Manfred Wildner

Hip fracture incidence in east and west germany: reassessement ten years after unification.

Abstract: The rising incidence of hip fractures is of world wide concern. In addition to the demographically aging populations world wide a secular trend of hip fracture incidence has been reported for various populations. The objective of the current study was to reassess hip fracture incidence ten years following German reunification and compare incidence rates in former East and West Germany.u2003Data from the German hospital discharge diagnosis registry were used to compare rates in former East and West Germany. A reassessment of a secular trend was done with directly age-standardized rates of the population 60 years old and over.u2003Significant differences were found between incidence rates in the East and West German states with higher rates in the West. Compared to earlier studies for East Germany, rate in East Germany have increased by on average annually 6% since reunification. This is a steep increase compared to the annual rise by about 3% between 1974 and 1989. Hip fracture incidence in East Germany thereby has doubled during the 25-year period from 1971 to 1996. Although the observed acceleration of a secular trend in East Germany probably has multiple causes, evidence suggests a significant influence of Western life style on hip fracture incidence.

Nurses' contacts and potential for infectious disease transmission.

These data can help predict staff availability and provide information for pandemic preparedness planning.

Exploratory causal modeling in epidemiology: Are all factors created equal?

The purpose of this study was to demonstrate the consequences of analyzing sequentially caused relationships with models assuming equally proximate causation. Monte Carlo simulations of data with well defined causations were performed. The logistic modeling approach was strongly misleading if a distant causal factor was treated as a factor being equally distant to the outcome as a proximal causal factor. In contrast, simple pathway analysis was able to correctly identify the true causation. In causal pathways, the relative risk of an intermediate cause with respect to the outcome needs to have a certain magnitude for the effect of the distant variable to be passed on. The results further show that the true relative risk of the distant variable is not dependent on its baseline prevalence. In contrast, the prevalence of the intermediate variable must be small enough to carry the influence of the distant variable through the causal chain. Practical epidemiologic exploration of etiological factors is presently dominated by stepwise multiple regression. This type of exploration is not model free but is often intuitively based on the structural assumption of equal proximity of all potential factors to the outcome. Equal proximity, however, is not likely in many etiologies, especially not if the causal factors under consideration are of different quality, like psychological and biological factors. In cases of causal pathways with some factors more distant and others more proximal to the outcome, the former tend to be dismissed by equal proximity modeling. Upstream exploration of more distant etiological factors is hindered by endemic stepwise multiple regression modeling, treating all variables as being equal in proximity to the outcome.

Independent Living after Fractures in the Elderly

Abstract: Although fractures are an important source of disability among the growing elderly populations of industrialized societies, patient-centered multidimensional outcome information is scarce. The purpose of this study was to quantify the natural history of recovery from fractures of the upper and lower extremities. From the 1994/95 WHO MONICA survey in Augsburg, Germany, we selected all persons aged 58–78 years who had experienced a fracture during the preceeding 10 years, along with a control population twice as large. The Health Assessment Questionnaire (HAQ) and the Medical Outcomes Study Short Form 36 (SF-36) were administered to these subjects in 1998. Patients’ recollection of fracture type and location were validated against medical records. The most recent fracture was in the upper extremity in 45 cases, lower extremity in 55 cases and elsewhere in 46 cases. Extremity fractures resulted in persistent and measurable impairment of the activities of daily living or general quality of life in patients 65 years or older, especially if the femur was involved. More than 40% of the interindividual variation of functional disability in the study group could be explained by age, sex, history of a fracture within 12 years and perceived difficulties walking. Existing generic and specific musculoskeletal outcome measurement instruments thus allow the assessment of functional recovery and health status after fractures in an elderly population. Geriatric assessment following fractures at higher age may improve ability to live independently. Difficulty walking deserves special attention, as it is associated with more general functional disability among the elderly.

