Increases in 'deaths of despair' during the COVID-19 pandemic in the United States and the United Kingdom.

OBJECTIVES: The COVID-19 pandemic significantly impacted mental health, health-related behaviours such as drinking and illicit drug use and the accessibility of health and social care services. How these pandemic shocks affected 'despair'-related mortality in different countries is less clear. This study uses public data to compare deaths from alcohol, drugs and suicide in the United States and the United Kingdom to identify similarities or differences in the impact of the pandemic on important non-COVID causes of death across countries and to consider the public health implications of these trends. STUDY DESIGN AND METHODS: Data were taken from publicly available mortality figures for England and Wales, Northern Ireland, Scotland and the United States of America, 2001-2021, and analysed descriptively through age-standardised and age-specific mortality rates from suicide, alcohol and drug use. RESULTS: Alcohol-specific deaths increased in all countries between 2019 and 2021, most notably in the United States and, to a lesser extent, England and Wales. Suicide rates did not increase markedly during the pandemic in any of the included nations. Drug-related mortality rates rose dramatically over the same period in the United States but not in other nations. CONCLUSIONS: Mortality from 'deaths of despair' during the pandemic has displayed divergent trends between causes and countries. Concerns about increases in deaths by suicide appear to have been unfounded, whereas deaths due to alcohol have risen across the United Kingdom and in the United States and across almost all age groups. Scotland and the United States had similarly high levels of drug-related deaths pre-pandemic, but the differing trends during the pandemic highlight the different underlying causes of these drug death epidemics and the importance of tailoring policy responses to these specific contexts.

The impact of pathogen burden on leukocyte telomere length in the Multi-Ethnic Study of Atherosclerosis.

Several infections have been linked to telomere shortening and in some cases these associations have varied by sex. We assessed the association between seropositivity to four persistent pathogens (cytomegalovirus (CMV), herpes simplex virus-1, Helicobacter pylori, Chlamydia pneumoniae), and total pathogen burden on leukocyte telomere length in a diverse US sample. Data came from the Multi-Ethnic Study of Atherosclerosis, a population-based cohort study. We utilized cross-sectional survey data, and biological samples from participants tested for pathogens and telomere length (N = 163). Linear regression was used to examine the association between seropositivity for individual pathogens as well as total pathogen burden and telomere length, adjusting for various confounders. CMV seropositivity and increased total pathogen burden level were significantly associated with shorter telomere length among females (ß = -0·1204 (standard error (s.e.) 0·06), P = 0·044) and (ß = -0·1057 (s.e. = 0·05), P = 0·033), respectively. There was no statistically significant association among males. Our findings suggest that prevention or treatment of persistent pathogens, in particular CMV, may play an important role in reducing telomere shortening over the life course among women. Future research is needed to confirm these novel findings in larger longitudinal samples.

Unpacking the 'black box' of total pathogen burden: is number or type of pathogens most predictive of all-cause mortality in the United States?

A 'black box' paradigm has prevailed in which researchers have focused on the association between the total number of pathogens for which individuals are seropositive (i.e. total pathogen burden) and various chronic diseases, while largely ignoring the role that seropositivity for specific combinations of pathogens may play in the aetiology of such outcomes and consequently mortality. We examined the association between total pathogen burden as well as specific pathogen combinations and all-cause mortality in the United States. Data were from individuals aged ⩾25 years tested for cytomegalovirus (CMV), herpes simplex virus (HSV)-1, HSV-2 and Helicobacter pylori, with mortality follow-up to 31 December 2006 in the National Health and Nutrition Examination Survey (NHANES) III (N = 6522). We did not observe a statistically significant graded relationship between total pathogen burden level and all-cause mortality. Furthermore, compared to those seronegative for all four pathogens, the greatest statistically significant rate of all-cause mortality was for those CMV+/HSV-2+ (hazard ratio 1·95, 95% confidence interval 1·13-3·35) adjusting for age, gender, race/ethnicity, education level, body mass index (kg/m2) and smoking status. Interventions targeting prevention or treatment of particular pathogens may be more effective for reducing mortality than those focused solely on reducing overall pathogen burden.

Long-term obesity and physical functioning in older Americans.

