A regional multidisciplinary team approach from the general paediatric perspective, in a tertiary centre for suspected PIMS-TS

BackgroundAlder Hey Children’s Hospital (AHCH) in Northwest England provides regional specialist services and local general paediatric care. Paediatric multisystem inflammatory syndrome temporally associated with Covid-19 (PIMS-TS) is a new disease entity requiring paediatricians from District General Hospitals (DGHs) to seek advice from a number of specialists. During the first/second peak of the pandemic, patients with suspected PIMS-TS were transferred to AHCH under general paediatricians with subspecialist input.To optimise patient care, during the 3rd peak of the pandemic (January 2021) an efficient virtual multidisciplinary team (MDT) consisting of rheumatology, cardiology, infectious disease and general paediatrics, was created to facilitate discussion of potential PIMS-TS cases. The MDT aimed to coordinate management of patients requiring specialist input, reduce unnecessary transfers whilst ensuring appropriate case management and utilisation of resources.Daily (including weekends) virtual meetings were held to discuss all active referrals including the patient’s lead clinician, with the option of discussion on consecutive days until clinical improvement.ObjectivesTo analyse the cohort discussed at the MDT (January-March 2021), including demographics, outcomes, and need for transfer to AHCH.MethodsAn online referral form using Microsoft SharePoint was distributed to regional DGHs for completion prior to the MDT. Discussion was documented on a database and outcome uploaded to AHCH patient records. These records were reviewed for this study.Results35 patients were referred over the 6 week study period. 14 (44%) were female. 21 referrals came from DGHs (66%), the remainder were internal. Age range was 4 months to 17 years;9.3% <1year, 25% 2–5 years, 40.6% 6–11 years and 25% 12–17 years. At time of discussion, six had a positive covid-19 PCR test and 13 had a confirmed positive household/family contact. PIMS-TS was diagnosed in 7(20%) patients, three of whom were referred from DGHs. One required transfer to AHCH for inotropic support and one for echocardiogram. Two additional transfers to AHCH for surgical opinions were subsequently referred to the MDT. Of the remaining 25 patients (18 from DGHs), four were treated locally for Kawasaki’s disease. 19 of 21 (90.5%) DGH referrals to the MDT (majority without PIMS-TS) avoided unnecessary transfer to AHCH for assessment.ConclusionsThe daily virtual MDT allowed efficient discussion with exchange of expertise and a collaborative approach from several specialties for suspected PIMS-TS cases across the region. It also enabled continuity across multiple discussions about individual cases. It provided the opportunity to discuss differentials in a new disease entity, empower DGH clinicians to start early treatment of PIMS-TS and recruit where appropriate to the RECOVERY trial. Unnecessary transfers were avoided in 90.5% of external cases. General paediatricians are key valued team members as the spectrum of disease and possible differential is wide. This MDT approach promoted the role of the general paediatrician in caring for these patients. Early treatment with a lower threshold to react and escalate has improved patient care. The use of better IT infrastructure helped bridge the gap of care delivery by geography. Feedback from DGH participants in the MDT was positive.

Developmentally appropriate transitional care during the Covid-19 pandemic for young people with juvenile-onset rheumatic and musculoskeletal diseases: the rationale for a position statement.

BACKGROUND: The importance of developmentally appropriate transitional care in young people with juvenile-onset rheumatic and musculoskeletal disease is well recognised. The Paediatric Rheumatology European Society (PReS) / European League Against Rheumatism (EULAR) Taskforce has developed international recommendations and standards for transitional care and a growing evidence base supports the positive benefits of such care. However, there is also evidence that universal implementation has yet to be realised. In 2020, against this background the COVID-19 pandemic arrived with significant impact on all our lives, young and old, patient, public and professional alike. The unfortunate reality of the pandemic with potential for unfavourable outcomes on healthcare provision during transition was acknowledged by the PReS working groups in a position statement to support healthcare professionals, young people and their caregivers. AIM: The aim of this review is to present the literature which provides the rationale for the recommendations in the PReS Position Statement. The following areas are specifically addressed: the prime importance of care coordination; the impact of the pandemic on the various aspects of the transition process; the importance of ensuring continuity of medication supply; the pros and cons of telemedicine with young people; ensuring meaningful involvement of young people in service development and the importance of core adolescent health practices such as routine developmental assessment psychosocial screening and appropriate parental involvement during transitional care.

Presentation, Treatment Response and Short-Term Outcomes in Paediatric Multisystem Inflammatory Syndrome Temporally Associated with SARS-CoV-2 (PIMS-TS).

The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the pathogen responsible for Coronavirus Disease 2019 (COVID-19). Whilst most children and young people develop mild symptoms, recent reports suggest a novel paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). Case definition and classification are preliminary, treatment is empiric and disease-associated outcomes are unclear. Here, we report 29 patients with PIMS-TS who were diagnosed, admitted and treated in the English North West between March and June 2020. Consistent with patterns observed internationally, cases peaked approximately 4 weeks after the initial surge of COVID-19-like symptoms in the UK population. Clinical symptoms included fever (100%), skin rashes (72%), cardiovascular involvement (86%), conjunctivitis (62%) and respiratory involvement (21%). Some patients had clinical features partially resembling Kawasaki disease (KD), toxic shock syndrome and cytokine storm syndrome. Male gender (69%), black, Asian and other minority ethnicities (BAME, 59%) were over-represented. Immune modulating treatment was used in all, including intravenous immunoglobulin (IVIG), corticosteroids and cytokine blockers. Notably, 32% of patients treated with IVIG alone went into remission. The rest required additional treatment, usually corticosteroids, with the exception of two patients who were treated with TNF inhibition and IL-1 blockade, respectively. Another patient received IL-1 inhibition as primary therapy, with associated rapid and sustained remission. Randomized and prospective studies are needed to investigate efficacy and safety of treatment, especially as resources of IVIG may be depleted secondary to high demand during future waves of COVID-19.