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Introduction Multidisciplinary team (MDT) assessment is associated with improved survival in locally advanced rectal cancer, but the effect of an MDT assessment on survival in locally advanced colon cancer has not been reported. The aim of this national population-based cohort study was to establish if preoperative MDT assessment affects prognosis in patients with primary locally advanced colon cancer. Material and methods All patients in Sweden with locally advanced colon cancer, without metastatic disease, who underwent an elective colon resection between 2010 and 2017 were identified through the Swedish Colorectal Cancer Registry (SCRCR), and the cohort was linked to national registers. Data on patient characteristics, preoperative staging, surgical procedures, recurrence and survival were collected from SCRCR. The association between MDT assessment and colon cancer-specific survival was evaluated using Kaplan-Meier survival curves and Cox proportional hazards models. The multivariable analysis was adjusted for sex, age, ASA grade, CCI, time period, pN, region and preoperative MDT. Results MDT assessment was performed in 2663 patients (84.4%) of 3157 eligible patients. The 3-year colon cancer-specific survival was higher following MDT, compared with no MDT assessment (80% versus 68%). MDT assessment was independently associated with reduced colon cancer-specific mortality (HR 0.70, 0.57–0.84 95% CI). Conclusion Preoperative MDT assessment is associated with an improved long-term survival in patients with locally advanced colon cancer and should be mandatory in patients with suspected locally advanced colon cancer.

Objectives To demonstrate the challenges of interpreting cross-country comparisons of paediatric asthma hospital admission rates as an indicator of primary care quality. Methods We used hospital administrative data from >10 million children aged 6–15 years, resident in Austria, England, Finland, Iceland, Ontario (Canada), Sweden or Victoria (Australia) between 2008 and 2015. Asthma hospital admission and emergency department (ED) attendance rates were compared between countries using Poisson regression models, adjusted for age and sex. Results Hospital admission rates for asthma per 1000 child-years varied eight-fold across jurisdictions. Admission rates were 3.5 times higher when admissions with asthma recorded as any diagnosis were considered, compared with admissions with asthma as the primary diagnosis. Iceland had the lowest asthma admission rates; however, when ED attendance rates were considered, Sweden had the lowest rate of asthma hospital contacts. Conclusions The large variations in childhood hospital admission rates for asthma based on the whole child population reflect differing definitions, admission thresholds and underlying disease prevalence rather than primary care quality. Asthma hospital admissions among children diagnosed with asthma is a more meaningful indicator for inter-country comparisons of primary care quality.

AIM The aim was to assess long-term prognosis after emergency resection versus primary diverting stoma followed by elective tumour resection. METHOD A national-register-based cohort study with retrospective analysis of prospectively collected data was performed. All Swedish patients with non-metastatic obstructive locally advanced colon cancer treated with emergency resection or diverting stoma, followed by an elective resection, between 2007 and 2017 were included. The Kaplan-Meier method and Cox proportional hazards model were used to compare all-cause mortality between patients with emergency resection and elective right- and left-sided resection. The multivariable model was adjusted for year of diagnosis, age at diagnosis, sex, Charlson Comorbidity Index, American Society of Anesthesiologists class, tumour location and pN stage. RESULTS In all, 751 patients with a tumour in the right colon and 700 patients with a tumour in the left colon were included. Emergency resection was more common in patients with right-sided colon tumours (681/751) than in patients with left-sided colon tumours (483/700). The 5-year overall survival in patients with right-sided tumours was 25% after emergency resection and 46% after diverting stoma followed by elective resection (log-rank test P = 0.001). The corresponding numbers for patients with left-sided colon tumours were 40% and 64% (P

Aim To study the association of parental country of origin - expressed as low-, medium-, and high Human Development Index (HDI) countries - with caries experience in children of immigrant families in Stockholm. Methods This registry-based cohort study included all children born in 2000-2003 who resided in Stockholm County, Sweden, at age 3 years (n=83,147) with follow-up at 7 years of age. A logistic regression was performed for the multivariate analysis with adjustments for sociodemographic factors. Results After adjustments, logistic regression analyses revealed that, compared with Swedish children of the same age, the risk of caries was highest when the immigrant parents originated in a medium (OR 4.22 (95% CI 3.99:4.47)) or low (OR 2.80 (95% CI 2.56:3.06)) income country background at age 7 years, but was increased also for high income country background, OR 1.77 (95% CI 1.52-2.05). Furthermore, the risk of presenting with caries experience at age 7 years increased for all children in the 1st (lowest) household income quintile in the host country Sweden. Conclusion This study shows that the developmental level of the parental country of birth as well as the family socioeconomic position in Sweden influence the risk for caries development in their children.

Introduction Although ethnically mixed couples are on the rise in industrialized countries, their health behaviors are poorly understood. We examined the associations between partner’s birthplace, age at immigration, and smoking during pregnancy among foreign-born women. Methods Population-based register study including all pregnancies resulting in a livebirth or stillbirth in Sweden (1991–2012) with complete information on smoking and parental country of birth. We compared the prevalence of smoking during pregnancy between women in dual same-origin foreign-born unions (n = 213 111) and in mixed couples (immigrant women with a Swedish-born partner) (n = 111 866) using logistic regression. Swedish-born couples were used as a benchmark. Results The crude smoking rate among Swedish women whose partners were Swedish was 11%. Smoking rates of women in dual same-origin foreign-born unions varied substantially by birthplace, from 1.3% among women from Asian countries to 23.2% among those from other Nordic countries. Among immigrant groups with prevalences of pregnancy smoking higher than that of women in dual Swedish-born unions, having a Swedish-born partner was associated with lower odds of smoking (adjusted odds ratios: 0.72–0.87) but with higher odds among immigrant groups with lower prevalence (adjusted odds ratios: 1.17–5.88). These associations were stronger among women immigrating in adulthood, whose smoking rates were the lowest. Conclusions Swedish-born partners “pull” smoking rates of immigrant women toward the level of smoking of Swedish-born women, particularly among women arrived during adulthood. Consideration of a woman’s and her partner’s ethnic background and life stage at migration may help understand smoking patterns of immigrant women. Implications We found that having a Swedish-born partner is associated with higher rates of smoking during pregnancy among immigrants from regions where women smoke less than Swedish women, but with lower smoking rates among immigrants from regions where women smoke more. This implies that prevention efforts should concentrate on newly arrived single women from low prevalence regions, such as Africa and Asia, whereas cessation efforts may target women from high prevalence regions, such as other European countries. These findings suggest that pregnancy smoking prevention or cessation interventions may benefit from including partners and approaches culturally tailored to mixed unions.

