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Purpose: To estimate the frequency of use of pressure-redistributing support surfaces (PRSS) among hip fracture patients and to determine whether higher pressure ulcer risk is associated with greater PRSS use. Design and Methods: Patients (n = 658) aged [greater than or equal to] 65 years who had surgery for hip fracture were examined by research nurses at baseline and on alternating days for 21 days. Information on PRSS use and pressure ulcer risk factors was recorded at each assessment visit. Other information was obtained by interview and chart review. Results: A PRSS was observed at 36.4% of the 5,940 study visits. The odds of PRSS use were lower in the rehabilitation setting (adjusted odds ratio [OR] 0.4, 95% confidence interval [CI] 0.3-0.6), in the nursing home (adjusted OR 0.2, 95% CI O. 1-0.3), and during readmission to the acute setting (adjusted OR 0.6, 95% CI 0.4-0.9) than in the initial acute setting. There was wide variation in frequency of PRSS use by admission hospital, even after adjusting for pressure ulcer risk factors. The relationships between PRSS use and pressure ulcer risk factors were not strong. Implications: In this study of hip fracture patients, adherence to guidelines for PRSS use was low and was based more on facility-related factors than on patient risk. There is an urgent need for health care providers to improve strategies for the prevention of pressure ulcers in high-risk patients. Key Words: Pressure ulcers, Hip fracture, Support surfaces, Prevention doi: 10.1093/geront/gnp101

Background. The mortality after hip fracture has remained high and stable the past 50 years despite improved surgical treatment. The aim of this study was to identify medications and medical factors associated with mortality after hip fracture. Methods. This is a prospective observational study with median observation time of 21 months. Three hundred and sixty-four patients, mean age 83.4 years and 75.8% women, were enrolled. Information on comorbidity, medications, surgery, and clinical findings were collected at the time of fracture. Information on cause and time of death was obtained from the Norwegian Cause of Death Register. Results. Six risk factors and one protective factor were identified by Cox proportional hazards model adjusted for propensity score: the use of diuretics (adjusted hazard ratio [HR] = 4.03, 95% confidence interval [CI] = 2.13-7.64), history of coronary heart disease (CHD) (HR = 2.61, CI = 1.37-4.98), male sex (HR = 2.32, CI = 1.27-4.24), Barthel Index [less than or equal to] 18/20 (HR = 2.48, CI = 1.23-5.01), heart rate > 100 on admission (HR = 2.47, CI = 1.18-5.14), body mass index [less than or equal to] 20 (HR = 1.94, CI = 1.13-3.34), and the use of statins (HR = 0.23, CI = 0.08-0.68). Patients using diuretics had increased risk of death from all causes, including death from CHD, chronic obstructive pulmonary disease, and falls or other accidents. Conclusions. The use of diuretics is the strongest predictor of mortality, followed by CHD at the time of fracture, whereas the use of statins is associated with improved survival. Future research is needed to evaluate whether improved diagnosis and management of CHD and congestive heart failure among hip fracture patients would improve survival. Key Words: Mortality--Hip fracture--Diuretics--Coronary heart disease. doi: 10.1093/gerona/glp199

Background. Little is known about mortality in nursing home residents with hip fracture. This study examined the effect of pre-fracture characteristics, hospital complications, and post-fracture complications on mortality in residents with hip fracture. Methods. This is a retrospective cohort study of 195 long-term care residents (153 women, 42 men) with hip fracture (1999-2006) followed for mortality until June 30, 2007. Pre-fracture characteristics (age, sex, cognition, functional status, comorbidities, body mass index), hospital complications (acute myocardial infarction, congestive heart failure, delirium, infection) and 6-month complications (delirium, pneumonia, pressure ulcer, urinary tract infection [UTI]) were evaluated as potential predictors of mortality. Results. During a median follow-up of 1.4 years, 150 participants (76.9%) died. Male residents were nearly twice as likely to die compared with female residents (hazard ratio [HR] = 1.9, 95% confidence interval [CI] 1.2-3.0). Other pre-fracture characteristics associated with increased mortality included older age (HR per 5 years = 1.3, 95% CI 1.1-1.6), low functional status (HR = 1.7, 95% CI 1.0-3.01, anemia (HR = 1.6, 95% CI 1.1-2.5), and coronary artery disease (HR = 2.0, 95% CI 1.3-2.9). Mortality was 70% greater among residents with a pressure ulcer or pneumonia within 6 months of hip fracture (pressure ulcer, HR = 1.7, 95% CI 1.2-2.6; pneumonia, HR = 1.7, 95% CI 1.1-2.7). Individual hospital complications and post-fracture delirium and UTI were not significant predictors of mortality. Conclusions. In addition to pre-fracture characteristics, potentially modifiable post-fracture complications including pressure ulcer and pneumonia were associated with increased mortality in nursing home residents with hip fracture. Prevention strategies to reduce pressure ulcers and pneumonia may he]p reduce mortality in this frail population. Key Words: Hip fracture--Nursing home--Mortality.

