Assessment of Dehydration in Children with Diarrhea in Resource-Limited Settings

资源有限环境下腹泻儿童脱水的评估

• 批准号: 8692494
• 负责人: Adam Carl Levine
• 金额: $ 13.69万
• 依托单位: RHODE ISLAND HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2012
• 资助国家: 美国
• 起止时间: 2012-09-20 至 2016-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8692494
• 关键词: Adverse event; Affect; Area; Bangladesh; Body Weight Changes; California; Caring; Cessation of life; Child; Childhood; Clinical; Clinical Trials Design; Clinics and Hospitals; Commit; Cost Effectiveness Analysis; Country; Data; Dehydration; Developed Countries; Developing Countries; Development; Diagnosis; Diagnostics Research; Diarrhea; Disease; Disease Outbreaks; Effectiveness; Ethics; Foundations; Functional disorder; Funding; Gold; Grant; Guidelines; Health; Healthcare; IV Fluid; Income; Inferior vena cava structure; International; Intervention; K-Series Research Career Programs; Knowledge; Lead; Length of Stay; Liquid substance; Low income; Malnutrition; Master of Public Health; Measures; Medicine; Mentored Research Scientist Development Award; Mentorship; Methods; Morbidity - disease rate; Nurses; Oral; Outcome; Pattern; Physicians; Physiological; Population; Prospective Studies; Public Health; Public Health Schools; Randomized Controlled Trials; Reading; Receiver Operating Characteristics; Refugee Camp; Regression Analysis; Rehydration Solutions; Rehydrations; Research; Research Training; Resources; Resuscitation; Rwanda; San Francisco; Scientist; Series; Severities; Severity of illness; Solid; Training; Ultrasonography; Universities; World Health Organization; base; care delivery; career; cooking; cost; cost effective; cost effectiveness; design; evidence base; experience; global health; hemodynamics; improved; international center; medical schools; mortality; novel diagnostics; parkin gene/protein; prevent; public health relevance; research study; skills; standard of care; tool; trial comparing; wasting

DESCRIPTION (provided by applicant): Diarrhea causes nearly two million deaths annually in children under five, or one fifth of all child deaths worldwide. As the severity of the disease depends on the degree of fluid loss, accurately assessing dehydration status remains a crucial step in preventing morbidity and mortality. While children with severe dehydration require immediate treatment with intravenous fluids to prevent hemodynamic compromise and death, children with mild to moderate dehydration have a significant reduction in hospital length of stay and fewer adverse events when treated with relatively inexpensive oral rehydration solution (ORS) as compared to treatment with costly intravenous fluids. While the World Health Organization (WHO) recommends using a four-point clinical scale for determining the severity of dehydration in children, this scale has never been validated against a physiologic gold standard (such as the accepted standard of percent weight change with rehydration). While several prior authors have developed alternative clinical prediction rules for severe dehydration in children, these scales have not been externally validated against a physiologic gold standard in a developing country, where the vast majority of pediatric deaths from diarrhea occur, and where clinician expertise and varying disease patterns may affect the accuracy of any clinical scale derived in a developed country. There is an urgent need for research into new clinical tools that can accurately and reliably assess dehydration in a resource-limited setting. As part of this K01 award, we will conduct a series of three studies that will derive, validate, and assess the reliability of a new clinical prediction rule for severe dehydration in children with diarrhea in te developing world. In addition, we will validate and assess the reliability of ultrasound of the inferior vena cava (IVC) for predicting severe dehydration in children with diarrhea in the developing world. Finally, we will compare the accuracy of each of these new diagnostic tools to that of the WHO scale, using percent weight change with rehydration as the gold standard for all of our measures of dehydration, in order to determine whether either of these new methods may improve upon the current standard of care. My prior training and research experience have provided me with a solid foundation for this career development award. I have completed a Doctorate of Medicine at the University of California, San Francisco and a Masters of Public Health in International Health at the University of California, Berkeley. I also have experience designing and managing two small research studies conducted in resource-limited settings, including one study providing preliminary data for this International Research Scientist Development Award (IRSDA) application. However, I would benefit from additional targeted training in specific areas, including advanced regression analysis and recursive partitioning, clinical trial design and management, cost- effectiveness analysis, the pathophysiology of diarrhea and malnutrition, and the ethics of conducting research in resource-limited settings, which will be completed during the five years of this K01 award through formal coursework, seminars, directed reading, and individualized tutorials. I will also benefit from the additional experience of managing large, prospective studies under the mentorship of three scientists with extensive experience in conducting public health and global health research, including Dr. Jennifer Friedman of Brown Medical School, Dr. Nur Haque Alam of the International Center for Diarrheal Disease and Research, Bangladesh (ICDDRB), and Dr. Earl F. Cook of the Harvard School of Public Health. After this K01 award, I plan to apply for an R01 grant to fund a randomized controlled trial comparing these new methods for diagnosing and managing dehydration in children with diarrhea to the current standard of care, analyzing both health-related outcomes, such as adverse events, and total costs. Improved methods for assessing severe dehydration have the potential to help clinicians in the developing world identify the children with diarrhea at greatest need for emergent intervention, while also preventing the adverse events and wasted resources associated with the inappropriate use of intravenous fluids. These new methods have the potential to improve the delivery of care in both developed and developing country hospitals and clinics, as well as in refugee camp settings where outbreaks of diarrheal disease are common. In addition to funding research into the development of these new methods, the IRSDA will also provide me with the support necessary to launch my career as an independently funded physician-scientist in translational global health research. Utilizing the knowledge and skills gained as part of the IRSDA, I am committed to a career aimed at improving the evidence base for the diagnosis and management of dehydration in resource-limited settings, thereby improving both the effectiveness and cost- effectiveness of care and potentially saving thousands of lives each year.

