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Background and purpose The conventional statistical methods employed in observational studies in orthopedics require the fundamental assumption that the outcomes are independent. However, fractures treated by the same surgeon cannot be regarded as being independent of each other and should be nested in the statistical analysis. If the effect on outcome of early rather than delayed surgery depends on the severity of the fracture, we have a case of interaction. This is rarely considered in orthopedic research, but could affect the conclusions drawn. The aim of this paper is to describe the concepts of multilevel modeling and interaction in orthopedics. Patients and methods In a cohort of 112 patients with single supracondylar humerus fractures, 78 patients were examined clinically on average 4 years after surgery. The range of motion was measured and the global satisfaction was assessed. The results were used to compare traditional least-squares regression analysis with a 2-level model with interactions. Results We found that 25% of the variance in outcome could be attributed to between-surgeon variance. We identified an interaction between the surgeons' experience and the severity of the fractures that influenced the conclusions. The variable 'number of pins' was not significant in the 2-level model (p = 0.07), while the ordinary least-squares analysis gave a result that was statistically significant (p = 0.01). Interpretation Researchers should consider the need for a 2-level model and the presence of interactions. Standard statistical methods might lead to wrong conclusions. [ABSTRACT FROM AUTHOR]

Rationale: The relationship between dust exposure and annual decline in lung function among employees in the smelting industry is unknown. Objectives: The aim of the study was to investigate the relationship between annual change in lung function and occupational dust exposure among workers in 15 Norwegian smelters. Methods: All employees (n = 2,620) were examined annually for 5 years (11,335 health examinations). At each examination spirometry was performed and a respiratory questionnaire was completed. The smelters were grouped as follows: (1) ferrosilicon alloys (FeSi) and silicon metal (Si-metal); and (2) silicon manganese (SiMn), ferromanganese (FeMn), and ferrochromium (FeCr). A job exposure matrix was available on the basis of 2,619 personal dust exposure measurements. The association between lung function expressed as FEV(1) and FVC per squared height (height(2)) and dust exposure was investigated using multivariate linear mixed model analyses. Measurements and Main Results: The annual change in FEV(1)/height(2) (deltaFEV(1)) related to dust exposure in the FeSi/Si-metal and SiMn/FeMn/FeCr smelters was -0.42 (95% confidence interval, -0.95 to 0.11) and -1.1 (-2.1 to -0.12) (ml/m(2)) x (mg/m(3))(-1) x year(-1), respectively. The annual decline in FEV(1)/height(2) was 1.6 ml/m(2) (0.15 to 3.1) steeper in smokers than in nonsmokers. The median geometric mean of the time-weighted dust exposure concentration levels of the employees was 2.3 mg/m(3) in the FeSi/Si-metal smelters and 1.6 mg/m(3) in the SiMn/FeMn/FeCr smelters. Among nonsmokers, deltaFEV(1) was -0.86 (-1.6 to -0.10) and -1.1 (-2.5 to 0.25) (ml/m(2)) x (mg/m(3))(-1) x year(-1) in the FeSi/Si-metal and SiMn/FeMn/FeCr smelters, respectively. Thus, for a 1.80 m tall employee the annual decline in FEV(1) associated with average dust exposure was 5.7 ml/year in the SiMn/FeMn/FeCr smelters, and 6.4 ml/year for a nonsmoker in the FeSi/Si-metal smelters. Conclusions: In all smelters combined, the annual change in FEV(1) was negatively associated with increasing dust exposure. This association was also significant among workers in SiMn/FeMn/FeCr smelters and among nonsmokers in the FeSi/Si-metal smelters. [ABSTRACT FROM AUTHOR]

