Childhood anemia at high altitude: risk factors for poor outcomes in severe pneumonia

Employing supervised machine learning algorithms for classification and prediction of anemia among youth girls in Ethiopia

In developing countries, one-quarter of young women have suffered from anemia. However, the available studies in Ethiopia have been usually used the traditional stastical methods. Therefore, this study aimed to employ multiple machine learning algorithms to identify the most effective model for the prediction of anemia among youth girls in Ethiopia. A total of 5642 weighted samples of young girls from the 2016 Ethiopian Demographic and Health Survey dataset were utilized. The data underwent preprocessing, with 80% of the observations used for training the model and 20% for testing. Eight machine learning algorithms were employed to build and compare models. The model performance was assessed using evaluation metrics in Python software. Various data balancing techniques were applied, and the Boruta algorithm was used to select the most relevant features. Besides, association rule mining was conducted using the Apriori algorithm in R software. The random forest classifier with an AUC value of 82% outperformed in predicting anemia among all the tested classifiers. Region, poor wealth index, no formal education, unimproved toilet facility, rural residence, not used contraceptive method, religion, age, no media exposure, occupation, and having more than 5 family size were the top attributes to predict anemia. Association rule mining was identified the top seven best rules that most frequently associated with anemia. The random forest classifier is the best for predicting anemia. Therefore, making it potentially valuable as decision-support tools for the relevant stakeholders and giving emphasis for the identified predictors could be an important intervention to halt anemia among youth girls.

What are the risk factors for death among children with pneumonia in low- and middle-income countries? A systematic review

Background

Knowledge of the risk factors for and causes of treatment failure and mortality in childhood pneumonia is important for prevention, diagnosis, and treatment at an individual and population level. This review aimed to identify the most important risk factors for mortality among children aged under ten years with pneumonia.

Methods

We systematically searched MEDLINE, EMBASE, and PubMed for observational and interventional studies reporting risk factors for mortality in children (aged two months to nine years) in low- and middle-income countries (LMICs). We screened articles according to specified inclusion and exclusion criteria, assessed risk of bias using the EPHPP framework, and extracted data on demographic, clinical, and laboratory risk factors for death. We synthesized data descriptively and using Forest plots and did not attempt meta-analysis due to the heterogeneity in study design, definitions, and populations.

Findings

We included 143 studies in this review. Hypoxaemia (low blood oxygen level), decreased conscious state, severe acute malnutrition, and the presence of an underlying chronic condition were the risk factors most strongly and consistently associated with increased mortality in children with pneumonia. Additional important clinical factors that were associated with mortality in the majority of studies included particular clinical signs (cyanosis, pallor, tachypnoea, chest indrawing, convulsions, diarrhoea), chronic comorbidities (anaemia, HIV infection, congenital heart disease, heart failure), as well as other non-severe forms of malnutrition. Important demographic factors associated with mortality in the majority of studies included age <12 months and inadequate immunisation. Important laboratory and investigation findings associated with mortality in the majority of studies included: confirmed Pneumocystis jirovecii pneumonia (PJP), consolidation on chest x-ray, pleural effusion on chest x-ray, and leukopenia. Several other demographic, clinical and laboratory findings were associated with mortality less consistently or in a small numbers of studies.

Conclusions

Risk assessment for children with pneumonia should include routine evaluation for hypoxaemia (pulse oximetry), decreased conscious state (e.g. AVPU), malnutrition (severe, moderate, and stunting), and the presence of an underlying chronic condition as these are strongly and consistently associated with increased mortality. Other potentially useful risk factors include the presence of pallor or anaemia, chest indrawing, young age (<12 months), inadequate immunisation, and leukopenia.

Epidemiology and mortality predictors for severe childhood community-acquired pneumonia in ICUs: A retrospective observational study

Background

To identify the epidemiology and mortality predictors of severe childhood community-acquired pneumonia (CAP) and evaluate the influence of medications on clinical outcomes in the real world.

Methods

We conducted a multicenter retrospective observational study among children aged ≤5 years with severe CAP, separately comparing the detailed information between those who experienced in-hospital death and those who survived in three different age groups. A multivariate logistic regression model was used to determine mortality predictors.

