Integration of e-learning approaches in a post-pandemic learning environment - Norwegian nursing students' recommendations from an action research study.

The covid-19 pandemic has profoundly led to changes in use of digital platforms, online teaching, and e-learning strategies. The aim of the present study was to examine how future pedagogical approaches can promote constructive learning environments and facilitate nursing students learning processes in future post-pandemic scenarios based on an action research study, which were conducted through several steps from January 2021 through January 2022 in a Bachelor of Nursing program at UiT the Arctic University of Norway. Students from the 2020 enrollment were invited to focus group interviews in March 2021. The interviews were transcribed, and content analyzed, resulting in concrete advice, which were implemented for the next enrollment. Students from the 2021 enrollment were invited to similar focus groups, resulting in refined advice, which will be presented. The pandemic situation resulted in extensive use of digital platforms for the 2020 enrollment. Students from this cohort described shock and disappointment connected to their study start. They expected a new life, meeting new friends and to develop a student identity, but their expectations were broken. The loss of social connections led to isolation and a weak link to the program and to the nursing profession. They recommended integrated training of theoretical and practical skills in small groups combined with short, well-prepared digital lectures equivalent to "flipped classroom" approaches. Implementing their advice, the 2021 enrollment's experience became different. This group was prepared for extensive use of digital platforms and gave future advise on increased flexibility and balance between the various learning activities centered around the clinical sessions. Based on these experiences during the pandemic, we suggest that digital platforms and e-learning strategies facilitate nursing students learning in combination with active and social learning environments.

Vertebral Fractures Assessed by Dual-Energy X-Ray Absorptiometry and All-Cause Mortality: The Tromsø Study, 2007-2020.

Vertebral fractures have been associated with increased mortality, but findings are inconclusive, and many vertebral fractures avoid clinical attention. We investigated this association in a general population of 2,476 older adults aged ≥55 years from Tromsø, Norway, who were followed over 2007-2020, using dual-energy x-ray absorptiometry (DXA) at baseline to evaluate vertebral fractures (mild, moderate, or severe). We used multiple Cox regression models to estimate hazard ratios (HRs) for all-cause mortality, adjusted for age, sex, body mass index, education, smoking, alcohol intake, cardiovascular disease, and respiratory disease. Mean follow-up in the cohort was 11.2 (standard deviation, 2.7) years; 341 participants (13.8%) had ≥1 vertebral fracture at baseline, and 636 participants (25.7%) died between baseline and follow-up. Full-adjustment models showed a nonsignificant association between vertebral fracture status (yes/no) and mortality. Participants with ≥3 vertebral fractures (HR = 2.43, 95% confidence interval: 1.57, 3.78) or ≥1 severe vertebral fracture (HR = 1.65, 95% confidence interval: 1.26, 2.15) had increased mortality compared with those with no vertebral fractures. Dual-energy x-ray absorptiometry-based screening could be a potent and feasible tool in detecting vertebral fractures that are often clinically silent yet independently associated with premature death. Our data indicated that detailed vertebral assessment could be warranted for a more accurate survival estimation.

Two-year changes in sleep duration are associated with changes in psychological distress in adolescent girls and boys: the fit futures study.

Objective: Studies indicate an inverse association between sleep duration and psychological distress. We aimed to explore associations between changes in sleep duration and changes in psychological distress in girls and boys. Methods: The Fit Futures Study is a broad adolescent study providing data from 373 girls and 294 boys aged 15-18 years collected in 2010/2011 (FF1) and 2012/2013 (FF2). Psychological distress was measured by the Hopkins Symptom Checklist (HSCL-10) and sleep duration was self-reported. Change score variables were calculated as the change between baseline and follow-up for sleep duration and HSCL-10, respectively. Associations between changes in sleep duration and changes in HSCL-10 were explored by linear regressions, in gender-stratified analyses. Results: At FF1, girls and boys slept on average 6.93 (SD = 1.08) and 7.05 (SD = 1.20) hours per night respectively, and correspondingly, 6.83 (SD = 1.19) and 6.85 (SD = 1.21) at FF2. At FF1, 22.8% of the girls and 25.8% of the boys slept ≤ 6 h per night, and correspondingly 28.0% and 28.2% at FF2. In girls and boys, one unit increase (30 min) in sleep duration was associated with a decrease in HSCL-10 score of B [95% CI] = -0.090 [-0.131, -0.048], p < 0.001, and -0.054 [-0.091, -0.017], p < 0.001, respectively. The associations remained significant after adjusting for confounders. Conclusion: Our findings show that increased sleep duration was associated with decreased psychological distress during adolescence. Future studies should examine the causality between sleep duration and psychological distress.

