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Derivation and Internal Validation of a Score to Predict Dehydration Severity in Patients over 5 Years with Acute Diarrhea
Meagan A. Barry
Meagan A. Barry
Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island;
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Kexin Qu
Kexin Qu
Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island;
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Monique Gainey
Monique Gainey
Rhode Island Hospital, Providence, Rhode Island;
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Christopher H. Schmid
Christopher H. Schmid
Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island;
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Stephanie C. Garbern
Stephanie C. Garbern
Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island;
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Sabiha Nasrin
Sabiha Nasrin
International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh;
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Nur H. Alam
Nur H. Alam
International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh;
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J. Austin Lee
J. Austin Lee
Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island;
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Eric J. Nelson
Eric J. Nelson
Departments of Pediatrics and Environmental and Global Health, Emerging Pathogens Institute, University of Florida, Gainesville, Florida;
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Rochelle Rosen
Rochelle Rosen
Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
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Adam C. Levine
Adam C. Levine
Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island;
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ABSTRACT.
Diarrheal disease accounts for more than one million deaths annually in patients over 5 years of age. Although most patients can be managed with oral rehydration solution, patients with severe dehydration require resuscitation with intravenous fluids. Scoring systems to assess dehydration have been empirically derived and validated in children under 5 years, but none have been validated for patients over 5 years. In this study, a prospective cohort of 2,172 patients over 5 years presenting with acute diarrhea to International Centre for Diarrhoeal Disease Research, Dhaka Hospital, Bangladesh, were assessed for clinical signs of dehydration. The percent difference between presentation and posthydration stable weight determined severe (≥ 9%), some (3–9%), or no (< 3%) dehydration. An ordinal regression model was derived using clinical signs and demographics and was then converted to a 13-point score to predict none (score of 0–3), some (4–6), or severe (7–13) dehydration. The Novel, Innovative Research for Understanding Dehydration in Adults and Kids (NIRUDAK) Score developed by our team included age, sex, sunken eyes, radial pulse, respiration depth, skin turgor, and vomiting episodes in 24 hours. Accuracy of the NIRUDAK Score for predicting severe dehydration, as measured by the area under the receiver operating characteristic curve, was 0.76 (95% confidence interval = 0.73–0.78), with a sensitivity of 0.78 and a specificity of 0.61. Reliability was also robust, with an Inter-Class Correlation Coefficient of 0.88 (95% confidence interval = 0.84–0.91). This study represents the first empirically derived and internally validated scoring system for assessing dehydration in children ≥ 5 years and adults with acute diarrhea in a resource-limited setting.
- Supplemental Materials (DOCX 36 KB)
Author Notes
Financial support: Funding for data collection was provided through grants from National Institute for Diabetes and Digestive and Kidney Diseases, National Institutes of Health (DK116163). The funders had no role in the study design, data collection or reporting processes.
Authors’ addresses: Meagan A. Barry, Stephanie C. Garbern, J. Austin Lee, and Adam C. Levine, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI, E-mails: meagan_barry@brown.edu, stephanie_garbern@brown.edu, jaustinlee@brown.edu, and adam_levine@brown.edu. Kexin Qu, Department of Biostatistics, Brown University School of Public Health, Providence, RI, E-mail: kexin_qu@brown.edu. Monique Gainey, Rhode Island Hospital, Providence, RI, E-mail: gaineym@bu.edu. Christopher H. Schmid, Department of Biostatistics, Brown University School of Public Health, Providence, RI, E-mail: christopher_schmid@brown.edu. Sabiha Nasrin and Nur H. Alam, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh, E-mails: sabiha.nasrin@icddrb.org and nhalam@icddrb.org. Eric J. Nelson, Departments of Pediatrics and Environmental and Global Health, Emerging Pathogens Institute, University of Florida, Gainesville, FL, E-mail: eric.nelson@ufl.edu. Rochelle Rosen, Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, E-mail: rochelle_rosen@brown.edu.
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
GBD 2017 Disease and Injury Incidence and Prevalence Collaborators , 2018. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 392: 1789–1858.
-
2.
