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1.  Assessing fear of hypoglycemia in a population-based study among parents of children with type 1 diabetes – psychometric properties of the hypoglycemia fear survey – parent version 
In the treatment of childhood type 1 diabetes, being aware of the parents’ fear of hypoglycemia is important, since the parents’ fear may influence the management of treatment and the children’s blood glucose regulation. The availability of proper instruments to assess the parents’ fear of hypoglycemia is essential. Thus, the aim of this study was to examine the psychometric properties of the Hypoglycemia Fear Survey – Parent version (HFS-P).
In a Norwegian population-based sample, 176 parents representing 102 children with type 1 diabetes (6–15 years old) completed the HFS-P, comprising a 15-item worry subscale and a 10-item behavior subscale. We performed exploratory and confirmatory factor analysis and further analysis of the scales’ construct validity, content validity and reliability.
The Norwegian version of the HFS-P had an acceptable factor structure and internal consistency for the worry subscale, whereas the structure and internal consistency of the behavior subscale was more questionable. The HFS-P subscales were significantly correlated (from moderately to weakly) with symptoms of emotional distress, as measured by the Hopkins Symptom Checklist – 25 items. The mothers scored higher than fathers on both HFS-P subscales, but the difference was not statistically significant for the worry subscale.
The HFS-P worry subscale seems to be a valid scale for measuring anxiety-provoking aspects of hypoglycemia, and the validity of the HFS-P behavior subscale needs to be investigated further.
PMCID: PMC4324848  PMID: 25599725
Hypoglycemia; Fear; Parents; HFS; HFS-P; Reliability; Validity
2.  Violence against children, later victimisation, and mental health: a cross-sectional study of the general Norwegian population 
European Journal of Psychotraumatology  2015;6:10.3402/ejpt.v6.26259.
Violence in childhood is associated with mental health problems and risk of revictimisation. Less is known about the relative importance of the various types of childhood and adult victimisation for adult mental health.
To estimate the associations between various types of childhood and adult violence exposure, and their combined associations to adult mental health.
This study was a cross-sectional telephone survey of the Norwegian adult population; 2,435 women and 2,092 men aged 18–75 participated (19.3% of those we tried to call and 42.9% of those who answered the phone). The interview comprised a broad array of violence exposure in both childhood and adulthood. Anxiety/depression was measured by the Hopkins Symptom Check List (HSCL-10).
Victimisation was commonly reported, for example, child sexual abuse (women: 10.2%, men: 3.5%), childhood–parental physical violence (women: 4.9%, men: 5.1%), and lifetime forcible rape (women: 9.4%, men: 1.1%). All categories of childhood violence were significantly associated with adult victimisation, with a 2.2–5.0 times higher occurrence in exposed children (p<0.05 for all associations). Anxiety/depression (HSCL-10) associated with adult abuse increased with the number of childhood violence categories experienced (p<0.001). All combinations of childhood violence were significantly associated with anxiety/depression (p<0.001 for all associations). Individuals reporting psychological violence/neglect had the highest levels of anxiety/depression.
Results should be interpreted in light of the low response rate. Childhood violence in all its forms was a risk factor for victimisation in adulthood. Adult anxiety/depression was associated with both the number of violence categories and the type of childhood violence experienced. A broad assessment of childhood and adult violence exposure is necessary both for research and prevention purposes. Psychological violence and neglect should receive more research attention, especially in combination with other types of violence.
PMCID: PMC4296052  PMID: 25591729
Violence; child abuse; child sexual abuse; rape; mental health; revictimisation; epidemiology; anxiety; depression
3.  Time to discontinuation of antipsychotic drugs in a schizophrenia cohort: influence of current treatment strategies 
Rates of discontinuation of antipsychotic treatment for patients with schizophrenia are high and evidence is limited by selective inclusion and high attrition in randomized controlled trials.
To study time to discontinuation of antipsychotic treatment for patients with schizophrenia.
All patients with schizophrenia (n = 396) discharged between 2005 and 2011 were followed until discontinuation (clinician or patient decided) of antipsychotic treatment or other endpoints. Univariate and multivariate survival analyses (with time on antipsychotic treatment as the dependent variable) using time-dependent variables were performed.
Clozapine displayed lower risk for all-cause (p < 0.001), clinician-decided (p = 0.012) and patient-decided (p = 0.039) discontinuation versus olanzapine oral treatment in the multivariate Cox regression. Second-generation long-acting injection antipsychotics (LAI) (p = 0.015) and first-generation long-acting injection antipsychotics (p = 0.013) showed significantly lower risks for patient-decided discontinuation than olanzapine oral.
Higher effectiveness of clozapine and LAI treatment versus oral olanzapine were identified in a clinical cohort of patients with schizophrenia.
PMCID: PMC4257983  PMID: 25489474
schizophrenia; antipsychotic; clozapine; treatment discontinuation; long-acting injection antipsychotics (LAI)
4.  A Prospective Study of the Potential Moderating Role of Social Support in Preventing Marginalization Among Individuals Exposed to Bullying and Abuse in Junior High School 
Journal of Youth and Adolescence  2014;43(10):1642-1657.
Negative physical and psychological long-term consequences of abuse and bullying are well documented. It is reasonable to assume that abuse and bullying early in life also may have an impact on the ability to work and stay economically independent later in life, but such prospective studies are lacking. This study investigates the consequences of exposure to abuse and bullying in junior high school, as measured by receiving long-term social welfare benefits in young adulthood. In addition, it explores the potential protective role of social support. Self-reported data from 13,633 (50.3 % female) junior high school students were linked to registry data on their use of social welfare benefits from the age of 18 and for eight consecutive years. Cox regression analyses were applied to test the relationship between exposure to life adversities and the use of social welfare benefits, and the potential moderating role of social support. The analyses showed that individuals exposed to abuse and bullying had an increased likelihood of receiving social-welfare benefits compared with individuals not exposed to these types of abuse. Exposure to multiple types of abuse led to a higher likelihood of using social welfare benefits compared with single types of abuse and no abuse. The findings on the potential moderating role of social support were mixed, depending on the source of social support. Family support and classmate relationships were protective in reducing the likelihood of the use of social welfare benefits, whereas peer and teachers’ support showed inconsistent patterns. These results are promising in terms of preventing the long-term negative consequences of abuse and bullying.
