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Blanco, Maite Silva-Díaz, Víctor Quevedo Vila, Daniel Seoane-Mato, Fernando Pérez Ruiz, Antonio Juan-Mas, José M. Pego-Reigosa, Javier Narváez, Neus Quilis, Raúl Cortés, Antonio Romero Pérez, Dolores Fábregas Canales, Teresa Font Gayá, Carolina Bordoy Ferrer, Carlos Sánchez-Piedra, Federico Díaz-González, Sagrario Bustabad-Reyes" "autores" => array:18 [ 0 => array:4 [ "nombre" => "Francisco J." 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Grupo IRIDIS, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo (Pontevedra), Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat (Barcelona), Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital General Universitario de Elda, Elda (Alicante), Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Unidad de Reumatología, Hospital General de Ontinyent, Ontinyent (Valencia), Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Sección de Reumatología, Complejo Hospitalario de Jaén, Jaén, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital de Barbastro, Barbastro (Huesca), Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Sección de Reumatología, Hospital Comarcal de Inca, Inca (Balearic Islands), Spain" "etiqueta" => "m" "identificador" => "aff0065" ] 13 => array:3 [ "entidad" => "Departamento de Medicina Interna, Dermatología y Psiquiatría, Universidad de La Laguna, La Laguna (Santa Cruz de Tenerife), Spain" "etiqueta" => "n" "identificador" => "aff0070" ] 14 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Universitario de Canarias, La Laguna (Santa Cruz de Tenerife), Spain" "etiqueta" => "o" "identificador" => "aff0075" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Prevalencia de artrosis sintomática en España: Estudio EPISER2016" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1494 "Ancho" => 2503 "Tamanyo" => 266513 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0125" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Prevalence of arthrosis in women and men.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Arthrosis cannot be described as a single disease, but rather as a heterogeneous group of diseases with similar clinical manifestations involving common pathological and radiological changes. The OARSI recently defined arthrosis as a disorder which affects the mobile joints that is characterised by cellular stress and degradation of the extracellular cartilage matrix and commences with micro- and macrolesions which activates poorly adapted repair responses, including innate immunity pro-inflammatory routes. The disease manifests firstly as a molecular alteration (abnormal joint tissue metabolism), followed by anatomical or physiological alterations (characterised by cartilage degradation, bone remodelling, joint inflammation and loss of normal joint function), which may culminate in the emergence of the disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Arthrosis is considered to be the most common rheumatological disease; nevertheless, epidemiological studies sometimes show different results. These differences are largely due to the definition of patients with arthrosis. Due to this it is important when interpreting epidemiological data to know whether the studies in question have defined cases as symptomatic or radiological arthrosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Three cross-sectional studies have been published in Spain which calculate the prevalence of arthrosis. The first of these, which was published in 1982, was based on a study undertaken in the town of Los Cortijos (Ciudad Real). A total of 827 individuals were analysed, 87% of the selected population, by means of their clinical history, physical examination, analysis and radiological study. 20% of the population were over the age of 60 years old. 26.1% suffered arthrosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The second study was undertaken in Asturias and published in 1993. 702 individuals over the age of 18 years were evaluated, 76% of the invited population, selected by randomised, stratified, multistage and proportional sampling. All of the subjects were interviewed by trained doctors, and validated criteria were applied to establish the diagnoses. 23.8% of the sample was diagnosed with arthrosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The third study was EPISER2000, promoted by the <span class="elsevierStyleItalic">Sociedad Española de Reumatología</span>, with subjects over the age of 20 years. It estimated that the prevalence of symptomatic knee arthrosis in Spain stood at 10.2% and that of the hands at 6.2%.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> It has to be underlined that EPISER2000 did not analyse the prevalence of axial arthrosis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Sociodemographic and lifestyle changes over recent years in Spain justify updating the epidemiological data corresponding to arthrosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The sociodemographic changes can be summarised as an increase in the proportion of individuals over the age of 64 years and an increase in the percentage of foreign population, according to <span class="elsevierStyleItalic">Instituto Nacional de Estadística</span> data.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Regarding lifestyle changes, an increase in obesity and overweight individuals has been observed, together with changes in tobacco consumption.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The main aim of the EPISER2016 study, which was promoted by the <span class="elsevierStyleItalic">Sociedad Española de Reumatología</span>, was to estimate the prevalence of the main rheumatic diseases within the adult population in Spain. These diseases include arthrosis in the locations already included in EPISER2000 (the hip, knee and hand) and this update expands to include the cervical and lumbar spinal column. As a secondary objective its associations with sociodemographic, anthropometric and lifestyle variables have also been examined.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">The methodology and sample characteristics of the EPISER2016 study have been described before.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,12</span></a> To summarise, it is a cross-sectional study of a population base. Multi-stage stratified and grouped sampling was used. Subjects who live in 78 towns of 17 autonomous communities took part, within the catchment area of 21 hospitals (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Given the size of the sample and the limited magnitude of the differences respecting the general population for the characteristics that were analysed, the sample finally included in EPISER2016 could be considered to be representative of the general adult population of Spain for the estimation of the prevalence of rheumatic diseases. The sample included in the arthrosis prevalence study was composed of 3336 individuals aged 40 years and above.