Mortality and clinical characteristics of multisystem inflammatory syndrome in children (MIS-C) associated with covid-19 in critically ill patients: an observational multicenter study (MISCO study)

Abstract Background The clinical presentation and severity of Multisystem Inflammatory Syndrome in Children associated with COVID-19 (MIS-C) is widespread and presents a very low mortality rate in high-income countries. This research describes the clinical characteristics of MIS-C in critically ill children in middle-income countries and the factors associated with the rate of mortality and patients with critical outcomes. Methods An observational cohort study was conducted in 14 pediatric intensive care units (PICUs) in Colombia between April 01, 2020, and January 31, 2021. Patient age ranged between one month and 18 years, and each patient met the requirements set forth by the World Health Organization (WHO) for MIS-C. Results There were seventy-eight children in this study. The median age was seven years (IQR 1-11), 18 % (14/78) were under one year old, and 56 % were male. 35 % of patients (29/78) were obese or overweight. The PICU stay per individual was six days (IQR 4-7), and 100 % had a fever upon arrival to the clinic lasting at least five days (IQR 3.7-6). 70 % (55/78) of patients had diarrhea, and 87 % (68/78) had shock or systolic myocardial dysfunction (78 %). Coronary aneurysms were found in 35 % (27/78) of cases, and pericardial effusion was found in 36 %. When compared to existing data in high-income countries, there was a higher mortality rate observed (9 % vs. 1.8 %; p=0.001). When assessing the group of patients that did not survive, a higher frequency of ferritin levels was found, above 500 ngr/mL (100 % vs. 45 %; p=0.012), as well as more cardiovascular complications (100 % vs. 54 %; p = 0.019) when compared to the group that survived. The main treatments received were immunoglobulin (91 %), vasoactive support (76 %), steroids (70.5 %) and antiplatelets (44 %). Conclusions Multisystem Inflammatory Syndrome in Children due to SARS-CoV-2 in critically ill children living in a middle-income country has some clinical, laboratory, and echocardiographic characteristics similar to those described in high-income countries. The observed inflammatory response and cardiovascular involvement were conditions that, added to the later presentation, may explain the higher mortality seen in these children.

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Mortality and Clinical Characteristics of Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 in critically ill patients: an observational multicenter study (MISCO STUDY)

10.21203/rs.3.rs-388266/v1 ◽

2021 ◽

Author(s):

Lorena Acevedo ◽

Byron Enrique Piñeres-Olave ◽

Laura Fernanda Niño-Serna ◽

Liliana Mazillo-Vega ◽

Ivan Jose Ardila Gómez ◽

...

Keyword(s):

