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Schöbi N, Sanchez C, Welzel T, Bamford A, Webb K, Rojo P, Tremoulet A, Atkinson A, Schlapbach LJ, Bielicki JA. Swissped-RECOVERY: masked independent adjudication for the interpretation of non-randomised treatment in a two-arm open-label randomised controlled trial (methylprednisolone vs immunoglobulins) in Paediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 (PIMS-TS) involving 10 secondary and tertiary paediatric hospitals in Switzerland. BMJ Open 2024; 14:e078137. [PMID: 38670610 PMCID: PMC11057320 DOI: 10.1136/bmjopen-2023-078137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVES In trials of acute severe infections or inflammations frequent administration of non-randomised treatment (ie, intercurrent event) in response to clinical events is expected. These events may affect the interpretation of trial findings. Swissped-RECOVERY was set up as one of the first randomised controlled trials worldwide, investigating the comparative effectiveness of anti-inflammatory treatment with intravenous methylprednisolone or intravenous immunoglobulins in children and adolescents with Paediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 (PIMS-TS). We present one approach towards improving the interpretation of non-randomised treatment in a randomised controlled trial. DESIGN This is a pre-planned ancillary analysis of the Swissped-RECOVERY trial, a randomised multicentre open-label two-arm trial. SETTING 10 Swiss paediatric hospitals (secondary and tertiary care) participated. PARTICIPANTS Paediatric patients hospitalised with PIMS-TS. INTERVENTIONS All patient-first intercurrent events, if applicable, were presented to an independent adjudication committee consisting of four international paediatric COVID-19 experts to provide independent clinical adjudication to a set of standardised questions relating to whether additional non-randomised treatments were clinically indicated and disease classification at the time of the intercurrent event. RESULTS Of 41 treatments in 75 participants (24/41 (59%) and 17/41 (41%) in the intravenous methylprednisolone and immunoglobulin arms of the trial, respectively), two-thirds were considered indicated. The most common treatment (oral glucocorticoids, 14/41, 35%) was mostly considered not indicated (11/14, 79%), although in line with local guidelines. Intercurrent events among patients with Shock-like PIMS-TS at baseline were mostly considered indicated. A significant proportion of patients with undifferentiated PIMS-TS at baseline were not attributed to the same group at the time of the intercurrent event (6/12 unchanged, 4/12 Kawasaki disease-like, 2/12 Shock-like). CONCLUSION The masked adjudication of intercurrent events contributes to the interpretation of results in open-label trials and should be incorporated in the future. TRIAL REGISTRATION NUMBERS SNCTP000004720 and NCT04826588.
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Affiliation(s)
- Nina Schöbi
- Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carlos Sanchez
- Paediatric Research Centre, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Tatjana Welzel
- Paediatric Research Centre, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Pediatric Rheumatology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Alasdair Bamford
- Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Kate Webb
- Division of Paediatric Rheumatology, School of Child and Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Pablo Rojo
- Pediatrics, Hospital Universitario Doce de Octubre. Universidad Complutense. Instituto de Investigación 12 Octubre, Madrid, Spain
| | - Adriana Tremoulet
- Paediatrics, University of California San Diego, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Andrew Atkinson
- Paediatric Research Centre, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, St Louis, Missouri, USA
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatalogy, and Children's Research Center, University Children's Hospital Zürich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Saint Lucia, Queensland, Australia
| | - Julia Anna Bielicki
- Paediatric Research Centre, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Centre for Neonatal and Paediatric Infection, St George's University, London, UK
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Blanchard-Rohner G, Sanchez C, Andre MC, Bressieux-Degueldre S, Grazioli S, Perez MH, Wütz D, Schöbi N, Welzel T, Atkinson A, Schlapbach LJ, Bielicki JA, Trück J. COVID-19 Vaccine Acceptance Among Parents of Children With Multisystem Inflammatory Syndrome in Children. Pediatr Infect Dis J 2024; 43:361-364. [PMID: 38241661 PMCID: PMC10919269 DOI: 10.1097/inf.0000000000004206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 01/21/2024]
Abstract
Data on COVID-19 vaccine acceptability among parents of children with multisystem inflammatory syndrome (MIS-C) are limited. In this cohort of children with MIS-C, enrolled in the Swissped RECOVERY trial (NCT04826588), comparing intravenous immunoglobulins or methylprednisolone, who, in accordance with Swiss guidelines, were recommended for SARS-CoV-2 vaccination, 65% (73/112) of parents reported being vaccinated against SARS-CoV-2 before the MIS-C, while 70% were vaccinated after the MIS-C episode of their child. None of the children were vaccinated before the occurrence of the MIS-C, and only 9% (5/56) received the COVID-19 vaccine after the MIS-C. The predominant barriers to COVID-19 vaccination were concerns over potential side effects and insufficient support from their doctors. This emphasizes the crucial role of health care providers in promoting COVID-19 vaccination among children.
