A comparison between raw and predicted mortality in a paediatric intensive care unit in South Africa

A Retrospective Observational Study of the Impact of HIV Status on the Outcome of Paediatric Intensive Care Unit Admissions at a Tertiary Hospital in South Africa (2015-2019)

HIV-infected and HIV-exposed but uninfected (HEU) children have unique health risks. Our study looked at how HIV exposure and infection impact presentation and outcomes in PICU in an era of improved ART. A retrospective analysis of children admitted to PICU was performed. The sample was divided into HIV negative, HEU and HIV infected, and presentation and outcomes were compared with a significance level set at α = 0.05. Our study showed that 16% (109/678) of children admitted to PICU were HEU and 5.2% (35/678) were HIV infected. HIV-infected children were admitted at a younger age (median two months) with an increased incidence of lower respiratory infections than HIV-negative children (p < 0.001); they also required longer ventilation and admission (p < 0.001). HIV-infected children had a higher mortality (40%) (p = 0.02) than HIV-negative (22.7%) children; this difference was not significant when comparing only children with a non-surgical diagnosis (p = 0.273). HEU children had no significant difference in duration of ICU stay (p = 0.163), ventilation (p = 0.443) or mortality (p = 0.292) compared to HIV-negative children. In conclusion, HIV-infected children presented with more severe disease requiring longer ventilation and admission. HEU had similar outcomes to HIV-negative children.

The magnitude of pediatric mortality and determinant factors in intensive care units in a low-resource country, Ethiopia: a systematic review and meta-analysis

Background

Pediatric mortality after being admitted to a pediatric intensive care unit in Ethiopia is high when compared to high-income countries. There are limited studies regarding pediatric mortality in Ethiopia. This systematic review and meta-analysis aimed to assess the magnitude and predictors of pediatric mortality after being admitted to an intensive care unit in Ethiopia.

Methods

This review was conducted in Ethiopia after retrieving peer-reviewed articles and evaluating their quality using AMSTAR 2 criteria. An electronic database was used as a source of information, including PubMed, Google Scholar, and Africa Journal of Online Databases, using AND/OR Boolean operators. Random effects of the meta-analysis were used to show the pooled mortality of pediatric patients and its predictors. A funnel plot was used to assess the publication bias, and heterogeneity was also checked. The final result were expressed as an overall pooled percentage and odds ratio with a 95% confidence interval (CI) of < 0.05%.

Results

In our review, eight studies were used for the final analysis with a total population of 2,345. The overall pooled mortality of pediatric patients after being admitted to the pediatric intensive care unit was 28.5% (95% CI: 19.06, 37.98). The pooled mortality determinant factors were included the use of a mechanical ventilator with an odds ratio (OR) of 2.64 (95% CI: 1.99, 3.30); the level of Glasgow Coma Scale <8 with an OR of 2.29 (95% CI: 1.38, 3.19); the presence of comorbidity with an OR of 2.18 (95% CI: 1.41, 2.95); and the use of inotropes with an OR of 2.36 (95% CI: 1.65, 3.06).

Conclusion

In our review, the overall pooled mortality of pediatric patients after being admitted to the intensive care unit was high. Particular caution should be taken in patients on the use of mechanical ventilators, the level of Glasgow Coma Scale of <8, the presence of comorbidity, and the use of inotropes.

Systematic review registration

https://www.researchregistry.com/browse-the-registry#registryofsystematicreviewsmeta-analyses/, identifier: 1460.

Cytomegalovirus Viremia Predicts Postdischarge Mortality in Kenyan HIV-Exposed Uninfected Children

BACKGROUND

Cytomegalovirus (CMV) viremia is associated with mortality in severely ill immunocompetent adults and hospitalized children with HIV (CWH). We measured CMV viremia in HIV-exposed and -unexposed Kenyan children aged 1-59 months discharged from hospital and determined its relationship with postdischarge mortality.

METHODS

CMV DNA levels were measured in plasma from 1024 children (97 of which were HIV exposed uninfected [HEU], and 15 CWH). Poisson and Cox proportional hazards regression models were used to identify correlates of CMV viremia ≥ 1000 IU/mL 
and estimate associations with 6-month mortality, respectively.

