Geographic variations in hip fracture incidence in a high-risk country stretching into the Arctic: a NOREPOS study.

There are geographic variations in hip fracture incidence rates across Norway, with a lower incidence in the coastal areas of the southwest and in the Arctic north, contrary to what may be expected with regard to vitamin D exposure from sunlight. The regional differences have become smaller in recent years. INTRODUCTION: To investigate geographic variation in hip fracture incidence within Norway and regional differences in time trends. METHODS: All hip fractures treated in Norwegian hospitals 2002-2013 were included, and demographic information was obtained from Statistics Norway. Age-standardized incidence rates were calculated separately for 19 counties. Incidence rate ratios with 95% confidence intervals for county differences and time trends were estimated using Poisson regression. RESULTS: Age-standardized number of hip fractures per 10,000 person-years varied between counties from 69 to 84 in women and from 34 to 41 in men. The highest rates were observed in the southeastern capital city of Oslo, while rates were low in the four northernmost counties. There was an east-west gradient, with lower incidence in the coastal southwest compared with the southeast. Women showed a statistically significant decline during 2002-2013 in almost all counties (up to 31%). In men, only a few counties showed a decline. In both genders, hip fracture rates at age 80 in the combined five counties with the highest rates were significantly higher than in the combined five counties with the lowest rates across the period, although the trends converged over time. CONCLUSIONS: In Norway, the hip fracture incidence was lower in the north compared with the south. In addition, we observed an east-west gradient with the highest incidence in the southeast and lower incidence in the coastal southwest. While there has been an overall declining trend in hip fracture incidence over time, regional differences are still apparent.

Uterine rupture: trends over 40 years.

OBJECTIVE: To follow trends of uterine rupture over a period of 40 years in Norway. DESIGN: Population-based study using data from the Medical Birth Registry, the Patient Administration System, and medical records. SETTING: Norway. SAMPLE: Women giving birth in 21 maternity units in Norway during the period 1967-2008 (n = 1 441 712 maternities). METHODS: The incidence and outcomes of uterine rupture were compared across four decades: 1967-1977; 1978-1988; 1989-1999; and 2000-2008. Multivariable logistic regression was used to determine the odds ratio (OR) for uterine rupture in each decade compared with the second decade. MAIN OUTCOME MEASURE: Trends in uterine rupture. RESULTS: We identified 359 uterine ruptures. The incidence rates per 10 000 maternities in the first, second, third, and fourth decade were 1.2, 0.9, 1.7, and 6.1, respectively. The ORs for complete and partial ruptures in the fourth versus the second decade were 6.4 (95% confidence interval, 95% CI 3.8-10.8) and 7.2 (95% CI 4.2-12.3), respectively. Significant contributing factors to this increase were the higher rates of labour augmentation with oxytocin, scarred uteri from a previous caesarean section, and labour induction with prostaglandins or prostaglandins combined with oxytocin. After adjusting for risk factors, the ORs for complete and partial ruptures were 2.2 (95% CI 1.3-3.8) and 2.8 (95% CI 1.6-4.8), respectively. Severe postpartum haemorrhage, hysterectomy, intrapartum death and infant death after complete uterine ruptures decreased significantly over time. CONCLUSIONS: A sharply increasing trend of uterine rupture was found. Obstetric interventions contributed to this increase, but could not explain it entirely. TWEETABLE ABSTRACT: A sharply increasing trend of uterine ruptures has been found in Norway in recent years.

Maternal age and emergency operative deliveries at term: a population-based registry study among low-risk primiparous women.

