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it was up to me. Okay, folks, that today I'm just gonna chapter get up like pins so we may or may not have heard of, like, pins and put your belly. And it's a section and more voices. So and this is just a new overview. You off the top today, so I'll be reviewing up by the burden of cool that 19, particularly in Children. And I also be providing a review of what pins is well and three and some symptoms. The investigations are abusive treatment. So in terms of Children improve in 19, high relevant is that, well, approximately 1 to 5% off coupon cases are in Children. They ever can't be a bit problematic to accurately. I'm asking it the burden of cool it in Children because the significant proportion of Children are actually asymptomatic and numbers are likely to. Under that present, the tree incidents on case fatality and in Children is 1.3% and but they have a high transmission weird off between 2 to 3. The diagram on the right is a grass just chewing and the cooler burden right. The UK and last year so in terms of Children in Cuba. 19. So, as I mentioned, most Children are asymptomatic or exhibit very marry symptoms. But in the last eight months, there have been a small number of chill Children who have been identified. We develop a significant on severe and inflammatory response. These affected Children have often deteriorated very quickly on the require input from a variety of teams, including pediatric intensive care, infectious diseases, cardiology on rheumatology on the diagram on the right there and congestion, some of the atypical presentations and Children with pins. So what is pens? So pins is a pediatric multi system inflammatory syndrome, which is a succeeded. It was cool in writing. Die around there in the bottom and it's just really to highlight that. And there are multiple definitions of pins, depending on where you are in the world. Um, but it is a medicine. Same condition and pins tends to her want to six weeks after the initial cooper, that 19 infection, which I find very interesting because I initially well, I heard a white pins. Oh, that it would occur the one of the Children present Children presenting in the acute phase of cool, inviting you with deteriorates but this is just a very important point. Two know that's up to six weeks after the initial and infections group in my team come a child and deteriorate it about all these other symptoms. So what assault that pins is is to do with a maladaptive immune response causing approved flammatory steel. So what about the epidemiology? High common? Is it so? And one and five size and cooler positive Children? Progress depends and a lot of the global statistic. So even though it's rare, I saw that actually find me just high corn. It is even the material in the UK they're being three deaths in the last year. Risk factors 4 lbs includes at being co morbidities obesity. Older age. So we'll just move on then to talk about the UK doctor. In terms of penance, this and I brown just use the data that's collect the UK and 20. So the two Children ages, the Children with spends range for 1 to 16 years, with the median age being 11. There was a NuvaRing presentation of meals on some of the Children had couple of days, but not three. So about his pains. Well, it appears to be quite bad, unfortunately, and all of the Children identified as having pins required admission to pick you're hatched. The news all required IV fluid, resuscitation and, importantly, 70% required in the tropics support. What's quite interesting here if you look at the PCR on immunoglobulin results? So if you go back to the previous life, this is that this was worked on the 30th cases. So all of the 30 of cases 24 Children, which put Colin negative on the PCR. So to me, that was very surprising because you thought about, like, the big they be cool, that negative, but he had developed pains. But this comes back to the initial point I needed where the pens come develop up to six weeks after the initial infection. Two Children may no longer be testing positive on the PCR test, but they have had coupon within the last six weeks and have them deteriorated. The blood results tend to be more positive or more accurate in terms old, indicating either current for previous proven 19 infection. But addressing the Children who go on to develop pains. Not all of them were positive. So what's the mechanism in terms of why some Children with cool with going to develop the Spanish severe disease, and we'll again. The timing's about a month after the initial cool, but the majority are negative based on this wall. But positive for the families on this suggests of the illness is mediated by the development of a prior to me, but they rather that direct final and injury. So one of the symptoms of pens and and Children There are a variety of symptoms on the key thing is, remember was it affects multi systems. Two Children also have a persistent temperature. They can have a headache and dry. Six is that there's a new some urological and push. They're often tachycardia, hypotensive. They can have myocarditis or ventricular dysfunction, so pins can affect the cardiac system as well. And also often some. Your group continues involvement and skin changes. Such a rash myalgias with the China I completely off muscle pee and our flu like symptoms. And there's often could