Exploring the mechanisms underlying increased risk of depressive disorder in ethnic minority populations in Europe: A causal loop diagram.

BACKGROUND: Multiple ethnic minority populations in Europe show high risk of major depressive disorder (MDD), with ethnic discrimination and low socioeconomic position (SEP) as established risk factors. How this risk is shaped by the interactions between these, and other social factors, remains to be elucidated. We aimed to develop a causal-loop diagram (CLD) to gain a better understanding of how factors at the intersection of ethnic discrimination and SEP dynamically interact to drive MDD risk. METHODS: We iteratively mapped the interactions and feedback loops between factors at the intersection of ethnic discrimination and SEP, drawing input from (i) a series of two interviews with a range of MDD domain experts, (ii) an existing CLD mapping the onset of MDD across psychological, biological, and social dimensions at the level of the individual, and (iii) other relevant literature. RESULTS: Through tracing the feedback loops in the resulting CLD, we identified ten driving mechanisms for MDD onset in ethnic minorities (two related to ethnic discrimination, SEP, social network and support, and acculturation, as well as one relating to the living environment and self-stigma towards MDD); and four factors that modulate these mechanisms (recent migration, religious affiliation, neighborhood social environment, and public stigma towards MDD). The intersecting nature of ethnic discrimination and SEP, combined with the reinforcing dynamics of the identified driving mechanisms across time- and spatial scales, underscores the excess exposure to circumstances that increase MDD risk in ethnic minorities. CONCLUSIONS: While this CLD requires validation through future studies, the intersecting and reinforcing nature of the identified driving mechanisms highlights that tackling the high risk of MDD in ethnic minorities may require intervening at multiple targets, from the individual (e.g., psychological interventions targeting negative beliefs or reducing stress) to the societal level (e.g., addressing labor market discrimination).

Assessing and comparing chest radiograph interpretation in the Department of Internal Medicine at the University of the Witwatersrand medical school, according to seniority.

Background: Chest radiographs are a common diagnostic tool in the internal medicine department, and correct interpretation is imperative for adequate patient management. Objectives: To determine the diagnostic accuracy of common pathologies in South Africa that are evident on chest radiographs, and to determine whether there are discrepancies according to different levels of qualification of doctors rotating through the internal medicine department, and which factors contribute to an accurate diagnosis. Methods: Fifteen chest radiographs with common pathologies were given to all doctors rotating through the Department of Internal Medicine at Chris Hani Baragwanath Academic Hospital, and they were asked to interpret them. Information pertaining to their experience, designation and confidence in chest radiograph interpretation was also obtained. Results: Diagnostic accuracy according to years of experience was as follows: 0 - 5 years 27.0%, 6 - 10 years 43.0%, and >10 years 47.9%. For different designations, accuracy was as follows: consultants 50.5%, registrars 40.9%, medical officers 36.4%, and interns 19.5%. Participants who were confident obtained a mean score of 39.4% and those who were not, a mean score of 31.6%. Conclusion: Chest radiographs are readily accessible and used daily in clinical practice in numerous facilities. An accurate diagnosis is important to provide quality healthcare. Improved training in interpretation for all, but especially for junior doctors, should be a priority in our training facilities. Study synopsis: What the study adds. This study tested the diagnostic accuracy with regard to common pathologies present on chest X ray by doctors rotating through, or stationed at the internal medicine department at an academic hospital. Implications of the findings. Interpretation of chest X-rays was generally poor but the study did find that this improves with experience and confidence in diagnostic ability. These findings are significant in that they indicate a need to implement improved teaching programs in radiological interpretation, especially at an undergraduate level.

Serum carotenoid concentrations and their association with ethnic differences in type 2 diabetes within the Healthy Life in an Urban Setting (HELIUS) study.

