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Background Domestic violence (DV) prior to, and during pregnancy is associated with increased risks for morbidity and mortality. As pregnant women routinely attend antenatal care this environment can be used to offer support to women experiencing DV. We have developed a video intervention that focuses on the use of behavioral coping strategies, particularly regarding disclosure of DV experiences. The effectiveness of this intervention will be evaluated through a randomized controlled trial (RCT) and a concurrent process evaluation. Methods All pregnant women between 12–22 weeks of gestation attending routine antenatal care at two tertiary level hospitals in Nepal are invited to participate. DV is measured using the Nepalese version of the Abuse Assessment Screen (N-AAS). Additionally, we measure participants’ mental health, use of coping strategies, physical activity, and food security through a Color-coded Audio Computer Assisted Self Interview (C-ACASI). Irrespective of DV status, women are randomized into the intervention or control arm using a computer-generated randomization program. The intervention arm views a short video providing information on DV, safety improving actions women can take with an emphasis on disclosing the violence to a trusted person along with utilizing helplines available in Nepal. The control group watches a video on maintaining a healthy pregnancy and when to seek healthcare. The primary outcome is the proportion of women disclosing their DV status to someone. Secondary outcomes are symptoms of anxiety and depression, coping strategies, the use of safety measures and attitudes towards acceptance of abuse. Follow-up is conducted after 32 weeks of gestation, where both the intervention and control group participants view the intervention video after completing the follow-up questionnaire. Additionally, a mixed methods process evaluation of the intervention will be carried out to explore factors influencing the acceptability of the intervention and the disclosure of DV, including a review of project documents, individual interviews, and focus group discussions with members of the research team, healthcare providers, and participants. Discussion This study will provide evidence on whether pregnant women attending regular antenatal visits can enhance their safety by disclosing their experiences of violence to a trusted person after receiving a video intervention. Trial registration The study is registered in ClinicalTrial.gov with identifier NCT05199935.

SummaryBisphosphonates reduce fractures in randomized controlled trials (RCT); however, there is less information from real life. In our population including 14,990 women and 13,239 men, use of bisphosphonates reduced risk of fractures in hip and forearm in women. The magnitude of the effect was comparable to results from RCT.IntroductionThe objective was to examine if treatment with bisphosphonates (BPs) was associated with reduced risk of fractures in the hip and forearm in women and men in the general population.MethodsIn a cohort study based on data from the third wave of the population-based HUNT Study (HUNT3), the fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database, 14,990 women and 13,239 men 50–85 years were followed from the date of participating in HUNT3 (2006–2008) until the date of first fracture in the hip or forearm, death, or end of study (31 December 2012). Hazard ratios with 95% confidence intervals for hip and forearm fracture according to use of BPs were estimated using Cox proportional hazards models with time-dependent exposure. Adjustment for individual FRAX® fracture risk assessment scores was included.ResultsBPs, predominantly alendronate, were used by 9.4% of the women and 1.5% of the men. During a median of 5.2 years of follow-up, 265 women and 133 men had a hip fracture, and 662 women and 127 men had a forearm fracture. Compared with non-users of BPs, the hazard ratios with 95% confidence interval for a fracture among users of BPs adjusted for age and FRAX® were 0.67 (0.52–0.86) for women and 1.13 (0.50–2.57) for men. Among users of glucocorticoids, the corresponding figures were 0.35 (0.19–0.66) and 1.16 (0.33–4.09), respectively.ConclusionsUse of BPs was associated with reduced risk of fractures in hip and forearm in women, and the magnitude of effect is comparable to results from RCTs.

SummaryFracture Risk Assessment Tool (FRAX) without bone mineral density (BMD) for hip fracture prediction was validated in a Norwegian population 50–90 years. Fracture risk increased with higher FRAX score, and the observed number of hip fractures agreed well with the predicted number, except for the youngest and oldest men.Self-reported fall was an independent risk factor for fracture in women.IntroductionThe primary aim was to validate FRAX without BMD for hip fracture prediction in a Norwegian population of men and women 50–90 years. Secondary, to study whether information of falls could improve prediction of fractures in the subgroup aged 70–90 years.MethodsData were obtained from the third survey of the Nord-Trøndelag Health Study (HUNT3), the fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database (NorPD), including 15,432 women and 13,585 men.FRAX hip without BMD was calculated, and hip fractures were registered for a median follow-up of 5.2 years.The number of estimated and observed fractures was assessed, ROC curves with area under the curve (AUC), and Cox regression analyses. For the group aged 70–90 years, self-reported falls the last year before HUNT3 were included in the Cox regression model.ResultsThe risk of fracture increased with higher FRAX score. When FRAX groups were categorized in a 10-year percentage risk for hip fracture as follows, <4, 4–7.9, 8–11.9, and ≥12%, the hazard ratio (HR) for hip fracture between the lowest and the highest group was 17.80 (95% CI: 12.86–24.65) among women and 23.40 (13.93–39.30) in men. Observed number of hip fractures agreed quite well with the predicted number, except for the youngest and oldest men. AUC was 0.81 (0.78–0.83) for women and 0.79 (0.76–0.83) for men. Self-reported fall was an independent risk factor for fracture in women (HR 1.64, 1.20–2.24), and among men, this was not significant (1.09, 0.65–1.83).ConclusionsFRAX without BMD predicted hip fracture reasonably well. In the age group 70–90 years, falls seemed to imply an additional risk among women.

