Radiograph accelerated detection and identification of cancer in the lung (RADICAL): a mixed methods study to assess the clinical effectiveness and acceptability of Qure.ai artificial intelligence software to prioritise chest X-ray (CXR) interpretation.

INTRODUCTION: Diagnosing and treating lung cancer in early stages is essential for survival outcomes. The chest X-ray (CXR) remains the primary screening tool to identify lung cancers in the UK; however, there is a shortfall of radiologists, while demand continues to increase. Image analysis by machine-learning software has the potential to support radiology workflows with a focus on immediate triage of suspicious X-rays. The RADICAL study will evaluate Qure.ai's 'qXR' software in reducing reporting time for suspicious X-rays in NHS Greater Glasgow & Clyde. METHODS AND ANALYSIS: This is a stepped-wedge cluster-randomised study consisting of a retrospective technical evaluation and prospective clinical effectiveness study alongside the assessment of acceptability via qualitative work and evaluation of cost-effectiveness via a cost utility analysis. The primary objective is to assess the clinical effectiveness of qXR to prioritise patients suspected with lung cancer on CXR for follow-up CT. Secondary objectives will look at the utility, safety, technical performance, health economics and acceptability of the intervention. The study period is 24 months, consisting of an initial 12 month data collection period and a 12 month follow-up period. All the standard care CXRs from outpatient and primary care requests will be securely transmitted to Qure.ai software 'qXR' for interpretation. Images with features of cancer will be flagged as 'Urgent Suspicion of Cancer' and be prioritised for radiologist review within the existing reporting workflow. ETHICS AND DISSEMINATION: The study will follow the principles of Good Clinical Practice. The protocol was granted REC approval in August 2023 from North West-Greater Manchester West Research Ethics Committee (REC 23/NW/0211). This study was registered on clinicaltrials.gov (NCT06044454). An interim report will be produced for use by the Scottish Government. The results from this study will be presented at artificial intelligence, radiology and respiratory meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT06044454.

Early Detection of Heart Failure with Autonomous AI-Based Model Using Chest Radiographs: A Multicenter Study.

The opportunistic use of radiological examinations for disease detection can potentially enable timely management. We assessed if an index created by an AI software to quantify chest radiography (CXR) findings associated with heart failure (HF) could distinguish between patients who would develop HF or not within a year of the examination. Our multicenter retrospective study included patients who underwent CXR without an HF diagnosis. We included 1117 patients (age 67.6 ± 13 years; m:f 487:630) that underwent CXR. A total of 413 patients had the CXR image taken within one year of their HF diagnosis. The rest (n = 704) were patients without an HF diagnosis after the examination date. All CXR images were processed with the model (qXR-HF, Qure.AI) to obtain information on cardiac silhouette, pleural effusion, and the index. We calculated the accuracy, sensitivity, specificity, and area under the curve (AUC) of the index to distinguish patients who developed HF within a year of the CXR and those who did not. We report an AUC of 0.798 (95%CI 0.77-0.82), accuracy of 0.73, sensitivity of 0.81, and specificity of 0.68 for the overall AI performance. AI AUCs by lead time to diagnosis (<3 months: 0.85; 4-6 months: 0.82; 7-9 months: 0.75; 10-12 months: 0.71), accuracy (0.68-0.72), and specificity (0.68) remained stable. Our results support the ongoing investigation efforts for opportunistic screening in radiology.

Comparing the Output of an Artificial Intelligence Algorithm in Detecting Radiological Signs of Pulmonary Tuberculosis in Digital Chest X-Rays and Their Smartphone-Captured Photos of X-Ray Films: Retrospective Study.

