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Objective To investigate the association between women's socioeconomic status and overall childbirth experience and to explore how women reporting an overall negative birth experience describe their experiences of intrapartum care. Methods We used both quantitative and qualitative data from the Babies Born Better (B3) survey version 2, including a total of 8317 women. First, we performed regression analyses to explore the association between women’s socioeconomic status and labour and birth experience, and then a thematic analysis of three open-ended questions from women reporting a negative childbirth experience (n = 917). Results In total 11.7% reported an overall negative labour and birth experience. The adjusted odds ratio (OR) of a negative childbirth experience was elevated for women with non-tertiary education, for unemployed, students and not married or cohabiting. Women with lower subjective living standard had an adjusted OR of 1.70 (95% CI 1.44–2.00) for a negative birth experience, compared with those with average subjective living standard. The qualitative analysis generated three themes: 1) Uncompassionate care: lack of sensitivity and empathy, 2) Impersonal care: feeling objectified, and 3) Critical situations: feeling unsafe and loss of control. Conclusion Important socioeconomic disparities in women’s childbirth experiences exist even in the Norwegian setting. Women reporting a negative childbirth experience described disrespect and mistreatment as well as experiences of insufficient attention and lack of awareness of individual and emotional needs during childbirth. The study shows that women with lower socioeconomic status are more exposed to these types of experiences during labour and birth.

Type 2 diabetes is one of the leading causes of death globally and its incidence has increased dramatically over the last two decades. Recent research suggests that loneliness is a possible risk factor for type 2 diabetes. This 20 year follow-up study examined whether loneliness is associated with an increased risk of type 2 diabetes. As both loneliness and type 2 diabetes have been linked to depression and sleep problems, we also investigated whether any association between loneliness and type 2 diabetes is mediated by symptoms of depression and insomnia.We used data from the Trøndelag Health Study (HUNT study), a large longitudinal health study based on a population from central Norway (n=24,024). Self-reports of loneliness (HUNT2 survey, 1995-1997) and data on HbADuring the 20 year follow-up period, 4.9% of the study participants developed type 2 diabetes. Various degrees of feeling lonely were reported by 12.6% of the participants. Individuals who felt most lonely had a twofold higher risk of developing type 2 diabetes relative to those who did not feel lonely (adjusted OR 2.19 [95% CI 1.16, 4.15]). The effect of loneliness on type 2 diabetes was weakly mediated by one subtype of insomnia but not by symptoms of depression.This study suggests that loneliness may be one factor that increases the risk of type 2 diabetes; however, there is no strong support that the effect of loneliness on type 2 diabetes is mediated by depression or insomnia. We recommend that loneliness should be included in clinical guidelines on consultations and interventions related to type 2 diabetes.

Purpose To evaluate the association between increased hearing loss and reduced physical performance in older people. Methods Cross-sectional population-based study using data from the fourth wave of the Trøndelag Health Survey (HUNT4) in Norway. Data were obtained from the subproject HUNT4 Hearing which collected audiometric data of people > 70 years (N = 13,197). Analyses were performed on all participants who had completed audiometry and measured balance using the Short Physical Performance Battery (SPPB), which was scored from 0 (worst score) to 12. The hearing threshold was expressed as a pure tone average (PTA). Associations between the hearing threshold for the best and worst ear and physical performance were analyzed by linear regression models adjusted for age, sex, education, diabetes, and cardiovascular disease. Hearing threshold was indicated with steps of 10 dB. Results Of 13,197 eligible participants, 4101 who completed audiometry and SPPB (52.3% women. mean age 76.3 years) were included. The analyses revealed an association between reduced SPPB and increased hearing threshold in the best ear (b = − 0.296; 95% CI − 0.343 to − 0. 249; P b = − 0.229; 95% CI − 0.270 to − 0.189; P Conclusions In this population study, we found that the increased hearing threshold was associated to reduced physical performance as measured by SPPB. The association seemed to be strongest for the best ear. The association between hearing threshold and physical performance illustrates the importance of assessing physical performance in people with hearing loss to prevent the risk of falls and disability. The underlying causes of the associations between hearing loss and poorer physical performance are not fully understood and should be further investigated. Level of evidence Level 3.

Aims/hypothesis Type 2 diabetes is one of the leading causes of death globally and its incidence has increased dramatically over the last two decades. Recent research suggests that loneliness is a possible risk factor for type 2 diabetes. This 20 year follow-up study examined whether loneliness is associated with an increased risk of type 2 diabetes. As both loneliness and type 2 diabetes have been linked to depression and sleep problems, we also investigated whether any association between loneliness and type 2 diabetes is mediated by symptoms of depression and insomnia. Methods We used data from the Trøndelag Health Study (HUNT study), a large longitudinal health study based on a population from central Norway (n=24,024). Self-reports of loneliness (HUNT2 survey, 1995–1997) and data on HbA1c levels (HUNT4 survey, 2017–2019) were analysed to evaluate the associations between loneliness and incidence of type 2 diabetes. Associations were reported as ORs with 95% CIs, adjusted for sex, age and education. We further investigated the role of depression and insomnia as potential mediating factors. Results During the 20 year follow-up period, 4.9% of the study participants developed type 2 diabetes. Various degrees of feeling lonely were reported by 12.6% of the participants. Individuals who felt most lonely had a twofold higher risk of developing type 2 diabetes relative to those who did not feel lonely (adjusted OR 2.19 [95% CI 1.16, 4.15]). The effect of loneliness on type 2 diabetes was weakly mediated by one subtype of insomnia but not by symptoms of depression. Conclusions/interpretation This study suggests that loneliness may be one factor that increases the risk of type 2 diabetes; however, there is no strong support that the effect of loneliness on type 2 diabetes is mediated by depression or insomnia. We recommend that loneliness should be included in clinical guidelines on consultations and interventions related to type 2 diabetes. Graphical abstract

Objectives To investigate whether infants exposed to antimicrobials in hospital during the first 3 months of life had an increased risk of ambulatory antimicrobial use during the following year compared with infants not exposed to antimicrobials during the first 3 months of life. Methods Norwegian cohort study of infants less than 3 months consisting of one group exposed to antimicrobials recruited during hospitalization and one group not exposed to antimicrobials. Ten unexposed infants were matched with one exposed infant according to county of residence, birth year and month, and sex. The Norwegian Prescription Database was applied to register antimicrobial use from the month after discharge and 1 year onward. We defined comorbidity based on antimicrobials prescribed as reimbursable prescriptions due to underlying diseases. Results Of 95 infants exposed to antimicrobials during the first 3 months of life, 23% had recurrent use compared with 14% use in 950 unexposed infants [relative risk (RR) = 1.7 (95% CI = 1.1–2.5) and comorbidity-adjusted RR = 1.4 (95% CI = 0.9–2.2)]. The recurrence use rate in exposed term infants (≥37 weeks, n = 70) was 27% compared with 12% in their unexposed matches [RR 2.3 = (95% CI = 1.4–3.7) and comorbidity-adjusted RR = 1.9 (95% CI = 1.2–3.2). Of 25 exposed preterm infants, 3 (12%) had recurrent use. The total antimicrobial prescription rate was 674/1000 in the exposed group and 244/1000 in the unexposed group [incidence rate ratio = 2.8 (95% CI = 1.6–4.9)]. Conclusions Infants exposed to antimicrobials during the first 3 months of life had an increased risk of recurrent use during the following year. This increased risk also appeared in term infants without infection-related comorbidity.

Purpose: The ‘Outcomes & Multi-morbidity in Type 2 Diabetes’ (OMIT) is an observational registry-based cohort of Norwegian patients with type 2 diabetes (T2D) established to study high-risk groups often omitted from randomised clinical trials. Participants: The OMIT cohort includes 57 572 patients with T2D identified via linkage of Norwegian Diabetes Register for Adults and the Rogaland-Oslo-Salten-Akershus-Hordaland study, both offering data on clinical patient characteristics and drug prescriptions. Subsequently these data are further linked to the Norwegian Prescription Database for dispensed medications, the Norwegian Population Register for data on death and migration, Statistics Norway for data on socioeconomic factors and ethnicity and the Norwegian Directorate of Health for data on the general practices and clinical procedures involved in the care of cohort patients. OMIT offers large samples for key high-risk patient groups: (1) young-onset diabetes (T2D at age 75 years) (n=15 540), (3) non-Western ethnic minorities (n=9000) and (4) low socioeconomic status (n=20 500). Findings to date: On average, patient age and diabetes duration is 67.4±13.2 and 12.3±8.3 years, respectively, and mean HbA1c for the whole cohort through the study period is 7.6%±1.5% (59.4±16.3mmol/mol), mean body mass index (BMI) and blood pressure is 30.2±5.9 kg/m2 and 135±16.1/78±9.8mm Hg, respectively. Prevalence of retinopathy, coronary heart disease and stroke is 10.1%, 21% and 6.7%, respectively. Future plans: The OMIT cohort features 5784 subjects with T2D in 2006, a number that has grown to 57 527 in 2019 and is expected to grow further via repeated linkages performed every third to fifth year. At the next wave of data collection, additional linkages to Norwegian Patient Registry and Norwegian Cause of Death Registry for data on registered diagnoses and causes of death, respectively, will be performed. The first phase of linkages was funded by the University of Oslo. Currently, senior researchers and one postdoctoral position (Western Norway University of Applied Sciences (HVL), Norway) are funded by their home institutions The cohort is also funded by The Norwegian Diabetes Association (Diabetesforbundet) and the Norwegian Research Fund for General Practice (Allmennmedisinsk forskningsfond), with the latter also funding one PhD-student (University of Oslo (UiO), Norway).

