The Epidemiology of Moderate and Severe Traumatic Brain Injury in Central Norway.

INTRODUCTION: Few studies account for prehospital deaths when estimating incidence and mortality rates of moderate and severe traumatic brain injury (msTBI). In a population-based study, covering both urban and rural areas, including also prehospital deaths, the aim was to estimate incidence and mortality rates of msTBI. Further, we studied the 30-day and 6-month case-fatality proportion of severe TBI in relation to age. METHODS: All patients aged ≥17 years who sustained an msTBI in Central Norway were identified by three sources: (1) the regional trauma center, (2) the general hospitals, and (3) the Norwegian Cause of Death Registry. Incidence and mortality rates were standardized according to the World Health Organization's world standard population. Case-fatality proportions were calculated by the number of deaths from severe TBI at 30 days and 6 months, divided by all patients with severe TBI. RESULTS: The overall incidence rates of moderate and severe TBI were 4.9 and 6.7 per 100,000 person-years, respectively, increasing from age 70 years. The overall mortality rate was 3.4 per 100,000 person-years, also increasing from age 70 years. Incidence and mortality rates were highest in men. The case-fatality proportion in people with severe TBI was 49% in people aged 60-69 years and 81% in people aged 70-79 years. CONCLUSION: The overall incidence and mortality rates for msTBI in Central Norway were low but increased from age 70 years, and among those ≥80 years of age with severe TBI, nearly all died. Overall estimates are strongly influenced by high incidence and mortality rates in the elderly, and studies should therefore report age-specific estimates, for better comparison of incidence and mortality rates.

Insomnia symptoms and risk of bloodstream infections: prospective data from the prospective population-based Nord-Trøndelag Health Study (HUNT), Norway.

Previous research suggests decreased immune function and increased risk of infections in individuals with insomnia. We examined the effect of insomnia symptoms on risk of bloodstream infections (BSIs) and BSI-related mortality in a population-based prospective study. A total of 53,536 participants in the second Norwegian Nord-Trøndelag Health Study (HUNT2) (1995-97) were linked to prospective data on clinically relevant BSIs until 2011. In Cox regression, we estimated hazard ratios (HRs) with 95% confidence intervals (CIs) for a first-time BSI and for BSI-related mortality (BSI registered ≤30 days prior to death) associated with insomnia symptoms. Compared with participants who reported "no symptoms", participants reporting having "difficulty initiating sleep" (DIS) often/almost every night had a HR for a first-time BSI of 1.14 (95% CI 0.96-1.34). Participants reporting "difficulties maintaining sleep" (DMS) often/almost every night had a HR of 1.19 (95% CI 1.01-1.40), whereas those having a feeling of "non-restorative sleep" once a week or more had a HR of 1.23 (95% CI 1.04-1.46). Participants frequently experiencing all three of the above symptoms had a HR of 1.39 (1.04-1.87), whilst those who had both DIS and DMS had a HR of 1.15 (0.93-1.41) and being troubled by insomnia symptoms to a degree that affected work performance was associated with a HR of 1.41 (95% CI 1.08-1.84). The HRs for BSI-related mortality suggest an increased risk with increasing insomnia symptoms, but the CIs are wide and inconclusive. We found that frequent insomnia symptoms and insomnia symptoms that affected work performance were associated with a weak positive increased risk of BSI.

Multimorbidity and co-occurring musculoskeletal pain do not modify the effect of the SELFBACK app on low back pain-related disability.

