Symptom trajectories of post-COVID sequelae in patients with acute Delta or Omicron infection in Bergen, Norway.

Introduction: A substantial proportion of the over 700 million COVID-19 cases world-wide experience long-term symptoms. The objectives of this study were to compare symptom trajectories and risk factors for post-COVID-19 condition after Delta and Omicron infection. Methods: This study consecutively recruited patients with SARS-CoV-2 infection from November 2021 to March 2022. We recorded demographics, comorbidities, vaccination status, sick leave, and 18 symptoms during acute infection and after 4 months. The primary outcome measures were symptoms during acute infection and after 4 months. Secondary outcome measures were work and school absenteeism. Results: We followed a cohort of 1,374 non-hospitalized COVID-19 patients in Bergen, Norway, at three time points. The median age was 39.8 years and 11% were children <16 years. Common acute upper respiratory symptoms waned during follow-up. Fatigue remained common from acute infection (40%) until after 4 months (37%). Four months post-infection, patients reported increased frequencies of dyspnea (from 15% during acute illness to 25% at 4 months, p < 0.001), cognitive symptoms (from 9 to 32%, p < 0.001) and depression (from 1 to 17%, p < 0.001). Patients infected with Omicron reported less dyspnea (22% versus 27%, p = 0.046) and smell/taste problems (5% versus 19%, p < 0.001) at 4 months follow-up than those with Delta infection. Comorbidities and female sex were risk factors for persistent dyspnea and cognitive symptoms. Ten percent reported sick leave after acute illness, and vaccination reduced the risk of absenteeism (adjusted risk ratio: 0.36, 95% confidence interval: 0.15, 0.72, p = 0.008). Conclusion: At 4 months, home-isolated patients infected with Omicron reported overall comparable symptom burden, but less dyspnea and smell/taste problems than Delta infected patients. Several acute symptoms waned during follow-up. It is worrying that dyspnea, neurocognitive symptoms, and particularly depression, increased significantly during the first 4 months after acute infection. Previous vaccination was protective against prolonged sick leave.

Social inequalities in the provision of obstetric services in Norway 1967-2009: a population-based cohort study.

BACKGROUND: Socioeconomic (SE) inequalities have been observed in a number of adverse outcomes of pregnancy and many of the risk factors for such outcomes are associated with a low SE level. However, SE inequalities persist even after adjustment for these risk factors. Less well-off women are more vulnerable, but may also get less adequate health services. The objective of the present study was to assess possible associations between SE conditions in terms of maternal education as well as ethnic background and obstetric care. METHODS: A population-based national cohort study from the Medical Birth Registry of Norway. The study population comprised 2 305 780 births from the observation period 1967-2009. Multilevel analysis was used because of the hierarchical structure of the data. Outcome variables included induction of labour, epidural analgesia, caesarean section, neonatal intensive care and perinatal death. RESULTS: While medical interventions in the 1970s were employed less frequently in women of short education and non-western immigrants, this difference was eliminated or even reversed towards the end of the observation period. However, an excess perinatal mortality in both the short-educated [adjusted relative risk (aRR) = 2.49] and the non-western immigrant groups (aRR = 1.75) remained and may indicate increasing health problems in these groups. CONCLUSION: Even though our study suggests a fair and favourable development during the last decades in the distribution across SE groups of obstetric health services, the results suggest that the needs for obstetric care have increased in vulnerable groups, requiring a closer follow-up.

Perinatal death and exposure to dental amalgam fillings during pregnancy in the population-based MoBa cohort.