OBJECTIVE: To study the association between maternal age and emergency operative delivery. The roles of in-labour indications, and birthweight ≥ 4000 g, gestational age ≥ 42 weeks, induction of labour, and epidural use, according to maternal age were explored. DESIGN: Population-based study. SETTING: Medical Birth Registry of Norway and Statistics Norway. POPULATION: We studied 169 583 low-risk primiparous mothers with singleton, cephalic labours, at ≥37 weeks of gestation, from 1999 to 2009. METHODS: The associations between maternal age and mode of delivery were analysed using multinomial regression analyses, adjusting for sociodemographic factors. MAIN OUTCOME MEASURES: Emergency caesarean section and operative vaginal delivery. RESULTS: Of women aged ≥40 years, 22% had emergency caesarean sections and 24% had operative vaginal deliveries, giving adjusted relative risk ratios (RRRs) of 6.60 (95% confidence interval, 95% CI 5.53-7.87) and 3.30 (95% CI 2.79-3.90), respectively, when compared with women aged 20-24 years. Adjustments for sociodemographic factors only slightly changed the estimates. Dystocia was the main indication, followed by fetal distress. All of the listed factors increased the level of emergency operative deliveries, mainly because of an increase in dystocia. The increase in risk for emergency caesarean section by all factors, and for operative vaginal deliveries by epidural, were greater in older than in younger women, but were significant for epidural only. CONCLUSIONS: We found a close association between maternal age and emergency operative delivery in low-risk primiparas. Contributory factors increased the risk for both emergency operative delivery and epidural more in older than in younger women.

Investigation into the reliability and validity of the measurement of elderly people's clinical walking speed: a systematic review.

The number of available walking tests has increased dramatically over the past decades. Therefore, it is highly important to help clinicians choose the most appropriate walking test for a specific setting. This systematic review aimed to critically evaluate the reliability, validity, and responsiveness of clinical walking speed in a broad population of elderly persons living in the community, sheltered housing, or institutions. Literature searches were performed in several different databases. Key words were based on the topic of the measurement properties of performance-based clinical tools for quantifying walking. The instrument selected for review was walking speed. The methods and results of all the evaluated measurement properties were rated by using a standard checklist for appraising the qualitative attributes and measurement properties of the instrument. A total number of 3,781 abstracts were reviewed, and 86 articles were chosen for inclusion. Habitual walking speed seems to be highly reliable in community-dwelling people and residents in mixed settings. There have not been any studies that accord with our inclusion and exclusion criteria that have evaluated the reliability of maximum walking speed in an aged population. Walking speed is a highly valid test, both at habitual and maximum speed. Few studies gave information about responsiveness for walking speed, which means that these results cannot be evaluated properly. Habitual walking speed is a reliable measure, but maximum walking speed needs further evaluation. Both habitual and maximum walking speeds are valid instruments, and they predict death, hospitalization/institutionalization, and decline in mobility.

Uterine rupture after previous caesarean section.

OBJECTIVE: To determine the risk factors, percentage and maternal and perinatal complications of uterine rupture after previous caesarean section. DESIGN: Population-based registry study. POPULATION: Mothers with births > or =28 weeks of gestation after previous caesarean section (n = 18 794), registered in the Medical Birth Registry of Norway, from 1 January 1999 to 30 June 2005. METHODS: Associations of uterine rupture with risk factors, maternal and perinatal outcome were estimated using cross-tabulations and logistic regression. MAIN OUTCOME MEASURE: Odds of uterine rupture. RESULTS: A total of 94 uterine ruptures were identified (5.0/1000 mothers). Compared with elective prelabour caesarean section, odds of rupture increased for emergency prelabour caesarean section (OR: 8.63; 95% CI: 2.6-28.0), spontaneous labour (OR: 6.65; 95% CI: 2.4-18.6) and induced labour (OR: 12.60; 95% CI: 4.4-36.4). The odds were increased for maternal age > or =40 years versus <30 years (OR: 2.48; 95% CI: 1.1-5.5), non-Western (mothers born outside Europe, North America or Australia) origin (OR: 2.87; 95% CI: 1.8-4.7) and gestational age > or =41 weeks versus 37-40 weeks (OR: 1.73; 95% CI: 1.1-2.7). Uterine rupture after trial of labour significantly increased severe postpartum haemorrhage (OR: 8.51; 95% CI: 4.6-15.1), general anaesthesia exposure (OR: 14.20; 95% CI: 9.1-22.2), hysterectomy (OR: 51.36; 95% CI: 13.6-193.4) and serious perinatal outcome (OR: 24.51 (95% CI: 11.9-51.9). Induction by prostaglandins significantly increased the odds for uterine rupture compared with spontaneous labour (OR: 2.72; 95% CI: 1.6-4.7). Prelabour ruptures occurred after latent uterine activity or abdominal pain in mothers with multiple or uncommon uterine scars. CONCLUSION: Trial of labour carried greater risk and graver outcome of uterine rupture than elective repeated caesarean section, although absolute risks were low. A review of labour management and induction protocol is needed.

