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Multicenter studies rely on data derived from different institutions. Forms can be designed to standardize the reporting process allowing reliable comparison of data.
The purpose of the report is to provide a standardized method, developed as a part of a multicenter study of vertically transmitted HIV, for assessing chest radiographic results.
Eigh...
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Context 1
... of the first three rounds of quality assurance are summarized in Table 1. The kappa statistics combining data from the three rounds were above 0.40 for all ques- tions except lung volume (kappa = 0.21) and enlarged heart (kappa = 0.23). ...
Context 2
... study shows a moderate to high inter-rater cor- relation for several observations made on chest radio- graphs of infants and small children (Tables 1, 2). ...
Context 3
... in part, may have been because of a lack of agreement among the radi- ologists as to the criteria for clearly differentiating be- tween the two observations. The kappa statistics for nodular densities and paren- chymal consolidation, considered as ªabsentº vs. ªpre- sentº, were 0.56 and 0.57 respectively, both suggesting moderate agreement among the radiologists (Table 1). However, the strength of agreement for lung volume (normal vs. low vs. increased) was low (kappa = 0.21). ...
Context 4
... the strength of agreement for lung volume (normal vs. low vs. increased) was low (kappa = 0.21). Since the prevalence of children with an enlarged heart as read by the original reader was only 6.9 %, and the observed and chance agreements were high (90.5 % and 87.7 % respectively) (Table 1), the low kappa statis- tic of 0.23 may be misleading. It is well recognized that the statistic depends upon the proportion of children (prevalence) in each category. ...
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Citations
... Inconsistent radiograph image quality due to patient movement, exposure setting alterations, and low lung volumes are a few of the many variables limiting assessment, and many researchers have demonstrated significant inter-observer variability in interpretation. [3][4][5][6][7] The advent of picture archiving and communication system (PACS) has allowed the user to manipulate the images by altering the brightness (window level) and/or contrast (window width) of each radiograph while developing their impression. This manipulation will vary the appearance of the radiograph, and in effect, each user will be basing their impression on their own uniquely obtained image. ...
... This has led to potential solutions such as double and triple reading of studies which are both costly and time-consuming. [6,7,[14][15][16] More recent research has shown even less inter-observer agreement on digital compared to analog studies. [4] Numerous factors can contribute to poor image quality, such as patient and cassette positioning, exposure techniques, body habitus, and motion, and the radiographic images obtained are often suboptimal. ...
... The study also demonstrates overall poor agreement in image interpretation which has been shown in the medical literature. [3,6,7,[14][15][16] Particularly, concerning is the percentage of opposing radiograph impressions which could result in significant changes to patient care and outcome. The ability to manipulate the appearance of the CXR images on PACS led to an increase in opposing interpretations in our study and raised the question of whether clinicians' access to image windowing/manipulation is of benefit to the patient. ...
Objective:
Variability in image interpretation has been attributed to differences in the interpreters' knowledge base, experience level, and access to the clinical scenario. Picture archiving and communication system (PACS) has allowed the user to manipulate the images while developing their impression of the radiograph. The aim of this study was to determine the agreement of chest radiograph (CXR) impressions among radiologists and neonatologists and help determine the effect of image manipulation with PACS on report impression.
Materials and methods:
Prospective cohort study included 60 patients from the Neonatal Intensive Care Unit undergoing CXRs. Three radiologists and three neonatologists reviewed two consecutive frontal CXRs of each patient. Each physician was allowed manipulation of images as needed to provide a decision of "improved," "unchanged," or "disease progression" lung disease for each patient. Each physician repeated the process once more; this time, they were not allowed to individually manipulate the images, but an independent radiologist presets the image brightness and contrast to best optimize the CXR appearance. Percent agreement and opposing reporting views were calculated between all six physicians for each of the two methods (allowing and not allowing image manipulation).
Results:
One hundred percent agreement in image impression between all six observers was only seen in 5% of cases when allowing image manipulation; 100% agreement was seen in 13% of the cases when there was no manipulation of the images.
Conclusion:
Agreement in CXR interpretation is poor; the ability to manipulate the images on PACS results in a decrease in agreement in the interpretation of these studies. New methods to standardize image appearance and allow improved comparison with previous studies should be sought to improve clinician agreement in interpretation consistency and advance patient care.
