Determinants of the size of incident vertebral deformities in European men and women in the sixth to ninth decades of age: the European Prospective Osteoporosis Study (EPOS).

UNLABELLED: More severe vertebral fractures have more personal impact. In the European Prospective Osteoporosis Study, more severe vertebral collapse was predictable from prior fracture characteristics. Subjects with bi-concave or crush fractures at baseline had a 2-fold increase in incident fracture size and thus increased risk of a disabling future fracture. INTRODUCTION: According to Euler's buckling theory, loss of horizontal trabeculae in vertebrae increases the risk of fracture and suggests that the extent of vertebral collapse will be increased in proportion. We tested the hypothesis that the characteristics of a baseline deformity would influence the size of a subsequent deformity. METHODS: In 207 subjects participating in the European Prospective Osteoporosis Study who suffered an incident spine fracture in a previously normal vertebra, we estimated loss of volume (fracture size) from plane film images of all vertebral bodies that were classified as having a new fracture. The sum of the three vertebral heights (anterior, mid-body, and posterior) obtained at follow-up was subtracted from the sum of the same measures at baseline. Each of the summed height loss for vertebrae with a McCloskey-Kanis deformity on the second film was expressed as a percentage. RESULTS AND CONCLUSIONS: In univariate models, the numbers of baseline deformities and the clinical category of the most severe baseline deformity were each significantly associated with the size of the most severe incident fracture and with the cumulated sum of all vertebral height losses. In multivariate modeling, age and the clinical category of the baseline deformity (crush > bi-concave > uni-concave > wedge) were the strongest determinants of both more severe and cumulative height loss. Baseline biconcave and crush fractures were associated at follow-up with new fractures that were approximately twice as large as those seen with other types of deformity or who previously had undeformed spines. In conclusion, the characteristics of a baseline vertebral deformity determines statistically the magnitude of vertebral body volume lost when a subsequent fracture occurs. Because severity of fracture and number of fractures are determinants of impact, the results should improve prediction of the future personal impact of osteoporosis once a baseline prevalent deformity has been identified.

Incidence of vertebral fracture in europe: results from the European Prospective Osteoporosis Study (EPOS).

Vertebral fracture is one of the major adverse clinical consequences of osteoporosis; however, there are few data concerning the incidence of vertebral fracture in population samples of men and women. The aim of this study was to determine the incidence of vertebral fracture in European men and women. A total of 14,011 men and women aged 50 years and over were recruited from population-based registers in 29 European centers and had an interviewer-administered questionnaire and lateral spinal radiographs performed. The response rate for participation in the study was approximately 50%. Repeat spinal radiographs were performed a mean of 3.8 years following the baseline film. All films were evaluated morphometrically. The definition of a morphometric fracture was a vertebra in which there was evidence of a 20% (+4 mm) or more reduction in anterior, middle, or posterior vertebral height between films--plus the additional requirement that a vertebra satisfy criteria for a prevalent deformity (using the McCloskey-Kanis method) in the follow-up film. There were 3174 men, mean age 63.1 years, and 3,614 women, mean age 62.2 years, with paired duplicate spinal radiographs (48% of those originally recruited to the baseline survey). The age standardized incidence of morphometric fracture was 10.7/1,000 person years (pyr) in women and 5.7/1,000 pyr in men. The age-standardized incidence of vertebral fracture as assessed qualitatively by the radiologist was broadly similar-12.1/1,000 pyr and 6.8/1,000 pyr, respectively. The incidence increased markedly with age in both men and women. There was some evidence of geographic variation in fracture occurrence; rates were higher in Sweden than elsewhere in Europe. This is the first large population-based study to ascertain the incidence of vertebral fracture in men and women over 50 years of age across Europe. The data confirm the frequent occurrence of the disorder in men as well as in women and the rise in incidence with age.

Social and emotional problems in early rheumatoid arthritis. 75 patients followed up for two years.