PMCID: PMC4162984  PMID: 24985489
Abuse; Bullying; Longitudinal; Social support; Use of social welfare benefits; Marginalization
5.  The change and the mediating role of parental emotional reactions and depression in the treatment of traumatized youth: results from a randomized controlled study 
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has been shown to efficiently treat children and youth exposed to traumatizing events. However, few studies have looked into mechanisms that may distinguish this treatment from other treatments. The objective of this study was to investigate whether the parents’ emotional reactions and depressive symptoms change over the course of therapy in the treatment conditions of TF-CBT and Therapy as Usual (TAU), and whether changes in the reactions mediate the difference between the treatment conditions on child post-traumatic stress (PTS) symptoms and child depressive symptoms.
A sample of 135 caregivers of 135 traumatized children and youth (M age = 14.8, SD = 2.2, 80% girls) was randomly assigned to receive either TF-CBT or TAU. The parents’ emotional reactions were measured using the Parental Emotional Reaction Questionnaire (PERQ), and their depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). The children’s outcomes were post-traumatic stress (PTS) reactions and depression, as measured by the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) and Mood and Feelings Questionnaire (MFQ), respectively.
The parents’ emotional reactions and depressive symptoms decreased significantly from pre- to post-therapy, but no significant differences between the two treatment conditions were found. The changes in reactions did not significantly mediate the treatment difference between TF-CBT and TAU on child PTS symptoms. However a mediating effect was found on child depressive symptoms.
The results showed that although the parents experienced reductions in emotional reactions and depressive symptoms when their child received therapy, this was only significantly related to the difference in outcome between TF-CBT and TAU on child depressive symptoms. Possible explanations for these results are discussed along with the implications for clinicians and suggestions for future research.
Trial registration
Clinical Trials identifier: NCT00635752
PMCID: PMC4005459  PMID: 24712976
Parents; Emotional reactions; Trauma treatment; Children and adolescents
6.  Mental health problems in the 10th grade and non-completion of upper secondary school: the mediating role of grades in a population-based longitudinal study 
BMC Public Health  2014;14:16.
School drop-out is a problem all over the world with adverse life-course consequences. The aim of this paper is to study how internalising and externalising problems in the 10th grade are associated with non-completion of upper secondary school, and to examine the mediating role of grade points in the 10th grade across general academic and vocational tracks in upper secondary school. We also study the impact of health behaviour.
Population-based health surveys were linked with Norwegian registries on education and sociodemographic factors (n = 10 931). Mental health was assessed by the self-report Strengths and Difficulties Questionnaire. Logistic regression was used to analyse the relations between mental health and health behaviour in 10th grade and non-completion of upper secondary school. The mediating effect of grade points was studied by causal mediation analysis.
Adolescents not completing upper secondary school reported more externalising problems and girls more internalising problems in the 10th grade, after adjustments. Smoking and physical inactivity increased the odds of non-completion of upper secondary school. Causal mediation analyses showed that a reduction in externalising problems of 10 percentage points led to lower rates of non-completion of 4–5 percentage points, and about three-quarters of this total effect was mediated by grades. For internalising problems the total effect was significant only for girls (1 percentage point), and the mediated effect of grades was about 30%. The effect of mental health problems on school dropout was mainly the same in both vocational and general tracks.
Assuming a causal relationship from mental health problems to school performance, this study suggests that externalising problems impair educational attainment. A reduction of such problems may improve school performance, reduce school drop-out and reduce the adverse life-course consequences.
PMCID: PMC3905670  PMID: 24406098
7.  Anxiety, depression and behavioral problems among adolescents with recurrent headache: the Young-HUNT study 
It is well documented that both anxiety and depression are associated with headache, but there is limited knowledge regarding the relation between recurrent primary headaches and symptoms of anxiety and depression as well as behavioral problems among adolescents. Assessment of co-morbid disorders is important in order to improve the management of adolescents with recurrent headaches. Thus the main purpose of the present study was to assess the relationship of recurrent headache with anxiety and depressive symptoms and behavioral problems in a large population based cross-sectional survey among adolescents in Norway.
A cross-sectional, population-based study was conducted in Norway from 1995 to 1997 (Young-HUNT1). In Young-HUNT1, 4872 adolescents aged 12 to 17 years were interviewed about their headache complaints and completed a comprehensive questionnaire that included assessment of symptoms of anxiety and depression and behavioral problems, i.e. conduct and attention difficulties.
In adjusted multivariate analyses among adolescents aged 12–14 years, recurrent headache was associated with symptoms of anxiety and depression (OR: 2.05, 95% CI: 1.61-2.61, p < 0.001), but not with behavioral problems. A significant association with anxiety and depressive symptoms was evident for all headache categories; i.e. migraine, tension-type headache and non-classifiable headache. Among adolescents aged 15–17 years there was a significant association between recurrent headache and symptoms of anxiety and depression (OR: 1.64, 95% CI: 1.39-1.93, p < 0,001) and attention difficulties (OR: 1.25, 95% CI: 1.09-1.44, p =0.001). For migraine there was a significant association with both anxiety and depressive symptoms and attention difficulties, while tension-type headache was significantly associated only with symptoms of anxiety and depression. Non-classifiable headache was associated with attention difficulties and conduct difficulties, but not with anxiety and depressive symptoms. Headache frequency was significantly associated with increasing symptoms scores for anxiety and depressive symptoms as well as attention difficulties, evident for both age groups.
