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BACKGROUND: In-hospital dermatological care has shifted from dedicated dermatology wards to consultation services, and some consulted patients may require postdischarge follow-up in outpatient dermatology. Safe and timely care transitions from inpatient-to-outpatient specialty care are critical for patient health, but communication around these transitions can be disjointed, and workflows can be complex. OBJECTIVE: In this 3-phase quality improvement effort, we developed and evaluated an intervention that leveraged an electronic health record (EHR) feature, known as SmartPhrase, to enable a new workflow to improve transitions from inpatient care to outpatient dermatology. METHODS: Phase 1 (February-March 2021) included interviews with patients and process mapping with key stakeholders to identify gaps and inform an intervention: a SmartPhrase table and associated workflow to promote collection of patient information needed for scheduling follow-up and closed-loop communication between dermatology and scheduling teams. In phase 2 (April-May 2021), semistructured interviews-with dermatologists (n=5), dermatology residents (n=5), and schedulers (n=6)-identified pain points and refinements. In phase 3, the intervention was evaluated by triangulating data from these interviews with measured changes in scheduling efficiency, visit completion, and messaging volume preimplementation (January-February 2021) and postimplementation (April-May 2021). RESULTS: Preintervention pain points included unclear workflow for care transitions, limited patient input in follow-up planning, multiple messaging channels (eg, EHR based, email, and phone messages), and time-inefficient patient tracking. The intervention addressed most pain points; interviewees reported the intervention was easy to adopt and improved scheduling efficiency, workload, and patient involvement. More visits were completed within the desired timeframe of 14 days after discharge during the postimplementation period (21/47, 45%) than the preimplementation period (28/41, 68%; P=.03). The messaging workload also decreased from 88 scheduling-related messages sent for 25 patients before implementation to 30 messages for 8 patients after implementation. CONCLUSIONS: Inpatient-to-outpatient specialty care transitions are complex and involve multiple stakeholders, thus requiring multifaceted solutions. With deliberate evaluation, broad stakeholder input, and iteration, we designed and implemented a successful solution using a standard EHR feature, SmartPhrase, integrated into a standardized workflow to improve the timeliness of posthospital specialty care and reduce workload.

International assessments inform education policy debates, yet little is known about their floor effects: To what extent do they fail to differentiate between the lowest performers, and what are the implications of this? TIMSS, SACMEQ, and LLECE data are analyzed to answer this question. In TIMSS, floor effects have been reduced through the introduction of a greater number of easy items. SACMEQ and LLECE, despite being specifically designed for developing countries, display substantial floor effects, a problem obscured by their strong reliance on multiple-choice questions. Consequently, some learners are officially classified as proficient who effectively score zero points beyond random guessing. Though floor effects do not substantially alter country rankings, they are large enough to distort trends over time. Designers of assessment programs need to limit floor effects through a greater number of easier multiple-choice items and more constructed-response items. The former solution is easiest to implement.

During the time of autonomy, the spiritual concerts were an important part of building up Finnish music culture. How does the organ repertoire from the period 1850–1917 differ from the repertoire in current time, and which were the reasons behind this progress? The author examines the research topics through the spiritual ideas of the time. The research material consists of the concert programmes, concert commentaries and other writing in newspapers, which refer to the attitudes and events that took place during the time of autonomy. Besides the education of organ playing at cantor-organist schools, the German conservatory model in Helsingin musiikkiopisto ["Helsinki music school"] made it possible for Finnish organist to get basic music education in Finland. The European academic network of Richard Faltin and Oskar Merikanto helped their organ students to study abroad. The article visualises the academic network and the transnationality of European musicians, which made it possible for the new European influences to spread fast to Finland. Besides the narrow-minded concept of church music, influenced by German idealism and Pietism, the new symphonic organ style at the end of the nineteenth century emancipated the organ from being only a cult instrument to becoming a concert solo instrument.

