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Novel conundrum of mis-c in childhood Covid-19

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by Dr B. J. C. Perera 

MBBS(Cey), DCH(Cey), DCH(Eng), MD(Paed), MRCP(UK), FRCP(Edin), FRCP(Lon), FRCPCH(UK), FSLCPaed, FCCP, Hony FRCPCH(UK), Hony. FCGP(SL) 

Specialist Consultant Paediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.

It is now common knowledge that no unvaccinated age group is immune to the vagaries of the microbe SARS-CoV-2 that causes the disease COVID-19. Quite contrary to popular belief, children and adolescents are as vulnerable as adults and the elderly to catch the disease. The difference perhaps is that in children it is largely without even symptoms and even when there are symptomatic effects on their bodies, the features are quite mild in children. There is a tendency amongst many people to take childhood COVID-19 rather lightly and nonchalantly because of these documented facts.

However, in a very small proportion of affected children, the disease can cause some real problems. In some of them, albeit in a very small minority, there could be severe disease, such as COVID Pneumonia, especially in those with a variety of different coexistent diseases which make them vulnerable to develop more severe disease.

Yet for all that, over the last few months, another enigmatic presentation of COVID-19 in children and adolescents, presenting as a severe and novel complication, has aroused intense interest worldwide. It is the Multi-system Inflammatory Syndrome in Children, abbreviated as MIS-C. As its name implies it shows clinical effects in many organ systems in the body and it is temporal or time-based association with COVID-19. It was first described in the United Kingdom in April 2020, that is over a year ago, and subsequently in other parts of Europe, USA and many other countries. In one research report, nearly 4000 cases of MIS-C and 35 deaths have been reported in the United States. There may be even a larger number of unreported cases worldwide.

A steep learning curve for the identification, diagnosis, and treatment of this condition has been effective through rapid communication globally among multidisciplinary specialists at pediatric centres who faced the challenge of caring for the affected children. In a triumph of collaboration, experts achieved consensus about diagnostic criteria and the need to induce rapid management strategies aimed at limiting the course of the illness. However, in the absence of randomized, controlled clinical trials, consensus around specific therapies has been more elusive, given the speed with which centres have had to establish cohorts and deliver treatment. This complication seems to be an abnormal immune response to the virus which, if left untreated or sub-optimally managed, tends to damage many organs and systems of the body.

It is now known that MIS-C tends to affect one in five thousand COVID-19 positive patients with a median age of between 8 to 11 years. At the Intensive Care Unit of the Lady Ridgeway Hospital for Children in Colombo, they have managed around 20 patients of age ranging from 1 to 14 years in the recent past. All of them have had high swinging fever and around 87% have had involvement of the gastrointestinal system of the abdomen while 70% have had the heart and the cardiovascular system being affected. It is imperative to note that almost any organ or system could be affected by MIS-C. Many have had sore eyes, skin rashes and involvement of mucous membranes of the mouth and tongue as well. Quite a few have had the heart being affected with low blood pressures and circulatory failure; a potentially fatal complication if not adequately and promptly treated. This complication of MIS-C appears to occur a little later than the severe COVID-19 effects such as pneumonia and as such when a definitive diagnosis could be made, the vast majority of the affected children are non-infective from the point of view of their ability to spread the disease. So far, in those cases where a definitive diagnosis of MIS-C could be made, there has not been any deaths. That speaks volumes for the dedication and expertise of those who are called upon to care for these cases of MIS-C, particularly in the Intensive Care Units of our hospitals.

The biggest problem for those healthcare personnel who are called upon to manage these children and adolescents with MIS-C is that the condition is a great mimicker. In its presentation it resembles a wide variety of other conditions that present with similar features, particularly the toxic shock syndromes following bacterial infections, which are a bit more commonly seen than this particular problem. In that sense, MIS-C is a sort of a diagnosis made by exclusion of other similar presentations and a variety of tests and investigations may be necessary before a definitive diagnosis can be made. A very high degree of suspicion is necessary to be able to sort out this condition from other similar disorders.

To make matters further complicated, a similar syndrome to MIS-C has also been noticed in adults over 21 years of age. It is known as MIS-A. There are some differences in the adult version but the basic symptoms are very similar. There is very little scientific studies on MIS-A and more definitive medical information is awaited.

It is imperative not to miss the diagnosis of MIS-C as a lot could be done if these patients are detected early. Specific treatment modalities have now been sorted out according to the scientific evidence available. If a child has sustained high fever with abdominal symptoms, lethargy, changes in the sensorium, skin rashes, redness of the whites of the eyes and soreness of the lining of the mouth and tongue, the diagnosis has to be strongly suspected. All these symptoms may not be there in each and every case and it is essential that the parents stay watchful if their child has any of these and looks ill.