OBJECTIVE: 'Four Habits' is the first larger generic clinical communication program to have a documented effect. It has not been evaluated outside USA. In a pilot study, Norwegian hospital physicians assessed its usefulness, and we developed a questionnaire where patients reported 'Four Habits'-specific physician behaviour. METHODS: We ran a 3-day course with 16 participants and three US facilitators. The questionnaire mapping 'Four Habits' with 23 items was distributed by participating physicians to 210 patients. Participating physicians met in evaluative focus groups 3 months after the course. RESULTS: The questionnaire was condensed to 10 items after factorial analysis. The resulting scale performed well. A large amount of missing data on some items suggested that patients found it difficult to evaluate details of 'Four Habits'-specific physician behaviour. Participants found that the 'Four Habits' short course led to improvement of their encounters. Some elements of the method were not perceived as relevant for all types of encounters (habits II and III). CONCLUSION: 'Four Habits' is applicable outside US with some adjustments. A shortened version of the questionnaire will be used in a planned randomized controlled trial. [ABSTRACT FROM AUTHOR]

Background: Frail older persons with cognitive impairment (CI) are at special risk of experiencing delirium during acute hospitalisation. The purpose of this study was to investigate whether a dementia-friendly hospital program contributes to improved detection and management of patients with CI and risk of delirium at an acute-care hospital in Norway. Furthermore, we aimed to explore whether the program affected the detection of delirium, pharmacological treatment, 30-day re-hospitalisation, 30-day mortality and institutionalisation afterwards., Methods: This study was part of a larger quality improvement project aiming at developing and implementing a new program for early screening and management of patients with CI. This study, evaluating the program are designed as a controlled clinical trial with a historical control group. It was conducted at two different medical wards at a large acute-care hospital in Norway from September 2018 to December 2019. A total of 423 acute hospitalised patients 75 years of age or older were included in the study. Delirium screening and cognitive tests were recorded by research staff with the 4 'A's Test (4AT) and the Confusion Assessment Measure (CAM), while demographic and medical information was recorded from the electronic medical records (EMR)., Results: Implementation of the dementia-friendly hospital program did not show any significant changes in the identification of patients with CI. However, the share of patients screened with 4AT within 24 h increased from 0% to 35.5% (P < .001). The proportion of the patients with CI identified by the clinical staff, who received measures to promote "dementia-friendly" care and reduce the risk for delirium increased by 32.2% (P < .001), compared to the control group. Furthermore, the number of patients with CI who were prescribed antipsychotic, hypnotic or sedative medications was reduced by 24.5% (P < .001). There were no differences in delirium detection, 30-day readmission or 30-day mortality., Conclusions: A model for early screening and multifactorial non-pharmacological interventions for patients with CI and delirium may improve management of this patient group, and reduce prescriptions of antipsychotic, hypnotic and sedative medications. The implementation in clinical practice of early screening using quality improvement methodology deserves attention., Trial Registration: The protocol of this study was retrospectively registered in the ClinicalTrials.gov Protocol Registration and Results System with the registration number: NCT04737733 and date of registration: 03/02/2021., (© 2022. The Author(s).)

Background/aim: Muscle loss, inflammation, and frailty are prevalent among older cancer patients. We aimed to evaluate whether inflammatory markers could identify muscle loss, and if muscle measures differed between frail and non-frail patients., Patients and Methods: A total of 115 patients ≥70 years old with solid tumors were included. Inflammation was measured using the Glasgow Prognostic Score (GPS), which is based on C-reactive protein (CRP) and albumin levels, and CRP alone. Frailty was evaluated using a modified geriatric assessment (mGA) of eight domains affecting older patients' health status. Computed tomography-derived muscle measures were collected at the level of the third lumbar vertebra., Results: Patients with GPS=2 and CRP>27 mg/l exhibited poorer muscle measures compared to patients with lower levels. No associations between mGA-based frailty and muscle mass were found., Conclusion: Inflammation has detrimental effects on muscle mass. However, GPS or CRP alone cannot be used to identify muscle loss, and muscle measures were not associated with frailty in this series., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Strategies to improve communication in people with dementia are warranted. We examined the effect of the Sonas programme on communication ability in persons with moderate to severe dementia., Methods: A 24-week 3-armed (Sonas, reading, and control group) randomized controlled trial including 120 nursing home residents with dementia was conducted; 105 completed the follow-up assessments. The main outcome was change in communication abilities measured by the Holden Communication Scale (HCS)., Results: We found no overall significant effect of the Sonas programme with regard to communication ability as measured by the HCS. However, an effect between the Sonas group and the reading group and between the Sonas group and the control group from T0 to T1 and T2 was found, as well as a significant improvement in communication in the Sonas group. Among people with severe dementia, the Sonas group scored significantly better on the HCS compared to the reading group after 12 weeks, but not after 24 weeks., Conclusion: This study failed to document an overall effect of the Sonas programme on communication; however, the findings indicate that the Sonas programme has a significant effect on communication among those with severe dementia.