Aim To estimate the prevalence of sexual dysfunction in women with type 1 diabetes (T1D) compared with women without diabetes and to analyse associations between sexual dysfunction and the presence of chronic physical diabetes complications, diabetes distress and depression in women with T1D. Methods This cross-sectional study was conducted in Norway, and 171 women with T1D and 60 controls completed the Female Sexual Function Index (FSFI) and the Hospital Anxiety and Depression Scale (HADS). Diabetes distress was assessed with the Problem Areas in Diabetes (PAID) scale. Data on diabetes complications were retrieved from medical records. We performed logistic regression to estimate differences in the prevalence of sexual dysfunction (defined as FSFI ≤26.55) between women with T1D and women without diabetes and to examine associations of sexual dysfunction with chronic diabetes complications, diabetes distress and depression in women with T1D. Results The prevalence of sexual dysfunction was higher in women with T1D (50.3%) compared with the controls (35.0%; unadjusted odds ratio [OR] 1.89 [95% confidence interval (CI) 1.06–3.37]; adjusted OR 1.93 [1.05–3.56]). In women with T1D, sexual dysfunction was associated with both diabetes distress (adjusted OR 1.03 [1.01–1.05]) and depression (adjusted OR 1.28 [1.12–1.46]), but there were no clear associations with chronic diabetes complications (adjusted OR 1.46 [0.67–3.19]). Conclusions This study suggests that sexual dysfunction is more prevalent in women with T1D compared with women without diabetes. The study findings emphasize the importance of including sexual health in relation to diabetes distress and psychological aspects in diabetes care and future research. publishedVersion

Aim To examine differences in health‐related quality of life between boys and girls in the first and third years of upper secondary school. Design Prospective longitudinal study. Methods The KIDSCREEN‐10 was used to assess health‐related quality of life. Differences in health‐related quality of life over time were estimated using a linear mixed‐effects model for correlated measurements. Results In the first‐year boys (N = 168) and girls (N = 228) reported a mean health‐related quality of life score of 76.3 (SD 10.7) and 69.8 (SD 11.5), respectively. In the third year, the mean health‐related quality of life score for boys and girls was 73.5 (SD 12.4) and 65.7 (SD 13.3), respectively. Boys had a significant decrease in health‐related quality of life mean score of −2.6 and girls a significant decrease of −3.8 (p

Self-selection into prospective cohort studies and loss to follow-up can cause biased exposure-outcome association estimates. Previous investigations illustrated that such biases can be small in large prospective cohort studies. The structural approach to selection bias shows that general statements about bias are not possible for studies that investigate multiple exposures and outcomes, and that inverse probability of participation weighting (IPPW) but not adjustment for participation predictors generally reduces bias from self-selection and loss to follow-up. We propose to substantiate assumptions in structural models of selection bias through calculation of genetic correlations coefficients between participation predictors, outcome, and exposure, and to estimate a lower bound for bias due to self-selection and loss to follow-up by comparing effect estimates from IPP weighted and unweighted analyses. This study used data from the Norwegian Mother and Child Cohort Study and the Medical Birth Registry of Norway. Using the example of risk factors for ADHD, we find that genetic correlations between participation predictors, exposures, and outcome suggest the presence of bias. The comparison of exposure-outcome associations from regressions with and without IPPW revealed meaningful deviations. Assessment of selection bias for entire multi-exposure multi-outcome cohort studies is not possible. Instead, it has to be assessed and controlled on a case-by-case basis.

ObjectiveMetabolic syndrome (MetS) includes hyperglycaemia, hypertension, central adiposity, elevated triglyceride levels and low levels of high-density lipoprotein cholesterol. All factors are identified as risk factors for cardiovascular disease and mortality. This longitudinal study examined whether loneliness, which has been shown to predict a range of negative health outcomes, increases the risk for MetS.MethodsWe used data from ‘the Nord-Trøndelag Health Study’ (HUNT) which is a large longitudinal health study based on a Mid-Norway county population (n=26 990). Self-reports, physical examinations and blood samples were analysed to evaluate the associations between loneliness and incidents of MetS after 10 years (follow-up survey conducted during 2006–2008). We also investigated the role of depression as a potential mediating factor.ResultsIndividuals who reported higher levels of loneliness had a higher odds for MetS (adjusted OR 1.09 (95% CI 1.02 to 1.16); p=0.007). This effect was mediated through depression.ConclusionsFindings suggest that loneliness may be an important factor that increases the risk for MetS. The effect of loneliness on MetS is mediated through depressive symptoms. Reducing loneliness may help prevent the incidence of MetS and related diseases.

ObjectiveTo pilot test the proposed DiaPROM trial components and address uncertainties associated with conducting a full-scale randomised controlled trial (RCT) to evaluate whether such a trial is feasible.DesignTwo-arm pilot RCT.ParticipantsAdults aged ≥18–39 years, with minimum 1 year type 1 diabetes duration, attending outpatient follow-up. Exclusion criteria were pregnancy, severe cognitive, somatic or psychiatric conditions and impaired vision.Randomisation and interventionAll participants completed electronic Patient-Reported Outcome Measures (PROMs) prior to the annual diabetes consultation. Using computer-generated block-randomisation without blinding, we assigned participants in a 1:1 ratio stratified by sex to receive standard care or an intervention. Physicians reviewed diabetes distress scores (Problem Areas In Diabetes scale) and referred individuals with scores ≥30 or single item(s) ≥3 to minimum two diabetes nurse consultations where reported problems were reviewed and discussed.OutcomesRecruitment and retention rates; participants perceptions about intervention components. Variance and estimated between-group differences in follow-up scores (Diabetes Distress Scale (DDS), WHO 5-Well-being Index, Perceived Competence for Diabetes Scale and glycaemic control) and DDS correlation with baseline scores, to assist sample size calculations.ResultsWe randomised 80 participants to the control or intervention arm (one participant was later excluded). 23/39 intervention arm participants qualified for additional consultations and 17 attended. 67/79 attended the 12-month follow-up (15.2% attrition); 5/17 referred to additional consultations were lost to follow-up (29.4% attrition). Participants reported PROMs as relevant (84.6%) and acceptable (97.4%) but rated the usefulness of consultations as moderate to low. Baseline mean±SD DDS score was 2.1±0.69; DDS SD was 0.71 (95% CI: 0.60 to 0.86) at follow-up; correlation between baseline and follow-up DDS scores was 0.8 (95% CI: 0.7 to 0.9).ConclusionsThe pilot trial revealed need for intervention modifications ahead of a full-scale trial to evaluate use of PROMs in diabetes consultations. Specifically, participant acceptability and intervention implementation need further investigation.

Background and Purpose Associations between dizziness, health-related quality of life, and musculoskeletal pain have not been systematically explored in patients with vestibular disorders. Such knowledge may be important for choice of treatments. The study objectives were to examine the extent and localization of musculoskeletal pain and explore whether pain was associated with dizziness and health-related quality of life. Methods The cross-sectional study investigated anonymized data from an earlier survey on patients with long-lasting dizziness (>3 months) examined in an oto-rhino-laryngological department. The sample includes patient between 18 and 70 years with Ménière's disease, vestibular schwannoma, benign positional paroxysmal vertigo, vestibular neuritis, non-otogenic dizziness, and cervicogenic dizziness. General musculoskeletal, that is, pain in muscles, tendons, and joints was registered by a yes/no question. A pain drawing registered localization of pain. Multiple binary logistic regression models were used to determine the association between pain and vertigo-balance and autonomic-anxiety related dizziness by the short Vertigo Symptom Scale (VSS) and sub-scales (VSS-V, VSS-A), and between pain and health-related quality of life by the SF-36, mental and physical component summary scale (SF-36 MCS, SF-36 PCS). Results The sample consisted of 503 patients, 60.2% were women, the median age was 50 years. General musculoskeletal pain was reported by 72.8% of patients, neck pain by 59.2% and widespread pain by 21.9%. Multiple binary logistic regression models demonstrated that all the pain measures were significantly associated with VSS-V and VSS-A and SF-36 PCS, but not SF-36 MCS. Discussions Musculoskeletal pain is prevalent in patients with long-lasting dizziness. The strong associations between pain, VSS, and SF-36 PCS could result in a self-sustaining complex condition. The findings imply that in addition to assessing and treating the vestibular symptoms, musculoskeletal symptoms and physical health should be addressed. publishedVersion

