Blantyre Coma Scale Research Articles

Identifying critically ill children in Malawi: A modified qSOFA score for low-resource settings.

In low-resource settings, a reliable bedside score for timely identification of children at risk of dying, could help focus resources and improve survival. The rapid bedside Liverpool quick Sequential Organ Failure Assessment (LqSOFA) uses clinical parameters only and performed well in United Kingdom cohorts. A similarly quick clinical assessment-only score has however not yet been developed for paediatric populations in sub-Saharan Africa. In a development cohort of critically ill children in Malawi, we calculated the LqSOFA scores using age-adjusted heart rate and respiratory rate, capillary refill time and Blantyre Coma Scale, and evaluated its prognostic performance for mortality. An improved score, the Blantyre qSOFA (BqSOFA), was developed (omitting heart rate, adjusting respiratory rate cut-off values and adding pallor), subsequently validated in a second cohort of Malawian children, and compared with an existing score (FEAST-PET). Prognostic performance for mortality was evaluated using area under the receiver operating characteristic curve (AUC). Mortality was 15.4% in the development (N = 493) and 22.0% in the validation cohort (N = 377). In the development cohort, discriminative ability (AUC) of the LqSOFA to predict mortality was 0.68 (95%-CI: 0.60-0.76). The BqSOFA and FEAST-PET yielded AUCs of 0.84 (95%-CI:0.79-0.89) and 0.83 (95%-CI:0.77-0.89) in the development cohort, and 0.74 (95%-CI:0.68-0.79) and 0.76 (95%-CI:0.70-0.82) in the validation cohort, respectively. We developed a simple prognostic score for Malawian children based on four clinical parameters which performed as well as a more complex score. The BqSOFA might be used to promptly identify critically ill children at risk of dying and prioritize hospital care in low-resource settings.

Outcome of tuberculous meningitis in children aged 9 months to 12 years at the end of intensive phase of treatment

BackgroundTuberculous meningitis (TBM) is associated with high morbidity and mortality. Most of the literature focuses on outcomes at the end of therapy when it may be too late for intervention to improve the outcomes. So, the present study addresses outcomes by the end of intensive course of therapy. MethodsIt was a prospective cohort observational study that enrolled 80 patients with TBM between 9 months and 12 years of age. Participants were classified into Definite, Probable and Possible TBM using Marais criteria. Survival/Mortality was evaluated at the end of hospital stay. Demographic, clinical, cerebrospinal fluid and radiological parameters were evaluated for predictors of morbidity and mortality. Standardized tools were used to assess possible impairments in different domains at the end of intensive phase of treatment, namely Gross Motor Functional Classification System for motor functional ability, Pediatric-Mini Mental score examination (MMSE), Blantyre Coma Scale (BCS) score and Vineland Social Maturity Scale (VSMS) for cognitive outcome, Auditory Brainstem Evoked Responses for hearing outcome and using Teller's/Snellen's visual acuity charts to assess visual impairment. ResultsA high Mortality rate of 42.5% was seen in the enrolled patients. Out of the total 80 patients, 20% recovered completely while 36.25% survived with disability (morbidity). Motor, Hearing, Cognitive and Vision impairment was present in 33.3%, 4%, 33.3% and 48.9% of the survivors respectively. On multivariate regression, raised intracranial tension and stage III disease were significantly associated with mortality. Morbidity was significantly associated with Stage III disease on multivariate analysis. ConclusionsDespite advances in treatment, Tuberculous meningitis is associated with high burden of deaths and devastating neurological sequelae. Timely diagnosis and intervention of neurological impairments is needed to improve the outcome of TBM in survivors.

