Validity of the Global Activity Limitation Indicator (GALI) to evaluate severity of disability.

Our aim was to estimate the validity of the Global Activity Limitation Indicator (GALI) when measuring the severity level of disability. Data came from 153 residents of Spain, who requested an evaluation of their degree of disability. We compared disability classifications (severe vs. non-severe) from GALI against those from the 36-item questionnaire WHODAS 2.0, the current gold standard measure of disability. The sensitivity of GALI to detect severe disability was 58.3% [95% confidence interval (CI):43.2-72.4], and the specificity was 84.8% (95% CI: 76.4-91.0). Thus, the validity of GALI to accurately categorize the degree of severity of an individual's disability is not high, this in great part due to its limited sensitivity.

Similarities of Variant Creutzfeldt-Jakob Disease Strain in Mother and Son in Spain to UK Reference Case.

We investigated transmission characteristics of variant Creutzfeldt-Jakob disease in a mother and son from Spain. Despite differences in patient age and disease manifestations, we found the same strain properties in these patients as in UK vCJD cases. A single strain of agent appears to be responsible for all vCJD cases to date.

A protective personal factor against disability and dependence in the elderly: an ordinal regression analysis with nine geographically-defined samples from Spain.

BACKGROUND: Sense of Coherence (SOC) is defined as a tendency to perceive life experiences as comprehensible, manageable and meaningful. The construct is split in three major domains: Comprehensibility, Manageability, and Meaningfulness. SOC has been associated with successful coping strategies in the face of illness and traumatic events and is a predictor of self-reported and objective health in a variety of contexts. In the present study we aim to evaluate the association of SOC with disability and dependence in Spanish elders. METHODS: A total of 377 participants aged 75 years or over from nine locations across Spain participated in the study (Mean age: 80.9 years; 65.3% women). SOC levels were considered independent variables in two ordinal logistic models on disability and dependence, respectively. Disability was established with the World health Organization-Disability Assessment Schedule 2.0 (36-item version), while dependence was measured with the Extended Katz Index on personal and instrumental activities of daily living. The models included personal (sex, age, social contacts, availability of an intimate confidant), environmental (municipality size, access to social resources) and health-related covariates (morbidity). RESULTS: High Meaningfulness was a strong protective factor against both disability (Odds Ratio [OR] = 0.50; 95% Confidence Interval [CI] = 0.29-0.87) and dependence (OR = 0.33; 95% CI = 0.19-0.58) while moderate and high Comprehensibility was protective for disability (OR = 0.40; 95% CI = 0.22-0.70 and OR = 0.39; 95%CI = 0.21-0.74), but not for dependence. Easy access to social and health resources was also highly protective against both disability and dependence. CONCLUSIONS: Our results are consistent with the view that high levels of SOC are protective against disability and dependence in the elderly. Elderly individuals with limited access to social and health resources and with low SOC may be a group at risk for dependence and disability in Spain.

Risk of transmission of sporadic Creutzfeldt-Jakob disease by surgical procedures: systematic reviews and quality of evidence.

BACKGROUND: Sporadic Creutzfeldt-Jakob disease (sCJD) is potentially transmissible to humans. OBJECTIVE: This study aimed to summarise and rate the quality of the evidence of the association between surgery and sCJD. DESIGN AND METHODS: Firstly, we conducted systematic reviews and meta-analyses of case-control studies with major surgical procedures as exposures under study. To assess quality of evidence, we used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Secondly, we conducted a systematic review of sCJD case reports after sharing neurosurgical instruments. RESULTS: Thirteen case-control studies met the inclusion criteria for the systematic review of case-control studies. sCJD was positively associated with heart surgery, heart and vascular surgery and eye surgery, negatively associated with tonsillectomy and appendectomy, and not associated with neurosurgery or unspecified major surgery. The overall quality of evidence was rated as very low. A single case-control study with a low risk of bias found a strong association between surgery conducted more than 20 years before disease onset and sCJD. Seven cases were described as potentially transmitted by reused neurosurgical instruments. CONCLUSION: The association between surgery and sCJD remains uncertain. Measures currently recommended for preventing sCJD transmission should be strongly maintained. Future studies should focus on the potential association between sCJD and surgery undergone a long time previously.