OBJECTIVES: The aim was to gain knowledge regarding the risk of perinatal death related to exposure to dental amalgam fillings in the mother. DESIGN: Population-based observational cohort study. SETTING: The Norwegian Mother and Child Cohort Study, a Norwegian birth cohort of children born in 1999-2008 conducted by the Norwegian Institute of Public Health. PARTICIPANTS: 72,038 pregnant women with data on the number of teeth filled with dental amalgam. MAIN OUTCOME MEASURES: Data on perinatal death (stillbirth ≥ 22 weeks plus early neonatal death 0-7 days after birth) were obtained from the Medical Birth Registry of Norway. RESULTS: The absolute risk of perinatal death ranged from 0.20% in women with no amalgam-filled teeth to 0.67% in women with 13 or more teeth filled with amalgam. Analyses including the number of teeth filled with amalgam as a continuous variable indicated an increased risk of perinatal death by increasing number of teeth filled with dental amalgam (crude OR 1.065, 95% CI 1.034 to 1.098, p<0.001). After adjustment for potential confounders (mothers' age, education, body mass index, parity, smoking during pregnancy, alcohol consumption during pregnancy) included as categorical variables, there was still an increased risk for perinatal death associated with increasing number of teeth filled with amalgam (ORadj 1.041, 95% CI 1.008 to 1.076, p = 0.015). By an increased exposure from 0 to 16 teeth filled with amalgam, the model predicted an almost doubled odds ratio (ORadj 1.915, 95% CI 1.12 to 3.28). In groups with 1 to 12 teeth filled with amalgam the adjusted odds ratios were slightly, but not significantly, increased. The group with the highest exposure (participants with 13 or more teeth filled with amalgam) had an adjusted OR of 2.34 (95% CI 1.27 to 4.32; p = 0.007). CONCLUSION: The current findings suggest that the risk of perinatal death could increase in a dose-dependent way based on the mother's number of teeth filled with dental amalgam. However, we cannot exclude that the relatively modest odds ratios could be a result of residual confounding. Additional studies on the relationship between exposure to dental amalgam fillings during pregnancy and perinatal death are warranted.

Prenatal exposure to dental amalgam and risk of symptoms of attention-deficit and hyperactivity disorder (ADHD).

BACKGROUND: ADHD is multifactorial, including both genetic and environmental factors. The safety of amalgam used in dental treatment has been discussed due to its content of mercury and potential risks for negative neurodevelopmental consequences in the offspring. The aim of the study was to investigate possible associations between symptoms related to ADHD in children of three and five years of age and prenatal exposure to mercury from mothers' amalgam fillings. METHODS: Data from the Norwegian Mother and Child Cohort Study (MoBa) were used. Data were collected by questionnaires sent to participating women in week 17 (Q1) and 30 (Q3) of pregnancy and when the child was three (Q6) and five years of age (Q7). Information about exposure to amalgam during pregnancy was obtained from Q3. Information about symptoms related to ADHD was obtained from Q6 and Q7. Valid data were obtained for 42 163 children at three years of age and 23 392 children at five years of age. Logistic regression models, including mothers' age, education, body mass index, parity, smoking and alcohol consumption during pregnancy, were used to estimate the association between ADHD symptoms and prenatal exposure to amalgam fillings. RESULTS: No significant associations between number of teeth with amalgam filling, amalgam fillings placed or removed during pregnancy, and symptoms related to ADHD in children of three and five years of age were found. CONCLUSIONS: In a large, prospective cohort study, we found no indication of increased risk of ADHD-related symptoms in children prenatally exposed to mother's amalgam fillings.

Quality indicators for the referral process from primary to specialised mental health care: an explorative study in accordance with the RAND appropriateness method.

BACKGROUND: Communication between involved parties is essential to ensure coordinated and safe health care delivery. However, existing literature reveals that the information relayed in the referral process is seen as insufficient by the receivers. It is unknown how this insufficiency affects the quality of care, and valid performance measures to explore it are lacking. The aim of the present study was to develop quality indicators to detect the impact that the quality of referral letters from primary care to specialised mental health care has on the quality of mental health services. METHODS: Using a modified version of the RAND/UCLA appropriateness method, a systematic literature review and focus group interviews were conducted to define quality indicators for mental health care expected to be affected by the quality of referral information. Focus group participants included psychiatrists, psychologists, general practitioners, patient representatives and managers. The existing evidence and suggested indicators were presented to expert panels, who assessed the indicators by their validity, reliability, sensitivity and feasibility. RESULTS: Sixteen preliminary indicators emerged during the focus group interviews and literature review. The expert panels recommended four of the 16 indicators. The recommended indicators measure a) timely access, b) delay in the process of assessing the referral, c) delay in the onset of care and d) the appropriateness of the referral. Adjustment was necessary for five other indicators, and seven indicators were rejected because of expected confounding factors reducing their validity and sensitivity. CONCLUSIONS: The quality of information relayed in the referral process from primary care to specialised mental health care is expected to affect a wide range of dimensions defining high quality care. The expected importance of the referral process for ensuring 'timely access'-one of the six aims of high-quality health care defined by the Institute of Medicine-is highlighted. Exploring the underlying mechanisms for the potential impact of referral information on patient outcomes is recommended to enhance quality of care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01374035 (28 April 2011).