Results

A total of 945 children were recruited: 341 young children aged 2-59 months, 47 infants aged 29 days to 2 months, and 557 neonates aged less than 28 days. A total of 88 deaths occurred (9.3%). There was low adherence to antimicrobial guidelines in the group aged 2-59 months, and carbapenems widely served as initial empirical regimens. However, analysis of all three age groups showed that the efficacy of antibacterial drugs with initial empirical selection grades higher than those recommended by the guidelines was not better than that of antibacterial drugs with grades recommended by the guidelines. In multivariate analyses, very severe pneumonia (odds ratio (OR): 3.48; 95% confidence interval (CI): 1.36-8.93), lower birth weight (OR: 4.64; 95% CI: 1.78-12.20), severe underweight (OR: 6.06; 95% CI: 2.34-15.63), mechanical ventilation (OR: 2.58; 95% CI: 1.00-6.62; OR: 15.63; 95% CI 3.25-76.92), a higher number of comorbidities (OR: 8.40; 95% CI: 1.89-37.04), comorbidities including anemia (OR: 5.24; 95% CI: 2.33-11.76) and gastrointestinal hemorrhage (OR: 3.79; 95% CI: 1.36-10.53), and the use of sedative-hypnotics (OR: 2.60; 95% CI: 1.14-5.95) were independent risk factors for death; infants treated with probiotics had a lower mortality rate (OR: 0.14; 95% CI: 0.06-0.33).

Conclusions

Severe CAP remains a primary cause of death in children under 5 years of age. Clinical characteristics, comorbidities and medications are evidently associated with death. Importantly, we should pay particular attention to the identification of mortality predictors and establish prophylactic measures to reduce mortality.

Anemia is associated with severe illness in COVID-19: A retrospective cohort study

Anemia commonly aggravates the severity of respiratory diseases, whereas thus far, few studies have elucidated the impact of anemia on coronavirus disease 2019 (COVID‐19). The aim of this study was to evaluate the clinical characteristics of patients with anemia, and to further explore the relationship between anemia and the severity of COVID‐19. In this single‐center, retrospective, observational study, a total of 222 confirmed patients admitted to Wuhan Ninth Hospital from 1 December 2019 to 20 March 2020 were recruited, including 79 patients with anemia and 143 patients without anemia. Clinical characteristics, laboratory findings, disease progression and prognosis were collected and analyzed. Risk factors associated with the severe illness in COVID‐19 were established by univariable and multivariable logistic regression models. In our cohort, compared to patients without anemia, patients with anemia were more likely to have one or more comorbidities and severe COVID‐19 illness. More patients demonstrated elevated levels of C‐reactive protein (CRP), procalcitonin (PCT) and creatinine in anemia group. Levels of erythrocyte sedimentation rate, D‐dimer, myoglobin, T‐pro brain natriuretic peptide (T‐pro‐BNP) and urea nitrogen in patients with anemia were significantly higher than those without. In addition, the proportion of patients with dyspnea, elevated CRP, and PCT was positively associated with the severity of anemia. The odd ratio of anemia related to the severe condition of COVID‐19 was 3.47 (95% confidence interval [CI]: 1.02‐11.75; P = .046) and 3.77 (95% CI: 1.33‐10.71; P = .013) after adjustment for baseline date and laboratory indices, respectively. Anemia is an independent risk factor associated with the severe illness of COVID‐19, and healthcare professionals should be more sensitive to the hemoglobin levels of COVID‐19 patients on admission. Awareness of anemia as a risk factor for COVID‐19 was of great significance.

Anemia is an independent risk factor associated with the severe illness of COVID‐19.

Covid‐19 patients with anemia exhibit severe inflammation response, which is positively associated with the severity of anemia.

Covid‐19 patients with anemia are older and exhibit severe organ injuries including poorer lung function, more serious myocardial injury and renal dysfunction.

Challenges in the diagnosis of paediatric pneumonia in intervention field trials: recommendations from a pneumonia field trial working group

Pneumonia is a leading killer of children younger than 5 years despite high vaccination coverage, improved nutrition, and widespread implementation of the Integrated Management of Childhood Illnesses algorithm. Assessing the effect of interventions on childhood pneumonia is challenging because the choice of case definition and surveillance approach can affect the identification of pneumonia substantially. In anticipation of an intervention trial aimed to reduce childhood pneumonia by lowering household air pollution, we created a working group to provide recommendations regarding study design and implementation. We suggest to, first, select a standard case definition that combines acute (≤14 days) respiratory symptoms and signs and general danger signs with ancillary tests (such as chest imaging and pulse oximetry) to improve pneumonia identification; second, to prioritise active hospital-based pneumonia surveillance over passive case finding or home-based surveillance to reduce the risk of non-differential misclassification of pneumonia and, as a result, a reduced effect size in a randomised trial; and, lastly, to consider longitudinal follow-up of children younger than 1 year, as this age group has the highest incidence of severe pneumonia.

