Prevalence of diabetes mellitus secondary to pancreatic diseases (type 3c).

BACKGROUND: Diabetes mellitus secondary to pancreatic diseases is a condition seldom thought of in clinical practice. Yet, a high percentage of exocrine pancreatic insufficiency has been reported for the general population and especially for diabetic subjects. Thus, we investigated the prevalence of diabetes mellitus due to pancreatic diseases. METHODS: In this study, we investigated 1868 patients diagnosed with diabetes mellitus who had been admitted to our hospital during the last 24 months. Patient data were diligently studied, and patients were reclassified according to the diabetes classification as proposed by the American Diabetes Association. RESULTS: Among 1868 subjects, 172 patients could be classified as type 3c diabetes mellitus (9.2%). Among these were 135 diagnosed with chronic pancreatitis (78.5%), 12 with hereditary haemochromatosis, 14 with pancreatic cancer and 7 with cystic fibrosis. Thus, diabetes mellitus due to chronic pancreatitis occurred in this collective in 7.2% of all diabetic subjects. Misclassification of these patients was very common. Only 51.2% (88/172) were initially classified correctly. Most type 3 diabetes patients were initially misclassified as type 2 diabetes (69/84). CONCLUSIONS: Diabetes mellitus secondary to pancreatic diseases (especially chronic pancreatitis) seems more common than generally believed with a prevalence of 9.2% among the subjects studied here. Because the awareness of this diabetes type is poor, misclassification is quite frequent. A common problem seems to be the differentiation between type 2 and type 3. Yet, the right classification of diabetes mellitus is important, because there are special therapeutic options and problems in patients with diabetes secondary to pancreatic diseases.

Determinants of Exocrine Pancreatic Function as Measured by Fecal Elastase-1 Concentrations (FEC) in Patients with Diabetes mellitus.

OBJECTIVE: Recently it has been shown that there is not only endocrine insufficiency in diabetic patients, but a frequent co-morbidity of both, the endocrine and exocrine pancreas. The present study was performed to further analyse the determinants of exocrine pancreatic function in patients with diabetes mellitus. METHODS: The records of 1992 patients with diabetes mellitus who had been treated in our hospital during a 2-year period were re-evaluated. Defined parameters were documented in standardized data sheets. Records were further checked for the results of imaging procedures of the pancreas. In 307 patients FEC had been performed and documented. Only these patients were included in further evaluation. RESULTS: FEC was inversely correlated with diabetes duration and HbA1c-levels but not with age. C-peptide levels correlated positively with FEC. BMI and FEC were also significantly correlated. There was no correlation between diabetes therapy and exocrine pancreatic function as there was no correlation with any concomitant medication. The presence of diabetes-associated antibodies was not related to FEC. According to the documented data 38 were classified as type-1 diabetes (12.4%), 167 as type-2 (54.4%), and 88 patients met the diagnostic criteria of type-3 (28.7%). Fourteen patients could not be classified because of lacking information (4.6%). CONCLUSIONS: Exocrine insufficiency might be explained as a complication of diabetes mellitus. However, it is more likely that type-3 diabetes is much more frequent than previously believed. Consequently the evaluation of exocrine function and morphology should be included into the clinical workup of any diabetic patient at least at the time of manifestation.

[Fractures in the elderly: are postal questionnaires sufficiently sensitive?]. / Frakturen im höheren Lebensalter: Wie sensitiv sind postalische Fragebögen?

Within the European Prospective Osteoporosis Study the validity of a postal questionnaire concerning fractures in the elderly was assessed. A sample of 144 men and women aged 50 to 84 hospitalized in an urban hospital due to fractures within the past 12 months was investigated. Eight percent of the respondents denied any recent fracture and turned out to be false negatives, less than previously recorded. Mode and frequency of questioning seem to influence the results. To assess fracture localisation, we used a graphical method (mannequin). Due to various factors, one third of all localisations were incorrect.

[Current musculoskeletal symptoms in peri and postmenopausal women: results of a multicenter population epidemiological study. The EVOS Study Group]. / Aktuelle muskuloskeletale Beschwerden bei peri- und postmenopausalen Frauen: Ergebnisse einer multizentrischen bevölkerungsepidemiologischen Studie. EVOS-Studiengruppe.

