Cardiovascular and respiratory hospitalizations and mortality among users of tiotropium in Denmark

Tiotropium (Spiriva is an inhaled, once-daily anticholinergic medication for chronic obstructive pulmonary disease (COPD). We conducted a population-based cohort study to examine the risk of cardiovascular and respiratory hospitalizations and mortality with tiotropium. Using the Danish healthcare registries, we identified persons >/=40 years old in three counties who were hospitalized for COPD from 1/1/1977 to 12/31/2003. Respiratory and cardiovascular medications were assessed from dispensing records. Cox regression was used to compute incidence rate ratios (RR) and 95% confidence intervals (CI) for hospitalization and death between 1/1/2002 and 12/31/2003, associated with periods of tiotropium use compared to non-use, controlling for age, gender, time since COPD, concomitant respiratory and cardiovascular medications, prior hospitalizations and Charlson comorbidity index. Among persons with COPD (10,603), 75% were >/=60 years old. Follow-up was >/=18 months for 64%. Among those exposed to tiotropium compared to periods of non-use, the RR for total and cause-specific hospitalization endpoints were not elevated except for COPD hospitalization (RR = 1.52, 95% CI: 1.29, 1.79). Mortality endpoints included total mortality (RR = 0.77, 95% CI: 0.65, 0.91), respiratory mortality (RR = 0.79, 95% CI: 0.60, 1.04), sudden death (RR = 0.71, 95% CI: 0.21, 2.34), cardiac arrest (RR = 0.74, 95% CI: 0.42, 1.32), heart failure (RR = 0.84, 95% CI: 0.41, 1.75), and myocardial infarction (RR = 1.25, 95% CI: 0.49, 3.17). Compared to periods of non-use, tiotropium was associated with reduced respiratory and overall mortality and was not associated with increased cardiac mortality. An increase in COPD hospitalization is inconsistent with clinical trial data and suggests preferential prescribing due to disease severity.     

Suicide among Indigenous Sami in Arctic Norway, 1970–1998

Suicide mortality was examined between 1970 and 1998 in a cohort of 19,801 persons categorized as indigenous Sami in Arctic Norway. Standardized mortality ratios (SMR) were calculated using the suicide rates of the rural population of Arctic Norway as reference. There was a significant moderate increased risk for suicide among indigenous Sami (SMR = 1.27, 95% Confidence interval (CI): 1.02–1.56). In the study period, 89 suicides occurred in the cohort (70 men and 19 women) with increased suicide mortality both for indigenous Sami males (SMR = 1.27; 95% CI: 0.99–1.61) and females (SMR = 1.27; 95% CI: 0.77–1.99). Significant increased suicide mortality was found for young Sami aged 15–24 for both males (SMR = 1.82; 95% CI: 1.13–2.78) and females (SMR = 3.17; 95% CI: 1.17–6.91). Significant increased suicide mortality was found for indigenous Sami males residing in Sami core area (SMR = 1.54; 95% CI: 1.04–2.20) and for indigenous Sami males not belonging to semi-nomadic reindeer herding (SMR = 1.30; 95% CI: 1.00–1.65). Clusters of suicides in Sami core area may explain the increased suicide mortality found in subgroups among indigenous Sami.     

Risk Factors Correlated with Post-operative Mortality for Hip Fracture Surgery in the Elderly: A Population-based Approach

Objectives: To estimate the effect of waiting time for surgery and volume of surgical activity on mortality in patients with hip fracture and to compare risk-adjusted outcomes between hospitals providing surgery for such patients. Design: Retrospective cohort study. Setting: Friuli Venezia Giulia, Italy. Participants: A total of 6,629 elderly people who underwent surgery for hip fracture between 1st January 1996 and 31th December 2000. Main outcome measures: In-hospital, 6-month and 1-year mortality rate Results: In-hospital mortality rate was 5.4%. At six months, the mortality rate was 20.0%, and at 1 year 25.3%. Age, male sex, and comorbidity were significant predictors of mortality. Logistic regression analysis indicated that, after controlling for main patients risk factors and taking into account the hospital level variability, there was no significant association between increase in mortality rate and more than 1 day of waiting time for surgery (OR 0.90; 95% CI 0.58–1.40 for in-hospital mortality). One hospital had a significantly higher mortality rate than the others; high hospital volume for hip fracture surgery was associated with worse outcomes (OR 1.57; 95% CI 1.38–1.78 for in-hospital mortality). Mortality after hip fracture decreased significantly from 1996 to 2000 (OR 0.85; 95% CI 0.80–0.90). Conclusions: Longer waiting time for surgery was not associated with mortality after adjusting for patient risk factors, and taking into account hospital level variability. Hospital level variability was statistically significant, and was partially explained by the total volume of hospital surgical activity. The decrease in mortality between 1996 and 2000 was confirmed by multivariate models.     