OBJECTIVE: Studies have reported an inverse association between a diet rich in fruits and vegetables and type 2 diabetes (T2D), but data on high-risk ethnic minority groups is limited. We investigated whether serum carotenoids, as biomarkers for fruit and vegetable intake, mediate ethnic differences in the prevalence of T2D. DESIGN: Age-adjusted serum carotenoid concentrations were compared using ANCOVA. A cross-sectional analysis was performed using Cox regression to estimate prevalence ratios (PR) and their 95 % CI of the association between serum carotenoid concentrations and T2D. To study whether serum carotenoids potentially mediate the differences in the prevalence of T2D across ethnic groups, we compared PR of the model including known risk factors and the model additionally adjusted for serum carotenoid concentrations using the Dutch group as reference. SETTING: A study among six ethnic groups living in Amsterdam, the Netherlands. PARTICIPANTS: Data on 204 Dutch, 203 South Asian Surinamese, 204 African Surinamese, 203 Turkish and 200 Moroccan-origin participants from the Healthy Life in an Urban Setting (HELIUS) study were used. RESULTS: Serum carotenoid concentrations differed across ethnic groups. After adjusting for confounders, the serum concentrations of total carotenoids (PR 0·67, 95 % CI 0·54, 0·84), α-carotene (PR 0·57, 95 % CI 0·42, 0·77), ß-carotene (PR 0·45, 95 % CI 0·32, 0·63) and ß-cryptoxanthin (PR 0·73, 95 % CI 0·58, 0·92) were inversely associated with T2D. Despite the associations, serum carotenoids did not mediate the ethnic differences in the prevalence of T2D. CONCLUSIONS: The limited contribution of serum carotenoids to ethnic differences in T2D suggests that a focus on increasing fruit and vegetable intake alone will not likely eliminate ethnic differences in T2D prevalence.

[Nutrition and mental disorders during the life span: an overview of scientific evidence]. / Voeding bij psychische aandoeningen gedurende de levensloop; een overzicht van de evidentie.

BACKGROUND: Nutritional interventions are scarcely used in the prevention and treatment of mental disorders.
AIM: To summarize scientific evidence on the relation between nutrition and mental health, across the life span.
METHOD: An overview of the literature based on recent knowledge syntheses, meta-analyses and original studies.
RESULTS: Healthy dietary patterns are associated with a lower risk for depressive symptoms among adults and potentially also among children and adolescents. Dietary interventions can be effective in reducing depressive symptoms among high-risk groups and can have a beneficial effect in the treatment of depression. Meta-analyses of randomised studies have shown that omega-3 fatty acid supplements can be of added value in the treatment of adhd in children and of depression in adults.
CONCLUSION: Promotion of healthy dietary patterns in line with National guidelines for healthy diets is important in the entire spectrum from good mental health to a chronic disorder. More attention for improving healthy dietary patterns among patients with mental disorders can lead to important health gains.

Dietary pattern derived by reduced rank regression and depressive symptoms in a multi-ethnic population: the HELIUS study.

BACKGROUND/OBJECTIVES: To investigate the association of dietary patterns derived by reduced rank regression (RRR) with depressive symptoms in a multi-ethnic population. SUBJECTS/METHODS: Cross-sectional data from the HELIUS study were used. In total, 4967 men and women (18-70 years) of Dutch, South-Asian Surinamese, African Surinamese, Turkish and Moroccan origin living in the Netherlands were included. Diet was measured using ethnic-specific food frequency questionnaires. Depressive symptoms were measured with the nine-item patient health questionnaire. RESULTS: By performing RRR in the whole population and per ethnic group, comparable dietary patterns were identified and therefore the dietary pattern for the whole population was used for subsequent analyses. We identified a dietary pattern that was strongly related to eicosapentaenoic acid+docosahexaenoic acid, folate, magnesium and zinc (response variables) and which was characterized by milk products, cheese, whole grains, vegetables, legumes, nuts, potatoes and red meat. After adjustment for confounders, a statistically significant inverse association was observed in the whole population (B: -0.03, 95% CI: -0.06, -0.00, P=0.046) and among Moroccan (B: -0.09, 95% CI: -0.13, -0.04, P=0.027) and South-Asian Surinamese participants (B: -0.05, 95% CI: -0.09, -0.01, P=<0.001), whereas no statistically significant association was found in the remaining ethnic groups. No statistically significant associations were found between the dietary pattern and significant depressed mood in any of the ethnic groups. CONCLUSIONS: No consistent evidence was found that consumption of a dietary pattern, high in nutrients that are hypothesized to protect against depression, was associated with lower depressive symptoms across different ethnic groups.