 

Parents are the people who know their children best and if there is any reason to be concerned, then the child must, I repeat MUST, be taken to a qualified doctor for assessment. Immediate response on the part of parents, care-givers and healthcare personnel is of absolute essence as so much can be done for this condition if treated early, so as to prevent unfortunate outcomes.

Although clinical trials are in progress on the efficacy and safety of available vaccines in children, we do not know whether immunisation against COVID-19 could prevent or mitigate against the disease complications like MIS-C as yet. Then there are the more recent ‘COVID variants of concern’, now being labelled using the letters of the Greek alphabet such as α (alpha), β (beta), γ (gamma), δ (delta), ε (epsilon) etc. As to whether some of these more potent mutant variants are liable to cause MIS-C in higher numbers of children and adolescents is also not all that well established. These variants have been around only for a relatively shorter time than the original index strains of SARS-CoV-2 and our knowledge on all these aspects is constantly evolving. It is important to remember that as the virus undergoes changes to its genetic code, so does its capability to surpass antibodies and immune defences of the human body as well.

The healthcare personnel need to remember that common things occur commonly and that over-diagnosis of MIS-C needs to be avoided. However, it is also crucial that we need to avoid missing the diagnosis of MIS-C as well. Sometimes, the doctors are caught between the devil and the deep blue sea and they need to respond swiftly and appropriately. All medicines and equipment that are needed to care for even the most severely affected children with MIS-C are available in all government hospitals in our country. I am quite sure that the healthcare staff who look after sick children in our hospitals will not let a child suffer unnecessarily or let him or her succumb to MIS-C without a determined and dedicated fight.

 

The writer is well aware of the fact that many parents are intensely worried about all the information and even misinformation, that is flying around, about MIS-C, especially in the social media. The parents, for their part, have to studiously employ cat-like vigilance and make sure that they take their children who are sick and who do not look quite right, to a suitable hospital, without any delay whatsoever. Undeterred and ever so very prompt action is absolutely vital and will certainly save the day.

 

(This article is based on the available research literature up to 30th June 2021 and a scientific webinar for doctors, transmitted on-line by the Paediatric Intensive Care Chapter of the Sri Lanka College of Paediatricians on 28th June 2021)



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Features

English in Mathematics

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By R.N.A. de Silva

 

“Which subject did you have most difficulties with, having switched the medium of instruction from Sinhala to English?” I posed this question to a Sri Lankan student who was following a pre-University course in an educational institution in Hong Kong, having completed studies up to the GCE Ordinary Level programme in the Sinhala medium in a leading girls’ school in Colombo. “It is definitely mathematics,” she replied. Having served as a teacher for a long period of time at this educational institution with students from over 80 countries, I realised the above-mentioned view was shared by other students, too, who had to change the medium of instruction to English. This does not seem to make sense as one would have expected mathematics to be the easiest subject to follow as it has its own symbolic language. Why then has this situation arisen?

I would like to separate these difficulties into two categories:

1. Hastiness due to mindset

2. Vocabulary issues

Sometimes hastiness can automatically occur due to the mindset that mathematics should be easy to follow even if you change the medium of instruction as you are dealing with symbols. This attitude can cause enormous problems as students may skip instructions or avoid reading the question fully and concentrate only on the symbolic part of the problem

As an example, consider the following question.

The graphs of lines 3y = 5x + 1 and 2y = 7 – 3x intersect at point P. Find the coordinates of P.

Seeing the word ‘graphs’ and the two equations, a student maybe tempted to draw the graphs of the two lines and thereby find the point of intersection, which is a time-consuming affair. If it was read properly, the student could have noticed that the solution can be obtained by solving the two equations algebraically, which is much more efficient.

To a fast reader, obtaining the correct answer to the following question can be a problem as it may end up with just finding the value of x.

If 2x+3 = 5x-3, find the value of 2x+3.

The students need to be trained to read the question fully and understand what is required to be done, before attempting it.

The time spent to grasp the aim of the question is not wasted time.

Many children consider mathematics as an alien language consisting of symbols and expressions. Most of the difficulties that students encounter is related to vocabulary. The mathematical interpretation of the meaning of a word may differ from the meaning given to it in the English language. The word ‘find’ in mathematics means to obtain an answer showing the working while in the English language, it refers to discover or search. The following sketch shows the funny side of this difference.

Two of the words that has caused much confusion are ‘or’ and ‘and’.

In general usage, A or B is considered as either A or B but not both, as shown in picture.

However, in mathematics ‘A or B’ means ‘it can belong to A or B including intersection’. This is shown in picture.

The above, in normal usage is interpreted as ‘A and B’. However, in mathematics A and B refers to only what is common to A and B as shown in picture.

Here are the mathematical meanings of some of the other words which can have a different meaning with the English language definitions.