Seventy-five patients with an early RA (disease duration between 2 and 12 months; 79% female; average age 49 years; 72% with "definite" RA) were followed in a prospective study over a period of 2 years. Within this 24 month observation period there was a drop in the average diagnostic ARA count from 5.0 to 4.2, in the ESR from 48 to 31 mm within the first hour and also in the number of affected joints from 13 to 9. Pain intensity and functional capacity showed a slight decrease in the average score. Despite a consistent antirheumatic therapy (72% on RID's after one year) there was a noticeable increase from 23 to 58% in the prevalence of patients with any erosive changes in the X-ray. Within the two years of this study one third of the patients employed at the onset had to quit their job. The number of patients retired due to RA rose from 0 to 23%. A comparison of two groups of patients (employed versus retired) revealed no significant differences in the initial examination with one exception: The patients eventually retired by the end of the study were significantly older with an average age of 51 versus 39 in the group of still employed patients. On the other hand, by the end of the study the patients remaining employed for the duration of the 2 years were significantly less active and also less severely diseased and handicapped. The number of patients with clinically relevant depression (BDI) or anxiety (STAI) did not change significantly over the 24 month period.(ABSTRACT TRUNCATED AT 250 WORDS)

[Do patients with active chronic polyarthritis get "basic therapy"?]. / Erhalten Kranke mit einer aktiven chronischen Polyarthritis eine "Basistherapie"?

The determination of the adequacy of an individual therapeutical regimen is part of the process evaluation of medical care. To evaluate the adequacy of individual antirheumatic therapy, we developed a five step procedure: 1. Assessment of the patient's health status; 2. assessment of his/her former and current therapy; 3. determination of the adequate antirheumatic therapy following an explicit norm; 4. formal comparison of current and adequate treatment; 5. clinical evaluation of possible differences between norm and reality. Due to methodological reasons we concentrated on the current treatment of rheumatoid arthritis (rA) patients with remission inducing drugs (RIDs; e.g. Chloroquine, Gold). The study analyzed the RID treatment of 75 rA-sufferers; 25 patients were referred to our outpatient department for the first time in late 1986; 25 patients were recruited from a social-medical study covering employed but actually disabled members of a major health insurance (AOK) in Hannover; 25 subjects were derived from an ongoing population study ("prevalence and care of rheumatoid arthritis in Hannover"). Only 9 out of 49 (18%) patients with an active disease, formally in need of treatment, were currently treated with RIDs. Thus 40 out of 49 (82%) seemed to be under an inadequate treatment. From the clinical point of view this formal judgement was assumed to be false positive in 5 and false negative in 15 cases. In relation to the clinical judgements we found for the formal procedure a sensitivity of 0.70 with a specificity of 0.80 and an overall agreement of 73% (kappa 0.44).

[Physician consultation and use of drugs for rheumatic symptoms]. / Arztbesuch und Medikamenteneinnahme wegen rheumatischer Beschwerden.

Between May 1986 and November 1987 we asked 4037 randomly sampled 25-74 year old german residents at Hannover (FRG) by a mailed questionnaire for back, neck and joint pain, for joint swelling and morning stiffness. Further we asked for the consultation of a physician during the past 12 months and for the use of drugs during the past 7 days because of rheumatoid complaints. 3426 members of the sample (85%) returned the questionnaire. 1828 (53%) reported at least one symptom "today" (= "the day you fill out this questionnaire"). The highest rate of persons suffering from complaints of the locomotor system was found among middle-aged women, with the maximum of 74% in the age group 50-54 years. For the illness behavior-physician consultation, use of drugs-the extent of complaints was of decisive importance. Sex was without, age of very low influence. The rate of those who reported the consultation of a physician and/or the use of drugs was increasing with the amount of positive answers to the questions on rheumatoid complaints. Nevertheless, of those who had answered in the affirmative all questions on complaints, 10% had denied the question on physician consultation. 41% had denied the question on the use of analgetic/antirheumatic drugs.

[Checklist for methodological quality of guidelines. A contribution to quality promotion of medical guidelines]. / Die Checkliste zur methodischen Qualität von Leitlinien. Ein Beitrag zur Qualitätsförderung ärztlicher Leitlinien.

