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Prehistoric chewed pitch has proven to be a useful source of ancient DNA, both from humans and their microbiomes. Here we present the metagenomic analysis of three pieces of chewed pitch from Huseby Klev, Sweden, that were dated to 9,890-9,540 before present. The metagenomic profile exposes a Mesolithic oral microbiome that includes opportunistic oral pathogens. We compared the data with healthy and dysbiotic microbiome datasets and we identified increased abundance of periodontitis-associated microbes. In addition, trained machine learning models predicted dysbiosis with 70-80% probability. Moreover, we identified DNA sequences from eukaryotic species such as red fox, hazelnut, red deer and apple. Our results indicate a case of poor oral health during the Scandinavian Mesolithic, and show that pitch pieces have the potential to provide information on material use, diet and oral health.

Objectives: To assess whether extended surveillance with repeated computed tomography (CT) scans for patients with clinical stage IIA (CS IIA; <2 cm abdominal node involvement) and negative markers (Mk−) non-seminomatous germ cell tumours (NSGCTs) can identify those with true CS I. To assess the rate of benign lymph nodes, teratoma, and viable cancer in retroperitoneal lymph node dissection (RPLND) histopathology for patients with CS IIA Mk− NSGCT. Patients and methods: Observational prospective population-based study of patients diagnosed 2008–2019 with CS IIA Mk− NSGCT in the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) registry. Patients were managed with surveillance, with CT scans, and tumour markers every sixth week for a maximum of 18 weeks. Patients with radiological regression were treated as CS I, if progression with chemotherapy, and remaining CS IIA Mk− disease with RPLND. The end-point was the number and percentage of patients down-staged to CS I on surveillance and rate of RPLND histopathology presented as benign, teratoma, or viable cancer. Results: Overall, 126 patients with CS IIA Mk− NSGCT were included but 41 received therapy upfront. After surveillance for a median (range) of 6 (6–18) weeks, 23/85 (27%) patients were in true CS I and four (5%) progressed. Of the remaining 58 patients with lasting CS IIA Mk− NSGCT, 16 received chemotherapy and 42 underwent RPLND. The RPLND histopathology revealed benign lymph nodes in 11 (26%), teratoma in two (6%), and viable cancer in 29 (70%) patients. Conclusions: Surveillance with repeated CT scans can identify patients in true CS I, thus avoiding overtreatment. The RPLND histopathology in patients with CS IIA Mk− NSGCT had a high rate of cancer and a low rate of teratoma.

Educational systems change in top-down and bottom-up processes. One example is when authorities introduce a new curriculum, but it can also be changed by agents active in the system. In education, agents of change include educators, students and institutions. In this article, we explore the narratives of educators (n = 4) in the bachelor’s programme for signed language interpreter education (both deaf and hearing students) at Humak University of Applied Sciences in Helsinki, Finland. Data were collected through interviews conducted in 2016. We used content analysis and the theory of agency as a framework for analysis. Here, agency is understood as threefold building on the past, present and future. We explore the different dimensions of becoming an agent of change, being an agent of change and being an agent in a changing field. We find that within the context of this sign language interpreting programme, educators’ previous experiences, intercultural competence and ideas about the future contribute to changes in the curriculum and possibly to social change.

In this paper, we explore Norwegian teachers’ perspectives on inclusive teaching practices in the mathematics classroom, defined as practices which maximise every pupil’s potential regardless of prior attainment. As previous research suggests, both mathematics teachers’ perspectives in general and the conceptualisation of inclusion, inclusive education, and inclusive practices are culturally situated, varying significantly across countries and educational systems. We draw on data from a large project in Norway focusing on the use of grouping by attainment and its relation to policy and pedagogical practices around inclusion in mathematics. Participants were 13 primary and lower-secondary mathematics teachers from six schools in the Oslo area. Analysis of semi-structured interviews focusing on strategies for inclusion of all pupils in mathematics classrooms reveals the cultural particularities of mathematics teachers’ perspectives on inclusive practices, highlighting the value of similar investigations in other cultural contexts.

Background and objective: There is an unmet need to avoid long-term morbidity associated with standard cytotoxic treatment for low-volume metastatic seminoma. Our aim was to assess the oncological efficacy and surgical safety of retroperitoneal lymph node dissection (RPLND) as treatment in a population-based cohort of metastatic seminoma patients with limited retroperitoneal lymphadenopathy. Methods: Sixty-two seminoma patients in Norway and Sweden were included in the cohort from 2019 to 2022. Patients with lymphadenopathy ≤3 cm, having primary clinical stage (CS) IIA/B or CS I with a relapse, were operated with uni- or bilateral template RPLND, open or robot assisted. The outcome measures included surgical complications as per Clavien-Dindo, and Kaplan-Meier survival estimates for 24-mo progression-free survival (PFS) and overall survival (OS). Key findings and limitations: In the cohort, 33 (53%) had CS I with a relapse during surveillance, six (10%) CS I with a relapse following adjuvant chemotherapy, and 23 (37%) initial CS IIA/B. Metastatic seminoma was verified in 58 patients (94%) with a median largest diameter of 18 mm (interquartile range [IQR] 13–24). Robot-assisted RPLND was performed in 40 patients (65%). Clavien-Dindo III complications were observed in three patients (5%); no grade ≥IV complications occurred. Eighteen patients (29%) received adjuvant chemotherapy after surgery. The median follow-up was 23 mo (IQR 16–30), and recurrence occurred in six patients (10%) after a median of 8 mo (IQR 4–14). PFS was 90% (95% confidence interval: 0.86–1) and OS was 100% at 24 mo. Conclusions and clinical implications: RPLND as primary treatment is an option for selected low-stage seminomas with a limited burden of disease, showing low complications and low relapse rates, with the potential to reduce long-term morbidity. Patient summary: In seminoma patients with limited metastatic spread, surgery is a treatment option offering an alternative to chemotherapy or

This appendix is a part of the report: Nomad Maas roaming final report.

The primary project addressed by the NOMAD (The Nordic Open Mobility and Digitalization) project is the need for seamless, cross-border journeys involving scheduled services and on-demand services like taxis, micro-mobility, and car-pooling. The challenge lies in compensating for services provided by different Maas agents, whether publicly or privately funded. The project proposes a solution by standardizing interfaces between mobility providers, enabling the roaming of travel services and creating unified, user-friendly experiences. The Maas roaming concept, inspired by mobile phone roaming, envisions using local Maas agent apps to plan, book and pay for trips across borders. In Summmary, the NOMAD project addresses the complex landscape of corss-border mobility challenges, striving to create a standardized, user-centric approach to Maas roaming.