BACKGROUND: Artificial intelligence (AI) based computer-aided detection devices are recommended for screening and triaging of pulmonary tuberculosis (TB) using digital chest x-ray (CXR) images (soft copies). Most AI algorithms are trained using input data from digital CXR Digital Imaging and Communications in Medicine (DICOM) files. There can be scenarios when only digital CXR films (hard copies) are available for interpretation. A smartphone-captured photo of the digital CXR film may be used for AI to process in such a scenario. There is a gap in the literature investigating if there is a significant difference in the performance of AI algorithms when digital CXR DICOM files are used as input for AI to process as opposed to photos of the digital CXR films being used as input. OBJECTIVE: The primary objective was to compare the agreement of AI in detecting radiological signs of TB when using DICOM files (denoted as CXRd) as input versus when using smartphone-captured photos of digital CXR films (denoted as CXRp) with human readers. METHODS: Pairs of CXRd and CXRp images were obtained retrospectively from patients screened for TB. AI results were obtained using both the CXRd and CXRp files. The majority consensus on the presence or absence of TB in CXR pairs was obtained from a panel of 3 independent radiologists. The positive and negative percent agreement of AI in detecting radiological signs of TB in CXRd and CXRp were estimated by comparing with the majority consensus. The distribution of AI probability scores was also compared. RESULTS: A total of 1278 CXR pairs were analyzed. The positive percent agreement of AI was found to be 92.22% (95% CI 89.94-94.12) and 90.75% (95% CI 88.32-92.82), respectively, for CXRd and CXRp images (P=.09). The negative percent agreement of AI was 82.08% (95% CI 78.76-85.07) and 79.23% (95% CI 75.75-82.42), respectively, for CXRd and CXRp images (P=.06). The median of the AI probability score was 0.72 (IQR 0.11-0.97) in CXRd and 0.72 (IQR 0.14-0.96) in CXRp images (P=.75). CONCLUSIONS: We did not observe any statistically significant differences in the output of AI in digital CXRs and photos of digital CXR films.

Artificial Intelligence-based automated CT brain interpretation to accelerate treatment for acute stroke in rural India: An interrupted time series study.

In resource-limited settings, timely treatment of acute stroke is dependent upon accurate diagnosis that draws on non-contrast computed tomography (NCCT) scans of the head. Artificial Intelligence (AI) based devices may be able to assist non-specialist physicians in NCCT interpretation, thereby enabling faster interventions for acute stroke patients in these settings. We evaluated the impact of an AI device by comparing the time to intervention (TTI) from NCCT imaging to significant intervention before (baseline) and after the deployment of AI, in patients diagnosed with stroke (ischemic or hemorrhagic) through a retrospective interrupted time series analysis at a rural hospital managed by non-specialists in India. Significant intervention was defined as thrombolysis or antiplatelet therapy in ischemic strokes, and mannitol for hemorrhagic strokes or mass effect. We also evaluated the diagnostic accuracy of the software using the teleradiologists' reports as ground truth. Impact analysis in a total of 174 stroke patients (72 in baseline and 102 after deployment) demonstrated a significant reduction of median TTI from 80 minutes (IQR: 56·8-139·5) during baseline to 58·50 (IQR: 30·3-118.2) minutes after AI deployment (Wilcoxon rank sum test-location shift: -21·0, 95% CI: -38·0, -7·0). Diagnostic accuracy evaluation in a total of 864 NCCT scans demonstrated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) in detecting intracranial hemorrhage to be 0·89 (95% CI: 0·83-0·93), 0·99 (0·98-1·00), 0·96 (0·91-0·98) and 0·97 (0·96-0·98) respectively, and for infarct these were 0·84 (0·79-0·89), 0·81 (0·77-0·84), 0·58 (0·52-0·63), and 0·94 (0·92-0·96), respectively. AI-based NCCT interpretation supported faster abnormality detection with high accuracy, resulting in persons with acute stroke receiving significantly earlier treatment. Our results suggest that AI-based NCCT interpretation can potentially improve uptake of lifesaving interventions for acute stroke in resource-limited settings.

Assessing the effectiveness of artificial intelligence (AI) in prioritising CT head interpretation: study protocol for a stepped-wedge cluster randomised trial (ACCEPT-AI).

