title: Safety of lumbar puncture in comatose children with clinical features of cerebral malaria.
abstract: OBJECTIVE
  We assessed the independent association of lumbar puncture (LP) and death in Malawian children admitted to the hospital with the clinical features of cerebral malaria (CM).
  
  
  METHODS
  This was a retrospective cohort study in Malawian children with clinical features of CM. Allocation to LP was nonrandom and was associated with severity of illness. Propensity score-based analyses were used to adjust for this bias and assess the independent association between LP and mortality.
  
  
  RESULTS
  Data were available for 1,075 children: 866 (80.6%) underwent LP and 209 (19.4%) did not. Unadjusted mortality rates were lower in children who underwent LP (15.3% vs 26.7% in the no-LP group) but differences in covariates between the 2 groups suggested bias in LP allocation. After propensity score matching, all covariates were balanced. Propensity score-based analyses showed no change in mortality rate associated with LP: by inverse probability weighting, the average risk reduction was 2.0% at 12 hours (95% confidence interval -1.5% to 5.5%, p = 0.27) and 1.7% during hospital admission (95% confidence interval -4.5% to 7.9%, p = 0.60). Undergoing LP did not change the risk of mortality in subanalyses of children with severe brain swelling on MRI or in those with papilledema.
  
  
  CONCLUSIONS
  In comatose children with suspected CM who were clinically stable, we found no evidence that LP increases mortality, even in children with objective signs of raised intracranial pressure.
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Christopher A
authors: CA
authors: Moxon
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Lei
authors: L
authors: Zhao
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Chenxi
authors: C
authors: Li
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Karl B
authors: KB
authors: Seydel
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Ian J
authors: IJ
authors: MacCormick
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Peter J
authors: PJ
authors: Diggle
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Macpherson
authors: M
authors: Mallewa
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Tom
authors: T
authors: Solomon
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Nicholas A
authors: NA
authors: Beare
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Simon J
authors: SJ
authors: Glover
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Simon P
authors: SP
authors: Harding
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Susan
authors: S
authors: Lewallen
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Sam
authors: S
authors: Kampondeni
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Michael J
authors: MJ
authors: Potchen
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY.
authors: Terrie E
authors: TE
authors: Taylor
authors: From the Institute of Infection and Global Health (C.A.M., T.S.) and Department of Eye and Vision Science, Institute of Ageing and Chronic Disease (I.J.M., N.A.B., S.P.G., S.P.H.), University of Liverpool (S.P.H.), UK; Departments of Epidemiology and Biostatistics (L.Z., C.L.) and Osteopathic Medical Specialties (K.B.S.) and International Neurology and Psychiatry Epidemiology Program (D.G.P.), Michigan State University, East Lansing; Lancaster University (P.J.D.), UK; Department of Paediatrics and Child Health (M.M.) and the Blantyre Malaria Project (T.E.T.), University of Malawi College of Medicine, Blantyre; St. Paul's Eye Unit (N.A.B.), Royal Liverpool University Hospital; School of Medicine (S.J.G.), University of St. Andrews, UK; Kilimanjaro Centre for Community Ophthalmology (KCCO) (S.L.), University of Cape Town, Department of Ophthalmology, OMB Groote Schuur Hospital Observatory, South Africa; Department of Radiology (S.K.), Queen Elizabeth Central Hospital, Blantyre, Malawi; and Department of Imaging Services (M.J.P.), University of Rochester, NY. douglas.postels@ht.msu.edu.
authors: Douglas G
authors: DG
authors: Postels
mesh_terms: D000293:Adolescent; D001921:Brain / Q000000981:diagnostic imaging; D002648:Child; D002675:Child, Preschool; D005260:Female; D006760:Hospitalization; D006801:Humans; D007223:Infant; D008279:Magnetic Resonance Imaging; D016779:Malaria, Cerebral / Q000000981:diagnostic imaging / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy; D008295:Malawi / Q000453:epidemiology; D008297:Male; D010211:Papilledema / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D057216:Propensity Score; D012189:Retrospective Studies; D012306:Risk; D012720:Severity of Illness Index; D013129:Spinal Puncture / Q000009:adverse effects*