Procedures for the conduct, content and format of eular/pres pediatric musculoskeletal ultrasound courses

Introduction: Recently several Pediatric Musculoskeletal ultrasound (PedMSUS) courses have been held. However, content, conduct and format of PedMSUS courses have never been internationally agreed. Objectives: To produce practical and educational recommendations for the conduct, content and format of EULAR/PReS PedMSUS courses. Methods: The project consisted of a joined EULAR/PReS effort and was conducted in two separate phases. 1.Through a systematic literature review, including extensive search on websites and networks on educational projects/events regarding PedMSUS, a list of potential items for the content, conduct and format of basic, intermediate, advanced courses and Teach-The-Theachers (TTT) Ped- MSUS courses, respectively, was identified. Through two Delphi processes, a panel of experts (project Taskforce) found agreement on the items to be considered for each PedMSUS level of competency. 2. Consensus on the proposed items was reached among a broader group of physicians and health care professionals with interest in pedMSUS and/or involved in previous EULAR/PReS MSUS educational events (Consensus Group). Agreement or consensus was achieved on each topic if selected by at least 75% of the participants. Results: Twenty-two out of 24 (92%) Taskforce members participated to the I Delphi-round, whereas 18/22 (82%) to the II round;45/114 (39%) members of the Consensus Group answered the consensus survey. Agreement and consensus were reached on: format of threelevel education model (basic, intermediate and advanced);courses placed prior to the annual PReS and EULAR or joined EULAR/PReS congresses;distribution between theoretical and practical part of 50%-50% for basic courses and 40%-60% for intermediate courses;a maximum of 4 participants per teacher in practical sessions;models at the basic courses should be represented by healthy children, whereas they should patients for intermediate and advanced courses;courses could be attended with by Pediatric Rheumatologists, Adult Rheumatologists and Radiologists;Faculty members/tutors should fulfil prerequisites and should have successfully attended EULAR MSUS TTT courses;TTT courses should be held just prior to the EULAR congress and linked to the EULAR/PReS PedMSUS course;the theoretical part should include how to prepare and deliver educational material, how to organize a PedMSUS course and how to conduct a practical session;practical and theoretical part in TTT should respectively cover 50% of the course;a certificate of attendance and a certificate of successful competency assessment should be provided for all the levels of competency. Conclusion: Shared EULAR/PReS procedures for the conduct, content and format of PedMSUS basic, intermediate, advanced and TTT courses were identified and will allow homogeneous and high-level educational events on PedMSUS under EULAR/PReS umbrella. The potential impact of the COVID-19 pandemia, that spread in the meaningwhile, could not be investigated and may deserve additional insights.

Clinical features and laboratory findings of multisystem inflammatory syndrome in children (MIS-C)

Introduction: Children mostly have mild or asymptomatic forms of SARS-CoV-2 infection, but during pandemic a higher incidence of Kawasaki disease, Kawasaki-like syndrome and the emergence of a new clinical entity, multisystem inflammatory post-covid syndrome (MIS-C) has also been observed. Objectives: The aim of this study is to determine clinical features and laboratory findings in patients with MIS-C. Methods: Retrospective analysis of clinical features and laboratory findings of MIS-C patients treated at our tertiary referal center (Clinic of Pediatric, University Clinical Centre Nis, Serbia). Results: From 18th of March 2020 till 30st of April 2021 there were 10 patients diagnosed as MIS-C according to CDC criteria. Eight patients were male and two were female. Patients age was 2 to 13 years (average 7.9 years, median 7 years). All patients had SARS -CoV-2 N-protein IgG antibodies but without history of disease symptoms and had positive contact four weeks prior to the onset of MIS-C symptoms. First symptom of MIS-C was fever (over 38C) which lasted in average for 4.4 days (3-7 days). Muco-cutaneous and gastrointestinal manifestations were most common. All patients had bulbar conjuctivitis, rash was present in 8 patients (80%), hand/foot oedema in 6 cases (60%), anterior cervical lymphadenopathy and cheliitis in 4 cases (40%) and periobital oedema in one case (details presented in Table 1. Clinical features of MIS-C patients). Nine patients (90%) presented with gastrointestinal symptoms while nervous system was affected in 5 patients. Three patients developed heart insuffitiency and one patient developed early signs of right coronary arthery aneurism. All patients had elevated inflammatory markers. Complete blood count showed elevated levels of white blood cells in 9 patients. Hypoalbuminemia and hypoproteinemia, low levels of serum potassium and sodium were present during ten days after the onset of symptoms. Troponines were elevated in 4 cases, proBNP in 5 cases. Abdominal ultrasound was performed and 6 patients presented with hepatoplenomegaly, 3 with enlarged spleen, one with enlagred liver and 4 had ascites. All patients were treated with combination of two antibiotics till cultures were proven negative, corticosteroid therapy and antiaggregation therapy. Three patients received a IVIG in a single dose (2gr/kg). All patients had good response to corticosteroid therapy (2mg/kg). Corticosteroid therapy was continued for four weeks (tapering). Conclusion: MIS-C can be a life-threatening condition in children. Early diagnosis and timely adequate treatment are of paramount importance. In children less than 5 years of age, the distinction between Kawasaki (Kawasaki shock) syndrome and MIS-C might be difficult, influencing the decision to use IVIG or steroids alone.

