Aetiology and outcome of non-traumatic coma in African children: protocol for a systematic review and meta-analysis

Background Non-traumatic coma is a common acute childhood presentation to healthcare facilities in Africa and is associated with high morbidity and mortality. Historically, the majority of cases were attributed to cerebral malaria (CM). With the recent drastic reduction in malaria incidence, non-malarial coma is becoming a larger proportion of cases and determining the aetiology is diagnostically challenging, particularly in resource-limited settings. The purpose of this study will be to evaluate the aetiology and prognosis of non-traumatic coma in African children. Methods With no date restrictions, systematic searches of MEDLINE, Embase, and Scopus will identify prospective and retrospective studies (including randomised controlled trials, cluster randomised trials, cohort studies, cross-sectional, and case-control studies) recruiting children (1 month–16 years) with non-traumatic coma (defined by Blantyre Coma Score ≤ 2 or comparable alternative) from any African country. Disease-specific studies will be included if coma is associated and reported. The primary outcome is to determine the aetiology (infectious and non-infectious) of non-traumatic coma in African children, with pooled prevalence estimates of causes (e.g., malaria). Secondary outcomes are to determine overall estimates of morbidity and mortality of all-cause non-traumatic coma and disease-specific states of non-traumatic coma, where available. Random effects meta-analysis will summarise aetiology data and in-hospital and post-discharge mortality. Heterogeneity will be quantified with τ2, I2, and Cochran’s Q test. Discussion This systematic review will provide a summary of the best available evidence on the aetiology and outcome of non-traumatic coma in African children. Systematic review registration PROSPERO CRD42020141937

STUDY OF NON TRAUMATIC COMA IN CHILDREN AT TERTIARY HOSPITAL.

Introduction: Non-traumatic coma can have varied etiology and clinical characteristics. These may determine the management and outcome of the patients. We aimed to study the etiology and outcomes of children diagnosed and treated for non-traumatic coma in our hospital. Methodology: Medical records of children aged 2 months to 18 years, diagnosed with non-traumatic coma from January 2020 till December 2020 were reviewed retrospectively. The nal outcome was determined by patient's death or neurological condition at the time of discharge. Results: In the present study, out of 45 patients of NTC, 44% of the patients were in the age group 2 months to 5 years, 31% in 6 years to 12 years and 24% in 13 years to 18 years and 42% were Males & 57% were Females. In etiology, Infectious and Non-infectious causes contributed equally. Among the infectious causes, the most common ones were acute encephalitis (22%), acute pyogenic meningitis (9%), TBM (9%) and remaining infectious causes contributed to 9%. Among the non-infectious causes, diabetic ketoacidotic coma (22%), epileptic encephalopathy and metabolic encephalopathy contributed to 7% each. In outcome of the sample of 45 patients, 39 (87%) were discharged home and mortality was observed in 6 (13%). Among the total patients discharged (87%), 53% were neurologically normal, 7% had mild disability, 9% had moderate disability and 18% had severe disability. In our study, mortality was 3% in children with moderate brain injury, 33% mortality in children with severe brain injury (p value < 0.01). Conclusions: In our study, mortality rate was high with severe brain injury as compared to mild and moderate brain injury as assessed by GCS at admission.

Value of coma scale in prediction of mortality in non-traumatic coma in 1-12 years old children

Background: Acute non-traumatic coma is a common problem in pediatric practice accounting for 10-15% of all hospital admissions and is associated with significant mortality. Assessment of the severity of coma is essential to comment on the likelihood of survival in comatose children. In the last three decades, various scores have been used to assess the severity of coma and to predict its outcome. Glasgow Coma Scale (MGCS) in spite of its various drawbacks has been widely used for assessing pediatric coma, though only few studies are available to support its use in pediatric coma as a whole. Hence the study was undertaken to evaluate the usefulness of coma scale in prediction of mortality in children between 1-12 years old admitted with coma of non-traumatic origin. Methods: A prospective study was conducted at Inpatient services of intensive medical care unit and general medical wards of Institute of child Health and Hospital for children, Egmore, Chennai, between October 2018 to November 2019. A Study Population consisting of children in the age group 1-12 years admitted in intensive care unit and medical wards with alteration in sensorium as one of the predominant complaints and admitted within 7 days of onset of coma were included. Sample size was 148. Chi-square test was used to study the association between the scores at Various times points and outcome. Results: It was observed that when the scores were between 3‐ 5 mortality rate was 67.0%, it was 17% when the minimal observed score was between 6-8. The group in which the minimal score never decreased be1ow 9 had no mortality. As the score increases the proportion of death decreases and the proportion having good recovery increases and vice versa. This type of association has been observed at different time points (Initial, 24 hrs, 48 hrs and 72 hrs). The significance of this association increases with the progression of time since admission. P value for the degree of association at various time points are: At presentation P < 0.00001, 24hrs - P < 0.000001, 48 hrs - P < 0.000001 and 72 hrs P < 0.00000001. Conclusion: There is highly statistically significant association between the GSC score levels and outcome. As the score increases the proportion of death decreases and the proportion having good recovery increases and vice versa.