ObjectiveSleep disturbances are common in pregnancy, and the prevalence increases during the third trimester. The aim of the present study was to assess sleep patterns, sleep behavior and prevalence of insomnia in pregnant women in the third trimester, by comparing them to a group of non-pregnant women. Further, how perceived stress and evening light exposure were linked to sleep characteristics among the pregnant women were examined.MethodsA total of 61 healthy nulliparous pregnant women in beginning of the third trimester (recruited from 2017 to 2019), and 69 non-pregnant women (recruited in 2018) were included. Sleep was monitored by actigraphy, sleep diaries and the Bergen Insomnia Scale. The stress scales used were the Relationship Satisfaction Scale, the Perceived Stress Scale and the Pre-Sleep Arousal Scale. Total white light exposure three hours prior to bedtime were also assessed.ResultsThe prevalence of insomnia among the pregnant women was 38%, with a mean score on the Bergen Insomnia Scale of 11.2 (SD = 7.5). The corresponding figures in the comparing group was 51% and 12.3 (SD = 7.7). The pregnant women reported lower sleep efficiency (mean difference 3.8; 95% CI = 0.3, 7.3), longer total sleep time derived from actigraphy (mean difference 59.0 minutes; 95% CI = 23.8, 94.2) and higher exposure to evening light (mean difference 0.7; 95% CI = 0.3, 1.2), compared to the non-pregnant group. The evening light exposure was inversely associated with total sleep time derived from actigraphy (B = -8.1; 95% CI = -14.7, -1.5), and an earlier midpoint of sleep (B = -10.3, 95% CI = -14.7, -5.9). Perceived stressors were unrelated to self-reported and actigraphy assessed sleep.ConclusionIn healthy pregnant participants sleep in the third trimester was preserved quite well. Even so, the data suggest that evening light exposure was related to shorter sleep duration among pregnant women.

Background Studies exploring risk factors for ankle fractures in adults are scarce, and with diverging conclusions. This study aims to investigate whether overweight, obesity and osteoporosis may be identified as risk factors for ankle fractures and ankle fracture subgroups according to the Danis-Weber (D-W) classification. Methods 108 patients ≥40 years with fracture of the lateral malleolus were included. Controls were 199 persons without a previous fracture history. Bone mineral density of the hips and spine was measured by dual-energy x-ray absorptiometry, and history of previous fracture, comorbidities, medication, physical activity, smoking habits, body mass index and nutritional factors were registered. Results Higher body mass index with increments of 5 gave an adjusted odds ratio (OR) of 1.30 (95% confidence interval (CI) 1.03–1.64) for ankle fracture, and an adjusted OR of 1.96 (CI 0.99–4.41) for sustaining a D-W type B or C fracture compared to type A. Compared to patients with normal bone mineral density, the odds of ankle fracture in patients with osteoporosis was 1.53, but the 95% CI was wide (0.79–2.98). Patients with osteoporosis had reduced odds of sustaining a D-W fracture type B or C compared to type A (OR 0.18, CI 0.03–0.83). Conclusions Overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible syndesmosis disruption and instability (D-W fracture type B or C) compared to the stable and more distal fibula fracture (D-W type A). Osteoporosis did not significantly increase the odds of ankle fractures, thus suffering an ankle fracture does not automatically warrant further osteoporosis assessment.

Background & aims: Being “at risk of malnutrition”, which includes both malnutrition and the risk to be so, is associated with increased morbidity and mortality in both surgical and non-surgical patients. Several strategies and guidelines have been introduced to prevent and treat this, but the effects are scarcely investigated. This study aims to evaluate the long-term effects of these efforts by examining trends concerning: 1) the prevalence of patients «at risk of malnutrition» and 2) the use of nutritional support and diagnostic coding related to malnutrition over an 11-year period in a large university hospital. Moreover, we wanted to investigate if there was a difference in trends between surgical and non-surgical patients. Methods: From 2008 to 2018, Haukeland University Hospital, Norway, conducted 34 point-prevalence surveys to investigate the prevalence of patients «at risk of malnutrition», as defined by Nutritional Risk Screening 2002, and the use of nutritional support at the hospital. Diagnostic coding included ICD-10 codes related to malnutrition (E43, E44 and E46) at hospital discharge, which were extracted from the electronic patient journal. Trend analysis by calendar year was investigated using logistic regression models with and without adjustment for age (continuous), gender (male/female) and Charlson Comorbidity Index (none, mild, moderate or severe). Results: The number of patients included in the study was 18 933, where 52.1% were male and the median (25th, 75th percentile) age was 65 (51, 76) years. Of these, 5121 (27%) patients were identified to be «at risk of malnutrition». Fewer surgical patients (21.2%) were «at risk of malnutrition», as compared to non-surgical patients (30.9%) (p < 0.001). Adjusted trend analysis did not identify any change in the prevalence of patients «at risk of malnutrition» from 2008 to 2018. The percentage of patients «at risk of malnutrition» who received nutritional support increased from 61.6% in 2008 to 71.9% in 2018 (p < 0.001), with a range from 55.6 to 74.8%. This trend was seen for both surgical and non-surgical patients (p < 0.001 for both). Similarly, dietitians were more involved in the patients’ treatment (range: 3.8–16.7%), and there was increased use of ICD-10 codes related to malnutrition during the study period (range: 13.0–41.8%) (p < 0.001). These trends were seen for both surgical patients and non-surgical patients (p < 0.001), despite use being less common for surgical patients, as compared to non-surgical patients (p < 0.001). Conclusions: This large hospital study shows no apparent change in the prevalence of patients «at risk of malnutrition» from 2008 to 2018. However, more patients «at risk of malnutrition», both surgical and non-surgical, received nutritional support, treatment from a dietitian and a related ICD-10 code over the study period, indicating improved nutritional routines as a result of the implementation of nutritional guidelines and strategies. publishedVersion

Aims: Immigrant women are at higher risk for gestational diabetes mellitus (GDM) than non-immigrant women. This study described the prevalence of GDM in immigrant women by maternal country of birth and examined the associations between immigrants’ length of residence in Norway and GDM. Methods: This Norwegian national population-based study included 192,892 pregnancies to immigrant and 1,116,954 pregnancies to non-immigrant women giving birth during the period 1990–2013. Associations were reported as odds ratios (ORs) with 95% confidence intervals (CIs) using logistic regression models, adjusted for year of delivery, maternal age, marital status, health region, parity, education and income. Results: The prevalence and adjusted OR [CI] for GDM were substantially higher in immigrant women from Bangladesh (7.4%, OR 8.38 [5.41, 12.97]), Sri Lanka (6.3%, OR 7.60 [6.71, 8.60]), Pakistan (4.3%, OR 5.47 [4.90, 6.11]), India (4.4%, OR 5.18 [4.30, 6.24]) and Morocco (4.3%, OR 4.35 [3.63, 5.20]) compared to non-immigrants (prevalence 0.8%). Overall, GDM prevalence increased from 1.3% (OR 1.25 [1.14, 1.36]) to 3.3% (OR 2.55 [2.39, 2.71]) after 9 years of residence in immigrants compared to non-immigrant women. This association was particularly strong for women from South Asia. Conclusions: Gestational diabetes mellitus prevalence varied substantially between countries of maternal birth and was particularly high in immigrants from Asian countries. GDM appeared to increase with longer length of residence in certain immigrant groups. acceptedVersion

Consequences of nondomestic violence are known to be multifaceted with high rates of emotional and psychological problems in addition to physical injuries, and victims report many trauma related symptoms. This study explore if perceived social support (PSS) (Social Provisions Scale [SPS]) and post-traumatic stress disorder (PTSD) symptoms (Impact of Event Scale [IES-22]) are interrelated among adult victims at four assessment points up until eight years after the exposure to physical assault; soon after the event (T1), three months after T1 (T2), one year after T1 (T3), and eight years after T1 (T4). One hundred and forty-three subjects participated at T1, 94 at T2, 73 at T3, and 47 accepted a follow-up at T4. At T1, 138 of 143 completed the questionnaires within 16 weeks after the incident. PTSD symptoms were highly correlated across time ( p < .001); PSS were significantly correlated only between T1 and T2 ( p < .001), T1 and T3 ( p < .05), and between T2 and T3 ( p < .05). Cross-lagged analyses showed an inverse relationship between prior PSS and later PTSD symptoms across all time points ( ps < .05); not proved between prior PTSD symptoms and later PSS ( ps > .1). PSS at T1 was an independent predictor of PSS one year and eight years after the incident. We conclude that higher perception of social support protects against the development of PTSD symptoms; diminished perception of social support increases the risk of developing PTSD symptoms. These findings suggest that PSS after experiencing a violent assault should be considered as an important factor in natural recovery in the long run, as well as essential alongside psychiatric treatment. Establishing psychosocial interventions for victims of physical violence in the acute phase may prevent prolonged trauma reactions.