Impact of Total Hip Replacements on the Incidence of Hip Fractures in Norway During 1999-2019. A Norwegian Epidemiologic Osteoporosis Studies (NOREPOS) Study.

The knowledge about why hip fracture rates in Norway have declined is sparse. Concurrent with decreasing hip fracture rates, the rates of total hip replacements (THRs) have increased. We wanted to investigate if hip fracture rates continued to decline, and whether the increase in THRs had any influence on this decline, assuming that living with a hip prosthesis precludes fracture of the operated hip. Information on hip fractures in Norway 1999-2019 was available from the Norwegian Epidemiologic Osteoporosis Studies (NOREPOS) hip fracture database and population size were available in official population tables from Statistics Norway. Primary THRs (for any cause except hip fracture) 1989-2019 were obtained from the Norwegian Arthroplasty Register. We calculated the annual age-standardized incidence rates of hip fracture by sex for the period 1999-2019. The hip fracture rates in a scenario with no hip prostheses were calculated by subtracting 0.5 persons from the population at risk for each prevalent hip prosthesis, considering that each person has two hips at risk of fracture. We estimated how much of the decline could be attributed to the increased prevalence of hip prostheses. From 1999 to 2019, age-standardized incidence rates of hip fracture decreased by 27% in women and 20% in men. The rates remained stable in those under 70 years and decreased in those 70 years and above. Excluding replaced hips from the population at risk led to higher incidence rates, and this impact was considerably larger at higher ages. The increased prevalence of hip prostheses over the period accounted for approximately 18% (20% in women and 11% in men) of the observed decline in hip fracture rates. In conclusion, the incidence of hip fractures continued to decline, and the increasing number of people living with hip prostheses contributed significantly to the observed declining time trends. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Corrigendum: C-Reactive Protein and TGF-α Predict Psychological Distress at Two Years of Follow-Up in Healthy Adolescent Boys: The Fit Futures Study.

[This corrects the article DOI: 10.3389/fpsyg.2022.823420.].

C-Reactive Protein and TGF-α Predict Psychological Distress at Two Years of Follow-Up in Healthy Adolescent Boys: The Fit Futures Study.

Objective: The scarcity of research on associations between inflammatory markers and symptoms of depression and anxiety during adolescence has yielded inconsistent results. Further, not all studies have controlled for potential confounders. We explored the associations between baseline inflammatory markers and psychological distress including moderators at follow-up in a Norwegian adolescent population sample. Methods: Data was derived from 373 girls and 294 boys aged 15-18 years at baseline, in the Fit Futures Study, a large-scale 2-year follow-up study on adolescent health. Baseline data was gathered from 2010 to 2011 and follow-up data from 2012 to 2013. Psychological distress was measured with Hopkins Symptom Checklist (HSCL-10). Serum levels of the following inflammatory markers were measured: C-reactive protein (CRP), Interleukin 6 (IL-6), Transforming growth factor alpha (TGF-α), Tumor necrosis factor alpha variant 1 (TRANCE), and variant 2 (TWEAK). Independent associations between baseline inflammatory markers and HSCL-10 at follow-up were explored by linear regressions, in sex-stratified analyses. Results: In girls, analyses showed positive associations between all inflammatory markers and HSCL-10, except for TRANCE. However, all associations were non-significant in crude as well as in adjusted analyses. In boys, CRP (p = 0.03) and TGF-α (p < 0.01) showed significant associations with HSCL-10, that remained significant after adjustment. Additionally, moderators were found. In boys, CRP was associated with HSCL-10 in those with high body fat and those being physical inactive, and the association between TWEAK and HSCL-10 was dependent upon sleep duration. Conclusion: There were significant prospective associations between CRP, TFG-α, and HSCL-10 in boys aged 15-18 years at baseline.

Are pro-inflammatory markers associated with psychological distress in a cross-sectional study of healthy adolescents 15-17 years of age? The Fit Futures study.