Given the right support, persons with CHARGE syndrome can overcome not only medical challenges but also various other obstacles, and lead fulfilling lives. This publication shows, through case studies and interviews, some daily lives, challenges, and achievements of persons living with CHARGE syndrome, emphasizing the importance of understanding and support from their community. Living with CHARGE syndrome can entail different aspects and challenges. Often, the focus revolves around the medical aspects, and less on how individuals can function in their day-to-day lives. There is a lack of case descriptions and interviews, telling the story from the perspective of the persons living with the syndrome themselves. In this publication you meet Thomas’s mother who gives a very personal account of how it was to learn that her newborn baby had CHARGE syndrome. Read about Dominic who is in primary school, knows three languages but also struggles with balance and sight, which makes him exhausted at the end of the day. Karl recently got his drivers’ licence and wants to move to the capital to get to know more people who knows sign language. Together with Charlie, Anna, Inga, and Linda they have all let us into their lives, displaying challenges, personal growth, and development. The aim of this publication is to show the diversity and give a voice to a group that seldom is heard. Hopefully, parents, legal guardians, and relatives can get a more positive picture of what life with CHARGE syndrome might look like.

In the last decades, the development of high-throughput molecular assays has revolutionised cancer diagnostics, paving the way for the concept of personalised cancer medicine. This progress has been driven by the introduction of such technologies through biomarker-driven oncology trials. In this review, strengths and limitations of various state-of-the-art sequencing technologies, including gene panel sequencing (DNA and RNA), whole-exome/whole-genome sequencing and whole-transcriptome sequencing, are explored, focusing on their ability to identify clinically relevant biomarkers with diagnostic, prognostic and/or predictive impact. This includes the need to assess complex biomarkers, for example microsatellite instability, tumour mutation burden and homologous recombination deficiency, to identify patients suitable for specific therapies, including immunotherapy. Furthermore, the crucial role of biomarker analysis and multidisciplinary molecular tumour boards in selecting patients for trial inclusion is discussed in relation to various trial concepts, including drug repurposing. Recognising that today's exploratory techniques will evolve into tomorrow's routine diagnostics and clinical study inclusion assays, the importance of emerging technologies for multimodal diagnostics, such as proteomics and in vivo drug sensitivity testing, is also discussed. In addition, key regulatory aspects and the importance of patient engagement in all phases of a clinical trial are described. Finally, we propose a set of recommendations for consideration when planning a new precision cancer medicine trial.image

Background: In the two European Union (EU)-funded projects, PCM4EU (Personalized Cancer Medicine for all EU citizens) and PRIME-ROSE (Precision Cancer Medicine Repurposing System Using Pragmatic Clinical Trials), we aim to facilitate implementation of precision cancer medicine (PCM) in Europe by leveraging the experience from ongoing national initiatives that have already been particularly successful. Patients and methods: PCM4EU and PRIME-ROSE gather 17 and 24 partners, respectively, from 19 European countries. The projects are based on a network of Drug Rediscovery Protocol (DRUP)-like clinical trials that are currently ongoing or soon to start in 11 different countries, and with more trials expected to be established soon. The main aims of both the projects are to improve implementation pathways from molecular diagnostics to treatment, and reimbursement of diagnostics and tumour-tailored therapies to provide examples of best practices for PCM in Europe. Results: PCM4EU and PRIME-ROSE were launched in January and July 2023, respectively. Educational materials, including a podcast series, are already available from the PCM4EU website (http://www.pcm4eu. eu). The first reports, including an overview of requirements for the reimbursement systems in participating countries and a guide on patient involvement, are expected to be published in 2024. Conclusion: European collaboration can facilitate the implementation of PCM and thereby provide affordable and equitable access to precision diagnostics and matched therapies for more patients.

Patient perspectives on the quality of care received are fundamental to mental health care. This study aimed to investigate the association between patient-reported mental health care quality, perceived coercion, and various demographic, clinical, and ward-related factors. Using a cross-sectional design, data were collected from 169 patients in Norwegian mental health wards using the quality in psychiatric care-inpatient (QPC-IP) instrument and experienced coercion scale (ECS). The analysis revealed a consistent pattern in which patients with higher perceived coercion consistently rated lower quality on all QPC-IP dimensions. The significant findings of the multiple regression models further supported this association. Beyond coercion, the factors influencing quality ratings include self-reported treatment results, participation in treatment planning, and knowledge of complaint procedures. Emphasizing the pivotal role of coercion in enhancing mental health care quality, these findings contribute to a nuanced understanding of patient experiences and underscore the importance of patient participation in mental health care improvement efforts.

Background and Objective: Several drugs on the market are substrates for P-glycoprotein (P-gp), an efflux transporter highly expressed in barrier tissues such as the intestine. Body weight, weight loss, and a Roux-en-Y gastric bypass (RYGB) may influence P-gp expression and activity, leading to variability in the drug response. The objective of this study was therefore to investigate digoxin pharmacokinetics as a measure of the P-gp phenotype in patients with obesity before and after weight loss induced by an RYGB or a strict diet and in normal weight individuals. Methods: This study included patients with severe obesity preparing for an RYGB (n = 40) or diet-induced weight loss (n = 40) and mainly normal weight individuals scheduled for a cholecystectomy (n = 18). Both weight loss groups underwent a 3-week low-energy diet (<1200 kcal/day) followed by an additional 6 weeks of <800 kcal/day induced by an RYGB (performed at week 3) or a very-low-energy diet. Follow-up time was 2 years, with four digoxin pharmacokinetic investigations at weeks 0, 3, and 9, and year 2. Hepatic and jejunal P-gp levels were determined in biopsies obtained from the patients undergoing surgery. Results: The RYGB group and the diet group had a comparable weight loss in the first 9 weeks (13 +/- 2.3% and 11 +/- 3.6%, respectively). During this period, we observed a minor increase (16%) in the digoxin area under the concentration-time curve from zero to infinity in both groups: RYGB: 2.7 mu g h/L [95% confidence interval (CI) 0.67, 4.7], diet: 2.5 mu g h/L [95% CI 0.49, 4.4]. In the RYGB group, we also observed that the time to reach maximum concentration decreased after surgery: from 1.0 +/- 0.33 hours at week 3 to 0.77 +/- 0.08 hours at week 9 (-0.26 hours [95% CI -0.47, -0.05]), corresponding to a 25% reduction. Area under the concentration-time curve from zero to infinity did not change long term (week 0 to year 2) in either the RYGB (1.1 mu g h/L [-0.94, 3.2]) or the diet group (0.9

