Access to and perceived unmet need for mental health services and support in a community sample of UK adolescents with and without experience of childhood adversity

AIMS

Children and adolescents with a history of adverse childhood experiences (ACEs) are more likely than their peers to develop mental health difficulties, but not enough is known about their help-seeking behaviours and preferences. We aimed to determine whether ACEs are associated with access to and perceived unmet need for mental health services and support amongst secondary school students.

METHODS

We used multi-level logistic regression with data from the 2020 OxWell Student Survey to assess whether ACEs were associated with (1) prior access to mental health support and (2) perceived unmet need for mental health services in a community sample of English secondary school students. We assessed ACEs as a cumulative score from the Center for Youth Wellness Adverse Childhood Experiences Questionnaire: Teen Self-Report version and accounted for current mental health difficulties as measured by the 25-item Revised Children's Anxiety and Depression Scale (RCADS).

RESULTS

Our analysis included 2018 students across 64 schools, of whom 29.9% (598/2002) reported prior access to mental health support. Of those not reporting prior access, 34.1% (469/1377) reported a perceived unmet need for services. In the unadjusted models, cumulative ACE scores were significantly positively associated with both prior access to mental health support (odds ratio (OR) = 1.36; 95% confidence interval (CI): 1.29-1.43) and perceived unmet need for mental health services (OR = 1.47; 95% CI: 1.37-1.59), meaning that students who had experienced adversity had a greater chance of having previously accessed support as well as perceiving an unmet need for services. After adjusting for mental health difficulties and other sociodemographic variables, cumulative ACE scores were positively associated with prior access (adjusted OR (aOR) = 1.25; 95% CI: 1.17-1.34 with a significant interaction between RCADS and ACE scores, aOR = 0.88; 95% CI: 0.84-0.93) as well as perceived unmet need (aOR = 1.32; 95% CI: 1.21-1.43 with a significant interaction between RCADS and ACE scores, aOR = 0.85; 95% CI: 0.78-0.91).

CONCLUSIONS

Although it is encouraging that adolescents with experience of adversity are more likely than their peers with similar levels of depression and anxiety symptoms to have accessed mental health support, there remains a concern that those who have not accessed support are more likely to perceive an as-yet unmet need for it. Mental health support must be available, accessible and acceptable to all who need it, especially for those groups that traditionally have not accessed services, including the more marginalised and vulnerable populations.

Failed Bilateral Total Silastic First Metatarsophalangeal Joint Implant Reconstructed with Osteochondral Allograft Implantation

First metatarsophalangeal joint (MPJ) arthritis is a very common form of arthritis seen in the foot. Some signs and symptoms include pain, swelling, decreased passive and active range of motion, difficulty with shoe gear, and so forth. Surgically, options for alleviating symptomatic hallux limitus and arthritis fall into two broad categories: joint sparing and joint sacrificing. In this case study, we present a patient with a bilateral failed total silastic implant of the first MPJ and our proposed revision using an osteochondral bone allograft to fill the deficit left behind from silastic implant removal. The ability for immediate weightbearing and to perform this procedure bilaterally is an advantage to this surgical treatment option compared with other described revision techniques. Postoperatively, the patient has adequate range of motion and no pain when ambulatory. We believe this osteochondral allograft implant may be a viable option for revision first MPJ arthroplasty in select patient populations.

Understanding the relationship between family income and conduct problems: findings from the mental health of children and young people survey

BACKGROUND

Children from low-socioeconomic backgrounds exhibit more behavioural difficulties than those from more affluent families. Influential theoretical models specify family stress and child characteristics as mediating this effect. These accounts, however, have often been based on cross-sectional data or longitudinal analyses that do not capture all potential pathways, and therefore may not provide good policy guidance.

METHODS

In a UK representative sample of 2399 children aged 5-15, we tested mediation of the effect of household income on parent and teacher reports of conduct problems (CP) via unhealthy family functioning, poor parental mental health, stressful life events, child physical health and reading ability. We applied cross-lagged longitudinal mediation models which allowed for testing of reciprocal effects whereby the hypothesised mediators were modelled as outcomes as well as predictors of CP.

RESULTS

We found the predicted significant longitudinal effect of income on CP, but no evidence that it was mediated by the child and family factors included in the study. Instead, we found significant indirect paths from income to parental mental health, child physical health and stressful life events that were transmitted via child CP.

CONCLUSION

The results confirm that income is associated with change in CP but do not support models that suggest this effect is transmitted via unhealthy family functioning, parental mental health, child physical health, stressful life events or reading difficulties. Instead, the results highlight that child CP may be a mediator of social inequalities in family psychosocial functioning.

Relationship between ambient temperature at sampling and the interferon gamma test result for bovine tuberculosis in cattle

Bovine tuberculosis (bTB) is a disease of significant economic and zoonotic importance, therefore, optimising tests for the identification of Mycobacterium bovis infected cattle is essential. The Interferon Gamma (IFN-γ) Release Assay (IGRA) can diagnose M. bovis infected cattle at an early stage, is easy to perform and can be used alongside skin tests for confirmatory purposes or to increase diagnostic sensitivity. It is known that IGRA performance is sensitive to environmental conditions under which samples are taken and transported. In this study, the association between the ambient temperature on the day of bleeding and the subsequent IGRA result for bTB was quantified using field samples from Northern Ireland (NI). Results of 106,434 IGRA results (2013-2018) were associated with temperature data extracted from weather stations near tested cattle herds. Model dependent variables were the levels of IFN-γ triggered by avian purified protein derivative (PPDa), M. bovis PPD (PPDb), their difference (PPD(b-a)) as well as the final binary outcome (positive or negative for M. bovis infection). IFN-γ levels after both PPDa and PPDb stimulation were lowest at the extremes of the temperature distribution for NI. The highest IGRA positive probability (above 6%) was found on days with moderate maximum temperatures (6-16 °C) or moderate minimum temperatures (4-7 °C). Adjustment for covariates did not lead to major changes in the model estimates. These data suggest that IGRA performance can be affected when samples are taken at high or low temperatures. Whilst it is difficult to exclude physiological factors, the data nonetheless supports the temperature control of samples from bleeding through to laboratory to help mitigate post-collection confounders.

