Evolution of Cardiovascular Findings in Multisystem Inflammatory Syndrome in Children (MIS-C) Across COVID-19 Variants: Common Trends and Unusual Presentations.

Multisystem inflammatory syndrome in children (MIS-C) is a rare condition following COVID-19 infection. Cardiac involvement is common and includes left ventricular systolic dysfunction, cardiac marker elevation, electrocardiogram (ECG) changes, and coronary artery dilation. This single-center retrospective cohort study compares cardiovascular disease between three major SARS-CoV-2 variants and describes the evolution of findings in medium-term follow-up. Of 69 total children (mean age 9.2 years, 58% male), 60 (87%) had cardiovascular involvement with the most common features being troponin elevation in 33 (47%) and left ventricular dysfunction in 22 (32%). Based on presumed infection timing, 61 patients were sorted into variant cohorts of Alpha, Delta, and Omicron. Hospitalization was longer for the Delta group (7.7 days) vs Alpha (5.1 days, p = 0.0065) and Omicron (4.9 days, p = 0.012). Troponin elevation was more common in Delta compared to Alpha (13/20 vs 7/25, p = 0.18), and cumulative evidence of cardiac injury (echocardiographic abnormality and/or troponin elevation) was more common in Delta (17/20) compared with Alpha (12/25, p = 0.013) or Omicron (8/16, p = 0.034). Forty-nine (77%) of the original cohort (n = 69) had no cardiac symptoms or findings beyond 3 months post-hospitalization. Cardiac MRI was performed in 28 patients (between 3 and 6 months post-hospitalization) and was normal in 25 patients (89%). The differences in the variant cohorts may be due to alteration of the immune landscape with higher severity of COVID-19 infection. Despite overall reassuring cardiac outcomes, it is important to note the variability of presentation and remain vigilant with future variants.

Modular cytosine base editing promotes epigenomic and genomic modifications.

Prokaryotic and eukaryotic adaptive immunity differ considerably. Yet, their fundamental mechanisms of gene editing via Cas9 and activation-induced deaminase (AID), respectively, can be conveniently complimentary. Cas9 is an RNA targeted dual nuclease expressed in several bacterial species. AID is a cytosine deaminase expressed in germinal centre B cells to mediate genomic antibody diversification. AID can also mediate epigenomic reprogramming via active DNA demethylation. It is known that sequence motifs, nucleic acid structures, and associated co-factors affect AID activity. But despite repeated attempts, deciphering AID's intrinsic catalytic activities and harnessing its targeted recruitment to DNA is still intractable. Even recent cytosine base editors are unable to fully recapitulate AID's genomic and epigenomic editing properties. Here, we describe the first instance of a modular AID-based editor that recapitulates the full spectrum of genomic and epigenomic editing activity. Our 'Swiss army knife' toolbox will help better understand AID biology per se as well as improve targeted genomic and epigenomic editing.

Acinetobacter baumannii from Samples of Commercially Reared Turkeys: Genomic Relationships, Antimicrobial and Biocide Susceptibility.

Acinetobacter baumannii is especially known as a cause of nosocomial infections worldwide. It shows intrinsic and acquired resistances to numerous antimicrobial agents, which can render the treatment difficult. In contrast to the situation in human medicine, there are only few studies focusing on A. baumannii among livestock. In this study, we have examined 643 samples from turkeys reared for meat production, including 250 environmental and 393 diagnostic samples, for the presence of A. baumannii. In total, 99 isolates were identified, confirmed to species level via MALDI-TOF-MS and characterised with pulsed-field gel electrophoresis. Antimicrobial and biocide susceptibility was tested by broth microdilution methods. Based on the results, 26 representative isolates were selected and subjected to whole-genome sequencing (WGS). In general, A. baumannii was detected at a very low prevalence, except for a high prevalence of 79.7% in chick-box-papers (n = 118) of one-day-old turkey chicks. The distributions of the minimal inhibitory concentration values were unimodal for the four biocides and for most of the antimicrobial agents tested. WGS revealed 16 Pasteur and 18 Oxford sequence types, including new ones. Core genome MLST highlighted the diversity of most isolates. In conclusion, the isolates detected were highly diverse and still susceptible to many antimicrobial agents.