Selection of confounding variables should not be based on observed associations with exposure

In observational studies, selection of confounding variables for adjustment is often based on observed baseline incomparability. The aim of this study was to evaluate this selection strategy. We used clinical data on the effects of inhaled long-acting beta-agonist (LABA) use on the risk of mortality among patients with obstructive pulmonary disease to illustrate the impact of selection of confounding variables for adjustment based on baseline comparisons. Among 2,394 asthma and COPD patients included in the analyses, the LABA ever-users were considerably older than never-users, but cardiovascular co-morbidity was equally prevalent (19.9% vs. 19.9%). Adjustment for cardiovascular co-morbidity status did not affect the crude risk ratio (RR) for mortality: crude RR 1.19 (95% CI 0.93–1.51) versus RR 1.19 (95% CI 0.94–1.50) after adjustment for cardiovascular co-morbidity. However, after adjustment for age (RR 0.95, 95% CI 0.76–1.19), additional adjustment for cardiovascular co-morbidity status did affect the association between LABA use and mortality (RR 1.01, 95% CI 0.80–1.26). Confounding variables should not be discarded based on balanced distributions among exposure groups, because residual confounding due to the omission of confounding variables from the adjustment model can be relevant.     

Mortality risks among heavy-smokers with special reference to women: a long-term follow-up of an urban population

Increased mortality risks associated with smoking are well established among men. There are very few population-based studies comprising a sufficient number of heavily smoking women, measuring the direct effect of smoking on mortality risks. Between 1974 and 1992, 8,499 women and 13,888 men attended a health screening programme including reporting of smoking habits. Individuals were followed for total mortality until 2005. All-cause, cancer, cardiovascular, lung cancer and respiratory mortality were calculated in smoking categories <10 g per day, 10–19 g per day, and ≥20 g per day with never-smokers as a reference group and with adjustments for co-morbidities, socio-economic and marital status. For respiratory mortality and lung cancer adjustments for FEV₁, socio-economic and marital status were performed. Smoking was associated with a two to almost threefold increased mortality risk among women and men. The relative risk (RR) with 95% confidence interval, (CI) for women who smoked 10–19 g per day was 2.44 (2.07–2.87), and for those who smoked 20 g per day or more the RR (95% CI) was 2.42 (2.00–2.92). Smoking was a strong risk factor for cardiovascular mortality among women, the RR (95% CI) for women who smoked 10–19 g per day was 4.52 (3.07–6.64). Ex-smoking women showed increased risks of all-cause mortality; RR (95% CI) 1.26 (1.04–1.52) cancer (excluding lung cancer); RR (95% CI) 1.42 (1.07–1.88) and lung cancer RR (95% CI) 2.71 (1.02–7.23) mortality. However, the cardiovascular; RR (95% CI) 1.18 (0.69–2.00) and respiratory; RR (95% CI) 0.79 (0.16–3.84) mortality risks were not statistically significant. This study confirms that as for men, middle-aged heavily smoking women have a two to threefold increased mortality risk. Adjustments for co-morbidity, socio-economic and marital status did not change these results.     

