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The risk of subsequent fracture is increased after initial fractures; however, proper understanding of its magnitude is lacking. This population-based study examines the subsequent fracture risk in women and men by age and type of initial incident fracture. All incident nonvertebral fractures between 1994 and 2009 were registered in 27,158 participants in the Tromso Study, Norway. The analysis included 3108 subjects with an initial incident fracture after the age of 49 years. Subsequent fracture (n = 664) risk was expressed as rate ratios (RR) and absolute proportions irrespective of death. The rates of both initial and subsequent fractures increased with age, the latter with the steepest curve. Compared with initial incident fracture rate of 30.8 per 1000 in women and 12.9 per 1000 in men, the overall age-adjusted RR of subsequent fracture was 1.3 (95% CI, 1.2–1.5) in women, and 2.0 (95% CI, 1.6–2.4) in men. Although the RRs decreased with age, the absolute proportions of those with initial fracture who suffered a subsequent fracture increased with age; from 9% to 30% in women and from 10% to 26% in men, between the age groups 50–59 to 80+ years. The type of subsequent fracture varied by age from mostly minor fractures in the youngest to hip or other major fractures in the oldest age groups, irrespective of type and severity of initial fracture. In women and men, 45% and 38% of the subsequent hip or other major fractures, respectively, were preceded by initial minor fractures. The risk of subsequent fracture is high in all age groups. At older age, severe subsequent fracture types follow both clinically severe and minor initial incident fractures. Any fragility fracture in the elderly reflects the need for specific osteoporosis management to reduce further fracture risk. © 2013 American Society for Bone and Mineral Research.

See also Machin SJ, Briggs C. Mean platelet volume: a quick, easy determinant of thrombotic risk? This issue, pp 146–7. Summary. Background: Platelet size, measured as mean platelet volume (MPV), is associated with platelet reactivity. MPV is increased in acute myocardial infarction, and has been identified as an independent risk factor for future myocardial infarction and stroke. Objectives: The purpose of the study was to determine the impact of platelet count and MPV on the incidence of venous thromboembolism (VTE) in a prospective, population-based study. Methods: Platelet count, MPV and baseline characteristics were registered in 25 923 subjects aged 25–96 years who participated in the Tromso Study in 1994–1995. Incident VTE events were registered to the end of follow-up (1 September 2007). Results: There were 445 validated incident VTE events (1.6 per 1000 person-years), of which 186 (42%) were unprovoked, during a mean of 10.8 years of follow-up. Subjects with MPV ≥ 9.5 fL had a 1.3-fold [95% confidence interval (CI) 1.0–1.7] higher risk of total VTE and a 1.5-fold (95% CI 1.1–2.3) higher risk of unprovoked VTE than subjects with MPV

Objectives— The purpose of this study was to assess the impact of various obesity measures on identification of subjects at risk and their respective risk estimates for VTE in a prospective population-based study. Methods and Results— Measures of body composition such as body mass index (BMI), waist circumference (WC), hip circumference (HC), and waist-hip ratio (WHR) were registered in 6708 subjects aged 25 to 84 years, who participated in the Tromsø Study (1994–1995). Incident VTE-events were registered during follow-up until September 1, 2007. There were 222 VTE-events during a median of 12.3 years of follow-up. All measures of obesity exhibited significantly increased HR for VTE in multivariable models with highest risk estimates for WC in both genders. The risk of VTE increased across quartiles of BMI, WC, and HC in both genders, but not for WHR. WC identified more subjects at risk using established criteria for obesity. WC had the highest area under the curve in both genders in ROC analysis, and WC above ROC-derived cut-off values (WC ≥85 cm in women and ≥95 cm in men) were associated with HRs of 1.92 (95% CI: 1.05 to 3.48) in women and 2.78 (95% CI: 1.47 to 5.27) in men. Conclusions— Our findings indicate that WC is the preferable anthropometric measure of obesity to identify subjects at risk and to predict risk of VTE.