BACKGROUND: SELFBACK, an artificial intelligence (AI)-based app delivering evidence-based tailored self-management support to people with low back pain (LBP), has been shown to reduce LBP-related disability when added to usual care. LBP commonly co-occurs with multimorbidity (≥ 2 long-term conditions) or pain at other musculoskeletal sites, so this study explores if these factors modify the effect of the SELFBACK app or influence outcome trajectories over time. METHODS: Secondary analysis of a randomized controlled trial with 9-month follow-up. Primary outcome is as follows: LBP-related disability (Roland Morris Disability Questionnaire, RMDQ). Secondary outcomes are as follows: stress/depression/illness perception/self-efficacy/general health/quality of life/physical activity/global perceived effect. We used linear mixed models for continuous outcomes and logistic generalized estimating equation for binary outcomes. Analyses were stratified to assess effect modification, whereas control (n = 229) and intervention (n = 232) groups were pooled in analyses of outcome trajectories. RESULTS: Baseline multimorbidity and co-occurring musculoskeletal pain sites did not modify the effect of the SELFBACK app. The effect was somewhat stronger in people with multimorbidity than among those with LBP only (difference in RMDQ due to interaction, - 0.9[95 % CI - 2.5 to 0.6]). Participants with a greater number of long-term conditions and more co-occurring musculoskeletal pain had higher levels of baseline disability (RMDQ 11.3 for ≥ 2 long-term conditions vs 9.5 for LBP only; 11.3 for ≥ 4 musculoskeletal pain sites vs 10.2 for ≤ 1 additional musculoskeletal pain site); along with higher baseline scores for stress/depression/illness perception and poorer pain self-efficacy/general health ratings. In the pooled sample, LBP-related disability improved slightly less over time for people with ≥ 2 long-term conditions additional to LBP compared to no multimorbidity and for those with ≥4 co-occurring musculoskeletal pain sites compared to ≤ 1 additional musculoskeletal pain site (difference in mean change at 9 months = 1.5 and 2.2, respectively). All groups reported little improvement in secondary outcomes over time. CONCLUSIONS: Multimorbidity or co-occurring musculoskeletal pain does not modify the effect of the selfBACK app on LBP-related disability or other secondary outcomes. Although people with these health problems have worse scores both at baseline and 9 months, the AI-based selfBACK app appears to be helpful for those with multimorbidity or co-occurring musculoskeletal pain. TRIAL REGISTRATION: NCT03798288 . Date of registration: 9 January 2019.

Thyroid function and risk of bloodstream infections: Results from the Norwegian prospective population-based HUNT Study.

OBJECTIVE: Previous studies on thyroid function and risk of infection is conflicting and often stem from intensive care cohorts were nonthyroidal illness syndrome (NTIS) may be present. The objective of this study was to identify the risk of bloodstream infections (BSI) and BSI-related mortality with thyroid-stimulating hormone (TSH) levels within the reference range in a general population. DESIGN: Prospective follow-up. PARTICIPANTS: The HUNT2 (1995-97) included 34,619 participants with information on TSH levels. MEASUREMENTS: Hazard ratios (HRs) with 95% confidence interval (CI) confirmed BSIs and BSI-related mortality until 2011. RESULTS: During a median follow-up of 14.5 years, 1179 experienced at least one episode of BSI and 208 died within 30 days after a BSI. TSH levels within the reference range of 0.5-4.5 mU/L were not associated with the risk of first-time BSI, with an HR of 0.97 (95% CI: 0.90-1.04) per mU/L. Stratified by baseline age < or ≥65 years, TSH was inversely associated with the risk of BSI (HR: 0.88; 95% CI: 0.78-1.00 per mU/L) in the youngest age group only. Persons with any baseline thyroid disease had a 30% risk and the hyperthyroid subgroup a 57%, and hypothyroidism a 20% increased risk of BSI. TSH levels were not clearly associated with BSI mortality, but the HRs were imprecise due to few BSI-related deaths. CONCLUSION: There was some evidence of a weak inverse association between TSH levels and the risk of BSI in persons below 65 years of age. The increased risk seen in persons with thyroid illness is probably explained by confounding by concurrent ill health.

Acute kidney injury in intensive care patients: Incidence, time course, and risk factors.

BACKGROUND: Acute kidney injury (AKI) is frequent and influences the prognosis of intensive care unit (ICU) patients. The aim of this study was to estimate the incidence, time-course, risk factors, and mortality of AKI among unselected ICU patients. METHODS: All adult ICU patients admitted to the ICU at the University Hospital in Central Norway from 2010 to 2015 with a stay of 24 h or more were included in the study. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. All patients were followed with respect to reversal of AKI. Risk factors for AKI were analyzed using Cox regression. RESULTS: Among 2325 ICU patients, 1245 developed AKI during the ICU stay, corresponding to an incidence of 53.5 % (CI, 51.5-55.5). The incidence according to KDIGO AKI stages 1, 2, and 3 was 26.2, 11.7, and 15.7%, respectively. The median duration of AKI was 24 (CI 19-24), 32 (CI 26-39), and 101 (CI 75-164) hours for AKI KDIGO stage 1, 2, and 3, respectively. AKI was transient, persistent, or AKD in 73.4, 16.5, and 10.0% of the patients with a known outcome. AKI reversal was observed in 72.9% of all AKI patients. Independent risk factors for AKI in a multivariate analysis were hypertension, diabetes, heart disease, and higher body weight. Episodes of mean arterial pressure below 73 mmHg were associated with a higher risk of AKI. CONCLUSIONS: In our material, the incidence of AKI was comparable to what has been reported previously. Risk factors for the development of AKI were a MAP below 73, hypertension, diabetes, heart disease, chronic kidney disease, and higher body weight. Most AKI patients regain their kidney function during the ICU stay, particularly in the KDIGO AKI stages 1 and 2.

