Performance of chest X-ray scoring in predicting disease severity and outcomes of patients hospitalised with COVID-19 in Bangladesh.

Introduction: Evaluation of potential outcomes of COVID-19-affected pneumonia patients using computed tomography scans may not be conceivable in low-resource settings. Thus, we aimed to evaluate the performance of chest X-ray scoring in predicting the disease severity and outcomes of adults hospitalised with COVID-19. Methods: This was a retrospective chart analysis consuming data from COVID-19-positive adults who had chest X-ray availability and were admitted to a temporary COVID unit, in Bangladesh from 23rd April 2020 to 15th November 2021. At least one clinical intensivist and one radiologist combinedly reviewed each admission chest X-ray for the different lung findings. Chest X-ray scoring varied from 0 to 8, depending on the area of lung involvement with 0 indicating no involvement and 8 indicating ⩾75% involvement of both lungs. The receiver operating characteristic curve was used to determine the optimum chest X-ray cut-off score for predicting the fatal outcomes. Result: A total of 218 (82.9%) out of 263 COVID-19-affected adults were included in the study. The receiver operating characteristic curve demonstrated the optimum cut-off as ⩾3 and ⩾5 for disease severity and death, respectively. In multivariate logistic regression analysis, a chest X-ray score of ⩾3 was found to be independently associated with disease severity (aOR: 8.70; 95% CI: 3.82, 19.58, p < 0.001) and a score of ⩾5 with death (aOR: 16.53; 95% CI: 4.74, 57.60, p < 0.001) after adjusting age, sex, antibiotic usage before admission, history of fever, cough, diabetes mellitus, hypertension, total leukocytes count and C-reactive protein. Conclusion: Using chest X-ray scoring derived cut-off at admission might help to identify the COVID-19-affected adults who are at risk of severe disease and mortality. This may help to initiate early and aggressive management of such patients, thereby reducing their fatal outcomes.

Prevalence and predictors of magnesium imbalance among critically ill diarrheal children and their outcome in a developing country.

Despite having essential roles in maintaining human body physiology, magnesium has gained little attention. We sought to evaluate the prevalence and predictors of magnesium imbalance in diarrheal children admitted to an intensive care unit. This retrospective data analysis was conducted among children admitted between January 2019 and December 2019. Eligible children were categorized by serum magnesium levels that were extracted from the hospital database. Among 557 participants, 29 (5.2%) had hypomagnesemia, 344 (61.8%) had normomagnesemia and 184 (33.0%) had hypermagnesemia. By multivariable multinomial logistic regression, we have identified older children (adjusted multinomial odds ratio, mOR 1.01, 95% CI: 1.004-1.018, p = 0.002) as a predictor of hypomagnesemia. Conversely, younger children (adjusted mOR 0.99, 95% CI: 0.982-0.998, p = 0.02), shorter duration of fever (adjusted mOR 0.92, 95% CI: 0.857-0.996, p = 0.04), convulsion (adjusted mOR 1.55, 95% CI: 1.005-2.380, p = 0.047), dehydration (adjusted mOR 3.27, 95% CI: 2.100-5.087, p<0.001), pneumonia (adjusted mOR 2.65, 95% CI: 1.660-4.240, p<0.001) and acute kidney injury (adjusted mOR 2.70, 95% CI: 1.735-4.200, p<0.001) as the independent predictors of hypermagnesemia. The mortality was higher among children with hypermagnesemia (adjusted mOR 2.31, 95% CI: 1.26-4.25, p = 0.007). Prompt identification and management of the magnesium imbalance among critically ill diarrheal children might have survival benefits, especially in resource-limited settings.

Derivation and validation of a clinical prediction model for risk-stratification of children hospitalized with severe pneumonia in Bangladesh.

Children with severe pneumonia in low- and middle-income countries (LMICs) suffer from high rates of treatment failure despite appropriate World Health Organization (WHO)-directed antibiotic treatment. Developing a clinical prediction rule for treatment failure may allow early identification of high-risk patients and timely intervention to decrease mortality. We used data from two separate studies conducted at the Dhaka Hospital of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) to derive and externally validate a clinical prediction rule for treatment failure of children hospitalized with severe pneumonia. The derivation dataset was from a randomized clinical trial conducted from 2018 to 2019, studying children aged 2 to 59 months hospitalized with severe pneumonia as defined by WHO. Treatment failure was defined by the persistence of danger signs at the end of 48 hours of antibiotic treatment or the appearance of any new danger signs within 24 hours of enrollment. We built a random forest model to identify the top predictors. The top six predictors were the presence of grunting, room air saturation, temperature, the presence of lower chest wall indrawing, the presence of respiratory distress, and central cyanosis. Using these six predictors, we created a parsimonious model with a discriminatory performance of 0.691, as measured by area under the receiving operating curve (AUC). We performed external validation using a temporally distinct dataset from a cohort study of 191 similarly aged children with severe acute malnutrition and pneumonia. In external validation, discriminatory performance was maintained with an improved AUC of 0.718. In conclusion, we developed and externally validated a parsimonious six-predictor model using random forest methods to predict treatment failure in young children with severe pneumonia in Bangladesh. These findings can be used to further develop and validate parsimonious and pragmatic prognostic clinical prediction rules for pediatric pneumonia, particularly in LMICs.

