Jacquet erosive diaper dermatitis in a child with COVID-19.

Since the start of the COVID-19 pandemic, several reports around the world indicated that the novel coronavirus could be associated with specific dermatologic manifestations. Among earlier articles, encountered features included erythematous maculopapular exanthems, chilblains-like acral skin lesions, vesicular, and urticarial rashes. We describe the first case of Jacquet erosive diaper dermatitis in a 17-month-old girl with a confirmed COVID-19 infection. This article may serve to expand the knowledge of the diverse clinical features of COVID-19 infection, particularly among the pediatric population.

An Overview About Pediatric Type 1 Diabetes Mellitus

Background: Diabetes mellitus (DM) represents one of the most common metabolic diseases in the world, with rising prevalence in recent decades. Most cases are generally classified into two major pathophysiological categories: type 1 diabetes mellitus (DM1), which progresses with absolute insulin deficiency and can be identified by genetic and pancreatic islet autoimmunity markers, and type 2 diabetes mellitus (DM2), which is the most prevalent form and involves a combination of resistance to the action of insulin with an insufficient compensatory response of insulin secretion. In the last two decades, in parallel with the increase in childhood obesity, there has also been an increase in the incidence of DM2 in young people in some populations. Other forms of diabetes may affect children and adolescents, such as monogenic diabetes (neonatal diabetes, MODY – maturity onset diabetes of the young, mitochondrial diabetes, and lipoatrophic diabetes), diabetes secondary to other pancreatic diseases, endocrinopathies, infections and cytotoxic drugs, and diabetes related to certain genetic syndromes, which may involve different treatments and prognoses. DM1 is considered an immuno-mediated disease that develops as a result of gradual destruction of insulin-producing pancreatic beta cells that eventually results in their total loss and complete dependence on exogenous insulin. Clinical presentation can occur at any age, but most patients will be diagnosed before the age of 30 years

Modification of Management Strategies During Sars COVID 2 Pandemic Improved the Quality, Criticality, and Outcomes of In-Patients

The second wave of the pandemic exposed many hospitals to their unpreparedness to handle sudden surge patients due to lack of infrastructure to handle the relentless inflow of pts whilst also running short of beds, o2, ventilators, trained HCW's, PPE, medications, and other essentials. The aim of the study was to use judiciously the available resources, fine-tune the patient care, reduce the workload and burden of HCW s, optimize pts care, and improve the outcomes. This observation was done at a tertiary care hospital. The following fine-tuning was done: 1. Oxygen: Robust O2 systems that would support the pandemic, would take time to put in place, so conducting training programmers in a short period for HCW regarding optimal usage and avoid misusing or wastage of O2 was done in a relatively short time. We selected an HCW as O2 provider, the only job to check o2 delivery and SPO2 around the clock. 2. Foleys Catheters and Diapers: Patients on high O2 requirements when mobilized, O2 delivery to patients were discontinued along with disruption of prone positions and derecruitment of lungs and had severe hypoxia. So we started catheterizing the pts on high O2 need. 3. Family Visit: Family visits made pts comfortable, more compliant to the care. And it also reduced the significant burden of HCW's who had to otherwise communicate multiple times with their relatives via audio or video phone calls. This also brought transparency of the care. 4. Simple Protocols: We simplified the charts with only two sheets, one for the doctor one for the staff. These simple changes made work easy and more efficient and also help in collecting data. 5. DRUG Boy: Drugs indenting and on-time delivery were challenging. We selected a person only for drug delivery and later with drugs becoming precious and anticipating problems, drug boy used to deliver medications to the patient in presence of family. 6. Continuous Monitoring by a Leader: COVID is a dynamic process and requires continuous monitoring, timely interventions. Leaders have to take complete charge continuously from admission to discharge. Fragmented care by multiple people worsens the situations. 7. DVT Stockings: COVID is a prothrombotic state for the prevention of clots all moderate to severe pts were applied DVT stockings, along with chemoprophylaxis which prevented DVT significantly. 8. Anxiolytics, Restricted Mobilization, and Spirometry: Mild anxiolytics reduced the stress, work of breathing, and good compliance to the NIV. Strict restriction in mobilizing and adequate spirometry was supervised in moderate to severe COVID patients in the early stages to help in early recovery from COVID-19. 9. Prone Position in COVID: In moderate and severe ARDS in patients on O2 with face mask, O2 by BIPAP support and in invasively ventilated patients were subjected to prone positioning for 16-18 hours/day, which helped in improving lung recruitment oxygenation of patients and better outcomes while reducing the oxygen requirements. Conclusion: COVID pandemic is very challenging. Conservative management and fine-tuning of the resources available will have multiple benefits and also improve outcomes. With these innovations, quality will improved was costeffective and easily replicable in any hospital.