The society of physicians of Germany and the society of panel physicians laid down in the "assessment criteria for guidelines in medical care" what kind of demands the medical selfadministration makes on guidelines. This measure also had the goal to support and strengthen the efforts of the AWMF for guidelines of high value. On the basis of these assessment criteria, a tool was compiled for the systematic registration and documentation of quality criteria for good guidelines for the first time in areas of German language. This check list is guided by the structure and content of the "Criteria for Appraisal for National Guidelines" by the Scottish Intercollegiate Guidelines Network.

[The current backache epidemic]. / Die aktuelle Rückenschmerzepidemie.

All available data presented show that we are confronted with a back-pain (BP) epidemic; it affects numerous industrialized countries. More severe forms of BP make up one fifth of the prevalence. The greater part of BP seems to be mild, especially among persons aged 25 to 54. The social insurance statistics, too, show an alarming trend. Cases of work incapacity and medical rehabilitation have increased drastically: one sixth of all cases of work incapacity as well as one third of all medical rehabilitations are to be accounted to BP. It is not easy to interpret the data. Do they represent an increasing BP epidemic? A long-term secular trend towards higher BP prevalences at the population level is to be assumed but cannot be proven at the moment. Is there any evidence that BP-related risk factors have increased? To our knowledge there are no reliable data. It is also to be considered that the 'natural' course of BP may have changed. Is the epidemic a consequence of an increasing 'chronification' of BP due to physical, psychosocial or medical influences? Do 'back-schools' and other factors regarding the BP business have only health-promoting effects? Does the date represent a changing perception and appraisal of pain and/or a changing 'pain-reporting behaviour'? Is 'pain' today what would have been 'discomfort' in former times? Does one complain about BP today when one would have been silent in former times? There are no valid data for these hypotheses, either. Finally, has the transition probability from pain to disability and to social benefits changed?(ABSTRACT TRUNCATED AT 250 WORDS)

[Grading of backache]. / Zur Graduierung von Rückenschmerzen.

Back pain is occurring in a broad spectrum of severity; therefore, a grading procedure which is derived from a sound conceptual basis and can be easily applied is of crucial importance in clinical research and in epidemiologic studies. Following a grading procedure which has been developed in epidemiologic studies in the U.S., a hierarchical model for grading is proposed. This comprises pain intensity and functional limitation as basic criteria as well as aspects of time, pain-related cognitions/emotions and concomitant complaints. An application of a simple grading procedure is used to illustrate the predictive utility of the proposed model.

[Minimum requirements in medical expert assessment of occupational disability of patients with chronic nonspecific pain]. / Mindestanforderungen an das ärztliche Gutachten zur erwerbsbezogenen Leistungsfähigkeit von Kranken mit chronisch-unspezifischen Schmerzen.

Assessing working capacity in patients with chronic nonspecific pain disorders applying for disability pensions is a core tasks of practical social medicine. Traditionally the evaluation focused on the nosological classification and clinical description of the pain disorder with rather vague concepts of its consequences in terms of disabilities and handicaps. The author proposes to reverse the sequence. Following the International Classification of Impairments, Disabilities and Handicaps (WHO 1980) work incapacity can be seen as an "occupational handicap". Its qualities, severity and credibility depend on the existence of objectifyable disabilities (especially behaviour, locomotor, body disposition, dexterity and situational disabilities). These may be attributed to clinical impairments and an underlying disease process. Among impairments pain has to be assessed multidimensionally. As in clinical medicine a nosological diagnosis is a useful but neither necessary nor sufficient prerequisite for a sociomedical evaluation of pain patients.

[Measuring work capacity in rheumatic diseases: functional disability, pain, pain-related cognitions and affects]. / Zur Messung des Leistungsvermögens bei rheumatischen Erkrankungen: Funktionsbehinderung, Schmerz, schmerzbezogene Kognitionen und Affekte.

Rheumatic diseases, particularly those affecting the back, cervical spine, and the joints, are widespread in the general population. The general costs, especially those associated with social medical services, show constant increases. Time and effectiveness lost from work due to back problems in the FRG accounted for most of the days off the job because of disability, time spent in the hospital or at a health spa facility. Therefore, the appropriate evaluation of the degree of disability plays an increasingly important role in the area of social benefits. Yet unambiguous and objective physical measurements of the disease and the degree of associated disability are lacking in most cases of rheumatic diseases. More attempts to address the subjective aspects of the disease should be included in such evaluations. For recent years, models of measurement have been developed and tested, which are suited to the multidimensional nature of rheumatic illnesses. It is recommended that these be introduced in routine use for physical evaluations.

