Prenatal maternal infections and early childhood developmental outcomes: analysis of linked administrative health data for Greater Glasgow & Clyde, Scotland.

BACKGROUND: Previous research has linked prenatal maternal infections to later childhood developmental outcomes and socioemotional difficulties. However, existing studies have relied on retrospectively self-reported survey data, or data on hospital-recorded infections only, resulting in gaps in data collection. METHODS: This study used a large linked administrative health dataset, bringing together data from birth records, hospital records, prescriptions and routine child health reviews for 55,856 children born in Greater Glasgow & Clyde, Scotland, 2011-2015, and their mothers. Logistic regression models examined associations between prenatal infections, measured as both hospital-diagnosed prenatal infections and receipt of infection-related prescription(s) during pregnancy, and childhood developmental concern(s) identified by health visitors during 6-8 week or 27-30 month health reviews. Secondary analyses examined whether results varied by (a) specific developmental outcome types (gross-motor-skills, hearing-communication, vision-social-awareness, personal-social, emotional-behavioural-attention and speech-language-communication) and (b) the trimester(s) in which infections occurred. RESULTS: After confounder/covariate adjustment, hospital-diagnosed infections were associated with increased odds of having at least one developmental concern (OR: 1.30; 95% CI: 1.19-1.42). This was broadly consistent across all developmental outcome types and appeared to be specifically linked to infections occurring in pregnancy trimesters 2 (OR: 1.34; 95% CI: 1.07-1.67) and 3 (OR: 1.33; 95% CI: 1.21-1.47), that is the trimesters in which foetal brain myelination occurs. Infection-related prescriptions were not associated with any clear increase in odds of having at least one developmental concern after confounder/covariate adjustment (OR: 1.03; 95% CI: 0.98-1.08), but were associated with slightly increased odds of concerns specifically related to personal-social (OR: 1.12; 95% CI: 1.03-1.22) and emotional-behavioural-attention (OR: 1.15; 95% CI: 1.08-1.22) development. CONCLUSIONS: Prenatal infections, particularly those which are hospital-diagnosed (and likely more severe), are associated with early childhood developmental outcomes. Prevention of prenatal infections, and monitoring of support needs of affected children, may improve childhood development, but causality remains to be established.

Increased family psychosocial focus during children's developmental assessments: a study of parents' views.

BACKGROUND: Family psychosocial challenges during the early years of a child's life are associated with later mental and physical health problems for the child. An increased psychosocial focus on parents in routine child developmental assessments may therefore be justified. METHODS: Participants in this qualitative study included 11 mothers and one parental couple (mother and father) with children aged 9-23 months. Participants were recruited to Project Family Wellbeing through their general practice in Denmark. Twelve interviews were conducted, transcribed and analysed with a deductive approach. The topic guide drew on the core components of the Health Belief Model, which also served as a framework for the coding that was conducted using thematic analysis. RESULTS: Results are presented in four themes and 11 subthemes in total. Parents welcome discussion of their psychosocial circumstances during their child's developmental assessments. Clinicians' initiatives to address psychosocial challenges and alignment of parents' and clinicians' expectations may be required to allow this discussion. A flowing conversation, an open communication style and a trustful relationship facilitate psychosocial discussion. Barriers included short consultation time, concerns about how information was used and when parents found specific psychosocial aspects stigmatising or irrelevant to discuss. CONCLUSION: Enquiry about the family's psychosocial circumstances in routine developmental assessments is acceptable among parents. Alignment of clinical and parental expectations of developmental assessments could facilitate the process. Future research should examine the predictive validity of the various components of developmental assessments. TRIAL REGISTRATION: This is a qualitative study. The study participants are part of the cohort from Project Family Wellbeing (FamilieTrivsel). The project's trial registry number: NCT04129359. Registered October 16th 2019.

Genu Valgum in Pediatric Patients Presenting With Patellofemoral Instability.

