有助於辨識孩童感染風險的警訊


  【24drs.com】February 5, 2010 — 根據線上發表於2月3日Lancet期刊的系統性回顧結果,呼吸急促、父母親的關心以及臨床醫師的直覺,是已開發國家中孩童嚴重感染的警訊之一。
  
  比利時魯汶Katholieke大學的Ann Van den Bruel醫師以及歐洲確認嚴重感染研究網絡的研究者們寫道,我們的目標是,辨識哪些臨床特徵可以作為確認或排除已開發國家非臥床孩童的嚴重感染可能性。
  
  回顧者搜尋了電子化資料庫(Medline、Embase、DARE、CINAHL)以及確認之相關文獻的參考資料,此外,他們詢問專家以確認評估孩童嚴重感染之臨床特徵的文章。
  
  納入規範是分析診斷準確度或預測規則的研究,對象是其他方面健康的1個月到18歲孩童、非臥床照護者,結果測量包括嚴重感染、非臥床照護者的可評估特徵、足夠的數據報告。
  
  根據「診斷準確度研究品質評估(Quality Assessment of Diagnostic Accuracy Studies)規範」評估研究品質,至於各個臨床特徵,回顧者計算結果出現(正面可能性比率)或未出現(負面可能性比率)的可能性比率,以及測驗前與測驗後的可能性。
  
  嚴重感染症的「紅旗」,也就是警訊,定義為正面可能性比率超過5.0之臨床特徵,排除徵兆定義為負面可能性比率小於0.2的臨床特徵。
  
  辨識的1939篇可能的相關研究中,符合篩選規範的30篇研究被納入分析,從多篇研究中獲得的警訊,包括發紺(正面可能性比率範圍:2.66 - 52.20)、呼吸急促(1.26 - 9.78)、不佳的週邊灌注(2.39 - 38.80)以及小出血點(6.18 - 83.70)。一篇初級照護研究中辨識為強烈警訊的因素,包括父母親的關心(正面可能性比率為14.40;95%信心區間[CI]為9.30 - 22.10)以及臨床醫師的直覺(正面可能性比率為23.50;95% CI,16.80 - 32.70)。
  
  在嚴重感染症低盛行率者中,體溫40°C以上也可作為警訊。不過沒有任一個臨床特徵具有排除價值,合併一些因素則有助於排除嚴重感染的可能性。舉例而言,如果孩童沒有呼吸短促且父母親也沒有特別擔心,不太可能是肺炎(負面可能性比率為0.07;95% CI,0.01 - 0.46)。
  
  研究作者們寫道,耶魯觀察量表(Yale Observation Scale)對於確認(正面可能性比率為1.10–6.70)或排除(負面可能性比率為0.16–0.97)感染可能性的價值有限,我們辨識的感染症警訊應例行性地被使用,但是,如果沒有有效使用預先警戒的方式,仍然會錯過一些重症。
  
  這篇回顧的限制包括納入之研究的固有限制,例如再現性與不佳的觀察者間同意度以及缺乏一線照護者的資料。
  
  研究作者們結論表示,此篇系統性回顧的主要強度,在於強調在目前罕見嚴重孩童疾病的國家,一線照護與醫院臨床醫師對於初次出現的重症孩童之診斷工作與責任的本質與難度,已經被世界衛生組織建議用於開發中國家的多數警訊,可以被用於已開發國家之非臥床孩童的初步評估。在診斷過程中,更應強調父母親的關心的重要性。
  
  加拿大蒙特婁大學的Martin Dawes醫師在評論中表示,如何有效地辨識或排除病童中的重症仍然不清楚,也沒有具凝聚力的全國或全球研究策略來探討這問題。
  
  Dawes醫師寫道,對於一線照護,我們需要設計更好的診斷與預後研究,這類研究需要適當地闡述歷史因素與檢查和追蹤,這都需要有組織的實務範圍,如果有妥善的居中協調,我們可以在一、兩年內獲得10倍以上的證據,這類研究必須要有適當的資金,全國或國際研究基金會應將之納為優先。
  
  健康科技評估與國家健康研究中心、國家一線照護研究學院等支持本研究。研究作者們與Dawes醫師皆宣告沒有相關財務關係。
  
  Lancet. 線上發表於2010年2月3日。

Red Flags May Help Identify Serious Infection in Children

By Laurie Barclay, MD
Medscape Medical News

February 5, 2010 — Rapid breathing, parental concern, and the clinician's instinct are among the red flags warning of serious infection in children in developed countries, according to the results of a systematic review reported online in the February 3 issue of The Lancet.