Determine

– Obtain the only possible answer

Plot

– Mark the position of points on a diagram

Write down

– Obtain the answer (Working need not be shown)

Constant

– A number that does not change

Similar

– Having the same shape but not the same size

Deduce

– To show a result using known information

Operation

– A procedure such as addition, subtraction, multiplication, etc.

Element

– A member of a set

Volume

– The extent of space occupied by a solid

The following illustrate some of the difficulties that the difference of meanings brings:

How odd these odd numbers are? The even numbers are even stranger.

Don’t be mean and help me to find the mean of these numbers.

Is right angle the right answer? Let me write it on the board.

The polysemous nature of some of the mathematical terms make it confusing for the students in the understanding of mathematical concepts. Mathematical terms have precise definitions to describe numerical relationships. At times these definitions resemble the everyday usage meaning but there are instances where the definitions notably differ. Consider ‘in general’ as an example. In mathematics there can be no exceptions to a result if it is considered to hold in general. However, in everyday usage, if a claim is said to be true in general, it would mean that it is true most of the time, but exceptions are possible.

To add to the problem, there are some terms such as ‘degree’ that can have many different meanings within mathematics while having a different meaning in everyday use. In mathematics, degree can refer to the measurement of an angle, the complexity of an algebraic equation and a unit of temperature.

Although mathematics deals essentially with symbols, it is taught through the medium of language which is the major means of communication. Students build understanding as they process ideas through language. It is important for students to give emphasis to the familiarisation with the mathematical vocabulary and at the same time understand the difference of meanings of terms mathematically and everyday usage. Teachers have an important role to play here in highlighting such terms and using them in different contexts for comfortable acclimatization. As Marcus Quintilianus quoted, “One should not aim at being possible to understand, but at being impossible to misunderstand.”

(The author is a senior mathematics examiner of the International Baccalaureate Organization and a member of the faculty of the Overseas School of Colombo.)

 

 

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Features

Success with debut single

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Fred-James Koch: Lots of airplay for ‘I’m Runnin’

 

Fred-James Koch seems to be more in the news, these days, than his illustrious father, Alston Koch.

The turning point in Fred-James career is, undoubtedly, the Hollywood film ‘Night Walk.’

His role in the film is two-fold – actor and singer.

It’s, in fact, his singing of the theme song, ‘I’m Runnin,’ that has generated quite a lot of excitement, among music lovers.

The song is now being heard, world-wide, over radio (in Sri Lanka, on Sun FM), while the video, too, has been seen by many, on social media.

An Australian magazine, ‘Music Injection,’ had this to say about Fred- James:

“Fred- James Koch has written an incredible theme song for the movie ‘Night Walk,’ called ‘I’m Runnin.’ Just released, this song is engaging and gives us a sense of urgency, as the song builds. Fred-James vocals have a unique tinge to them and with the video having scenes from ‘Night Walk,’ it encourages me to watch the movie. ‘I’m Runnin’ features AZ Sheriff.” – Jen.

Following the debut spin for ‘I’m Runnin,’ on The Music Director programme, on 88.3 Southern FM Melbourne, the track was also played on the All New Saturday Ausmosis programme.

And, guess what! It’s now No. 3 on the Australian Top 20 Download chart. and No. 2 on the Australian Top 20 Stream chart.

 

 

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Features

Inklings of change in national reconciliation policy

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By Jehan Perera

 

The government comfortably overcame a vote of no-confidence in one of its key ministers over the rise in the price of fuel.  Those who expected to have greater numbers supporting the no-confidence motion miscalculated that the apparent differences and rivalries within the government would be uppermost.  Any government, or institution for that matter, would have its internal differences.  The current government is better secured against these differences that might otherwise split it into different competing parts on account of the familial bonds that bind the leadership together.  The President, Prime Minister, newly appointed Finance Minister, as well as the former Speaker who is now Irrigation and Internal Security Minister, are closely knit brothers who have gone through trials and tribulations together. 

An iconic photograph of recent times would be the joy on (then) President Mahinda Rajapaksa’s face when he embraced his brother (then) Defence Secretary Gotabaya Rajapaksa shortly after the latter survived a suicide bomb attack at the height of the war.  The brothers, however, have different strengths and constituencies.  They have different groups who follow and advise them, and each of these groups would prefer if their leader was the first among equals.  President Gotabaya Rajapaksa’s comment that he has another eight years in which to achieve his goals has been widely discussed.  It would send a signal to others in the polity that it would be premature to gather around another member of the family at this time in anticipation that the baton would be passed on at the conclusion of the President’s current term in 2024.

On his part, the President has been promoting the institution he once served and to which most of his confidantes belonged or continue to belong.  The institution of the military is one where the closest of human bonds can be forged, because on the battlefield each depends on the other for their lives.  In his early period in office, the President has been promoting the military, both serving and retired, wherever he can, as ambassadors to foreign nations, as Covid health guideline monitors and as a supra grade of administrators in government departments.  It is often the case that those appointed to these positions are not the best suited to the tasks they have been set to do.  But the President evidently trusts them and they are his support base.  Unlike any other president in the past, President Gotabaya Rajapaksa is not a member of a political party.  Civil society organisations have periodically called for a non-party presidency who is non-partisan in decision making. 