... [1][2][3] Reliability in interpretation of these studies is crucial to guide appropriate timely patient care. [4][5][6][7] It also helps to ensure reproducibility in clinical research studies so as to reduce sample size requirements and allow true-positive trial findings. Utilization of standardized reporting criteria, proctoring, and double readings have shown to improve agreement of image interpretation, helping to address issues such as interpreter experience and fatigue. ...
... Utilization of standardized reporting criteria, proctoring, and double readings have shown to improve agreement of image interpretation, helping to address issues such as interpreter experience and fatigue. [5,6] Radiographic image quality and the techniques used to obtain the images also contribute to the physicians' ability to reliably interpret and compare a patients' chest radiographs. [4,5,[8][9][10] Inherent differences in the patients' lung volumes and body habitus alter exposure leading to a variable appearance of the chest radiograph, making it more difficult to assess for changes between studies. ...
... [4,5,[8][9][10] Inherent differences in the patients' lung volumes and body habitus alter exposure leading to a variable appearance of the chest radiograph, making it more difficult to assess for changes between studies. [5,6] Numerous technical factors including patient positioning, exposure settings, overlying support apparatus, etc., can also alter the appearance of the radiograph contributing to inter-/intra-variation in interpretation. There are few data addressing these image acquisition difficulties, which will contribute to the poor inter-/intra-observer variation in chest radiograph reporting. ...
To determine whether a novel method and device, called a variable attenuation plate (VAP), which equalizes chest radiographic appearance and allows for synchronization of manual image windowing with comparison studies, would improve consistency in interpretation.
Research ethics board approved the prospective cohort pilot study, which included 50 patients in the intensive care unit (ICU) undergoing two serial chest radiographs with a VAP placed on each one of them. The VAP allowed for equalization of density and contrast between the patients' serial chest radiographs. Three radiologists interpreted all the studies with and without the use of VAP. Kappa and percent agreement was used to calculate agreement between radiologists' interpretations with and without the plate.
Radiologist agreement was substantially higher with the VAP method, as compared to that with the non-VAP method. Kappa values between Radiologists A and B, A and C, and B and C were 46%, 55%, and 51%, respectively, which improved to 73%, 81%, and 66%, respectively, with the use of VAP. Discrepant report impressions (i.e., one radiologist's impression of unchanged versus one or both of the other radiologists stating improved or worsened in their impression) ranged from 24 to 28.6% without the use of VAP and from 10 to 16% with the use of VAP (χ (2) = 7.454, P < 0.01). Opposing views (i.e., one radiologist's impression of improved and one of the others stating disease progression or vice versa) were reported in 7 (12%) cases in the non-VAP group and 4 (7%) cases in the VAP group (χ (2) = 0.85, P = 0.54).
Numerous factors play a role in image acquisition and image quality, which can contribute to poor consistency and reliability of portable chest radiographic interpretations. Radiologists' agreement of image interpretation can be improved by use of a novel method consisting of a VAP and associated software and has the potential to improve patient care.
... 12 The potential for interobserver variation in the interpretation of grade 0 (normal) and grade 1 (mild/moderate) radiographic abnormalities is well recognised. 31 However, interobserver variation is less likely to impact on the reported incidence of more radiologically overt severe findings which, in our study, were mostly multifocal or diffusely distributed. Good interobserver agreement can be achieved by systematic and standardised reporting of such features, 32 as in our study. ...
There is limited knowledge of chest radiographic abnormalities over time in HIV-infected children in resource-limited settings.
To investigate the natural history of chest radiographic abnormalities in HIV-infected African children, and the impact of antiretroviral therapy (ART).
Prospective longitudinal study of the association of chest radiographic findings with clinical and immunological parameters. Chest radiographs were performed at enrolment, 6-monthly, when initiating ART and if indicated clinically. Radiographic abnormalities were classified as normal, mild or moderate severity and considered persistent if present for 6 consecutive months or longer. An ordinal multiple logistic regression model assessed the association of enrolment and time-dependent variables with temporal radiographic findings.