Family History Influences the Effectiveness of Home Exercise in Older People With Chronic Low Back Pain: A Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: To investigate whether a family history of low back pain (LBP) influences patient outcomes and treatment effects following home exercises in older people with chronic LBP. DESIGN: Secondary analysis of a randomized controlled trial. SETTING: Local community. PARTICIPANTS: People older than 55 years with chronic LBP (N=60). INTERVENTIONS: Participants in the intervention group completed video game exercises for 60 minutes 3 times per week for 8 weeks. Participants in the control group were instructed to maintain their usual levels of activity and care seeking behaviors. MAIN OUTCOMES MEASURES: Participants indicated whether any of their immediate family members had a history of "any" LBP or "activity-limiting" LBP at baseline. We collected self-reported measures of pain, function, pain self-efficacy, care seeking, physical activity, disability, fear of movement and/or reinjury, and falls efficacy at baseline, 8 weeks, 3 months, and 6 months. We performed regression analyses to determine whether a family history of LBP predicted patient outcomes and moderated the effects of home exercise. RESULTS: Participants with a family history of any LBP were less likely to be highly active than those without a family history (odds ratio, 0.08; 95% CI, 0.01-0.42; P=.003). Home-based video game exercises led to improvements in function in those without a family history of activity-limiting LBP (ß=1.78; 95% CI, 0.56-3.00; P=.006) but not in those with a family history (ß=-0.17; 95% CI, -2.56 to 2.21; P=.880) (interaction P=.049). A family history of LBP did not influence the remaining patient outcomes or treatment effects. CONCLUSIONS: A family history of LBP appears to negatively influence physical activity levels in older people with chronic LBP. Further, home-based video game exercises appear to be beneficial for older people with chronic LBP that do not have a family history of LBP.

Long-term changes in body weight and physical activity in relation to all-cause and cardiovascular mortality: the HUNT study.

BACKGROUND: Most previous studies have relied on single measurements of body weight and physical activity and have not considered the interplay between long-term changes in body weight and physical activity in relation to mortality. The aim of the current study was therefore to examine the joint effect of changes in body weight and leisure-time physical activity over a period of ~ 10 years on all-cause and cardiovascular mortality. METHODS: The study population comprised 34,257 individuals who participated in the first (1984-86) and second (1995-97) waves of the HUNT Study, and were followed up through the Norwegian Cause of Death Registry until December 31st, 2013. We used Cox regression to estimate hazard ratios (HR) with 95% confidence intervals (CI) of death associated with changes in body weight and leisure-time physical activity. RESULTS: Compared to the reference group with stable weight who were long-term physically active, people who gained ≥5% of their weight had a HR for all-cause mortality of 1.54 (95% CI: 1.28-1.85) if they were long-term physically inactive; a HR of 1.23 (1.09-1.40) if they became physically active, and a HR of 1.00 (95% CI 0.94-1.06) if they were long-term physically active. The corresponding HRs for cardiovascular mortality were 1.57 (95% CI 1.17-2.12), 1.28 (95% CI 1.04-1.58) and 1.06 (95% CI 0.96-1.16), respectively. Long-term physical inactivity was associated with increased all-cause (HR 1.29; 95% CI 1.08-1.53) and cardiovascular (HR 1.37; 95% CI 1.05-1.79) mortality among those who were weight stable. CONCLUSIONS: The risk of all-cause and cardiovascular mortality is particularly evident among people who gain weight while remaining inactive during a ~ 10 year period. However, participants who remained physically active had the lowest risk of premature mortality, regardless of maintenance or increase in weight. These findings suggest that there is an interplay between long-term changes in body weight and physical activity that should receive particular attention in the prevention of premature mortality.

Serum 25-hydroxyvitamin D levels and risk of lung cancer and histologic types: a Mendelian randomisation analysis of the HUNT study.