Background and purpose Norwegian Psychomotor Physiotherapy (NPMP) has been an established treatment approach for more than 50 years, mostly in the Scandinavian countries, usually applied to patients with widespread and long-lasting musculoskeletal pain and/or psychosomatic disorders. Few studies have investigated the outcomes of NPMP, and no randomized clinical trials (RCT) with a comparing treatment group have systematically been tried out on individuals. Methods This is a pragmatic, single-blinded RCT where 128 participants with long-lasting widespread musculoskeletal pain and/or pain located to the neck and shoulders were block randomized to NPMP or Cognitive Patient Education combined with active individualized physiotherapy (COPE-PT). Intention-to-treat with linear mixed models were used to estimate the group differences in treatment effects. The outcomes at 3, 6, and 12 months follow-up were pain intensity, function, anxiety and depression, quality of life, sleep, fear of movement, and subjective health complaints. Risk profile (Orebro) was examined at 3 and 6 months. All participants underwent physical tests at baseline and 6 months. Results One-year data were available for 66.4% of the original participants. Calculated with intention-to-treat analysis, at 3 months statistically significant differences were found in favor of COPE-PT for pain, anxiety and depression, quality of life-physical dimension, risk profile and fear of movement. At 6 months, statistically significant differences in favor of COPE-PT were found for anxiety and depression, and sleep. At 12 months, the improvements were still statistically significant for anxiety, depression and sleep. Both groups improved, but no statistically significant differences were found between the groups on the physical tests at 6 months. Conclusions COPE-PT, which is targeted towards pain-coping and increasing activity, contribute to more improvements than NPMP.

Background In order to change antibiotic prescribing behaviour, we need to understand the prescribing process. The aim of this study was to identify targets for antibiotic stewardship interventions in hospitals through analysis of the antibiotic prescribing process from admission to discharge across five groups of infectious diseases. Methods We conducted a multi-centre, observational cohort study, including patients with lower respiratory tract infections, exacerbation of chronic obstructive pulmonary disease, skin- and soft tissue infections, urinary tract infections or sepsis, admitted to wards of infectious diseases, pulmonary medicine and gastroenterology at three teaching hospitals in Western Norway. Data was collected over a 5-month period and included antibiotics prescribed and administered during admission, antibiotics prescribed at discharge, length of antibiotic therapy, indication for treatment and discharge diagnoses, estimated glomerular filtration rate (eGFR) on admission, antibiotic allergies, place of initiation of therapy, admittance from an institution, patient demographics and outcome data. Primary outcome measure was antibiotic use throughout the hospital stay, analysed by WHO AWaRe-categories and adherence to guideline. Secondary outcome measures were a) antibiotic prescribing patterns by groups of diagnoses, which were analysed using descriptive statistics and b) non-adherence to the national antibiotic guidelines, analysed using multivariate logistic regression. Results Through analysis of 1235 patient admissions, we identified five key targets for antibiotic stewardship interventions in our population of hospital inpatients; 1) adherence to guideline on initiation of treatment, as this increases the use of WHO Access-group antibiotics, 2) antibiotic prescribing in the emergency room (ER), as 83.6% of antibiotic therapy was initiated there, 3) understanding prescribing for patients admitted from other institutions, as this was significantly associated with non-adherence to guideline (OR = 1.44 95% CI 1.04, 2.00), 4) understanding cultural and contextual drives of antibiotic prescribing, as non-adherent prescribing differed significantly between the sites of initiation of therapy (between hospitals and ER versus ward) and 5) length of therapy, as days of antibiotic therapy was similar across a wide range of diagnoses and with prolonged therapy after discharge. Conclusions Analysing the process of antibiotic prescribing in hospitals with patient-level data identified important targets for antibiotic stewardship interventions in hospitals.

Aims To examine changes and explanatory variables for changes in health-related quality of life in patients treated with long-term mechanical ventilation over a six-year period. Background Long-term mechanical ventilation is a treatment for individuals with chronic hypercapnic respiratory failure, primarily caused by neuromuscular diseases, obesity hypoventilation syndrome, chronic obstructive pulmonary and restrictive thoracic diseases. Studies on long-term outcome on health-related quality of life and factors influencing it are lacking. Design Prospective cohort study. Methods Data were collected from the Norwegian Long-Term-Mechanical-Ventilation Registry and from patient reported questionnaire in 2008 and 2014. Health-related quality of life was measured by the Severe Respiratory Insufficiency questionnaire, containing 49 items and seven subdomains. Linear mixed effects models were used to measure changes and identify factors for changes. Results After six years, 60 patients were still participating, out of 127 at baseline. Health-related quality of life improved significantly in the total score and in four subdomains of the questionnaire. Satisfaction with training in long-term mechanical ventilation was an explanatory variable for improved ‘psychological well-being’ and follow-up for improvement of ‘anxiety’. Side effects of the treatment like facial soreness were associated with the total score. High age and high forced vital capacity were related to lower ‘physical function’ and improved ‘social functioning’, respectively. Conclusion Long-term mechanical ventilation over six years improved health-related quality of life in most patients. Patient training, follow-up and reduction of side effects, largely delivered by trained nurses, contribute to achieve the main goal of the treatment - improved health-related quality of life. This article is protected by copyright. All rights reserved.

Publisher's version (útgefin grein)., Background: Overweight status and asthma have increased during the last decades. Being overweight is a known risk factor for asthma, but it is not known whether it might also increase asthma risk in the next generation. Objective: We aimed to examine whether parents being overweight in childhood, adolescence, or adulthood is associated with asthma in their offspring. Methods: We included 6347 adult offspring (age, 18-52 years) investigated in the Respiratory Health in Northern Europe, Spain and Australia (RHINESSA) multigeneration study of 2044 fathers and 2549 mothers (age, 37-66 years) investigated in the European Community Respiratory Health Survey (ECRHS) study. Associations of parental overweight status at age 8 years, puberty, and age 30 years with offspring's childhood overweight status (potential mediator) and offspring's asthma with or without nasal allergies (outcomes) was analyzed by using 2-level logistic regression and 2-level multinomial logistic regression, respectively. Counterfactual-based mediation analysis was performed to establish whether observed associations were direct or indirect effects mediated through the offspring's own overweight status. Results: We found statistically significant associations between both fathers' and mothers' childhood overweight status and offspring's childhood overweight status (odds ratio, 2.23 [95% CI, 1.45-3.42] and 2.45 [95% CI, 1.86-3.22], respectively). We also found a statistically significant effect of fathers' onset of being overweight in puberty on offspring's asthma without nasal allergies (relative risk ratio, 2.31 [95% CI, 1.23-4.33]). This effect was direct and not mediated through the offspring's own overweight status. No effect on offspring's asthma with nasal allergies was found. Conclusion: Our findings suggest that metabolic factors long before conception can increase asthma risk and that male puberty is a time window of particular importance for offspring's health., This study was funded by the European Union's Horizon 2020 research and innovation program as part of the ALEC study (Ageing Lungs in European Cohorts study, grant no. 633212). The RHINESSA generation study also received funding by the Research Council of Norway (grant nos. 214123 and 228174), the Bergen Medical Research Foundation (Norway), the Western Norwegian Regional Health Authorities (grant nos. 912011, 911892, and 911631), the Norwegian Labour Inspection, the Norwegian Asthma and Allergy Association, the Danish Woods Foundation (grant no. 444508795), the Danish Working Environment Authority (grant no. 20150067134), the Swedish Lung Foundation, the Swedish Asthma and Allergy Association, and the Estonian Research Council (grant no. PUT562). The funding agencies had no direct role in the conduct of the study; the collection, management, statistical analysis, and interpretation of the data; and the preparation or approval of the manuscript.