The inter-rater reliability and prognostic value of coma scales in Nepali children with acute encephalitis syndrome

BackgroundAcute encephalitis syndrome (AES) is a common cause of coma in Nepali children. The Glasgow coma scale (GCS) is used to assess the level of coma in these patients and predict outcome. Alternative coma scales may have better inter-rater reliability and prognostic value in encephalitis in Nepali children, but this has not been studied. The Adelaide coma scale (ACS), Blantyre coma scale (BCS) and the Alert, Verbal, Pain, Unresponsive scale (AVPU) are alternatives to the GCS which can be used.MethodsChildren aged 1–14 years who presented to Kanti Children’s Hospital, Kathmandu with AES between September 2010 and November 2011 were recruited. All four coma scales (GCS, ACS, BCS and AVPU) were applied on admission, 48 h later and on discharge. Inter-rater reliability (unweighted kappa) was measured for each. Correlation and agreement between total coma score and outcome (Liverpool outcome score) was measured by Spearman’s rank and Bland–Altman plot. The prognostic value of coma scales alone and in combination with physiological variables was investigated in a subgroup (n = 22). A multivariable logistic regression model was fitted by backward stepwise.ResultsFifty children were recruited. Inter-rater reliability using the variables scales was fair to moderate. However, the scales poorly predicted clinical outcome. Combining the scales with physiological parameters such as systolic blood pressure improved outcome prediction.ConclusionThis is the first study to compare four coma scales in Nepali children with AES. The scales exhibited fair to moderate inter-rater reliability. However, the study is inadequately powered to answer the question on the relationship between coma scales and outcome. Further larger studies are required.

Postdischarge mortality in children with acute infectious diseases: derivation of postdischarge mortality prediction models

ObjectivesTo derive a model of paediatric postdischarge mortality following acute infectious illness.DesignProspective cohort study.Setting2 hospitals in South-western Uganda.Participants1307 children of 6 months to 5 years of age were admitted with...

Neurologic outcomes in retinopathy-negative cerebral malaria survivors

Patients surviving retinopathy-positive cerebral malaria (CM) are at high risk for the development of epilepsy, developmental disabilities, and behavioral abnormalities. We aimed to establish whether retinopathy-negative CM is also a risk factor for these outcomes. Between 2005 and 2007, survivors of CM and concurrently hospitalized controls in Blantyre, Malawi, were followed to assess the development of neurologic abnormalities. At discharge and every 3 months thereafter, incident cases of epilepsy and developmental disabilities were ascertained using screening questionnaires and confirmatory neurologic examinations. Incident cases of epilepsy and developmental disabilities were compared in retinopathy-negative CM survivors to controls and retinopathy-positive CM survivors. Thirty-five retinopathy-negative CM survivors were enrolled. Their neurologic outcomes were compared to 132 retinopathy-positive CM survivors and 272 controls. Compared to survivors of retinopathy-positive CM, children without malaria retinopathy have an equal odds of adverse neurologic outcome (odds ratio [OR] = 1.0, 95% confidence interval [CI] 0.4-2.2). Eleven of 35 survivors of retinopathy-negative CM had at least 1 adverse neurologic outcome compared to 2 of 272 controls (OR 61.9, 95% CI 13.0-295.5). In retinopathy-negative CM survivors, a Blantyre Coma Scale score ≤ 1 on admission was associated with an adverse outcome. Compared with controls, children surviving either retinopathy-negative or -positive CM are at similar high risk for adverse neurologic outcomes. Studies to evaluate preventive and therapeutic strategies in children with both retinopathy-negative and -positive CM are needed to improve mortality, morbidity, or both.

Prognostic accuracy of five simple scales in childhood bacterial meningitis

AbstractBackground: In childhood acute bacterial meningitis, the level of consciousness, measured with the Glasgow coma scale (GCS) or the Blantyre coma scale (BCS), is the most important predictor of outcome. The Herson–Todd scale (HTS) was developed for Haemophilus influenzae meningitis. Our objective was to identify prognostic factors, to form a simple scale, and to compare the predictive accuracy of these scales. Methods: Seven hundred and twenty-three children with bacterial meningitis in Luanda were scored by GCS, BCS, and HTS. The simple Luanda scale (SLS), based on our entire database, comprised domestic electricity, days of illness, convulsions, consciousness, and dyspnoea at presentation. The Bayesian Luanda scale (BLS) added blood glucose concentration. The accuracy of the 5 scales was determined for 491 children without an underlying condition, against the outcomes of death, severe neurological sequelae or death, or a poor outcome (severe neurological sequelae, death, or deafness), at hospital...

