>>THANK YOU ALL. I THINK ALL OF US WERE GIVEN THIS INVITATION PERHAPS A LITTLE UNEXPECTEDLY BUT IT LOOKS LIKE THIS WAS REALLY COMPLETELY DESIGNED TO TRY TO CREATE A VERY DIVERSE PANEL OF PEOPLE WITH SIGNIFICANT INTERESTS IN THIS. SO I WANTED TO DO A SLIGHTLY SEPARATE CHARGE THAN WE GOT AT THE MAIN SESSION AND THEN GO THROUGH A BIT OF AN AGENDA. I'VE HAD A LITTLE BIT OF CONCERN THAT OUR 80-90 MINUTE SESSION MAY END UP BEING NOT ENOUGH TO TALK ABOUT THIS. IT IS VERY CLEAR THERE IS WAY TOO MUCH TO TALK ABOUT SO I THOUGHT WE WOULD TRY TO SET EXPECTATIONS. ALSO, I DO JUST WANT TO REMIND PEOPLE THAT THERE ARE 15-20 PEOPLE THAT ARE ON THIS ZOOM CALL AND FOR THESE OF YOU WHO ARE THE ACTIVE PARTICIPANTS YOU COULD USE THE CHAT, UNMUTE, WE HOPE AT TIMES YOU'LL SHOW YOUR FACE AS WELL AND JUST TO BE FOREWARNED THAT THERE ARE A SCORE OF OTHER PEOPLE JOINING BY VIDEOCAST SO MAKE SURE JUST AS YOUR MOTHER TOLD YOU IF YOU DON'T WANT -- JUST BE CAREFUL WHAT YOU SAY BECAUSE THERE IS LOTS OF OTHER PEOPLE WATCHING. SO I KNOW BY FOLLOWING THE PARTICIPANT LIST THAT THERE WERE A NUMBER OF YOU WHO WERE ABLE TO ATTEND AT LEAST PART OF THIS FIRST DAY OF THIS NIAID SPONSORED WORKSHOP ON POST-ACUTE SEQUELAE AND I THOUGHT I WOULD REVIEW THE WRAPUP OF THAT TO FOCUS A LITTLE BIT. WE'LL SHOW THE BREAKOUT PARTICIPANTS SPECIFICALLY RELATED TO THEIR SPECIALTIES AND THEN WE'VE GOT TWO BROAD SORT OF SETS OF QUESTIONS AND I HAVE ALT ERED THESE A LITTLE BIT TO MAKE THEM A LITTLE BIT MORE FOCUSED TO THE THINGS THAT WE LEARNED ON DAY ONE AND WE'LL SPEND 30 MINUTES EACH ON THOSE AND THEN I THINK OUR BEST HOPE IS THAT I KNOW THAT ONE OF THE THINGS THAT'S REALLY REMARKABLE ABOUT PEDIATRIC SUBSPECIALISTS AND PEDIATRICIANS WE WORK REALLY WELL TOGETHER. SO I'D LIKE TO US WORK IN THE LAST 20 MINUTES OF COMING UP WITH A REVIEW SUMMARY AND REPORT OUT OF WHAT WE WOULD PRESENT BACK TO THE MAIN SESSION. SO THE OVERARCHING GOAL IS TO SUMMARIZE EXISTING KNOWLEDGE OF WHAT WAS ORIGINALLY DEFINED AS POST-ACUTE SEQUELAE OF BREAKOUT GROUPS WHICH I'VE LISTED HERE. I THOUGHT WE SHOULD MAKE SURE THAT WE RUN THIS A LITTLE BIT LIKE AN NIH STUDY SECTION AND MAKE SURE THAT WE, THAT THE THINGS THAT ARE UNIQUE TO PEDIATRICS THAT MIGHT GET FOR GOTTEN WHEN YOU TALK SPECIFICALLY ABOUT VARIOUS ORGAN SYSTEMS ARE IN FACT INCLUDED. ALL RIGHT. SO THIS IS WHAT THE LONG-TERM GOAL IS GOING TO BE. THE FINAL REPORT FOR THE PEDIATRIC SUBGROUP. WE'VE GOT ABOUT 10 MINUTES FOR WHEN WE ALL GET BACK TOGETHER AFTER THE BREAKOUT SESSIONS ARE DONE AND THE FIRST THING I'D LIKE US TO PUT INTO BUCKETS IS WHAT DO WE REALLY KNOW ABOUT LONG COVID IN CHILDREN? AND I THINK WE MAY ACTUALLY HAVE SOMEWHAT OF A BIT OF A HEAD START COMPARED TO SOME ADULTS AS WE, MOST OF THE SYMPTOMATOLOGY PATIENTS WE TAKE CARE OF ARE PATIENTS OF LONG COVID INSTEAD OF ACUTE COVID. AND LIKE THERE OTHER BRAKE OUTS THERE WILL BE A NUMBER OF KNOWLEDGE GAPS BUT WHAT ARE THE TOP THREE KNOWLEDGE GAPS THAT EXIST IN PEDIATRICS. AND THEN IT IS IMPOSSIBLE TO ADDRESS THIS BREAKOUT SESSION SINCE WE'RE THE ONLY BREAKOUT SESSION THAT IS INVOLVING THE ENTIRE HUMAN ORGANISM TO PUT A FEW COMMENTS IN THESE OTHER TWO BUCKETS, WHICH ARE SOMETHING, SOME UNIQUE PEDIATRIC THINGS THAT MIGHT NOT BE APPRECIATED WITH OTHER ORGAN SYSTEMS, OR BARRIERS TO ILIFFING THOSE KNOWLEDGE GAPS AND THEN THE GRAB BAG WHICH IS EVERYBODY'S FAVORITE. WHAT DO WE WANT THE NIH AND NIAID AND GENERAL PUBLIC TO KNOW THAT WAS NOT ACTUALLY COVERED KIND OF IN OUR STARTER QUESTIONS SO I'M GOING TO STOP FOR JUST A SECOND. WE'VE GOT TWO ADDITIONAL FACILITATORS TO TRY TO KEEP ME ON THE STRAIGHT AND NARROW. BILL FROM NIH WILL TRY TO KEEP US ON TIME. BILL, DO YOU WANT TO SAY HEY. >> YES. GOOD MORNING, EVERYBODY. >> IT IS STILL MORNING BUT WE'LL GET TO THE AFTERNOON AT LEAST FOR THOSE ON THE EASTERN COAST. SO BILL IS GOING TO TRY TO ACT AS THE PARLIAMENTENITARIAN IN CASE ANY OF YOU GUYS GET PARTICULARLY ROWDY. AND ALSO FROM THE NIH BOB TIMROR O BOB IS GOING TO TRY TO CATALOG WHAT WE'RE SAYING LARGE LY WHILE WE'RE HAVING THIS DISCUSSION AND THEN WE'LL GET BACK TO THIS PARTICULAR SLIDESET BOB IS GOING TO TRY TO PUT THE START OUR SUMMARY SLIDES AND THEN WE CAN REVIEW THEM AT THE END. BOB, DO YOU WANT TEW SAY HEY TO EVERYBODY. >> YES. THANKS ANDY. I'M LOOKING FORWARD TO THE DISCUSSION AND BEAR WITH ME IF MY NOTES AREN'T GREAT. >> WE'LL BE PATIENT WITH YOU. OKAY. I'M GOING TO ZOOM AHEAD BECAUSE I'D LIKE US TO REALLY GET OO THE AUDIENCE PARTICIPATION ASPECT OF THINGS. SO I'VE MADE A MODIFICATION FOR THOSE OF YOU WHO ARE ABLE TO ATTEND THE ENTIRE DAY ONE THERE WAS WRAPUP SLIDES AT THE VERY END. I'VE MODIFIED THOSE A BIT AND I THINK THESE ARE VERY INTERESTING TO TRY TO PUT SOME CONTEXT TO OUR FUTURE DISCUSSION. SO DAY ONE STARTED WOULD TONY FAUCI AND THESE ARE SOME OBVIOUS THINGS THAT WE KNOW DESPITE THE FACT THAT THERE ARE NOT VERY COMMON LONG-TERM COMPLICATIONS DUE TO COVID, THE OVERALL SIZE AND BREATH OF THE PANDEMIC IS GOING TO CREATE A SIGNIFICANT PUBLIC HEALTH IMPACT THAT NEED TO BE BETTER UNDERSTOOD. THE SECOND THING AND THIS CAME UP WITH TONY FAUCI AND THIS WAS REALLY ALSO KIND OF RE- EMPHASIZED BY OUR PEDIATRIC CONTENT EXPERT THAT SPOKE YESTERDAY PETER ROW IS THAT THIS PERHAPS IS NOT A ONE-AND-DONE EXERCISE. WE HAVE THIS OPPORTUNITY TO LEARN ABOUT LONG-TERM COMPLICATIONS THAT MAY EXIST FROM OTHER INFECTIONS AND PETER HAS DONE GREAT WORK WITH CHRONIC FATIGUE AND REMINDED US ALL ON DAY ONE THE OPPORTUNITIES TO DIFFERENT WAYS TO LOOK AT THIS. THE THIRD POINT THAT I THOUGHT WAS FASCINATING AND I THINK AS PEDIATRIC PROVIDERS WE APPRECIATE THIS QUITE A BIT IS THAT THERE WERE SOME TRUE TESTIMONYIALS BOTH FROM PATIENTS AS WELL AS PROVIDER WHOSE HAPPEN TO GET COVID AND THE AGENDAS FOR WHAT IS IMPORTANT TO YOU MAY BE EXTRAORDINARILY DIFFERENT. I THINK ALL OF US PARTICIPATE IN RESEARCH SO THERE IS CLEARLYY RESEARCH AGENDA FOR HOW TEW GET THE MOST SCIENTIFICALLY RIGOROUS AND PRESTIGIOUS RESEARCH DONE AND THAT DOESN'T ALWAYS ALIGN WITH THE BEST CLINICAL CARE AGENDA. JUST WANT TO KEEP THAT IN MIND BECAUSE I DON'T THINK THAT OUR GOAL CAN BE BOTH OF THESE BUT IT PROBABLY SHOULDN'T EXCLUDE ONE OF THESE. IT IS VERY HARD TO MAKE ASSIGN MENTS OF IMPORTANCE AND VARIOUS CARE CONTINUUMS AND PLAN S IF YOU DON'T ACTUALLY HAVE A DEFINITION. SO THIS WAS ONE DEFINITION THAT WE SAW YESTERDAY THAT ACUTE COVID PERHAPS IS IN THE FIRST TWO WEEKS. THIS INTERESTING TERM POST-ACUTE COVID IS LONG WEEKS AND SYMPTOMS THAT PERSIST AFTER FOUR WEEKS AND THIS IS STILL SOMETHING THAT WE DON'T HAVE DEFINED AND WE MAY SPEND TIME DISCUSSING OURSELVES. IT IS VERY CLEAR THAT ACTIVE DATA COLLECTION IS KEY TO DETECT ING LONG-TERM COMPLICATION S BUT EVEN IN ADULTS WHERE THIS HAS BEEN GO TOING ON LONGER IN PEDIATRICS THE NUMBERS ARE QUITE SMALL. THERE WAS A LOT OF ATTENTION TO NEURLOGIC BEHAVIORAL MENTAL SYMPTOMS THAT ARE PREVALENT, OBVIOUSLY MOST IN ADULTS BUT WE'VE STARTED TO SEE THESE IN CHILDREN. AGAIN FROM THE PARTICIPANTS THAT ARE REAL PATIENTS THERE REMAINS A STIGMA, A LOT OF PEOPLE HAVE STRUGGLED TO BE ACTUALLY DIAGNOSED ESPECIALLY THOSE AFFECTED EARLY ON IN THE DIAGNOSIS WITH POOR TESTING AND SOME STILL STRUGGLE TO BE BELIEVED THAT THEY HAVE SYMPTOMS DESPITE THE FACT THEY ARE WELL OVER THIS. THERE IS A MASSIVE AMOUNT OF ON-GOING RESEARCH, A NUMBER OF THAT PARTICIPANTS ON THIS CALL WITH IMMUNE RESPONSESES INCLUDING B CELLS, T CELLS, MASS CELLS DEVELOP AUTOANTIBODIES WITH IMPLICATIONS FOR LONG-TERM COVID. ONE OF THE THINGS I FOUND FASCINATING IS UNLIKE THE OTHER COMMON CORONAVIRUSES THE ACTUAL VIRAL PARTICLES ARE NOT PRESENT IN BODY TISSUES IN AUTOPSY WHICH IN MY ESTIMATION IS ONE OF THE REASONS WE SEE SUCH INTERESTING MIS-C AS THE POST-ACUTE IN FLAMMATORY STUFF. THERE WERE CERTAINLY OBSERVATION S AS WHAT WE SEE AT MIS-C IS CERTAINLY WHAT MIRRORS ACUTE-COVID IN ADULTS AND THE DESCRIBED MIS-A IS MUCH LESS REPORTED THAN MIS-C AND I THINK IT IS FASCINATING TO DISCUSS WHETHER THAT'S SORT OF A SAMP LING ERROR AND WHETHER THAT MIGHT ACTUALLY BE TRUE. AND FINALLY PEOPLE REMARKED OVERALL THAT LONG-TERM COVID HAS HETEROGENIUS EFFECTS ON MULTIPLE ORGAN SYSTEMS AND IT DAWNED ON ME IN PEDIATRICS HAVE EXISTING MODELS FOR THIS WITH KAWASAKI DISEASE AND WE ARE ALSO SORT OF USED TO GIVEN THE KAWASAKI DISEASE EXAMPLE OF WORKING TOGETHER AS SUBSPECIALISTS ULTIMATELY BOTH IN RESEARCH AND CLINICAL CARE. ALL RIGHT. SO HERE ARE THE BREAKOUT SCISSIONS MEMBERS. I'M NOT GOING TO INTRODUCE EVERYBODY BUT I WOULD SUGGEST WHEN YOU UNMUTE TO GIVE SOME IN PUT THAT YOU JUST IDENTIFY YOURSELF THAT WOULD BE GREAT. I JUST WANTED TO REALIZE THAT WE DO HAVE A LOT OF DIFFERENT SPECIALTIES, I THINK THIS IS IMPORTANT AND THIS IS HOW I BELIEVE THAT ALL OF OUR INDIVIDUAL SITES HAVE KIND OF DONE BOTH RESEARCH IN CLINICAL CARE. CARDIOLOGISTS, GENERAL CARE, A