Erik Allander

The apparent incidence of hip fracture in Europe: a study of national register sources.

The objective of this study was to examine the apparent incidence of hip fracture from discharge rates in European countries. A request was sent to the Ministries of Health in all European countries, asking for the number of hip fracture patients by age and sex, between the years 1983 and 1985. Seventeen countries responded. As expected, hip fracture was most frequently found amongst the elderly, particularly women. The incidence of hip fracture rose exponentially with age in both sexes. It was higher in women than men and there was a three-fold range between countries in the female to male sex ratio. There was an eleven-fold range in apparent incidence amongst women and a seven-fold range amongst men between the various countries. The highest incidence was found in the northern part of Europe and the lowest in the Mediterranean area. There was a significant positive correlation between the age-standardized incidence rates reported in men from each country and that in women. There was a larger difference in incidence between countries than between sexes, which suggests important genetic or environmental factors in the causation of hip fracture. The extent to which this reflects imperfect capture of data is uncertain but will be important to determine in order to identify reasons for differences and to enable confident projections of the future magnitude of this disorder.

Risk Factors for Hip Fracture in Men from Southern Europe: The MEDOS Study

Abstract: The aims of this study were to identify risk factors for hip fracture in men aged 50 years or more. We identified 730 men with hip fracture from 14 centers from Portugal, Spain, France, Italy, Greece and Turkey during the course of a prospective study of hip fracture incidence and 1132 age-stratified controls selected from the neighborhood or population registers. The questionnaire examined aspects of work, physical activity past and present, diseases and drugs, height, weight, indices of co-morbidity and consumption of tobacco, alcohol, calcium, coffee and tea. Significant risk factors identified by univariate analysis included low body mass index (BMI), low sunlight exposure, a low degree of recreational physical activity, low consumption of milk and cheese, and a poor mental score. Co-morbidity including sleep disturbances, loss of weight, impaired mental status and poor appetite were also significant risk factors. Previous stroke with hemiplegia, prior fragility fractures, senile dementia, alcoholism and gastrectomy were associated with significant risk, whereas osteoarthrosis, nephrolithiasis and myocardial infarction were associated with lower risks. Taking medications was not associated with a difference in risk apart from a protective effect with the use of analgesics independent of co-existing osteoarthrosis and an increased risk with the use of anti-epileptic agents. Of the potentially ‘reversible’ risk factors, BMI, leisure exercise, exposure to sunlight and consumption of tea and alcohol and tobacco remained independent risk factors after multivariate analysis, accounting for 54% of hip fractures. Excluding BMI, 46% of fractures could be explained on the basis of the risk factors sought. Of the remaining factors low exposure to sunlight and decreased physical activity accounted for the highest attributable risks (14% and 9% respectively). The use of risk factors to predict hip fractures had relatively low sensitivity and specificity (59.6% and 61.0% respectively). We conclude that lifestyle factors are associated with significant differences in the risk of hip fracture. Potentially remediable factors including a low degree of physical exercise and a low BMI account for a large component of the total risk.

Prevalence, Incidence, And Remission Rates of Some Common Rheumatic Diseases Or Syndromes

An epidemiological survey of joint diseases was performed during the period 1965–68 covering 15000 subjects, age-range 34–74 years. For common degenerative joint syndromes or diseases criteria for epidemiological use are scarce and not generally accepted. A scheme of such criteria for 12 common rheumatic diseases or syndromes is presented. They were used to establish age- and sex-specific figures for prevalence, incidence, and estimates of remission rates. Special attention was paid to arthrosis of knee and hip joints and “tennis elbow”. Furthermore, the amount of “concealed” prevalence, i.e. a subjectively symptomless disease, was calculated for hallux valgus, hallux rigidus, hydrops of the knee, and Heberdens nodes. It could be shown that incidence and prevalence figures and remission rates indicate clear sex differences in the natural history of selected, rheumatic diseases, implying different exposure to the wear and tear of daily life. The annual incidence of painful shoulders was highest and more t...