Thromboprophylaxis for children hospitalized with COVID-19 and MIS-C.

Background: Limited data exist about effective regimens for pharmacological thromboprophylaxis in children with acute coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C). Objectives: Study the outcomes of institutional thromboprophylaxis protocol for primary venous thromboembolism (VTE) prevention in children hospitalized with acute COVID-19/MIS-C. Methods: This single-center retrospective cohort study included consecutive children (aged less than 21 years) with COVID-19/MIS-C who received tailored intensity thromboprophylaxis, primarily with low-molecular-weight heparin, from April 2020 through October 2021. Thromboprophylaxis was given to those with moderate to severe disease based on the World Health Organization scale and exposure to two or more VTE risk factors. Therapeutic intensity was considered for severe illness. Clinical recovery along with D-dimer improvement determined thromboprophylaxis duration. Outcomes were incident VTEs, bleeding, and mortality. Results: Among 211 hospitalizations, 45 (21.3%) received thromboprophylaxis (COVID-19, 16; MIS-C, 29). Median age was 14.8 years (interquartile range [IQR], 8.9-16.1). Among 35 (77.8%) with severe illness, 27 (60.0%) required respiratory support, and 19 (42.2%) required an intensive care unit stay. Median hospitalization was 6 days (IQR, 5.0-10.5). Median thromboprophylaxis duration was 19 days (IQR, 6.0-31.0) with therapeutic intensity in 24 (53.3%) and prophylactic in 21 (46.7%). Outcomes were as follows: VTE, 1 (2.2%); death, 1 (2.2%, unrelated to bleeding/thrombosis); major/clinically relevant nonmajor bleeding, 0; and minor bleeding, 7 (15.5%). D-dimer was elevated in a majority at diagnosis (median, 2.3; IQR, 1.2-3.3 mg/ml fibrinogen-equivalent units) and was noninformative in assessing disease severity. D-dimer normalized at thromboprophylaxis discontinuation. Conclusions: Our experience of using clinically directed thromboprophylaxis with tailored intensity approach for children hospitalized with COVID-19 and MIS-C favors its inclusion in current standard of care. The role of D-dimer in directing thromboprophylaxis management deserves further evaluation.

Respiratory Distress: Three Patient Cases.

As mentioned in the January 2022 Pediatrics in Review Commentary, we now present three patients who have a common chief complaint followed by 5 questions for CME credit. All three cases have discussions on presentation, the differential diagnosis, and management that collectively serve as a Review article. The common theme here is that all three patients have difficulty breathing. We hope you will enjoy this review format.

A Quality Improvement Initiative to Reduce Screen Time in a Children's Hospital.

OBJECTIVES: The American Academy of Pediatrics strongly recommends that children age 2 and under should have little to no digital media exposure. However, most children are exposed to regular screen time at home. This may also be true for hospitalized children. Through education and access to alternatives, we aimed to reduce screen exposure in our children's hospital for children 2 and under. METHODS: Between January 2020 and May 2021, we designed and implemented a quality improvement intervention to educate staff and caregivers on the American Academy of Pediatrics screen time recommendations and offer alternatives for hospitalized children. Our primary aim was to decrease screen time exposure for children age 2 and under by 50% within 12 months of project initiation. Balancing measures included staff perception of workload when using screens and perceived parental acceptance of screens being turned off. RESULTS: During baseline data collection period, screens were on for an average of 63% of the audits. Following interventions, the average was reduced to 40%. The outcome measure met special cause with 8 consecutive points below the center line. There was a significant increase in staff who reported offering screen alternatives after intervention. Staff perception of workload and perceived parental acceptance was unchanged. CONCLUSIONS: Through implementation of this quality improvement initiative, we reduced screen time by approximately 37% without impacting staff workload. Most importantly, we were able to educate staff and model best practices for caregivers, which may carry into the home, leading to a reduction of screen time and improved health overall.