We assessed the association between the rate of forearm bone loss and non-vertebral fracture. Bone loss at the distal forearm predicted fractures, independently of baseline BMD, but not independently of follow-up BMD in women. The BMD level where an individual ends up is the significant predictor of fracture risk. Bone loss may predict fracture risk independently of baseline BMD. The influence of follow-up BMD on this prediction is unknown. The aim of this study was to assess the association between bone loss and fracture risk in both sexes in a prospective population-based study. We included 1,208 postmenopausal women (50 to 74 years), and 1,336 men (55 to 74 years) from the Tromso Study, who had repeated distal and ultra-distal forearm BMD measurements. Non-vertebral fractures were registered from 2001 to 2005. A total of 100 women and 46 men sustained fractures during the follow-up time. Independent of baseline BMD, the RR associated with distal site bone loss of 1 SD %/year was 1.23 (1.01-1.50) for low-trauma fractures (excluding hand, foot, skull & high-trauma) and 1.32 (1.07-1.62) for osteoporotic fractures (hip, wrist and shoulder). However, bone loss did not predict fracture after adjusting for follow-up BMD. The BMD level where an individual ends up became the significant predictor of fracture risk and not the rate of bone loss. Follow-up BMD at ultra-distal site was associated with low-trauma fractures in both sexes. While ultra-distal site BMD changes were not associated with fracture risk in both sexes. Bone loss at the distal forearm predicted non-vertebral fractures, independently of baseline BMD, but not independently of follow-up BMD, in women. The BMD level where an individual ends up is the significant predictor of fracture risk and not the rate of bone loss.

Summary. Background: The metabolic syndrome is a cluster of cardiovascular risk factors, including abdominal obesity, hypertension, dyslipidemia and insulin resistance, associated with increased risk of cardiovascular diseases and all cause mortality. Objectives: The purpose of the study was to assess the impact of the metabolic syndrome, and its individual components, on the risk of venous thromboembolism (VTE) in a prospective population-based study. Methods: Individual components of the metabolic syndrome were registered in 6170 subjects aged 25–84 years in the Tromso Study in 1994–1995, and first ever VTE events were registered until 1 September 2007. Results: The metabolic syndrome was present in 21.9% (1350 subjects) of the population. There were 194 validated first VTE events (2.92 per 1000 person-years) during a mean of 10.8 years of follow-up. Presence of metabolic syndrome was associated with increased risk of VTE (HR, 1.65; 95% CI, 1.22–2.23) in age- and gender-adjusted analysis. The risk of VTE increased with the number of components in the metabolic syndrome (P

We carried out a prospective study of the effect of neurosurgical teleconsultations on patient management in northern Norway. The total number of teleradiology image transfers during an eight-month study period was 723. We recorded data on 99 (14%) of these teleconsultations, which concerned 92 patients; the remainder were transfers to other departments at our hospital and transfers of routine examinations from a small community hospital that did not have a radiologist. The neurosurgeon on call noted the clinical condition and response time for each consultation. The consequences of the teleconsultation and the eventual benefits of the image transfer were evaluated. All 10 referring hospitals in the region used the service. The median response time was 3 hours (range 1–21 hours) in emergency cases and 1 day (range 1–7 days) in ordinary consultations. The response time was significantly shorter for patients with head injuries (median 3 hours) than for those with intracranial tumours (median 24 hours). Image transfer was considered beneficial for the patient in 93% of the cases. Avoidance of unnecessary patient transfer, changes of treatment at the referring hospital on the advice of the neurosurgeon and initiation of emergency transfer occurred in 34%, 42% and 13% of cases, respectively. The results confirm that teleconsultations between referring hospitals and a regional neurosurgical service influence patient management and reduce the frequency of patient transfer.

We have studied the relation of occupational and recreational physical activity to fractures at different locations. All men born between 1925 and 1959 and all women born between 1930 and 1959 in the city of Tromsø were invited to participate in surveys in 1979-1980 and 1986-1987 (The Tromsø Study). Of 16,676 invited persons, 12,270 (73.6%) attended both surveys. All nonvertebral fractures (n = 1435) sustained from 1988 to 1995 were registered in the only hospital in the area. Average age in the middle of the follow-up period (December 31, 1991) was 47.3 years among men and 4501 years among women, ranging from 32 to 66 years. Fracture incidence increased with age at all locations among women, but it decreased with or was independent of age among men. Low-energetic fractures constituted 74.4% of all fractures among women and 55.2% among men. When stratifying by fracture location, the most physically active persons among those 45 years or older suffered fewer fractures in the weight-bearing skeleton (relative risk [RR] 0.6, confidence interval [CI] 0.4-0.9, age-adjusted), but not in the non-weight-bearing skeleton (RR 1.0, CI 0.7-1.2, age-adjusted) compared with sedentary persons. The relative-risk of a low-energetic fracture in the weight-bearing skeleton among the most physically active middle-aged was 0.3 (CI 0.1-0.7) among men and 0.9 (CI 0.4-1.8) among women compared with the sedentary when adjusted for age, body mass index, body height, tobacco smoking, and alcohol and milk consumption. It seems that the beneficial effect on the skeleton of weight-bearing activity is reflected also in the incidence of fractures at different sites.