The variable incidence of hip fracture in southern Europe: the MEDOS Study.

We assessed the incidence of hip fracture and ecological correlates in residents of 14 communities in six countries of Southern Europe. Hip fracture cases were recorded prospectively in defined catchment areas over a 1-year interval. A retrospective questionnaire was used to assess ecological differences between communities. During a 1-year period of observation a total of 3629 men and women over the age of 50 years were identified with hip fracture from a catchment of 3 million. In all communities the fracture rate increased exponentially with age. There were large and significant differences between centres in the doubling time for hip fracture risk with age and in crude and age-standardized rates. Greater than 4-fold and 13-fold differences in age-standardized risk were found amongst men and women respectively. The lowest rates were observed from Turkey and the highest from Seville, Crete and Porto. Fractures were significantly more frequent among women than men with the exception of three rural Turkish centres. Indeed, in rural Turkey the normal female/male ratio was reserved. Variations in incidence between regions were greater than the differences within centres between sexes, and there was a close and significant correlation between incidence rates for men and those for women in the regions studied. Excess female morbidity increased progressively from the age of 50 years but attained a plateau after the age of 80 years, suggesting a finite duration of the effect of the menopause. The retrospective questionnaire completed by 80% of cases suggested that differences in incidence between the communities studied could not be explained by differences in gonadal status in women. In both men and women cross-cultural associations were found with factors related to age or socioeconomic prosperity, the majority of which disappeared after adjustment for age. We conclude that there are marked and sizeable differences in the incidence rates of hip fracture throughout Southern Europe. The reasons for these differences are not known but affect both men and women, and are likely to be related to lifestyle or genetic factors rather than to differences in endocrine status.

Evidence for efficacy of drugs affecting bone metabolism in preventing hip fracture.

OBJECTIVE--To examine the effects of taking drugs affecting bone metabolism on the risk of hip fracture in women aged over 50 years. DESIGN--Retrospective, population based, case-control study by questionnaire. SETTING--14 centres in six countries in southern Europe. SUBJECTS--2086 women with hip fracture and 3532 control women matched for age. MAIN OUTCOME MEASURES--Number of drugs affecting bone metabolism taken and length taken for. RESULTS--Women taking drugs affecting bone metabolism had a significantly decreased risk of hip fracture. After adjustment for differences in other risk factors, the relative risk of hip fractures was 0.55 (95% confidence interval 0.31 to 0.85) in women taking oestrogens, 0.75 (0.60 to 0.94) in those taking calcium, and 0.69 (0.51 to 0.92) in those taking calcitonin. The fall in risk was not significant for anabolic steroids (0.6 (0.29 to 1.22)). Neither vitamin D nor fluorides were associated with a significant decrease in the risk of hip fracture. The effect on hip fracture risk increased significantly with increasing duration of exposure (risk ratio 0.8 (0.61 to 1.05) for less than median exposure v 0.66 (0.5 to 0.88) for greater than median exposure). Drugs were equally effective in older and younger women, with the exception of oestrogen. CONCLUSIONS--Oestrogen, calcium, and calcitonins significantly decrease the risk of hip fracture. Short term intervention late in the natural course of osteoporosis may have significant effects on the incidence of hip fracture.

Increased Mortality Among Persons with Rheumatoid Arthritis, But Where RA Does Not Appear on Death Certificate: Eleven-Year Follow-Up of an Epidemiological Study

We have performed an 11-year follow-up study on mortality in rheumatoid arthritis (RA). The population was selected by random sampling and consisted of 293 persons with RA fulfilling two sets of relevant criteria and a contrast group of 453 healthy persons. The mortality in the RA group was found elevated, when compared with both the contrast group and the general Stockholm population. The mortality was correlated with the severity of the disease, as defined by the numbers of criteria for RA fulfilled, the Steinbrocker functional grading, and serological titres. The differences in the distribution of causes of death between RA and contrast groups were not large enough to warrant special consideration. Only 9 out of 84 death certificates in the RA group mentioned rheumatic disease, and 4 of these had RA as underlying cause of death.