NT-proBNP Levels Following IVIG Treatment of Multisystem Inflammatory Syndrome in Children.

BACKGROUND AND OBJECTIVES: N-terminal of probrain natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) levels are often elevated in multisystem inflammatory syndrome in children (MIS-C) secondary to inflammation, myocardial dysfunction, or increased wall tension. Intravenous immunoglobulin (IVIG), accepted treatment of MIS-C, may transiently increase myocardial tension and contribute to an increase in NT-proBNP. We sought to study the association between pre- and post-IVIG levels of NT-proBNP and CRP and their clinical significance. METHODS: This single-center, retrospective, cohort study included consecutive children, aged ≤21 years, with diagnosis of MIS-C who received IVIG from April 2020 to October 2021. Data collection included clinical characteristics, laboratory tests, management, and outcomes. Study cohort consisted of patients who received IVIG and had NT-proBNP levels available pre- and post-IVIG. RESULTS: Among 35 patients with MIS-C, 30 met inclusion criteria. Twenty-four, 80%, showed elevation in NT-proBNP post-IVIG. The median NT-proBNP level pre-IVIG was 1921 pg/mL (interquartile range 548-3956), significantly lower than the post-IVIG median of 3756 pg/mL (interquartile range 1342-7634)) (P = .0010). The median pre-IVIG CRP level was significantly higher than the post-IVIG level (12 mg/dL vs 8 mg/dL, P = .0006). All but 1 recovered before discharge, and none had signs of worsening cardiac function post-IVIG. In those who recovered, NT-proBNP had normalized by discharge or 1-week follow-up. CONCLUSIONS: Our study shows that NT-proBNP levels often transiently increase immediately after IVIG therapy without signs of worsening myocardial function. These values should be interpreted in the context of CRP levels and clinical recovery.

APOBECs orchestrate genomic and epigenomic editing across health and disease.

APOBEC proteins can deaminate cytosine residues in DNA and RNA. This can lead to somatic mutations, DNA breaks, RNA modifications, or DNA demethylation in a selective manner. APOBECs function in various cellular compartments and recognize different nucleic acid motifs and structures. They orchestrate a wide array of genomic and epigenomic modifications, thereby affecting various cellular functions positively or negatively, including immune editing, viral and retroelement restriction, DNA damage responses, DNA demethylation, gene expression, and tissue homeostasis. Furthermore, the cumulative increase in genomic and epigenomic editing with aging could also, at least in part, be attributed to APOBEC function. We synthesize our cumulative understanding of APOBEC activity in a unifying overview and discuss their genomic and epigenomic impact in physiological, pathological, and technological contexts.

Encephalitis Associated with Sarcocystis halieti Infection in a Free-Ranging Little Owl (Athene noctua).

A juvenile Little Owl (Athene noctua) was diagnosed with granulomatous encephalitis and muscular sarcocysts. Sarcocystis halieti was identified in the brain and muscle tissue by PCR and subsequent sequencing. This is the first report of S. halieti as a potential encephalitis-causing pathogen in birds.

IgG Fc N-Glycosylation Translates MHCII Haplotype into Autoimmune Skin Disease.

The major histocompatibility complex haplotype represents the most prevalent genetic risk factor for the development of autoimmune diseases. However, the mechanisms by which major histocompatibility complex-associated genetic susceptibility translates into autoimmune disease are not fully understood. Epidermolysis bullosa acquisita is an autoimmune skin-blistering disease driven by autoantibodies to type VII collagen. Here, we investigated autoantigen-specific plasma cells, CD4+ T cells, and IgG fraction crystallizable glycosylation in murine epidermolysis bullosa acquisita in congenic mouse strains with the disease-permitting H2s or disease-nonpermitting H2b major histocompatibility complex II haplotypes. Mice with an H2s haplotype showed increased numbers of autoreactive CD4+ T cells and elevated IL-21 and IFN-γ production, associated with a higher frequency of IgG autoantibodies with an agalactosylated, proinflammatory N-glycan moiety. Mechanistically, we show that the altered antibody glycosylation leads to increased ROS release from neutrophils, the main drivers of autoimmune inflammation in this model. These results indicate that major histocompatibility complex II-associated susceptibility to autoimmune diseases acuminates in a proinflammatory IgG fraction crystallizable N-glycosylation pattern and provide a mechanistic link to increased ROS release by neutrophils.