Background International guidelines in 2008 recommended orchidopexy for undescended testis at 6–12 months of age to reduce the risk of testicular cancer and infertility. Using administrative data from England, Finland, Ontario (Canada), Scotland and Sweden (with data from Victoria (Australia) and Iceland in supplementary analyses), the aim of this study was to investigate compliance with these guidelines and identify potential socioeconomic inequities in the timing of surgery before 1 and 3 years. Methods All boys born in 2003–2011 with a diagnosis code of undescended testis and procedure codes indicating orchidopexy before their fifth birthday were identified from administrative health records. Trends in the proportion of orchidopexies performed before 1 and 3 years of age were investigated, as were socioeconomic inequities in adherence to the guidelines. Results Across all jurisdictions, the proportion of orchidopexies occurring before the first birthday increased over the study period. By 2011, from 7·6 per cent (Sweden) to 27·9 per cent (Scotland) of boys had undergone orchidopexy by their first birthday and 71·5 per cent (Sweden) to 90·4 per cent (Scotland) by 3 years of age. There was limited evidence of socioeconomic inequities for orchidopexy before the introduction of guidelines (2008). Across all jurisdictions for boys born after 2008, there was consistent evidence of inequities in orchidopexy by the first birthday, favouring higher socioeconomic position. Absolute differences in these proportions between the highest and lowest socioeconomic groups ranged from 2·5 to 5·9 per cent across jurisdictions. Conclusion Consistent lack of adherence to the guidelines across jurisdictions questions whether the guidelines are appropriate., International guidelines recommend orchidopexy before 12 months of age. This study, using international administrative health data, found that this was achieved in only a minority of cases and that there were socioeconomic inequities in this outcome. Guidelines not widely applied

Background Young maternal age is associated with lower birthweight and higher rates of preterm birth and childhood hospitalisations. Internationally, teen pregnancy rates vary widely, reflecting differences in social, welfare, and health care factors in different cultural contexts. Objectives To determine whether the increased risk of adverse infant outcomes among teenage mothers varies by country, reflecting different national teenage birth rates and country‐specific social/welfare policies, in Scotland (higher teenage pregnancy rates), England, New South Wales (NSW; Australia), Ontario (Canada), and Sweden (lower rates). Methods We used administrative hospital data capturing 3 002 749 singleton births surviving to postnatal discharge between 2010 and 2014 (2008‐2012 for Sweden). We compared preterm birth (24‐36 weeks’ gestation), mortality within 12 months of postnatal discharge, unplanned hospital admissions, and emergency department visits within 12 months of postnatal discharge, for infants born to mothers aged 15‐19, 20‐24, 25‐29, and 30‐34 years. Results Compared to births to women aged 30‐34 years, risks of adverse outcomes among teenage mothers were higher in all countries, but the magnitude of effects was not related to country‐specific rates of teenage births. Teenage mothers had between 1.2% (95% confidence interval [CI] 0.7, 1.7, Sweden) and 2.0% (95% CI 1.4, 2.5, NSW) more preterm births, and between 9.8 (95% CI 7.2, 12.4, England) and 19.7 (95% CI 8.7, 30.6, Scotland) more deaths per 10 000 infants, compared with mothers aged 30‐34. Between 6.4% (95% CI 5.5, 7.4, NSW) and 25.4% (95% CI 24.7, 26.1, Ontario), more infants born to teenage mothers had unplanned hospital contacts compared with those born to mothers aged 30‐34. Conclusions Regardless of country, infants born to teenage mothers had universally worse outcomes than those born to older mothers. This excess risk did not vary by national rates of livebirths to teenage mothers. Current mechanisms to support teenage mothers have not eliminated maternal age‐related disparities in infant outcomes; further strategies to mitigate excess risk in all countries are needed.

Refugee children in the Nordic countries have been reported to perform poorly in school and carry a high burden of familial posttraumatic stress. The present study aimed to investigate the impact of maternal and paternal posttraumatic stress on the school performance of refugee children. We used national register data on school grades at age 15-16 along with demographic and migration indicators during 2011-2017 in a population of 18,831 children in refugee families in Stockholm County, Sweden. Parental posttraumatic stress was identified in regional data from three levels of care, including a tertiary treatment center for victims of torture and war. Multivariable linear and logistic regression models were fitted to analyze (a) mean grade point averages as Z scores and (b) eligibility for upper secondary school. In fully adjusted models, children exposed to paternal posttraumatic stress had a lower mean grade point average, SD = -0.14, 95% CI [-0.22, -0.07], and higher odds of not being eligible for upper secondary education, OR = 1.37, 95% CI [1.14, 1.65]. Maternal posttraumatic stress had a similar crude effect on school performance, SD = -0.15, 95% CI [-0.22, -0.07], OR = 1.25, 95% CI [1.00, 1.55], which was attenuated after adjusting for single-parent households and the use of child psychiatric services. The effects were similar for boys and girls as well as for different levels of care. Parental posttraumatic stress had a small negative effect on school performance in refugee children, adding to the intergenerational consequences of psychological trauma.

Parental psychiatric morbidity related to experiences of war and trauma has been associated with adverse psychological outcomes for children. The aim of this study was to investigate parental post-traumatic stress in relation to psychiatric care utilization among children of refugees with particular attention on the child’s own refugee status, sex of both child and parents, and specific psychiatric diagnoses. This was a register study in a population of 16 143 adolescents from refugee families in Stockholm County born 1995–2000 and followed between 2011 and 2017 (11–18 years old). Parental post-traumatic stress, identified in three levels of care, was analysed in relation to child and adolescent psychiatric care use. Cox regression analysis was used to estimate hazard ratios (HR) and 95% confidence intervals (CI), adjusted for duration of residence and demographic and socioeconomic variables. Having a mother with post-traumatic stress was associated with higher psychiatric care utilization, with adjusted HR 2.44 (95% CI 1.90–3.14) among foreign-born refugee children and HR 1.77 (1.33–2.36) among Swedish-born children with refugee parents, with particularly high risks for children with less than five years of residence (HR 4.03; 2.29–7.10) and for diagnoses of anxiety and depression (HR 2.71; 2.11–3.48). Having a father with post-traumatic stress was not associated with increased HRs of psychiatric care utilization. Similar results were seen for boys and girls. Treatment for post-traumatic stress should be made available in refugee reception programmes. These programmes should use a family approach that targets both parents and children.