Critically Ill ◽

Clinical Characteristics ◽

Clinical Laboratory ◽

Myocardial Dysfunction ◽

Cardiovascular Complications ◽

High Income ◽

Critically Ill Children ◽

Middle Income ◽

One Year ◽

Inflammatory Syndrome

Abstract Background The clinical presentation and severity of Multisystem Inflammatory Syndrome in Children associated with COVID-19 is widespread and presents a very low mortality rate in highincome countries. This research describes the clinical characteristics of MIS-C in critically ill children in middle-income countries compared to described series in high-income countries along with the factors associated with mortality and worse outcomes. Methods An observational cohort study was conducted in 14 PICUs in Colombia between April 01, 2020 and January 31, 2021. Patient´s age ranged between one month and 18 years and they met the requirements set forth by WHO for MIS-C. Results There were seventy-eight children in this study. The median age was seven years (IQR 1- 11), 18% (14/78) were under one year old, and 56% were male. Thirty-five percent (29/78) were obese or overweight. The PICU stay was six days (IQR 4-7), and 100% had a fever on admission lasting five days (IQR 3.7-6). Seventy percent (55/78) had diarrhea, and 87% (68/78) had shock or myocardial dysfunction (78%). Compared to the United Kingdom (UK) study, there were more children under the age of five (37% vs. 10%; p=0.004), and there was a higher frequency of obesity (29.5% vs. 10%; p=0.008). With regard to the US study, there was more lymphadenopathy (23% vs. 13%; p=0.02), diarrhea (70.5% vs. 53%; p=0.001), lymphopenia (64% vs. 35%; p=0.001), shock (87% vs. 35%; p=0.001), elevated troponin (51% vs. 31%; p=0.006) and elevated proBNP (82% vs 43%; p=0.001), as well as greater mortality (9% vs 1.8%; p=0.001). The group that did not survive had a longer duration of the disease until admission to the PICU (6 days vs. 5 days; p = 0.003), more frequency of ferritin above 500 ngr/mL (100% vs. 45%; p = 0.012) and more cardiovascular complications (100% vs. 54%; p = 0.019) compared to the group that survived. Conclusions Multisystem Inflammatory Syndrome in Children due to SARS-CoV-2 in critically ill children living in a middle-income country has some clinical, laboratory, and echocardiographic characteristics similar to those described in high-income countries. It was observed inflammatory response, and cardiovascular involvement were conditions that, added to the difficulties in accessing healthcare systems in countries with limited resources, may explain the higher mortality seen in these children.

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Strain Echocardiography and Myocardial Dysfunction in Critically Ill Children With Multisystem Inflammatory Syndrome Unrecognized by Conventional Echocardiography

Pediatric Critical Care Medicine ◽

10.1097/pcc.0000000000002850 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Sonali Basu ◽

Esther J. Kim ◽

Matthew P. Sharron ◽

Ashley Austin ◽

Murray M. Pollack ◽

...

Keyword(s):

Critically Ill ◽

Myocardial Dysfunction ◽

Critically Ill Children ◽

Inflammatory Syndrome ◽

Conventional Echocardiography ◽

Strain Echocardiography

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542. SARS CoV-2-Associated Multisystem Inflammatory Syndrome of Children (MIS-C) in the Washington DC Metropolitan Region

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.736 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S338-S338

Author(s):

Roberta L DeBiasi ◽

Karen L Smith ◽

Michael Bell ◽

Charles Berul ◽

Emily Ansusinha ◽

...

Keyword(s):

Critically Ill ◽

Medical Condition ◽

Myocardial Dysfunction ◽

Demographic Data ◽

Response To Therapy ◽

Metropolitan Region ◽

Critically Ill Children ◽

Washington Dc ◽

Long Term Outcome ◽

Inflammatory Syndrome

Abstract Background Background: Multi-system Inflammatory Syndrome of Children (MIS-C) has recently emerged internationally as a serious inflammatory complication of SARS-CoV-2 infection with significant morbidity for the pediatric population. Methods This observational retrospective cohort study includes 33 children meeting CDC criteria for MIS-C treated between March 15 and June 17, 2020 at Children’s National Hospital in Washington DC. Clinical and demographic data were extracted from medical records and are summarized. Results Of 33 hospitalized MIS-C patients, 42% were critically ill, and 58% were non-critically ill. The median age was 8.9 years (0.7–18.7 years). More males (58 %) than females (43 %) were represented in the MIS-C cohort. The majority (75%) of children had no underlying medical condition. Criteria for incomplete or complete Kawasaki Disease (KD) were present in 39% of patients, while an additional 9% had some features of KD. However the remaining 52% of MIS-C patients presented with other sub-phenotypes including prominent severe abdominal pain and/or nonspecific multiorgan dysfunction. 30% presented with shock requiring volume and/or inotropic support. SARS-CoV-2 antibodies were present in 61% of patients. Virus was detectable by PCR in 36% of patients. At the time of initial evaluation, 39% (13/33) of children had identified cardiac abnormalities including myocardial dysfunction (5/33; 15%), coronary ectasia (4/33; 12%), coronary aneurysm (3/33; 9%), or pericardial effusion 5/33; 15%) either alone or in combination. Cytokine profiling identified elevation of several cytokines in this cohort, including IL-6. Treatment has included intravenous immunoglobulin, aspirin, anakinra and other immunomodulatory therapies, with overall rapid response to therapy. No deaths have occurred. Conclusion The emergence of MIS-C late in the surge of SARS-CoV-2 circulation in the Washington DC metropolitan region has added to the already significant burden of hospitalized and critically ill children in our region. A significant percentage of these children present with cardiac dysfunction and abnormalities, whether or not with KD features at presentation. Detailed characterization of immune responses and long term outcome of these patients is a priority. Disclosures Andrea Hahn, MD, MS, Johnson and Johnson (Consultant)