258 children (median (IQR) age: 28 (13-51) months; median CD4+%: 21 (15-24)) were followed for a median of 24 (18-42) months. 70 (27%) were on ART at enrolment; 130 (50%) (median age: 33 (18-56) months) commenced ART during the study. 154 (60%) had persistent severe radiographic abnormalities, with median duration 18 (6-24) months. Among children on ART, 69% of radiographic changes across all 6-month transition periods were improvements, compared with 45% in those not on ART. Radiographic severity was associated with previous radiographic severity (OR=120.80; 95% CI 68.71 to 212.38), lack of ART (OR=1.72; 95% CI 1.29 to 2.27), enrolment age <18 months (OR=1.39; 95% CI 1.06 to 1.83), diffuse, severe radiographic abnormality at enrolment (OR=2.18; 95% CI 1.33 to 3.56), hospitalisation for lower respiratory tract infection during the previous 6 months (OR=1.88; 95% CI 1.06 to 3.30) and length of follow-up: at 18-24 months (OR=0.66; 95% CI 0.49 to 0.90), and at 30-54 months (OR=0.42; 95% CI 0.32 to 0.56).
Most children had severe radiographic abnormalities persisting for at least 18 months. ART was beneficial, reducing the risk of radiographic deterioration or increasing the likelihood of radiological improvement.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
... Reporting methodology was defined in three studies (6%) [66][67][68]. Norton [67] utilized the forced-choice template of the Prospective Study of Paediatric Pulmonary and Cardiovascular Complications of Vertically transmitted Human Immunodeficiency Virus Infection (P2C2 HIV study) [69]. Nodule dimension was the basis of the documentation of LIP by Oldham [66], and Iriso [70] invoked clinico-radiological criteria for the identification of PTB. ...
... The potential for interobserver variation in the interpretation of CXR features is well recognized, especially for mild changes. 25 Therefore, some observer-dependent under-or over-reporting of grade 1 findings may have occurred. However, interobserver variation is less likely to impact on the reported incidence of the more overt grade 2 findings, which had a multifocal or diffuse distribution in most cases. ...
The chest X-ray (CXR) abnormalities of human immunodeficiency virus (HIV)-infected children in low/middle income countries (LMIC's) have not been well studied.
To describe the CXR abnormalities and associated clinical/immunological features in HIV-infected South African children.
A prospective study of HIV-infected children who underwent baseline chest radiography and clinical and immunological HIV-staging. CXR abnormalities were stratified as grade 1 (mild) or grade 2 (moderate/severe). Univariate and multiple logistic regression analyses assessed associations between radiological severity and clinical/immunological parameters.
Three hundred thirty children (53% male), median age 23.8 months, were included; 303 (92%) had moderate/severe clinical disease and 225 (68%) moderate/severe immune suppression; 52 (16%) had a normal CXR; 169 (51%) had grade 2 CXR abnormalities, manifesting as: confluent opacification (n = 91, 28%), nodules (n = 37, 11%), or nodules with opacification (n = 41, 12%) Grade 2 abnormality was associated with more advanced clinical HIV disease (OR: 6.9; 95% CI: 1.9-25.6), CD4+ less than 20% (OR: 1.8; 95% CI: 1.0-3.0) and age over 24 months (OR: 4.1; 95% CI: 2.1-8.0).
CXR abnormalities are common in HIV-infected children in LMIC's. The extent of radiological abnormality correlates with age and clinical and immunological severity of HIV-disease. Pediatr Pulmonol. © 2013 Wiley Periodicals, Inc.
... Previous studies of HIV-related CLD in this age group are limited to CXR findings [9,37,38], which are insensitive and subject to observer error and inconsistent use of terminology [39]. The strengths of this study are its prospective design, unselected recruitment, exclusion of acutely unwell patients, use of HRCT, and low interobserver variability in CXR and HRCT scoring. ...
Long-term survivors of vertically acquired human immunodeficiency virus (HIV) infection are reaching adolescence in large numbers in Africa and are at high risk of delayed diagnosis and chronic complications of untreated HIV infection. Chronic respiratory symptoms are more common than would be anticipated based on the HIV literature.
Consecutive adolescents with presumed vertically acquired HIV attending 2 HIV care clinics in Harare, Zimbabwe, were recruited and assessed with clinical history and examination, CD4 count, pulmonary function tests, Doppler echocardiography, and chest radiography (CXR). Those with suspected nontuberculous chronic lung disease (CLD) were scanned using high-resolution computed tomography (HRCT).
