Unsuccessful validation of 2004 model for predicting academic or behavioural limitations after childhood bacterial meningitis.

AIM: In 2004, a model identifying children at risk of academic or behavioural limitations after bacterial meningitis (BM) was presented. Risk factors were male gender, low birthweight, lower educational level of the father, Streptococcus pneumoniae, lower cerebrospinal fluid (CSF) leucocyte count, delay between admission and start of antibiotics, dexamethasone <2 days, seizures and prolonged fever. The aim of this study was to validate that prediction model in an independent cohort. METHODS: Academic or behavioural limitations were determined in 93 Dutch school-age BM survivors. Risk factors for limitations were obtained from medical files. Validation was performed by applying the model in the cohort, then assessing discrimination and goodness of fit. Multiple imputation techniques were used to deal with missing values. RESULTS: Although fit of the model appeared good when it came to similarity of expected and observed cases (p-value of the Hosmer-Lemeshow test 0.24-0.57), discrimination was poor. Area under the curve (AUC) of the receiver operated characteristics (ROC) curve of the model was 0.83 (95% CI: 0.77-0.89) in the development cohort and 0.53 (95% CI: 0.41-0.65) in the validation cohort. CONCLUSION: External validation of the model was unsuccessful. It is not suitable for implementation in practice.

Prediction of academic and behavioural limitations in school-age survivors of bacterial meningitis.

AIM: To develop a prediction rule to identify postmeningitic children at high risk of academic and behavioural limitations. METHODS: 182 children (mean age 10 y; range 5-14) were selected from a cohort of 674 school-age survivors of bacterial meningitis. These children had neither meningitis with "complex onset", nor prior cognitive or behavioural problems, nor severe disease sequelae. On average, 7 y after the meningitis, they were evaluated using an "Academic Achievement Test", and their parents filled in the "Child Behaviour Checklist". By reviewing the medical records, potential risk factors for academic and/or behavioural limitations were collected. Independent predictors were identified using multivariate logistic regression analysis, leading to the formulation of a prediction rule. RESULTS: The cumulative incidence of academic and/or behavioural limitations among children who survived bacterial meningitis without severe disease sequelae was 32%. The prediction rule was based on nine independent risk factors: gender, birthweight, educational level of the father, S. pneumoniae, cerebrospinal fluid leukocyte count, delay between admission and start of antibiotics, dexamethasone use, seizures treated with anticonvulsive therapy, and prolonged fever. When 10 was taken as a cut-off point for the risk score computed using this rule, 76% of the children with limitations could be identified, while 38% of the children in the cohort were selected as at risk for these limitations. CONCLUSION: With a prediction rule based on nine risk factors, postmeningitic children at high risk of developing academic and/or behavioural limitations could be identified. Additional research is required to further validate this prediction rule. In the future, a careful follow-up of high risk children may enhance early detection and treatment of these limitations.

Parental perception of educational, behavioural and general health problems in school-age survivors of bacterial meningitis.

AIM: To determine the occurrence of educational, behavioural and general health problems in Dutch school-age survivors of bacterial meningitis. METHODS: A cohort of 680 school-age survivors of meningitis caused by the most common Gram-positive and Gram-negative bacteria was established approximately 6y after the children's illness. Children with Haemophilus influenzae type b (Hib) meningitis were excluded because this form of the disease has virtually disappeared. Parents completed questionnaires on educational, behavioural and general health problems. The reference group comprised 304 school-age siblings and peers. RESULTS: Postmeningitic children were more likely than controls to under achieve at school: 20% vs 5% (odds ratio 5.6; 95% confidence interval 3.0-10.7). The postmeningitic children repeated a year twice as often as the children in the reference group (16% vs 8%, odds ratio: 2.5, 95% confidence interval 1.5-4.2) and were referred to a special-needs school four times more frequently (8% vs 2%, odds ratio: 5.5; 95% confidence interval 2.0-15.4). Parents also reported more behavioural problems at home. More than half of the postmeningitic children experienced general health problems. The causative pathogen or age at infection had no influence on the relative frequency of educational and behavioural problems, and reduced auditory functioning played only a small part in these problems. CONCLUSION: Parents perceive educational, behavioural and general health problems in more than 30% of postmeningitic children. Until it is clear which children are at highest risk of developing these problems, it will be necessary to follow postmeningitic children into their school-age years.

[Postmenopausal hormone replacement therapy and cancer of the female genitalia and breast]. / Postmenopauzale hormonale suppletietherapie en kanker van de vrouwelijke geslachtsorganen en de mamma.

Oestrogen replacement therapy (ORT) significantly increases the relative risk (RR) of endometrial cancer, especially long-term oestrogen use (RR: 9.5; 95% confidence interval (CI): 7.4-12.3). Addition of a progestin to ORT reduces this increased risk completely or largely. The risk of breast cancer is increased after ORT of 5 years or longer (RR: 1.23; 95% CI: 1.08-1.40). Addition of a progestin does not reduce this increased risk. The possibility cannot be excluded that long-term ORT increases the risk of epithelial ovarian cancer. No significant association between ORT and cervical cancer has been demonstrated. It is safe to prescribe ORT for a period shorter than 5 years for women with menopausal symptoms. Addition of a progestin is indicated when the uterus is in situ. Hormonal supplementation therapy is to be discouraged in women treated for breast cancer, may be considered in young women previously treated for endometrial or ovarian cancer with a good prognosis and severe menopausal symptoms and is justified in women previously treated for cervical cancer.