Predicting deaths in a resource-limited neonatal intensive care unit in Nepal.

BackgroundThis study aimed to determine whether the Neonatal Acute Physiology (SNAP) scoring system (SNAP II) and with perinatal extension (SNAP II PE) can be used to predict neonatal deaths in a resource-limited neonatal intensive care unit in Nepal.MethodsA prospective observational study was conducted in a neonatal intensive care unit (NICU) of Kanti Children's Hospital in Kathmandu, Nepal. Data required for the SNAP II and SNAP II PE scores were collected. The relationships between the SNAP II and SNAP II PE scores and neonatal mortality were analyzed.ResultsThere were 135 neonates admitted during the 6 month study period, of whom 126 met the inclusion criteria. Of these 126 neonates, 29 (23.0%) died. Mortality was 83% (5/6) when SNAP II was >40, and 66.7% (6/9) when SNAP II PE was >50. A SNAP II score of ≥12 had a sensitivity of 75.9%, and specificity of 73.2% for predicting mortality, and a SNAP II PE score of ≥14 had a sensitivity of 82.8% and specificity of 67.0% for it.ConclusionsSNAP II and SNAP II PE scoring of neonates can be used to predict prognosis of neonates in resource-limited NICUs in Nepal

A preliminary randomized double blind placebo-controlled trial of intravenous immunoglobulin for Japanese encephalitis in Nepal

BACKGROUND: Japanese encephalitis (JE) virus (JEV) is a mosquito-borne flavivirus found across Asia that is closely related to West Nile virus. There is no known antiviral treatment for any flavivirus. Results from in vitro studies and animal models suggest intravenous immunoglobulin (IVIG) containing virus-specific neutralizing antibody may be effective in improving outcome in viral encephalitis. IVIG's anti-inflammatory properties may also be beneficial. METHODOLOGY/PRINCIPAL FINDINGS: We performed a pilot feasibility randomized double-blind placebo-controlled trial of IVIG containing anti-JEV neutralizing antibody (ImmunoRel, 400mg/kg/day for 5 days) in children with suspected JE at two sites in Nepal; we also examined the effect on serum neutralizing antibody titre and cytokine profiles. 22 children were recruited, 13 of whom had confirmed JE; 11 received IVIG and 11 placebo, with no protocol violations. One child (IVIG group) died during treatment and two (placebo) subsequently following hospital discharge. Overall, there was no difference in outcome between treatment groups at discharge or follow up. Passive transfer of anti-JEV antibody was seen in JEV negative children. JEV positive children treated with IVIG had JEV-specific neutralizing antibody titres approximately 16 times higher than those treated with placebo (p=0.2), which was more than could be explained by passive transfer alone. IL-4 and IL-6 were higher in the IVIG group. CONCLUSIONS/SIGNIFICANCE: A trial of IVIG for JE in Nepal is feasible. IVIG may augment the development of neutralizing antibodies in JEV positive patients. IVIG appears an appealing option for JE treatment that warrants further study. TRIAL REGISTRATION: ClinicalTrials.gov NCT01856205

Baseline characteristics of trial participants.

<p>Data presented as number of patients (proportion) or median (range). No.—number of patients in the clinical group where data for the parameter was available. <i>P—</i>P value for Fisher’s Exact or Mann Whitney U test between groups.</p><p>NS.—not significant.</p><p>Baseline characteristics of trial participants.</p

Outcome for trial participants.

<p>Data are number of patients (proportion) or median (range). LOS = Liverpool Outcome Score (LOS): 1—died; 2—severe sequelae; 3—moderate sequelae; 4—minor sequelae; 5—full recovery. NC: not calculable</p><p>Outcome for trial participants.</p

Interleukin (IL)-4 and IL-6 abundance in children with acute encephalitis syndrome receiving intravenous immunoglobulin (IVIG) and placebo.

<p>Median and inter-quartile range of change in cytokine abundance (pg/ml) pre and post treatment is presented for IL-4 and IL-6 separately. Cytokine abundance increased for both IL-4 and IL-6. This increase was significant for IL-4 (p = 0.043 and p = 0.068 for IL-4 and IL-6 respectively). Difference in abundance was assessed via Wilcoxon-Mann-Whitney test. Note: Four patients (three who received IVIG and one who received saline) were not included in this analysis because of insufficient sample to undertake the ELISA.</p

Difference in neutralizing antibody titres to JEV in children with acute encephalitis syndrome treated with IVIG or placebo.

<p>Median and inter-quartile range of the difference in JEV PRNT₅₀ titres pre and post treatment is presented. Patients are grouped according to treatment. Difference in tires was assessed via Wilcoxon-Mann-Whitney test. Note: Two patients who received IVIG were not included in this analysis because of insufficient sample to undertake PRNT measurements.</p

Flow diagram of study participants’ recruitment and follow-up.

<p>All children enrolled, fitting the trial criteria, who were alive at discharge were attempted to be followed-up (n = 21). Twenty-one families were successfully contacted. Among these families, two children had died.</p