Ethnic differences in gastro-oesophageal reflux disease

OBJECTIVES: To see whether the anecdotal statement that gastro-oesophageal reflux disease is less common in blacks than in white Caucasians is true. DESIGN: Study of the racial origin of adult patients who, at endoscopy, have oesophageal damage due to gastro-oesophageal reflux. SETTING: Gastroenterology unit of a teaching hospital in inner city in Birmingham, UK. MAIN OUTCOME MEASURE: Ethnicity and endoscopic grade of oesophageal damage (reflux oesophagitis) were recorded in every patient in whom oesophageal damage due to gastro-oesophageal reflux was diagnosed. RESULTS: Over the eight-year period 1989-1996, 1101 patients with endoscopically diagnosed grades I-V reflux oesophagitis have been seen, of whom 893 (81.9 percent) were white, 156 (14 percent) were Indian and 52 (5 percent) were Afro-Caribbeans. There were fewer patients with reflux oesophagitis from the two non-white ethnic groups than would be expected from their prevalence in the catchment population, and severe reflux oesophagitis was less common than expected in the two non-white groups. In all groups, patients with grades III, IV and V reflux oesophagitis were older than patients with grades I and II disease. Whites tended to be older than Afro-Caribbeans or Indians. CONCLUSION: There were fewer non-whites with reflux oesophagitis than would be expected but the reasons for this are unclear. This study has been useful as a pilot but further studies are needed in ethnically mixed non-migrant populations both in hospital, primary care and the community to clarify racial differences in reflux oesophagitis.(Au)

Standardized comparison of glucose intolerance in West African-origin populations of rural and urban Cameroon, Jamaica, and Caribbean migrants to Britain

OBJECTIVE: To compare the prevalence of glucose intolerance in genetically similar African-origin populations within Cameroon and from Jamaica and Britain. RESEARCH DESIGN AND METHODS: Subjects studied were from rural and urban Cameroon or from Jamaica, or were Caribbean migrants, mainly Jamaican, living in Manchester, England. Sampling bases included a local census of adults aged 25-74 years in Cameroon, districts statistically representative in Jamaica, and population registers in Manchester. African-Caribbean ethnicity required three grandparents of this ethnicity. Diabetes was defined by the World Health Organization (WHO) 1985 criteria using a 75-g oral glucose tolerance test (2-h > or = 11.1 mmol/l or hypoglycemic treatment) and by the new American Diabetes Association criteria (fasting glucose > or = 7.0 mmol/l or hypoglycemic treatment). RESULTS: For men, mean BMIs were greatest in urban Cameroon and Manchester (25-27 kg/m2); in women, these were similarly high in urban Cameroon and Jamaica and highest in Manchester (27-28 kg/m2). The age-standardized diabetes prevalence using WHO criteria was 0.8 percent in rural Cameroon, 2.0 percent in urban Cameroon, 8.5 percent in Jamaica, and 14.6 percent in Manchester, with no difference between sexes (men: 1.1 percent, 1.0 percent, 6.5 percent, 15.3 percent, women: 0.5 percent, 2.8 percent, 10.6 percent, 14.0 percent), all tests for trend P < 0.001. Impaired glucose tolerance was more frequent in Jamaica. CONCLUSIONS: The transition in glucose intolerance from Cameroon to Jamaica and Britain suggests that environment determines diabetes prevalence in these populations of similar genetic origin.(Au)

Trends in mortality from diabetes in England and Wales among those born in the Indian subcontinent and the Caribbean Commonwealth

Focuses on trends from deaths attributed to diabetes in England and Wales among those born in the Indian subcontinent and the Caribbean Commonwealth. Increase in deaths from diabetes in 1980; Emphasis on the management of diabetes that has shifted from secondary to primary care.(AU)

A visit to Trinidad and Tobago

Trinidad and Tobago are the two southerly of the Caribbean islands off the coast of Venezuela. Trinidad is industrial, having natural deposits of oil, gas and bitumen, while Tobago is a tropical holiday island, sometimes known as Robinson Crusoe Island. The population of 1.3 million represents races from Africa, India, Europe and Asia, who live and work together harmoniously; Trinidadian women are renowned for their beauty, resulting from this rich mix. The centre of Trinidad is heavily forested and-apart from the capital, Port-of-Spain the towns are small and rural in character. Fruits grows abundantly, especially mangoes, bananas, pineapples, citrus fruits, paw-paw and coconuts.(AU)

Urinary 5-L-oxoproline (pyroglutamic acid) excretion is greater in infants in Jamaican than in infants in England

