Date de publication: / Author: Zhang, Cherri - Lunaris - Découvrez les données de recherche canadiennes Résultats de recherche

Epidemiology of pediatric post-discharge mortality in Rwanda

Borealis

Umuhoza, Christian; Zhang, Cherri; Hooft, Anneka; Trawin, Jessica; Uwiragiye, Emmanuel; Mfuranziza, Cynthia Grace; Nguyen, Vuong; Lewis, Peter; Kornblith, Aaron E; Kenya-Mughisha, Nathan; Wiens, Matthew O — 2024-04-18 Background:In Sub-Saharan Africa, pediatric post-discharge death is increasingly recognized as an important contributor to mortality. To address morbidity and mortality during this period, it is critical to generate a representative evidence base throughout sub-Saharan Africa to inform resource prioritization, as well as policy and guideline development. To date, no studies have been conducted in Rwanda, limiting the understanding of the epidemiology of post-discharge mortality in this region. This study aims to describe the epidemiology of post-discharge mortality in a group of children admitted for suspected sepsis in Rwanda. Methods: We prospectively recruited children aged 0-60 months admitted for suspected sepsis at two sites in Rwanda: Ruhengeri Referral Hospital in Musanze, Rwanda (rural) and University Hospital of Kigali in Kigali, Rwanda (urban) from May 2022 - February 2023. Clinical, laboratory and social variables were collected at admission. Following discharge, participants were followed up to 6 months to determine vital status and health-seeking. We analyzed data in two age-specific cohorts, defined a priori: 0-6m and 6-60m. Multivariate logistic regression was used to identify risk factors. Age-stratified Kaplan-Meier curves were used to estimate the cumulative hazard of 6-month post-discharge mortality. Findings:Of 1218 children enrolled, 115 died (11%): 50% in-hospital (n=57) and 50% after discharge (n=58). Post-discharge mortality was higher in 0-6m cohort (n=28/274, 10%) than in those 6-60m (30/850, 4%), and in Kigali (n=37/413, 9%) vs Ruhengeri (n=21/805, 3%). Median time to post-discharge death was ~1 month (38d in 0-6m; 33d in 6-60m). In both cohorts, increased odds of post-discharge death were associated with weight-for-age z-score <-3 (OR=3.16 (1.26-7.93), 0-6m; OR=7.44 (2.93-18.89), 6-60m) while higher maternal education was protective (OR=0.15 (0.03-0.85), 0-6m; OR=0.09 (0.02-0.75), 6-60m). Abnormal coma scale (OR=3.29 (1.47-7.38)), travel time of >2h (OR=4.63 (1.40-15.22)) and being referred for higher level of care (OR=4.09 (1.04-16.12)) were significant in 6-60 months. Younger children were at highest risk of cumulative mortality. Ethics Declaration: Ethical approval was obtained from the University of Rwanda College of Medicine and Health Sciences (No 411/CMHS IRB/2021); University Teaching Hospital of Kigali (EC/CHUK/005/2022), University of California San Francisco (381688) and the University of British Columbia (H21-02795).

Smart Discharges to improve pediatric post-discharge survival

Borealis

Wiens, Matthew O; Tagoola, Abner; Kissoon, Niranjan; Ansermino, J Mark; Oyella Sherine, Sheila; Byaruhanga, Emmanuel; Ssemwanga, Edwards; Zhang, Cherri; Nguyen, Vuong; Bone, Jeffery N; Kenya Mugisha, Nathan; Kumbakumba, Elias; Kabakyenga, Jerome — 2024-07-22 Background: In Sub-Saharan Africa, pediatric post-discharge death is increasingly recognized as an important contributor to mortality. Current studies evaluating interventional approaches for post-discharge mortality focus on pharmacologic therapy, though only malaria prophylaxis post-discharge appears effective. Approaches to reduce vulnerability through health system strengthening approaches may further help to improve outcomes. This study aimed to evaluate the impact of a risk-differentiated approach to improved peri-discharge care on post-discharge mortality among children under 60 months. Methods: We conducted a prospective parallel cluster crossover trial at 6 hospitals in Uganda. Children <60 months admitted due to suspected infectious illness were eligible for enrollment. Phase 1 was a comparative control. During phase 2, enrolled children were screened for post-discharge mortality risk at admission using a multivariable risk algorithm. All children received counselling on post-discharge care practices during admission and at discharge. High-risk children received referrals and automated SMS engagement at 2, 7 and 14 days at a clinic of their choice, or by a community health worker. Survival analysis, adjusting for age, sex, site, period time and predicted risk of mortality was used to estimate the effect of the intervention on 6-month all-cause post-discharge mortality. Findings: 13,050 patients were enrolled (phase 1: n=6954; phase 2: n=6096) and had complete 6-month follow-up. Baseline characteristics were similar between groups. The median age was 0.8 months (IQR: 0.2-1.7), with 56% of participants male. The multivariable risk algorithm gave a mean predicted risk of post-discharge mortality of 6.1% in phase 1 and 5.9% in phase 2. The rate of post-discharge mortality was 6.0% during phase 1 and 4.9% during phase 2, with an adjusted hazard ratio of 0.77 (95% CI – 0.90), favoring the intervention. Additional sensitivity analysis using different sets of covariates in the model showed similar results. Ethics Declaration: These studies were approved by the Mbarara University of Science and Technology (No. 15/10-16), the Uganda National Council for Science and Technology (HS 2207), and the University of British Columbia (H16-02679). NOTE for restricted files: If you are not yet a CoLab member, please complete our <a href = "https://rc.bcchr.ca/redcap/surveys/?s=EDCYL7AC79">membership application survey</a> to gain access to restricted files within 2 business days. Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator at <a href = mailto:sepsiscolab@bccchr.ca>sepsiscolab@bcchr.ca</a> or visit our <a href = "https://wfpiccs.org/pediatric-sepsis-colab/">website</a>.