INTRODUCTION: Diagnostic imaging is vital in emergency departments (EDs). Accessibility and reporting impacts ED workflow and patient care. With radiology workforce shortages, reporting capacity is limited, leading to image interpretation delays. Turnaround times for image reporting are an ED bottleneck. Artificial intelligence (AI) algorithms can improve productivity, efficiency and accuracy in diagnostic radiology, contingent on their clinical efficacy. This includes positively impacting patient care and improving clinical workflow. The ACCEPT-AI study will evaluate Qure.ai's qER software in identifying and prioritising patients with critical findings from AI analysis of non-contrast head CT (NCCT) scans. METHODS AND ANALYSIS: This is a multicentre trial, spanning four diverse sites, over 13 months. It will include all individuals above the age of 18 years who present to the ED, referred for an NCCT. The project will be divided into three consecutive phases (pre-implementation, implementation and post-implementation of the qER solution) in a stepped-wedge design to control for adoption bias and adjust for time-based changes in the background patient characteristics. Pre-implementation involves baseline data for standard care to support the primary and secondary outcomes. The implementation phase includes staff training and qER solution threshold adjustments in detecting target abnormalities adjusted, if necessary. The post-implementation phase will introduce a notification (prioritised flag) in the radiology information system. The radiologist can choose to agree with the qER findings or ignore it according to their clinical judgement before writing and signing off the report. Non-qER processed scans will be handled as per standard care. ETHICS AND DISSEMINATION: The study will be conducted in accordance with the principles of Good Clinical Practice. The protocol was approved by the Research Ethics Committee of East Midlands (Leicester Central), in May 2023 (REC (Research Ethics Committee) 23/EM/0108). Results will be published in peer-reviewed journals and disseminated in scientific findings (ClinicalTrials.gov: NCT06027411) TRIAL REGISTRATION NUMBER: NCT06027411.

AI assisted reader evaluation in acute CT head interpretation (AI-REACT): protocol for a multireader multicase study.

INTRODUCTION: A non-contrast CT head scan (NCCTH) is the most common cross-sectional imaging investigation requested in the emergency department. Advances in computer vision have led to development of several artificial intelligence (AI) tools to detect abnormalities on NCCTH. These tools are intended to provide clinical decision support for clinicians, rather than stand-alone diagnostic devices. However, validation studies mostly compare AI performance against radiologists, and there is relative paucity of evidence on the impact of AI assistance on other healthcare staff who review NCCTH in their daily clinical practice. METHODS AND ANALYSIS: A retrospective data set of 150 NCCTH will be compiled, to include 60 control cases and 90 cases with intracranial haemorrhage, hypodensities suggestive of infarct, midline shift, mass effect or skull fracture. The intracranial haemorrhage cases will be subclassified into extradural, subdural, subarachnoid, intraparenchymal and intraventricular. 30 readers will be recruited across four National Health Service (NHS) trusts including 10 general radiologists, 15 emergency medicine clinicians and 5 CT radiographers of varying experience. Readers will interpret each scan first without, then with, the assistance of the qER EU 2.0 AI tool, with an intervening 2-week washout period. Using a panel of neuroradiologists as ground truth, the stand-alone performance of qER will be assessed, and its impact on the readers' performance will be analysed as change in accuracy (area under the curve), median review time per scan and self-reported diagnostic confidence. Subgroup analyses will be performed by reader professional group, reader seniority, pathological finding, and neuroradiologist-rated difficulty. ETHICS AND DISSEMINATION: The study has been approved by the UK Healthcare Research Authority (IRAS 310995, approved 13 December 2022). The use of anonymised retrospective NCCTH has been authorised by Oxford University Hospitals. The results will be presented at relevant conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT06018545.

Implementing a chest X-ray artificial intelligence tool to enhance tuberculosis screening in India: Lessons learned.