Prognostic accuracy of five simple scales in childhood bacterial meningitis

In childhood acute bacterial meningitis, the level of consciousness, measured with the Glasgow coma scale (GCS) or the Blantyre coma scale (BCS), is the most important predictor of outcome. The Herson-Todd scale (HTS) was developed for Haemophilus influenzae meningitis. Our objective was to identify prognostic factors, to form a simple scale, and to compare the predictive accuracy of these scales. Seven hundred and twenty-three children with bacterial meningitis in Luanda were scored by GCS, BCS, and HTS. The simple Luanda scale (SLS), based on our entire database, comprised domestic electricity, days of illness, convulsions, consciousness, and dyspnoea at presentation. The Bayesian Luanda scale (BLS) added blood glucose concentration. The accuracy of the 5 scales was determined for 491 children without an underlying condition, against the outcomes of death, severe neurological sequelae or death, or a poor outcome (severe neurological sequelae, death, or deafness), at hospital discharge. The highest accuracy was achieved with the BLS, whose area under the curve (AUC) for death was 0.83, for severe neurological sequelae or death was 0.84, and for poor outcome was 0.82. Overall, the AUCs for SLS were ≥0.79, for GCS were ≥0.76, for BCS were ≥0.74, and for HTS were ≥0.68. Adding laboratory parameters to a simple scoring system, such as the SLS, improves the prognostic accuracy only little in bacterial meningitis.

Cerebral Malaria: Presentation and Outcome in Children in Sokoto

Malaria remains a major cause of high mortality in African Children. A high percentage of these deaths are caused by cerebral malaria (CM). Therefore, this study sought to determine prospectively, the clinical pattern and outcome of CM in children aged 6months to l2years admitted consecutively into the Emergency Paediatrics Unit (EPU), Usmanu Danfodiyo University Teaching Hospital Sokoto, over a one-year period. (1” June 1999 and 31st May 2000). The level of consciousness was assessed using the Blantyre coma scale for children. Intravenous Quinine dihydrochloride was the antimalarial drug of choice. A total of 971 children were admitted into EPU over the study period. Seventy eight (8.0%) of them had CM. fifty (64%) of the patients were aged 1-5 years. The principal presenting clinical features were fever in seventy eight (100%), loss of consciousness, 78 (100%), and convulsions, 66 (85%). Signs of decerebration, retinal haemorrhages and papilloedema occurred in 23 (30%), 7 (9%), and 5 (6.4%) patients, respectively. Fifty-eight (74%) patients survived, while 20 (26%) died. In conclusion, the hospital prevalence of CM in this series was 8% and ages I to 5 years were the ages of greatest susceptibility. Age less than 3 years, Blantyre coma score of 0, signs of decerebrate rigidity, acidotic (Kussmaul's) respiration, retinal haemorrhages, papilloedema, hypoglycaemia, and raised plasma urea concentrations were indicators, on admission, of poor outcome/prognosis. The case fatality rate of 26%, though within the range reported in literature, remains significantly high. Therefore, skilled, meticulous, and appropriate medical and good nursing care of these patients is strongly advocated. Nigerian Medical Practitioner Vol. 50 (3&4) 2006: pp. 55-61

In-Hospital Risk Estimation in Children with Malaria--Early Predictors of Morbidity and Mortality

