Factors Affecting Human Papillomavirus Vaccine Trends in the United States of America.

Background Routine immunization of both girls and boys starting from nine years of age with the human papillomavirus (HPV) vaccine is the current recommendation. The objective of this retrospective study using National Health and Nutrition Examination Survey data was to evaluate the influence of sociodemographic factors on the series initiation and completion of the HPV vaccine from 2011 to 2020. Methodology The chi-square test was used to examine the statistical significance of the association between categorical variables and receipt of the HPV vaccine. The Cochran-Armitage test for trend was employed to assess the statistical significance of temporal trends in risk factors associated with rates of HPV vaccination. These trends were further quantified by a significant rate ratio by comparing them against the most recent survey years. Results HPV vaccine uptake was higher in the 9-14-year age group across survey years and had increased for both males and females over that time. The first dose of the HPV vaccine was most likely to be received by the 11-18-year age group. In the most recent survey of 2017-2020, the highest number of vaccination series completion was achieved for Gardasil®. Conclusions Improved physician efforts and strategies to vaccinate males, low socioeconomic strata patients, and ethnic minorities in more numbers are needed.

Socioeconomic Factors Associated With the Risk and Prevalence of Dental Caries and Dental Treatment Trends in Children: A Cross-Sectional Analysis of National Survey of Children's Health (NSCH) Data, 2016-2019.

Introduction In the United States of America, early childhood caries (ECC) is the most common chronic childhood disease of early onset, with dental caries being the most prevalent chronic disease among children aged 6-19 years. Children without an established medical home, from low-income households, and who are uninsured have historically shown to be prone to dental caries and attribute to higher health care costs. Early recognition of these risk factors by a pediatrician helps prevent the development of medical and psychosocial complications in the child. Methods The cross-sectional data of the prevalence of dental caries and dental treatment trends in children and three socioeconomic risk factors, namely establishment of a medical home, household income, and child's health insurance, were accessed from the National Survey of Children's Health (NSCH) for the years 2016-2019. The association of the risk factors with the prevalence of dental caries and with the prevalence of dental treatment were analyzed using two-sample proportion tests and chi-square (χ2) tests for dichotomous categorical variables and non-dichotomous categorical variables, respectively. Standardized residuals were calculated and analyzed as well. Furthermore, the odds ratios were calculated and utilized to quantify the influence of each category on the highly associated category with having teeth decay and not receiving dental treatment under each socioeconomic risk factor. Results The results of this study revealed that the three socioeconomic factors considered have statistically significant associations with tooth decay and dental treatment. The prevalence and associative risk of tooth decay and untreated caries were the highest in the children without a medical home. Additionally, the odds of having tooth decay was >50% higher for the children from the lowest household income category (0-99% federal poverty level [FPL]) compared to those from the high household income categories (200-399% FPL and >400% FPL). Public insurance coverage was associated with the highest prevalence of dental caries and not receiving fluoride treatment. Furthermore, the likelihood of not availing dental treatment is nearly two times or more higher for the uninsured children than children having public insurance, or private insurance, or a combination of both. Conclusion Our study findings reveal that children belonging to certain socioeconomic risk categories are at a higher risk of developing dental caries and not receiving dental treatment. As a consequence, the study implies that increased support and expansion of public health insurance will benefit oral health care for the children. Pediatricians play an integral part in developing a medical home for the child by providing preventative dental care and establishing continued care through dental referrals.

Risk Factors, Trends, and Preventive Measures for 30-Day Unplanned Diabetic Ketoacidosis Readmissions in the Pediatric Population.