Geographical validation of the Smart Triage Model by age group

Borealis

Zhang, Cherri; Wiens, Matthew O; Dunsmuir, Dustin; Pillay, Yashodani; Huxford, Charly; Kimutai, David; Tenywa, Emmanuel; Ouma, Mary; Kigo, Joyce; Kamau, Stephen; Chege, Mary; Kenya-Mugisha, Nathan; Mwaka, Savio; Dumont, Guy A; Kisson, Niranjan; Akech, Samuel; Ansermino, J Mark — 2024-06-12 Background: Age is an important risk factor among critically ill children with neonates being the most vulnerable. Clinical prediction models need to account for age differences and must be externally validated and updated, if necessary, to enhance reliability, reproducibility, and generalizability. We externally validated the Smart Triage model using a combined prospective baseline cohort from three hospitals in Uganda and two in Kenya using admission, mortality, and readmission. Methods: We evaluated model discrimination using area under the receiver-operator curve (AUROC) and visualized calibration plots. In addition, we performed subsetting analysis based on age groups (< 30 days, ≤ 2 months, ≤ 6 months, and < 5 years). We revised the model for neonates (< 1 month) by re-estimating the intercept and coefficients and selected new thresholds to maximize sensitivity and specificity. 11595 participants under the age of five (under-5) were included in the analysis. Results: The proportion with an outcome ranged from 8.9% in all children under-5 (including neonates) to 26% in the neonatal subset alone. The model achieved good discrimination for children under-5 with AUROC of 0.81 (95% CI: 0.79-0.82) but poor discrimination for neonates with AUROC of 0.62 (95% CI: 0.55-0.70). Sensitivity at the low-risk thresholds (CI) were 0.85 (0.83-0.87) and 0.68 (0.58-0.76) for children under-5 and neonates, respectively. Specificity at the high-risk thresholds were 0.93 (0.93-0.94) and 0.96 (0.94-0.98) for children under-5 and neonates, respectively. After model revision for neonates, we achieved an AUROC of 0.83 (0.79-0.87) with 13% and 41% as the low- and high-risk thresholds, respectively. Discussion: The Smart Triage model showed good discrimination for children under-5. However, a revised model is recommended for neonates due to their uniqueness in disease susceptibly, host response, and underlying physiological reserve. External validation of the neonatal model and additional external validation of the under-5 model in different contexts is required. NOTE for restricted files: If you are not yet a CoLab member, please complete our <a href = "https://rc.bcchr.ca/redcap/surveys/?s=EDCYL7AC79">membership application survey</a> to gain access to restricted files within 2 business days. Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator at <a href = mailto:sepsiscolab@bccchr.ca>sepsiscolab@bcchr.ca</a> or visit our <a href = "https://wfpiccs.org/pediatric-sepsis-colab/">website</a>.

