Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




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Aug 2018




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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2007 | Month : February | Volume : 1 | Issue : 1 | Page : 10 - 16

Morbidity Index: An Objective Scoring System for Predicting Neonatal Outcome

MATHUR P, DAWAR S

Department of Paediatrics, Moolchand Khairati Ram hospital. Lajpat nagar,Delhi, India

Correspondence Address :
Dr Preeta Mathur
E-mail: preetamathur29@yahoo.co.in

Abstract

Objective: The goal of the study was to evaluate the efficacy of a scoring system called ‘morbidity index’(MI) consisting of a combination of grades of electronic foetal heart rate patterns, five-minute Apgar scores and cord arterial base deficit to predict death before discharge in neonatal period.

Design: This was a prospective, analytic cohort study.

Methods & Material: 985 live born infants irrespective of gestational age and birth weight were enrolled. A relevant obstetric history was recorded for each case. FHR, umbilical cord (arterial) blood base deficit (BD)values and 5 minute Apgar scores of all babies were collected and graded as per Portman(1990) criteria ( Grades (GR)of Foetal Heart Rate patterns: GR 0 - Normal tracings, GR I-Variable decelerations, GR II -Severe Variable / Late decelerations, GR III Prolonged bradycardia; 5 minute Apgar score grades: GR 0 - > 6, GR I - 5 - 6, GR II 3 - 4, GR III 0 - 2; Cord blood BD grades: GR 0 BD - <10mEq/L, GR I BD 10 -14 mEq/L, GR II BD 15 -19 mEq/L, GR III BD ≥ 20 mEq/L.) All the grades were added up to form the MI for each baby (MI = FHR GR + Apgar Score GR + Cord BD GR). The MI was then analyzed statistically for its efficacy in predicting neonatal mortality.

Results: Larger MI values were found to predict neonatal mortality with better specificity than the three predictors taken individually. However sensitivity of MI was relatively low.

Conclusion: Morbidity index, as compared to the three individual predictors under study, is a better predictor of neonatal mortality. This is easy to do and the score provides more information than the traditional Apgar score.

Keywords

Morbidity index, neonatal mortality, newborns

Introduction

An accurate prediction of newborn status after perinatal asphyxia would be immensely beneficial as it would identify newborns at risk for short- term complications, facilitate monitoring, diagnostic tests, specific therapies and supportive interventions and considerations for new and developing therapies to minimize asphyxial injury(1). It would also help in identifying those infants on whom support can be withdrawn due to high likelihood of neonatal death and long-term morbidity. The present study is an attempt to evaluate the prognostic value of a scoring system published by Portman et al in 1990 (2) and later validated by Carter et al in 1998(3), with respect to prediction of mortality of perinatal asphyxia. The clinical scoring system as described by Portman et al, comprised of graded abnormalities of intrapartum FHR monitoring, umbilical arterial base deficit and the five-minute Apgar score for identifying term newborns at risk of multiple organ system involvement of acute perinatal asphyxia (1). As against the original study by Portman et al, the score termed morbidity index in the present study has been applied to (1) all inborn babies, irrespective of gestational age and weight. The study population therefore also includes preterm and low birth weight babies; (2) The study did not limit itself to babies that experienced acute perinatal asphyxia (3) considering the fact that asphyxia can manifest in myriad ways and other conditions may mimic asphyxia in a newborn(4), all morbidities in the early neonatal period were taken into account; (4) in addition, the score has been used to evaluate its predictive potential for long-term neurodevelopment at 9 months of age of the study subjects.

The present study is a part of a much larger study. Here we limit ourselves in presenting finding related to neonatal mortality only.

Material and Methods

The study was carried out in the neonatal unit of the department of Paediatrics, Moolchand Khairati Ram Hospital, New Delhi. This is a 350 bedded private, tertiary level multi-speciality hospital in Delhi. Approximately 900 deliveries occur every year in this hospital.

This was a prospective, analytic cohort study. In the study, 985 inborn live babies irrespective of gestational age and birth weight were enrolled. The time period of enrolment extended from December 2001 to July 2003. Infants on whom data was missing in any of the three constituent parameters (FHR,APGAR, Cord BD) were not enrolled in the study This study was done as a part of Diplomate of National Board thesis.