Background There has been a steady rise in types 1 and 2 diabetes mellitus among the youth in the USA from 2001 to 2017. Diabetic ketoacidosis (DKA) is a common and preventable presentation of both types of diabetes mellitus. According to the Centers for Disease Control and Prevention's (CDC) United States Diabetes Surveillance System, during 2004-2019 an increase in DKA hospitalization rates by 59.4% was noted, with people aged less than 45 years having the highest rates. Readmissions reflect the quality of disease management, which is integrally tied to care coordination and communication with the patient and their families. This study analyzes the trends and risk factors contributing to 30-day unplanned DKA readmissions in the pediatric age group and looks into possible preventive measures to decrease them. Methods A retrospective study was performed using the National Readmission Database (NRD) from January 1, 2017, to December 1, 2017. Pediatric patients aged 18 years and younger with the primary diagnosis of DKA were included using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code E10.10. All statistical analysis was performed using IBM SPSS Statistics for Windows, version 1.0.0.1327 (IBM Corp., Armonk, NY, USA). Pearson's chi-square test was used for categorical variables and Mann-Whitney U test was used for continuous variables. To independently determine the predictors of readmission within each clinical variable, multiple logistic regressions with values presented as odds ratios (OR) with 95% confidence intervals (CI) were performed. Results A weighted total of 19,519 DKA-related pediatric index admissions were identified from the 2017 NRD. Of these pediatric patients, 831 (4.3%) had 30-day DKA readmission. The median age of a child for readmission was 16 years with an interquartile range of 0 to 18 years. A sharp rise in 30-day DKA readmissions was noted for ages 16 years and over. Females in the 0-25th percentile median household income category, with Medicaid covered, large metropolitan areas with at least 1 million residents, and metropolitan teaching hospitals were found to have a statistically significant higher percentage of readmissions. The mean length of stay for those who had a DKA readmission was 2.06 days, with a standard deviation of 1.84 days. The mean hospital charges for those who had a DKA readmission were $ 20,339.70. The 30-day DKA readmission odds were seen to be increased for female patients, Medicaid-insured patients, admissions at metropolitan non-teaching hospitals, and children from 0-25th percentile median household income category. Conclusion There has not been much of a change in the trend and risk factors contributing to the 30-day unplanned DKA readmissions over the years despite the steady rise in cases of diabetes mellitus. The length of stay for those who did not get readmitted within 30 days was longer than for those who did. This could reflect more comprehensive care and discharge planning that may have prevented them from readmission. Diabetes mellitus is a chronic disease that demands a team effort from the patient, family, healthcare personnel, insurance companies, and lawmakers. There is scope for a lot of improvement with the way our patients are being managed, and a more holistic approach needs to be devised.

Impact of Sociodemographic Factors on Dental Caries in Children and Availing Fluoride Treatment: A Study Based on National Survey of Children's Health (NSCH) Data 2016-2019.

Introduction Dental caries is a global health issue. It is a largely preventable, multifactorial non-communicable disease. Given the gravity of the situation, in 2014 United States Preventive Services Task Force recommended that the primary care physician apply fluoride varnish from the eruption of the first tooth till the child attains five years of age. Using 2016-2019 National Survey of Children's Health (NSCH) cross-sectional representative data, the aim of this study was to determine if the child's age, gender, and race are predictors of the child having decayed teeth or cavities in the past 12 months and if they had availed preventative dental services from the dentist in the past 12 months in the US and if so, did they receive fluoride treatment. Methods The prevalence of dental caries and dental treatment among children under each category of sociodemographic risk factors were estimated using 2016-2019 NSCH's cross-sectional representative data on two survey questions. Then, the statistical significance of the association of the categorical risk factors with the prevalence of dental caries and the association of the categorical risk factors with the prevalence of fluoride dental treatment were tested using two-sample proportion tests and chi-square tests. Further, chi-square residual analysis was employed to better understand the nature of the association and to reveal the degree of contribution to the test statistic from each categorical combination of risk factors. Results Prevalence and associative risk of tooth decay in children was the highest in the 6-11 years age group across all three years under study. The 6-11 years age group had the highest prevalence and association of receiving fluoride treatment across all three years. In our study, the prevalence of dental caries in children by race varied according to the year. In 2016-2017 and 2018-2019, it was the Hispanic population with the highest prevalence of tooth decay. In 2017-2018 the highest prevalence was seen in the Non-Hispanic Black (NHB) population. Across all three years, the Hispanic population had the highest associative risk of tooth decay. The Non-Hispanic White (NHW) population had the highest prevalence and association with receiving fluoride treatment across all three years. Male children were found to have the higher prevalence and associative risk of decayed teeth across all three survey years. Conclusion Dental caries is a worldwide health burden. However, it can be prevented by different precautionary measures. The results of our study revealed that certain sociodemographic factors such as age, gender, and race of the child make certain groups of the child population more at risk for the development of dental caries; most notable findings were that the male children were significantly associated to have decayed teeth and not availing dental fluoride treatment for which limited information is available in the literature. Additionally, the age groups 1-5 and 6-11 were significantly associated with the prevalence of not receiving dental treatment and the prevalence of dental caries, respectively. More active participation of pediatricians in getting trained for the application of fluoride varnish and helping getting their patients established with dental services per recommendations will help streamline preventative dental care.