Otolaryngology

Pediatric otolaryngology procedures constitute a diverse set of procedures, each with different degrees of invasiveness and special anesthetic considerations. Patients undergoing otolaryngologic surgery can have potentially life-threatening upper airway obstruction or have severe pulmonary insufficiency requiring diagnostic or therapeutic procedures. Even in patients without life-threatening pathology, common to the majority of these surgical procedures is their proximity to the airway, requiring the pediatric anesthesiologist to develop strategic approaches to mitigate the risk of perioperative airway complications.

Evoked Potentials

Evoked potentials are electrophysiologic responses of the nervous system to electrical stimuli. They involve applying a current to a sensory nerve and measuring the response on the sensory cortex with a scalp electrode. They serve as a surrogate measure for neurologic functional integrity for patients under general anesthesia during a variety of neurosurgical procedures and occasionally nonneurosurgical procedures, including cardiopulmonary bypass and deep circulatory arrest. Evoked potentials commonly monitored in the operating room include motor, sensory, visual, and auditory potentials. Changes in evoked potentials can serve as indicators for risk of neural injury and guide interventions to prevent permanent damage undertaken by both the surgeon and anesthesiologist.

Coagulopathy in Trauma Patients

Despite advances in trauma care, trauma remains a leading cause of disability and death globally due to uncontrolled hemorrhage. This is because one-quarter to one-third of trauma patients develop a biochemically evident coagulopathy. Coagulopathy arising in trauma patients is complex and multifactorial, with overlapping etiologies disrupting the balance of hemostatic and fibrinolytic processes. Contributing etiologies include acidosis, hypothermia, dilutional resuscitation, disseminated intravascular coagulation, platelet dysfunction, and trauma-induced coagulopathy. The last is due to a combination of tissue injury and shock resulting in molecular and physiologic perturbations. Ultimately, this complex coagulopathy in trauma patients manifests as uncontrolled hemorrhage, organ failure, thromboembolic complications, and death.

Improvement in angina pectoris after percutaneous coronary interventions in focal and diffuse coronary artery disease

Objective

To investigate the effect of PCI on patient-reported outcomes in focal and diffuse coronary artery disease (CAD) as defined by the pullback pressure gradient (PPG).

Background

Improvements in fractional flow reserve (FFR) following PCI are associated with freedom from angina. CAD patterns influence the FFR change after stenting. Therefore, CAD patterns might be essential to assess the likelihood of PCI success in terms of angina relief.

Methods

This is a sub-analysis of the TARGET-FFR randomized clinical trial (NCT03259815). The 7-item Seattle Angina Questionnaire (SAQ-7) and EuroQol five-level EQ-5D questionnaire (EQ-5D-5L) were administered at baseline and three months after PCI. The PPG index was calculated from manual pre-PCI FFR pullbacks and the median PPG value was used to define focal and diffuse CAD.

Results

103 patients (51 with focal and 52 with diffuse disease) were analyzed. There were no differences in baseline characteristics between patients with focal and diffuse CAD. Patients with focal disease had larger increases in FFR with PCI than those with diffuse disease (0.30±0.14 units vs 0.19±0.12 units, p<0.001). Patients who underwent PCI to focal CAD had significantly higher SAQ-7 summary scores at follow-up compared to those with diffuse CAD (87.1±20.3 vs. 75.6±24.4, mean difference 11.5 [95% CI 2.8 to 20.3], p=0.01). Following PCI, residual angina was present in 39.8% of all patients but was significantly lower among those with treated focal CAD (27.5% vs 51.9%, p-value=0.020).

Conclusion

Persistent angina after PCI was almost twice as common in patients with diffuse CAD as defined by the pre-PCI PPG. Patients with focal disease reported greater improvement in angina and quality of life with PCI. The likelihood of successful angina relief from PCI can be predicted by the baseline pattern of CAD.

Funding Acknowledgement

Type of funding sources: None.

Coronary perforation incidence and temporal trends (COPIT): systematic review and meta-analysis

Background

Despite advancements in Percutaneous Coronary Intervention (PCI) technology and techniques, iatrogenic coronary artery perforation (CAP) remains a dreaded potential complication within the cardiac catheterisation laboratory. Data detailing the incidence of coronary perforation during PCI has previously been obtained from relatively small datasets. A swell of large data published in recent times provides invaluable information regarding PCI related CAP.

Purpose

COPIT is a systematic review and meta-analysis targeted at detailing the incidence, outcomes, etiology and treatment modalities of PCI related CAP including evaluation of temporal trends since the inception of PCI to contemporary practice. Additionally, COPIT provides hypothesis generating data regarding predictors of CAP during PCI.

Methods

A prospective systematic review and meta-analysis using MEDLINE and EMBASE via the OVID interface (PROSPERO ID: CRD42020207881) was performed according to the PRISMA guidelines. Identified relevant studies were used in a pre-specified sensitivity analysis to detail incidence, outcomes, etiology, treatment modalities and risk factors of PCI complicated by CAP. Studies limited to PCI in high risk populations only such as CTO-PCI or rotational atherectomy only were excluded.

Results

67 studies met eligibility criteria detailing 5,568,191 PCIs over a 38-year period (1982–2020). The pooled incidence of CAP was 0.39% (95% CI: 0.34–0.45%) with no change in incidence over that time. Approximately 1 in 5 perforations led to cardiac tamponade (21.1%). Ellis 3 perforations are increasing in frequency and account for 43% of all perforations. Mortality due to perforation occurs in 7.5% of all CAP (95% CI 6.7% - 8.4%) but has declined over the studied period. Meta-regression suggested that female gender, hypertension, chronic kidney disease and previous coronary bypass grafting were all associated with higher incidence of CAP. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%.