We aimed to investigate potential causal associations between serum 25-hydroxyvitamin D (25(OH)D) levels and incidence of lung cancer overall and histologic types.We performed a Mendelian randomisation analysis using a prospective cohort study in Norway, including 54 580 individuals and 676 incident lung cancer cases. A 25(OH)D allele score was generated based on the vitamin D-increasing alleles rs2282679, rs12785878 and rs10741657. Hazard ratios with 95% confidence intervals for incidence of lung cancer and histologic types were estimated in relation to the allele score. The inverse-variance weighted method using summarised data of individual single nucleotide polymorphisms was applied to calculate the Mendelian randomisation estimates.The allele score accounted for 3.4% of the variation in serum 25(OH)D levels. There was no association between the allele score and lung cancer incidence overall, with HR 0.99 (95% CI 0.93-1.06) per allele score. A 25 nmol·L-1 increase in genetically determined 25(OH)D level was not associated with the incidence of lung cancer overall (Mendelian randomisation estimate HR 0.96, 95% CI 0.54-1.69) or any histologic type.Mendelian randomisation analysis did not suggest a causal association between 25(OH)D levels and risk of lung cancer overall or histologic types in this population-based cohort study.

Do physical activity and body mass index modify the association between chronic musculoskeletal pain and insomnia? Longitudinal data from the HUNT study, Norway.

We investigated the prospective association between chronic musculoskeletal pain and risk of insomnia, and if leisure-time physical activity and body mass index modify this association. The study comprised historical data on 11 909 women and 9938 men in the Norwegian HUNT study without sleep problems at baseline in 1995-97 and followed-up for insomnia in 2006-08. Poisson regression was used to estimate adjusted risk ratios (RRs) with 95% confidence intervals (CIs). Compared to pain-free participants, any chronic pain was associated with a RR of insomnia of 2.27 (95% CI: 1.93, 2.66) in women and 1.58 (95% CI: 1.28, 1.95) in men, whereas reporting ≥5 chronic pain sites gave RRs of 3.20 (95% CI: 2.60, 3.95) and 2.40 (95% CI: 1.76, 3.27), respectively. Analysis of joint effects showed that: (i) compared to pain-free physically active people, RRs in people with ≥5 chronic pain sites were 3.77 (95% CI: 2.42-5.85) if they were inactive and 2.76 (95% CI: 2.29, 3.31) if they were active; and (ii) compared to pain-free people with normal weight, RRs in people with ≥5 chronic pain sites were 3.52 (95% CI: 2.81, 4.40) if they were obese and 2.93 (95% CI: 2.24, 3.84) if they had normal weight. In conclusion, chronic musculoskeletal pain increases the risk of insomnia, particularly among those who report several pain sites. Although there was no clear evidence of modifying effects, our results suggest that a healthy active lifestyle reduces the risk of insomnia in people with chronic musculoskeletal pain.

Risk classification of patients referred to secondary care for low back pain.

BACKGROUND: Nonspecific low back pain is characterized by a wide range of possible triggering and conserving factors, and initial screening needs to scope widely with multilevel addressment of possible factors contributing to the pain experience. Screening tools for classification of patients have been developed to support clinicians. The primary aim of this study was to assess the criterion validity of STarT Back Screening Tool (STarT Back) against the more comprehensive Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), in a Norwegian sample of patients referred to secondary care for low back pain. Secondary aims were to assess risk classification of the patients, as indicated by both instruments, and to compare pain and work characteristics between patients in the different STarT Back risk categories. METHODS: An observational, cross-sectional survey among patients with low back pain referred to outpatient secondary care assessment at Trondheim University Hospital, Norway. Cohen's Kappa coefficient, Pearson's r and a Bland-Altman plot were used to assess criterion validity of STarT Back against ÖMPSQ. Furthermore, linear regression was used to estimate mean differences with 95% CI in pain and work related variables between the risk groups defined by the STarT Back tool. RESULTS: A total of 182 persons participated in the study. The Pearsons correlation coefficient for correspondence between scores on ÖMPSQ and STarT Back was 0.76. The Kappa value for classification agreement between the instruments was 0.35. Risk group classification according to STarT Back allocated 34.1% of the patients in the low risk group, 42.3% in the medium risk, and 23.6% in the high risk group. According to ÖMPSQ, 24.7% of the participants were allocated in the low risk group, 28.6% in the medium risk, and 46.7% in the high risk group. Patients classified with high risk according to Start Back showed a higher score on pain and work related characteristics as measured by ÖMPSQ. CONCLUSION: The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. Screening for work factors may be important in patients referred to multidisciplinary management in secondary care.

The adverse association of diabetes with risk of first acute myocardial infarction is modified by physical activity and body mass index: prospective data from the HUNT Study, Norway.