The Mediterranean osteoporosis (MEDOS) study questionnaire

SummaryThe Mediterranean osteoporosis study (MEDOS) questionnaire was designed by a group of specialists in bone disease from Southern Europe (MAB Group) and the WHO Collaborating Centre for the Epidemiology of Rheumatic Conditions, assisted by experts from WHO in Geneva and from the European Foundation for Osteoporosis and Bone Disease. The purpose of the questionnaire was to identify putative risk factors for hip fracture in a retrospective case control study applied during a prospective study of the incidence of hip fracture in 14 regions of Europe.

CIRCUMSTANCES AROUND THE FALL IN A MULTINATIONAL HIP FRACTURE RISK STUDY :A DIVERSE PATTERN FOR PREVENTION

Hip fracture is a major public health problem, but with a potential for prevention. Data from a European multicentre study on hip fracture epidemiology with a case control design, the MEDOS study, were used to describe and analyse circumstances around falls associated with hip fracture. The study includes 2185 fracture cases age > 50 years from 14 centres in southern Europe: Portugal, Spain, France, Italy, Greece and Turkey. Information was collected by a standardized and validated questionnaire translated into six languages and administered by trained interviewers. Circumstances around the fall were categorized according to: (1) place, age group and time of day; (2) functional disability; (3) drug consumption including alcohol; and (4) environmental factors. Possibilities for prevention were also analysed. High risk falls were identified using seven reasonably well-established risk factors, and similarly eight risk factors were used to identify high risk fallers. Selected trains of events were also studied. A pattern of great diversity was found both among the fallers and the environment in which they fell and fractured the hip. Those with more than one factor involved constituted only 14.7% of female and 19.7% of male fractures. A majority of cases were not physically disabled before the fall. A majority (66.5%) fell and fractured their hip indoors and only 4.3% outside in darkness. Cardiovascular and cerebrovascular comborbidity were observed with 4.9 and 7.8%, of falls respectively. Falls in a stairway comprised 11% of falls. The correlation between the number of the risk factors of the faller and in the environment was 0.07 and there was no difference between males and females. The pattern of causality behind falls that cause hip fracture and therefore of prevention comprises many sometimes small groups and intricate time sequence. The results suggest that global preventive strategies could presently not be implemented. Instead, the pattern of prevention should include different target groups and be country and site specific. For the high risk group of institutionalized patients prevention can be implemented without delay.

Do oral contraceptives reduce the incidence of rheumatoid arthritis? A pilot study using the Stockholm County Medical information system.

The Stockholm County medical information system was used to select cases for a pilot study on the association between oral contraceptive (OC) use and the incidence of rheumatoid arthritis (RA). A selection procedure is described by which we obtained 76 cases of RA. These were compared in a case-control study with 152 healthy controls with regard to OC use prior to the onset of RA. For all women who had used OCs for more than one year the relative risk of RA was 0.70 (0.40, 1.24). The relative risk decreased with advancing age at onset of RA, being 0.40 (0.10, 1.65) for women with age at onset over 40. Although the material is small, and there are some inconsistencies in the results, our findings are compatible with the hypothesis that the use of OCs is associated with a reduced incidence of RA.

Regional Distribution of Rheumatic Complaints in Sweden

Regional differences regarding prevalence of rheumatic complaints were found in a nation-wide interview survey of the adult Swedish population. A higher prevalence was found in regions of low population density, the highest being in the North. Osteo-arthritis was more prevalent in Northern Sweden, particularly among men, while back disorders were more common in all regions of low population density. Physically strenuous working conditions were found more frequently in all regions of low population density. Among other possible factors contributing to the regional differences in rheumatic complaints, genetic differences in HLA B27 within the Swedish population and the occurrence of cryophilic arthritogenic microbial flora, are discussed.