Urinary incontinence and mortality among older adults residing in care homes.

AIM: To assess the association between baseline urinary incontinence and long-term, all-cause mortality. BACKGROUND: Urinary incontinence is a common disorder among older institutionalised adults, with important consequences for morbidity and quality of life. Moreover, while it is a consistent mortality marker, the extent to which this association might be causal remains controversial. DESIGN: A cohort study. METHODS: We conducted a mortality follow-up study on a cohort of 675 nursing-home residents in the city of Madrid (Spain), from their 1998-1999 baseline interviews to September 2013. Study subjects or their caregivers were asked whether the resident had experienced any involuntary leakage of urine in the preceding 14 days, with subjects being subsequently defined as continent, mildly incontinent, or severely incontinent. Hazard ratios for all-cause mortality were estimated using Cox proportional hazards models. RESULTS: After a 4061 person-year follow-up (median/maximum of 4·6/15·2 years), 576 participants had died. In fully-adjusted models, urinary incontinence was associated with a 24 per cent increased risk of all-cause mortality. There was a graded relationship across severity levels, with hazard ratios 7% higher for mild and 44% higher for severe incontinence as compared with the continent group. The adjusted mortality fraction attributable to urinary incontinence was 11 per cent. CONCLUSION: It would appear that urinary incontinence is not only a marker but also a real determinant of survival in the institutionalized population. This finding, which seems plausible in a population of frail older adults, warrants further research into mechanisms that could help to elucidate this hypothesis.

Accuracy of screening instruments for detection of neuropsychiatric syndromes in Parkinson's disease.

Parkinson's disease includes neuropsychiatric manifestations, such as depression, anxiety, apathy, psychosis, and impulse control disorders, which often are unreported by patients and caregivers or undetected by doctors. Given their substantial impact on patients and caregivers as well as the existence of effective therapies for some of these disorders, screening for neuropsychiatric symptoms is important. Instruments for screening have a particular methodology for validation, and their performance is expressed in terms of accuracy compared with formal diagnostic criteria. The present study reviews the attributes of the screening instruments applied for detection of the aforementioned major neuropsychiatric symptoms in Parkinson's disease. A quasi-systematic review (including predefined selection criteria, but not evaluating the quality of the reviewed studies) was carried out on the basis of previous systematic reviews (commissioned by the American Academy of Neurology and the Movement Disorder Society) and made current by conducting a literature search (2005-2014). For depression, 11 scales and questionnaires were shown to be valid for Parkinson's disease screening. The recently developed Parkinson Anxiety Scale and the Geriatric Anxiety Inventory demonstrate satisfactory properties as screening instruments for anxiety, and the Lille Apathy Rating Scale for detection of apathy. No scale adequately screens for psychosis, so a specific psychosis instrument should be developed. The Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (Questionnaire and Rating Scale) are valid for comprehensive screening of impulse control disorders, and the Parkinson's Disease-Sexual Addiction Screening Test for hypersexuality specifically.

Guillain-Barré syndrome following the 2009 pandemic monovalent and seasonal trivalent influenza vaccination campaigns in Spain from 2009 to 2011: outcomes from active surveillance by a neurologist network, and records from a country-wide hospital discharge database.