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Affiliation(s)
- Geraldine Blanchard-Rohner
- From the Division of General Pediatrics, Department of Child, Woman and Adolescent Medicine, Pediatric Immunology and Vaccinology Unit, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Carlos Sanchez
- Paediatric Research Centre, University Children’s Hospital Basel, University of Basel, Basel, Swizerland
| | - Maya C. Andre
- Division of Respiratory and Critical Care Medicine, University Children’s Hospital Basel, University of Basel, Basel, Switzerland
- Department of Pediatric Hematology and Oncology, University Children’s Hospital, Eberhard Karls University, Tuebingen, Germany
| | - Sabrina Bressieux-Degueldre
- Department of Women-Mother-Child, Paediatric Cardiology Unit, University Hospital of Lausanne and Lausanne University, Lausanne, Switzerland
| | - Serge Grazioli
- Division of Neonatal and Pediatric Intensive Care, Department of Child, Woman and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marie-Helene Perez
- Department of Women-Mother-Child, Paediatric Intensive and Intermediate Care Units, University Hospital of Lausanne and Lausanne University, Lausanne, Switzerland
| | - Daniela Wütz
- Division of Pediatric Cardiology, Pediatric Heart Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Nina Schöbi
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tatjana Welzel
- Paediatric Research Centre, University Children’s Hospital Basel, University of Basel, Basel, Swizerland
- Division of Pediatric Rheumatology, University Children’s Hospital Basel, University of Basel, Basel, Switzerland
| | - Andrew Atkinson
- Paediatric Research Centre, University Children’s Hospital Basel, University of Basel, Basel, Swizerland
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, Children`s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Paediatric Intensive Care Unit, Child Health Research Centre, Queensland Children’s Hospital, The University of Queensland, Brisbane, Australia
| | - Julia A. Bielicki
- Centre for Neonatal and Paediatric Infection, St George’s University, London, United Kingdom
| | - Johannes Trück
- Divisions of Allergy and Immunology, Children’s Research Center, University Children’s Hospital Zurich, University of Zurich (UZH), Zurich, Switzerland
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Perrier Q, Tuloup V, Chevallier-Brilloit C, Bedouch P, Chanoine S. Polyvalent immunoglobulin use: Issues between good use, economic constraints and shortages over 25 years. Eur J Intern Med 2024:S0953-6205(24)00124-9. [PMID: 38531763 DOI: 10.1016/j.ejim.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Q Perrier
- Univ. Grenoble Alpes, INSERM, LBFA, U1055, Pharmacy department, Grenoble Alpes University Hospital, Grenoble, France.
| | - V Tuloup
- Univ. Grenoble Alpes, Pharmacy department, Grenoble Alpes University Hospital, Grenoble, France
| | - C Chevallier-Brilloit
- Univ. Grenoble Alpes, Pharmacy department, Grenoble Alpes University Hospital, Grenoble, France.