The results from the present study indicate that both anxiety and depressive symptoms and behavioral problems are associated with recurrent headache, and should accordingly be considered a part of the clinical assessment of children and adolescents with headache. Identification of these associated factors and addressing them in interventions may improve headache management.
PMCID: PMC4062897  PMID: 24925252
Recurrent headache; Migraine; Tension-type headache; Anxiety; Depression; Behavioral problems; Conduct difficulties; Attention difficulties; Adolescents
8.  Recurrent headache and interpersonal violence in adolescence: the roles of psychological distress, loneliness and family cohesion: the HUNT study 
Recurrent headache is the most common and disabling pain condition in adolescence. Co-occurrence of psychosocial adversity is associated with increased risk of chronification and functional impairment. Exposure to interpersonal violence seems to constitute an important etiological factor. Thus, knowledge of the multiple pathways linking interpersonal violence to recurrent headache could help guide preventive and clinical interventions. In the present study we explored a hypothetical causal model where the link between exposure to interpersonal violence and recurrent headache is mediated in parallel through loneliness and psychological distress. Higher level of family cohesion and male sex is hypothesized to buffer the adverse effect of exposure to interpersonal violence on headache.
The model was assessed using data from the cross-sectional, population-based Young-HUNT 3 study of Norwegian adolescents, conducted from 2006–2008. A cohort of 10 464 adolescents were invited. The response rate was 73% (7620), age ranged from 12 and 20 years, and 50% (3832) were girls. The study comprised self-report measures of exposure to interpersonal violence, loneliness, psychological distress and family cohesion, in addition to a validated interview on headache, meeting the International Classification of Headache Disorders criteria. Recurrent headache was defined as headache recurring at least monthly during the past year, and sub-classified into monthly and weekly headache, which served as separate outcomes.
In Conditional Process Analysis, loneliness and psychological distress consistently posed as parallel mediating mechanisms, indirectly linking exposure to interpersonal violence to recurrent headache. We found no substantial moderating effect of family cohesion or sex.
Loneliness and psychological distress seem to play crucial roles in the relationship between exposure to interpersonal violence and recurrent headache. To facilitate coping and recovery, it may be helpful to account for these factors in preventive and clinical interventions. Trauma-informed, social relationship-based interventions may represent a major opportunity to alter trajectories of recurrent headache.
PMCID: PMC4085726  PMID: 24912800
Interpersonal violence; Sexual abuse; Bullying; Loneliness; Social isolation; Psychological distress; Family cohesion; Social support; Recurrent headache
9.  Sperm counts and endocrinological markers of spermatogenesis in long-term survivors of testicular cancer 
British Journal of Cancer  2012;107(11):1833-1839.
The objective of this study was to assess markers of spermatogenesis in long-term survivors of testicular cancer (TC) according to treatment, and to explore correlations between the markers and associations with achieved paternity following TC treatment.
In 1191 TC survivors diagnosed between 1980 and 1994, serum-follicle stimulating hormone (s-FSH; n=1191), s-inhibin B (n=441), and sperm counts (millions per ml; n=342) were analysed in a national follow-up study in 1998–2002. Paternity was assessed by a questionnaire.
At median 11 years follow-up, 44% had oligo- (<15 millions per ml; 29%) or azoospermia (15%). Sperm counts and s-inhibin B were significantly lower and s-FSH was higher after chemotherapy, but not after radiotherapy (RT), when compared with surgery only. All measures were significantly more abnormal following high doses of chemotherapy (cisplatin (Cis)>850 mg, absolute cumulative dose) compared with lower doses (Cis ⩽850 mg). Sperm counts were moderately correlated with s-FSH (−0.500), s-inhibin B (0.455), and s-inhibin B : FSH ratio (−0.524; all P<0.001). All markers differed significantly between those who had achieved post-treatment fatherhood and those with unsuccessful attempts.
The RT had no long-term effects on the assessed markers of spermatogenesis, whereas chemotherapy had. At present, the routine evaluation of s-inhibin B adds little in the initial fertility evaluation of TC survivors.
PMCID: PMC3504949  PMID: 23169336
germ cell tumour; inhibin B; late effects; paternity; spermatogenesis; testicular cancer
10.  Potentially traumatic interpersonal events, psychological distress and recurrent headache in a population-based cohort of adolescents: the HUNT study 
BMJ Open  2013;3(7):e002997.
Recurrent headache co-occurs commonly with psychological distress, such as anxiety or depression. Potentially traumatic interpersonal events (PTIEs) could represent important precursors of psychological distress and recurrent headache in adolescents. Our objective was to assess the hypothesised association between exposure to PTIEs and recurrent migraine and tension-type headache (TTH) in adolescents, and to further examine the potential impact of psychological distress on this relationship.
Population-based, cross-sectional cohort study. The study includes self-reported data from youth on exposure to potentially traumatic events, psychological distress and a validated interview on headache.
The adolescent part of the Nord-Trøndelag Health Study 2006–2008 (HUNT), conducted in Norway.
A cohort of 10 464 adolescents were invited to the study. Age ranged from 12 to 20 years. The response rate was 73% (7620), of whom 50% (3832) were girls.
Main outcome measures
Data from the headache interview served as the outcome. Recurrent headache was defined as headache recurring at least monthly during the past year, and was subclassified into monthly, weekly and daily complaints. Subtypes were classified as TTH, migraine, migraine with TTH and/or non-classifiable headache, in accordance with the International Classification of Headache Disorders criteria, second edition.
