August 4, 2021 | Volume 12 | Issue 31
Effect of high dose zinc and ascorbic acid supplementation vs. usual care on symptom length and reduction among ambulatory patients with SARS CoV-2 infection
From a clinical trial of 214 ambulatory adult patients with confirmed SARS-CoV-2 infection who received outpatient care and were randomized to receive either 10 days of zinc gluconate (40mg), ascorbic acid (8,000mg), both agents or “standard of care” where the number of days required to reach a 50% reduction in symptoms (including fever, cough, shortness of breath and fatigue) and time to symptomless was measured, it appears that neither zinc carbonate, ascorbic acid nor a combination of the 2 supplements has any beneficial effect on symptomatology (compared to standard care).
Nodular mass in the earlobe of an 18-month old girl
An interesting and somewhat unusual clinical presentation describes a healthy 18-month-old infant who presenting with a 1-year history of an asymptomatic, slow-growing, firm, nodular, pinkish, non-tender mass which moved freely in the posterior aspect of her right earlobe. Histopathology following complete excision identified 2 cell types; basaloid and ghost cell without a nucleus. Diagnosis - a pilomatricoma. At 6 months post-surgery the wound was well healed with no recurrence.

Pilomatricomas are thought to arise from hair matrix cells, with most (40%) cases occurring before the age of 10 years (more often in girls). A frequent anatomical location is in the head and neck (>50%) and they present as a solitary, slow growing, asymptomatic, superficial or deeply seated, freely mobile, firm to rock-hard mass up to 5cm in diameter. Multiple tumors and familial cases can occur. Plain x-rays reveal non-specific calcification; computed tomography (CT) or magnetic resonance imaging (MRI) reveals a sharply demarcated subcutaneous opaque lesion that does not enhance on injection of contrast medium. Aspiration identifies 2 types of cells; ghost squamous cells and basaloid/basophilic squamous cells. Following total surgical excision recurrences are rare.


See related video HERE and below:
Effect of oral azithromycin vs. placebo on COVID-19 symptoms in patients with SARS-CoV-2 infection
“Azithromycin has a wide spectrum of activity characterized by resistance to beta-lactamase producing microbes and efficacy against gram positive and gram negative bacterial pathogens including Haemophilus influenza.” It also has anti-inflammatory/enhanced immunological properties and antiviral activity via several actions.

From a randomized outpatient trial of 263 adults with SARS-CoV-2 infection treated with a single oral dose of azithromycin (vs. placebo) it appears that azithromycin DOES NOT increase the likelihood of being symptom free 14 days post treatment.
Evaluation and management of well-appearing febrile infants 8-60 days old
“Efforts to develop an evidence-based approach to the evaluation and management of young febrile infants have spanned more than 4 decades.” A number of approaches have evolved over the years with a variety of clinical prediction rules (using clinical and laboratory criteria) defined in an attempt to provide more precise recommendations; mostly ignored by community and Emergency physicians (without deleterious effect on outcomes!).

Because of the multiple differing approaches the American Academy of Pediatrics (AAP) has developed this guideline grounded in “continually expanding evidence and including new technologies” which addresses the evaluation and management of well-appearing, term infants 8-60 days of age with a fever > 38.0°C. Three age-based algorithms are outlined (for 8-21 day old infants, for those 22-28 days old, and 29-60 day olds). Each algorithm is extensively explained.

Though it is anticipated that in the future “personalized medicine” will allow for each individual infant with fever to be evaluated on his/her own particular characteristics, the 3 outlines presented give a relatively simple and straight forward approach to the management of the well-infant with fever that will enhance clinical decision making in a situation which can be clinically challenging. (Worth reading; Ed.)


See related video HERE and HERE.
Longitudinal outcomes for Multisystem Inflammatory Syndrome in children
Multisystem Inflammatory Syndrome in children (MIS-C) is a potentially serious but uncommon condition in children (usually 3-12 years of age) where different body parts become inflamed (e.g. heart, lungs, kidneys, brain, skin, eyes and/or gastrointestinal system) approximately 4 weeks following a SARS-CoV-2 infection (asymptomatic or symptomatic). Long-term outcome remains unknown.

A study of 45 hospitalized children admitted with a diagnosis of MIS-C evaluated outcomes at 1-4 weeks, 1-4 months and 4-9 months post-discharge.

Though the majority of children with MIS-C are critically ill (76% require intensive care and 64% vasopressors and/or inotropes), most inflammatory markers normalize by 1-4 weeks and almost all children are essentially back to normal by 4-9 months.
Effect of combined atropine and patching (CAPT) vs. patching alone for the treatment of severe amblyopia in children aged 3-12 years
Vision as a system develops during the first 7-10 years of life. Amblyopia (“lazy eye”), a familial condition of early childhood (where the brain favors and develops pathways to one eye) is the most common cause of decreased vision in children. There are 3 kinds of amblyopia (Refractive, Strabismic and Deprivation amblyopia). Clinically amblyopia may be symptomless (the child may not notice or report any problem), carers/teachers may notice misaligned eyes, squinting, tilting of the head or covering one eye. Untreated amblyopia can lead to permanent loss of sight/perception in the affected eye. Early treatment is recommended which depends on the type of amblyopia present (and includes glasses/contact lenses, patching the better-seeing eye or surgery).

From a randomized clinical trial of 108 children (2-12 years of age) with severe amblyopia (from strabismus) which compared the efficacy of combining patch plus atropine treatment (to patching alone) it appears that while improvement in vision occurs with both forms of treatment, the improvement with CAPT appears greater.


See related video HERE and below:
Masks use and ventilation improvements to reduce COVID-19 incidence in Elementary schools (Georgia, November 19-December 11 2020)
Debate continues regarding the best strategies (if any!) to prevent spread of SARS-CoV-2 in children attending school.

From an imperfect study of SARS-CoV-2 transmission in children (<12 years of age) from kindergarten to Grade 5, it appears that COVID-19 incidence is 37% lower in schools requiring teachers and staff members to use masks and 39% lower in schools with improved ventilation (a 21% lower incidence in schools that required mask use among students was not statistically different to those schools were masks were optional).
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From the Editor

It appears to me that we in the USA have entered a new phase in the ongoing Covid-19 pandemic. While some states appear to have the case/hospitalization and death rates under control, a number continue to report spread with children & young adults being the predominant groups requiring hospitalization (fortunately deaths remain relatively few).       

While vaccination against SARS-Cov-2 certainly appears to be of great value in preventing spread and protecting the population, recent data from Israel suggests that it’s efficacy is significantly less than previously thought (~ 64% vs 95%). In addition, and equally concerning, the Delta (and Delta Plus) mutation, now the predominant variant in the USA, and a new spike protein mutation labeled Lambda by the WHO, presently circulating in South America, are all believed to be not only significantly more infectious but also more successful in evading vaccine immunity. A booster vaccine dose requirement now seems quite likely.

A recent interesting modeling article looks at what has been a very successful system in minimizing the pandemic. In Taiwan the focus on containing the pandemic has been primarily on public health measures (vs. vaccination) e.g. face masks, social distancing and hand sanitation, with great benefit to all. (The CDC still recommends the wearing of face masks!)

It appears that success against SARS-Cov-2 infection is possible and we’ve known how to achieve it for some time! It’s a combination of vaccination, with distances between us, in our hands (pardon the pun!) and on our faces!

Vaccinate and take care.

Jack Wolfsdorf, MD
Editor in Chief
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