| | - P Bedouch
- Univ. Grenoble Alpes, CNRS, TIMC, IMR5525, Pharmacy department, Grenoble Alpes University Hospital, Grenoble, France
| | - S Chanoine
- Univ. Grenoble Alpes, CNRS, TIMC, IMR5525, Pharmacy department, Grenoble Alpes University Hospital, Grenoble, France
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Andre MC, Sanchez C, Bressieux-Degueldre S, Perez MH, Wütz D, Blanchard-Rohner G, Grazioli S, Schöbi N, Trück J, Welzel T, Atkinson A, Schlapbach LJ, Bielicki J. Cardiac assessment and inflammatory markers in children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV2 (PIMS-TS) treated with methylprednisolone versus intravenous immunoglobulins: 6-month follow-up outcomes of the randomised controlled Swissped RECOVERY trial. EClinicalMedicine 2024; 67:102358. [PMID: 38107550 PMCID: PMC10722439 DOI: 10.1016/j.eclinm.2023.102358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023] Open
Abstract
Background Previous findings from the Swissped RECOVERY trial showed that patients with Pediatric Inflammatory Multisystem Syndrome-Temporally Associated with SARS-CoV-2 (PIMS-TS) who were randomly assigned to intravenous immunoglobulins or methylprednisolone have a comparable length of hospital stay. Here, we report the 6-month follow-up outcomes of cardiac pathologies and normalisation of clinical or laboratory signs of inflammation from this study population. Methods This pre-planned follow-up of patients with PIMS-TS included the Swissped RECOVERY Trial reports on the 6-month outcomes of the cohort after randomisation, with a focus on cardiac, haematological, and biochemical findings. The trial was an investigator-initiated randomised multicentre open-label two-arm trial in children and adolescents hospitalised with PIMS-TS at ten hospitals in Switzerland. Cardiological assessments and laboratory analyses were prospectively collected in the intention-to-treat analysis on pre-defined intervals after hospital discharge. Differences between randomised arms were investigated using Chi-square test for categorical and Wilcoxon test for continuous variables. The trial is registered with the Swiss National Clinical Trials Portal (SNCTP000004720) and ClinicalTrials.gov (NCT04826588). Findings Between May 21, 2021 and April 15, 2022, 75 patients with a median age of 9.1 years (IQR 6.2-12.2) were included in the intention-to-treat population (37 in the methylprednisolone group and 38 in the intravenous immunoglobulin group). During follow-up, the incidence of abnormal left ventricular systolic function, coronary artery aneurysms (CAA), and other signs of inflammation were comparable in both groups. However, we detected cardiac abnormalities with low incidence and a mild degree grade of pathology. CAAs were observed in 2/38 children (5.3%) in the IVIG group and 1/37 children (2.7%) in the methylprednisolone group at 6-month follow-up (difference proportion 0.75; 95% confidence interval (CI) -0.05 to 1.0; p = 0.39). Interpretation Methylprednisolone alone may be an acceptable first-line treatment as left ventricular systolic dysfunction and clinical/laboratory evidence for inflammation quickly resolved in all children. However, our findings need further confirmation through larger studies as our sample size is likely to be of insufficient power to address rare clinically relevant adverse outcomes. Funding NOMIS, Vontobel, and Gaydoul Foundation.
