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Objective: Norway has a high incidence of forearm fractures, however, the incidence rates based on secondary care registers can be underestimated, as some fractures are treated exclusively in primary care. We estimated the proportion of forearm fracture diagnoses registered exclusively in primary care and assessed the agreement between diagnosis for forearm fractures in primary and secondary care. Design: Quality assurance study combining nationwide data from 2008 to 2019 on forearm fractures registered in primary care (Norwegian Control and Payment of Health Reimbursement) and secondary care (the Norwegian Patient Registry). Setting and patients: Forearm fracture diagnoses in patients aged ≥20 treated in primary care (n = 83,357) were combined with injury diagnoses for in- and outpatients in secondary care (n = 3,294,336). Main outcome measures: Proportion of forearm fractures registered exclusively in primary care, and corresponding injury diagnoses for those registered in both primary and secondary care. Results: Of 189,105 forearm fracture registrations in primary and secondary care, 13,948 (7.4%) were registered exclusively in primary care. The proportion ranged from 4.9% to 13.5% on average between counties, but was higher in some municipalities (>30%). Of 66,747 primary care forearm fractures registered with a diagnosis in secondary care, 62% were incident forearm fractures, 28% follow-up controls, and 10% other fractures or non-fracture injuries. Conclusion: An overall small proportion of forearm fractures were registered only in primary care, but it was larger in some areas of Norway. Failing to include fractures exclusively treated in primary care could underestimate the incidence rates in these areas. Norwegian forearm fracture incidence based on secondary care may be underestimated by not including fractures treated exclusively in primary care. The mean proportion of forearm fractures exclusively handled in primary care is 7% and varies from 5% to 14% between counties. Fractures treated in primary care can be considered for more accurate national incidence rates. Correct fracture diagnosis needs further investigation.

Additional file 1. Directed Acyclic Graphs.

Problemstilling: Hvordan kan sykepleier ivareta barn som pårørende av foreldre som er alvorlig psykisk syke? Metode: Litteraturstudie, som inkluderer fem forskningsartikler og relevant teori. Funn: Funnene viser at sykepleiere mangler kunnskap og kompetanse, samt tydelige retningslinjer og rammeverk. Barneansvarlige har utfordringer som mangel på tid og rutiner, som resulterer i at det er tilfeldig hvilken oppfølging barna får. Sykepleiere opplever det utfordrende å samarbeide med foreldrene, da de mangler forståelse for hvordan den psykiske lidelsen påvirker barnet. Drøfting: Funn i forskningsartikler og teori drøftes opp mot problemstillingen. Jeg tar for meg hvordan barneansvarliges funksjon fungerer i praksis, viktigheten av informasjon og åpenhet, og familiefokusert sykepleie. Konklusjon: Det er viktig at sykepleiere involverer barnet i forelderens sykdom, ved å gi tilpasset informasjon i forhold til alder, og bruke åpenhet som medisin. Det er viktig å skape en tillitsbasert relasjon, ha kunnskap om barnets utvikling og identifisere eventuelle risikofaktorer. Sykepleiere bør ta utgangspunkt i familiefokusert omsorg, og trenger tydeligere retningslinjer for en helhetlig ivaretakelse av barnet.