Conclusion

Coronary perforations occurs in approximately 1 in 250 all-comer PCI procedures. A tendency towards increase in coronary perforations is likely reflective of contemporary trends towards high pressure post-dilatation with 1:1 vessel sizing as well as an ageing population with increasingly complex, calcific coronary disease. However, reduction in CAP related mortality suggests earlier recognition and effective treatment with transcatheter techniques.

Funding Acknowledgement

Type of funding sources: None.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

A quality improvement study: Optimizing pneumococcal vaccination rates in children with cochlear implants

Children with cochlear implants are at increased risk of invasive pneumococcal disease, with national and international guidelines recommending additional pneumococcal vaccines for these children. This study aimed to examine the pneumococcal immunization status and rate of invasive pneumococcal disease in children with cochlear implants at a tertiary paediatric hospital over a 12-year period. Additionally, the impacts of vaccination reminders and a dedicated immunization clinic on pneumococcal vaccination rates were assessed. This quality improvement study included 200 children who had received a cochlear implant through the Children's Hearing Implant Program at a tertiary paediatric hospital servicing the state of Western Australia. The majority of children (88%) were not up to date with additionally recommended pneumococcal vaccinations. Over the 12-year study period, 2% of children developed invasive pneumococcal disease associated with cochlear implant infections. Generic and personalized electronic immunization reminders improved pneumococcal vaccine up-take in this paediatric cochlear implant setting from 12% (19/153) at baseline to 49% (75/153, p < 0.0001) post implementation. The value of a nurse-led dedicated immunization clinic was also demonstrated with all children (42/42, 100%) up to date with Prevenar13 and the majority (34/42, 81%) up to date with Pneumovax23 post initiation of this referral pathway. These data support the expansion of this model to other medically-at-risk paediatric groups that have been highlighted consistently to be under-vaccinated.

Feasibility and Safety of Tethered Capsule Endomicroscopy in Patients With Barrett's Esophagus in a Multi-Center Study

BACKGROUND & AIMS

Tethered capsule endomicroscopy (TCE) involves swallowing a small tethered pill that implements optical coherence tomography (OCT) imaging, procuring high resolution images of the whole esophagus. Here, we demonstrate and evaluate the feasibility and safety of TCE and a portable OCT imaging system in patients with Barrett's esophagus (BE) in a multi-center (5-site) clinical study.

METHODS

Untreated patients with BE as per endoscopic biopsy diagnosis were eligible to participate in the study. TCE procedures were performed in unsedated patients by either doctors or nurses. After the capsule was swallowed, the device continuously obtained 10-μm-resolution cross-sectional images as it traversed the esophagus. Following imaging, the device was withdrawn through mouth, and disinfected for subsequent reuse. BE lengths were compared to endoscopy findings when available. OCT-TCE images were compared to volumetric laser endomicroscopy (VLE) images from a patient who had undergone VLE on the same day as TCE.

RESULTS

147 patients with BE were enrolled across all sites. 116 swallowed the capsule (79%), 95/114 (83.3%) men and 21/33 (63.6%) women (P = .01). High-quality OCT images were obtained in 104/111 swallowers (93.7%) who completed the procedure. The average imaging duration was 5.55 ± 1.92 minutes. The mean length of esophagus imaged per patient was 21.69 ± 5.90 cm. A blinded comparison of maximum extent of BE measured by OCT-TCE and EGD showed a strong correlation (r = 0.77-0.79). OCT-TCE images were of similar quality to those obtained by OCT-VLE.

CONCLUSIONS

The capabilities of TCE to be used across multiple sites, be administered to unsedated patients by either physicians or nurses who are not expert in OCT-TCE, and to rapidly and safely evaluate the microscopic structure of the esophagus make it an emerging tool for screening and surveillance of BE patients. Clinical trial registry website and trial number: NCT02994693 and NCT03459339.

Heart Failure as the Initial Presentation of Anomalous Left Coronary Artery From the Pulmonary Artery

Coronary arteries arising from the pulmonary artery have an incidence of 0.002% in the general population. We present a 29-year-old woman who presented to our hospital with acute decompensated heart failure and atrial fibrillation with a rapid ventricular rate. She underwent a cardiac catheterization to rule out ischemic disease, which revealed retrograde contrast flow through the left coronary artery from the right coronary artery. A coronary computed tomography (CT) angiogram was pursued which showed the presence of an anomalous left coronary artery arising from the pulmonary artery (ALCAPA). For the management of her atrial fibrillation, she was electrically cardioverted. She was discharged on guideline-directed medical therapy for her heart failure, with a cardiac surgery referral for the surgical fixation of her ALCAPA.

Immunisation status of children and adolescents with a new diagnosis of inflammatory bowel disease

BACKGROUND

Patients with Inflammatory Bowel Disease (IBD) are at increased risk of serious infections, including vaccine preventable diseases. Current evidence suggests uptake of additional recommended special risk vaccinations is low. Identification of IBD patients prior to commencing immunosuppressive therapy allows for optimisation of vaccination, including timely administration of live-attenuated and additional recommended vaccines, such as influenza and pneumococcal vaccines.

METHODS

Paediatric patients (0-18 years) seen at the tertiary Royal Children's Hospital, Melbourne, Australia, with a recent diagnosis of IBD were referred by the Gastroenterology Unit to our Specialist Immunisation Clinic (SIC) for assessment and provision of routine and special risk vaccines. Data was collected via a standardised REDCap questionnaire completed in or post attendance at the SIC and included serology results where available.