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Profile and outcomes of critically ill children in a lower middle-income country

Emergency Medicine Journal ◽

10.1136/emermed-2016-205720 ◽

2017 ◽

Vol 35 (1) ◽

pp. 52-55 ◽

Cited By ~ 3

Author(s):

Muhammad Irfan Habib ◽

Khalid Mehmood A Khan

Keyword(s):

Critically Ill ◽

Respiratory Symptoms ◽

Gastrointestinal Symptoms ◽

Middle Income Country ◽

Income Country ◽

Critically Ill Children ◽

Age Group ◽

Middle Income ◽

Lower Middle Income Country ◽

Level 1

ObjectiveTo determine the clinical profile and outcome of critically ill children presenting to a paediatric ED in a lower middle-income country.MethodsWe performed a retrospective analysis of children (<14 years) presenting to the ED of the National Institute of Child Health, Karachi, between January and December 2014 who were assigned to acuity 1 (requiring immediate life-saving interventions) according to the Emergency Severity Index. Data included demographic variables, presenting complaints, interventions and outcomes in the ED.ResultsThere were 172 162 visits during the year. Of these, 13 551 (8%) were level 1. 64% of level 1 patients were transported to the ED without ambulance service. Neonates (0–28 days) constituted 48% of level 1 children; their most frequent presenting complaints were respiratory symptoms, followed by fever and reluctance to feed. Above the neonatal age group, the most common presenting complaints were gastrointestinal symptoms (with signs of hypoperfusion), followed by seizures, reluctance to feed and respiratory symptoms. 64% of children of >28 days presenting were malnourished. Interventions included cardiopulmonary resuscitation, application of bubble continuous positive airway pressure and endotracheal intubation. Overall mortality was 13%; 63% of all deaths were in the neonatal age group.ConclusionChildren with the highest triage acuity represent 8% of all visits to a paediatric ED. In this group, neonates account for nearly half of all the children, and more than half of all the deaths among critically ill children came in ED. A large proportion of high-acuity children are malnourished.

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Thromboelastography profiles in critically ill children with multisystem inflammatory syndrome

Pediatric Blood & Cancer ◽

10.1002/pbc.29426 ◽

2021 ◽

Author(s):

Kavita Morparia ◽

Philip C. Spinella ◽

Derrick McQueen ◽

Meena Kalyanaraman ◽

Maria Bergel ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Children ◽

Inflammatory Syndrome

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Functional gender differences in autism: An international, multidisciplinary expert survey using the International Classification of Functioning, Disability, and Health model

Autism ◽

10.1177/1362361320975311 ◽

2020 ◽

pp. 136236132097531

Author(s):

Karl Lundin ◽

Soheil Mahdi ◽

Johan Isaksson ◽

Sven Bölte

Keyword(s):