Epidemiologie der Extremitätenfrakturen

ZusammenfassungÜber die 3. MONICA-Augsburg-Querschnittsstudie (1994/95) wurden alters- und geschlechtsspezifische Häufigkeiten von Extremitätenfrakturen (Eigenangaben) analysiert.Von 4854 Personen im Alter von 25–74 Jahren (2404 Männer, 2450 Frauen) wurden Daten zu Knochenbrüchen erhoben. Neben der Berechnung von Prävalenzen und altersspezifischen Inzidenzraten erfolgte eine Untersuchung der Frakturumstände. Die altersstandardisierten kumulativen Frakturprävalenzen für 25- bis 74-jährige Männer (M) lagen bei 45% und bei Frauen (F) gleichen Alters bei 31%. Bei den Frauen zeigten sich im jüngeren Alter (25–64 Jahre) um >10% geringere Prävalenzen als bei den Männern; nach einem signifikanten Anstieg waren die Frakturprävalenzen im Alter von 65–74 Jahren bei beiden Geschlechtern jedoch nahezu gleich (M: 42%, F: 40%). Ein Gipfel der Inzidenzraten fand sich bei Männern zwischen 15 und 24 Jahren [insgesamt 2017 Frakturen/100.000 Personenjahre (PY)] bzw. zwischen 45 und 54 Jahren (insgesamt 1640 Frakturen/100.000 PY) und bei Frauen zwischen 65 und 74 Jahren (insgesamt 3214 Frakturen/100.000 PY).Die Osteoporoseprävalenz nach Eigenangaben lag bei 25- bis 74-jährigen Frauen mit 7% deutlich über der der Männer (1%). Durch einen Sturz wurden 43% (F: 59%, M: 33%), durch äußere Gewalteinwirkung 40% (M: 47%, F:29%) und durch sportliche Aktivitäten 15% (M: 18%, F: 10%) aller Frakturen verursacht.Weitere Risikofaktorforschung zu Frakturen kann dazu beitragen, künftig auch in diesen Bereichen gezielte Präventivmaßnahmen zu ergreifen. Die Prävention bzw. effiziente Behandlung einer bestehenden und oft nicht diagnostizierten Osteoporose sowie die Sturzprävention bei älteren Menschen sollten in Zukunft ein wichtiges Anliegen der öffentlichen Gesundheit sein.AbstractTo analyze age- and sex-specific frequencies of peripheral fractures, we used data from the third MONICA-Augsburg Survey (1994/95).The study comprises 2404 male and 2450 female participants (age 25 to 74 years) who were questioned regarding fracture history. We investigated fracture prevalence, age-specific incidence rates, and the circumstances under which the fractures occurred. The age-standardized, cumulative fracture prevalence among men (m) 25 to 74 years of age was 45% and among women (w) of the same age 31%. Fracture prevalence among women was more than 10% lower than among men in the younger age groups (age 25 to 64 years), but after an significant increase in the 65 to 74-year-olds the fracture prevalence corresponded to that of men (m: 42%, w: 40%). A peak of incidence rates was found among men at age 15–24 (overall incidence rate: 2017 fractures/100,000 person-years) and at age 45–54 (overall incidence rate: 1640 fractures/100,000 PY), respectively, and among women at age 65–74 (overall incidence rate: 3214 fractures/100,000 PY).The prevalence of self-reported osteoporosis (age 25 to 74 years) was higher in women (7%) than in men (1%). Falls caused 43% (w: 59%, m: 33%) of all fractures, external violence 40% (m: 47%, w: 29%), and sports activities 15% (m: 18%, w: 10%). Further investigation of risk factors related to fractures can contribute to the development of specific preventive measures in that field. In the future, the prevention and efficient treatment of an existing or an often undiagnosed osteoporosis and also the prevention of falls in elderly persons should be an important public health concern.

