Comparison of suspected and confirmed internal EVD-related infections: a prospective multi-centre U.K. observational study

Background

Diagnosis of internal external ventricular drain (EVD)-related infections (iERI) is an area of diagnostic difficulty. Empiric treatment is often initiated on clinical suspicion. There is limited guidance around antimicrobial management of confirmed versus suspected iERI.

Methods

Data on patients requiring EVD insertion were collected from 21 neurosurgical units in the United Kingdom from 2014 to 2015. Confirmed iERI was defined as clinical suspicion of infection with positive cerebrospinal fluid (CSF) culture and/or Gram stain. Cerebrospinal fluid, blood, and clinical parameters and antimicrobial management were compared between the 2 groups. Mortality and Modified Rankin Scores were compared at 30 days post-EVD insertion.

Results

Internal EVD-related infection was suspected after 46 of 495 EVD insertions (9.3%), more common after an emergency insertion. Twenty-six of 46 were confirmed iERIs, mostly due to Staphylococci (16 of 26). When confirmed and suspected infections were compared, there were no differences in CSF white cell counts or glucose concentrations, nor peripheral blood white cell counts or C-reactive protein concentrations. The incidence of fever, meningism, and seizures was also similar, although altered consciousness was more common in people with confirmed iERI. Broad-spectrum antimicrobial usage was prevalent in both groups with no difference in median duration of therapy (10 days [interquartile range {IQR}, 7–24.5] for confirmed cases and 9.5 days [IQR, 5.75–14] for suspected, P = 0.3). Despite comparable baseline characteristics, suspected iERI was associated with lower mortality and better neurological outcomes.

Conclusions

Suspected iERI could represent sterile inflammation or lower bacterial load leading to false-negative cultures. There is a need for improved microbiology diagnostics and biomarkers of bacterial infection to permit accurate discrimination and improve antimicrobial stewardship.

Brain pseudotumour secondary to Behçet's disease

Neuro-Behçet's disease (NBD) is a serious manifestation of Behçet's disease (BD) and can affect either the central or peripheral nervous systems, or both. It occurs in 10-50% of patients with BD. We report on a patient with an unusual intraparenchymal lesion, initially thought to be a brain tumour. Histological examination revealed vasculitis consistent with BD. Clinicians should include NBD as a differential diagnosis when considering an isolated inflammatory intracranial lesion.

Temperament in young adulthood and later mortality: prospective observational study

STUDY OBJECTIVE

To determine the association between a clinician assessment of temperament in early adulthood and cause specific mortality.

DESIGN

Prospective observational study.

SETTING

Glasgow University.

PARTICIPANTS

9239 male former students aged 16-30 (mean 20.5) years who participated in an ongoing health survey from 1948-68. A physician recorded free text assessment of temperament, which seemed to capture aspects of personality (trait) and mental health (state), was coded into: stable, anxious, schizoid, hypomanic, odd, depressed, immature, hypochondriacal, unstable, and obsessive. Associations between temperament and mortality were investigated using Cox proportional hazards models.

MAIN RESULTS

There were 878 deaths. Most students-8342 (90.3%)-were assessed as stable, the remaining 897 (9.7%) having at least one, and 103 (1.1%) having more than one, temperament type. The second most common temperament was anxiety, recorded in 520 (5.6%) students. In multivariable analyses, having at least one temperament type was associated with increased all cause and stroke mortality, hazard ratios (95% confidence intervals): 1.23 (1.01 to 1.50) and 1.95 (1.06 to 3.59) respectively, compared with stable students. Students with more than one temperament type had higher risk of death from: all causes, 2.05 (1.36 to 3.09); stroke, 3.26 (1.01 to 10.56); and cancer, 2.90 (1.62 to 5.20). Anxiety was positively associated with all cause and cancer mortality, respective hazard ratios: 1.36 (1.07 to 1.72) and 1.51 (1.04 to 2.20). Men labelled hypomanic had increased cardiovascular mortality risk, 1.90 (1.05 to 3.44).

CONCLUSIONS

Markers of early adult psychological distress are associated with increased mortality. Mechanisms underlying these associations require investigation.

Is maternal transmission of coronary heart disease risk stronger than paternal transmission?

OBJECTIVE

To test whether intergenerational transmission of coronary heart disease (CHD) to offspring is greater from the mother than from the father, the association between parental history of CHD and coronary mortality in male offspring was examined.

DESIGN

Prospective cohort study with 43 years of follow up.

SETTING

University of Glasgow.

PARTICIPANTS

Male students (n = 8402) aged 16-30 years when examined in 1948 to 1968.

MAIN OUTCOME MEASURE

Fatal CHD.