Artificial Intelligence (AI) based chest X-ray (CXR) screening for tuberculosis (TB) is becoming increasingly popular. Still, deploying such AI tools can be challenging due to multiple real-life barriers like software installation, workflow integration, network connectivity constraints, limited human resources available to interpret findings, etc. To understand these challenges, PATH implemented a TB REACH active case-finding program in a resource-limited setting of Nagpur in India, where an AI software device (qXR) intended for TB screening using CXR images was used. Eight private CXR laboratories that fulfilled prerequisites for AI software installation were engaged for this program. Key lessons about operational feasibility and accessibility, along with the strategies adopted to overcome these challenges, were learned during this program. This program also helped to screen 10,481 presumptive TB individuals using informal providers based on clinical history. Among them, 2,303 individuals were flagged as presumptive for TB by a radiologist or by AI based on their CXR interpretation. Approximately 15.8% increase in overall TB yield could be attributed to the presence of AI alone because these additional cases were not deemed presumptive for TB by radiologists, but AI was able to identify them. Successful implementation of AI tools like qXR in resource-limited settings in India will require solving real-life implementation challenges for seamless deployment and workflow integration.

Multi-system Inflammatory Syndrome in Children (MIS-C) in two private, urban, tertiary hospitals in Metro Manila, Philippines

Background@#MIS-C is an infrequent, but serious complication encountered after acquiring COVID-19 illness in children. There is a lack of local data on MIS-C in the Philippines.@*Objective@#To identify demographic data, co-morbidities, clinical manifestations, laboratory results, 2D-echocardiography findings, acute co-illnesses and complications, treatment, and outcome of children with MIS-C, seen in two, private, urban, tertiary hospitals.@*Methodology@#This is a retrospective, descriptive study of all consecutive MIS-C cases, using the 2020 US CDC definition, seen between July 2020 to January 2023, by a single infectious disease physician. Demographic, epidemiologic, clinical, and physical examination findings; results of laboratory, 2-DE, and radiologic tests; co-illnesses and complications; and therapeutic and outcome data, were entered in a case report form for each patient.@*Results@#Thirty-six patients were seen. MIS-C cases had a median age of 6 years, presented with fever in 97%, while one-half had abdominal pain, vomiting, diarrhea and/or rash. CRP, D-dimer, ferritin, LDH and procalcitonin were generally elevated, and thrombocytopenia was seen in 39%. The most common 2-DE abnormalities were pericardial effusion (50%), coronary artery dilatation or aneurysm (39%) and mitral regurgitation (36%); the 2-DE was normal in 22%. The main complications were pneumonia (31%), myocarditis (28%) and hypotension (14%); 8% had ARDS. Treatment was with corticosteroids (89%) and IVIG (84%). Most (94%) recovered, and the hospital stay was five days, or less, in 86%. The two mortalities were a severely wasted adolescent with previously undiagnosed HIV infection; and an adolescent on chemotherapy for AML, who was also being treated for disseminated TB.@*Conclusions@#There is a need to create a greater awareness of MIS-C as, like Kawasaki disease, it has the potential to be an important cause of acquired heart disease among children.

A systematic review and meta-analysis on the safety and efficacy of Second Dose Immunoglobulin versus High Dose Pulse Methylprednisolone in Refractory Kawasaki Disease

Background@#There is limited information available regarding the management of IVIG-refractory Kawasaki Disease (KD). @*Objective@#This study aimed to evaluate the safety and efficacy of a second intravenous immunoglobulin (IVIG) infusion versus intravenous methylprednisolone (IVMP) in patients with IVIG-refractory KD.@*Methodology@#Cochrane Library, PubMed, Medline, Elsevier (Science Direct), Springer Link and BMJ databases were searched from May 1, 2020 to December 31, 2020. We included randomized controlled trials (RCTs) and high-quality prospective and retrospective studies, with population restricted to children 0 months to 18 years, with KD refractory to initial IVIG at 2g/kg, who remained febrile for 24-48 hours after completion of initial IVIG, and who received second-line monotherapy with either a second dose IVIG or IVMP. We conducted a meta-analysis using Review Manager [RevMan] 5.4.1 software.@*Results@#A total of six studies (n=188 patients) were analyzed. The incidence of coronary artery lesions was comparable between a second dose of IVIG and IVMP (RR 0.82, 0.34-1.96, P=0.66) in patients with IVIG-refractory KD. The rate of fever resolution to a second IVIG, compared to IVMP, was not significantly different between groups (RR 0.97, 0.84-1.13, P=0.72). There was a significantly higher incidence of adverse events in the IVMP group (RR 0.42, 0.26-0.57, P=0.0002), but these were all transient and resolved without further treatment. @*Conclusion@#There is no significant difference in the incidence of coronary artery lesions and rate of fever resolution post-retreatment with a second dose of IVIG versus IVMP in IVIG-refractory KD. More adverse events were reported in the IVMP group.