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Interviewers in a call centre screened the sample using a telephonic questionnaire that covered two complementary routes: self-diagnosis and screening according to symptoms (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, Appendix A, annex 1). If the patients stated that they had already been diagnosed, a rheumatologist subsequently confirmed their diagnosis by reviewing their clinical history. The patients who had no previous diagnosis, based on their replies to the symptom-based screening, either fulfilled the criteria for suspicion or did not. If they did not fulfil these criteria, their participation in the study was terminated. If they did fulfil the criteria, the next step consisted of a rheumatologist applying another more specific telephonic questionnaire (Appendix A, annex 2) to select the individuals with a persistent suspicion of diagnosis of arthrosis. These patients were given an appointment with the rheumatologist for a physical and radiological examination, to definitively confirm or rule out the diagnosis.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Cases were considered to have been lost when the subject completed the initial telephonic questionnaire with a positive result in the screening for arthrosis and the rheumatologist was unable to confirm or rule out the diagnosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">All of the subjects were asked to give their informed consent orally in the first telephonic contact. This was also requested in writing from those participants who visited the surgery for physical examination and complementary tests. The study was approved by the Research Ethics Committee of the <span class="elsevierStyleItalic">Hospital Universitario de Canarias</span>, which acted as the reference committee, and it was also approved by the research ethics committees of the participating hospitals when this was required.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Case definition (for the symptom-based screening process)</span><p id="par0050" class="elsevierStylePara elsevierViewall">The flow to define the case in one of the locations was as follows:</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Cervical spinal column arthrosis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Given the lack of criteria defined by a scientific society for the diagnosis of axial arthrosis (cervical and lumbar spinal column), a member of the scientific committee who specialises in arthrosis (FJB) set the criteria used in this study. They were accepted by the chief researcher and the other members of the scientific committee.</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Symptom-based screening</span>: this was considered positive if the individual had had cervical pain that was not due to trauma or over-exertion during at least 3 months (even when the intensity of the pain varied) and it was exacerbated by neck movements.</p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sustained suspicion</span>: the individual was questioned once again to confirm the characteristics of the pain described in the screening section. If they were present, they were asked if a radiological study had been performed, and if so, about the results of the same. The suspicion was maintained if the individual mentioned pain with the characteristics described in the radiological study with abnormal results in the X-ray, or without the said study.</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Confirmation of diagnosis</span>: no criteria have been approved by a scientific society or group for this disease, so that the following criteria were defined specifically for this study:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Cervical mechanical pain that evolved over more than 3 months.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Rigidity for at least 30<span class="elsevierStyleHsp" style=""></span>min or the absence of rigidity.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Vertebral osteophytes or reduction of the intervertebral space, with plate sclerosis.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Facet joint sclerosis.</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">The diagnosis was confirmed if both clinical criteria (1 and 2) were fulfilled, together with at least one of the radiological criteria (3 and 4).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Lumbar spinal column arthrosis</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Symptom-based screening</span>: this was considered positive had had lumbar pain that was not due to trauma or over-exertion during at least 3 months (even when the intensity of the pain varied) and that it was exacerbated by picking up weight or making an effort.</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sustained suspicion</span>: the individual was questioned once again to confirm the characteristics of the pain described in the screening section. If they were present, they were asked if a radiological study had been performed, and if so, about the results of the same. The suspicion was maintained if the individual mentioned pain with the characteristics described in the radiological study and the abnormal results in the X-ray, or without the said study.</p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Confirmation of diagnosis</span>: no criteria have been approved by a scientific society or group for this disease, so that the following criteria were defined specifically for this study:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1.</span><p id="par0115" class="elsevierStylePara elsevierViewall">Lumbar mechanical pain that had evolved over more than 3 months.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2.</span><p id="par0120" class="elsevierStylePara elsevierViewall">Rigidity lasting at least 30<span class="elsevierStyleHsp" style=""></span>min or the absence of rigidity.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3.</span><p id="par0125" class="elsevierStylePara elsevierViewall">Vertebral osteophytes or a reduction of the space between vertebras with plate sclerosis.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">4.</span><p id="par0130" class="elsevierStylePara elsevierViewall">Facet joint sclerosis.</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">The diagnosis was confirmed if both clinical criteria (1 and 2) were confirmed, together with at least one of the radiological criteria (3 and 4).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Hip arthrosis</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Symptom-based screening:</span> this was considered positive if the individual mentioned hip or groin pain that was not caused by trauma or over-exertion and lasted for more than 4 weeks, being exacerbated by effort, walking or going up or down stairs.</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sustained suspicion:</span> the suspicion was maintained if the individual mentioned pain with the described characteristics and an abnormal result in a previous X-ray image, or without an X-ray image.