A secular trend in hip fracture incidence in east Germany

Abstract: The central Inpatient Register of the former German Democratic Republic was used to study the population-based epidemiology of hip fractures among 16.5 million East Germans. Incidence rates for hospital discharges for proximal femoral fractures for the age group 60 years and over were calculated for the years 1971 to 1989, the year before unification. Incidence rates for 1989 are similar to figures reported from the UK and The Netherlands, but lower than Scandinavian rates. A decrease in the admission rate was noted from 1971 to 1974 of 4.5% each year on average, and an increase from 1974 onwards of 4.4% on average. This change was observed to a different extent in all age groups. The female:male ratio of the standardized discharge incidence was stable at 2.3:1 and the female:male ratio of manifest cases increases from 4.1:1 in 1971 to 5.1:1 in 1989. An exponential increase in the incidence rates was observed with age. This apparent rate overestimates both the rate for true incident cases (by about 25–30%, if adjustments are made for readmissions and transfers) and their trend. Adjusted estimates for incident fractures show an increase of 2% annually. Cohort effects due to changed selective forces appear to be one reasonable causal explanation.

Wirtschaftlichkeitsuntersuchung zur autologen Chondrozytentransplantation (ACT)

Die zur Behandlung von isolierten Gelenkknorpeldefekten entwickelte autologe Chondrozytentransplantation (ACT) wird seit 1987 national und international an verschiedenen Zentren routinemäßig angewendet, wobei die Kostenerstattung uneinheitlich geregelt ist. Ziel dieser Studie war die Untersuchung der Wirtschaftlichkeit der ACT im Vergleich zu anderen Therapieverfahren, wobei die maximal beste bisher verfügbare Evidenz zugrunde gelegt wurde. Für die ökonomische Wertung wurde eine inkrementelle Kosten-Effektivitäts-Analyse (CEA) mit Literaturdaten und Expertenangaben durchgeführt. Die ökonomische Evaluation der ACT vs. anderer Behandlungsverfahren erfolgte aus der Sicht der Kostenträger (Krankenkassen), da die für eine Beurteilung aus gesellschaftlicher Perspektive benötigte Datengrundlage sowohl in Deutschland als auch in anderen Ländern fehlt. Unter Berücksichtigung der verfügbaren Evidenz scheint die ACT den konventionellen Verfahren hinsichtlich der Wirksamkeitüberlegen. Bei unsicherer Datengrundlage beziehen sich die Berechnungen zu Lasten der ACT auf eine identische Krankenvorgeschichte und eine identische mittelfristige Prognose, die in der Praxis wegen der unterschiedlichen Wirksamkeit der Verfahren wahrscheinlich nicht gegeben sind. Es konnte gezeigt werden, dass sich unter den Modellannahmen durch 1000 ACT-Behandlungen (number needed to treat) 310 nachfolgende Endoprothesenoperationen und etwa 3 endoprothesenoperationsbedingte Todesfälle vermeiden ließen. Daraus lässt sich errechnen, dass bei einer Behandlung von jährlich 3400 isolierten Knorpeldefekten mit konventionellen Verfahren im Verlauf des weiteren Lebens etwa 2000 Gelenkersatzoperationen notwendig werden würden; 25% dieser Eingriffe sind Wechseloperationen. Bei der ACT-Behandlung kann diese Zahl jedoch auf 1000 halbiert werden. Im Vergleich aller Verfahren ist die Mikrofrakturierung das kostengünstigste, jedoch nicht das wirksamste Vergleichsverfahren. Die ACT scheint bei dem verwendeten konservativen Modell aus Sicht der Kostenträger potenziell kosteneffektiv, d.u2002h. den höheren Kosten steht eine im Kontext eines entwickelten Sozialstaats angemessene höhere Wirksamkeit gegenüber, sofern sich die Ergebnisse in weiteren klinischen und gesundheitsökonomischen Studien erhärten.Autologous chondrocyte transplantation (ACT) was developed as an innovative treatment for isolated cartilage defects. This treatment option has been used since 1987 in various national and international centers. The aim of the study was the economic evaluation of autologous chondrocyte transplantation (ACT) compared to other therapies. The study is based on the best available evidence. A marginal cost-effectiveness analysis (CEA) was conducted based on literature review and expert knowledge. Economic evaluation was conducted from the “health insurance” point of view, because the necessary data for an evaluation viewpoint are missing for Germany and for other countries. Based on the available evidence, ACT appears to have a superior effectiveness compared to conventional treatment options. The statistical comparison of ACT assumes an identical anamnesis and an identical intermediate prognosis. This puts ACT at a disadvantage, due to a probable different effectiveness of treatment options in clinical practice. It can be demonstrated that in 1000 ACT treatments (number needed to treat), 310 subsequent joint replacement operations and 3 surgery-related deaths are avoided. Due to the treatment of 3400 isolated cartilage defects per annum by other methods, about 2000 joint replacements become necessary; 25% being exchange operations. Using the ACT treatment, this number can be cut down to 1000. In comparison to all methods, microfracturing appears to be most economic but less effective. ACT appears in the conservative economic model from the health insurance as potentially cost-efficient, i.e., the increased treatment costs are balanced by a higher effectiveness which is reasonable in the context of other common social contributions within an economically developed country. From the perspective of health insurance, ACT is cost-effective and is the recommended strategy, if current results on ACT are corroborated by further clinical and economic studies.

