IntroductionLemierre's syndrome is an extremely rare and almost universally fatal disease characterized as thrombophlebitis of the internal jugular venous system with subsequent metastatic infection. Fusobacterium necrophorum is the most common organism implicated in causation of Lemierre's syndrome. Group A Streptococcus has mainly been observed as a polymicrobial organism in the syndrome. We report a rare finding of a rare disease where Group A Streptococcus was the sole organism triggering Lemierre's syndrome. To our knowledge, this is only the third recorded patient with such an occurrence.Case presentationWe describe a 9-year-old African American boy, who presented with otitis media and mastoiditis that culminated in Lemierre's syndrome. Isolates bore only Group A Streptococcus. The patient was appropriately treated and responded with full recovery from the syndrome.ConclusionSince Lemierre's syndrome is classically detected by clinical diagnosis, these findings should prompt clinicians to consider Group A Streptococcus as an alternative catalyst. It should be pondered that patients who present with typical Group A streptococcal infections have the possibility for developing Lemierre's syndrome. Though this complication appears to be rare, early diagnosis and prompt intervention have proven critical in survival outcome. Indeed, what would seem to be a routine case of strep throat or otitis media easily treated with antibiotics could end up being an unalterable progression to death unless Lemierre's syndrome is immediately diagnosed and treated.

To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the best predictors and used these to create the COVIDsurg Mortality Score (https://covidsurgrisk.app). Our data demonstrates that it is safe to restart a wide range of surgical services for selected patients.

Behavioral health integration within primary care has been evolving, but literature traditionally focuses on smaller scale efforts. We detail how behavioral health has been integrated across a large, urban pediatric hospital system's six primary care clinics (serving over 35,000 children annually and insured predominately through Medicaid) and discuss strategies for success in sustaining and expanding efforts to achieve effective integration of behavioral health into primary care. In a time span of 3 years, the clinics have implemented routine, universal behavioral health screening at well child visits, participated in a 15-month behavioral health screening quality improvement learning collaborative, and integrated the work of psychologists and psychiatrists. Additional work remains to be done in improving family engagement, further expanding services, and ensuring sustainability.

We are clinicians in busy health centers, and we are seeing the impact of school closures for in-person learning-including school disengagement, mental health challenges, unhealthy weight gain, food insecurity, immunization delay, and soaring rates of new-onset type 2 diabetes. 1 These immediate, visible consequences of school closures are harbingers of long-term outcomes, including decreased life expectancy for US schoolchildren. 2 Across the country, jurisdictions have eased restrictions, reopened schools, and returned to business as usual, and vaccine eligibility has expanded to include children 5 years and older. It is easy to focus primarily on these hopeful signs of progress during the pandemic, and fall back on the argument that children are resilient. However, we cannot waver in our focus on children. Children are resilient, but this resiliency requires individual support, systemic scaffolding, societal investment, and scientific research into the short-, medium-, and long-term impacts of the pandemic on children. In this issue of JAMA Pediatrics, Viner et al 3 present an important international review of the impacts of school closures on the health and well-being of children during the first wave of the pandemic (February through June 2020) and urge a balance between measures to contain infectious disease and to bolster the physical and mental health of children. The findings in this study can help identify clinical practices, policy and systems interventions, and research priorities that may mitigate the harms caused by school closures.In their research, the authors conducted a review following Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) guidelines to examine school closures during social lockdown and mental health, health behaviors, and child well-being during the first wave of the pandemic. Their search strategy used a machine learning approach and included both medical and educational research databases as well as consultation with experts in the field to identify any studies that may have been missed. They initially identified more than 16 000 possible studies, of which they conducted a full review of 151 and then deemed 36 of those to be relevant. They presented a narrative review that grouped studies by outcome(s) of interest and weighted studies based on type and quality. The heterogeneity of the studies precluded a metaanalysis. As a result of this approach, they were able to take a wide-ranging look at research during the initial phase of the pandemic, and ultimately report findings from 36 studies representing 11 countries. Outcome measures were mental health and well-being; child abuse notifications; sleep; health behaviors including physical activity, screen time, and diet; and overweight.