BACKGROUND: Studies have shown a slight excess risk in Guillain-Barré syndrome (GBS) incidence associated with A(H1N1)pdm09 vaccination campaign and seasonal trivalent influenza vaccine immunisations in 2009-2010. We aimed to assess the incidence of GBS as a potential adverse effect of A(H1N1)pdm09 vaccination. METHODS: A neurologist-led network, active at the neurology departments of ten general hospitals serving an adult population of 4.68 million, conducted GBS surveillance in Spain in 2009-2011. The network, established in 1996, carried out a retrospective and a prospective study to estimate monthly alarm thresholds in GBS incidence and tested them in 1998-1999 in a pilot study. Such incidence thresholds additionally to observation of GBS cases with immunisation antecedent in the 42 days prior to clinical onset were taken as alarm signals for 2009-2011, since November 2009 onwards. For purpose of surveillance, in 2009 we updated both the available centres and the populations served by the network. We also did a retrospective countrywide review of hospital-discharged patients having ICD-9-CM code 357.0 (acute infective polyneuritis) as their principal diagnosis from January 2009 to December 2011. RESULTS: Among 141 confirmed of 148 notified cases of GBS or Miller-Fisher syndrome, Brighton 1-2 criteria in 96 %, not a single patient was identified with clinical onset during the 42-day time interval following A(H1N1)pdm09 vaccination. In contrast, seven cases were seen during a similar period after seasonal campaigns. Monthly incidence figures did not, however, exceed the upper 95 % CI limit of expected incidence. A retrospective countrywide review of the registry of hospital-discharged patients having ICD-9-CM code 357.0 (acute infective polyneuritis) as their principal diagnosis did not suggest higher admission rates in critical months across the period December 2009-February 2010. CONCLUSIONS: Despite limited power and underlying reporting bias in 2010-2011, an increase in GBS incidence over background GBS, associated with A(H1N1)pdm09 monovalent or trivalent influenza immunisations, appears unlikely.

Prevalence of and factors associated with homebound status among adults in urban and rural Spanish populations.

BACKGROUND: There is a marked growth in the number of homebound older adults, due mainly to increased life expectancy. Although this group has special characteristics and needs, it has not been properly studied. This study thus aimed to measure the prevalence of homebound status in a community-dwelling population, and its association with both socio-demographic, medical and functional characteristics and the use of health care and social services. METHODS: We used instruments coming under the WHO International Classification of Functioning (ICF) framework to carry out a cross-sectional study on populations aged 50 years and over in the province of Zaragoza (Spain), covering a total of 1622 participants. Persons who reported severe or extreme difficulty in getting out of the house in the last 30 days were deemed to be homebound. We studied associations between homebound status and several relevant variables in a group of 790 subjects who tested positive to the WHODAS-12 disability screening tool. RESULTS: Prevalence of homebound status was 9.8 % (95 % CI: 8.4 to 11.3 %). Homebound participants tended to be older, female and display a lower educational level, a higher number of diseases, poorer cognition and a higher degree of disability. In fully adjusted models including disability as measured with the ICF-Checklist, the associated variables (odds ratios and [95 % confidence intervals]) were: female gender (3.75 [2.10-6.68]); urban population (2.36 [1.30-4.29]); WHODAS-12 disability (6.27 [2.56-15.40]); depressive symptoms (2.95 [1.86-4.68]); moderate pain (2.37 [1.30-4.31] and severe pain (3.03 [1.31-7.01]), as compared to the group with no/mild pain; hospital admissions in the previous 3 months (2.98 [1.25-7.11]); and diabetes (1.87 [1.03-3.41]). Adjustment for ICF-Checklist disability had a notable impact on most associations. CONCLUSIONS: The study shows that homebound status is a common problem in our setting, and that being disabled is its main determinant. Socio-demographic characteristics, barriers and chronic diseases can also be assumed to be playing a role in the onset of this condition, indicating the need for further research, including longitudinal studies on its incidence and associated factors.

Sense of coherence and health of community-dwelling older adults in Spain.

BACKGROUND: In light of the demographic aging trend in Europe, investigation into successful aging is a public health priority. This paper describes the sense of coherence (SOC) of a sample of community-dwelling older adults in Spain and analyzes the relationship between SOC and both health and sociodemographic variables. SOC measures the extent to which an individual conceptualizes the world as comprehensible, manageable, and meaningful. Strong SOC may promote good health. METHODS: The study followed a cross-sectional design involving a nationally representative sample of 1,106 community-dwelling adults aged 60 years and older in Spain. The sample was collected by geographically based proportional stratified sampling. RESULTS are based on responses to a questionnaire requesting sociodemographic information and including the following validated scales: SOC, Barthel index (BI), functional independence scale (FIS), personal wellbeing index (PWI), EQ-5D dimensions (mobility, personal care, daily activities, pain/discomfort, anxiety/depression), and the depression subscale of the hospital anxiety and depression scale (HADS-D). A multivariate linear regression model analyzed determinants of SOC. RESULTS: Personal wellbeing (b = -0.32), depression (b = 0.26), and educational level (b = -0.06) were significant determinants of SOC. Lower SOC was associated with problems in all EQ-5D dimensions and moderate/severe disability as measured by the BI. CONCLUSIONS: SOC in older adults is related to functional status, mental health status, personal wellbeing, and educational level. Public health initiatives should work to reduce the psychological and physiological impact of aging by focusing on the conditions that facilitate the coping of older adults.