AIMS/HYPOTHESIS: Diabetes increases the risk of acute myocardial infarction (AMI) and effective means for primary prevention are warranted. We prospectively examined the joint association of diabetes and leisure-time physical activity, as well as of diabetes and BMI, with the risk of AMI. METHODS: A total of 55,534 men and women in the Norwegian HUNT Study were followed-up for first AMI by hospital admission registries and the Cause of Death Registry. Cox proportional adjusted HRs with 95% CIs were estimated. RESULTS: Overall, 1,887 incident AMIs occurred during 12.3 years. Compared with inactive people without diabetes, inactive people with diabetes had an HR of 2.37 (95% CI 1.58, 3.57), whereas the HR among highly active persons with diabetes was 1.04 (95% CI 0.62, 1.74). Normal-weight (BMI 18.5-25 kg/m(2)) persons with diabetes had an HR of 1.60 (95% CI 1.05, 2.44) and obese (BMI > 30 kg/m(2)) persons with diabetes had an HR of 2.55 (95% CI 1.97, 3.29) compared with normal-weight persons without diabetes. The data suggest biological interaction between diabetes and physical activity, with a relative excess risk of inactivity and diabetes of 1.43 (95% CI 0.08, 2.78). For obesity and diabetes, the excess risk due to interaction was smaller (0.67; 95% CI -0.24, 1.58). CONCLUSIONS/INTERPRETATION: Body weight and, in particular, physical activity modified the association between diabetes and risk of first AMI. This highlights the potential importance of physical activity and weight maintenance in primary prevention of AMI among people with diabetes.

Hours lying down per day and mortality from all-causes and cardiovascular disease: the HUNT Study, Norway.

Time spent sitting has been positively associated with mortality in several studies, whereas time lying down per day has not been extensively studied. The authors prospectively examined the association between hours lying down per day and risk of death from all-causes and from cardiovascular disease among 39,175 persons aged 20-79 years in the population-based HUNT Study in Norway. Adjusted hazard ratios (HRs) with 95 % confidence intervals (CIs) were obtained from Cox regression, using people lying down for 7 h per day as reference. During a median follow-up of 12.3 years a total of 2,659 persons died (851 from cardiovascular disease). People lying 11-18 h per day had a HR of 1.60 (95 % CI 1.29, 1.98) for death from all causes and a HR of 1.91 (95 % CI 1.35, 2.71) for cardiovascular death. Analyses stratified by leisure time physical activity showed a positive association with cardiovascular mortality also among physically active people, with HRs of 1.38 (95 % CI 0.97, 1.96) and 1.84 (95 % CI 1.07, 3.16) among people lying down 10 and 11-18 h per day, respectively. In this large prospective study, excessive hours lying down per day were associated with increased all-cause and cardiovascular mortality, even among physically active persons.

Longitudinal Patterns of Systolic Blood Pressure, Diastolic Blood Pressure, Cardiorespiratory Fitness, and Their Association With Dementia Risk: The HUNT Study.

BACKGROUND: High blood pressure and poor cardiorespiratory fitness are independent risk factors for dementia. However, few studies have examined if combined longitudinal patterns of these modifiable risk factors are associated with dementia risk. METHODS: In this prospective cohort study, we used data from the population-based Trøndelag Health (HUNT) Study, Norway. We applied group-based multidimensional trajectory modeling to identify age-specific multidimensional trajectories of SBP, DBP, and estimated cardiorespiratory fitness across 3 surveys (HUNT1, 1984-1986 to HUNT3, 2006-2008). Dementia was diagnosed in the HUNT4 70+ substudy in 2017-2019. We used multivariate logistic regression to estimate odds ratios (ORs) and risk differences (RDs) of dementia. RESULTS: In total, 7 594 participants (54.9% women) were included, with a mean age of 44.7 (SD 6.3) years at HUNT1. Dementia was diagnosed in 1 062 (14.0%) participants. We identified 2 multidimensional trajectories throughout adulthood within 3 age groups: one with higher systolic blood pressure (SBP) and diastolic blood pressure (DBP), and lower estimated cardiorespiratory fitness (the poorer group), and one with lower SBP and DBP, and higher cardiorespiratory fitness (the better group). After adjustment for sex, apolipoprotein E ε4 status, education, marital status, and diabetes, the better group had consistently lower risk of dementia in all age groups with the lowest OR in the middle-aged group of 0.63 (95% confidence intervals [95% CI]: 0.51, 0.78) with corresponding RD of -0.07 (95% CI: -0.10, -0.04). CONCLUSIONS: Having a beneficial multidimensional trajectory of SBP, DBP, and cardiorespiratory fitness in adulthood was associated with reduced dementia risk. Aiming for optimal SBP, DBP, and estimated cardiorespiratory fitness throughout adulthood may reduce dementia risk.