Red cell distribution width and its association with Neonatal Bacteremia: A case-control study

Background@#Bacteremia is a major cause of prolonged hospital stay and mortality in neonates and its early diagnosis remains a challenge to pediatricians. Red cell distribution width (RDW) is a component of a complete blood count test which is accessible and inexpensive and has been reported to be a possible diagnostic marker for neonatal bacteremia. This study determined the association of RDW with neonatal bacteremia in term and preterm neonates. @*Methodology@#This is a retrospective case-control study of 26 bacteremic neonates as cases and 104 non-bacteremic neonates, either symptomatic or with risk factors for bacteremia, as controls. Included newborns were seen between January 1, 2010 to September 30, 2021. Laboratory data obtained were CBC, C-reactive protein and blood culture. @*Results@#RDW values between bacteremic and non-bacteremic neonates were not significantly different. There was an association between RDW and neonatal bacteremia at an RDW level of > 16.1, where the likelihood of bacteremia was three times higher compared with lower RDW values. Significantly lower levels of hemoglobin, hematocrit, RBC count, WBC count, platelet count, MCH and MCHC, and a higher CRP level were seen among bacteremic neonates compared to those who were not. The median RDW for both term and preterm neonates was close to 16, with a narrow inter-quartile range at 1 and 2 for controls and cases, respectively. The range (minimum to maximum) of RDW values of bacteremic preterm neonates was more variable than those of term neonates. Using RDW to detect bacteremia, it had an equivocal discriminatory power or AUC of 0.6056. We found insufficient evidence to demonstrate a correlation between RDW and other CBC parameters, except for MCHC. For MCHC, the results suggest a very weak and indirect correlation. @*Conclusion@#RDW was not significantly different between bacteremic and non-bacteremic neonates, but there was a suggested association between RDW and bacteremia at an RDW level of > 16.1, at which level there was a 3-fold risk for bacteremia.

Multi-System Inflammatory Syndrome in Neonate (MIS-N) presenting as Bowel Obstruction: A case report

Background@#Since the start of SARS-CoV-2 pandemic, a post-infection hyperinflammatory process in children with features similar to Kawasaki disease, termed multisystem inflammatory syndrome in children (MIS-C),1 was identified. Thousands of MIS-C cases have already been reported worldwide.2 As possible cases of MIS-C in neonates were increasingly identified, multisystem inflammatory syndrome in neonates (MIS-N) as a distinct entity was proposed as neonates may not manifest all the typical features described in older children. @*Case Presentation@#We describe the case of a previously well term neonate with sudden signs of bowel obstruction who later had multisystem involvement (cardiac, gastrointestinal, and hematologic). The baby was born to a 23-yearold multigravida with an unremarkable prenatal history except for COVID-19 infection during her 34th week age of gestation. The mother presented with mild respiratory symptoms and resolved with supportive management. Our patient was born stable, then had sudden manifestations of feeding intolerance on the 16th day of life and upon work-up had moderate anemia, elevated inflammatory and cardiac markers, ileus, and dilatation of proximal left coronary artery. RT-PCR for SARS-CoV2 was negative. The baby was managed with intravenous immunoglobulin (IVIG) and steroids, with rapid clinical and laboratory parameters improvement thereafter. @*Conclusion@#MIS-N is still evolving as a disease entity with no clear, directed guidance yet on diagnosis and management. Management is extrapolated from treatment of MIS-C. Additional case reports and series are warranted to increase awareness and enable better understanding of the disease pathology among clinicians for timely investigation, diagnosis, and management.