BACKGROUND: Lower extremity valgus is a commonly described factor associated with patellofemoral instability (PFI) and, if identified before skeletal maturity, can be treated with guided growth. The prevalence of valgus alignment in the pediatric and adolescent PFI population is largely unknown. PURPOSE: The aim of this study was to report the prevalence of valgus alignment in adolescent patients presenting with PFI; with secondary assessment of high-grade valgus (zone II or III), coronal asymmetry, and associations of these findings with body mass index (BMI). STUDY DESIGN: A retrospective cohort study. METHODS: A total of 279 consecutive patients (349 knees) with a diagnosis of PFI presenting to a single orthopedic pediatric sport medicine surgeon were identified. A retrospective chart review was performed to collect demographic and clinical data, chronologic and bone age, sex, BMI, mechanism of injury, and the presence of osteochondral fracture. Full-length standing hip-to-ankle alignment radiographs were graded for knee alignment mechanical zone utilizing standard linear femoral head center to talar center assessment. In addition, mechanical axis deviation, mechanical lateral distal femoral angle and medial proximal tibial angle (MPTA) were also calculated. RESULTS: Mean patient age was 14.0±2.5 years. There were 162 (58.1%) females and mean BMI was 24.3±6.4. Seventy patients (25.1%) had bilateral PFI. Standing alignment radiographs were available for 81.4% of knees (n=284). Valgus alignment was present in 172 knees with PFI (60.6%). High-grade valgus, defined as zone 2 or greater, was present in 66 knees (23.3%). Overall, 48.9% had asymmetry of coronal alignment (n=139). The mean mechanical lateral distal femoral angle was 85.4±2.8 and the mean MPTA was 88.2±2.6. There was a greater MPTA in female patients (88.8±2.4 vs. 87.5±2.7, P <0.001). A higher BMI (24.87±6.95, P =0.03) was associated with valgus alignment. CONCLUSIONS: There is a high (60%) prevalence of lower extremity valgus in adolescent patients presenting with PFI, with nearly 1 in 4 presenting with high-grade valgus. The treatment team should be aware of this association as it may be an important consideration in the pediatric and adolescent PFI populations. LEVEL OF EVIDENCE: Level III.

Changes in Fracture Shortening Occur in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures.

BACKGROUND: Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment. The degree to which shortening may change in the initial weeks following injury has not been well studied. The purpose of this study was to evaluate the change in shortening of adolescent clavicle fractures in the first 2 weeks following injury. METHODS: This was a multicenter study of prospectively collected data, which was acquired as a part of a cohort study of adolescent clavicle fractures. A consecutive series of patients 10 to 18 years of age with completely displaced diaphyseal clavicle fractures with baseline radiographs 0 to 6 days from the date of injury, as well as 7 to 21 days from the date of injury, were included. Measurements of end-to-end (EES) and cortex-to-corresponding-cortex (CCS) shortening were performed. RESULTS: A total of 142 patients were included. Baseline radiographs were obtained at a mean of 1.0 day following injury with mean EES of 22.3 mm, and 69% of patients demonstrating >20 mm of shortening. Follow-up radiographs obtained at a mean of 13.8 days postinjury demonstrated a mean absolute change in EES of 5.4 mm. Forty-one percentage of patients had >5 mm of change in EES. When analyzing changes in shortening relative to the specific threshold of 20 mm, 18 patients (41%) with <20 mm EES increased to ≥20 mm EES, and 19 patients (19%) with ≥20 mm EES decreased to <20 mm EES at 2-week follow-up. CONCLUSIONS: Clinically significant changes in fracture shortening occurred in 41% of adolescents with completely displaced clavicle fractures in the first 2 weeks after injury. In 26% of patients, this resulted in a change from above or below the commonly used shortening threshold of 20 mm, potentially altering the treatment plan by many providers. There is no evidence to suggest that adolescent clavicle fracture shortening affects outcomes, and as such, the authors do not advocate for the use of this parameter to guide treatment. However, among physicians who continue to use this parameter to guide treatment, this study supports that repeat radiographic assessment 2 weeks postinjury may be a better measure of the true shortening of this common adolescent injury. LEVEL OF EVIDENCE: Level IV-case series.

Collaboration between general practitioners and health visitors about children of concern in Denmark: a qualitative study.

