David Taylor-Robinson

Suicides associated with the 2008-10 economic recession in England: time trend analysis

Objective To determine whether English regions worst affected by the economic recession in the United Kingdom in 2008-10 have had the greatest increases in suicides. Design Time trend analysis comparing the actual number of suicides with those that would be expected if pre-recession trends had continued. Multivariate regression models quantified the association between changes in unemployment (based on claimant data) and suicides (based on data from the National Clinical Health Outcomes Database). Setting 93 English regions, based on the Nomenclature of Territorial Units Statistics level 3 groupings of local authorities at county level and groups of unitary local authorities. Participants Men and women with a record of death from suicide or injury of undetermined cause in 2000-10. Main outcome measure Number of excess suicides during the economic recession (2008-10). Results Between 2008 and 2010, we found 846 (95% confidence interval 818 to 877) more suicides among men than would have been expected based on historical trends, and 155 (121 to 189) more suicides among women. Historically, short term yearly fluctuations in unemployment have been associated with annual changes in suicides among men but not among women. We estimated that each 10% increase in the number of unemployed men was significantly associated with a 1.4% (0.5% to 2.3%) increase in male suicides. These findings suggest that about two fifths of the recent increase in suicides among men (increase of 329 suicides, 126 to 532) during the 2008-10 recession can be attributed to rising unemployment. Conclusion The study provides evidence linking the recent increase in suicides in England with the financial crisis that began in 2008. English regions with the largest rises in unemployment have had the largest increases in suicides, particularly among men.

Detection and widespread distribution of Chlamydia pneumoniae in the vascular system and its possible implications.

AIMS: To attempt to detect Chlamydia pneumoniae DNA in atheromatous vascular tissue. METHODS: A modification of an existing polymerase chain reaction (PCR) assay and immunofluorescence staining with a monoclonal antibody directed against C pneumoniae were used to detect C pneumoniae. Specimens from 32 patients undergoing abdominal aortic aneurysm repair were examined. Vascular tissue, ostensibly normal, from six liver transplant donors was also examined for comparison. Altogether, 43 vessels from these 38 subjects (age range 36-85 years) were examined. RESULTS: C pneumoniae was detected in 11 (44%) of 25 aortas, five (55%) of nine iliac arteries, two (40%) of five femoral arteries, and one of two iliac veins. Immunofluorescence staining supported positive PCR results in three of 12 cases in which it was used. Overall, C pneumoniae was detected in the arteries of 14 (44%) of the patients undergoing vascular surgery and three (50%) of the donors. CONCLUSIONS: This study is the first in the UK in which C pneumoniae organisms have been found in atherosclerotic vessels and the tendency for the organisms to be present most often in such vessels exhibiting chronic inflammatory changes suggests that a search for them in various forms of arteritis may also be rewarding.

Association of Mycoplasma genitalium with acute non-gonococcal urethritis

Chlamydia trachomatis is known to be a cause of acute non-gonococcal urethritis (NGU), though the aetiology of this disorder is not fully understood. Mycoplasma genitalium has been isolated from a few men with NGU, but culture has remained difficult and reliable detection became possible only with a specific polymerase chain reaction (PCR). We have used the PCR to examine the role of M genitalium in NGU. M genitalium was detected in urethral samples from 24 (23%) of 103 men with symptoms, signs, or both, of acute NGU, but from only 3 (6%) of 53 men without NGU (p < 0.006). This association was independent of the presence of C trachomatis and could not be explained by differences in age, ethnic, origin, lifetime number of sexual partners or a change in sexual partner during the previous 3 months. The clinical response of the mycoplasma-positive men to doxycycline treatment was at least as satisfactory as that of the chlamydia-positive men. These findings suggest that the association of M genitalium with NGU is likely to be causal, a notion consistent with the known virulence characteristics of this microorganism and its ability to cause urethritis in male sub-human primates.

A longitudinal study of the vaginal flora over a menstrual cycle

Healthy female volunteers participated in an anonymous study to monitor vaginal flora by taking daily vaginal samples and making a smear for later Gram-staining, as well as recording information on genital symptoms, sexual activity, contraceptive and bathing practices. A modification of Spiegels criteria was used to categorize the Gram-stained smears, an intermediate category between normal flora and bacterial vaginosis (BV) being recognized. Of the 22 volunteers who completed the study, one was excluded because of pregnancy. Of the remaining 21 women, 10 (48%) had a normal flora throughout the study, 4 (19%) had an abnormal flora throughout and 7 (33%) had a basically normal flora which underwent a change to either an intermediate flora in 5 women or fully developed BV in 2 of them. In 5 (71%) of these women the change occurred within the first 9 days of the cycle. Transient changes in the vaginal microbial flora occurred predominantly in the first part of the menstrual cycle which suggests that in some women hormonal changes could have a role in the pathogenesis of bacterial vaginosis.