There is growing evidence on the observed and expected consequences of climate change on population health worldwide. There is limited understanding of its consequences for child health inequalities, between and within countries. To examine these consequences and categorize the state of knowledge in this area, we conducted a review of reviews indexed in five databases (Medline, Embase, Web of Science, PsycInfo, Sociological Abstracts). Reviews that reported the effect of climate change on child health inequalities between low- and high-income children, within or between countries (high- vs low–middle-income countries; HICs and LMICs), were included. Twenty-three reviews, published between 2007 and January 2021, were included for full-text analyses. Using thematic synthesis, we identified strong descriptive, but limited quantitative, evidence that climate change exacerbates child health inequalities. Explanatory mechanisms relating climate change to child health inequalities were proposed in some reviews; for example, children in LMICs are more susceptible to the consequences of climate change than children in HICs due to limited structural and economic resources. Geographic and intergenerational inequalities emerged as additional themes from the review. Further research with an equity focus should address the effects of climate change on adolescents/youth, mental health and inequalities within countries.

BackgroundPrevious Scandinavian studies have shown increased levels of psychiatric morbidity in young refugees and international adoptees with an origin outside Europe. This study investigated their risk of non-affective psychotic disorders (NAPD) and whether this risk is influenced by early childhood adversity, operationalised as age at adoption/residency, and/or gender.MethodsRegister study in Swedish national cohorts born 1972–1990 including 21 615 non-European international adoptees, 42 732 non-European refugees that settled in Sweden at age 0–14 years and 1 610 233 Swedish born. The study population was followed from age 18 to year 2016 for hospitalisations with a discharge diagnosis of NAPD. Hazard ratios (HRs) were calculated in gender stratified Cox regression models, adjusted for household income at age 17.ResultsThe adjusted risks of NAPD were 2.33 [95% confidence interval (CI) 2.07–2.63] for the international adoptees and 1.92 (1.76–2.09) for the former child refugees, relative to the Swedish-born population. For the international adoptees there was a stepwise gradient for NAPD by age of adoption from adjusted HR 1.66 (1.29–2.03) when adopted during the first year of life to adjusted HR 4.56 (3.22–6.46) when adopted at ages 5–14 years, with a similar risk pattern in women and men. Age at residency did not influence the risk of NAPD in the refugees, but their male to female risk ratio was higher than in Swedish-born and the adoptees.ConclusionThe risk pattern in the international adoptees gives support to a link between early childhood adversity and NAPD. Male gender increased the risk of NAPD more among the refugees.

Aim The aim of this study was to describe sociodemographic and family predictors for behavioural and emotional problems in pre-schoolers. Methods This was a cross-sectional study including 30 795 children in the Stockholm region whose parents had completed the Strength and Difficulties Questionnaire (SDQ) prior to a routine visit to a well-baby clinic at age 3 years. Multivariate logistic regression was used to analyse predictors for having a high total SDQ difficulties score. Results Young parental age and a low level of parental education predicted high total SDQ score in a stepwise pattern. Being a first-born child was associated with a high SDQ score with an adjusted odds ratio of 2.10 (95% C.I. 1.84-2.41), compared with having older siblings. A sole physical custody arrangement predicted a high total SDQ score after parental separation. The percentage of children with a high total SDQ score increased with the Care Need Index (CNI) of the well-baby clinic. Conclusions This study identified socioeconomic disadvantage and being the first-born child as the main predictors of poor mental health at age 3 years. Well-baby clinics with socioeconomically disadvantaged catchment areas should be provided with adequate resources and methods for equitable prevention.

Background Undocumented migrants face many hardships in their everyday life such as poor living conditions, discrimination, and lack of access to healthcare. Previous studies have demonstrated considerable health care needs for psychiatric disorders as well as physical diseases. The aim of this paper was to find out the main barriers that undocumented migrants experience in accessing the Swedish healthcare system and to explore their relation with socioeconomic factors. Methods A cross-sectional study with adult undocumented migrants was performed in the three largest cities of Sweden in 2014–2016. Sampling was done via informal networks. A socioeconomic questionnaire was constructed including 22 barriers to health care. Trained field workers conducted the interviews. A principal component analysis was conducted of all barriers to reveal central components. Then, Pearson’s chi-squared test was used to explore the characteristics of undocumented migrants experiencing barriers to care. Results Two main components/barriers were extracted: “Fear of being taken by police/authorities”, which was related to fear of disclosure by or in relation to seeking health care, and “Structural and psychosocial factors” which was related to practical obstacles or shame of being ill. Lower age (74.1 % vs 56.0 %), lower level of education (75.0 % vs. 45.1 %), and having no children (70.3 % vs. 48.1 %) were significantly related to a higher likelihood of experiencing a barrier. Conclusion Fear of deportation and practical and psychosocial factors constitute hinderance of access to healthcare for undocumented migrants in Sweden. This highlights the importance of clear instructions, both to undocumented migrants and health professionals about the right to health care according to the international law on human rights as well as the law of confidentiality.

Background An increasing number of migrants have fled armed conflict, persecution and deteriorating living conditions, many of whom have also endured risky migration journeys to reach Europe. Despite this, little is known about the perinatal health of migrant women who are particularly vulnerable, such as refugees, asylum-seekers, and undocumented migrants, and their access to perinatal care in the host country. Methods Using the Swedish Pregnancy Register, we analyzed indicators of perinatal health and health care usage in 31 897 migrant women from the top five refugee countries of origin between 2014 and 2017. We also compared them to native-born Swedish women. Results Compared to Swedish-born women, migrant women from Syria, Iraq, Somali, Eritrea and Afghanistan had higher risks of poor self-rated health, gestational diabetes, stillbirth and infants with low birthweight. Within the migrant population, asylum-seekers and undocumented migrants had a higher risk of poor maternal self-rated health than refugee women with residency, with an adjusted risk ratio (RR) of 1.84 and 95% confidence interval (95% CI) of 1.72–1.97. They also had a higher risk of preterm birth (RR 1.47, 95% CI 1.21–1.79), inadequate antenatal care (RR 2.56, 95% CI 2.27–2.89) and missed postpartum care visits (RR 1.15, 95% CI 1.10–1.22). Conclusion Refugee, asylum-seeking and undocumented migrant women were vulnerable during pregnancy and childbirth. Living without residence permits negatively affected self-rated health, pregnancy and birth outcomes in asylum-seekers and undocumented migrants. Pregnant migrant women’s special needs should be addressed by those involved in the asylum reception process and by health care providers.