Purpose: The study aims to investigate long-term development in annual labor income (ALI) among patients with colorectal cancer (CRC) compared to individually matched cancer-free controls., Methods: In a register-based cohort study based on data from Norwegian national registries, 752 patients diagnosed with CRC 1992-1996 at the age 45-54 years were observed annually up to 10 years post-diagnosis. Also, 752 individually matched controls were observed correspondingly. The relationship of CRC and ALI development was modeled by linear mixed model statistics., Results: CRC was associated with reduced ALI in females in the year of diagnosis, irrespective of extent of disease. From the year after diagnosis and onwards, ALI decreased in female patients and controls, most strongly in females with distant CRC, and also in males with regional and distant CRC. Five years after diagnosis, mean ALI was reduced by 22 % in females and 6 % in males with localized CRC. Corresponding numbers were 21 % in females and 11 % in males with regional CRC and 6 % reduction in female and less than 1 % reduction in male controls. After adjustment for post-diagnostic disability pension and days of employment, ALI developed similarly in male patients and controls, whereas CRC remained associated with reduced ALI in the year of diagnosis in females and throughout observation in females with distant CRC., Conclusion: Except for males with localized cancer, CRC was associated with negative development in ALI in both sexes, varying by extent of disease. The work ability and income status of female CRC patients and males with metastasing disease should be checked during follow-up.

To explore the relationships between vitamin A, D and E and inflammation in relapsing remitting multiple sclerosis, we assessed their associations with 11 inflammation markers in 9 serial serum samples from 85 patients, before and during interferon-β1a treatment. A negative association was found between vitamin A and pentraxin 3 independent of interferon-β1a use, whereas positive associations between vitamin D and interleukin-1 receptor antagonist and secreted frizzled-related protein 3 were seen before, and between vitamin E and chemokine (C-X-C motif) ligand 16 during interferon-β1a treatment. These findings suggest associations with diverse inflammatory pathways, which may be differentially influenced by interferon-β1a treatment., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Few have studied how personal activities of daily living (P-ADL) develop over time in nursing home residents with dementia. Thus, the aim was to study variables associated with the development of P-ADL functioning over a 52-month follow-up period, with a particular focus on the importance of the degree of dementia., Method: In all, 932 nursing home residents with dementia (Clinical Dementia Rating-CDR- Scale ≥ 1) were included in a longitudinal study with four assessments of P-ADL functioning during 52 months. P-ADL was measured using the Lawton and Brody's Physical Self-Maintenance Scale. Degree of dementia (CDR), neuropsychiatric symptoms and use of psychotropic medication were assessed at the same four time points. Demographic information and information about physical health was included at baseline. Linear regression models for longitudinal data were estimated., Results: Follow-up time was positively associated with a decline in P-ADL functioning. Degree of dementia at baseline was associated with a decline in P-ADL functioning over time. The association between degree of dementia and P-ADL functioning was strongest at baseline, and then flattened over time. A higher level of neuropsychiatric symptoms such as agitation and apathy and no use of anxiolytics and antidementia medication were associated with a decline in P-ADL functioning at four time points. Higher physical co-morbidity at baseline was associated with a decline in P-ADL functioning., Conclusion: P-ADL functioning in nursing home patients with dementia worsened over time. The worsening was associated with more severe dementia, higher physical comorbidity, agitation, apathy and no use of anxiolytics and antidementia medication. Clinicians should pay attention to these variables (associates) in order to help the nursing home residents with dementia to maintain their level of functioning for as long as possible.