Burden, predictors, and outcome of unconsciousness among under-five children hospitalized for community-acquired pneumonia: A retrospective study from a developing country.

Despite the reduction of death from pneumonia over recent years, pneumonia has still been the leading infectious cause of death in under-five children for the last several decades. Unconsciousness is a critical condition in any child resulting from any illness. Once it occurs during a pneumonia episode, the outcome is perceived to be fatal. However, data on children under five with pneumonia having unconsciousness are scarce. We've retrospectively analyzed the data of under-five children admitted at the in-patient ward of Dhaka Hospital of icddr,b during 1 January 2014 and 31 December 2017 with World Health Organization classified pneumonia or severe pneumonia. Children presented with or without unconsciousness were considered as cases and controls respectively. Among a total of 3,876 children fulfilling the inclusion criteria, 325 and 3,551 were the cases and the controls respectively. A multivariable logistic regression analysis revealed older children (8 months vs. 7.9 months) (adjusted odds ratio, aOR 1.02, 95% CI: 1.004-1.04, p = 0.015), hypoxemia (aOR 3.22, 95% CI: 2.39-4.34, p<0.001), severe sepsis (aOR 4.46, 95% CI: 3.28-6.06, p<0.001), convulsion (aOR 8.90, 95% CI: 6.72-11.79, p<0.001), and dehydration (aOR 2.08, 95% CI: 1.56-2.76, p<0.001) were found to be independently associated with the cases. The cases more often had a fatal outcome than the controls (23% vs. 3%, OR 9.56, 95% CI: 6.95-13.19, p<0.001). If the simple predicting factors of unconsciousness in children under five hospitalized for pneumonia with different severity can be initially identified and adequately treated with prompt response, pneumonia-related deaths can be reduced more effectively, especially in resource-limited settings.

In-person training on COVID-19 case management and infection prevention and control: Evaluation of healthcare professionals in Bangladesh.

BACKGROUND: As COVID-19 was declared a global pandemic, the major focus of healthcare organizations shifted towards preparing healthcare systems to handle the inevitable COVID-19 burden at different phases and levels. A series of in-person training programs were operated in collaboration with government and partner organizations for the healthcare workers (HCW) of Bangladesh. This study aimed to assess the knowledge of HCWs regarding SARS-CoV-2 infection, their case management, infection prevention and control to fight against the ongoing pandemic. METHODS: As a part of the National Preparedness and Response Plan for COVID-19 in Bangladesh, the training program was conducted at four district-level hospitals and one specialized hospital in Bangladesh from July 1, 2020 to June 30, 2021. A total of 755 HCWs participated in the training sessions. Among them, 357 (47%) were enrolled for the evaluation upon completion of the data, collected from one district hospital (Feni) and one specialized hospital (National Institute of Mental Health). RESULTS: The mean percentage of pre-test and post-test scores of all the participants were found to be 57% (95% CI 8.34-8.91; p 0.01) and 65% (95% CI 9.56-10.15; p <0.001) respectively. The difference of score (mean) between the groups was significant (p<0.001). After categorizing participants' knowledge levels as poor, average and fair, doctors' group has shown to have significant enhancement from level of average to fair compared to that of the nurses. Factors associated with knowledge augmentation of doctors were working in primary health care centers (aOR: 4.22; 95% CI: 1.80, 9.88), job experience less than 5 years (aOR: 4.10; 95% CI: 1.01, 16.63) and experience in caring of family member with COVID-19 morbidity (aOR: 2.06; 95% CI: 1.03, 4.10), after adjusting for relevant covariates such as age, sex and prior COVID-19 illness. CONCLUSION: Considering the series of waves of COVID-19 pandemic with newer variants, the present paper underscores the importance of implementing the structured in-person training program on case management, infection prevention and control for the HCWs that may help for successful readiness prior to future pandemics that may further help to minimize the pandemic related fatal consequences.

Prevalence and outcome of anemia among children hospitalized for pneumonia and their risk of mortality in a developing country.