Infant anemia is associated with reduced TLR-stimulated cytokine responses and increased nasopharyngeal colonization with Moxarella catarrhalis

Anemia is a major public health problem in young children. Reports on the role of anemia on infectious diseases remained controversial. We aim to investigate the effect of anemia on innate immunity, nasopharyngeal bacterial colonization, and subsequent infectious outcome. Blood tests were examined at the age of 12 months. TLR-induced cytokine production was assessed by ELISA. Bacteria from nasopharyngeal specimens were identified with traditional culture. Clinical infectious diseases were followed yearly until 3 years of age. Result showed that of the 423 infants, 72 had hemoglobin level ≤ 11 g/dL, among which 55% had normal iron level. There was significant association between hemoglobin level and TLR1-2, and 4 induced IL-6 (p = 0.04, 0.02) and that of TLR4 stimulated TNF-α response (p = 0.04). Children with anemia had higher nasopharyngeal colonization with Moxarella catarrhalis. Clinical analysis did not show anemia to be associated with infectious morbidity. However, children who developed LRTIs had mean lower ferritin levels. We speculated that iron might be the key factor related to infectious morbidity. Thus, to investigate the role of anemia in infectious diseases, it is important to first consider the prevalence of iron deficit, since the incidence of iron deficiency-induced anemia may vary among different regions.

Appropriateness of clinical severity classification of new WHO childhood pneumonia guidance: a multi-hospital, retrospective, cohort study

BACKGROUND

Management of pneumonia in many low-income and middle-income countries is based on WHO guidelines that classify children according to clinical signs that define thresholds of risk. We aimed to establish whether some children categorised as eligible for outpatient treatment might have a risk of death warranting their treatment in hospital.

METHODS

We did a retrospective cohort study of children aged 2-59 months admitted to one of 14 hospitals in Kenya with pneumonia between March 1, 2014, and Feb 29, 2016, before revised WHO pneumonia guidelines were adopted in the country. We modelled associations with inpatient mortality using logistic regression and calculated absolute risks of mortality for presenting clinical features among children who would, as part of revised WHO pneumonia guidelines, be eligible for outpatient treatment (non-severe pneumonia).

FINDINGS

We assessed 16 162 children who were admitted to hospital in this period. 832 (5%) of 16 031 children died. Among groups defined according to new WHO guidelines, 321 (3%) of 11 788 patients with non-severe pneumonia died compared with 488 (14%) of 3434 patients with severe pneumonia. Three characteristics were strongly associated with death of children retrospectively classified as having non-severe pneumonia: severe pallor (adjusted risk ratio 5·9, 95% CI 5·1-6·8), mild to moderate pallor (3·4, 3·0-3·8), and weight-for-age Z score (WAZ) less than -3 SD (3·8, 3·4-4·3). Additional factors that were independently associated with death were: WAZ less than -2 to -3 SD, age younger than 12 months, lower chest wall indrawing, respiratory rate of 70 breaths per min or more, female sex, admission to hospital in a malaria endemic region, moderate dehydration, and an axillary temperature of 39°C or more.

INTERPRETATION

In settings of high mortality, WAZ less than -3 SD or any degree of pallor among children with non-severe pneumonia was associated with a clinically important risk of death. Our data suggest that admission to hospital should not be denied to children with these signs and we urge clinicians to consider these risk factors in addition to WHO criteria in their decision making.

FUNDING

Wellcome Trust.

Differences in Nutritional and Health Status in School Children from the Highlands and Lowlands of Bolivia

Children in the Bolivian Andes are exposed to endemic infections and meager nourishment, and live under poor hygienic conditions. The prevention of children malnutrition is a priority in many countries including Bolivia. In this study, the health status of schoolchildren in Taraco, a Puna district, at 4,000 meters above sea level (masl) and in Caranavi, at 650 masl in the wealthier subtropical valleys, was compared. The weight, height, and hematological and biochemical parameters in blood, parasites in stool, and clinical information in 120 children from rural Taraco and in 96 from semi-urban Caranavi, both predominantly of Aymara ethnicity, were registered. Eleven percent of Taraco children were undernourished compared with 3% in Caranavi. Instead, 41% of the children in Caranavi were obese or overweight, compared with 8% in Taraco. Anemia was found in 74% of the children in Taraco compared with 7% in Caranavi. Albumin levels were normal in all samples, albeit lower in Taraco. Similar and normal serum zinc levels were measured in both groups. Approximately 60% of the children in both locations showed insufficient vitamin D levels, with lower levels in Taraco children. Hymenolepis nana and Entamoeba coli, parasites determinant of poor hygienic conditions, were respectively detected in 78% and 21% of fecal samples from Taraco, and in 29% and 8% of samples from Caranavi. We show increased anemia, nutritional deficiencies, and indications of poor hygienic conditions in highlands compared with lowlands. The prevalence of obesity in the lowlands demands addressing diverse nutritional deficiencies in the regions of Bolivia.