OBJECTIVE: To determine the pattern of excretion in urine of 5-L-oxoproline, as a measure of glycine status, during the first six weeks of life in Jamaican infants. DESIGN: Spot samples of urine were collected from term and preterm infants at birth and longitudinally to four weeks of age, or at six weeks of age. 5-L-oxoproline was isolated by column chromatography and hydrolysed to L-glutamic acid, which was measured enzymatically and results expressed relative to creatinine excretion. SETTING: Maternity wards and postnatal clinic of the University Hospital of the West Indies. SUBJECTS: African-Caribbean infants, 19 term and 21 preterm, from birth to four weeks of age, and 79 term infants at six weeks of age. RESULTS: There was no difference between term and preterm infants. Excretion of 5-L-oxoproline increased progressively from birth, 141 æmol/mmol creatinine at four weeks of age. At six weeks of age, excretion was significantly greater than at birth or four weeks of age, 525 æmol/mmol creatinine. Compared with infant born in England, the excretion of 5-L-oxoproline was not different at birth, but was significantly greater in Jamaican infant at six weeks of age. CONCLUSIONS: Glycine status, indicated by increased excretion of 5-L-oxoproline, is marginal in Jamaican infants at six weeks of age, and this is possibly reflects a limitation in the endogenous biosynthesis of glycine due to a dietary limitation of folate or vitamin B-12. (AU)

Sickle Cell Retionapathy

We have conducted screening programmes at King's College Hospital for the assessment of the ocular manifestations of sickle cell disease in adults as well as in children. We have followed the same protocol used in the cohort study carried out in Jamaica. Fundus flourescein angiograms were performed on patients over the age of five. Our findings were compared to those of the Jamaican cohort. The studies were agreed by the Medical ethical committee at King's College Hospital. Some of the results have already been published. We have also documented some cases of retionopathy in patiens with AS and AC haemoglobinopathy. The eye is an invaluable window that provides an opportunity to assess the presence and progression of small vessel disease. The ocular manifestations of sickle cell haemoglobinopathies provide useful clues to the understanding of this condition. I propose to present a summary of our results so far. This study was supported by the locally organized research scheme and was conducted in association with Professor Alastair Bellingham and Dr. Arya from the Haemotology department at King's College Hospital and Professor A C Bird from Moorfields eye Hospital.(AU)

Ethnic differences in substance use and alcohol-use-related mortality among first generation migrants to England and Wales

Epidemiological studies among migrant ethnic groups are potentially important as a way to provide insight into the relative importance of genetic, cultural, and socioeconomic factors in the etiology of substance use disorders. This paper summarizes prior United Kingdom studies of the prevalence of substance-use-associated problems in different ethnic groups before analyzing trends in recent mortality data by country of birth. On this evidence, rates of alcohol-related mortality may be marginally higher for those born in the Caribbean than for the native British, but are substantially raised for those born in Ireland and the Indian subcontinent. There is some indication that rates for the Caribbean and possibly the Irish groups have risen more rapidly than for the national population over a 12-year period. These difference in mortality rates seem to have arisen for complex reasons.(AU)

Comparison of urinary 5-L-oxoproline (L-pyroglutamate) during normal pregnancy in women in England and Jamaica

Urinary 5-L-oxoproline was measured during normal pregnancies in Southampton, England and Kingston, Jamaica. The CV of 5-L-oxoproline excretion in urine, determined over 7 d in a non-pregnant woman and three pregnant women, was 10-36 percent. Compared with non-pregnant women, urinary 5-L-oxoproline increased three to four times from early pregnancy in women in Southampton, a highly significant difference, and remained elevated at similar levels during mid and late pregnancy. For women in Kingston, the excretion of 5-L-oxoproline was similar to that of Southampton women in the non-pregnant group and during early pregnancy. However, there was a progressive increase in the excretion of 5-L-oxoproline as pregnancy advanced and by late pregnancy excretion was from three to ten times greater than the average for the non-pregnant women. There was a significant difference between the women in Southampton and the women in Kingston during mid and late pregnancy, with women in Kingston excreting twice as much 5-l-oxoproline during late pregnancy. If the excretion of 5-L-oxoproline is a measure of glycine insufficiency, the results would indicate that in some pregnancies the ability of the mother to provide glycine for herself and the developing fetus is marginal or inadequate and the constraint appears more marked in Jamaica than in England.(AU)

The need and demand for renal replacement therapy in ethnic minorities in England