Validation of a risk-prediction model for pediatric post-discharge mortality at two hospitals in Rwanda

Borealis

Hooft, Anneka; Kornblith, Aaron E; Umhoza, Christian; Trawin, Jessica; Mfuranziza, Cynthia Grace; Uwiragiye, Emmanuel; Zhang, Cherri; Nguyen, Vuong; Lewis, Peter; Wiens, Matthew O — 2024-04-11 NOTE for restricted files: If you are not yet a CoLab member, please complete our <a href = "https://rc.bcchr.ca/redcap/surveys/?s=EDCYL7AC79">membership application survey</a> to gain access to restricted files within 2 business days. Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator at <a href = mailto:sepsiscolab@bccchr.ca>sepsiscolab@bcchr.ca</a> or visit our <a href = "https://wfpiccs.org/pediatric-sepsis-colab/">website</a>. Background:Mortality following hospital discharge remains a significant threat to child health, particularly in resource-limited settings. In Uganda, the Smart Discharges risk-prediction models have demonstrated success in their ability to predict those at highest risk of death after discharge and use this to guide a risk-based approach to post-discharge care in children admitted with suspected sepsis. Respective prediction models for post-discharge mortality in ages 0-6 months and ages 6-60 months were developed in this cohort but have not yet been validated outside of Uganda. This study aimed to externally validate existing risk prediction models for pediatric post-discharge mortality within the Rwandan context. Methods: Prospective cohort of children 0d-60 mos admitted with suspected sepsis at two hospitals in Rwanda: Ruhengeri Referral Hospital in Musanze (rural) and University Hospital of Kigali in Kigali (urban) from May 2022 to February 2023. Vital status follow up was conducted at 2-, 4- and 6-months post-discharge. Five existing models from Smart Discharges Uganda were validated in this cohort: two models for children 0-6 months, and three for children 6-60 months. Models were applied to each participant in the Rwanda cohort to obtain a risk score which was then used to calculate predicted probability of post-discharge death. Model performance was evaluated by comparing to observed outcomes and to determine sensitivity, specificity, and AUROC. Threshold was set at 80% sensitivity. . Findings:In a cohort of 1218 children, 1123 children (96.7%) completed follow up. The overall rate of post-discharge mortality was 4.8% (n=58). The highest performing models had an AUROC of 0.75 (0-6 mos) and 0.74 (6-60mos), respectively. All five prediction models tested achieved an AUROC greater than 0.7 (range 0.706 - 0.738). Model degradation (determined by the percent reduction in AUC between the original model and the derived model) was relatively low, ranging from from 1.1% to 7.7%. Calibration plots showed good calibration for all models at predicted probabilities below 10%. There were too few outcomes to assess calibration among those at higher levels of predicted risk. Data Processing Methods: Ethics Declaration: Ethical approval was obtained from the University of Rwanda College of Medicine and Health Sciences (No 411/CMHS IRB/2021); University Teaching Hospital of Kigali (EC/CHUK/005/2022), University of California San Francisco (381688) and the University of British Columbia (H21-02795).

Smart Discharges Uganda Under 5: Phase I clinical data of children 0-6 months - Covid-19 cohort

Borealis

Zhang, Cherri; Akter, Tanjila; Nguyen, Vuong; Bone, Jeff; Wiens, Matthew — 2024-10-22 This data is a subset of the Smart Discharges Uganda Under 5 years parent study and is specific to the Phase I observation cohort of children aged 0-6 months collected during the Covid-19 pandemic in 2020. Objective(s): Used as part of the Smart Discharge prediction modelling for adverse outcomes such as post-discharge death and readmission. Data Description: All data were collected at the point of care using encrypted study tablets and these data were then uploaded to a Research Electronic Data Capture (REDCap) database hosted at the BC Children’s Hospital Research Institute (Vancouver, Canada). At admission, trained study nurses systematically collected data on clinical, social and demographic variables. Following discharge, field officers contacted caregivers at 2 and 4 months by phone, and in-person at 6 months, to determine vital status, post-discharge health-seeking, and readmission details. Verbal autopsies were conducted for children who had died following discharge. . Data Processing: Created z-scores for anthropometry variables using height and weight according to WHO cutoff. Distance to hospital was calculated using latitude and longitude. Extra symptom and diagnosis categories were created based on text field in these two variables. BCS score was created by summing all individual components. Limitations: There are missing dates and the admission, discharge, and readmission dates are not in order. Ethics Declaration: This study was approved by the Mbarara University of Science and Technology Research Ethics Committee (No. 15/10-16), the Uganda National Institute of Science and Technology (HS 2207), and the University of British Columbia / Children & Women’s Health Centre of British Columbia Research Ethics Board (H16-02679). This manuscript adheres to the guidelines for STrengthening the Reporting of OBservational studies in Epidemiology (STROBE). NOTE for restricted files: If you are not yet a CoLab member, please complete our <a href = "https://rc.bcchr.ca/redcap/surveys/?s=EDCYL7AC79">membership application survey</a> to gain access to restricted files within 2 business days. Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator at <a href = mailto:sepsiscolab@bccchr.ca>sepsiscolab@bcchr.ca</a> or visit our <a href = "https://wfpiccs.org/pediatric-sepsis-colab/">website</a>.