MAIN RESULTS

Of the 8402 men studied, 615 (7.3%) reported a history of CHD in at least one of the parents: 479 (5.8%) for fathers only, 124 (1.6%) for mothers only, and a further 12 (0.2%) for both their parents. During follow up, 373 (4.4%) men died of CHD. Parental history of disease was associated with fatal CHD and controlling for personal risk factors such as cigarette smoking, body mass index, systolic blood pressure, and father's social class did not attenuate this relation. The fully adjusted hazard ratios were 1.53 (95% confidence interval (CI) 1.08 to 2.18), 1.19 (95% CI 0.61 to 2.32), and 8.65 (95% CI 2.65 to 28.31) for father only, mother only, and both parents with CHD, respectively, compared with men whose parents did not have CHD. There was some evidence for interaction between parental histories (p = 0.049), with particularly high risk if both parents reported a history of CHD.

CONCLUSIONS

This study found no differential transmission of CHD. Paternal history of CHD was at least as important as maternal history. Data from other comparable cohorts provide no consistent evidence of differential transmission. Intergenerational transmission of CHD does not appear to have differential effects between mothers and fathers.

Associations of adult measures of childhood growth with breast cancer: findings from the British Women's Heart and Health Study

Since the two components of adult height - leg length and trunk length - are poorly correlated with each other and appear to be influenced by different early life factors, examining their separate influence on breast cancer may provide additional insights into the mechanisms responsible for the positive association between adult height and breast cancer. In a cross-sectional study of 4286 women aged 60-79 years, in whom there were 170 cases of breast cancer, we found total height, leg length and trunk length were all modestly positively and linearly associated with breast cancer. The magnitudes of the associations of leg and trunk length were similar: fully adjusted odds ratio (95% confidence interval) of breast cancer for a one standard deviation (s.d.) increase in leg length 1.17 (0.98, 1.39) and for a 1 s.d. increase in trunk length 1.19 (0.99, 1.41). Self-reported birth weight (available on 33% of the sample) was positively and linearly associated with breast cancer: fully adjusted odds ratio of breast cancer for a 1 s.d. increase in birth weight 1.30 (0.93, 1.80). These associations were all independent of each other and other potential confounding factors and are likely to reflect different mechanisms by which factors operating prenatally and prepubertally influence breast cancer risk.

Trends in body mass index from 1948 to 1968: results from the Glasgow Alumni Cohort

Most published studies suggest that the rising prevalence of overweight and obesity is a recent phenomenon. We have investigated whether secular trends in body mass index (BMI) existed in the 1950s and 1960s, using data collected from young adults attending Glasgow University. Mean BMI increased from 1948 to 1968 in men, and decreased slightly in women. The proportion of men who were overweight increased, whereas that of women changed little. These data must be interpreted in light of the fact that the study participants were relatively affluent, and not representative of the whole population in terms of socioeconomic position in childhood. The increases of BMI in men evident from 1948 to 1968 suggest that recent changes in exercise and dietary patterns do not fully explain changes in body weight over time.

Body mass index in young adulthood and cancer mortality: a retrospective cohort study

STUDY OBJECTIVE

To examine the relation between body mass index (BMI) in young adulthood and subsequent mortality from cancer.

DESIGN

Cohort study.

SETTING

University of Glasgow student health service. Weight and height were measured by a physician, and used to calculate BMI.

PARTICIPANTS

8335 men and 2340 women who attended the student health service while at university between 1948 and 1968, and who were followed up with the NHS central register.

MAIN RESULTS

The main outcome measure was cancer mortality. Three hundred and thirty nine men and 82 women died of cancer during the follow up (mean 41 years). BMI was associated with mortality from all cancers in men and women, although it did not reach conventional statistical significance. The adjusted hazard ratio (HR) (95% CI) per 5 kg/m(2), was 1.22 (0.97 to 1.53) in men and 1.43 (0.95 to 2.16) in women. Two hundred men and 61 women died from cancers not related to smoking. The adjusted HR for mortality from these were 1.36 (1.02 to 1.82) and 1.80 (1.13 to 2.86) respectively. These results are adjusted for height, number of siblings, pulse rate, year of birth, age, smoking, birth order, number of siblings, and age at menarche in women. Site specific analyses, comparing the highest with the lowest quartile of the BMI distribution found increased risks of prostate cancer (n=28) and breast cancer among heavier subjects. No association between BMI and colorectal cancer was found.

CONCLUSIONS

BMI in adolescence has lasting implications for risk of cancer mortality in later life. Future research will include measures of BMI throughout the lifecourse, to determine the period of greatest risk of obesity, in terms of cancer mortality.