Discordance between physician-rated health and an objective health measure among institutionalized older people.

BACKGROUND: Although physician-rated health is emerging as a potentially useful variable in research, with implications in practice, it has not been analyzed. Moreover, one of its most important aspects, namely, concordance with patients' objective health state, has not been investigated. This study sought to measure concordance between physician-rated health and an objective health measure, and assess both measures' validity in predicting death. METHODS: The data for the study were drawn from a 1998-1999 survey and subsequent mortality follow-up of residential and nursing homes in Madrid (Spain). Study subjects were 630 residents aged ≥65 years, and their respective facility physicians. Measures included agreement between physicians' rating of residents' overall health (good, intermediate or poor) and an objective measure of residents' health (good, intermediate or poor), based on functional capacity, cognitive status, and number of chronic conditions. Overrating was defined as any case where health, rated as good by a physician, was objectively rated as poor. RESULTS: Whereas 45% of physicians and 55% of residents rated their health as good, only 4% of such residents had good objective health. Of those who received a physician rating of good/very good health, 39.0% had poor objective health. There was evidence of clear overrating in 18% of the population, and clear to moderate overrating in 73% of the population. In terms of power to predict mortality, the pattern of behavior shown by the objective health measure was good, graded and congruent, and better than that shown by physician-rated health. CONCLUSION: Physician overrating of the overall health of older persons in residential and nursing homes, would appear to be very high. Although some degree of contextualization by physicians in this setting might be considered reasonable, the degree of overrating in our population seems nevertheless excessive.

Incidence of multiple sclerosis in Northern Lisbon, Portugal: 1998-2007.

BACKGROUND: There are few, recent, well assessed, multiple sclerosis (MS) incidence surveys on European populations. This study sought to measure MS incidence in a Northern Lisbon population and assess it using capture-recapture methods (CRMs). METHODS: Among the population residing in the Northern Lisbon Health Area, registered MS diagnoses were obtained from general practitioners in three primary-care districts covering a population of 196,300, and a neurology unit at the main referral hospital. Cases with onset during the periods 1978-1997 and 2008-2012 were excluded due to perceived poor access to image-supported neurological diagnosis and administrative changes in patient referral respectively. Age- and sex-specific incidences for the period 1998-2007 were calculated using McDonald diagnostic criteria, and CRMs were used to correct age-specific incidence rates. The corrected figures were also adjusted for age using the European Standard Population as reference. RESULTS: When applied to 62 MS patients with onset in the period 1998-2007, the rates per 100,000 population were as follows for both sexes: crude, 3.16; age-adjusted, 3.09 (95% CI 2.32 to 3.87); CRM-adjusted, 4.53 (95% CI 3.13 to 5.94); and age- and CRM-adjusted, 4.48 (3.54-5.41). In general, the rates were 3-fold higher among women than among men. Negative source dependency and CRM impact were highest at ages 35-44 years, where a 60% rise led to a peak incidence. CONCLUSIONS: MS incidence in Northern Lisbon, Portugal, is moderately lower than that yielded by surveys on European populations. CRMs, which in this instance suggest undercounts, are a potentially useful tool for case-finding assessment but their application may introduce bias.

Association Between Disability and Suicide Mortality in the Spanish Community-Dwelling Adult Population. A Population-Based Follow-Up Study.