Objective: To investigate voice characteristics and exercise related respiratory symptoms in extremely preterm born 11-year-old children, focusing particularly on associations with management of a patent ductus arteriosus (PDA). Study design: Prospective follow-up of all children born in Norway during 1999–2000 at gestational age

This is the pre-peer reviewed version of the following article: Mæland, K. S., Morken, N. H., Schytt, E., Aasheim, V., & Nilsen, R. M. (2021). Placental abruption in immigrant women in Norway: A population‐based study. Acta Obstetricia et Gynecologica Scandinavica., which has been published in final form at https://doi.org/10.1111/aogs.14067. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. Introduction Placental abruption is a serious complication in pregnancy. While its incidence varies across countries, the information of how abruption varies in immigrant populations is limited. The aims of this study were to estimate the incidence of placental abruption in immigrant women compared to non‐immigrants by maternal country and region of birth, reason for immigration and length of residence. Material and methods We conducted a nationwide population‐based study using data from the Medical Birth Registry of Norway and Statistics Norway (1990‐2016). The study sample included 1,558,174 pregnancies, in which immigrant women accounted for 245,887 pregnancies and 1,312,287 pregnancies were to non‐immigrants. Crude and adjusted odds ratios with 95% confidence intervals (CI) for placental abruption in immigrant women compared to non‐immigrants were estimated by logistic regression with robust standard error estimations (accounting for within‐mother clustering). Adjustment variables included year of birth, maternal age, parity, multiple pregnancies, chronic hypertension and level of education. Results The incidence of placental abruption decreased during the study period for both immigrants (from 0.68% to 0.44%) and non‐immigrants (from 0.80% to 0.34%). Immigrant women from the sub‐Saharan African region had an adjusted odds ratio of 1.35 (95% CI: 1.15‐1.58) compared to non‐immigrants for placental abruption, whereas immigrant women from Ethiopia had an adjusted odds ratio of 2.39 (95% CI 1.67‐3.41). We found a small variation in placental abruption incidence by other countries or regions of birth, length of residence and reason for immigration. Conclusions Immigrant women from sub‐Saharan Africa, especially Ethiopia, have increased odds for placental abruption when giving birth in Norway. Reason for immigration and length of residence had little impact on the incidence of placental abruption.

Background This study compares subsequent birth outcomes in migrant women who had already had a child before arriving in Norway with those in migrant women whose first birth occurred in Norway. The aim of this study was to investigate the associations between country of first birth and adverse neonatal outcomes (very preterm birth, moderately preterm birth, post-term birth, small for gestational age, large for gestational age, low Apgar score, stillbirth and neonatal death) in parous migrant and Norwegian-born women. Methods National population-based study including second and subsequent singleton births in Norway from 1990 to 2016. Data were retrieved from the Medical Birth Registry of Norway and Statistics Norway. Neonatal outcomes were compared between births to: 1) migrant women with a first birth before immigration to Norway (n = 30,062) versus those with a first birth after immigration (n = 66,006), and 2) Norwegian-born women with a first birth outside Norway (n = 6205) versus those with a first birth in Norway (n = 514,799). Associations were estimated as crude and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using multiple logistic regression. Results Migrant women with a first birth before immigrating to Norway had increased odds of adverse outcomes in subsequent births relative to those with a first birth after immigration: very preterm birth (22–31 gestational weeks; aOR = 1.27; CI 1.09–1.48), moderately preterm birth (32–36 gestational weeks; aOR = 1.10; CI 1.02–1.18), post-term birth (≥42 gestational weeks; aOR = 1.19; CI 1.11–1.27), low Apgar score ( Conclusions The increased odds of adverse neonatal outcomes for migrant and Norwegian-born women who had their first births outside Norway should serve as a reminder of the importance of taking a careful obstetric history in these parous women to ensure appropriate care for their subsequent pregnancies and births in Norway.

Introduction: Extremely preterm born (EPB) infants are prone to a patent ductus arteriosus (PDA), and these infants often need prolonged invasive ventilation (IV), both of which might influence laryngeal function leading to abnormal voice characteristics and/or respiratory symptoms. Aim: Study associations between days on invasive ventilation, PDA surgery and voice/respiratory related symptoms in EPB children. Method: We surveyed a national cohort of 372 EPB children at 11 years of age. Parents of 91/143 children with PDA responded, 35 of them had undergone PDA surgery. The questions were based on the International Study of Asthma and Allergies in Childhood (ISAAC) and the Voice Handicap Index questionnaires with outcomes assessed using logistic regression, reporting odds ratios (95% confidence intervals). Result: Days on IV was associated with increased OR of a voice that is hoarse OR 1.11 (1.05-1.18), weak OR 1.05 (1.01-1.09), cracks when shouting OR 1.06 (1.02-1.10), influences singing OR 1.06 (1.02-1.11) and influences social participation OR 1.04 (1.01-1.08). Days on IV was also associated with breathing problems and grinding sound during physical exertion, both OR 1.05 (1.01-1.09), but not with wheeze during or after physical activity OR 1.01 (0.98-1.05). Adjusted for PDA surgery, OR for all variables except “weak voice” and “influences social participation” was reduced, but still associated with days on IV. Conclusion: Days on IV was associated with increased odds of voice/respiratory related symptoms in 11 years old EPB children. PDA surgery influenced most of the associations, suggesting causal factors also related to PDA surgery.

To investigate the association between different clinical parameters, particularly subnormal serum vitamin B12 and anemia, in older nursing home patients. No association was observed between subnormal B12 and anemia, while strong associations were observed between renal failure, inflammation/infection, iron deficiency and anemia. Vitamin B12 probably plays a limited role in the etiology and treatment of mild/moderate anemia in older patients, living in a Western society, and not suffering from pernicious anemia. Since evidence of an association between vitamin B12 (B12) deficiency and anemia in older people is limited and inconclusive, we wanted to investigate this association in old, frail nursing home patients. The study includes patients admitted to short-term, post-acute care (n = 765) and residents in long-term care (LTC) (n = 1665), in the municipality of Bergen. Anemia was defined according to the WHO criteria: Hb 650 pmol/L) B12, and the association between anemia and clinical parameters, and including B12, was analyzed using logistic regression models. The use of B12 supplementation was investigated in the LTC patients. Mean age of the 2430 patients was 86 ± 7 years. WHO-defined anemia was seen in 1023 (42%), and moderate/severe anemia in 384 (16%) of the patients. In multiple logistic regression analyses, we found no statistically significant associations of subnormal B12 with WHO-defined anemia or moderate/severe anemia. Renal insufficiency, iron deficiency and CRP > 10 mg/L were significantly associated with both types of anemia, (p 650 pmol/L. In older nursing home patients, no association was observed between subnormal B12 and anemia. Older patients in Western societies with mild/moderate anemia should not be treated with B12 supplements without further investigation.

The iterative reconstruction methods ASiR and ASiR-V have been accepted by hundreds of sites as their standard of care for a variety of protocols and applications. While the reduction in noise has been significant some readers have a preference for the classic image appearance. To maintain the classic image appearance of FBP at the same dose levels used for the standard of care with ASiR-V we introduce, Deep Learning Image Reconstruction (DLIR), a technique using artificial neural networks. This paper demonstrates that DLIR can maintain or improve upon the performance of the conventional iterative reconstruction algorithm (ASiR-V) in terms of low contrast detectability, noise, and spatial resolution.

Aims: Like most European countries, Norway has refrained from mandatory food fortification with folic acid to reduce the number of neural tube defects. We explored the role of folic acid and multivitamin supplements in the prevention of neural tube defects among newborn infants. Methods: We used data from the Medical Birth Registry of Norway, 1999–2013. A total of 528,220 women had 880,568 pregnancies resulting in 896,674 live- and stillborn infants, of whom 270 had neural tube defects. Relative risks were estimated with log-binomial regression. Results: From 1999 to 2013, intake of folic acid supplements increased from 4.8% to 27.4%. Vitamin supplement use was more frequent in older, married or cohabiting women and those with lower parity, as well as women who did not smoke during pregnancy. The overall adjusted relative risk of infant neural tube defects associated with maternal vitamin intake before pregnancy relative to no intake was 0.76 (95% confidence interval: 0.53–1.10). When we divided our study period in two (1999–2005 and 2006–2013), we found a significantly reduced risk of neural tube defects overall by vitamin use in the second time period, but not in the first: adjusted relative risk 0.54 (95% confidence interval: 0.31–0.91) and 1.02 (95% confidence interval: 0.63–1.65), respectively. Conclusions:Over the full study period, we found no statistically significant association between vitamin use and neural tube defects overall. However, vitamin use was associated with a significantly lower risk of neural tube defects in the second half of the study period, 2006–2013.