NUMBER OF NIH FACILITATORS, RHEUMTOLOGY. IT IS VERY IMPORTANT TO HAVE PHYSICAL REHAB, RHEUMTOLOGY AND A WIDE DIVERSE THING AND I'M TAKING THIS CALL FROM CHARLESTON , SOUTH CAROLINA. ALL RIGHT. NOW I'M GOING TO OPEN THIS UP HOPEFULLY TO THE MORE AUDIENCE PARTICIPATION. SO THIS IS KIND OF THE FIRST SET OF QUESTIONS THAT WE'LL HAVE TO DISCUSS AND WE'VE GOT AT LEAST 30 MINUTES TO DISCUSS THEM. BASED ON BOTH SLIDES THAT I SENT A COUPLE DAYS AGO AND INSPUT THAT A NUMBER OF YOU HAVE PUT I'VE KIND OF REORIENTED THIS. SO WE'RE GOING TO START WITH WHAT'S THE INCIDENTS AND PREVALENCE OF CERTAIN POST-ACUTE SEQUELAE SPECIFICALLY WITHIN PEDIATRIC. AND I'LL FORWARD INPUT THAT I GOT FROM SOME OF YOU THAT AGREED THAT THE LONG-TERM SEQUELAE IN CHILDREN ARE NOT SURVEYED IN A VERY REGULAR FASHION AND VERY SYMPTOMATICALLY AT THIS TIME AND WHAT LITTLE PUBLISHED EXISTS IS SCANT ESPECIALLY IN ANYTHING THAT IS NOT MIS-C. AND THEN THE OTHER, WHICH I THOUGHT WAS A REALLY FASCINATING CONUNDRUM THAT SOMEONE SUGGEST RED THE INFIRSTS IN SEQUELAE IN CHILDREN IN CERTAIN POPULATION DUE TO THE INCIDENCE OF ACUTE INFECTION OR GIVEN THE INFECTION ARE THEY MORE LIKELY TO DEVELOP SEQUELAE. SO I'M GOING TO CLOSE THE DOOR OF THE ROOM I'M IN SINCE THERE IS INSTALLATION HAPPENING IN MY KITCHEN AND HOPEFULLY SOMEBODY COMES OFF MUTE TO GIVE ME SOME IDEA OF WHAT YOU ALL THINK OF PREVALENCE. >> ANDY I CAN START. THIS IS JANE RUGGER IN CARDIOLOGY. I THINK FROM ALCARDIAC VIP THERE ARE RELATIVELY LARGE CROSS SECTIONAL OR SHORT-TERM SERIES IN MANY STUDIES BUT TEW DATE NO SYMPTOMATICALLY SURVEYED DATA ACROSS MULTIPLE CENTERS WITH A PRO-SPECTIVE PROTOCOL AND EXCELLENT IMAGING. SO THERE IS A TREMENDOUS AMOUNT THAT WE DON'T KNOW ABOUT THE HEART. WE DON'T KNOW WHAT HAPPENS TO CORONARY ANEURYSMS OVERTIME, WHETHER THEY ARE SIMILAR TO THOSE IN KAWASAKI DISEASE WITH ACTUAL DESTRUCTION OF THE ARTER IAL WALL VERSUS JUST EX TREME VASODILATION. WE DON'T KNOW ABOUT THE DETAILS YET OF LONG-TERM RECOVERY OF FUNCTION, ALTHOUGH IT APPEARS GOOD THERE ARE DATA THAT SUGGEST S STRAIN AND DIASTOLIC FUNCTION DON'T NORMALIZE IN THE NEAR-TERM. SO I THINK THERE IS A LOT OF WORK TO BE DONE. WE HOPE SOME OF THAT WILL BE DONE THROUGH THE NHLBI'S MUSIC STUDY AND WE'RE LOOKING FORWARD TO GATHERING THOSE DATA. >> JANE, I THINK YOU BRING UP A GREAT POINT THAT I DO THINK PROBABLY WE SHOULD PUT IN OUR BUCKET OF WHAT'S KNOWN AND THE ACCOMPLISHMENTS, I THINK MOST IF NOT ALL OF THE PEOPLE ON THE CALL ARE AWARE OF A NUMBER OF LONGITUDINAL COVID STUDIES THAT ARE SPONSORED. JANE SPECIFICALLY ADDRESSED THE ONE THAT'S GOT A CARDIAC FOCUS AND ALTHOUGH WE'LL BE LIMITED BY WHATEVER THE TOTAL NUMBER OF IN PUT IS IT SEEMS AS IF THAT WILL LIKELY HAVE A VERY GOOD OPPORTUNITY TO DESCRIBE SOMEBODY OF THE THINGS THAT YOU WERE DISCUSSING JANE THAT KIND OF DO YOU HAVE LONG-TERM RECOVERY, ARE THERE ADDITIONAL SEQUELAE THAT PERSISTS AND PERHAPS ALSO AT LEAST GIVES A ROAD MAP TO TRY TO COMPARE POTENTIALLY PATH O PHYSIOLOGY BETWEEN MIS-C AND SOMETHING WE'VE USED TO TREAT MIS-C WHICH IS KD FROM HISTORIC POPULATIONS. SO JANE AND I ARE BOTH CARDIOLOGISTS SO WE OBVIOUSLY ENJOY THE HEART, IT IS THE CENTRAL FEATURE, NONE OF THE ORGAN SYSTEMS WOULD GET ANY BLOOD IF IT WASN'T FOR OUR ORGAN SYSTEM, BUT I AM INTRIGUED BY PEOPLE IN OTHER SPECIALTIES ESPECIALLY SINCE WE'RE TALKING ABOUT LONG-TERM, I DON'T WANT TO DISSUADE THE AMAZING CARE TO KEEP THESE PATIENTS ALIVE AND TREAT THEM DURING BOTH THE ACUTE AND MIS-A PHASE IN THE CRITICAL CARE PHASE, BUT MORE, WHAT DO WE HAVE DONE AND WHAT ARE WE COMPLETELY MISSING ON IMMUNOBI OLOGY FRONT, INFECTIOUS DISEASE FRONTS? >> THIS IS MARYBETH, RHEUMATOLOGIST AT BOSTON CHILDRENS, AND I THINK THERE ARE SEVERAL BUCKETS OF KIDS THAT WE COULD TALK ABOUT IN TERMS OF FOLLOWING LONG-TERM, SUCH AS SPECTRUM OF ILLNESS WITH ACUTE COVID AND POST-COVID EVERYTHING FROM ATHLETES THAT NEEDED TO RETURN TO SPORTS TO KIDS WITH MIS-C AND EXTREMELY ILL IN THE E CU AND DISCHARGED ON A VARIETY OF MEDICATIONS THAT NEED FOLLOW-UP AND TAPERING. I THINK THAT THERE IS, THE CO HORT OF KIDS WITH MIS-C WHO ARE DISCHARGED ON MEDICATIONS LIKE STEROIDS OR BIOLOGICS THEY ARE BEING FOLLOWED CLOSELY AND I THINK AT EVERY INSTITUTION IT IS GOING TO DIFFER BUT I THINK RHEUMATOLOGISTS TO SOME DEGREE ARE FOLLOWING THESE KIDS AND TAPERING MEDICATIONS AND I THINK IT IS REALLYNERING TO GET A SENSE OF HOW LONG THOSE KIDS NEED FOLLOW-UP AND IF THEY GET ALL BETTER FROM INFLAMMATORY. YISM LEAVE THE CARDIAC STUFF TO THE EXPERTS, BUT I THINK THAT THERE IS A LOT TO BE LEARNED IN TERMS OF WHAT'S HAPPENING WITH THE IMMUNE SYSTEM, HOW LONG THE INFLAMMATION GOES ON AND ARE THERE ANY LONG-TERM IMPACTS FROM HAVING HAD THAT DEGREE OF INFLAMMATION SPECIFICALLY TALKING ABOUT THE MIS-C PATIENTS AND MUCH LESS KNOWN ABOUT KIDS SYMPTOMATICWALK COVID BUT NEVER COMING INTO THE HOSPITAL AND THEREFORE CONNECTED WITH US. >> MICHAEL CABANA, GENERAL PEDIATRICS IN THE BRONX. MARYBETH AND JANE, WHENEVER YOU'RE TALKING ABOUT INSTANCE OR PREVALENCE IS THE DENOMINATOR KIDS HOSPITALIZED, SYMPTOMATIC OR KIDS THAT HAD A POSITIVE PCR? SO IN GENERAL PEDIATRICS WE MIGHT SEE SOME OF THOSE KIDS AND NOT KNOW WHAT TO DO SO HOW WOULD YOU DEFINE THE DENOMINATOR FOR SOME OF THOSE STATEMENTS? >> I THINK THE DENOMINATOR FOR MIS-C BY DEFINITION REQUIRES HOSPITALIZATION AT PRESENT AND SO A LOT OF THE CARDIAC WORK THAT IS PERSPECTIVE I THINK IS HAPPENING IN THAT SITUATION. SPEAKING AS A CARDIOLOGIST THE OTHER GROUP THAT WE ARE SEEING A LOT OF, A LOT OF KIDS FOR RIGHT NOW ARE THOSE WHO HAD COVID A CUTE-COVID-19 AND WERE NOT HOSPITALIZED AND NOW ARE TRYING TO RETURN TO SPORTS. WE HAVE HAD TEAMS, WE'VE HAD, THERE ARE JUST MANY KIDS COMING IN FOR SCREENING AND SOME DO SEEM TO BE PERSISTENTLY SYMPTOMATIC WHETHERAS OTHERS WERE ASYMPTOMATIC OR JUST HAD SOME MILD SYMPTOM FOR A FEW DAYS SO I THINK THAT GROUP IS HARDER AS A CARDIOLOGIST TO GET YOUR HANDS ON THE DENOMINATOR FOR. I'LL JUST POINT OUT ON DAY ONE THERE OBVIOUSLY IT WAS MOSTLY A DULT FOCUS BECAUSE THAT'S WHERE MOST OF THE DATA AND ALBEIT SPARSE IS, AND CERTAINLY THE DEVELOPMENT OF A POST-ACUTE COVID THERAPY TEAMS AND THEY ONLY START WITH THE DENOUMENALL IER OF THOSE HOSPITAL IZED AND I THINK THAT'S INTERESTING BECAUSE THE SIMILARITIES OF MIS-C AND MAYBE ACUTE-COVID IN ADULTS BEING MORE SIMILAR. WE DO HAVE SOME GREAT REPRESENTATION FROM THE CDC, WHICH BOTH I THINK COULD HELP US UNDERSTAND A LITTLE BIT BETTER ABOUT THE DENOUMENALLIER CERTAINLY AT MIS-C AND I WAS ALSO WONDERING IF Y'ALL HAD ANY OTHER IDEA OF KIND OF ANY OTHER KIND OF LONG-TERM STUFF AND THEN THE OTHER PART THAT THE CDC CERTAINLY HELPS WITH IS IF WE WERE GOING TO USE THE OVERALL DE NOMINATOR OF POSITIVE PCR EVEN THOUGH MOST OF THOSE DON'T NEED MUCH ATTENTION WE PROBABLY HAVE THAT; IS THAT RIGHT, MAT? >> SO IT GETS CHALLENGING WHEN YOU TRY TO FIGURE OUT THE DENOM INATORS. WE'VE BEEN TRYING TO LOOK AT THAT SECOND BULLETIN YOU HAVE FOR INSTANCE, WHAT ARE THE DISPARITIES WE'RE SEEING WITH THE LONG-TERM. WE'VE APPROACHED IT FROM DIFFERENT BUCKETS THAT IS I DEALLY THE GREATICATE NOMINATOR WE'D LIKE TO HAVE IS HOW MANY KIDS HAD PCR POSITIVITY BUT I THINK WE ALL KNOW THAT THAT NUMBER IS ANY NUMBER WE GET IS A GROSS UNDER-ESTIMATION AND THAT DENOMINATORSER HARD TO PINPOINT. WHEN WE LOOK AT THE NUMBER OF A DULTS AND ASSUME THAT'S IN THE POPULATION OR PREVALENT STUDIES. I THINK YESTERDAY THERE WERE A COUPLE TALKS FROM EARLY ON LOOK ING AT DIFFERENT METHODS AT GETTING TO THE OVERALL NUMBERS AND THAT'S HARD IN ADULTS AND I THINK THAT'S EVEN HARDER IN CHILDREN SINCE SO MANY ARE ASYMPTOMATIC YET WE ARE SEEING SOME OF THESE LONG-TERM OUTCOMES WHETHER THEY BE CARDIAC OR OTHER THINGS LIKE JANE WAS SAYING A LOT OF THE OUT-PATIENT THINGS ARE HARD TO CAPTURE, YOU KNOW LITTLE PUBLISHED DATA THAT WE KNOW I THINK THERE ARE SOME KIDS WHO HAVE ON-GOING FATIGUE WHO HAVE ON-GOING NEURLOGIC MANIFESTATIONS, KIND OF THE CRIT ICAL THINKING PROBLEMS THAT WE HEARD ABOUT YESTERDAY BUT DON'T RISE TO THE LEVEL OF MIS-C OR ADMISSION. I JUST THOSE KIDS ARE VERY HARDER TO FIND. I DON'T THINK WE'RE ANYWHERE CLOSE TO GETTING ANY SORT OF INCIDENCE OR PREVALENCE IN SEQUELAE IN KIDS WHO DON'T MAKE IT TO THE HOSPITAL. >> MAT, I HAVE A QUESTION TEE ADD TO THAT. I WAS LISTENING TO JOHN BROOKS, MY FRIEND DOWN THERE TALK ABOUT YESTERDAY I THINK HE ACTUALLY PUT IN THE COMMENT BOX THAT THERE IS GOING TO BE A REALLY IMPRESSIVE EFFORT TO TRY TO CAP TURE THE FEMA TYPE OF WHAT THIS DISEASE IS IN ADULTS AND I WAS SORT OF WANTING TO COME BACK AND SAY WHAT ARE WE GOING TO BE DOING TO TRY TO BUILD THE FEMA TYPE OF WHAT POST-ACUTE COVID IS IN CHILDREN; CAN YOU SPEAK A LITTLE TO ANY OF THOSE EFFORTS? >> YES, SO A LOT OF THE FEMA TYPE OR POST-ACUTE IN CHILDREN HAVE BEEN FOCUSED ON MIS-C, THAT'S THE LOW-HANGING