Fine Tuning of Simple Things During Pandemic Improves Quality, Criticality, and Outcomes

COVID pandemic has made the health care system difficult to prepare for demanding situations. Second wave of the pandemic made many hospitals unable to handle the relentless inflow of patients whilst also running short of beds, oxygen cylinders, health care workers, and other essentials, with limited resources, we had two challenges to secure better supplies and judiciously use the resources. The aim of the study was to use judiciously the resources, fine tune the patient care, reduce the work load/burden of HCW and improve the outcomes and to see whether these fine tuning will sustain better care and improve the outcomes This observation is done at tertiary care centre. The innovation or fine-tuning were done as follows, 1. Oxygen Boy: The O2 is lifesaving in COVID-19 and its a long game. The neglect of O2 systems have been partly market failure, partly lack of knowledge and anticipation, and misuse Robust O2 systems that would support the pandemic take time to put in place, so conducting training programmes in short period for HCW regarding using or misusing O2 can be done in the relatively short times if there is good planning and management. We selected an HCW as O2 boy;his job was only checking O2 delivery and monitoring SPO2. He was given SPO2 targets to maintain. He would adjust the O2 depending on the targets, we found care was better, reduced O2 misuse, and less burden on HCW including hospital authorities. He also used to monitor continuous prone positions. 2. Foleys Catheters and Diapers: Due to the shortage of ICU/HDU beds during the peak of pandemic, moderate to severe patients were managed in wards with close monitoring. In the initial stages, we faced problems in patients on high o2 when they were mobilized to restrooms. Continuous o2 awake prone was disturbed and derecruited and had severe hypoxia with symptoms and few near codes. So we started catheterizing the patients on high o2 requirements/ elderly, and diapers used if very hypoxic. After these changes the surprises were less, compliance for care was more, and complaints from the patients were very less. 3. Family Visit: Allowing family person visit with precautions was very useful. Family visits made patients comfortable, more compliant with the care, families were happy and reduced the significant burden of HCW's and brought transparency of the care. Complaints of misusing of the drugs were less. 4. Simple Protocols: Due to scarcity of HCW and over working, we analyzed the work flow and found more time was taken for documenting and following the reports than actual patient care. So we simplified the charts with only two sheets, one for the doctor one for the staff. These simple changes made work easy and more efficient and also help in collecting data. 5. 'Drug' Boy: Drugs indenting and on-time delivery was challenging with limited staff and a high workload. We selected a person only for drug delivery and later with drugs becoming precious and anticipating problems, drug boy used to deliver in family presence. This reduced the further burden of HCW's. 6. Continuous Monitoring by a Leader: COVID is a dynamic process and requires continuous monitoring, timely interventions. Leaders have to take complete charge continuously from admission to discharge. Fragmented care by multiple people worsens the situation. 7. Support from the Other Specialities: With above mentioned fine tuning, we found rounds by any specialists doctors was comfortable, less time-consuming, and could manage many patients. This reduces the burden of intensivists and physicians. 8. Monitored Hydration: Most patients were hydrated in view of reduced appetite, druginduced, third spacing, and on NIV. This simple regime significantly reduced acute kidney injuries. 9. DVT Stockings: COVID is a prothrombotic state for the prevention of clots all moderate to severe patients were applied DVT stockings, this prevented DVT significantly. 10. Anxiolytics, Restricted Mobilization, and Spirometry: Mild anxiolytics reduce the stress, work of breathing, and good compliance to the NIV. Stric restriction in mobilizing and no spirometry in moderate to severe COVID in early stages. Conclusion: COVID pandemic is very challenging, till data no proper pharmacological treatment available. So fine tuning of the resources available will have multiple benefits and also improve outcomes. With these innovations, quality improves, cost-effective, and can easily be replicable in any centre.

Impact of COVID-19 on Infants Followed After Discharge from the Neonatal Intensive Care Unit via a Telemedicine Model