BACKGROUND: Inflammatory markers have been associated with depression and anxiety disorder in adolescents. Less is known about the association between inflammation and subclinical symptoms in the form of psychological distress. We investigated prevalence of psychological distress and examined the associations between common pro-inflammatory markers and psychological distress in an adolescent population sample. METHODS: The study was based on data from 458 girls and 473 boys aged 15-17 years from the Fit Futures Study, a large-scale study on adolescent health, conducted in Northern Norway. Psychological distress was measured with the Hopkins Symptom Checklist (HSCL-10). Serum-levels of the following low-grade inflammatory markers were measured: C-reactive protein (CRP), interleukin 6 (IL-6), transforming growth factor-alpha (TGF-α), tumor necrosis factor alpha variant 1 (TRANCE) and tumor necrosis factor alpha variant 2 (TWEAK). Associations between quartiles of inflammatory markers and HSCL-10 were examined by logistic regression and adjusted for potential confounders in sex-stratified analyses. RESULTS: The proportion of psychological distress above cutoff were 26.9% and 10.8% among girls and boys, respectively. In both girls and boys, crude analysis showed positive associations between all inflammatory markers and HSCL-10, except for TWEAK and TRANCE in boys. However, none of these associations were statistically significant. Further, there were no significant findings in the adjusted analyses. CONCLUSION: There was a higher prevalence of psychological distress in girls compared to boys. Pro-inflammatory markers were not significantly associated with psychological distress in data from healthy adolescents aged 15-17 years.

A 15-year follow-up study of hip bone mineral density and associations with leisure time physical activity. The Tromsø Study 2001-2016.

AIMS: The aim was to investigate the long-term association between leisure time physical activity and hip areal bone mineral density (aBMD), in addition to change in hip aBMD over time, in 32-86 years old women and men. METHODS: Data were retrieved from the 2001, 2007-2008, and 2015-2016 surveys of the Tromsø Study, a longitudinal population study in Norway. Leisure time physical activity was assessed by the four-level Saltin-Grimby Physical Activity Level Scale which refers to physical exertion in the past twelve months. Hip aBMD was assessed by Dual-Energy X-ray Absorptiometry. Linear Mixed Model analysis was used to examine long-term associations between physical activity and hip aBMD (n = 6324). In addition, the annual change in hip aBMD was analyzed in a subsample of 3199 participants. RESULTS: Physical activity was significantly and positively associated with total hip aBMD in the overall cohort (p<0.005). Participants who reported vigorous activity had 28.20 mg/cm2 higher aBMD than those who were inactive (95% CI 14.71; 41.69, controlled for confounders), and even light physical activity was associated with higher aBMD than inactivity (8.32 mg/cm2, 95% CI 4.89; 11.76). Associations between physical activity and femoral neck aBMD yielded similar results. Hip aBMD decreased with age in both sexes, although more prominently in women. From 2001 to 2007-2008, aBMD changed by -5.76 mg/cm2 per year (95% CI -6.08; -5.44) in women, and -2.31 mg/cm2 (95% CI -2.69; -1.93), in men. From 2007-2008 to 2015-2016, the change was -4.45 mg/cm2 per year (95% CI -4.84; -4.06) in women, and -1.45 mg/cm2 (95% CI -1.92; -0.98) in men. CONCLUSIONS: In this cohort of adult men and women, physical activity levels were positively associated with hip aBMD in a dose-response relationship. Hip aBMD decreased with age, although more pronounced in women than men.

The influence of snuff and smoking on bone accretion in late adolescence. The Tromsø study, Fit Futures.