The impacts of health examinations and smoking on disease mortality risk in Japan: a longitudinal cohort of 720,611 Japanese life insured persons

Objectives To evaluate the impacts of health examinations (HE) and smoking on disease mortality risk in Japan. Methods By using the large cohort database of a Japanese life insurance company, 720,611 subjects aged 20 to 80 years, who had contracted for life insurance between April 1, 1995 and March 31, 1998, were followed up until September 30, 1999. Cox’s proportional hazard model was used to estimate age-adjusted relative risk (RR) for disease death. Results After adjusting for age, disease mortality in smokers was significantly higher than that in non-smokers (men, RR 1.51, 95% CI: 1.25–1.81; women, RR 1.54, 95% CI: 1.12–2.11). Meanwhile, disease mortality in HEees (those who had got HE within the past 2 years) was significantly lower than that in non-HEees (men, RR 0.70, 95% CI: 0.56–0.88; women, RR 0.71, 95% CI: 0.54–0.92). The magnitude of the impact of HE on disease mortality risk varied according to smoking status. Non-smokers showed a significantly lower risk associated with HE, whereas smokers did not. Conclusions HE may allow an appreciable reduction in disease mortality, however, the reduction effect may be limited to non-smokers. Smoking cessation may be essential to improve the preventive effects of HE.     

Health-related quality of life as a predictor of mortality among community-dwelling older persons

Health-related quality of life (HRQOL) measures predict cause-specific mortality, but few studies have explored whether generic self-reported HRQOL measures are independently associated with mortality in community-dwelling older persons. We postulated that a general measure of HRQOL, the short form 36-item questionnaire (SF-36), would be independently predictive of mortality among community-dwelling older persons. To evaluate this hypothesis, we followed a fixed cohort of 4,424 community-dwelling older persons recruited from a 2000 population-based survey in Taiwan until 2003 and investigated whether HRQOL was predictive of 3-year mortality, even after adjusting for traditional clinical risk variables. The data were collected via a door-to-door survey, and interviewers collected information on the subjects’ demographics, medical history, utilization of health services, functional ability, falls, and self-reported physical and mental symptoms. Of the 6053 eligible subjects, 4,424 residents agreed to participate in the baseline survey and were contacted in 2003. During the 3-year period, the 3-year cumulative mortality rate for the study population was 5%. Mortality was significantly higher among males (5.57% vs. 4.27%, p = 0.049), and cumulative mortality increased with age (χ ²-test for trend; χ ² = 7.734, p = 0.001). For all scales except bodily pain, there was a significant relationship between a 10-point lower baseline score and mortality. Our primary multivariate risk model, which included two summary measures of HRQOL and significant clinical variables, demonstrated that a 10-point decrease in either the baseline Physical Component Summary (PCS) score or the baseline Mental Component Summary (MCS) score was associated with higher mortality (PCS: RR: 1.60, 95% CI: 1.39–1.83; p < 0.001; MCS: RR: 1.16, 95% CI: 1.01–1.34; p = 0.036). The findings suggested that low baseline PCS and MCS scores were important independent risk factors for 3-year mortality among community-dwelling older persons, even after adjusting for other risk factors.     

Risk Factors for Hip Fracture and a Possible Effect Modification by Hormone Replacement Therapy. The Danish Nurse Cohort Study

Objective: To identify risk factors for hip fracture and to examine whether hormone replacement therapy (HRT) modifies the effect of these risk factors. Design: Prospective cohort study. Setting: The Danish Nurse Cohort Study. Participants: 14,015 female nurses aged 50 years and above who in 1993 completed a questionnaire on general health and lifestyle issues, reproductive history including information on HRT, and family history of osteoporosis and personal history of a wrist fracture. Outcome measures: End-point was the first-ever hip fracture registered in the Danish National Hospital Register during the period from 1993 to 1999. Results: During the follow-up period 245 hip fractures were identified. Ever users of HRT had a lower risk of hip fracture (hazard ratio 0.69; 0.50–0.94). Women reporting a poor health (hazard ratio 2.01; 1.30–3.11), restrictions in daily activities (hazard ratio 1.52; 1.05–2.21), low body mass index (hazard ratio 1.65; 0.98–2.77), and leisure time sedentary physical activity (hazard ratio 1.88; 1.30–2.70) were main identified risk factors for hip fracture. HRT did not modify the effect of risk factors on the risk of hip fracture. Conclusion: This study confirms that women with a frail health are at increased hip fracture risk and that ever use of HRT decreases the risk of hip fracture. HRT did not modify the effect of these risk factors, indicating that the preventive effect of this therapy is independent of risk factors.     