Maternal Smoking Status in Successive Pregnancies and Risk of Having a Small for Gestational Age Infant.

BACKGROUND: Smoking during pregnancy is linked to having a small for gestational age (SGA) baby. We estimated SGA risk among women who smoked persistently, quit smoking or started smoking during their first two pregnancies. METHODS: Data from the population-based Medical Birth Registry of Norway was used to evaluate self-reported smoking at the beginning and end of two successive pregnancies among 118 355 Nordic women giving birth 1999-2014. Relative risks (RR) with 95% confidence intervals (CI) of SGA in the second pregnancy were estimated using adjusted generalised linear models with non-smokers during both pregnancies serving as referent category. RESULTS: Daily smokers throughout both pregnancies had almost threefold increased SGA risk in the second pregnancy (RR 2.9, 95% CI 2.7, 3.1). Daily smokers in the first pregnancy, who abstained in the second, had a 1.3-fold increased risk (95% CI 1.1, 1.5). Intermediate risks were found among persistent daily smokers who quit by the end of the second pregnancy (RR 2.0, 95% CI 1.6, 2.4) and non-smokers in first pregnancy who smoked daily throughout their second (RR 1.8, 95% CI 1.4, 2.3). Persistently smoking women without SGA in first pregnancy, had a 2.7-fold increased risk of SGA in second pregnancy (95% CI 2.5, 3.0). CONCLUSIONS: Smoking throughout two successive pregnancies was associated with the greatest increased SGA risk compared with non-smokers, while cessation before or during the second pregnancy reduced this risk. Women who smoked in the first pregnancy without experiencing SGA are not protected against SGA in second pregnancy if they continue smoking.

Socio-economic risk factors for preterm birth in Norway 1999-2009.

AIMS: Preterm birth is a major cause of perinatal mortality and morbidity and is strongly associated with socio-economic factors. The objective of this study was to examine the associations of maternal education, marital status and ethnicity with preterm birth and to determine the extent to which such associations can be explained by the established risk factors of maternal age, parity and smoking. METHODS: This was a register-based cohort study with data from the Medical Birth Registry of Norway 1999-2009 and Statistics Norway. The sample included all singleton spontaneous births in Norway from 1999 to 2009 (n=494,073). The main outcome measure was preterm birth (gestational age <37 weeks). RESULTS: Low maternal education and single motherhood were associated with preterm birth. After adjustment for the established risk factors, the excess risks were reduced, but remained statistically significant. The relative risk for low education was reduced from 1.50 to 1.36 and for single motherhood from 1.50 to 1.28. Women from Asia had a higher risk of preterm birth than Norwegian-born women (relative risk 1.29) with minor effects of adjustment. CONCLUSIONS SEVERAL SOCIO-ECONOMIC RISK FACTORS ARE ASSOCIATED WITH PRETERM BIRTH IN NORWAY IN ADDITION TO THE ESTABLISHED RISK FACTORS, PRENATAL HEALTH CARE SHOULD FOCUS ON HIGH-RISK GROUPS DEFINED BY MATERNAL EDUCATION, MARITAL STATUS AND ETHNICITY.

Prenatal exposure to dental amalgam and pregnancy outcome.

OBJECTIVE: Questions have been raised about potential risks of prenatal exposure to mercury from amalgam fillings during pregnancy. The aim of this study was to assess possible associations between exposure to amalgam fillings in pregnant women participating in a large cohort study and adverse pregnancy outcome. METHODS: In the Norwegian Mother and Child Cohort Study (MoBa), a valid information about the number of teeth with amalgam fillings and dental treatment, including new amalgam fillings placed or removed during pregnancy, was available from 69 474 pregnancies. The information was obtained from two questionnaires sent to the women at 17 and 30 weeks of pregnancy, and the data were linked to the Medical Birth Registry of Norway. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence intervals (95% CI) as a measure of association between pregnancy outcome and prenatal exposure to amalgam fillings. RESULTS: Logistic regression models, including mothers' age, education, BMI, parity, smoking during pregnancy, and alcohol consumption during pregnancy revealed no significant associations between the number of teeth with amalgam fillings and early preterm delivery, late preterm delivery, low birthweight, malformation or stillbirth. CONCLUSIONS: We found no evidence for serious perinatal consequences of maternal exposure to amalgam fillings during pregnancy.