Epigenetic modifications, including DNA methylation, represent a potential mechanism for environmental impacts on human disease. Maternal smoking in pregnancy remains an important public health problem that impacts child health in a myriad of ways and has potential lifelong consequences. The mechanisms are largely unknown, but epigenetics most likely plays a role. We formed the Pregnancy And Childhood Epigenetics (PACE) consortium and meta-analyzed, across 13 cohorts (n = 6,685), the association between maternal smoking in pregnancy and newborn blood DNA methylation at over 450,000 CpG sites (CpGs) by using the Illumina 450K BeadChip. Over 6,000 CpGs were differentially methylated in relation to maternal smoking at genome-wide statistical significance (false discovery rate, 5%), including 2,965 CpGs corresponding to 2,017 genes not previously related to smoking and methylation in either newborns or adults. Several genes are relevant to diseases that can be caused by maternal smoking (e.g., orofacial clefts and asthma) or adult smoking (e.g., certain cancers). A number of differentially methylated CpGs were associated with gene expression. We observed enrichment in pathways and processes critical to development. In older children (5 cohorts, n = 3,187), 100% of CpGs gave at least nominal levels of significance, far more than expected by chance (p value < 2.2 × 10−16). Results were robust to different normalization methods used across studies and cell type adjustment. In this large scale meta-analysis of methylation data, we identified numerous loci involved in response to maternal smoking in pregnancy with persistence into later childhood and provide insights into mechanisms underlying effects of this important exposure. The BAMSE cohort was supported by The Swedish Research Council, The Swedish Heart-Lung Foundation, Freemason Child House Foundation in Stockholm, MeDALL (Mechanisms of the Development of ALLergy), a collaborative project conducted within the European Union (grant agreement No. 261357), Centre for Allergy Research, Stockholm County Council (ALF), Swedish foundation for strategic research (SSF, RBc08-0027, EpiGene project), the Strategic Research Programme (SFO) in Epidemiology at Karolinska Institutet, The Swedish Research Council Formas and the Swedish Environment Protection Agency.

Objective To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway. Design Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990–2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region. Main outcome Epidural analgesia for labour pain. Results Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50–0.59) and Somalia (adjOR 0.63; CI 0.58–0.68) and highest in women from Iran (adjOR 1.32; CI 1.19–1.46) and India (adjOR 1.19; CI 1.06–1.33). Refugees (adjOR 0.83; CI 0.79–0.87) and newly arrived migrants (adjOR 0.92; CI 0.89–0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11–1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02–1.10) had higher odds. Conclusion The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use. publishedVersion

Background Knowledge of the effect of marine protein hydrolysate (MPH) supplementation to promote recovery after high intensity performance training is scarce. The aim of this study was to examine the effect of MPH supplementation to whey protein (WP) and carbohydrate (CHO): (CHO-WP-MPH), on short-term recovery following high intensity performance, compared to an isoenergetic and isonitrogenous supplement of WP and CHO: (CHO-WP), in male cyclists. Methods This was a double-blinded crossover study divided into three phases. Fourteen healthy men participated. In phase I, an incremental bicycle exercise test was performed for establishment of intensities used in phase II and III. In phase II (9–16 days after phase 1), the participants performed first one high intensity performance cycling session, followed by nutrition supplementation (CHO-WP-MPH or CHO-WP) and 4 hours of recovery, before a subsequent high intensity performance cycling session. Phase III (1 week after phase II), was similar to phase II except for the nutrition supplementation, where the participants received the opposite supplementation compared to phase II. Primary outcome was difference in time to exhaustion between the cycling sessions, after nutrition supplementations containing MPH or without MPH. Secondary outcomes were differences in heart rate (HR), respiratory exchange ratio (RER), blood lactate concentration and glucose. Results The mean age of the participants was 45.6 years (range 40–58). The maximal oxygen uptake (mean ± SD) measured at baseline was 54.7 ± 4.1 ml∙min− 1∙kg− 1. There were no significant differences between the two nutrition supplementations measured by time to exhaustion at the cycling sessions (meandiff = 0.85 min, p = 0.156, 95% confidence interval (CI), − 0.37, 2.06), HR (meandiff = 0.8 beats pr.min, p = 0.331, 95% CI, − 0.9, 2.5), RER (meandiff = − 0.05, p = 0.361, 95% CI -0.07 – 0.17), blood lactate concentration (meandiff = − 0.24, p = 0.511, 95% CI, − 1.00, 0.53) and glucose (meandiff = 0.23, p = 0.094, 95% CI, − 0.05, 0.51). Conclusions A protein supplement with MPH showed no effects on short-term recovery in middle-aged healthy male cyclists compared to a protein supplement without MPH. Trial registration The study was registered 02.05.2017 at ClinicalTrials.gov (Protein Supplements to Cyclists, NCT03136133, https://clinicaltrials.gov/ct2/show/NCT03136133?cond=marine+peptides&rank=1.

IntroductionAlthough diabetes distress is found to be associated with decreased glycaemic control among adults with type 1 diabetes, the psychological and emotional impact of living with the condition is often not recognised and often under-reported in diabetes care. Therefore, regular assessment of diabetes distress is recommended. Assessment of diabetes distress using patient-reported outcome measures (PROMs) in clinical practice has the potential to enhance care for people with diabetes by identifying problems and improving patient–clinician communication. In this study protocol, we describe a pilot randomised controlled trial (RCT) aiming to test the feasibility of all components of an empowerment-based intervention using PROMs as dialogue support in clinical diabetes consultations, and to address the uncertainties associated with running a fully powered evaluation study.Methods and analysisWe will undertake a two-arm pilot RCT of an intervention using the Problem Areas In Diabetes (PAID) scale in clinical diabetes consultations in order to conclude whether a fully powered trial is appropriate and/or feasible. The study will also include qualitative indepth interviews with participants and healthcare providers. Our objectives are to (1) evaluate the recruitment procedures and attrition rates; (2) evaluate the performance of the randomisation procedure; (3) evaluate the participants’ mean scores on the outcome measures before and after the intervention; (4) evaluate if the intervention consultations are acceptable and feasible; and (5) explore patients’ and healthcare providers’ experiences with the use of PAID as dialogue support and empowerment-based communication skills in clinical diabetes consultations. The quantitative data analysis includes descriptive statistics (frequencies, percentages, means, SD and CI). For the qualitative data, we will perform thematic analysis.Ethics and disseminationEthical approval has been obtained from the Western Norway Regional Committee for Medical and Health Research Ethics (2017/1506/REC west). We will present the findings from the study phases at national and international conferences and submit manuscripts to peer-reviewed journals and popular science journals.Trial registration numberNCT03471104; Pre-results.

Background: Effective use of microbiology test results may positively influence patient outcomes and limit the use of broad-spectrum antibiotics. However, studies indicate that their potential is not fully utilized. We investigated microbiology test ordering practices and the use of test results for antibiotic decision-making in hospitals. Methods: A multicentre cohort study was conducted during five months in 2014 in Medical departments across three hospitals in Western Norway. Patients treated with antibiotics for sepsis, urinary tract infections, skin and soft tissue infections, lower respiratory tract infections or acute exacerbations of chronic obstructive pulmonary disease were included in the analysis. Primary outcome measures were degree of microbiology test ordering, compliance with microbiology testing recommendations in the national antibiotic guideline and proportion of microbiology test results used to inform antibiotic treatment. Data was obtained from electronic- and paper medical records and charts and laboratory information systems. Results: Of the 1731 patient admissions during the study period, mean compliance with microbiology testing recommendations in the antibiotic guideline was 89%, ranging from 81% in patients with acute exacerbations of chronic obstructive pulmonary disease to 95% in patients with sepsis. Substantial additional testing was performed beyond the recommendations with 298/606 (49%) of patients with lower respiratory tract infections having urine cultures and 42/194 (22%) of patients with urinary tract infections having respiratory tests. Microbiology test results from one of the hospitals showed that 18% (120/672) of patient admissions had applicable test results, but only half of them were used for therapy guidance, i.e. in total, 9% (63/672) of patient admissions had test results informing prescription of antibiotic therapy. Conclusions: This study showed that despite a large number of microbiology test orders, only a limited number of tests informed antibiotic treatment. To ensure that microbiology tests are used optimally, there is a need to review the utility of existing microbiology tests, test ordering practices and use of test results through a more targeted and overarching approach. publishedVersion

Background The Severe Respiratory Insufficiency (SRI) questionnaire is a specific measure of health-related quality of life (HRQoL) in patients treated with long-term mechanical ventilation (LTMV). The aim of the present study was to examine whether SRI sum scores and related subscales are associated with mortality in LTMV patients. Methods The study included 112 LTMV patients (non-invasive and invasive) from the Norwegian LTMV registry in Western Norway from 2008 with follow-up in August 2014. SRI data were obtained through a postal questionnaire, whereas mortality data were obtained from the Norwegian Cause of Death Registry. The SRI questionnaire contains 49 items and seven subscales added into a summary score (range 0–100) with higher scores indicating a better HRQoL. The association between the SRI score and mortality was estimated as hazard ratios (HRs) with 95% confidence intervals (95% CI) using Cox regression models and HRs were estimated per one unit change in the SRI score. Results Of the 112 participating patients in 2008, 52 (46%) had died by August 2014. The mortality rate was the highest in patients with chronic obstructive pulmonary disease (75%), followed by patients with neuromuscular disease (46%), obesity hypoventilation syndrome (31%) and chest wall disease (25%) (p