Understanding the natural progression in %FEV1 decline in patients with cystic fibrosis: a longitudinal study

Background Forced expiratory volume in 1 s as a percentage of predicted (%FEV1) is a key outcome in cystic fibrosis (CF) and other lung diseases. As people with CF survive for longer periods, new methods are required to understand the way %FEV1 changes over time. An up to date approach for longitudinal modelling of %FEV1 is presented and applied to a unique CF dataset to demonstrate its utility at the clinical and population level. Methods and findings The Danish CF register contains 70 448 %FEV1 measures on 479 patients seen monthly between 1969 and 2010. The variability in the data is partitioned into three components (between patient, within patient and measurement error) using the empirical variogram. Then a linear mixed effects model is developed to explore factors influencing %FEV1 in this population. Lung function measures are correlated for over 15 years. A baseline %FEV1 value explains 63% of the variability in %FEV1 at 1 year, 40% at 3 years, and about 30% at 5 years. The model output smooths out the short-term variability in %FEV1 (SD 6.3%), aiding clinical interpretation of changes in %FEV1. At the population level significant effects of birth cohort, pancreatic status and Pseudomonas aeruginosa infection status on %FEV1 are shown over time. Conclusions This approach provides a more realistic estimate of the %FEV1 trajectory of people with chronic lung disease by acknowledging the imprecision in individual measurements and the correlation structure of repeated measurements on the same individual over time. This method has applications for clinicians in assessing prognosis and the need for treatment intensification, and for use in clinical trials.

Austerity, sanctions, and the rise of food banks in the UK

Doctors are witnessing increasing numbers of patients seeking referrals to food banks in the United Kingdom. Rachel Loopstra and colleagues ask, is this due to supply or demand?

Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact.

Background: Interventions to promote healthy eating make a potentially powerful contribution to the primary prevention of non communicable diseases. It is not known whether healthy eating interventions are equally effective among all sections of the population, nor whether they narrow or widen the health gap between rich and poor. We undertook a systematic review of interventions to promote healthy eating to identify whether impacts differ by socioeconomic position (SEP). Methods: We searched five bibliographic databases using a pre-piloted search strategy. Retrieved articles were screened independently by two reviewers. Healthier diets were defined as the reduced intake of salt, sugar, trans-fats, saturated fat, total fat, or total calories, or increased consumption of fruit, vegetables and wholegrain. Studies were only included if quantitative results were presented by a measure of SEP. Extracted data were categorised with a modified version of the “4Ps” marketing mix, expanded to 6 “Ps”: “Price, Place, Product, Prescriptive, Promotion, and Person”. Results: Our search identified 31,887 articles. Following screening, 36 studies were included: 18 “Price” interventions, 6 “Place” interventions, 1 “Product” intervention, zero “Prescriptive” interventions, 4 “Promotion” interventions, and 18 “Person” interventions. “Price” interventions were most effective in groups with lower SEP, and may therefore appear likely to reduce inequalities. All interventions that combined taxes and subsidies consistently decreased inequalities. Conversely, interventions categorised as “Person” had a greater impact with increasing SEP, and may therefore appear likely to reduce inequalities. All four dietary counselling interventions appear likely to widen inequalities. We did not find any “Prescriptive” interventions and only one “Product” intervention that presented differential results and had no impact by SEP. More “Place” interventions were identified and none of these interventions were judged as likely to widen inequalities. Conclusions: Interventions categorised by a “6 Ps” framework show differential effects on healthy eating outcomes by SEP. “Upstream” interventions categorised as “Price” appeared to decrease inequalities, and “downstream” “Person” interventions, especially dietary counselling seemed to increase inequalities. However the vast majority of studies identified did not explore differential effects by SEP. Interventions aimed at improving population health should be routinely evaluated for differential socioeconomic impact.

Chlamydia pneumoniae in atheroma: consideration of criteria for causality.