Whom to treat? The contribution of vertebral X-rays to risk-based algorithms for fracture prediction. Results from the European Prospective Osteoporosis Study.

INTRODUCTION: Vertebral fracture is a strong risk factor for future spine and hip fractures; yet recent data suggest that only 5-20% of subjects with a spine fracture are identified in primary care. We aimed to develop easily applicable algorithms predicting a high risk of future spine fracture in men and women over 50 years of age. METHODS: Data was analysed from 5,561 men and women aged 50+ years participating in the European Prospective Osteoporosis Study (EPOS). Lateral thoracic and lumbar spine radiographs were taken at baseline and at an average of 3.8 years later. These were evaluated by an experienced radiologist. The risk of a new (incident) vertebral fracture was modelled as a function of age, number of prevalent vertebral fractures, height loss, sex and other fracture history reported by the subject, including limb fractures occurring between X-rays. Receiver Operating Characteristic (ROC) curves were used to compare the predictive ability of models. RESULTS: In a negative binomial regression model without baseline X-ray data, the risk of incident vertebral fracture significantly increased with age [RR 1.74, 95% CI (1.44, 2.10) per decade], height loss [1.08 (1.04, 1.12) per cm decrease], female sex [1.48 (1.05, 2.09)], and recalled fracture history; [1.65 (1.15, 2.38) to 3.03 (1.66, 5.54)] according to fracture site. Baseline radiological assessment of prevalent vertebral fracture significantly improved the areas subtended by ROC curves from 0.71 (0.67, 0.74) to 0.74 (0.70, 0.77) P=0.013 for predicting 1+ incident fracture; and from 0.74 (0.67, 0.81) to 0.83 (0.76, 0.90) P=0.001 for 2+ incident fractures. Age, sex and height loss remained independently predictive. The relative risk of a new vertebral fracture increased with the number of prevalent vertebral fractures present from 3.08 (2.10, 4.52) for 1 fracture to 9.36 (5.72, 15.32) for 3+. At a specificity of 90%, the model including X-ray data improved the sensitivity for predicting 2+ and 1+ incident fractures by 6 and 4 fold respectively compared with random guessing. At 75% specificity the improvements were 3.2 and 2.4 fold respectively. With the modelling restricted to the subjects who had BMD measurements (n=2,409), the AUC for predicting 1+ vs. 0 incident vertebral fractures improved from 0.72 (0.66, 0.79) to 0.76 (0.71, 0.82) upon adding femoral neck BMD (P=0.010). CONCLUSION: We conclude that for those with existing vertebral fractures, an accurately read spine X-ray will form a central component in future algorithms for targeting treatment, especially to the most vulnerable. The sensitivity of this approach to identifying vertebral fracture cases requiring anti-osteoporosis treatment, even when X-rays are ordered highly selectively, exceeds by a large margin the current standard of practice as recorded anywhere in the world.

[On informing in-patients, and the problem of hospitalism (author's transl)]. / Die Aufklärung des Krankenhauspatienten und das Problem des Hospitalismus.

Sixty-seven in-patients, admitted to neurological or surgical wards of an acute hospital, were repeatedly interviewed during an average stay of 15 days to test their need for information about their illness, their satisfaction with information received and their knowledge about their illness. Parallel to these interviews psychometric tests were performed on the second, seventh and penultimate day of the hospital stay, in the evening, to assess the extent of any disturbance in their subjective condition. Independent of the initial state, there were consistently less favourable results in those patient groups which (using several indicators) had a deficit in subjective information. These group-specific differences were in part statistically significant. An intervening influence of 12 personality dimensions was not definitely established. These findings support the hypothesis that deficient instruction and information of in-patients represents an important stress component which in the majority of these patients can give rise to an objectifiable psychosocial hospitalism.

[Chronic pain: epidemiology and health care utilization]. / Chronischer Schmerz: Epidemiologie und Inanspruchnahme.