Within the European vertebral osteoporosis study four stratified systematic samples of German residents aged 50-79 in Lübeck, Heidelberg, Jena and East Berlin have been drawn. Overall 4628 subjects were included, of whom 4385 were contactable and 3106 (71%) responded to the postal questionnaire enquiring about rheumatic complaints "today". 2348 (54%) followed an invitation to a medical examination in which a specific gynaecological history was taken. The prevalence of current back-, neck- and joint-pain is consistently higher in females than in males in all age groups. Females show a peak prevalence in the age group 55-64. 104/1134 women were pre- or perimenopausal. 1030 women had not had their period for at least 13 months and were classified as "postmenopausal". Neither the menopausal status nor the duration of the postmenopause were statistically significantly associated with the frequency of the three rheumatic complaints.

[European Study of Vertebral Osteoporosis (EVOS): design and implementation in 8 German study centers]. / Die europäische Studie zur vertebralen Osteoporose (EVOS): Design und Durchführung in acht deutschen Studienzentren.

BACKGROUND: The European Vertebral Osteoporosis Study (EVOS), a multinational multicenter cross sectional study, was aimed to determine the prevalence of vertebral deformities, their risk factors and health impact. METHODS: Between 1991 and 1993 4487 men and women aged 50 to 79 years were examined in 8 German study centres. Health impact, back pain and functional capacity were assessed in postal questionnaires. In medical interviews data was also collected on putative risk factors for osteoporosis including details on personal and medical history, drug use, diet, smoking, alcohol, exercise and gynaecological characteristics. Four thousand one hundred and twenty-two persons underwent a lateral X-ray examination of the thoracical and lumbar spine, representing a quarter of the 16,000 European participants.

[European Study of Vertebral Osteoporosis (EVOS): cooperation of participants and selection bias in Germany]. / Die europäische Studie zur vertebralen Osteoporose (EVOS): Teilnahmebereitschaft und Selektionsverzerrung in Deutschland.

BACKGROUND: In population-based studies non-participation rates of about one third of the sample can be expected. The number of refusals may even be higher, if personal attendance of the subjects is requested. A different participation behaviour of the diseased and non-diseased may affect the prevalence estimation of a disease as well as the risk factor association. METHODS AND RESULTS: The European Vertebral Osteoporosis Study (EVOS) is an international, multicenter, cross-sectional survey in men and women aged 50 to 79 years. Within Europe 36 centres recruited 17,342 participants. The 8 German centres contribute about one forth of the data. In Germany subjects were recruited in several steps: random sample drawing from population registries, initial postal questionnaire, medical interview, lateral X-rays of the thoracic and lumbar spine. Depending on the extent of participation a variable amount of sociodemographic data and information on subjective health is available from the non-reachable, non-responders, and responders with incomplete and with complete examination. A comparison of the different participation groups showed, that especially old women were lost from the study. Compared to those, who only answered to an initial questionnaire, subjects, who were interviewed and X-rayed, more often suffered from back pain but reported a better functional capacity. This could be a hint on a selection of a population of the "worried well". CONCLUSION: On the whole the selection processes seem to have a minor influence on the outcome. The initial postal questionnaire turned out to be effective in collecting basic information from those who refused to attend a personal examination.

[The reliability of radiologic findings for differential diagnosis of vertebral osteoporosis]. / Die Reliabilität radiologischer Befunde zur Differentialdiagnose der vertebralen Osteoporose.

BACKGROUND: Radiologically identified vertebral deformities, e.g. wedge-, fish-, or crush-vertebrae are not always a consequence of local osteoporosis. Other frequent pathomechanisms include Morbus Scheuermann, degenerative changes, overt trauma, and congenital dysplasia. This requires differential diagnosis of vertebral deformities. Radiological classification criteria have to satisfy various methodological requirements to ensure reliability of the results. METHODS: Inter-rater reliability of more than 30 radiological findings was assessed in 4 German centres of the European Vertebral Osteoporosis Study (EVOS). One hundred randomly selected EVOS cases from the West-Berlin population, each contributing 2 lateral X-rays from the thoracic and lumbar spine respectively, were independently evaluated by 7 observers. All observers were medical doctors, 4 of them heads or members of clinical radiological departments. Thus each observer read 200 radiographs. Radiological alterations in the form and structure of 13 vertebrale which were considered to be relevant for the differential diagnosis of osteoporosis were recorded in a standardized documentation form. Additionally global judgements (e. g. "osteoporotic spine" yes/no) were required. To quantify agreement Fleiss' kappa (kappa) for nominal data and multiple observers was used.