Background: Vitamin A has immunomodulatory properties and may regulate the transcription of genes involved in remyelination., Objective: To investigate the association between retinol and disease activity in multiple sclerosis (MS)., Methods: Cohort study of 88 relapsing-remitting MS patients, originally included in a randomised placebo-controlled trial of omega-3 fatty acids in MS (the OFAMS study), followed prospectively for 24 months with repeated assessments of serum-retinol and magnetic resonance imaging (MRI). All patients were initiated on interferon β-1a after month 6., Results: Each 1 µmol/L increase in serum-retinol reduced the odds (95% confidence interval) for new T1 gadolinium enhanced (Gd(+)) lesions by 49 (8-70)%, new T2 lesions by 42 (2-66)%, and combined unique activity (CUA) by 46 (3-68)% in simultaneous MRI scans, and 63 (25-82)% for new T1Gd(+) lesions, 49 (3-73)% for new T2 lesions and 43 (12-71)% for CUA the subsequent month. Serum-retinol also predicted new T1Gd(+) and T2 lesions six months ahead. The associations were not affected by HLA-DRB1*15, or serum levels of 25-hydroxyvitamin D, eicosapentaenoic acid or docosahexaenoic acid., Conclusion: Serum retinol is inversely associated with simultaneous and subsequent MRI outcomes in RRMS.

Unlabelled: Intake of trans fatty acids from hydrogenated fish oils has been related to increased risk of coronary heart diseases. The possible effect on colorectal carcinogenesis is unclear., Materials and Methods: Multiple intestinal neoplasia (Min/+) mice were fed one of four experimental diets: either raw fish oil (FO), low (LHFO)-, high (HHFO)- or fully-hydrogenated fish oil (FFHO), from 0 to 9 weeks of age. The number and size of intestinal tumors were recorded., Results: There was no difference between the intervention groups in the numbers of developed intestinal tumors. The tumor size was statistically significantly lower in HHFO vs. the FO-group in male Min/+ mice. The HHFO and FHFO groups had lower weight gain than did the FO group (p=0.008 and p=0.04, respectively), but gender differences, due to effect of dietary intervention on weight gain, were found in Min/+ mice., Conclusion: When compared with raw fish oil, different degrees of hydrogenation of the fish oil had no effect on intestinal carcinogenesis in Min/+ mice.

Background: Chronic headache (headache ≥ 15 days/month for at least 3 months) affects 2-5% of the general population. Medication overuse contributes to the problem. Medication-overuse headache (MOH) can be identified by using the Severity of Dependence Scale (SDS). A "brief intervention" scheme (BI) has previously been used for detoxification from drug and alcohol overuse in other settings. Short, unstructured, individualised simple information may also be enough to detoxify a large portion of those with MOH. We have adapted the structured (BI) scheme to be used for MOH in primary care., Methods/design: A double-blinded cluster randomised parallel controlled trial (RCT) of BI vs. business as usual. Intervention will be performed in primary care by GPs trained in BI. Patients with MOH will be identified through a simple screening questionnaire sent to patients on the GPs lists. The BI method involves an approach for identifying patients with high likelihood of MOH using simple questions about headache frequency and the SDS score. Feedback is given to the individual patient on his/her score and consequences this might have regarding the individual risk of medication overuse contributing to their headache. Finally, advice is given regarding measures to be taken, how the patient should proceed and the possible gains for the patient. The participating patients complete a headache diary and receive a clinical interview and neurological examination by a GP experienced in headache diagnostics three months after the intervention. Primary outcomes are number of headache days and number of medication days per month at 3 months. Secondary outcomes include proportions with 25 and 50% improvement at 3 months and maintenance of improvement and quality of life after 12 months., Discussion: There is a need for evidence-based and cost-effective strategies for treatment of MOH but so far no consensus has been reached regarding an optimal medication withdrawal method. To our knowledge this is the first RCT of structured non-pharmacological MOH treatment in primary care. Results may hold the potential of offering an instrument for treating MOH patients in the general population by GPs.