Kawasaki-like syndrome associated with COVID-19: clinical characteristics of mild to moderate forms of a disease

Introduction: In setting of global pandemic of coronavirus disease 19 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), cases resembling Kawasaki disease (KD) were repeatedly reported. Soon afterwards it began to be considered as separate entity named multisystem inflammatory syndrome in children (MIS-C). In addition to this newly recognized syndrome which has overlapping features with KD and is still occasionally described as its from, during COVID-19, a high incidence of Kawasaki-like syndrome (KLS) with mild to moderate symptoms was also noted. Recently, it was proposed that even such cases should, in clinical context, be treated as MIS-C if appropriate criteria are met. On the other hand, clear distinction of the two entities can help researchers to answer the question of its etiology and pathogenesis and could direct the clinicians what to expect during the course of the disease. Objectives: The aim was to describe main epidemiologic and clinical characteristics of KLS during the first year of COVID-19 pandemic. Methods: This retrospective study included analysis of medical documentation of patients treated for KLS at Clinic of Pediatrics, University Clinical Center Niš, between March 2020 and 2021. Inclusion criteria was fulfillment of KD or KLS criteria, based on CDC1 or WHO2 recommendation. Severe form of the disease with signs of a shock was exclusion criteria. The results were elaborated with the statistical method of descriptive and quantitative analysis. Results: A total of 21 subjects fulfilled the criteria for KLS during the study period. The cumulative incidence was 8.48 per 105 minors. Male to female ratio was 2:1 and mean age at diagnosis was 6.5 years (min. 8 months;max. 17 years). In fourteen cases current or recent COVID-19 infection or confirmed COVID-19 exposure was observed. When only these patients are analyzed average age was 8.2 years. Antibodies against SARS-CoV-2 were confirmed in seven patients, three had positive PCR test for COVID-19 and one had close contact with someone who has COVID-19 but COVID-19 was not proved. Interestingly, three patients that were antigen positive had respiratory organ involvement. In the reaming seven cases all the other possible causes of symptoms were ruled out and possible contact with SARS-CoV-2 was assumed. In addition to prolonged fever, that was present in all patients, polymorphous rash (95%) was the most common clinical feature flowed by bilateral nonpurulent conjunctivitis (47%). Gastrointestinal tract involvement was the most common internal organ manifestation. Treatment included corticosteroids (15 patients), intravenous immunoglobulin (1 patient) and two patients received nonsteroidal anti-inflammatory drug in anti-inflammatory dose, while the rest were only treated symptomatically. Favorable outcome was achieved in all patients with no morphological changes observed on echocardiography during the hospitalization and 2 weeks after discharge. Conclusion: Our findings suggest connection between infection and occurrence of the disease in susceptible children. Yet, a large portion of the population had contact with SARS-CoV-2, thus the exact role of infectious agent and pathophysiological mechanisms have to be determined. Gender distribution with male dominance among our patients is expected. Still, average age at diagnosis was bit higher than what is usually observed in classic KD and is more in line with characteristics of MIS-C. Further research are to be done in order to define what determine progression of the disease and are there any signs that may point in which way it will develop. Only in that way the clinicians would made right choices regarding the patients treatment.