Diabetes severity and the role of leisure time physical exercise on cardiovascular mortality: the Nord-Trøndelag Health study (HUNT), Norway.

BACKGROUND: Physical activity has been associated with lower cardiovascular mortality in people with diabetes, but how diabetes severity influence this association has not been extensively studied. METHODS: We prospectively examined the joint association of diabetes severity, measured as medical treatment status and disease duration, and physical exercise with cardiovascular mortality. A total of 56,170 people were followed up for 24 years through the Norwegian Cause of Death Registry. Cox proportional adjusted hazard ratios (HRs) with 95% confidence intervals (CI) were estimated. RESULTS: Overall, 7,723 people died from cardiovascular disease during the follow-up. Compared to the reference group of inactive people without diabetes, people with diabetes who reported no medical treatment had a hazard ratio (HR) of 1.65 (95% CI: 1.34, 2.03) if they were inactive and a HR of 0.99 (95% CI: 0.68, 1.45) if they reported ≥2.0 hours physical exercise per week. Among people who received oral hypoglycemic drugs or insulin, the corresponding comparison gave HRs of 2.46 (95% CI: 2.08-2.92) and 1.58 (95% CI: 1.21, 2.05), respectively. CONCLUSIONS: The data suggest a more favourable effect of exercise in people with diabetes who used medication than in those who did not, suggesting that physical exercise should be encouraged as a therapeutic measure additional to medical treatment.

Sleep problems and risk of fibromyalgia: longitudinal data on an adult female population in Norway.

OBJECTIVE: Sleep problems are common among patients with fibromyalgia (FM). However, it is not known whether poor sleep is a contributing factor in FM or a consequence of the illness. The aim of the current study was to prospectively investigate the association between self-reported sleep problems and risk of FM among adult women. METHODS: We longitudinally studied 12,350 women who did not have FM, musculoskeletal pain, or physical impairments at baseline (1984-1986). A generalized linear model was used to calculate the adjusted relative risk (RR) of FM at followup in 1995-1997. RESULTS: Incident FM was reported by 327 women at followup. A dose-dependent association was found between sleep problems and risk of FM (P for trend<0.001), with an adjusted RR of 3.43 (95% confidence interval [95% CI] 2.26-5.19) among women who reported having sleep problems often or always, compared to women who never experienced sleep problems. Age-stratified analysis showed that women age≥45 years who reported having sleep problems often or always had an adjusted RR of 5.41 (95% CI 2.65-11.05), whereas the corresponding RR for women ages 20-44 years who reported having sleep problems often or always was 2.98 (95% CI 1.76-5.05). CONCLUSION: These prospective data indicate a strong dose-dependent association between sleep problems and risk of FM. The association is somewhat, although not significantly, stronger in middle-aged and older women than in younger women.

Temporal stability in the prevalence and pattern of co-occurring musculoskeletal pain among people with persistent low back pain: population-based data from the Norwegian HUNT Study, 1995 to 2019.

ABSTRACT: People with persistent low back pain (LBP) often report co-occurring persistent musculoskeletal (MSK) pain in other body regions that may influence prognosis as well as treatment approaches and outcomes. This study describes the prevalence and patterns of co-occurring persistent MSK pain among people with persistent LBP based on consecutive cross-sectional studies over 3 decades in the population-based HUNT Study, Norway. The analyses comprised 15,375 participants in HUNT2 (1995-1997), 10,024 in HUNT3 (2006-2008), and 10,647 in HUNT4 (2017-2019) who reported persistent LBP. Overall, ∼90% of participants in each of the HUNT surveys with persistent LBP reported persistent co-occurring MSK pain in other body sites. The age-standardized prevalence of the most common co-occurring MSK pain sites was consistent across the 3 surveys: 64% to 65% report co-occurring neck pain, 62% to 67% report shoulder pain, and 53% to 57% report hip or thigh pain. Using latent class analysis (LCA), we identified 4 distinct patterns of persistent LBP phenotypes that were consistent across the 3 surveys: (1) "LBP only," (2) "LBP with neck or shoulder pain," (3) "LBP with lower extremity or wrist or hand pain," and (4) "LBP with multisite pain," with conditional item response probabilities of 34% to 36%, 30% to 34%, 13% to 17%, and 16% to 20%, respectively. In conclusion, 9 of 10 adults in this Norwegian population with persistent LBP report co-occurring persistent MSK pain, most commonly in the neck, shoulders, and hips or thighs. We identified 4 LCA-derived LBP phenotypes of distinct MSK pain site patterns. In the population, both the prevalence and pattern of co-occurring MSK pain and the distinct phenotypic MSK pain patterns seem stable over decades.