The use of digital twins is a rapidly emerging field for improved real-time control (RTC) and decision support for the operation of collection systems and water resource recovery facilities (WRRFs). Digital twins for collection systems can help minimize the impacts of flow variation due to extreme weather events, attenuate flows to the WRRF, and reduce sewer overflows and the associated effects. Similarly, digital twins for WRRFs can help improve process, energy, and cost efficiency, fully utilise plant volumes, reduce carbon footprint, and support operator training. The current study provides an overview of two digital twin applications for collection systems (Future City Flow) and WRRFs (TwinPlant) and presents a first example of digital twin integration for proactive collection system-WRRF operation under wet-weather conditions. Current applications of the integrated digital twin are described, including (i) proactive implementation of wet-weather operation mode in WRRF based on inflow forecast and (ii) evaluation of the impacts of RTC in collection systems on WRRF performance. Other potential application examples are described together with the challenges related to the use of this solution. Overall, this new approach has a wide potential to support the cooperation within water utilities towards the adoption of integrated wastewater management. HIGHLIGHTS Digital twins can provide a sound base for controlling catchments and water resource recovery facilities.; High-quality online data from the twinned facilities is a key for reliable digital twins.; Digital twins must be robust to gain operator trust.; Connected digital twins provide a basis for system-wide optimization.; Helps to move from siloed to integrated management.;

Abstract Although many studies predict extensive future biodiversity loss and redistribution in the terrestrial realm, future changes in marine biodiversity remain relatively unexplored. In this work, we model global shifts in one of the most important marine functional groups—ecosystem-structuring macrophytes—and predict substantial end-of-century change. By modelling the future distribution of 207 brown macroalgae and seagrass species at high temporal and spatial resolution under different climate-change projections, we estimate that by 2100, local macrophyte diversity will decline by 3–4% on average, with 17 to 22% of localities losing at least 10% of their macrophyte species. The current range of macrophytes will be eroded by 5–6%, and highly suitable macrophyte habitat will be substantially reduced globally (78–96%). Global macrophyte habitat will shift among marine regions, with a high potential for expansion in polar regions.

Abstract Background Although the importance of quantitative SPECT has increased tremendously due to newly developed therapeutic radiopharmaceuticals, there are still no accreditation programs to harmonize SPECT imaging. Work is currently underway to develop an accreditation for quantitative 177Lu SPECT/CT. The aim of this study is to verify whether the positioning of the spheres within the phantom has an influence on the recovery and thus needs to be considered in SPECT harmonization. In addition, the effects of these recovery coefficients on a potential partial volume correction as well as absorbed-dose estimates are investigated. Methods Using a low-dose CT of a SPECT/CT acquisition, a computerized version of the NEMA body phantom was created using a semi-automatic threshold-based method. Based on the mass-density map, the detector orbit, and the sphere centers, realistic SPECT acquisitions of all possible 720 sphere configurations of both the PET and the SPECT versions of the NEMA Body Phantom were generated using Monte Carlo simulations. SPECT reconstructions with different numbers of updates were performed without (CASToR) and with resolution modeling (STIR). Recovery coefficients were calculated for all permutations, reconstruction methods, and phantoms, and their dependence on the sphere positioning was investigated. Finally, the simulation-based findings were validated using SPECT/CT acquisitions of six different sphere configurations. Results Our analysis shows that sphere positioning has a significant impact on the recovery for both of the reconstruction methods and the phantom type. Although resolution modeling resulted in significantly higher recovery, the relative variation in recovery within the 720 permutations was even larger. When examining the extreme values of the recovery, reconstructions without resolution modeling were influenced primarily by the sphere position, while with resolution modeling the volume of the two adjacent spheres had a larger influence. The SPECT measurements confirmed these observations, and the recovery curves showed good overall agreement with the simulated data. Conclusion Our study shows that sphere positioning has a significant impact on the recovery obtained in NEMA sphere phantom measurements and should therefore be considered in a future SPECT accreditation. Furthermore, the single-measurement method normally performed for PVC should be reconsidered to account for the position dependency.