Persistent Raynaud's Phenomenon Following Methylphenidate Hydrochloride Use During the COVID-19 Pandemic.

Raynaud's phenomenon (RP) is a medical condition characterized by vasospasm of the digital vessels in the fingers and toes. The prevalence of RP in the general population is estimated at 3-5% and can vary based on climate. It is classified into primary and secondary RP based on causality. RP has been reported in some cases diagnosed with coronavirus disease 2019 (COVID-19) infection. We report the case of a 14-year-old Caucasian female who presented during the pandemic with chief complaints of suicidal ideations and attempted suicide and had a history of attention-deficit hyperactivity disorder (ADHD) and persistent RP after a stimulant trial. After an initial failure of treatment with lisdexamfetamine, she was switched to methylphenidate hydrochloride (MPH). Within two months of starting MPH, the patient noticed skin discoloration of the lower legs and feet along with numbness. The discoloration of skin was mainly limited to her feet and gradually moved up her legs. She was advised to discontinue the MPH, but her symptoms persisted for four more months until her admission. Other etiologies were ruled out by multi-specialties and during her hospitalization. She was started on atomoxetine and buspirone with appropriate dose titration. Post-discharge from the hospital, no improvement was observed in the patient's RP at an outpatient follow-up performed within a month. The development of RP following MPH treatment and its persistence after stopping MPH is a fascinating event. Clinicians should be aware of the potential rare side effects of stimulants and stimulant-like medications, including vascular, hematological, and dermatological effects. Adolescents with ADHD may be particularly distressed by the COVID-19 pandemic and display increased behavioral issues. Stress can be a trigger for RP; therefore, minimizing stress in at-risk patients is essential.

Medically underserved areas and International Medical Graduates (IMGs) in the United States: challenges during the COVID-19 era.

Background: Given that nearly a quarter of the US physician workforce are international medical graduates (IMGs), many of whom remain on temporary work visas for prolonged periods due to processing delays, the pandemic has posed unique challenges to these frontline workers and has arbitrarily limited our physician workforce. Methods: This is cross-sectional survey data obtained from IMGs on temporary work visas pertaining to their role in healthcare, impact of visa-related restrictions on their professional and personal lives was sent to the participants. Results: A total of 2630 IMGs responded to the survey. Most of the respondents (1493, 56.8%) were physicians in active practice, with Internal Medicine (1684, 65.7%) being the predominant specialty encountered. 64.1% were practicing in Medically Underserved Areas (MUA) or Health Professional Shortage Areas (HPSA), with 45.6% practicing in a rural area. Nearly 89% of respondents had been involved with direct care of COVID-19 patients, with 63.7% assuming administrative responsibilities for COVID-19 preparedness. 261 physicians (11.5%) were subject to quarantine, while 28 (1.2%) reported a confirmed COVID-19 infection. 93% physicians expressed inability to serve in COVID-19 surge areas due to visa-related restrictions, while 57% had been approached by recruiters due to staffing shortages. 72% physicians reported that their families would be at risk for deportation in case of their disability or death. Most respondents (98.8%) felt that permanent resident status would help alleviate the above concerns. Conclusion: A significant proportion of the US physician workforce is adversely impacted by work-based visa restrictions and processing backlog. Mitigating these restrictions could significantly bolster the current physician workforce and prove beneficial in our response to the COVID-19 pandemic.