Rapid diagnosis and adequate therapy are crucial to prevent development of severe disease and death in children suffering from malaria. A reliable but easy system for disease severity assessment would help to fast track seriously ill children and provide suitable therapies for different patient groups. To examine risk factors and appropriate scoring systems in children suffering from malaria for outcome in terms of morbidity and mortality. A prospective, consecutive study in children admitted to the Muhimbili Medical Centre in Dar es Salaam was conducted to evaluate risk factors and test appropriate scoring systems. The simplified Multi-Organ Dysfunction Score (sMODS), a severity of disease classification consisting mainly of clinical data, was applied. Chosen outcome parameters were morbidity and mortality. Results were compared to those obtained from the World Health Organisation (WHO) classification of severe malaria, the Blantyre Coma Scale (BCS) and selected single clinical parameters. Seventy-five children were recruited into the study. Mean age was 28 months ranging from 6 months to 8 years. 'Severe Malaria', according to WHO criteria was evident in 57 patients (76%). Mean sMODS on admission was 15.6 +/- 2. Seven patients (9%) died. Among single symptoms, impaired consciousness and respiratory distress predicted both, fatal outcome and morbidity. In terms of scoring systems, the sMODS correlated with both outcome parameters. In comparison, the WHO criteria did not correlate with any of the two parameters, the BCS correlated with mortality only. In our study, sMODS has been shown to represent a useful quantitative approach towards disease severity classification in resource poor settings and can be used for risk estimation in children suffering from malaria in terms of both morbidity and mortality.

Severe anaemia in childhood cerebral malaria is associated with profound coma.

Severe anaemia in children with cerebral malaria has been associated with respiratory distress secondary to lactic acidosis and/or hypoxia. The ensuing metabolic derangement may further depress the level of consciousness culminating in presentation with profound coma. This association has poorly been studied. To determine the relationship between profound coma at presentation and the presence of severe anaemia in children with cerebral malaria. This cross-sectional study involved 100 children with cerebral malaria who were consecutively recruited at admission in the Paediatric emergency unit of Mulago hospital in Uganda from July to December 2000. Clinical and laboratory evaluation was done using the hospital's guidelines for the management of severe malaria. The exposure factor of interest was severe anaemia (Hb < 5.0 g/dl) and occurrence of profound coma (Blantyre coma Scale 0) was the outcome measure. Severe anaemia and profound coma were seen in 20% and 9% of the children respectively. Severe anaemia was independently associated with profound coma, adjusted OR 1.34 (CI 1.17 - 1.95), p = 0. 002 and age < 3 years, adjusted OR 1.42 (CI 1.13 - 1.54), p = 0.001). Thirty percent of those with severe anaemia had deep sighing (acidotic) breathing compared to only 15% of those with haemoglobin (Hb) > 5 g/dl, OR 1.21 (CI 0.90 - 1.64), p = 0.118. There was no association between the malaria parasite density and severe anaemia. A similar proportion of those with severe anaemia regained consciousness within 24 hours compared to those with Hb > 5 g/dl (30 vs 42.5%), OR 1.56 (0.65 - 3.71), p = 0.307. The findings suggest that profound coma in cerebral malaria may not only result from primary malaria encephalitis but possibly also from a metabolic dysfunction due to severe anaemia.

Coma scales for children with severe falciparum malaria

The Blantyre coma scale (BCS) is used to assess children with severe falciparum malaria, particularly as a criterion for cerebral malaria, but it has not been formally validated. We compared the BCS to the Adelaide coma scale (ACS), for Kenyan children with severe malaria. We examined the interobserver agreement between 3 observers in the assessment of coma scales on 17 children by measuring the proportion of agreement (PA), disagreement rate (DR) and fixed sample size κ (κn). We assessed the sensivitity and specificity of the scales in detecting events (seizures and hypoglycaemia) in 240 children during admission and the usefulness of the scales in predicting outcome. There was considerable disagreement between observers in the assessment of both scales (BCS: PA = 0·55, DR= 0·09 and κn = 0·27; ACS: PA = 0·36, DR = 0·31, and κn = 0·31), particularly with the verbal component of the BCS (κn = 0·02). Compared to the ACS, the BCS was more specific (0·85 for BCS and 0·80 for ACS), but less sensitive (0·25–0·69 vs. 0·38–0·88 respectively) in detecting events and was a worse predictor of neurological sequelae. The BCS provided a better overall assessment of a child's incapacity from falciparum malaria, but the ACS was more useful in assessing neurological disturbances.