Abstract Multiple myeloma (MM) is a disease, that at times poses diagnostic and monitoring challenges. Over the last decades laboratory methods have been expanded with serum free light chain (FLC) analysis. Alerted by two index cases with clinical impact due to failure of the FLC analysis to indicate a disease progression, we aimed to identify any clinical consequences due to known differences between FLC analysis methods. We applied two FLC analysis methods (Freelite Binding Site [FBS] and N‐Latex Siemens [NLS]) on all patients with MM and monoclonal gammopathy of uncertain significance diagnosed/followed up at Södra Älvsborg Hematology Unit, from April to December 2022. From a total of 123 patients with malignant plasma cell disorder, we identified five cases (4.1%) where solely the FBS method, as opposed to NLS, urine and serum electrophoresis, could support diagnosis or detect progression. The consequences of this discrepancy included not only change of diagnosis or delayed therapy but also change of treatment. Our findings indicate that a stronger awareness of the potential weaknesses of different FLC methods is needed, which calls for a closer collaboration between clinical chemists and hematologists.

Abstract Background Women who are migrants experience discrimination and face major risks, including sexual exploitation, trafficking, and violence, which affect their health and well-being. This study explored critical health incidents experienced by immigrant Thai women in marriage migration. Methods A qualitative explorative approach with in-depth interviews was used. Forty immigrant Thai women who currently or previously had a Swedish spouse were recruited for the study. An inductive critical incident technique was used to collect and analyze the data as the first step. In a second deductive step, the Newman system model was used to categorize health dilemmas. Results The women reported 438 critical health incidents in five main areas. Psychological health dilemmas included emotional abuse, feeling overwhelmed due to family responsibilities and the stress of leaving family behind. Sociocultural health dilemmas included transnational family duties or not performing family duties. Physiological health dilemmas included experiencing physical violence and environmental, domestic or work accidents. Developmental health dilemmas included failing health, difficulties upholding the duties expected of a spouse in the target culture and caring for an elderly husband. Spiritual health dilemmas included critical incidents in which the women perceived themselves to have failed in their hopes and duties as a wife, which intensified their dependence on faith, particularly the Buddhist concept of karma. Conclusion Professionals in health and welfare practices in Thailand together with professionals in Western countries who work with women in marriage migration situations need to recognize the psychological, sociocultural, physiological, developmental, and spiritual health dilemmas experienced by these women. Furthermore, civil organizations that meet Thai women in foreign countries, such as Buddhist cultural associations, would benefit from the multicultural knowledge revealed by the present study. This knowledge can facilitate healthcare and welfare support for women in marriage migration situations.

Abstract Background Insights derived from athletes who have completed the final phase of rehabilitation and successfully returned to their respective sports after anterior cruciate ligament (ACL) reconstruction could potentially contribute to the enhancement of therapeutic strategies. Therefore, the aim of this study was to explore athletes’ experiences, thoughts, and behaviours of final phase rehabilitation and return to sport after ACL reconstruction and to describe their thoughts about the risk of reinjury. Methods This qualitative interview study included individual semi-structured interviews with 15 athletes after ACL reconstruction. All athletes were aged between 15 and 35 years (median, 23 years), had returned to their preinjury contact sport at elite or recreational competitive level, rehabilitated with different physioterapists (working in hospital, primary care or sport clinics), and had undergone primary ACL reconstruction between 14 and 59 months (median, 23 months) before the interviews. Data were analysed using qualitative content analysis. Results Analysis of the data resulted in the following 4 main categories related to athletes’ experiences of the return to sport process and their thoughts about the risk of reinjury: Athletes’ strategies for safe return to sport; Support during rehabilitation and return to sport; The rehabilitation journey was worthwhile to be able to play again; and Reinjury is beyond one’s control. Conclusions Athletes described strategies for a safe return to sport after ACL reconstruction, emphasizing continuous increased load, not forcing return to sport, injury prevention exercises, and seeking support from professionals and coaches. Despite loving their sport, the athletes had mixed feelings about undergoing additional rehabilitation if reinjured. The athletes recognized the high reinjury risk, attributing it to fate. These findings enhance understanding of athletes’ return to sport experiences after ACL reconstruction, their strategies to minimize reinjury risk, which might help optimizing care for this patient group.