ObjectiveTo compare mortality in children aged DesignBirth cohort study using linked administrative health databases from England and Sweden.Setting and participantsSingleton live births between 2003 and 2012 in England and Sweden, followed up from age 31 days until the fifth birthday, death or 31 December 2013.Main outcome measuresThe main outcome measures were HR for RTI-related mortality at 31–364 days and at 1–4 years and SUDI mortality at 31–364 days in England versus Sweden estimated using Cox proportional hazards models. We calculated unadjusted HRs and HRs adjusted for birth characteristics (gestational age, birth weight, sex and congenital anomalies) and socioeconomic factors (maternal age and socioeconomic status).ResultsThe English cohort comprised 3 928 483 births, 768 RTI-related deaths at 31–364 days, 691 RTI-related deaths at 1–4 years and 1166 SUDIs; the corresponding figures for the Swedish cohort were 1 012 682, 131, 118 and 189. At 31–364 days, unadjusted HR for RTI-related death in England versus Sweden was 1.52 (95% CI 1.26 to 1.82). After adjusting for birth characteristics, the HR reduced to 1.16 (95% CI 0.96 to 1.40) and for socioeconomic factors to 1.11 (95% CI 0.92 to 1.34). At 1–4 years, unadjusted HR was 1.58 (95% CI 1.30 to 1.92) and decreased to 1.32 (95% CI 1.09 to 1.61) after adjusting for birth characteristics and to 1.30 (95% CI 1.07 to 1.59) after further adjustment for socioeconomic factors. For SUDI, the respective HRs were 1.59 (95% CI 1.36 to 1.85) in the unadjusted model, and 1.40 (95% CI 1.20 to 1.63) after accounting for birth characteristics and 1.19 (95% CI 1.02 to 1.39) in the fully adjusted model.ConclusionInterventions that improve maternal health before and during pregnancy to reduce the prevalence of adverse birth characteristics and address poverty could reduce child mortality due to RTIs and SUDIs in England.

Background Childhood adversity (CA) is a risk indicator for psychiatric morbidity. Although CA has been linked to violent offending, limited research has considered adolescent psychiatric disorder as a mediating factor. The current study examined whether adolescent psychiatric disorder mediates the association between CA and violent offending. Methods We used a cohort of 476 103 individuals born in 1984–1988 in Sweden. Register-based CAs included parental death, substance abuse and psychiatric disorder, parental criminal offending, parental separation, public assistance, child welfare intervention and residential instability. Adolescent psychiatric disorder was defined as being treated with a psychiatric diagnosis prior to age 20. Estimates of risk of violent offending after age 20 were calculated as incidence rate ratios (IRRs) with 95% confidence intervals (CIs). Mediation was tested with the bootstrap method. Results Exposure to CA was positively associated with violent offending, especially when accumulated. Individuals exposed to 4+ CAs who were also treated for psychiatric disorder had a 12-fold elevated risk for violent offending (adjusted IRR 12.2, 95% CI 10.6–14.0). Corresponding IRR among 4+ CA youth with no psychiatric disorder was 5.1 (95% CI 4.5–5.6). Psychiatric disorder mediated the association between CA and violent offending. Conclusion CA is associated with elevated risk for violent offending in early adulthood, and the association is partly mediated by adolescent psychiatric disorder. Individuals exposed to cumulative CA who also develop adolescent psychopathology should be regarded as a high-risk group for violent offending, by professionals in social and health services that come into contact with this group.

Studies have found that sibling loss is associated with an increased risk of death from external causes (i.e. suicides, accidents and homicides). Increased psychiatric health problems following bereavement could underlie such an association. We studied the influence of sibling loss during childhood on psychiatric care in young adulthood, adjusting for psychosocial covariates shared by siblings in childhood. A national cohort born in Sweden in 1973–1982 (N = 701,270) was followed prospectively until 2013. Cox proportional hazards models were used to analyse the association between sibling loss during childhood and psychiatric inpatient and outpatient care identified by the Hospital Discharge Register. After adjustment for confounders, the HRs of psychiatric care in men who experienced sibling loss were 1.17 (95% CI 1.07–1.27) while the associations turned non-significant in women after adjustment for family-related psychosocial covariates, HR 1.07 (95% CI 0.99–1.16). An increased risk was found in men bereaved in early childhood (1.22 95% CI 1.07–1.38) and adolescence (1.27 95% CI 1.08–1.48). Among women, loss of a sibling during adolescence was significantly associated with psychiatric care (1.19 95% CI 1.03–1.36). Increased psychiatric health problems following bereavement could underlie the previously found association between sibling loss and mortality from external causes. Family-related psychosocial conditions shared by siblings in childhood may account for the association between sibling death and psychiatric care in adulthood. Electronic supplementary material The online version of this article (10.1007/s00787-019-01324-6) contains supplementary material, which is available to authorized users.

