Neonatal mortality risk assessment using SNAPPE- II score in a neonatal intensive care unit.

BACKGROUND: There are many scoring systems to predict neonatal mortality and morbidity in neonatal intensive care units (NICU). One of the scoring systems is SNAPPE-II (Score for Neonatal Acute Physiology with Perinatal extension-II). This study was carried out to assess the validity of SNAPPE-II score (Score for Neonatal Acute Physiology with Perinatal Extension-II) as a predictor of neonatal mortality and duration of stay in a neonatal intensive care unit (NICU). METHODS: This prospective, observational study was carried out over a period of 12 months from June 2015 to May 2016. Two hundred fifty five neonates, who met the inclusion criteria admitted to NICU in tertiary care hospital, BPKIHS Hospital, Nepal were enrolled in the study and SNAPPE-II score was calculated. Receiver Operating Characteristic (ROC) curve was constructed to derive the best SNAPPE-II cut-off score for mortality. RESULTS: A total of 305 neonates were admitted to NICU over a period of one year. Among them, 255 neonates fulfilled the inclusion criteria. Out of 255 neonates, 45 neonates (17.6%) died and 210 were discharged. SNAPPE-II score was significantly higher among neonates who died compared to those who survived [median (IQR) 57 (42-64) vs. 22 (14-32), P < 0.001]. SNAPPE II score had discrimination to predict mortality with area under ROC Curve (AUC): 0.917 (95% CI, 0.854-0.980). The best cut - off score for predicting mortality was 38 with sensitivity 84.4%, specificity 91%, positive predictive value 66.7% and negative predictive value 96.5%. SNAPPE II score could not predict the duration of NICU stay (P = 0.477). CONCLUSION: SNAPPE- II is a useful tool to predict neonatal mortality in NICU. The score of 38 may be associated with higher mortality.

Diagnosis of neglected tropical diseases among patients with persistent digestive disorders (diarrhoea and/or abdominal pain ≥14 days): Pierrea multi-country, prospective, non-experimental case-control study.

BACKGROUND: Diarrhoea still accounts for considerable mortality and morbidity worldwide. The highest burden is concentrated in tropical areas where populations lack access to clean water, adequate sanitation and hygiene. In contrast to acute diarrhoea (<14 days), the spectrum of pathogens that may give rise to persistent diarrhoea (≥14 days) and persistent abdominal pain is poorly understood. It is conceivable that pathogens causing neglected tropical diseases play a major role, but few studies investigated this issue. Clinical management and diagnostic work-up of persistent digestive disorders in the tropics therefore remain inadequate. Hence, important aspects regarding the pathogenesis, epidemiology, clinical symptomatology and treatment options for patients presenting with persistent diarrhoea and persistent abdominal pain should be investigated in multi-centric clinical studies. METHODS/DESIGN: This multi-country, prospective, non-experimental case-control study will assess persistent diarrhoea (≥14 days; in individuals aged ≥1 year) and persistent abdominal pain (≥14 days; in children/adolescents aged 1-18 years) in up to 2000 symptomatic patients and 2000 matched controls. Subjects from Côte d'Ivoire, Indonesia, Mali and Nepal will be clinically examined and interviewed using a detailed case report form. Additionally, each participant will provide a stool sample that will be examined using a suite of diagnostic methods (i.e., microscopic techniques, rapid diagnostic tests, stool culture and polymerase chain reaction) for the presence of bacterial and parasitic pathogens. Treatment will be offered to all infected participants and the clinical treatment response will be recorded. Data obtained will be utilised to develop patient-centred clinical algorithms that will be validated in primary health care centres in the four study countries in subsequent studies. DISCUSSION: Our research will deepen the understanding of the importance of persistent diarrhoea and related digestive disorders in the tropics. A diversity of intestinal pathogens will be assessed for potential associations with persistent diarrhoea and persistent abdominal pain. Different diagnostic methods will be compared, clinical symptoms investigated and diagnosis-treatment algorithms developed for validation in selected primary health care centres. The findings from this study will improve differential diagnosis and evidence-based clinical management of digestive syndromes in the tropics. TRIAL REGISTRATION: ClinicalTrials.gov; identifier: NCT02105714 .

Assessment of control of bronchial asthma in children using Childhood Asthma Control Test.

BACKGROUND: The use of Childhood Asthma Control Test (C-ACT) has been advised for monitoring asthma control by the Global Initiative for Asthma (GINA) guidelines. OBJECTIVE: To validate the tool C-ACT for the assessment of control of asthma and to examine the correlation between C-ACT score and lung function assessed by forced expiratory volume in one second (FEV1). METHODS: This was a prospective observational study conducted between January 2010 to January 2011. Children diagnosed to have bronchial asthma and aged 5 to 14 years, were enrolled in the study. Asthma severity and control status were classified according to the National Asthma Education and Prevention Programme (NAEPP) and GINA guidelines, respectively. Patients were followed-up at three and six months and C-ACT and spirometric measurements were obtained. RESULTS: Significant positive correlations were found between C-ACT score and FEV1 at enrollment (r = 0.772) (p < 0.001), three months (r = 0.815) (p < 0.001) and at six months follow-up (r = 0.908) (p < 0.001). Baseline C-ACT score was useful for predicting the levels of control of asthma upto three months (0.004), but not at six months follow-up (0.787). A cut-off C-ACT value of > or = 19 had a sensitivity, specificity, positive predictive value, negative predictive value and area under the curve (AUC) 98.5%, 89.1%, 94.9%, 96.6%, 0.717, respectively for the control of asthma. CONCLUSION: C-ACT is a simple and feasible tool to assess and predict the levels of control in children with bronchial asthma upto three months.