The purpose of this study was to evaluate whether digitized analog images displayed on a digital workstation can be improved by using a preprocessing algorithm, and if so, whether the quality of the resulting images can reach that of the original films. The material contained 120 difficult cases (about 50% with selected pathology). Four radiologists each evaluated half of the randomly ordered cases with the digital workstation and half of the cases with the original radiographs. The data were compared with a previous similar study, where the workstation had no option for preprocessed images. Preprocessed digital images were clearly superior to digital images without preprocessing, although for those of the highest diagnostic difficulty they were inferior to the original films. The preprocessing algorithm has improved the diagnostic quality of the digital workstation. There is room yet for improvement compared to plain films, although the current setup may be sufficient in some settings.

Since September 1992, Troms Military Hospital (Norway) has been connected to the larger University Hospital of Tromsø by a teleradiology link transmitting about 6000 examinations annually. In the spring of 1995, the system was upgraded with a digital X-ray unit, thereby almost eliminating the scanning of analog radiographs. This article describes the technical development of the link. The discussion suggests ways of improving the teleradiology link, particularly in terms of integrating the radiology information system (RIS) and picture archiving and communication system (PACS).

Purpose: We have used receiver operating characteristic (ROC) analysis to compare screen assessment of digitized radiographic films transmitted by a teleradiology system, with evaluation of the original radiographs on film. Material and Methods: The material contained 120 cases (about 50% with selected pathology) that were difficult to diagnose. Four radiologists each evaluated half of the cases on film, and half on computer screen. The screen display was 1024×836 pixels with 8 bits/pixel. Results: We found the accuracy and sensitivity of the teleradiology system to be clearly inferior to film evaluation. Conclusion: Improvement is needed both in the teleradiology system, and in the training of radiologists to work on the electronic workstation.

Despite reported bone loss during pregnancy and lactation, no study has shown deleterious long-term effects of parity or breastfeeding. Studies have shown higher bone mineral density and reduced risk for fracture in parous than in nulliparous women or no effect of parity and breastfeeding, so long-term effects are uncertain. We studied the effect of parity and breastfeeding on risk for hip, wrist and non-vertebral fragility fractures (hip, wrist, or proximal humerus) in 4681 postmenopausal women aged 50 to 94 years in the Tromso Study from 1994-95 to 2010, using Cox's proportional hazard models. During 51 906 person-years, and a median of 14.5 years follow-up, 442, 621, and 1105 of 4681 women suffered incident hip, wrist, and fragility fractures, and the fracture rates were 7.8, 11.4, and 21.3 per 1000 person-years, respectively. The risk for hip, wrist, and fragility fracture did not differ between parous (n = 4230, 90.4%) and nulliparous women (n = 451, 9.6%). Compared with women who did not breast-feed after birth (n = 184, 4.9%), those who breastfed (n = 3564, 95.1%) had 50% lower risk for hip fracture (HR 0.50; 95% CI 0.32 to 0.78), and 27% lower risk for fragility fracture (HR 0.73; 95% CI 0.54 to 0.99), but similar risk for wrist fracture, after adjustment for age, BMI, height, physical activity, smoking, a history of diabetes, previous fracture of hip or wrist, use of hormone replacement therapy, and length of education. Each 10 months longer total duration of breastfeeding reduced the age-adjusted risk for hip fracture by 12% (HR 0.88; 95% CI 0.78 to 0.99, p for trend = 0.03) before, and marginally after, adjustment for BMI and other covariates (HR 0.91; 95% CI 0.80 to 1.04). In conclusion, this data indicates that pregnancy and breastfeeding has no long-term deleterious effect on bone fragility and fractures, and that breastfeeding may contribute to a reduced risk for hip fracture after menopause.