Weight loss and distal forearm fractures in postmenopausal women: the Nord-Trøndelag health study, Norway.

SUMMARY: Weight loss is a risk factor for hip fractures, but few studies have evaluated the effect of weight loss on distal forearm fracture risk. In this longitudinal study including 7,871 postmenopausal women, weight loss of 5% or more was associated with an increased risk of distal forearm fractures. INTRODUCTION: Weight loss is an established risk factor for hip fractures, but little is known about weight loss and distal forearm fractures risk. METHODS: The study included 7,871 women aged 65 years or more in the Nord-Trøndelag health study (HUNT) in 1994-1995 (HUNT II) who also had their height and weight measured in 1984-1986 (HUNT I). Forearm bone mineral density (BMD) by single energy x-ray absorptiometry was available for 5,688 women (HUNT II). Fractures sustained after HUNT II were registered during an average of 5.8 years. RESULTS: A total of 536 women sustained a distal forearm fracture. After adjustments for age and body mass index (BMI) at HUNT I, women who lost > or =5% of their weight between HUNT I and HUNT II had a relative risk of fractures of 1.33 (95% confidence interval: 1.09, 1.62) compared with the rest of the women. The higher risk of forearm fracture among women with weight loss was at least partially explained by their lower forearm BMD. CONCLUSION: Weight loss of 5% or more was associated with a 33% increased risk of distal forearm fractures.

Risk of hip fractures in soft protected, hard protected, and unprotected falls.

OBJECTIVE: To compare hip fracture risk in soft and hard protected falls with the risk in unprotected falls and to compare the incidence of hip fractures in nursing homes providing soft and hard hip protectors. METHODS: An observational study conducted within the framework of a cluster randomized trial in 18 nursing homes. Nursing homes were randomized to offer either soft or hard hip protectors. Individual participants were followed for falls for 18 months. RESULTS: Of 1236 participating residents, 607 suffered 2926 falls; 590 of the 2926 falls were categorized as soft protected, 852 as hard protected, and 1388 as unprotected falls. Sixty-six verified hip fractures occurred: eight in soft protected falls, 11 in hard protected falls, and 45 in unprotected falls. The hip fracture risk in soft and hard protected falls was almost 60% lower than in unprotected falls (OR (soft) 0.36, 95% CI 0.17 to 0.77; OR (hard) 0.41, 95% CI 0.19 to 0.89). The incidence of hip fracture was 4.6 and 6.2 per 100 person-years in nursing homes providing soft and hard hip protectors, respectively (p = 0.212). CONCLUSION: Both types of hip protector have the potential, when worn correctly, to reduce the risk of a hip fracture in falls by nearly 60%. Both can be recommended to nursing-home residents as a means of preventing hip fractures.

Prevalence and risk factors of severe obstetric haemorrhage.

OBJECTIVE: To determine the prevalence, causes, risk factors and acute maternal complications of severe obstetric haemorrhage. DESIGN: Population-based registry study. POPULATION: All women giving birth (307,415) from 1 January 1999 to 30 April 2004 registered in the Medical Birth Registry of Norway. Information about socio-economic risk factors was obtained from Statistics Norway. METHODS: Cross-tabulation was used to study prevalence, causes and acute maternal complications of severe obstetric haemorrhage. Associations of severe obstetric haemorrhage with demographic, medical and obstetric risk factors were estimated using multiple logistic regression models. MAIN OUTCOME MEASURE: Severe obstetric haemorrhage (blood loss of > 1500 ml or blood transfusion). RESULTS: Severe obstetric haemorrhage was identified in 3501 women (1.1%). Uterine atony, retained placenta and trauma were identified causes in 30, 18 and 13.9% of women, respectively. The demographic factors of a maternal age of > or =30 years and South-East Asian ethnicity were significantly associated with an increased risk of haemorrhage. The risk was lower in women of Middle Eastern ethnicity, more than three and two times higher for emergency caesarean delivery and elective caesarean than for vaginal birth, respectively, and substantially higher for multiple pregnancies, von Willebrand's disease and anaemia (haemoglobin <9 g/dl) during pregnancy. Admissions to an intensive care unit, postpartum sepsis, hysterectomy, acute renal failure and maternal deaths were significantly more common among women with severe haemorrhage. CONCLUSION: The high prevalence of severe obstetric haemorrhage indicates the need to review labour management procedures. Demographic and medical risk factors can be managed with extra vigilance.