描述（由申请人提供）：腹泻每年在全世界五岁以下的儿童或五分之一的儿童死亡中导致近200万人死亡。由于疾病的严重程度取决于液体损失程度，因此准确评估脱水状态仍然是预防发病率和死亡率的关键步骤。尽管患有严重脱水的儿童需要立即用静脉液体治疗以防止血液动力学损害和死亡，但与具有成本的静脉内液体的治疗相比，患有相对廉价的口服再水解溶液（ORS）治疗相对较便宜的口服再水解溶液（ORS）治疗时，住院时间长到中度的儿童的住院时间很大，不良事件的不良事件较少。尽管世界卫生组织（WHO）建议使用四点临床量表来确定儿童脱水的严重程度，但该量表从未通过生理金标准（例如，重量变化的公认的重量百分比变化标准随着再加水的方式）进行了验证。尽管几位先前的作者已经制定了儿童严重脱水的替代性临床预测规则，但这些量表尚未在发展中国家的生理金标准上进行外部验证，在发展中国家，绝大多数腹泻的儿科死亡发生，并且临床医生的专业知识和不同的疾病模式可能会影响发达国家的临床规模的准确性。迫切需要研究新的临床工具，这些工具可以在资源有限的环境中准确，可靠地评估脱水。作为该K01奖的一部分，我们将进行一系列三项研究，这些研究将得出，验证和评估TE发展中国家腹泻儿童的新临床预测规则的可靠性。此外，我们将验证和评估下腔静脉（IVC）超声的可靠性，以预测发展中国家腹泻儿童的严重脱水。最后，我们将将这些新的诊断工具的准确性与WHO量表的准确性进行比较，使用重量变化百分比作为我们所有脱水措施的金标准，以确定这些新方法中的任何一种都可以根据当前的护理标准改善。我先前的培训和研究经验为我为这个职业发展奖提供了坚实的基础。我已经在加利福尼亚大学，旧金山大学完成了医学博士学位，并在加利福尼亚大学伯克利分校的国际健康公共卫生硕士学位完成了医学博士学位。我还具有设计和管理在资源有限的环境中进行的两项小型研究的经验，其中包括一项为该国际研究科学家发展奖（IRSDA）应用程序提供初步数据的研究。 However, I would benefit from additional targeted training in specific areas, including advanced regression analysis and recursive partitioning, clinical trial design and management, cost- effectiveness analysis, the pathophysiology of diarrhea and malnutrition, and the ethics of conducting research in resource-limited settings, which will be completed during the five years of this K01 award through formal coursework, seminars, directed reading, and individualized tutorials.在三位科学家的指导下，我还将受益于在进行公共卫生和全球健康研究方面的丰富经验，包括布朗医学院的詹妮弗·弗里德曼（Jennifer Friedman）博士，孟加拉国国际腹泻病与研究中心的尼尔·哈克（Nur Haque Alam），孟加拉国（ICDDRB）（ICDDRB），以及伯爵F. Cook of the Hostard Public health of Hostarard Public Health of Hover of Hover of Hover of Cock。在获得K01奖之后，我计划申请R01赠款，以资助一项随机对照试验，以比较这些新方法诊断和管理腹泻儿童脱水与当前护理标准的脱水，并分析了与健康相关的结果，例如不良事件，例如不良事件和总成本。改进的评估严重脱水的方法有可能帮助发展中国家的临床医生确定腹泻儿童最需要紧急干预，同时还可以防止与不适当使用静脉注射液相关的不良事件和浪费资源。这些新方法有可能改善发达国家和发展中国家医院和诊所的护理服务，以及在腹泻病爆发很常见的难民营地环境中。除了为这些新方法的开发提供资金研究外，IRSDA还将为我提供所需的支持，以启动我作为转化全球健康研究的独立医师科学家的职业。利用作为IRSDA的一部分获得的知识和技能，我致力于一项职业，旨在改善资源有限环境中脱水的诊断和管理证据基础，从而提高护理的有效性和成本效益，并潜在地挽救数千个生命。