The diagnosis, treatment and prevention of CAPD peritonitis

Introduced in 1976, continuous ambulatory peritoneal dialysis (CAPD) is an effective and increasingly popular form of long-term dialysis. Infective peritonitis is its main drawback. This can be caused by a wide variety of micro-organisms, but usually by bacteria from the skin or gut. The commonest and most troublesome causative organism is the coagulase-negative staphylococcus. Although improvements in methods of diagnosis, treatment and prevention were made during the first five years of its use, CAPD continued to be plagued by peritonitis in most centres.This study was carried out between 1982 and 1984 in the Queen Elizabeth Hospital, Birmingham. A CAPD service began there in 1981 and peritonitis quickly became the main threat to its success. It was soon evident that the methods then in use for the microbiological diagnosis of CAPD peritonitis were inadequate. A simple method of culture was developed which greatly increased the chances of a positive microbiological diagnosis. This method became the cornerstone of a more effective and economical laboratory service to the CAPD progranme.The antibiotic sensitivities of organisms causing CAPD peritonitis were studied with the aim of establishing a more effective initial treatment policy. Vancomycin was found to be the most consistently active of the antibiotics tested against Gram positive isolates in general and the coagulase-negative staphylococcus in particular. Aminoglycosides were the most consistently active against Gram negative isolates. A trial of intra-peritoneal vancomycin and tobramycin showed that this combination was much more effective in the initial treatment of CAPD peritonitis than cefuroxime, previously the antibiotic of first choice. However, potentially ototoxic levels of tobramycin were encountered.With the aim of making initial treatment both simpler and safer, a modified protocol involving once-daily intra-peritoneal vancomycin and gentamicin was developed. One hundred episodes of CAPD peritonitis were treated, of which 88 were cured without recourse to other antibiotics. This study showed for the first time that most episodes of CAPD peritonitis could be safely treated at home using intra-peritoneal antibiotics self-administered oncedaily. The problem of aminoglycoside toxicity was not solved, however.Many episodes of CAPD peritonitis follow contamination of the administration set with organisms on the patient's hands. Contamination usually occurs during the dialysate exchange procedure. We studied how effectively bacteria were removed from the patients' hands by washing with povidone iodine detergent or 70% ethyl alcohol. Surprisingly, povidone iodine was often found to be counter-productive. Ethyl alcohol was much more effective and convenient.Despite improvements in the diagnosis and treatment of CAPD peritonitis, its incidence at the Queen Elizabeth Hospital has recently increased. This may in part be due to a steady decline in the amount of time staff can devote to training and supervising individual patients: staffing of the programme has failed to keep pace with the rapid rise in patient numbers. The thesis ends with a review of a variety of recently developed techniques and strategies which aim to prevent CAPD peritonitis

Cause specific mortality, social position, and obesity among women who had never smoked: 28 year cohort study

Objective To investigate the relations between causes of death, social position, and obesity in women who had never smoked

Comparison of drug use and psychiatric morbidity between prostitute and non-prostitute female drug users in Glasgow, Scotland

Aims: To compare psychiatric morbidity between 176 female drug users with lifetime involvement in prostitution (prostitutes) and 89 female drug users with no involvement (non-prostitutes) in Glasgow, Scotland. Method: The Revised Clinical Interview Schedule (CIS-R) measured current neurotic symptoms. Results: Prostitutes were more likely to report adult physical (OR 1.8) or sexual abuse (OR 2.4), to have attempted suicide (OR 1.7) and to meet criteria for current depressive ideas (OR 1.8) than non-prostitutes. Seventy-two percent of prostitutes and sixty-seven percent of non-prostitutes met criteria for a level of current neurotic symptoms likely to need treatment (CIS-R ≥18). Being in foster care (OR 8.9), being prescribed medication for emotional problems in the last 30 days (OR 7.7), adult sexual abuse (OR 4.5), poly drug use in the last 30 days (OR 3.6) and adult physical abuse (OR 2.6) were significantly associated with a CIS-R score of ≥18 for prostitutes using multiple logistic regression. Conclusions: Higher rates of adulthood abuse among prostitutes may explain the greater proportion of prostitutes than non-prostitutes meeting criteria for current depressive ideas and lifetime suicide attempts

Does smoking reduction in midlife reduce mortality risk? Results of 2 long-term prospective cohort studies of men and women in Scotland