Review of COVID-19 Variants and COVID-19 Vaccine Efficacy: What the Clinician Should Know?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a beta coronavirus that belongs to the Coronaviridae family. SARS-CoV-2 is an enveloped spherical-shaped virus. The ribonucleic acid (RNA) is oriented in a 5'-3'direction which makes it a positive sense RNA virus, and the RNA can be read directly as a messenger RNA. The nonstructural protein 14 (nsp14) has proofreading activity which allows the rate of mutations to stay low. A change in the genetic sequence is called a mutation. Genomes that differ from each other in genetic sequence are called variants. Variants are the result of mutations but differ from each other by one or more mutations. When a phenotypic difference is demonstrated among the variants, they are called strains. Viruses constantly change in two different ways, antigenic drift and antigenic shift. SARS-CoV-2 genome is also prone to various mutations that led to antigenic drift resulting in escape from immune recognition. The Center of Disease Control and Prevention (CDC) updates the variant strains in the different classes. The classes are variant of interest, variant of concern and variant of high consequence. The current variants included in the variant of interest by the USA are: B.1.526, B.1.525, and P.2; and those included in the variant of concern by the USA are B.1.1.7, P.1, B.1.351, B.1.427, and B.1.429. The double and triple mutant variants first reported in India have resulted in a massive increase in the number of cases. Emerging variants not only result in increased transmissibility, morbidity and mortality, but also have the ability to evade detection by existing or currently available diagnostic tests, which can potentially delay the diagnosis and treatment, exhibit decreased susceptibility to treatment including antivirals, monoclonal antibodies and convalescent plasma, possess the ability to cause reinfection in previously infected and recovered individuals, and vaccine breakthrough cases in fully vaccinated individuals. Hence, continuation of precautionary measures, genomic surveillance and vaccination plays an important role in the prevention of spread, early identification of variants, prevention of mutations and viral replication, respectively.

Review of COVID-19 Vaccines Approved in the United States of America for Emergency Use.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus causing a global pandemic. Coronaviruses are a large family of single-stranded ribonucleic acid (RNA) viruses. The virus has four essential structural proteins which include the spike (S) glycoprotein, matrix (M) protein, nucleocapsid (N) protein and small envelope (E) protein. Different technologies are being used for vaccine development to battle the pandemic. There are messenger ribonucleic acid (mRNA)-based vaccines, deoxyribonucleic acid (DNA) vaccines, inactivated viral vaccines, live attenuated vaccines, protein subunit-based vaccines, viral vector-based vaccines and virus-like particle-based vaccines. Vaccine development has five stages. In the clinical developmental stage, vaccine development can be sped up by combining phase 1 and 2. The vaccines can also be approved more swiftly on an emergent basis and released sooner for usage. The United States Food and Drug Administration (USFDA) has approved Pfizer-BioNTech, Moderna and Janssen coronavirus disease 2019 (COVID-19) vaccines for emergency use. There are other vaccines that have been approved around the world. The mRNA vaccines have been created using a novel technology and they contain a synthetically created RNA sequence of virus fragments encoding the S-protein which is injected. These vaccines have a relatively low cost of production and faster manufacturing time but can have comparatively lower immunogenicity and more than one dose of vaccine may be required. In the case of viral vector-based vaccines, genes encoding the SARS-CoV-2 S protein are isolated and following gene sequencings are introduced into the adenovirus vector. These vaccines have a relatively fast manufacturing time but the efficacy of the vaccine is variable based on the host's immune response to the viral vector. At the time of this paper, there were 81 vaccines in clinical development stage and 182 vaccines in preclinical development stage. Vaccines are an essential tool in our battle against COVID-19. Some of the COVID-19 vaccines have completed their phase III trials while many other potential vaccines are still in developmental stages. It used to take close to a decade for a vaccine to be developed and undergo rigorous testing until its production and availability to the public, but over the past year, we have seen multiple vaccines in different phases of testing against SARS-CoV-2 virus.