Objectives: To assess the association of disability with suicide mortality, separately for women and men by age group. Methods: Information was obtained from a representative national sample of 161,809 community-dwelling adults (≥18 years). Participants contributed to follow-up time from baseline interview (2008) until suicide, death by other causes, or 2017. We calculated, by sex, standardized suicide mortality differences (SSMD), comparing persons with and without disabilities standardized to sociodemographic distribution of disability population. Results: 29 women died by suicide during 800,754 person-years follow-up and 97 men during 735,709 person-years. Among women with disabilities, SSMD (95% Confidence interval) per 100,000 person-years at 5 years was 54.4 deaths (-17.2 to 126.1) [100.0 (-27.4 to 227.4) in women <65 years and -4.8 (-27.3 to 17.7) in women ≥65 years (P homogeneity = 0.11)]. Among men, SSMD increased by 122.2 deaths (4.1 to 240.3) [37.2 (-40.2 to 114.6) in men <65 years and 74.7 (-51.8 to 200.5) in men ≥65 years (P homogeneity = 0.62)]. Conclusion: Suicide risk was higher in women and men with disability. In women higher risk was only notable for those <65. Men presented similar effects in both age groups. Nevertheless, due to imprecision of estimates, results should be viewed cautiously.

Late-in-life surgery associated with Creutzfeldt-Jakob disease: a methodological outline for evidence-based guidance.

BACKGROUND: There is increasing epidemiological evidence of etiological links between general surgery and sporadic Creutzfeldt-Jakob disease (sCJD) with long incubation periods. The purpose of this study was to identify specific surgical procedures potentially associated with sCJD to be targeted for preventive presurgical-intervention guidance. RESULTS: We propose a three-step clinical guidance outline where surgical procedures associated with sCJD clinical onset - potentially more contaminant - are taken into account. Data on hospital discharges and surgical procedures were obtained from Danish and Swedish national in-patient hospital registries for 167 sCJD cases, onset 1987-2003, and for 835 matched and 2,224 unmatched population controls. Surgery was allocated to different life-time periods as previously reported, and frequencies were compared using logistic regression analysis. In the year preceding clinical onset, persons with sCJD underwent a statistically significant higher number of minor surgical interventions (OR (95% CI): 17.50 (3.64-84.24)), transluminal endoscopies (OR: 2.73 (1.01-7.37)) and gastrointestinal operations (OR: 3.51 (1.21-10.19)) compared to matched controls. Surgical discharges clustered towards clinical onset. These differences increased during the clinical period, with statistically significant higher frequencies for both endoscopies and minor surgery (OR: 13.91 (5.87-32.95), and for main surgical procedures (OR: 2.10 (1.00-4.39)), particularly gastrointestinal surgery (OR: 6.00 (1.83-19.66)), and surgery contacting skeletal muscle. Comparisons with unmatched controls yielded similar results for neurosurgery in the clinical period (OR: 19.40 (2.22-168.34)). CONCLUSIONS: These results suggest that some types of surgical procedures are associated with sCJD, after clinical onset or particularly just before onset. Selective planning of such surgery to minimize instrument/device contamination or quarantining might be feasible. Conditional to progress in sCJD etiological research, results are relevant for guidance development.

Incidence of multiple sclerosis among European Economic Area populations, 1985-2009: the framework for monitoring.

BACKGROUND: A debate surrounding multiple sclerosis epidemiology has centred on time-related incidence increases and the need of monitoring. The purpose of this study is to reassess multiple sclerosis incidence in the European Economic Area. METHODS: We conducted a systematic review of literature from 1965 onwards and integrated elements of original research, including requested or completed data by surveys authors and specific analyses. RESULTS: The review of 5323 documents yielded ten studies for age- and sex-specific analyses, and 21 studies for time-trend analysis of single data sets. After 1985, the incidence of multiple sclerosis ranged from 1.12 to 6.96 per 100,000 population, was higher in females, tripled with latitude, and doubled with study midpoint year. The north registered increasing trends from the 1960s and 1970s, with a historic drop in the Faroe Islands, and fairly stable data in the period 1980-2000; incidence rose in Italian and French populations in the period 1970-2000, in Evros (Greece) in the 1980s, and in the French West Indies in around 2000. CONCLUSIONS: We conclude that the increase in multiple sclerosis incidence is only apparent, and that it is not specific to women. Monitoring of multiple sclerosis incidence might be appropriate for the European Economic Area.