Background. The study aim was to determine the kinetics of serum pro- and anti-inflammatory cytokines and C-reactive protein (CRP) in hip-fracture patients over a month postfracture, and their relationship to postoperative (postop) complications and cognitive level. Methods. Forty-one elderly hip-fracture patients were prospectively followed. Serum was obtained during the first 10 hours postfracture and presurgery, 48-60 hours postop, 7 and 30 days postop, measuring CRP, interleukin-1[beta] (1L-1[beta]), IL-6, IL-8, tumor necrosis factor-[alpha] (TNF-[alpha]), IL-10, and IL-1 receptor antagonist (IL-1RA). Results. A significant increase was found postop for CRP, IL-6, TNF-[alpha], IL-1RA (p < .001), IL-10 (p < .002), and IL-8 (p = .05). CRP kinetics curves were higher in patients with complications as a group, and in those suffering from infections, delirium, and cardiovascular complications (p < .05). IL-6 increase in patients with complications approached significance. Additional complications appeared in patients with impaired mental status (IMS) versus cognitively normal patients (p = .037). Higher kinetics curves in the IMS patients were found for CRP and IL-6 (p < .05). Analyzing the interaction effect of complications and IMS on CRP and cytokines production demonstrated that the increase in CRP was independently related to complications and IMS. IL-6, IL-8, and IL-10 were higher in IMS patients but not in patients with complications without IMS (p < .05). Conclusions. Serum CRP and cytokines increased drastically in postop hip-fracture elderly patients. Only CRP significantly and independently increased in IMS patients and in patients with complications, whereas cytokines significantly increased only in IMS patients. This study raises questions about possible effects that cytokine generation, after hip-fracture repair, might have on cognition and complications.

Introduction: Hip fracture is a major public health problem, annually affecting over 350,000 persons in the United States and 1.6 million worldwide. Consequences include decreased survival, loss of independence, and increased risk of subsequent fractures. A substantial decline in bone mineral density (BMD) also occurs, yet the magnitude of the decline specifically attributable to hip fracture has not been documented. Methods: To determine the amount of BMD decline attributable to hip fracture, the rate of decline in BMD in a cohort of hip fracture patients was compared with that in a cohort of women of similar age and BMD but without hip fracture. All subjects were community dwelling when enrolled. Hip fracture patients in the Baltimore Hip Studies (BHS) came from two hospitals in Baltimore, Maryland, from 1992 through 1995; comparison subjects came from the Study of Osteoporotic Fracture (SOF) enrolled in four areas of the United States during the same period. Eighty-four white, female hip fracture patients 65 years and older from the BHS were compared with 168 SOF participants matched on age, race, and BMD at baseline. BMD of the femoral neck and total hip was measured by dual-energy x-ray absorptiometry. Results: Hip fracture patients had a greater decline in BMD during the 12-month postfracture follow-up than that expected on the basis of the nonfracture cohort: 4.9% vs. 0.4% at the femoral neck and 3.5% vs. 0.7% for the total hip. The decline in BMD in hip fracture patients was 11.8 times the amount expected at the femoral neck (matched on age and baseline BMD and adjusted for between-cohort differences in smoking prevalence) and 4.9 times that expected for the total hip at the end of 1 year after the hip fracture. Conclusion: In this sample of older women, bone loss over the year following hip fracture far exceeded that expected and is an important clinical management concern. Keywords Aging * Body composition * Bone mineral density * Epidemiology * Orthopaedics * Osteoporosis

Byline: Lois E. Wehren (5), William G. Hawkes (1), J. Richard Hebel (1), Denise Orwig (1), Sheryl I. Zimmerman (2), Kathleen M. Fox (3), Janet Yu-Yahiro (4), Jay Magaziner (1) Keywords: Bone density; Hip fracture; Longitudinal study; Outcomes; Predictors Abstract: Although accelerated bone mineral density (BMD) loss follows hip fracture, little is known about factors associated with this loss. We examined potential predictors of BMD loss in a cohort of community-dwelling women who had sustained hip fracture and who were followed for 1 year after fracture. BMD was measured at the femoral neck, intertrochanteric region, and total body, during hospitalization and 2, 6, and 12 months later. Demographic, health, lifestyle, clinical, surgical, and functional characteristics at baseline, and postfracture activity were evaluated for associations with baseline BMD and BMD 1 year later. To examine possible BMD-dependent effects, high and low baseline BMD groups were defined. None of the studied factors consistently predicted either baseline BMD or BMD at 1 year after fracture, among women with either high or low baseline BMD. Baseline BMD was the only factor that substantially and consistently predicted change, explaining 70% to 90% of variation. These results suggest that BMD will not be preserved by general rehabilitative measures and that prompt, specific intervention to minimize bone loss after hip fracture is an essential element of clinical management of the hip fracture patient. Author Affiliation: (1) University of Maryland, Baltimore, Maryland, USA (2) University of North Carolina, Chapel Hill, North Carolina, USA (3) Managed EDGE/EURO RSCG, New York, New York, USA (4) Union Memorial Hospital, Baltimore, Maryland, USA (5) Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, 660 West Redwood Street, Baltimore, MD 21201, USA Article History: Received Date: 27/12/2002 Accepted Date: 04/08/2003 Online Date: 05/12/2003