The aim of the study was to assess morphological predictors for lymph node metastases (Stage III disease) in colon cancer on computed tomography. Ninety-four patients with histology-proven colon cancer (adenocarcinoma) who underwent elective primary curative resection between the years 2012 and 2014 were included. Contrast-enhanced CT examinations were independently reviewed by two blinded observers regarding tumor location, depth of tumor invasion, and presence of lymph node metastases. Ocular presence of internal heterogeneity and presence of irregular outer border were used as morphological criteria for lymph node involvement. Protocol-based histopathology after curative surgery served as reference standard. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, and accuracy for each morphological criterion for prediction of stage III disease were calculated. Inter-observer agreement was compared using Kappa statistics. According to histopathology, 59 patients were staged as I–II disease and 35 patients were staged as stage III disease. The presence of internal heterogeneity in a lymph node on CT resulted in moderate sensitivity (66–77%) but high specificity (95–95%) for prediction of Stage III disease by both observers. The presence of irregular outer border also resulted in poor sensitivity (49–54%) but high specificity (97–97%). The combination of either internal heterogeneity and/or irregular outer border per patient resulted in a moderate sensitivity (67–77%) and high specificity (95–95%), PPV (89–96%), and NPV (84–88%). Inter-observer agreement (Cohens Kappa) was 0.72. Consensus reading for the combined criteria resulted in sensitivity and specificity of 69% and 100%, respectively. Using morphological criteria for lymph node metastases on CT examination in patients with colon cancer results in high specificity but moderate sensitivity in predicting stage III disease.

BackgroundIn the context of containment measures against the COVID-19 pandemic, the aims were to examine the impact of lockdown and school closures on childs’ and adolescents’ health and well-being and social inequalities in health.MethodsLiterature review by searching five databases until November 2020. We included quantitative peer-reviewed studies reporting health and well-being outcomes in children (0–18 years) related to closure measures' impact due to COVID-19. A pair of authors assessed the risk of bias of included studies. A descriptive and narrative synthesis was carried out.FindingsTwenty-two studies, including high-income, middle-income and low-income countries, fulfilled our search criteria and were judged not to have an increased risk of bias. Studies from Australia, Spain and China showed an increase in depressive symptoms and decrease in life satisfaction. A decrease in physical activity and increase in unhealthy food consumption were shown in studies from two countries. There was a decrease in the number of visits to the emergency department in four countries, an increase in child mortality in Cameroon and a decrease by over 50% of immunisations administered in Pakistan. A significant drop of 39% in child protection medical examination referrals during 2020 compared with the previous years was found in the UK, a decrease in allegations of child abuse and neglect by almost one-third due to school closures in Florida, and an increase in the number of children with physical child abuse trauma was found in one centre in the USA.InterpretationFrom available reports, pandemic school closure and lockdown have adverse effects on child health and well-being in the short and probably long term. We urge governments to take the negative public health consequences into account before adopting restrictive measures in childhood.

Aim Parental separation has been associated with poor mental health in children with better outcomes in children living in joint physical custody compared with those living with one parent after the separation. In this study, we investigated socioeconomic and relational predictors in early childhood of later parental separation and family arrangements thereafter. Methods This study included 34 768 children from the Danish National Birth Cohort, who were living with both parents at the 6 months' data collection and followed up in 2010-2014 at age 11 years. Questionnaire data from the two data collections were linked with population registers in Statistics Denmark about parental income, education and psychiatric care and analysed in logistic regression models. Results Socioeconomic indicators of the family and parental psychiatric disorders before birth of the child and family relationships in infancy predicted parental separation at age 11 year. For children with separated parents, a high family income and a high parental educational level were the main predictors of living in joint physical custody at the 11-year follow-up. Conclusion Socioeconomic living conditions predict parental separation as well as living arrangements thereafter. Studies of consequences of living arrangements after parental separation should account for family factors preceding the separation.

AIM: This study compared mental health after parental separation in seven-year-old children living in joint physical custody with sole physical custody family arrangements.METHODS: The study population included 39,661 children from the Danish National Birth Cohort, living in a nuclear family at age six months. Child mental health was measured at age 7 years with maternal reports of the Strength and Difficulties Questionnaire (SDQ) operationalized as a high total score. Associations between living arrangements and mental health were analysed using logistic regression models, taking into account early childhood indicators of family relations, parental mental health and socioeconomic conditions.RESULTS: There were no statistically significant differences between the living arrangements after parental separation with joint physical custody having an odds ratio (OR) of 1.37 (95%-CI 1.10-1.70), sole physical custody without a new partner OR 1.33 (95%-CI 1.19-1.47) and OR 1.55 (95%-CI 1.30-1.84) for sole physical custody with new partner, with children in a nuclear family as reference.CONCLUSION: This study indicates that living arrangements after parental separation have a minimal influence on child mental health at age 7 years.

Publisher's version (útgefin grein), Background: To analyse the impact of austerity measures taken by European governments as a response to the 2008 economic and financial crisis on social determinants on child health (SDCH), and child health outcomes (CHO). Methods: A systematic literature review was carried out in Medline (Ovid), Embase, Web of Science, PsycInfo, and Sociological abstracts in the last 5 years from European countries. Studies aimed at analysing the Great Recession, governments' responses to the crisis, and its impact on SDCH were included. A narrative synthesis of the results was carried out. The risk of bias was assessed using the STROBE and EPICURE tools. Results: Fourteen studies were included, most of them with a low to intermediate risk of bias (average score 72.1%). Government responses to the crisis varied, although there was general agreement that Greece, Spain, Ireland and the United Kingdom applied higher levels of austerity. High austerity periods, compared to pre-austerity periods were associated with increased material deprivation, child poverty rates, and low birth weight. Increasing child poverty subsequent to austerity measures was associated with deterioration of child health. High austerity was also related to poorer access and quality of services provided to disabled children. An annual reduction of 1% on public health expenditure was associated to 0.5% reduction on Measles-Mumps-Rubella vaccination coverage in Italy. Conclusions: Countries that applied high level of austerity showed worse trends on SDCH and CHO, demonstrating the importance that economic policy may have for equity in child health and development. European governments must act urgently and reverse these austerity policy measures that are detrimental to family benefits and child protection., No funding was received for this article. Open access funding provided by Stockholm University.

Aim Refugee children have been shown to underutilise psychiatric services in Scandinavia. The aim of this study was to investigate determinants of psychiatric care utilisation in adolescents in refugee families. Methods The study used regional data on healthcare use linked to sociodemographic data from national registers in a total population of 93 537 adolescents in the Stockholm County born in 1995‐2000, including 18 831 with a refugee background. Cox regression analyses were fitted to estimate Hazard ratios (HRs) of psychiatric care utilisation in the age‐span 11‐18 years. Results Psychiatric care use was lower in the large majority of adolescents in refugee families that originated in low‐ and middle‐income countries, with adjusted HRs 0.34 (95% CI 0.28‐0.42) and 0.51 (95% CI 0.46‐0.56), respectively, compared with the Swedish majority population. Among the foreign‐born refugee adolescents, psychiatric care use increased with duration of residence in Sweden and was higher in children who obtained residency as asylum seekers compared with those who settled in family reunification. Conclusion Adolescents in newly settled refugee families with a background in low‐ and middle‐income countries should be a priority in mental health assessment of refugee children and referral to psychiatric care facilitated for children in need.

