title: Proposal of a Clinical Decision Tree Algorithm Using Factors Associated with Severe Dengue Infection.
abstract: BACKGROUND
  WHO's new classification in 2009: dengue with or without warning signs and severe dengue, has necessitated large numbers of admissions to hospitals of dengue patients which in turn has been imposing a huge economical and physical burden on many hospitals around the globe, particularly South East Asia and Malaysia where the disease has seen a rapid surge in numbers in recent years. Lack of a simple tool to differentiate mild from life threatening infection has led to unnecessary hospitalization of dengue patients.
  
  
  METHODS
  We conducted a single-centre, retrospective study involving serologically confirmed dengue fever patients, admitted in a single ward, in Hospital Kuala Lumpur, Malaysia. Data was collected for 4 months from February to May 2014. Socio demography, co-morbidity, days of illness before admission, symptoms, warning signs, vital signs and laboratory result were all recorded. Descriptive statistics was tabulated and simple and multiple logistic regression analysis was done to determine significant risk factors associated with severe dengue.
  
  
  RESULTS
  657 patients with confirmed dengue were analysed, of which 59 (9.0%) had severe dengue. Overall, the commonest warning sign were vomiting (36.1%) and abdominal pain (32.1%). Previous co-morbid, vomiting, diarrhoea, pleural effusion, low systolic blood pressure, high haematocrit, low albumin and high urea were found as significant risk factors for severe dengue using simple logistic regression. However the significant risk factors for severe dengue with multiple logistic regressions were only vomiting, pleural effusion, and low systolic blood pressure. Using those 3 risk factors, we plotted an algorithm for predicting severe dengue. When compared to the classification of severe dengue based on the WHO criteria, the decision tree algorithm had a sensitivity of 0.81, specificity of 0.54, positive predictive value of 0.16 and negative predictive of 0.96.
  
  
  CONCLUSIONS
  The decision tree algorithm proposed in this study showed high sensitivity and NPV in predicting patients with severe dengue that may warrant admission. This tool upon further validation study can be used to help clinicians decide on further managing a patient upon first encounter. It also will have a substantial impact on health resources as low risk patients can be managed as outpatients hence reserving the scarce hospital beds and medical resources for other patients in need.
authors.affiliation: Department of Medicine, Taiping Hospital, Perak, Malaysia.
authors.forename: Jayashamani
authors.identifier: http://orcid.org/0000-0002-9231-014X
authors.initials: J
authors.lastname: Tamibmaniam
authors.affiliation: Clinical Research Centre, Taiping Hospital, Perak, Malaysia.
authors.forename: Narwani
authors.initials: N
authors.lastname: Hussin
authors.affiliation: Department of Medicine, Taiping Hospital, Perak, Malaysia.
authors.forename: Wee Kooi
authors.initials: WK
authors.lastname: Cheah
authors.affiliation: Department of Medicine, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia.
authors.forename: Kee Sing
authors.initials: KS
authors.lastname: Ng
authors.affiliation: Clinical Research Centre, Taiping Hospital, Perak, Malaysia.
authors.forename: Prema
authors.initials: P
authors.lastname: Muninathan
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D015415:Biomarkers; D000066491:Clinical Decision-Making; D003663:Decision Trees; D019468:Disease Management; D005260:Female; D006801:Humans; D016015:Logistic Models; D008296:Malaysia; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D012698:Serologic Tests; D019595:Severe Dengue / Q000175:diagnosis* / Q000628:therapy* / Q000821:virology
chemical_list: D015415:Biomarkers