Aim: To explore adolescents' experiences of having a parent with heart disease. Design: This qualitative study was performed with semi-structured individual interviews. Methods: Interviews were conducted with 33 adolescents between 13 and 19 years old, who either had a mother or father with one of these diagnoses: ischemic heart disease, arrhythmia, heart failure, cardiac arrest or heart valve disease. The parent had been ill for at least 6 months and up to 5 years. The study was carried out in Denmark, Norway and Sweden between 2019 and 2022. The analysis was inspired by Reflexive Methodology. Results: Three central themes emerged: Response to parental heart disease; Growing up ahead of time; and Strategies in a changed life situation. For the adolescents, heart disease was experienced as an acute and lethal disease that put their parents' lives in danger. New routines and roles not only changed everyday life within the family but they also enhanced maturity and appreciation of life. To maintain a balance in life, the adolescents pursued normality and sought a safe space to have a normal youthful life. Conclusion: In a period known to be significant for development, life with parental heart disease appeared as a biographical disruption because adolescents renegotiated their identity to manage their new life situation.ImpactIt is important to help younger family members adapt to parental heart disease by informing them about possible reactions and supporting them in how to adapt to their new life by seeking breaks and normality.Patient or Public ContributionNo patient or public involvement.

Background The Molecular International Prognostic Scoring System (IPSS-M) is the new gold standard for diagnostic outcome prediction in patients with myelodysplastic syndromes (MDS). This study was designed to assess the additive prognostic impact of dynamic transfusion parameters during early follow-up. Methods We retrieved complete transfusion data from 677 adult Swedish MDS patients included in the IPSS-M cohort. Time-dependent erythrocyte transfusion dependency (E-TD) was added to IPSS-M features and analyzed regarding overall survival and leukemic transformation (acute myeloid leukemia). A multistate Markov model was applied to assess the prognostic value of early changes in transfusion patterns. Results Specific clinical and genetic features were predicted for diagnostic and time-dependent transfusion patterns. Importantly, transfusion state both at diagnosis and within the first year strongly predicts outcomes in both lower (LR) and higher-risk (HR) MDSs. In multivariable analysis, 8-month landmark E-TD predicted shorter survival independently of IPSS-M (p < 0.001). A predictive model based on IPSS-M and 8-month landmark E-TD performed significantly better than a model including only IPSS-M. Similar trends were observed in an independent validation cohort (n = 218). Early transfusion patterns impacted both future transfusion requirements and outcomes in a multistate Markov model. Conclusion The transfusion requirement is a robust and available clinical parameter incorporating the effects of first-line management. In MDS, it provides dynamic risk information independently of diagnostic IPSS-M and, in particular, clinical guidance to LR MDS patients eligible for potentially curative therapeutic intervention., Funding Agencies|Edward P. Evans Foundation

BackgroundPatients with heart failure (HF) and colorectal cancer (CRC) are prone to comorbidity, a high rate of readmission, and complex healthcare needs. Self-care for people with HF and CRC after hospitalisation can be challenging, and patients may leave the hospital unprepared to self-manage their disease at home. eHealth solutions may be a beneficial tool to engage patients in self-care.MethodsA randomised controlled trial with an embedded evaluation of intervention engagement and cost-effectiveness will be conducted to investigate the effect of eHealth intervention after hospital discharge on the self-efficacy of self-care. Eligible patients with HF or CRC will be recruited before discharge from two Norwegian university hospitals. The intervention group will use a nurse-assisted intervention-eHealth@Hospital-2-Home-for six weeks. The intervention includes remote monitoring of vital signs; patients' self-reports of symptoms, health and well-being; secure messaging between patients and hospital-based nurse navigators; and access to specific HF and CRC health-related information. The control group will receive routine care. Data collection will take place before the intervention (baseline), at the end of the intervention (Post-1), and at six months (Post-2). The primary outcome will be self-efficacy in self-care. The secondary outcomes will include measures of burden of treatment, health-related quality of life and 30- and 90-day readmissions. Sub-study analyses are planned in the HF patient population with primary outcomes of self-care behaviour and secondary outcomes of medication adherence, and readmission at 30 days, 90 days and 6 months. Patients' and nurse navigators' engagement and experiences with the eHealth intervention and cost-effectiveness will be investigated. Data will be analysed according to intention-to-treat principles. Qualitative data will be analysed using thematic analysis.DiscussionThis protocol will examine the effects of the eHealth@ Hosp, Funding Agencies|Norges Forskningsrd

Background: Clinical reasoning (CR) is a crucial ability that can prevent errors in patient care. Despite its important role, CR is often not taught explicitly and, even when it is taught, typically not all aspects of this ability are addressed in health professions education. Recent research has shown the need for explicit teaching of CR for both students and teachers. To further develop the teaching and learning of CR we need to improve the understanding of students' and teachers' needs regarding content as well as teaching and assessment methods for a student and trainer CR curriculum. Methods: Parallel mixed-methods design that used web-surveys and semi-structured interviews to gather data from both students (nsurvey = 100; ninterviews = 13) and teachers (nsurvey = 112; ninterviews = 28). The interviews and surveys contained similar questions to allow for triangulation of the results. This study was conducted as part of the EU-funded project DID-ACT (https://did-act.eu). Results: Both the surveys and interview data emphasized the need for content in a clinical reasoning (CR) curriculum such as “gathering, interpreting and synthesizing patient information”, “generating differential diagnoses”, “developing a diagnostic and a treatment plan” and “collaborative and interprofessional aspects of CR”. There was high agreement that case-based learning and simulations are most useful for teaching CR. Clinical and oral examinations were favored for the assessment of CR. The preferred format for a train-the-trainer (TTT)-course was blended learning. There was also some agreement between the survey and interview participants regarding contents of a TTT-course (e.g. teaching and assessment methods for CR). The interviewees placed special importance on interprofessional aspects also for the TTT-course. Conclusions: We found some consensus on needed content, teaching and assessment methods for a student and TTT-course in CR. Future research could investigate the effects of CR

