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Background: Understanding the clinical course and short-term outcomes of suspected myocarditis after the coronavirus disease 2019 (COVID-19) vaccination has important public health implications in the decision to vaccinate youth. Methods: We retrospectively collected data on patients Results: We report on 139 adolescents and young adults with 140 episodes of suspected myocarditis (49 confirmed, 91 probable) at 26 centers. Most patients were male (n=126, 90.6%) and White (n=92, 66.2%); 29 (20.9%) were Hispanic; and the median age was 15.8 years (range, 12.1–20.3; interquartile range [IQR], 14.5–17.0). Suspected myocarditis occurred in 136 patients (97.8%) after the mRNA vaccine, with 131 (94.2%) after the Pfizer-BioNTech vaccine; 128 (91.4%) occurred after the second dose. Symptoms started at a median of 2 days (range, 0–22; IQR, 1–3) after vaccination. The most common symptom was chest pain (99.3%). Patients were treated with nonsteroidal anti-inflammatory drugs (81.3%), intravenous immunoglobulin (21.6%), glucocorticoids (21.6%), colchicine (7.9%), or no anti-inflammatory therapies (8.6%). Twenty-six patients (18.7%) were in the intensive care unit, 2 were treated with inotropic/vasoactive support, and none required extracorporeal membrane oxygenation or died. Median hospital stay was 2 days (range, 0–10; IQR, 2–3). All patients had elevated troponin I (n=111, 8.12 ng/mL; IQR, 3.50–15.90) or T (n=28, 0.61 ng/mL; IQR, 0.25–1.30); 69.8% had abnormal ECGs and arrhythmias (7 with nonsustained ventricular tachycardia); and 18.7% had left ventricular ejection fraction Conclusions: Most cases of suspected COVID-19 vaccine myocarditis occurring in persons

Objectives We determined how often emergency physician pediatric musculoskeletal (MSK) radiograph interpretations were discordant to that of a radiologist and led to an adverse event (AE). We also established the variables independently associated with this outcome. Methods This prospective cohort study was conducted in an urban, tertiary care children's emergency department (ED). We enrolled children who presented to an ED with an extremity injury and received radiographs. ED physicians documented their radiograph interpretation, which was compared to a radiology reference standard. Patients received telephone follow-up and had institutional medical records reviewed in 3 weeks. An AE occurred if there were clinical sequelae and/or repeat health care visits due to a delay in correct radiograph interpretation. Results We enrolled 2,302 children (mean [±SD] age = 9.0 [4.4] years; 1,288 (56.0%) male]. Of these, 180 (7.8%; 95% confidence interval = 6.8 to 9.0) ED physician discordant interpretations resulted in an AE. Specifically, there were no negative clinical outcomes; however, relative to cases diagnosed correctly at the index ED, patients whose fracture was not initially identified encountered 77.2% more subsequent ED visits, while those falsely diagnosed with a fracture experienced 41.5% additional orthopedic clinic visits. Odds of an ED discrepant interpretation was significantly higher if a physician's pretest probability of a fracture was ≤ 20% versus> 20% (adjusted odds ratio [aOR] = 1.6), patient's pain score was ≤ 2 versus> 2 (aOR = 1.6), and injury was located in a joint versus other location (aOR = 1.7). Conclusions Emergency physician discordant pediatric MSK radiograph interpretations that resulted in an AE occurred with regular frequency in a pediatric ED setting. AEs were primarily an increase in subsequent health care visits. Importantly, a low clinical suspicion for a fracture or injury located in the joint were risk factors for ED physician discordant interpretations.