Objective: To describe the process for developing interrater reliability (IRR) for the Four Habits Coding Scheme (4HCS) for a heterogeneous material as part of a randomized controlled trial., Methods: Videotapes from 497 hospital encounters involving 71 doctors from most clinical specialties were collected. Four experienced psychology students were trained as raters. We calculated Pearson's r and the intraclass correlation (ICC) on the total score across consecutive samples of twenty videos, and Pearson's r on single videos across items in the initial coding phase., Results: After 18h of training and one rating session, the total score Pearson's r and ICC exceeded .70 for all pairs of raters. Across items within single videos, the Pearson's r was never below 0.60 after the first 50 videos. At item and habit level Pearson's r remained unsatisfactory for some rater pairs mostly due to low variance on some items., Conclusion: Based on the evaluation of the effect of communication skills training via a total score, IRR was satisfactory for the 4HCS as applied to heterogeneous material. However, good reliability at item level was difficult to achieve., Practice Implications: 4HCS may be used as an outcome measure for clinical communication skills in randomized controlled trials., (Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To compare biometric measurements of the pubovisceral muscle during rest, measured using transperineal three-dimensional (3D) ultrasound and magnetic resonance imaging (MRI)., Methods: In this prospective study, 18 female volunteers underwent 3D perineal ultrasound examination and MRI. All women were examined at rest in the supine position and the following measurements were taken: area and anteroposterior and transverse diameters of the levator hiatus; thickness of the pubovisceral muscle, measured lateral to the vagina and to the rectum, on the right and left sides; length of the levator-urethra gap (LUG), measured from the center of the urethra to the insertion of the pubovisceral muscle on the pubic bone. Interclass correlation coefficients (ICC) between the measurements obtained with 3D ultrasound and with MRI were calculated. To quantify the intermeasurement agreement, the bias and SDs were calculated, and limits of agreement constructed. One investigator performed all the analyses., Results: There was no significant difference between the mean values of the measurements by 3D perineal ultrasound and those by MRI. The ICC values showed very good agreement (range, 0.80-0.97). There was a significant positive bias for LUG on the left side and muscle thickness on the right side of the vagina., Conclusion: These results suggest that 3D ultrasound could be used instead of MRI when evaluating static pelvic floor anatomy in women without pelvic organ prolapse at rest., ((c) 2010 ISUOG. Published by John Wiley & Sons, Ltd.)

Objective: To observe cerebrospinal fluid opening pressure (CSFOP) in different clinical settings and in patients with acute, chronic and no pain and to observe possible differences because of age and sex., Method: In this prospective study, CSFOP was measured in lumbar puncture in three different settings of clinical investigations; patients with acute headache investigated for subarachnoidal haemorrhage (n = 222), patients with sciatica undergoing myelography (n = 61), and patients in an outpatient neurological clinic (n = 65)., Results: The mean CSFOP in cm H(2)O was 17.3 for the myelography patients, 19.1 for the outpatients, 19.3 for the primary headache patients and 22.4 for the patients with secondary headache. Large proportions of patients in all groups had CSFOP above 20 cm H(2)O. The female patients in all groups had lower mean CSFOP than the male patients., Conclusion: The CSFOP levels found in clinical practice among patients without intracranial lesions or infectious conditions were broader than expected. Measurement of CSFOP is of limited value as diagnostic procedure if not closely linked to clinical symptoms and finds.

The aim of this study was to investigate the diagnostic value of pericranial muscle tenderness (PT) and neck mobility assessment in differentiating primary from secondary headache in patients with acute headache, when life-threatening conditions like subarachnoid haemorrhage (SAH) and meningitis have been ruled out. Two neurologists made diagnoses independently, placing patients in either a primary or a secondary headache group. Patients without SAH or meningitis were examined for PT and neck mobility by a single examiner. Headache-free patients acted as controls. We found no significant difference in PT between primary and secondary headache patients, or between secondary headache patients and controls. There were no significant differences in neck mobility between any groups. Our findings suggest that assessment of PT and neck mobility does not help to distinguish acute primary from secondary headaches when SAH and meningitis have been excluded.

