AAPM task group report 305: Guidance for standardization of vendor-neutral reject analysis in radiography.

Reject rate analysis is considered an integral part of a diagnostic radiography quality control (QC) program. A rejected image is a patient radiograph that was not presented to a radiologist for diagnosis and that contributes unnecessary radiation dose to the patient. Reject rates that are either too high or too low may suggest systemic department shortcomings in QC mechanisms. Due to the lack of standardization, reject data often cannot be easily compared between radiography systems from different vendors. The purpose of this report is to provide guidance to help standardize data elements that are required for comprehensive reject analysis and to propose data reporting and workflows to enable an effective and comprehensive reject rate monitoring program. Essential data elements, a proposed schema for classifying reject reasons, and workflow implementation options are recommended in this task group report.

Comparison of efficacy of a 7-day versus a 14-day course of intravenous antibiotics in the treatment of uncomplicated neonatal bacterial sepsis: study protocol of a randomized controlled non-inferiority trial.

BACKGROUND: Neonatal sepsis is a global public health problem. There is no consensus regarding the optimum duration of antibiotics for culture-proven neonatal sepsis. Published randomized controlled trials (RCTs) comparing shorter versus longer courses of antibiotics provide low-quality evidence with serious risk of bias. We hypothesized that among neonates with uncomplicated culture-proven sepsis, antibiotic duration of 7 days is not inferior to 14 days. METHODS: This is a multi-centric, parallel-group, stratified, block-randomized, active-controlled, non-inferiority trial with outcome assessment blinded. Stratification is by center and birth weight. Neonates weighing ≥1000 g at birth, with blood-culture-proven sepsis (barring Staphylococcus aureus and fungi), without conditions warranting > 14 days antibiotics, and who clinically remit, are enrolled in the RCT on day 7 of administration of sensitive antibiotics. They are randomly allocated to no further antibiotics (intervention arm: total 7 days) or 7 more days of the same antibiotics (control arm: total 14 days). Allocation is concealed by opaque, sealed envelopes. The primary outcome is "definite or probable relapse" within 21 days after antibiotic completion. Secondary outcomes include definite and probable relapses at various timepoints until day 35 post-randomization, secondary infections, and adverse events. The neonatologist adjudicating probable relapses and lab personnel are blinded. Three hundred fifty subjects will be recruited in each arm, assuming a non-inferiority margin of 7%, one-sided alpha error 5%, and power of 90%. Analysis will be per protocol and by intention-to-treat. An independent Data Safety Monitoring Board monitors adverse events and will perform one interim analysis when 50% of expected primary outcomes have occurred or 50% of subjects have completed follow-up, whichever is earlier. O'Brien-Fleming criteria will be used to stop for mid-term benefit and Pocock's to stop for mid-term harm. A priori subgroup analyses are planned by birth weight categories, gram-stain status of pathogens, and radiological pneumonia. DISCUSSION: This trial will provide evidence to guide practice regarding optimum duration of antibiotics for culture-proven neonatal bacterial sepsis. If a 7-day regime is proved to be non-inferior to a 14-day regime, it is likely to reduce hospital stay, costs, adverse effects of drugs, and nosocomial infections. TRIAL REGISTRATION: Clinical Trials Registry India CTRI/2017/09/009743 . Registered on 13 September 2017.

Transport characteristics and predictors of mortality among neonates referred to a tertiary care centre in North India: a prospective observational study.

OBJECTIVE: The paucity of specialised care in the peripheral areas of developing countries necessitates the referral of sick neonates to higher centres. Organised interhospital transport services provided by a skilled and well-equipped team can significantly improve the outcome. The present study evaluated the transport characteristics and predictors of mortality among neonates referred to a tertiary care centre in North India. DESIGN: Prospective observational study. SETTINGS: Tertiary care teaching hospital in North India. PATIENTS: 1013 neonates referred from peripheral health units. MAIN OUTCOME MEASURES: Mortality among referred neonates on admission to our centre. RESULTS: Of the 1013 enrolled neonates, 83% were transferred through national ambulance services, 13.7% through private hospital ambulances and 3.3% through personal vehicles. Major transfer indications were prematurity (35%), requirement for ventilation (32%), birth asphyxia (28%) and hyperbilirubinaemia (19%). Hypothermia (32.5%, 330 of 1013), shock (19%, 192 of 1013) and requirement for immediate cardiorespiratory support (ICRS) (10.4%, 106 of 1013) on arrival were the major complications observed during transfer. A total of 305 (30.1%, N=1013) deaths occurred. Of these, 52% (n=160) died within 24 hours of arrival. On multivariate logistic analysis, unsupervised pregnancy (<4 antenatal visits; p=0.037), antenatal complications (p<0.001), prematurity ≤30 weeks (p=0.005), shock (p=0.001), hypothermia (p<0.001), requirement for ICRS on arrival (p<0.001), birth asphyxia (p=0.004), travel time >2 hours (p=0.005) and absence of trained staff during transfer (p<0.001) were found to be significant predictors of mortality. CONCLUSION: The present study depicts high mortality among infants referred to our centre. Adequate training of peripheral health personnel and availability of pre-referral stabilisation and dedicated interhospital transport teams for sick neonate transfers may prove valuable interventions for improved outcomes.