The mRNA vaccines against COVID-19 infection have been effective in reducing the number of symptomatic cases worldwide. With widespread uptake, case series of vaccine-related myocarditis/pericarditis have been reported, particularly in adolescents and young adults. Males tend to be affected with greater frequency, and symptom onset is usually within one week following vaccination. Clinical course appears to be mild in the overwhelming majority of cases. Based on the available evidence, we highlight a clinical framework to guide providers on how to assess, investigate, diagnose and report suspected and confirmed cases. In any patient with highly suggestive symptoms temporally related to COVID-19 mRNA vaccination, standardized work-up includes serum troponin measurement and PCR testing for COVID-19 infection, routine additional labwork, and a 12-lead ECG. Echocardiography is recommended as the imaging modality of choice for patients with unexplained troponin elevation and/or pathologic ECG changes. Cardiovascular specialist consultation and hospitalization should be considered based on the results of standard investigations. Treatment is largely supportive, and myocarditis/pericarditis that is diagnosed by defined clinical criteria should be reported to Public Health authorities in every jurisdiction. Finally, we recommend COVID-19 vaccination in all individuals in accordance with the Health Canada and NACI guidelines. In patients with suspected myocarditis/pericarditis following the 1st dose of an mRNA vaccine, deferral of 2nd dose is recommended until additional reports become available. With widespread uptake of COVID-19 mRNA vaccines, reports of vaccine-related myocarditis/pericarditis have emerged. Based on the available evidence, we highlight a clinical framework to guide providers on how to assess, investigate, diagnose and report suspected and confirmed cases. We recommend COVID-19 vaccination in all individuals in accordance with the Health Canada and NACI guidelines. For patients with suspected myocarditis/pericarditis following the 1st dose of mRNA vaccine, deferral of 2nd dose is recommended pending further data.

Background: The full clinical continuum of post-COVID-associated multisystem inflammatory syndrome of childhood (MIS-C)/Paediatric Inflammatory Multi-system Syndrome (PIMS) is still being defined, with different names and case definitions continuing to be used across jurisdictions. Refinement of criteria and better stratification of affected children will facilitate international collaborations towards improving health outcomes. Our objective is to describe the clinical characteristics and outcomes of children with MIS-C/PIMS stratified by case definition and clinical phenotype. Methods: Prospective study of 137 multi-ethnic hospitalized patients with presumed MIS-C, at a tertiary care pediatric centre in Toronto, Canada from March 2020 to February 2021. Clinical and laboratory features at presentation, organ system complications, therapeutic management, and outcomes were captured. Descriptive statistics were performed to assess differences between case definitions and clinical phenotype. Findings: The most striking differences between the case definitions were reflected in measures of disease severity and outcomes, with the MIS-C classifications capturing the more severe end of the hyperinflammatory spectrum compared to PIMS. Children in the MIS-C group were older and had more cardiac abnormalities and macrophage activation syndrome, which were reflected in more intensive care admission and corticosteroid therapy. Comparisons of clinical phenotypes (shock, Kawasaki Disease, and fever with hyperinflammation) and COVID exposure demonstrate similar clinical features, disease severity and outcomes. Interpretation: Case definition had the greatest impact on measures of disease severity, course, and outcome. Stratification by known disease phenotype led to homogeneous groupings of patients regardless of SARS-CoV-2 exposure status, confirming that recognition of known clinical entities can guide case recognition, classification and management, with our data supporting the notion that KD and MIS-C both fit on the same disease spectrum. The use of a common case definition is needed to ensure comparability in studies among international networks, reliability of public health surveillance data, and proper case ascertainment. Funding: None to declare. Declaration of Interest: None to declare. Ethical Approval: These studies were approved by the institutional Research Ethics Board, and the requirement for individual consent was waived.

Background: Interest is growing surrounding functional foods, which provide health benefits in addition to nutritional value. In particular, there is a focus on pulse crops which contain high levels of polyphenolics, such as lentils. Methods: In this study, polyphenols were extracted from five L. culinaris varieties and characterized by both their antioxidant profile and cytotoxic activity. Result: Hulled varieties had a high content of secondary metabolites (>70 mg GAE/g), while all varieties demonstrated high antioxidant potential (1570-2020 Oxygen Radical Absorbance Capacity index). Furthermore, all extracts showed significant cytotoxicity against H9C2, HepG2, A549 and Calu-1 cancer cell lines. This recommends further investigation into the specific compounds present in L. culinaris, which could potentially be exploited for their anti-cancer activity.