FRUIT. CERTAINLY DISCUSSIONS ABOUT ARE THERE OTHER THINGS. WE'VE HAD DISCUSSIONS, LIKE JANE SAID, ABOUT HOW DO WE CAPTURE THE ATHLETES OR THE OTHER KIDS WHO HAVE OTHER THINGS OUTPATIENT OR THE NEUROSTUFF, IS THERE A WAY TO CONCLUDE THAT IN SURVEYS GO TOING OUT. SO CERTAINLY SOMETHING BEING DISCUSSED. I CAN'T SAY THERE ARE ANY GREAT SOLUTIONS APARTMENT FROM THE MIS -- SOLUTIONS APART FROM THE MIS-C. >> I'M AN INFECTIOUS DISEASE SPECIALISTS AND WE'RE LEADING A NATIONAL EFFORT WITH THE COVID-19 PEDIATRIC REGISTRY. SO I THINK WHAT IS INTERESTING IS WE CAN START ASKING THE QUESTIONS BUT WHAT QUESTIONS TO ASK BECAUSE WE HAVE 28 DAY SURVEY BUT WHEN WE BUILT IT WE WERE ONLY INK THING ABOUT AS YOU'VE SAID ABOUT MIS-C WHICH IS THE HIGHEST FREQUENCY WE HAVE, WE'VE LOOKED AT 5,000 OF OUR 28 SURVEYS AND THE BIGGEST FREQUENT SIES AND MAJORITY OF THE KIDS WE HAVE NOT THE THINGS WE'VE MENTIONED BUT HOW DO WE START CAPTURING THINGS IF WE DON'T KNOW WHAT QUESTIONS TO ASK AND HOW DO WE ASK THEM? OUR REGISTRY IS FROM WHATEVER IS IN THE AMR AND OBVIOUSLY WE'RE NOT AS IN THE GENERAL, IN THE CLINICAL SIDE WE'RE NOT ASKING THE QUESTIONS THAT WE NEED TO BE ASKING TO THESE CHILDREN WHO HAD COVID-19 AND THIS IS PCR POSITIVE NOT JUST MIS-C, IT IS ACROSS THE BOARD INPATIENT AND OUTPATIENTING AND WHAT WE CAP TURE AT 28 DAYS IS ESSENTIAL AS FAR AS SEQUELAE. >> YOU POINT OUT THE ISSUE THAT WE ALL HAVE, IT IS EASIEST THOO GET THE MOST AMOUNT OF DATA WHEN YOU DON'T HAVE CONSENT BUT YOU'RE LIMITED TO THE DATA SET YOU GET TONS MORE DATA IF YOU CAN IN FACT SPECIFICALLY ASK THE QUESTIONS, I'M JUST GOING TO PRO POSE THAT ONE POTENTIAL MO DALITY IS AS WE LEARN MORE ABOUT THIS THE OPPORTUNITY TO DO , ADD EITHER OTHER QUESTIONS TO EXISTING OBSERVATIONAL CO HORTS THAT ARE BEING FOLLOWED OR ANCILLARY STUDIES IN THAT POP ULATION. IT SEEMS AS A GROUP WE'VE DONE A REASONABLEGLE JOB OF BEING SOMEWHAT UNIFORM OF OUR TREATMENT AT MIS-C. I'M INTRIGUED BY PEOPLE'S DISCUSSION ABOUT THE FACT THAT OUTSIDE OF MIS-C THE ONLY KIND OF TARGETED POPULATION THAT WE SPECIFICALLY LOOK FOR LONG-TERM EFFECTS ARE THOSE ATHLETES. I'M INTERESTED IN WHETHER WE'VE GOT SORT OF A UNIFORM AMOUNT OF TESTING OF THE ATHLETES AND COULD WE USE THE CONCEPT OF WHAT WE FIND IN THE ASYMPTOMATIC ATHLETES THAT ARE REQUIRED TO GO THROUGH TESTING BEFORE THEY GO BACK TO PLAY SPORTS TO POTENTIAL LY COME UP WITH A SCREENING TOOL THAT WE MAY SAY IS NECESSARY FOR ANYBODY THAT HAS HAD COVID-19 PCJ NOT HOSPITALIZED. THIS IS SARAH HOPKINS, I'M A NEUROLOGIST AT THE CHILDREN'S HOSPITAL IN PHILADELPHIA. I THINK THAT'S ACTUALLY A REALLY INTERESTING IDEA USING THE ATHLETES KIND OF TO FURTHER DESCRIBE THE PROBLEM. MOSTLY BECAUSE YOU KNOW AS A NEUROLOGIST IN GENERAL NEUROLOGY CLINTHIC KIDS THAT I SEE ARE MOSTLY THE PATIENTS THE DR. ROW DESCRIBED, THE ONES THAT ARE HAVING CHRONIC FATIGUE, THE ONES THAT ARE DIZZY BECAUSE THEY HAVE AUTONOMIC INSTABILITY. IT IS TRUE THAT IT IS THE ATHLETES COMPLAINING ABOUT IT THE MOST BECAUSE THEIR PREMORBID STATUS WAS SO GREAT THAT THEY REALLY NOTICED THAT DIFFERENCE. SO I THINK THAT'S AN INTERESTING IDEA MAYBE WITH SOME POTENTIAL BECAUSE I'M AFRAID THAT JUST, IF WE WERE TO JUST TAKE THE KIDS THAT WE SEE IN NEUROLOGY CLINICS BECAUSE THESE PROBLEMS ARE REALLY BAD WE'RE JUST HITTING THE TIP OF THE ICEBERG AND EVEN THOSE KIDS IF WE WERE TO JUST LOOK AT THEM THEY LOOK TOTALLY FINE, THEY ARE NOT FUNCTIONING WELL, AND YOU KNOW SOMETIMES THEY ARE VERY TIRED BUT YOU KNOW THERE IS NOTHING OBVIOUS OTHERWISE THAT WOULD LET YOU PICK THEM UP IF THEY HADN'T IDENTIFIED THEMSELVES. >> THIS IS MELISSA TRIVATA ONE OF THE REHAB DOCS AT KENNEDY. I THINK THAT'S AN INTERESTING PLACE TO START. IATE DO THINK WHAT WE'RE SEEING HERE AND DR. MARO WHO IS ON COMMENT AS WELL BECAUSE SHE IS THE DOCTOR IN THE CLINIC BUT WE'RE SEEING A LOT OF THE SAME THINGS THAT DR. ROW DESCRIBEDDED AND WE TEND TO SHARE PATIENTS SO WITH CHRONIC FATIGUE ANDAL NOT ALL OF THEM HAVE BEEN ATHLETES. I ALSO THINK FROM ALPEDIATRIC PERSPECTIVE SORT OF THINKING BE GINNING AND END BUT LIKE IN TERMS OF THE FATIGUE AND STUFF ARE THEY GETTING BACK TO SCHOOL? ARE THEY ABLE TO PARTICIPATE IN WHAT THEY WERE PARTICIPATING IN AND NOT FORGETTING IT IS NOT ONLY THE ATHLETES RIGHT IT IS ARE THEY ABLE TO GO TO SCHOOL OR VIRTUALLY OR WHATEVER IT IS AND DO WHAT THEY NEED TO DO AND I THINK WE NEED TO BE CAPTURING THE KIDS THAT AREN'T EVEN ABLE TO PARTICIPATE AT THAT LEVEL, WHICH MAYBE WERE NOT ATHLETES TEE START WITH AND MAYBE WE'RE NOT CAPTURING THEM UNTIL THEIR SCHOOL PERFORMANCE GETS SO BAD THAT THE PARENTS GET SO WORRIED AND IT TAKES MONTH BEFORE THEY END UP WITH DR. O OR WITH US TO FIGURE OUT MORE SUBTLE CHRONIC FATIGUE AND HELP THEM GET BACK ON THEIR FEET. SO YES OR NO OF A WAY TO CAPTURE THAT IF WE HAD A QUESTIONNAIRE BUT DIGGING INTO THAT CHRONIC FATIGUE AND SCHOOL QUESTIONS FROM ALREHAB PERSPECTIVE I THINK IT IS IMPORTANT. >> I THINK THAT THE SCHOOL QUESTION IS REALLY EASY AND THOSE ARE THE KINDS OF THINGS THAT COULD EASILY BE INCORPORAT ED INTO EXISTING COG HORT STUDIES. I'M INTERESTED. WE ALL ULTIMATELY SEE MORE OF THE ONES MORE ACUTELY AFFECTED AND SEEK US OUT. FROM THE REHAB OR PETER OR NEUR LOGIC ARE THERE SOME REALLY BASIC EASY SCREENING TESTS FOR SOME OF THESE DEFICITS THAT ARE EASY ENOUGH THAT GENERAL PEDIATRICIANS COULD DO THIS? AND I DON'T MEAN GENERAL, IN AN OFFICE? IS THAT YOU, PETER? >> YES. FOR THE CHRONIC FATIGUE SYNDROME PATIENTS THERE ARE A NUMBER OF FAIRLY EASY QUESTIONNAIRES THAT CAN CAPTURE AT LEAST THE LEVEL OF DYSFUNCTION AND IN OUR STUD IES WE'VE USED TWO PRIMARY ONES, ONE IS THE PEATS QL, QUALITY OF LIFE MEASURE WHICH IS PRETTY USEFUL IN PEDIATRICS AND PROVIDES A NICE COMPARE COMPARISON 1 CONDITIONS AND THESE PATIENTS A LOT OF THE FUNCTIONAL COMPONENTS THAT'S CAP TURE IN THAT QUESTIONNAIRE REALLY DEPENDS ON WHETHER YOU CAN GET TO SCHOOL LIKE MELISSA WAS SAYING, SO WHEN YOU MEASURE THE PEATS QL TOTAL SCORE IN CHRONIC FATIGUE SYNDROME PATIENTS THEY ARE WORSE WITH KIDS WITH SICKLE CELL DISEASE, CYSTIC FIBROSIS, THIS IS ALL DATA PUBLISHED IN THE JOURNAL OF PEDIATRICS FROM THE GROUP IN CINCINNATI BUT THEY ARE WAY WORSE. THIS IS ONE OF THE MOST COMMON CAUSES OF PROLONGED SCHOOL ABSENCE IN ANY JURISDICTION SO YOU CAN CAP CHAR THAT WITH THE PEATS QL. THE OTHER ONE IS EASY, IT IS A SIMPLE ONE PAGER IS THE FUNCTION AL DISABILITY INVENTORY WHICH GETS 70 ON PEATS QL AND THEN PEATS QL MULTI-DIMENSIONAL FATIGUE INVENTORY THAT GETS THE COGNITIVE STUFF AS WELL. THREE REALLY SIMPLE ONES. KEEP IN MIND THESE PATIENTS WHEN THEY COME IN DON'T HAVE ALL OF THE ENERGY IN THE WORLD SO THERE IS A BURDEN THAT WE PLACE ON THEM IF WE GIVE THEM TOO MANY QUESTIONNAIRES TO FILL OUT. BUT THOSE ARE SOME REALLY GOOD ONES THAT I THINK PEOPLE CAN EM PLOY. >> I WOULD SAY TOO, FROM IF YOU'RE ACTUALLY SEEING SOMEBODY IN A CLINKING AND THIS COULD BE DONE IN A GENERAL PEDIATRIC SAID SETTING AND WE'VE EVEN HAD SUCCESS IN TELEHEALTH IS REALLY DOING THAT STANDING TOLERANCE TEST. AS PETER WAS TALKING YESTERDAY PEOPLE CAN USE THEIR FITBIT FOR SOMETHING ELSE IF THEY HAVE SOME SORT OF APP OR COUNT THEIR PULSE BUT PRETTY CLEAR WHEN THEY'VE BEEN STANDING UP LONG ENOUGH AND HAVE SYMPTOMS EVEN IF YOU CAN'T GET ALL OF THE DATA YOU CAN FIGURE OUT DO THEY HAVE SOME DIS AUTONOMIA AND WHAT DO WE NEED TO DO TO IMPROVE THAT AND I THINK THAT CAN BE DONE REGARD LESS OF WHERE THEY ARE ACCESSING THEIR CARE IT IS JUST MORE ABOUT PUTTING THE WORD OUT AND TEACHING PEOPLE ABOUT IT TO BE ABLE TO MAKE THAT POSSIBLE FOR EVERYBODY TO ACCESS. >> GREAT. GO AHEAD. >> MARYBETH FROM RHEUMATOLOGIST ERTOLOGY. I WAS GOING TO SAY QUICKLY WE SEE A LOT OF THE POST-VIRAL KIDS AND THIS WOULD FALL UNDER THE POST-VIRAL SYSTEM. TO SOME DEGREES IN RHEUMTOLOGY SYMPTOMS ARE NOT ALWAYS SO BAD THEY TEND NOT TO GO TO SCHOOL BUT HAVE OTHER PHYSICAL EXAM FINDINGS YOU CAN RELY ON. I THINK IT'S BEEN REALLY ENTANGLED WITH THE STRESSERS OF THE PANDEMIC SO IT IS HARDER TO TELL IF THEIR FUNCTION IS LOW BECAUSE THEY HAVE TWO CHARACTERISTICS OF THE SYNDROME VERSUS AT THE STRESSERS THAT TYPICALLY THEADOLESCENTS ARE EXPERIENCING FROM THE PANDEMIC. I DO THINK THE MEASURES THAT DR. ROW MENTI ONED WHICH ARE PRETTY STRAIGHT FORWARD AND SIMPLE TO COLLECT WOULD GIVE US MORE OBJECTIVE DATA ON HOW TO MEASURE THIS OVER TIME. >> MARYBETH THAT'S A GREAT POINT AND I'M NOT SO SURE THAT WHAT YOU SAID ISN'T WHAT ACTUALLY MAKES THE MOST SENSE. ONE OF THE THINGS THAT WE'VE SPECIFICALLY SORT OF WEREN'T CHARGED TO DO BUT I REFUSE TO IGNORE IS THAT THERE ARE MASSIVE LONG-TERM EFFECTS OF THE PANDEMIC ON CHILDREN THAT HAVE NOTHING TO DO WITH THE DISEASE PROCESS AND PEATS QL, WHICH WE EVEN CARDIOLOGISTS USE IS REALLY EFFECTIVE IN GIVING THAT HOLIST IC CONCEPT, WHICH IS PROBABLY THE, IF WE'RE GOING TO REALLY KIND OF DO WHAT WE CAN