Smart Discharges Uganda Under 5: Phase II clinical data of children 0-6 months

Borealis

Zhang, Cherri; Akter, Tanjila; Nguyen, Voung; Bone, Jeff; Wiens, Matthew — 2024-10-22 This data is a subset of the Smart Discharges Uganda Under 5 years parent study and is specific to the Phase II interventional cohort of children aged 0-6 months. Objective(s): Used as part of the Smart Discharge prediction modelling for adverse outcomes such as post-discharge death and readmission. Data Description: All data were collected at the point of care using encrypted study tablets and these data were then uploaded to a Research Electronic Data Capture (REDCap) database hosted at the BC Children’s Hospital Research Institute (Vancouver, Canada). At admission, trained study nurses systematically collected data on clinical, social and demographic variables. Following discharge, field officers contacted caregivers at 2 and 4 months by phone, and in-person at 6 months, to determine vital status, post-discharge health-seeking, and readmission details. Verbal autopsies were conducted for children who had died following discharge. . Data Processing: Created z-scores for anthropometry variables using height and weight according to WHO cutoff. Distance to hospital was calculated using latitude and longitude. Extra symptom and diagnosis categories were created based on text field in these two variables. BCS score was created by summing all individual components. Limitations: There are missing dates and the admission, discharge, and readmission dates are not in order. Ethics Declaration: This study was approved by the Mbarara University of Science and Technology Research Ethics Committee (No. 15/10-16), the Uganda National Institute of Science and Technology (HS 2207), and the University of British Columbia / Children & Women’s Health Centre of British Columbia Research Ethics Board (H16-02679). This manuscript adheres to the guidelines for STrengthening the Reporting of OBservational studies in Epidemiology (STROBE). NOTE for restricted files: If you are not yet a CoLab member, please complete our <a href = "https://rc.bcchr.ca/redcap/surveys/?s=EDCYL7AC79">membership application survey</a> to gain access to restricted files within 2 business days. Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator at <a href = mailto:sepsiscolab@bccchr.ca>sepsiscolab@bcchr.ca</a> or visit our <a href = "https://wfpiccs.org/pediatric-sepsis-colab/">website</a>.

Smart Discharges Uganda Under 5: Phase II clinical data of children 6-60 months

Borealis

Zhang, Cherri; Akter, Tanjila; Nguyen, Voung; Bone, Jeff; Wiens, Matthew — 2024-10-22 This data is a subset of the Smart Discharges Uganda Under 5 years parent study and is specific to the Phase II interventional cohort of children aged 6-60m. Objective(s): Used as part of the Smart Discharge prediction modelling for adverse outcomes such as post-discharge death and readmission. Data Description: All data were collected at the point of care using encrypted study tablets and these data were then uploaded to a Research Electronic Data Capture (REDCap) database hosted at the BC Children’s Hospital Research Institute (Vancouver, Canada). At admission, trained study nurses systematically collected data on clinical, social and demographic variables. Following discharge, field officers contacted caregivers at 2 and 4 months by phone, and in-person at 6 months, to determine vital status, post-discharge health-seeking, and readmission details. Verbal autopsies were conducted for children who had died following discharge. . Data Processing: Created z-scores for anthropometry variables using height and weight according to WHO cutoff. Distance to hospital was calculated using latitude and longitude. Extra symptom and diagnosis categories were created based on text field in these two variables. BCS score was created by summing all individual components. Limitations: There are missing dates and the admission, discharge, and readmission dates are not in order. Ethics Declaration: This study was approved by the Mbarara University of Science and Technology Research Ethics Committee (No. 15/10-16), the Uganda National Institute of Science and Technology (HS 2207), and the University of British Columbia / Children & Women’s Health Centre of British Columbia Research Ethics Board (H16-02679). This manuscript adheres to the guidelines for STrengthening the Reporting of OBservational studies in Epidemiology (STROBE). NOTE for restricted files: If you are not yet a CoLab member, please complete our <a href = "https://rc.bcchr.ca/redcap/surveys/?s=EDCYL7AC79">membership application survey</a> to gain access to restricted files within 2 business days. Some files may remain restricted to CoLab members. These files are deemed more sensitive by the file owner and are meant to be shared on a case-by-case basis. Please contact the CoLab coordinator at <a href = mailto:sepsiscolab@bccchr.ca>sepsiscolab@bcchr.ca</a> or visit our <a href = "https://wfpiccs.org/pediatric-sepsis-colab/">website</a>.

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