Background Immune checkpoint inhibitors have shown minimal clinical activity in hormone receptor-positive metastatic breast cancer (HR + mBC). Doxorubicin and low-dose cyclophosphamide are reported to induce immune responses and counter regulatory T cells (Tregs). Here, we report the efficacy and safety of combined programmed cell death protein-1/cytotoxic T-lymphocyte-associated protein 4 blockade concomitant with or after immunomodulatory chemotherapy for HR + mBC. Methods Patients with HR + mBC starting first-/second- line chemotherapy (chemo) were randomized 2:3 to chemotherapy (pegylated liposomal doxorubicin 20 mg/m 2 every second week plus cyclophosphamide 50 mg by mouth/day in every other 2-week cycle) with or without concomitant ipilimumab (ipi; 1 mg/kg every sixth week) and nivolumab (nivo; 240 mg every second week). Patients in the chemo-only arm were offered cross-over to ipi/nivo without chemotherapy. Co-primary endpoints were safety in all patients starting therapy and progression-free survival (PFS) in the per-protocol (PP) population, defined as all patients evaluated for response and receiving at least two treatment cycles. Secondary endpoints included objective response rate, clinical benefit rate, Treg changes during therapy and assessment of programmed death-ligand 1 (PD-L1), mutational burden and immune gene signatures as biomarkers. Results Eighty-two patients were randomized and received immune-chemo (N=49) or chemo-only (N=33), 16 patients continued to the ipi/nivo-only cross-over arm. Median follow-up was 41.4 months. Serious adverse events occurred in 63% in the immune-chemo arm, 39% in the chemo-only arm and 31% in the cross-over-arm. In the PP population (N=78) median PFS in the immune-chemo arm was 5.1 months, compared with 3.6 months in the chemo-only arm, with HR 0.94 (95% CI 0.59 to 1.51). Clinical benefit rates were 55% (26/47) and 48% (15/31) in the immune-chemo and chemo-only arms, respectively. In the cross-over-arm (ipi/nivo-only, SCOPUS: ar.j, info:eu-repo/semantics/published

This study introduces the Place Standard Tool as an instrument for assessing urban social sustainability. The Place Standard Tool was developed in Scotland as a simple framework to evaluate physical (e.g., buildings, public spaces, transport system), social (e.g., social interaction, identity and belonging, safety), and procedural (e.g., public participation, sense of control) aspects concerning places, neighborhoods, and districts. The tool was tested in three cities in Norway – Kristiansand, Stavanger, and Fredrikstad – through a transdisciplinary collaboration between researchers, municipalities, and local stakeholders. We first present the methodology we applied for testing the tool and then report some indicative findings. Next, municipal advisors present their qualitative assessment of the tool discussing its usefulness for urban planning and local governance. Finally, researchers offer theoretical and methodological guidance: they theoretically discuss the relevance of the tool for urban social sustainability, present its strengths and weaknesses, and provide methodological recommendations for future applications.

Background Older men (aged ≥75 years) with high risk, non-metastatic prostate cancer (PCa) are increasingly treated with curative therapy (surgery or radiotherapy). However, it is unclear if curative therapy prolongs life and improves health-related quality of life (HRQoL) in this age group compared to conservative therapy, which has evolved considerably during the last decade. Study Design The Scandinavian Prostate Cancer Group (SPCG) 19/Norwegian Get-Randomized Research Group-Prostate (GRand-P) is a randomised, two-armed, controlled, multicentre, phase III trial carried out at study centres in Norway, Denmark, Finland, and Sweden. Endpoints The primary endpoints are overall survival and HRQoL (burden of disease scale, European Organisation for the Research and Treatment of Cancer [EORTC] Elderly Cancer patients). Secondary endpoints are PCa-specific survival, metastasis-free survival, role-functioning scale (EORTC quality of life questionnaire 30-item core), urinary irritative/obstructive scale (26-item Expanded Prostate Cancer Index Composite [EPIC-26]), bowel scale (EPIC-26), intervention-free survival, PCa morbidity, use of secondary and tertiary systemic therapies, mean quality-adjusted life-years (QALYs), and mean total healthcare costs. Patients and Methods A total of 980 men (aged ≥75 years) with non-metastatic, high-risk PCa will initially be screened with Geriatric 8 (G8) health status screening tool and Mini-COG© brief cognitive test. Participants identified by G8 as ‘fit’ or ‘frail’ will be randomised (ratio 1:1) to either immediate curative therapy (radiotherapy or prostatectomy) or conservative therapy (endocrine therapy or observation). Participants who are unable or unwilling to participate in randomisation will be enrolled in a separate observation group. Randomised patients will be followed for 10 years. Trial Registration Ethics approval has been granted in Norway (457593), Denmark (H-220519, Background: Older men (aged ≥75 years) with high risk, non-metastatic prostate cancer (PCa) are increasingly treated with curative therapy (surgery or radiotherapy). However, it is unclear if curative therapy prolongs life and improves health-related quality of life (HRQoL) in this age group compared to conservative therapy, which has evolved considerably during the last decade. Study Design: The Scandinavian Prostate Cancer Group (SPCG) 19/Norwegian Get-Randomized Research Group-Prostate (GRand-P) is a randomised, two-armed, controlled, multicentre, phase III trial carried out at study centres in Norway, Denmark, Finland, and Sweden. Endpoints: The primary endpoints are overall survival and HRQoL (burden of disease scale, European Organisation for the Research and Treatment of Cancer [EORTC] Elderly Cancer patients). Secondary endpoints are PCa-specific survival, metastasis-free survival, role-functioning scale (EORTC quality of life questionnaire 30-item core), urinary irritative/obstructive scale (26-item Expanded Prostate Cancer Index Composite [EPIC-26]), bowel scale (EPIC-26), intervention-free survival, PCa morbidity, use of secondary and tertiary systemic therapies, mean quality-adjusted life-years (QALYs), and mean total healthcare costs. Patients and Methods: A total of 980 men (aged ≥75 years) with non-metastatic, high-risk PCa will initially be screened with Geriatric 8 (G8) health status screening tool and Mini-COG

We show how the spectrum of normal discrete short-range infinite-volume operators can be approximated with two-sided error control using only data from finite-sized local patches. As a corollary, we prove the computability of the spectrum of such infinite-volume operators with the additional property of finite local complexity and provide an explicit algorithm. Such operators appear in many applications, e.g. as discretizations of differential operators on unbounded domains or as so-called tight-binding Hamiltonians in solid state physics. For a large class of such operators, our result allows for the first time to establish computationally also the absence of spectrum, i.e. the existence and the size of spectral gaps. We extend our results to the $\varepsilon$-pseudospectrum of non-normal operators, proving that also the pseudospectrum of such operators is computable.