AIMS: (1) To seek evidence of the existence of Chlamydia pneumoniae in a spectrum of atheromatous lesions in different types of arteries from individuals of different ages, using a polymerase chain reaction (PCR) assay supported by electron microscopy and immunocytochemistry; (2) to use electron microscopy to examine interactions between C pneumoniae and the cells present in the arterial tissue; (3) to assess the extent to which the data fulfil the criteria for causality. METHODS: At necropsy examination, 35 arterial specimens were taken from 25 subjects. The grade of atheroma was determined macroscopically and microscopically and the tissues coded and examined by the three techniques. RESULTS: Of the 35 specimens, 24 had macroscopic or microscopic atheromatous lesions of varying degree. Twenty two of the 35 specimens were examined by electron microscopy, C pneumoniae-like bodies being found in 11 (50%); seven specimens were examined by the immunocytochemical method, positive staining being detected in three; and all specimens were examined by the PCR technique, 15 (43%) being PCR positive. Overall, of the 24 specimens with lesions, 17 (71%) were positive by at least one of the three tests, whereas of the 11 specimens without lesions, only one was positive. The positive specimens comprised 10 of 19 aortas, three of six iliac arteries, and one coronary and one pulmonary artery. C pneumoniae was detected in four of six specimens in which there were early changes and in a 20 year old subject. Concerning the 25 subjects, of 17 who had atheromatous arteries, 14 (82%) were C pneumoniae positive and of the eight who had normal arteries, none was positive. CONCLUSIONS: There is a strong correlation between C pneumoniae and arterial atheromatous lesions. The organism may contribute to the disease process by damaging smooth muscle cells.

Sensitivity of detecting Chlamydia trachomatis elementary bodies in smears by use of a fluorescein labelled monoclonal antibody: comparison with conventional chlamydial isolation.

Commercially produced fluorescein labelled monoclonal antibodies for the detection of Chlamydia trachomatis have recently become available. One is for detecting inclusions in cell culture (culture confirmation) and the other for detecting elementary bodies in smears from potentially infected sites. We have compared the two monoclonal antibodies with our routine isolation method, which utilises Giemsa staining of cycloheximide treated McCoy cell cultures. The culture confirmation system offered no advantages over Giemsa staining for the detection of inclusions in cell monolayers. By contrast, using monoclonal antibody to detect elementary bodies in smears was much quicker and simpler and slightly more sensitive than isolation of chlamydiae in cell culture. For specimens from seven babies with conjunctivitis and from 35 female contacts of men with non-gonococcal urethritis, there was complete agreement between the results of detecting inclusions in culture and those of seeking elementary bodies in smears. For samples from 100 men with non-gonococcal urethritis and from 100 men with gonorrhoea there was 99% and 94% agreement, respectively, between the results of the two tests. Other aspects and possible uses of the new detection system are discussed.

Evaluation of enzyme immunoassay (Chlamydiazyme) for detecting Chlamydia trachomatis in genital tract specimens.

An enzyme immunoassay (Chlamydiazyme) for detecting Chlamydia trachomatis was evaluated on genital specimens from 96 men and 272 women attending a clinic for sexually transmitted diseases (STD clinic). Compared with a direct immunofluorescence test for chlamydial elementary bodies, the enzyme immunoassay had a sensitivity of 58% on specimens from men, a specificity of 90%, a positive predictive value of 93%, and a negative predictive value of 88%; the assay had a sensitivity of 67% on specimens from women, a specificity of 89%, a positive predictive value of 63% and a negative predictive value of 90%. Immunofluorescence provided the most stringent test for the performance of the enzyme immunoassay as values were improved a little when a cell culture procedure was used for comparison. Further evidence for the lack of sensitivity was the detection of elementary bodies, sometimes in large numbers, in the enzyme immunoassay buffer of 13 of 19 specimens that had given a negative enzyme immunoassay result and the finding in comparative titrations of four laboratory strains that the enzyme immunoassay was at least 100-fold less able to detect chlamydiae than either immunofluorescence or the cell culture procedure. Lack of specificity may be associated with the finding that the enzyme immunoassay antibody reacted with strains of Acinetobacter calcoaceticus, Escherichia coli, Gardnerella vaginalis, Neisseria gonorrhoeae and group B streptococci. The enzyme immunoassay was not considered to be sufficiently sensitive, specific, or reproducible for routine use.