Iron Status at Age 6 Months in Colombian Infants Exclusively Breast-fed for 4 to 5 Versus 6 Months

OBJECTIVES

The optimal age for introducing complementary feeding to breast-fed infants may differ depending on the setting. Prolonged exclusive breast-feeding (EBF) protects against infection but may increase the risk of iron deficiency (ID)/anaemia (IDA) in vulnerable infants. The aim of the present study was to compare haemoglobin (Hb), serum ferritin (SF), anaemia (Hb < 11 g/L), ID (SF < 12 μg/L) and IDA (Hb < 10.5 g/dL + Hct < 33% + ID) using observational analyses in 6-month old infants from Bogota, Colombia who were EBF for 4 to 5 versus 6 months or older, and examine predictors.

METHODS

Infant feeding was recorded, anthropometry performed, and blood obtained for Hb and SF at 6 months in healthy term infants (birth weight > 2500 g), all EBF for ≥4 months.

RESULTS

One hundred eight infants (54% boys) were recruited; 46% EBF for 4 to 5 months, 54% EBF at 6 months. Prevalence of anaemia, ID, and IDA was 20%, 10%, and 5%, with no significant difference between EBF4-5 and EBF6 groups. In multivariate models, anaemia/ID were predicted by greater weight gain from 0 to 6 months, and anaemia also by caesarean delivery; Hb was lower in infants with higher intake of cows' milk; SF was lower in boys and those with greater weight gain. EBF4-5 versus EBF6 was not a significant predictor of any outcome.

CONCLUSIONS

Anaemia and ID were common at 6 months but were not affected by EBF for 4 to 5 versus 6 months, suggesting 6 months EBF is safe in this population. Further research is, however, required to examine effects on later iron status. The findings highlight the need to emphasise avoidance of cow's milk before 12 months.

Etiology of severe pneumonia in Ecuadorian children

BACKGROUND

In Latin America, community-acquired pneumonia remains a major cause of morbidity and mortality among children. Few studies have examined the etiology of pneumonia in Ecuador.

METHODS

This observational study was part of a randomized, double blind, placebo-controlled clinical trial conducted among children aged 2-59 months with severe pneumonia in Quito, Ecuador. Nasopharyngeal and blood samples were tested for bacterial and viral etiology by polymerase chain reaction. Risk factors for specific respiratory pathogens were also evaluated.

RESULTS

Among 406 children tested, 159 (39.2%) had respiratory syncytial virus (RSV), 71 (17.5%) had human metapneumovirus (hMPV), and 62 (15.3%) had adenovirus. Streptococcus pneumoniae was identified in 37 (9.2%) samples and Mycoplasma pneumoniae in three (0.74%) samples. The yearly circulation pattern of RSV (P = 0.0003) overlapped with S. pneumoniae, (P = 0.03) with most cases occurring in the rainy season. In multivariable analysis, risk factors for RSV included younger age (adjusted odds ratio [aOR] = 1.9, P = 0.01) and being underweight (aOR = 1.8, P = 0.04). Maternal education (aOR = 0.82, P = 0.003), pulse oximetry (aOR = 0.93, P = 0.005), and rales (aOR = 0.25, P = 0.007) were associated with influenza A. Younger age (aOR = 3.5, P = 0.007) and elevated baseline respiratory rate were associated with HPIV-3 infection (aOR = 0.94, P = 0.03).

CONCLUSION

These results indicate the importance of RSV and influenza, and potentially modifiable risk factors including undernutrition and future use of a RSV vaccine, when an effective vaccine becomes available.

TRIAL REGISTRATION

ClinicalTrials.gov NCT 00513929.

Emergency treatment and nursing of children with severe pneumonia complicated by heart failure and respiratory failure: 10 case reports

Pneumonia refers to lung inflammation caused by different pathogens or other factors, and is a common pediatric disease occurring in infants and young children. It is closely related to the anatomical and physiological characteristics of infants and young children and is more frequent during winter and spring, or sudden changes in temperature. Pneumonia is a serious disease that poses a threat to children's health and its morbidity and mortality rank first, accounting for 24.5-65.2% of pediatric inpatients. Due to juvenile age, severe illness and rapid changes, children often suffer acute heart failure, respiratory failure and even toxic encephalopathy at the same time. The concurrence in different stages of the process of emergency treatment tends to relapse, which directly places the lives of these children at risk. Severe pneumonia constitutes one of the main causes of infant mortality. In the process of nursing children with severe pneumonia, intensive care was provided, including condition assessment and diagnosis, close observation of disease, keeping the airway unblocked, rational oxygen therapy, prevention and treatment of respiratory and circulatory failure, support of vital organs, complications, and health education. The inflammatory response was proactively controlled, to prevent suffocation and reduce mortality. In summary, positive and effective nursing can promote the rehabilitation of children patients, which can be reinforced with adequate communication with the parents and/or caretakers.