Our aim was to examine associations between leisure time physical activity and risk of non-vertebral fractures in men and women aged ≥55 years, with focus on the anatomical fracture location. Self-reported physical activity was registered in 3,450 men and 4,072 women aged 55–97 years at baseline in the Tromso Study, Norway, in 1994–1995. Non-vertebral fractures were registered through December 31, 2009. During 75,546 person-years at risk, 1,693 non-vertebral fractures were identified. Risk of any non-vertebral fracture decreased with increasing physical activity level in men (P trend = 0.006) and non-significantly in women (P trend = 0.15), after adjustment for age, body mass index, height, smoking, and previous fracture. The reduced fracture risk was due to a reduced risk in the weight-bearing skeleton, particular at the hip, whereas risk of fracture in the non-weight-bearing skeleton was not related to physical activity. At weight-bearing sites, an inverse relationship between physical activity and fracture risk was present in both sexes (P trend ≤ 0.013). Compared with sedentary subjects, the most active men and women had respectively 37% (HR = 0.63, 95% CI: 0.45, 0.88) and 23% (HR = 0.77, 95% CI: 0.62, 0.95) reduced fracture risk in the weight-bearing skeleton. Physical activity is associated with reduced fracture risk at weight-bearing sites, with no associations at non-weight-bearing sites, in both sexes. Habitual physical activity is an important amendable approach to prevent hip fracture.

In this longitudinal study of 4,160 postmenopausal women (3,947 without and 213 with self-reported diabetes), smoking was strongly related to fracture risk in those with diabetes. Smoking is related to low bone mass and increased risk of fracture risk in postmenopausal women of the general population. The aim of the present longitudinal population-based study was to examine the effect of smoking on the risk of non-vertebral fractures in women ≥55 years of age, with specific focus on its relationship with diabetes. A total of 4,160 women (3,947 without and 213 with self-reported diabetes) from the municipality of Tromso, Norway, were followed for a mean of 7.6 years. Measurements of height and weight and questionnaire information concerning smoking and alcohol consumption habits, physical activity, prevalent diseases, and use of medication were collected before the start of follow-up. Non-vertebral fractures were registered during follow-up. A total of 1,015 without and 66 with diabetes sustained a new non-vertebral fracture. Smoking status (never, past, and current) was significantly associated with an increased risk of fracture both in women with and without diabetes (p values for trend 0.02 and

Few studies have examined the association between body mass index (BMI) change and fracture in a general population. We observed that BMI loss was associated with increased fracture risk in non-smoking men and women, but not in smokers. BMI gain was associated with decreased fracture risk in women. Weight loss has been associated with increased fracture risk, but few studies have included men. The aim of this study was to examine the association between BMI change and fracture risk in both genders. A population-based cohort study in Tromso, Norway, of adults, aged 20 to 54 years in 1979, who participated in two or three health surveys in 1979–1980, 1986–1987, and 1994–1995. Weight and height were measured at each survey. Information about lifestyle was obtained by questionnaires. Poisson regression was used to estimate incidence rates and Cox proportional hazards regression model to assess the association between fracture risk and BMI change. Fractional polynomials were used to accommodate non-linear associations. A total of 5,549 men and 5,428 women participated. There were 1,135 fractures during 10 years of follow-up. Reduction in BMI was associated with increased non-vertebral fracture risk in non-smokers, but not in smokers. The hazard ratio in male and female non-smokers per 10-year BMI decrease of 2 kg/m2 versus a BMI increase of 1 kg/m2 was 1.79 (95% confidence interval (CI), 1.17–2.75) and 1.60 (95% CI, 1.28–1.99), respectively. The association was not significantly modified by initial BMI or age or by exclusion of subjects with cardiovascular diseases, diabetes, or cancer. In female non-smokers, weight gain was inversely associated with fracture risk. In a general Norwegian population, reduction in BMI was significantly associated with increased fracture risk in male and female non-smokers, but not in smokers. These findings could not be explained by preexisting disease.

Aim of this study is to estimate the gender- and age-specific 10-year and lifetime absolute risks of non-vertebral and osteoporotic (included hip, distal forearm and proximal humerus) fractures in a large cohort of men and women. This is a population-based 10 years follow-up study of 26,891 subjects aged 25 years and older in Tromso, Norway. All non-vertebral fractures were registered from 1995 throughout 2004 by computerized search in radiographic archives. Absolute risks were estimated by life-table method taking into account the competing risk of death. The absolute fracture risk at each year of age was estimated for the next 10 years (10-year risk) or up to the age of 90 years (lifetime risk). The estimated 10-year absolute risk of all non-vertebral fracture was higher in men than women before but not after the age of 45 years. The 10-year absolute risk for non-vertebral and osteoporotic fractures was over 10%, respectively, in men over 65 and 70 years and in women over 45 and 50 years of age. The 10-year absolute risks of hip fractures at the age of 65 and 80 years were 4.2 and 18.6% in men, and 9.0 and 24.0% in women, respectively. The risk estimates for distal forearm and proximal humerus fractures were under 5% in men and 13% in women. The estimated lifetime risks for all fracture locations were higher in women than men at all ages. At the age of 50 years, the risks were 38.1 and 24.8% in men and 67.4 and 55.0% in women for all non-vertebral and osteoporotic fractures, respectively. The estimated gender- and age-specific 10-year and lifetime absolute fracture risk were higher in Tromso than in other populations. The high lifetime fracture risk reflects the increased burden of fractures in this cohort.