Secular changes in blood pressure in childhood, adolescence and young adulthood: systematic review of trends from 1948 to 1998

One plausible reason for the decline in cardiovascular disease (CVD), and in particular stroke, in the last century is population reductions in blood pressure. Blood pressure tracks from childhood into adulthood, and early-life blood pressure is associated with increased cardiovascular risk but few studies have reported on blood pressure trends among young individuals who are free of CVD and not taking antihypertensive medication. Knowledge of such trends may improve understanding of the causes of hypertension and enhance prevention. We report that declines in blood pressure have been taking place in high-income countries in 5 to 34-year-olds of both sexes and from a range of ethnic groups for at least the last 50 years, indicating that exposures acting in early life are important determinants of blood pressure. Possible explanations for these favourable trends include improvements in early-life diet and there is also intriguing evidence suggesting that blood pressure may be programmed by sodium intake in infancy. Occurring throughout the blood pressure distribution, these trends may have made important contributions to declining CVD rates. There may therefore be scope for intervening in early life to prevent high blood pressure in adulthood, and the downward trends reported in several recent studies suggest that the prevalence of adult hypertension and cardiovascular risk will continue to decline. However, persisting high rates of CVD in the developed world, the impending CVD epidemic in developing countries, along with increasing childhood obesity, and the possibility that favourable blood pressure trends may be plateauing point to the need for enhanced measures to control blood pressure, and for further research to improve understanding of its determinants.

Changes in blood pressure among students attending Glasgow University between 1948 and 1968: analyses of cross sectional surveys

OBJECTIVES

To examine the changes in blood pressure over time in a cohort of young adults attending university between 1948 and 1968.

DESIGN

Cross sectional study.

SETTING

Glasgow University.

PARTICIPANTS

12 414 students aged 16-25 years-9248 men (mean age 19.9 years) and 3164 women (19.2 years)-who participated in health screening on entering university between 1948 and 1968.

MAIN OUTCOME MEASURES

Systolic and diastolic blood pressure.

RESULTS

In male students mean systolic blood pressure adjusted for age decreased from 134.5 (95% confidence interval 133.8 to 135.2) mm Hg in those born before 1929 to 125.7 (125.0 to 126.3) mm Hg in those born after 1945, and diastolic blood pressure dropped from 80.3 (79.8 to 80.8) mm Hg to 74.7 (74.2 to 75.1) mm Hg. For female students the corresponding declines were from 129.0 (127.5 to 130.5) mm Hg to 120.6 (119.8 to 121.4) mm Hg and from 79.7 (78.7 to 80.6) mm Hg to 77.0 (76.5 to 77.5) mm Hg. Adjustment for potential confounding factors made little difference to these findings. The proportion of students with hypertension declined substantially in both sexes.

CONCLUSIONS

Substantial declines in systolic and diastolic blood pressure over time were occurring up to 50 years ago in young adults who were not taking antihypertensive medication. Since blood pressure tracks into adult life, the results of the cross sectional comparisons suggest that factors acting in early life may be important in determining population risk of cardiovascular disease. Changes in such factors may have made important contributions to the decline in rates of cardiovascular diseases, particularly stroke, seen in developed countries during the past century.

Age at menarche: secular trends and association with adult anthropometric measures

BACKGROUND

Age at menarche has been used as a marker of environmental conditions during childhood. Previous work has shown trends of decreasing age at menarche throughout the 19th century, but reported trends in the 20th century have been less consistent. The nature of the relationship between age at menarche and adult life anthropometric measures may be important in understanding the importance of this measure on disease in later life.

AIM

To establish whether mean age at menarche changed during the first half of the 20th century, and to determine the nature of associations between age at menarche and anthropometric measures in young adulthood.

SUBJECTS AND METHODS

3433 female students, who were born between 1919 and 1952 and who attended health checks at the student health service of the University of Glasgow between 1948 and 1968.

RESULTS

Mean age at menarche decreased from 13.2 years in the earliest born to 12.5 years in the latest born students. These results were not explained by changes in socio-demographic factors. Menarcheal age was positively associated with height and negatively associated with weight and BMI, results independent of socio-demographic and behavioural factors.

CONCLUSIONS

The falling age at menarche described here may be related to nutritional influences in the first half of the 20th century. The influence of menarche on BMI in early adulthood may have important health consequences.

Height and cancer mortality: results from the Glasgow University student cohort

The aim of the study was to examine the association between height and cancer mortality in a socially homogeneous group of subjects. The study was based on a cohort of students, 8397 men and 2329 women, aged 16-30 y, who attended the University of Glasgow between 1948 and 1968. Mean follow-up time was 40 y. Height was measured at a medical examination performed at the student health service. The outcome measures used in the study were all-cause mortality and mortality from: all cancers, smoking and non-smoking related cancers and cancers related to sex hormones. No substantial or statistically significant associations were seen between height and all-cause or all-cancer mortality in either sex. Neither were any significant associations found between height and any of the sub-types of cancer studied (ie those related to smoking, those not related to smoking, and those related to sex hormones). Previous observations which have shown positive associations between height and cancer mortality have generally been based on populations with diverse social origins, among whom the variation in height will reflect variation in health and nutrition in childhood. The relatively low level of such variation in the present study may account for the negative findings. Public Health (2000) 114, 451-455

Blood pressure in young adulthood and mortality from cardiovascular disease

Blood pressure measured in young adult men is positively associated in later life with increased cardiovascular disease mortality. The implication of this finding is that risk of cardiovascular disease starts in early life.