Gender Differences ◽

High Income ◽

International Classification ◽

World Health ◽

International Classification Of Functioning ◽

Disability And Health ◽

Middle Income ◽

The World ◽

Health Organization

Few studies have addressed gender differences in autism in relation to functioning and across cultures. We aimed to explore functional gender differences in autism from a multidisciplinary, global perspective using the International Classification of Functioning, Disability, and Health. Perceptions among professionals in high-income countries and middle-income countries were examined based on qualitative survey data from N = 225 professionals. Of these, n = 131 professionals provided information on functional gender differences in autism. Thirty-two professionals reported perceiving no gender differences. Remaining respondents ( n = 99)—representing 31 countries, all World Health Organization regions, and 10 different professions—were included in a content analysis on functional gender differences, which generated three main categories and 13 subcategories. The subcategories were subsequently linked to International Classification of Functioning, Disability, and Health categories. Autistic males were described as displaying more externalizing behaviors, and females as having more internalizing problems and being more socially motivated. Thirty-two International Classification of Functioning, Disability, and Health categories were identified, of which 31 were covered by the comprehensive Core Set for autism. Gender differences in core symptoms and co-existing problems were acknowledged by professionals from both high-income countries and middle-income countries, while differences in social behaviors, including camouflaging, were more frequently described by experts from high-income countries. Lay abstract In this study, we explored if professionals working with autistic people in different regions of the world perceive differences between females and males diagnosed with the condition. A total of 131 professionals responded to a survey that included an open question about gender differences in autism. Of these, 32 responded that they do not perceive gender differences in autism. The information provided by the other 99 experts was analyzed to identify common patterns. Three main differences were found, (1) Matching the clinical conceptualization of autism where professionals described differences in core symptoms of autism, and that autistic females were less similar to the conceptualization of autism. In (2) Co-existing problems, professionals described that autistic males display more apparent problems including hyperactivity, while autistic females were perceived as having more internalizing issues such as anxiety and eating disorders. In the last category, (3) Navigating the social environment, experts perceived autistic females as more socially motivated, and more inclined to camouflage social difficulties, making their challenges less evident. Professionals also perceived differences in the social environment, for example, that autistic girls receive more support from their peers while autistic boys are more often bullied. Our results suggest that professionals working in different parts of the world acknowledge gender differences in autism, but also that there might be some regional differences. Finally, we found that gender differences reported by the international professionals could largely be assessed with a shortened version of the International Classification of Functioning by the World Health Organization, specifically developed for autism.

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Is the long-term decline in cardiovascular-disease mortality in high-income countries over? Evidence from national vital statistics

International Journal of Epidemiology ◽

10.1093/ije/dyz143 ◽

2019 ◽

Vol 48 (6) ◽

pp. 1815-1823 ◽

Cited By ~ 33

Author(s):

Alan D Lopez ◽

Tim Adair

Keyword(s):

Cardiovascular Disease ◽

Mortality Rate ◽

Vital Statistics ◽

High Income ◽

World Health ◽

Death Rates ◽

Males And Females ◽

Rate Of Decline ◽

Cvd Mortality

Abstract Background The substantial decline in cardiovascular-disease (CVD) mortality in high-income countries has underpinned their increasing longevity over the past half-century. However, recent evidence suggests this long-term decline may have stagnated, and even reversed in younger populations. We assess recent CVD-mortality trends in high-income populations and discuss the findings in relation to trends in risk factors. Methods We used vital statistics since 2000 for 23 high-income countries published in the World Health Organization Mortality Database. Age-standardized CVD death rates by sex for all ages, and at ages 35–74 years, were calculated and smoothed using LOWESS regression. Findings were contrasted with the Global Burden of Disease (GBD) Study. Results The rate of decline in CVD mortality has slowed considerably in most countries in recent years for both males and females, particularly at ages 35–74 years. Based on the latest year of data, the decline in the CVD-mortality rate at ages 35–74 years was <2% (about half the annual average since 2000) for at least one sex in more than half the countries. In North America (US males and females, Canada females), the CVD-mortality rate even increased in the most recent year. The GBD Study estimates, after correcting for misdiagnoses, suggest an even more alarming reversal, with CVD death rates rising in seven countries for at least one sex in 2017. The rate of decline and initial level of CVD mortality appear largely unrelated. Conclusions A significant slowdown in CVD-mortality decline is now apparent across high-income countries with diverse epidemiological environments. High and increasing obesity levels, limited potential future gains from further reducing already low smoking prevalence, especially in English-speaking countries, and persistent inequalities in mortality risk pose significant challenges for public policy to promote better cardiovascular health.