A long-term cohort study of working men in Israel found that smokers who reduced their cigarette consumption had lower subsequent mortality rates than those who did not. We conducted comparable analyses in 2 populations of smokers in Scotland. The Collaborative Study included 1,524 men and women aged 40–65 years in a working population who were screened twice, in 1970–1973 and 1977. The Renfrew/Paisley Study included 3,730 men and women aged 45–64 years in a general population who were screened twice, in 1972–1976 and 1977–1979. Both groups were followed up through 2010. Subjects were categorized by smoking intensity at each screening as smoking 0, 1–10, 11–20, or ≥21 cigarettes per day. At the second screening, subjects were categorized as having increased, maintained, or reduced their smoking intensity or as having quit smoking between the first and second screenings. There was no evidence of lower mortality in all reducers compared with maintainers. Multivariate adjusted hazard ratios of mortality were 0.91 (95% confidence interval (CI): 0.75, 1.10) in the Collaborative Study and 1.08 (95% CI: 0.97, 1.20) in the Renfrew/Paisley Study. There was clear evidence of lower mortality among quitters in both the Collaborative Study (hazard ratio = 0.66, 95% CI: 0.56, 0.78) and the Renfrew/Paisley Study (hazard ratio = 0.75, 95% CI: 0.67, 0.84). In the Collaborative Study only, we observed lower mortality similar to that of quitters among heavy smokers (≥21 cigarettes/day) who reduced their smoking intensity. These inconclusive results support the view that reducing cigarette consumption should not be promoted as a means of reducing mortality, although it may have a valuable role as a step toward smoking cessation

Ethnic variations in falls and road traffic injuries resulting in hospitalisation or death in Scotland: the Scottish Health and Ethnicity Linkage Study (SHELS) Public Health

Objectives: To investigate ethnic differences in falls and road traffic injuries (RTIs) in Scotland. Study design: A retrospective cohort of 4.62 million people, linking the Scottish Census 2001, with self-reported ethnicity, to hospitalisation and death records for 2001–2013. Methods: We selected cases with International Classification of Diseases–10 diagnostic codes for falls and RTIs. Using Poisson regression, age-adjusted risk ratios (RRs, multiplied by 100 as percentages) and 95% confidence intervals (CIs) were calculated by sex for 10 ethnic groups with the White Scottish as reference. We further adjusted for country of birth and socio-economic status (SES). Results: During about 49 million person-years, there were 275,995 hospitalisations or deaths from fall-related injuries and 43,875 from RTIs. Compared with the White Scottish, RRs for falls were higher in most White and Mixed groups, e.g., White Irish males (RR: 131; 95% CI: 122–140) and Mixed females (126; 112–143), but lower in Pakistani males (72; 64–81) and females (72; 63–82) and African females (79; 63–99). For RTIs, RRs were higher in other White British males (161; 147–176) and females (156; 138–176) and other White males (119; 104–137) and females (143; 121–169) and lower in Pakistani females (74; 57–98). The ethnic variations differed by road user type, with few cases among non-White motorcyclists and non-White female cyclists. The RRs were minimally altered by adjustment for country of birth or SES. Conclusion: We found important ethnic variations in injuries owing to falls and RTIs, with generally lower risks in non-White groups. Culturally related differences in behaviour offer the most plausible explanation, including variations in alcohol use. The findings do not point to the need for new interventions in Scotland at present. However, as the ethnic mix of each country is unique, other countries could benefit from similar data linkage-based research

Differences in all-cause hospitalisation by ethnic group: a data linkage cohort study of 4.62 million people in Scotland, 2001–2013

Background: Immigration into Europe has raised contrasting concerns about increased pressure on health services and equitable provision of healthcare to immigrants /ethnic minorities. We assessed hospital use by ethnic group in Scotland. Methods: We anonymously linked Scotland?s Census 2001 records for 4.62 million people, including their ethnic group, to National Health Service general hospitalisation records for 2001-2013. We used Poisson regression to calculate hospitalisation rate ratios (RRs) in 14 ethnic groups, presented as percentages of the White Scottish reference group (RR=100), for males and females separately. We adjusted for age and socio-economic status and compared those born in the United Kingdom or the Republic of Ireland (UK/RoI) with elsewhere. We calculated mean lengths of hospital stay. Results: 9,789,975 hospital admissions were analysed. Compared to the White Scottish, unadjusted RRs for both males and females in most groups were about 50-90, e.g. Chinese males 49 (95% CI 45-53) and Indian females 76 (71-81). The exceptions were White Irish males, 120 (117-124) and females 115 (112-119) and Caribbean females, 103 (85-126). Adjusting for age increased the RRs for most groups towards or above the reference. Socio-economic status had little effect. In many groups, those born outside the UK/RoI had lower admission rates. Unadjusted mean lengths of stay were substantially lower in most ethnic minorities. Conclusions: Use of hospital beds in Scotland by most ethnic minorities was lower than by the White Scottish majority, largely explained by their younger average age. Other countries should use similar methods to assess their own experiences