Primary health care services are responsible for preventive measures to optimize child development in the first years of life. In Denmark, these services are shared between general practitioners and municipality health visitors. National guidelines mandate collaboration between these professionals but in reality, they work in parallel. We aimed to explore how professionals experience collaboration and communication regarding children with professional concern about their wellbeing. Seventeen semi-structured interviews were conducted with general practitioners, and health visitors. Both professions considered closer collaboration to be important in meeting children's needs. Barriers to collaboration and communication included differing legal obligations, Information Technology-systems (IT), lack of financial incentives, lack of mutual professional acknowledgment and respect, and absence of routines for sharing knowledge. The traditional division of responsibilities between physicians and nurses in which all professionals involved in preventive child health care are acculturated seems to impede collaboration based on unequal professional status. IT infrastructure needs to support information sharing and structures to support informal meetings between professionals are warranted to support more collaborative practice.

Clinicians' experiences in signposting an online mental health resource to expectant mothers: a qualitative study.

BACKGROUND: Poor maternal mental well-being and a lack of secure parent-infant attachment, have been identified as important factors associated with adverse mental health outcomes later in a child's life. Interventions designed to care for maternal mental well-being during pregnancy and early parenthood, are therefore likely to support healthy child development. Mentalization is a skill parents can practice, improving the emotional bond to the child, offering insights into their own and the child's mental states and potentially improving parental mental well-being. Most pregnant women in Denmark schedule antenatal consultations in general practice, potentially offering a solid platform to promote web-based interventions aiming to enhance mentalization skills. Signposting towards online resources has several advantages including high accessibility, ease of distribution and cost-effectiveness. We aimed to explore the attitudes and experiences of clinicians in general practice in signposting women towards a web-intervention to increase parental mentalization skills. METHODS: The intervention was offered to pregnant women at their primary preventive antenatal consultation in Danish general practice around week eight of pregnancy, and was designed to be incorporated into the following antenatal- and pediatric consultations until the child's second birthday. Semi-structured interviews about clinicians' experiences with signposting the intervention were conducted with 11 general practitioners (GP), three practice midwives (MW) and one practice nurse (NR). RESULTS: Clinicians wanted to enhance the focus on mental well-being in pregnancy and early childhood during preventive consultations. The main barriers to signposting the web-program were decreasing motivation over time, lack of financial viability and time limitations. Utilizing a psychoeducational web-intervention was generally accepted by clinicians, but ideally not carried out solely in general practice. CONCLUSION: Signposting web-programs to improve parental mentalization skills can be welcomed by clinicians in general practice but need to be more tailored to suit the everyday workflow of the clinics. Addressing parental mentalization remains largely unchartered territory for pregnant women and clinicians alike, therefore training clinicians on the subject and its presentation should be offered. TRIAL REGISTRATION: The study is part of a larger project that has been approved by the Research Ethics Committee at the University of Copenhagen, Nov. 2019 (reference number 504-0111/19-5000).

Health-related quality of life of children from low-income families: the new patterns study.

BACKGROUND: Child poverty has been gradually rising, and about 12% of all Norwegian children are living in a state of relative poverty. This study was part of the New Patterns project, which recruits low-income families requiring long-term welfare services. Included families receive integrated welfare services, with the help of a family coordinator. The current study objectives were to explore the associations between HRQoL, demographic variables (age, gender, immigration status) and leisure activities in children and adolescents in low-income families. METHODS: A cross-sectional survey was conducted among low-income families. Participating families had children (N = 214) aged 8-18 years.The family had a household income below 60% of the equivalized median population income for three consecutive years and needed long-term welfare services. HRQoL was measured using the KIDSCREEN-27 self-report instrument. Descriptive statistics, including means, standard deviations, and proportions, were calculated, and ordinary least squares regressions were performed, clustering standard errors at the family level. RESULTS: Compared with boys, girls reported lower HRQoL on only one out of five dimensions, physical wellbeing. In the regression analysis we found statistically significant positive associations between migrant status and HRQoL on all five dimensions: physical wellbeing, psychological wellbeing, parents and autonomy, peers and social support, and school environment. In addition, age was associated with school environment, and age, gender and participation in leisure activities was associated with better physical wellbeing. CONCLUSIONS: Baseline results regarding HRQoL among children and adolescents in low-income families indicate that they have overall good HRQoL, though some participants had low HRQoL scores, especially on the physical and social support dimensions. Children with an immigrant background report higher HRQoL than do children without an immigrant background.