Of 116 participants (43% male; mean age, 14 ± 2.6 years, mean age at HIV diagnosis, 12 years), 69% were receiving antiretroviral therapy. Chronic cough and reduced exercise tolerance were reported by 66% and 21% of participants, respectively; 41% reported multiple respiratory tract infections in the previous year, and 10% were clubbed. More than 40% had hypoxemia at rest (13%) or on exercise (29%), with pulmonary hypertension (mean pulmonary artery pressure >25 mm Hg) in 7%. Forced expiratory volume in 1 second (FEV(1)) was <80% predicted in 45%, and 47% had subtle CXR abnormalities. The predominant HRCT pattern was decreased attenuation as part of a mosaic attenuation pattern (31 of 56 [55%]), consistent with small airway disease and associated with bronchiectasis (Spearman correlation coefficient (r(2) = 0.8) and reduced FEV(1) (r(2) = -0.26).
Long-term survivors of vertically acquired HIV in Africa are at high risk of a previously undescribed small airway disease, with >40% of unselected adolescent clinic attendees meeting criteria for severe hypoxic CLD. This condition is not obvious at rest. Etiology, prognosis, and response to treatment are currently unknown.
... 12,13 One used the classification developed by Oldham et al., 12 while the second used the standardized reporting method of the P2C2 study as previously described. 14 In no instance was radiological terminology defined. ...
... 14 A modified reporting tool is proposed for specific use in prospective studies of LIP. This combines the reporting methods previously used by Oldham et al. 12 and Cleveland et al., 14 with some analytical features invoked by McLoud et al. 10 and terminology recommended by the Fleischner Society. 11 A limitation of this study is its inclusion of only English language articles. ...
To review the radiological features of biopsy-proven lymphocytic interstitial pneumonitis (LIP) in human immunodeficiency virus (HIV)-infected children and establish whether these are based on systematic radiological analysis, and to investigate whether more specific radiological diagnostic criteria can be developed.
A Medline search of English-language articles on the radiological features of biopsy-proven LIP in HIV-infected children was conducted for the period 1982 to 2007 inclusive. Radiological findings were compared with the Centers for Disease Control and Prevention (CDC) criteria for a presumptive diagnosis of LIP.
Pulmonary pathology was recorded as "diffuse" and "bilateral" in 125 (97.6%) of 128 reported cases of LIP. Twenty-five different terms were used to describe the pulmonary parenchyma. In 96 (75%), the terminology was consistent with CDC diagnostic criteria. Radiological evolution was documented in 43 (33.5%). Persistent focal opacification superimposed on diffuse pulmonary nodularity was demonstrated in 10 (7.8%). The method of radiological evaluation was described in six (4.6%). In no instance was the terminology defined.
The radiological features of LIP have not been systematically analysed. However, CDC criteria remain reliable, allowing diagnosis of at least 75% of cases. The sensitivity of these criteria may be increased by including cases with persistent focal pulmonary opacification superimposed on diffuse nodularity. Longitudinal studies utilizing standardized radiographic analysis are needed to elucidate the natural history of LIP.
... 15 The presence or absence of cardiomegaly on chest radiography was noted by a pediatric radiologist. 16 Cardiomegaly was not formally defined by the study radiologists, who followed standard terminology defining cardiomegaly as a cardiac width >50% of the cardiothoracic ratio on frontal examination 17 and slightly more in a neonate on a supine film. 18 ...
To describe the 5-year cumulative incidence of cardiac dysfunction in human immunodeficiency virus (HIV)-infected children.Study design: We used a prospective cohort design, enrolling children at 10 hospitals. Group I included 205 vertically HIV-infected children enrolled at a median age of 1.9 years. Group II consisted of 600 HIV-exposed children enrolled prenatally or as neonates, of whom 93 were ultimately HIV-infected. The main outcome measures were echocardiographic indexes of left ventricular dysfunction.
In group I, the 5-year cumulative incidence of left ventricular fractional shortening </=25% was 28.0%. The 5-year incidence of left ventricular end-diastolic dilatation was 21.7%, and heart failure and/or the use of cardiac medications 28.8%. The mortality rate 1 year after the diagnosis of heart failure was 52.5% [95% CI, 30.5-74.5]. Within group II, the 5-year cumulative incidence of decreased fractional shortening was 10.7% in the HIV-infected compared with 3.1% in the HIV-uninfected children (P =.01). Left ventricular dilation, heart failure, and/or the use of cardiac medications were more common in infected compared with uninfected children.