Resident Peer Review Process: An Innovative Teaching Model in an Internal Medicine Residency Program.

Introduction Medical peer review is an integral part of the performance improvement process in any hospital. The very first exposure to the peer review process in a physician's career is typically after graduation and when they start practicing as an attending physician. We implemented a "Resident Peer Review Process" training module in our Internal Medicine residency program with an intention to familiarize the residents about peer review. Methods The resident peer review process was implemented over a period of four weeks with the "resident peer review committee" having representation from all three Postgraduate Year (PGY) levels. The committee reviews the cases referred to them over a period of four weeks through a process of weekly meetings and adjudicates the cases. If any deficiency is identified, the committee will provide feedback to the residents involved in the case and presents the educational points identified from the adjudication at the end of the module as a morning report. Results Eighty-nine (89) cases were reviewed through this process over a span of two years. About 77.5% of the cases were identified to have a deficiency. Teaching points were identified and presented in Week 4 meetings in 80.9% of the cases that had a deficiency. The residents provided a positive response and said that the process improved their quality of patient care (98%), professionalism (95%), systems-based practice, practice-based learning (90%), medical knowledge (88%), and interpersonal and communications skills (87%).  Discussion This resident-driven, novel, and innovative model can be a successful teaching methodology for Internal Medicine residents to augment Patient Safety and Quality Improvement and could be implemented in residency programs irrespective of the size and specialty.

A case series of vestibular symptoms in positive or suspected COVID-19 patients.

Respiratory symptoms are the most common presentation of an acute COVID-19 infection, but thromboembolic phenomena, encephalopathy and other neurological symptoms have been reported. With these case series, we present multiple presentations of COVID-19 induced vestibular symptoms namely dizziness, vertigo and nystagmus. The patients reported in this case series are from different parts of the world, belong to different age groups and had manifested these symptoms in different periods of the pandemic. The pathophysiology of vestibular neuritis induced by COVID-19 is similar to any other viral infection. Whether in the inpatient or outpatient settings, COVID-19 should be considered in the differential diagnosis for patients presenting with these symptoms, irrespective of the presence of respiratory symptoms or hypoxia.

Dermatillomania: A Case Report and Literature Review.

Skin picking disorder, also termed dermatillomania is a condition that leads to repetitive picking of their skin ending up in skin and soft tissue damage. It is classified in Diagnostic and Statistical Manual of Mental Disorder Fifth edition under the "obsessive compulsive and related disorders" section. Often associated with other psychiatric conditions like autism, alcohol abuse, obsessive compulsive, body dysmorphic, mood, anxiety and borderline personality disorders, it is a disorder that is quite often underreported. The patient in this case report is a 58-year-old male with a diagnosis of obsessive compulsive disorder (OCD) who reported severe anxiety and skin picking episodes over several years. He presented to the emergency room with an extensive wound on distal left foot with exposure of the underlying muscle tissue, that resulted from the excessive picking of skin from the left foot. This compulsive behavior started off with picking the skin around his nail beds and slowly got worse. The skin picking would get worse whenever he gets nervous or anxious. The wound was treated with topical wound care and antibiotics. At the time of discharge, he was prescribed oral antibiotics to complete his course of treatment and was referred to the hospital's cognitive behavioral therapy (CBT) program that specializes in treatment of OCD and anxiety disorders. Treatment of dermatillomania is a multipronged approach and should include treatment of the underlying psychiatric illness, the treatment for pruritus and topical treatment of the lesions. Selective serotonin reuptake inhibitors (SSRIs) have proved to be the most effective in treating the psychiatric component of dermatillomania. Non-pharmacological treatments such as behavioral therapy, habit reversal exercises and support groups have also proved to be helpful and are well tolerated amongst patients suffering from dermatillomania.