CD8 T cells drive anorexia, dysbiosis, and blooms of a commensal with immunosuppressive potential after viral infection.

Infections elicit immune adaptations to enable pathogen resistance and/or tolerance and are associated with compositional shifts of the intestinal microbiome. However, a comprehensive understanding of how infections with pathogens that exhibit distinct capability to spread and/or persist differentially change the microbiome, the underlying mechanisms, and the relative contribution of individual commensal species to immune cell adaptations is still lacking. Here, we discovered that mouse infection with a fast-spreading and persistent (but not a slow-spreading acute) isolate of lymphocytic choriomeningitis virus induced large-scale microbiome shifts characterized by increased Verrucomicrobia and reduced Firmicute/Bacteroidetes ratio. Remarkably, the most profound microbiome changes occurred transiently after infection with the fast-spreading persistent isolate, were uncoupled from sustained viral loads, and were instead largely caused by CD8 T cell responses and/or CD8 T cell-induced anorexia. Among the taxa enriched by infection with the fast-spreading virus, Akkermansia muciniphila, broadly regarded as a beneficial commensal, bloomed upon starvation and in a CD8 T cell-dependent manner. Strikingly, oral administration of A. muciniphila suppressed selected effector features of CD8 T cells in the context of both infections. Our findings define unique microbiome differences after chronic versus acute viral infections and identify CD8 T cell responses and downstream anorexia as driver mechanisms of microbial dysbiosis after infection with a fast-spreading virus. Our data also highlight potential context-dependent effects of probiotics and suggest a model in which changes in host behavior and downstream microbiome dysbiosis may constitute a previously unrecognized negative feedback loop that contributes to CD8 T cell adaptations after infections with fast-spreading and/or persistent pathogens.

Molecular identification of novel and genetically diverse adenoviruses in Passeriform birds.

Knowledge about adenoviruses in birds of the order Passeriformes is very scarce. Based on molecular characterizations, only two siadenoviruses, great tit adenovirus 1 and Gouldian finch adenovirus, have been described so far occurring in great tits and Gouldian finches, respectively. Assuming a broader occurrence of adenoviruses, various passeriform birds including pet, zoo, and wild birds were examined using a broad-range PCR targeting a fragment of the adenovirus DNA polymerase gene. Adenoviruses were detected in 25 individual birds belonging to 13 species and seven zoological families (Ploceidae, Fringillidae, Estrildidae, Paridae, Sylviidae, Turdidae, Muscicapidae). The putative viruses were further characterized by sequencing the PCR products and phylogenetic analyses. DNA of adenoviruses affiliating to 3 genera including aviadenovirus, siadenovirus, and atadenovirus was found. Viruses with sequences identical or closely related to great tit adenovirus 1 and Gouldian finch adenovirus 1 were detected in a great tit and in two zebra finches, respectively. Based on polymerase amino acid sequence comparisons, the viruses found in the remaining 22 birds revealed phylogenetic distances larger than 15% to adenoviruses known so far suggesting that they may belong to at least 14 different virus species. In some bird species (great tit, zebra finch, vitelline masked weaver) varying adenovirus genera were detected. These results suggest a broad variety of adenoviruses circulating in passeriform birds.

Activation by substoichiometric inhibition.