Introduction: Rosuvastatin pharmacokinetics is mainly dependent on the activity of hepatic uptake transporter OATP1B1. In this study, we aimed to investigate and disentangle the effect of Roux-en-Y gastric bypass (RYGB) and weight loss on oral clearance (CL/F) of rosuvastatin as a measure of OATP1B1-activity. Methods: Patients with severe obesity preparing for RYGB (n = 40) or diet-induced weight loss (n = 40) were included and followed for 2 years, with four 24-hour pharmacokinetic investigations. Both groups underwent a 3-week low-energy diet (LED; < 1200 kcal/day), followed by RYGB or a 6-week very-low-energy diet (VLED; < 800 kcal/day). Results: A total of 80 patients were included in the RYGB group (40 patients) and diet-group (40 patients). The weight loss was similar between the groups following LED and RYGB. The LED induced a similar (mean [95% CI]) decrease in CL/F in both intervention groups (RYGB: 16% [0, 31], diet: 23% [8, 38]), but neither induced VLED resulted in any further changes in CL/F. At Year 2, CL/F had increased by 21% from baseline in the RYGB group, while it was unaltered in the diet group. Patients expressing the reduced function SLCO1B1 variants (c.521TC/CC) showed similar changes in CL/F over time compared with patients expressing the wild-type variant. Conclusions: Neither body weight, weight loss nor RYGB per se seem to affect OATP1B1 activity to a clinically relevant degree. Overall, the observed changes in rosuvastatin pharmacokinetics were minor, and unlikely to be of clinical relevance.

Comorbidities influence the mortality in patients with myelodysplastic syndromes, and a growing body of evidence suggest that comorbidity history should be used in addition to established prognostic indices. A comorbidity index specific for MDS, the MDS-CI, was introduced a decade ago. In this study we aim to construct an MDS-CI version based on diagnoses from register data only, to expand its use beyond the clinical setting to retrospective and register based studies. We further test this version on a Swedish population-based MDS cohort of 2947 patients, and compare its prognostic accuracy to that of Charlson Comorbidity Index. Our register based MDS-CI divided patients into three risk groups of similar proportions as have been published for the original MDS-CI. Compared to low risk patients, intermediate and high risk patients had 50 % and 70 % higher mortality, respectively. The prognostic value of MDS-CI was equal to that of Charlson comorbidity index. Adding MDS-CI to the established prognostic factors IPSS-R and age increased the prognostic accuracy. In summary, we demonstrate that MDS-CI can be adequately estimated from diagnoses recorded in registers only, and that it is a useful tool in any future study on myelodysplastic syndromes with a need to adjust for comorbidities.

The Oslo Chronic Fatigue Consortium consists of researchers and clinicians who question the current narrative that chronic fatigue syndromes, including post-covid conditions, are incurable diseases. Instead, we propose an alternative view, based on research, which offers more hope to patients. Whilst we regard the symptoms of these conditions as real, we propose that they are more likely to reflect the brains response to a range of biological, psychological, and social factors, rather than a specific disease process. Possible causes include persistent activation of the neurobiological stress response, accompanied by associated changes in immunological, hormonal, cognitive and behavioural domains. We further propose that the symptoms are more likely to persist if they are perceived as threatening, and all activities that are perceived to worsen them are avoided. We also question the idea that the best way to cope with the illness is by prolonged rest, social isolation, and sensory deprivation.Instead, we propose that recovery is often possible if patients are helped to adopt a less threatening understanding of their symptoms and are supported in a gradual return to normal activities. Finally, we call for a much more open and constructive dialogue about these conditions. This dialogue should include a wider range of views, including those of patients who have recovered from them.

Background: Identifying occupational health hazards among Registered Nurses (RNs) and other health personnel and implementing effective preventive measures are crucial to the long-term sustainability of health services. The objectives of this study were (1) to assess the 12-month prevalence rates of exposure to workplace aggression, including physical violence, threats of violence, sexual harassment, and bullying; (2) to identify whether the perpetrators were colleagues, managers, subordinates, or patients and their relatives; (3) to determine whether previous exposure to these hazards was associated with RNs' current turnover intention; and (4) to frame workplace aggression from an occupational health and safety perspective. Methods: The third version of the Copenhagen Psychosocial Questionnaire (COPSOQ III) was used to assess RNs' exposure to workplace aggression and turnover intention. A national sample of 8,800 RNs in Norway, representative of the entire population of registered nurses in terms of gender and geography, was analysed. Binary and ordinal logistic regression analyses were conducted, and odds for exposure and intention to leave are presented, with and without controls for RNs' gender, age, and the type of health service they work in. Results: The 12-month prevalence rates for exposure were 17.0% for physical violence, 32.5% for threats of violence, 12.6% for sexual harassment, and 10.5% for bullying. In total, 42.6% of the RNs had experienced at least one of these types of exposure during the past 12 months, and exposure to more than one of these hazards was common. Most perpetrators who committed physical acts and sexual harassment were patients, while bullying was usually committed by colleagues. There was a strong statistical association between exposure to all types of workplace aggression and RNs' intention to leave. The strongest association was for bullying, which greatly increased the odds of looking for work elsewhere. Conclusions: Efforts t

Intensive forestry is a threat to biodiversity, and therefore actions are made to mitigate this loss. The actions are, however, designed based on available knowledge about the requirements of species, and for saproxylic insects this concerns mainly Coleoptera, while the diverse but poorly known Hymenoptera has contributed less. In this paper we therefore asked whether the substrate requirements of Hymenoptera (divided as parasitoids and non-parasitoids) are similar to those of Coleoptera and Diptera. We used an insect material reared from logging residue wood for the comparison. Theoretically parasitoid Hyme- noptera should be less specialised than Coleoptera and other host species as they belong to a higher trophic level. However, we found no such difference and even an opposite trend, that parasitoids were more specialised than beetles. Parasitoids had significantly more species in newly dead wood of fine diameter (1–4 cm, compared to coarse wood of 8–15 cm) compared to other groups. This is probably due to that many of them have bark beetles as hosts. The non-parasitoids were less specialised than the other groups and more confined to old wood (4–5 years), which is in line with that many of them are aculeate wasps building nests in emergence holes from other insects. Implications for insect conservation The habitat requirements of Hymenoptera suggest that the conservation actions designed for the well known groups are also applicable for them. The parasitoids’ association to trivial substrates (fine wood) sug- gest a good supply of breeding habitat, whereas their high specialisation in combination with higher trophic level suggest they contain an even higher proportion of threatened species than Coleoptera. How this is traded off needs further studies.