Lena-Karin Gustafsson,1 Els-Marie Anbacken,2 Gunnel Östlund,2 Anna Bondesson,1 Tina Pettersson,1 Viktoria Zander3 1Division of Caring Science, School of Health, Care and Social Welfare, Mälardalens University, Eskilstuna, Sweden; 2Division of Social Work, School of Health, Care and Social Welfare, Mälardalens University, Eskilstuna, Sweden; 3Division of Health and Welfare Technology, School of Health, Care and Social Welfare, Mälardalens University, Eskilstuna, SwedenCorrespondence: Lena-Karin Gustafsson, Division of Caring Science, School of Health, Care and Social Welfare, Mälardalens University, Eskilstuna, Sweden, Tel +46 70 7874420, Email lena-karin.gustafsson@mdu.seAim: This study aims to describe experiences of the implementation of a new integrated healthcare model for older adults with complex care needs due to multimorbidity, living at home, from a health and welfare personnel perspective. The goal was to diminish hospitalization and still carry out high quality care at home for older adults living with multimorbidity. The model was implemented by two organizations working in cooperation, the municipality, and the region that handles interprofessional social care and healthcare in people’s homes.Materials and Method: Open-ended group interviews with personnel were carried out, three of the group interviews pre-implementations of the model, and three of the group interviews post-implementation. The interviews were audiotaped and analysed according to the procedure of thematic analysis.Results: The quality of the integrated care model was based on care-chain cooperation, shared professionalism, and creating relations with the patient including closeness to next of kin, which was underlined by the participants. Unencumbered time gave the professionals the possibility to develop quality in integrated healthcare as part of integrated and person-centred care. The coproduction of education, research interviews and the follow-up meeting identified successes in diminishing hospitalization rates according to the participants’ experiences of the post-implementation interviews. An identified failure was, however, that shared professionalism was not developed over time, rather the different responsibilities were accentuated according to the information retrieved at the follow-up meeting.Conclusion: Quality aspects of the model were identified in the present study. However, when implementation of a new model is completed, the organizations always have their own interpretation of how to further understand the model in question.Plain language summary: The intention of the present study was to follow the process of working with a new model of providing care at home, thus preventing increased numbers of hospital readmissions, based on the professionals´ point of view of what quality care is for older adults with complex care needs due to multimorbidity, living in their own home. The professionals were interviewed in group settings on several occasions during the implementation.The result showed hopeful expectations expressed by the professionals before the new model was implemented, such as a hope for getting more time for high-quality care for the older adults with multimorbidity. During the teamwork, the conversation within the team members was praised as a key factor that included shared professionalism from professionals with different levels of education and focus on their work. According to the staff, unnecessary hospital stays were reduced, while the interprofessional care-chain cooperation was improved through the work of the integrated care team. For many team members, the positive difference in both work and care satisfaction was highlighted in comparison to regular home care as they were able to use their multi-disciplinary skills and support.Keywords: integrated-care model, multi-morbidity, interprofessional care, home-based care, person-centred integrated care

Abstract Aims This study aimed to characterize a contemporary population with subtypes of incident or prevalent heart failure (HF) based on reduced (HFrEF), mildly reduced, or preserved (HFpEF) left ventricular ejection fraction (LVEF) and to assess how outcomes, healthcare, treatments, and healthcare costs vary between each subtype of incident HF. Methods and results Using Swedish data from the CardioRenal and Metabolic disease Heart Failure (CaReMe HF) study, updated to cover a more recent time period, this population‐based study characterized patients from Stockholm County, Sweden, with incident HF (patients with a first HF diagnosis between 1 January 2015 and 31 December 2019) or prevalent HF (patients with a first HF diagnosis before 1 January 2020). Patients with incident HF had LVEF measured by echocardiography within ±90 days of their first HF diagnosis, and patients with prevalent HF within 5 years prior to the index date. The 13 375 patients with prevalent HF (39.2% women, mean age 73.9 years) had multiple comorbidities (cardiovascular diseases, chronic kidney disease, diabetes, and cancer). These were already highly prevalent at the time of the first HF diagnosis in the 8042 patients with incident HF (40.5% women, mean age 72.3 years). Patients with incident HFpEF received less specialist HF care at outpatient secondary care facilities following their first HF diagnosis than those with incident HFrEF. Patients with HFrEF had higher risks of complications and exerted a higher burden, in terms of care for and costs of HF, on the healthcare system. Conclusions This study of contemporary patients with incident HF demonstrates that those with HFpEF and HFrEF differ considerably in terms of clinical presentation, prognosis, and care, highlighting a potential to improve HF outcomes.