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Affiliation(s)
- Maya C Andre
- Division of Respiratory and Critical Care Medicine, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Department of Pediatric Haematology and Oncology, University Children's Hospital, Eberhard Karls University, Tuebingen, Germany
| | - Carlos Sanchez
- Paediatric Research Centre, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Sabrina Bressieux-Degueldre
- Paediatric Cardiology Unit, Department of Women-Mother-Child, University Hospital of Lausanne and Lausanne University, Lausanne, Switzerland
| | - Marie-Helene Perez
- Paediatric Intensive and Intermediate Care Units, Department of Women-Mother-Child, University Hospital of Lausanne and Lausanne University, Lausanne, Switzerland
| | - Daniela Wütz
- Division of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Geraldine Blanchard-Rohner
- Pediatric Immunology and Vaccinology Unit, Division of General Pediatrics, Department of Child, Woman and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Serge Grazioli
- Division of Neonatal and Pediatric Intensive Care, Department of Child, Woman and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Nina Schöbi
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Trück
- Divisions of Allergy and Immunology and Children's Research Center, University Children's Hospital Zurich, University of Zurich (UZH), Zurich, Switzerland
| | - Tatjana Welzel
- Paediatric Research Centre, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Pediatric Rheumatology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Andrew Atkinson
- Paediatric Research Centre, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Paediatric Intensive Care Unit, Child Health Research Centre, Queensland Children's Hospital, The University of Queensland, Brisbane, Australia
| | - Julia Bielicki
- Paediatric Research Centre, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Centre for Neonatal and Paediatric Infection, St George's University, London, United Kingdom
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Uka A, Bressieux-Degueldre S, Buettcher M, Kottanattu L, Plebani M, Niederer-Loher A, Schöbi N, Hofer M, Tomasini J, Trück J, Villiger R, Wagner N, Wuetz D, Ritz N, Zimmermann P. Cardiac involvement in children with paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS): data from a prospective nationwide surveillance study. Swiss Med Wkly 2023; 153:40092. [PMID: 37852002 DOI: 10.57187/smw.2023.40092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) may occur 4 to 8 weeks after SARS-CoV-2 infection. The acute presentation of PIMS-TS has been well described, but data on longer-term outcomes, particularly cardiac, is scarce. METHODS This prospective nationwide surveillance study included children and adolescents less than 18 years of age who were hospitalised with PIMS-TS in Switzerland between March 2020 and March 2022. Data was collected from all 29 paediatric hospitals through the Swiss Paediatric Surveillance Unit (SPSU) during hospitalisation and approximately six weeks after discharge. The data was analysed after categorising the participants into three groups based on their admission status to the intensive care unit (ICU) (non-ICU, ICU-moderate) and the requirement for invasive ventilatory and/or inotropic support (ICU-severe). RESULTS Overall, 204 children were included of whom 194 (95.1%) had follow-up data recorded. Median age was 9.0 years (interquartile range [IQR] 6.0-11.5) and 142 (69.6%) were male. In total, 105/204 (51.5%) required ICU admission, of whom 55/105 (52.4%) received inotropic support and 14/105 (13.3%) mechanical ventilation (ICU-severe group). Echocardiography was performed in 201/204 (98.5%) children; 132 (64.7%) had a cardiac abnormality including left ventricular systolic dysfunction (73 [36.3%]), a coronary artery abnormality (45 [22.4%]), pericardial effusion (50 [24.9%]) and mitral valve regurgitation (60 [29.9%]). Left ventricular systolic dysfunction was present at admission in 62/201 (30.8%) children and appeared during hospitalisation in 11 (5.5%) children. A coronary artery abnormality was detected at admission in 29/201 (14.2%) children and developed during hospitalisation or at follow-up in 13 (6.5%) and 3 (1.5%) children, respectively. None of the children had left ventricular systolic dysfunction at follow-up, but a coronary abnormality and pericardial effusion were found in 12 (6.6%) and 3 (1.7%) children, respectively. School absenteeism at the time of follow-up was more frequent in children who had been admitted to the ICU (2.5% in the non-ICU group compared to 10.4% and 17.6% in the ICU-moderate and ICU-severe group, respectively) (p = 0.011). CONCLUSION Cardiac complications in children presenting with PIMS-TS are common and may worsen during the hospitalisation. Irrespective of initial severity, resolution of left ventricular systolic dysfunction is observed, often occurring rapidly during the hospitalisation. Most of the coronary artery abnormalities regress; however, some are still present at follow-up, emphasising the need for prolonged cardiac evaluation after PIMS-TS.