Increasing the psychosocial focus in child developmental assessments: a qualitative study.

BACKGROUND: Previous studies have indicated a need for increased psychosocial focus on children and their families to improve children's wellbeing and mental health. Child developmental assessments could be a place to implement changes to achieve this. A standardised record might be helpful to clinicians trying to increase psychosocial focus. The aim of this study is to investigate clinical barriers and facilitators when introducing standardised child records with increased focus on psychosocial wellbeing and mental health into child developmental assessments. METHODS: This is a qualitative study based on 12 semi-structured interviews with four midwives and nine doctors who carry out child developmental assessments in general practice. Data is analysed in the framework of Normalisation Process Theory. RESULTS: General practice-based clinicians were positive towards increasing the psychosocial focus in child developmental assessments. The main barriers when clinicians used the standardised child records were: feeling forced to ask certain questions, in turn making the conversation rigid; leaving less room for parents to bring up other issues; making clinicians feel awkward when addressing problems that they cannot solve; the need for extended consultation time; and medico-legal concerns when registering findings. The experience of positive aspects when using the standardised child records facilitated continuous use of the records. Positive aspects included having a standardised approach to recording important findings, thereby uncovering psychosocial problems that could potentially be overlooked. Additionally, structured observation of parent-child interaction and gaining a new vocabulary to describe the findings were valued by clinicians. Balancing a standardised approach with clinicians' ability to steer the consultation and explore topics in depth while preserving the potential for patients to bring up other issues became an important theme. CONCLUSION: Clinicians need to be well-equipped to handle psychosocial problems through coping strategies, referral options and communication techniques in the psychosocial domain. The parent-child-interaction assessment might expose potentially dysfunctional parenting behaviours and could improve communication between health professionals. Implementing standardised child development records with an increased psychosocial focus is feasible but improvements could optimise the use of the records. Parental views on an increased psychosocial focus during child developmental assessments should be investigated prior to further implementation. TRIAL REGISTRATION: Trial registry number for the FamilieTrivsel (Family Wellbeing) trial: NCT04129359.

The development and productivity of a measure for identifying low language abilities in children aged 24-36 months.

BACKGROUND: Accurate early identification of children with low language ability is important but existing measures generally have low sensitivity. This remains an area of concern for preventive and public health services. This study aimed to create and evaluate a measure of child language, communication and related risks which can be used by community health nurses to accurately identify children with low language aged 24-30 months. METHODS: The Early Language Identification Measure (ELIM) was developed and comprised five measurement sections, each measuring different aspects of development combined into a single measure. This was tested blind against a reference standard language measure, the Preschool Language Scale-5 (PLS-5), at the universal 24-30-month health visitor review in England. The threshold for likely low language was the tenth centile or below on the PLS-5. The aim was to ascertain the performance of the five individual sections in the scale, and consider the optimum combination of sections, for predicting low language ability. Specificity, sensitivity, and positive and negative predictive values were reported for each of the five sections of the ELIM alone and in conjunction with each other. The performance for children from monolingual English-speaking families and those who spoke languages other than English were also considered separately. RESULTS: Three hundred and seventy-six children were assessed on both the ELIM identification measure and the PLS-5 with 362 providing complete data. While each section of the ELIM predicted low language ability, the optimal combination for predicting language outcome was the parent reported vocabulary checklist coupled with the practitioner observation of the child's communication and related behaviours. This gave a sensitivity of 0·98 with a specificity of 0·63. CONCLUSIONS: A novel measure has been developed which accurately identifies children at risk of low language, allowing clinicians to target resources efficiently and intervene early.

A critical examination of Danish norms for the Strengths and Difficulties Questionnaire (SDQ).