Background Migrant women’s overall increased risk of adverse pregnancy outcomes is well known. The aim of this study was to investigate possible associations between stillbirth and maternal country of birth and other migration related factors (paternal origin, reason for immigration, length of residence and birthplace of firstborn child) in migrant women in Norway. Methods Nationwide population-based study including births to primiparous and multiparous migrant women (n = 198,520) and non-migrant women (n = 1,156,444) in Norway between 1990 and 2013. Data from the Medical Birth Registry of Norway and Statistics Norway. Associations were investigated by multiple logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CIs). Results Primiparous women from Sri-Lanka and Pakistan, and multiparous women from Pakistan, Somalia, the Philippines and Former Yugoslavia had higher odds of stillbirth when compared to non-migrant women (adjusted OR ranged from 1.58 to 1.79 in primiparous and 1.50 to 1.71 in multiparous women). Primiparous migrant women whose babies were registered with Norwegian-born fathers had decreased odds of stillbirth compared to migrant women whose babies were registered with foreign-born fathers (aOR = 0.73; CI 0.58–0.93). Primiparous women migrating for work or education had decreased odds of stillbirth compared to Nordic migrants (aOR = 0.58; CI 0.39–0.88). Multiparous migrant women who had given birth to their first child before arriving in Norway had higher odds of stillbirth in later births in Norway compared with multiparous migrant women who had their first child after arrival (aOR = 1.28; CI 1.06–1.55). Stillbirth was not associated with length of residence in Norway. Conclusions This study identifies sub-groups of migrant women who are at an increased risk of stillbirth, and highlights the need to improve care for them. More attention should be paid to women from certain countries, multiparous women who had their first baby before arrival and primiparous women whose babies have foreign-born fathers. Electronic supplementary material The online version of this article (10.1186/s12884-018-2140-3) contains supplementary material, which is available to authorized users.

This study examines how preconception folic acid supplement use varied in immigrant women compared with non-immigrant women. We analyzed national population-based data from Norway from 1999&ndash, 2016, including 1,055,886 pregnancies, of which 202,234 and 7,965 were to 1st and 2nd generation immigrant women, respectively. Folic acid supplement use was examined in relation to generational immigrant category, maternal country of birth, and length of residence. Folic acid supplement use was lower overall in 1st and 2nd generation immigrant women (21% and 26%, respectively) compared with Norwegian-born women (29%). The lowest use among 1st generation immigrant women was seen in those from Eritrea, Ethiopia, Morocco, and Somalia (around 10%). The highest use was seen in immigrant women from the United States, the Netherlands, Denmark, and Iceland (&gt, 30%). Folic acid supplement use increased with increasing length of residence in immigrant women from most countries, but the overall prevalence was lower compared with Norwegian-born women even after 20 years of residence (adjusted odds ratio: 0.63, 95% confidence interval: 0.60&ndash, 0.67). This study suggests that immigrant women from a number of countries are less likely to use preconception folic acid supplements than non-immigrant women, even many years after settlement.

Background: We found that a father’s overweight in puberty was associated with non-allergic asthma in his future offspring.Aim: We explored the associations of both fathers and their offsprings own ...

To compare injections of hyaluronic acid (HA) and autologous fat (AF) for the treatment of unsightly temporal hollowing after lateral orbital wall decompression in thyroid eye disease.In this nonblinded prospective comparative interventional study, patients received injections of HA in the right temple and AF in the left temple. Additional injections were given when needed at follow-up after 6, 12, 18, and 24 months. Follow-up included an interview; clinical examination with an evaluation of symmetry, contour, and skin surface; and ultrasound measurements. From photographs, the temporal hollowing was graded 1-3. The main endpoints were grading of temporal hollowing and temporal soft tissue thickness.Seventeen patients were treated bilaterally and 12 unilaterally (five received HA and seven AF). Injection(s) of HA and AF administered at each site were a median (range) of 1 (1-4) and 2 (1-5), respectively. The total combined volume of HA injected per site was 0.9 (0.2-2.0) ml and that of AF was 3.1 (0.5-9.6) ml. At the final examination, a statistically significant difference in mean (SD) grading scores of temporal hollowing due to HA (1.18 (0.26)) compared to those of AF (1.85 (0.44)) was observed (p 0.001). Six months after administering an injection of HA, the temporal soft tissue thickness was 2.35 (0.24) cm compared to 2.19 (0.28) cm obtained with an injection of AF (p 0.001). By using a linear mixed-effect model and adjusting for baseline values, age, sex, and refill, the difference in favor of HA persisted at all later follow-ups. Increased fibrosis of the subcutaneous tissue developed at 5/24 sites that received AF.Injection of HA is superior to that of AF for treating temporal hollowing after lateral orbital wall decompression.

Background Despite extensive knowledge of smoking effects on respiratory disease, there is no study including all age windows of exposure among ever smokers. The objective of this study was to assess the effects from smoking exposure in utero, early childhood, adolescence and adulthood on respiratory health outcomes in adult male and female ever smokers. Methods Respiratory health outcomes were assessed in 10,610 participants of the European Community Respiratory Health Survey (ECRHS) I who reported a history of ever smoking by questionnaire. The associations of maternal smoking in utero, maternal smoking during childhood, age of smoking debut and pack-years of smoking with respiratory symptoms, obstructive diseases and bronchial hyperreactivity were analysed using generalized linear regression, non-linearity between age of smoking debut and outcomes were assessed by Generalized additive mixed models. Results Respiratory symptoms and asthma were more frequent in adults if their mother smoked during pregnancy, and, in men, also if mother smoked in childhood. Wheeze and ≥3 respiratory symptoms declined with later smoking debut among women [≤10 years: OR = 3.51, 95% CI 1.26, 9.73; 11–12 years: 1.57[1.01–2.44]; 13–15 years: 1.11[0.94–1.32] and ≤10 years: 3.74[1.56–8.83]; 11–12 years: 1.76[1.19–2.56]; 13–15 years: 1.12[0.94–1.35], respectively]. Effects of increasing number of packyears were pronounced in women (Chronic Obstructive Pulmonary Disease (COPD): OR/10 packyears women: 1.33 [1.18, 1.50], men: 1.14 [1.04, 1.26] pinteraction = 0.01). Conclusions Among ever smokers, smoking exposure in each stage of the lifespan show persistent harmful effects for adult respiratory health, while women appeared to be more vulnerable to an early age of smoking debut and amount of smoking in adulthood.

BACKGROUND: Respiratory complications represent the major cause of death in amyotrophic lateral sclerosis (ALS). Noninvasive respiratory support is the mainstay therapy, but treatment becomes challenging as the disease progresses, possibly due to a malfunctioning larynx, which is the entrance to the airways. We studied laryngeal response patterns to mechanically assisted cough (mechanical insufflation-exsufflation) as ALS progresses. METHODS: This prospective longitudinal study of 13 consecutively included subjects with ALS were followed up during 2011–2016 with repeated tests of lung function, neurological status, and laryngeal responses to mechanical insufflation-exsufflation using video-recorded flexible transnasal fiberoptic laryngoscopy. RESULTS: Follow-up time was median 17 (range 6–59) months. In total, 751 laryngoscopy recordings from 67 individual examinations (median 4 per subject, range 2–11 per subject) were analyzed. Adverse laryngeal events that developed with disease progression during insufflation included adduction of true vocal folds in 8 of 9 spinal-onset subjects and adduction of aryepiglottic folds in all subjects, initially at the highest positive pressure and prior to onset of other bulbar symptoms in spinal-onset subjects. As cough became less expulsive with disease progression, laryngeal adduction occurred at lower insufflation pressures. Retroflex movement of the epiglottis was observed in 7 of 13 subjects regardless of insufflation pressures and independent of bulbar involvements. Backward movement of the tongue base occurred regardless of insufflation pressures in all but 1 subject. During exsufflation, constriction of the hypopharynx was observed in all subjects regardless of the presence of bulbar symptoms, after the adverse events that occurred during insufflation. CONCLUSIONS: Applying high insufflation pressures during mechanically assisted cough in ALS can become counterproductive as the disease progresses as well as prior to the onset of bulbar symptoms. The application of positive inspiratory pressures should be tailored to the individual patient, and laryngoscopy during ongoing treatment appears to be a feasible tool.