FOR THE ENTIRE POPULATION OF CHILDREN MAYBE THAT, THE FACT THAT WE CAN'T TEASE IT OUT IS NOT NECESSARILY ARBAD THING. I'M GOING TO MOVE US DOWN A LITTLE BIT JUST SO WE CAN, I THINK THIS HAS BEEN A RICH CONVERSATION. DO WE HAVE ANYTHING, ANY REASON TO BELIEVE AND I'M GOING TO REALLY PUSH ON BACK TO YOU MARY BETH. ANY REASON TOON SPECIFIC THE PATH OF PHYSIOLOGICAL MECHANISMS ARE SIGNIFICANTLY DIFFERENT AND DO WE NEED, EXCUSE ME, DO WE NEED SIGNIFICANT MORE SAMPLES IN CHILDREN BECAUSE WHATEVER IS EASILYECT WHICHED IN ADULTS WOULD NEVER TELL US THE INFORMATION WE NEED TO KNOW FOR KIDS? >> I CAN START. I'M SURE THERE IS OTHERS WHO HAVE A LOT OF THOUGHTS ABOUT THIS AS WELL. I REMAIN STRUCK BY THE FACT THAT WE'RE TALKING ABOUT THIS GROUP OF CHILDREN AS THOUGH THEY ARE SOMEWHAT HEMOGYNISTS AND SO I THINK THAT IF YOU TALK ABOUT PATH OPHYSIOLOGICAL MECHANISMS AND MIS-C WE HAVE SOME DATA WHERE KIDS WHO HAVE HAD ACUTE COVID-19 PNEUMONIA BUT NEVER GOT HOSPITALIZED AND KIDS WITH ASYMPTOMATIC FUNCTIONS AND CARDIAC FINDING SAID ON MR, VERSUS KIDS WITH CARDIAC SYMPTOM S MY BETSET IT IS DIFFERENT FROM SOMEDEGREE. SO HAVING THIS MULTI-LAYER APPROACH LIKE TODAY IS CRITICAL. I THINK THAT TO TRY TO ANSWER YOUR QUESTION DIRECTLY IN TERMS OF WHAT'S DIFFERENT WITH ADULTS I THINK DEVELOPING IMMUNE SYSTEM DOES HAVE DIFFERENT VULNERABILITIES THAN A MATURE ONE AND WE'RE LEARNING MORE ABOUT WHICH ADULTS ARE AT HIGHER RISK FOR ACUTE COVID IN THE REALM BUT THERE IS A LOT TO BE LEARNED AND I DON'T THINK WE SHOULD ASSUME IT IS THE SAME BETWEEN THE KIDS AND ADULTS ESPECIALLY ACROSS THE SPECTRUM OF POST-COVID. >> TRISIS ADRIAN RANDOLPH AND I SUPER THE OVERCOMING COVID-19 COB HORT. WE HAVE ACUTE COVID, AS WELL AS MIS-C IN OUR COHORT AND ONE THING THAT'S REALLY DIFFERENT IN ACUTE SEVERE COVID-19 IS SOME OF THE RISK FACTORS IN ADULTS ARE SIMILAR,: OBESITY AND UNDERLYING CONDITIONS ARE MUCH MORE PREVALENT IN THAT GROUP OF PATIENTS AND THEIR OLDER, ESPECIALLY FOR TEENAGERS IT SEEM S LIKE THEY SEEM VERY SIMILAR TO YOU KNOW THE ADULTS. I'M NOT SURE IF THAT MEANS THEIR SEQUELAE ARE SIMILAR BECAUSE THEY HAVE A MUCH LONGER LIFESPAN AND AND WE ALSO HAVE NOT LOOKED AT ALL OF THE LUNGS OF THESE CHILDREN WHO ARE HOSPITALIZE WOULD RESPIRATORY COMPLICATIONS TO LOOK FOR FIBROSISIS AND OTHER THINGS THEY ARE LOOKING FOR AND ADULTS HAVE FOLLOWED THEM UP FOR YOU KNOW TO SEE IF THEY ARE HAVING SYMPTOMS. THE OTHER BIG GROUP IS INFANTS BORN TO MOTHER WHOSE ARE COVID POSITIVE OR GET COVID POSITIVE VERY EARLY IN LIFE. I KNOW THERE ARE SOME FOLLOW-UP STUDIES OF THOSE HOSPITALIZED AND MOST OF THEM UNDER THREE MONTHS OF AGE AND IT IS CLEAR THAT THE LABORATORY TESTS SHOW THEIR IMMUNE SYSTEMS AFFECTED WITH LYMPH NODE AND SOME GROUPS ARE VERY DIFFERENT. THE TEENAGERS IT IS UNCLEAR IF THEY ARE VERY SIMILAR TO THE UNG I ADULTS WITH ACUTE-COVID WHEREAS THE MIS-C SEEM TO BE A VERY DIFFERENT GROUP OF PATIENTS AGE AND UNDERLYING CONDITIONS- WISE WITH A YOUNGER AGE AND LESS UNDERLYING CONDITIONS. >> THANKS ADRIAN. I THINK YOU CAN TELL FROM YOUR GREAT COHORT STUDIES THAT WE'RE GOING TO BE ABLE TO TRACK A LOT OF THAT LONG-TERM SEQUELAE AND WHAT THEY ARE. I THINK THE PATH SAYSOLOGY YOU'LL BE ABLE TO GET SOME AND THOSE WHO ARE PARTICIPATING IN THE PRISM STUDY SIMILARLY THAT'S GOT A MORE IMMUNOLOGICAL FOCUS. I EQUALLY THINK IT IS FASCINATING WITH THE SEQUELAE PATH OF PHYSIOLOGY IS PROBABLY DIFFERENT MORE SO WITH THE AGE OF THE CHILDREN THAN BETWEEN THE CHILDREN AND ADULTS. I AM GOING TO KEEP MOVING US A HEAD BECAUSE THIS IS GREAT. SOMEBODY WAS JUST ABOUT TO SAY SOMETHING. >> ANDY I WAS JUST GOING TO ADD I THINK THE ANSWER TO THAT QUESTION IS THAT THINGS WILL BE VERY DIFFERENT FROM ADULTS. IT IS NICE TO EXTRAPOLATE WHAT WE CAN FROM THEM BUT IN THE LIMITED THINGS THAT WE HAVE IN TRYING TO EXTRAPOLATE ANDT RE PRODUCE I'VE BEEN SHOCKED AT HOW DIFFERENT SOME THINGS ARE. AS A CARDIOLOGIST LIKE I SAID JUSTICE TO GIVE THE EXAMPLE SOME OF THESE KIDS HAVE BEEN REALLY SICK, NEEDING PRESSERS, VERY CHALLENGING TO TAKE CARE OFQUAL THEN WE GET THEIR MRIs THREE MONTHS LATER YES, IT IS A LIMIT ED EXPERIENCE BUT WE'VE HAD OVER A DOZEN NOW AND I WAS EXPECTING TO SEE SIGNIFICANT FINDINGS ESPECIALLY BASED ON THAT STUDY OUT OF GERMANY THAT SAID 70% OF ADULTS WHO EVEN HAD ASYMPTOMATIC COVID, SOME OF THEM , HAVE FINDINGS ON THEIR MRI AND THE KIDS REBOUND JUST DIFFERENTLY. SO THAT'S GOOD NEWS BUT I THINK TOOL ANSWER YOUR QUESTION, YES WE'RE GOING TO HAVE DIFFERENT MECHANISMS IN KIDS THAN ADULTS FOR SURE. >> I'M GOING TO BRING UP THE OBVIOUS OTHER PART WHICH IS ADRIAN YOU'RE ABSOLUTELY RIGHT THE OLDER TEENAGERS SO MUCH LIKE THE ADULT BUT I THINK CHILDREN IN GENERAL POTENTIALLY ARE SO DIFFERENT IN ADULTS BASED EX CLUSIVELY ON THE FACT THAT THEY ARE MUCH MORE, THIS SOUNDS LACK OF A BETTER WORD, PURE, THEY ARE NOT RIDDLED WITH COMORB IDITIES, SO THE PATH OF PHYSIOLOGICAL MECHANISMS THAT WE DO MANAGE TO OBTAIN ESPECIALLY THOSE WITHOUT SIGNIFICANT OBESITY, TEENAGERS, MAY ACTUALLY GIVE US THE BEST IDEA OF WHAT ACTUALLY DISEASES ARE DOING AS OPPOSED TO ALL OF THE EXTRA COMPLICATED FEATURES OF COMORB IDITIES. >> I THINK POTENTIALLY ALONG THAT LINE IS THE OTHER THING IS THAT KIDS SEE PHYSICIANS MORE THAN ADULTS. SO WE MAY HAVE MORE BETTER BASE LINE ON OUR AGENDA THAN A DULTS. >> WE'RE ABOUT TO GET TO SOMETHING REALLY SEXY ON THE NEXT SLIDE SO I'M GOING TO GO THROUGH. WE'RE NOT SURE, WE CERTAINLY DON'T BELIEVE THAT CHILDREN ARE GOING TO BE THE SAME AS LITTLE A DULTS SO WE NEED THE ON-GOING COG HORT DATA FOR THAT. SIMILARLY, I THINK EVERYBODY REALIZES WE'RE NOT ENTIRELY SURE WHAT THE RISK FACTORS AND RISK MARKERS ARE BUT THOSE ALSO WOULD BE BEST ASCERTAINED BY A MORE THOROUGH COHORT SORT OF THINGS AND THEN THE LAST BULLET, WHICH WOULD GET A LOT OF ATTENTION, BUT I DO WANT TO MAKE SURE THAT WE REALIZE THAT WE ARE TRYING TO FOCUS ON LONG-TERM EFFECTS AND NOT THE ACUTE EFFECTS BUT IN PARTICULAR I WANTED TO GIVE A LITTLE BIT OF OXYGEN TO THIS REALLY INTERESTING COMMENT THAT IS RED BULLET NUMBER THREE AND WITH LIMITED TESTING DOWN TO AGE 12 IN RELATIVE SMALL NUMBERS OF CHILDREN IN PLANNING TO GET TEST ED HOW DO WE DETERMINE SAFETY IN VACCINES IN CHILDREN? OKAY THAT'S A BIG ONE. >> ANDY THIS IS MAT AGAIN FROM C DC IN SOUTH CAROLINA. I PUT IN THAT BULLETIN. SO THE REASON I BRING THAT UP IS WE WERE JUST DOING SOME NUMBERS TRYING TO ESTIMATE INCIDENCE OF MIS-C TRYING TO TAKE INTO ACCOUNT OF THE THINGS WE TALK ABOUT EARLIER ON WHAT IS THE TRUE BURDEN AS FAR AS COV V2 IN FECTIONS AND WE GOT BALLPARK SOMEWHERE AROUND ONE AND 5,000 AS FAR AS COV-2 THAT MIGHT BE A HIGH NUMBER OR LOW STILL IT IS A NUMBER THAT IS MOVING. IT IS A MOVING TARGET NUMBER BUT JUST AUSE THAT NUMBER. I SAW THIS WEEK THAT MODERNA SAID THEY ARE GOING TO TEST THEIR VACCINE IN 3,000 CHILDREN AND I DON'T EVEN KNOW IF THAT'S 1500 TO GET THE VACCINE AND 1500 IN PLACEBO SO IT KIND OF BEGGED THE QUESTION THEN LET'S SAY IT TAKE SAID 5,000 NUMBER NEEDED TO TREAT TO SEE A CASE OF MIS-C AND YOU'RE ONLY TESTING 1500 OR 3,000. IF YOU DON'T SEE ANY CASES OF MIS-C FROM THE VACCINE, WHICH PEOPLE RECOGNIZE THE THEORETICAL RISKS DON'T REALLY KNOW THE FULL MECHANISM OF MIS-C YET, WOULD YOU DEEM THAT VACCINE SAFE FOR CHILDREN? AND YOU KNOW, WHAT ARE THE SAFETY THINGS THAT NEED TO COME IN FOR CHILDREN? CERTAINLY WE'RE STILL ALWAYS AWAY FOR A VACCINE FOR CHILDREN BUT I THINK THE SOONER WE START IGE THING ABOUT THAT THE BETTER. JUST TO JUMP IN. WHEN WE THINK ABOUT THE SAFETY OF THE VACCINES WE HAVE TO WEIGH THAT RISK AND BENEFIT RIGHT. SO SINCE THE VAST MAJORITY OF CHILDREN HAVE ALMOST NO PROBLEMS WITH THIS VIRUS AT ALL AT LEAST ACUTELY AND WE OF COURSE ARE TALKING ABOUT THE UNKNOWN LONG-TERM SEQUELAE WHICH WE'RE ALL WORRIED ABOUT BUT SO FAR THEY DO VERY, VERY WELL IN THE A CUTE SETTING AT LEAST WITH THIS VIRUS SO WHEN YOU START THINKING ABOUT WEIGHING THE RISK AND BENEFITS OF THIS VACCINE BY AND LARGE I THINK THIS VACCINE IS TO PROTECT THEIR TEACHERS AND FAMILIES RIGHT, NOT TO PROTECT THE CHILDREN THEMSELVES FROM THIS ACUTE INFECTION. >> I THINK THAT WAS A GREAT COMMENT. AND THIS IS GOING TO BE LESS OF A PROBLEM IN PEDIATRICS BUT I'M REALLY FASCINATING TO KNOW WHETHER THE OTHER BREAKOUT SESSIONICIZE GOING TO WRESTLE WITH WHAT MY NEXT COMMENT IS, WHICH IS THERE IS A HUGE STRUGGLE ABOUT WHAT THE DEFINITION IS AND YOU CAN'T AND WHETHER YOU CAN GET HEALTH CARE AS AN ADULT UNLESS YOU'VE ACTUALLY BEEN DIAGNOSED WITH COVID-19 AND I'M FASCINATED TO KNOW WHEN THE VACCINE COMES OUT AND YOU ACTUALLY CAN MEASURE ANTIBODIES DUE TO THE VACCINE DOES THAT SUPER COMPLICATE THINGS WITH RESPECT TO EVER DETERMINING WHETHER YOU HAD COVID-19 BECAUSE NOW YOU'VE GOT THIS WOULDN'T BE POSITIVE BUT YOU WOULD BE ANTIBODY POSITIVE. AND EVEN WITHIN RESEARCH YOU WOULD THEN HAVE A COHORT THAT'S BEEN