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Indian Pediatr 2010;47:
366-367 |
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Score for Neonatal Acute Physiology II
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We read with interest the article by Sundaram, et al.(1). One of
the main objective of this paper was to evaluate the ability of SNAP score
II for the prediction of death in septicemic neonates. In the study
subjects, the mortality was 62.5% (25 of the 40 enrolled subjects died).
What clinical use would be any predictive score when the population itself
is at such a high risk of mortality? As in the study, by applying the SNAP
II score the predictive ability went up by 15.5% (i.e. from baseline 62.5%
to 88%). How will a patient benefit if the clinician says the risk of
death is 2/3rd or 3/4th.
Srinivas Murki
and Ashish Jaiswal
Fernandez
Hospital,
Bogulkunta,
Hyderabad, India.
Email:
[email protected]
Reference
1. Sundaram V, Dutta S, Ahluwalia J, Narang A. Score
for neonatal acute physiology II predeicts mortality and persistent organ
dysfunction in neonates with severe septicemia. Indain Pediatr 2009; 46:
775-780.
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In a recent article(1), the authors have cited their own primary study(2)
as reference no 6, on "adapted criteria" for organ dysfunction adapted
from article in reference no 10. I retrieved reference no 6(2) but could
not find any adaptation criteria. Secondly, it is known that among low
birth weight (LBW) babies , small for gestational age (SGA) babies have
differing hormonal responses to stress(3) which can affect physiological
response in return. In this study, 30% of enrolled babies were SGA. I
wonder as to what was the impact of SGA status on SNAP II scores?
Baljeet Maini,
MMIMSR, Mullana,
Ambala 133 203,
Haryana,India.
Email:
[email protected]
References
1. Sundaram V, Dutta S, Ahluwalia J, Narang A. Score
for neonatal acute physiology II predicts mortality and persistent organ
dysfunction in neonates with severe septicemia. Indian Pediatr 2009; 46:
775-780.
2. Venkataseshan S, Dutta S, Ahluwalia J, Narang A. Low
plasma protein C values predict mortality in low birth weight neonates
with septicemia. Pediatr Infect Dis J 2007; 26: 684-688.
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Reply
We thank Murki S, et al. and Maini B for showing
interest in our article and for their comments.
Firstly, the high baseline risk of death (62.5%)
observed in our study is due to the inclusion of relatively more sick
neonates due to stringent inclusion criteria. However we felt it was
prudent to test a clinical tool that can improve the predictive ability
further to prognosticate and triage the clinical care in severely sick
neonates. The negative likelihood ratio (LR-) was
0.47 making a posttest probability of dying equal to 43% if the SNAP II
score is below 40. This amounts to an absolute decline of 20% from the
baseline risk. If, on the basis of a relatively simple tool like SNAP II,
the risk categorization can be separated into 88% versus 43%, the
information is valuable both for the clinician as well as the patient.
In response to the comments from Maini B, the criteria
for organ dysfunction were adapted by us from Barton P, et al.(1)
and were used in the primary study(2). It was not published but only cross
referred in our primary study due to limitation of space. SGA is a potent
perinatal variable that can modify the risk of mortality independent of
the other physiologic derangements. SNAP-perinatal extension II is an
admission score derived by the addition of SGA and two other independent
perinatal variables with SNAP II to enable prediction of risk of
mortality(3). However, we could not use SNAPPE II for the obvious reason
of it being an admission score. To the best of our knowledge, no
literature is available as of now that has specifically analyzed the
effect of SGA status on the performance of SNAP II.
Venkataseshan
Sundaram and Sourabh Dutta,
Email:
[email protected]
References
1. Barton P, Kalil AC, Nadel S, Goldstein B,
Okhuysen-Cawley R, Brilli RJ, et al. Safety, Pharmacokinetics, and
pharmacodynamics of drotrecogin alfa (activated) in children with severe
septicemia. Pediatrics 2004; 113: 7-17.
2. Venkataseshan S, Dutta S, Ahluwalia J, Narang A. Low
plasma protein C values predict mortality in low birth weight neonates
with septicemia. Pediatr Infect Dis J 2007; 26: 684-688.
3. Richardson DK, Corcoran JD, Escobar GJ, Lee SK. SNAP
II and SNAPPE II: Simplified newborn illness severity and mortality risk
scores, for the Canadian NICU network, The Kaiser Permanente Neonatal
minimum data set wide area network, and the SNAP II study group. J Pediatr
2001; 138: 92-100.
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