Impact of Dementia on Long-Term Hip Fracture Surgery Outcomes: An Electronic Health Record Analysis

ObjectiveOlder adults with dementia are at higher risk for sustaining hip fracture and their long-term health outcomes after surgery are usually worse than those without dementia. Widespread adoption of electronic health records (EHRs) may allow hospitals to better monitor long-term health outcomes in patients with dementia after hospitalization. This study aimed to (1) estimate how dementia influences discharge location, mortality, and readmission 180 days and 1 year after hip fracture surgery in older adults, and (2) demonstrate the feasibility of using selection-bias reduced EHR data for research and long-term health outcomes monitoring.DesignRetrospective observational cohort study using EHRs.Setting and ParticipantsA cohort of 1171 patients over age 65 years who had an initial hip fracture surgery between October 2015 and December 2018 was extracted from EHRs of one health system; 376 of these patients had dementia.MethodsLogistic regression was applied to estimate influences of dementia on discharge disposition and Cox proportional hazards model for mortality. The Fine and Gray regression model was used to analyze readmission, accounting for the competing risk of death. To reduce selection bias in EHRs, inverse probability of treatment weighting using propensity scores was implemented before modeling.ResultsDementia had significant impacts on all outcomes: being discharged to facilities [odds ratio (OR) = 2.11, 95% confidence interval (CI) 1.19–3.74], 180-day mortality [hazard ratio (HR) = 1.69, 95% CI 1.20–2.38], 1-year mortality (HR = 1.78, 95% CI 1.33–2.38), 180-day readmission (HR = 1.62, 95% CI 1.39–1.89), and 1 year readmission (HR = 1.39, 95% CI 1.21–1.58).Conclusions and ImplicationsDementia was a significant risk factor for worse long-term outcomes. The inverse probability of treatment weighting approach can be used to reduce selection bias in EHR data for research and monitoring long-term health outcomes in the target population. Such monitoring could foster collaborations with post-acute and long-term health care services to improve recovery outcomes in patients with dementia after hip fracture surgery.     

Chronic obstructive pulmonary disease severity and cardiovascular outcomes

Objective: To identify predictors of chronic obstructive pulmonary disease (COPD) severity and assess the relation between COPD severity and risk of cardiovascular outcomes. Study design and setting: A␣cohort of patients with diagnosed and treated COPD was compiled from the Saskatchewan Health longitudinal databases. We used multivariate modeling to identify predictors of hospitalization for COPD as an indicator of COPD severity, and we used the model to characterize patients according to quintiles of COPD severity. These severity levels were used as independent variables in multivariate models of cardiovascular outcomes. Results: Determinants of COPD severity included emphysema, recent nebulizer use, home oxygen services, corticosteroid use, frequent bronchodilator use, pneumonia and prior COPD exacerbation. The 20% of patients with the highest COPD severity were 1.27 (CI: 1.07–1.50) times more likely to have arrhythmia, 1.25 (CI: 1.07–1.46) times more likely to have ischemic heart disease, 1.38 (CI: 1.11–1.71) times more likely to have angina, 2.28 (CI: 1.95–2.66) times more likely to have congestive heart failure, and 1.63 (CI: 1.22–2.16) times more likely to die of cardiovascular causes than the least severe 20% of patients. Conclusions: Patients with more severe COPD, as defined by our model, had higher cardiovascular morbidity and mortality than patients with less severe COPD.     

Country of birth and survival after a first myocardial infarction in Stockholm, Sweden

Aim To analyse survival after a first myocardial infarction among immigrants in Stockholm, Sweden. Methods All cases of first myocardial infarction among persons 30–74 years of age during 1985–1996 in Stockholm, Sweden were identified using registers of hospital discharges and deaths. Cases surviving 28 days were followed with regard to mortality during one year. Information on country of birth was obtained from national censuses and from a register on immigration. Early mortality was analysed by odds ratios (OR) through logistic regression and 1 year mortality by hazard ratios (HR) through cox proportional hazards regression. Results Male immigrants had a lower mortality within 28 days after a first myocardial infarction compared to Sweden-born after adjustment for socioeconomic status (OR 0.84; 95% CI 0.76–0.94). Among women there was a weak similar tendency (OR 0.92; 95% CI 0.76–1.10). There were essentially no differences overall between foreign-born and Sweden-born in 1-year-mortality after adjustment for socioeconomic status (men HR 1.13; 95% CI 0.91–1.41; women HR 0.90; 95% CI 0.61–1.34). Conclusion Immigrants in Sweden in general do not seem to have a higher mortality after a first myocardial infarction than Sweden-born, in particular when differences in socioeconomic status are accounted for. A higher CHD mortality in immigrants appears to be primarily due to an elevated disease incidence.     

