Paediatric inflammatory multisystem syndrome in Canada: population-based surveillance and role of SARS-CoV-2 linkage.

BACKGROUND: Paediatric inflammatory multisystem syndrome (PIMS) is a rare condition temporally associated with SARS-CoV-2 infection. Using national surveillance data, we compare presenting features and outcomes among children hospitalized with PIMS by SARS-CoV-2 linkage, and identify risk factors for intensive care (ICU). METHODS: Cases were reported to the Canadian Paediatric Surveillance Program by a network of >2800 pediatricians between March 2020 and May 2021. Patients with positive versus negative SARS-CoV-2 linkages were compared, with positive linkage defined as any positive molecular or serologic test or close contact with confirmed COVID-19. ICU risk factors were identified with multivariable modified Poisson regression. RESULTS: We identified 406 children hospitalized with PIMS, including 49.8% with positive SARS-CoV-2 linkages, 26.1% with negative linkages, and 24.1% with unknown linkages. The median age was 5.4 years (IQR 2.5-9.8), 60% were male, and 83% had no comorbidities. Compared to cases with negative linkages, children with positive linkages experienced more cardiac involvement (58.8% vs. 37.4%; p < 0.001), gastrointestinal symptoms (88.6% vs. 63.2%; p < 0.001), and shock (60.9% vs. 16.0%; p < 0.001). Children aged ≥6 years and those with positive linkages were more likely to require ICU. CONCLUSIONS: Although rare, 30% of PIMS hospitalizations required ICU or respiratory/hemodynamic support, particularly those with positive SARS-CoV-2 linkages. IMPACT: We describe 406 children hospitalized with paediatric inflammatory multisystem syndrome (PIMS) using nationwide surveillance data, the largest study of PIMS in Canada to date. Our surveillance case definition of PIMS did not require a history of SARS-CoV-2 exposure, and we therefore describe associations of SARS-CoV-2 linkages on clinical features and outcomes of children with PIMS. Children with positive SARS-CoV-2 linkages were older, had more gastrointestinal and cardiac involvement, and hyperinflammatory laboratory picture. Although PIMS is rare, one-third required admission to intensive care, with the greatest risk amongst those aged ≥6 years and those with a SARS-CoV-2 linkage.

Differentiation of Multi-system Inflammatory Syndrome Associated with COVID-19 Versus Kawasaki Disease Using Cardiac Biomarkers.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) after COVID-19 shares clinical similarities to Kawasaki disease (KD). We sought to determine whether cardiac biomarker levels differentiate MIS-C from KD and their association with cardiac involvement. METHODS: Subjects included 38 MIS-C patients with confirmed prior CoVID-19 and 32 pre-pandemic and 38 contemporaneous KD patients with no evidence of COVID-19. Patient, clinical, echocardiographic, electrocardiographic and laboratory data timed within 72 hours of cardiac biomarker assessment were abstracted. Groups were compared, and regression analyses were used to determine associations between biomarker levels, diagnosis and cardiac involvement, adjusting for clinical factors. RESULTS: MIS-C patients had fewer KD clinical features, with more frequent shock, ICU admission, inotrope requirement, and ventricular dysfunction, with no difference regarding coronary artery involvement. Multivariable regression analysis showed that both higher N-terminal pro-B-type natriuretic peptide (NTproBNP) and cardiac troponin I (TnI) were associated with MIS-C versus KD, after adjusting for significant covariates. Receiver operating characteristic curves for diagnosis showed that any detectable TnI greater than 10 ng/L was predictive of MIS-C versus KD with 91% sensitivity and 76% specificity. NTproBNP >2000 ng/L predicted MIS-C versus KD with 82% sensitivity and 82% specificity. Higher TnI but not NTproBNP was associated with lower LV ejection fraction; neither biomarker was associated with coronary artery involvement. CONCLUSIONS: Positive TnI and higher NTproBNP may differentiate MIS-C from KD, which may become more relevant as evidence of prior COVID-19 becomes more challenging to determine. Cardiac biomarkers may have limited associations with cardiac involvement in this setting.

