Derivation of a Clinical Prediction Rule for Pediatric Abusive Head Trauma
Derivation of a Clinical Prediction Rule for Pediatric Abusive Head Trauma
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DOI：
10.1097/pcc.0b013e3182712b09
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发表时间：
2013-02-01
影响因子：
4.1
通讯作者：
Narang, Sandeep K.
中科院分区：
文献类型：
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作者：
Hymel, Kent P.;Willson, Douglas F.;Narang, Sandeep K.
目的：虐待性头部创伤是婴儿和儿童早期创伤性死亡和残疾的主要原因。没有针对虐待性头部创伤的循证筛查工具。我们的研究目标是：1）测量虐待性头部创伤与孤立的、有区别的和可靠的临床变量之间的预测关系; 2）推导出一个可靠的、敏感的、虐待性头部创伤临床预测规则，如果得到验证，可以告知儿科重症监护医师早期决定是否启动设计：前瞻性、多中心、横断面、观察性。设置：14个PICU。患者：3岁以下的急性头部受伤儿童入院接受重症监护。干预措施：无。测量和主要结果：应用虐待性头部创伤的先验定义标准，我们确定了具有鉴别力和可靠性的临床变量，计算了虐待的似然比和后测概率，并应用递归分割来导出具有最大灵敏度的虐待性头部创伤临床预测规则，以帮助排除虐待性头部创伤（如果阴性的话）。在我们的研究人群中，虐待性头部创伤的预测概率（患病率）为0.45（209人中有95人）。测试后的概率虐待性头部创伤的孤立，歧视，和可靠的临床变量范围从0.1到0.86。其中一些变量，当积极的，改变了滥用的概率大大上升，但当消极的改变不大。其他变量，当消极的，在很大程度上排除虐待头部创伤，但增加虐待的概率只有轻微的积极。一些区分变量表现出较差的评分者间的可靠性。一组五个区别和可靠的变量可在或接近入院时确定97%的研究患者符合虐待性头部创伤的先验定义标准。结论：对独立、可区分、可靠变量的特异性预测质量有更全面的了解，可提高筛查的准确性。如果得到验证，一个可靠的，敏感的，虐待性头部创伤的临床预测规则可以被儿科重症监护医生用来计算一个基于证据的，患者特异性的估计滥用的可能性，可以告知-而不是口述-他们的早期决定启动（或放弃）滥用的评估。（Pediatr Crit Care Med 2013; 14：210-220）
Objectives: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that-if validated-can inform pediatric intensivists' early decisions to launch (or forego) an evaluation for abuse.Design: Prospective, multicenter, cross-sectional, observational.Setting: Fourteen PICUs.Patients: Acutely head-injured children less than 3 years old admitted for intensive care.Interventions: None.Measurements and Main Results: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity-to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%.Conclusions: A more complete understanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform-not dictate-their early decisions to launch (or forego) an evaluation for abuse. (Pediatr Crit Care Med 2013; 14:210-220)