RESULTS

Sixty-nine paediatric patients were recruited to the study between 2014 and 2017. Median age at IBD diagnosis was 11.25 years (IQR 4.64 years), with median time between diagnosis and SIC review of 0.88 years (IQR 2.84 years). At initial review 84.1% (58/69) of patients were up to date with vaccines on the Australian National Immunisation Program (NIP) schedule. Of those who were tested, serological evidence of immunity was demonstrated in 38.3% (23/60) of patients for Hepatitis B, 66.7% (36/54) for measles, 51.9% (28/54) for rubella and 41.9% (26/62) for Varicella Zoster Virus. Prior to SIC review 47.8% (33/69) had additional vaccinations and 92.8% (64/69) had vaccinations administered in the 12 months following SIC assessment. The Pneumococcal conjugate vaccine (76.8%, 53/69) was the most commonly administered vaccine after SIC review, followed by influenza vaccine (69.6%, 48/69). Within 12 months of SIC review 43.5% (30/69) of patients had completed the schedule and were up-to-date as recommended by the SIC.

CONCLUSIONS

Children with IBD and other special risk groups can benefit from early referral to a SIC team to ensure optimal administration of routine and additionally recommended vaccines, especially live and additional special risk vaccines. The value of optimising immunisations could also be applied to other special risk groups, including adult IBD cohorts, particularly those commencing newer biologic immunosuppressive medications.

Estimating the impact of child and early adolescent depression on subsequent educational attainment: secondary analysis of an existing data linkage

AIMS

Depression is thought to be associated with lower subsequent educational attainment during school. But, without longitudinal studies which take account of prior attainment and other potential confounders, estimates of the impact of clinically recognised depression in childhood and early adolescence are unknown. We investigated whether a clinical diagnosis of depression is associated with lower subsequent educational attainment, and whether the association is modified by gender, ethnicity and socioeconomic status.

METHODS

We conducted a secondary analysis of an existing administrative data linkage between national educational data and a large mental healthcare provider in London, UK (2007-2013). Depression diagnosis before age 15 (exposure) was measured from electronic health records, and subsequent educational attainment at age 15-16 (outcome) was measured from educational records. We fitted logistic regression models and adjusted for gender, ethnicity, socioeconomic status, relative age in school year, neurodevelopmental disorder diagnosis and prior attainment. We investigated effect modifiers using interaction terms.

RESULTS

In total, n = 63 623 were included in analysis, of whom n = 242 had record of a depression diagnosis before age 15. Depression was associated with lower odds of subsequently achieving expected attainment levels in national exams, after adjustment for all covariates (odds ratio = 0.60, 95% confidence interval = 0.43 to 0.84, p = 0.003). There was no evidence that gender, ethnicity or socioeconomic status modified this association.

CONCLUSIONS

These findings support a relationship between depression and lower subsequent educational attainment. This highlights the need for tailored educational interventions to support children and adolescents with depression, particularly in the lead up to key educational milestones.

Nanopore-based metagenomics analysis reveals prevalence of mobile antibiotic and heavy metal resistome in wastewater

In-depth studies of the microbiome and mobile resistome profile of different environments is central to understanding the role of the environment in antimicrobial resistance (AMR), which is one of the urgent threats to global public health. In this study, we demonstrated the use of a rapid (and easily portable) sequencing approach coupled with user-friendly bioinformatics tools, the MinION (Oxford Nanopore Technologies), on the evaluation of the microbial as well as mobile metal and antibiotic resistome profile of semi-rural wastewater. A total of 20 unique phyla, 43 classes, 227 genera, and 469 species were identified in samples collected from the Amherst Wastewater Treatment Plant, both from primary and secondary treated wastewater. Alpha diversity indices indicated that primary samples were significantly richer and more microbially diverse than secondary samples. A total of 1041 ARGs, 68 MRGs, and 17 MGEs were detected in this study. There were more classes of AMR genes in primary than secondary wastewater, but in both cases multidrug, beta-lactam and peptide AMR predominated. Of note, OXA β-lactamases, some of which are also carbapenemases, were enriched in secondary samples. Metal resistance genes against arsenic, copper, zinc and molybdenum were the dominant MRGs in the majority of the samples. A larger proportion of resistome genes were located in chromosome-derived sequences except for mobilome genes, which were predominantly located in plasmid-derived sequences. Genetic elements related to transposase were the most common MGEs in all samples. Mobile or MGE/plasmid-associated resistome genes that confer resistance to last resort antimicrobials such as carbapenems and colistin were detected in most samples. Worryingly, several of these potentially transferable genes were found to be carried by clinically-relevant hosts including pathogenic bacterial species in the orders Aeromonadales, Clostridiales, Enterobacterales and Pseudomonadales. This study demonstrated that the MinION can be used as a metagenomics approach to evaluate the microbiome, resistome, and mobilome profile of primary and secondary wastewater.

The longitudinal relationship between child emotional disorder and parental mental health in the British Child and Adolescent Mental Health surveys 1999 and 2004

BACKGROUND

Research suggests parental psychopathology has an adverse effect on child mental health. However, due to the interactional nature of parent-child relationships and with a high rate of emotional disorders reported in school-age children, it is important to know whether the effect is reciprocal.

METHODS

We explored the longitudinal relationship between child and parent mental health in the British Child and Adolescent Mental Health Surveys (N=7,100 child-parent dyads) and their three-year follow-ups. The Development and Well-Being Assessment with DSM-IV diagnostic criteria was used to measure child psychiatric diagnoses, while parental mental health was assessed using the General Health Questionnaire. Multivariable logistic regression was used to explore the longitudinal association between child emotional disorder and parent mental health.

RESULTS

Parents of children who had an emotional disorder at baseline were more likely to have poor mental health three years later compared with parents whose children had no psychiatric diagnosis (33.3% versus 16.7%; crude odds ratio=2.52; adjusted odds ratio=2.19, 95% CI=1.58 to 3.05, p<0.001). Children of parents with poor mental health at baseline were more likely to develop an emotional disorder three years later compared with children whose parents had good mental health (5.2% versus 2.5%; crude odds ratio=2.08; adjusted odds ratio=1.63, 95% CI=1.18 to 2.25, p=0.003).

LIMITATIONS

The findings of this research are limited by the survey data collected, the measures used and survey dropout.