Background: While the prevalence of SARS-CoV-2 has remained low among newborns, there is increasing evidence that the COVID-19 pandemic impacted healthcare for families with infants in the neonatal intensive care unit (NICU). However, little is known about the impact of COVID-19 on families with infants discharged from the NICU. During the initial pandemic shutdown, our Neonatal Follow-Up Program (NFP) transitioned to a virtual platform and implemented a survey about new/worsened obstacles families might be facing due to the pandemic as standard of care. We aimed to: 1) evaluate for patient-level differences in virtual neonatal follow-up visit rates;and 2) characterize the social impact of the pandemic on families followed via a large, urban NFP. Methods: All infants scheduled for NFP visits during our telemedicine epoch (March 13, 2020- July 31, 2020) were eligible for inclusion. We compared the family demographics and medical history of infants whose televisits occurred to those for whom televisits did not occur as scheduled. Secondly, we conducted a descriptive analysis of caregiver responses to the pandemic-specific challenges survey. Given the known disproportionate impact of SARS-CoV-2 on communities of color, we also assessed for differences in responses by self-identified race. Data was manually extracted by three coders from the electronic medical record who showed high interrater agreement. Results: After excluding visits cancelled by the provider team, we found 499 clinic encounters for 678 scheduled visits during the study period (i.e. a show-rate of 73.6%). When comparing patients who completed their virtual visit to those who did not, we found no differences in infants' sex, birthweight or gestational age at birth, nor in their reliance on medical technology at discharge. (Table 1). There were also no differences by caregiver self-reported race/ethnicity, but infants whose visits did not occur were more often covered by public insurance. (Table 1). In addition, 43.9% of caregivers reported that their employment had changed since the onset of the shutdown and 6.1% reported housing changes. (Table 2). Eight percent of families endorsed having trouble accessing at least one basic infant necessity (i.e. formula, diapers or medical supplies) due to cost issues and 10% of families endorsed having trouble accessing such necessities due to availability. Non-Hispanic Black caregivers reported this challenge and other infant food-related challenges more often than non-Hispanic White caregivers. Conclusion: We found socioeconomic disparities with respect to virtual follow-up visit rates after discharge from the NICU during the initial COVID-19 shutdown. In addition to navigating the discharge of their infant, families also reported pandemic-enhanced stressors related to difficulty accessing basic infant needs as well as employment and housing changes. Our study highlights the importance of proactive strategies to screen for and mitigate the unique economic vulnerabilities of families discharged from the NICU even beyond the pandemic. (Table Presented).