Depressive symptoms and associated factors in an older Spanish population positively screened for disability.

OBJECTIVES: To measure the prevalence of depressive symptoms and its association with a comprehensive set of variables and to study the potential modifying effects of sex and age. METHODS: In a cross-sectional study, subjects who tested positive to the 12-item World Health Organization disability screening tool were selected from a probabilistic sample of persons aged 65 years or older in a rural area of Spain. Measurements included EURO-D depression scale, socio-demographics, habits, anthropometrics, medical history, cognition, disability, functional dependence, self-rated health and pain. Logistic regression models were used to obtain adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for the association between depression and variables. The modifying effects of age and sex were assessed. RESULTS: Prevalence (95% CI) of current depressive symptoms among the 438 participants was 35.8% (31.3-40.3%). Depressive symptomatology was higher among women (aOR = 2.98). An inverse association was observed with alcohol (aORs of 0.52 and 0.27 for consumption of 1-2 and >2 standard units/day, respectively, versus abstainers). Depressive symptomatology was associated with heart failure (aOR = 4.24), urinary incontinence (aOR = 2.68), ischemic heart disease (aOR = 1.87), poor self-rated health and pain. Sex and age modified the effect of several variables. CONCLUSION: Prevalence of depressive symptoms, albeit high, was less than expected. The consistently strong negative association between depressive symptoms and alcohol consumption warrants further in-depth research. Awareness of effect modification by key variables, such as sex and age, may enable the probability of suffering depression to be more accurately assessed, with a view to performing a potential diagnostic work-up.

Factors associated with falls among older adults living in institutions.

BACKGROUND: Falls have enormous impact in older adults. Yet, there is insufficient evidence regarding the effectiveness of preventive interventions in this setting. The objectives were to measure the frequency of falls and associated factors among older people living institutions. METHODS: Data were obtained from a survey on a probabilistic sample of residents aged ≥65 years, drawn in 1998-99 from institutions of Madrid (Spain). Residents, their caregivers, and facility physicians were interviewed. Fall rates were computed based on the number of physician-reported falls in the preceding 30 days. Adjusted rate ratios were computed using negative binomial regression models, including age, sex, cognitive status, functional dependence, number of diseases, and polypharmacy. RESULTS: The final sample comprised 733 residents. The fall rate was 2.4 falls per person-year (95% confidence interval [CI], 2.04-2.82). The strongest risk factor was number of diseases, with an adjusted rate ratio (RR) of 1.32 (95% CI, 1.17-1.50) for each additional diagnosis. Other variables associated with falls were: urinary incontinence (RR = 2.56 [95% CI, 1.32-4.94]); antidepressant use (RR = 2.32 [95% CI, 1.22-4.40]); arrhythmias (RR = 2.00 [95% CI, 1.05-3.81]); and polypharmacy (RR = 1.07 [95% CI, 0.95-1.21], for each additional medication). The attributable fraction for number of diseases (with reference to those with ≤ 1 condition) was 84% (95% CI, 45-95%). CONCLUSIONS: Number of diseases was the main risk factor for falls in this population of institutionalized older adults. Other variables associated with falls, probably more amenable to preventive action, were urinary incontinence, antidepressants, arrhythmias, and polypharmacy. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here:http://www.diagnosticpathology.diagnomx.eu/vs/3916151157277337.

Sensitivity to biases of case-control studies on medical procedures, particularly surgery and blood transfusion, and risk of Creutzfeldt-Jakob disease.