Visual analogue scales (VAS) are well-validated instruments for assessing pain intensity, but have an impractical format. The aim of the study was to validate a vertical against a horizontal VAS for pain intensity registration. Out-patients with headache or non-headache pain were included. Participants completed a horizontal and a vertical VAS. Both were completed twice for test-retest. Headache was diagnosed according to the International Classification of Headache Disorders, 2nd edition. The results on vertical and horizontal VAS did not differ significantly in the different headache or chronic pain groups. For test-retest evaluation, effect sizes and Cohen's delta values were < 0.029 with < 1.5% change from test to retest (P < 0.01). Correlation coefficients were > 0.95. Bland-Altman analysis showed good agreement between vertical and horizontal scores with correlation coefficients > 0.84. A vertical VAS is equally valid as a horizontal VAS for registration of pain intensity in headache and non-headache patients.

Background: The increasing attention on functional assessments in medical and vocational rehabilitation requires a focus change for the general practitioners (GP) into paying attention to patient resources, possibilities and coping instead of symptoms, problems and limitations. The GPs report difficulties in performing the requested explicit functional assessments. The purpose of this study was to implement a structured method in general practice for assessing functional ability in persons with long-term sick leave. The study aim was to evaluate intervention effects on important GP parameters; knowledge, attitudes, self-efficacy towards functional assessments and knowledge about patient work factors., Methods: Fifty-seven GPs were randomly assigned to an intervention or a control group. The intervention group GPs attended an introductory one-day work-shop and implemented structured functional assessments during an eight months intervention period. GP knowledge, GP attitudes, and GP self-efficacy towards functional assessments, as well as GP knowledge of patient work factors, were collected before, after and six months after the intervention period started. Evaluation score-sheets were filled in by both the intervention GPs and their patients immediately after the consultation to evaluate the GPs' knowledge of patient work factors., Results: The intervention GPs reported increased knowledge (B: 0.56, 95% CI (0.19, 0.91)) and self-efficacy (B: 0.90, 95% CI (0.53, 1.26)) towards functional assessments, and increased knowledge about their patients' workplace (B: 0.75, 95% CI (0.35, 1.15)) and perceived stressors (B: 0.55, 95% CI (0.23, 0.88)) with lasting effects at the second follow-up. No intervention effect was seen in relation to GP attitudes. Both before and after the intervention, the GPs were most informed about physical stressors, and less about mental and work organisational stressors (Guttman's reproducibility coefficient: 0.95 and 1.00). After the consultation, both the intervention GPs and their patients reported that the GPs' knowledge about patient work factors had increased (GP B: 0.60 (95% CI: 0.42, 0.78); patient B: 0.50 (95% CI: 0.34, 0.66))., Conclusion: Introducing and implementing structured functional assessments in general practice made the GPs capable to assess functional ability of their patients in a structured manner. Intervention effects of increased GP knowledge and GP self-efficacy sustained at the second follow-up.

Musculoskeletal pain that affects multiple body sites is typically regarded as comorbidity to single-site pain. Pain present in multiple sites, however, is more severe and disabling compared to single-site pain. This study aimed to prospectively investigate the change in the number of pain sites over 14years, in addition to identifying predictors of multi-site pain. In 1990 and 2004, questionnaires about musculoskeletal pain were mailed to six birth cohorts in Ullensaker, Norway. Data on demographic, lifestyle, and health-related variables were also collected. Participation rate in 1990 was 67.2% and among those 60.4% participated in 2004. A slight increase in the average number of pain sites occurred between 1990 and 2004, but results showed a relatively stable pattern of pain reporting over a period of 14 years. Several demographic, lifestyle, and health-related variables in 1990 predicted the number of pain sites at follow-up in the bivariate analyses. However, only sex, age, sleep quality, and educational level remained significant in the final multivariate model after controlling for the number of pain sites at baseline. The final model explained 35% of the variance, of which nearly 80% was accounted for by the number of pain sites at baseline. As the pattern of reporting the number of pain sites appears relatively stable across adulthood and baseline multi-site pain demonstrated strong predictive utility, studies investigating the occurrence of multi-site pain in children and adolescents are recommended to determine potential causal factors contributing to the early course and development of multi-site musculoskeletal pain.

