5.9.17

Association of Childhood Body Mass Index and Change in Body Mass Index With First Adult Ischemic Stroke.

Gjærde LK, Gamborg M, Ängquist L, Truelsen TC, Sørensen TIA, Baker JL.

JAMA Neurol. 2017 Aug 21. doi: 10.1001/jamaneurol.2017.1627. [Epub ahead ofprint]
Importance: The incidence of ischemic stroke among young adults is rising and is 
potentially due to an increase in stroke risk factors occurring at younger ages, 
such as obesity.
Objectives: To investigate whether childhood body mass index (BMI) and change in 
BMI are associated with adult ischemic stroke and to assess whether the
associations are age dependent or influenced by birth weight.
Design, Setting, and Participants: This investigation was a population-based
cohort study of schoolchildren born from 1930 to 1987, with follow-up through
national health registers from 1977 to 2012 in Denmark. Participants were 307 677
individuals (8899 ischemic stroke cases) with measured weight and height at ages 
7 to 13 years. The dates of the analysis were September 1, 2015, to May 27, 2016.
Main Outcomes and Measures: Childhood BMI, change in BMI, and birth weight.
Ischemic stroke events were divided into early (≤55 years) or late (>55 years)
age at diagnosis.
Results: The study cohort comprised 307 677 participants (approximately 49%
female and 51% male). During the study period, 3529 women and 5370 men
experienced an ischemic stroke. At all ages from 7 to 13 years, an above-average 
BMI z score was positively associated with early ischemic stroke. At age 13
years, a BMI z score of 1 was associated with hazard ratios (HRs) of 1.26 (95%
CI, 1.11-1.43) in women and 1.21 (95% CI, 1.10-1.33) in men. No significant
associations were found for below-average BMI z scores. Among children with
above-average BMI z scores at age 7 years, a score increase of 0.5 from ages 7 to
13 years was positively associated with early ischemic stroke in women (HR, 1.10;
95% CI, 1.01-1.20) and in men (HR, 1.08; 95% CI, 1.00-1.16). Similarly, among
children with below-average BMI z scores at age 7 years, a score increase of 0.5 
from ages 7 to 13 years was positively associated with early ischemic stroke in
women (HR, 1.14; 95% CI, 1.06-1.23) and in men (HR, 1.10; 95% CI, 1.04-1.18).
Adjusting for birth weight minimally affected the associations.
Conclusions and Relevance: Independent of birth weight, above-average childhood
BMI and increases in BMI during childhood are positively associated with early
adult ischemic stroke. To avoid the occurrence of early ischemic stroke
associated with childhood overweight and obesity, these results suggest that all 
children should be helped to attain and maintain healthy weights.

21.7.17

Priority setting in paediatric preventive care research.

Abstract
To identify the unanswered research questions in paediatric preventive care that are most important to parents and clinicians, and to explore how questions from parents and clinicians may differ.
Design 
Iterative mixed methods research priority setting process.
Setting 
Toronto, Ontario, Canada.
Participants 
Parents of children aged 0–5 years enrolled in a research network in Toronto, and clinicians practising in Toronto, Ontario, Canada.
Interventions 
Informed by the James Lind Alliance’s methodology, an online questionnaire collected unanswered research questions in paediatric preventive care from study participants. Similar submissions were combined and ranked. A consensus workshop attended by 28 parents and clinicians considered the most highly ranked submissions and used the nominal group technique to select the 10 most important unanswered research questions.
Results 
Forty-two clinicians and 115 parents submitted 255 and 791 research questions, respectively, which were combined into 79 indicative questions. Most submissions were about nutrition, illness prevention, parenting and behaviour management. Parents were more likely to ask questions about screen time (49 parents vs 8 clinicians, p<0.05) and environmental toxins (18 parents vs 0 clinicians, p<0.05). The top 10 unanswered questions identified at the workshop related to mental health, parental stress, physical activity, obesity, childhood development, behaviour management and screen time.
Conclusion 
The top 10 most important unanswered research questions in paediatric preventive care from the perspective of parents and clinicians were identified. These research priorities may be important in advancing preventive healthcare for children.

4.7.17

Facilitators and barriers for the adoption, implementation and monitoring of child safety interventions: a multinational qualitative analysis. (Qué funciona y qué no, y por qué, en intervenciones para prevenir accidentes infantiles).