The Etiology of childhood inpatient Pneumonias in two private, tertiary, Metro Manila Hospitals from 1993-2021 seen by one pediatric infectious disease specialist

Introduction@#The scarce local data on the etiology of childhood pneumonia admitted in a hospital has come from a few urban and rural government hospitals. There is no data from private hospitals. Knowing the most likely etiology of pneumonia is of outmost importance as this has implications on the diagnostic modalities requested and the institution of therapy. @*Objectives@#The purpose of this study is to identify clinical and microbiologic diagnoses of clinically- and radiographically-confirmed pediatric pneumonia cases admitted in a private hospital. Secondarily, a discussion of specific etiologies is made. @*Methodology@#Each consecutive, inpatient, pneumonia referral/admission in either one of two private, urban, tertiary hospitals, of a child 18 years and below from 1993 to 2021 was logged into a computer daily by a single pediatric infectious disease specialist. Clinical, epidemiologic, diagnostic and therapeutic data were recorded. All pneumonia cases, except those seen in newborns before their discharge from the nursery, were included. @*Results@#Of the 496 cases, there was a clinical and/or microbiologic etiology in 43% of cases. The bacteremia rate was 6.3%. The most common identifiable etiologies were Mycoplasma pneumoniae (11.9%), Mycobacterium tuberculosis (5.2%), and Staphylococcus aureus (4.2%), while bronchiolitis (5.5%) and measles (4.8%) were the most common clinical diagnoses. There were several cases of ventilator-associated pneumonia and Pneumocystis jirovecii pneumonia. @*Conclusions@#Mycoplasma pneumoniae, tuberculosis, Staphylococcus aureus and Pneumocystis jirovecii are important pneumonia etiologies that have not been widely considered locally. The data presented here mirrors the practice of one pediatric infectious disease doctor in two hospitals where diagnostic and treatment options are readily available and utilized.

A comparative study of pediatric patients with Complete vs. Incomplete Kawasaki Disease in a tertiary Hospital: An eleven year review

Introduction@#Kawasaki disease (KD) is the leading cause of acquired heart disease in childhood, but its diagnosis remains challenging since a significant number of cases do not meet the diagnostic criteria (Incomplete KD). This may delay the diagnosis and initiation of treatment, and increase the risk of morbidity from coronary artery complications.@*Objectives@#This study compared the clinical profile and treatment outcomes of children with complete and incomplete KD. @*Methods@#This is a cross-sectional, retrospective study of pediatric patients diagnosed with KD and admitted in a tertiary hospital from January 1, 2010 to December 31, 2020. Demographics, clinical manifestations, laboratories, 2D echocardiography (2DE) findings and treatment outcomes were obtained by review of medical records and analyzed using descriptive statistics. @*Results@#Among 135 patients studied, 71% were classified as Incomplete Kawasaki Disease. Majority (89%) were children more than 1 year old and predominantly male (55%). Five classic features, other than fever, were more frequent in complete KD – bilateral bulbar conjunctivitis, mucosal changes in the lip and oral cavity, polymorphous exanthem, changes in extremities, and cervical lymphadenopathy. Fever (100%), conjunctivitis (100%), rashes (97%) and oral changes (90%) were the most common findings in complete KD, while fever (100%), rashes (56%), conjunctivitis (46%) and oral changes (35%) were noted in incomplete KD. Higher CRP (167 mg/L vs. 100 mg/L) and lower albumin levels (30 g/L vs. 38 g/L) were seen in complete KD. Coronary artery dilatation (56% vs. 48%) was frequently detected in both complete and incomplete KD. Majority (96%) of cases received only one dose of IVIG and 4% needed additional treatment with methylprednisone. @*Conclusion@#The five principal features of KD other than fever, elevated CRP and lower albumin levels were significantly more common in complete cases. No significant differences in the demographics and 2DE findings of children with complete and incomplete KD were observed.

Global COVID-19 Transmission and Mortality-Influence of Human Development, Climate, and Climate Variability on Early Phase of the Pandemic.