Estimating the mutation load in human genomes

Next-generation sequencing technology has facilitated the discovery of millions of genetic variants in human genomes. A sizeable fraction of these variants are predicted to be deleterious. Here, we review the pattern of deleterious alleles as ascertained in genome sequencing data sets and ask whether human populations differ in their predicted burden of deleterious alleles - a phenomenon known as mutation load. We discuss three demographic models that are predicted to affect mutation load and relate these models to the evidence (or the lack thereof) for variation in the efficacy of purifying selection in diverse human genomes. We also emphasize why accurate estimation of mutation load depends on assumptions regarding the distribution of dominance and selection coefficients - quantities that remain poorly characterized for current genomic data sets.

Risk factors for a poor outcome among children admitted with clinically severe pneumonia to a university hospital in Rabat, Morocco

•

Pneumonia remains one of the major killers of children in a middle-income country such as Morocco.

•

A history of prematurity, a history of fever, leaving in a house with smokers, impaired consciousness, cyanosis, pallor, having ronchi on auscultation and human metapneumovirus infection are all independent risk factors for an adverse outcome.

•

A history of asthma is independently associated with a positive outcome.

•

Early identification of risk factors for an adverse outcome could improve overall prognosis.

Objectives

Data on prognostic factors among children with severe pneumonia are scarce in middle-income countries. We investigated prognostic factors for an adverse outcome among children admitted to the Hôpital d’Enfants de Rabat, Morocco with World Health Organization-defined clinically severe pneumonia (CSP).

Methods

Children aged 2–59 months admitted to the hospital and fulfilling the CSP definition were recruited into this 13-month prospective study. A poor prognosis was defined as death, a need for intensive care, or a Respiratory Index of Severity in Children (RISC) score ≥3. Multivariate logistic regression was performed to ascertain independent predictive factors for a poor prognosis.

Results

Of the 689 children included in this analysis, 55 (8.0%) required intensive care and 28 died (4.0%). Five hundred and two (72.8%) children were classified as having a good prognosis and 187 (27.2%) as having a poor prognosis. A history of prematurity (odds ratio (OR) 2.50, 95% confidence interval (CI) 1.24–5.04), of fever (OR 2.25, 95% CI 1.32–3.83), living in a house with smokers (OR 1.79, 95% CI 1.18–2.72), impaired consciousness (OR 10.96, 95% CI 2.88–41.73), cyanosis (OR 2.09, 95% CI 1.05–4.15), pallor (OR 2.27, 95% CI 1.34–3.84), having rhonchi on auscultation (OR 2.45, 95% CI 1.58–3.79), and human metapneumovirus infection (OR 2.13, 95% CI 1.13–4.02) were all independent risk factors for an adverse outcome, whereas a history of asthma (OR 0.46, 95% CI 0.25–0.84) was the only independent risk factor for a positive outcome.

Conclusions

The early identification of factors associated with a poor prognosis could improve management strategies and the likelihood of survival of Moroccan children with severe pneumonia.

Global emergency medicine: a review of the literature from 2013

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and grey literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a worldwide audience of academics and clinical practitioners.

METHODS

This year 8,768 articles written in six languages were identified by our search. These articles were distributed among 22 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the grey literature. A total of 434 articles were deemed appropriate by at least one reviewer and approved by an editor for formal scoring of overall quality and importance.

RESULTS

Of the 434 articles that met our predetermined inclusion criteria, 65% were categorized as emergency care in resource-limited settings, 18% as EM development, and 17% as disaster and humanitarian response. A total of 24 articles received scores of 18 or higher and were selected for formal summary and critique. Interrater reliability for two reviewers using our scoring system was good, with an intraclass correlation coefficient of 0.63 (95% confidence interval = 0.55 to 0.69). Infectious diseases, trauma, and the diagnosis and treatment of diseases common in resource-limited settings represented the majority of articles selected for final review.

CONCLUSIONS

In 2013, there were more emergency care in resource-limited settings articles, while the number of disaster and humanitarian response articles decreased, when compared to the 2012 review. However, the distribution of articles selected for full review did not change significantly. As in prior years, the majority of articles focused on infectious diseases, as well as trauma and injury prevention.