Multisystem inflammatory syndrome in children (MIS-C) and the coronavirus pandemic: Current knowledge and implications for public health.

The coronavirus disease 2019 (COVID-19) pandemic has caused widespread mortality and morbidity. Though children are largely spared from severe illness, a novel childhood hyperinflammatory syndrome presumed to be associated with and subsequent to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has emerged with potentially severe outcomes. Multisystem inflammatory disorder in children (MIS-C) most commonly affects young, school-aged children and is characterized by persistent fever, systemic hyperinflammation, and multisystem organ dysfunction. While uncommon and generally treatable, MIS-C presents potentially life-altering medical sequelae, complicated by a dearth of information regarding its etiology, pathophysiology, and long-term outcomes. The severity of MIS-C may warrant the need for increased awareness and continued COVID-19 mitigation efforts, particularly until potential factors conferring a predisposition to MIS-C can be clarified through additional research. Well-informed guidelines will be critical as the school year progresses. In this article, current knowledge on MIS-C is reviewed and the potential implications of this novel syndrome are discussed from a public health perspective.

A multi-imaging modality study of bone density, bone structure and the muscle - bone unit in end-stage renal disease.

End stage renal disease (ESRD) is associated with sarcopenia and skeletal fragility. The objectives of this cross-sectional study were to (1) characterize body composition, bone mineral density (BMD) and bone structure in hemodialysis patients compared with controls, (2) assess whether DXA areal BMD (aBMD) correlates with peripheral quantitative CT (pQCT) measures of volumetric BMD (vBMD), cortical dimensions and MRI measures of trabecular microarchitecture, and (3) determine the magnitude of bone deficits in ESRD after adjustment for muscle mass. Thirty ESRD participants, ages 25 to 64 years, were compared with 403 controls for DXA and pQCT outcomes and 104 controls for MRI outcomes; results were expressed as race- and sex- specific Z-scores relative to age. DXA appendicular lean mass index (ALMI kg/m2) and total hip, femoral neck, ultradistal and 1/3rd radius aBMD were significantly lower in ESRD, vs. controls (all p < 0.01). pQCT trabecular vBMD (p < 0.01), cortical vBMD (p < 0.001) and cortical thickness (due to a greater endosteal circumference, p < 0.02) and MRI measures of trabecular number, trabecular thickness, and whole bone stiffness were lower (all p < 0.01) in ESRD, vs. controls. ALMI was positively associated with total hip, femoral neck, ultradistal radius and 1/3rd radius aBMD and with tibia cortical thickness (R = 0.46 to 0.64). Adjustment for ALMI significantly attenuated bone deficits at these sites: e.g. mean femoral neck aBMD was 0.79 SD lower in ESRD, compared with controls and this was attenuated to 0.33 with adjustment for ALMI. In multivariate models within the dialysis participants, pQCT trabecular vBMD and cortical area Z-scores were significant and independently (all p < 0.02) associated with DXA femoral neck, total hip, and ultradistal radius aBMD Z-scores. Cortical vBMD (p = 0.01) and cortical area (p < 0.001) Z-scores were significantly and independently associated with 1/3rd radius areal aBMD Z-scores (R2 = 0.62). These data demonstrate that DXA aBMD captures deficits in trabecular and cortical vBMD and cortical area. The strong associations with ALMI, as an index of skeletal muscle, highlight the importance of considering the role of sarcopenia in skeletal fragility in patients with ESRD.

Fragmented care for inner-city minority children with attention-deficit/hyperactivity disorder.

OBJECTIVES: To identify systematic problems in coordinating care for inner-city minority youths with attention-deficit/hyperactivity disorder. METHODS: We recruited participants from inner-city minority communities in a single metropolitan area for a focus group study. We held separate meetings for pediatricians, mental health therapists, school staff, and parents (both black and Latino). We audiotaped and transcribed the meetings. We identified themes by consensus and used root cause analysis as a conceptual framework to guide our analysis. RESULTS: We held 13 focus group meetings. Participants uniformly perceived insufficient communication and coordination of care. Five themes representing system and human factors that contributed to this fragmentation in care emerged: (1) a lack of consensus about who should oversee care; (2) changes in health care providers or teachers; (3) uncertainty in the diagnosis, insufficient training, and few resources; (4) distrust and blame that emerged when relationships among people who care for the child were absent or otherwise inadequate; and (5) lack of support from employers, friends, and family to engage in collaborative care. CONCLUSIONS: Using a root cause analysis framework, we identified system- and human-level factors that were perceived to impede communication and coordination of care for this population of children with attention-deficit/hyperactivity disorder. These results suggest that better organizational policies that define provider responsibilities and accountability, support the coordination of care, bridge relationships between agencies, and provide additional education and resources may improve collaboration. Additional study is needed to assess the generalizability of these finding to other settings.