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Affiliation(s)
- Anita Uka
- Department of Community Health, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Department Women-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Sabrina Bressieux-Degueldre
- Paediatric Cardiology Unit, Department Women-Mother-Child, University Hospital of Lausanne, Lausanne, Switzerland
| | - Michael Buettcher
- Paediatric Infectious Diseases, Children's Hospital Lucerne, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Department of Health Science and Medicine, University Lucerne, Lucerne, Switzerland
- Paediatric Pharmacology and Pharmacometrics Research Centre, University Children's Hospital Basel, Basel, Switzerland
| | - Lisa Kottanattu
- Clinic of pediatrics, Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Margerita Plebani
- Pediatric Infectious Diseases and Vaccinology Unit, Department Women-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Anita Niederer-Loher
- Divison of Infectious Diseases and Hospital Hygiene, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Nina Schöbi
- Division of Pediatric Infectious Disease, Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Michael Hofer
- Pediatric Immuno-Rheumatology of Western Switzerland, Department Women-Mother-Child, Lausanne University Hospital, Lausanne, and University Hospitals of Geneva, Geneva, Switzerland
| | - Julie Tomasini
- Department of Community Health, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Johannes Trück
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, University of Zurich (UZH), Zurich, Switzerland
| | - Reto Villiger
- Department of Paediatrics, Hospital Center of Biel, Biel, Switzerland
| | - Noémie Wagner
- Department of Paediatrics, Gynaecology and Obstetrics, General Paediatrics Division, Geneva University Hospitals, Geneva, Switzerland
| | - Daniela Wuetz
- Division of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nicole Ritz
- Paediatric Infectious Diseases, Children's Hospital Lucerne, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Mycobacterial and Migrant Health Research, University Children's Hospital Basel and Department for Clinical Research, University of Basel, Basel, Switzerland
- Department of Paediatrics, The University of Melbourne, Australia
| | - Petra Zimmermann
- Department of Community Health, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Department of Paediatrics, The University of Melbourne, Australia
- Department of Paediatrics, Fribourg Hospital, Fribourg, Switzerland
- Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Australia
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Nagem Lopes LP, da Cunha LG, Silva ARO, Land MGP, Fonseca AR, Lopes LC, Lima EC. Multisystem inflammatory syndrome drug treatment in countries with different income profiles: a scoping review. Front Pharmacol 2023; 14:1228986. [PMID: 37680713 PMCID: PMC10481533 DOI: 10.3389/fphar.2023.1228986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023] Open
Abstract
Objective: The purpose of this study was to map and describe the studies that have investigated therapeutic alternatives for the management of paediatric multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. Considering the origin of the studies performed (low-, middle- and high-income countries), a systematic scoping review was conducted with primary studies that reported the use of medications for the treatment of patients with MIS-C. Sources: The searches were performed in MEDLINE, Embase, Lilacs, Epistemonikos, CINAHL, and CENTRAL, in the grey literature (theses and dissertations from CAPES, ProQuest, and PROSPERO) and in clinical trial databases until May 2022. The selection and extraction of studies were performed independently by two reviewers. Summary of the findings: A total of 173 studies were included, most of which were published as case reports or series. No randomized controlled clinical trials (RCTs) were identified. The investigated drugs were immunoglobulins, glucocorticoids, monoclonal antibodies, anticoagulants, and antiplatelet agents. Conclusion: The dosages, when reported, were heterogeneous among the studies. The ethnicity and comorbidity of the participants were poorly reported. Monoclonal antibodies, drugs with higher costs, were mostly described in studies of high-income countries.
