title: Prospective validation of pediatric disease severity scores to predict mortality in Ugandan children presenting with malaria and non-malaria febrile illness.
abstract: BACKGROUND
  The development of simple clinical tools to identify children at risk of death would enable rapid and rational implementation of lifesaving measures to reduce childhood mortality globally.
  
  
  METHODS
  We evaluated the ability of three clinical scoring systems to predict in-hospital mortality in a prospective observational study of Ugandan children with fever. We computed the Lambaréné Organ Dysfunction Score (LODS), Signs of Inflammation in Children that Kill (SICK), and the Pediatric Early Death Index for Africa (PEDIA). Model discrimination was evaluated by comparing areas under receiver operating characteristic curves (AUCs) and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. Sub-analyses were performed in malaria versus non-malaria febrile illness (NMFI), and in early (≤48 hours) versus late (>48 hours) deaths.
  
  
  RESULTS
  In total, 2089 children with known outcomes were included in the study (99 deaths, 4.7% mortality). All three scoring systems yielded good discrimination (AUCs, 95% confidence interval (CI): LODS, 0.90, 0.88 to 0.91; SICK, 0.85, 0.83 to 0.86; PEDIA, 0.90, 0.88 to 0.91). Using the Youden index to identify the best cut-offs, LODS had the highest positive likelihood ratio (+LR, 95% CI: LODS, 6.5, 5.6 to 7.6; SICK, 4.4, 3.9 to 5.0; PEDIA, 4.4, 3.9 to 5.0), whereas PEDIA had the lowest negative likelihood ratio (-LR, 95% CI: LODS, 0.21, 0.1 to 0.3; SICK, 0.22, 0.1 to 0.3; PEDIA, 0.16, 0.1 to 0.3), LODS and PEDIA were well calibrated (P = 0.79 and P = 0.21 respectively), and had higher AUCs than SICK in discriminating between survivors and non-survivors in malaria (AUCs, 95% CI: LODS, 0.92, 0.90 to 0.93; SICK, 0.86, 0.84 to 0.87; PEDIA, 0.92, 0.90 to 0.93), but comparable AUCs in NMFI (AUCs, 95% CI: LODS, 0.86, 0.83 to 0.89; SICK, 0.82, 0.79 to 0.86; PEDIA, 0.87, 0.83 to 0.893). The majority of deaths in the study occurred early (n = 85, 85.9%) where LODS and PEDIA had good discrimination.
  
  
  CONCLUSIONS
  All three scoring systems predicted outcome, but LODS holds the most promise as a clinical prognostic score based on its simplicity to compute, requirement for no equipment, and good discrimination.
authors: Depatment of Medicine, University of Toronto, Toronto, M5S1A8, Canada. andrea.conroy@gmail.com.|Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, M5G1L7, Canada. andrea.conroy@gmail.com.
authors: Andrea L
authors: AL
authors: Conroy
authors: Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, T6G1C9, Canada. mthawkes@ualberta.ca.
authors: Michael
authors: M
authors: Hawkes
authors: Depatment of Medicine, University of Toronto, Toronto, M5S1A8, Canada. kylahayford@jhu.edu.|Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, M5G1L7, Canada. kylahayford@jhu.edu.
authors: Kyla
authors: K
authors: Hayford
authors: Department of Pediatrics, Jinja Regional Referral Hospital, P.O. Box 43, Jinja, Uganda. snamasopo@yahoo.com.
authors: Sophie
authors: S
authors: Namasopo
authors: Department of Paediatrics and Child Health, Mulago Hospital and Makerere University, P.O. Box 7051, Kampala, Uganda. opokabob@yahoo.com.
authors: Robert O
authors: RO
authors: Opoka
authors: Division of Global Pediatrics, Department of Pediatrics, University of Minnesota, Minneapolis, MN, 55414, USA. ccj@umn.edu.
authors: Chandy C
authors: CC
authors: John
authors: Department of Medicine, University of Washington, Seattle, WA, 98195, USA. wcliles@medicine.washington.edu.
authors: W Conrad
authors: WC
authors: Liles
authors: Depatment of Medicine, University of Toronto, Toronto, M5S1A8, Canada. kevin.kain@uhn.ca.|Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Toronto, M5G1L7, Canada. kevin.kain@uhn.ca.|Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada. kevin.kain@uhn.ca.|Sandra Rotman Centre, Suite 10-351, Toronto Medical Discovery Tower, MaRS Centre, 101 College Street, Toronto, M5G1L7, Canada. kevin.kain@uhn.ca.
authors: Kevin C
authors: KC
authors: Kain
mesh_terms: D002675:Child, Preschool; D005260:Female; D005334:Fever / Q000145:classification / Q000401:mortality*; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007249:Inflammation; D007362:Intensive Care Units; D008288:Malaria / Q000145:classification / Q000401:mortality*; D008297:Male; D063305:Organ Dysfunction Scores; D011446:Prospective Studies; D012372:ROC Curve; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D014454:Uganda