be abdominal pian, vomiting or diarrhea on on what we're more likely to see. Improve it. Our associate in school been would be half increased respiratory me. Yet like Oxy, an issue. But interestingly from the data, the three systems that appeared to be affected most on present, often in terms of pins would be the cardiac symptoms. The rash on the abdominal symptoms are not the respiratory symptoms, which would be the ones that we would often to thank God when we think of a Chinese, cool it. So I thought this diagram and this was done by the long Cupid's Kids Federation, like just thought it was really a very effective in demonstrating How you can try to remember what happens is so there are a few things with pains. Okay, so there's the temperature of creating from 30 years, and it's persistent. The inflammatory markers girls and allergies is there is often multi organ dysfunction off, they mention in the previous SATS side, you want to look for symptoms that support your diagnosis, which often then who's on to the T, which is you want to remove some differentials. A swell need to shoot the Damage Street are sort of like those, but we'll come on to those in a moment on then. Also, your colon test is important in terms of your PCR, but also as I mentioned your antibody test. So in terms off pins, and it's just important to be aware there are a few some types of pins. So there's the Risperdal, the subtypes about the Chinese, the call of shorts of breath yet, and they appear to be more likely to be positive in terms of school results, but negative in terms of serum. This is quite a high mortality area of five, and you didn't get a callous a GI disease like pins form on. This is often the child the presents with your lash, your protein use of all. They appear to be negative for the PCR, but positive person serology don't need to remember any of that. In terms of PCR and serology, it's just to be aware, and both are often you school, so another type of pains would be accepted shock or toxic shock like pins. And that's where you get your shot on a cardiac dysfunction. Predominant, these Children are extremely young well from the start, and then the fourth type would be your feet bright on a million Chinese. So this is the child with a high temperature of the easiest inflammatory markers, so it's just to be aware that there are several subtypes of pens that becomes relevant later in terms of treatment. So why does it China with pins progress? Well, unfortunately, it's fairly going who for the first the child off the percents with atypical symptoms. Over a few days, they deteriorate rapidly because of the acute proven phenomenally see it they can also developed pancarditis in Shock doesn't mention before they are ultra card for the after intensive care. So again, often the prevention with that sweet vaccination on social distancing and all those things, but importantly, But I want to catch the child out the yellow arm or at the Red Arrow. But we don't really want to miss anything beyond that point because they deteriorate. It's very quickly. So that's why the the purposes is talk is just to increase our awareness or pins. And to think I signed the box. And if we see on the Children on the whole thing, could just depends. Um, I missing something So this falls are various people and diagram for Mace. So whenever I start to review the pins and biting, and it was very overwhelming, one of the tests that are lysed so they were taxed that Okay, I'm more familiar with the adults, but not Children. I didn't know even higher. But I interpret the results in a child for new contacts for any of these. So, um, a paper was written on published just last year on it. Help to kind of guy. Probably invest to be a potential Children with pins. So they said, Just break it down and keep it simple. So if it's in a very broad shines, I have a blue clinical suspicion. Don't want them out further. Want in a few Bronstein's no obvious source under clinically suspicious, she would do your initial investigations. So those initial investigations include FBT urinating CRP on a lefty's um, based on news results San, you can proceed all into second line investigations, and but if you have a very high clinical suspicion in a normal child, then you do all the investigations up months. But this just helped, really to die or investigations you do in the first instance, and if there was neutrophilia lymphopenia thrombocytopenia on a CRP lies in your initial investigation. So basically, if your initial investigations are normal, then you proceed on to your second line investigations. But if they invest, initial investigations are all normal then it's not likely to depends. So if you see a child on the very well on your height of suspicious pimples, are you doing with your initial investigations, then these other investigations that were suggested to be done they would also be done. It's part of a wider take that pronounced day with the hospital seeing a chest X ray and these Children. We often see patchy infiltrate of changes very similarly to not find in adults ago. And he said, you're very important, particularly in pens, because these Children often have my own card itis valvulitis pericardial effusion. On importantly, that coronary artery died attention, which is really unheard of Children. Abdominal all the signed has also been shown to be useful, and pins