Association of Genetically Predicted Insomnia With Risk of Sepsis: A Mendelian Randomization Study.

Importance: Insomnia has been associated with altered inflammatory response as well as increased risk of infections and sepsis in observational studies. However, these studies are prone to bias, such as residual confounding. To further understand the potential causal association between insomnia and sepsis risk, a 2-sample Mendelian randomization (MR) approach should be explored. Objective: To evaluate whether genetically predicted insomnia is associated with risk of sepsis. Design, Setting, and Participants: Two-sample MR was performed to estimate the association between genetically predicted insomnia and sepsis risk. Data were obtained from a genome-wide association study identifying 555 independent genetic variants (R2 < 0.01) strongly associated with insomnia (P < 5 × 10-8). Sensitivity analyses were conducted to address bias due to pleiotropy and sample overlap, along with mediation analyses and sex-stratified analyses. The insomnia data set included 2.4 million individuals of European ancestry from the UK Biobank and 23andMe. For sepsis, 462 918 individuals of European ancestry from the UK Biobank were included. Data were extracted between February and December 2022 and analyzed between March 2022 and March 2023. Exposure: Genetically predicted insomnia. Main Outcome and Measure: Sepsis. Results: There were 593 724 individuals with insomnia and 10 154 cases of sepsis. A doubling in the population prevalence of genetically predicted insomnia was associated with an odds ratio of 1.37 (95% CI, 1.19-1.57; P = 7.6 × 10-6) for sepsis. Sensitivity analyses supported this observation. One-third of the association between genetically predicted insomnia and risk of sepsis was mediated through a combination of cardiometabolic risk factors for sepsis (body mass index, type 2 diabetes, smoking, or cardiovascular disease; overall proportion, 35.2%; 95% CI, 5.1-76.9). The association between insomnia and sepsis was more pronounced among women compared with men (women: odds ratio, 1.44; 95% CI, 1.24-1.68; men: OR, 1.10; 95% CI, 0.86-1.40). Conclusions and Relevance: The concordance between these findings and previous observational studies supports that insomnia is potentially causally associated with the risk of sepsis. Thus, insomnia is a potential preventable risk factor of sepsis that should be further investigated, also in non-European populations.

The selfBACK artificial intelligence-based smartphone app can improve low back pain outcome even in patients with high levels of depression or stress.

BACKGROUND: selfBACK provides individually tailored self-management support for low back pain (LBP) via an artificial intelligence-based smartphone app. We explore whether those with depressive/stress symptoms can benefit from this technology. METHODS: Secondary analysis of the selfBACK randomized controlled trial (n = 461). Participants with LBP were randomized to usual care (n = 229), or usual care plus selfBACK (n = 232). PRIMARY OUTCOME: LBP-related disability (Roland-Morris Disability Questionnaire, RMDQ) over 9 months. SECONDARY OUTCOMES: global perceived effect (GPE)/pain self-efficacy (PSEQ)/satisfaction/app engagement. Baseline depressive symptoms were measured using the patient health questionnaire (PHQ-8) and stress with the perceived stress scale (PSS). Outcomes stratified by baseline PHQ-8/PSS scores to assess associations across the whole cohort, and intervention versus control groups. RESULTS: Participants with higher levels of depressive/stress symptoms reported more baseline LBP-related disability (RMDQ 3.1; 1.6 points higher in most vs least depressed/stressed groups respectively); lower self-efficacy (PSEQ 8.1; 4.6 points lower in most vs least depressive/stressed groups respectively). LBP-related disability improved over time; relative risk of improvement in those with greatest depressive/stress symptoms versus nil symptom comparators at 9 months: 0.8 (95% CI: 0.6 to 1.0) and 0.8 (95% CI: 0.7 to 1.0) respectively. No evidence that different baseline levels of depressive/perceived stress symptoms are associated with different RMDQ/GPE/PSEQ outcomes. Whilst participants with higher PHQ-8/PSS were less likely to be satisfied or engage with the app, there was no consistent association among PHQ-8/PSS level, the intervention and outcomes. CONCLUSIONS: The selfBACK app can improve outcomes even in those with high levels of depressive/stress symptoms and could be recommended for patients with LBP. SIGNIFICANCE: We have demonstrated that an app supporting the self-management of LBP is helpful, even in those with higher levels of baseline depression and stress symptoms. selfBACK offers an opportunity to support people with LBP and provides clinicians with an additional tool for their patients, even those with depression or high levels of stress. This highlights the potential for digital health interventions for chronic pain.

