“Of MS and Men” Morbidity & Mortality Outcomes Mitchell T. Wallin, MD, MPH MS Clinic Director Department of Veterans Affairs Medical Center Washington, DC Assistant Professor of Neurology Georgetown University Medical School
“Of MS and Men” Morbidity & Mortality Outcomes I. Definitions II. Morbidity Data III. Mortality & Survival Data IV. Conclusions
Multiple Sclerosis Subtypes (Coyle P, 2002; adapted from Lublin F, et al Neurology 1996)
Secondary Progressive MS vs. Primary Progressive MS RR-SP MSPP MS Age at onset (mean) 30 yrs40 yrs Sex ratio (M:F) 2:11:1 Race disability progression in AA Onset symptoms Sensory, visualParaparesis
“Of MS and Men” Morbidity & Mortality Outcomes I. Definitions II. Morbidity Data III. Mortality & Survival Data IV. Conclusions 2
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:
Veteran Integrated Service Network (VISN)-5 MS Subtypes
Veteran Integrated Service Network (VISN)-5 MS Demographic Data
MS Morbidity in the US n Nationwide Prevalence u 58/100,000 population (Baum, 1981) u /100,000 population (Anderson, 1992) u 85/100,000 population (Noonan, 2002) n Olmsted County, MN (Mayr 2003) u Raw Incidence: 7.5/100,000 person-yrs u Raw Prevalence: 177/100,000 person-yrs
Estimated prevalence of MS per 100,000 by report in the US NHIS Survey, (Noonan, 2002)
Estimated number of persons with MS in the US Noonan, 2002
Persons per 100,000 with MS Noonan, 2002
Vietnam and later military service MS cohort Study Population Flow Chart (Wallin, et al 2004) MS Cases Analyzed 4951 Controls Analyzed 9378 Eligible MS patients Eligible Controls
Adjusted case-control ratios for MS by race and sex at EAD WWII-KC CohortVietnam and later Cohort Race-sex category # of MS cases Case-control ratio (95% CI) # of MS cases Case-control ratio (95% CI) White female (1.44 – 2.38) ( ) Black female41.33 (0.23 – 9.10) ( ) Other race-female ( ) White male4, (0.98 – 1.10) 3, ( ) Black male (0.38 – 0.54) ( ) Other race-male (0.14 – 0.39) ( ) TOTAL5, ,
Vietnam & Later Service Case Control Ratios x 100 < to to to 149 > WWII-KC Case Control Ratios x 100 < to to to 149 >
Time from MS onset to EDSS 4.0 Confavreux, 2000
Risk of Bone Loss in Men Weinstock-Guttman, male MS patients, mean: EDSS 5.8; Age 51yrs n 32 (80%) with reduced bone loss of lumbar spine or femur u 17 (43%) had osteopenia u 15 (38%) had osteoporosis n 8/38 (21%) with fractures of ribs, vertebrae or extremities n Risk factors for low bone mineral density u Femoral neck: EDSS and BMI u Lumbar spine: EDSS
“Of MS and Men” Morbidity & Mortality Outcomes I. Definitions II. Morbidity Data III. Mortality & Survival Data IV. Conclusions 2
MS Survival n 10 years shorter than age-matched general population (Brønnum-Hansen, 2004) n US Veteran WWII Cohort (Wallin, 2000) u Men: median survival F Black males: 30 yrs F White males: 34 yrs u White women: median survival 43 yrs n Secular trend for improved survival over the past 50 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 Survival Study Year of Study RegionTotal cases Age at onset SexClin course Leibowitz1967Israel266+/-+ Visscher1980USA941+NS Phadke1980UK1055+NS+ Riise1986Norway598+NS+ Poser1981Germany224/ Wynn1984USA206++ Brønnum-Hansen1986Denmark Midgard1991Norway251+NS+ Wallin1996USA2489++
MS Cause-specific mortality n MS as underlying or contributing cause of death in 47%-83% of cases (Sadovnick, 1991; Larsen, 1985) n Other causes (Brønnum-Hansen, 2004) u Cardiovascular disease: SMR 1.32 ( ) u Cancer: SMR 0.85 ( ) u Suicide/Accidents: 1.42 ( )
Conclusions Despite a lower prevalence of MS, men are more likely to present with the PP subtype and generally have increased morbidity and mortality compared to women Implications for clinical studies Differential pathology by sex Endocrine effects More large longitudinal studies needed to evaluate sex differences in MS 9
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