Areal bone mineral density (aBMD) predicts future fracture risk. This study explores associations between use of tobacco and bone accretion in Norwegian adolescents. Our results indicate that use of snuff is negatively associated with accretion of aBMD in adolescence and may be a signal of increased future fracture risk. PURPOSE: Bone mineral accrual in childhood and adolescence is a long-term primary preventive strategy of osteoporosis. Areal bone mineral density (aBMD) is a surrogate measure of bone strength and a predictor of fracture risk. The aim of this population-based 2-year follow-up cohort study was to explore associations between use of snuff and smoking and changes (∆) in aBMD in Norwegian girls and boys aged 15-17 years at baseline. METHODS: The first wave of the Tromsø study, Fit Futures was conducted from 2010 to 2011. Femoral neck (FN), total hip (TH), and total body (TB) bone mineral content (BMC) and aBMD were measured by dual-energy X-ray absorptiometry. Information on use of snuff, smoking habits, and other lifestyle related variables were collected through self-administered questionnaires. Two years later, during 2012-2013, the measurements were repeated in the second wave. The present study included 349 girls and 281 boys and compared "non-users" (n = 243 girls, 184 boys) with "users" (n = 105 girls, 96 boys) of snuff and "non-smokers" (n = 327 girls, 249 boys) with "smokers" (n = 21 girls, 31 boys) using linear regression adjusted for age, baseline height and weight, change in height and weight, pubertal maturation, physical activity, ethnicity, alcohol consumption, diagnosis known to affect bone, and medication known to affect bone. The influence of "double use" on bone accretion was also explored. RESULTS: In girls, no associations between use of snuff and ∆aBMD were found. In boys, use of snuff was associated with reduced bone accretion in all ∆aBMD models. Sensitivity analysis with exclusion of "sometimes" users of snuff strengthened associations at femoral sites in girls and attenuated all associations in boys. In girls, no associations between smoking and ∆aBMD were found. In boys, only the association with TB ∆aBMD was significant in the fully adjusted models. In girls, "double users" analyses showed similar association to smoking. In boys, nearly all models showed statistically significant associations with a difference of ~ 1-2% in ∆aBMD between "non-users" and "double users" during 2 years of follow-up. CONCLUSIONS: Our results indicate that tobacco use in late adolescence could be detrimental to bone accretion and may be a signal of increased fracture risk in adult life.

Association between objectively measured physical activity and longitudinal changes in body composition in adolescents: the Tromsø study fit futures cohort.

OBJECTIVES: Physical activity may be important in deterring the obesity epidemic. This study aimed to determine whether objectively measured physical activity in first year of upper secondary high school predicted changes in body composition over 2 years of follow-up in a cohort of Norwegian adolescents (n=431). DESIGN: A longitudinal study of adolescents (mean age of 16 (SD 0.4) at baseline, 60.3% girls) participating in the Fit Futures studies 1 (2010-2011) and 2 (2012-2013). SETTING: All eight upper secondary high schools in two municipalities in Northern Norway. PARTICIPANTS: Students participating in both studies and under the age of 18 at baseline and with valid measurement of physical activity at baseline and body composition in both surveys. PRIMARY AND SECONDARY OUTCOMES: Change in objectively measured body mass index and waist circumference and change in dual-energy X-ray absorptiometry measured fat mass index, lean mass index (LMI) and appendicular LMI (aLMI) between baseline and follow-up. RESULTS: At baseline, boys had significantly higher physical activity volume (p=0.01) and spent on average of 6.4 (95% CI 2.1 to 10.6) more minutes in moderate-to-vigorous physical activity (MVPA) than girls (p<0.01). In girls, multivariate regression analyses showed that more sedentary time was negatively associated with changes in LMI (p<0.01) and aLMI (p<0.05), whereas more light activity had opposite effects on these measures (p<0.01 and p<0.05, respectively). No significant associations between measures of baseline physical activity and changes in body composition parameters were observed in boys. CONCLUSIONS: In this cohort of Norwegian adolescents, sedentary and light physical activity was associated with changes in LMI and aLMI in girls, but not boys. Minutes spent in MVPA in first year of upper secondary high school was not associated with changes in measures of body composition in neither sex after 2 years.

Can bone mineral density loss in the non-weight bearing distal forearm predict mortality?