STUDY OBJECTIVE: The study aimed to determine the relative risk of being accepted for renal replacement treatment of black and Asian populations compared with whites in relation to age, sex and underlying cause. The implications for population need for renal replacement therapy in these populations and for the development of renal services were also considered. DESIGN/SETTING: This was a cross sectional retrospective survey of all patients accept for renal replacement treatment in renal units in England in 1991 and 1992. PATIENTS: These comprised all 5901 patients resident in England with end-stage renal failure who had been accepted for renal replacement therapy in renal units in England and whose ethnic category was available form the units. Patients were catergorised as white, Asian, black, or other. Population denominators for the ethnic populations were taken from the 1991 census. The census categories Indian, Pakistani, and Bangladeshi were aggregated to form the denominator for Asian patients and black Caribbeans, black Africans, and black others were aggregated to form the denominator for black patients. MAIN RESULT: Altogether 7.7 percent of patients accepted were Asian and 4.7 percent were black; crude relative acceptance rates compared with whites were 3.5 and 3.2 respectively. Age sex specific relative acceptance ratios increased with age in both ethnic populations and were greater in females. Age standardised acceptance ratios were increased 4.2 and 3.7 times in Asian and black people respectively. The most common underlying cause in both these populations was diabetes; relative rates of acceptance for diabetic end-stage renal failure were 5.8 and 6.5 respectively. The European Dialysis and Transplant Association coding system was inaccurate for disaggregating non-insulin and insulin dependent forms. Unknown causes were an important category in Asians with a relative acceptance of rate 5.7. The relative rates were reduced only slightly when the comparison was confined to the district health authorities with large ethnic minority populations, suggesting that geographical access was not a major factor in the high rates for ethnic minorities. CONCLUSION: Acceptance rates for renal replacement treatment are increased significantly in Asian and black populations. Although data inaccuracies and access factors may contributed to these findings, the main reason is probably the higher incidence of end-stage renal failure.(AU)

Abnormal eating attitudes and behaviours in two ethnic groups from a female British urban population

African-Caribbean (N=136) and White British (N=192) female family planning clinic attenders were administered the Bulimic Investigatory Test, Edinburgh (BITE) and the General Health Questionnaire (GHQ-28). A proportion of the participants were subsequently interviewed. The African-Caribbeans were found to have both significantly more disordered eating attitudes and a significantly higher level of abnormal eating behaviour than the White British. Although the African-Caribbean group had a significantly higher mean Body Mass Index this did not mediate the difference in levels of eating attitudes. When compared with the White British group more African-Caribbean women reported feelings of failure, guilt, abnormality and self consciousness concerning their eating habits. The results indicate that eating problems may be highly prevalent in this ethnic minority population and suggest that there may be differences in the nature of eating disorder psychopathology between ethnic groups. (AU)

Do doctors address the concerns of patients with diabetes?

Diabetes has an impact on people at both a biomedical and a holistic level. Furthermore there is a legitimate and substantial "medical agenda" which doctors must address. But does this mean that they fail to deal with the concerns of their patients? A questionnaire study of diabetic patients attending the Manchester Diabetes Centre found that not all the patients' concerns were addressed in 25.5 percent of consultations. 220 (98 percent) patients were recruited from 225 approached. Not surprisingly, those who expressed three or more concerns were significantly less likely to have all their concerns addressed compared with those who had only one or two concerns (p=0.001). The probability of having an individual concern addressed was 0.82. It was also found that Black-Caribbeans were significantly less likely to have their concerns adressed than Whites especially if they were over 60 years old (p=0.03). This study concludes that doctors should be particularly aware of the needs of patients who express many concerns, and especially if they are Black-Caribbeans. Further research should develop strategies for improving the ability of doctors to identify and address the concerns of their patients (AU)

Low prevalence of rheumatoid arthritis in Black-Caribbeans compared with whites in inner city Manchester

OJECTIVES- to compare the prevalence of rheumatoid arthtitis (RA) in Black-Caribbeans and whites living in the same urban area. METHODS- cases of inflammatory joint disease were ascertained initially from a postal screening survey of 1851 blacks and 1829 age and sex-matched non-Blacks identified from general practices in the Moss Side and Hulme districts of Manchester. The ethnicity of the respondents was confirmed using data from a postal screening questionnaire. Those reporting joint swelling or a history of arthritis were reviewed by a rheumatologist at surgeries held in each practice. The clinical records of the questionnaire non-responders and questionnaire-positive non-attenders at surgery were reviewed. RESULTS- in an adjusted denominator population of 1046 Black-Caribbeans and 997 whites, the cumulative prevalence of RA was 2.9/1000 in Black-Caribbeans and 8/1000 in whites, representing a prevalence in Black Caribbeans of 0.36 times that found in whites (95 percent confidence interval 0.1-1.3). CONCLUSIONS- rheumatoid arthritis occurs less commonly in Black-Caribbeans than in Whites. The findings are consistent with published studies showing a low RA prevalence in rural black populations (AU)