Many of the respiratory pathogens show seasonal patterns and association with environmental factors. In this article, we conducted a cross-sectional analysis of the influence of environmental factors, including climate variability, along with development indicators on the differential global spread and fatality of COVID-19 during its early phase. Global climate data we used are monthly averaged gridded data sets of temperature, humidity and temperature anomaly. We used Human Development Index (HDI) to account for all nation wise socioeconomic factors that can affect the reporting of cases and deaths and build a stepwise negative binomial regression model. In the absence of a development indicator, all environmental variables excluding the specific humidity have a significant association with the spread and mortality of COVID-19. Temperature has a weak negative association with COVID-19 mortality. However, HDI is shown to confound the effect of temperature on the reporting of the disease. Temperature anomaly, which is being regarded as a global warming indicator, is positively associated with the pandemic's spread and mortality. Viewing newer infectious diseases like SARS-CoV-2 from the perspective of climate variability has a lot of public health implications, and it necessitates further research.

Fever of unknown origin among children in two private, urban, tertiary hospitals: A 27-year retrospective study

Introduction@#Fever of unknown origin (FUO) is a problem commonly encountered by infectious disease specialists, and even general pediatricians, in spite of the improvement in diagnostic modalities. There is no local study on childhood FUO from a private hospital. Thus, there is a need to determine the etiology of FUO seen in private practice, which may be different from those encountered in government or teaching hospitals.@*Objectives@#The purpose of this study is to identify the etiologies of childhood FUO from two private, urban, tertiary hospitals, as evaluated by a single pediatric infectious disease physician; and to discuss epidemiologic, clinical and diagnostic clues for the most common etiologies. @*Methods@#Childhood FUO cases were compiled from 1993 to 2020. Each consecutive, inpatient, admission or referral of a patient, 18 years or younger, was logged into a personal computer, and the discharge diagnosis for the FUO was recorded. Clinical, epidemiologic, diagnostic and therapeutic data, relevant to the FUO diagnosis were likewise recorded. FUO was defined as daily fever of 380C for ten consecutive days, or more, with no etiology identified after being admitted for seven days. @*Results@#Of 171 cases of childhood FUO, the etiology was an infection in 68%, collagen-vascular disease in 13%, miscellaneous cause in 8%, malignancy in 6%, and no diagnosis in 5%. The most common infections were Epstein Barr Virus (EBV) mononucleosis, tuberculosis, enteric fever, sinusitis, pneumonia and incomplete Kawasaki disease. The most common collagen vascular diseases were juvenile idiopathic arthritis and systemic lupus erythematosus. Hemophagocytic lymphohistiocytosis was the most common miscellaneous cause. Lymphoma was the most common malignancy. @*Conclusion@#This study found EBV mononucleosis, sinusitis, pneumonia, incomplete Kawasaki disease, lymphoma, HLH and Kikuchi-Fujimoto disease to be FUO etiologies not reported previously in other local reports.

Etiology, treatment and outcome of children diagnosed with Secondary Hemophagocytic Lymphohistiocytosis in a tertiary hospital

Background@#Hemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome that is associated with a variety of underlying conditions leading to the same characteristic hyperinflammatory phenotype. @*Objectives@#To describe the clinical profile of patients diagnosed with HLH admitted between January 1, 2010 to September 30, 2019 in a tertiary care hospital. @*Methods@#Retrospective descriptive study of pediatric patients diagnosed with HLH in a tertiary care hospital. @*Results@#Eleven subjects were included in the study. Age distribution showed a bimodal pattern: < 5 years old (5, 46%) and 10-15 years old (4, 36%). Male to female ratio is 4.5:1. All patients presented with fever (100%) followed by hepatomegaly (5, 45%) and splenomegaly (4, 36%) on physical examination. All eleven subjects fulfilled the following criteria for HLH such as fever, splenomegaly, and hyperferritinemia. Six out of eleven showed hypofibrinogemia (55%) and hypertriglyceridemia (55%). Among the eleven with two cell cytopenia, five presented with anemia (46%), six with neutropenia (55%), while all of them had thrombocytopenia (100%). Other laboratory findings noted were elevated ALT (5, 46%), CRP (4, 36%), AST (3, 27%), alkaline phosphatase (3, 27%), and hyponatremia (3, 27%). EBV and dengue (3, 27%) were the most common etiologies. Pneumonia (3, 27%) was the most common complication, followed by sepsis (2, 18%). All but one patient were responsive to either dexamethasone (7, 64%) and or IVIG (5, 45%) and chemotherapy (1, 9%). The antibiotic most commonly used was piperacillin tazobactam (3, 27%). The median hospital stay was 17 days. There was one mortality (9%). @*Conclusion@#HLH should be considered in children presenting with prolonged fever, hepatomegaly, and or splenomegaly, with hyperferritinemia, thrombocytopenia, anemia and neutropenia.