Summary. Background: Recent studies indicate that arterial cardiovascular diseases and venous thromboembolism (VTE) share common risk factors. A family history of myocardial infarction (MI) is a strong and independent risk factor for future MI. Objectives: The purpose of the present study was to determine the impact of cardiovascular risk factors, including family history of MI, on the incidence of VTE in a prospective, population-based study. Patients and methods: Traditional cardiovascular risk factors and family history of MI were registered in 21 330 subjects, aged 25–96 years, enrolled in the Tromso study in 1994–95. First-lifetime VTE events during follow-up were registered up to 1 September 2007. Results: There were 327 VTE events (1.40 per 1000 person-years), 138 (42%) unprovoked, during a mean of 10.9 years of follow-up. In age- and gender-adjusted analysis, age [hazard ratio (HR) per decade, 1.97; 95% confidence interval (CI), 1.82–2.12], gender (men vs. women; HR, 1.25; 95% CI, 1.01–1.55), body mass index (BMI; HR per 3 kg m−2, 1.21; 95% CI, 1.13–1.31), and family history of MI (HR, 1.31; 95% CI, 1.04–1.65) were significantly associated with VTE. Family history of MI remained a significant risk factor for total VTE (HR, 1.27; 95% CI, 1.01–1.60) and unprovoked VTE (HR, 1.46; 95% CI, 1.03–2.07) in multivariable analysis. Blood pressure, total cholesterol, HDL-cholesterol, triglycerides, and smoking were not independently associated with total VTE. Conclusions: Family history of MI is a risk factor for both MI and VTE, and provides further evidence of a link between venous and arterial thrombosis.

In order to compare different methods of fracture registration, we sought all nonvertebral fractures suffered during 8 years (1988–95) among 21 441 persons invited to a survey in 1979/80. We registered a total of 54 hip fracture cases through three separate sources (self-report, computer linkage to the local radiographic archives, discharge register), whereas forearm fractures (a total of 291 cases) were registered through two separate sources (self-report, computer linkage to the radiographic archives). The registration of fractures at other sites (a total of 1321 cases) were from one source (computer linkage to the local radiographic archives), and we have compared three ways of obtaining data from this single source (no ascertainment, ascertainment of records coded as fracture, ascertainment of all records). Ninety-three percent of all hip fractures and 97% of all wrist fractures in the entire study population were found by computer linkage to the radiographic archives, whereas the discharge register detected 87% of all the hip fractures. Computer linkage with ascertainment gave no overreporting of fractures. Among the 11 626 persons who answered a follow-up questionnaire in 1994/95, 97% (CI 84–100%) of all hip fractures and 72% (CI 66–78%) of all wrist fractures were self-reported. We conclude that a computerized search of radiographic archives is a viable method of fracture registration.

We have developed a system for routine teleradiology between a local clinic and a central hospital, where the dictation is digital, and sound data is transmitted in real-time over a digital 64 kbit/s network. The need to stock, transfer, and account for analog tapes is eliminated. The dictation is integrated in a program for viewing the patient images, so that the audio data is automatically connected with the current patient. The doctor uses a commercial workstation running UNIX, with image display on multiple X windows servers. The dictation is transcribed by the secretary who uses an ordinary PC equipped with a popular sound board. Sound data is transmitted over the teleradiology network during playback, and the text file containing the transcription is also connected with the patient.© (1992) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

The organization of radiological practices differs in Scandinavian countries from that of many other countries. Regular formal meetings take place daily in the radiology department where the senior radiologist demonstrates findings from the imaging procedures of the previous day for the clinicians at the hospital. This procedure which is considered very valuable, should become even more effective with the planned IMAC installations. The article describes routines common to Nordic radiological departments that hopefully can be implemented in future IMAC.