"Our aim was to identify which clinical features have value in confirming or excluding the possibility of serious infection in children presenting to ambulatory care settings in developed countries," write Ann Van den Bruel, MD, from Katholieke Universiteit in Leuven, Belgium, and colleagues from the European Research Network on Recognising Serious Infection investigators.

The reviewers searched electronic databases (Medline, Embase, DARE, CINAHL) and bibliographies of identified relevant studies. In addition, they asked experts to identify articles evaluating clinical characteristics of serious infection in children.

Inclusion criteria for studies were analysis of diagnostic accuracy or prediction rules, enrollment of otherwise healthy children aged 1 month to 18 years, ambulatory care setting, outcome measure of serious infection, features evaluable in the ambulatory care setting, and sufficient data reported.

Evaluation of study quality was based on Quality Assessment of Diagnostic Accuracy Studies criteria. For each clinical feature, the reviewers calculated likelihood ratios for the presence (positive likelihood ratio) or absence (negative likelihood ratio) of the outcome, as well as pretest and post-test probabilities.

Red flags, or warning signs for serious infection, were defined as clinical characteristics with a positive likelihood ratio of more than 5.0. Rule-out signs were defined as clinical characteristics with a negative likelihood ratio of less than 0.2.

Of 1939 potentially relevant studies identified, 30 studies met selection criteria and were included in the analysis. Red flags identified from several studies were cyanosis (positive likelihood ratio range, 2.66 - 52.20), rapid breathing (1.26 - 9.78), poor peripheral perfusion (2.39 - 38.80), and petechial rash (6.18 - 83.70). Factors identified as strong red flags in 1 primary care study were parental concern (positive likelihood ratio, 14.40; 95% confidence interval [CI], 9.30 - 22.10) and clinician instinct (positive likelihood ratio, 23.50; 95% CI, 16.80 - 32.70).

In settings with a low prevalence of serious infection, a temperature of 40°C or more had value as a red flag. Although no single clinical characteristic had rule-out value, some combinations were helpful in ruling out the possibility of serious infection. For example, if the child is not short of breath and there is no parental concern, pneumonia is very unlikely (negative likelihood ratio, 0.07; 95% CI, 0.01 - 0.46).

"The Yale Observation Scale had little value in confirming (positive likelihood ratio range 1.10–6.70) or excluding (negative likelihood ratio range 0.16–0.97) the possibility of serious infection," the study authors write. "The red flags for serious infection that we identified should be used routinely, but serious illness will still be missed without effective use of precautionary measures. We now need to identify the level of risk at which clinical action should be taken."

Limitations of this review are primarily those inherent in the included studies, such as reproducibility and poor interobserver agreement, and the paucity of studies from first-contact care settings.

"The main strength of this systematic review is that it highlights the nature and difficulty of the diagnostic task facing primary care and hospital clinicians responsible for identifying seriously ill children at initial presentation in countries where serious childhood illness is now rare," the study authors conclude. "Most of the red flags already recommended by WHO [World Health Organization] for use in developing countries can be used in the initial assessment of children presenting to ambulatory care settings in developed countries. There should be more emphasis on parental concern in the diagnostic process."

In an accompanying comment, Martin Dawes, MBBS, MD, from McGill University in Montreal, Canada, notes that how to effectively recognize or rule out severe disease in ill children is still unclear and that there is no cohesive national or global research strategy to address this problem.

"We need better-designed diagnostic and prognostic studies in primary care," Dr. Dawes writes. "Such studies require properly documented histories and examination as well as follow-up, but both are well within the scope of an organised practice and if centrally coordinated we could have ten times the evidence within a year or two. This research cannot be done without adequate funding and should be a priority for national and international research foundations."

Health Technology Assessment and National Institute for Health Research National School for Primary Care Research supported this study. The study authors and Dr. Dawes have disclosed no relevant financial relationships.

Lancet. Published online February 3, 2010.

    



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