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Monitoring Frameworks for Universal Health Coverage: What About High-Income Countries?

International Journal of Health Policy and Management ◽

10.15171/ijhpm.2019.21 ◽

2019 ◽

Vol 8 (7) ◽

pp. 387-393 ◽

Cited By ~ 3

Author(s):

Nicole Bergen ◽

Arne Ruckert ◽

Ronald Labonté

Keyword(s):

Universal Health Coverage ◽

High Income ◽

World Health ◽

Future Research ◽

Health Coverage ◽

Middle Income ◽

The Sustainable Development ◽

Development Goals ◽

Health Organization ◽

Universal Health

Implementing universal health coverage (UHC) is widely perceived to be central to achieving the Sustainable Development Goals (SDGs), and is a work program priority of the World Health Organization (WHO). Much has already been written about how low- and middle-income countries (LMICs) can monitor progress towards UHC, with various UHC monitoring frameworks available in the literature. However, we suggest that these frameworks are largely irrelevant in high-income contexts and that the international community still needs to develop UHC monitoring framework meaningful for high-income countries (HICs). As a first step, this short communication presents preliminary findings from a literature review and document analysis on how various countries monitor their own progress towards achieving UHC. It furthermore offers considerations to guide meaningful UHC monitoring and reflects on pertinent challenges and tensions to inform future research on UHC implementation in HIC settings.

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Prevalence and Clinical Characteristics of SARS-CoV-2 Confirmed and Negative Kawasaki Disease Patients During the Pandemic in Spain

Frontiers in Pediatrics ◽

10.3389/fped.2020.617039 ◽

2021 ◽

Vol 8 ◽

Author(s):

Elisa Fernández-Cooke ◽

Carlos D. Grasa ◽

Sara Domínguez-Rodríguez ◽

Ana Barrios Tascón ◽

Judith Sánchez-Manubens ◽

...

Keyword(s):

Kawasaki Disease ◽

Clinical Characteristics ◽

Myocardial Dysfunction ◽

Clinical Signs ◽

Pediatric Intensive Care ◽

Terminal Segment ◽

C Reactive Protein ◽

Reactive Protein ◽

Aneurysm Development ◽

Inflammatory Syndrome

Introduction: COVID-19 has a less severe course in children. In April 2020, some children presented with signs of multisystem inflammation with clinical signs overlapping with Kawasaki disease (KD), most of them requiring admission to the pediatric intensive care unit (PICU). This study aimed to describe the prevalence and clinical characteristics of KD SARS-CoV-2 confirmed and negative patients during the pandemic in Spain.Material and Methods: Medical data of KD patients from January 1, 2018 until May 30, 2020 was collected from the KAWA-RACE study group. We compared the KD cases diagnosed during the COVID-19 period (March 1–May 30, 2020) that were either SARS-CoV-2 confirmed (CoV+) or negative (CoV–) to those from the same period during 2018 and 2019 (PreCoV).Results: One hundred and twenty-four cases were collected. There was a significant increase in cases and PICU admissions in 2020 (P-trend = 0.001 and 0.0004, respectively). CoV+ patients were significantly older (7.5 vs. 2.5 yr) and mainly non-Caucasian (64 vs. 29%), had incomplete KD presentation (73 vs. 32%), lower leucocyte (9.5 vs. 15.5 × 109) and platelet count (174 vs. 423 × 109/L), higher inflammatory markers (C-Reactive Protein 18.5vs. 10.9 mg/dl) and terminal segment of the natriuretic atrial peptide (4,766 vs. 505 pg/ml), less aneurysm development (3.8 vs. 11.1%), and more myocardial dysfunction (30.8 vs. 1.6%) than PreCoV patients. Respiratory symptoms were not increased during the COVID-19 period.Conclusion: The KD CoV+ patients mostly meet pediatric inflammatory multisystem syndrome temporally associated with COVID-19/multisystem inflammatory syndrome in children criteria. Whether this is a novel entity or the same disease on different ends of the spectrum is yet to be clarified.

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