Byline: Sachin Bahl (1), Penelope S. Coates (2), Susan L. Greenspan (2) Keywords: Hip fracture; Osteoporosis Abstract: To determine if physicians have improved the recognition and treatment of osteoporosis in patients with an acute hip fracture, we performed a retrospective analysis of discharge data from 1995 and 2000 at the University of Pittsburgh Medical Center, a large tertiary care, academic institution. We examined patients admitted with an acute hip fracture in 1995 and 2000 and age- and sex-matched patients admitted with community acquired pneumonia in 2000. Outcomes included age, gender, race, discharge diagnoses (from ICD-9 codes) and discharge medications (from discharge summaries) in all patients. There were 136 acute hip fracture patients (mean age 73+-18 years) in 1995, 117 acute hip fracture patients (mean age 76+-16 years) in 2000 and 116 patients with community-acquired pneumonia (mean age 78+-7 years). Patients admitted in 2000 with an acute hip fracture were more likely to be diagnosed with osteoporosis (18% vs. 4%, P&lt 0.02), more likely to be discharged on calcium (17% vs. 7%, P&lt 0.02) and more likely to be discharged on antiresorptive therapy (15% vs. 2%, P&lt 0.001) than those admitted in 1995. Moreover, patients admitted with community-acquired pneumonia were just as likely to receive calcium, vitamin D or antiresorptive agents at the time of discharge as those with an acute hip fracture in 2000. Patients with a diagnosis of osteoporosis in 2000 were older and more likely to receive antiresorptive agents than those without a diagnosis (29% vs. 11%, P&lt 0.05). None of the patients received a bone mineral density examination while in the hospital. Although there was an improvement in the management of osteoporosis after an acute hip fracture from 1995 to 2000, there was no difference in management of patients with hip fracture versus pneumonia in the year 2000. However, patients with a 'diagnosis' of osteoporosis in 2000 were more likely to be discharged on appropriate therapeutic options. We conclude that although we have improved our care of osteoporosis for elderly in general from 1995 to 2000, patients with an acute hip fracture are not receiving any additional treatment unless they have a diagnosis of osteoporosis. Further studies are needed to determine which factors are needed to target patients for appropriate diagnosis and treatment. Author Affiliation: (1) Division of Endocrinology, Department of Medicine, University of Pittsburgh Medical Center, Shadyside Hospital, Pittsburgh, PA, USA (2) Osteoporosis Prevention and Treatment Center, Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Kaufmann Medical Building, Suite 1110, 3471 Fifth Avenue, Pittsburgh, PA, 15213--3221, USA Article History: Received Date: 03/09/2002 Accepted Date: 28/01/2003 Online Date: 16/10/2003

Byline: Cathleen Colon-Emeric (1,5), Maragatha Kuchibhatla (1), Carl Pieper (1), William Hawkes (2), Lisa Fredman (3), Jay Magaziner (2), Sheryl Zimmerman (4), Kenneth W. Lyles (1,5) Keywords: Aged; Epidemiology; Hip fracture Abstract: Background: The contribution of hip fracture to the risk of subsequent fractures is unclear. Methods: Data from the Baltimore Hip Studies and the Established Populations for Epidemiologic Studies of the Elderly (EPESE) were used. Baltimore subjects enrolled at the time of hip fracture (n=549) and EPESE subjects without previous fractures at baseline (n=10,680) were followed for 2--10 years. Self-reported nonhip skeletal fracture was the outcome, and hip fracture was a time-varying covariate in a survival analysis stratified by study site. The model was adjusted for race, sex, age, BMI, stroke, cancer, difficulty walking across a room, dependence in grooming, dependence in transferring, and cognitive impairment. Results: The rate of all subsequent self-reported fractures after hip fracture was 10.4 fractures/100 person-years. The unadjusted hazard of nonhip skeletal fracture was 2.52 (95% confidence interval 2.05 to 3.12) for subjects with hip fracture compared with subjects without when adjusted for other known fracture risk factors the hazard ratio was 1.62 (1.30 to 2.02). Men and women had a similar relative risk increase. The increased risk of secondary fracture after hip fracture persisted over time. Conclusions: A hip fracture is associated with a 2.5-fold increased risk of subsequent fracture, which is not entirely explained by prefracture risk factors. Careful attention to secondary prevention is warranted in these patients. Author Affiliation: (1) Center for the Study of Aging and Human Development, Department of Biometry and Bioinformatics, Duke University Medical Center, Box 3003, Durham, NC 27710, USA (2) Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA (3) Department of Epidemiology and Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA (4) Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA (5) Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina, USA Article History: Received Date: 14/11/2002 Accepted Date: 14/05/2003 Online Date: 03/10/2003