OBJECTIVE: The objective was to describe observed differences between the official Danish Strengths and Difficulties Questionnaire (SDQ)-norms and data from a sample based on the Danish National Birth Cohort (DNBC) including children born between 1996 and 2003. We compared the risk classification, cut-off bandings and the group sizes between the Danish norms and the values found in our sample at ages 7, 11 and 18 years. RESULTS: Two sets of norms are used in Denmark: Arnfred's norms, based on a sample from one single Danish municipality and Niclasen's norms, based on multiple Danish cohorts, including the DNBC. Inconsistencies were found between banding scores in the two existing norms and the banding scores identified in our sample from DNBC: discrepancies included banding scores for several of the problem scales for children and preadolescents. For adolescents, we found less apparent inconsistencies between Arnfred's sample and the DNBC. Results demonstrate that the existing SDQ norms do not apply well to a large-scale cohort sample in Denmark. The usefulness of the SDQ as a screening instrument for mental health problems depends on appropriate norms. We therefore urge that the current Danish SDQ norms are used with caution, and preferably they should be revised.

Evaluation of the Danish version of the prenatal parental reflective functioning questionnaire in early pregnancy as a screening tool.

Parental reflective functioning (PRF) is the capacity to focus on feelings and experiences in oneself as a parent and in the child. Research has demonstrated that, the better the PRF the better outcomes for the child. This paper evaluated the Danish version of the prenatal parental reflective functioning questionnaire (P-PRFQ). We used data from a cluster-randomized trial of pregnant women recruited from Danish general practice. The sample included 605 mothers. Factor structure and internal consistency were investigated. Linear regression analysis was used to examine the associations between the P-PRFQ score and the five most predictive variables. The confirmatory factor analyses supported the three-factor model. The P-PRFQ had moderate internal consistency. The regression analysis showed a decrease in the P-PRFQ score with increasing age, increasing parity, current employment, better self-reported health, lower anxiety score, and fewer negative life events with persistent impact. The directions of the associations between P-PRFQ score and the predictive variables were opposite of what was hypothesized raising questions about whether the P-PRFQ can be used as an early pregnancy screening tool assessing prenatal PRF. Further validation studies are required to assess the extent to which the P-PRFQ truly measures reflective functioning.

El funcionamiento con reflexión de los padres es la capacidad de enfocarse en sentimientos y experiencias en uno mismo como progenitor y en el niño. La investigación ha demostrado que mientras mejor es el funcionamiento con reflexión, mejores son los resultados para el niño. Este ensayo evalúa la versión danesa del cuestionario prenatal del funcionamiento con reflexión de los progenitores (P-PRFQ). Usamos datos de un ensayo con un grupo al azar de mujeres embarazadas reclutadas de la práctica general danesa. El grupo muestra estaba compuesto de 605 madres. Se investigaron la estructura de factores y la consistencia interna. Se usaron análisis de regresión lineal para examinar la asociación entre los puntajes del P-PRFQ y las cinco variables más predictivas. Los análisis de factores confirmatorios apoyaron el modelo de tres factores. El P-PRFQ presentó una consistencia interna moderada. Los análisis de regresión mostraron una baja en los puntajes del P-PRFQ con el aumento de la edad, el aumento de la paridad, el empleo actual, una mejor auto reportada salud, más bajo puntaje de ansiedad y menos eventos negativos en la vida con impacto persistente. Las direcciones de las asociaciones entre el puntaje del P-PRFQ y las variables predictivas resultaros lo opuesto de la hipótesis propuesta, lo cual genera preguntas sobre si se puede usar el P-PRFQ como una herramienta de examen temprano del embarazo para evaluar el funcionamiento con reflexión prenatal de los progenitores. Se requieren estudios posteriores de validación para evaluar hasta qué punto el P-PRFQ mide verdaderamente el funcionamiento con reflexión.