PURPOSE: Low bone mineral density (BMD) is associated with increased risk of fractures and mortality. We investigated if rate of BMD loss in the distal forearm over seven years predicted mortality. METHODS: 1725 postmenopausal women and 1879 men aged 50-74 who participated in the longitudinal Tromsø Study waves 4 (1994-95) and 5 (2001-2002) were included. Cox regression models adjusted for lifestyle- and health related variables were used to assess associations between BMD change over seven years and subsequent mortality during up to 17 years of follow-up in participants with normal and low BMD at baseline. RESULTS: Baseline BMD decreased and seven-year bone loss increased with increasing age. Overall, mortality rates were higher among those with low versus normal BMD (38 vs 19 per 1000 py in women, 56 vs 34 in men) and at higher bone loss rates (rate ratio high:low = 1.2 in women, 1.7 in men). BMD change was associated with increased mortality only in men with normal baseline BMD. In this group, men with a BMD loss of >4% had significantly higher mortality (HR 1.50, 95% CI 1.21, 1.87) than men with increased or unchanged BMD. BMD change was not significantly associated with increased mortality in women or in men with low BMD at baseline. CONCLUSIONS: BMD loss in the distal forearm was associated with increased mortality in men with normal BMD at baseline, but not in women. We found no clear association between BMD loss and mortality in those with low BMD at baseline.

Self-reported health as a predictor of mortality: A cohort study of its relation to other health measurements and observation time.

Self-reported health (SRH) is widely used as an epidemiological instrument given the changes in public health since its introduction in the 1980s. We examined the association between SRH and mortality and how this is affected by time and health measurements in a prospective cohort study using repeated measurements and physical examinations of 11652 men and 12684 women in Tromsø, Norway. We used Cox proportional hazard regression to estimate hazard ratios (HRs) of death for SRH, controlling for pathology, biometrics, smoking, sex and age. SRH predicted mortality independently of other, more objective health measures. Higher SRH was strongly associated with lower mortality risk. Poor SRH had HR 2.51 (CI: 2.19, 2.88). SRH is affected by disease, mental health and other risk factors, but these factors had little impact on HRs (Poor SRH: HR 1.99; CI: 1.72, 2.31). SRH predicted mortality, but with a time-dependent effect. Time strongly affected the hazard ratio for mortality, especially after ten-year follow-up (Poor SRH HR 3.63 at 0-5 years decreased to HR 1.58 at 15-21 years). SRH has both methodological and clinical value. It should not be uncritically utilised as a replacement instrument when measures of physical illness and other objective health measures are lacking.

The association between anthropometric measures of adiposity and the progression of carotid atherosclerosis.

BACKGROUND: Few reports are available on the contribution of general and abdominal obesity to the progression of carotid atherosclerosis in late adulthood. This study investigated the impact of four simple anthropometric measures of general and abdominal obesity on the progression of carotid atherosclerosis and the extent to which the association between adiposity and the progression of plaque burden is mediated by cardiometabolic markers. METHODS: Four thousand three hundred forty-five adults (median age 60) from the population-based Tromsø Study were followed over 7 years from the first carotid ultrasound screening to the next. The progression of carotid atherosclerosis was measured in three ways: incidence of plaques in previously plaque-free participants; change in the number of plaques; and total plaque area (TPA). We used generalised linear models to investigate the association between each adiposity measure - body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) - and each outcome. Models were adjusted for potential confounders (age, sex, smoking, education, physical activity). The pathways through which any associations observed might operate were investigated by further adjusting for cardiometabolic mediators (systolic blood pressure, cholesterol, and HbA1c). RESULTS: There was little evidence that adiposity was related to the formation of new plaques during follow-up. However, abdominal adiposity was associated with TPA progression. WHtR showed the largest effect size (mean change in TPA per one standard deviation (SD) increase in WHtR of 0.665 mm2, 95% confidence interval 0.198, 1.133) while BMI showed the smallest. Effect sizes were substantially reduced after the adjustment for potential mediators. CONCLUSIONS: Abdominal obesity indirectly measured with WC seems more strongly associated with the progression of TPA than general obesity. These associations appear to be largely mediated by known cardiometabolic markers.

A population-based study of inflammatory mechanisms and pain sensitivity.

Two recent studies suggest that experimental pain sensitivity is associated with low-grade systemic inflammation. However, only 2 biomarkers have been identified, and the studies were conducted in adult individuals where confounding effects of comorbid diseases cannot be excluded. We therefore tested associations between pain sensitivity and 119 inflammation-related serum biomarkers in 827 healthy adolescents (15-19 years) in the population-based Tromsø Study: Fit Futures. The main outcome measure was cold-pressor pain tolerance (CPT), tested by placing the dominant hand in circulating cold (3°C) water for a maximum of 105 seconds. Secondary outcomes were heat and pressure pain threshold and tolerance. Twelve proteins and 6 fatty acids were significantly associated with CPT after adjustment for possible confounding factors and correction for multiple comparisons. Of these, all fatty acids and 10 proteins were protective, ie, higher biomarkers levels were associated with increased CPT, whereas 2 biomarkers were associated with lower tolerance. Taken together, these biomarkers predicted completion of the tolerance test with a C-statistic of 0.65. Results for heat and pressure pain tolerance were remarkably similar, strengthening the generalizability of our findings. In this cohort of young healthy individuals, we found a relationship between inflammation-related biomarkers and pain tolerance and thresholds. Biomarkers with anti-inflammatory and analgesic effects predominated, suggesting that the development of prophylactic dietary or pharmaceutical treatments may be possible.