VACCINATED VERSUS NOT SCUT ANYWAY. ONE OF THE MANY REASONS. >> THAT'S AN IMPORTANT QUESTION, ANDY BECAUSE ESPECIALLY IF WE'RE DIAGNOSED AS MIS-C WHERE PEOPLE VERY MUCH GET THE ANTIBODY TEST ING AND I ASKED FLORAE KRAMER THAT WHO IS AN ANTIBODY EXPERT AND HERE IS THERE ARE SOME ANTIBODIES THAT ARE NOT IN ANY OF THE VACCINES THAT WON'T BE TRIGGERED BY VACCINES SO YOU KNOW THERE WILL, IN THE FUTURE, BE A WAY POTENTIALLY TO TEST FOR ANTIBODIES THAT ARE NON-VACCINE AND DUE TO ACUTE INFECTION. >> THAT'S REALLY GREAT ADRIAN. THAT WAS ELUDEDDED TO A LITTLE BIT YESTERDAY THAT MAYBE THERE MIGHT BE A D CELL OR A T CELL TEST THAT HAS MEMORY ABILITY TO BE ABLE TO TELL YOU ACTUALLY HAVE THE INFECTION. I WANT TO GIVE A SECOND TO SEE IF ANYBODY ELSE WANTS TO TALK ABOUT THE TOPIC SAID THAT ARE ON THIS PAGE. AGAIN, EVERYTHING IS RELATED SODE WE'VE GOT ONE MORE PAGE I WAS GOING TO PIVOT TO NEXT. >> ANDY CAN I MAKE TWO POINTS: ONE, IS THAT WE HAVE VERY LITTLE DATA YET ON THESE LONG COVID PATIENTS THAT LOOK LIKE THEY HAVE MIS-CS. BUT ALL WERE ANTIBODY NEGATIVE. NOW I SUPPOSE IT IS POSSIBLE THEY DIDN'T HAVE COVID BUT THE OTHER INTERESTING QUESTION THAT RAISES IS IF THEY DID WHAT'S WRONG WITH THEIR IMMUNE RESPONSE AND IS THAT PARTLY WHAT PREDIS POSES THEM TEE THIS KIND OF INFECTION, THAT'S ONE POINT. THE SECOND IS ABOUT THE QUESTION IN THE FIRST, OR THE FIRST QUESTION WHEREAS IS THIS SOMETHING THAT THESE RISK FACTOR S ARE DIFFERENT THAN THE ONES WHO GET THE ACUTE HOSPITALIZATIONS? AND GOING BACK FOOTHE MECFS EPIDEMIOLOGY ONE OF THE THING THAT'S STRIKING IS THERE IS A COUPLE STUDIES WHERE PEOPLE RECRUITED MECFS CHILDRENNER AND CLAIM THE RATES OF ILLNESS ARE MUCH HIGHER IN AFRICAN AMERICANS AND HISPANICS AND CAUCASIANS LESS SO AND THAT THEY ARE LESS COMMON IN PROFESSIONAL CLASSES, WHAT WE FIND IN CLINIC AND I THINK THIS IS A UNIVERSAL PHENOMENON IS THAT DOESN'T HOLD AT ALL, THAT ALMOST ALL OF THESE PATIENTS ARE CAUCASIAN AND IT DOESN'T HAVE ANYTHING TO DO WITH ACCESS TO CARE. YOU KNOW, THAT WAS THE INITIAL THOUGHT THAT THE RISEN WE'RE NOT SEEING THE AFRICAN AMERICAN KIDS IS BECAUSE OF SOME FACTOR RELATED TO POVERTY OR HEALTH INSURANCE BUT WHEN YOU LOOK AT A PLACE LIKE AUSTRALIA AND THEY HAVE A BIG CHRONIC FATIGUE SYNDROME IN MELBOURNE AND IT IS A VERY MULTI-ETHNIC POPULATION 95% OF THEIR PATIENTS ARE CELTIC OR SCANDINAVIAN EVEN THOUGH 40% OF THE POPULATION OF MELBOURNE AND THEY HAVE NO PROBLEMS WITH ACCESS TEES CARE. ACCESS TO CARE. YOU CAN MAKING THE ARGUMENT OF GENETIC MIGRATION PATTERNS THAT PUT PEOPLE WITH IRISH, ENGLISH, SCOTTISH AND SCANDINAVIAN BACK GROUNDS ARE SOMEHOW AT A GREATER RISK FOR THIS PROBLEM, I DON'T THINK YOU COULD ATTRIBUTE IT JUST TO SES WHICH SOME THE EASIEST EXPLANATION, THEY USED TO CALL IT-UPY-- YUPPY FLU AND A WAY OF BLAMING THE PATIENTS. THAT MIGHT GET US TO THE PATH OF PHYSIOLOGY OF THE ILLNESS BETTER >> PETER THAT WAS A GREAT SETUP. ONE OF THE THINGS I GOT REALLY, I GUESS IT DIDN'T PUT IT HERE, IT IS THE VERY LAST BULLET. I THINK THERE IS A DIFFERENT WAY TO SPIN EXACTLY WHAT YOU SAID WHICH YOU KNOW WE HAD A GREAT TALK AT THE VERY BEGINNING OF TODAY'S SESSION ABOUT THE SOCIAL DETERMINANTS OF HEALTH BASED EX CLUSIVELY ON THE DEMOGRAPHICS OF DISEASE BURDEN, NOT AT ALL ON PATH OPHYSIOLOGY AND ONE OF YOU PUT THIS PRECKISHLY IN A STATEMENT IN PEDIATRICS WE CAP TURE SOCIAL DATA MORE OFTEN THAN IN MEDICINE AND GIVEN THE IMPACT IT HAS ON PEDIATRIC PATIENTS OR OTHER REASONS, BE I DEAL TO STUDY THE IMPACT ON SOCIAL DETERMINANTS ON THE LONG-TERM SEQUELAE. I ALSO THINK AGAIN THERE IS NO DOUBT THAT THERE ARE SOCIAL DETERMINANTS OF HEALTH AND UNDER -PRIVILEGED CARE WITHIN CHILDREN BUT ONE OF THE THINS THAT HAPPENED WITHIN DAY ONE THAT WAS REALLY REMARKABLE IS THERE IS A CLEAR DEMARCATION ABOUT ACCESS TO CARE IF YOU WERE IN EUROPEAN COUNTRY OR CANADA VERSUS THE UNITED STATES AND ALTHOUGH YOU KNOW YOU CAN'T SAY THIS WORD IN PUBLIC WE PRETTY MUCH HAVE SOCIALITED HEALTH CARE FOR CHILDREN WHICH IS VERY DIFFERENT THAN KIDS SO WHEN YOU GO HOME THINGS MAY BE DIFFERENT BUT YOUR ACCESS TO HEALTH CARE IS CONSIDERABLY DIFFERENT IN CHILDREN THAN ADULTS SO TRYING TO TEASE OUT THE REAL SOCIAL DETERMINANTS OF HEALTH VERSUS PERHAPS GENETIC PREDLICATIONS THAT MAKE YOU MORE SUSCEPTIBLE CAN PROBABLY BE MORE EASILY DONE IN PEDIATRICS. WHAT TO OTHERS THINK ABOUT THAT? I GUESS I DISAGREE SLIGHTLY. IT IS ABOUT WHETHER OR NOT YOU HAVE THE ENTIRE INFRASTRUCTURE THAT ALLOWS YOU TO ACCESS HEALTH CARE SO FAMILIES OF CENTRAL WORK ERS WHO CAN'T TAKE OFF WORK OR ACCESS TELEHEALTH THERE IS LOTS OF WAYS CHILDREN CAN FAIL TO ACCESS CARE THAT IS INDEPENDENT OF THEIR ABILITY TO PAY FOR IT. >> I DON'T DISAGREE WETHAT I'M JUST TRYING TO UNDERSTAND WHAT WE HAVE SEEN IN THE MIS-C POP ULATION WHERE IT IS AN EVEN HIGHER PREPONDERANCE OF DISEASE IN WHAT WE CLASSIFY AS BLACK AND BROWN POPULATIONS. >> I THINK THAT IS A LITTLE DIFFERENT RIGHT BECAUSE THEY ARE HOSPITALITED AND ACUTELY ILL AND NO ONE IS, THEY GET BROUGHT IN BY HOOK OR BY CROOK BUT I THINK WHEN YOU HAVE MORE CHRONIC, MORE SUBTLE FINDINGS OF NOT THINKING CLEARLY OR FATIGUE OR THOSE KINDS OF THINGS THAT'S A BITTAL BIT YOU HAVE TO ADVOCATE FOR YOUR KID TO GET THEM INTO CARE IN A WAY YOU DON'T HAVE TO ADVOCATE IN A WAY WHEN YOUR KID DOESN'T HAVE A BLOOD PRESSURE. >> ONE THING TOO IS LANGUAGE BARRIERS THAT WE FIND IN OUR STUDY TRYING TO DO FOLLOW-UP. SO WE HAVE AN ARM OF OUR STUDY WITH INFORMED CONSENT AND FOLLOW FOLLOW-UP AND QUITE A BIT OF PAYMENT FOR TRANSLATORS AND IT IS INCREDIBLY HARD TO DO FOLLOW-UP SURVEYS AND WE DO A CUTE COVID AND MIS-C AND IT IS JUST GETTING THE TRANSLATOR IT IS ALL OVER THE PHONE, THERE IS NOT JUST SPANISH, IT IS THIS RANGE OF LANGUAGES AND I KNOW SOME OF THE STUDIES ON-GOING RIGHT NOW ARE LIMITED TO SPANISH AND ENGLISH, WHICH IS GOING TO MISS A LOT OF THE POPULATION OF PATIENTS WHO ARE COMING IN AND SO I THINK THAT THERE IS A LOT OF BARRIERS TO GETTING ACCURATE INFORMATION, AT LEAST SURVEYS IF YOU HAVE THEMSELVES DO IT ARE NOT EVEN TRANSLATED INTO SPANISH , IF YOU HAVE THEM SELF- APPLIED SO THESE ARE I THINK SOMETHING OF THE DATA WE'RE GETTING ISN'T, IS MAYBE IN ACCURATE. YES. I DON'T WANT TO BEAT THIS BUT ONE OTHER THING I WANTED TO THROW OUT IT DOES APPEAR THAT FOR THE FORESEEABLE FUTURE ESSENTIALLY NO CHILD IS GOING TO ACTUALLY BE CONSIDERED VULNERABLE ENOUGH TO GET AT VACCINE AND THIS IS REALLY ISN'T OUR NECESSARILY THE CHARGE OF THIS PARTICULAR THING BUT WE, IT SEEMS AS IF WE REALLY KNOW THAT THERE ARE ALMOST CERTAINLY IS AN AT-RISK POPULATION THAT IF WE EVER GOT GOT TO PEDIATRIC VACCINATIONS SHOULD WE AT LEAST CONSIDER WHETHER WE IDENTIFY HIGHER RISK CHILDREN. >> WELL I THINK WHEN I HEAR DR. RANDOLPH SPEAK ABOUT HOW MIS -C AND ACUTE COVID GROUP THE OLDER ADOLESCENTS ARE ACTING LIKE YOUNG ADULTS SO IF WE THINK AT SOME POINT YOUNG ADULTS NEED TO GET IMMUNIZED WE SHOULD THINK OF THE OLDER ADOLESCENTS KIND OF IN THE SAME GROUP, IF YOU WILL. >> ALL RIGHT. I'M OBVIOUSLY GOING TO GET OFF OF THAT. WE'VE GOT BILL IS FOLLOWING THE SIMULCAST THAT HAVE A COUPLE QUESTIONS SO ONE IS ONE THAT I THINKING A NUMBER OF US HAVE STRUGGLED WITH THAT THE MIS-C DEFINITION HAS BEEN MODIFIED OVER TIME AND PERHAPS MAY NOT BE IDEAL. I THINK THAT IS TRUE FROM A RESEARCH PERSPECTIVE I'M A LITTLE WEARY ABOUT TRYING TO CHANGE WHAT WE CURRENTLY CALL PLUS-C BECAUSE IT WILL MAKE IT MORE DIFFICULT BUT I DO THINK THAT THE CONCEPT OF FOLLOWING MORE SEQUELAE DOESN'T NECESSARILY HAVE TO BE TRAPPED IN MIS-C. MAT, DO YOU HAVE ANY CONCEPT OF WHETHER THE CDC IS PLANNING TO MODIFY ANY DEFINITIONS? >> WE'VE HAD DISCUSSIONS. I GUESS I CAN TALK A LITTLE ON THE DEFINITION AND WHAT'S BEHIND IT. IT ISNERINGING TO HEAR NARROW S I DON'T THINK IT IS TOO NARROW BECAUSE WE GET MORE COMPLAINTS IT IS TOO BROAD BUT I THINK REALLY IT ALL COMES DOWN TO ON WHAT ARE YOU TRYING TO TRACK, DO SURVEILLANCE WITH THE DEFINITION RIGHT. & SO IF YOU'RE TRYING TO TRACK YOU KNOW JUST THOSE KIDS WHO HAVE SOME SORT OF TRUE SYNDROME THAT REQUIRES HOSPITALIZATION AND SEVERE TREATMENT THEN YOU KNOW I THINK THE DEFINITION DOES THAT JOB BUT I THINK YOU'RE EXACTLY RIGHT IN A BROADER PICTURE IF YOUR GOAL IS TO TRACK ALL POST-ACUTE SEQUELAE OF KIDS WHO MIGHT HAVE SOME SORT OF CHILD LONG COVID-19 OR PEDIATRIC LONG COVID OR WHATEVER YOU WANT TO CALL IT BUT AREN'T REACHING THE LEVEL OF THIS TRUE SYNDROME THEN THE DEFINITION DOESN'T CAP TURE THOSE, JUST LIKE MANY OTHER SYNDROMES WE HAVE IN PEDIATRICS WHERE KIDS MAY NOT HAVE ENOUGH THINGS TO BE CONSIDERED PART OF THE MEANING OF THE KETCHNITION OF THAT SYNDROME BUT STILL SOMETHING IMPORTANT THAT YOU WANT TO FOLLOW. I THINK THAT'S CERTAINLY A BROAD ER DISCUSSION THAT'S WORTH CONSIDERING. >> MEREDITH DICKSON AT CDC. I JUST THINK IN A WAY IT MADE A LITTLE BIT BE LOOKING FOR A NEEDLE IN THE HAYSTACK