Gastroenteritis in Haryana, India Post Introduction of Rotavirus Vaccine.

OBJECTIVE: To evaluate the epidemiology of rotavirus gastroenteritis in Haryana post-introduction of rotavirus vaccine. Expanded National rotavirus surveillance network in India reported high burden of rotavirus diarrhea in India. The Government of India introduced the monovalent rotavirus vaccine made in India by Bharat Biotech in the national immunization programme from 2016 onward along with oral polio vaccine (OPV) and Pentavalent vaccines. METHODS: A multi-centric, hospital-based surveillance study in the initial vaccine introducing states was started in a phased manner over a period of 3 y. PGIMS, Rohtak is a tertiary care center and was a part of the surveillance from 2016 to 2019. Children aged 0-59 mo admitted with acute gastroenteritis were enrolled into the surveillance and their stool samples were collected. Samples were tested at Christian Medical College (CMC), Vellore to detect rotavirus and reverse transcription-polymerase chain reaction (RT-PCR) was used for G and P typing. RESULTS: A total of 904 children were enrolled in the present surveillance over a period of 3 y starting 1st July 2016 to 30th June 2019. Stool samples were collected and analyzed for 827 children and out of them 141 samples were positive for rotavirus (17.1%). Maximum rotavirus positivity was observed during the winter months. Rotavirus positivity percentage was observed maximum in 12-23 mo age group. A declining trend was observed in rotavirus positivity from 22.8% in 2016 to 14.5% in 2019. Most common strains of rotavirus isolated were G3P[8] followed by G1P[8]. CONCLUSION: This study highlights that epidemiology of acute gastroenteritis among children less than 5 y of age in Haryana postintroduction of rotavirus vaccination in the state and the decline in rotavirus positivity from 22.8% in 2016 to 14.5% in 2019.

Epidemiology of Hospitalized Intussusception Cases from Northern States in India.

OBJECTIVE: To describe epidemiology of intussusception post-introduction of the rotavirus vaccine. METHODS: Hospital-based active surveillance system was set up in three tertiary care hospitals in Chandigarh and Haryana, India, to enroll children <2 y of age admitted with intussusception as per Brighton Collaboration Level-I criteria. The clinical characteristics, treatment modalities, seasonal trends, and outcome of the illness episodes were described. RESULTS: A total of 224 cases were reported. Majority were males (71%) and infants (69.5%). Number of intussusception was more in summer season. Location of intussusception was ileo-colic in 85% of the cases. Nearly 54% cases were treated conservatively and 46% needed surgical intervention. CONCLUSION: Surveillance data provided the epidemiological description of intussusception cases post-introduction of the rotavirus vaccine in northern India. This data could be used to assess the impact of vaccine and safety with a special focus on intussusception.

Development Delay in a Child with Microcephaly and Birth Asphyxia: Explore Diagnosis beyond Hypotonic Cerebral Palsy.

We describe a case of a 2-year-old female child who presented as emergency with acute gastroenteritis and severe dehydration. In this patient, there was a history of severe birth asphyxia, and the developmental milestones were delayed. The child was managed as hypotonic cerebral palsy elsewhere with antiepileptic drug and nutritional supplements. However, persistent abnormal pattern of breathing after adequate hydration and noncontributory metabolic profile raised the suspicion of alternate etiology. Later, the diagnosis of Joubert syndrome was established on contrast-enhanced magnetic resonance imaging of brain with findings of "molar tooth sign" appearance along with vermian hypoplasia. We present this case to alert the clinicians to explore all the differential diagnoses carefully whenever a child presents with the developmental delay associated with multisystem involvement.

Enhancing Kangaroo Mother Care Uptake Through Implementation of an Education Protocol.