Clinical and ultrasonographic measurement of liver size in normal children.

OBJECTIVES: To measure the normal range of dimensions of liver in children of various age groups and to compare the liver measurement obtained by palpation-percussion, auscultation and ultrasonography. METHODS: This was a cross-sectional comparative study in which 500 normal (weight for height between ± 2 SD of WHO standards for children aged less than 5 y and BMI between ± 2 SD of WHO standards for children aged more than 5 y) children (0-15 y) divided in 5 age groups (100 in each age group). Subjects were enroled from normal hospital delivery neonates, children visiting immunization and well baby clinics, children visiting outpatient and inpatient department with minor illnesses and healthy school children. RESULTS: The normal range of dimensions of liver in children were estimated and percentile tables of liver size were established. Though the measurements obtained by clinical methods were significantly (P < 0.001) lower than those obtained by ultrasonography, there was a strong correlation between clinical and ultrasonographic measurement. Palpation-percussion method could estimate the liver size within ± 1.0 cm of what was obtained by ultrasonography in 88 % of cases. In more than half of the study children (54.2 %), this estimation was within ± 0.5 cm. CONCLUSIONS: Clinical methods of liver span estimation strongly correlate with ultrasonographic measurement. The performance of palpation-percussion method is better than that of auscultation. Clinical methods should continue to be used for the estimation of liver size.

Urinary screening for detection of renal abnormalities in asymptomatic school children.

BACKGROUND: Urinary screening tests for early detection of renal diseases in asymptomatic school children and adolescents are important in the detection of silent renal diseases. OBJECTIVES: The purpose of the study was to determine the prevalence of occult renal diseases by dipstick test (reagent strips) in asymptomatic Nepalese children. PATIENTS AND METHODS: A total of 2,243 school children, aged 5-15 years, were screened for urinary abnormalities using dipstick test screening. The children who tested positive in the first screening were re-tested after 2-4 weeks. RESULTS: In the first screening, 123 children (5.5%) tested positive for isolated hematuria and proteinuria and for combined hematuria and proteinuria. Of these children, 16 (0.71%) cases tested positive in a second screening. Subsequently, 1 child from the secondary screening group was lost to follow up, 5 tested normal and 10 revealed abnormalities. Glomerulonephritis was the most commonly detected disorder (50%). CONCLUSIONS: Urinary screening was found to be useful in identifying occult renal diseases in asymptomatic children. Urinary screening would therefore not only help in early detection but also in the prevention of the deterioration of renal function later in life.

Clinical and etiological profile of acute febrile encephalopathy in eastern Nepal.

OBJECTIVE: To investigate the clinical and etiological profile of acute febrile encephalopathy in children presenting to a tertiary care referral center of Eastern Nepal. METHODS: 107 children (aged 1 month to 14 yrs) presenting to the emergency with fever (> 38 C) of less than 2 weeks duration with altered sensorium with/or without seizure were prospectively investigated for etiological cause. The investigations included blood and CSF counts, blood and CSF cultures, peripheral smear and serology for malarial parasite, and serology for Japanese encephalitis (JE) virus. Other investigations included EEG and CT or MRI wherever indicated. RESULTS: The most common presenting complaints apart from fever and altered sensorium were headache and vomiting. Convulsions, neck rigidity, hypertonia, brisk deep tendon reflexes, extensor plantar response and focal neurological deficits were seen in 50%, 57%, 22.4%, 28%, 39.3% and 9.3% of the subjects, respectively. The diagnoses based on clinical presentation and laboratory findings were pyogenic meningitis in 45 (42%), non JE viral encephalitis in 26 (25%), JE in 19 (18%), cerebral malaria in 8 (7%), herpes encephalitis and tubercular meningitis in 4 (4%) each, and typhoid encephalopathy in 1 case. CONCLUSION: Pyogenic meningitis and viral encephalitis including JE are the most common causes of acute presentation with fever and encephalopathy. Preventive strategies must be directed keeping these causes in mind.

Modified posterior sagittal transanorectal approach in repair of urogenital sinus anomalies.

INTRODUCTION: To describe the operative details and results of a modified posterior sagittal transanorectal approach for the reconstruction of urogenital sinus (UGS) anomalies. TECHNICAL CONSIDERATIONS: Six children with UGS anomalies underwent surgery using this technique. In a prone jack-knife position, a midline incision was continued to the puborectalis muscle. A plane of dissection was created circumferentially around the rectum separating it from the underlying UGS. Circumferential transanal mucosectomy and a transanal dissection was carried proximally for 5 to 10 cm. The mucosal tube with the serosal wall was resected, exposing the proximal part of the UGS. The posterior and anterior sphincters, anus, and perineal body were then divided in the midline, completely exposing the UGS. Reconstruction of the urethra and vagina was done. At completion of UGS reconstruction, an endoanal pull through of the rectal tube and a low coloanal anastomosis were performed. The muscle complex and perineal body were closed in layers. The modified technique of posterior sagittal transanorectal approach allowed excellent exposure in all 6 patients. None developed any complications related to suture line leak. Fecal and urinary continence was preserved in patients who were continent before the operation. CONCLUSIONS: The modified posterior sagittal transanorectal approach is a safe and effective technique in the treatment of UGS anomalies and can be performed without the need for a protective colostomy.