and least 10 to commend was more abdominal symptoms, abdominal over signing and you're going to be useful and detecting your cholitis I'll be I can smell that neuropathy ascites down to Pakistan and accolade Um, and they also advised considering a sinking chest. So where do we start in terms of treatment any day you And if we have a known well, child, I'm thinking of like pins. So I suppose just becoming the base experts supportive treatment for any on, well, child in terms of your flare adult easier on the practical surgeon. And then this is the triangle I kind of thought helped to provide us for the free work. So after a substitute, the challenge. But again you do that causes state. And because sometimes you can be on element of heart failure and these Children, and so again, just costs them. Substitute the child, consider IV on together cover. They recommend catheterizing clindamycin. And because this is approved inflammatory stand, it has been linked with quite in opposites of clots. So it husband finds to consider happen. Aspirin, adult parent in terms of, uh, the coagulation on the inflammatories are also very useful in terms of just stumbling, darling. Lot of inflammatory state of IV steroids are recommended night and in terms of other treatments of beer, biologics, you know, really in any probably wouldn't be starting the biologics and being more of an MD T approach on often these Children where we're thinking that they got pins then warmed, and a UK wide medical trial of the minute that would really be done. And consultations with the AcipHex and so previously I mentioned about the different types off over distorts a little bit rales in terms of treatment. So if it's a respiratory rate, some type or the toxic shock subtype or the food right or inflamed, sometimes basically any type of, uh, in the car, it's active type you treat anyway. I mentioned previously, considering your aspirin years over there every time, progressive, the biologics. But it is a Kawasaki to see some type when you treat us pair of the local color sake disease Perfect. But you won't go wrong if you follow your basic supportive measures. Consultant worsen tickles. So what are the long term I comes for? These Children were fortunate, not truly normal on was the that 70 being connected in that? But they think that there is like basically spiritually icons and also risk thrombosis. These Children are off the amount of credibility for up to six months after the initial pens response. Cardiac comes and have been a big cancer, and these Children on there often monitored and with four weekly scans, and then you've got to consider really this long cooler, which is something to be aware of because that that has been she wanted. Fact Children, too. So we are at the end off that listens stopped her in terms of pin suggested see, and I haven't been told to sleep. I thought I would ask a few medium question the way that hard and in terms of which of the following are true you regarding the epidemiology off pins so you can select more than one answer. So there's a slight female predominant. So if you think that's true or false, you have anything like that and be in groups are more commonly affected. So that's something to think about it on Cases have been identified and Children as young as three months of age. So what do you think? Do you think is tree or false? Any ideas? Fantastic, Sharon. That's clear. So, yeah, so in turn, is actually and more common and meals, I'll just Well, we get it for me nationally. Yep, so that's that's yet. So there's a slight air predominant and meals. Actually, it is more common in the being grip on cases have been a dent. If I'd in Children as young as three months of it. So then the next final question to worry. So which of the following is true regarding investigations for pens? And this was just one of the things I wanted. To be sure that is, the taking message to the first line investigation should include Ferritin D dimer on triple Lumen. So if you think that's true or false, we're gonna have you thought about that one. And negative Cool and antibody tests excludes a diagnosis of pins. But that's true or false on then site online investigations should only be performed at the initial investigations show. Significant abnormality. So what do you think? There's not anybody any ideas? So in terms of the first line investigations, and what do you think? So at what did that show give you? The answer a little bit, but I was born in the wrong direction and pen of fiber. And so which of the following this tree. So the first line investigation should include bad on the diamond report, and that's false because I think that before we don't always know how to interpret the results in Children who don't want to do those as a first line investigation. I'm not sure. Ah, 100% sure on the insurance is pins because we'll create a problem. So next one negative source and antibody excludes pins. That's false because we have sure that Children comport can be PCR. Calls with the pins can be antibody positive, but PCR negative developed pins on weirdly Children can be both negative and developments. So it's a little bit of a mystery free and then, in terms of the second line investigations on that street. So you only one you want to send my investigations if you have normal is in first. So thank you for this one. I will have any questions.