To determine the association between maternal age at delivery and caries in offspring.This registry-based cohort study included all children born between 2000 and 2003 and who were residing in Stockholm County, Sweden, at 7 years of age. Between 2007 and 2010, the cohort (The lowest mean deft occurred in children born to mothers aged 25-34 years. The final model - adjusted for sex, income, educational level, migration background, family situation, smoking, obesity, small for gestational age, and number of siblings - found that young mothers and older mothers were significant risk indicators for caries experience at 7 years of age.The present study found a U-shaped relationship between maternal age at childbirth and caries experience in the offspring at age 7 years. The offspring of mothers under 25 or over 34 years of age are at greater risk of having more teeth with caries experience.

Background Birth order has been shown to affect the health of the child; less is known, however, about how birth order affects caries development in children. Thus, the present study investigated the association between birth order and dental caries development in young children. Methods This retrospective registry-based cohort study included all children born in 2000–2003 who were residing in Stockholm County, Sweden, at age 3 years (n = 83,147). The study followed the cohort until subjects reached 7 years of age. Children with registry data on dental examinations and sociodemographic characteristics at ages 3- and 7 years constituted the final study cohort (n = 65,259). The outcome variable was “caries increment from age 3- to 7 years” (Δdeft > 0) and the key exposure, “birth order”, was divided into five groups. A forward stepwise logistic binary regression was done for the multivariate analysis with adjustments for sociodemographic factors. Results At age 3 years, 94% had no fillings or manifest caries lesions. During the study period, 22.5% (n = 14,711) developed dental caries. The final logistic regression analysis found a statistically significant positive association between birth order and caries increment. Further, excess risk increased with higher birth order; with the mother’s first-born child as reference, risk for the second-born child was OR 1.17, 95% CI = 1.12–1.23; for the third-born child, OR 1.47, 95% CI = 1.38–1.56; for the fourth-born child, OR 1.69, 95% CI = 1.52–1.88; and for the fifth-born or higher birth-order child, OR 1.84, 95% CI = 1.58–2.14. Conclusions These findings show that birth order influences caries development in siblings, suggesting that birth order can be regarded as a predictor for caries development in young children. This factor may be helpful in assessing caries risk in preschool children and should be considered in caries prevention work in young children with older siblings.

Background: Non-European international adoptees in Sweden were shown to have a three-to fourfold higher risk of suicidal behaviour in youth during 1986-1995 compared with the general population. The aim of this study was to investigate whether this high risk persists beyond youth and in later cohorts. Methods: A register study of Swedish national cohorts born 1972-86 including 20 625 non-European international adoptees, and comparison populations of 10 915 non-European immigrants and 1 435 167 Swedish born was performed. The study population was followed from age 18 between 1991 and 2016, with suicide and hospital admissions due to suicide attempt as outcomes. Poisson regression models of person time in the study, adjusted for gender and household income at age 17, were fitted to calculate relative risks (RR). Findings: Adjusted RR for suicide in non-European international adoptees was high at age 18-22, 2.74 (95% C. I. 1.95-3.86), but decreased gradually to age 33-43 when the risk was similar to Swedish-born. Adjusted RR for suicide attempts in international adoptees was 2.33 (2.15-2.52) at age 18-22, decreased slightly with older age, but remained higher than Swedish born in all age-classes. Risks for both outcomes were greatest, around three times higher compared with the Swedish-born in the oldest birth cohorts of non-European international adoptees, born 1972-76. Risks for both suicidal outcomes increased with higher age at adoption. Interpretation: The risk of suicidal behaviour in non-European international adoptees in Sweden decreases with age and is lower in later birth cohorts and in infant adoptions. (c) 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

AIM: Decades of research confirm that children and adolescents in out-of-home care (foster family, residential care) have much greater healthcare needs than their peers. A systematic literature review was conducted to evaluate organizational healthcare models for this vulnerable group. METHODS: A systematic literature search was undertaken of the following databases: Academic Search Elite, CENTRAL, Cochrane Database of Systematic Reviews, Cinahl, DARE, ERIC, HTA, PsycInfo, Psychology and Behavioural Sciences Collection, PubMed, SocIndex. Randomized and non-randomized controlled trials were to be included. Two pairs of reviewers independently assessed abstracts of the identified published papers. Abstracts meeting the inclusion criteria were ordered in full text. Each article was reviewed independently, by pairs of reviewers. A joint assessment was made based on the inclusion criteria and relevance. Cases of disagreement were resolved by consensus discussion. RESULTS: No study with low or medium risk of bias was identified. CONCLUSION: In the absence of studies of acceptable quality, it is not possible to assess the impact of organizational models intended to ensure adequate health and dental care for children and adolescents in out-of-home care. Therefore, well-designed follow-up studies should be conducted following the implementation of such models. This article is protected by copyright. All rights reserved.

Aim The aim of this narrative review was to evaluate the evidence for interventions for children's secure attachment relationships and parents’ caregiving sensitivity that could potentially be implemented in the context of a well‐baby clinic. Methods Literature search on programmes for parental caregiving sensitivity and secure attachment for infants aged 0‐24 months. Randomised controlled trials (RCTs) published 1995‐2018 with interventions starting from one week postpartum, and with a maximum of 12 sessions (plus potential booster session) were included. Results We identified 25 studies, of which 22 studied effects of home‐based programmes using video feedback techniques. Positive effects of these interventions in families at risk were found on parental caregiving sensitivity and to a lesser extent also on children's secure or disorganised attachment. The effects of two of these programmes were supported by several RCTs. Three intervention studies based on group and individual psychotherapy showed no significant positive effects. Most of the interventions targeted mothers only. Conclusion The review found some evidence for positive effects of selective interventions with video feedback techniques for children's secure attachment and strong evidence for positive effects on parental caregiving sensitivity. Important knowledge gaps were identified for universal interventions and interventions for fathers and parents with a non‐Western background.