BACKGROUND: Americans are becoming obese earlier in their lives, increasing the average exposure to obesity. Nonetheless, the impact of long-term obesity on later life functioning is not well known. METHODS: We analyzed data from 7258 adults aged 60-79 years from the US 1999-2010 National Health and Nutrition Examination Survey. Respondents were defined as limited if they reported 'some difficulty' 'much difficulty' or 'unable to do' any of the eight functional tasks. Respondents were defined as severely limited if they reported 'much difficulty' or 'unable to do' any task. Generalized regression models (logistic and Poisson) predicted the relative odds of any limitation, severe limitation, the total number of limitations and each individual limitation as a function of body mass index (BMI) at age 25 years and current BMI. Models were adjusted for age, sex, race/ethnicity and level of education. RESULTS: Overall, being overweight or obese at age 25 years was associated with higher odds of being functionally limited, but these associations were greatly diminished or eliminated after adjustment for current BMI. For example, those obese at age 25 years had 2.38 times the odds (95% confidence interval (CI): 1.77, 3.20) of reporting any functional limitations compared with those normal weight at 25 years, but only 1.28 times the odds (95% CI: 0.93, 1.76) after adjustment for current BMI. For severe limitations, the corresponding results were 2.72 (95% CI: 2.13-3.46) and 1.32 (95% CI:1.00-1.75) before and after adjustment for current BMI. Some associations between obesity at age 25 years and individual tasks remained significant after adjustment for current BMI. CONCLUSIONS: We conclude that long-term overweight/obesity are significantly associated with later life functional limitations, though this is largely explained by their strong association with higher levels of later-life BMI. Prevention of additional weight gain for those who are overweight or obese early in life could help mitigate their risk of future loss of functioning.

Socioeconomic disparities in the seroprevalence of cytomegalovirus infection in the US population: NHANES III.

There is a strong relationship between socioeconomic status (SES) and health outcomes in the United States, although the mechanisms are poorly understood. Increasing evidence points to links between lifelong exposure to infectious disease and subsequent chronic disease. Exposure and susceptibility to infections may be one way SES affects long-term health, although little population-based research to date has examined social patterning of infections in the United States. This paper tests the relationship between income, education, race/ethnicity and seroprevalence of cytomegalovirus (CMV) infection at different ages in a representative sample of the US population, and tests potential mediators for these relationships. The study finds significant racial and socioeconomic disparities in CMV seroprevalence beginning at early ages and persisting into middle age. Potential exposures do not explain the relationship between SES and CMV positivity. Because reactivation of latent CMV infections may contribute to chronic disease and immune decline later in life, future research should determine the exposure or susceptibility pathways responsible for these disparities in the prevalence of CMV infection.

Measuring patient satisfaction: a case study.

Health care providers are under tremendous pressure to meet consumer demands in order to compete in the rapidly changing health care arena. Through evaluating patient satisfaction, health care providers can learn what the consumer wants from the health care system. This article informs the reader of issues surrounding patient satisfaction data collection instruments, especially the problem of lack of standardization. That is, each instrument measures satisfaction according to different standards. This article presents a case study analysis of one patient satisfaction data collection instrument entitled the Picker-Commonwealth Survey on Patient-Centered Care. Suggestions for revision and further work are addressed.

Acute pyelonephritis after transrectal ultrasonographically guided biopsy of the prostate: diagnosis by computed tomography.

Acute pyelonephritis developed in a 67-yr-old man after transrectal ultrasonographically guided biopsy of the prostate. The clinical presentation and results of excretory urography were nondiagnostic. Diagnosis was made by computed tomography, which was delayed 12 h after i.v. administration of contrast medium.

Surgical treatment of prostatic hyperplasia.

BACKGROUND: For more than seven decades prostates have been enucleated surgically, and for almost six decades they have been resected endoscopically. Results have been impressive and increasingly better, and the procedure has been reasonably safe. Variations to these two approaches have abounded and have made it safer, quicker, and easier, but never cheaper. METHODS: Currently, an abundance of alternatives have surfaced and for a variety of reasons. All alternatives share several shortcomings: results are not predictable, there is no tissue, and serendipitous prostate cancer could be missed. In addition, it may be categorically said that rarely does any of the alternatives achieve the effectiveness of prostatectomy that is appropriately indicated and properly performed. RESULTS: Urologists should participate in an objective assessment of the comparative merits and deficiencies of the variations of and alternatives to prostatectomy. Assessment of outcomes, safety, efficacy, and cost, as well as the development of guidelines, should continue. CONCLUSIONS: With our counsel and the government's reimbursement, the public will decide which alternatives are safe and reasonably effective and should survive.