RESULTS

CMV viremia was detected in 31% of children, with levels ≥ 1000 IU/mL in 5.8%. HIV infection, age < 2 years, breastfeeding, and midupper arm circumference < 12.5 cm were associated with CMV viremia ≥ 1000 IU/mL. Among HEU children, CMV ≥ 1000 IU/mL (hazard ratio [HR] = 32.0; 95% confidence interval [CI], 2.9-354.0; P = .005) and each 1-log increase in CMV viral load (HR = 5.04; 95% CI, 1.7-14.6; P = .003) were associated with increased risk of mortality. CMV viremia was not significantly associated with mortality in HIV-unexposed children.

CONCLUSIONS

CMV levels at hospital postdischarge predict increased risk of 6-month mortality in Kenyan HEU children. CMV suppression may be a novel target to reduce mortality in HEU children.

CLINICAL TRIAL REGISTRATION

NCT02414399.

An Artificial Neural Network Model for Pediatric Mortality Prediction in Two Tertiary Pediatric Intensive Care Units in South Africa. A Development Study

OBJECTIVES

The performance of mortality prediction models remain a challenge in lower- and middle-income countries. We developed an artificial neural network (ANN) model for the prediction of mortality in two tertiary pediatric intensive care units (PICUs) in South Africa using free to download and use software and commercially available computers. These models were compared to a logistic regression model and a recalibrated version of the Pediatric Index of Mortality 3.

DESIGN

This study used data from a retrospective cohort study to develop an artificial neural model and logistic regression model for mortality prediction. The outcome evaluated was death in PICU.

SETTING

Two tertiary PICUs in South Africa.

PATIENTS

2,089 patients up to the age of 13 completed years were included in the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The AUROC was higher for the ANN (0.89) than for the logistic regression model (LR) (0.87) and the recalibrated PIM3 model (0.86). The precision recall curve however favors the ANN over logistic regression and recalibrated PIM3 (AUPRC = 0.6 vs. 0.53 and 0.58, respectively. The slope of the calibration curve was 1.12 for the ANN model (intercept 0.01), 1.09 for the logistic regression model (intercept 0.05) and 1.02 (intercept 0.01) for the recalibrated version of PIM3. The calibration curve was however closer to the diagonal for the ANN model.

CONCLUSIONS

Artificial neural network models are a feasible method for mortality prediction in lower- and middle-income countries but significant challenges exist. There is a need to conduct research directed toward the acquisition of large, complex data sets, the integration of documented clinical care into clinical research and the promotion of the development of electronic health record systems in lower and middle income settings.

Pediatric Index of Mortality 3-An Evaluation of Function Among ICUs In South Africa

OBJECTIVES

To evaluate the performance of the Pediatric Index of Mortality 3 as mortality risk assessment model.

DESIGN

This prospective study included all admissions 30 days to 18 years old for 12 months during 2016 and 2017. Data gathered included the following: age and gender, diagnosis and reason for PICU admission, data specific for the Pediatric Index of Mortality 3 calculation, PICU outcomes (death or survival), and length of PICU stay.

SETTING

Nine units that care for children within tertiary or quaternary academic hospitals in South Africa.

PATIENTS

All admissions 30 days to 18 years old, excluding premature infants, children who died within 2 hours of admission, or children transferred to other PICUs, and those older than 18 years old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 3,681 admissions of which 2,253 (61.3%) were male. The median age was 18 months (interquartile range, 6-59.5 mo). There were 354 deaths (9.6%). The Pediatric Index of Mortality 3 predicted 277.47 deaths (7.5%). The overall standardized mortality ratio was 1.28. The area under the receiver operating characteristic curve was 0.81 (95% CI 0.79-0.83). The Hosmer-Lemeshow goodness-of-fit test statistic was 174.4 (p < 0.001). Standardized mortality ratio for all age groups was greater than 1. Standardized mortality ratio for diagnostic subgroups was mostly greater than 1 except for those whose reason for PICU admission was classified as accident, toxin and envenomation, and metabolic which had an standardized mortality ratio less than 1. There were similar proportions of respiratory patients, but significantly greater proportions of neurologic and cardiac (including postoperative) patients in the Pediatric Index of Mortality 3 derivation cohort than the South African cohort. In contrast, the South African cohort contained a significantly greater proportion of miscellaneous (including injury/accident victims) and postoperative noncardiac patients.

CONCLUSIONS

The Pediatric Index of Mortality 3 discrimination between death and survival among South African units was good. Case-mix differences between these units and the Pediatric Index of Mortality 3 derivation cohort may partly explain the poor calibration. We need to recalibrate Pediatric Index of Mortality 3 to the local setting.