The prevalence of chronic pain in the general population ranges from 10% to over 40%, depending on the investigation and definition. Chronic pain is tied to high direct and indirect costs for the health care system on the one hand and considerable personal impairment of the quality of life on the other. The present paper provides an overview of the frequency and distribution of chronic pain in the general population and among those receiving treatment. The limitations of epidemiological investigations lie in the difficulty of validly assessing subjective internal experiences of the patients. Moreover, it is not possible to make diagnoses in the proper sense. In contrast, the examination of patients seeking and receiving treatment offers a further diagnostic differentiation and better assessment of the qualitative aspects of the pain experience. However, the meaningfulness of these studies is also limited due to the qualitative problems. Despite the methodological limitations of the studies investigated, the wide distribution and meaning of chronic pain becomes clear particularly when evaluating studies on the general population and populations receiving treatment.

[The attitude of medical students towards informing patients of their condition (author's transl)]. / Wie stehen vorklinische Medizinstudenten zur Aufklärung der Patienten?

During the winter term 1976/77 and in the summer term 1977 233 medical students of the fourth term were asked about their "attitudes and experiences" as "to which extent the patient wants to be and should be informed about his illness". About half of the investigated students--the number varies with the indicator--displayed attitudes and experiences corresponding to the patients' reality and needs. This was rated as an indicator of patient-centered orientation. The rest displayed patterns of attitudes and presuppositions similar to those we noted in physicians in hospital. The patients' great need of information is usually underrated, the individual aspects are not clearly recognized and there is only a slight inclination to tell the patient the whole truth, especially with regards to the prognosis. Age, sex, experiences in hospitals and professional objective of each of the investigated students do not have a relationship with these orientations. Having given a critical discussion of methods the authors demonstrate the didactic conclusions which the Marburg Institute of Medical Sociology would draw from its investigations.

[Fibromyalgia syndrome. Current contributions to the etiology, diagnosis and therapy of so-called "soft tissue rheumatism"]. / Das fibromyalgische Syndrom. Ein aktueller Beitrag zur Atiologie, Diagnose und Therapie des sogenannten "Weichteilrheumatismus".

The fibromyalgia syndrome (FMS) is an extraarticular rheumatic disease. Typical features are the chronic, polytopic pain in the musculoskeletal system and the provocation of pain by pressure on defined tender points. Mainly medium age women are affected by the disease. In histomorphological studies of muscle tissue non-specific changes were demonstrated, which were thought to be due to ischemia. Furthermore, sleep disturbance and a reduced pain threshold, which may be related to psychological factors, are discussed in the etiology. In FMS a primary and a secondary form related to other diseases can be differentiated. The treatment consists mainly of behaviour therapy and physiotherapy.

[Arthritic pain and psychological distress in patients with chronic polyarthritis]. / Arthritische Schmerzen und seelische Leiden bei Patienten mit einer chronischen Polyarthritis.

Pain intensity and sensory dimensions of pain experience were studied in four samples totalling 346 patients with rheumatoid arthritis. 35%-61% of these patients suffer from severe pain. Arthritic pain is not automatically associated with emotional disorder. However, we met significant correlations of pain intensity with depression, trait anxiety, and state anxiety. Three hypotheses about the relation between pain and emotional state are discussed. Within one third of the patients we observed a paradoxical pain-mood pattern. Within the greater part of the patients severe pain is accompanied by considerable emotional suffering. The question of whether pain intensity is the cause of or the result from depression cannot be answered. However, predicting pain intensity from depression scores is much easier than predicting depression from pain intensity.

[Epidemiology of rheumatic diseases in the German Federal Republic-- current state and perspectives]. / Rheumaepidemiologie in der Bundesrepublik Deutschland--Stand und Perspektiven.