BACKGROUND: Evidence of risk of Creutzfeldt-Jakob disease (CJD) associated with medical procedures, including surgery and blood transfusion, is limited by susceptibility to bias in epidemiological studies. METHODS: Sensitivity to bias was explored using a central-birth-cohort model using data from 18 case-control studies obtained after a review of 494 reports on medical procedures and risk of CJD, systematic for the period January 1, 1989 to December 31, 2011. RESULTS: The validity of the findings in these studies may have been undermined by: recall; control selection; exposure assessment in life-time periods of different duration, out of time-at-risk of effect, or asymmetry in case/control data; and confounding by concomitant blood transfusion at the time of surgery. For sporadic CJD (sCJD), a history of surgery or blood transfusion was associated with risk in some, but not all, recent studies at a ≥10 year lag time, when controls were longitudinally sampled. Space-time aggregation of surgical events was not seen. Surgery at early clinical onset might be overrepresented among cases. Neither surgical history nor blood transfusion unlabelled for donor status, dental treatments or endoscopic examinations were linked to variant CJD (vCJD). CONCLUSIONS: These results indicate the need for further research. Common challenges within these studies include access to and content of past medical/dental treatment records for diseases with long incubation periods.

Incidence of nontraumatic spinal cord injury: a Spanish cohort study (1972-2008).

OBJECTIVES: To assess the incidence of nontraumatic spinal cord injury (SCI) in a determined catchment area in Spain, and to evaluate clinical presentations and trends over time. DESIGN: Population-based case series study between January 1972 and December 2008 [corrected]. SETTING: A hospital with a specialized SCI unit in a delimited health area in Spain. PARTICIPANTS: Hospital inpatients and outpatients with nontraumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Age- and sex-specific incidence rates. RESULTS: An adjusted incidence rate of 11.4 per million population was found for this region (12.3 for males, 10.4 for females). A total of 541 cases (53% male) were reported over the 37-year study period. Incidence rates increased with age, with a peak in the 60- to 69-year age group. Tumors were the major cause of SCI. Most of the lesions were at the thoracic level, and C and D were the most frequently observed American Spinal Injury Association grades. CONCLUSIONS: Nontraumatic SCI shows a relatively even sex distribution and tends to affect older adults. Injuries are mainly attributable to age-related conditions and result mostly in incomplete lesions, which present with paraplegia. This study revealed that although incidence rates for nontraumatic SCI are similar to those previously reported for traumatic SCI in the same area and during the same period, demographic and clinical characteristics are different. These findings have important implications regarding the delivery of rehabilitation and support services to this group of patients, and suggest the need for health policies that involve improved care and prevention resources.

Nosocomial transmission of sporadic Creutzfeldt-Jakob disease: results from a risk-based assessment of surgical interventions.

OBJECTIVES: Evidence of surgical transmission of sporadic Creutzfeldt-Jakob disease (sCJD) remains debatable in part due to misclassification of exposure levels. In a registry-based case-control study, the authors applied a risk-based classification of surgical interventions to determine the association between a history of surgery and sCJD. DESIGN: Case-control study, allowing for detailed analysis according to time since exposure. SETTING: National populations of Denmark and Sweden. PARTICIPANTS: From national registries of Denmark and Sweden, the authors included 167 definite and probable sCJD cases with onset during the period 1987-2003, 835 age-, sex- and residence-matched controls and 2224 unmatched. Surgical procedures were categorised by anatomical structure and presumed risk of transmission level. The authors used logistic regression to determine the odds ratio (OR) for sCJD by surgical interventions in specified time-windows before disease-onset. RESULTS: From comparisons with matched controls, procedures involving retina and optic nerve were associated with an increased risk at a latency of ≥1 year OR (95% CI) 5.53 (1.08 to 28.0). At latencies of 10 to 19 years, interventions on peripheral nerves 4.41 (1.17 to 16.6) and skeletal muscle 1.58 (1.01 to 2.48) were directly associated. Interventions on blood vessels 4.54 (1.01 to 20.0), peritoneum 2.38 (1.14 to 4.96) and skeletal muscle 2.04 (1.06 to 3.92), interventions conducted by vaginal approach 2.26 (1.14 to 4.47) and a pooled category of lower-risk procedures 2.81 (1.62 to 4.88) had an increased risk after ≥20 years. Similar results were found when comparing with unmatched controls. INTERPRETATION: This observation is in concordance with animal models of prion neuroinvasion and is likely to represent a causal relation of surgery with a non-negligible proportion of sCJD cases.