Summary This population study investigated the association between birth characteristics and fracture risk in 11,099 young adults (aged 19–54 years). Our findings indicate that birth weight, gestational age, and birth weight for gestational age were not associated with fractures in the wrist, humerus, hip, and spine in this population. Purpose Skeletal development starts during fetal life, and it is estimated that most bone formation occurs in the 3rd trimester. This study examined the association between birth characteristics and fractures of the wrist, humerus, hip, and spine, in young adults (19–54 years). Methods 11.099 participants in the 3 rd survey of the HUNT Study (2006–2008) were linked with the Medical Birth Registry of Norway and hospital records. Fractures of the wrist, humerus, hip, and spine were identified using ICD9/10 codes between 1988 and 2021. Follow-up was from date of participation in HUNT until a first fracture, emigration, death, or end of study. Cox regression was used to estimate hazard ratios (HR) of fracture associated with birth characteristics (95% CI), adjusted for birth year, sex, maternal age, and maternal morbidity. In a secondary analysis, follow-up started in 1988. Results During a median follow-up of 14.0 years (153,657 person-years), 290 fractures occurred. Mean age at first fracture was 41.4 years (SD 7.4). Overall, there were no clear associations between birth characteristics and fractures in these data. HR for fracture was 0.43 (0.15–1.24) for those with a birth weight < 2.5 kg (reference birth weight 3.5 − 3.9 kg); 1.04 (0.74 − 1.46) for those born small for gestational age (< 10th percentile, reference 10 − 90 th percentile); and 0.63 (0.33 − 1.23) for those born preterm (reference term births). The secondary analysis from 1988, including 539 fractures, gave similar results as the main analysis. Conclusion Birth weight, gestational age, or birth weight for gestational age was not associated with an increased risk of fractures of the wrist, humerus, hip, and spine in young adults.

SummaryProton pump inhibitors (PPIs) have been linked to increased risk of fracture; the data have, however, been diverging. We did not find any increased risk of fractures among users of PPIs in a Norwegian population of 15,017 women and 13,241 men aged 50–85 years with detailed information about lifestyle and comorbidity.IntroductionProton pump inhibitors (PPIs) are widely prescribed and have been linked to increased risk of fracture.MethodsWe used data from the Nord-Trøndelag Health Study (HUNT3), The Fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database, including 15,017 women and 13,241 men aged 50–85 years. The study population was followed from the date of participating in HUNT3 (2006–2008) until the date of first fracture (forearm or hip), death, or end of study (31 December 2012). The Cox proportional hazards model with time-dependent exposure to PPIs was applied, and each individual was considered as unexposed until the first prescriptions was filled. To be included, the prescription of PPIs should minimum be equivalent to 90 defined daily doses (DDD) in the period. Individuals were defined as exposed until 6 months after end of drug supply.ResultsThe proportion of women and men using PPIs was 17.9% and 15.5%, respectively. During a median of 5.2 years follow-up, 266 women and 134 men had a first hip fracture and 662 women and 127 men, a first forearm fracture. The combined rate/1000 patient-years for forearm and hip fractures in women was 49.2 for users of PPIs compared with 64.1 among non-users; for men 18.6 and 19.8, respectively. The hazard ratios with 95% confidence interval for the first forearm or hip fracture among users of PPIs in the age-adjusted analysis were 0.82 (0.67–1.01) for women and 1.05 (0.72–1.52) for men. Adjusting for age, use of anti-osteoporotic drugs, and FRAX, the HR declined to 0.80 (0.65–0.98) in women and 1.00 (0.69–1.45) in men.ConclusionsUse of PPIs was not associated with an increased risk of fractures.