Startling reports described the paradoxical triggering of the human mitogen-activated protein kinase pathway when a small-molecule inhibitor specifically inactivates the BRAF V600E protein kinase but not wt-BRAF. We performed a conceptual analysis of the general phenomenon "activation by inhibition" using bacterial and human HtrA proteases as models. Our data suggest a clear explanation that is based on the classic biochemical principles of allostery and cooperativity. Although substoichiometric occupancy of inhibitor binding sites results in partial inhibition, this effect is overrun by a concomitant activation of unliganded binding sites. Therefore, when an inhibitor of a cooperative enzyme does not reach saturating levels, a common scenario during drug administration, it may cause the contrary of the desired effect. The implications for drug development are discussed.

Chemical Validation of DegS As a Target for the Development of Antibiotics with a Novel Mode of Action.

Despite the availability of hundreds of antibiotic drugs, infectious diseases continue to remain one of the most notorious health issues. In addition, the disparity between the spread of multidrug-resistant pathogens and the development of novel classes of antibiotics exemplify an important unmet medical need that can only be addressed by identifying novel targets. Herein we demonstrate, by the development of the first in vivo active DegS inhibitors based on a pyrazolo[1,5-a]-1,3,5-triazine scaffold, that the serine protease DegS and the cell envelope stress-response pathway σE represent a target for generating antibiotics with a novel mode of action. Moreover, DegS inhibition is synergistic with well-established membrane-perturbing antibiotics, thereby opening promising avenues for rational antibiotic drug design.

First detection and characterization of Psittaciform bornaviruses in naturally infected and diseased birds in Thailand.

In Thailand a proventricular dilation disease (PDD)-like syndrome commonly occurs in captive psittacine birds. The etiology, however, has been unknown to date and studies to detect parrot bornaviruses have never been performed in Southeastern Asia. Therefore, 111 psittacines (22 different species) including birds with suspected PDD based on clinical examination results (n = 65), cage mates of PDD suspected parrots without any clinical signs (n = 39) and dead birds with previous clinic suspicious for PDD (n = 7) were tested for bornaviruses using various reverse transcription polymerase chain reaction (RT-PCR) and realtime RT-PCR protocols, an enzyme-linked immunosorbent assay (ELISA), immunohistochemistry, and genome sequencing. Bornaviral infections, indicated by the presence of RNA or antibody positive reactions were detected in 60 birds (54.1%) belonging to 15 psittaciform species and originating from 41 owners. Occurrence of Psittaciform 1 orthobornavirus was confirmed by sequencing of PCR products in 24 of these birds. Parrot bornavirus (PaBV)-5, belonging to the species Psittaciform 2 orthobornavirus and found only in single birds in the United States of America, Japan and Hungary until now, was identified in a macaw. Full genome sequencing revealed features shared with other strains of this virus. PaBV-4 was the prevalent virus type and the viruses grouped in two of the five genetic PaBV-4 subclusters known so far while PaBV-2 was found in a single patient. Forty-five psittacines of the group of PDD-suspected birds (69.2%), 4 dead birds and 11 clinically healthy cage mates were positive in at least one test the latter suggesting inefficient horizontal transmission in natural infections. Lymphoplasmacytic infiltrations (non-purulent inflammation, ganglioneuritis) and bornavirus antigen were detected in diverse tissues confirming PDD as the disease involved. These results may have a major impact on conservation projects including the five near-threatened parrot species living in the wild in Thailand.

Improving Standardization of Paging Communication Using Quality Improvement Methodology.