Studies of therapy-related AML (t-AML) are usually performed in selected cohorts and reliable incidence rates are lacking. In this study, we characterized, defined the incidence over time and studied prognostic implications in all t-AML patients diagnosed in Sweden between 1997 and 2015. Data were retrieved from nationwide population-based registries. In total, 6,779 AML patients were included in the study, of whom 686 (10%) had t-AML. The median age for t-AML was 71 years and 392 (57%) patients were females. During the study period, the incidence of t-AML almost doubled with a yearly increase in t-AML of 4.5% (95% confidence interval: 2.8%-6.2%), which contributed significantly to the general increase in AML incidence over the study period. t-AML solidly constituted over 10% of all AML cases during the later period of the study. Primary diagnoses with the largest increase in incidence and decrease in mortality rate during the study period (i.e., breast and prostate cancer) contributed significantly to the increased incidence of t-AML. In multivariable analysis, t-AML was associated with poorer outcome in cytogenetically intermediate-and adverse-risk cases but t-AML had no significant impact on outcome in favorable-risk AML, including core binding leukemias, acute promyelocytic leukemia and AML with mutated NPM1 without FLT3-ITD. We conclude that there is a strong increase in incidence in t-AML over time and that t-AML constitutes a successively larger proportion of the AML cases. Furthermore, we conclude that t-AML confers a poor prognosis in cytogenetically intermediate-and adverse-risk, but not in favorable-risk AML., Funding Agencies|Swedish Cancer Foundation; Swedish Research Council; Stockholm County Council

The 8.2 ka event is a short-lived climate anomaly that occurred in the end of the early Holocene. The event was first recognized in the Greenland ice cores but has also been identified in marine and terrestrial records over wide parts of the globe. It is widely accepted that the event was triggered by input of freshwater from Lake Agassiz-Ojibway to the North Atlantic Ocean. Although the exact number of freshwater pulses, routing and volume are still debated, it is commonly thought that the freshwater that entered the North Atlantic Ocean was sufficient to disrupt the Atlantic Meridional Overturning Circulation. However, there are still uncertainties regarding the precise timing of the event and details about its climate impacts, even across Europe. The overall aim of this thesis if to advance our understanding of the precise timing and regional climate impacts of the 8.2 ka event in Europe through the use of speleothem palaeoclimate records. Speleothems can provide high-resolution records of the 8.2 ka event that are well-constrained by precise and accurate chronologies. This thesis is guided by two key aims. The first aim seeks to improve the spatial coverage of regional high-resolution records to reconstruct climate changes triggered by the 8.2 ka event across Europe and to achieve a more precise timing and duration for the event through the generation of new high-resolution palaeoclimate speleothem records. Two speleothem records were selected from western and eastern Europe: one from El Soplao Cave in northern Spain, and another from Ascunsa Cave in Romania. The Soplao speleothem record represents early Holocene palaeoclimate in northern Spain, an important region to study the impact of AMOC perturbations on south-western Europe. Throughout the entire record the oxygen isotope variability is related to changes in effective recharge. This is supported by the pattern of changes in the carbon isotopes, Mg/Ca and growth rate. The 8.2 ka event is marked as a negativ

Objectives: Concept maps are a learning tool that fosters clinical reasoning skills in healthcare education. They can be developed by students in combination with virtual patients to create a visual representation of the clinical reasoning process while solving a case. However, in order to optimize feedback, there is a need to better understand the role of connections between concepts in student-generated maps. Therefore, in this study we investigated whether the quality of these connections is indicative of diagnostic accuracy.Methods: We analyzed 40 concept maps created by fifth-year medical students in the context of four virtual patients with commonly encountered diagnoses. Half of the maps were created by students who made a correct diagnosis on the first attempt; the other half were created by students who made an error in their first diagnosis. The connections in the maps were rated by two reviewers using a relational scoring system. Analysis of covariance was employed to examine the difference in mean connection scores among groups while controlling for the number of connections.Results: There were no differences between the groups in the number of concepts or connections in the maps; however, maps made by students who made a correct first diagnosis had higher scores for the quality of connections than those created by students who made an incorrect first diagnosis (12.13 vs 9.09; p=0.03). We also observed students' general reluctance to use connections in their concept maps.Conclusion: Our results suggest that the quality, not the quantity, of connections in concept maps is indicative of their diagnostic accuracy., Zielsetzung: Concept Maps sind ein Werkzeug, das die Fähigkeiten zur klinischen Entscheidungsfindung in der Ausbildung in den Gesundheitsberufen fördert. Sie können von Studierenden in Kombination mit virtuellen Patient*innen erstellt werden, um so den klinischen Denkprozess bei der Lösung eines Falles zu visualisieren. Um das Feedback zu optimieren, ist es jedoch notwendig, die Bedeutung der Verbindungen zwischen den Konzepten in den von den Studierenden erstellten Maps besser zu verstehen. Daher haben wir in dieser Studie untersucht, ob die Qualität von Verbindungen ein Indikator für die Diagnosegenauigkeit ist.Methoden: Wir analysierten 40 Concept Maps, die von Medizinstudierenden im fünften Studienjahr während der Bearbeitung von vier virtuellen Patient*innen mit häufigen Erkrankungen erstellt wurden. Die eine Hälfte der Concept Maps wurde von Studierenden erstellt, die beim ersten Versuch eine korrekte Diagnose stellten, die andere von Studierenden, die bei ihrer ersten Diagnose einen Fehler machten. Die Verbindungen in den Maps wurden von zwei Reviewer*innen auf Basis eines relationalen Punktesystems bewertet. Mithilfe einer Kovarianzanalyse untersuchten wir den Unterschied der Durchschnittsscores für die Verbindungen zwischen den Gruppen unter Kontrollierung der Anzahl der Verbindungen.Ergebnisse: Es gab keine Unterschiede zwischen den Gruppen bezüglich Anzahl der Konzepte oder Verbindungen in den Maps. Allerdings hatten die Maps der Studierenden, mit korrekter Erstdiagnose, eine höhere Qualität der Verbindungen als die Maps mit falscher Erstdiagnose (12,13 vs. 9,09; p=0,03). Wir beobachteten auch, dass die Studierenden generell wenige Verbindungen in ihren Concept Maps zogen.Schlussfolgerung: Unsere Ergebnisse deuten darauf hin, dass die Qualität, nicht die Quantität, der Verbindungen in Concept Maps für die Diagnosegenauigkeit ausschlaggebend ist.

Nordic Innovation´s Smart Connectivity project facilitates innovation and change within the transport sector. The aim of this report is to: 1. Present an overview of different domains within smart connectivity. This includes: - Three domains within Smart Connectivity: personal mobility, logistics and road traffic management - Data as such and within the domain of Smart Connectivity 2. Present some of the overall challenges found so far, specific and generic, that will form a basis for the next step in this project, namely, to prioritize the areas for the calls that test the systemic model that this project is based upon.