Validation of the SQUASH Physical Activity Questionnaire in a Multi-Ethnic Population: The HELIUS Study.

PURPOSE: To investigate the reliability and validity of the SQUASH physical activity (PA) questionnaire in a multi-ethnic population living in the Netherlands. METHODS: We included participants from the HELIUS study, a population-based cohort study. In this study we included Dutch (n = 114), Turkish (n = 88), Moroccan (n = 74), South-Asian Surinamese (n = 98) and African Surinamese (n = 91) adults, aged 18-70 years. The SQUASH was self-administered twice to assess test-re-test reliability (mean interval 6-7 weeks) and participants wore an accelerometer and heart rate monitor (Actiheart) to enable assessment of construct validity. RESULTS: We observed low test-re-test reliability; Intra class correlation coefficients ranged from low (0.05 for moderate/high intensity PA in African Surinamese women) to acceptable (0.78 for light intensity PA in Moroccan women). The discrepancy between self-reported and measured PA differed on the basis of the intensity of activity: self-reported light intensity PA was lower than measured but self-reported moderate/high intensity PA was higher than measured, with wide limits of agreement. The discrepancy between questionnaire and Actiheart measures of moderate intensity PA did not differ between ethnic minority and Dutch participants with correction for relevant confounders. Additionally, the SQUASH overestimated the number of participants meeting the Dutch PA norm; Cohen's kappas for the agreement were poor, the highest being 0.30 in Dutch women. CONCLUSION: We found considerable variation in the test-re-test reliability and validity of self-reported PA with no consistency based on ethnic origin. Our findings imply that the SQUASH does not provide a valid basis for comparison of PA between ethnic groups.

Development of the HELIUS food frequency questionnaires: ethnic-specific questionnaires to assess the diet of a multiethnic population in The Netherlands.

OBJECTIVES: Ethnic minorities are often not included in studies of diet and health because of a lack of validated instruments to assess their habitual diets. Given the increased ethnic diversity in many high-income countries, insight into the diets of ethnic minorities is needed for the development of nutritional policies and interventions. In this paper, we describe the development of ethnic-specific food frequency questionnaires (FFQs) to study the diets of Surinamese (African and South Asian), Turkish, Moroccan and ethnic Dutch residents of The Netherlands. METHODS: An existing Dutch FFQ was adapted and formed the basis for three new FFQs. Information on food intake was obtained from single 24 h recalls. Food items were selected according to their percentage contribution to and variance in absolute nutrient intake of the respective ethnic groups. A nutrient database for each FFQ was constructed, consisting of data from the Dutch Food Composition table; data on ethnic foods were based on new chemical analyses and available international data. RESULTS: We developed four ethnic-specific FFQs using a standardised approach that included ~200 food items each and that covered more than 90% of the intake of the main nutrients of interest. CONCLUSIONS: The developed FFQs will enable standardised and comparable assessment of the diet of five different ethnic groups and provide insight into the role of diet in differences in health between ethnic groups. The methodology described in this paper and the choices made during the development phase may be useful in developing similar FFQs in other settings.

Influences on body weight of female Moroccan migrants in the Netherlands: a qualitative study.

