COVID-19: The heart of the issue Beth Woodward BMedSc (Hons)1, Muhammed Kermali2College of Medical and Dental Sciences, University of Birmingham, Birmingham, UKSt. George’s, University of London, London, UKCorresponding author:Beth WoodwardBMedSc (Hons)College of Medical and Dental SciencesUniversity of BirminghamBirmingham, UKe-mail: email@example.comTel: 07947766140Funding: none obtainedConflict of Interest: none to be declaredKey words: COVID-19, angiotensin, ACEiBW and MK contributed equally.
The impact of wearing a mask on face-touching behavior is unknown. We conducted a brief survey and observational study to assess the perception and to quantify how masks affect face-touching behavior. Most felt that the mask would alter their face-touching behavior with only 18.3% feeling that masks would not affect it. During a total of 330 person-minutes of observation, overall face-touching rate was 15.1 face touches/hour (FT/hr), 6.4 FT/hr while wearing a mask and 20.1 FT/hr without a mask (p <0.01). Masks are an effective barrier and reduce face-touching behavior amongst healthcare professionals.
This is a report of an 8-year-old male with Schwartz-Jampel syndrome with severe obstructive sleep apnea. Dental findings include severe maxillary crowding, posterior crossbite, missing lower incisors, and supernumerary lower premolar. Significant craniofacial characteristics include Type I skeletal relationship with bimaxillary hypoplasia, hyperdivergent skeletal pattern, severe constriction of dental arches.
Comment on: The COVID-19 Pandemic: A rapid global response for children with cancer from SIOP, COG, SIOP-E, SIOP-PODC, IPSO, PROS, CCI and St. Jude Global.Chetan Dhamne MSc MD1, Tushar Vora MD1, Maya Prasad MD1, Nirmalya Roy Moulik MD PhD1, Badira C Parambil MD DM1, Akanksha Chichra MD1, Girish Chinnaswamy MD1, Shripad Banavali MD1, Gaurav Narula MD11 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India2. Homi Bhabha National Institute, Anushaktinagar, Mumbai, IndiaCorrespondence to:Gaurav Narula Pediatric Hematolymphoid Disease Management Group, Department of Medical Oncology, Tata Memorial Center, Parel Mumbai, 400012 Email: firstname.lastname@example.orgText word count: 576Brief running title: Letter to Editor (COVID-19) Global responseKeywords: COVID-19, SARS-CoV2, Pediatric Oncology, Children with cancerTables: 1Abbreviations
International guidelines have recommended the use of inhaled beta-2 agonists and systemic corticosteroids (SC) as the first-line treatment for acute asthma. Objective: To evaluate the evidence for the efficacy of inhaled corticosteroids (ICS) in addition to SC compared to SC alone in children with acute asthma in the ED or during hospitalization. Data sources: Five electronic databases were searched. Study Selection: All RCTs that compared ICS (via nebulizer or metered dose inhaler) plus SC (oral or parenteral) with placebo (or standard care) plus SC were included without language restriction. Data extraction: Two reviewers independently reviewed all studies. The primary outcomes were hospital admission or hospital length of stay [LOS], and secondary outcomes were readmissions during follow-up, ED-LOS, lung function, asthma clinical score, oxygen saturation, and heart and respiratory rates. Results: Nine studies (n=1473) met the inclusion criteria. In all the studies, the ICS was budesonide. Compared to SC alone, adding budesonide to SC did not affect hospitalization rate, but decreased hospital LOS by more than one day (MD= -29.08 hours [-39.9 to -18.3]; I2=0%, p=<0.00001). Moreover, adding budesonide (especially with ≥2mg doses) significantly improved the acute asthma severity score among patients at ED. Conclusions: Compared to SC alone, adding budesonide to SC did not affect hospitalization rate, but decreases the LOS and improves the acute asthma score in children at ED setting.
Covid has blatantly uncovered the disconnect between the healthcare professionals who have the responsibility for the health of the nation but little of the authority, and politicians and business people who have the authority and political power over healthcare, but none of the responsibility for the health of the nation. The time has come to review this dichotomy and to reinvent medical education in order to empower and train healthcare professionals, particularly mid-career ones, to become adept in the business of medicine; including budgeting, management, leadership, hiring and firing, brand building and other important aspects of running complex healthcare entities. It is no longer acceptable for physicians to accept backseat for non-physician managers and concede their rules and regulations without question. The time is now for health professionals to train themselves and take charge of the profession.