During 5 years of follow-up, cardiac dysfunction occurred in 18% to 39% of HIV-infected children and was associated with an increased risk of death. We recommend that HIV-infected children undergo routine echocardiographic surveillance for cardiac abnormalities.
... Quality assurance was centrally coordinated as previously reported. 17 Reticular densities and increased bronchovascular markings categories were combined for the analyses because the quality assurance studies revealed that inter-reader agreement was greatly improved when the categories were combined. 17 In the absence of lung biopsyproven diagnosis, presumptive LIP/PLH was defined as the appearance of nodules on chest radiograph that persisted for longer than 2 months. ...
... 17 Reticular densities and increased bronchovascular markings categories were combined for the analyses because the quality assurance studies revealed that inter-reader agreement was greatly improved when the categories were combined. 17 In the absence of lung biopsyproven diagnosis, presumptive LIP/PLH was defined as the appearance of nodules on chest radiograph that persisted for longer than 2 months. ...
Infants with human immunodeficiency virus type 1 (HIV-1) can be divided into rapid progressors (RPs) and non-rapid progressors (non-RPs) based on symptoms and immunologic status, but detailed information about cardiac and pulmonary function in RP and non-RP children needs to be adequately described.
Cardiac, pulmonary, and immunologic data and HIV-1 RNA burden were periodically measured in 3 groups: group I, 205 vertically infected children enrolled from 1990 to 1994 and followed through 1996; group II, a prospectively studied cohort enrolled at birth that included 93 infected (group IIa); and 463 noninfected infants (group IIb).
Mean respiratory rates were generally higher in group IIa RP than non-RP children throughout the period of follow-up, achieving statistical signifance at 1 month, 12 months, 24 months, 30 months, and 48 months of follow-up. Non-RP and group IIb (HIV-uninfected children) had similar mean respiratory rates from birth to 5 years of age. Significant differences in mean respiratory rates were found between group I RP and non-RP at 7 age intervals over the first 6 years of life. Mean respiratory rates were higher in RP than in non-RP at <1 year, 2.0 years, 2.5 years, 3.0 years, 3. 5 years, 4.0 years, and 6.0 years of age. Mean heart rates in group IIa RP, non-RP, and group IIb differed at every age. Rapid progressors had higher mean heart rates than non-RP at all ages through 24 months. Mean heart rates at 30 months through 60 months of age were similar for RP and non-RP children. Non-RP children had higher mean heart rates than did group IIb at 8 months, 24 months, 36 months, 42 months, 48 months, 54 months, and 60 months of age. In group I, RP had higher mean heart rates than non-RP at 2.0 years, 2.5 years, 3.0 years, and 4.0 years of age. After 4 years of age, the non-RP and RP had similar mean heart rates. Mean fractional shortening differed between the 3 group II subsets (RP, non-RP, and IIb) at 4, 8, 12, 16, and 20 months of age. Although mean fractional shortening was lower in RP than in non-RP in group II at all time points between 1 and 20 months, the mean fractional shortening was significantly lower in RP only at 8 months when restricting the statistical comparisons to the 2 HIV-infected groups (RP and non-RP). Mean fractional shortening increased in the first 8 months of life followed by a gradual decline through 5 years of age among group IIb children. No significant differences among the 3 groups in mean fractional shortening were detected after 20 months of age. In group I, differences between RP and non-RP in mean fractional shortening were detected at 1.5, 2.0, 2.5, and 3.0 years of age. After 3 years of age, group means for fractional shortening in RP and non-RP did not differ. Because of the limited data from the first months of the group I patients, it could not be determined whether this group experienced the gradual early rise in mean fractional shortening seen in the group II infants. In group IIa, RP had more clinical (eg, oxygen saturation <96%) and chest radiographic abnormalities (eg, cardiomegaly) at 18 months of life. RP also had significantly higher 5-year cumulative mortality than non-RP, higher HIV-1 viral burdens than non-RP, and lower CD8(+) T-cell counts.
Rapid disease progression in HIV-1- infected infants is associated with significant alterations in heart and lung function: increased respiratory rate, increased heart rate, and decreased fractional shortening. The same children exhibited the anticipated significantly increased 5-year cumulative mortality, increased serum HIV-1 RNA load, and decreased CD8(+) (cytotoxic) T-cell counts. Measurements of cardiopulmonary function in HIV-1-infected children seem to be useful in the total assessment of HIV-1 disease progression.