Multiple logistic regression analysis, adjusted for sociodemographics, showed consistently significant associations between exposure to PTIEs and recurrent headache, regardless of the frequency or subtype of headache. Increasing exposure to PTIEs was associated with higher prevalence of recurrent headache, indicating a dose–response relationship. The strength of associations between exposure to PTIEs and all recurrent headache disorders was significantly attenuated when psychological distress was entered into the regression equation.
The empirical evidence of a strong and cumulative relationship between exposure to PTIEs, psychological distress and recurrent headache indicates a need for the integration of somatic and psychological healthcare services for adolescents in the prevention, assessment and treatment of recurrent headache. Prospective studies are needed.
PMCID: PMC3731723  PMID: 23901028
Public Health
11.  Vinorelbine and gemcitabine vs vinorelbine and carboplatin as first-line treatment of advanced NSCLC. A phase III randomised controlled trial by the Norwegian Lung Cancer Study Group 
British Journal of Cancer  2012;107(3):442-447.
Platinum-based doublet chemotherapy is the standard first-line treatment for advanced non-small cell lung cancer (NSCLC), but earlier studies have suggested that non-platinum combinations are equally effective and better tolerated. We conducted a national, randomised study to compare a non-platinum with a platinum combination.
Eligible patients had stage IIIB/IV NSCLC and performance status (PS) 0–2. Patients received up to three cycles of vinorelbine 60 mg m−2 p.o.+gemcitabine 1000 mg m−2 i.v. day 1 and 8 (VG) or vinorelbine 60 mg m−2 p.o. day 1 and 8+carboplatin area under the curve=5 (Calvert's formula) i.v. day 1 (VC). Patients ⩾75 years received 75% of the dose. Endpoints were overall survival, health-related quality of life (HRQoL), toxicity, and the use of radiotherapy.
We randomised 444 patients from September 2007 to April 2009. The median age was 65 years, 58% were men and 25% had PS 2. Median survival was VG: 6.3 months; VC: 7.0 months, P=0.802. Vinorelbine plus carboplatin patients had more grade III/IV nausea/vomiting (VG: 4%, VC: 12%, P=0.008) and grade IV neutropenia (VG: 7%, VC: 19%, P<0.001). Infections, HRQoL and the use of radiotherapy did not differ significantly between the treatment groups.
The two regimens yielded similar overall survival. The VG combination had only a slightly better toxicity profile.
PMCID: PMC3405221  PMID: 22759880
advanced NSCLC; vinorelbine; gemcitabine; carboplatin; lung cancer; palliative chemotherapy
12.  Lower treatment intensity and poorer survival in metastatic colorectal cancer patients who live alone 
British Journal of Cancer  2012;107(1):189-194.
Socioeconomic status (SES) and social support influences cancer survival. If SES and social support affects cancer treatment has not been thoroughly explored.
A cohort consisting of all patients who were initially diagnosed with or who developed metastatic colorectal cancer (mCRC, n=781) in three Scandinavian university hospitals from October 2003 to August 2006 was set up. Clinical and socioeconomic data were registered prospectively.
Patients living alone more often had synchronous metastases at presentation and were less often treated with combination chemotherapy than those cohabitating (HR 0.19, 95% CI 0.04–0.85, P=0.03). Surgical removal of metastases was less common in patients living alone (HR 0.29, 95% CI 0.10–0.86, P=0.02) but more common among university-educated patients (HR 2.22, 95% CI 1.10–4.49, P=0.02). Smoking, being married and having children did not influence treatment or survival. Median survival was 7.7 months in patients living alone and 11.7 months in patients living with someone (P<0.001). Living alone remained a prognostic factor for survival after correction for age and comorbidity.
Patients living alone received less combination chemotherapy and less secondary surgery. Living alone is a strong independent risk factor for poor survival in mCRC.
PMCID: PMC3389401  PMID: 22576591
colorectal cancer; socioeconomic status; education; living alone; social support; comorbidity
13.  Secular reduction of excess mortality in hip fracture patients >85 years 
BMC Geriatrics  2013;13:25.
More than 20% of the hip fracture patients die within the first year after the incident. Few data are available on the trends in mortality following a hip fracture. The present aim was to study changes in excess mortality after hip fracture from 1978/79 up to 1996/97.
Data on 5180 hip fracture patients aged ≥ 50 years, identified in three earlier, well validated, incidence studies from Oslo were used. The studies took place in the two years periods 1978–79 and 1989–89 and in a one year period from 1st of May 1996 to 30th of April 1997. The study was designed as a historic cohort study. Exposure was sustaining a hip fracture in the registration periods. Outcome was death of all causes. Age- and sex-specific one year-mortality rates were provided by Statistics Norway. Standardized mortality ratios (SMR) were calculated for the three cohorts for each sex and age-group, for the 0–6 months, 6–12 months, 0–1 year, 1–5 years and 5–10 years intervals after fracture. To assess the duration of the excess mortality in hip fracture patients, time-framed Kaplan-Meier curves for consecutive 5-years intervals were conducted for the hip fracture patients and the corresponding background population. Only patients still alive at the start of the time interval were included. One sample log rank tests were used to test for statistical significance.
The one-year SMR ranged from 3.64 (2.82 – 4.61) to 4.53 (3.67 – 5.54) in men and from 2.78 (2.39 – 3.19) to 3.60 (3.19 – 4.05) in women. In the 0–6 months interval a reduction in SMR from 1978/79 to 1996/97 was observed in women aged ≥85 years. The duration of excess mortality ranged from two years in men ≥85 years to more than ten years in men and women aged 65–84 years.
Excess mortality among hip fracture patients remains high. Over the decades, a reduced excess mortality was mainly seen in the oldest patients, suggesting that specific efforts intending to improve prevention and treatment of osteoporosis and osteoporotic fractures in the youngest elderly are required.