During the last few years epidemiologic research on rheumatic diseases in the Federal Republic of Germany has been sponsored, primarily, by the Ministry of Research and Technology. The projects, either completed, ongoing or planned, concentrate on health services research, population studies of the prevalence of specific diseases or complaints (rheumatoid arthritis, back pain, juvenile chronic arthritis, osteoarthritis) and clinical epidemiology, especially concerning early arthritis. As a result of the general shortage of public funds, less projects could be sponsored than expected. The aim of the Ministry to establish research organizations that will continue to exist even if public funding is curtailed seems to be jeopardized. Therefore, not only the federal government, but also the federal states and institutions like the Deutsche Forschungsgemeinschaft should be engaged in this field. More groups should have the opportunity to work in epidemiology of rheumatic diseases, and groups which are able to work in close connection with basic scientists and rheumatological clinicians should be institutionally affiliated on a permanent basis. This is critical for the further development of this discipline which is important for health services research, quality assurance, as well as for analytical research and prevention.

[Inpatient medical rehabilitation in diabetes mellitus in light of evidence based practice guidelines: an evaluation on the basis of BfA routine data]. / Leistungen der medizinischen Rehabilitation bei Diabetes mellitus vor dem Hintergrund evidenzbasierter Behandlungsleitlinien: Eine Evaluation auf der Basis von Routinedaten der BfA.

OBJECTIVE: Multidisciplinary team care is an opportunity to improve the long-term metabolic situation of patients with diabetes mellitus, hence can help reduce the individual and financial burden of diabetes-related complications. The aim of this study is to evaluate the extent to which patients undergoing rehabilitation carried by the German Federal Insurance Institute for Salaried Employees (BfA) were treated in accordance with recent evidence-based clinical practice guidelines on diabetes mellitus. METHODS: We extracted specific treatment recommendations relevant to inpatient rehabilitation from national and international evidence-based guidelines and allocated them to general subjects of diabetes care (e. g. [disease specific] education, physical activity, psychosocial interventions). In the "Classification of Therapeutic Procedures (KTL)", an instrument used to classify therapeutic procedures in rehabilitation, we then identified those procedures that represented the recommendations of the guidelines. The coded procedures were allocated to the general aspects of diabetes care, too. In total, 9 "therapeutic modules" were designed, each containing guideline-recommendations and coded procedures. Using the KTL codes documented as a routine in discharge reports, we were able to describe, analyse and evaluate the procedures performed during rehabilitation. The data set we used contained KTL codes and medical information from 9,456 patients whose rehabilitation was carried by the BfA diagnosed with either diabetes mellitus type 1 or 2, who received an inpatient rehabilitation procedure during the years 2000 and 2001. RESULTS: The number of patients who received at least one procedure out of the particular therapeutic module is as follows (numbers in brackets represent the total number of KTL codes in that therapeutic module): Therapeutic module "Education (3)" - 98.66 %, "Exercise Training (63)" - 92.42 %, "Nutrition Training (14)" - 96.44 %, "Stress (18)" - 35.33 %, "Motivation (15)" - 82.87 %, "Coping Skills (15)" - 27.42 %, "Social Work (26)" - 11.44 %, "Alcohol and Nicotine (24)" - 3.69 %, "Diabetic Complications (81)" - 75.42 %. On average patients received procedures out of 5.2 different therapeutic modules. The results were consistent over subgroups (type 1/type 2 diabetes, men/women) but varied considerably between clinics. The care provided in clinics with higher numbers of diabetic patients is more in line with guideline specifications. DISCUSSION: A substantial number of patients received procedures out of the therapeutic modules "Education", "Exercise Training", "Nutrition Training" and "Motivation". In other therapeutic modules (e. g. "Alcohol and Nicotine") deficits were noted. These deficits as well as the substantial variation between clinics demonstrate the need to develop clinical practice guidelines for rehabilitation of patients with diabetes. In principle, the results of this study have to be interpreted carefully because we did not examine to which extent the documented processes are in accordance with the realities. CONCLUSIONS: Inpatient rehabilitation of diabetic patients carried by the BfA can be characterised as multidisciplinary and in accordance with the recommendations of recent evidence-based guidelines. Certain problematic aspects should be put into focus. A guideline taking into account all rehabilitative aspects, including the preparation for and the care after the rehabilitation process, can be instrumental in reducing deficits in rehabilitative care as well as differences between clinics. To gain wide acceptance, guideline development should be coordinated by a scientific institute and involve members of all groups concerned (e. g. the rehabilitative team, GPs, patients). Within certain limits the "KTL" instrument permits evaluation of process quality in rehabilitation of patients with diabetes mellitus.