Toxic Alcohol Ingestion: A Case Report and Review of Management Pathways.

Toxic alcohol ingestion can be fatal or produce irreversible tissue damage and hence timely recognition and treatment are very important. The physician has to often rely on clinical features and different lab values in order to derive the possible causative agent consumed. Gas chromatography is the definitive diagnostic test to detect the toxic alcohol but is unfortunately not available to run in house in most hospital laboratories in the acute clinical setting. We present a 41-year-old gentleman who was brought to the ED for further evaluation of vomiting and upper abdominal pain. Our clinical impression was that the patient had possible mixed toxic alcohol ingestion. General principles and treatment of alcohol intoxication include gastric lavage or use of activated charcoal. Administration of ethanol or fomepizole to delay or prevent generation of toxic metabolites needs to be initiated while sufficient alcohol remains and metabolized and measurement of blood alcohol concentrations and/or serum osmolality can be helpful. Dialysis is helpful in removing unmetabolized alcohol and possibly toxic metabolites and delivering base to patients to ameliorate metabolic acidosis.

COVID-19 Encephalopathy in Adults.

Many patients with COVID-19 are asymptomatic. However, among the patients that are symptomatic, influenza-like illnesses including fever, myalgia and respiratory symptoms seem to be the most common presentation across age groups. Though respiratory illness seems to be the primary presentation, about 36.4% to 69% of hospitalized COVID-19 patients have exhibited neurological manifestations.  We present two patients who were hospitalized for the presenting symptom of acute encephalopathy. Both the patients regained consciousness within 24 to 48 hours of initiating treatment. The first patient was known to have mild cognitive impairment and a thorough work-up was done in the emergency department which did not reveal any other causes apart from positive SARS-CoV-2 rapid PCR test. The second patient was from a long-term care facility with underlying dementia, usually alert, awake and oriented to self and presented with severe encephalopathy with a Glasgow Coma Scale of 3 on admission. Her work up was notable only for a positive SARS-CoV-2 rapid polymerase chain reaction test. Both patients responded well to standard remdesivir and steroid therapy and returned to baseline cognition. SARS-COV 2 virus appears to be a causative agent of acute onset encephalopathy. Very little is known about the pathophysiology of neurological manifestations in COVID-19 illness. There are several theoretical possibilities of pathogenesis such as of blood-brain barrier disruption secondary to SARS-CoV-2 binding to angiotensin-converting enzyme 2, autoimmune sequelae, ischemic injury via systemic hypoxia or local vascular endothelial information or thrombosis, toxic metabolic encephalopathies and long-term impact of systemic proinflammatory state that have been considered.

Purpuric Rash and Thrombocytopenia After the mRNA-1273 (Moderna) COVID-19 Vaccine.

The mRNA-1273 vaccine, popularly called the "Moderna vaccine" is being widely administered in the United States for the prevention of COVID-19 infection since December 2020. Mild to moderate intensity side effects like low-grade fever, myalgia, chills and malaise were reported in the trials related to the vaccine. With this case report, we report a case of purpuric rash and thrombocytopenia after receiving the first dose of the m-RNA-1273 vaccine. The patient, in this case, is a 60-year-old male patient who received the first vaccine dose and within two days, he developed diffuse papular rash associated with some thrombocytopenia. He had a history of tobacco use, Hepatitis C liver cirrhosis, chronic kidney disease stage 4, untreated hypertension and systolic congestive heart failure at the baseline. With review of the limited literature related to the vaccine and its side effect profile and with no other etiology explaining the sudden onset of rash, we attribute this thrombocytopenia and purpuric rash as the side effects of the mRNA-1273 vaccine.