We aimed to gain insight into the influences on Moroccan migrant women's weight and weight-related behavior by enriching their perspectives with those of their non-migrant compatriots living in Morocco. In focus groups with migrant women in Amsterdam, participants attributed overweight to traditional Moroccan foods and food culture. In contrast, focus group participants in Morocco emphasized that overweight in migrants was largely due to their adoption of the Western diet. Results from women in both locations indicate a general lack of knowledge regarding appropriate physical activity. Migrants attributed their lower levels of physical activity to changes in lifestyle due to migration and reported having problems adjusting to these changes. All participants reported a cultural shift in preference towards slimmer body sizes. However, weight gain still tends to be seen as a sign of success. In designing interventions, universal approaches may be sufficient to address migration-related influences on behavior; however behavior that is driven by migrants' socio-cultural context may require more culturally appropriate strategies.

Air-freshener burns: a new paradigm in burns etiology?

OBJECTIVES: We report a rare case of burns following the use of automated air-fresheners. METHODS: We present a case report with a brief overview of the literature relating to burns associated with air-fresheners. The mechanism and treatment of these types of injuries are also described. RESULTS: A 44 year-old female was admitted under the care of the burns team following burns secondary to an exploding air-freshener canister. The patient sustained burns to the face, thorax and arms resulting in a seven-day hospital admission. The burns were treated conservatively. CONCLUSIONS: To our knowledge this is one of the few documented cases of burns as a result of air-fresheners. As they become more ubiquitous, we anticipate the incidence of such cases to increase. As such, they pose a potential public health concern on a massive scale.

Dutch versus English advantage in the epidemic of central and generalised obesity is not shared by ethnic minority groups: comparative secondary analysis of cross-sectional data.

BACKGROUND: Ethnic minority groups in Western European countries tend to have higher levels of overweight than the majority populations for reasons that are poorly understood. Investigating relative differences between countries could enable an investigation of the importance of national context in determining these inequalities. OBJECTIVE: To explore: (1) whether Indian and African origin populations in England and the Netherlands are similarly disadvantaged compared with the White populations in terms of the prevalence of overweight and central obesity; (2) whether the previously known Dutch advantage of relatively low overweight prevalence is also observed in Dutch ethnic minority groups and (3) the contribution of health behaviour and socio-economic position to the differences observed. METHODS: Secondary analyses of population-based studies of 16 406 participants from England and the Netherlands. Prevalence ratios were estimated using regression models. RESULTS: Except for African men, ethnic minority groups in both countries had higher rates of overweight and central obesity than their White counterparts. However, the Dutch minority groups were relatively more disadvantaged than English minority groups as compared with the majority populations. The Dutch advantage of the low prevalence of obesity was only seen in White men and women and African men. In contrast, English-Indian (prevalence ratio=0.87, 95% confidence interval (CI): 0.81-0.93) and English-Caribbean (prevalence ratio=0.82, 95% CI: 0.76-0.89) women were less centrally obese than their Dutch equivalents. The Dutch-Indian men were very similar to the English-Indian men. The contribution of health behaviour and socio-economic position to the observed differences were small. CONCLUSION: Contrary to the patterns in White groups, the Dutch ethnic minority women were more obese than their English equivalents. More work is needed to identify factors that may contribute to these observed differences.

Risk groups for overweight and obesity among Turkish and Moroccan migrants in The Netherlands.

OBJECTIVES: The association between sociodemographic factors and acculturation with overweight/obesity in Turks and Moroccans was studied to identify target groups for prevention. STUDY DESIGN: A cross-sectional study was undertaken among a sample of 1384 Turks and Moroccans aged 35-74 years in Amsterdam, The Netherlands. METHODS: Data were collected by structured face-to-face interviews. Body mass index (BMI) was calculated from self-reported height and weight data. Sociodemographic variables collected were sex, age, educational level, marital status, parity and income level. Acculturation was measured by cultural orientation and length of residence in The Netherlands. Data of 1095 Turks and Moroccans were analysed using logistic regression, with overweight/obesity (BMI 25.0) as the dependent variable. RESULTS: The prevalence of overweight/obesity was high (57-89%). Age, marital status, parity, income level, cultural orientation and length of residence were not associated or only weakly associated with overweight/obesity. Educational level and overweight/obesity were strongly associated in Turkish women (odds ratio 4.56; 95% confidence intervals 1.54-13.51). CONCLUSIONS: The high prevalence of overweight/obesity in Turkish and Moroccan migrants varies little across sociodemographic groups and is not associated with acculturation. Poorly educated Turkish women are at particularly high risk.