... Chest radiographs were read at each clinical center by a pediatric radiologist specifying the presence or absence of cardiomegaly. 17 Management of cardiac abnormalities was not directed by the study, and reflected the individual center's usual standard of care. The presence of congestive heart failure (CHF) in the study was determined by a pediatric cardiologist at each center. ...
... The observed agreement between radiologists for the diagnosis of cardiac enlargement on chest radiograph was 90.5%. 17 All study data were analyzed in a coded fashion to protect the identity of the patient. Because the HIV status of children under 5 months of age was usually unknown, studies before that age were usually blinded to the HIV status of the infant. ...
Although numerous cardiac abnormalities have been reported in HIV-infected children, precise estimates of the incidence of cardiac disease in these children are not well-known. The objective of this report is to describe the 2-year cumulative incidence of cardiac abnormalities in HIV-infected children.
Prospective cohort (Group I) and inception cohort (Group II) study design.
A volunteer sample from 10 university and public hospitals.
Group I consisted of 205 HIV vertically infected children enrolled at a median age of 22 months. This group was comprised of infants and children already known to be HIV-infected at the time of enrollment in the study. Most of the children were African-American or Hispanic and 89% had symptomatic HIV infection at enrollment. The second group included 611 neonates born to HIV-infected mothers, enrolled during fetal life or before 28 days of age (Group II). In contrast to the older Group I children, all the Group II children were enrolled before their HIV status was ascertained.
According to the study protocol, children underwent a series of cardiac evaluations including two-dimensional echocardiogram and Doppler studies of cardiac function every 4 to 6 months. They also had a 12- or 15-lead surface electrocardiogram (ECG), 24-hour ambulatory ECG monitoring, and a chest radiograph every 12 months.
Main outcome measures were the cumulative incidence of an initial episode of left ventricular (LV) dysfunction, cardiac enlargement, and congestive heart failure (CHF). Because cardiac abnormalities tended to cluster in the same patients, we also determined the number of children who had cardiac impairment which we defined as having either left ventricular fractional shortening (LV FS) </=25% after 6 months of age, CHF, or treatment with cardiac medications.
CARDIAC ABNORMALITIES: In Group I children (older cohort), the prevalence of decreased LV function (FS </=25%) was 5.7% and the 2-year cumulative incidence (excluding prevalent cases) was 15.3%. The prevalence of echocardiographic LV enlargement (LV end-diastolic dimension z score >2) at the time of the first echocardiogram was 8. 3%. The cumulative incidence of LV end-diastolic enlargement was 11. 7% after 2 years. The cumulative incidence of CHF and/or the use of cardiac medications was 10.0% in Group I children. There were 14 prevalent cases of cardiac impairment (LV FS </=25% after 6 months of age, CHF, or treatment with cardiac medications) in Group I. After excluding these prevalent cases, the 2-year cumulative incidence of cardiac impairment was 19.1% among Group I children and 80.9% remained free of cardiac impairment after 2 years of follow-up. Within Group II (neonatal cohort), the 2-year cumulative incidence of decreased LV FS was 10.7% in the HIV-infected children compared with 3.1% in the HIV-uninfected children. LV dilatation was also more common in Group II infected versus uninfected children (8.7% vs 2.1%). The cumulative incidence of CHF and/or the use of cardiac medications was 8.8% in Group II infected versus 0.5% in uninfected subjects. The 1- and 2-year cumulative incidence rates of cardiac impairment for Group II infected children were 10.1% and 12.8%, respectively, with 87.2% free of cardiac impairment after the first 2 years of life. MORTALITY: In the Group I cohort, the 2-year cumulative death rate from all causes was 16.9% [95% CI: 11.7%-22. 1%]. The 1- and 2-year mortality rates after the diagnosis of CHF (Kaplan-Meier estimates) were 69% and 100%, respectively. In the Group II cohort, the 2-year cumulative death rate from all causes was 16.3% [95% CI: 8.8%-23.9%] in the HIV-infected children compared with no deaths among the 463 uninfected Group II children. Two of the 4 Group II children with CHF died during the 2-year observation period and 1 more died within 2 years of the diagnosis of CHF. The 2-year mortality rate after the