Can 'early programming' be partly explained by smoking? Results from a prospective, population-based cohort study.

BACKGROUND: Numerous studies have focused the association between low birthweight and later disease. Our objective was to study the association between birthweight and later adult smoking and thereby explore a possible mechanism for the association between low birthweight and later adult disease. METHODS: We studied associations between birthweight of women (n=247704) born in 1967-1995 and smoking habits at the end of their pregnancy 13-42 years later in a prospective, population-based cohort study from The Medical Birth Registry of Norway. Similarly, the association between birthweight of men (n=194393) and smoking habits of their partners were assessed. Finally, we studied the relation between smoking habits of the participating women and the cause specific death of their mothers (n=222808). RESULTS: Twenty per cent of women with birthweight less than 2000 g were adult daily smokers compared with 11% with birthweight 4000-4499 g [relative risk=1.8, 95% confidence interval 1.4, 2.2]. Similarly, we found an association between men's birthweight and their partners smoking habits. Mothers of smoking women had doubled risk of dying from lung cancer and from cardiovascular disease compared with mothers of non-smoking women. CONCLUSIONS: Being born with low birthweight is associated with smoking in adulthood. Associations of adult smoking with partners' birthweight and mothers' smoking-related causes of death suggest a shared smoking environment, and may account for some of the established association between birthweight and later cardiovascular disease.

Patient experiences with interventions to reduce surgery cancellations: a qualitative study.

BACKGROUND: The cancellation of planned surgery harms patients, increases waiting times and wastes scarce health resources. Previous studies have evaluated interventions to reduce cancellations from medical and management perspectives; these have focused on cost, length of stay, improved efficiency, and reduced post-operative complications. In our case a hospital had experienced high cancellation rates and therefore redesigned their pathway for elective surgery to reduce cancelations. We studied how patients experienced interventions to reduce cancellations. METHODS: We conducted a comparative, qualitative case study by interviewing 8 patients who had experienced the redesigned pathway, and 8 patients who had experienced the original pathway. We performed a content analysis of the interviews using a theory-based coding scheme. Through a process of coding and condensing, we identified themes of patient experience. RESULTS: We identified three common themes summarizing patients' positive experiences with the effects of the interventions: the importance of being involved in scheduling time for surgery, individualized preparation before the hospital admission, and relationships with few clinicians during their hospital stay. CONCLUSIONS: Patients appreciated the effects of interventions to reduce cancellations, because they increased their autonomy. Unanticipated consequences were that the telephone reminder created a personalized dialogue and centralization of surgical preparation and discharge processes improved continuity of care. Thus apart from improving surgical logistics, the pathway became more patient-centered.

Smokers' increased risk for disability pension: social confounding or health-mediated effects? Gender-specific analyses of the Hordaland Health Study cohort.

BACKGROUND: Studies indicate that cigarette smokers have an increased risk for disability pension, presumably mediated by adverse health effects. However, smoking is also related to socioeconomic status. The current study examined the association between smoking and subsequent disability pension, and whether the association is explained by social confounding and/or health-related mediation. METHODS: A subsample of 7934 men and 8488 women, aged 40-46, from the Hordaland Health Study, Norway (1997-1999), provided baseline information on smoking status, self-reported health measures and socioeconomic status. Outcome was register-based disability pension from 12 months after baseline to end of 2004. Gender stratified Cox regression analyses were used adjusted for socioeconomic status, physical activity, self-reported health and musculoskeletal pain sites. RESULTS: A total of 155 (2%) men and 333 (3.9%) women were granted disability pension during follow-up. The unadjusted disability risk associated with heavy smoking versus non-smoking was 1.88 (95% CI 1.23 to 2.89) among men and 3.06 (95% CI 2.23 to 4.20) among women. In multivariate analyses, adjusting for socioeconomic status, HRs were 1.33 (95% CI 0.84 to 2.11) among men and 2.22 (95% CI 1.58 to 3.13) among women. Final adjustment for physical activity, self-reported health and musculoskeletal pain further reduced the effect of heavy smoking in women (HR=1.53, 95% CI 1.09 to 2.16). CONCLUSIONS: Socioeconomic status confounded the smoking-related risk for disability pension; for female heavy smokers, however, a significant increased risk persisted after adjustment. Women may be particularly vulnerable to heavy smoking and to its sociomedical consequences, such as disability pension.