BACKGROUND AND OBJECTIVES: Paging is a primary mode of communication in hospitals, but message quality varies. With this project, we aimed to standardize paging, thus improving end user (EU) satisfaction, patient safety, and efficiency. Objectives were to increase the percent of pages containing 6 critical elements (CEs) (ie, the sender's first and last name, a 7-digit callback number, patient name, room number, and urgency indicator [information only, call, or come] to 90%); improve EU satisfaction to 80% rating paging communication as good or excellent; and decrease the frequency of safety events related to paging. METHODS: This multidisciplinary, system-wide quality improvement study was conducted at our stand-alone academic children's hospital. CEs were determined by EU consensus. Outcome measures were inclusion of all 6 CEs, provider satisfaction, and frequency of safety events. Process measures were inclusion of individual CEs and appropriateness and timeliness of response to pages. Balancing measures included number of work-arounds (WAs). Interventions included education, engineering a platform with required fields, and optimization enhancements. Statistical process control charts (p-charts; XmR) were used to track the impact of interventions. RESULTS: Special-cause improvement was noted in use of all 6 CEs (4.4%-79.7%) and individual CEs. EU satisfaction improved from 50% to 85% rating paging communication as good or excellent. Safety events related to paging remain infrequent. Specific WA use decreased by 60%. CONCLUSIONS: System-wide use of required fields produced significant improvement in inclusion of all 6 CEs and EU satisfaction. WAs were curbed by improving the ease of CE incorporation. Required fields should be considered at institutions seeking improved paging communication.

Addressing Reproductive Health in Hospitalized Adolescents-A Missed Opportunity.

PURPOSE: Adolescents are at high risk for sexually transmitted infections (STIs) and pregnancy. Since many adolescents have poor access to preventive care, hospitalizations present a critical opportunity to address adolescents' reproductive health. The purpose of this study was to assess provision of reproductive health services within a hospital setting. METHODS: Retrospective study of a consecutive sample of adolescent patients aged 13 years and older hospitalized on the hospitalist service at a large academic pediatric tertiary care center. Measures included sexual history documentation, pregnancy and STI testing, Human papillomavirus immunization status and administration, and provision of contraception. RESULTS: Only 55% of 150 patients had sexual history documentation, and of those, 47% endorsed sexual activity. Associations with increased likelihood of sexual history documentation included female patients (67% vs. 36%, p < .01), hospitalizations for ingestion (71% vs. 48%, p < .01), hospitalizations to hospital medicine compared with critical care (59% vs. 14%, p < .01), and admission note written by an intern compared with a senior resident, advanced practice provider, or fellow (67% vs. 44%, 29%, 13%, p < .01). Eighteen patients (12%) were tested for STIs. Only 19% of patients due for human papillomavirus immunization received it. Sixty percent of females received a pregnancy test. Contraception was provided in two encounters (2% of females). CONCLUSIONS: Results demonstrate a substantial missed opportunity to provide reproductive health services to hospitalized adolescents. Providers in hospital settings should optimize the opportunity to screen for sexual activity and reproductive health needs, provide indicated services, and offer education regarding reproductive health to hospitalized adolescents.

Adverse Childhood Experiences and Trauma-Informed Care: An Online Module for Pediatricians.

Introduction: The epidemic of adverse childhood experiences (ACEs) has many known health consequences. Robust research has linked ACEs to increased morbidity and mortality. Because of their frequent interaction with children and their families, pediatricians should be educated to recognize ACEs and practice trauma-informed care (TIC). There is a lack of education for pediatric residents on ACEs despite their significance. Our goals were to identify residents' baseline perceived importance, confidence, and frequency of discussion of ACEs, TIC, toxic stress, and resiliency and evaluate the efficacy of an educational module addressing these topics. Methods: A 25-minute self-directed module was created for pediatric residents. The module was accessible online and independently completed by residents during the child advocacy rotation. Pre- and postmodule surveys using a 5-point Likert scale (1 = low, 5 = high) were administered, and median scores of 11 participants who completed both surveys were compared using the Wilcoxon signed rank test. Results: Presurvey results demonstrated that residents were not confident discussing ACEs, TIC, or resiliency (median = 2). Residents reported that it was very important to discuss ACEs, toxic stress, and resiliency with families (median = 5), although they were rarely discussed in clinic (median = 1 or 2). Matched pre/post data showed significant increases in knowledge, confidence, and discussion frequency. Discussion: The results demonstrated a need for ACE education for pediatric residents. The matched survey results showed the module's success in knowledge and behavior change. The module can be adapted to other learners to enhance understanding of ACEs.