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Affiliation(s)
| | | | | | | | - Adriana Rodrigues Fonseca
- Post-Graduate Program in Saúde Materno Infantil, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luciane Cruz Lopes
- Post-Graduate Program in Pharmaceutical Sciences, University of Sorocaba, São Paulo, Brazil
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Ouldali N, Son MBF, McArdle AJ, Vito O, Vaugon E, Belot A, Leblanc C, Murray NL, Patel MM, Levin M, Randolph AG, Angoulvant F. Immunomodulatory Therapy for MIS-C. Pediatrics 2023:e2022061173. [PMID: 37376963 DOI: 10.1542/peds.2022-061173] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 06/29/2023] Open
Abstract
CONTEXT Studies comparing initial therapy for multisystem inflammatory syndrome in children (MIS-C) provided conflicting results. OBJECTIVE To compare outcomes in MIS-C patients treated with intravenous immunoglobulin (IVIG), glucocorticoids, or the combination thereof. DATA SOURCES Medline, Embase, CENTRAL and WOS, from January 2020 to February 2022. STUDY SELECTION Randomized or observational comparative studies including MIS-C patients <21 years. DATA EXTRACTION Two reviewers independently selected studies and obtained individual participant data. The main outcome was cardiovascular dysfunction (CD), defined as left ventricular ejection fraction < 55% or vasopressor requirement ≥ day 2 of initial therapy, analyzed with a propensity score-matched analysis. RESULTS Of 2635 studies identified, 3 nonrandomized cohorts were included. The meta-analysis included 958 children. IVIG plus glucocorticoids group as compared with IVIG alone had improved CD (odds ratio [OR] 0.62 [0.42-0.91]). Glucocorticoids alone group as compared with IVIG alone did not have improved CD (OR 0.57 [0.31-1.05]). Glucocorticoids alone group as compared with IVIG plus glucocorticoids did not have improved CD (OR 0.67 [0.24-1.86]). Secondary analyses found better outcomes associated with IVIG plus glucocorticoids compared with glucocorticoids alone (fever ≥ day 2, need for secondary therapies) and better outcomes associated with glucocorticoids alone compared with IVIG alone (left ventricular ejection fraction < 55% ≥ day 2). LIMITATIONS Nonrandomized nature of included studies. CONCLUSIONS In a meta-analysis of MIS-C patients, IVIG plus glucocorticoids was associated with improved CD compared with IVIG alone. Glucocorticoids alone was not associated with improved CD compared with IVIG alone or IVIG plus glucocorticoids.
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Affiliation(s)
- Naïm Ouldali
- Division of Infectious diseases, Department of Pediatric Infectious Diseases, Sainte Justine University Hospital, University of Montreal, Quebec, Canada
- Infection, Antimicrobials, Modelling, Evolution, Inserm, UMR 1137, Paris University, Paris, France
- Association Clinique et, Thérapeutique Infantile du Val-de-Marne, St Maur-des-Fossés, France
| | - Mary Beth F Son
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Andrew J McArdle
- Section of Pediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, United Kingdom
| | - Ortensia Vito
- Section of Pediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, United Kingdom
| | - Esther Vaugon
- Division of Infectious diseases, Department of Pediatric Infectious Diseases, Sainte Justine University Hospital, University of Montreal, Quebec, Canada
| | - Alexandre Belot
- Hospices Civils de Lyon, Pediatric Nephrology, Rheumatology, Dermatology, Hopital Femme, Mère Enfant, Centre International de Recherche en Infectiologie/INSERM U1111, Bron, France
| | - Claire Leblanc
- Department of General Pediatrics, Pediatric Infectious Disease and Internal Medicine, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université De Paris, Paris, France
| | - Nancy L Murray
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Manish M Patel
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael Levin
- Section of Pediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, United Kingdom
| | - Adrienne G Randolph
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - François Angoulvant
- Department of General Pediatrics, Pediatric Infectious Disease and Internal Medicine, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université De Paris, Paris, France
- Service of Pediatrics, Department Women-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
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8