La fonction réflexive parentale est la capacité à se focaliser sur ses propres sentiments et ses expériences en tant que parent et chez l'enfant. Les recherches ont démontré que mieux fonctionne la fonction réflexive parentale, mieux s'avère le résultat pour l'enfant. Cet article a évalué la version danoise du questionnaire de la fonction réflexive parentale prénatale (P-PRFQ). Nous avons utilisé des données d'un essai randomisé par grappes de femmes enceintes recrutées dans un service de médecine générale au Danemark. L'échantillon a inclus 605 mères. La structure de facteur et la cohérence interne ont fait l'objet des recherches. Une analyse par régression linéaire a été utilisée afin d'examiner les liens entre le score P-PRFQ et les cinq variables les plus prédictives. Les analyses factorielles confirmatoires ont soutenu le modèle à trois facteurs. Le P-PRFQ a eu une cohérence internet. L'analyse par régression a montré une baisse dans le score P-PRFQ avec un âge plus avancé, une parité augmentée, un emploi courant, une meilleure santé auto-rapportée, un score d'anxiété plus bas et moins d'événements négatifs de la vie ayant un impact persistent. Les directions des liens entre le score P-PRFQ et les variables prédictives étaient à l'opposé de l'hypothèse, soulevant des questions sur si le P-PRFQ peut être utilisé en tant qu'outil de dépistage au début de la grossesse pour évaluer la fonction réflexive parentale prénatale. Des études de validation supplémentaires sont nécessaires pour évaluer dans quelle mesure le P-PRFQ mesure vraiment la fonction réflexive.

A protocol for a systematic review of randomised evaluations of strategies to improve recruitment of rural participants to randomised controlled trials.

INTRODUCTION: People living rurally face health inequities fuelled by social exclusion, access to and awareness of health services, and poor transport links. In order to improve the acceptability, accessibility and applicability of health and care interventions, it is important that clinical trial participant populations include people living rurally. Identifying strategies that improve recruitment of rural participants to trials will support trialists, reduce research waste and contribute to alleviating health inequalities experienced by rural patients. The objective of the review is to quantify the effects of randomised evaluations of strategies to recruit rural participants to randomised controlled trials. METHODS: The following databases will be searched for relevant studies: Ovid MEDLINE, Embase, Cochrane Library, Web of Science All, EBSCO CINAHL, Proquest, ERIC, IngentaConnect, Web of Science SSCI and AHCI, and Scopus. Any randomised evaluation of a recruitment intervention aiming to improve recruitment of rural participants to a randomised trial will be included. We will not apply any restriction on publication date, language or journal. The primary, and only, outcome of our review will be the proportion of participants recruited to a randomised controlled trial. Two reviewers will independently screen abstracts and titles for eligible studies, and then full texts of relevant records will be reviewed by the same two reviewers. Where disagreements cannot be resolved through discussion, a third reviewer will adjudicate. RESULTS: We will assess the methodological quality of individual studies using the Cochrane risk of bias tool, and the GRADE approach will be applied to determine the certainty of the evidence within each comparison. CONCLUSION: This systematic review will quantify the effects of randomised evaluations of strategies to recruit rural participants to trials. Our findings will contribute to the evidence base to support trial teams to recruit a participant population that represents society as a whole, informing future research and playing a part to alleviate health inequalities between rural and urban populations.

Mental well-being during stages of COVID-19 lockdown among pregnant women and new mothers.

BACKGROUND: Pregnancy and early motherhood are sensitive times where epidemic disease outbreaks can affect mental health negatively. Countries and health care systems handled the pandemic and lockdowns differently and knowledge about how the COVID-19 pandemic affected the mental well-being of pregnant women and new mothers is limited and points in different directions. AIM: To investigate symptoms of anxiety and depression in a population of pregnant women and new mothers in various stages of infection pressure and lockdown during the first 15 months of the COVID-19 pandemic in Denmark. METHODS: The study population was nested an inception cohort of women recruited in their first trimester of pregnancy. Data about mental health of the woman were obtained in relation to pregnancy and child development (first trimester, 8 weeks postpartum and 5 months postpartum), and data were analysed cross-sectionally according to calendar time (periods defined by infection rate and lock-down during the COVID-19 pandemic). RESULTS: No differences in reported levels of depressive symptoms between the six examined time periods of the pandemic were observed. Specifically, symptoms remained unchanged after the first lock-down. No major changes in anxiety symptoms were observed in relation to increased infection pressure or lockdowns, but a small increase was observed during the second lockdown in women 8 weeks postpartum. CONCLUSION: No clear change in mood among pregnant women was seen between during the stages of COVID-19 pandemic in Denmark.