Summary The previously reported decline in age-adjusted hip fracture rates in Norway during 1999–2008 continued after 2008. The annual number of hip fractures decreased in women and increased in men. Introduction Norway has among the highest hip fracture incidence rates ever reported despite previously observed declining rates from 1999 through 2008. The aim of the present study was to investigate whether this downward trend continued through 2013, and to compare gender-specific trends in 5 year age-groups during three time periods: 1999–2003, 2004–2008, and 2009–2013. Methods All hip fractures (cervical, trochanteric, and sub-trochanteric) admitted to Norwegian hospitals were retrieved. Annual age-standardized incidence rates of hip fracture per 10,000 person-years by gender were calculated for the period 1999–2013. Time trends were tested by age-adjusted Poisson regression. Results From 1999 through 2013 there were 140,136 hip fractures in persons aged 50 years and above. Age-adjusted hip fracture incidence rates declined by 20.4 % (95 % CI: 18.6–20.1) in women and 10.8 % (95 % CI: 7.8–13.8) in men, corresponding to an average annual age-adjusted decline of 1.5 % in women and 0.8 % in men. Except for the oldest men, hip fracture rates declined in all age-groups 70 years and older. The average annual number of fractures decreased in women (−0.3 %) and increased in men (+1.1 %). Conclusions During the past 15 years, hip fracture rates have declined in Norway. The forecasted growing number of older individuals might, however, cause an increase in the absolute number of fractures, with a substantial societal economic and public health burden.

Summary The present study investigated the risk of incident hip fractures according to serum concentrations of vitamin K 1 and 25-hydroxyvitamin D in elderly Norwegians during long-term follow-up. The results showed that the combination of low concentrations of both vitamin D and K 1 provides a significant risk factor for hip fractures. Introduction This case-cohort study aims to investigate the associations between serum vitamin K 1 and hip fracture and the possible effect of 25-hydroxyvitamin D (25(OH)D) on this association. Methods The source cohort was 21,774 men and women aged 65 to 79 years who attended Norwegian community-based health studies during 1994–2001. Hip fractures were identified through hospital registers during median follow-up of 8.2 years. Vitamins were determined in serum obtained at baseline in all hip fracture cases ( n  = 1090) and in a randomly selected subcohort ( n  = 1318). Cox proportional hazards regression with quartiles of serum vitamin K 1 as explanatory variable was performed. Analyses were further performed with the following four groups as explanatory variable: I: vitamin K 1  ≥ 0.76 and 25(OH)D ≥ 50 nmol/l, II: vitamin K 1  ≥ 0.76 and 25(OH)D < 50 nmol/l, III: vitamin K 1  < 0.76 and 25(OH)D ≥ 50 nmol/l, and IV: vitamin K 1  < 0.76 and 25(OH)D < 50 nmol/l. Results Age- and sex-adjusted analyses revealed an inverse association between quartiles of vitamin K 1 and the risk of hip fracture. Further, a 50 % higher risk of hip fracture was observed in subjects with both low vitamin K 1 and 25(OH)D compared with subjects with high vitamin K 1 and 25(OH)D (HR 1.50, 95 % CI 1.18–1.90). The association remained statistically significant after adjusting for body mass index, smoking, triglycerides, and serum α-tocopherol. No increased risk was observed in the groups low in one vitamin only. Conclusion Combination of low concentrations of vitamin K 1 and 25(OH)D is associated with increased risk of hip fractures.

SummaryUse of anti-osteoporotic drugs (AODs) was examined in a Norwegian population 50–85 years. Among them with Fracture Risk Assessment Tool (FRAX) score for major osteoporotic fracture ≥ 20, 25% of the women and 17% of the men received AODs. The strongest predictors for AODs were high age in women and use of glucocorticoids among men.IntroductionTo examine the use of anti-osteoporotic drugs (AODs) and to identify predictors for prescriptions.MethodsData were obtained from the Nord-Trøndelag Health Study (HUNT3) performed in 2006–2008 and the Norwegian Prescription Database, including 15,075 women and 13,386 men aged 50–85 years. Bone mineral density (BMD) in the femoral neck was measured in a subgroup of 4538 women and 2322 men. High fracture risk was defined as a FRAX score for major osteoporotic fracture (MOF) ≥ 20%; in the subgroup with BMD, high risk was in addition defined as FRAXMOF ≥ 20% or T-score ≤ − 2.5. Hazard ratios (HRs) for predictors of incident use of AODs within 2 years after HUNT3 were estimated by Cox’ proportional hazards model.ResultsAmong individuals with FRAX MOF ≥ 20%, 25% of the women and 17% of the men were treated with AODs. Among those with FRAX MOF < 20%, 3% and 1% were treated, respectively. In the subgroup with BMD measurement, 24% of the women and 16% of the men at high risk of fractures were treated, compared to 3 and 1% in women and men not fulfilling the criteria. In women, high age was the strongest predictor for treatment (HR 3.84: 95% confidence interval 2.81–5.24), followed by use of glucocorticoids (GCs) (2.68:1.84–3.89). In men, predictors were use of GCs (5.28: 2.70–10.35) followed by multimorbidity (3.16:1.31–7.63). In the subgroup with BMD, T-score ≤ − 2.5 was the strongest predictor (women 3.98:2.67–5.89; men 13.31:6.17–28.74).ConclusionsThis study suggests an undertreatment of AODs in individuals at high risk of fracture.