PMCID: PMC3610125  PMID: 23496953
14.  Changes in alcohol consumption after a natural disaster: a study of Norwegian survivors after the 2004 Southeast Asia tsunami 
BMC Public Health  2013;13:58.
Many studies suggest that disaster exposure is related to a subsequent increase in alcohol consumption. Most of these studies have relied on retrospective self-reports to measure changes in alcohol use. The aim of the present study was to examine the association between disaster exposure and drinking behaviors more closely, analyzing data on both self-perceived changes in alcohol consumption and current drinking habits in groups with different extents of disaster exposure.
A sample of Norwegian adults (≥ 18 years) who resided in areas affected by the 2004 Southeast Asia tsunami (N = 899) were assessed by a postal questionnaire 6 months after the disaster. Based on detailed questions about experiences with the tsunami, participants were grouped according to their extent of disaster exposure. The Impact of Event Scale-Revised was applied to measure the level of post-traumatic stress. Participants were asked whether they had increased or decreased their alcohol consumption after the disaster. Moreover, weekly alcohol consumption and frequency of intoxication during the past month were used as indicators of current drinking behaviors.
Severely exposed individuals more often reported changing their alcohol consumption compared with those who were less exposed. Severe exposure to the tsunami was associated with both a self-perceived increase (OR 21.38, 95% CI 2.91–157.28) and decrease in alcohol consumption (OR 7.41, 95% CI 1.74–31.51). The odds ratios decreased and were not significant when adjusting for post-traumatic stress symptoms. Weekly consumption and frequency of intoxication during the past month did not vary with extent of disaster exposure.
Our findings indicate a polarization effect of severe disaster exposure on self-perceived changes in alcohol consumption; that is, disaster exposure was associated with self-perceived increases and decreases in drinking. However, the absence of associations between disaster exposure and indicators of current drinking behaviors suggests that the observed polarization effect may be overestimated because of attribution and recall bias.
PMCID: PMC3560117  PMID: 23336627
Alcohol use; Disasters; Post-traumatic stress; Epidemiology
15.  The day Norway cried: Proximity and distress in Norwegian citizens following the 22nd July 2011 terrorist attacks in Oslo and on Utøya Island 
European Journal of Psychotraumatology  2012;3:10.3402/ejpt.v3i0.19709.
Terrorism may create fear and stress reactions not only in the direct victims, but also in the general population.
This study investigated emotional responses in the Norwegian population following the 22nd July 2011 terrorist attacks. We hypothesized that Oslo residents would report a higher level of fear responses compared with people living outside Oslo and that proximity would be associated with early distress and later post-traumatic stress reactions.
Representative samples were drawn from the Norwegian Population Registry. Telephone interviews were conducted 4–5 months after the attacks. The response rate for the Oslo sample (N=465) was 24% of the total sample, and 43% of those who were actually reached by phone and asked to participate. Corresponding figures for the sample living outside Oslo (N=716) were 19% and 30%.
Our results show strong immediate emotional responses, particularly sadness and a feeling of unreality, in both samples. Jumpiness and other fear responses were significantly higher among Oslo residents. Current level of risk perception was low 4–5 months after the attacks; however, a significant minority reported to feel less safe than before. Geographical and psychological proximity were associated with early emotional responses. Psychological proximity was significantly associated with post-traumatic stress reactions, while measures of geographical proximity were not. Immediate emotional responses, first-week reactions, and first-week jumpiness were uniquely and significantly associated with post-traumatic stress reactions. Post-traumatic stress reactions were elevated in ethnic minorities.
The terrorist attacks seem to have had a significant effect on the Norwegian population, creating sadness and insecurity, at least in the short term. Proximity to the terrorist attacks was strongly associated with distress in the population, and early distress was strongly related to later post-traumatic stress reactions. Our results indicate that psychological proximity is more strongly associated with post-traumatic stress reactions than geographical proximity, and underline the importance of differentiated measurements of various aspects of early distress.
PMCID: PMC3520479  PMID: 23236567
terrorism; PTSD; emotions; safety; epidemiology
16.  Posttraumatic growth, depressive symptoms, posttraumatic stress symptoms, post-migration stressors and quality of life in multi-traumatized psychiatric outpatients with a refugee background in Norway 
Psychiatric outpatients with a refugee background have often been exposed to a variety of potentially traumatizing events, with numerous negative consequences for their mental health and quality of life. However, some patients also report positive personal changes, posttraumatic growth, related to these potentially traumatic events. This study describes posttraumatic growth, posttraumatic stress symptoms, depressive symptoms, post-migration stressors, and their association with quality of life in an outpatient psychiatric population with a refugee background in Norway.
Fifty five psychiatric outpatients with a refugee background participated in a cross-sectional study using clinical interviews to measure psychopathology (SCID-PTSD, MINI), and four self-report instruments measuring posttraumatic growth, posttraumatic stress symptoms, depressive symptoms, and quality of life (PTGI-SF, IES-R, HSCL-25-depression scale, and WHOQOL-Bref) as well as measures of social integration, social network and employment status.
All patients reported some degree of posttraumatic growth, while only 31% reported greater amounts of growth. Eighty percent of the patients had posttraumatic stress symptoms above the cut-off point, and 93% reported clinical levels of depressive symptoms. Quality of life in the four domains of the WHOQOL-Bref levels were low, well below the threshold for the’life satisfaction’ standard proposed by Cummins.
A hierarchic regression model including depressive symptoms, posttraumatic stress symptoms, posttraumatic growth, and unemployment explained 56% of the total variance found in the psychological health domain of the WHOQOL-Bref scale. Posttraumatic growth made the strongest contribution to the model, greater than posttraumatic stress symptoms or depressive symptoms. Post-migration stressors like unemployment, weak social network and poor social integration were moderately negatively correlated with posttraumatic growth and quality of life, and positively correlated with psychopathological symptoms. Sixty percent of the outpatients were unemployed.