Primary Care Shortage in Medically Underserved and Health Provider Shortage Areas: Lessons from Delaware, USA.

OBJECTIVE: To examine the reasons contributing to the physician shortage in the country's medically underserved areas using the state of Delaware as a focus state. METHOD: A literature review regarding the shortage of physicians with data compilation from Delaware Department of Public Health (DPH) and Delaware Health and Social services (DHSS) was performed. A review of the "Conrad 30 J1 VISA waiver program," the most important and primary supplier of physicians to underserved areas of the state was performed. A survey interviewing the physicians recruited through this program to identify any challenges faced by them was designed and conducted. RESULTS: The number of primary care physicians providing direct patient care in Delaware in 2018 had declined about 6% from 2013. The average wait time to see a PCP was 8.2 days in 1998 as compared to 23.5 days in 2018. Forty-six percent of physicians serving in HPSAs in Delaware are IMGs recruited through the J1 VISA waiver program. Eighty percent of these IMGs are actively considering leaving the United States due to anxieties around physician immigration policies, mainly "Immigration backlog." CONCLUSION: The existing programs to recruit physicians to underserved areas seem to be inadequate. The state and the hospital systems should be able to utilize the J1 program to its full potential and focus on retaining these physicians after their assigned services. As the challenges of IMGs continue to worsen every day; the medical societies, hospitals, the state and federal government should advocate for policies that resolve these challenges.

A Case of Osteodiscitis in a Preschool-Aged Child.

Infectious discitis and osteodiscitis in children are rare. The usual age of occurrence is between two and five years. The diagnosis is most often delayed due to mild presenting symptoms. We present the case of a five and half year old child who presented with progressively worsening lower back pain over a period of two weeks, which was made worse with bending forward. He did not have fever, pain in his lower extremities, or any other accompanying symptoms. He did not have a history of recent illnesses or trauma to the lower back. The laboratory work revealed an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and rest of the parameters were within normal limits. CT scan of his spine showed findings of well-defined defects on the endplates of L4-L5 with prevertebral soft tissue thickening. MRI with and without contrast of the spine confirmed the findings and detected mild focal erosive changes at the opposing endplates of L4-L5 with disc space narrowing, thin fluid along the anterior margin of the disc, and shallow disc bulging, which were consistent with osteodiscitis. A conservative approach with intravenous antibiotics followed by a switch to oral antibiotics was undertaken with good clinical recovery. Treatment strategy for osteodiscitis in children is generally antibiotic therapy. Prognosis in children is good. In some cases based on the pain severity, other measures such as bed rest, analgesics, and casting for immobilization may be required. Biopsy tends to be reserved in uncertain cases or in those that have poor response to pain control measures and antibiotics.

Pediatric Care Struggles of US Trained International Medical Graduate Pediatricians in COVID-19 Pandemic.

