The Greater Manchester Child Friendly Dental Practice Scheme: Using a Transformational Commissioning Approach to Align Paediatric Dental Service Provision with Childhood Oral Health Needs in Greater Manchester

In response to the impact of the COVID-19 pandemic on access to already oversubscribed specialist paediatric dental services, a pilot of an enhanced primary care paediatric dental pathway, known as the Child Friendly Dental Practice (CFDP) scheme, was commissioned by the Greater Manchester Health and Social Care Partnership. Supported by a transformational commissioning approach, the ambition of the CFDP pilot was to manage or stabilise the oral health of high-need paediatric patients who had been referred to specialist dental services within Community or Hospital Dental Service settings, through timely access to primary care clinicians who were confident and experienced in treating children. The theory of change of the CFDP pilot proposed that rapid access to enhanced primary dental care would reduce the need for onward referral to specialist paediatric dental services, whilst also stabilising the oral health of children who require more complex management in specialist services. A formative evaluation of the phase one pilot implementation of the CFDP Scheme has demonstrated the potential of the CFDP Scheme to improve access to dental services for paediatric patients referred from their General Dental Practitioner. Comparison of waiting times between the CFDP pathway and the standard paediatric dental referral pathway have revealed substantially reduced waiting times to access care along the CFDP pathway, while less than 30% of those who attended CFDPs required onward referral to specialist paediatric dental services. Encouragingly, similar attendance and treatment completion rates were noted among patients from all levels of socio-economic deprivation, reducing concerns regarding the potential for service-based interventions to increase oral health inequalities. Following successful completion of the phase one pilot implementation and evaluation, the CFDP Scheme has now been rolled out across all localities in Greater Manchester as part of a second phase pilot implementation. Public Health Competencies; Equitable healthcare provision, Partnership working, Evidence-based public health, Systems thinking, Transformational commissioning, Healthcare evaluation.

Modifiable predictors of depression following childhood maltreatment: a systematic review and meta-analysis

Although maltreatment experiences in childhood increase the risk for depression, not all maltreated children become depressed. This review aims to systematically examine the existing literature to identify modifiable factors that increase vulnerability to, or act as a buffer against, depression, and could therefore inform the development of targeted interventions. Thirteen databases (including Medline, PsychINFO, SCOPUS) were searched (between 1984 and 2014) for prospective, longitudinal studies published in English that included at least 300 participants and assessed associations between childhood maltreatment and later depression. The study quality was assessed using an adapted Newcastle-Ottawa Scale checklist. Meta-analyses (random effects models) were performed on combined data to estimate the effect size of the association between maltreatment and depression. Meta-regressions were used to explore effects of study size and quality. We identified 22 eligible articles (N=12 210 participants), of which 6 examined potential modifiable predictors of depression following maltreatment. No more than two studies examined the same modifiable predictor; therefore, it was not possible to examine combined effects of modifiable predictors with meta-regression. It is thus difficult to draw firm conclusions from this study, but initial findings indicate that interpersonal relationships, cognitive vulnerabilities and behavioral difficulties may be modifiable predictors of depression following maltreatment. There is a lack of well-designed, prospective studies on modifiable predictors of depression following maltreatment. A small amount of initial research suggests that modifiable predictors of depression may be specific to maltreatment subtypes and gender. Corroboration and further investigation of causal mechanisms is required to identify novel targets for intervention, and to inform guidelines for the effective treatment of maltreated children.