CONCLUSIONS

We detected a bi-directional relationship between child and parent mental health, suggesting that effective intervention for one individual may benefit other family members.

Novel Technique for the Treatment of a Tongue-Type Calcaneal Fracture in the Setting of Chronic Osteomyelitis

Osteomyelitis of the calcaneus combined with a pathologic fracture is a rare and difficult presentation for any practicing foot and ankle surgeon. Treatment for achieving an aseptic nonunion involves a variety of steps, including surgical debridement, antibiotic administration, and fracture stabilization. In this case series, we report a novel technique for the treatment of a tongue-type calcaneal fracture in the setting of chronic osteomyelitis using the Biomet JuggerLoc bone-to-bone system for fixation.

Case Report: Neonatal Varicella Acquired From Maternal Zoster

The incidence of neonatal varicella has decreased dramatically since the introduction of the varicella vaccination. Although the varicella zoster virus is often associated with a mild infection, it may cause severe morbidity and mortality, particularly in the neonatal period and immunocompromised hosts. We report a case of neonatal varicella acquired from maternal zoster in a mother on biological immunosuppressive therapy. Following the diagnosis, the baby improved on antiviral therapy without any neurological sequelae. This case highlights the limited published data on neonatal varicella following herpes zoster reactivation to inform practice. This includes the role of varicella zoster immunoglobulin in neonates exposed to maternal zoster, the degree of trans-placental immunity and optimum antiviral dosing and duration.

Barriers and predictors of medication use for childhood ADHD: findings from a UK population-representative cohort

PURPOSE

Little is known about sociodemographic and clinical factors that predict and act as barriers to ADHD medication independently of symptom severity. We examined the proportion of children using medication for ADHD, age of initiation of medication, and predictors of medication use in a population-representative cohort.

METHODS

Data from the Millennium Cohort Study on child ADHD, medication use for ADHD at age 14 (in 2014-2015) and child, parent and sociodemographic variables were collated. Logistic regression models were used to identify factors that predict medication use for ADHD (the main outcome measure), adjusting for symptom severity at age seven.

RESULTS

The weighted prevalence of ADHD was 3.97% (N = 11,708). 45.57% of children with ADHD (N = 305) were taking medication. The median age at initiation was 9 years (range 3-14). Male gender (AOR 3.66, 95% CI 1.75, 7.66) and conduct problems at age seven (AOR 1.24 95% CI 1.04, 1.47) and 14 predicted medication use at age 14 after adjusting for symptom severity.

CONCLUSIONS

Our study is the first to assess predictors of medication whist adjusting for ADHD symptom severity. Girls with ADHD were less likely to be prescribed medication, even when they displayed similar ADHD symptom levels to boys. Conduct problems also predicted medication independently of ADHD symptoms. ADHD may be more often medicated in boys because clinicians may think a prototypical ADHD child is male, and perhaps conduct problems make boys more disruptive in the classroom, leading to boys being more often treated.

127Prevalence of coronary artery disease and coronary microvascular dysfunction in heart failure with preserved ejection fraction

Background/Introduction

The prevalence of epicardial coronary artery disease (CAD) and coronary microvascular dysfunction (CMD) have not been studied systematically in an unselected cohort of patients with heart failure and preserved ejection fraction (HFpEF). Both types of coronary disease may play an important role in the pathophysiology and prognosis of HFpEF.

Methods

This prospective multi-centre observational study enrolled near-consecutive patients hospitalized with HFpEF. Patients underwent invasive coronary angiography. Where possible, patients also had guidewire-based assessment of fractional flow reserve, coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) performed, followed by vasoreactivity testing with intracoronary acetylcholine.

Results

A total of 75 patients underwent invasive coronary angiography. Guidewire-based assessment of FFR/CFR/IMR was performed in 62 patients, and vasoreactivity testing was possible in 41 patients. Obstructive epicardial CAD was identified in 38 patients (51%). CMD (defined as a CFR <2.0 and/or IMR ≥25) was present in 66% of patients assessed and was similarly prevalent in those with and without obstructive epicardial disease (62% vs. 69%, p 0.52). During vasoreactivity testing, 24% of those assessed had evidence of coronary microvascular endothelial dysfunction. Patients with obstructive CAD were more often male (63% vs. 38%, p 0.028), and had a history of CAD (50% vs. 19%, p 0.005), diabetes mellitus (63% vs. 41%, p 0.05), and a higher E/e' on echocardiography (median 14.4 vs. 12.3, p 0.044) than those without obstructive coronary disease. Patients with CMD had higher B-type natriuretic peptide levels (median 569 vs. 197 pg/ml, p 0.036) than those without microvascular dysfunction.

Selected baseline characteristics No obstructive CAD (n=37) Obstructive CAD (n=38) p-value No CMD (n=21) CMD (n=41) p-value Age (mean, years) 72 73 0.4 74 72 0.41 Female, n (%) 23 (62%) 14 (37%) 0.028 11 (52%) 22 (54%) 0.92 CAD history, n (%) 7 (19%) 19 (50%) 0.005 7 (33%) 12 (29%) 0.74 Diabetes mellitus, n (%) 15 (41%) 24 (63%) 0.05 11 (52%) 22 (54%) 0.92 BNP (median, pg/ml) 323 315 0.9 197 569 0.036 Ejection fraction (median, %) 59 58 0.35 60 56 0.064 E/e' (median) 12.3 14.4 0.044 14.2 12.4 0.74

Study flow diagram

Conclusion

Both epicardial CAD and CMD are common in HFpEF and each may be a therapeutic target in this condition. Although it has been hypothesized that CMD may be due to endothelial dysfunction, our findings suggest that CMD is predominantly due to structural abnormalities in HFpEF.