Lamberti LM, Fischer Walker CL, Black RE, 2012. Systematic review of diarrhea duration and severity in children and adults in low- and middle-income countries. BMC Public Health 12: 276.
-
3.
GBD 2017 Causes of Death Collaborators , 2018. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 392: 1736–1788.
-
4.
GBD 2016 Diarrhoeal Disease Collaborators , 2018. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis 18: 1211–1228.
-
5.
World Health Organization , 2005. The Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health Workers. Available at: http://apps.who.int/iris/bitstream/10665/43209/1/9241593180.pdf. Accessed October 15, 2016.
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6.
World Health Organization , 2012. First Steps for Managing an Outbreak of Acute Diarrhoea. Available at: http://www.who.int/cholera/technical/prevention/control/en/. Accessed December 26, 2016.
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7.
World Gastroenterology Organisation , 2012. Acute Diarrhea in Adults and Children: A Global Perspective. Available at: http://www.worldgastroenterology.org/UserFiles/file/guidelines/acute-diarrhea-english-2012.pdf. Accessed January 12, 2017.
-
8.
Fonseca BK, Holdgate A, Craig JC, 2004. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med 158: 483–490.
-
9.
Morisawa K, Fujitani S, Taira Y, 2019. The downside of aggressive volume administration in critically ill patients—“aggressive” may lead to “excessive.” J Intensive Care 7: 10.
-
10.
Khan AI et al., 2020. Electronic decision support and diarrhoeal disease guideline adherence (mHDM): a cluster randomised controlled trial. Lancet Digit Health 2: e250–e258.
-
11.
Popowski LA, Oppliger RA, Patrick Lambert G, Johnson RF, Kim Johnson A, Gisolf CV, 2001. Blood and urinary measures of hydration status during progressive acute dehydration. Med Sci Sports Exerc 33: 747–753.
-
12.
Fleming S, Gill P, Jones C, Taylor JA, Van den Bruel A, Heneghan C, Roberts N, Thompson M, 2015. The diagnostic value of capillary refill time for detecting serious illness in children: a systematic review and meta-analysis. PLoS One 10: e0138155.
-
13.
McGee S, Abernethy WB 3rd, Simel DL, 1999. The rational clinical examination. Is this patient hypovolemic? JAMA 281: 1022–1029.
-
14.
Vivanti A, Harvey K, Ash S, 2010. Developing a quick and practical screen to improve the identification of poor hydration in geriatric and rehabilitative care. Arch Gerontol Geriatr 50: 156–164.
-
15.
Gross CR, Lindquist RD, Woolley AC, Granieri R, Allard K, Webster B, 1992. Clinical indicators of dehydration severity in elderly patients. J Emerg Med 10: 267–274.
-
16.
Hooper L et al., 2015. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. Cochrane Database Syst Rev CD009647.
-
17.
Steiner MJ, DeWalt DA, Byerley JS, 2004. Is this child dehydrated? JAMA 291: 2746–2754.
-
18.
Levine AC, Glavis-Bloom J, Modi P, Nasrin S, Atika B, Rege S, Robertson S, Schmid CH, Alam NH, 2016. External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study. Lancet Glob Health 4: e744–e751.
-
19.
Levine AC, Glavis-Bloom J, Modi P, Nasrin S, Rege S, Chu C, Schmid CH, Alam NH, 2015. Empirically derived dehydration scoring and decision tree models for children with diarrhea: assessment and internal validation in a prospective cohort study in Dhaka, Bangladesh. Glob Health Sci Pract 3: 405–418.
-
20.
Goldman RD, Friedman JN, Parkin PC, 2008. Validation of the clinical dehydration scale for children with acute gastroenteritis. Pediatrics 122: 545–549.
-
21.
Falszewska A, Dziechciarz P, Szajewska H, 2014. The diagnostic accuracy of Clinical Dehydration Scale in identifying dehydration in children with acute gastroenteritis: a systematic review. Clin Pediatr (Phila) 53: 1181–1188.
-
22.