Termination of pregnancy according to immigration status: a population-based registry linkage study.

OBJECTIVE: Frequency of termination of pregnancy (TOP) and associated risk factors according to immigration status were studied. DESIGN: Population-based registry study linking hospital data with information from the Central Population Registry of Norway. SETTING: Oslo, Norway. POPULATION: All women 15-49 years undergoing TOP and resident in Oslo, Norway from 1 January 2000 to 31 July 2003. METHODS: TOP rates per 1000 women/year were calculated. The association of socio-economic variables such as maternal age, marital status, number of children and education level within the study groups were estimated as odds ratios and using logistic regression. MAIN OUTCOME MEASURE: Termination of pregnancy. RESULTS: Refugees (30.2, 95% CI = 28.5-31.8) and labour migrants (19.9, 95% CI = 18.7-21.3) had significantly higher TOP rates than nonmigrants (16.7, 95% CI = 16.3-17.1). Except in women less than 25 years, labour migrants had higher TOP rates than nonmigrants. Refugees had the highest rates in all age groups. Being unmarried was associated with a substantially increased risk of TOP among the nonmigrants; such effect was not observed among labour migrants and refugees. Two or more children were associated with increased risk among nonmigrants and refugees compared with four or more among the labour migrants. Generally, higher education showed a protective effect that was most pronounced among nonmigrants. Compared with nonmigrants, adjusted risk of TOP was 1.37 (95% CI = 1.25-1.50) for labour migrants and 1.94 (95% CI = 1.79-2.11) for refugees. CONCLUSION: Public health efforts to increase the use of contraceptives among refugees and labour migrants above 25 years should be encouraged.

Uptake and adherence with soft- and hard-shelled hip protectors in Norwegian nursing homes: a cluster randomised trial.

UNLABELLED: A comparison between soft- and hard-shelled hip protectors in nursing homes shows no clinical relevant difference in acceptance and probability of continued use. However, significantly more users of the soft hip protector used the protector 24 hours a day. INTRODUCTION AND HYPOTHESIS: Uptake and adherence with the use of hip protectors are poor due to discomfort and impracticality. The aim of the study was to compare uptake and adherence between soft- and hard-shelled hip protectors. We hypothesized a higher uptake and adherence with soft hip protectors than with hard ones. METHODS: This cluster randomized study was performed for 18 months in 18 Norwegian nursing homes. Each nursing home was randomly allocated either soft or hard hip protectors. A total of 1,236 participants were enrolled in the study of which 314 and 290 started to use soft and hard hip protectors, respectively. RESULTS: The uptake among participants in nursing homes provided soft hip protectors was not significantly different from the uptake in nursing homes provided hard protectors. The probability of continued use was a little higher among users of soft hip protector. There were significantly more 24-hour users among those people using the soft protector. CONCLUSION: Our results indicate that changing the design might not solve the compliance issue, but may be a step in the right direction, especially for those people who are in need of 24-hour use.

Compliance with external hip protectors in nursing homes in Norway.

OBJECTIVES: To investigate compliance with hip protector use. DESIGN: Observational prospective study. SETTING: 19 nursing homes (1040 beds). SUBJECTS: All residents during an 18 month period were included in this study. INTERVENTION: Hip protectors were introduced as a regular part of health care service for all residents. Residents at high risk were encouraged to use hip protectors regularly. Each nursing home had a contact person. MAIN OUTCOME MEASURES: The percentage of residents accepting the hip protector offer, probability of continued use, reasons for terminating use, and percentage of falls with hip protector were evaluated. RESULTS: Fifty five percent of the residents accepted the hip protector offer. The percentage increased by age, but showed no significant dependence on gender, profession of the contact person, or size of nursing home. The probability of continued use showed no significant dependence on age and gender. Nursing homes with a nurse as contact person showed 51% higher risk of residents terminating regular hip protector use than nursing homes with a physiotherapist as contact person (relative risk (RR) 1.51, 95% confidence interval (CI) 1.11 to 2.05, p = 0.008). The corresponding result for large (75-92 beds) compared with small (24-68 beds) nursing homes was RR = 1.44 (95% CI 1.02 to 2.02, p = 0.036). Seventy six percent of 2323 falls occurred while using hip protectors. CONCLUSION: The contact person and size of the nursing home seemed to be important factors for continued use of hip protectors while age and gender seemed to be less important.