Unlike true virtual care where there is no expectation of a physical examination, the patients being reviewed virtually have undergone a triage assessment with documentation of vital signs, and a physical examination by a physician assistant (PA) Medicolegal concerns are low provided that the clinician is acting in good faith, within their normal scope of practice, and with the support of their hospital leadership team (Canadian Medical Protective Association, personal communication, correspondence, March 23, 2020) 1,2 PAs provide medical care for patients through physician delegation, which may include both written medical directives and direct orders 3 Each province has specific guidance available on the requirements and limitations of medical delegation Nearly all jurisdictions recognize that this supervision may be indirect with the supervising physician off-site 4 The PAs that work in our institution are also required to maintain certification with the Canadian Association of Physician Assistants and hold individual malpractice insurance to further mitigate medicolegal risks At the end of the call, depending on the complexity of the case, the virtual physician may relay the information to the on-site physician or nursing team leader if required, otherwise, documentation is noted in our EMR system

Background: Intravenous immunoglobulin (IVIG) is the mainstay of treatment for Kawasaki Disease (KD). Due to the consolidation of IVIG manufacturers in 2008, different preparations of IVIG are currently available in Canada. An increase in adverse effects, especially hemolytic anemia, has been observed. Objective: To characterize the natural history of IVIG-associated hemolytic anemia in KD. Methods: A single-centre retrospective study was conducted at Toronto’s SickKids Hospital between January 2002 and December 2012. Medical records of all KD patients were reviewed and hemolytic anemia identified (drop in hemoglobin ≥20mg/dl post-IVIG treatment with 2 or more of the following criteria: reticulocytosis, positive direct anti-globulin test (DAT), and morphological changes on blood film). For statistical analysis, Chi-square tests and ANOVA with Tukey’s post-hoc correction for multiple comparisons were utilized. Results: Between 2002 and 2008, 2 of 370 patients diagnosed with KD who received Iveegam had hemolytic anemia (0.5%). After 2008, the rates of IVIG-associated hemolysis were as follows: Privigen 17% (8/48, p5) in the hemolysis group (17% vs. 5.3%). All patients who hemolyzed had non-O+ blood types. Out of the 17 patients with hemolysis, 9 required red cell transfusions (60%). Starting in 2012, a detailed hemolysis work-up was included as standard protocol for all KD patients. Hemolysis was mediated by anti-blood group A & B antibodies resulting in DAT positivity, but no complement fixation. This extravascular hemolysis was maximal at 72 hours post-IVIG infusion and appeared to be dose dependent. Conclusions: Hemolysis is seen in up to 17% of those receiving new IVIG preparations, which also appear to be less efficacious - associated with treatment failure and, possibly, poor coronary outcome. There are important implications for patient safety. Further study is required to develop evidence-based guidelines to improve our management of these children.

Objective: The objectives of this study were to measure noise levels in a tertiary care pediatric emergency department (ED) and to identify attending staff physicians' and first-year residents' perceptions of background noise levels and its impact on communication and teaching. Methods: A mixed methodology was used in this study. A sound level meter measuring 30 to 140 dB was placed in the ED for a week. All consenting staff physicians and first-year residents were surveyed using a semistructured questionnaire during the study period to assess their perceptions of background noise and its impact. Descriptive statistics were used for quantitative analysis. Narrative answers were coded and analyzed using the method of meaning condensation to assess the impact of background noise on both communication and teaching. Results: The average noise level in the ED is 68.73 dB for a 24-hour period. The number sound peaks higher than 80 dB, with an average of 309 dB/d (minimum, 193 dB; maximum, 461 dB). Only 35% of staff physicians' surveys and 22% of residents' surveys identified the noise levels to be uncomfortable. However, background noise in the ED was perceived as stressful, affecting interaction, communication, and teaching between residents and staff physicians. Staff physicians and residents stated that they feel helpless when it is too noisy and did not have good strategies to reduce background noise in the ED. Conclusions: The high background noise levels in a pediatric ED are perceived as stressful and interfering with communication and teaching. Noise levels in EDs should be measured, and noise reduction strategies should be implemented because physicians are not consistent in identifying excessive noise levels.