THE NEUROPSYCHOLOGY OF METAPHORS IN PATIENTS AWAKENED FROM POST-TRAUMATIC COMA

Metaphor simply is defined as a verbal construct with two referents: one literal, based on the ordinary, concrete meanings of the word or words involved, and the other metaphorical, that is one derived from an implicit analogy between the literal referent and some other phenomenon, usually an abstraction that is implied, but not named. The aim of this paper is a description of the neuropsychology of metaphors in patients awakened from post-traumatic coma. A group of 34 patients awakened from post-traumatic coma and treated at the Reintegrative and Teaching Centre of the Polish Neuropsychological Society, Poland during the period 2017- 2019 participated in this study. This group included 15 women and 17 men, with an average age of 31.2 ± 8.72 years; as a group, the women were somewhat older (32.6 ± 9.79 vs. 31.1 ± 9.18). We recorded the patients’ utterances with the use of video record- ings of open-ended conversations, and made occasional efforts to introduce proverbs, idioms, and other metaphors into their conversation, but this was done on an impromptu basis. The analysis of recordings of 100 randomly selected statements obtained from each patient revealed the presence of 4 types of errors: (1) non-comprehension, i.e. the listener’s inability to comprehend the meaning of the metaphor used by the speaker, as indicated by the lack of an adequate response, an expression of puzzlement, or a question as to the meaning of the metaphor used by the speaker; (2) concretization, which occurs when the listener reacts to the literal meaning of the word, phrase, or sentence, rather than its metaphorical referent; (3) misapplication, when the speaker uses a familiar metaphor in an inappropriate context; (4) the use of incomprehensible or bizarre metaphors by the speaker, so that the intended meaning is difficult or impossible for the listener to ascertain. On many occasions, however, the gist of the metaphor emerged at some later point in the discourse, despite the surface problems. It was found that the TBI patients we studied showed a marked tendency in spontaneous conversation to concretize or misunderstand the metaphors used by others, and to use inappropriate or bizarre metaphors in their own speech. On many occasions, however, the gist of the metaphor emerged at some later point in the discourse, despite the surface problems.

Aetiology and Outcome of Non-Traumatic Coma in African Children: Protocol for a Systematic Review and Meta-Analysis

Background: Non-traumatic coma is a common acute childhood presentation to healthcare facilities in Africa and is associated with high morbidity and mortality. Historically, the majority of cases were attributed to cerebral malaria (CM). With the recent drastic reduction in malaria incidence, non-malarial coma is becoming a larger proportion of cases and determining the aetiology is diagnostically challenging, particularly in resource-limited settings. The purpose of this study will be to evaluate the aetiology and prognosis of non-traumatic coma in African children.Methods: From inception onwards, systematic searches of MEDLINE, Embase, and Scopus, will identify prospective and retrospective studies (including randomised controlled trials, cluster randomised trials, cohort studies, cross-sectional, and case-control studies) recruiting children (1 month-16 years) with non-traumatic coma (defined by Blantyre Coma Score ≤2 or comparable alternative) from any African country. Disease-specific studies will be included given that coma is associated and reported. The primary outcome is to determine the aetiology (infectious and non-infectious) of non-traumatic coma in African children, with pooled prevalence estimates of causes (e.g. malaria). Secondary outcomes are to determine overall estimates of morbidity and mortality of all cause non-traumatic coma and disease-specific states of non-traumatic coma, where available. Random effects meta-analysis will summarize aetiology data and in-hospital and post-discharge mortality. Heterogeneity will be quantified with τ2, I2, and Cochran’s Q test.Discussion: This systematic review will provide a summary of the best available evidence on the aetiology and outcome of non-traumatic coma in African children. Systematic Review Registration: This review is registered in PROSPERO International Prospective Register of Systematic Reviews (CRD42020141937).