Sustainability of healthcare improvement: what can we learn from learning theory?

BACKGROUND: Changes that improve the quality of health care should be sustained. Falling back to old, unsatisfactory ways of working is a waste of resources and can in the worst case increase resistance to later initiatives to improve care. Quality improvement relies on changing the clinical system yet factors that influence the sustainability of quality improvements are poorly understood. Theoretical frameworks can guide further research on the sustainability of quality improvements. Theories of organizational learning have contributed to a better understanding of organizational change in other contexts. To identify factors contributing to sustainability of improvements, we use learning theory to explore a case that had displayed sustained improvement. METHODS: Førde Hospital redesigned the pathway for elective surgery and achieved sustained reduction of cancellation rates. We used a qualitative case study design informed by theory to explore factors that contributed to sustain the improvements at Førde Hospital. The model Evidence in the Learning Organization describes how organizational learning contributes to change in healthcare institutions. This model constituted the framework for data collection and analysis. We interviewed a strategic sample of 20 employees. The in-depth interviews covered themes identified through our theoretical framework. Through a process of coding and condensing, we identified common themes that were interpreted in relation to our theoretical framework. RESULTS: Clinicians and leaders shared information about their everyday work and related this knowledge to how the entire clinical pathway could be improved. In this way they developed a revised and deeper understanding of their clinical system and its interdependencies. They became increasingly aware of how different elements needed to interact to enhance the performance and how their own efforts could contribute. CONCLUSIONS: The improved understanding of the clinical system represented a change in mental models of employees that influenced how the organization changed its performance. By applying the framework of organizational learning, we learned that changes originating from a new mental model represent double-loop learning. In double-loop learning, deeper system properties are changed, and consequently changes are more likely to be sustained.

Exposure to tobacco smoke in utero and subsequent plasma lipids, ApoB, and CRP among adult women in the MoBa cohort.

BACKGROUND: Recent findings suggest that maternal smoking during pregnancy may play a role in the development of metabolic alterations in offspring during childhood. However, whether such exposure increases the risk of developing similar metabolic alterations during adulthood is uncertain. OBJECTIVE: We evaluated the association of in utero exposure to maternal tobacco smoke with plasma lipids, apolipoprotein B (apoB), and C-reactive protein (CRP) in adulthood. METHODS: The study was based on a subsample of the Norwegian Mother and Child Cohort Study (MoBa) and included 479 pregnant women with plasma lipids, apoB, and CRP measurements. Information on in utero exposure to tobacco smoke, personal smoking, and other factors were obtained from the women by a self-completed questionnaire at enrollment, at approximately 17 weeks of gestation. RESULTS: Women exposed to tobacco smoke in utero had higher triglycerides [10.7% higher; 95% confidence interval (CI): 3.9, 17.9] and lower high-density lipoprotein cholesterol (HDL) (-1.9 mg/dL; 95% CI: -4.3, 0.5) compared with unexposed women, after adjusting for age, physical activity, education, personal smoking, and current body mass index (BMI). Exposed women were also more likely to have triglycerides ≥ 200 mg/dL [adjusted odds ratio (aOR) = 2.5; 95% CI: 1.3, 5.1] and HDL < 50 mg/dL (aOR = 2.3; 95% CI: 1.1, 5.0). Low-density lipoprotein cholesterol, total cholesterol, and apoB were not associated with the exposure. CRP was increased among exposed women; however, after adjustment for BMI, the association was completely attenuated. CONCLUSIONS: In this population, in utero exposure to tobacco smoke was associated with high triglycerides and low HDL in adulthood, 18-44 years after exposure.