Background: A previous Lancet article about international adoptees in Sweden showed a three-to fourfold higher risk of suicidal behaviour in youth during 1986-1995. The aim of this study was to investigate whether this high risk persists during later years, beyond youth and in later cohorts. Methods: Register study in Swedish national cohorts born 1972-86 including 20,625 non-European international adoptees, and comparison populations of 10 915 non-European immigrants and 1 435 167 Swedish born. The study population was followed from age 18 to the year 2016 with suicide death and hospital admissions due to suicide attempt as outcomes. Poisson regression models of person time in the study, adjusted for gender and household income at age 17, were fitted to calculate relative risks (RR). Outcomes: Adjusted RR for suicide death in international adoptees was high at age 18-22, 2·74 (95% C.I. 1·95-3·86), but decreased gradually to age 33-43 when the risk was similar to Swedish-born. Adjusted RR for suicide attempts in international adoptees was 2·33 (2·15-2·52) at age 18-22, decreased slightly with older age, but remained higher than Swedish born in all age-classes. Risks for both outcomes were greatest, around three times higher compared with the majority population, in the oldest birth cohorts of international adoptees, born 1972-76. Risks for both suicide outcomes increased with higher age at adoption. Interpretation: The risk of suicidal behaviour in international adoptees in Sweden decreases in middle age and is lower in later birth cohorts and in infant adoptions. Funding Statement: None to declare. Declaration of Interests: Dr. Lindblad reports that he is an adoptive father, all other authors have nothing to declare. Ethics Approval Statement: Our study has been approved by the Regional ethics committee in Stockholm region (No. 2014/415-31/5).

Background Fathers may affect expectant mothers’ daily living situations, which in turn might influence pregnancy outcomes. We investigated the association between paternal violent criminality and risk of preterm birth (≤36 weeks). Methods We conducted a register-based study with all live singleton births in the Swedish Medical Birth Register from 1992 to 2012, linked with records of paternal violent crime convictions from the National Crime Register from 1973 to 2012. Results Paternal violent criminality was associated with increased risk of preterm birth and lower gestational age. The association was especially pronounced among infants of reoffenders: men convicted of three or more violent crimes (adjusted odds ratio [aOR] 1.23 [95% CI 1.17, 1.29]). Maternal half sibling-comparisons, an analytic approach controlling for maternal factors stable across pregnancies, also suggested increased risk of preterm birth and lower gestational age when exposed to a violently reoffending father compared to a father without violent criminal convictions (aOR 1.30 [0.99, 1.72], adjusted mean difference − 1.07 [− 1.78, − 0.36]). Conclusions Persistent paternal violent criminality was associated with increased risk of preterm birth, even after controlling for maternal characteristics that did not change between pregnancies.

Low birth weight has been shown to be related to increased risk of depression later in life – but the evidence is not conclusive. We examined the association of size at birth with repeatedly measured depressive symptoms in 947 individuals from the Northern Swedish Cohort, a community-based age-homogeneous cohort born in 1965, and followed with questionnaires between ages 16 and 43 (participation rate above 90% in all the surveys). Information on birth size was retrieved from archived birth records. Length of gestation was known for a subsample of 512 individuals (54%). We studied the association of birth weight and ponderal index with self-reported depressive symptoms at ages 16, 21, 30 and 43; with the life-course average of depressive symptoms score and with longitudinal trajectories of depressive symptoms retrieved by latent class growth analysis. Socioeconomic background, mental illness or alcohol problems of a parent, exposure to social adversities in adolescence and prematurity were accounted for in the analyses. We did not find any relationship between weight or ponderal index at birth and our measure of depressive symptoms between ages 16 and 43 in a series of different analyses. Adjustment for length of gestation did not alter the results. We conclude that size at birth is not associated with later-life depressive symptoms score in this cohort born in the mid-1960s in Sweden. The time and context need to be taken into consideration in future studies.

We examined whether women experiencing severe maternal morbidity (SMM) are more likely to be treated for a psychiatric illness or be prescribed psychotropic medications in the postpartum year than mothers who did not experience SMM. We also examine the relationship between SMM and specific mental health-related outcomes, and the relationship between specific SMM diagnoses/procedures and postpartum mental-health-related outcomes. The national registers in Sweden were used to create a population-based matched cohort. Every delivery with SMM between July 1, 2006, and December 31, 2012 (n = 8558), was matched with two deliveries without SMM (n = 17,116). Conditional logistic regression models assessed the relationship between SMM and postpartum mental health-related outcomes. Women who experienced SMM had significantly greater odds of being treated for a psychiatric disorder (aOR 1.22; 95% CI 1.03-1.45) and being prescribed psychotropic medications (aOR 1.40; 95% CI 1.24-1.58) in the postpartum year. Specifically, they had significantly greater odds of being treated for neuroses (aOR 1.35; 95% CI 1.09-1.69) and having a prescription for anxiolytics/hypnotics (aOR 1.36; 95% CI 1.18-1.58) or antidepressants (aOR 1.35; 95% CI 1.17-1.55). Women who were diagnosed with shock or uterine rupture/obstetric laparotomy during delivery had the greatest odds of postpartum mental health-related outcomes. This study identified mothers with SMM as a group at high risk for postpartum mental illness. Postpartum mental health services should be provided to ensure the well-being of these high-risk mothers.

International research has consistently reported that youth in secure residential care have high rates of somatic/dental health problems. Here, we report results from the first such study in a Nordic country. An experienced paediatrician performed systematic somatic and rudimentary dental health assessments of 91 youths, age 13–17, recently admitted to four secure residential units in Sweden. Girls were oversampled. Participants were tested for sexually transmitted diseases (STD). We found large unmet needs of health/dental care, similar to reports from other countries: 75% of the girls and 53% of the boys had at least one previously known health problem that was poorly followed up or was unknown before the assessment. Over 40% of the girls had severe dental decay. Only two cases of STD were identified (Chlamydia). Some 91% of the girls and 64% of the boys were referred to a health or a dental care clinic. (Less)