Acknowledgement/Funding

Chief Scientist Office

The relationship between exclusion from school and mental health: a secondary analysis of the British Child and Adolescent Mental Health Surveys 2004 and 2007

BACKGROUND

Children with poor mental health often struggle at school. The relationship between childhood psychiatric disorder and exclusion from school has not been frequently studied, but both are associated with poor adult outcomes. We undertook a secondary analysis of the British Child and Adolescent Mental Health Surveys from 2004 and its follow-up in 2007 to explore the relationship between exclusion from school and psychopathology. We predicted poorer mental health among those excluded.

METHOD

Psychopathology was measured using the Strengths and Difficulties Questionnaire, while psychiatric disorder was assessed using the Development and Well-Being Assessment and applying Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM IV) criteria. Exclusion from school and socio-demographic characteristics were reported by parents. Multi-variable regression models were used to examine the impact of individual factors on exclusion from school or psychological distress.

RESULTS

Exclusion from school was commoner among boys, secondary school pupils and those living in socio-economically deprived circumstances. Poor general health and learning disability among children and poor parental mental health were also associated with exclusion. There were consistently high levels of psychological distress among those who had experienced exclusion at baseline and follow-up.

CONCLUSIONS

We detected a bi-directional association between psychological distress and exclusion. Efforts to identify and support children who struggle with school may therefore prevent both future exclusion and future psychiatric disorder.

Which children and young people are excluded from school? Findings from a large British birth cohort study, the Avon Longitudinal Study of Parents and Children (ALSPAC)

BACKGROUND

Exclusion from school is increasingly recognized as pertinent to child health. National educational data reveal that boys, children who are looked-after, living in poverty, have special educational needs, or from certain ethnic minorities, are disproportionately excluded from school. As population-based data on the wider characteristics of excluded children are scarce, we aimed to describe predictors of school exclusion in the Avon Longitudinal Study of Parents and Children.

METHOD

Avon Longitudinal Study of Parents and Children, a prospective U.K. population-based birth cohort study, collected parent reports of permanent school exclusions by 8 years and parent and self-reports of permanent and fixed-term exclusions in the preceding 12 months at 16 years. Potential risk factors were examined for associations with exclusion using logistic regression, with a focus on child mental health and neurodevelopment.

RESULTS

Analyses were based on all available data on 53/8,245 (0.6%) pupils excluded from school by 8 years and 390/4,482 (8.7%) at 16 years. Key factors associated with exclusion at both time points included male gender, lower socio-economic status, maternal psychopathology, mental health and behavioural difficulties, psychiatric disorder, social communication difficulties, language difficulties, antisocial activities, bullying/being bulled, lower parental engagement with education, low school engagement, poor relationship with teacher, low educational attainment, and special educational needs (all p < .05).

CONCLUSION

Exclusion from school was associated with child, family and school-related factors identifiable at, or prior to, primary school age. Child health professionals have an important role in the holistic, multidisciplinary assessment of children who are at risk of exclusion from school. Mental health and neurodevelopmental difficulties should be recognized and supported, to improve the health and educational outcomes among this vulnerable group.

Attitudes Towards Problem-Based Learning of Faculty Members at 12 U.S. Medical and Dental Schools: A Comparative Study

Problem-based learning (PBL) is a teaching method used in medical and dental education to promote students' problem-solving skills. It may also be a viable tool for interprofessional education in which medical and dental students learn together, collaborate, and learn about, from, and with each other. The aim of this study was to compare medical and dental faculty members' attitudes about and perceptions of PBL at 12 U.S. medical and dental schools known to use PBL. In 2015, 111 medical and 132 dental faculty members (combined n=243) from six medical and six dental schools completed a survey containing ten statements and an open comment section. The response rate was 42% of those who received the survey. In the results, the medical faculty participants showed significantly higher enthusiasm for and agreement with PBL benefits than did the dental faculty participants (p˂0.05). The two groups agreed that PBL should be used to supplement conventional teaching (p>0.05). There were no opposite attitudes or contrasts found between the two groups with regards to PBL. The strongest themes expressed by both groups were that PBL should not be used as the sole method of instruction and that students needed a solid foundation in the subject prior to engaging in PBL.

Polymorphic Ventricular Tachycardia Secondary to Subarachnoid Haemorrhage: A Rare Occurrence in the Setting of Normal QTc

Subarachnoid hemorrhage (SAH) is a neurologic emergency associated with high mortality rate. Polymorphic ventricular tachycardia (VT) is a rare arrhythmia. It can occur in any setting of a long QT interval and bradycardia. This may result from a cardiomyopathy (both ischemic and non-ischemic), acute coronary ischemia, congenital long QT syndrome, electrolyte disturbances and cerebrovascular diseases. We report a rare case of polymorphic VT of unclear etiology with a normal corrected QT, likely secondary to SAH. Reports associating ventricular arrhythmias and SAH have been described, yet the mechanism of this association remains unclear. Previous observations of VT seen in patients with SAH suggest a relationship with QT prolongation. The QT interval, however, remained normal in our patient, suggesting an alternative and unknown mechanism for the polymorphic VT.

Charting Our Course: Chaplain Documentation as a Performance Improvement Project

This article presents the results of a 30-month process improvement initiative examining the spiritual assessment documentation patterns of staff chaplains as well as CPE residents and interns at an academic medical center. Preliminary examination of chaplain documentation patterns led to a multidimensional intervention to address perceived documentation limitations and enhance reliability. The intervention resulted in positive changes in documentation patterns as assessed by an expert panel of experienced chaplains. Results offer opportunities for the use of electronic medical record documentation in training of chaplains.

Examining the psychological and social impact of relative age in primary school children: a cross-sectional survey

BACKGROUND

A number of studies demonstrate that children who are younger within their school year have poorer academic attainment and are more likely to have special educational needs. Few, however, have considered the impact relative age may have on child mental health, behaviour and happiness in school.