Demographic and Outcome Characteristics of Children Hospitalized with Acute COVID-19 versus Multisystem Inflammatory Syndrome in Children in Canada (preprint)

Direct comparisons of pediatric hospitalizations for acute COVID-19 and multisystem inflammatory syndrome in children (MIS-C) can inform health system planning. While there were more hospitalizations and deaths from acute COVID-19 amongst Canadian children between March 2020-May 2021, MIS-C cases were more severe, requiring more intensive care and vasopressor support.

American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 3.

OBJECTIVE: To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of SARS-CoV-2 infection. Recommendations are also provided for children with hyperinflammation during COVID-19, the acute, infectious phase of SARS-CoV-2 infection. METHODS: The Task Force is composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting. RESULTS: The guidance was approved in June 2020 and updated in November 2020 and October 2021, and consists of 41 final guidance statements accompanied by flow diagrams depicting the diagnostic pathway for MIS-C and recommendations for initial immunomodulatory treatment of MIS-C. CONCLUSION: Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.

Knowing me, knowing you: Humanitas in work-integrated learning during adversity

Work-Integrated Learning (WIL) is a variety of learning opportunities that can extend beyond the application of theory to practice, to include complex situational, personal, material, and organisational factors. Central to forming successful WIL experiences is the partnership, support, and collaboration extended by all key stakeholders. The Covid-19 pandemic disrupted WIL experiences, with many developed partnerships and sustained practices being abruptly impacted. In 2020, a multidisciplinary group of Australasian WIL academics, administrators and students joined in weekly virtual coffee chats to share concerns and experiences during this rapidly changing educational landscape. These conversations led to establishing a Small Significant Online Network Group (SSONG) and became the basis for this article. We explored the lessons learned from WIL practitioners to be better informed of the practice of WIL and, generally, to examine the role of collaborations in higher education. Using a collaborative autoethnographic approach, this study incorporated written reflections on WIL experiences during COVID-19 lockdowns, followed by Zoom conversations to gain deeper insights. All data was aggregated and analysed thematically, both inductively and deductively, to interpret the practice experiences of individuals in their socio-cultural contexts. This article intends to demonstrate how creative solutions, such as adopting a HUMANE framework, become valuable paradigms. These enhance and nurture relationships between all WIL stakeholders, to enrich and sustain WIL experiences for all. Practitioner Notes 1. Successful WIL relationships rely on collaboration between all stakeholders to ensure sustainability. 2. Adopting a humanistic approach, in this case, the HUMANE framework, has positive outcomes for WIL stakeholders and higher education. 3. A SSONG is an effective mechanism for supporting collaboration in any educational context facing disruption. 4. Technology enables WIL stakeholders to connect globally, and through these connections, reflect on differing experiences to broaden creative responses to challenges. 5. The power of connecting and collaborating provides opportunities to work together and enhances agency, performance, and outcomes that benefit WIL and higher education. © 2021, University of Wollongong. All rights reserved.

Comparing Apples to Apples in Post-COVID-Associated Multisystem Inflammatory Syndrome in Children (MIS-C) (preprint)