Visual search behaviour in skeletal radiographs: a cross-specialty study.

AIM: To determine whether experience improves the consistency of visual search behaviour in fracture identification in plain radiographs, and the effect of specialization. MATERIAL AND METHODS: Twenty-five observers consisting of consultant radiologists, consultant orthopaedic surgeons, orthopaedic specialist registrars, orthopaedic senior house officers, and accident and emergency senior house officers examined 33 skeletal radiographs (shoulder, hand, and knee). Eye movement data were collected using a Tobii 1750 eye tracker with levels of diagnostic confidence collected simultaneously. Kullback-Leibler (KL) divergence and Gaussian mixture model fitting of fixation distance-to-fracture were used to calculate the consistency and the relationship between discovery and reflective visual search phases among different observer groups. RESULTS: Total time spent studying the radiograph was not significantly different between the groups. However, the expert groups had a higher number of true positives (p<0.001) with less dwell time on the fracture site (p<0.001) and smaller KL distance (r=0.062, p<0.001) between trials. The Gaussian mixture model revealed smaller mean squared error in the expert groups in hand radiographs (r=0.162, p=0.07); however, the reverse was true in shoulder radiographs (r=-0.287, p<0.001). The relative duration of the reflective phase decreases as the confidence level increased (r=0.266, p=0.074). CONCLUSIONS: Expert search behaviour exhibited higher accuracy and consistency whilst using less time fixating on fracture sites. This strategy conforms to the discovery and reflective phases of the global-focal model, where the reflective search may be implicated in the cross-referencing and conspicuity of the target, as well as the level of decision-making process involved. The effect of specialization appears to change the search strategy more than the effect of the length of training.

Acculturation and education level in relation to quality of the diet: a study of Surinamese South Asian and Afro-Caribbean residents of the Netherlands.

BACKGROUND: To consider the changes in overall diet quality following migration we examined the associations of acculturation variables and education level with diet in Surinamese South Asian and Surinamese Afro-Caribbean origin on the one hand, and ethnic Dutch residents of the Netherlands on the other. Surinam is a former Dutch colony in South America. METHODS: We randomly selected men and women aged 35-60 years: ethnic Dutch, n = 552; South Asian, n = 306; Afro-Caribbean, n = 660. Intakes of fruit, vegetables, red meat, fish, vegetable oils, breakfast and salt were measured using a short questionnaire that formed the basis for a 'diet quality indicator' score. Highest education was measured and acculturation of the Surinamese groups was assessed by age at migration, number of resident years and a scale measure of social contacts with ethnic Dutch. RESULTS: Compared with ethnic Dutch, both Surinamese groups scored higher on overall diet quality (P < or = 0.001) but some aspects of diet (breakfast and salt use) were less prudent. Education was positively associated with diet quality in ethnic Dutch (P < or = 0.01), but not consistently so in Surinamese. Associations with social contact with ethnic Dutch varied for different quality aspects of the diet. Residence duration (mean = 22 years) and age at migration (mean = 21 years) were not associated with diet. CONCLUSIONS: A greater degree of acculturation does not necessarily lead to a less healthful diet in migrants. In addition, the association of education level with diet may differ for migrant groups. The diet of migrants differ from host populations, suggesting that migrant groups should be considered in the development of nutrition health promotion activities.

Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting--comparison between off-pump and on-pump techniques.

