscript. Upon his death, the award was transferred to M.N.A. M.R.A., N.S.P, and R.K were supported by NIHR21GM151703. R.K. was supported by R01GM139967.
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Affiliation(s)
- Mihir R Atreya
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA.
| | - Shayantan Banerjee
- Department of Biotechnology, Bhupat and Jyoti Mehta School of Biosciences, Indian Institute of Technology Madras, Chennai, 600 036, India
| | - Andrew J Lautz
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Matthew N Alder
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Brian M Varisco
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, 43205, OH, USA; Department of Pediatrics, Ohio State University, Columbus, 43205, OH, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, 43205, OH, USA; Department of Pediatrics, Ohio State University, Columbus, 43205, OH, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, 60611, IL, USA; Department of Health and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, 60611, IL, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, 30322, GA, United States; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, 30322, GA, United States
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Knappett M, Nguyen V, Chaudhry M, Trawin J, Kabakyenga J, Kumbakumba E, Jacob ST, Ansermino JM, Kissoon N, Mugisha NK, Wiens MO. Pediatric post-discharge mortality in resource-poor countries: a systematic review and meta-analysis. EClinicalMedicine 2024; 67:102380. [PMID: 38204490 PMCID: PMC10776442 DOI: 10.1016/j.eclinm.2023.102380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
Background Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to overall child mortality. With a substantial recent expansion of research and novel data synthesis methods, this study aims to update the current evidence base by providing a more nuanced understanding of the burden and associated risk factors of pediatric post-discharge mortality after acute illness. Methods Eligible studies published between January 1, 2017 and January 31, 2023, were retrieved using MEDLINE, Embase, and CINAHL databases. Studies published before 2017 were identified in a previous review and added to the total pool of studies. Only studies from countries with low or low-middle Socio-Demographic Index with a post-discharge observation period greater than seven days were included. Risk of bias was assessed using a modified version of the Joanna Briggs Institute critical appraisal tool for prevalence studies. Studies were grouped by patient population, and 6-month post-discharge mortality rates were quantified by random-effects meta-analysis. Secondary outcomes included post-discharge mortality relative to in-hospital mortality, pooled risk factor estimates, and pooled post-discharge Kaplan-Meier survival curves. PROSPERO study registration: #CRD42022350975. Findings Of 1963 articles screened, 42 eligible articles were identified and combined with 22 articles identified in the previous review, resulting in 64 total articles. These articles represented 46 unique patient cohorts and included a total of 105,560 children. For children admitted with a general acute illness, the pooled risk of mortality six months post-discharge was 4.4% (95% CI: 3.5%-5.4%, I2 = 94.2%, n = 11 studies, 34,457 children), and the pooled in-hospital mortality rate was 5.9% (95% CI: 4.2%-7.7%, I2 = 98.7%, n = 12 studies, 63,307 children). Among disease subgroups, severe malnutrition (12.2%, 95% CI: 6.2%-19.7%, I2 = 98.2%, n = 10 studies, 7760 children) and severe anemia (6.4%, 95% CI: 4.2%-9.1%, I2 = 93.3%, n = 9 studies, 7806 children) demonstrated the highest 6-month post-discharge mortality estimates. Diarrhea demonstrated the shortest median time to death (3.3 weeks) and anemia the longest (8.9 weeks). Most significant risk factors for post-discharge mortality included unplanned discharges, severe malnutrition, and HIV seropositivity. Interpretation Pediatric post-discharge mortality rates remain high in resource-poor settings, especially among children admitted with malnutrition or anemia. Global health strategies must prioritize this health issue by dedicating resources to research and policy innovation. Funding No specific funding was received.
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Affiliation(s)
- Martina Knappett
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Vuong Nguyen
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Maryum Chaudhry
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jessica Trawin
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jerome Kabakyenga
- Maternal Newborn & Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
- Faculty of Medicine, Dept of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Dept of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Shevin T. Jacob
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - J. Mark Ansermino
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
| | - Niranjan Kissoon
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
- Dept of Pediatrics, BC Children’s Hospital, University of British Columbia, Rm 2D19, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada
| | | | - Matthew O. Wiens
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
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Knappett M, Hooft A, Maqsood MB, Lavoie PM, Kortz T, Mehta S, Duby J, Akech S, Maina M, Carter R, Popescu CR, Daftary R, Mugisha NK, Mwesigwa D, Kabakyenga J, Kumbakumba E, Ansermino JM, Kissoon N, Mutekanga A, Hau D, Moschovis P, Kangwa M, Chen C, Firnberg M, Glomb N, Argent A, Reid SJ, Bhutta A, Wiens MO. Verbal Autopsy to Assess Postdischarge Mortality in Children With Suspected Sepsis in Uganda. Pediatrics 2023; 152:e2023062011. [PMID: 37800272 PMCID: PMC11006254 DOI: 10.1542/peds.2023-062011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Reducing child mortality in low-income countries is constrained by a lack of vital statistics. In the absence of such data, verbal autopsies provide an acceptable method to determining attributable causes of death. The objective was to assess potential causes of pediatric postdischarge mortality in children younger than age 5 years (under-5) originally admitted for suspected sepsis using verbal autopsies. METHODS Secondary analysis of verbal autopsy data from children admitted to 6 hospitals across Uganda from July 2017 to March 2020. Structured verbal autopsy interviews were conducted for all deaths within 6 months after discharge. Two physicians independently classified a primary cause of death, up to 4 alternative causes, and up to 5 contributing conditions using the Start-Up Mortality List, with discordance resolved by consensus. RESULTS Verbal autopsies were completed for 361 (98.6%) of the 366 (5.9%) children who died among 6191 discharges (median admission age: 5.4 months [interquartile range, 1.8-16.7]; median time to mortality: 28 days [interquartile range, 9-74]). Most deaths (62.3%) occurred in the community. Leading primary causes of death, assigned in 356 (98.6%) of cases, were pneumonia (26.2%), sepsis (22.1%), malaria (8.5%), and diarrhea (7.9%). Common contributors to death were malnutrition (50.5%) and anemia (25.7%). Reviewers were less confident in their causes of death for neonates than older children (P < .05). CONCLUSIONS Postdischarge mortality frequently occurred in the community in children admitted for suspected sepsis in Uganda. Analyses of the probable causes for these deaths using verbal autopsies suggest potential areas for interventions, focused on early detection of infections, as well as prevention and treatment of underlying contributors such as malnutrition and anemia.
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Affiliation(s)
- Martina Knappett
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
| | - Anneka Hooft
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Muhammad Bilal Maqsood
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Pascal M. Lavoie
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
| | - Teresa Kortz
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, California
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California
| | - Sonia Mehta
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Jessica Duby
- Department of Pediatrics, McGill University, Montreal, Canada
| | - Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Centre for Geographic Medicine Research–Coast, Kilifi, Kenya
| | - Michuki Maina
- Health Services Research Group, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Rebecca Carter
- Division of Neonatology, Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Constantin R. Popescu
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
- Division of Neonatology, Department of Pediatrics, Université Laval, Québec, Canada
| | - Rajesh Daftary
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | | | | | - Jerome Kabakyenga
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - J. Mark Ansermino
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Niranjan Kissoon
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | - Duncan Hau
- Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Peter Moschovis
- Division of Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mukuka Kangwa
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Carol Chen
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Maytal Firnberg
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Nicolaus Glomb
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Andrew Argent
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Stephen J. Reid
- Department of Family, Community and Emergency Care, University of Cape Town, Cape Town, South Africa
| | - Adnan Bhutta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew O. Wiens
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Walimu, Kampala, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
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