OBJECTIVES: Kangaroo mother care (KMC) uptake is low despite KMC being an evidence based tool to decrease neonatal mortality. It is important that local strategies be developed to enhance KMC usage. This study aimed to assess the effect of implementing an education protocol on the usage of KMC in the NICU and at home after discharge. METHODS: Preterm mother-infant dyads admitted to the NICU were enrolled prospectively. In initial 3 mo, baseline data on KMC usage in the unit and at home after discharge was collected. In the next three months, a KMC education protocol consisting of one-to-one counseling, education and sensitization of the mother and family members regarding benefits and procedure of KMC and focussed group discussions was implemented such that it became a unit work protocol. In the next 3 mo, data on KMC usage in the unit and at home after discharge was again collected and compared with the baseline data. RESULTS: Implementation of the education protocol resulted in earlier initiation of KMC (2.49 ± 0.67 vs. 4.65 ± 0.99 d, p < 0.05); increased duration of KMC (8 h/d vs. 3 h/d, p < 0.05); a higher proportion of eligible preterms receiving KMC during hospital stay (100% vs. 75%, p < 0.05) and at home (87% vs. 28%, p < 0.05) and KMC being provided more often by other family members (27.1% vs. 5.7%, p < 0.05). CONCLUSIONS: Implementation of a KMC education protocol resulted in improved KMC usage in the unit and at home 4 wk after discharge.

Clinical profile and predictors of mortality among the referred neonates at a tertiary care centre in north India: a prospective observational study.

The National Family Health Survey (NFHS-4) shows encouraging improvement in infant and under-five mortality rates in India. However, the neonatal mortality rate (NMR) still remains high as India contributes to about one-fifth of global deaths. This prospective study was conducted from 15 January to 30 April 2016 to examine the clinical profile and predictors of mortality among referred neonates at our centre. Among 301 neonates, prematurity (40%) was the most common indication for referral followed by need for ventilation (38%) and birth asphyxia (28%). Approximately 73% neonates were referred within 24 h of birth. Ninety (29.9%) neonates died; of these, 63% died within 24 h of presentation. Prematurity, birth asphyxia, hypothermia, shock at presentation and extreme low birth weight were the most significant predictors of mortality. Adequate training of peripheral health personnel, dedicated teams for neonatal referral and strengthening of peripheral sick newborn care units (SNCUs) seem to be promising interventions for favourable outcome.

Coexistence of disseminated tuberculosis and peripheral deep vein thrombosis in a child with newly diagnosed celiac disease: A rare entity.

Some case reports have been published suggesting association of celiac disease (CD) with tuberculosis (TB) and with deep vein thrombosis (DVT) but mostly in adult populations and in different patients. We report a 13-year-old girl recently diagnosed with CD presented to pediatric emergency at a tertiary teaching hospital in north India with complaints of generalized weakness, pain and swelling over left lower limb that subsequently was diagnosed to have disseminated TB and left lower limb DVT. She was treated with course of anti-tubercular drugs, short-term anticoagulant therapy, and gluten free diet with positive outcomes over next 3 months. To the best of authors' knowledge, no previous reports have yet suggested a coexistence of disseminated TB and peripheral deep vein thrombosis and CD in one single pediatric patient.

Tuberculosis presenting as septic shock in immunocompetent child: An unusual presentation.

As per latest Global TB Report (2018), an estimated 2.2 lakh children get tuberculosis (TB) each year in India and illness constitutes a very high global burden. Here we report an unusual case of a child aged 14 years (female), who presented to Emergency with complaints of cough and restlessness for the past 1 day. Working diagnosis of septic shock was kept and child was started on intravenous ionotropes, vasopressors, and an antibiotic. There was no significant history suggestive of TB. Patient was shifted to PICU and managed for shock accordingly. X-ray lung showed single right-sided cavitatory lesion. Bronchoalveolar lavage was positive for acid fast bacilli, confirming the diagnosis of pulmonary TB. The patient was started on antitubercular drug regimen (ATT) for 6 months and showed significant improvement with complete resolution. Literature was searched for association of septic shock in tubercular patients as a presenting complaint, which is a rare entity.

Tubercular liver abscess rupturing into the pleural cavity: a rare complication.

Liver abscesses, either pyogenic or amoebic, with or without the involvement of the pleura, are not infrequently encountered in children. Isolated tubercular liver abscess without active pulmonary, gastrointestinal or other clinical evidence of tuberculosis is, however, rare and more so its rupture into the pleura. We report a case of a 14-year-old girl who presented with a liver abscess rupturing into the pleura causing an empyema. Successful management was achieved by intercostal tube drainage and antitubercular treatment.

Diagnostic challenges in late-presenting congenital diaphragmatic hernia: a 16-year experience from tertiary care centre in North India.

With increasing use of ultrasound screening, the prenatal diagnosis of congenital diaphragmatic hernia (CDH) in better resourced areas has become the norm. However, early diagnosis is still not universal in resource-poor settings and late presentations of CDH continue. We retrospectively analysed the medical records of children operated for late-presenting CDH from 2001 to 2016 at our tertiary care centre in North India. A total of 32 patients were operated during the period with a male-to-female ratio of 3:1. Of these, 78% presented with respiratory symptoms, 37% with recurrent vomiting and 18% with an acute abdomen. Nine (28%) had been treated erroneously for gastroenteritis and another six (18%) had received anti-tubercular therapy for variable periods. A plain chest radiograph with a Ryle's tube in situ was confirmatory in 75% (24/32). In conclusion, initial misdiagnosis and subsequent unnecessary therapeutic interventions were the leading cause of morbidity .