Early social mixing and childhood Type 1 diabetes mellitus: a case-control study in Yorkshire, UK

AIMS

Evidence from animal models shows an increased risk of Type 1 diabetes mellitus associated with the absence of early life exposure to pathogens. To test this 'hygiene hypothesis', patterns of social mixing and infections in the first year of life and the risk of developing autoimmune diabetes in childhood were examined.

METHODS

Personal interviews were conducted with the mothers of 220 children with Type 1 diabetes (0-15 years) and 433 age/sex matched controls from a population-based case control study in Yorkshire, UK. Social mixing including attendance at daycare, and infections occurring under 1 year of age were measures of exposure. Adjusted odds ratios (OR) were derived using conditional logistic regression.

RESULTS

Frequency of attendance at daycare during the 1st year of life was inversely associated with childhood diabetes (OR 0.71, 95% confidence interval 0.51-1.00, P = 0.05), a finding not explained by mother's age, level of education or maternal diabetes. Increasing numbers of children in the daycare setting and numbers of sessions attended were significantly associated with increasing protection from diabetes. The strongest effect was observed in children with diabetes diagnosed aged 0-4 years.

CONCLUSIONS

Social mixing through attendance at daycare in early infancy appears to confer protection against the development of childhood diabetes. This may be mediated through exposure to infectious agent(s) as a significant dose-response effect was evident with increasing numbers of child 'contacts'. These findings suggest early infectious exposure may play a role in the development of immunoregulatory mechanisms which protect against diabetes and further work is warranted.

Determinants of adolescent blood pressure: findings from the Glasgow University student cohort

OBJECTIVE

To establish whether the blood pressure (BP) of young adults is related to their physical or behavioural attributes.

DESIGN

Cross-sectional study.

SUBJECTS

A total of 11,284 males and 3491 females who attended the University of Glasgow between 1948 and 1968.

OUTCOME MEASURES

Systolic and diastolic BP.

RESULTS

Body mass index (BMI) and weight were positively associated with BP in males and females. Height had a small positive association with male systolic BP and female diastolic BP. Haemoglobin levels were associated with raised BP in females. Albuminuria was associated with raised BP in males but not females. Smoking and alcohol consumption were associated with small negative effects on BP, although the measurement of alcohol consumption in the study was crude, and these results may not be free of confounding. Insufficient outdoor exercise was associated with higher BP in females but not males. No social class gradients in BP levels were seen, although having a higher number of siblings was associated with slightly lower BP in males.

CONCLUSION

The results from the current study indicate that modifiable risk factors, such as weight and exercise affect the BP of young adults. The impact of these factors, coupled with the known tracking of BP from adolescence to adulthood, emphasise the importance of healthy behaviour patterns in young people.

Life course exposure and later disease: a follow-up study based on medical examinations carried out in Glasgow University (1948-68)

Evidence for the relationship between exposures in fetal life, infancy, childhood and early adulthood, and risk of chronic disease in later middle-age continues to accumulate. Further understanding of the associations between exposures acting over the life course and current morbidity and mortality in middle-age and later must depend upon the follow-up of previously established cohorts. This paper describes the design of, and background to, a follow-up of individuals who participated in a survey of student health in the University of Glasgow between 1948 and 1968. 15 332 students, almost a quarter of whom were female, had detailed medical information collected from a doctor-administered questionnaire and physical examination. Participation was voluntary; approximately 50% of the student population took part and these students were rep-resentative of the entire student population. Data collected include: socio-demographic, behavioural, developmental, anthropometric, and clinical details, as well as details of medical history and family health and structure. Data are over 95% complete for most variables. Over 40% of students were examined on two or more occasions with 1026 students (6.8%) having four or more examinations. Over 90% of students were from social classes I-III. Eighty-two per cent (12 533/15 322) of the students have been traced and flagged through the National Health Service Central Register and attempts are on-going to increase this figure. Those study members who have been traced are representative of the original cohort. To date 1111 (7.2%) of those traced have died. These data constitute a unique record of the health and physical development of a large cohort of students from Glasgow. Follow-up to investigate the relationship between indices of health and development, (height, weight, blood pressure), health behaviours and social circumstances in childhood and young adulthood, and mortality and morbidity in later adulthood is under way.