In the midst of a global public health crisis, medical providers find themselves on the frontline of unprecedented circumstances caring for patients as they fight the coronavirus disease 2019 (COVID-19) pandemic. Pediatricians are faced with the reality that COVID-19 positions marginalized groups of children and youths at an increased vulnerability to health care inequities. These at-risk groups include children and youth who are ethnic and racial minorities, immigrants, LGBTQ, homeless, in foster care, as well as those who have medically complex health conditions and/or mental health and substance use disorders (1, 2, 3). Now more than ever, health disparities have the potential to result in fatal health outcomes and healthcare professionals have the power to advocate for and protect their young patients. Given the urgent and pressing impacts of the current pandemic, Tsai and Kesselheim offer a timely and critical dialogue in this issue of Pediatric Blood & Cancer, focused on the effects of provider implicit bias that contribute to health disparities.Tsai and Kesselheim underscore the well documented literature on implicit bias in pediatric medical oncology and note the limited research in pediatric hematology-oncology, despite the complexities that exists in prognosis and treatment plans for this clinical population. Additionally, the case examples are thoughtful, transparent self-reflections from the authors personal clinical experiences with implicit bias in the field of pediatric hematology-oncology. The authors then outline a plan of action towards mitigating implicit bias in healthcare. They first emphasize the importance of acknowledging implicit bias, which is ubiquitous in human nature and exists under many circumstances. Subsequently, upon acknowledgment of existing implicit bias, providers should cultivate self-awareness via medical education in order to have the autonomy and ability to identify and detect implicit bias that negatively affect patient care. Moreover, the authors deduce that diversifying the medical team, both demographically and interprofessionally, can optimize detection of implicit bias. The authors go on to conclude that more research is needed in the specialty field of hematology-oncology to identify how implicit bias specifically affects provider’s ability to communicate complex diagnoses, prognoses, and treatment options.Derived from social psychology research, implicit bias refers to unconscious, unintentional, and automatic positively or negatively skewed classifications people make based on their own experiences and demographic background which then influences behavior and perceptions. The Institute of Medicine published a pivotal report illuminating how implicit bias can negatively influence patient care and may lead to health disparities (4). Examples of implicit bias affecting health outcomes include biases toward race, weight, sexual orientation, socioeconomic status, age, marital status and history of drug use (5, 6). There are two paths that may explain how implicit bias amongst medical providers may contribute to health disparities (5, See Figure 1). Path A suggests provider judgements and decisions regarding patient care can result in health disparities. Path B proposes that implicit bias amongst providers can lead to ineffective communication which affects the providers ability to cultivate a trusting relationship and environment. Patient’s distrust with their providers affects their willingness and ability to adhere to treatment recommendations which subsequently leads to health disparities. Moreover, this model also explains the conduit for interaction effects between path A and B. That is, compromised judgment leading to poor medical decisions may strengthen the probability of poor communication and distrust in the provider-patient relationship or the inverse. Also imperative to the discourse of health disparities and bias, not discussed by Tsai and Kesselheim, is the notion of “privilege” that, unlike minorities, many non-minorities may experience in their rise to becoming a medical professional as well as their medical decision making (7). Such privilege can inadvertently bias providers to behave in ways that illuminate implicit bias. Therefore, the ability to acknowledge privilege is essential to increasing one’s proclivity to recognize their implicit biases. The authors provide vignettes that pointedly describe the importance of self-awareness. Practicing self-awareness promotes the ability to detect implicit biases that may affect patient care and result in unintentional health disparities. Moreover, central to the author’s argument, it is fundamentally important to identify and implement practical steps to address provider implicit bias.The use of research to inform best clinical practice by implementing skills training is key in addressing health disparities related to provider implicit bias. A potential barrier to successful training and education on provider implicit bias is limited support from institutional leadership (8). Committed leadership on curricula related to implicit bias at an institutional level is likely to reflect long-term systemic change (9, 10). Furthermore, providing a nonjudgmental and safe environment for providers to address difficult content is also key in fostering self-awareness that is more likely to result in long-term change (10). Considering the role of power dynamics in practice and training is also fundamental for cultivating a safe environment for self-disclosure and self-awareness and bringing about systemic long-standing modifications. Tsai and Kesselheim highlight the importance of building demographically diverse and interdisciplinary medical teams. Purposeful team development can also reveal and mitigate any systemic workforce and recruitment biases (11). Having various perspectives while discussing a treatment plan can combat implicit bias. For example, if a complex case is presented at morning rounds with a team that is homogeneous in background and trainings there is potential for groupthink that is anchored in one or two individuals’ implicit biases. Specific to complex cases in pediatric hematology-oncology this can be critical especially during a pandemic that is particularly impacting vulnerable populations, who are often less likely to be represented among medical decision makers. A diverse team can provide insight for culturally competent care as well as provide important perspectives that could optimize diagnostic and treatment outcomes.As a clinician, it is not an easy task to be open to becoming vulnerable to exploring self-awareness as it relates to implicit bias. It is also our ethical duty to do no harm. Acknowledging implicit bias as a catalyst to health disparities while implementing effective skills training to address implicit bias is crucial to protecting our most vulnerable pediatric patients.ReferencesSilliman Cohen RI, Adlin Bosk E. Vulnerable youth and the COVID-19 pandemic. Pediatrics . 2020; doi: 10.1542/peds.2020-1306Cholera R, Falusi OO, Linton JM. Sheltering in place in a xenophobic climate: 12 COVID-19 and children in immigrant families. Pediatrics. 2020; doi: 10.1542/peds.2020-1094Wong CA, Ming D, Maslow G, Gifford EJ. Mitigating the impacts of the COVID-19 pandemic response on at-risk children. Pediatrics . 2020; doi: 10.1542/peds.2020-0973Smedley BD, Stith SY, Nelson AR, Smedley BD, Stith SY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Institute of Medicine. National Academies Press; Washington, D.C: 2002. doi.org/10.17226/12875Zestcott C, Blair I, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Processes & Intergroup Relations . 2016;19(4):528-542. doi:10.1177/1368430216642029DelFattore J. Death by Stereotype? Cancer Treatment in Unmarried Patients. New England Journal of Medicine . 2019;381(10):982-985. doi:10.1056/nejmms1902657Hall J, Carlson K. Marginalization. Advances in Nursing Science . 2016;39(3):200-215. doi:10.1097/ans.0000000000000123Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making. Academic Emergency Medicine. 2017;24(8):895-904. doi:10.1111/acem.13214Pereda B, Montoya M. Addressing Implicit Bias to Improve Cross-cultural Care. Clin Obstet Gynecol . 2018;61(1):2-9. doi:10.1097/grf.0000000000000341Sherman M, Ricco J, Nelson S, Nezhad S, Prasad S. Implicit Bias Training in Residency Program: Aiming for Enduring Effects. Fam Med. 2019;51(8):677-681. doi:10.22454/fammed.2019.947255Hall W, Chapman M, Lee K et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Am J Public Health. 2015;105(12):2588-2588. doi:10.2105/ajph.2015.302903a
During coronavirus disease 2019 (COVID-19) pandemic, coinfections with other viral infections are not uncommon, but concomitant atypical bacteria are rare. Herein, we describe a young female COVID-19 patient who developed acute cold agglutinin disease secondary to Mycoplasma pneumoniae. Using an azithromycin-containing COVID-19 therapeutic regimen, both pneumonia and anemia resolved uneventfully.
A 63 year old patient with chronic lymphocytosis and neutropenia is described. A bone marrow biopsy showed a markedly hypercellular specimen with an interstitial and intrasinusoidal lymphoid infiltrate. Immunohistochemistry and immunophenotyping identified these as LGLs. With paucity of erythropoiesis diagnosis of LGL leukemia with pure red cell aplasia is reached.
Roe deer (Capreolus spp.) are a little odd. They are one of only a few placental mammals — and the only genus among even-toed ungulates — capable of putting embryonic development “on ice”, also known as embryonic diapause (Fig. 1). It would seem such an unusual trait is likely the product of natural selection, but a big question is, how does selection for important traits, such as diapause, interact with the historical demography of a species? In a ‘From the Cover’ article in this issue of Molecular Ecology, de Jong et al. (2020) demonstrate that selection is acting on genes associated with reproductive biology in roe deer, despite heightened genetic drift due to reduced effective population size through the Pleistocene.