Multi-traumatized refugees in outpatient clinics reported both symptoms of psychopathology and posttraumatic growth after exposure to multiple traumatic events. Symptoms of psychopathology were negatively related to the quality of life, and positively related to post-migration stressors such as unemployment, weak social network and poor social integration. Posttraumatic growth was positively associated with quality of life, and negatively associated with post-migration stressors. Hierarchical regression modeling showed that posttraumatic growth explained more of the variance in quality of life than did posttraumatic stress symptoms, depressive symptoms or unemployment. It may therefore be necessary to address both positive changes and psychopathological symptoms when assessing and treating multi-traumatized outpatients with a refugee background.
PMCID: PMC3416737  PMID: 22824521
17.  Reliability and validity of the Norwegian child and parent versions of the DISABKIDS Chronic Generic Module (DCGM-37) and Diabetes-Specific Module (DSM-10) 
International guidelines on type 1 diabetes advocate routine screening of health-related quality of life (HRQOL). DISABKIDS questionnaires are the first instruments developed across cultures and nations to provide age-appropriate measures of HRQOL in children with chronic diseases. DISABKIDS includes a Chronic Generic Module 37 (DCGM-37) and disease-specific modules. The purpose of this study was to examine reliability and validity of the Norwegian versions of the DISABKIDS questionnaires in children and adolescents with type 1 diabetes.
The DCGM-37 and the Diabetes Specific Module-10 (DDM-10) were translated into Norwegian using standard forward-backward translation. Eight to 19 year old children and adolescents with type 1 diabetes scheduled for routine follow-up at three diabetic clinics in Norway and one of their parents were invited to complete the DCGM-37 and the DDM-10. Internal consistency was determined using Cronbach's alpha. Results were compared with those of the Child Health Questionnaire Children Form-87 (CHQ-CF87) and Child Health Questionnaire Parent Form-50 which are established generic questionnaires. DISABKIDS results were related to age, gender, duration of diabetes, mode of insulin delivery and metabolic control. Clinical data were obtained from the Norwegian Childhood Diabetes Registry.
Of 198 eligible child-parent dyads, 103 (52%) completed the questionnaires. Mean age was 13.6 (2.6), range 8-19 yrs, 52% were boys. Cronbach's alpha was > 0.70 for all the DISABKIDS sub-scales except two (physical ability and social inclusion). There were moderate to high correlations (0.65-0.81) between the DISABKIDS scales and mental/emotional sub-scales of CHQ-CF87. Increasing age and higher HbA1c were significantly associated with reduced HRQOL scores. Parents tended to score their child's HRQOL lower than the children/adolescents themselves.
The study shows that the DISABKIDS instruments are applicable to a Norwegian childhood diabetes population. They seem to be a relevant supplement to other clinical indicators in medical practice and research.
PMCID: PMC3296581  PMID: 22300248
Health-related quality of life; Type 1 diabetes; Children; Adolescents; Psychometrics; Reliability; Validity; DISABKIDS
18.  Psychosocial family factors and glycemic control among children aged 1-15 years with type 1 diabetes: a population-based survey 
BMC Pediatrics  2011;11:118.
Being the parents of children with diabetes is demanding. Jay Belsky's determinants of parenting model emphasizes both the personal psychological resources, the characteristics of the child and contextual sources such as parents' work, marital relations and social network support as important determinants for parenting. To better understand the factors influencing parental functioning among parents of children with type 1 diabetes, we aimed to investigate associations between the children's glycated hemoglobin (HbA1c) and 1) variables related to the parents' psychological and contextual resources, and 2) frequency of blood glucose measurement as a marker for diabetes-related parenting behavior.
Mothers (n = 103) and fathers (n = 97) of 115 children younger than 16 years old participated in a population-based survey. The questionnaire comprised the Life Orientation Test, the Oslo 3-item Social Support Scale, a single question regarding perceived social limitation because of the child's diabetes, the Relationship Satisfaction Scale and demographic and clinical variables. We investigated associations by using regression analysis. Related to the second aim hypoglycemic events, child age, diabetes duration, insulin regimen and comorbid diseases were included as covariates.
The mean HbA1c was 8.1%, and 29% had HbA1c ≤ 7.5%. In multiple regression analysis, lower HbA1c was associated with higher education and stronger perceptions of social limitation among the mothers. A higher frequency of blood glucose measurement was significantly associated with lower HbA1c in bivariate analysis. Higher child age was significantly associated with higher HbA1c both in bivariate and multivariate analysis. A scatterplot indicated this association to be linear.
Most families do not reach recommended treatment goals for their child with type 1 diabetes. Concerning contextual sources of stress and support, the families who successfully reached the treatment goals had mothers with higher education and experienced a higher degree of social limitations because of the child's diabetes. The continuous increasing HbA1c by age, also during the years before puberty, may indicate a need for further exploring the associations between child characteristics, context-related variables and parenting behavior such as factors facilitating the transfer of parents' responsibility and motivation for continued frequent treatment tasks to their growing children.
PMCID: PMC3282662  PMID: 22185481
19.  Family structure and posttraumatic stress reactions: a longitudinal study using multilevel analyses 
BMC Psychiatry  2011;11:195.
There is limited research on the relevance of family structures to the development and maintenance of posttraumatic stress following disasters. We longitudinally studied the effects of marital and parental statuses on posttraumatic stress reactions after the 2004 Southeast Asian tsunami and whether persons in the same households had more shared stress reactions than others.