Longitudinal changes in body composition and waist circumference by self-reported levels of physical activity in leisure among adolescents: the Tromsø study, Fit Futures.

BACKGROUND: It is not clear how physical activity affects body composition in adolescents. Physical activity levels are often reduced during this period, and the relative proportion of body fat mass and lean mass undergo natural changes in growing adolescents. We aimed to examine whether self-reported physical activity in leisure time at baseline or change in activity during follow-up affect changes in four measures of body composition; body mass index (kg/m2), waist circumference, fat mass index (fat mass in kg/m2) and lean mass index (lean mass in kg/m2). METHODS: We used data from the Tromsø Study Fit Futures, which invited all first year students in upper secondary high school in two municipalities in northern Norway in 2010-2011. They were reexamined in 2012-2013. Longitudinal data was available for 292 boys and 354 girls. We used multiple linear regression analyses to assess whether self-reported level of physical activity in leisure time at baseline predicted changes in body composition, and analysis of covariance to assess the effects of change in level of activity during follow-up on change in body composition. All analyses were performed sex-specific, and a p-value of < 0.05 was considered statistically significant. RESULTS: There were no associations between self-reported leisure time physical activity in the first year of upper secondary high school and changes in any of the considered measure of body composition after 2 years of follow up, with the exception of waist circumference in boys (p = 0.05). In boys, change in fat mass index differed significantly between groups of activity change (p < 0.01), with boys adopting activity or remaining physically active having less increase in fat mass index than the consistently inactive. In girls, change in lean mass index differed significantly between groups of activity change (p = 0.04), with girls adopting physical activity having the highest increase. CONCLUSIONS: Self-reported leisure time physical activity does not predict changes in body composition in adolescents after 2 years of follow up. Change in the level of physical activity is associated with change in fat mass index in boys and lean mass index in girls.

Body Weight and Body Mass Index Influence Bone Mineral Density in Late Adolescence in a Two-Year Follow-Up Study. The Tromsø Study: Fit Futures.

Determinants of bone acquisition in late adolescence and early adulthood are not well-described. This 2-year follow-up study explored the associations of body weight (BW), body mass index (BMI), and changes in weight status with adolescent bone accretion in a sample of 651 adolescents (355 girls and 296 boys) between 15 and 19 years of age from The Tromsø Study: Fit Futures. This Norwegian population-based cohort study was conducted from 2010 to 2011 and was repeated from 2012 to 2013. We measured femoral neck, total hip, and total body bone mineral content and areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry. We measured height, BW, calculated BMI (kg/m 2), and collected information on lifestyle at both surveys. Mean BMI (SD) at baseline was 22.17 (3.76) and 22.18 (3.93) in girls and boys, respectively. Through multiple linear regression, baseline BW and BMI were positively associated with ∆aBMD over 2 years of follow-up at all skeletal sites in boys ( p < 0.05), but not in girls. ∆BW and ∆BMI predicted ∆aBMD and ∆BMC in both sexes, but the strength of the associations was moderate. Individuals who lost weight during follow-up demonstrated a slowed progression of aBMD accretion compared with those gaining weight, but loss of BW or reduction of BMI during 2 years was not associated with net loss of aBMD. In conclusion, our results confirm that adequate BW for height in late adolescence is important for bone health. Associations between change in weight status and bone accretion during follow-up were moderate and unlikely to have any clinical implication on adolescents of normal weight. Underweight individuals, particularly boys, are at risk of not reaching optimal peak bone mass and could benefit from an increase in BMI. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Urban-Rural Differences in Hip Fracture Mortality: A Nationwide NOREPOS Study.