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Welzel T, Atkinson A, Schöbi N, Andre MC, Bailey DGN, Blanchard-Rohner G, Buettcher M, Grazioli S, Koehler H, Perez MH, Trück J, Vanoni F, Zimmermann P, Sanchez C, Bielicki JA, Schlapbach LJ. Methylprednisolone versus intravenous immunoglobulins in children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS): an open-label, multicentre, randomised trial. Lancet Child Adolesc Health 2023; 7:238-248. [PMID: 36746174 PMCID: PMC9897729 DOI: 10.1016/s2352-4642(23)00020-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/03/2023] [Accepted: 01/13/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The emergence of paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) led to the widespread use of anti-inflammatory treatments in the absence of evidence from randomised controlled trials (RCTs). We aimed to assess the effectiveness of intravenous methylprednisolone compared with intravenous immunoglobulins. METHODS This is an open-label, multicentre, two-arm RCT done at ten hospitals in Switzerland in children younger than 18 years hospitalised with PIMS-TS (defined as age <18 years; fever and biochemical evidence of inflammation, and single or multiorgan dysfunction; microbiologically proven or putative contact with SARS-CoV-2; and exclusion of any other probable disease). Patients were randomly assigned 1:1 to intravenous methylprednisolone (10 mg/kg per day for 3 days) or intravenous immunoglobulins (2 g/kg as a single dose). The primary outcome was length of hospital stay censored at day 28, death, or discharge. Secondary outcomes included proportion and duration of organ support. Analyses were done by intention-to-treat. The study was registered with Swiss National Clinical Trials Portal (SNCTP000004720) and ClinicalTrials.gov (NCT04826588). FINDINGS Between May 21, 2021, and April 15, 2022, 75 patients with a median age of 9·1 years (IQR 6·2-12·2) were included in the intention-to-treat population (37 in the methylprednisolone group and 38 in the intravenous immunoglobulins group). The median length of hospital stay was 6·0 days (IQR 4·0-8·0) in the methylprednisolone group and 6·0 days (IQR 5·0-8·8) in the intravenous immunoglobulins group (estimated effect size -0·037 of the log10 transformed times, 95% CI -0·13 to 0·065, p=0·42). Fewer patients in the methylprednisolone group (ten [27%] of 37) required respiratory support compared with the intravenous immunoglobulin group (21 [55%] of 38, p=0·025). Need and duration of inotropes, admission to intensive care units, cardiac events after baseline, and major bleeding and thrombotic events were not significantly different between the study groups. INTERPRETATION In this RCT, treatment with methylprednisolone in children with PIMS-TS did not significantly affect the length of hospital stay compared with intravenous immunoglobulins. Intravenous methylprednisolone could be an acceptable first-line treatment in children with PIMS-TS. FUNDING NOMIS Foundation, Vontobel Foundation, and Gaydoul Foundation.
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Affiliation(s)
- Tatjana Welzel
- Paediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Pediatric Rheumatology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Andrew Atkinson
- Paediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Nina Schöbi
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maya C Andre
- Division of Respiratory and Critical Care Medicine, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Department of Pediatric Hematology and Oncology, University Children's Hospital, Eberhard Karls University, Tuebingen, Germany
| | - Douggl G N Bailey
- Pediatric and Neonatal Intensive Care Unit, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
| | - Geraldine Blanchard-Rohner
- Pediatric Immunology and Vaccinology Unit, Division of General Pediatrics, Department of Child, Woman and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Michael Buettcher
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Paediatric Infectious Diseases Unit, Department of Pediatrics, Cantonal Hospital Lucerne, Lucerne, Switzerland; Faculty of Health Sciences and Medicine, University Lucerne, Lucerne, Switzerland
| | - Serge Grazioli
- Division of Neonatal and Pediatric Intensive Care, Department of Child, Woman and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Henrik Koehler
- Department of Pediatrics, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Marie-Helene Perez
- Pediatric Intensive Care Unit, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Johannes Trück
- Division of Immunology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Federica Vanoni
- Institute of Pediatrics of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Petra Zimmermann
- Department of Community Health, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland; Department of Paediatrics, Fribourg Hospital, Fribourg, Switzerland; Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Carlos Sanchez
- Paediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Julia A Bielicki
- Paediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Centre for Neonatal and Paediatric Infection, St George's University, London, UK
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.
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