A new pathway for elective surgery to reduce cancellation rates.

BACKGROUND: The cancellation of planned surgeries causes prolonged wait times, harm to patients, and is a waste of scarce resources. To reduce high cancellation rates in a Norwegian general hospital, the pathway for elective surgery was redesigned. The changes included earlier clinical assessment of patients, better planning and documentation systems, and increased involvement of patients in the scheduling of surgeries. This study evaluated the outcomes of this new pathway for elective surgery and explored which factors affected the outcomes. METHODS: We collected the number of planned operations, performed operations, and cancellations per month from the hospital's patient administrative system. We then used Student's t-test to analyze differences in cancellation rates (CRs) before and after interventions and a u-chart to analyze whether the improvements were sustained. We also conducted semi-structured interviews with employees of the hospital to explore the changes in the surgical pathway and the factors that facilitated these changes. RESULTS: The mean CR was reduced from 8.5% to 4.9% (95% CI for mean reduction 2.6-4.5, p < 0.001). The reduction in the CR was sustained over a period of 26 months after the interventions. The median number of operations performed per month increased by 17% (p = 0.04). A clear improvement strategy, involvement of frontline clinicians, introduction of an electronic scheduling system, and engagement of middle managers were important factors for the success of the interventions. CONCLUSION: The redesign of the old clinical pathway contributed to a sustained reduction in cancellations and an increased number of performed operations.

A biobank of primary teeth within the Norwegian Mother and Child Cohort Study (MoBa): a resource for the future.

The Norwegian Mother and Child Cohort Study (MoBa) is a prospective population-based cohort study including >100 000 pregnancies and following the children through childhood, using questionnaires and collecting biological samples. The aim of MoBa is to test specific aetiological hypotheses by estimating the association between exposure and disease, aiming at prevention. A biobank for exfoliated primary teeth collected from the children participating in MoBa has been established (MoBaTooth Biobank). Samples of tooth tissues from the primary dentition can give information about exposure to toxic and essential elements during fetal life and early infancy. Prenatally and postnatally formed tooth tissues permanently document early exposures unlike other biomarkers, as teeth form incrementally at a known rate. Results from tooth analyses will be coupled with corresponding information in the multiple questionnaires and data from analysis of other biological samples collected by MoBa. Invitations to donate one or more teeth are sent to all mothers/children in the period 2008-2016, when the child is 6.75 years old. By August 2011, 7400 participants had been recorded into the MoBaTooth database donating altogether 9798 teeth (1.3 teeth per child). The response rate was 24%, but there is a lag of >1 year in the response. Data from the tooth biobank can supply MoBa with important additional information on the uptake of trace elements during fetal life and early infancy. This information can illuminate possible causal factors of health and disease in the future.

Self-reported smoking status and plasma cotinine concentrations among pregnant women in the Norwegian Mother and Child Cohort Study.

INTRODUCTION: Underreporting of smoking in epidemiologic studies is common and may constitute a validity problem, leading to biased association measures. In this prospective study, we validated self-reported tobacco use against nicotine exposure assessed by plasma cotinine in the Norwegian Mother and Child Cohort Study (MoBa). METHODS: The study was based on a subsample of 2,997 women in the MoBa study who delivered infants during the period 2002-2003. Self-reported tobacco use (test variable) and plasma cotinine concentrations (gold standard) were assessed at approximately gestational week 18. RESULTS: Daily smoking was reported by 9% of the women, occasional smoking by 4%, and nonsmoking by 86% of the women. Sensitivity and specificity for self-reported smoking status were calculated using a cotinine cut-off estimated from the study population (30 nmol/l). Plasma cotinine concentrations ≥30 nmol/l were found in 94% of self-reported daily smokers, 66% of occasional smokers, and 2% of nonsmokers. After the numbers of self-reported nonsmokers with cotinine concentrations above the cut-off limit were added, the daily smoking prevalence increased from 9 to 11%. The sensitivity and specificity for self-reported daily smoking, using 30 nmol/l as the cut-off concentration, were 82 and 99%, respectively. DISCUSSION: These findings suggest that self-reported tobacco use is a valid marker for tobacco exposure in the MoBa cohort.