Byline: R. D. Chapurlat (1), D. C. Bauer (1), M. Nevitt (1), K. Stone (1), S. R. Cummings (1) Keywords: Estrogen Osteoporosis Risk factors Second hip fracture Abstract: Women with hip fracture have an increased risk of second hip fracture but other risk factors for a second hip fracture have not been established. We sought to determine the incidence and risk factors for second hip fracture, in a prospective cohort study of community-dwelling postmenopausal women over 65 years: the Study of Osteoporotic Fractures. From a cohort of 9,704 women, 632 women with a documented first hip fracture during the study were followed up until a second hip fracture or the end of follow-up. Clinical risk factors and bone mineral density were assessed at the beginning of the study. Fifty-three second hip fractures were validated by radiographs. Women with hip fracture had a 2.3% per year risk of second hip fracture. Women who walked for exercise at baseline were less likely to sustain a second hip fracture with a relative risk (RR) of 0.5 [0.3--0.9], as were those who had normal depth perception (RR=0.5 [0.3--0.9]). Women who lost weight since age 25 years had an increased risk of second incident hip fracture (RR = 2.7 [1.6--4.6]), as did those who had a low calcaneal bone mineral density (RR=1.5 [1.1--2.0] per standard deviation decrease in bone mineral density). Current use of estrogen replacement therapy at baseline was protective (RR=0.5 [0.3--0.9]) up to 2 years of follow-up. We conclude that community-dwelling women with a first hip fracture have a high risk of second hip fracture, and risk factors for this second fracture are similar to those of first hip fracture. Author Affiliation: (1) Prevention Sciences Group, University of California at San Francisco, California, USA (2) Department of Rheumatology and Bone Diseases, Pavillon F, Hospital E Herriot, 5 Place d'Arsonval, 69437, Lyon cedex 03, France Article History: Received Date: 07/03/2002 Accepted Date: 03/09/2002 Article note: Electronic Publication

Byline: J. Power (1), N. Loveridge (1), N. Rushton (2), M. Parker (3), J. Reeve (1) Keywords: Alkaline phosphatase Bone Morphometry Osteoporosis Periosteum Abstract: Age-related expansion of the external surface of the femoral neck in order to offset generalized bone loss is potentially an important mechanism whereby hip strength and hence resistance to hip fracture is maintained. However, it has been widely assumed that bone formation is precluded from this external interface due to the presence of a synovial membrane associated with the hip joint. In this study we have demonstrated histologically that bone formation does indeed occur on the outer 'periosteal' surface of the proximal femoral neck. It was therefore hypothesized that an impairment or reduction in periosteal bone formation might be seen in cases of femoral neck fracture compared with age-matched controls. Qualitative analysis of whole femoral neck samples from female subjects and age- and sex-matched post-mortem controls demonstrated that these groups expressed similar distributions of the bone formation marker, alkaline phosphatase (AP), at the periosteal surface [whole biopsy mean % periosteal AP-positive surface: control=16.0 (range=0.5--43.0), fracture=13.4 (range=1.0--34.6), p=0.44]. In conclusion, despite a wide intersubject variation, bone formation at the femoral neck periosteum is a feature of elderly women even if they have had a hip fracture. Author Affiliation: (1) Bone Research Group (MRC), Department of Medicine (Box 157), University of Cambridge, Addenbrooke's Hospital, Hills Road, CB2 2QQ, Cambridge, UK (2) Orthopaedic Research Unit, University of Cambridge Clinical School, Cambridge, UK (3) , Peterborough District Hospital, Peterborough, UK Article History: Received Date: 27/06/2002 Accepted Date: 26/09/2002 Article note: Electronic Publication

Byline: Miriam Casey (1), Bernard Walsh (1) Author Affiliation: (1) Falls and Osteoporosis Unit, Mercers Institute for Research on Aging, St. James Hospital, Dublin 8, Ireland Article History: Registration Date: 11/12/2003 Online Date: 30/03/2004