Short- and long-term mortality after acute myocardial infarction: comparison of patients with and without diabetes mellitus

Aims To compare short- and long-term mortality after a first acute myocardial infarction (AMI) in patients with and without diabetes mellitus. Methods and results A nationwide cohort of 2,018 diabetic and 19,547 nondiabetic patients with a first hospitalized AMI in 1995 was identified through linkage of the national hospital discharge register and the population register. Follow-up for mortality lasted until the end of 2000. At 28 days and 5 years respectively, absolute mortality risks were 18 and 53% in diabetic men, 12 and 31% in nondiabetic men, 22 and 58% in diabetic women, and 19 and 42% in nondiabetic women. Crude mortality was significantly higher in diabetic patients than in nondiabetic patients in both men (28-day hazard ratio (HR) 1.55; 95% confidence interval (CI) 1.32–1.81, 5-year HR 2.01; 95% CI 1.84–2.21) and women (28-day HR 1.19; 95% CI 1.03–1.37, 5-year HR 1.53; 95% CI 1.40–1.67). After multivariate adjustment, risk differences became nonsignificant at 28 days, but diabetes was still associated with a significantly higher long-term mortality in both men (28-day HR 1.16; 95% CI 0.99–1.36, 5-year HR 1.49; 95% CI 1.36–1.64) and women (28-day HR 1.12; 95% CI 0.97–1.28, 5-year HR 1.39; 95% CI 1.27–1.52). The interaction between diabetes mellitus and gender did not reach significance in the analyses. Conclusion Our findings in an unselected cohort covering a complete nation show a significantly higher long-term mortality after a first acute myocardial infarction in diabetic patients. Yet, short-term mortality is not significantly higher in diabetic patients. Risks appear to be equally elevated in men and women.     

Risk of Hip Fracture in Benzodiazepine Users With and Without Alzheimer Disease

Objectives

To investigate the association between benzodiazepine and related drug (BZDR) use and hip fracture as well as postfracture mortality and duration of hospital stay in community-dwellers with and without Alzheimer disease (AD).

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.     

Metabolic syndrome and all-cause mortality: a meta-analysis of prospective cohort studies

To synthesize the available data on the association between metabolic syndrome and all-cause mortality, we conducted a meta-analysis of prospective cohort studies. We performed a literature search using Medline, EMBASE and Cochrane Library from 2001 to December 2009, with no restrictions. We included studies if they were prospective, had an assessment of metabolic syndrome at baseline and risk of all-cause mortality. We recorded several characteristics for each study. We extracted relative risks (RR) and 95% confidence intervals (CI) and pooled them using fixed or random effects models. We performed sensitivity analysis, and assessed heterogeneity and publication bias. A total of 21 studies including 372,411 participants were included in our meta-analysis. 18,556 deaths from any cause occurred during a mean follow-up of 11.5 years. Individuals with the metabolic syndrome, compared to those without, had an increased mortality from all causes (pooled RR 1.46; 95% CI 1.35–1.57). The RR of all-cause mortality associated with metabolic syndrome was higher in studies using the National Cholesterol Education Program Adult Treatment Panel (NCEP) than the revised NCEP criteria (RR: 1.45 vs. 1.25; P = 0.0002). Metabolic syndrome is an important risk factor for all-cause mortality. The diagnosis and treatment of the underlying risk factors for the metabolic syndrome should be an important strategy for the reduction of all-cause mortality associated with metabolic syndrome in the general population.     

Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials

BACKGROUND: The role of total calcium intake in the prevention of hip fracture risk has not been well established. OBJECTIVE: The objective of the study was to assess the relation of calcium intake to the risk of hip fracture on the basis of meta-analyses of cohort studies and clinical trials. RESULTS: In women (7 prospective cohort studies, 170,991 women, 2,954 hip fractures), there was no association between total calcium intake and hip fracture risk [pooled risk ratio (RR) per 300 mg total Ca/d = 1.01; 95% CI: 0.97, 1.05]. In men (5 prospective cohort studies, 68,606 men, 214 hip fractures), the pooled RR per 300 mg total Ca/d was 0.92 (95% CI: 0.82, 1.03). On the basis of 5 clinical trials (n = 5666 women, primarily postmenopausal, plus 1074 men) with 814 nonvertebral fractures, the pooled RR for nonvertebral fractures between calcium supplementation (800-1600 mg/d) and placebo was 0.92 (95% CI: 0.81, 1.05). On the basis of 4 clinical trials with separate results for hip fracture (6,504 subjects with 139 hip fractures), the pooled RR between calcium and placebo was 1.64 (95% CI:1.02, 2.64). Sensitivity analyses including 2 additional small trials with <100 participants or per-protocol results did not substantially alter results. CONCLUSIONS: Pooled results from prospective cohort studies suggest that calcium intake is not significantly associated with hip fracture risk in women or men. Pooled results from randomized controlled trials show no reduction in hip fracture risk with calcium supplementation, and an increased risk is possible. For any nonvertebral fractures, there was a neutral effect in the randomized trials.     

Paternal exposure to Agent Orange and spina bifida: a meta-analysis

The objective of this study is to conduct a meta-analysis of published and unpublished studies that examine the association between Agent Orange (AO) exposure and the risk of spina bifida. Relevant studies were identified through a computerized literature search of Medline and Embase from 1966 to 2008; a review of the reference list of retrieved articles and conference proceedings; and by contacting researchers for unpublished studies. Both fixed-effects and random-effects models were used to pool the results of individual studies. The Cochrane Q test and index of heterogeneity (I ²) were used to evaluate heterogeneity, and a funnel plot and Egger’s test were used to evaluate publication bias. Seven studies, including two Vietnamese and five non-Vietnamese studies, involving 330 cases and 134,884 non-cases were included in the meta-analysis. The overall relative risk (RR) for spina bifida associated with paternal exposure to AO was 2.02 (95% confidence interval [CI]: 1.48–2.74), with no statistical evidence of heterogeneity across studies. Non-Vietnamese studies showed a slightly higher summary RR (RR = 2.22; 95% CI: 1.38–3.56) than Vietnamese studies (RR = 1.92 95% CI: 1.29–2.86). When analyzed separately, the overall association was statistically significant for the three case–control studies (Summary Odds Ratio = 2.25, 95% CI: 1.31–3.86) and the cross sectional study (RR = 1.97, 95% CI: 1.31–2.96), but not for the three cohort studies (RR: 2.11; 95% CI: 0.78–5.73). Paternal exposure to AO appears to be associated with a statistically increased risk of spina bifida.     

Sarcopenia Combined With FRAX Probabilities Improves Fracture Risk Prediction in Older Chinese Men

ObjectivesTo examine whether the inclusion of sarcopenia in prediction models adds any incremental value to fracture risk assessment tool (FRAX).Design, Setting, and ParticipantsData from a prospective cohort of 4000 community-dwelling Chinese men and women aged 65 years and older with adjudicated fracture outcomes were analyzed.MeasurementsAt baseline, femoral neck bone mineral density (BMD) was assessed, as were the clinical risk factors included in FRAX, along with additional appendicular skeletal muscle mass, grip strength, and gait speed. Sarcopenia was defined according to the Asian Working Group for Sarcopenia algorithm. Incident fractures were documented during the follow-up period from 2001 to 2013.ResultsOf 4000 participants, 565 experienced at least 1 type of incident fracture and 132 experienced a hip fracture during a follow-up of 10.2 years. Hazard ratios (HRs) for 1-unit increase in FRAX score without BMD in men were 1.12 [95% confidence interval (CI) 1.08–1.16] for all fractures combined and 1.19 (95% CI 1.13–1.27) for hip fracture, and in women were 1.04 (95% CI 1.03–1.06) for all fractures combined and 1.08 (95% CI 1.06–1.11) for hip fracture. Similar to results of the FRAX score without BMD, HRs for 1-unit increase in FRAX score with BMD in men were 1.04 (95% CI 1.03–1.06) for all fractures combined and 1.19 (95% CI 1.13–1.25) for hip fracture, and in women were 1.04 (95% CI 1.03–1.05) for all fractures combined and 1.06 (95% CI 1.05–1.08) for hip fracture. Sarcopenia was significantly associated with all fractures combined (Adjusted HR 1.87; 95% CI 1.30–2.68) and hip fracture (Adjusted HR 2.67; 95% CI 1.46–4.90) in men but not in women. The discriminative values for fracture, as measured by the area under the receiver operating characteristic curve, were 0.60–0.73 and 0.62–0.76 for FRAX without and with BMD, respectively. Adding sarcopenia did not significantly improve the discriminatory capacity over FRAX (P > .05). Using reclassification techniques, sarcopenia significantly enhanced the integrated discrimination improvement by 0.6% to 1.2% and the net reclassification improvement by 7.2% to 20.8% in men, but it did not contribute to predictive accuracy in women.ConclusionsSarcopenia added incremental value to FRAX in predicting incident fracture in older Chinese men.     