In this chapter, you will find an overview of the most used hydrological drought characteristics and their derivation. This includes single low flow indices, such as percentiles from the flow duration curve; drought deficit characteristics derived by the threshold level method, such as duration and deficit volume, standardised indices, such as the Standardised Groundwater Level Index, multivariate indices based on modelling or a combination of ‘stand alone’ indices, and spatial drought indices. We explain methods of calculation in terms of both time series and single indices and give examples of how to derive different indices through worked examples. The methods described are applicable for both observed and simulated time series of hydrological variables representing a flux, such as river flow, or a state variable, such as groundwater levels. We also give general recommendations for the choice of index based on the problem under study, data availability and climatic and regional characteristics. Finally, we describe the relationship between different drought indices.

OBJECTIVE: To map existing organizational care pathways in clinical centers of expertise that care for pregnant women affected by rare and complex connective tissue diseases (rcCTDs). METHODS: An international working group composed of experts in the field of pregnancy in rcCTDs co-designed a survey focused on organizational aspects related to the patient's pathway before, during, and after pregnancy. The survey was distributed to subject experts through referral sampling. RESULTS: Answers were collected from 69 centers in 21 countries. Patients with systemic lupus erythematosus and/or antiphospholipid syndrome were followed by more than 90% of centers, whereas those with disorders such as IgG4-related diseases were rarely covered. In the majority of centers, a multidisciplinary team was involved, including an obstetrician/gynecologist in 91.3% of cases and other healthcare professionals less frequently. Respondents indicated that 96% of the centers provided routine pre-pregnancy care, whereas the number of patient visits during pregnancy varied across centers. A formalized care pathway was described in 49.2% of centers, and 20.3% of centers had a predefined protocol for the monitoring of pregnant patients. Access to therapies during pregnancy also was heterogeneous among different centers. CONCLUSION: In international referral centers, a high level of care is provided to patients with rcCTDs before, during, and after pregnancy. No significant discrepancies were found between European and non-European countries. However, this work highlights a potential benefit to streamlining the care approaches across countries to optimize pregnancy and perinatal outcomes among patients with rcCTDs.

In this population-based study, we aimed to characterize and compare subgroups of therapy-related Myelodysplastic syndromes (t-MDS) and define the implications of type of previous treatment and primary disease. We combined data from MDS patients, diagnosed between 2009 and 2017 (n = 2705), in the nationwide Swedish MDS register, with several health registers. Furthermore, using matched population controls, we investigated the prevalence of antecedent malignancies in MDS patients in comparison with the general population. This first ever nationwide study on t-MDS confirms a shorter median survival for t-MDS compared to de novo MDS (15.8 months vs 31.1 months, p < 0.001). T-MDS patients previously treated with radiation only had disease characteristics with a striking resemblance to de novo-MDS, in sharp contrast to patients treated with chemotherapy who had a significantly higher risk profile. IPSS-R and the WHO classification differentiated t-MDS into different risk groups. As compared with controls, MDS patients had a six-fold increased prevalence of a previous hematological malignancy but only a 34% increased prevalence of a previous solid tumor. T-MDS patients with a previous hematological malignancy had a dismal prognosis, due both to mortality related to their primary disease and to high-risk MDS.

BACKGROUND: Physical activity (PA) monitoring is applied in a growing number of studies within cancer research. However, no consensus exists on how many days PA should be monitored to obtain reliable estimates in the cancer population. The objective of the present study was to determine the minimum number of monitoring days required for reliable estimates of different PA intensities in cancer survivors when using a six-days protocol. Furthermore, reliability of monitoring days was assessed stratified on sex, age, cancer type, weight status, and educational level. METHODS: Data was obtained from two studies where PA was monitored for seven days using the SenseWear Armband Mini in a total of 984 cancer survivors diagnosed with breast, colorectal or prostate cancer. Participants with ≥22 hours monitor wear-time for six days were included in the reliability analysis (n = 736). The intra-class correlation coefficient (ICC) and the Spearman Brown prophecy formula were used to assess the reliability of different number of monitoring days. RESULTS: For time in light PA, two monitoring days resulted in reliable estimates (ICC >0.80). Participants with BMI ≥25, low-medium education, colorectal cancer, or age ≥60 years required one additional monitoring day. For moderate and moderate-to-vigorous PA, three monitoring days yielded reliable estimates. Participants with BMI ≥25 or breast cancer required one additional monitoring day. Vigorous PA showed the largest within subject variations and reliable estimates were not obtained for the sample as a whole. However, reliable estimates were obtained for breast cancer survivors (4 days), females, BMI ≥30, and age <60 years (6 days). CONCLUSION: Shorter monitoring periods may provide reliable estimates of PA levels in cancer survivors when monitored continuously with a wearable device. This could potentially lower the participant burden and allow for less exclusion of participants not adhering to longer protocols.

Introduction. In the visual-gestural modality, the interpreter needs to find linguistic strategies to convey not only the content of a message, but also the stance being taken on the situation(Janzen & Shaffer, 2013). In the tactile modality, in which tactile sign language is used, interpreters are also responsible for communicating environmental information which isconveyed either by the visual or the auditory channel (Gabarró-López & Mesch, 2020). Amongthe communication strategies used by people affected by different degrees of deafblindness, there is the so called “social-haptic communication”, which consists of various touch messages on the person's body to provide information about the environment, other participants’ nonverbal expressions and minimal-response signals (Raanes & Slettebakk Berge, 2016). Socialhaptic touch includes interaction with the skin, active touch, and environmental orientation touch (Lahtinen, 2008). The goal of this work is to look at social-haptic communication in an interpreting setting where tactile Norwegian Sign Language (tNTS) is used, focusing on theuse of the body of the interpreter and of the deafblind signer to express references. Referential mapping and depiction. In sign languages, the use of space is crucial to create areferential mapping through the use of loci. Loci in the signing space are actual locations of present referents or arbitrary locations that are assigned to non-present referents (Pfau et al.,2018). There are two main ways to establish loci: i) manually, i.e., signing the lexical sign denoting the referent with a hand located at the locus, or by pointing; ii) via non-manual markers, i.e., by leaning the body towards the locus or by directing eye-gaze towards it (Khun,2016). Moreover, the expression of movement and the description of objects, animate referents and actions can be conveyed through the use of a diverse semiotic repertoire. One of the strategies used is depiction, which refers to the ab

