ObjectivesTo determine the indirect consequences of the COVID-19 pandemic on paediatric healthcare utilisation and severe disease at a national level following lockdown on 23 March 2020.DesignNational retrospective cohort study.SettingEmergency childhood primary and secondary care providers across Scotland; two national paediatric intensive care units (PICUs); statutory death records.Participants273 455 unscheduled primary care attendances; 462 437 emergency department attendances; 54 076 emergency hospital admissions; 413 PICU unplanned emergency admissions requiring invasive mechanical ventilation; and 415 deaths during the lockdown study period and equivalent dates in previous years.Main outcome measuresRates of emergency care consultations, attendances and admissions; clinical severity scores on presentation to PICU; rates and causes of childhood death. For all data sets, rates during the lockdown period were compared with mean or aggregated rates for the equivalent dates in 2016–2019.ResultsThe rates of emergency presentations to primary and secondary care fell during lockdown in comparison to previous years. Emergency PICU admissions for children requiring invasive mechanical ventilation also fell as a proportion of cases for the entire population, with an OR of 0.52 for likelihood of admission during lockdown (95% CI 0.37 to 0.73), compared with the equivalent period in previous years. Clinical severity scores did not suggest children were presenting with more advanced disease. The greatest reduction in PICU admissions was for diseases of the respiratory system; those for injury, poisoning or other external causes were equivalent to previous years. Mortality during lockdown did not change significantly compared with 2016–2019.ConclusionsNational lockdown led to a reduction in paediatric emergency care utilisation, without associated evidence of severe harm.

Background: Chronic kidney disease (CKD) is commonly comorbid with hypertension, diabetes and cardiovascular disease (CVD). However, the extent of comorbidity in CKD across a wider range of conditions is not well documented. Aim: To ascertain the prevalence of comorbidity (across 39 physical and mental health comorbidities) in adults aged 25 years and over with CKD in a large nationally representative primary care population. Design and Setting: Cross-sectional analysis of a primary care dataset representing 1,274,374 adults in Scotland. Method: Secondary analysis of general practice electronic medical record data. Comparison was made with the entire population without CKD, standardised for age, sex, and socioeconomic status (SES). Results: A total of 98.2% of adults with CKD had at least one comorbidity (vs. 51.8% in controls). After adjustment for age, sex, and deprivation, people with CKD were more likely to have 1-3 conditions (OR 11.2, 95% CI 10.3-12.2), 4-6 conditions (OR 24.9, 95% CI 22.9-27.0), and ≥7 conditions (OR 38.9, 95% CI 35.6-42.6. Furthermore, all concordant (7 out of 7) and the majority of discordant physical health conditions (17 out of 24) and mental health conditions (6 out of 8) had significantly positive associations with CKD after adjustment. Conclusion: CKD is associated with extreme comorbidity, across a wide range of mental and physical conditions. Routine care for people with CKD should include recognition and management of comorbidities and clinical guidelines should support clinicians to do this.

BackgroundAdmission rates are rising despite no change to burden of illness, and interventions to reduce unscheduled admission to hospital safely may be justified.ObjectiveTo systematically examine admission prevention strategies and report long-term follow-up of admission prevention initiatives.Data sourcesMEDLINE, Embase, OVID SP, PsychINFO, Science Citation Index Expanded/ISI Web of Science, The Cochrane Library from inception to time of writing. Reference lists were hand searched.Study eligibility criteriaRandomised controlled trials and before-and-after studies.ParticipantsIndividuals aged <18 years.Study appraisal and synthesis methodsStudies were independently screened by two reviewers with final screening by a third. Data extraction and the Critical Appraisals Skills Programme checklist completion (for risk of bias assessment) were performed by one reviewer and checked by a second.ResultsTwenty-eight studies were included of whom 24 were before-and-after studies and 4 were studies comparing outcomes between non-randomised groups. Interventions included referral pathways, staff reconfiguration, new healthcare facilities and telemedicine. The strongest evidence for admission prevention was seen in asthma-specific referral pathways (n=6) showing 34% (95% CI 28 to 39) reduction, but with evidence of publication bias. Other pathways showed inconsistent results or were insufficient for wider interpretation. Staffing reconfiguration showed reduced admissions in two studies, and shorter length of stay in one. Short stay admission units reduced admissions in three studies.Conclusions and implicationsThere is little robust evidence to support interventions aimed at preventing paediatric admissions and further research is needed.