METHODS

This paper utilized data from the Supporting Teachers and Children in Schools study (2075 pupils aged 5 to 9 years from 80 primary schools) to explore the relationship among relative age, behaviour and happiness in school. Behavioural and emotional development was assessed by using the teacher-reported and parent-reported Strengths and Difficulties Questionnaire and the Pupil Behaviour Questionnaire. Children's happiness within school was assessed by using the How I Feel About My School Questionnaire.

RESULTS

Relatively younger children had higher Total Difficulties scores on the Strengths and Difficulties Questionnaire than their peers. There was a mean increase per 30-day decrease in relative age of 0.09 (95% CI: 0.03 to 0.16; p = 0.007) in teacher-reported and 0.08 (0.001 to 0.16; p = 0.05) in parent-reported scores. There was little evidence of a relationship between relative age and children's behaviour and happiness in school.

CONCLUSIONS

For children with complex difficulties, being relatively young for their school year may be an additional stressor that may undermine mental health.

The predictors of persistent DSM-IV disorders in 3-year follow-ups of the British Child and Adolescent Mental Health Surveys 1999 and 2004

BACKGROUND

The identification of the factors that influence the persistence of psychiatric disorder may assist practitioners to focus on young people who are particularly prone to poor outcomes, but population-based samples of sufficient size are rare.

METHOD

This secondary analysis combined data from two large, population-based cross-sectional surveys in Great Britain (1999 and 2004) and their respective follow-ups (2002 and 2007), to study homotypic persistence among the 998 school-age children with psychiatric disorder at baseline. Psychiatric disorder was measured using the Development and Well-Being Assessment applying DSM-IV criteria. Factors relating to the child, family, and the severity and type of psychopathology at baseline were analysed using logistic regression.

RESULTS

Approximately 50% of children with at least one psychiatric disorder were assigned the same diagnostic grouping at 3-year follow-up. Persistent attention-deficit/hyperactivity disorder and anxiety were predicted by poor peer relationship scores. Persistent conduct disorder was predicted by intellectual disability, rented housing, large family size, poor family function and by severer baseline psychopathology scores.

CONCLUSIONS

Homotypic persistence was predicted by different factors for different groups of psychiatric disorders. Experimental research in clinical samples should explore whether these factors also influence response to interventions.

Global Forum: Spine Research and Training in Underserved, Low and Middle-Income, Culturally Unique Communities: The World Spine Care Charity Research Program's Challenges and Facilitators

The World Spine Care (WSC), established by volunteers from 5 continents, is dedicated to providing sustainable, evidence-based spine care to individuals and communities in low and middle-income countries consistent with available health-care resources and integrated within the local culture. The research committee approves and oversees the WSC's collaborative research and training projects worldwide and serves to create a sustainable research community for underserved populations focused on preventing disability from spinal disorders. The purpose of this article is to describe 4 projects overseen by the WSC research committee and to discuss several challenges and specific facilitators that allowed successful completion of initiatives. These novel projects, which involved establishing spine surgery expertise and data collection in the WSC clinics and surrounding communities, all met their aims. This was achieved by overcoming language and resource challenges, adapting to local customs, and taking time to build mutual respect and to nurture relationships with local investigators and stakeholders.

Implementation of Problem-Based Learning by Faculty Members at 12 U.S. Medical and Dental Schools

The aim of this study was to assess the perspectives of medical and dental faculty members regarding implementation of problem-based learning (PBL). A survey instrument was designed with demographic questions and two open-ended questions to investigate faculty members' perceptions of the most suitable subjects or courses in which to use PBL and examples of how they incorporated PBL into their instruction. The survey was sent to 12 U.S. medical and dental schools known to use PBL, and 73 medical faculty members and 88 dental faculty members completed the survey (n=161), for an overall response rate of 28% of those who were sent the survey at each school (not each's total faculty). In the results, 41% of the medical faculty respondents and 22% of the dental faculty respondents stated that PBL is applicable for all subjects. Members of both groups perceived that PBL is primarily applicable in clinical education, including clinical courses or the clinical applications of courses. The respondents' perceptions about PBL implementation varied significantly, and both groups reported a wide range of approaches in which they implement PBL in their instruction, some of which were not consistent with the purpose of PBL.

Does father-child conflict mediate the association between fathers' postnatal depressive symptoms and children's adjustment problems at 7 years old?

BACKGROUND

Paternal depressive symptoms are associated with children's emotional and behavioural problems, which may be mediated by negative parenting. But there is no research on the influence of paternal depressive symptoms on children's emotion regulation and limited literature investigating fathers' parenting as a mediator in the pathway between paternal depressive symptoms and children's externalizing and internalizing problems. We aimed to investigate the mediating role of father-child conflict (at 3 years) in the association between postnatal paternal depressive symptoms (at 9 months) and children's emotional and behavioural problems (at 7 years) (aim 1). We also examined whether mediation pathways were more pronounced for boys or for girls (aim 2).

METHOD

Secondary data analysis was conducted on the Millennium Cohort Study, when children were 9 months, 3 years and 7 years old (n = 3520). Main study variables were measured by self-report questionnaires. Fathers completed the Rutter Scale (depressive symptoms) and the Parent-Child Relationship Questionnaire (father-child conflict), while mothers completed the Strengths and Difficulties Questionnaire and the Social Behaviour Questionnaire (child emotional and behavioural problems, emotion regulation). We used structural equation modelling to estimate direct, indirect and total effects of paternal depressive symptoms on child outcomes, mediated by father-child conflict whilst adjusting for relevant covariates (maternal depressive symptoms, child temperament, marital conflict, and socio-economic factors such as poverty indicator and fathers' education level). Multi-group and interaction analysis was then conducted to determine the differential effect by gender of the association between paternal depressive symptoms on child outcomes via father-child conflict.

RESULTS

Father-child conflict mediated the association between paternal depressive symptoms and emotion regulation problems [standardized indirect effect (SIE) 95% confidence interval (CI) -0.03 to -0.01, p < 0.001; standardized total effect (STE) 95% CI -0.05 to -0.01, p < 0.05] (aim 1). Father-child conflict mediated a larger proportion of the effect in boys (SIE 95% CI -0.03 to -0.01, p < 0.001; STE 95% CI -0.05 to 0.00, p = 0.063) than it did in girls (SIE 95% CI -0.02 to -0.01, p < 0.001; STE 95% CI -0.04 to 0.01, p = 0.216) (aim 2).