Teachable Moments in Clinical Medicine

Sir William Osler said, To study the phenomena of disease without books is to sail an unchartered sea, while to study books without patients is not to go to sea at all. This quote is a bleak reminder of the state of clinical teaching after nearly two years of Covid disrupting the implementation of our curriculums across the country given the recent roll out of a Competency-based Curriculum. We cannot allow the undergraduate course to slip into a distant online mode for fear of losses of competences mandated to perform professional roles as physicians of first contact. The focus of this brief lecture is on Undergraduate Teaching-Learning in Clinical Medicine though post-graduate education is not necessarily exempt from these ideas. It will attempt to suggest possibilities given the existing context of the transformation towards the new Competency-based Curriculum and the facts of faculty-student ratios that challenge us. Assumptions must be stated at the beginning that faculty are not only motivated but also enthusiastic and interested in their task to educate their undergraduates to learn and the vice versa exists especially in dealing with students in their clinical phase of studentship. If the patient needs to return to the centre of our education, then moving very moment of teaching to the bedside, Outpatient clinic, Emergency and even Operation Theatre are the needs of the hour. Key elements towards achieving competences and outcomes require us to insist on small groups (usually not more than 15-20 per unit) and formative assessments ongoing throughout phases of teaching clinical medicine. To force multiply we need to include Senior Residents and Postgraduates (even the special Intern) into the pool of 'Faculty' and more importantly use every opportunity to provide experiences in the clinical settings mentioned above not restricted to 'nine to five work hours'. Outpatient (Ambulatory) clinic has great potential to teach small groups of clinical students assigned to shadow faculty and residents/interns working up patients in regular outpatient clinics even participating actively in the actual care and treatment of patients. Since clinical postings occur usually through three semesters leading up to final examinations, judicious involvement in 'work ups' documented in case notes or logbooks as students under supervision of faculty/residents makes fabulous learning. Initial postings begin with history and anthropometric measurements and growth charting leading to physical examination both General and Systems finally even deciding on differentials with investigation plan and writing then counselling regards prescriptions. All this is after it is present to the faculty/resident in the presence of the parents for confirmation or clarifications. Undergraduates enjoys a single patient work up by every student assigned to a faculty/resident is enjoyed by undergraduates simply because it is realistic. Of course, informing the patient or attender of the patient and appropriate allocation even of healthy or follow up patients for this exercise makes this a possibility. It is rare that such an informed patient or attender disallows such an exercise. Depending upon outpatient space, the clinical exercise may occur while sitting opposite the faculty/resident in the same consult room or in a nearby room to return to the faculty/resident's room for presentation in front of the parents. One may hasten the process by focusing on a one patient-one key learning system and various models have been described by John Dent and Ronald Harden classified on Student - Faculty ratios. As an example, in the case of Paediatrics, focusing on growth charting, practical immunisation, nutrition counselling, discussing most likely differentials, investigation approaches, form filling, rational therapeutic choices, optimal prescriptions, education and counselling may be chosen as learning points for different students seeing different patients. Initially, case notes of history and examination are allowed onto outpatient charts followed by assisting by investigation requests, discussing results when relevant and finally actually writing prescriptions to be scrutinised and signed off by faculty/residents. The obvious disadvantage is that it does slow down patient clearance but while students work up their patient's one can continue to clear other patients and every patient does not need to be handed over to students to work up. Their involvement in actual patient care makes great inspiration to learn more. Ambulatory settings also allow one to direct students to the immunisation room or pharmacy to observe and under supervision begin to even administer common vaccines while recognising components of the many prescriptions we dispense. We all know that to do is the best way to strengthen the learning experience. Teaching in the wards at the bedside of patients is also rather fulfilling and motivational for students to understand and want to learn the art and science of medicine. The bedside clinic has been the cornerstone of clinical education only to disintegrate as one 'Bakra' works up and presents the chosen allocated patient to the faculty while the remaining clinical batch of students passively stand by hopefully learning. Allocating patients or beds to individual students or a pair of students, the latter in early postings, with mandatory responsibility of working up and seeing 'their' patients every morning of the clinical posting with details entered in the logbook book is the first step. The faculty assigned for the bedside that day, does not reveal the patient to be discussed but may randomly pick up one of the patients asking the student(s) 'responsible' to present. This mandates that all students posted have to be up to date with history, examination, investigation results and treatment if not daily assessments and care plan. Another successful involving method is to walk up to the batch allocated patients from the parent unit after they have seen their patients for the day and conducting teaching rounds mimicking realistic patient service rounds. Each student or pair of students presents updates of their patients and discussions occur similar to one has on regular rounds. Differentials are argued, Investigation results analysed and Treatment options even choice of antibiotics with doses and duration justified. This clerkship exercise is an early extension of internship and we all know that most learning occurs during Internship at least in our times. Documentation may occur in student logbooks but one may make provisions that patient progress notes be clearly identified as student learning notes and documented as such. The student-doctor then needs to not only interact with patients, practice examining patients, documenting the same, to chase results and cross consults. Common non-medical issues faced in care and treatment are then experienced by students. It is only in the ward that feeding, introducing intravenous cannula, performing phlebotomy, medications administration, infusions, monitoring transfusions, transportation within hospital, changing diapers and even bed making is experienced. It is in the wards that opportunities to participate in procedures like LPs, biopsies, etc. occur making sure that documentation occurs in logbooks. To enable more excitement in learning, the mandating evening duties as observers from 6-8 pm assigned to report to duty residents/postgraduates as they deal with emergencies and regular work documenting what they observe during such duties. Observation in Operation Theatres or in areas where procedures occur only makes good learning if there is a structured system in place, where the teacher briefs the students preparing them for what they are to witness and observe followed by the actual witnessing of the procedure/intervention ending with debriefing of the steps involved and findings. The continuum of learning must continue into the postoperative period to complete the learning by student participation in post-operative rounds. In later postings, the occasional opportunity to scrub up to 'participate' in the intervent on adds to the inspiration to learn. In all these encounters, students must adhere to norms expected of professional behaviour And patient consent by the primary care provider essential. Patients if informed do understand the need and accept reasonable student interaction during their stay in medical college settings. Involving them in providing feedback of students who interviewed and examined them also makes great learning points right from dress code to demonstrating respect. This brief lecture shares ideas to recognise and optimise utilisation of possible teachable moments in clinical medicine thus opening up possibilities of many other ideas from participants.

Diaper Need During the COVID-19 Pandemic Associated with Poverty, Food Insecurity, and Chronic Illness: An Analysis of a Representative State Sample of Caretakers with Young Children.

Objectives: Diaper need is an important form of material hardship for families with young children. This study quantified diaper need during the COVID-19 pandemic and examined factors associated with diaper need. Methods: Using a representative statewide sample of adults in Massachusetts, diaper need was assessed during the COVID-19 pandemic among respondents with at least one child 0-4 years of age in diapers (n=353). Bivariate tests examined associations between diaper need and individual and household factors. Multivariable regression was used to examine associations between diaper need and demographic factors, job loss, and mental health during the pandemic. Results: More than one in three respondents reported diaper need (36.0%). Demographic factors associated with diaper need were age <25 years, Latino ethnicity, having less than a high school degree, unemployment before the pandemic, household income <$50,000, household food insecurity, or having a household member with a chronic disease. Diaper need was higher among respondents who utilized a nutrition assistance program or a food pantry during the pandemic. In multivariable analyses considering job loss and mental health during the pandemic, diaper need was associated with household income <$50,000 (odds ratio [OR] 3.61; confidence interval [95% CI] 1.40-9.26) and a chronic disease diagnosis within the household (OR 4.26; 95% CI 1.77-10.29). Conclusions: This study indicates a level of diaper need similar to what was documented before the COVID-19 pandemic despite federal stimulus payments and increased distributions by local diaper banks. The findings identify groups at increased risk and suggest opportunities to reach those at risk through food assistance programs.