The Most recent Foetal Heart Rate (FHR) tracing strips prior to birth, (after admission to labour ward); arterial vessel sample, taken from a doubly clamped section of the cord; and Apgar Score was noted for each baby. These were then graded per the criteria of the Portman study (Table/Fig 1). Morbidity Index (MI) was assigned to every baby. The Primary Outcome studied was death before discharge from hospital

Assignment of Morbidity Index (MI)
It is a sum of the grades of the three parameters under study ─

MI = FHR Grade + Apgar Score Grade + Cord BD Grade

Statistical Analysis
Bi-variate logistic regression was performed using statistical package for the social sciences (SPSS version 11.5.0, SPSS.inc, Chicago I ll,USA 2002).

Results

BASELINE CHARACTERISTICS

Out of 985 babies enrolled – 53 %( 517) babies were males and 47 %( 468) were females (M:F=1.1:1). 86% of the babies were of term (n=847), 12 % were preterm (n=118) and 2% were postterm (n=20). Mean gestational age was 38 weeks (range 22 to 42 weeks).
The mean birth weight was 3000 (range 680 to 4900 gm). Low birth babies (birth weight < 2500 grams) formed 15.8 % (n=156).

No correlation was found between maternal parity or mode of delivery and neonatal mortality.

51 babies died. The mean wt of babies who died was 2.3 kg (median 2.3 kg) and 41% of these were male babies. Babies who left against medical advice (13) or were transferred to other hospitals (9) were excluded from all calculations involving mortality. Data on outcome of these babies was lacking.

(Table/Fig 2):(Neonatal outcome)

PRIMARY OUTCOMES

Morbidity index and its constituents
The following distribution of FHR pattern grades, five-minute Apgar score grades, cord base deficit grades and morbidity index was seen in the study population:

(Table/Fig 3):(FHR distribution)
(Table/Fig 4):(APGAR distribution)
(Table/Fig 5):(Cord BD distribution)
(Table/Fig 6):(MI distribution)

All the three predictors i.e. FHR pattern grades, 5 minute Apgar score grades and Cord Base Deficit grades were found to be positively associated with neonatal mortality.(p values <0.001).

(Table/Fig 7):(Morbidity index and percent of babies who died)
(Table/Fig 8):(ROC for probability of Death using MI as predictor)
(Table/Fig 9):(MI score utility Based on ROC curve)
(Table/Fig 10):(R square value after controlling for gestational age for MI and its constituent)

However the r square change was maximum for the MI than for any individual predictor, after controlling for gestational age. Therefore a combination of the three predictors (i.e. MI or Morbidity index) was found to be more accurate in predicting neonatal outcome than the three predictors taken individually. The three individual predictors were also significantly correlated with each other. (P-value <0.001).

Discussion

In the present study, foetal heart rate patterns, 5 minute Apgar scores and cord blood base deficit of 985 inborn babies were graded as per Portman grading system(2). Thereby, gestational age, low birth weight babies or the presence of disease process experienced by the baby did not limit the study population. Portman et al had included only asphyxiated babies in their study. In the present study, the criterion for inclusion was not targeted at a specific disease population.

With respect to neonatal survival, both specificity (99%) and negative predictive values (96%) were found to be very high. The positive predictive value was however low at 50%.

Overall, the presence of a high MI, owing to its high specificity and negative predictive value can warn the treating physician and prompt him to heighten surveillance, plan adequate treatment and if required, transfer the baby to centres with more specialized care.

On taking the three individual predictors into consideration, a positive correlation was found between all the three of them taken separately and neonatal mortality. Foetal heart patterns were found to be associated significantly with neonatal mortality. 11 out of the 27 babies with FHR grade of 3 died. The results of the present study are in agreement with previous literature (5)(6). However the study findings did not match that of Caravale et al(7) and Leuthner et al (8) who have reported a lack of correlation between the FHR patterns and neonatal mortality.

