“Of MS and Men” Morbidity & Mortality Outcomes Mitchell T. Wallin, MD, MPH MS Clinic Director...
-
Upload
dwain-fields -
Category
Documents
-
view
215 -
download
1
Transcript of “Of MS and Men” Morbidity & Mortality Outcomes Mitchell T. Wallin, MD, MPH MS Clinic Director...
“Of MS and Men”Morbidity & Mortality
Outcomes
Mitchell T. Wallin, MD, MPHMitchell T. Wallin, MD, MPHMS Clinic Director MS Clinic Director
Department of Veterans Affairs Medical CenterDepartment of Veterans Affairs Medical CenterWashington, DCWashington, DC
Assistant Professor of NeurologyAssistant Professor of NeurologyGeorgetown University Medical SchoolGeorgetown University Medical School
“Of MS and Men”Morbidity & Mortality Outcomes
I. DefinitionsI. Definitions
II. Morbidity DataII. Morbidity Data
III. Mortality & Survival DataIII. Mortality & Survival Data
IV. ConclusionsIV. Conclusions
Multiple Sclerosis Subtypes(Coyle P, 2002; adapted from Lublin F, et al Neurology 1996)
Secondary Progressive MSvs.
Primary Progressive MS RR-SP MS PP MS
Age at onset (mean)
30 yrs 40 yrs
Sex ratio (M:F) 2:1 1:1
Race disability progression in AA
disability progression in AA
Onset symptoms
Sensory, visual Paraparesis
“Of MS and Men”Morbidity & Mortality Outcomes
I. DefinitionsI. Definitions
II. Morbidity DataII. Morbidity Data
III. Mortality & Survival DataIII. Mortality & Survival Data
IV. ConclusionsIV. Conclusions
22
Prevalence of Subtypes of MS(N = 3019)
Relapsing-remitting(RR)55%
Secondary-progressive(SP)30%
Primary-progressive
(PP)10%
Progressive-relapsing
(PR)5%
Jacobs et al. Mult Scler. 1999;5:369-376.
Veteran Integrated Service Network (VISN)-5 MS Subtypes
Secondary Progressive(41%)
Relapsing Remitting(47%)
Primary Progressive(6%)
Unknown(6%)
N=218
Veteran Integrated Service Network (VISN)-5 MS Demographic Data
0
20
4060
80
100
120
140160
180
200
Black White Unknown Total
Males
Females
MS Morbidity in the US
Nationwide PrevalenceNationwide Prevalence 58/100,000 population (Baum, 1981)58/100,000 population (Baum, 1981) 102-139/100,000 population (Anderson, 1992)102-139/100,000 population (Anderson, 1992) 85/100,000 population (Noonan, 2002)85/100,000 population (Noonan, 2002)
Olmsted County, MN (Mayr 2003)Olmsted County, MN (Mayr 2003) Raw Incidence: 7.5/100,000 person-yrsRaw Incidence: 7.5/100,000 person-yrs Raw Prevalence: 177/100,000 person-yrs Raw Prevalence: 177/100,000 person-yrs
Estimated prevalence of MS per 100,000 by report in the US NHIS Survey, 1982-1996 (Noonan, 2002)
Estimated number of persons with MS in the US Noonan, 2002
Persons per 100,000 with MSNoonan, 2002
Vietnam and later military service MS cohort Study Population Flow Chart (Wallin, et al 2004)
O ther Fem a les1 6 /9
B lack F em ales1 23 /85
W hite Fem ales6 04 /40 2
O the r M ales3 5 /2 31
B lack M ales4 15 /12 25
W hite M ales3 75 8 /7 42 6
MS CasesAnalyzed
4951
Controls Analyzed
9378
Eligible MS
patients 55345
Eligible Controls10683
394 1305
Adjusted case-control ratios for MS by race and sex at EAD
WWII-KC Cohort Vietnam and later Cohort
Race-sex category
# of MS cases
Case-control ratio (95% CI)
# of MS cases
Case-control ratio (95% CI)
White female 182 1.86 (1.44 – 2.38)
604 2.85 (2.49-3.25)
Black female 4 1.33 (0.23 – 9.10)
123 2.74 (2.00-3.52)
Other race-female
2 ---- 16 3.37 (1.52-7.56)
White male 4,923 1.04 (0.98 – 1.10)
3,758 0.96 (0.90-1.00)
Black male 177 0.45 (0.38 – 0.54)
415 0.64 (0.57-0.43)
Other race-male
17 0.23 (0.14 – 0.39)
35 0.29 (0.20-0.41)
TOTAL 5,305 1.00 4,951 1.00
Vietnam & Later Service
103
46
55
74