Antimicrobial Stewardship (AMS) program in private hospitals in the Philippines: Its acceptability, barriers, and enablers

Background@#Antimicrobials are drugs that are often misused and inappropriate antimicrobial prescribing often results in poor clinical outcome and drug resistance. Monitoring and regulation of antimicrobial use is currently being done by the Department of Health through the Antimicrobial Stewardship (AMS) Program. There is a need to determine the factors that affect successful implementation of an AMS program in private hospitals in the Philippines. This study was conducted to identify the enablers and potential barriers in implementing an AMS program in nine (9) private hospitals. @*Methodology@#A concurrent mixed methods design was used to assess various stakeholders’ (physicians, administrators, other AMS members) perceptions of existing or proposed AMS programs, and to identify barriers and enablers in their implementation. Quantitative data were collected using self-administered survey questionnaire to assess clinician’s acceptance of AMS programs. Qualitative data were collected through semi-structured one-on-one interviews of clinicians and other AMS personnel and focus group discussions (FGD) of selected clinician groups. Data were gathered from October 2018 to October 2019. @*Results@#409 clinicians were surveyed, 52 were interviewed and 46 sat for 13 sessions of FGDs. Overall, the survey established that physicians were well aware of antimicrobial resistance problem. Majority of the clinicians indicated general agreement with the currently practiced antimicrobial protocols in their hospitals and with the AMS program. However, there were disagreements in perceptions with how antimicrobial restrictions impair prescribing practices and overuse of the same. These responses were strong points of discussion during the Key Informant Interviews (KII) and FGDs. All respondents were amenable with the institutionalization of an AMS program in their hospitals. The hospital leadership’s commitment was determined to be the key enabler of a successful AMS program’s implementation. Barriers identified for hospitals with existing AMS programs were: lack of dedicated staff, resistance and/or non-cooperation of physicians, lack of support from non-medical departments, and inadequate cooperation between hospital personnel. Barriers identified, regardless of the status of the AMS programs were: deficiency in knowledge with developing and implementing an AMS program, inadequate information dissemination, unavailability of an IT-based monitoring for antibiotic use, and the influence of pharmaceutical companies on stakeholders with regards to antimicrobial use. @*Conclusion@#Similar enablers and barriers to a successful implementation of an AMS program were seen in the different hospitals. A hospital leadership’s commitment was determined to be the key enabler. The success or failure of any AMS program appears to depend on physician understanding, commitment and support for such a program. By involving the main players in an AMS program- the hospital administrators, clinicians and other key members, perceived barriers will be better identified and overcome, and enablers will help allow a successful implementation of an AMS program. This multi-center study was funded by Philippine Council on Health Research and Development ( PCHRD) and Pediatric Infectious Disease Society of the Philippines ( PIDSP) and was conducted by the PIDSP Research Committee.

Infection control and prevention of COVID-19 transmission: Interim recommendations for schools in the Philippine setting (as of August 6,2020)

@#THIS GUIDANCE AIMS TO SUPPORT PHYSICIANS WHO COLLABORATE WITH SCHOOLS AND GOVERNMENT IN CREATING INFECTION CONTROL POLICIES FOR SCHOOL RE-ENTRY IN THE TIME OF COVID-19 PANDEMIC, WHILE TAKING INTO CONSIDERATION THE OVER-ALL HEALTH OF EVERYONE, BASED ON AVAILABLE EVIDENCE. THE GUIDANCE IS DYNAMIC AND MAY CHANGE DEPENDING ON THE RAPIDLY EVOLVING KNOWLEDGE, DATA, AND UNDERSTANDING OF SARS-COV-2 IN THE COUNTRY.