Data are limited on the prevalence and outcome of anemia and its risk on mortality among children under five years of age hospitalized for pneumonia/severe pneumonia. Thus, we conducted a secondary analysis of data extracted from Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh to address the evidence gap. Among 3468 children fulfilling the study criteria,1712 (49.4%) had anemia. If children aged ≤ 1.0, > 1.0 to 2.0, > 2.0 to < 6.0, and ≥ 6.0 to 59 months had blood hemoglobin (Hb) value of ≤ 10.7 g/dL, ≤ 9.4 g/dL, ≤ 9.5 g/dL, and ≤ 11 g/dl respectively; we considered them anemic. The trend of prevalence of anemia was found to be inversely related to increasing age (Chi-square for linear trend analysis was done to understand the relation of anemia with increasing age, which was = 6.96; p = 0.008). During hospitalization anemic children more often developed respiratory failure (7.2% vs. 4.4%, p < 0.001) and fatal outcome (7.1.0% vs. 4.2%, p < 0.001) than the children who did not have anemia. After adjusting for potential confounders, such as female sex, lack of immunization, abnormal mental status, severe acute malnutrition, dehydration, hypoxemia, severe sepsis, and bacteremia using multivariable logistic regression analysis, anemia was found to be independently associated with fatal outcome (OR = 1.88, 95% CI 1.23-2.89, p = 0.004). Thus, future interventional studies on the early management of anemia may be warranted to understand whether the intervention reduces the morbidity and deaths in such children.

Prevalence, Predictive Factors, and Outcomes of Respiratory Failure in Children With Pneumonia Admitted in a Developing Country.

Background: Pneumonia has been the leading infectious cause of morbidity and mortality in children under 5 years of age for the last several decades. Although most of these deaths occur due to respiratory failure, published data are limited regarding predicting factors and outcomes of respiratory failure in children hospitalized with pneumonia or severe pneumonia. Objective: This study aimed to explore the prevalence, predicting factors, and outcomes of respiratory failure in children under-five with pneumonia or severe pneumonia. Methods: In this retrospective chart analysis, we enrolled children under 5 years of age hospitalized with pneumonia or severe pneumonia in the Dhaka Hospital of International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) between August 2013 and December 2017. Comparisons were made between children with respiratory failure (n = 212) and those without respiratory failure (n = 4,412). Respiratory failure was defined when the oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) was <315. Results: A total of 4,625 children with pneumonia or severe pneumonia were admitted during this study period. Among them, 212 (4.6%) children developed respiratory failure and formed the case group. A total of 4,412 (95.3%) children did not develop respiratory failure and formed the comparison group. In logistic regression analysis, after adjusting with potential confounders, severe sepsis [adjusted odds ratio (aOR): 12.68, 95% CI: 8.74-18.40], convulsion (aOR: 4.52, 95% CI: 3.06-6.68), anemia (aOR: 1.76, 95% CI: 1.20-2.57), and severe underweight (aOR: 1.97, 95% CI: 1.34-2.89) were found to be independently associated with respiratory failure. As expected, children with respiratory failure more often had fatal outcome than without respiratory failure (74, 1%, p < 0.001). Conclusion: The results of our analyses revealed that prevalence of respiratory failure was 4.6% among under-five children hospitalized for pneumonia or severe pneumonia. Severe sepsis, convulsion, anemia, and severe underweight were the independent predictors for respiratory failure in such children and their case-fatality rate was significantly higher than those without respiratory failure. Early recognition of these predicting factors of respiratory failure may help clinicians imitating prompt treatment that may further help to reduce deaths in such children, especially in resource-limited settings.

Anthropometric Indices of Giardia-Infected Under-Five Children Presenting with Moderate-to-Severe Diarrhea and Their Healthy Community Controls: Data from the Global Enteric Multicenter Study.

Among all intestinal parasitosis, giardiasis has been reported to be associated with delayed growth in malnourished children under 5 living in low- and middle-income countries. Relevant data on the nutritional status of children aged 0-59 months presenting with moderate-to-severe diarrhea (MSD) and giardia infection were collected from sentinel health facilities of the Global Enteric Multicenter Study's (GEMS) seven field settings, placed in diverse countries of Sub-Saharan Africa and South Asia between, December 2007 and February 2011. Then, this study analyzed a robust dataset of study participants (n = 22,569). Children having giardiasis with MSD constituted as cases (n = 1786), and those without MSD constituted as controls (n = 3470). Among the seven field sites, symptomatic giardiasis was 15% and 22% in Asian and African sites, respectively, whereas asymptomatic giardia infection (healthy without MSD) in Asian and African sites was 21.7% and 30.7%, respectively. Wasting and underweight were more frequently associated and stunting less often associated with symptomatic giardiasis (for all, p < 0.001). Symptomatic giardiasis had a significant association with worsening of nutritional status in under-five children. Improved socio-economic profile along with proper sanitation and hygienic practices are imperative to enhance child nutritional status, particularly in resource limited settings.