Friedman JN, Goldman RD, Srivastava R, Parkin PC, 2004. Development of a clinical dehydration scale for use in children between 1 and 36 months of age. J Pediatr 145: 201–207.
-
23.
World Health Organization , 2012. IMAI District Clinician Manual: Hospital Care Adolescents and Adults: Guidelines for the Management of Illnesses with Limited Resources. Available at: https://apps.who.int/iris/handle/10665/77751. Accessed September 22, 2020.
-
24.
Fischer Walker CL, Sack D, Black RE, 2010. Etiology of diarrhea in older children, adolescents and adults: a systematic review. PLoS Negl Trop Dis 4: e768.
-
25.
Kotloff KL et al., 2013. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet 382: 209–222.
-
26.
Platts-Mills JA et al., 2015. Pathogen-specific burdens of community diarrhoea in developing countries: a multisite birth cohort study (MAL-ED). Lancet Glob Health 3: e564–e575.
-
27.
Faruque AS, Malek MA, Khan AI, Huq S, Salam MA, Sack DA, 2004. Diarrhoea in elderly people: aetiology, and clinical characteristics. Scand J Infect Dis 36: 204–208.
-
28.
Hall AJ, Curns AT, McDonald LC, Parashar UD, Lopman BA, 2012. The roles of Clostridium difficile and norovirus among gastroenteritis-associated deaths in the United States, 1999–2007. Clin Infect Dis 55: 216–223.
-
29.
Truninger K, 2014. Diarrhea in the elderly. Ther Umsch 71: 545–550.
-
30.
World Health Organization , 2005. Handbook: IMCI Integrated Management of Childhood Illness. Available at: https://apps.who.int/iris/handle/10665/42939. Accessed September 22, 2020.
-
31.
Levine AC et al., 2021. Derivation of the first clinical diagnostic models for dehydration severity in patients over five years with acute diarrhea. PLoS Negl Trop Dis 15: e0009266.
-
32.
World Health Organization , 2017. Adolescent Health. Available at: http://www.who.int/topics/adolescent_health/en/. Accessed October 20, 2017.
-
33.
United Nations , 2020. World Population Aging 2019. Available at: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_worldpopulationageing_report.pdf. Accessed Februbary 4, 2021.
-
34.
Cheuvront SN, Ely BR, Kenefick RW, Sawka MN, 2010. Biological variation and diagnostic accuracy of dehydration assessment markers. Am J Clin Nutr 92: 565–573.
-
35.
Kavouras SA, 2002. Assessing hydration status. Curr Opin Clin Nutr Metab Care 5: 519–524.
-
36.
Shirreffs SM, 2003. Markers of hydration status. Eur J Clin Nutr 57 (Suppl 2): S6–S9.
-
37.
Gorelick MH, Shaw KN, Murphy KO, 1997. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics 99: E6.
-
38.
Duggan C, Santosham M, Glass RI, 1992. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. Centers for Disease Control and Prevention. MMWR Recomm Rep 41: 1–20.
-
39.
Collins GS, Reitsma JB, Altman DG, Moons KG, 2015. Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): the TRIPOD statement. Ann Intern Med 162: 55–63.
-
40.
Harrell FE Jr, Lee KL, Mark DB, 1996. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med 15: 361–387.
-
41.
Royston P, Moons KG, Altman DG, Vergouwe Y, 2009. Prognosis and prognostic research: Developing a prognostic model. BMJ 338: b604.
-
42.
Stiell IG, Wells GA, 1999. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 33: 437–447.
-
43.
Hand DJ, Till RJ, 2001. A simple generalisation of the area under the ROC curve for multiple class classification problems. Mach Learn 45: 171–186.
-
44.
Van Calster B, Van Belle V, Vergouwe Y, Steyerberg EW, 2012. Discrimination ability of prediction models for ordinal outcomes: relationships between existing measures and a new measure. Biom J 54: 674–685.
-
45.
Miao Y, Francisco S, Boscardin WJ, Francisco S, Francisco S, 2013. Estimating Harrell’s optimism on predictive indices using bootstrap samples. SAS Global Forum 2013: Statistics and data analysis.
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