ObjectiveMany patients with primary adrenal insufficiency (Addison's disease) take extra doses of glucocorticoids during stressful events, but a benefit has not been demonstrated in controlled trials. Here, we investigated the effects of a pre-exercise hydrocortisone dose on cardiorespiratory, hormonal and metabolic parameters in response to short-term strenuous physical activity.DesignThis was a randomized placebo-controlled, cross-over clinical trial.ParticipantsTen women with Addison's disease and 10 age-matched healthy females participated in the study.MeasurementsAll women in the study underwent maximal incremental exercise testing. A stress dose of 10 mg hydrocortisone or placebo was given 1 h prior to exercise on two occasions. Blood samples were drawn before, and 0, 15 and 30 min post exercise. Oxygen uptake, maximal aerobic capacity, endocrine and metabolic responses to physical activity, as well as health status by questionnaires were evaluated.ResultsMaximal aerobic capacity and duration of exercise were significantly lower in patients than in healthy subjects and did not improve with the treatment. After an extra hydrocortisone dose serum cortisol was significantly higher than in the healthy subjects (PConclusionsThe patients did not benefit from an extra dose of hydrocortisone in short strenuous exercise. Stress dosing may not be justified in this setting. Whether stress dosing is beneficial in other types of physical activity will have to be examined further.

Results from previous studies on maternal folic acid intake and infant oral clefts are inconclusive. The aim of the present study was to investigate the association between women’s use of folic acid and/or multivitamin supplements and the risk for oral cleft in the newborn. We used data from the Medical Birth Registry of Norway based on all births in Norway from 1999 to 2013. A total of 528 220 women had 880 568 pregnancies, resulting in 896 674 live births and stillbirths, of which 1623 had oral clefts (isolated oral clefts, n 1311; non-isolated oral clefts, n 312). Altogether, 21·5 % of women were vitamin supplement users before pregnancy. The birth prevalence of oral clefts was 1·81/1000 live births and stillbirths. Relative risks (RR) were estimated with log-binomial regression. For pregnancies with maternal use of vitamins, the adjusted RR for clefts overall was 0·90 (95 % CI 0·79, 1·04). The adjusted RR for cleft palate only (n 586) was 0·84 (95 % CI 0·66, 1·06) and that for cleft lip with or without cleft palate (n 1037) was 0·94 (95 % CI 0·79, 1·13). Associations were stronger for cleft cases that occurred in combination with other malformations (adjusted RR 0·63; 95 % CI 0·45, 0·88), although vitamin supplements provided no protection against isolated clefts (adjusted RR 0·98; 95 % CI 0·84, 1·15). In conclusion, our study demonstrates no statistically significant association between vitamin use and isolated oral clefts. However, we found lower risk for oral clefts that occurred in combination with other malformations.

Background The diagnosis of diabetes mellitus (DM) is based on either fasting plasma glucose levels or an oral glucose tolerance test (OGTT). Recently, an HbA1c value of ≥ 48 mmol/mol (6.5%) has been included as an additional test to diagnose DM. The purpose of this study was to validate HbA1c versus OGTT as a method to diagnose DM in vascular surgery patients. Methods The study population consisted of 345 patients admitted consecutively due to peripheral arterial disease. Sixty-seven patients were previously diagnosed with DM. Glucose levels of OGTT and HbA1c values were analyzed in 275 patients. The OGTT results were categorized into three groups according to the World Health Organization 1999 criteria: 1) DM defined as fasting plasma glucose (FPG) ≥ 7.0 mmol/L and/or two-hour value (2-h-value) ≥ 11.1 mmol/L; 2) intermediate hyperglycaemia, which consists of IGT (FPG

This is the author's manuscript (preprint) of an article published by Taylor & Francis in Scandinavian Journal of Gastroenterology on 28 Sep 2018, available online: https://www.tandfonline.com/doi/full/10.1080/00365521.2018.1509122 Backgroud: Patients with celiac disease (CD), including adults with subclinical disease, have low bone mineral density (BMD), deteriorated bone microarchitecture; metanalysis show an increased risk of fracture. Immunoglobulin A (IgA) against transglutaminase 2 (IgA TG2) is a highly reliable marker to detect CD. Main objective: To explore the prevalence of positive IgA TG2 and CD in patients with distal radius and ankle fracture compared to community-based controls. Methods: 400 patients age 40 years or above with distal fractures were included in a case-control study. 197 controls were identified from the National Population Registry, those included had never suffered a fracture. BMD was measured, and comorbidities, medications, physical activity, smoking habits, body mass index (BMI) and nutritional factors were registered. Blood analysis to detect common causes of secondary osteoporosis was performed. Results: 2.5% of the fracture patients had positive IgA TG2, compared to 1% in the control group. The odds ratio, adjusted for sex and age, of having positive IgA TG2 was 2.50 (95% CI 0.54 – 11.56). Conclusions: There were no significantly increased odds of CD in adult patients with fractures compared to controls, however results imply that positive IgA TG2 is more prevalent in fracture patients than in controls. This study indicates that universal screening for CD in fracture patients is not warranted, but supports current clinical practice in Norway to suspect and investigate for CD in patients with fracture, osteoporosis and other risk factors for CD.

Background To investigate whether the occurrence of preeclampsia varied by maternal reasons for immigration. Methods We included 1,287,270 singleton pregnancies (163,508 to immigrant women) in Norway during 1990–2013. Individual data were obtained through record linkage between the Medical Birth Registry of Norway and Statistics Norway. Analyses were performed for preeclampsia overall and in combination with preterm birth

Background: Maternal predictors of folic acid (FA) supplementation use to reduce offspring risk of neural tube defects are well known, while paternal determinants for maternal FA use are less known. Such knowledge is important to increase women’s compliance to recommended periconceptional FA use. Methods: In a nation-wide study of 683,785 births registered in the Medical Birth Registry of Norway during 1999–2010, the associations between paternal characteristics (age, education, occupation, country of origin) and maternal FA use were estimated by relative risks (RR) with 95% confidence intervals (CI), using log-binomial regression. Results: Maternal FA use before and during pregnancy (adequate FA use) was found in 16% of the births. The association between paternal age and adequate FA use was inversely U-shaped; adjusted RRs for adequate FA use were 0.35 (95% CI 0.28–0.43) and 0.72 (95% CI 0.71–0.74) for paternal age

BackgroundA review of the literature reveals a lack of validated instruments that particularly measure quality in the hospital discharge process. This study aims to develop and validate a survey instrument feasible for measuring quality (≥65 years) related to the discharge process based on elderly patients' experiences.MethodsConstruction of the Discharge Care Patient Experience Survey (DICARES) was based on 16 items identified by literature reviews. Intraclass correlation for test-retest was applied to assess consistency of the survey. Explorative factors analysis was applied to identify and validate the factor structures of the DICARES. Cronbach's α was used to assess internal reliability. To evaluate the external validity of the final DICARES questionnaire the patients' scores were correlated with scores obtained from the three other questionnaires; the Nordic Patient Experiences Questionnaire, the 12-Item Short-Form Health Survey and Subjective Health Complaints. The DICARES association with readmissions was examined.ResultsA total of 270 patients responded (64.4%). The mean age of participants was 77.1 years and 57.8% were men. The exploratory factor analysis resulted in a 10-item instrument consisting of three factors explaining 63.5% of the total variance. The Cronbach's α were satisfactory (≥70). Overall intraclass correlation was 0.76. A moderate Spearman correlation (rho = 0.54, p ConclusionWe have developed a 10-item questionnaire consisting of three factors which may be a feasible instrument for measuring quality of the discharge process in elderly patients. Further testing in a wider population should be carried out before implementation in health care settings.

Surgical site infections (SSI) are amongst the most common health care-associated infections and have adverse effects for patient health and for hospital resources. Although surgery guidelines recognize poor nutritional status to be a risk factor for SSI, they do not tell how to identify this condition. The screening tool Nutritional Risk Screening 2002 is commonly used at hospitals to identify patients at nutritional risk. We investigated the association between nutritional risk and the incidence of SSI among 1194 surgical patients at Haukeland University Hospital (Bergen, Norway). This current study combines data from two mandatory hospital-based registers: a) the incidence of SSI within 30 days after surgery, and b) the point-prevalence of patients at nutritional risk. Patients with more than 30 days between surgery and nutritional risk screening were excluded. Associations were assessed using logistic regression, and the adjusted odds ratio included age (continuous), gender (male/female), type of surgery (acute/elective) and score from The American Society of Anesthesiologists Physical Status Classification System. There was a significant higher incidence of SSI among patients at nutritional risk (11.8%), as compared to those who were not (7.0%) (p = 0.047). Moreover, the incidence of SSI was positively associated with the prevalence of nutritional risk in both simple (OR 1.76 (95% CI: 1.04, 2.98)) and adjusted (OR 1.81 (95% CI: 1.04, 3.16)) models. Answering “yes” to the screening questions regarding reduced dietary intake and weight loss was significantly associated with the incidence of SSI (respectively OR 2.66 (95% CI: 1.59, 4.45) and OR 2.15 (95% CI: 1.23, 3.76)). In conclusion, we demonstrate SSI to occur more often among patients at nutritional risk as compared to those who are not at nutritional risk. Future studies should investigate interventions to prevent both SSI and nutritional risk among surgical patients. publishedVersion