Predicting early mortality among elderly patients hospitalised in medical wards via emergency department: The SAFES cohort study

Objectives: The aim of the study was, by early identification of deleterious prognostic factors that are open to remediation, to be in a position to assign elderly patients to different mortality risk groups to improve management.Design: Prospective multicentre cohort.Setting: Nine French teaching hospitals.Participants: One thousand three hundred and six (1 306) patients aged 75 and over, hospitalised after having passed through Emergency Department (ED).Measurements: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. A Cox survival analysis was performed to identify prognostic variables for six-week mortality. Receiver Operating Characteristics analysis was used to study the discriminant power of the model. A mortality risk score is proposed to define three risk groups for six-week mortality.Results: Crude mortality rate after a six-week follow-up was 10.6% (n=135). Prognostic factors identified were: malnutrition risk (HR=2.1; 95% CI: 1.1–3.8; p=.02), delirium (HR=1.7; 95% CI: 1.2-2.5; p=.006), and dependency: moderate dependency (HR=4.9; 95% CI: 1.5–16.5; p=.01) or severe dependency (HR=10.3; 95% CI: 3.2–33.1; p< .001). The discriminant power of the model was good: the c-statistic representing the area under the curve was 0.71 (95% IC: 0.67 – 0.75; p< .001). The six-week mortality rate increased significantly (p< .001) across the three risk groups: 1.1% (n=269; 95% CI=0.5–1.7) in the lowest risk group, 11.1% (n=854; 95% CI=9.4–12.9) in the intermediate risk group, and 22.4% (n=125; 95% CI=20.1–24.7) in the highest risk group.Conclusions: A simple score has been calculated (using only three variables from the CGA) and a practical schedule proposed to characterise patients according to the degree of mortality risk. Each of these three variables (malnutrition risk, delirium, and dependency) identified as independent prognostic factors can lead to a targeted therapeutic option to prevent early mortality.     

Cancer incidence among priests: 45?years of follow-up in four Nordic countries

Previously published studies on the risk of cancer among male priests have been based on cancer mortality with the exception of one case–control study. The aim of this study was to present estimates of cancer incidence among Nordic male priests. The study cohort for our analyses consisted of 6.5 million men aged 30–64 years old who had participated in any computerised population census in four Nordic countries in 1990 or earlier. Follow-up was done by drawing linkages with the national population and cancer registries. 13,491 priests were identified by their job title codes. We estimated the standardised incidence ratio (SIR) and 95% confidence intervals (95% CI) for the priests using the male population as a reference. Priests had a lower cancer incidence than the general population (overall SIR 0.85, 95% CI: 0.82–0.88). The majority of smoking- and alcohol-related cancers were associated with decreased SIR estimates. Increased risks were observed for skin melanoma (SIR 1.34, 95% CI: 1.11–1.62), acute myeloid leukemia (SIR 1.75, 95% CI: 1.20–2.47) and thyroid cancer (SIR 1.86, 95% CI: 1.22–2.73). This is the first cohort study regarding the incidence of cancer among priests. The lower incidence of smoking and alcohol-related cancers among Nordic male priests can be explained by their lower exposure to cigarettes and alcohol when compared to the general population. A greater risk of melanoma is typical of highly-educated people, but it is unclear why priests should have an increased risk of acute myeloid leukemia or thyroid cancer.