[The need for rehabilitation services: concept and data]. / Bedarf an rehabilitativen Leistungen: Theorie und Empirie.

Whether rehabilitation services are initiated, applied for and (granted by German statutory pension funds) according to objectifyable need is uncertain as long as we lack a scientifically valid and operationally defined concept of "rehabilitation need". Traditionally three criteria are mentioned: neediness, ability, and prognosis. The text extends and specifies these criteria based on theoretical grounds, research evidence, and sociolegal considerations. It introduces a screening algorithm to objectify and assess individual rehabilitation needs focusing, as far as they are risk factors for participation restrictions, on a central disorder and its complications, risk and prognostic factors, comorbidities, motivational and other context factors. It proposes to relate more or less complex disturbances of functional health to more or less complex rehabilitation programmes and to indicate the typically complex ("holistic") in-patient rehabilitation only for equally complex health impairments and participation restrictions. Illustrative empirical data relate to three disorders, diabetes mellitus type 2, chronic disabling back pain, and chronic obstructive lung disease.

[Chronic back pain: more than pain in the back. Findings of a regional survey among insurees of a workers pension insurance fund]. / Chronische Rückenschmerzen: Mehr als Schmerzen im Rücken. Ergebnisse eines regionalen Surveys unter Versicherten einer Landesversicherungsanstalt.

BACKGROUND: Surveys with a main focus on back pain tend to isolate the complaint from possibly concomitant pains, other symptoms and disorders. Severe chronic back pain is assumed here to imply more than pain in the back. PARTICIPANTS AND METHODS: We report results from a two stage survey conducted in 1998 - 2000. The initial postal questionnaire addressed all 10,000 actively employed blue collar workers from a regional pension fund (Landesversicherungsanstalt Schleswig-Holstein) aged 40 - 54 and residing in or around Luebeck/Germany (68 % males). Subjects reporting severe and disabling back pain were invited to a socio-medical examination. The response and participation rates were 58 % and 65 % respectively. Non-response and non-participation seem to result in minor though opposite, effects. RESULTS: The prevalence of current back pain (back pain of any severity within the past 7 days) is high (68 %; including 16 % with severe, disabling back pain) despite the preponderance of males and a probable healthy worker effect. 82 % of subjects participating in the second round reported recurrent or persisting back pain on the day of examination, in the majority with a chronic fluctuating and overall deteriorating course pattern. 18 % reported no current back pain and hence gave prospective (and additionally retrospective) evidence of an episodic-intermittent course of the disorder. The former group showed significantly more pains, bodily complaints, dysfunctional cognitions, emotional distress and concomitant disorders. 35 % of them indicated back pain as their dominant health problem; 49 % identified back pain and another disorder as dominant, and 16 % reported other prominent health problems. More than 70 % of "other" disorders originated from the musculoskeletal system often involving the extremities. SUMMARY AND CONCLUSION: Back pain is very common among blue collar workers. Severe disabling back pain is usually associated with numerous other pains, bodily complaints, disorders, and indicators of psychological distress ("amplified back pain"). However, even amplified back pain is not always the sole or dominant health problem. Assessing the degree of "amplification" seems helpful in splitting a previously homogeneous group of severely affected back pain sufferers-with possible prognostic and therapeutic consequences.

[Physical impairments and comorbidities in a sample of members of a pension fund of blue-collar workers suffering from severe low back pain]. / Anamnestische und klinische Befunde bei schweren Rückenschmerzen: eine klinisch epidemiologische Untersuchung an einer Stichprobe von LVA-Versicherten.