Violence and fear of violence in East and West Germany

The purpose of this research was to assess the effect of major social changes in Germany since 1989 on mortality due to intentional injury. Mechanisms and types of fatal intentional injury in East and West Germany between 1970 and 1995 were determined from death certificates and compared with judicial data on violent crime convictions and recent public survey data on citizen fear of crime. The number of homicides among East German males increased between 1989 and 1991, and the homicide rate remains high when compared with West German males (although lower than that of American males). Homicide among German females is less common, presently about equally likely in East and West. Violent crime in general has become more frequent in Germany, and citizen fear of crime has increased markedly, especially in the East. Non-citizens are convicted for an increasing number of homicides and assaults. Rates of suicide were declining in East and West before reunification, and these rates have continued to decline. Social changes in Europe since 1989 have led to noticeable increases in violence and homicide in Germany, which in turn have reduced feelings of security among German citizens, especially in the East. Suicide rates have not been affected.

Development of a questionnaire for quantitative assessment in the field of health and human rights.

We hypothesize that a human rights framework would be able to analyse central health-related societal issues within important settings like the work place, the family or the health care system. Our study goal was the development and population-based evaluation of a questionnaire for assessment of the perceived human rights status. A questionnaire (HR-14) was developed from the guiding principles of international human rights legislation. For its psychometric evaluation, computer-assisted telephone interviews were conducted in four cities in Europe (Munich, Dresden, Vienna and Bern). Cronbachs alpha for internal consistency was 0.76. Factor analysis supported the concept of human rights as indivisible and interdependent. Extracted factors were consistent with the preliminary settings of family and friends, health care system and community at large, and a supplementary setting workplace. Perceived human rights status was associated with physical function, mental/emotional health, age, study region, general health and employment status. We conclude that it is possible to develop a human rights questionnaire with good psychometric properties. Measurement of the perceived human rights status of populations and population groups may contribute to health policies sensitive to human rights.

Apolipoprotein E polymorphism has no independent effect on plasma levels of lipoprotein(a)

Previous studies show conflicting results concerning an influence of apolipoprotein E (apo E) phenotype on lipoprotein(a) (Lp(a)) plasma levels. We speculated that it is not the apo E phenotype itself but rather its effect on plasma lipid concentrations that might influence Lp(a) levels. In 1562 subjects concentrations of triglycerides, LDL-cholesterol and Lp(a) were measured by standard laboratory methods. Apo(a) and apo E isoforms were determined by sodium dodecyl sulfate gel electrophoresis and isoelectric focusing, respectively, followed by immunoblotting. An univariate analysis revealed a significant influence of apo(a) isoforms, apo E phenotype, triglycerides and LDL-cholesterol on Lp(a) plasma levels (ANOVA: P < 0.001, P < 0.02, P < 0.001 and P < 0.001, respectively). In a multivariate analysis, however, the influence of the apo E phenotype was no longer significant (P>0.10), whereas apo(a) isoforms, LDL-cholesterol quintiles and triglyceride quintiles explained 29.2, 2.8 and 1.0% of the variation of the Lp(a) levels (for all three variables: P < 0.001). We conclude that apo E polymorphism does not exert an independent effect on Lp(a) concentrations. Any influence is mediated through the effect of apo E polymorphism on plasma lipids.