Prognostic factors and scoring system for death from visceral leishmaniasis: an historical cohort study in Brazil.

Coura-Vital W, Araújo VE, Reis IA, Amancio FF, Reis AB, Carneiro M - PLoS Negl Trop Dis (2014)

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pntd-0003374-g002: Prognostic scoring system and range of probability of death from visceral leishmaniasis.
Mentions: The range of probability of death according to the prognostic score of the patients included in the primary series is presented in Fig. 2. Because the same score can be obtained with different prognostic factors (coefficients of the regression), a range of probability of death was defined. These ranges were calculated based on the sum of the smallest and largest regression coefficients for each point comprising the score. For example, for a score of 4, the range of probability of death was calculated as follows: The idea behind the presentation of a range of probability is that a patient can have a given value for the score in different ways. For example, a patient older than 1 year or younger than 20 years can have a score of 4 if that patient presents with splenomegaly and bleeding (pminor), or if the patient is older than 0.5 years or younger than 1 year and presents with bacterial infection and edema, (pmajor). The standardization of the coefficients gives the score of 4 for both situations. However, the probability of death is calculated based on the original coefficients, which leads to some difference in values. A score of 3 or less corresponds to a probability of death of less than 3.2%. It is noteworthy that a patient with a score of 4 has approximately 4.5% probability of death from VL, which is relevant from a clinical point of view. The ranges of probability of death are 4.8% to 8.3% and 7.2% to 13.0% when the score is 5 and when the score is 6, respectively. When the patient has a score of 11, the range of probability of death increases to 44.3% to 56.0%; with a score of 14, the range of probability of death is 81.3% to 82.9% (Fig. 2).

Bottom Line: Multivariate logistic regression models were performed to identify factors associated with death from VL, and these were included in the scoring system.The factors associated with death from VL were: bleeding (score 3); splenomegaly (score 1); edema (score 1); weakness (score 1); jaundice (score 1); Leishmania-HIV co-infection (score 1); bacterial infection (score 1); and age (≤0.5 years [score 5]; >0.5 and ≤1 [score 2]; >19 and ≤50 [score 2]; >50 and <65 [score 3]; ≥65 [score 5]).The scoring system based on risk factors for death showed good performance in identifying patients with signs of severity at the time of clinical suspicion of VL and can contribute to improving the surveillance system for reducing case fatalities.

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Affiliation: Pós-graduação em Ciências da Saúde, Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil; Núcleo de Pesquisas em Ciências Biológicas, Instituto de Ciências Exatas e Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brasil.

ABSTRACT

Background: In Brazil, case-fatality rates attributable to visceral leishmaniasis (VL) are high and knowledge of the risk factors associated with death may help reduce mortality. The aim of this study was to construct and validate a scoring system for prognosis of death from VL by using all cases reported in Brazil from 2007 to 2011.

Methodology: In this historical cohort study, 18,501 VL cases were analyzed; of these, 17,345 cases were cured and 1,156 cases caused death. The database was divided into two series: primary (two-thirds of cases), to develop the model score, and secondary (one-third of cases), to validate the scoring system. Multivariate logistic regression models were performed to identify factors associated with death from VL, and these were included in the scoring system.

Principal findings: The factors associated with death from VL were: bleeding (score 3); splenomegaly (score 1); edema (score 1); weakness (score 1); jaundice (score 1); Leishmania-HIV co-infection (score 1); bacterial infection (score 1); and age (≤0.5 years [score 5]; >0.5 and ≤1 [score 2]; >19 and ≤50 [score 2]; >50 and <65 [score 3]; ≥65 [score 5]). It was observed that patients with a score of 4 had a probability of death of approximately 4.5% and had a worse prognosis. The sensitivity, specificity, and accuracy of this score were 89.4, 51.2, and 53.5, respectively.

Conclusions/significance: The scoring system based on risk factors for death showed good performance in identifying patients with signs of severity at the time of clinical suspicion of VL and can contribute to improving the surveillance system for reducing case fatalities. The classification of patients according to their prognosis for death may assist decision-making regarding the transfer of the patients to hospitals more capable of handling their condition, admission to the intensive care unit, and adequate support and specific treatment.

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