Background and aims: Cardiovascular disease (CVD) poses significant health challenges globally. While substantial data exists for most populations, the Arctic Inuit's CVD incidence rates remain understudied. This research aimed to change this by estimating CVD incidence and mortality rates in Greenland from 1994 to 2021. Methods: Using nationwide registers, a retrospective observational study was conducted, focusing on individuals born in Greenland to Greenlandic-born parents. Data were sourced from the Greenlandic Hospital Discharge Register and the nationwide electronic medical record. Results: A total of 65,824 individuals were included. the age- and sex-specific incidence rates (IR) of ischemic heart disease, stroke, and heart failure (HF) declined from 1994 to 2021, with the most substantial decline observed for HF among women. Conversely, the IR of atrial fibrillation/flutter increased in both men and women, while the IR of myocardial infarction rose among men. The IR for stroke was particularly elevated compared to other CVD subgroups. Mortality rates for those diagnosed with CVD were 2.4 times higher than those without. Men exhibited a 40 % elevated mortality risk relative to women. Conclusion: The study provides pivotal insights into CVD trends within the Arctic Inuit population, highlighting both positive developments and areas of concern. Given the increasing elderly demographic in Greenland, proactive health strategies are crucial. Emphasizing primary prevention and addressing specific CVD risks, particularly the elevated stroke IR, is imperative for future public health efforts.

Abstract The major ampullate Spidroin 1 (MaSp1) is the main protein of the dragline spider silk. The C-terminal (CT) domain of MaSp1 is crucial for the self-assembly into fibers but the details of how it contributes to the fiber formation remain unsolved. Here we exploit the fact that the CT domain can form silk-like fibers by itself to gain knowledge about this transition. Structural investigations of fibers from recombinantly produced CT domain from E. australis MaSp1 reveal an α-helix to β-sheet transition upon fiber formation and highlight the helix No4 segment as most likely to initiate the structural conversion. This prediction is corroborated by the finding that a peptide corresponding to helix No4 has the ability of pH-induced conversion into β-sheets and self-assembly into nanofibrils. Our results provide structural information about the CT domain in fiber form and clues about its role in triggering the structural conversion of spidroins during fiber assembly.

Abstract Epicardial adipose tissue (EAT) is the cardiac visceral fat depot proposed to play a role in the etiology of various cardiovascular disease outcomes. Little is known about EAT determinants in a general population. We examined cardiometabolic, dietary, lifestyle and socioeconomic determinants of echocardiograpghically measured EAT in early adulthood. Data on cardiometabolic, dietary, lifestyle and socioeconomic factors were collected from participants of the Cardiovascular Risk in Young Finns Study (YFS; N = 1667; age 34–49 years). EAT thickness was measured from parasternal long axis echocardiograms. Multivariable regression analysis was used to study potential EAT determinants. Possible effect modification of sex was addressed. Mean EAT thickness was 4.07 mm (95% CI 4.00–4.17). Multivariable analysis [β indicating percentage of change in EAT(mm) per one unit increase in determinant variable] indicated female sex (β = 11.0, P