Single nucleotide polymorphism in IL1B is associated with infection risk in paediatric acute myeloid leukaemia

We evaluated single nucleotide polymorphisms (SNPs) associated with infection risk in children with newly diagnosed acute myeloid leukaemia (AML). We conducted a multicentre, prospective cohort study that included children aged ≤18 years with de novo AML. DNA was isolated from blood lymphocytes or buccal swabs, and candidate gene SNP analysis was conducted. Primary outcome was the occurrence of microbiologically documented sterile site infection during chemotherapy. Secondary outcomes were Gram-positive and -negative infections, viridans group streptococcal infection and proven/probable invasive fungal infection. Interpretation was guided by consistency in risk alleles and microbiologic agent with previous literature. Over the study period 254 children and adolescents with AML were enrolled. Overall, 190 (74.8%) had at least one sterile site microbiologically documented infection. Among the 172 with inferred European ancestry and DNA available, nine significant associations were observed; two were consistent with previous literature. Allele A at IL1B (rs16944) was associated with decreased microbiologically documented infection, and allele G at IL10 (rs1800896) was associated with increased risk of Gram-positive infection. We identified SNPs associated with infection risk in paediatric AML. Genotype may provide insight into mechanisms of infection risk that could be used for supportive-care novel treatments.

Cognitive styles and future depressed mood in early adulthood: the importance of global attributions

BACKGROUND

Cognitive theories of depression suggest that beliefs of low self-worth and the tendency to attribute negative events to causes that are global (widespread rather than specific) and stable (will persist rather than change in the future) are associated with the development of depressed mood. Such theories are supported by evidence from prospective studies and have guided the development of successful treatment and prevention strategies such as CBT. However, the relative importance of different psychological constructs within cognitive theories is unknown. This is important to refine cognitive theories and develop more efficient prevention strategies.

METHOD

We used prospective data from over 3500 young adults from the Avon Longitudinal Study for Parents and Children (ALSPAC) cohort in the UK to investigate the association between cognitive style, measured by short forms of the Dysfunctional Attitudes Scale (DAS) and Cognitive Styles Questionnaire-Short Form (CSQ-SF) at age 18, and future depressed mood at age 19. Structural equation modelling techniques were used to separate cognitive style constructs.

RESULTS

Cognitive styles were associated with future depressed mood, independently of baseline mood, both as measured by the DAS-SF and the CSQ-SF. Of the different CSQ-SF constructs, only global attributions were associated with both baseline and future mood independently of other constructs.

LIMITATIONS

The study was subject to attrition and the follow-up was relatively short (10 months).

CONCLUSION

The findings suggest that the tendency to attribute negative events specifically to global causes could be particularly important for depression. Reducing global attributions is potentially important in the prevention and treatment of depression.

Introducing care pathway commissioning to primary dental care: measuring performance

Care pathways have been used in a variety of ways: firstly to support quality improvement through standardising clinical processes, but also for secondary purposes, by purchasers of healthcare, to monitor activity and health outcomes and to commission services. This paper focuses on reporting a secondary use of care pathways: to commission and monitor performance of primary dental care services. Findings of a project involving three dental practices implementing a system based on rating patients according to their risk of disease and need for care are outlined. Data from surgery-based clinical databases and interviews from commissioners and providers are reported. The use of both process and outcome key performance indicators in this context is discussed, as well as issues which arise such as attributability of outcome measures and strategic approaches to improving quality of care.

Bullying victimization in youths and mental health problems: 'much ado about nothing'?

Bullying victimization is a topic of concern for youths, parents, school staff and mental health practitioners. Children and adolescents who are victimized by bullies show signs of distress and adjustment problems. However, it is not clear whether bullying is the source of these difficulties. This paper reviews empirical evidence to determine whether bullying victimization is a significant risk factor for psychopathology and should be the target of intervention and prevention strategies. Research indicates that being the victim of bullying (1) is not a random event and can be predicted by individual characteristics and family factors; (2) can be stable across ages; (3) is associated with severe symptoms of mental health problems, including self-harm, violent behaviour and psychotic symptoms; (4) has long-lasting effects that can persist until late adolescence; and (5) contributes independently to children's mental health problems. This body of evidence suggests that efforts aimed at reducing bullying victimization in childhood and adolescence should be strongly supported. In addition, research on explanatory mechanisms involved in the development of mental health problems in bullied youths is needed.