Background: The full clinical continuum of post-COVID-associated multisystem inflammatory syndrome of childhood (MIS-C)/Paediatric Inflammatory Multi-system Syndrome (PIMS) is still being defined, with different names and case definitions continuing to be used across jurisdictions. Refinement of criteria and better stratification of affected children will facilitate international collaborations towards improving health outcomes. Our objective is to describe the clinical characteristics and outcomes of children with MIS-C/PIMS stratified by case definition and clinical phenotype.Methods: Prospective study of 137 multi-ethnic hospitalized patients with presumed MIS-C, at a tertiary care pediatric centre in Toronto, Canada from March 2020 to February 2021. Clinical and laboratory features at presentation, organ system complications, therapeutic management, and outcomes were captured. Descriptive statistics were performed to assess differences between case definitions and clinical phenotype.Findings: The most striking differences between the case definitions were reflected in measures of disease severity and outcomes, with the MIS-C classifications capturing the more severe end of the hyperinflammatory spectrum compared to PIMS. Children in the MIS-C group were older and had more cardiac abnormalities and macrophage activation syndrome, which were reflected in more intensive care admission and corticosteroid therapy. Comparisons of clinical phenotypes (shock, Kawasaki Disease, and fever with hyperinflammation) and COVID exposure demonstrate similar clinical features, disease severity and outcomes.Interpretation: Case definition had the greatest impact on measures of disease severity, course, and outcome. Stratification by known disease phenotype led to homogeneous groupings of patients regardless of SARS-CoV-2 exposure status, confirming that recognition of known clinical entities can guide case recognition, classification and management, with our data supporting the notion that KD and MIS-C both fit on the same disease spectrum. The use of a common case definition is needed to ensure comparability in studies among international networks, reliability of public health surveillance data, and proper case ascertainment.Funding: None to declare. Declaration of Interest: None to declare. Ethical Approval: These studies were approved by the institutional Research Ethics Board, and the requirement for individual consent was waived.

American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 2.

OBJECTIVE: To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Recommendations are also provided for children with hyperinflammation during coronavirus disease 2019 (COVID-19), the acute, infectious phase of SARS-CoV-2 infection. METHODS: The Task Force was composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting. RESULTS: The first version of the guidance was approved in June 2020, and consisted of 40 final guidance statements accompanied by a flow diagram depicting the diagnostic pathway for MIS-C. The document was revised in November 2020, and a new flow diagram with recommendations for initial immunomodulatory treatment of MIS-C was added. CONCLUSION: Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.

GoodWIL placements: How COVID-19 shifts the conversation about unpaid placements

This paper discusses how the COVID-19 pandemic can shift the conversation of paid and unpaid placements from an economic to a pedagogical and goodwill perspective. During the pandemic lockdown many placements were cancelled or postponed. Some continued as agreed but with students working from home, while other placements became unpaid. We build on the pertinent literature that raises legal, ethical, economic and pedagogical implications of paid versus unpaid placement models and what motivates placement organizations to offer placements. Four interdisciplinary trans-Tasman case studies are discussed to better understand the complex situations for placement organizations and universities to sustain WIL placements during this pandemic. Conclusions include recommendations to be vigilant and ensure goodwill is not used to mask the exploitation of students, but rather, positively influence the motivation behind offering placements during these trying times and beyond. © 2020 International Journal of Work-Integrated Learning. All rights reserved.

American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 1.

OBJECTIVE: To provide guidance on the management of multisystem inflammatory syndrome in children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and to provide recommendations for children with hyperinflammation during coronavirus disease 2019 (COVID-19), the acute, infectious phase of SARS-CoV-2 infection. METHODS: A multidisciplinary task force was convened by the American College of Rheumatology (ACR) to provide guidance on the management of MIS-C associated with SARS-CoV-2 and hyperinflammation in COVID-19. The task force was composed of 9 pediatric rheumatologists, 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved 2 rounds of anonymous voting and 2 webinars. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate), and consensus was rated as low, moderate, or high based on dispersion of the votes along the numeric scale. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, as prespecified prior to voting. RESULTS: The ACR task force approved a total of 128 guidance statements addressing the management of MIS-C and hyperinflammation in pediatric COVID-19. These statements were refined into 40 final clinical guidance statements, accompanied by a flow diagram depicting the diagnostic pathway for MIS-C. CONCLUSION: Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. The guidance provided in this "living document" reflects currently available evidence, coupled with expert opinion, and will be revised as further evidence becomes available.