Summary We wanted to study mortality after hip fractures among elderly women in Norway. We found that excess mortality was highest short time after hip fracture, but persisted for several years after the fracture. The excess mortality was not explained by pre-fracture medical conditions. Introduction The purpose of the present study was to investigate short and long term mortality after hip fracture, and to evaluate how comorbidity, bone mineral density, and lifestyle factors affect the survival after hip fractures. Methods The study cohort emerges from a population-based health survey in the county of Nord-Trøndelag, Norway. Women aged 65 or more at participation at the health survey who sustained a hip fracture after attending the health survey are cases in this study ( n  = 781). A comparison cohort was constructed based on participants at HUNT 2 with no history of hip fractures ( n  = 3, 142). Kaplan–Meier survival curves were used to evaluate crude survival, and Cox regression analyses were used to study age-adjusted hazard ratios for mortality and for multivariable analyses involving relevant covariates. Results Mean length of follow-up after fracture was 2.8 years. Within the first 3 months of follow-up, 78 (10.0%) of the hip fracture patients died, compared to only 39 (1.7%) in the control group. HR for mortality 3 months after hip fracture was 6.5 (95% CI 4.2–9.6). For the entire follow-up period women who sustained a hip fracture had an HR for mortality of 1.9 (95% CI 1.6–2.3), compared with women without a hip fracture. Conclusions We found that elderly women who sustained a hip fracture had increased mortality risk. The excess mortality was highest short time after the fracture, but persisted for several years after the fracture, and was not explained by pre-fracture medical conditions.

Summary We investigated the risk of hip fracture according to circulating alpha-tocopherol, a plant-derived substance with antioxidant properties, in community-dwelling older Norwegians. We found a linear increasing risk of hip fracture with lower serum alpha-tocopherol concentrations, with a 51 % higher risk in the lowest compared to the highest quartile. Introduction Oxidative stress is a suggested contributing cause of osteoporosis and fractures. Vitamin E (α-tocopherol) has potent antioxidant properties in humans. The relationship between circulating α-tocopherol and fracture risk is not established. The aim of this study was to investigate the association between serum α-tocopherol concentrations and risk of hip fracture during up to 11 years of follow-up. Methods We performed a case-cohort analysis among 21,774 men and women aged 65–79 years who participated in four community-based health studies in Norway 1994–2001. Serum α-tocopherol concentrations at baseline were determined in 1,168 men and women who subsequently suffered hip fractures (median follow-up 8.2 years) and in a random sample ( n  = 1,434) from the same cohort. Cox proportional hazard regression adapted for gender-stratified case-cohort data was performed. Results Median (25, 75 percentile) serum α-tocopherol was 30.0 (22.6, 38.3) μmol/L, and it showed a linear inverse association with hip fracture: hazard ratio (HR) 1.11 (95 % confidence interval (CI) 1.04–1.20) per 10-μmol/L decrease in serum α-tocopherol, adjusted for gender and study center. The lowest compared to the highest quartile conferred an HR of 1.51 (95 % CI 1.17–1.95), adjusted for gender and study center. Adjustment for smoking, month of blood sample, BMI, education, physical inactivity, self-rated health, and serum 25-hydroxyvitamin D (25(OH)D) yielded similar results. Taking serum total cholesterol concentration into account attenuated the association somewhat: HR of hip fracture was 1.37 (95 % CI 1.05–1.77) in first versus fourth quartile of serum α-tocopherol/total cholesterol ratio. Conclusions Low serum concentrations of α-tocopherol were associated with increased risk of hip fracture in older Norwegians.