Is the neodymium:YAG laser effective therapy for invasive bladder cancer?

The neodymium:YAG (yttrium-aluminum-garnet) laser can cause transmural coagulation necrosis of bladder tumor or bladder wall. Pathologic specimens of 18 patients prospectively treated with the neodymium:YAG laser before radical cystectomy were reviewed to compare the initial clinical stage of bladder tumor with the final pathologic stage and to assess the destructive tissue effects of neodymium:YAG laser therapy. Eleven of 18 patients were unchanged pathologically in stage of tumor or had tumor progression. Seven patients had a lower pathologic tumor stage; 3 of these patients had pathologic Stage T0 with no residual tumor, with the remainder of patients showing superficial disease. One asymptomatic small bowel injury was discovered at operation. Healing lesions showed marked granulation tissue, coagulation necrosis, and persistent ulceration.

Balloon dilatation of the prostate.

It is important to be objective in selecting candidates for this procedure and in evaluating their outcome. The size of the prostate does not seem to be relevant. Alpha blockers and balloons still produce unpredictable results, and neither alternative duplicates the results of transurethral resection. If, however, the patient is not in serious voiding trouble and is willing to exercise genuine patience, one approach could be a blocker if he has early symptoms and is not in trouble; otherwise, use the balloon. When either or both fail, TURP is required if the patient's condition permits, for TURP remains the standard. Objective assessment with an open mind is essential. Balloon dilatation is a safe, simple, but unpredictable alternative to transurethral resection. It may be done on an ambulatory basis, although it requires anesthesia, and has led to neither impotence or incontinence. It may be performed on the limited-risk patient. It has succeeded in two thirds of patients in retention or who did not respond to alpha blockers. Nonetheless, objective measures of success rarely duplicate those regularly achieved by TURP.

Transurethral prostatectomy: practice aspects of the dominant operation in American urology.

In a national survey of all American urologists transurethral prostatectomy accounted for 38 per cent of the major surgical procedures performed by the respondents. They regarded the operation as complex and they believe achievement of proficiency requires that more be performed during residency training than any other urological operation. Furthermore, they assigned transurethral prostatectomy a significantly higher relative value than have medical economists doing research in the field of physician reimbursement. The effect of recent legislated congressional reductions in the allowable Medicare fees for transurethral prostatectomy is discussed along with the impact of these reductions on urological patient care and the American urologist. Practice patterns and geographic variations in the costs of transurethral prostatectomy also are considered.

Neurocutaneous syndromes and retroperitoneal tumors.

A patient with multiple basal cell carcinoma syndrome, a symptom complex characteristized by nevoid basal cell carcinomas of the skin, jaw cysts, skeletal abnormalities, and hyporesponsiveness to parathormone is presented. In addition, the patient had a retroperitoneal lymphagiomyoma, a hamartomatous lesion, causing ureteral obstruction. The association of neuroectodermic syndromes and retroperitoneal and intra-abdominal tumors is reviewed.

Optimal nutritional support in surgery for bladder cancer: preservation of visceral protein by amino acid infusions.

Seventeen patients undergoing 19 major urological operations for bladder cancer or rectal leiomyosarcoma (1 case) were studied after randomization for 3 hypocaloric dietary regimens, preoperative keto-adaptation by a carbohydrate-free, oral protein diet continued in the postoperative period by isotonic amino acid infusions, postoperative amino acid infusions only and 5 per cent dextrose infusions. In these normally nourished patients serum transferrin (plus 13 mg./dl. minus 30 mg./dl., minus 69 mg./dl., p less than 0.05 for the first and combined amino acid groups against the third group) and 2 other short half-life hepatic secretory proteins, prealbumin and retinol-binding protein, represented sensitive indexes of visceral protein and nutritional support, superior to nitrogen balance, anthropometric assays, delayed hypersensitivity skin test reactivity and serum albumin. Near isotonic amino acid infusions were more effective in preserving visceral protein status than 5 per cent dextrose but preoperative keto-adaptation was not shown to have any increased benefit over protein-sparing therapy given only after an operation.

Hamartoma and renal transplant implications.

A 19-year-old woman with tuberous sclerosis, bilateral renal hamartomas and polycystic kidneys required separate nephrectomies for severe hemorrhages 6 months apart. The case is presented, the diagnoses of the disease in relation to a negative family history are considered and the importance of early diagnosis in a potential transplant recipient and the use of leukocyte-free transufusions are discussed.