A Cross-Sectional Study of Disparities in Screening Guideline Concordance Within a Student-Run Clinic.

Examination of screening guideline concordance can help clinics and institutions identify and understand disparities within their own practices. We conducted a study to examine whether screening completion rates within a student-run free clinic (SRFC) reflected, exacerbated, or narrowed population-level disparities in outcomes by race/ethnicity and primary language. We compared completion rates for cervical cancer (n = 114), diabetic retinopathy (n = 91), colorectal cancer (n = 114), and breast cancer (n = 63) by race/ethnicity (Black, n = 37; Hispanic, n = 133; white, n = 54; other, n = 29) and primary language (English, n = 106; Spanish, n = 136; other, n = 11) among patients at Shade tree clinic (STC), an SFRC in Nashville, TN. There were no differences in screening completion rate by race/ethnicity, and Spanish-speaking patients had slightly higher rates of cervical cancer screening [91% (95% confidence interval 84-97%)] than English-speaking patients [72% (57-86%)]. Overall screening rates were comparable to national averages, and in the case of screenings performed within clinic-cervical cancer [82%; (75-89%)] and diabetic retinopathy screening [86% (79-92%)]-exceeded national averages and/or affiliated academic medical center goals. These findings extend the existing literature supporting the ability of SRFCs to provide effective care by also demonstrating one measure of equity in clinic processes, providing a framework for future studies of equity within SRFCs and traditional primary care practices.

Educational associations with missed GP appointments for patients under 35 years old: administrative data linkage study.

BACKGROUND: There is an evidence gap about whether levels of engagement with public services such as schools and health care affect people across the lifespan. Data on missed patient appointments from a nationally representative sample of Scottish general practices (GP) (2013-2016) were probabilistically linked to secondary school pupil data. We tested whether school attendance, exclusions (2007-2011) or lower educational attainment (2007-2016) was associated with an increased risk of missing general practice appointments. METHODS: School attendance data were classified into quartiles of possible days attended for years we had data. School exclusions were derived as a categorical variable of 'ever excluded'. Attainment data were categorised via the Scottish Credit and Qualifications Framework (SCQF) level 3 or 6; a cumulative measure of attainment on leaving school. The associations between school attendance, exclusions and attainment and risk of missing medical appointments were investigated using negative binomial models, offset by number of GP appointments made and controlling for potential confounders. RESULTS: 112,534 patients (all aged under 35) had GP appointment and retrospective school attendance and exclusion data, and a subset of 66,967 also had attainment data available. Patients who had lower attendance, had been excluded from school or had lower educational attainment had an increased risk of missing GP appointments (all rate ratios > 1.40). CONCLUSIONS: This study provides the first evidence from a population-representative sample in a high-income country that increased numbers of missed appointments in health care are associated with reduced school attendance, higher levels of school exclusion and lower educational attainment. Insights into the epidemiology of missingness across public services can support future research, policy and practice that aim to improve healthcare, health outcomes and engagement in services.

The New Patterns study: coordinated measures to combat child poverty.

BACKGROUND: Child poverty rates are rising in Norway with potential negative consequences for children. Services for families with low income are often fragmented and poorly integrated, and few coordinated initiatives have been implemented and evaluated in Norway. AIMS: The aim of the current study is to evaluate how integrated and coordinated services provided over a prolonged period by a family coordinator are related to changes across a wide range of health, wellbeing and home environment indicators for the participants. METHODS: The study uses a mixed methods approach utilising survey and register data, as well as information from interviews and shadowing, to document and evaluate outcomes associated with the intervention and the process of implementation. Data are gathered at baseline and annually throughout the duration of the study. Participants are identified to facilitate longer-term follow-up using register data. CONCLUSIONS: This project will develop important knowledge about the implementation of coordinated services to families with a low income, and how this way of organizing services influences important outcomes for the family members in the short and long term.

Depression and anxiety symptoms in pregnant women in Denmark during COVID-19.