AIM: Idiopathic (unspecific) low back pain is the most common rheumatological complaint. Results of international studies give evidence that in about 80 % of the cases a specific diagnosis is not possible, thus creating an unsatisfactory situation for the orthopaedist. We feel that it is necessary to keep the discussion on the rate of specific causes for low back pain open. METHODS: In the context of a research project on the need for rehabilitation, 335 subjects suffering from severe low back pain were subjected to a physical (orthopaedic-neurological) examination. Also, a questionnaire was distributed assessing psychological status, work situation, comorbid conditions, risk factors, and demography. RESULTS: In more than half of the subjects, clues for a specific cause for the back pain were found; in more than one third of the cases there were one or more neurological signs. CONCLUSION: The data presented demonstrate that specific causes for low back pain might be more common than generally assumed. This leads us to the conclusion that there is a need for more clinically-oriented, population-based (epidemiological) research on possible pathologic causes of low back pain and comorbid conditions.

[Rehabilitation score for patients with type 2 Diabetes mellitus: An instrument to standardize assessment of the need for rehabilitation]. / Reha-Score für Typ-2-Diabetes mellitus: Ein Instrument zur Abschätzung des Rehabilitationsbedarfs.

Type 2 diabetes is considered a multidimensional health impairment which includes several components like risk factors, cofactors and complications. The early and consequent therapy of all of these components reduces secondary complications. Instead of simply applying drug treatment, a more holistic concept including behavioural medicine therapy and empowerment of patients has been found much more effective. The facilities required for such a multifactorial therapy by different health care professions could easily be provided by the medical rehabilitation services available under the German pension insurance scheme. However, this emphasizes the demand for standardized protocols to achieve an objective allocation of rehabilitation services to individuals in need. In an epidemiological study on 12 429 working insurants (age 41 - 60 years) of the pension insurance fund in the region of Luebeck, persons suffering from type 2 diabetes were identified and evaluated regarding a need for medical rehabilitation. Therefore, an algorithm was developed quantifying the multidimensional disturbances which accumulate in type 2 diabetes mellitus. The following indicators are taken into consideration: risk factors like eating behaviour, lack of physical activity, smoking and stress; metabolic parameters such as HbA1c and plasma lipids; cofactors like hypertension and depression and, additionally, the acute complication of hypoglycaemia. Based on this rehabilitation score, 19 % of cases in a preliminary evaluation of 79 patients with type 2 diabetes showed a need for medical rehabilitation therapy.

Validity of self-report of fractures: results from a prospective study in men and women across Europe. EPOS Study Group. European Prospective Osteoporosis Study Group.

In population-based studies of osteoporosis, ascertainment of fractures is typically based on self-report, with subsequent verification by medical records. The aim of this analysis was to assess the validity of self-report of incident nonspine fractures using a postal questionnaire. The degree of overreporting of fracture (false positives) was assessed by comparing self-reports of new fracture from respondents in the multicenter European Prospective Osteoporosis Study with data from other sources including radiographs and medical records. In the analysis, 563 subjects reported nonspine fractures. Verification of the presence of fracture was possible in 510 subjects. Of these, fractures were not confirmed in 11% (false positives). The percentage of false positives was greater in men than in women (15% vs 9%, p = 0.04), and less for fractures of the distal forearm and hip than for fractures at other sites. In a separate study, the degree of underreporting (false negatives) was assessed by follow-up of 251 individuals with confirmed fracture ascertained from the records of fracture clinics in three European centers (Lubeck, Oviedo, Warsaw). Questionnaire responses were received from 174 (69%) subjects. Of these, 12 (7%) did not recall sustaining a fracture (false negatives). The percentage of false negatives was lower for hip and distal forearm fractures with only 3 of 90 (3%) such fractures not recalled. Using the combined data from both studies, of those who reported a 'date' of fracture on the questionnaire, 91% of subjects were correct to within 1 month of the actual date of the fracture. A postal questionnaire is a relatively simple and accurate method for obtaining information about the occurrence of hip and distal forearm fractures, including their timing. Accuracy of ascertainment of fractures at other sites is less good and where possible self-reported fractures at such sites should be verified from other sources.