IN TERMS OF POST-ACUTE SEQUELAE IN CHILDREN BECAUSE SO MANY BEING ASYMPTOMATIC AND THE TESTING LIM ITATIONS DEPENDING ON WHERE YOU WERE IN THE COUNTRY AND WHERE YOUR EPIDEMIC WAS. I THINK IT IS A REALLY BIG QUESTION IN TERMS OF PREVALENCE. WHAT ARE, AND ALL OF THE THINGS THAT ARE PREVENTING PEOPLE FROM ACCESSING CARE, THE FACT CHILDREN AREN'T IN SCHOOL, MAYBE THEY ARE LITTLE OFF AND NOT SO SEVERE THAT THEY'LL GET TAKEN IN , BUT I THINK FOR ME AS A GENERAL PEDIATRICIAN IS ALSO A BIG QUESTION, HOW MANY OF THOSE KIDS ARE OUT THERE THAT MAY BE NEVER GOT TESTED, THEY'LL BE HARD TO FIND, THEY ARE NOT COMING IN BECAUSE THEIR SYMPTOMS AREN'T SEVERE. I DON'T THINK, I MEAN THERE IS VERY LITTLE PUBLISHED IN CHILDREN WITH LONG SEQUELAE ANYWAY. I THINK THERE IS A LOT TO BE LEARNED IN THAT AREA. THANK YOU. >> I THINK THAT SEGUE IS GREAT TO MOST OF THE BULLETS ON THIS SLIDE, CERTAINLY THE FIRST BULLET, THE SECOND BUMP AND THE FOURTH BULLET. WE HAVE KIND OF TALKED ABOUT THERE IS OBSERVATIONAL COHORTS AND I'LL THROW IN ONE THAT I KNOW AT LEAST THE PRISM STUDY TRULY IS TRYING TO ATTRACT THE FULL SPECTRUM OF ANY CHILD THAT IS COV-2 POSITIVE INCLUDING THE ASYMPTOMATIC SO IT WILL BE THAT AT LEAST POTENTIALLY GIVES YOU A DENOMINATOR THAT ISN'T OFTEN SELECTED. SOMEONE DID. >> COULD YOU TALK ABOUT WHAT THAT STUDY IS, PRISM. >> PRISM IS THE PEDIATRIC FOLK ESCED NIAID STUDY THAT IS LARGELY # MOSTLY FOLLOWING IMMUNE OBIOLOGIC MARKERS, IT IS JUST LAUNCHING, PROBABLY THREE PATIENTSINIZE ROLLED. IT IS GOING TO BE 22 CENTERS FOLLOWING FOR IT IS EITHER 12 MONTHS OR 18 MONTHS. IT IS EITHER 6, 12 OR 18 I'M GETTING MY COHORTS MIXED UP A LITTLE BIT BUT IT IS THE FIRST AND THIS ACTUALLY GETS TEE THE THIRD BULLET IT IS THE FIRST THAT ACTUALLY HAS AN ARM TO SYMPTOMATICALLY GET CHEST IMAGING, THIS IS CT IMAGING, OBVIOUSLY THIS WASN'T DONE BY A CARDIOLOGIST, WE PREFERRED DIFFERENT THINGS BUT THIS IS REALLY TO LOOK AT LUNG AND AND A REAL PUSH TO SERIALY FOLLOW IMMUNOBIOLOGICAL MARKERS IN BLOOD, STOOL, AND URINE OVERTIME THAT SOUND REALLY GREAT ESPECIALLY IF YOU CAN ROLL 10,000 PEOPLE IN HALF OR 60% WERE ASYMPTOMATIC I THINK IT WILL REALLY, THE CHALLENGE OF COURSE IS HOW DOES ONE IN RESEARCH ENROLL IN ASYMPTOMATIC BUT POTENTIALLY INFECTIOUS PATIENT. AT MY CENTER WE CAN'T EVEN BRING THEM IN UNLESS THEY ARE SICK ENOUGH TO COME IN. SO ALTHOUGH THERE ARE SOME EFFORTS TO TRY TO BE ABLE TO GET THINGS DONE TRULY REMOTELY SO WE'LL SEE ABOUT THAT. >> RELATED TO THE COHORTS, PETER ASKED ABOUT THAT ONE. SOMEONE HAD ADDED NEUROCOVID AND I WAS JUST TRYING TO MAKE SURE THAT THE WHOLE GROUP WAS AWARE OF THAT. >> HI, THIS IS ERICA, INTENSIVE CARE DOC HERE AT CHILDRENS OF ST. PETERSBURG AND COLLEAGUE. WE'RE PART OF A CONSORTIUM THAT IS LOOKING AT PEDIATRIC AND CO HORTS AND LOOKING AT WHAT IS THE FREQUENCY AND WHAT ARE THE OUTCOMES OF CHILDREN WHO ARE HOSPITALIZED WITH COVID EITHER DIAGNOSED, YOU KNOWUAL PCR, ANTI BODY OR PRESUMED COVID. WHAT'S THE FREQUENCY OF NEUR LOGIC MANIFESTATIONS AND THE SECOND PIECE WOULD REQUIRE CONSENT TO GET POST-DISCHARGE OUTCOMES ON HOW THU CHILD IS FAIRING ON TERMS OF FUNCTIONAL OUTCOME, QUALITY OF LIFE, FAMILY FUNCTIONING, THAT WOULD INCLUDE THIS SOCIAL DETERMINANTS AND ON-GOING SYMPTOMS OR NEW SYMPTOM S. SO THESE ARE THE MORE OBVIOUS KIDS TO FOLLOW UP FOR A RISK OF SEQUELAE BUT I TOTALLY JUST WANTED TO POINT OUT, I THINK IT IS REALLY IMPORTANT TO THINK ABOUT THE KIDS WHO ARE NOT ADMIT TED LIKE YOU'VE BEEN DISCUSSING AND LOOKING AT EVEN THOUGH THEY ARE NOT PART OF OUR STUDY WHEN WE'RE GETTING A LIST OF THE NUMBER OF PATIENTS ELIGIBLE FOR OUR STUDY FROM APPROVED SITES BOTH HERE IN THE U.S. AND ABROAD ARE INCLUDED AND SO FAR AS TWICE AS MANY KIDS SHOW TUPE THE ED GET TESTED AND GO HOME THAN ARE ADMITTED AND SO IT SAID CERTAINLY A BIGGER POP ULATION. MAYBE THERE TRULY ARE UNA AFFECTED BUT I AGREE WETHE OTHER SPEAKERS THAT MENTIONED YOU DON'T REALLY KNOW UNLESS YOU LOOK SOMETIMES AND IN PAST STUDIES I'VE DONE A CHILD MAY SEEM OKAY UNTIL YOU ACTUALLY PUT THEM BACK IN SCHOOL AND THEN SOME MEMORY ISSUES OR COGNITIVE ISSUES COME TO LIGHT AND BY THEN IT IS A LOT LATER THAN IF WE WOULD HAVE TESTED THEM SOONER OF COURSE. >> FOLLOWING UP ON ERICA'S COMMENT, WHEN YOU'RE LOOKING FOR THE ANOTHER STATX INTOLERANCE WE'VE LEARNED THAT WE HAVE TO NOT JUST ASK PEOPLE IF THEY GET LIGHT HELD WHEN THEY STAND UP BECAUSE THE ADOLESCENCE OFTEN THINK EVERYBODY IS LIGHT HEADED OR WE'LL GET THE RESPONSE DO YOU GET LIGHT HEADED WHEN YOU STAND UP NO BUT I GET A HEAD RUSH EVERY TIME. WELL ILER CALL THAT LIGHT HEADED NESS. SO WE HAVE TO ASK VERY SPECIFICALLY THINGS LIKE HOW DO YOU DO IN A SITUATION WHERE YOU'RE INVOLVED IN QUIET UPRIGHT POSTURE. HOW DO YOU DO IN A HOT SHOWER. DO YOU HAVE TO SIT DOWN IN THE SHOWER OR LIE DOWN AFTERWARDS. HOW DO YOU DO STANDING IN LINE, HOW DO YOU DO IN CHORUS OR BAND AND THE BEST ONE IS HOW DO YOU DO GOING TO THE SHOPPING MALL. AND THESE KIDS WITH ORTHOUGH STATIC INTOLERANCE DON'T LIKE GOING. IF YOU'VE GOT AN ADOLESCENT WHO DOESN'T WANT TO GO TO THE MALL YOU'VE GOT AN ORGANIC PROBLEM UNTIL PROVEN OTHERWISE. >> GOOD POINT. >> I WOULD LIKE TO ASK THE QUESTION THIS IS MORE A CLINICAL QUESTION THAT I THINK EVENTUALLY MAY TRICKLE DOWN INTO RESEARCH. WITH THE EXPERTISE IN THIS GROUP DO WE, AT THIS POINT, HAVE A FEELING OF WHAT WE SHOULD BE ASK ING; FOR EXAMPLE, PATIENTT THAT COME BACK TO THE PEDIATRIC CLINIC OR INFECTIOUS DISEASE CLINIC IF THEY HAVE COVID AND NOT HOSPITALIZED WHAT ARE BASIC QUESTIONS WE SHOULD BE ASKING THESE KIDS, NOT, MAYBE NOT JUST FOR RESEARCH BUT THAT IT IS DOCUMENTED AND WHAT ARE WE MISS ING. CAN I KNOW NOW A LOT OF GENERAL PIECES DONEFUL TELEHEALTH WHAT SHOULD WE BE ASKING CHILDREN. WERE YOU DIAGNOSE WOULD COVID-19 , YES. WAS SOMEBODY IN YOUR FAMILY DIAGNOSED WOULD COVID-19 AND WHAT ARE THE FOLLOW-UP QUESTIONS TO HELP US ON THE CLINICAL SIDE AS WELL. THAT'S AN EXCELLENT QUESTION. I I WISH I HAD AN EXCELLENT ANSWER. >> WE HAD TO DESIGN IN MUSIC, WHICH HAS AL-- VISITS AT TWO WEEKS AND SIX WEEKS FOR THE MIS- Cs WE'RE VERY ELABORATE QUESTION HEIR BUT WHAT IT BOILS DOWN TO I COULD SAY IS A CLIN ICAL CARDIOLOGISTS IS A VERY GOOD 12-POINT REVIEW OF SYSTEMS INCLUDING ISSUES ON WHETHER THEY FEEL LIKE THEY ARE BACK TO NORM AL, HOW IS SLEEP, HOW'S LEARNING, SO I THINK EVERY SYSTEM AND IF IT IS NORMAL IT WILL GO VERY QUICKLY AND IF IT ISN'T YOU'LL HAVE TO DELVE IN USING YOUR USUAL CLINICAL SKILLS BUT YOU CAN MAKE A SYMPTOMATIC QUESTIONNAIRE. IF YOU'RE DOING A RESEARCH STUDY >> AND THEORETICALLY THERE IS NO REASON FROM A RESEARCH PERSPECTIVE, WELL FROM A CLIN ICAL PERSPECTIVE, IF YOU WOULD LIKE TO VALIDATE IT IN SOME WAY, BUT I THINK ONE OF THE THINGS THAT HAS BEEN UNIQUE ABOUT RESEARCH WITHIN THIS FIELD AT LEAST IN PEDIATRICS IS THERE IS AN UNBELIEVABLE AMOUNT OF SHARING, EITHER OF RED CAP FORMS , THE PROMISE TO SHARE THE FINAL RESULTS OF LABORATORY SAMP LES THAT POTENTIALLY CAN ONLY BE COLLECTED IN ONE STUDY AND COULDN'T ALSO BE COLLECTED IN ANOTHER STUDY. AND JANE I KNOW SPECIFICALLY IN MUSIC YOU DESIGNEDDED A TON OF THIS TO BE ABLE TO BE DONE WITHOUT ALTERING KIND OF STANDARD OF CARE, MAKIC THINGS NOT NECESSARILY SO RESEARCH BASED WHICH WOULD MAKE IT EASIER TO ENROLL PATIENTS. WOULD THAT INCLUDE BEING ABLE TOOL GET THE PUBLIC TO SHARE THAT 12 POINT SYSTEM. >> WELL I THINK, I CAN'T THINK OF ANY REASONS PEOPLE COULDN'T SEE THE DATA FORMS. I HAVE TO SAY THAT THEY ARE IN RED CAP AND SO QUESTIONS ONLY SHOW UP WHEN SOMETHING IS POSITIVE BUT I KNOW GALE PIERSON IS SOMEWHERE ON THIS CALL BUT WE'VE BEEN VERY WILLING TO SHARE ALMOST ANY ASPECT OF THIS STUDY IF IT COULD BE USEFUL TO ANYBODY ELSE. >> I DO KNOW THAT GALE UNFORTUNATELY HAD A CONFLICT AND COULDN'T BE ON THE CALL BUT I WILL TELL THIS GROUP, I THINK SOME OF YOU KNOW AND I'LL JUST RE-STATE IT, GALE WORKED AT THE NHLBI BUT SHE IS NOW BEEN PUT IN CHARGE OF REALLY HAVING AT LEAST THESE FEDERALLY SPONSORED STUD IES IN PEDIATRICS THAT ARE LAUNCHED DUE TO LONGITUDINAL CO HORT TO AGREE IN FACT SHARE DATA ACROSS US, WHICH WILL ALLOW US IN A FASCINATING NOVELQUAL OBVIOUSLY GREAT WAY TO GET AS THE MOST INFORMATION OUT OF THE MOST AMOUNT OF PATIENTS WE CAN. >> RIGHT. SO I'M QUITE SURE WE CAN SHARE DATA FORMS IF THEY ARE HELPFUL. ALONG THOSE LINES THERE IS A NUMBER OF WORKING GROUPS THAT SHOULD BE INLIN OF THESE STUDIES SO THAT WE CAN'T COMPARE THAT. AL THAT DOES GET TO, WE'VE BUMP ED AROUND ALL OF THESE OPTIMAL MEASUREMENTS AND I THINK PETER AND SOME OF THE REST OF US WHO HAVE DONE THESE HOLISTIC QUEUES THOSE ARE REALLY GREAT. WE STILL ARE TRYING TO FIGURE OUT WHAT THE RIGHT HEART AND LUNG IMAGING ARE BUT THOSE ARE IN FACT AT LEAST INCORPORATED INTO SOME OF THESE LONGITUDINAL STUDIES. WE TALKED ABOUT VACCINE AND THAT CHALLENGE AND ADRIAN THANK YOU FOR SUGGESTING THAT