Respiratory conditions, including asthma, and height in primary school

The National Study of Health and Growth (NSHG) of primary school children has examined the relationships between height and each of six separate respiratory conditions, one of which was asthma, in children aged 5-11 years, allowing for a number of genetic and enviromental confounding factors, in particular for parental height. The relationships were investigated in a 'representative' sample of 4974 Caucasian English children in 1984 and in an 'ethnic/inner city' sample of 3419 Afro-Caribbean/Indian and Pakistani/Caucasian English children in 1985. None of the respiratory conditions was found to be related to height except for wheeze most days', whether or not it was accompanied by an asthma attack in the last 12 months. The Caucasian children in the 'representative' sample who had 'wheeze most days', were 0.17 height standard deviation score (95 percent confidence interval 0.03 to 0.31) less (approximately 1cm) than those with no wheeze. Comparisons with previous results for NSHG 'representative' Caucasian English children in 1973 showed good agreement except for children with three or more asthma attacks who were found to be shorter in 1973, but not in 1984, which may reflect improved treatment, or milder asthma being reported in 1984. It was concluded that, in the 1980s, the respiratory conditions were not related to height. The exception was 'wheeze most days'. It is suggested that this is an indicator of sickness, most likely asthma, which is being experienced with sufficient severity to affect growth slightly (AU)

Psychiatric morbidity and compulsory admission among UK-born Europeans, Afro - Caribbeans and Asians in central Manchester

Psychaitry admissions in Central Manchester of Europeans, Afro-Caribbeans, and Asians (within three age-bands) were studied over four years. Among the Afro-Caribbean group there were more single or unemployed persons than in either the Asian or European groups, which suggested greater socio-economic disadvantages. Rates for first admissions and readmissions among Afro-Caribbeans were greater; among Asians they were similar except for the 16-29-year age-group, who tended to have lower rates than Europeans. A higher proportion of Afro-Caribbean and Asians were psychotic. In the Afro-Caribbean group, the raised rates of admission were largely attributable to increase rates of schizophrenia. The highest rate occurred in second-generation (UK-born) Afro-Caribbeans and was nine times that among Europeans. The police were more frequently involved in the admissions of Afro-Caribbean compared with Europeans or Asians. Higher proportions of Afro-Caribbeans and Asians who were readmitted were detained under the Mental Health Act 1983, when compared with Europeans (AU)

Schizophrenia and Afro-Caribbeans: a case-control study

A case-control study was performed using 90 percent of all first-contact patients with a clinical diagnosis of schizophrenia residing in the London borough of Camberwell between 1965 and 1984. Cases and controls were obtained from the Camberwell psychiatric case register. Controls were those presenting with first episodes of non-psychotic disorders, matched for age, sex and period. The risk of schizophrenia was greater in those of Afro-Caribbean ethnicity, irrespective of age, gender or place of birth. This risk increased over the study period. The results cannot be explained by changes in the age, gender or ethnic structure of the local population. Effects of misdiagnosis or change in diagnostic practice were reduced by using uniform operational criteria. Possible explanations include maternal exposure to unfamiliar infective agents, a differential fall in the age at onset of illness, or worsening social adversity. (AU)

Attitudes of relatives of Afro-Caribbean patients: do they affect admission?

This pilot study explored suggestions made in the literature that high rates of Afro-Caribbean patients compulsorily admitted to hospital can be explained by the attitudes of relatives. In particular relatives who hold negative attitudes towards psychiatric services and adopt non-medical explanations for the onset of illness might delay in contacting hospital services. This could delay the process of admission and make a compulsory admission more likely. The attitudes and experiences of relatives of 15 patients admitted compulsorily and 10 admitted informally were compared. The relatives' attitudes did not differ between the two groups. There was also no difference in the severity of current symptoms of the relative's assessment of dangerousness. Neither group was characterised by the sorts of attitudes to illness that had been hypothesised

Multiple scherosis, tropical spastic paraparesis and HTLV-1 infection in Afro-Caribbean patients in the United Kingdom

Forty four consecutive patients of Afro-Caribbean origin resident in the United Kingdom (UK) were studied, based on a provisional diagnosis of myelopathy of unknown cause, tropical spastic paraparesis (TSP) or multiple scherosis (MS). Of 30 patients with progressive paraparesis 27 had serum antibodies to HTLV-1 and were classified as having TSP. Fourteen patients fulfilled the criteria for MS and none of 12 tested had HTLV-1 antibodies. All the TSP patients and nine of those with MS were born in West Indies. Five of the West Indian born MS patients had migrated to the UK after adolescence but the duration of residents in the UK before symptoms of MS developed was similar to those born in the UK (average 18 years). The features that differentiated MS from TSP patients, apart from HTLV-1 status, included clinical evidence of cranial nerve involvement, more extensive abnormalities on the brain and cervical cord MRI and asymmetry of the VEP latency increase, all of which were more frequent in the MS group. Of the three patients without a diagnosis one, born in the UK, had marked abnormalities on MRI of the brain indistinguishable from those seen in MS (AU)