Congenital pulmonary airway malformation mimicking as pulmonary tuberculosis in five paediatric patients: a diagnostic dilemma.

A series of five children with delayed presentation of congenital pulmonary airway malformation (CPAM), all initially misdiagnosed as pulmonary tuberculosis, is described. All five children presented with recurrent respiratory infections and failure to thrive, having shown poor response to multiple antibiotics course, including anti-tubercular therapy for variable periods. Successful surgical intervention was belatedly instigated.

Type 0 Spinal Muscular Atrophy in rare association with congenital Contracture and generalized osteopenia.

Spinal muscular atrophy (SMAs) is a group of rare autosomal recessive diseases in which there is degeneration of alpha motor neurons in the spinal cord leading to progressive distal motor weakness. Here we report a case of type 0 SMA in a female neonate born at the Department of Pediatrics, PGIMS, Rohtak (Haryana) India, associated with generalized osteopenia and bony deformity in form of unilateral club foot. It may be emphasized that diagnosis of SMA should be kept in mind as a differential in cases of unexplained severe generalized hypotonia and severe respiratory compromise immediately after birth.

Congenital Giant Dysplastic Kidney Presenting as Respiratory Distress: A Case Report.

Multicystic dysplastic kidney (MCDK) is the most common form of renal cystic disease in children and is one of the most common causes of abdominal mass in infancy. Here in we are reporting a rare case of a large MCKD that caused respiratory compromise and the infant presented with respiratory distress.

A Case of Deep Vein Thrombosis and Intracranial Sinus Thrombosis: Possible rare complications of childhood abdominal tuberculosis.

Severe pulmonary tuberculosis (TB) complicated by deep vein thrombosis (DVT) in adults has been reported previously in the medical literature; however, childhood extrapulmonary TB complicated by DVT is rare. We report a 13-year-old girl who presented to the Department of Pediatrics at the Postgraduate Institute of Medical Sciences in Rohtak, India, in 2012 with abdominal TB complicated by DVT and intracranial sinus thrombosis. She was treated with a course of four antitubercular drugs and short-term anticoagulation therapy with a positive outcome over the next six months. To the best of the authors' knowledge, no previous reports have yet suggested a possible association between childhood TB and intracranial sinus thrombosis.

Neonatal Duodenal Obstruction: A 15-Year Experience.

BACKGROUND: Congenital duodenal obstruction is one of the commonest causes of neonatal intestinal obstruction. We are presenting our 15-year experience by analyzing clinical spectrum and outcome in neonates with duodenal obstruction admitted at our center. MATERIAL AND METHODS: The hospital records of all neonates admitted with duodenal obstruction from June 2000 to June 2015 were reviewed. The patient records were analyzed for antenatal diagnosis, age, sex, clinical presentation, diagnosis, associated anomalies, surgical procedures performed; postoperative morbidity and mortality. We excluded from our study malrotation of gut associated with congenital diaphragmatic hernia and abdominal wall defects. RESULTS: A total of 81 patients were admitted, out of which 56 were males and 25 were females. Polyhydramnios was detected in 24 (30%) pregnancies. Average birth weight was 2.1±1.0Kg and average gestational age was 38 (SD±1) weeks with 17 (21%) preterm neonates. Presenting features were vomiting in 81(100%) which was bilious in 81% and non-bilious in 19%, epigastric fullness in 56 (69%) and dehydration in 18 (22%) and failure to thrive in 16 (19%). Most common cause of obstruction was duodenal atresia in 38 (46.9%), followed by malrotation of gut in 33 (40.7%), and annular pancreas in 4 cases. Depending upon site of location, infra-ampullary obstruction was the most common in 64 (79%), supra-ampullary in 9 (7.4%) and ampullary 8 neonates. Both duodenal atresia and malrotation of gut was present in 4 cases. X-ray abdomen was most commonly used investigation to confirm the diagnosis. All cases were managed surgically by open laparotomy. Eleven (13.5%) patients died due to sepsis and associated congenital anomalies. CONCLUSION: Congenital duodenal obstruction most commonly presents in early neonatal period with features of upper GIT obstruction like vomiting and epigastrium fullness as in our series. Early antenatal diagnosis and surgical interventions hold the key in achieving good outcome. Associated congenital anomalies, prematurity, sepsis and delayed presentation are the main risk factors for post-operative mortality and morbidity.