BACKGROUND: Pediatrician shortage and healthcare access has been a serious issue especially in medically underserved and rural areas aplenty in the USA and has further worsened during the coronavirus disease 2019 (COVID-19) pandemic. Many US trained international medical graduates (IMGs) on a visa status serve these areas to fill in the physician gap. These physicians are usually on a visa and the majority of them have approved immigration petitions. During this pandemic, the sudden changes in immigration policies in addition to the longstanding administrative backlog and processing times had posed new challenges to the pediatricians and the communities served by them. The objective of this study was to determine the demographics, level of training and practice, immigration status, the clinical role they played in the communities they served and the various professional and personal setbacks they faced during the pandemic. METHODS: A survey was created and data were collected using data collection platform "Survey Monkey". Screening questions were designed to include only IMG pediatricians on a visa status. RESULTS: A total of 267 IMG pediatricians qualified for the survey on a nationwide basis. Of the physicians that participated in the survey, 58.4% were working in either medically underserved or physician shortage areas, 36% of the total physicians were working in a rural setting, 10.6% of the pediatricians had to be quarantined due to exposure to COVID-19, 0.8% were infected with COVID-19 themselves, and 81.3% of the pediatricians had faced hindrance in being able to work at a COVID-19 hotspot due to work site restrictions because of their visa status. CONCLUSION: IMG pediatricians play a valuable role in taking care of the children in medically underserved areas. The challenges surrounding the immigration backlog are contributing to significant hardships for these pediatricians and their families and are causing a hindrance to healthcare access to the children in medically underserved communities during the pandemic especially limiting the pediatricians' scope and geographic radius of the practice, thus not allowing them to practice to the full extent of their license.

Age- and Diagnosis-Based Trends for Unplanned Pediatric Rehospitalizations in the United States.

BACKGROUND AND OBJECTIVES: Hospital readmission rate helps to highlight the effectiveness of post-discharge care. There remains a paucity of plausible age-based categorization especially for ages below one year for hospital readmission rates. METHODS: Data from the 2017 Healthcare Cost and Utilization Project National Readmissions Database was analyzed for ages 0-18 years. Logistic regression analysis was performed to identify predictors for unplanned early readmissions.  Results: We identified 5,529,389 inpatient pediatric encounters which were further divided into age group cohorts. The overall rate of readmissions was identified at 3.2%. Beyond infancy, the readmission rate was found to be 6.7%. Across all age groups, the major predictors of unplanned readmission were cancers, diseases affecting transplant recipients and sickle cell patients. It was determined that reflux, milk protein allergy, hepatitis and inflammatory bowel diseases were significant diagnoses leading to readmission. Anxiety, depression and suicidal ideation depicted higher readmission rates in those older than 13 years. Across ages one to four years, dehydration, asthma and bronchiolitis were negative predictors of unplanned readmission.  Conclusions: Thirty-day unplanned readmissions remain a problem leading to billions of taxpayer dollars lost per annum. Effective strategies for mandatory outpatient follow-up may help the financial aspect of care while also enhancing the quality of care.

Review of COVID-19 viral vector-based vaccines and COVID-19 variants.

The concept of viral vector-based vaccine was introduced in 1972 by Jackson et al and in 1982 Moss et al introduced the use of vaccinia virus as a transient gene expression vector. The technology has been used to make Ebola vaccines and now COVID-19 vaccines. There are two types of viral vector-based vaccines i.e. replicating and non-replicating. Non-replicating viral vector-based vaccines use replication-deficient viral vectors to deliver genetic material of a particular antigen to the host cell to induce immunity against the desired antigen. Replicating vector vaccines produce new viral particles in the cells they enter, which then go on to enter more new cells which will also make the vaccine antigen. Non-replicating vector-based vaccines are more commonly utilized. Adenovirus, vesicular stomatitis virus, vaccinia virus, adenovirus associated virus, retrovirus, lentivirus, cytomegalovirus, and sendai virus have been used as vectors. Current adenovirus vector-based vaccines being administered against SARS-CoV-2 infection are JNJ-78435735 by Johnson and Johnson (Janssen) along with Beth Israel Deaconess Medical Center, AZD1222 by Oxford-AstraZeneca, Sputnik V and Sputnik Light by Gamaleya Research Institute of Epidemiology and Microbiology, and Convidecia vaccine by CanSino Biologics. Of the five vaccines, the United States Food and Drug Administration (FDA) has approved Janssen vaccine for emergency use. Efficacy against COVID-19 variants has been found in all but the Convidecia vaccine so far. Heterologous prime-boost COVID-19 vaccination regimen may be the new face and more efficient immunization approach for enhanced immunity against COVID-19.