Risk of hip fracture in protected and unprotected falls in nursing homes in Norway.

OBJECTIVES: To compare the probability of hip fracture in protected and unprotected falls in a real world setting in nursing homes. DESIGN: Observational study. SETTING: Seventeen nursing homes (965 beds) in Norway. SUBJECTS: All residents in the nursing homes with at least one fall during the intervention period. INTERVENTION: Hip protectors were introduced as a regular part of the health care service for all the residents for an intervention period of 18 months. Residents who were considered high risk were especially encouraged to be regular users of hip protectors. MAIN OUTCOME MEASURES: Hip fracture in protected and unprotected falls. RESULTS: At the time of the first fall within each faller, 430 were non-users of hip protectors, while 84 were registered as users, but did not wear it, and 191 were users and did wear it. The odds ratio of suffering a hip fracture was 0.31, 95% confidence interval 0.13 to 0.75 for wearers compared with non-wearers in the first fall, adjusted for age, gender, and whether they were registered as users or not. CONCLUSION: The odds of suffering a hip fracture for nursing home high risk residents was reduced to less than a third in protected falls compared with unprotected falls. Or, in other words, the odds of hip fracture showed a 69% reduction in protected falls compared with unprotected falls.

[Registration of injuries with the help of ICD-10 at Norwegian hospitals]. / Skaderegistrering ved hjelp av ICD-10 ved norske sykehus.

BACKGROUND: One in ten hospital beds in Norway is occupied by a patient with an injury diagnosis. So far, the national injury sample registry has been the most extensive source of information on external causes of injury. From 1 January 1999, the ICD-10 (International Classification of Diseases, 10th version) was implemented as a new system for registration of diagnosis at Norwegian hospitals. The aim of this study was to find out to what extent the codes for external causes of injury were utilised by the hospitals. MATERIAL AND METHODS: Data were collected from the Norwegian Patient Register on all patients in somatic hospitals who were admitted with a new injury in 1999. RESULTS: Of about 60,000 hospital admissions due to injuries at Norwegian hospitals, information on external causes was registered according to chapter XX in ICD-10 for only 39%. The registration was complete for only 23%. INTERPRETATION: Due to the incomplete use of chapter XX in ICD-10, data from this register do not, at present, give a good overview of the incidence of injuries in Norway. Hospitals should put more effects into registration in order to get high quality data.

How do reproductive and lifestyle factors influence bone density in distal and ultradistal radius of early postmenopausal women? The Nord-Trøndelag Health Survey, Norway.

In a population-based health survey, densitometry was performed at the distal and ultradistal radius with single-energy X-ray absorptiometry. Bone mineral density (BMD) data and self-reported reproductive and lifestyle data from 1652 randomly selected peri- and postmenopausal women aged 50-59 years were analyzed. A total of 893 (54.1%) postmenopausal women reported no prior use of hormone replacement therapy (HRT) and constituted the principal group of study. These women were more frequently smokers, consumed less alcohol, more coffee and had made less use of oral contraceptives (OC) than women in the HRT group. The strongest association with both distal and ultradistal radius bone densities was found for age, weight, time since menopause and a history of bilateral oophorectomy. Among reproductive factors, nulliparous women had lower BMD than parous women; however, no linear relationship was found between parity and bone density. A weak, positive relationship was found for OC and BMD in bivariate, but not in multivariate analyses. A history of hysterectomy was positively associated with BMD, stronger at the ultradistal than distal radius. A positive relationship between alcohol consumption and BMD was found at the ultradistal radius. Present or prior smokers had lower BMD than never smokers. In the multivariate model, interaction between pack-years of smoking and daily coffee intake was observed at the distal radius, and both factors had a stronger negative influence on distal than ultradistal radius bone density. In perimenopausal women, most reproductive and lifestyle risk factors found to be associated with BMD of the radius may be explained by different levels of estrogen.

Diabetes mellitus and the incidence of hip fracture: results from the Nord-Trøndelag Health Survey.