Scholtes, B, Schröder-Bäck P, MacKay JM, Vincenten J, Förster K, Brand H.
Inj Prev.2017 Jun;23(3):197-204. doi: 10.1136/injuryprev-2016-042138. Epub 2016 Dec 2.

The efficiency and effectiveness of child safety interventions are determined by the quality of the implementation process. This multinational European study aimed to identify facilitators and barriers for the three phases of implementation: adoption, implementation and monitoring (AIM process). Twenty-seven participants from across the WHO European Region were invited to provide case studies of child safety interventions from their country. Cases were selected by the authors to ensure broad coverage of injury issues, age groups and governance level of implementation (eg, national, regional or local). Each participant presented their case and provided a written account according to a standardised template. Presentations and question and answer sessions were recorded. The presentation slides, written accounts and the notes taken during the workshops were analysed using thematic content analysis to elicit facilitators and barriers. Twenty-six cases (from 26 different countries) were presented and analysed. Facilitators and barriers were identified within eight general themes, applicable across the AIM process: management and collaboration; resources; leadership; nature of the intervention; political, social and cultural environment; visibility; nature of the injury problem and analysis and interpretation. The importance of the quality of the implementation process for intervention effectiveness, coupled with limited resources for child safety makes it more difficult to achieve successful actions. The findings of this study, divided by phase of the AIM process, provide practitioners with practical suggestions, where proactive planning might help increase the likelihood of effective implementation.

19.5.17

Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales.

Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ.


Background
Prediction of suicidal behaviour is an aspirational goal for clinicians and policy makers; with patients classified as 'high risk' to be preferentially allocated treatment. Clinical usefulness requires an adequate positive predictive value (PPV). AimsTo identify studies of predictive instruments and to calculate PPV estimates for suicidal behaviours.
Method
A systematic review identified studies of predictive instruments. A series of meta-analyses produced pooled estimates of PPV for suicidal behaviours.
Results
For all scales combined, the pooled PPVs were: suicide 5.5% (95% CI 3.9-7.9%), self-harm 26.3% (95% CI 21.8-31.3%) and self-harm plus suicide 35.9% (95% CI 25.8-47.4%). Subanalyses on  self-harm found pooled PPVs of 16.1% (95% CI 11.3-22.3%) for high-quality studies, 32.5% (95% CI 26.1-39.6%) for hospital-treated self-harm and 26.8% (95%  CI 19.5-35.6%) for psychiatric in-patients.
Conclusions
No 'high-risk' classification was clinically useful. Prevalence imposes a ceiling on PPV. Treatment should reduce exposure to modifiable risk factors and offer effective interventions for selected subpopulations and unselected clinical populations.

5.5.17

Self-Reported Mental Health Problems Among Adults Born Preterm: A Meta-analysis

Pyhälä R, Wolford E, Kautiainen H, Andersson S, Bartmann P, Baumann N, Brubakk AM, Evensen KA, Hovi P, Kajantie E, Lahti M, Van Lieshout RJ, Saigal S, Schmidt LA, Indredavik MS, Wolke D, Räikkönen K.

CONTEXT: Preterm birth increases the risk for mental disorders in adulthood, yet findings on abstract self-reported or subclinical mental health problems are mixed.
OBJECTIVE: To study self-reported mental health problems among adults born preterm at very low birth weight (VLBW; ≤1500 g) compared with term controls in an individual participant data meta-analysis.
DATA SOURCES: Adults Born Preterm International Collaboration.
STUDY SELECTION: Studies that compared self-reported mental health problems using the Achenbach Young Adult Self Report or Adult Self Report between adults born preterm at VLBW (n = 747) and at term (n = 1512).
DATA EXTRACTION: We obtained individual participant data from 6 study cohorts and compared preterm and control groups by mixed random coefficient linear and Tobit regression.
RESULTS: Adults born preterm reported more internalizing (pooled β = .06; 95% confidence interval .01 to .11) and avoidant personality problems (.11; .05 to .17), and less externalizing (–.10; –.15 to –.06), rule breaking (–.10; –.15 to –.05), intrusive behavior (–.14; –.19 to –.09), and antisocial personality problems (–.09; –.14 to –.04) than controls. Group differences did not systematically vary by sex, intrauterine growth pattern, neurosensory impairments, or study cohort.
LIMITATIONS: Exclusively self-reported data are not confirmed by alternative data sources.
CONCLUSIONS: Self-reports of adults born preterm at VLBW reveal a heightened risk for internalizing problems and socially avoidant personality traits together with a lowered risk for externalizing problem types. Our findings support the view that preterm birth constitutes an early vulnerability factor with long-term consequences on the individual into adulthood.