CONCLUSIONS

Father-child conflict may mediate the association between postnatal paternal depressive symptoms and children's emotion regulation problems. Paternal depressive symptoms and father-child conflict resolution may be potential targets in preventative interventions.

Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom

Background

Schools have long been viewed as a good setting in which to encourage healthy lifestyles amongst children, and schools in many countries aspire to more comprehensive, integrated approaches to health promotion. Recent reviews have identified evidence of the effects of school health promotion on children’s and young people’s health. However, understanding of how such programmes can be implemented in schools is more limited.

Methods

We conducted a realist review to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools. We used the international literature to develop programme theories which were then tested using evaluations of school health promotion programmes conducted in the United Kingdom (UK). Iterative searching and screening was conducted to identify sources and clear criteria applied for appraisal of included sources. A review advisory group comprising educational and public health practitioners, commissioners, and academics was established at the outset.

Results

In consultation with the review advisory group, we developed four programme theories (preparing for implementation, initial implementation, embedding into routine practice, adaptation and evolution); these were then refined using the UK evaluations in the review. This enabled us to identify transferable mechanisms and enabling and constraining contexts and investigate how the operation of mechanisms differed in different contexts. We also identified steps that should be taken at a senior level in relation to preparing for implementation (which revolved around negotiation about programme delivery) and initial implementation (which centred on facilitation, support, and reciprocity—the latter for both programme deliverers and pupils). However, the depth and rigour of evidence concerning embedding into routine practice and adaptation and evolution was limited.

Conclusions

Our findings provide guidance for the design, implementation, and evaluation of health promotion in schools and identify the areas where further research is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0338-6) contains supplementary material, which is available to authorized users.

Implementing health promotion programmes in schools: a realist systematic review of research and experience in the United Kingdom

BACKGROUND

Schools have long been viewed as a good setting in which to encourage healthy lifestyles amongst children, and schools in many countries aspire to more comprehensive, integrated approaches to health promotion. Recent reviews have identified evidence of the effects of school health promotion on children's and young people's health. However, understanding of how such programmes can be implemented in schools is more limited.

METHODS

We conducted a realist review to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools. We used the international literature to develop programme theories which were then tested using evaluations of school health promotion programmes conducted in the United Kingdom (UK). Iterative searching and screening was conducted to identify sources and clear criteria applied for appraisal of included sources. A review advisory group comprising educational and public health practitioners, commissioners, and academics was established at the outset.

RESULTS

In consultation with the review advisory group, we developed four programme theories (preparing for implementation, initial implementation, embedding into routine practice, adaptation and evolution); these were then refined using the UK evaluations in the review. This enabled us to identify transferable mechanisms and enabling and constraining contexts and investigate how the operation of mechanisms differed in different contexts. We also identified steps that should be taken at a senior level in relation to preparing for implementation (which revolved around negotiation about programme delivery) and initial implementation (which centred on facilitation, support, and reciprocity-the latter for both programme deliverers and pupils). However, the depth and rigour of evidence concerning embedding into routine practice and adaptation and evolution was limited.

CONCLUSIONS

Our findings provide guidance for the design, implementation, and evaluation of health promotion in schools and identify the areas where further research is needed.

Cross-sectional survey of daily junk food consumption, irregular eating, mental and physical health and parenting style of British secondary school children

BACKGROUND

Previous research has established that poor diets and eating patterns are associated with numerous adverse health outcomes. This study explored the relationships between two specific eating behaviours (daily junk food consumption and irregular eating) and self-reported physical and mental health of secondary school children, and their association with perceived parenting and child health.

METHODS

10 645 participants aged between 12 and 16 completed measures of junk food consumption, irregular eating, parental style, and mental and physical health through the use of an online survey implemented within 30 schools in a large British city.

RESULTS

2.9% of the sample reported never eating regularly and while 17.2% reported daily consumption of junk food. Young people who reported eating irregularly and consuming junk food daily were at a significantly greater risk of poorer mental (OR 5.41, 95% confidence interval 4.03-7.25 and 2.75, 95% confidence interval 1.99-3.78) and physical health (OR 4.56, 95% confidence interval 3.56-5.85 and 2.00, 95% confidence interval 1.63-2.47). Authoritative parenting was associated with healthier eating behaviours, and better mental and physical health in comparison to other parenting styles.

DISCUSSION

A worrying proportion of secondary school children report unhealthy eating behaviours, particularly daily consumption of junk food, which may be associated with poorer mental and physical health. Parenting style may influence dietary habits. Interventions to improve diet may be more beneficial if also they address parenting strategies and issues related to mental and physical health.

U.S. Dental students' and faculty members' attitudes about technology, instructional strategies, student diversity, and school duration: a comparative study

In this study, attitudes and perceptions of U.S. dental students and faculty members were evaluated regarding four aspects of dental education: technology integration, instructional strategies, student diversity, and school duration. A survey instrument with eight statements using a five-point Likert scale and a free-text comment section was developed and distributed through Survey Monkey. A total of 426 students and 187 faculty members from ten U.S. dental schools participated, a response rate of 17 percent of those surveyed. Faculty and student responses were compared using the Mann-Whitney U test. The results of this analytic procedure revealed that the groups differed in their average responses for seven of the eight statements. Analysis of the faculty and student comments revealed similar themes between the two groups. Both dental students and dental faculty members stated that technology integration should be viewed as only a supplement to conventional instruction and showed mixed opinions about electronic textbooks. Further, both groups had positive views of the roles of problem-based learning, community service, and the integration of research practice into dental education. Both groups also valued diversity in the student body and supported the current four-year duration of dental school.