I 2018 sto nye Heimdal videregående skole ferdig som et pilotprosjekt med høye energi- og miljøambisjoner. Bygget har et energisystem bestående av et CHP-anlegg, geotermiske varmepumper og solcelleanlegg. Hensikten med denne oppgaven er å evaluere energisystemet ved skolen og den tilhørende flerbrukshallen ved å sammenligne målte og prosjekterte verdier fra innsamlet data. På denne måten kan eventuelle avvik avdekkes og grunner til dem undersøkes og forklares. Det skal også vurderes tiltak som kan gjennomføres ved oppføring av tilsvarende bygg for å forbedre energiregnskapet med tanke på energi og miljø. Sammenligning av målte og prosjekterte verdier viste at CHP-anlegget var i drift fra november til mars. Bruksmønsteret og størrelsen på varmeveksleren i Husebyhallen førte til at en mindre andel av produksjonen enn prosjektert resulterte i termisk eksport. Oppvarmingsbehovet til bygget var 130,4 % høyere enn prosjektert grunnet lengre brukstid, høyere settpunkttemperatur og trolig dårlig samspill mellom radiatorer og soneinndelt ventilasjon. Oppvarmingsbehovet til tappevann hadde et avvik på -78,0 % fra beregnet verdi. Usikkerhet i beregningsmetoder og høye standardverdier førte til at dette behovet ble prosjektert for høyt. Heimdal vgs. har bidratt som et av flere referansebygg til å revidere standardverdier til den nye standarden SN-NSPEK 3031:2020. Over systemgrensen ble det totalt importert 4,8 % mindre energi enn beregnet, med 31,5 % mindre biogassimport og 114,5 % mer fjernvarmeimport. Energiregnskapet hadde et avvik på kun -7,7 % fra EPC-korrigerte verdier. Til tross for noen store enkeltavvik er dette akseptabelt i henhold til EPC-kontrakten. Skolen ble satt opp som en av Norges mest miljøvennlige skoler, og har som pilotprosjekt fungert godt med innovative løsninger. Prosjektet har bidratt til å styre bygg- og anleggsmarkedet i en mer miljøvennlig retning. For å forbedre energiregnskapet kan flere tiltak vurderes. Ved å forlenge produksjonsperioden til CHP-anlegget vil den termiske eksporten øke og import av fjernvarme bli redusert. Under prosjektering av tilsvarende bygg anbefales det å se på en løsning med rominndelt ventilasjon til tross for dårlig erfaring med dette tidligere. For bygg med soneinndelt ventilasjon burde radiatorene kobles opp mot SD-anlegg for å enklere justere settpunkttemperatur mot ventilasjon. REFTEC-varmepumpen og energibrønnene kunne vært dimensjonert større for å kunne dekke en større del av oppvarmingsbehovet. In 2018 the new Heimdal vgs. was finished as a pilot project with high energy and environmental ambitions. The building's energy system consists of a CHP-system, geothermal heat pumps, and a photovoltaic system. The purpose of this thesis is to evaluate the school's energy system and the associated multi-purpose hall by comparing measured and estimated values from collected data. This way any deviations can be detected and their reasons examined and explained. There will also be considered measures to help minimize energy consumption and environmental impact of similar buildings. A comparison of measured and estimated values revealed that the CHP-system was in operation from November to March. A smaller proportion than expected of the production resulted in thermal export, as a result of the usage pattern and size of the heat exchanger at Husebyhallen. The building's heating requirement was 130,4 % higher than estimated value due to extended annual operation of hours, higher set temperature and seemingly poor cooperation between the radiators and the sectioned ventilation system. The tap water heating requirement had a deviation of -78,0 % from estimated value. This heating requirement was estimated too high due to uncertainty in the calculation method and overestimated default values. Heimdal vgs. contributed as one of several reference buildings to update the default values in the new standard SN-NSPEK 3031:2020. 4,8 % less energy than estimated was imported over the system boundary, with 31,5 % less imported biogas and 114,5 % more import of district heating. The energy accounting had a deviation of only -7,7 % from the EPC-emended values. Despite certain larger deviations, these values are approved accordingly to the EPC-agreement. The school was constructed as one of Norway's most environmentally friendly schools, and has been a success being a pilot project with several innovative solutions. The project has contributed to influence the construction market in a more environmentally friendly direction. Several measures can be considered to improve the energy accounting. By extending the usage pattern of the CHP-system the thermal export would increase and the import of district heating would decrease. While constructing equivalent buildings, a solution with room divided ventilation system is recommended despite bad experiences in the past. In buildings with sectioned ventilation systems, the radiators should be connected to the industrial control system so that the set temperature might be more easily adjusted toward the ventilation. To cover a bigger part of the heating requirement, the REFTEC heat pump and energy wells could have a larger design.

Summary Determinants of trabecular bone score (TBS) and vertebral fractures assessed semiquantitatively (SQ1–SQ3) were studied in 496 women with fragility fractures. TBS was associated with age, parental hip fracture, alcohol intake and BMD, not SQ1–SQ3 fractures. SQ1–SQ3 fractures were associated with age, prior fractures, and lumbar spine BMD, but not TBS. Introduction Trabecular bone score (TBS) and vertebral fractures assessed by semiquantitative method (SQ1–SQ3) seem to reflect different aspects of bone strength. We therefore sought to explore the determinants of and the associations between TBS and SQ1–SQ3 fractures. Methods This cross-sectional sub-study of the Norwegian Capture the Fracture Initiative included 496 women aged ≥ 50 years with fragility fractures. All responded to a questionnaire about risk factors for fracture, had bone mineral density (BMD) of femoral neck and/or lumbar spine assessed, TBS calculated, and 423 had SQ1–SQ3 fracture assessed. Results Mean (SD) age was 65.6 years (8.6), mean TBS 1.27 (0.10), and 33.3% exhibited SQ1–SQ3 fractures. In multiple variable analysis, higher age (βper SD = − 0.26, 95% CI: − 0.36,− 0.15), parental hip fracture (β = − 0.29, 95% CI: − 0.54,− 0.05), and daily alcohol intake (β = − 0.43, 95% CI − 0.79, − 0.08) were associated with lower TBS. Higher BMD of femoral neck (βper SD = 0.34, 95% CI 0.25–0.43) and lumbar spine (βper SD = 0.40, 95% CI 0.31–0.48) were associated with higher TBS. In multivariable logistic regression analyses, age (ORper SD = 1.94, 95% CI 1.51–2.46) and prior fragility fractures (OR = 1.71, 95% CI 1.09–2.71) were positively associated with SQ1–SQ3 fractures, while lumbar spine BMD (ORper SD = 0.75 95% CI 0.60–0.95) was negatively associated with SQ1–SQ3 fractures. No association between TBS and SQ1–SQ3 fractures was found. Conclusion Since TBS and SQ1–SQ3 fractures were not associated, they may act as independent risk factors, justifying the use of both in post-fracture risk assessment.