</p><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Confirmation of diagnosis</span>: the clinical and radiological criteria of the ACR were used.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Knee arthrosis</span><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Symptom-based screening:</span> this was considered positive if the individual mentioned knee pain that was not caused by trauma or over-exertion and that lasted more than 4 weeks, becoming exacerbated by effort, walking or going up or down stairs.</p><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sustained suspicion:</span> the suspicion was maintained if the individual mentioned pain with the described characteristics and an abnormal result in a previous X-ray image, or without an X-ray image.</p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Confirmation of diagnosis:</span> ACR clinical and radiological criteria used as well as the clinical criteria.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The clinical criteria were the same as the ones used in EPISER2000.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Hand arthrosis</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Symptom-based screening:</span> this was considered positive if the individual mentioned hand pain that was not caused by trauma or over-exertion and that lasted for more than 4 weeks, became worse with use of the hands or finger movement.</p><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sustained suspicion</span>: the suspicion was maintained if the individual mentioned pain with the described characteristics and an abnormal result in a previous X-ray image, or without an X-ray image.</p><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Confirmation of diagnosis</span>: The clinical criteria of the ACR were used,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> the same ones that were also used in EPISER2000.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Statistical analysis</span><p id="par0185" class="elsevierStylePara elsevierViewall">Sample design was taken into account to calculate prevalence and its corresponding 95% confidence interval, and weightings were calculated according to the probability of selection in each one of the sampling stages, based on population distribution in Spain according to registration data of the <span class="elsevierStyleItalic">Instituto Nacional de Estadística</span>. This weighting was performed considering participants’ age, sex and geographical origin (three zones were defined: North [Galicia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Asturias<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Cantabria<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Basque Country<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Navarre<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>La Rioja], Mediterranean and Canary Islands [Catalonia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Comunidad Valenciana<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Balearic Islands<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Murcia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Andalusia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>the Canary Islands] and the Centre [Comunidad de Madrid<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Castilla y León<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Aragon<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Castile-La Mancha<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Extremadura]).</p><p id="par0190" class="elsevierStylePara elsevierViewall">Lastly, predictive models were designed to analyse which of the sociodemographic, anthropometric and lifestyle variables included in the telephonic questionnaire were associated with each one of the diseases included in EPISER2016. To do this, bivariant analysis of the association of disease with each variable was first calculated, followed by the construction of binary logistic regression models based on the variables with a value of P<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.2 in the bivariant analysis (age and sex were included in the model, regardless of the value of <span class="elsevierStyleItalic">P</span> in the bivariant). Associations where <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05 were considered to be statistically significant. To compare different areas in Spain it was decided to use the North as the reference category, as in the majority of the multivariant analyses of the different locations of arthrosis it was found that this was the category with the lowest rates of the disease. V22 of the IBM SPSS Statistics program was used for analysis.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0195" class="elsevierStylePara elsevierViewall">The prevalence of symptomatic arthrosis in Spain, in one or more of the locations studied (cervical and lumbar spinal column, hips, knees or hands), amounted to 29.35% (CI 95%: 27.77–30.97) and it increased with age, reaching its highest figures in subjects over the age of 80 years (52.6%; CI 95%: 46.97–58.29). It was more common in women, above all those over the age of 60 years (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Cervical spinal column arthrosis</span><p id="par0200" class="elsevierStylePara elsevierViewall">613 subjects screened positively for cervical arthrosis after the initial interview, and 28 of these were lost. The prevalence of cervical arthrosis was 10.10% (CI 95%: 9.07–11.24). In 93.33% (322/345) of cases the diagnosis was clinical – radiographical, and 78.26% (270/345) had been diagnosed prior to the study. The negative predictive value (NPV) of the complete call centre questionnaire (in its totality) in screening for cervical arthrosis was 99.19% (one case of the 123 subjects aged 40 or more years who were selected at random from the participants who had obtained a negative screening result for all of the diseases studied in EPISER2016).</p><p id="par0205" class="elsevierStylePara elsevierViewall">Cervical arthrosis was associated in a statistically significant way with age, age, educational level, obesity and zone in Spain (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). It was more frequent in women and at older ages (with prevalence peaking from 60 to 69 years old), and in cases of obesity and basic educational levels. Regarding the geographical area in Spain, cervical arthrosis was less common in the subjects in the north than it was in those in the Mediterranean area (+the Canary Islands) and the centre of Spain. Tobacco consumption, living in a rural or urban environment and having been born abroad were not associated with cervical arthrosis.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Lumbar spinal column arthrosis</span><p id="par0210" class="elsevierStylePara elsevierViewall">777 subjects screened positively for lumbar arthrosis after the first interview, of which 31 were lost&