Background: Many drugs should be avoided or require dose-adjustment in chronic kidney disease (CKD). Previous estimates of potentially inappropriate prescribing rates have been based on data on a limited number of drugs and mainly in secondary care settings. Aim: To determine the prevalence of contraindicated and potentially inappropriate primary care prescribing in a complete population of people with CKD. Method: Cross-sectional study of prescribing patterns in a complete geographical population of people with CKD defined using laboratory data. Drugs were organised by British National Formulary advice. Contraindicated (CI) drugs: “avoid”. Potentially high risk (PHR) drugs: “avoid if possible”. Dose inappropriate (DI) drugs: dose exceeded recommended maximums. Results: 28,489 people with CKD were included in analysis, of whom 70.0% had CKD 3a, 22.4% CKD 3b, 5.9% CKD 4, and 1.5% CKD 5. 3.9% (95%CI 3.7-4.1) of people with CKD stages 3a-5 were prescribed one or more CI drug, 24.3% (95%CI 23.8-24.8) PHR drug, and 15.2% (95% CI 14.8-15.62) DI drug. CI drugs differed in prevalence by CKD stage, and were most commonly prescribed in CKD stage 4 with a prevalence of 36.0% (95%CI 33.7–38.2). PHR drugs were commonly prescribed in all CKD stages ranging from 19.4% (95%CI 17.6-21.3) in stage 4 to 25.1% (95%CI 24.5–25.7) in stage 3b. DI drugs were most commonly prescribed in stage 4, 26.4% (95%CI 24.3-28.6). Conclusion: Potentially inappropriate prescribing is common at all stages of CKD. Development and evaluation of interventions to improve prescribing safety in this high-risk populations are needed.

Background: Severe disease directly associated with SARS-CoV-2 infection in children is rare. However, the indirect consequences of the COVID-19 pandemic on paediatric health have not been fully quantified. We examined paediatric health-care utilisation, incidence of severe disease, and mortality during the lockdown period in Scotland. Methods: This national retrospective cohort study examined national data for emergency childhood primary and secondary care utilisation following national lockdown on March 23, 2020. To determine whether social distancing measures and caregiver behavioural changes were associated with delayed care-seeking and increased disease severity on presentation, unplanned, emergency admissions requiring invasive mechanical ventilation for the two national Paediatric Intensive Care Units (PICUs) were analysed. PICU admissions were grouped by diagnostic category, and disease severity on presentation calculated. National statutory death records were consulted to establish childhood mortality rates and causes of death. For all observations, the lockdown period was compared to equivalent dates in 2016-2019. Findings: We identified 273,455 unscheduled primary care attendances; 462,437 emergency department attendances; 54,076 emergency hospital admissions; 413 PICU emergency admissions; and 415 deaths during the lockdown study period and equivalent dates in previous years. The rates of emergency presentations to primary and secondary care fell during lockdown in comparison to previous years. Emergency PICU admissions for children requiring invasive mechanical ventilation also fell, with an odds ratio of 0.52 for chance of admission during lockdown (95% CI 0.37-0.73, p < 0.001). Clinical severity scores did not suggest children were presenting with more advanced disease. The greatest reduction in PICU admissions was for diseases of the respiratory system; those for injury, poisoning or other external causes were equivalent to previous years. Mortality during lockdown did not change significantly compared to 2016-2019. Interpretation: National lockdown led a reduction in paediatric emergency care utilisation, without associated evidence of severe harm. Funding: None.