Vitamin D status of children with paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS).

Coronavirus disease 2019 (COVID-19) has caused mild illness in children, until the emergence of the novel hyperinflammatory condition paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS). PIMS-TS is thought to be a post-SARS-CoV-2 immune dysregulation with excessive inflammatory cytokine release. We studied 25 hydroxyvitamin D (25OHD) concentrations in children with PIMS-TS, admitted to a tertiary paediatric hospital in the UK, due to its postulated role in cytokine regulation and immune response. Eighteen children (median (range) age 8·9 (0·3-14·6) years, male = 10) met the case definition. The majority were of Black, Asian and Minority Ethnic (BAME) origin (89 %, 16/18). Positive SARS-CoV-2 IgG antibodies were present in 94 % (17/18) and RNA by PCR in 6 % (1/18). Seventy-eight percentage of the cohort were vitamin D deficient (< 30 nmol/l). The mean 25OHD concentration was significantly lower when compared with the population mean from the 2015/16 National Diet and Nutrition Survey (children aged 4-10 years) (24 v. 54 nmol/l (95 % CI -38·6, -19·7); P < 0·001). The paediatric intensive care unit (PICU) group had lower mean 25OHD concentrations compared with the non-PICU group, but this was not statistically significant (19·5 v. 31·9 nmol/l; P = 0·11). The higher susceptibility of BAME children to PIMS-TS and also vitamin D deficiency merits contemplation. Whilst any link between vitamin D deficiency and the severity of COVID-19 and related conditions including PIMS-TS requires further evidence, public health measures to improve vitamin D status of the UK BAME population have been long overdue.

Evaluation of a multidisciplinary team model of care in paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS)

BackgroundCoronavirus disease (COVID-19) pandemic has seen the emergence of a novel paediatric condition Paediatric Inflammatory Multisystem Syndrome Temporally associated with Severe acute respiratory syndrome coronavirus 2 (PIMS-TS). Royal College of Paediatric and Child Health guidance for the management of PIMS-TS recommends early discussion with relevant specialists in a multi-disciplinary team (MDT) setting.A regional MDT panel including representatives from cardiology, general paediatrics, infectious diseases, intensive care, rheumatology, research and pharmacy was established in May 2020 at pace with the evolution of PIMS -TS. Daily clinical decision support was provided using a video conference platform for all regional paediatric units.ObjectivesWe describe the evaluation of the newly configured PIMS-TS MDT, using a mixed-methods survey to capture user experience and feedback.MethodsEvaluation was conducted in July 2020. All users of the MDT service including chairpersons, panel members and referring clinicians were invited to complete the online survey. A 28-point questionnaire based on validated MDT evaluation methodology was developed and included 5 domains relevant to the PIMS-TS MDT: 1. Meeting organisation and process 2. Meeting infrastructure and logistics 3. Clinical decisions 4. Working and culture 5. Meeting feedback.ResultsSurvey response rate was 75%. Results from each domain is as below:Meeting organisation and process: – Users (90%) were aware of referral criteria, referral processes (86%) and MDT configuration including chairperson (90%) and panel members (75%). Majority were not aware (27%) or uncertain (25%) of specific meeting structure and protocols.Infrastructure & logistics: Majority (63%) found accessing videoconference platform straightforward (90%), with only (18%) reporting quality issues. Notably, nearly half the MDT users (49%) reported capacity and time restraints affecting their ability to attend the MDT.Clinical decisions: Clarity of clinical recommendations was acknowledged by majority (90%). Two thirds (65%) were aware of case referral proforma, nonetheless, majority were unsure or not aware of processes around post-MDT documentation in patient records.Working and culture: There was 98% agreement that MDT facilitated constructive discussion, supported learning and research and had positively impacted patient care.Meeting feedback: Rapid access to specialist expertise and complex decision-making support was universally acknowledged. Areas highlighted for improvement pertained to time and capacity constraints limiting participation, and to embed an MDT culture which encouraged inclusive, supportive behaviours and a collaborative team ethos.ConclusionsOur evaluation of the new PIMS-MDT demonstrates the process of agile adaptation to change followed by continuous learning and improvement, required to create efficient healthcare systems. User survey feedback identified excellent practice of achieving region-wide standardised care but also highlighted time and capacity constraints and the importance of fostering a supportive culture, which were subsequently incorporated in developing the MDT processes. Rapid implementation of system-wide changes at unprecedented scale and pace has been the norm during the COVID-19 pandemic, but this must be coupled with iterative cycles of learning and improvement to ensure optimal care.

Paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS) and Vitamin D deficiency

BackgroundCoronavirus disease 2019 (COVID-19), has caused mild illness in children, until the emergence of the novel hyperinflammatory condition PIMS-TS: Paediatric Inflammatory Multisystem Syndrome Temporally associated with Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). PIMS-TS is thought to be a post- SARS-CoV-2 immune dysregulation with excessive inflammatory cytokine release.ObjectivesThere has been a long-standing interest in the role of 25 hydroxyvitamin D (25OHD) in cytokine-storm induced critical illnesses due to the premise of its anti-inflammatory actions including regulation of cytokine release. Vitamin D deficiency in critically ill individuals in intensive care has been linked to poor cardiovascular outcome and increased mortality.We report the vitamin D status of children with PIMS-TS admitted to a single tertiary paediatric hospital in the Midlands region of the United Kingdom (U.K).MethodsWe studied 25OHD levels in children admitted to a tertiary paediatric hospital in the U.K., fulfilling the case definition of PIMS-TS detailed by the Royal College of Paediatrics and Child Health. Children were managed either on paediatric intensive care unit (PICU group) or on the wards (non-PICU group). 25OHD concentrations were measured by quantitative liquid chromatography tandem mass spectrometry. Statistical analysis used a two-sample t-test, assuming unequal variances.ResultsFifty children [median (range) age 8.8 (0.99 to 14.6) years, male = 24] met the case definition. The majority were of Black, Asian and Minority Ethnic (BAME) origin [78%, 39/50]. SARS-CoV-2 IgG antibodies were confirmed in 64% (32/50) and SARS-CoV-2 RNA detected by PCR in 6% (3/50) of the study population. Of those patients without serology or PCR data available, the majority had a confirmed Covid 19 positive contact.Eighty-two percent of the cohort were vitamin D deficient (<30nmol/L). The mean 25OHD concentration was significantly lower when compared to the population mean from the 2015/16 National Diet and Nutrition Survey, a cohort of healthy children with no medical conditions, aged 4–10 years [22 vs 54nmol/L (95% CI: 15.9, 24.1);p<0.001]. Children from BAME backgrounds had reduced vitamin D levels compared to children from a white background [mean 25OHD concentration 17.7 vs 28.2;p=0.12]. The PICU group had lower mean 25OHD concentrations compared to the non-PICU group, although this was not statistically significant [16.9 vs 28 nmol/L;p=0.071].ConclusionsPIMS-TS has seen an over-representation of children from BAME background, who are also at greatest risk of vitamin D deficiency. Whilst any link between vitamin D deficiency and the severity of COVID-19 and related conditions, including PIMS-TS, requires further evidence, public health measures to improve vitamin D status of the U.K BAME population has been long overdue. Given the safety profile of vitamin D supplementation and the over-representation of BAME individuals with vitamin D deficiency and PIMS-TS, mandated year-round supplementation of all high-risk children should be the way forward.