AIMS/HYPOTHESIS: To study if people with Type I (insulin-dependent) or Type II (non-insulin-dependent) diabetes mellitus have increased risk of hip fracture. METHODS: The study population consisted of 35,444 people 50 years of age and older, attending a health screening in a Norwegian county. They were followed up with respect to hip fracture for 9 years, and 1643 new hip fractures were recorded. RESULTS: The relative risk of hip fracture for women with Type I diabetes compared with women without diabetes was 6.9 (95% confidence interval 2.2-21.6) adjusted for age, body mass index and daily smoking. The relative risk for men was nearly the same, but not statistically significant. Among women 50-74 years of age with Type II diabetes for more than 5 years, the relative risk was 1.8 (95% confidence interval 1.1-2.9). This increased risk persisted when insulin-treated women were excluded from the analysis. After additional adjustment for possible medical consequences of diabetes (impaired vision, impaired motor abilities and history of stroke) the relative risk among women 50-75 years of age with Type II diabetes was reduced to 1.5 (95% confidence interval 0.9-2.5). CONCLUSION/INTERPRETATION: We found an increased risk of hip fracture in women younger than 75 years with Type I diabetes or with Type II diabetes of long duration. In older men, there was an increased risk associated with Type II diabetes of shorter duration. Whether the increased risk is attributed to reduced bone mass or to factors associated with falling has not been determined.

Survival after hip fracture: short- and long-term excess mortality according to age and gender.

The purpose of this study was to analyze the excess mortality after hip fracture and to reveal whether, and eventually when, the excess mortality vanished in different groups of age and gender. A population-based, prospective, matched-pair, cohort study among persons 50 years of age and older was conducted involving 1338 female and 487 male hip fracture patients with 11 086 and 8141 controls respectively. Occurrence of hip fracture and mortality were recorded from 1986 until 1995. We studied the excess mortality of the hip fracture patients versus controls by using Kaplan-Meier curves and extended Cox regression with hip fracture (yes/no) as time-dependent covariate. The male hip fracture patients had higher mortality than the women the first year after the injury, irrespective of age, both in absolute terms (31% and 17% respectively) and relative to their age-matched controls. The relative risk (RR) of dying within 1 year for hip fracture patients versus controls was 3.3 (95% confidence interval (CI) 2.1-5.2) for women and 4.2 (95% CI 2.8-6.4) for men below 75 years of age. The corresponding figures for persons 85 years and older were 1.6 (95% CI 1.2-2.0) for women and 3.1 (95% CI 2.2-4.2) for men. All groups of age and gender, except women 85 years and older, had a large and significant excess mortality lasting for many years after the hip fracture - at least 5-6 years for women below 75 years of age (RR = 3.2, 95% CI 1.9-5.6). The excess mortality after hip fracture for women 85 years and older had vanished after 3 months (RR = 1.0, 95% CI 0.8-1.1). When referring to the excess mortality after hip fracture it is therefore necessary to specify sex, age and time since injury.

Mental distress and risk of hip fracture. Do broken hearts lead to broken bones?

OBJECTIVE: Mental distress may entail increased risk of hip fracture, but it is uncertain whether the effect consists solely of an indirect effect through use of medication, or whether it is also mediated through other mechanism. The purpose of this study was to examine the association between mental distress and risk of hip fracture in women, adjusted for medication (that is, use of tranquillisers/sedatives or hypnotics). DESIGN: A three year follow up of hip fracture was conducted on 18,612 women, consisting of 92.5% of all women aged 50 years or older in a Norwegian county. Three hundred and twenty nine suffered a hip fracture. A mental distress index was based on questions about life dissatisfaction, nervousness, loneliness, sleep disorders, troubled and uneasy feelings, depression and impairment attributable to psychological complaints. Relative risk with 95% confidence intervals (CI) of hip fracture with respect to mental distress were controlled for medication, age, body mass index (BMI), smoking, physical inactivity, and physical illness by means of Cox regression. RESULTS: The 10% of women with the highest mental distress had more than twofold increased risk of hip fracture compared with the 10% of women with the lowest mental distress, after adjustment for age and medication. The relative risk was 1.95 (95% CI 1.2, 3.3) after additional control for BMI, smoking, physical inactivity, and physical illness. The relative risk of hip fracture for daily users of medication compared with never users was 2.1 (95% CI 1.6, 2.9). After adjusting for mental distress it was 1.5 (95% CI 1.0, 2.2). CONCLUSIONS: Risk of hip fracture was positively related to mental distress, also after adjustment for medication use. The effect of tranquillisers/sedatives or hypnotics on hip fracture risk may be overestimated in studies with no adjustments for mental distress.

