BackgroundStudies on neighbourhood characteristics and depression show equivocal results. AimsThis large-scale pooled analysis examines whether urbanisation, socioeconomic, physical and social neighbourhood characteristics are associated with the prevalence and severity of depression. MethodCross-sectional design including data are from eight Dutch cohort studies (n = 32 487). Prevalence of depression, either DSM-IV diagnosis of depressive disorder or scoring for moderately severe depression on symptom scales, and continuous depression severity scores were analysed. Neighbourhood characteristics were linked using postal codes and included (a) urbanisation grade, (b) socioeconomic characteristics: socioeconomic status, home value, social security beneficiaries and non-Dutch ancestry, (c) physical characteristics: air pollution, traffic noise and availability of green space and water, and (d) social characteristics: social cohesion and safety. Multilevel regression analyses were adjusted for the individual's age, gender, educational level and income. Cohort-specific estimates were pooled using random-effects analysis. ResultsThe pooled analysis showed that higher urbanisation grade (odds ratio (OR) = 1.05, 95% CI 1.01-1.10), lower socioeconomic status (OR = 0.90, 95% CI 0.87-0.95), higher number of social security beneficiaries (OR = 1.12, 95% CI 1.06-1.19), higher percentage of non-Dutch residents (OR = 1.08, 95% CI 1.02-1.14), higher levels of air pollution (OR = 1.07, 95% CI 1.01-1.12), less green space (OR = 0.94, 95% CI 0.88-0.99) and less social safety (OR = 0.92, 95% CI 0.88-0.97) were associated with higher prevalence of depression. All four socioeconomic neighbourhood characteristics and social safety were also consistently associated with continuous depression severity scores. ConclusionsThis large-scale pooled analysis across eight Dutch cohort studies shows that urbanisation and various socioeconomic, physical and social neighbourhood characteristics are associated with depression, indicating that a wide range of environmental aspects may relate to poor mental health. Declaration of interestNone.
Recently, EAONO/JOS's joint consensus paper on definitions, classification, and staging of middle ear cholesteatoma was published 1 .As it is the era of collection of and report on uniform and comparable data, this is a welcome consensus statement. Currently, we are setting up a new nationwide multicenter study in the Netherlands, entitled Dutch Cholesteatoma Data, in which we would like to implement this guideline. To inform colleagues about our local experiences and choices so far, we are writing this letter.Although the EAONO/JOS consensus statements are clearly presented, we encountered some difficulties with the classification. First, we believe that the divisions of the middle ear space need further specifications. The anatomical sites as presented in the figure and the text of the consensus statements 1 can be variously interpreted and show some "blank spots. " For instance, the borders used for the anterior epitympanic space are unclear, which, in addition to the variation in anatomy and exposition in this area (canal wall up, canal wall down, microscopic, and endoscopic), will most likely result in a non-uniform registration. Second, we strongly believe that there is a primary need to elaborate on the classification rather than simplify it with a staging system. Gathering classification data on extent, complication, and ossicular state, using an easy format will make it possible to monitor surgical outcomes. This will allow comparisons of data among different hospitals, publications, and classifications. When large numbers of data on outcomes in relation to classification become available, results can be used to propose different stages. To improve the practical applicability of the EAONO/JOS joint statement in our national study, we have proposed to our participating ENT surgeons the following modifications:1. The borders of divisions of the middle ear and mastoid are further defined, and consequently, the figure of the consensus paper is refined [1] . In the EAONO/JOS consensus statement, the middle ear and mastoid spaces are divided into four sites to classify the extent of the cholesteatoma: difficult access sites (S), tympanic cavity (T), attic (A), and mastoid and antrum (M). The difficult access sites (S) further include S1 (the supratubal recess) and S2 (the sinus tympani). We propose to define the anatomical divisions of the middle ear and mastoid in more detail using surgical and anatomical landmarks. These landmarks based on a selection of published papers on this topic are highly likely to be identified both on CT scans and during all types of surgical approaches and are thus less prone to various interpretations [2][3][4] . Table 1 summarizes our suggestions for further specification of borders between the different sites of the middle ear and mastoid. In addition, Figure 1 shows the updated illustration based on those refined borders.An advantage of a more detailed description of these borders can be illustrated by the following examples that describe the difference between A and S1 ant...
Hearing ability in noise was longitudinally associated with loneliness. Decline in hearing ability in noise was related to increase in loneliness for specific subgroups of participants. One of these subgroups included participants whose hearing deteriorated over 5 years, but who continued to report nonuse of hearing aids. This is an important and alarming finding that needs further investigation.
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