AIMS: Maternal mental distress in pregnancy can be damaging to the mother's and child's physical and mental health. This study aimed to provide an insight into mental well-being of pregnant women in Denmark during COVID-19 by assessing symptoms of depression and anxiety. METHODS: Data from two cohorts of pregnant women recruited from Danish general practice were compared. A COVID-19 lockdown cohort (N=330) completed questionnaires between 8 April and 6 May. Responses were compared to those from a control cohort of women from 2016 (N=1428). Mental well-being was measured with the Major Depression Inventory (MDI) and the Anxiety Symptom Scale (ASS). RESULTS: Questionnaires were returned by 83% of the COVID-19 lockdown cohort and by 93% of the control cohort. Multivariable analysis controlling for age, cohabitation status, occupation, smoking, alcohol use, chronic disease, fertility treatment, parity and children living at home showed no difference in depressive symptoms (MDI). Anxiety symptoms (ASS) were slightly worse in the COVID-19 lockdown cohort (mean difference=1.4 points), mainly driven by questions concerning general anxiety. The largest differences in anxiety were seen in first trimester (adjusted mean difference=4.0 points). CONCLUSIONS: Pregnant women questioned during the COVID-19 pandemic showed no change in symptoms of depression and only a modest elevation of anxiety when compared to pregnant women questioned during a non-pandemic period in 2016.

Variation in referrals from primary care to scheduled paediatric services in North and East Scotland -a cross-sectional study.

BACKGROUND: Factors contributing to decisions to refer children for scheduled appointments at medical paediatric outpatient clinics are not well understood. Our aim was to describe practice-level characteristics associated with referrals to general paediatric clinics. METHODS: In this cross-sectional study the setting was general practices in three health boards in Scotland, NHS Grampian, NHS Highland and NHS Tayside The outcome was average annual number of referrals per 1000 children between 2011 and 2017. Univariate and multivariate analyses related the outcome to practice characteristics. For each practice the following characteristics were determined: distance from hospital; area deprivation; number of children registered; presence of ≥ 1 general practitioner with a child health interest and practice ownership. RESULTS: There were 62 practices in NHS Grampian, 63 in NHS Highland, and 65 in NHS Tayside; representative annual number of referrals to paediatric clinics per capita were 22, 34, and 35/1000 respectively. In the multivariate model, the number of referrals was inversely related to number of children in the practice (0.8 % fall per 1000 children [95 % confidence interval, CI, 0.5, 1.1]) and was higher from practices in the more deprived areas by a mean 55 % [95 % CI 9, 121] compared to less deprived areas. The number of referrals from a practice rose by 0.91 % [95 % CI 0.86, 0.97] for each additional partner in the practice. CONCLUSION: Some practice-level characteristics were related to the standardised number of referrals, and associations differed between regions.

What's New in the Management of Pediatric Anterior Cruciate Ligament Tears and Tibial Spine Fractures.

As the number of pediatric and adolescent patients participating in sports continues to increase, so too does the incidence of anterior cruciate ligament (ACL) tears in this population. There is increasing research on pediatric and adolescent ACL tears; hundreds of articles on the topic have been published in the past few years alone. It is important to highlight the most pertinent information in the past decade. In discussing pediatric ACL tears, it is also important to review tibial spine fractures. These injuries are rightfully grouped together because tibial spine fractures often occur with a mechanism of injury similar to that of ACL tears, but typically in a younger age group. Because management is different, understanding the similarities and differences between the two pathologies is important. Recent updates on the epidemiology, diagnosis, management, and outcomes of both pediatric ACL tears and tibial spine fractures need to be reviewed.

What's New in Osteochondritis Dissecans of the Knee, Elbow, and Ankle.

Osteochondritis dissecans is a condition of the subchondral bone, with secondary effects on the articular cartilage. It most commonly affects the knee, elbow, and ankle and is typically seen in young, active populations. Many osteochondritis dissecans lesions are asymptomatic, but more advanced lesions can cause pain, swelling, and mechanical symptoms. Multiple treatment options have been proposed, including nonsurgical and surgical approaches. It is important to be aware of the epidemiology, presenting symptoms, and indications for nonsurgical and surgical treatment options for osteochondritis dissecans of the knee, elbow, and ankle.