Research on widespread pain often relies upon case definitions bounded by duration limits or "cut-offs." In clinical reality, however, there are no natural cut-off points between localized and widespread pain. Rather, pain is best represented by a continuum of "widespreadness" from localized pain to pain spread across the body. The objective of this paper was to describe the number of pain sites (NPS) reported in a population study and its association with demographic, lifestyle, and health-related factors. Using a cross-sectional design, the Standardized Nordic Questionnaire was used to measure musculoskeletal pain among seven age groups in Ullensaker, Norway (n=2926). Results showed that women reported a higher mean NPS than men. A higher NPS was also found for individuals who were separated or divorced, undergoing rehabilitation, or who had a disability pension. Additionally, greater NPS was reported by smokers, individuals with less physical activity, and a higher BMI. A strong linear relationship was found between NPS and reduction in overall health, sleep quality, and psychological health. Results from a multivariate linear regression analysis showed that overall health, sleep quality, and gender demonstrated the strongest associations with increasing NPS, accounting for 31.4% of the variance. Our study indicates that the straightforward and simple method of counting the NPS could be important in managing the complex problem of musculoskeletal pain.

Background: In the smelting industry airborne pollutants are emitted into the workplace atmosphere during the production process. Our aim in this study was to investigate the relationship between production and lung function among employees at Norwegian smelters., Methods: Spirometry was performed on 3,924 employees, who also completed a standardized questionnaire. The employees were classified by job functions: (i) line operators were employed full-time on the production line, (ii) non-exposed employees did not work in production, and (iii) the remainder of the employees were classified as non-line operators., Results: The mean age of the participants was 38.6 (range 20.0-55.0) years, 88.5% were males. The multivariate analyses showed that, compared to the forced expiratory volume in one second (FEV(1)) in non-exposed employees, the FEV(1) (95% confidence interval) was 87 (33-141) ml and 65 (12-118) ml lower in line and non-line operators, respectively. The prevalence of airflow limitation (FEV(1)/forced vital capacity (FVC) below the 5th percentile of the predicted value) was 4.7% in non-exposed employees, 7.5% in non-line operators and 8.3% in line operators., Conclusion: Compared with non-exposed employees, impairment of lung function among employees at Norwegian smelters was significantly related to the job categories of line operator and non-line operator., ((c) 2008 Wiley-Liss, Inc.)

Background: There is variation in the number of response alternatives used within health-related questionnaires. This study compared a four-and a five-point scale version of the Norwegian Function Assessment Scale (NFAS) by evaluating data quality, internal consistency and validity., Methods: All inhabitants in seven birth cohorts in the Ullensaker municipality of Norway were approached by means of a postal questionnaire. The NFAS was included as part of The Ullensaker Study 2004. The instrument comprises 39 items derived from the activities/participation component in the International Classification for Functioning, Disabilities and Health (ICF). The sample was computer-randomised to either the four-point or the five-point scale version., Results: Both versions of the NFAS had acceptable response rates and good data quality and internal consistency. The five-point scale version had better data quality in terms of missing data, end effects at the item and scale level, as well as higher levels of internal consistency. Construct validity was acceptable for both versions, demonstrated by correlations with instruments assessing similar aspects of health and comparisons with groups of individuals known to differ in their functioning according to existing evidence., Conclusion: Data quality, internal consistency and discriminative validity suggest that the five-point scale version should be used in future applications.