Five-minute Apgar scores were found to be similarly significantly associated with neonatal mortality. 9 out of 18 babies with Apgar score grade of 3 (5 min Apgar 0-2) died. The results of the present study are in agreement with those of Casey et al (9) and Heller et al(10) to name a few.

There was a significant association noted between cord base deficit values and neonatal mortality in the present study. 3 out of 7 babies with base deficit grade 2(15-19meq/l) died. We did not have any baby with cord deficit more than 20 meq/l.

The presence of antenatal complications was seen to be associated with an adverse neonatal outcome. In this study, no significant correlation of the outcome with respect to sex of the baby could be ascertained. A significant correlation between gestational age and neonatal mortality was seen. Prematurity was therefore a confounding factor in the study.

Conclusion

Value of this scoring system lies in its immediate availability and simplicity; specificity; its potential for affecting early clinical management of the newborn, including transfer to tertiary centres and closer follow up and early rehabilitation for developmental delays. Therefore, it can be concluded that morbidity index, as compared to the three individual predictors under study, is a better predictor of neonatal outcome. It can serve as a good prognostic indicator and should be assigned to all babies at birth.


EDITORIAL COMMENT

This study was done as part of a mandatory post graduate thesis by a DNB student in a private hospital. Due to the private nature of care, there is a tendency towards early withdrawal of care in
such setups. Therefore, the mortality may have been skewed upwards. Moreover, the authors did not present the data on the babies who left the hospital against medical advice. This number was significant when compared to the number of babies who died. As it is, more information on such cases would have been useful, where a moribund baby whom the parents elect to take home for final hours, rather than recording them as missing data.Similarly, with regard to those cases which were transferred to other hospitals, no data was presented. The data did not segregate the cases with congenital abnormalities. Hence, though prospective, with a large number of cases and an interesting topic, we caution the readers about the interpretation of the study results.

Key Message

Morbidity index, as compared to the three individual predictors under study, is a better predictor of neonatal mortality. This is easy to do and the score provides more information than the traditional Apgar score

Acknowledgement

JCDR services were used for editing and statistics in this article.

References

1.
Paneth N, Fox HE. The relationship of Apgar score o neurologic handicap: a survey of clinicians. Obstet Gynecol 1983 May; 61(5): 547-550
2.
Portman RJ, Carter BS, Gaylord MS et al. Predicting neonatal morbidity after Perinatal asphyxia: A Scoring System Am J Obstet Gynaecol, 1990, 162: 174-182.
3.
Carter BS, McNabb Faith, Merenstein Gerald. Prospective validation of a scoring system for predicting neonatal morbidity after acute perinatal asphyxia. The Journal of Paediatrics, 1998; 132 (4): 619-623.
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Paul Ekert, Max Perlman et al. Predicting the outcome of postasphyxial hypoxic-ischemic encephalopathy within 4 hours of birth. J.Pediatr, 1997 Oct; 131(4): 613-617.
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Behrman, Kliegman, Jenson. The First Year. In: Nelson Textbook of Pediatrics (17th edition-2004): pg. 35
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Illingworth R.S .The development of the infant and young child. Normal and abnormal. Ninth edition. Chapter 5.
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Sheiner F, Hadar A, Hallak M et al. Clinical significance of fetal heart tracings during the second stage of labor. Obstet Gynecol 2001 May; 97 (5 pt1): 747-52
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Berkus MD, Langer O, Samueloff A et al. Electronic fetal monitoring: what’s reassuring? Acta Obstet Gynecol Scand 1999 Jan; 78(1): 15-21.
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Caravale B, Allemand F et al. Factors predictive of seizures and neurologic outcome in perinatal depression. Pediatr Neurol 2003 Jul; 29 (1): 18-25.
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Leuthner SR, Das UG. Low Apgar scores and the definition of birth asphyxia. Pediatr Clin North A 2004 Jun; 51 (3): 737-45.
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Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. New England Journal of Medicine 2001 Feb 15; 344 (7): 467-471.
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Heller G, Schnell RR et al. Umbilical blood pH, Apgar scores and early neonatal mortality.Z.Geburtshilfe Neonatol 2003 May-Jun; 207 (3): 84-9.
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Talati AJ, Yang W et al. Combination of early perinatal factors

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