 

CHALLENGE EXCESSSES

However, there is a need to challenge the excesses.  The president’s pardoning of a soldier who was held by several courts, including the Supreme Court, to have deliberately killed children and (adults, eight in all), outside of the battlefield may be due to his conviction that loyalty to the military counts most.  However, the President is expected to uphold the system of checks and balances, and if he favours one institution at the expense of the others, it leads to a weakening of the entire structure of governance.  Another looming challenge is that posed to the autonomy of institutions of higher education and specifically the universities.  The government decision to vest the Kotelawala Defence University with powers to accredit other institutions of higher education is a threat to the freedom of thought and expression.  The military hierarchy who will head the KDU can be expected to have values that are important to the military, but not to democracy which is based on human rights.

The KDU law needs to be opposed as indeed the Federation of University Teachers Associations (FUTA) has urged along with opposition political parties.  At the same time there are other issues on which civil society can consider giving constructive support to governmental initiatives.  For instance, they do not engage with NGOs who provide a variety of services complementing the work of the government. The most important of these is the national reconciliation process.  There are indications that the government is shifting its stance on the issues of post-war reconciliation.  President Gotabaya Rajapaksa’s election victory on a highly nationalist platform won him a big majority of votes of the Sinhalese ethnic majority.  The government felt empowered to publicly declare its intention to withdraw from the post-war reconciliation process initiated by its predecessor government with support from the international community.  This was followed by withdrawal from UNHRC resolution 30/1 of 2015 co-sponsored by the previous government. 

However, the four subsequent internationally driven resolutions against Sri Lanka, emanating from Geneva (UNHRC), Ottawa (Ontario Parliament), Washington DC (US Congress) and Brussels (EU Parliament) seem to have led to a serious rethink within the government about its policy towards post-war reconciliation.  All four make human rights and the ethnic conflict their centerpiece.  Though not yet publicly commented upon, the signs of change are two-fold.  The first is the increased visibility of the US Embassy in meeting with the leaders of the Tamil and Muslim parties.  The media has reported that US Embassy officials discussed issues of post-war reconciliation efforts, devolution of power, rule of law and the Prevention of Terrorism Act with SLMC leader Rauff Hakeem. Recently, a US Embassy delegation, led by Ambassador Alaina B. Teplitz, held similar discussions with TNA leader R. Sampanthan where the focus was on the proposed new Constitution.

 

CHANGING WINDS

The second sign of a change is the statement from the Presidential Secretariat announcing a recommendation, emanating from the President Commission of Inquiry for Appraisal of the Findings of Previous Commissions and Committees on Human Rights and the Way Forward headed by Justice AHMD Nawaz.  This is with regard to the EU call for the abolishing of the Prevention of Terrorism Act long seen by those promoting national security as part of the country’s first line of defence.  The Commission said that it cannot agree with calls for repealing the PTA but Sri Lanka’s anti-terrorism law should be reformed in line with similar laws in other countries, including the UK.  This would be aimed at affirming Sri Lankan sovereignty and national security interests, which are important to the government’s voter base, while complying with the requirements of the EU parliament which has called for the repeal of the PTA on the grounds that it violated human rights. 

The Presidential Secretariat statement also contains a significant section in which it mentioned that “It is the policy of the Government to work with the United Nations and its agencies to ensure accountability and human resource development in order to achieve lasting peace and reconciliation. The Government is committed to providing solutions for the issues to be resolved within the democratic and legal process and to ensure justice and reconciliation by implementing necessary institutional reforms.”  This is the first official indication that the Government is reconsidering its earlier position that it would blaze is own path with an indigenously generated reconciliation model which would not require international assistance. In this context it would be useful if the government focused closer attention to the achievement of the UN Sustainable Goals.

Veteran Tamil political leader V Anandasangaree, who has championed Tamil rights for a long time, and whose son is a Canadian parliamentarian, has referred to these recent developments and said that the President who holds the defence portfolio, Prime Minister and Finance Minister being members of Rajapaksa family could ensure genuine post-war reconciliation.  He also urged President Gotabaya Rajapaksa’s government not to leave the problem for a future administration to resolve, but address it now.  If the President is to successfully address the problem that has eluded a solution since independence, and been the biggest disaster to Sri Lanka’s development, he will need to broad base his support at multiple levels.  He will not only need the support of the ruling party, led by his brothers, as well as civil society, but also that of the ethnic minority parties and the opposition political parties.  This will require patience, dialogue and self-sacrifice, and the need to break from past and chart a reconciliatory course of action.

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