Objectives: To develop a qualitative exposure classification of employees in Norwegian smelters and to investigate the relationship between respiratory symptoms and occupational exposure using this classification., Methods: The 3,924 participants completed a standardised questionnaire including questions of respiratory symptoms, familial asthma, allergy, doctor-diagnosed asthma, smoking habits, previous exposure and occupation. The employees were classified according to their current job function: (1) line operators were employed full time on the production line, (2) non-exposed employees did not work in production, (3) the remaining employees were classified as non-line operators. The association between the prevalence of respiratory symptoms and job category was examined using multivariate logistic regression., Results: The mean age of the participants was 38.6 years (standard deviation 9.2 years), 88.5% were males. The odds ratios (OR) (95% confidence intervals in parenthesis) for dyspnoea, cough and phlegm regarding previous exposure compared with no previous exposure were 1.4 (1.1-1.7), 1.4 (1.2-1.8) and 1.3 (1.0-1.7), respectively. The OR in line operators compared with non-exposed employees was 1.2 (0.9-1.7) for dyspnoea, 1.3 (1.0-1.8) for cough and 1.9 (1.4-2.7) for phlegm. The OR for respiratory symptoms was higher in relation to previous exposure than current job function except for phlegm., Conclusion: In Norwegian smelters respiratory symptoms appear to be positively related to both current job function and previous exposure. Previous exposure appears to be more important than current job function.

Background: The increasing focus on functional ability assessments in relation to sickness absence necessitates the measurement of population functional levels. This study assessed the reliability of the Norwegian Function Assessment Scale (NFAS) and presents normative population data., Methods: All inhabitants in seven birth cohorts in Ullensaker municipality in 2004 were approached by means of a postal questionnaire. The NFAS was included as part of The Ullensaker Study 2004. The instrument comprises 39 items derived from the activities/participation component in the International Classification for Functioning, Disabilities and Health (ICF). Based on the results of principal component analysis, these items comprise seven domains. Non-parametric tests for independent samples were used to compare subgroups. Internal consistency was assessed by Cronbach's alpha. Two-week test-retest reliability was assessed by total proportions of agreement, weighted kappa, and intraclass correlation coefficient (ICC)., Results: The response rate was 54% (1620 persons) and 75.4% (101 persons) for the retest. Items had low levels of missing data. Test-retest reliability was acceptable with high proportions of absolute agreement; kappa and ICC values ranged from 0.38 to 0.83 and 0.79 to 0.83, respectively. No difficulty on all 39 functional activities was reported by 33.1% of respondents. Females, older persons and persons with lower levels of education reported more functional problems than their respective counterparts (p < 0.05). The age gradient was most evident for three of the physical domains. For females aged 24-56 and males aged 44-76, a clear education gradient was present for three of the physical domains and one mental domain after adjusting for age and gender., Conclusion: This study presents population based normative data on functional ability, as measured by the NFAS. These data will serve as basis for the development of national population norms and are necessary for score interpretation. Data quality and test-retest reliability of the NFAS were acceptable.

Pneumonia may mask or be the first sign of lung cancer. The literature is, however, sparse. We compared the incidence of lung cancer among patients hospitalised for pneumonia with a general population. The patients (index group, N=7044) were hospitalised for pneumonia from 1988 to 2002 at Akershus University Hospital. The reference group was recruited from a general population survey (N=81,373) performed during 1984-1986 and 1995-1997. We had detailed information on smoking habits in both groups. Data on lung cancer incidence, emigration, and death were obtained from the Cancer Registry of Norway. Data were analyzed using multivariate Poisson regression. There were 177 cases of lung cancer in the index group and 608 cases in the reference group. Current smoking modified the association between pneumonia and lung cancer. Among current smokers and non-smokers the incidence density ratio (IDR) was 6.0 (95% confidence interval) (4.6-7.8) and 12.0 (8.6-16.9) in the index group compared with the references, respectively. The crude IDR decreased from 78.4 (43.8-146) 0-3 months after the inclusion to 2.4 (1.4-3.7) 6 years after inclusion. In the index group the IDR was only slightly higher for smokers than non-smokers. Patients hospitalised for pneumonia had an increased incidence of lung cancer compared with the general population. This risk persisted for 6 years after the onset of the lung infection.