Interplay between chronic widespread pain and lifestyle factors on the risk of type 2 diabetes: longitudinal data from the Norwegian HUNT Study.

INTRODUCTION: Chronic widespread pain (CWP) and diabetes commonly co-occur; however, it is unclear whether CWP infers an additional risk for diabetes among those with known risk factors for type 2 diabetes. We aimed to examine if CWP magnifies the effect of adverse lifestyle factors on the risk of diabetes. RESEARCH DESIGN AND METHODS: The study comprised data on 25 528 adults in the Norwegian HUNT Study without diabetes at baseline (2006-2008). We calculated adjusted risk ratios (RRs) with 95% CIs for diabetes at follow-up (2017-2019), associated with CWP and body mass index (BMI), physical activity, and insomnia symptoms. The relative excess risk due to interaction (RERI) was calculated to investigate the synergistic effect between CWP and adverse lifestyle factors. RESULTS: Compared with the reference group without chronic pain and no adverse lifestyle factors, those with BMI ≥30 kg/m2 with and without CWP had RRs for diabetes of 10.85 (95% CI 7.83 to 15.05) and 8.87 (95% CI 6.49 to 12.12), respectively; those with physical activity <2 hours/week with and without CWP had RRs for diabetes of 2.26 (95% CI 1.78 to 2.88) and 1.54 (95% CI 1.24 to 1.93), respectively; and those with insomnia symptoms with and without CWP had RRs for diabetes of 1.31 (95% CI 1.07 to 1.60) and 1.27 (95% CI 1.04 to 1.56), respectively. There was little evidence of synergistic effect between CWP and BMI ≥30 kg/m2 (RERI=1.66, 95% CI -0.44 to 3.76), low physical activity (RERI=0.37, 95% CI -0.29 to 1.03) or insomnia symptoms (RERI=-0.09, 95% CI -0.51 to 0.34) on the risk of diabetes. CONCLUSIONS: These findings show no clear interaction between CWP and adverse lifestyle factors on the risk of diabetes.

Change in physical activity and systolic blood pressure trajectories throughout mid-life and the development of dementia in older age: the HUNT study.

BACKGROUND: There is lack of research on combinations of possible modifiable risk factors for dementia in a life-time perspective. Dementia has currently no cure, and therefore new knowledge of preventive factors is important. The purpose of this study is to investigate if changes in physical activity (PA) in combinations with systolic blood pressure (SBP) trajectories in mid to late life are related to development of dementia in older age. METHODS: This prospective cohort study uses data from four consecutive surveys of the HUNT Study, Norway. Dementia was assessed in the HUNT4 70 + sub-study (2017-19). Group-based trajectory modelling identified three SBP trajectories from HUNT1 (1984-86) to HUNT3 (2006-2008): low, middle, and high. Change in PA was categorized into four groups based on high or low PA level at HUNT1 and HUNT3 and were combined with the SBP trajectories resulting in 12 distinct categories. Logistic regression was used to estimate odds ratios (ORs) of dementia. RESULTS: A total of 8487 participants (55% women, mean age (SD) 44.8 (6.5) years at HUNT1) were included. At HUNT4 70 + , 15.2% had dementia. We observed an overall decrease in OR of dementia across the PA/SBP categories when ranked from low to high PA (OR, 0.96; 95% CI, 0.93 to 1.00, P = 0.04). Within PA groups, a low SBP trajectory was associated with lower OR for dementia, apart from those with decreasing PA. The strongest association was observed for people with stable high PA and low SBP trajectory (OR, 0.38; 95% confidence interval (CI), 0.13 to 1.10 and adjusted risk difference, -8.34 percentage points; 95% CI, -15.32 to -1.36). CONCLUSION: Our findings illustrate the clinical importance of PA and SBP for dementia prevention and that favorable levels of both are associated with reduced occurrence of dementia.