In utero exposure to maternal tobacco smoke and subsequent obesity, hypertension, and gestational diabetes among women in the MoBa cohort.

BACKGROUND: Environmental factors influencing the developmental origins of health and disease need to be identified and investigated. In utero exposure to tobacco smoke has been associated with obesity and a small increase in blood pressure in children; however, whether there is a corresponding increased risk of conditions such as diabetes and hypertension during adulthood remains unclear. OBJECTIVE: Our goal was to assess the association of self-reported in utero exposure to tobacco smoke with the prevalence of obesity, hypertension, type 2 diabetes mellitus (T2DM), and gestational diabetes mellitus (GDM) in women 14-47 years of age. METHODS: We conducted a cross-sectional analysis of the Norwegian Mother and Child Cohort Study, which enrolled pregnant women in Norway from 1999 thorough 2008. Exposure to tobacco smoke in utero (yes vs. no) was ascertained on the baseline questionnaire (obtained at ~ 17 weeks' gestation); the outcomes were ascertained from the Medical Birth Registry of Norway and the questionnaire. Our analysis included 74,023 women. RESULTS: Women exposed to tobacco smoke in utero had 1.53 times the odds of obesity [95% confidence interval (CI): 1.45, 1.61] relative to those unexposed, after adjusting for age, education, and personal smoking. After further adjustment for body mass index, the odds ratio for hypertension was 1.68 (95% CI: 1.19, 2.39); for T2DM 1.14 (95% CI: 0.79, 1.65); and for GDM 1.32 (95% CI: 1.10, 1.58) among exposed compared with unexposed. CONCLUSIONS: Exposure to tobacco smoke in utero was associated with obesity, hypertension, and GDM in adult women. The possibility that the associations were attributable to unmeasured confounding cannot be excluded.

The Western Norway mental health interface study: a controlled intervention trial on referral letters between primary care and specialist mental health care.

BACKGROUND: Referral letters are the main communication means between Primary and Specialised Mental Health Care. However, studies of referral letters reveal that they lack important information, and how this lack of information affects the care for patients is unknown. This study aims to explore if and to what degree the quality of referral letters within Mental Health Care for adults can be improved and the potential improvement's impact on defined patient, professional and organisational related outcomes. METHODS AND DESIGN: A controlled study with pre and post test will be prepared and accomplished to explore the correlation between the content of referral letters and outcomes of the care for the referred patients. The study is performed in accordance with the guideline of the Medical Research Council on development and evaluation of complex interventions. Using a mixed method design, a stepwise model will be conducted: Firstly, process and outcome measures will be developed and tested. Secondly, by these measures, the results from an intervention group of General Practitioners (GPs) who receive a complex quality improvement intervention will be compared with results from a control group who perform "care as usual". Compliance to the introduced guideline will be measured as a mediator. DISCUSSION: The Western Norway Mental Health Interface Study is among the first trials to evaluate the impact of the quality of referral letters on the organization of care. This study will provide information that will be usable for healthcare managers and clinicians in both Primary and Specialised Care settings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01374035.

Reproducibility of reported in utero exposure to tobacco smoke.

PURPOSE: In studies of the fetal origins of disease and life course epidemiology, measures of fetal exposure may be based on information reported by the adults who were exposed in utero. In particular, the full spectrum of consequences of in utero exposure to maternal tobacco smoking is now an area of active investigation, and the ability to report such exposure reproducibly is of interest. We evaluated the reproducibility of in utero exposure to tobacco smoke, reported by the adult daughter during consecutive pregnancies. METHODS: This study was based on 11,257 women who enrolled for more than one pregnancy in the Norwegian Mother and Child Cohort Study (MoBa). Participants completed a questionnaire around 17 weeks of gestation, which asked about their in utero exposure to tobacco smoke. Kappa statistics were calculated. Determinants of agreement were evaluated using logistic regression. RESULTS: Weighted Kappa for in utero exposure for the first and second reports was 0.80. Determinants of agreement were higher education (better) and longer time between reports (worse). CONCLUSIONS: Information on in utero exposure to maternal tobacco smoking provided by adult women was highly reproducible in this population.