The study included a tourist population of 641 Norwegian adult citizens, many of them from families with children. We measured posttraumatic stress symptoms with the Impact of Event Scale-Revised at 6 months and 2 years post-disaster. Analyses included multilevel methods with mixed effects models.
Results showed that neither marital nor parental status was significantly related to posttraumatic stress. At both assessments, adults living in the same household reported levels of posttraumatic stress that were more similar to one another than adults who were not living together. Between households, disaster experiences were closely related to the variance in posttraumatic stress symptom levels at both assessments. Within households, however, disaster experiences were less related to the variance in symptom level at 2 years than at 6 months.
These results indicate that adult household members may influence one another's posttraumatic stress reactions as well as their interpretations of the disaster experiences over time. Our findings suggest that multilevel methods may provide important information about family processes after disasters.
PMCID: PMC3280194  PMID: 22171549
family structure; multilevel analyses; posttraumatic stress reactions; PTSD; tsunami
20.  A proposed method to investigate reliability throughout a questionnaire 
Questionnaires are used extensively in medical and health care research and depend on validity and reliability. However, participants may differ in interest and awareness throughout long questionnaires, which can affect reliability of their answers. A method is proposed for "screening" of systematic change in random error, which could assess changed reliability of answers.
A simulation study was conducted to explore whether systematic change in reliability, expressed as changed random error, could be assessed using unsupervised classification of subjects by cluster analysis (CA) and estimation of intraclass correlation coefficient (ICC). The method was also applied on a clinical dataset from 753 cardiac patients using the Jalowiec Coping Scale.
The simulation study showed a relationship between the systematic change in random error throughout a questionnaire and the slope between the estimated ICC for subjects classified by CA and successive items in a questionnaire. This slope was proposed as an awareness measure - to assessing if respondents provide only a random answer or one based on a substantial cognitive effort. Scales from different factor structures of Jalowiec Coping Scale had different effect on this awareness measure.
Even though assumptions in the simulation study might be limited compared to real datasets, the approach is promising for assessing systematic change in reliability throughout long questionnaires. Results from a clinical dataset indicated that the awareness measure differed between scales.
PMCID: PMC3203093  PMID: 21974842
21.  Effects of In Vitro HIV-1 Infection on Mycobacterial Growth in Peripheral Blood Monocyte-Derived Macrophages▿  
Infection and Immunity  2010;78(9):4022-4032.
Coinfection with human immunodeficiency virus type 1 (HIV-1) and opportunistic mycobacteria, especially Mycobacterium tuberculosis, is a cause of high morbidity and mortality worldwide. Both mycobacteria and HIV-1 may infect macrophages, and thus, coinfection may generate conditions that reciprocally influence the intracellular replication of the pathogens. Elucidation of the interaction between HIV-1 and mycobacteria in their common target cell is important for understanding pathogenesis in coinfected individuals. In this study, we investigated the effects of in vitro HIV-1 infection on the growth of M. tuberculosis, M. avium, and M. paratuberculosis in human peripheral blood monocyte-derived macrophages. Interestingly, HIV-1 infection induced a greater bacterial burden in coinfected cell cultures for all of the mycobacterial species tested and specifically induced accelerated growth of M. tuberculosis with a reduced mean generation time. The interaction of HIV-1 and M. tuberculosis was especially detrimental to the host cell, causing a significant synergistic reduction in macrophage viability. Also, in M. tuberculosis/HIV-1-coinfected cultures, increased levels of interleukin-1β (IL-1β), IL-6, IL-8, and granulocyte-macrophage colony-stimulating factor were observed and viral replication was enhanced. Overall, the present data suggest that HIV-1 infection of macrophages may impair their ability to contain mycobacterial growth. Furthermore, coinfection with HIV-1 and M. tuberculosis seems to give rise to synergistic effects at the cellular level that mutually enhance the replication of both pathogens. This may, in part, contribute to the increased morbidity and mortality seen in coinfected individuals.
PMCID: PMC2937445  PMID: 20624908
22.  Paternal predictors of the mental health of children of Vietnamese refugees 
Intergenerational transmission of trauma as a determinant of mental health has been studied in the offspring of Holocaust survivors and combat veterans, and in refugee families. Mainly negative effects on the children are reported, while a few studies also describe resilience and a possible positive transformation process. A longitudinal prospective cohort study of Vietnamese refugees arriving in Norway in 1982 reports a 23 years follow-up, including spouses and children born in Norway, to study the long-term effects of trauma, flight, and exile on the offspring of the refugees.
Objectives of the study:
1. To study the association between the psychological distress of Vietnamese refugee parents and their children after 23 years resettlement.
2. To analyse paternal predictors for their children's mental health.
Information from one or both parents at arrival in 1982 (T1), at follow-up in 1985 (T2), and 23 years after arrival (T3) was included. The mental health was assessed by the Global Severity Index (GSI) of the self-report Symptom Check List-90-R (SCL-90-R) for parents (n = 88) and older children (age 19-23 yrs, n = 12), while children aged 4-18 (n = 94) were assessed using the Strengths and Difficulties Questionnaire (SDQ).
Thirty percent of the families had one parent with a high psychological distress score ("probable caseness" for a mental disorder), while only 4% of the children aged 10 - 23 years were considered as probable cases. In spite of this, there was an association between probable caseness in children and in fathers at T3. A significant negative paternal predictor for the children's mental health at T3 was the father's PTSD at arrival in Norway, while a positive predictor was the father's participation in a Norwegian network three years after arrival.
Children of refugees cannot be globally considered at risk for mental health problems. However, the preceding PTSD in their fathers may constitute a specific risk for them.
PMCID: PMC3024952  PMID: 21219651
23.  Type 1 plasminogen activator inhibitor (PAI-1) in clear cell renal cell carcinoma (CCRCC) and its impact on angiogenesis, progression and patient survival after radical nephrectomy 
BMC Urology  2010;10:20.