Just weeks following the fifth anniversary of the landmark Montgomery v Lanarkshire Health Board Supreme Court judgment, the Royal College of Obstetricians and Gynaecologists (RCOG) has delivered the fourth edition of its Green-top guideline on forceps and vacuum assisted births1. The irony of this is not lost on those who expected real change following last year’s peer review consultation (19 physicians and 6 maternity care organisations responded, including the first two signatories of this letter). The guideline opens with a fundamental question: Can assisted vaginal birth be avoided? The answers RCOG provides are solely in the context of labour (evidence on continuous support, epidural analgesia, positions adopted, delayed pushing), but a legal interpretation of Montgomery advises birth is “a situation that allows for significant advance planning and accordingly plans must be made.”2 The guideline concurs: women “should be informed about assisted vaginal birth in the antenatal period, especially during their first pregnancy [and] in advance of labour”. Nevertheless, while “lower rates in midwifery-led care settings” is included, ‘lower rates with planned caesarean’ is not, and there is no direct equivalent Green-top for this birth mode. The Montgomery judgment on consent specifically states that doctors are “under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.” It also emphasises that in any pregnancy, the “principal choice is between vaginal delivery and caesarean section.” RCOG may argue that referencing the “alternative choice of a caesarean section late in the second stage of labour” sufficiently addresses these points. However, a Queen’s Counsel who was involved in the Montgomery case reminds doctors that the mother “was not advised that an alternative to vaginal birth (i.e. caesarean section) was an option available to her… and there was an increased risk… should vaginal birth be attempted.”2 He warns, “Where the patient asks a question, it must be answered honestly and fully”, which suggests that planned caesarean birth omission from this Green-top could have serious legal consequences, and there is every chance the Montgomery case could reoccur.Despite aiming “to provide evidence-based recommendations”, RCOG does not include pelvic organ prolapse as an adverse outcome. Instead, it says women who “achieve an assisted vaginal birth rather than have a caesarean birth… are far more likely to have an uncomplicated vaginal birth in subsequent pregnancies”, and that “much of the pelvic floor morbidity reported… may not be causally related to the procedure.” Furthermore, the stated aim of RCOG’s clinical Green-tops is to identify “good practice and desired outcomes”, which will be “used globally.”4 This is relevant because many countries define this as low caesarean birth rates. In the UK, the National Institute for Health and Care Excellence (NICE) does not advocate targets, and recommends support for prophylactic caesarean birth requests.3 Yet decades of promoting vaginal birth rather than informed choice has obstructed autonomy and contributed substantially to rising litigation costs.5The truth is, the NHS simply cannot afford to keep repeating the same communication and consent mistakes, and in our view, this NICE accredited Green-top guideline clearly demonstrates that lessons from Montgomery have still not been learned.Pauline M Hull, Founder, Caesarean BirthKim Thomas, CEO, Birth Trauma OrganisationDr. Elizabeth Skinner, Faculty of Medicine, University of SydneyAmy Dawes, Co-founder and CEO, Australasian Birth Trauma AssociationPenny Christensen, Executive Director, Birth Trauma Canada
Typical form of Hemolytic Uremic Syndrome is caused most commonly enterohemorrhagic E. coli strain O157:H71. Here we report a unique case of HUS secondary to enteropathogenic E. coli infection, with a discussion on the diagnosis of HUS and how it is distinguished from other thrombotic microangiopathies (TMAs).
Alternatives to traditional aortic valve replacement now form part of the valve surgeon's armamentarium. Sutureless valves offer decreased bypass and crossclamp times, excellent maneuverability, and promising outcomes. We present a case of a sutureless aortic valve replacement for a late failed David procedure, complicated by post-operative development of severe paravalvular regurgitation. We attempted off-label balloon post-dilation to improve expansion of the valve, however paravalvular regurgitation persisted. The patient underwent subsequent aortic valve replacement using a mechanical valve and experienced no further paravalvular leak.