Higher hip fracture incidence in urban than in rural areas has been demonstrated, but urban-rural differences in posthip fracture mortality have been less investigated, and the results are disparate. Hence, the aims of the present register-based cohort study were to examine possible urban-rural differences in short- and long-term mortality in Norwegian hip fracture patients and their potential associations with sociodemographic variables, and to investigate possible urban-rural differences in excess mortality in hip fracture patients compared with the general population. Data were provided from the NOREPOS hip fracture database, the 2001 Population and Housing Census, and the National Registry. The urbanization degree in each municipality was determined by the proportion of inhabitants living in densely populated areas (rural: <1/3, semirural: 1/3 to 2/3, and urban: >2/3). Age-adjusted mortality rates and standardized mortality ratios were calculated for hip fracture patients living in rural, semirural, and urban municipalities. A flexible parametric model was used to estimate age-adjusted average and time-varying HRs by category of urbanization with the rural category as reference. Among 96,693 hip fracture patients, urban residents had higher mortality than their rural-dwelling counterparts. The HR of mortality in urban compared with rural areas peaked during the first 1 to 2 years postfracture with a maximum HR of 1.20 (95% CI, 1.10 to 1.30) in men and 1.15 (95% CI, 1.08 to 1.21) in women. The differences were significant during approximately 5 years after fracture. Adjusting for sociodemographic variables did not substantially change the results. However, absolute 30-day mortality was not significantly different between urban and rural residents, suggesting that health-care quality immediately postfracture does not vary by urbanization. The novel findings of a higher long-term mortality in urban hip fracture patients might reflect disparities in health status or lifestyle, differences in posthip fracture health care or rehabilitation, or a combination of several factors. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

A cross-sectional and 6-year follow-up study of associations between leisure time physical activity and vertebral fracture in adults.

INTRODUCTION: Vertebral fractures are common osteoporotic fractures, affecting 2-46% of the population, causing morbidity and increased risk of mortality. Physical activity has beneficial effects for bone health, including increased bone mineral density and reduced hip fractures. However, evidence concerning prevention of vertebral fractures is scarce. Therefore, the aim of this study was to investigate the association between leisure time physical activity and vertebral fracture risk. METHODS: The data were retrieved from the 2001 and 2007-2008 surveys of the Tromsø Study, a longitudinal population study in Norway. A total of 1904 participants (1030 women and 874 men, age 38-87 yr and 40-87 yr respectively) were included in the cross-sectional analysis (2007-2008). Prospective follow-up data (2001 to 2007) on physical activity were available for 1131 participants (636 women and 495 men, age 32-69 yr and 33-69 yr respectively). Physical activity was assessed by a questionnaire and vertebral fracture by lateral vertebral fracture assessment from dual-energy x-ray absorptiometry scans. Logistic regression was used to examine associations between physical activity and vertebral fracture. RESULTS: After controlling for confounders (age, height, weight, smoking, osteoporosis, osteoporosis medication, left hip total bone mineral density, and use of hormones in women only), no cross-sectional associations between physical activity levels and vertebral fracture were observed, OR 1.13 (95% CI: 0.59-2.13), for moderately active women and 1.44 (0.61-3.42) for highly active women, compared with sedentary women. In men, the respective ORs were 1.74 (95% CI: 0.91-3.35) and 1.64 (0.78-3.41). In the prospective analyses, OR for vertebral fracture in women with reduced physical activity was 0.81 (95% CI: 0.18-3.62), 1.24 (95% CI: 0.29-5.26) for increased physical activity and 1.54 (95% CI: 0.43-5.50) for active unchanged physical activity pattern, compared with sedentary unchanged physical activity. In men, the respective ORs were 2.05 (95% CI: 0.57-7.42), 2.23 (95% CI: 0.63-7.87), and 1.81 (95% CI: 0.54-6.02). Subanalyses of women and men ≥50 yr showed similar results. CONCLUSIONS: Our findings suggest that physical activity does not play a major role in preventing vertebral fractures in Norwegian adults. Future studies may benefit from data on incident vertebral fracture, and objectively measured physical activity.

Correction: Violence Affects Physical and Mental Health Differently: The General Population Based Tromsø Study.

[This corrects the article DOI: 10.1371/journal.pone.0136588.].