To examine the expression of type 1 plasminogen inhibitor (PAI-1) in clear cell renal cell carcinoma (CCRCC), and its possible association with microvessel density (MVD), the expression of thrombospondin-1 (TSP-1), nuclear grade, tumour stage, continuously coded tumour size (CCTS) and to assess the value of PAI as a prognostic marker in 162 patients with CCRCC treated with radical nephrectomy.
A total of 172 consecutive patients with CCRCC treated with radical nephrectomy were enrolled in the study. The expression of PAI-1, TSP-1 and factor VIII were analysed on formalin-fixed, paraffin-embedded tissues without knowledge of the clinical outcome. Ten cases, where PAI-1 immunohistochemistry was not possible due to technical problems and lack of material, were excluded. Sixty-nine patients (43%) died of RCC, while 47 patients (29%) died of other diseases. Median follow-up was 13.8 years for the surviving 46 patients (28%).
Nine percent of the tumours showed PAI-1 positivity. High expression of PAI-1 was significantly inversely correlated with TSP-1 (p = 0.046) and directly with advanced stage (p = 0.008), high NG (3+4) (p = 0.002), tumour size (p = 0.011), microvessel density (p = 0.049) and disease progression (p = 0.002). In univariate analysis PAI-1 was a significant prognosticator of cancer-specific survival (CSS) (p < 0.001). Multivariate analysis revealed that TNM stage (p < 0.001), PAI-1 (p = 0.020), TSP-1 (p < 0.001) and MVD (p = 0.007) were independent predictors of CSS.
PAI-1 was found to be an independently significant prognosticator of CSS and a promoter of tumour angiogenesis, aggressiveness and progression in CCRCC.
PMCID: PMC3002359  PMID: 21129210
24.  Patient-reported outcomes as predictors of 10-year survival in women after acute myocardial infarction 
Patient-reported outcomes are increasingly seen as complementary to biomedical measures. However, their prognostic importance has yet to be established, particularly in female long-term myocardial infarction (MI) survivors. We aimed to determine whether 10-year survival in older women after MI relates to patient-reported outcomes, and to compare their survival with that of the general female population.
We included all women aged 60-80 years suffering MI during 1992-1997, and treated at one university hospital in Norway. In 1998, 145 (60% of those alive) completed a questionnaire package including socio-demographics, the Sense of Coherence Scale (SOC-29), the World Health Organization Quality of Life Instrument Abbreviated (WHOQOL-BREF) and an item on positive effects of illness. Clinical information was based on self-reports and hospital medical records data. We obtained complete data on vital status.
The all-cause mortality rate during the 1998-2008 follow-up of all patients was 41%. In adjusted analysis, the conventional predictors s-creatinine (HR 1.26 per 10% increase) and left ventricular ejection fraction below 30% (HR 27.38), as well as patient-reported outcomes like living alone (HR 6.24), dissatisfaction with self-rated health (HR 6.26), impaired psychological quality of life (HR 0.60 per 10 points difference), and experience of positive effects of illness (HR 6.30), predicted all-cause death. Major adverse cardiac and cerebral events were also significantly associated with both conventional predictors and patient-reported outcomes. Sense of coherence did not predict adverse events. Finally, 10-year survival was not significantly different from that of the general female population.
Patient-reported outcomes have long-term prognostic importance, and should be taken into account when planning aftercare of low-risk older female MI patients.
PMCID: PMC3004873  PMID: 21108810
25.  High-dose chemoradiotherapy followed by surgery versus surgery alone in esophageal cancer: a retrospective cohort study 
We aimed to assess whether high-dose preoperative chemoradiotherapy (CRT) improves outcome in esophageal cancer patients compared to surgery alone and to define possible prognostic factors for overall survival.
Hundred-and-seven patients with disease stage IIA - III were treated with either surgery alone (n = 45) or high-dose preoperative CRT (n = 62). The data were collected retrospectively. Sixty-seven patients had adenocarcinomas, 39 squamous cell carcinomas and one undifferentiated carcinoma. CRT was given as three intensive chemotherapy courses by cisplatin 100 mg/m2 on day 1 and 5-fluorouracil 1000 mg/m2/day, from day 1 through day 5 as continuous infusion. One course was given every 21 days. The last two courses were given concurrent with high-dose radiotherapy, 2 Gy/fraction and a median dose of 66 Gy. Kaplan-Meier survival analysis with log rank test was used to obtain survival data and Cox Regression multivariate analysis was used to define prognostic factors for overall survival.
Toxicity grade 3 of CRT occurred in 30 (48.4%) patients and grade 4 in 24 (38.7%) patients of 62 patients. One patient died of neutropenic infection (grade 5). Fifty percent (31 patients) in the CRT group did undergo the planned surgery. Postoperative mortality rate was 9% and 10% in the surgery alone and CRT+ surgery groups, respectively (p = 1.0). Median overall survival was 11.1 and 31.4 months in the surgery alone and CRT+ surgery groups, respectively (log rank test, p = 0.042). In the surgery alone group one, 3 and 5 year survival rates were 44%, 24% and 16%, respectively and in the CRT+ surgery group they were 68%, 44% and 29%, respectively. By multivariate analysis we found that age of patient, performance status, alcoholism and > = 4 pathological positive lymph nodes in resected specimen were significantly associated with overall survival, whereas high-dose preoperative CRT was not.
We found no significant survival advantage in esophageal cancer stage IIA-III following preoperative high-dose CRT compared to surgery alone. Patient's age, performance status, alcohol abuse and number of positive lymph nodes were prognostic factors for overall survival.
PMCID: PMC2890519  PMID: 20515502

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