Table S1. Characteristics of NoMIC current study population, full cohort and general population of birth-giving mothers in Norway. Table S2. Distribution of diversity measures and short-chain fatty acids in infant fecal samples at 1 month. Table S3. Greengenes lineage for deblurred FASTA sequences. Table S4. Differentially abundant taxa in the high (>80th percentile) vs. low (

Importance Fragility fracture is a major health issue because of the accompanying morbidity, mortality, and financial cost. Despite the high cost to society and personal cost to affected individuals, secondary fracture prevention is suboptimal in Norway, mainly because most patients with osteoporotic fractures do not receive treatment with antiosteoporotic drugs after fracture repair. Objectives To improve secondary fracture prevention by introducing a standardized intervention program and to investigate the effect of the program on the rate of subsequent fractures. Design, Setting, and Participants Trial protocol of the Norwegian Capture the Fracture Initiative (NoFRACT), an ongoing, stepped wedge cluster randomized clinical trial in 7 hospitals in Norway. The participating hospitals were cluster randomized to an intervention starting date: May 1, 2015; September 1, 2015; and January 1, 2016. Follow-up is through December 31, 2019. The outcome data were merged from national registries of women and men 50 years and older with a recent fragility fracture treated at 1 of the 7 hospitals. Discussion The NoFRACT trial is intended to enroll 82 000 patients (intervention period, 26 000 patients; control period, 56 000 patients), of whom 23 578 are currently enrolled by January 2018. Interventions include a standardized program for identification, assessment, and treatment of osteoporosis in patients with a fragility fracture that is led by a trained coordinating nurse. The primary outcome is rate of subsequent fracture (per 10 000 person-years) based on national registry data. Outcomes before (2008-2015; control period) and after (2015-2019; intervention period) the intervention will be compared, and each hospital will act as its own control. Use of outcomes from national registry data means that all patients are included in the analysis regardless of whether they are exposed to the intervention (intention to treat). A sensitivity analysis with a transition window will be performed to mitigate possible within-cluster contamination. Results Results are planned to be disseminated through publications in peer-reviewed journals and presented at local, national, and international conferences. Conclusions By introducing a standardized intervention program for assessment and treatment of osteoporosis in patients with fragility fractures, we expect to document reduced rates of subsequent fractures and fracture-related mortality. This is an open access article distributed under the terms of the CC-BY License.

Background: For mainly unknown reasons, the Norwegian population has among the highest incidence rates of osteoporotic fractures in the world. The risk of fracture has been shown to vary within Norway, with higher risks in the urban compared to rural areas. Norwegian drinking water is distinct; it contains less minerals and is more corrosive towards water pipes compared to water in many other countries. Drinking water quality has generally improved in recent years, but the quality still differs across Norway. The overall aim of this thesis was to examine whether the variations in quality of drinking water could be related to the risk of osteoporotic fractures, such as fractures of the hip and the forearm. Methods: To link area information on water quality to individual fracture outcomes, a map of the waterworks supply-areas was produced using Geographic Information Systems. Water quality information was provided by the Norwegian Waterworks Register and by a survey of trace metals in water, whereas fracture information came from the Cohort of Norway (CONOR) collection of health surveys and a recently established database of hip fractures named “NORHip”. Using logistic regression, variations in risk of self-reported forearm-fracture in CONOR were assessed between groups of varying water-acidity (pH). Differences in incidence of hip fractures in NORHip by levels of calcium, magnesium and three toxic metals (cadmium, lead and aluminum) were evaluated by Poisson-regression. Available background information, along with other water quality factors were taken into account, testing for confounding, mediation, effect modification and interaction. Main Results: The risk of forearm fracture was found to be higher when the water was slightly acidic (pH