21.4.17

Priority setting in paediatric preventive care research.

Lavigne M, Birken CS, Maguire JL, Straus S, Laupacis A.

OBJECTIVES: To identify the unanswered research questions in paediatric preventive care that are most important to parents and clinicians, and to explore how questions from parents and clinicians may differ.
DESIGN: Iterative mixed methods research priority setting process.
SETTING: Toronto, Ontario, Canada.
PARTICIPANTS: Parents of children aged 0-5 years enrolled in a research network in Toronto, and clinicians practising in Toronto, Ontario, Canada.
INTERVENTIONS: Informed by the James Lind Alliance's methodology, an online questionnaire collected unanswered research questions in paediatric preventive care from study participants. Similar submissions were combined and ranked. A consensus workshop attended by 28 parents and clinicians considered the most highly ranked submissions and used the nominal group technique to select the 10 most important unanswered research questions.
RESULTS: Forty-two clinicians and 115 parents submitted 255 and 791 research questions, respectively, which were combined into 79 indicative questions. Most submissions were about nutrition, illness prevention, parenting and behavior management. Parents were more likely to ask questions about screen time (49 parents vs 8 clinicians, p<0.05) and environmental toxins (18 parents vs 0 clinicians, p<0.05). The top 10 unanswered questions identified at the workshop related to mental health, parental stress, physical activity, obesity, childhood development, behaviour management and screen time.
CONCLUSION: The top 10 most important unanswered research questions in paediatric preventive care from the perspective of parents and clinicians were identified. These research priorities may be important in advancing preventive healthcare for children.

20.4.17

Provider Perspectives on Adding Biomarker Screening for Tobacco Smoke Exposure to Lead Screening at Well-Child Visits.


Ghidei W, Brottman G, Lenne E, Quan T, Joseph A.

INTRODUCTION: Measurement of cotinine, a biomarker of tobacco smoke exposure, can accurately identify children at risk of health consequences from secondhand smoke. This study reports perspectives from pediatric health care providers on incorporating routine cotinine screening into well-child visits.
METHODS: Key informant interviews (N = 28) were conducted with pediatric primary  care providers: physicians, nurse practitioners, and registered nurses.
RESULTS: Themes identified in the interviews included the following: (a) Cotinine screening would assess children's exposure to tobacco smoke more reliably tan parental report; (b) Addressing positive cotinine screening results might require additional resources; (c) Wheezing and a history of emergency department visits increased the salience of cotinine screening; and (d) A better understanding of the significance of specific cotinine test values would improve utility.
DISCUSSION: Pediatric providers see advantages of biomarker screening for tobacco smoke exposure at well-child visits, especially for children with wheezing, but have concerns about limited capacity for follow-up with parents.


A Clinical Care Algorithmic Toolkit for Promoting Screening and Next-Level Assessment of Pediatric Depression and Anxiety in Primary Care.

Honigfeld L, Macary SJ, Grasso DJ.
With a documented shortage in youth mental health services, pediatric primary care (PPC) providers face increased pressure to enhance their capacity to identify and manage common mental health problems among youth, such as anxiety and depression. Because 90% of U.S. youth regularly see a PPC provider, the primary care setting is well positioned to serve as a key access point for early identification, service provision, and connection to mental health services. In to assist PPC providers in overcoming barriers to practice-wide mental health the context of task shifting, we evaluated a quality improvement project designed screening through implementing paper and computer-assisted clinical care family mental health histories, next-level actions, and referral options. Task algorithms. PPC providers were fairly successful at changing practice to better address mental health concerns when equipped with screening tools that included when guided by computer-assisted algorithms. shifting is a promising strategy to enhance mental health services, particularly when guided by computer-assisted algorithms.