THERE MAY BE SOPHISTICATED WAIFS TO TEST FOR THINGS THAT WOULD NOT BE IN THE VACCINE. ONE OF THE SPECIFIC THINGS IS WE HAVE MORE CHALLENGING GETTING COLLECTING AND IMAGING, SO WE'RE GOING TO HAVE TO ULTIMATELY DO THAT ON A SMALLER PATIENTS AND LIKELY ON THOSE MORE ACUTELY AFFECTED. BOB, YOU SORT OF DID SOMETHING ABOUT COMMON DATA ELEMENTS BUT I'M ALSO INTRIGUED BECAUSE I THINK WE'VE GOT SUBMIT OTHER PEOPLE THAT PERHAPS WORKING WITH BIG DATA. ONALL OF THE PROMISE OF AN ELECTRONIC HEALTH RECORD IS WE'D BE ABLE TO EASILY SHARE ALL SORTS OF THINGS AND DO PEOPLE ON THIS AUDIENCE SEE A POTENTIAL WAY WHERE WE COULD USE HEALTH SYSTEM DATA TO ACTUALLY COLLECT INFORMATION EVEN ON THOSE WHO ARE HOSPITALIZED. >> PEDIATRIC RHEUMATOLOGISTS HAVE A KARA REGISTRY SO WE STRUGGLE WITH THIS QUITE A BIT AND I WOULD SAY THAT THERE ARE SOME GROUPS THEY ARE SO EPIC SPEAKS VERY NICELY TO EACH OTHER I THINK WITH LOW HAPPENING FRUIT YOU COULD CREATE FORMS, OUT PATIENT VISITS TRIGGERED BY A POSITIVE COVID-19 TEST BUT TRY ING TO HARMONIZE DATA FIELDS ACROSS DIFFERENT TYPES OF EHRs LIKE CERTAINA AND OTHER THINGS IS HARD AND IN THE END MANUAL DATA EXTRACTION IS USUALLY PART OF THE GAME. I'M ALL FOR MAKING THIS AS EASY AS POSSIBLE BUT I THINK THERE ARE REAL CHALLENGES THERE. >> AND YOU ARE ONLY AS GOOD AS YOUR QUESTIONS SO IF ESPECIALLY IN ELECTRONIC MEDICAL RECORD BEING DONE FOR CLINICAL PURCHASE S IF YOU ASKED THE QUESTION YOU'RE GOING TO RUN INTO PROBLEMS SO THAT'S WHY THE QUESTIONS WE ASK ARE VERY IMPORTANT. >> THISSIS GINA FROM NIAID. WHEN WE WERE TALKING ABOUT THE USE ONE OF THE MAIN IS HOW GOOD IS THE BASELINE DATA THAT WE ARE COLLECTING, BECAUSE YOU KNOW IF WE DON'T HAVE A GOOD BASELINE DATA WHICH TYPE OFDITEA PATIENTS WE HAVE THOSE WOULD BE CONSIDERED COMPLICATIONS AND THAT'S BASICALLY A WRONG CALL. SO I THINK USING THAT IS VERY CHALLENGING BUT IT DOESN'T MEAN THAT IT CAN NOT BE DONE. THE OTHER THING I WANTED TO COMMENT ON IS THAT ANOTHER ASPECT THAT SHOULD BE ADDRESSED FOR THESE PATIENTS AND FAMILIES IS ACTUALLY MENTAL HEALTH. AND SUBSTANCE ABUSE AS WELL. I WANTED TO BRING IT UP ANOTHER QUESTION. I KNOW THAT PEOPLE HAVE BEEN TALKING ABOUT PROMISE, ANOTHER ONESON CRISIS. IS THE CORONAVIRUS HEALTH IMPACT SURVEY THAT HAS BEEN USED, I KNOW THERE IS SOME DATA IN A DULTS RECOMMENDED BY THE NEURO DEVELOPMENTAL GROUP HERE SO THAT'S ANOTHER CONSIDERATION BECAUSE KIND OF ALSO ADDS THOSE QUESTIONS ABOUT SUBSTANCE ABUSE, QUESTIONS ABOUT ALSO MENTAL HEALTH ISSUES AS WELL. THE OTHER CONSIDERATION IS ALSO THE FREQUENCY OF LIKE PTSD FROM PATIENTS WHO WERE IN THE ICU AND DISCHARGED AND THEN THERE WERE DISCUSSIONS ABOUT THAT YESTERDAY FOR THE ADULT COHORT. >> WHAT WAS THU NAME OF THE FIRST TEST YOU DESCRIBED? >> CRISIS, I WILL SEND THE LINK NOW ON THE CHAT FOR THE EVERYONE >> I DON'T KNOW IF THIS IS THE RIGHT TIME TO BRING THIS UP AND I'M ALSO NOT SURE IF IT IS THE RIGHT QUESTION FOR THE GROUP, SO I JUST WANTED TO FOLLOW-UP TO WHAT GINA SAID ABOUT THE MENTAL HEALTH ISSUES RELATED. THERE ARE REAL PRACTICAL IMPACTS FROM COVID IN TERMS OF MENTAL HEALTH ISSUES IN CHILDREN. IN OUR HOSPITAL FOR EXAMPLE WE'RE HAVING AG LOT OF DIFFICULTY A LOT OF INPATIENT BEDS ARE FILL WOULD CHILDREN WITH MENTAL HEALTH ISSUES AND WE'RE UNABLE TO GET THEM TO THE FACILITIES TO GET THEM THE FACILITIES THEY NEED. IF WE'RE TALKING ABOUT SPECIFIC PEDIATRIC ISSUES NOT YET ADDRESS ED I FEEL LIKE THE MENTAL HEALTH ONE IS A BIG ONE AND GROUPS WORKING ON THAT BUT I WANTED TO RAISE THAT. I THINK IT IS BOTH RELATED TO COVID-19 AND I THINK THERE IS REAL IMPACTS ON A DAY-TO-DAY BASIS FOR THESE FAMILIES, KIDS, AND FOR US AS HEALTH CARE PROVIDERS. >> MARYBETH YOU'RE SPOT ON AND IT WAS SPECIFICALLY THAT TOPIC THAT MADE ME CREATE THIS FOURTH THING WHICH IS SOMETHING THAT ISN'T SPECIFICALLY ASKED OR ADDRESSED IN OUR QUESTIONS BUT IS SO INCREDIBLY IMPORTANT. SO THAT WAS I WAS HOPING THAT THE GROUP WOULD HAVE AGREED TO PUT THAT INTHEN. I MEAN THERE IS ALL SORTS OF INDIVIDUAL TESTIMONIALS. THE ONE THAT I HAVE AT MY HOSPITAL, WHICH IS FASCINATING IS THAT THE PEDIATRIC EMERGENCY DEPARTMENT CENSUS IS STILL ONLY 70-75% OF WHAT IT WAS IN THE PRE PRE-COVID DAYS BUT THE PERCENTAGE THAT ARE BEHAVIORAL AND MENTAL HEALTH IS ASTRO NOMICAL TO THOSE SO REALLY RIDICULOUSLY OVER REPRESENTED. I THINK WE'VE GOT TOON A POSITION WHERE WE CAN GO TO # OUR NEXT SLIDE WHERE WE'VE PUT REL ATIVE BUCKETS OF THINGS IN THERE. SO WE AS OO GROUP UNFORTUNATELY YOU'LL HAVE TO USE ME AS YOUR MOUTH PIECE ARE JUST GOING TO RECORD OUT BASICALLY ON THESE THREE THINGS. SO BOB HAS BEEN TAKING? NOTES, MAYBE WE'LL, IT IS NEVER QUITE CERTAIN WHEN WE'RE ON THE FLY, WE'VE NEVER DONE THIS BEFORE, ON WHAT'S THE BEST WAY TO OPTIMIZE THIS, BUT I THOUGHT THE BEST WAY FOR BOB WAS TO HAVE US ALL FOR THE NEXT 15-20 MINUTES KIND OF DO KIND OF A GROUP SUMMARY OF WHAT WE THINK ARE KIND OF THE TOP THREE TO FIVE THINGS THAT WE KNOW ABOUT LONG-TERM COVID. THE THREE AND WE REALLY CAN GO TO MORE THAN THREE BUT WE REALLY PROBABLY OUGHT TO PRIORITIZE WHAT WE THINK ARE THE NEXT ADDRESSABLE KNOWLEDGE GAPS AND THEN A LITTLE BIT OF THE UNIQUE PEDIATRIC AND THAT FOURTH PART. >> ANDY, IF IT IS POSSIBLE FOR ME TEE SHARE MY SCREEN I COULD PUT THE SLIDES THAT I TRY TO PUT INTO THOSE BUCKETS SO PEOPLE COULD LOOK AT IT. >> I HAVE STOPPED SHARING MINE. >> CAN PEOPLE SEE MY SCREEN? >> YES. >> WE'RE SEEING THE AGENDA RIGHT NOW. >> I CAN'T SEE ANYTHING BUT THAT YOU'RE SHARING. >> CAN YOU SEE SLIDES NOW. JUST THE AGENDA. IT JUST LOOKS LIKE THE DAY TWO AGENDA. YOU KNOW, I'M GOING TO TRY ONE OTHER THING HERE. THIS GROUP PROBABLY UNDERSTAND THIS BUT I DON'T KNOW IF IT IS WORTH CLARIFYING. NOW SAY THE 28 DAY SURVEY THE ANSWER IS NOT FINDING SEQUELAE. THEY ARE NOT FINDING IT PROBABLY BECAUSE IT HAS ONLY BEEN 28 DAYS , SOME OF THIS WE'RE NOT SEEING UNTIL LATER SO I WANTED TO CLARIFY THEY ARE NOT FINDING IT BECAUSE IT IS TOO EARLY TO START ASKING. >> I TOTALLY AGREE MELISSA AND I HOPE THAT COMES UP AS ONE OF OUR GAPS IS THAT SIMILARLY WITH EVERYBODY WE PROBABLY HAVE NOT DEFINED LONG-TERM COVID ACCURATE LY AND THOSE DEFINED AS OVER A MONTH ARE PROBABLY CLOSER TO HAVING IT RIGHT THAN WHEN WE HAVE DEFINER VINED THE LARGE CO HORT STUDIES IN 28 DAYS. >> AS OF RIGHT NOW WE'RE THINK ING IF I HAD TO SAY WHAT ARE THE LONG-TERM SEQUELAE OF COVID THAT WE KNOW RIGHT NOW WOULD WE DEFINE THIS AS CARDIOVASCULAR, NEURLOGIC, PULMONARY NEURLOGIC, WHAT DO WE KNOW RIGHT NOW FROM THE STUDIES THAT ARE ON-GOING? >> HAVE YOU FOUND THE THROMBOTIC TO BE LONG-TERM STUFF OR REALLY JUST ACUTE STUFF? >> WELL IT IS RARE BUT SEVERE. SO YOU KNOW I THINK IT IS THE QUAG LOPATHY, I THINK IT NEEDS MORE INVESTIGATION, IT IS EVEN MORE RARE WE FOUND THAT THE SEVERE THROMBOSIS ALTHOUGH QUAG IALOPATHY IS NOT RARE. BUT VERY SEVERE CASES. >> I LIKE HAVING THE CONCEPT THAT WE ARE THE ONLY BREAKOUT SESSION THAT IN FACT IS AGE- BASED AND NOT ORGAN BASED AND I THINK WE REALLY SHOULD ACTUALLY STRESS AND WE KNOW THAT THERE IS A HETEROGENIUS, WE APPRECIATE THAT THERE IS A HETEROGENIUS PHENEO TYPE IN CHILDREN. THE STUFF THAT PETER TALKS ABOUT IS THE CHRONIC FATIGUE-LIKE STUFF. ANDY, SOME PEOPLE WOULD PUT THE MECFS GROUP UNDER CARDIOVASCULAR , YOU COULD ARGUE THAT'S NEUROLOGICAL BUT I WOULD MAKING IT ITS OWN SEPARATE CATEGORY BECAUSE WHEN PEOPLE ARE TALKING ABOUT CARDIOVASCULAR THEY ARE TALKING ABOUT THE HEART AND OUR PATIENTS HAVE A NORMAL HEART THEY JUST DON'T HAVE ADEQUATE BLOOD FLOWING GETTING TO THE BRAIN. >> I THINK THAT I KNOW YOUR ENTIRE LIFE IS BEING ACTUALLY GETTING PEOPLE TOOL APPRECIATE THAT IT IS NOT OUGHT FAKE DISEASE, IT IS FASCINATING IT MAY HELP, I HOPE THIS HELPS TO SHOW THAT PROBABLY IS CARDIOVASCULAR AND NEURLOGIC COMPLICATIONS. ANYBODY ELSE? I THINK WE PROBABLY HAVE THIS. PROBABLY MORE IMPORTANT IS IN FACT THE NEXT SLIDE WHERE WE START TO ADDRESS THE, WE KNOW LET'S START OFF WITH WE KNOW THERE IS A TON OF KNOWLEDGE GAPS SO BOB YOU'RE SET UP PERFECTLY. >> SO THE FIRST ONE WHERE PEOPLE TONG TALK ABOUT IS THE DENOM INATOR, DOES IT EFFECT PATIENTS, HOSPITAL PATIENTS, SYMPTOMATIC. I GAVE A FEW EXAMPLES OF WHAT PEOPLE TALKED ABOUT. WHAT QUESTIONS SHOULD BE ASK ICIDE A VERY COMMON THING I HEARD COMING OUT A LOT ON WE COULD GO THROUGH SOME OF THE THINGS HERE. HOW DO WE ASK THEM. CAN WE GET DOWN TO VHR AND IF WE WE ARE WE'VE GOT TO IMPROVE OUR CLINICAL QUESTION ASKING. RIGHT NOW THE QUESTIONS SEEM TO BE GATHERING VERY LITTLE OF THIS DATA AND AGAIN ONE OF THE WAYS IS QUESTIONS HAVE TO BE SPECIFIC ARE THEY GOING TO THE MALL AND ABLE TO SHOWER AND NOT JUST TOTALLY RUN DOWN. TALKED ABOUT THU DIFFICULTY OF MERGING ASSETS TIPLY DATA. IT IS IMPORTANT TO HAVE DATA THAT IS GOOD AND ROBUST. WE TALKED ABOUT WE NEED TO KNOW MORE ABOUT THE MENTAL HEALTH ISSUES AND SUBSTANCE ABUSE AND I MADE A NOTE TO MYSELF ABOUT