Lack of association of the COMT (Val158/108 Met) gene and schizophrenia: a meta-analysis of case-control studies

There is strong evidence for a genetic contribution to schizophrenia, but the contribution of individual candidate genes remains uncertain. We attempted to replicate a recent meta-analysis that reported an association of the catechol O-methyltransferase (COMT) Val allele with schizophrenia, and suggested that this effect may be moderated by ancestry. We included reports published subsequent to the original meta-analysis, and included a formal test of the moderating effect of ancestry in order to test whether the association operates differently in populations of European ancestry compared to populations of Asian ancestry. A corrected P-value for the 5% significance threshold was employed where appropriate, using Bonferroni's method, and studies that demonstrated departure from Hardy-Weinberg equilibrium among controls were excluded. When all studies were included in a meta-regression, there was evidence for a significant association of COMT Val allele frequency with schizophrenia case status and a significant main effect of ancestry. The interaction of COMT Val allele frequency and ancestry was also significant. However, when only studies that reported allele frequencies that did not depart significantly from Hardy-Weinberg equilibrium among controls were included, these effects were no longer significant. The results of our meta-analysis do not support an association between the COMT Val allele and schizophrenia case status, and do not support recent claims that this association may be moderated by ancestry.

Combination treatment of melasma with pulsed CO2 laser followed by Q-switched alexandrite laser: a pilot study

BACKGROUND

Melasma is very difficult to treat and often refractory to treatment with topical creams and pigmented-lesion lasers.

OBJECTIVE

Pulsed CO2 laser alone is compared with the combination of pulsed CO2 laser followed by Q-switched alexandrite laser in the treatment of dermal-type melasma. This combination is proposed to be effective by first destroying the abnormal melanocytes with the pulsed CO2 laser and then selectively eliminating the dermal melanin with the alexandrite laser.

METHODS

Four patients were randomly chosen for each treatment arm. There were multiple follow-up visits for examination by an objective blinded investigator.

RESULTS

All patients in the combination laser group showed complete resolution, and two patients in the CO2 laser only group had peripheral hyperpigmentation in the long-term follow-up evaluation.

CONCLUSION

These laser therapies are safe, as there was no scarring and no infection. The combination laser therapy was highly effective in removing the hyperpigmentation and all patients in this group showed complete resolution without any peripheral hyperpigmentation.

Comparison of the 585 nm pulse dye laser and the short pulsed CO2 laser in the treatment of striae distensae in skin types IV and VI

BACKGROUND

Striae distensae, or stretch marks, are a very common cosmetic problem. The successful management of stretch marks has long been a source of frustration and curiosity for both the clinician and the researcher. Recent studies suggest lasers may have a role in their management. As yet, no study has reported on the effects of either of these lasers in the treatment of stretch marks on persons with skin types 4 to 6.

OBJECTIVE

To assess the efficacy of short pulsed CO2 laser and pulsed dye laser for the treatment of stretch marks in skin types 4, 5, and 6.

METHODS

Four patients were initially enrolled in the study. All were female with abdominal stretch marks, present for a range of 8 to 19 years. The patients had skin types ranging from 4 to 6. The test area consisted of a stretch mark long enough to be divided into three contiguous 2 cm sections, labeled A, B, and C. Section A served as the short pulsed CO2 test site, section B served as a control, while section C served as the 585 nm pulsed dye site. Patients were seen for evaluation after 1 week, then every 4 weeks for a total of 20 weeks. Patients were evaluated subjectively by the investigators, and the patients' own self-evaluation was reported as well.

RESULTS

Following the 585 nm pulse dye laser, at 20 week follow-up patients with type 4 skin showed no improvement, while type 6 skin showed hyperpigmentation. The short pulsed CO2 test site showed persistent erythema in type 4 skin and marked hyperpigmentation in type 6 skin.

CONCLUSIONS

For patients with types 4, 5, and 6 skin, laser treatment of striae should be avoided or used with great caution.