59
56
73
62
62
81
67
83
67
6381
5454
75
83
86
152
138
111
144
160
143 116
141
169
147
216
Case Control Ratios x 100
< 60 61 to 90 91 to 120 121 to 149
>150
81
116
141113
230
126
115
101
80 79
108
110
180
92
107
WWII-KC
61
172
44
61
59
132
52
56
52
74
61
95
6461
4148
50
72
92
198
145
200
131
131
161 211
133
183
138
203
Case Control Ratios x 100
< 60 61 to 90 91 to 120 121 to 149
>150
66
131
117118
118
105
101
116
86109
118
121
127
67
78
129
167
85
94
64
Time from MS onset to EDSS 4.0Confavreux, 2000
Risk of Bone Loss in MenWeinstock-Guttman, 2004
40 male MS patients, mean: EDSS 5.8; Age 51yrs40 male MS patients, mean: EDSS 5.8; Age 51yrs 32 (80%) with reduced bone loss of lumbar spine or femur32 (80%) with reduced bone loss of lumbar spine or femur
17 (43%) had osteopenia17 (43%) had osteopenia 15 (38%) had osteoporosis15 (38%) had osteoporosis
8/38 (21%) with fractures of ribs, vertebrae or extremities8/38 (21%) with fractures of ribs, vertebrae or extremities Risk factors for low bone mineral densityRisk factors for low bone mineral density
Femoral neck: EDSS and BMI Femoral neck: EDSS and BMI Lumbar spine: EDSS Lumbar spine: EDSS
“Of MS and Men”Morbidity & Mortality Outcomes
I. DefinitionsI. Definitions
II. Morbidity DataII. Morbidity Data
III. Mortality & Survival DataIII. Mortality & Survival Data
IV. ConclusionsIV. Conclusions
22
MS Survival
10 years shorter than age-matched general 10 years shorter than age-matched general population (Brpopulation (Brøønnum-Hansen, 2004)nnum-Hansen, 2004)
US Veteran WWII Cohort (Wallin, 2000)US Veteran WWII Cohort (Wallin, 2000) Men: median survival Men: median survival
Black males: 30 yrsBlack males: 30 yrs White males: 34 yrsWhite males: 34 yrs
White women: median survival 43 yrsWhite women: median survival 43 yrs
Secular trend for improved survival over the past Secular trend for improved survival over the past 50 years50 years
Survival in VA MS Cases: Sex/Race
Survival in VA MS Cases: Age at Onset
Survival in VA MS Cases: SES
Risk Factors for MS SurvivalStudy Year of
StudyRegion Total
casesAge at onset
Sex Clincourse
Leibowitz 1967 Israel 266 +/- +
Visscher 1980 USA 941 + NS
Phadke 1980 UK 1055 + NS +
Riise 1986 Norway 598 + NS +
Poser 1981 Germany 224/1429 + +
Wynn 1984 USA 206 + +
Brønnum-Hansen 1986 Denmark 6727 + +
Midgard 1991 Norway 251 + NS +
Wallin 1996 USA 2489 + +
MS Cause-specific mortality
MS as underlying or contributing cause of MS as underlying or contributing cause of death in 47%-83% of cases (Sadovnick, death in 47%-83% of cases (Sadovnick, 1991; Larsen, 1985)1991; Larsen, 1985)
Other causes (BrOther causes (Brøønnum-Hansen, 2004)nnum-Hansen, 2004) Cardiovascular disease: SMR 1.32 (1.22-1.43)Cardiovascular disease: SMR 1.32 (1.22-1.43) Cancer: SMR 0.85 (0.77-0.94)Cancer: SMR 0.85 (0.77-0.94) Suicide/Accidents: 1.42 (1.22-1.64)Suicide/Accidents: 1.42 (1.22-1.64)
Conclusions
Despite a lower prevalence of MS, men are more Despite a lower prevalence of MS, men are more likely to present with the PP subtype and generally likely to present with the PP subtype and generally have increased morbidity and mortality compared have increased morbidity and mortality compared to womento women
Implications for clinical studies Implications for clinical studies Differential pathology by sex Differential pathology by sex Endocrine effects Endocrine effects
More large longitudinal studies needed to evaluate More large longitudinal studies needed to evaluate sex differences in MSsex differences in MS
9
National WWII Memorial