OBJECTIVE: To assess early outcomes in the elderly population undergoing coronary revascularisation with and without cardiopulmonary bypass (CPB). METHODS: Meta-analysis of all retrospective, non-randomised studies comparing off-pump coronary artery bypass (OPCAB) versus CPB techniques in the elderly (> 70 years) between 1999 and 2005. Age-related early outcomes of interest were death, stroke, atrial fibrillation (AF), renal failure and length of stay in hospital. The random effects model was used. Sensitivity and heterogeneity were analysed. RESULTS: Analysis of 14 non-randomised studies comprising 4921 patients (OPCAB, 1533 (31.1%) and CPB, 3388 (68.9%)) showed a significantly lower incidence of death in the OPCAB group (odds ratio (OR) 0.48, 95% CI 0.28 to 0.84). This effect was greater in OPCAB octogenarians (OR 0.26, 95% CI 0.12 to 0.57). The pattern of incidence of stroke among the OPCAB octogenarians (OR 0.19, 95% CI 0.07 to 0.56) was similar. The incidence of AF was lower in the OPCAB group (OR 0.77, 95% CI 0.61 to 0.97). The incidence of renal failure did not differ. Length of hospital stay was shorter in the OPCAB group, although with significant heterogeneity. CONCLUSIONS: OPCAB may be associated with lower incidence of death, stroke and AF in the elderly, which may result in shorter length of hospital stay. A large randomised trial would confirm whether the elderly would benefit more from OPCAB surgery.

Comparison of laparoscopic and open ileocecal resection for Crohn's disease: a metaanalysis.

BACKGROUND: The role of laparoscopic surgery for patients with ileocecal Crohn's disease is a contentious issue. This metaanalysis aimed to compare open resection with laparoscopically assisted resection for ileocecal Crohn's disease. METHODS: A literature search of the Medline, Ovid, Embase, and Cochrane databases was performed to identify comparative studies reporting outcomes for both laparoscopic and open ileocecal resection. Metaanalytical techniques were applied to identify differences in outcomes between the two groups. Sensitivity analysis was undertaken to evaluate the heterogeneity of the study. RESULTS: Of 20 studies identified by literature review, 15 satisfied the criteria for inclusion in the study. These included outcomes for 783 patients, 338 (43.2%) of whom had undergone laparoscopic resection, with an overall conversion rate to open surgery of 6.8%. The operative time was significantly longer in the laparoscopic group, by 29.6 min (p = 0.002), although the blood loss and complications in the two groups were similar. In terms of postoperative recovery, the laparoscopic patients had a significantly shorter time for recovery of their enteric function and a shorter hospital stay, by 2.7 days (p < 0.001). CONCLUSIONS: For selected patients with noncomplicated ileocecal Crohn's disease, laparoscopic resection offered substantial advantages in terms of more rapid resolution of postoperative ileus and shortened hospital stay. There was no increase in complications, as compared with open surgery. The contraindications to laparoscopic approaches for Crohn's disease remain undefined.

Spontaneous rupture of a true uterine artery aneurysm: a cause of retroperitoneal haematoma.

We report the first case of spontaneous rupture of a true uterine artery aneurysm in a 69-year-old woman presenting with severe abdominal pain, a left iliac fossa mass, anaemia and a retroperitoneal haematoma on CT scanning. In this patient, the aneurysm was successfully embolised using microcoils. The different imaging modalities used for diagnosis and the treatment options are discussed.

Successful use of Botulinum toxin-A for the treatment of neck and anterior chest wall flushing.

Neck and anterior chest wall flushing can be a social handicap to the sufferer and current treatment options are often unsatisfactory. We report the case of a 48-year-old woman with severe flushing of the anterior neck and anterior chest wall which resolved after three treatments of intracutaneous botulinum toxin A injections. We believe that this treatment method for skin flushing is simple, effective and free of significant side effects at these sites. Further studies are needed to evaluate the duration of the therapeutic effect.