In the visual-gestural modality, the expression of movement and the description of objects, animate referents and actions can be conveyed through the use of a diverse semiotic repertoire. One of the main strategies used is depiction, which refers to the use of signs and grammatical structures with a high visual component.This work focuses on the study of the use of depiction when interpreting in a tactile modality from Norwegian to tactile Norwegian Sign Language (tNTS). The data analyzed for the current study is a one-hour long lecture about Ragnhild Kåta, a relevant figure in the Norwegian deafblind community. In this task participated two deafblind tNTS signers and two hearing interpreters with more than 15 years of experience as interpreters. The depiction strategies considered were classifiers, constructed action and constructed dialogue. Classifiers were further classified into entity, handling and size and shape specifiers, with the function of describing a referent or a movement/action, or to locate a referent. In order to prompt the use of depiction, the lecture contained the description of episodes where, for example, the verb expressing the action could be expanded with classifiers, a conversation was reported or situations involving body parts and several objects in interaction were presented in detail.Of the three types of depiction, classifiers were used more frequently. Entity classifiers and size and shape specifiers were the ones used the most, especially to locate and describe referents. Interestingly, it appears that the acquaintance of the interpreter with the deafblind person can be a factor that influences the use of depiction. While the interpreter and the deafblind person in pair A knew each other well and had previous experience in interpreting settings, pair B met for the first time at the data collection. The data show that interpreter A tended to use the body of the signer to help convey depiction, while interpreter B did not interact wit

Although the Coupled Model Intercomparison Project 6 (CMIP6) protocol provides an experiment to estimate effective radiative forcing (ERF), it is only quantified for few models. We present new estimates of ERF for models participating in CMIP6 by applying the method developed in Fredriksen et al. (2021, https://doi.org/10.1029/2020JD034145), and validate our approach with available fixed-SST forcing estimates. We estimate ERF for experiments with abrupt changes of CO2, 1% increase of CO2, historical forcings, and future scenarios, and demonstrate that CMIP6 ERF is lower than CMIP5 ERF at the end of the historical period, but grows faster than CMIP5 in the future scenarios, ending up at higher levels than CMIP5 at the end of the 21st century. The simulated radiative efficiency of CO2 has not changed much, suggesting that the larger future increase in CO2 concentrations in CMIP6 compared to CMIP5 is important for explaining the forcing difference.

BACKGROUND AND AIMS: To investigate the prognostic value of blood neurofilament light chain protein (NfL) levels in the acute phase of coronavirus disease 2019 (COVID-19). METHODS: We conducted an individual participant data (IPD) meta-analysis after screening on MEDLINE and Scopus to May 23rd 2022. We included studies with hospitalized adult COVID-19 patients without major COVID-19-associated central nervous system (CNS) manifestations and with a measurement of blood NfL in the acute phase as well as data regarding at least one clinical outcome including intensive care unit (ICU) admission, need of mechanical ventilation (MV) and death. We derived the age-adjusted measures NfL Z scores and conducted mixed-effects modelling to test associations between NfL Z scores and other variables, encompassing clinical outcomes. Summary receiver operating characteristic curves (SROCs) were used to calculate the area under the curve (AUC) for blood NfL. RESULTS: We identified 382 records, of which 7 studies were included with a total of 669 hospitalized COVID-19 cases (mean age 66.2 ± 15.0 years, 68.1% males). Median NfL Z score at admission was elevated compared to the age-corrected reference population (2.37, IQR: 1.13-3.06, referring to 99th percentile in healthy controls). NfL Z scores were significantly associated with disease duration and severity. Higher NfL Z scores were associated with a higher likelihood of ICU admission, need of MV, and death. SROCs revealed AUCs of 0.74, 0.80 and 0.71 for mortality, need of MV and ICU admission, respectively. CONCLUSIONS: Blood NfL levels were elevated in the acute phase of COVID-19 patients without major CNS manifestations and associated with clinical severity and poor outcome. The marker might ameliorate the performance of prognostic multivariable algorithms in COVID-19.

BACKGROUND: Employers are legally obligated to ensure the safety and health of employees, including the organizational and psychosocial working environment. The Copenhagen Psychosocial Questionnaire (COPSOQ III) covers multiple dimensions of the work environment. COPSOQ III has three parts: a) work environment b) conflicts and offensive behaviours and c) health and welfare. We translated all three parts into Norwegian and evaluated the statistical properties of the 28 work environment dimensions in part a), using a sample of registered nurses. METHODS: The original English version was translated into Norwegian and back translated into English; the two versions were compared, and adjustments made. In total, 86 of 99 items from the translated version were included in a survey to which 8804 registered nurses responded. Item response theory models designed for ordinal manifest variables were used to evaluate construct validity and identify potential redundant items. A standard confirmatory factor analysis was performed to verify the latent dimensionality established in the original version, and a more exploratory factor analysis without restrictions is included to determine dependency between items and to identify separable dimensions. RESULTS: The measure of sampling adequacy shows that the data are well suited for factor analyses. The latent dimensionality in the original version is confirmed in the Norwegian translated version and the scale reliability is high for all dimensions except 'Demands for Hiding Emotions'. In this homogenous sample, eight of the 28 dimensions are found not to be separate dimensions as items covering these dimensions loaded onto the same factor. Moreover, little information is provided at the low and high ends of exposure for some dimensions in this sample. Of the 86 items included, 14 are found to be potential candidates for removal to obtain a shorter Norwegian version. CONCLUSION: The established Norwegian translation of COPSOQ III can be

Clinical reasoning is a complex and crucial ability health professions students need to acquire during their education. Despite its importance, explicit clinical reasoning teaching is not yet implemented in most health professions educational programs. Therefore, we carried out an international and interprofessional project to plan and develop a clinical reasoning curriculum with a train-the-trainer course to support educators in teaching this curriculum to students. We developed a framework and curricular blueprint. Then we created 25 student and 7 train-the-trainer learning units and we piloted 11 of these learning units at our institutions. Learners and faculty reported high satisfaction and they also provided helpful suggestions for improvements. One of the main challenges we faced was the heterogeneous understanding of clinical reasoning within and across professions. However, we learned from each other while discussing these different views and perspectives on clinical reasoning and were able to come to a shared understanding as the basis for developing the curriculum. Our curriculum fills an important gap in the availability of explicit clinical reasoning educational materials both for students and faculty and is unique with having specialists from different countries, schools, and professions. Faculty time and time for teaching clinical reasoning in existing curricula remain important barriers for implementation of clinical reasoning teaching.