Introduction: Maternal health during pregnancy plays a part in child health, and several conditions have been associated with adverse child outcomes. Objectives: To determine the socioeconomic determinants and maternal health factors associated with dental caries in young children. Methods: This cross-sectional study is part of a register-based cohort study including all children who were born from 2000 to 2003 and were residing in Stockholm County, Sweden, at age 3 y ( n = 73,658). The study followed the cohort until individuals were 7 y old. The final study cohort comprised all children examined at 3 and 7 y ( n = 65,259). Data on socioeconomic conditions, maternal health, and maternal health behavior were extracted from Swedish national registries. The multivariate analyses used 2 outcomes: caries experience at age 3 and 7 y (deft > 0 [decayed, extracted, and filled teeth]). Results: The results of this study show that socioeconomic and maternal health behaviors during pregnancy are important determinants of oral health in their preschool offspring. When all significant risk factors were present, the cumulative probability of being diagnosed with dental caries at age 7 y was 75%. Conclusion: This study also showed that maternal obesity and smoking during pregnancy were predictors of dental caries in preschool children. Strategies must be developed for increasing maternal motivation and self-efficacy and providing mothers with knowledge and caries-preventive tools. Knowledge Transfer Statement: The results of this study inform clinicians about the importance of including a more detailed history regarding maternal health and maternal health behaviors during pregnancy to assess caries risk in preschool children. Education, income, and other socioeconomic factors are difficult to modify in the short term. Therefore, strategies must be developed to increase parental motivation and self-efficacy to give parents the determination, knowledge, and tools for prevention.

AIM We investigated socio-economic and geographical determinants of hospital care for viral gastroenteritis in young children. METHOD This is a register-based study in a national birth cohort of 752 078 children 0-5 years of age in Sweden during 2006-2012. Hazard ratios (HR) of time to first admission and first episode of outpatient emergency department (ED) care with a diagnosis of viral gastroenteritis were estimated with Cox regression. RESULTS The adjusted HRs for hospital admission with a diagnosis of viral gastroenteritis were increased when the mother was below 25 years at the birth of the child, 1.30 (95% CI: 1.24-1.35), had a short (

Objective Although the relationship between childhood adversity (CA) and depression is widely accepted, there is little information on what proportion of depression is attributable to CA. Method We used a Swedish cohort of 478,141 individuals born in 1984–1988 in Sweden. Register-based CA indicators included parental death, parental substance abuse and psychiatric morbidity, parental criminality, parental separation, public assistance recipiency, child welfare intervention, and residential instability. Estimates of risk of depression, measured as retrieval of prescribed antidepressants and/or psychiatric care with a clinical diagnosis of depression, between 2006 and 2012 were calculated as Hazard Ratios (HR) with 95% confidence intervals (CI), using a Cox regression analysis. Results All CAs predicted depression in early adulthood. Furthermore, the predictive association between the CA indicators and depression was graded, with highest HRs observed for 4+ CAs (HR: 3.05 (95% CI 2.83–3.29)) for a clinical diagnosis for depression and HR: 1.32 (95% CI 1.25–1.41) for antidepressant medication after adjustments were made for important confounding factors. Of the studied CAs, child welfare intervention entailed highest HR for depression. Conclusion Regardless of causality issues, children and youth with a history of multiple CA should be regarded as a high-risk group for depression by professionals in social, and health services that come into contact with this group.

Background Local recurrence of rectal cancer (LRRC) is associated with poor survival unless curative treatment is performed. The aim of this study was to investigate predictive factors for treatment with curative intent in patients with LRRC. Methods Population-based data for patients treated for primary rectal cancer between 1995 and 2002, and with LRRC reported as first event were collected from the Swedish Colorectal Cancer Registry and medical records. The associations between patient-, primary tumour- and LRRC-related factors and intention of the treatment for LRRC were determined. The impact of the identified predictive factors on prognosis after treatment with curative intent was also assessed. Results A total of 426 patients were included in the study, of whom 149 (35·0 per cent) received treatment with curative intent. Factors significantly associated with treatment of the LRRC with palliative intent were primary surgery with abdominoperineal resection (odds ratio (OR) 5·16, 95 per cent c.i. 2·97 to 8·97), age at diagnosis of LRRC at least 80 years (OR 4·82, 2·37 to 9·80), symptoms at diagnosis (OR 2·79, 1·56 to 5·01) and non-central location of the LRRC (OR 1·79, 1·15 to 2·79). The overall 5-year survival rate was 8·9 per cent for all patients and 23·1 per cent among those treated with curative intent. In patients treated with curative intent, factors associated with increased risk of death were age 80 years or more (hazard ratio (HR) 2·44, 95 per cent c.i. 1·55 to 3·86), presence of symptoms (HR 1·92, 1·20 to 3·05), non-central tumour location (HR 1·51, 1·01 to 2·26) and presence of hydronephrosis (HR 2·02, 1·18 to 3·44). Conclusion Non-central location of the LRRC, presence of symptoms and age at least 80 years at diagnosis of the LRRC were associated with treatment with palliative intent.

Background To investigate the association between maternal country of birth and father's origin and unplanned and planned caesarean birth in Sweden. Methods Population-based register study including all singleton births in Sweden between 1999 and 2012 (n = 1 311 885). Multinomial regression was conducted to estimate odds ratios (OR) for unplanned and planned caesarean with 95% confidence intervals for migrant compared with Swedish-born women. Analyses were stratified by parity. Results Women from Ethiopia, India, South Korea, Chile, Thailand, Iran, and Finland had statistically significantly higher odds of experiencing unplanned (primiparous OR 1.10–2.19; multiparous OR 1.13–2.02) and planned caesarean (primiparous OR 1.18–2.25; multiparous OR 1.13–2.46). Only women from Syria, the former Yugoslavia and Germany had consistently lower risk than Swedish-born mothers (unplanned: primiparous OR 0.76–0.86; multiparous OR 0.74–0.86. Planned; primiparous OR 0.75–0.82; multiparous OR 0.60–0.94). Women from Iraq and Turkey had higher odds of an unplanned caesarean but lower odds of a planned one (among multiparous). In most cases, these results remained after adjustment for available social characteristics, maternal health factors, and pregnancy complications. Both parents being foreign-born increased the odds of unplanned and planned caesarean in primiparous and multiparous women. Conclusions Unplanned and planned caesarean birth varied by women's country of birth, with both higher and lower rates compared with Swedish-born women, and the father's origin was also of importance. These variations were not explained by a wide range of social, health, or pregnancy factors.