title: Secular changes in Paget's disease: contrasting changes in the number of new referrals and in disease severity in two neighboring regions of Spain.
abstract: CONCLUSIONS
  We studied the changes in the number of new referrals with Paget's disease of bone (PDB) and severity of PDB in a high prevalence focus and its neighboring region. Referral of patients changed only in the high prevalence focus. The severity of PDB decreased in both regions. These results could suggest the effects of an environmental influence on disease activity.
  
  
  BACKGROUND
  The prevalence and severity of PDB have decreased in several countries over recent years. We previously reported a high radiological prevalence of PDB in Vitigudino. Here we sought to determine if secular changes in the number of new referrals and severity of PDB had occurred over recent years.
  
  
  METHODS
  We studied 280 patients with clinically diagnosed PDB who were evaluated at a regional referral center for metabolic bone disease between 1986 and 2009. Changes in the number of new referrals were calculated by relating these data to the number of subjects at risk as determined by population registers. Trends in disease severity were analyzed with alkaline phosphatase (ALP) activity and disease extent on scan.
  
  
  RESULTS
  Referrals from the Vitigudino region increased substantially between 1986 and 2003 but fell markedly between 2004 and 2009, although by this time there had been depopulation of the region due to emigration. No significant changes in the rates of referral occurred in the remainder of Salamanca. ALP activity and disease extent decreased in Salamanca, but only ALP activity decreased in Vitigudino. Referrals rate and severity of PDB in Vitigudino were greater than in the remainder of Salamanca.
  
  
  CONCLUSIONS
  Referral of patients with clinically diagnosed PDB has remained stable for most of Salamanca during the past 24 years, but substantial changes have been observed in Vitigudino. In agreement with other reports, the severity of PDB has decreased in both regions consistent with the effects of an environmental influence on disease activity.
authors.affiliation: Department of Internal Medicine, RETICEF, Hospital el Bierzo, Medicos sin Fronteras 7. Ponferrada, 24411, Leon, Spain. lcorral@saludcastillayleon.es
authors.forename: L
authors.initials: L
authors.lastname: Corral-Gudino
authors.forename: J
authors.initials: J
authors.lastname: García-Aparicio
authors.forename: M D
authors.initials: MD
authors.lastname: Sánchez-González
authors.forename: J A
authors.initials: JA
authors.lastname: Mirón-Canelo
authors.forename: J F
authors.initials: JF
authors.lastname: Blanco
authors.forename: S H
authors.initials: SH
authors.lastname: Ralston
authors.forename: J
authors.initials: J
authors.lastname: del Pino-Montes
mesh_terms: D000367:Age Factors; D000368:Aged; D000469:Alkaline Phosphatase / Q000097:blood; D015415:Biomarkers / Q000097:blood; D004796:Clinical Enzyme Tests / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010001:Osteitis Deformans / Q000175:diagnosis / Q000453:epidemiology*; D015995:Prevalence; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012720:Severity of Illness Index; D013030:Spain / Q000453:epidemiology
chemical_list: D015415:Biomarkers; D000469:Alkaline Phosphatase