THE CRISIS AND THE CARDIAC STAND POINT ALTHOUGH WE DO HAVE SOME LARGE SHORT-TERM SERIES STARTING WE REALLY WANT TO HAVE A LOT OF SYMPTOMATIC DATA WITH PERSPECTIVE PROTOCOLS INCLUDING IMAGING. WE DON'T KNOW WHAT HAPPENS TO THE HEART IN RELATIONS TO KAWASAKI. A LOT OF EGGS THAT WE'RE HOPING TO ADDRESS. LITTLE DATA ON THE PATIENTS WITH PREDISPOSURE AND THE WHAT ARE THE RISK FACTORS. I THOUGHT WE HAD A GREAT DISCUSSION ON HIGHER RATES OF AFRICAN AMERICANS AND LATINO POP ULATION BUT OTHERS ARE FIND ING IT MORE COMMONLY IN CAUCASIAN AND WE TALKED ABOUT WHY OR WHY THAT MAY NOT BE. THEY HAVE MORE SUBTLE FINDINGS AND HAVE BETTER ADVOCACY OR BETTER ACCESS TO HEALTH CARE BUT SOMETHING THAT WE TALKED ABOUT. AND THEN WE TALKED QUITE A BIT ABOUT DEVELOPING IMMUNE SYSTEMS AND RESPONDING DIFFERENTLY FOR CHILDREN AND WE CAN NOT ASSUME THAT IT IS THE SAME. ADRIAN MADE SOME GREAT POINTS TALKING ABOUT HOW THE ADOLESCENCE PARTICULARLY ADOLESCENCE MAY MIRROR THE THE A DULT POPULATION A LITTLE BIT MERE COMMONLY. I WAS JUST TRYING TO MAKE A SIMILAR SLIDE THERE WHILE WE WERE TALKING. ONE OF THE OTHER KNOWLEDGE GAP ICIZE DO WE HAVE THE KNOWLEDGE TO ACCESS THE DETERMINANTS OF HEALTH. CHILDREN MAY HAVE ACCESS TO HEALTH CARE, I TALKED ABOUT THE NEED FOR BETTER ADVOCACY. I THOUGHT ADRIANS POINT ABOUT THE LANGUAGE BARRIER PHYSICAL WE JUST FOCUS ON SPANISH AND ENGLISH PATIENTS WE'LL MISS MANY PATIENTS. IF WE ALLOW PEOPLE TO SELF REPORT WE'RE GOING TO MISS A LOT OF PATIENTS AND THEN I'M GOING TO INCLUDE THE NEXT SLIDE, WHAT ARE THE NEXT THREE STEPS TO ADDRESS THIS GAP BECAUSE THEY ARE ALL LINING INTO THE SAME THING. CAN WE USE THIS SCREEN TOOL FOR ATHLETES APPLIED TO EVERYONE? AGAIN, THE NEXT THING IS IS THE SUBTLETIES TALKING ABOUT THE DIFFERENCE OF THE ATHLETES WITH A HIGHER BASELINE. THE SCHOOL QUESTION, ARE WE MISS ING A LOT OF THIS BECAUSE CHILDREN AREN'T GOING TO SCHOOL AND SOME OF THESE SYMPTOMS WOULD HAVE BEEN PICKED UP SOONER BUT NOT BEING PICKED UP UNTIL WE SEE A DEFINITIVE PERFORMANCE AND THEN FINALLY ARE WE ONLY SEEING PATIENTS WHO SEEK US OUT AND HOW CAN WE DO A ETBER JOB OF IDENTIFYING PATIENTS THAT AREN'T ACTIVELY SEEKING US OUT. LET ME STOP THERE AND TAKE SOME NEW NOTES. >> BOB THAT WAS GREAT. I GUSH WANTED TO ASK ONE QUESTION. RELATING TO THE SCHOOL QUESTION AND PERFORMANCE. >> I THINK I HAD THAT THERE BUT I'M NOT GOING TO TAKE ANY CHANCES SO LET'S PUT IT DOWN. >> IAL PUT IN THE CHAT BECAUSE WE'RE OUT OF TIME BUT SINCE HE IS TYPING THERE IS AN EFFORT TO REPURPOSE THE DDCC AT NYU TO LOOK AT NEUROCOVID IN ADULTS AND NEWBORNS TO PUT DATA INTO. AND THE WHO IS DOING SOMETHING SIMILAR. I HAVE BEEN INVOLVED WITH THEIR NEUROEFFORTS AND I APPRECIATE THE DISCUSSION HERE AND I AM CURIOUS ON HOW THIS WILL SORT US OUT IN TURNS OF DATA HARMONIZATION, I THINK THAT WOULD BE A BIG STRENGTH IF THAT COULD HAPPEN. >> ONE COMMENT ABOUT THE NEURO COGNITIVE OUTCOMES IS WHEN YOU EXAMINE PATIENTS WHO COM PLAIN OF BRAIN FOG WITH FORM AL NEUROPSYCHE TESTING THEY CAN USUALLY SUM UP THE THE ABILITY TO ANSWER CORRECTLY SO IT IS ONLY WHETHER THEY ARE STRESSED THAT YOU FIND THE DIFFERENCE IN HEALTHY CONTROL. SO JULIE AND STEWART AT THE NEW YORK MEDICAL COLLEGE DID A TEST WITH AN NBACK MEASURE WHERE THEY FOUND AS THEY TILTED PATIENTS UP PROGRESSIVELY THAT'S WHEN THEY STARTED SEEING ERRORS AND MIS TAKES IN REACTION TIME AND DE LAYS BUT THE PATIENTS SIMILAR TO THE HEALTHY CONTROLS WHEN SU PLINE. SO SOMETIMES IT TAKES A STRESSER TO BRING OUT REAL COGNITIVE IN NORMALITIES. ON FUNCTIONAL MRI TESTING THEY CAN SCORE THE SAME BUT THEY ARE USING WAY MORE NETWORKS IN THE BRAIN TO GENERATE THAT KNOWLEDGE SO IT IS A SUBTLE THING BUT VERY INTERESTING STUDIES ON THE FMRI FRONT. >> I WOND WONDER IF WE SHOULD PUT THE PSYCHIATRIC DISEASES UNDER THIS BECAUSE SOME PEOPLE IN THE HOSPITALIZED THERE IS A LOT OF PATIENT WHOSE ARE COVID POSITIVE BECAUSE THEY GET SCREEN TESTED PRIOR TO PSYCHIATRIC AD MISSION AND THEN THEY ARE WAIT ING PSYCHIATRIC BED THAT AREN'T REALLY THAT SICK BUT HAVE A LOT EXCEPT FOR THEIR PSYCHIATRIC ISSUES BUT CERTAIN THINGS LIKE DELIRIUM AND PARA NOIA AND THINGS LIKE THAT MIGHT BE MORE NEUROLOGIC EFFECTS ON THESE YOUNG INDIVIDUALS WHO SOME OF THEM PREVIOUSLY DON'T HAVE ANY HISTORY SO I THINK IT IS SOMETHING THAT NEEDS TO BE LOOKED AT AS WELL I THINK AND NEUROLOGIC OR NEUROCOGNITIVE. >> I THINK YOU MAKE A GREAT POINT AND I ALSO THINK EVENTEN IT IS NOT A DIRECT NEUROLOGIC EFFECT IT IS SO OFT AN CONFOUND ER OF THE OTHER THINGS WE'RE LOOKING FOR SO IMPORTANT TO INCLUDE THAT TOO. >> AT WHAT POINT THAT WAS MADE EARLIER, I THOUGHT IT WAS IMPORTANT IS HOW MANY OF THESE PSYCH ISSUES ARE DUE TO THE DISEASE AND HOW MANY ON THE PANDEMIC AND THE STRESSERS IT IS PUTTING ON ALL OF US OUTSIDE OF THE DISEASE SQUECERTAINLY WHAT COMBINATION OF THEM. >> PRECISELY SQUEI THINK THAT'S #, IT GOES ALONG WITH KIND OF WHAT SOME OF THE PARTICIPANTS SAID YESTERDAY ABOUT SOME SORT OF SIG MAW STIGMA, YOU EITHER THINK THEIR KIDS ARE CRAZY, ANYWAY IT IS FASCINATING. SO WE'RE GETTING TO BE FAIRLY WE'VE GOT FIVE MINUTES BEFORE. >> CAN I PROPOSE SOMETHING SINCE YOU ONLY HAVE THREE THINGS TO PUT THERE, JUST HEARING WHAT PEOPLE ARE SAYING ON THREE AREAS , SOUNDS LIKE WE'VE GOT ONE BIG AREA WE TALKED ABOUT BUT PEOPLE ARE TALKING ABOUT THE LONG-TERM OUTCOMES, ANOTHER BIG AREA ARE ALL OF THE OTHER NEUROLOGIC, CHRONIC FATIGUE, WHETHER THAT BE JUST OTHER EFFECTS FROM HAVING COVID AND THEN I THINK I AGREE WITH YOU WE CAN'T YOU KNOW PASS UP THE OPPORTUNITY TO REMIND PEOPLE OF THE EFFECT ON CHILDREN EVEN THOSE WHO DON'T HAVE CHILDREN. THEY MAY HAVE SEQUELAE FROM THE EFFECTS ON CHILDREN, FAMILY OR SCHOOLS THAT PEOPLE ARE TALKING ABOUT. >> WE ARE DEFINITELY GOING TO NEED CONTROLS FOR A LOT OF THESE QUESTIONS AND I WONDER AS WE GET FURTHER OUT WE'VE BEEN TAKING A COHORT APPROACH TO THIS BUT IF SOME OF THESE COMPLICATIONS ARE RARE YOU MAY NEED TEE DO MORE OF A CASE CONTROL KIND OF STUDY DESIGN TO BE EFFICIENT. >> YOU CAN DO CASE CONTROLS USUALLY WITHIN FAMILIES BUT YOU CAN'T DO IT HERE. JUST A COUPLE OTHER THINGS I PUT DOWN TO MAKE SURE WE TOUCH EVERYTHING HERE. WE TALKED ABOUT THE EFFECT ON THE PANDEMIC, WE TALKED ABOUT MASTER CHAINING THE VACCINE AND SAFETY IN CHILDREN AND WE TALK ABOUT MAYBE DIFFERENCES IN HEALTH CARE, MENTAL HEALTH ISSUE S, WE JUST KIND OF WENT THROUGH SO I THINK WE TAKING A LOOK AT THE NOTES THAT I HAD AND IF I MISS ANYONE'S COMMENTS I APOLOGIZE IN TRYING TO GET EVERYTHING DONE THAT EVERYONE WAS SAYING. >> BOB, MAYBAL WHAT WE, GO AHEAD >> I WAS JUST GOING TO ASK ARE WE COVERERRING THE BARRIERS BULLET FROM YOUR EARLIER SLIDE OR IS THAT AFTER LUNCH? >> WE'VE GOT TO COVER IT NOW. WE'VE GOT NO AFTER LUNCH. NO AFTER LUNCH OPPORTUNITY. >> CAN I JUST MAKE ONE COMMENT THEN AND THAT IS WE ARE SERIOUS LY MISMATCHED IN TERMS OF THE NUMBER OF PEOPLE WHO ARE INTERESTED AND TRAINED TO TAKE CARE OF THE MECMS GROUP. I THINK I RUN THE ONLY SUB- SPECIALTY MCFS CLINIC IN THE PEDIATRIC INSTITUTION IN THE COUNTRY, THAT IS SHAMEFULFUL SOMETHING THAT IS THIS COMMON. SO WE'VE GOT TO HAVE EACH OF OUR INSTITUTIONS STEP UP OR HAVE FUNDING LIKE O'RYAN WHITE INITIATIVE. I THINK THE QUESTIONS ARE SO INTERESTING IN THIS FIELD THAT IF YOU GIVE PEOPLE CONSISTENT FUNDING IT WILL ATTRACT FOLKS IN JUST LIKE IT DID FOR THE AIDS EPIDEMIC, YOU KNOW 40-50 YEARS A GO. THAT'S A GREAT POINT. BILL I'M GOING TO ASK YOU BASIC, AND MAYBE OUR I.T. HELP CAN HELP US, I BELIEVE THAT THERE IS BUILT IN A SHORT BREAK AND THEN WE ALL COME BACK TO THE SAME SESSION. WE DON'T COME BACK TO THIS SESSION WE COME BACK TO THE SESSION THAT WE STARTED AT AT THE BEGINNING. >> THERE IS AN AGENDA AND AFTER THE BREAK THERE IS ANOTHER THAT WILL TAKE US TO THE REPORT OUT. >> AND I APOLOGIZE I DON'T HAVE THAT ON ME, THAT SESSION BEGINS AT? >> IT BEGINS AT 12:25 ON THE AGENDA. >> OH, YES, THAT'S CORRECT. >> ALL RIGHT. WELL WHAT I WILL DO IF IT IS ALL RIGHT WITH YOU, FIRST THANK YOU TREMENDOUSLY. WE'LL PUT A FORK IN THIS REALLY IMPORTANT SESSION. BOB, IF BEFORE YOU CALL THE SLIDES DOWN IF YOU COULD SAVE AB VERSION THAT HAD KIND OF THE MOST FLESHED-OUT STUFF AND WE'LL SHARE THAT WITH THIS ENTIRE PANEL OF WHOM WE'VE BEEN SHARING ADDITIONAL E-MAILS WITH IN PREPARATION FOR THIS AND BOB YOU AND I CAN THEN FROM THERE FORMAT IT A LITTLE FURTHER DOWN FOR A PRESENTATION THIS AFTERNOON. >> I JUST SENT IT OUT SO IT SHOULD BE IN YOUR E-MAIL BOX. >> AWESOME. GREAT. ALL RIGHT WHOLE THIS HAS BEEN A FASCINATING SEEMINGLY REALLY QUICK VISIT. I WISH WE WERE ACTUALLY ABLE TO ALL NOW GO TOGETHER AND HAVE LUNCH SO THAT WE COULD KEEP DISCUSSING THIS BUT I REALLY DO APPRECIATE YOU ALL'S ATTENTION AND I'M FASCINATED BY THE OVERALL INTEREST AND PARTICIPATION OF EVERYBODY. AND NOW YOU HAVE THIS COOL E-MAIL DISTRIBUTION SO DON'T HES ITATE TO KEEP SHARING INFORMATION.