Ex-smokers and risk of hip fracture.

OBJECTIVES: The purpose of this study was to examine the reversibility of the effect of smoking on hip fracture incidence rates. METHODS: A 3-year follow-up cohort study was conducted involving 35,767 adults 50 years of age or older. Of these individuals, 421 suffered a hip fracture. RESULTS: Among participants less than 75 years of age, the relative risk (RR) of hip fracture was elevated for ex-smokers, even for those who had quit smoking more than 5 years previously (men: RR = 4.4, 95% confidence interval [CI] = 1.2, 15.3; women: RR = 1.3, 95% CI = 0.6, 3.0), but was not as high as that for current smokers (men: RR = 5.0, 95% CI = 1.5, 16.9; women: RR = 1.9, 95% CI = 1.2, 3.1). CONCLUSIONS: The effect of smoking on risk of hip fracture was not reversed completely 5 years after smoking cessation.

Low blood pressure and mortality in the elderly: a 6-year follow-up of 18,022 Norwegian men and women age 65 years and older.

Several studies have shown that low blood pressure in individuals age 65 years and older is related to increased overall mortality. We hypothesize that this association is secondary to serious underlying illness, which has caused blood pressure reduction and, subsequently, has increased the risk of dying. Our study population was comprised of individuals age 20 years and older in the county of Nord Trøndelag in Norway, who were studied in a general health survey between 1984 and 1986. We had measurements of blood pressure, blood glucose, weight, height, and other information for 9,732 women and 8,290 men age 65 years or older. During approximately 6 years of follow-up, 2,122 women and 2,578 men died. For both genders, low systolic pressure was not associated with increased mortality, and the mortality curve did not display a J-shaped relation, after adjustment for age, marital status, body mass index, blood glucose, self-assessed health, use of antihypertensive medication, and history of diabetes and cardiovascular diseases. For diastolic pressure, however, women in the lowest category (< 75 mmHg) had an adjusted mortality rate ratio of 1.21 (95% confidence limits = 1.05, 1.39), compared with reference women (80-87 mmHg). Among men, the analogous mortality rate ratio was 1.16 (95% confidence limits = 1.02, 1.31). To reduce further the potential confounding between diastolic pressure and underlying illness, we excluded users of antihypertensive medication as well as the 2 first years of follow-up. After these procedures, the J-shaped mortality curve was not present among women, and it was substantially reduced among men. Thus, the results for both men and women indicated that the age-adjusted J-shaped relation between diastolic blood pressure and mortality was confounded with indicators of ill health, and that the often-found association between low diastolic blood pressure and increased mortality is indirect, possibly caused by serious underlying disease.

Interaction between current smoking, leanness, and physical inactivity in the prediction of hip fracture.

To study the association between smoking habits and the incidence of hip fracture, adjusted for leanness and physical inactivity, a cohort study with 3 years follow-up was conducted. Subjects were 34,856 adults aged 50 years or older who attended a health screening in Nord-Trøndelag County in Norway in 1984-1986 (91% of eligible subjects in 1986, n = 38,356). Of these, 421 suffered a hip fracture during the years 1986-1989. Using Cox regression models, the relative risk (with 95% confidence interval) of suffering a hip fracture for female smokers versus nonsmokers was 1.5 (1.0-2.4). These results refer to females when the female body mass index (BMI) was set at 25 kg/m2 in the female model (the mean BMI for the smoking female population in this study). Among thinner females, however, smoking had a much stronger effect. For instance, if the female BMI was set at 20 kg/m2, the relative risk was 3.0 (1.8-5.0). The relative risk of hip fracture for male smokers versus nonsmokers was 1.8 (1.2-2.9) irrespective of BMI. Smoking is associated with incidence of hip fracture in both sexes and also after adjusting for body mass index and physical inactivity (the effect of physical inactivity was adjusted for self-reported ill health because ill health was included in the model). For lean females, the association with current smoking was large, as large as if they added 10 years to their age.