Societal Impact Statement Seagrass ecosystems are of fundamental importance to our planet and wellbeing. Seagrasses are marine flowering plants, which engineer ecosystems that provide a multitude of ecosystem services, for example, blue foods and carbon sequestration. Seagrass ecosystems have largely been degraded across much of their global range. There is now increasing interest in the conservation and restoration of these systems, particularly in the context of the climate emergency and the biodiversity crisis. The collation of 100 questions from experts across Europe could, if answered, improve our ability to conserve and restore these systems by facilitating a fundamental shift in the success of such work. Summary Seagrass meadows provide numerous ecosystem services including biodiversity, coastal protection, and carbon sequestration. In Europe, seagrasses can be found in shallow sheltered waters along coastlines, in estuaries & lagoons, and around islands, but their distribution has declined. Factors such as poor water quality, coastal modification, mechanical damage, overfishing, land‐sea interactions, climate change and disease have reduced the coverage of Europe’s seagrasses necessitating their recovery. Research, monitoring and conservation efforts on seagrass ecosystems in Europe are mostly uncoordinated and biased towards certain species and regions, resulting in inadequate delivery of critical information for their management. Here, we aim to identify the 100 priority questions, that if addressed would strongly advance seagrass monitoring, research and conservation in Europe. Using a Delphi method, researchers, practitioners, and policymakers with seagrass experience from across Europe and with diverse seagrass expertise participated in the process that involved the formulation of research questions, a voting process and an online workshop to identify the final list of the 100 questions. The final list of questions covers areas across nine themes: Biodiversity & Ecology; Ecosystem services; Blue carbon; Fishery support; Drivers, Threats, Resilience & Response; Monitoring & Assessment; Conservation & Restoration; Governance, Policy & Management; and Communication. Answering these questions will fill current knowledge gaps and place European seagrass onto a positive trajectory of recovery.

Abstract Background Monitoring elite athletes’ body composition (BC) is vital for health and optimizing performance in sports emphasizing leanness, such as athletics. This study aims to investigate and compare sex- and event-specific off-to in-season BC changes in endurance and power event athletics competitors. Methods Elite male and female endurance athletes (> 800 m runners; n = 21) and power event athletes (sprinters, jumpers; n = 32) underwent dual-energy X-ray absorptiometry (DXA) scans for whole and regional lean mass (LM), fat mass (FM), bone mineral content (BMC), and density (BMD) during off-season (September-October) and in-season (April-May). Linear mixed models tested between-group off-season differences in BC, within-group off-season to in-season changes, and between-group differences in change. To assess meaningful or least significant changes (LSC) in BC, DXA precision errors were determined from two consecutive total body scans in a subsample of athletes (n = 30). Results Male athletes (n = 26) gained significantly (p

Abstract Background Myxoid liposarcoma (MLS) displays a distinctive tumor microenvironment and is characterized by the FUS::DDIT3 fusion oncogene, however, the precise functional contributions of these two elements remain enigmatic in tumor development. Methods To study the cell-free microenvironment in MLS, we developed an experimental model system based on decellularized patient-derived xenograft tumors. We characterized the cell-free scaffold using mass spectrometry. Subsequently, scaffolds were repopulated using sarcoma cells with or without FUS::DDIT3 expression that were analyzed with histology and RNA sequencing. Results Characterization of cell-free MLS scaffolds revealed intact structure and a large variation of protein types remaining after decellularization. We demonstrated an optimal culture time of 3 weeks and showed that FUS::DDIT3 expression decreased cell proliferation and scaffold invasiveness. The cell-free MLS microenvironment and FUS::DDIT3 expression both induced biological processes related to cell-to-cell and cell-to-extracellular matrix interactions, as well as chromatin remodeling, immune response, and metabolism. Data indicated that FUS::DDIT3 expression more than the microenvironment determined the pre-adipocytic phenotype that is typical for MLS. Conclusions Our experimental approach opens new means to study the tumor microenvironment in detail and our findings suggest that FUS::DDIT3-expressing tumor cells can create their own extracellular niche.

Abstract Background Older individuals with functional decline and homecare are frequent visitors to emergency departments (ED). Homecare workers (HCWs) interact regularly with their clients and may play a crucial role in their well-being. Therefore, this study explores if and how HCWs perceive they may contribute to the prevention of ED visits among their clients. Methods In this qualitative study, 12 semi-structured interviews were conducted with HCWs from Sweden between July and November 2022. Inductive thematic analysis was used to identify barriers and facilitators to prevent ED visits in older home-dwelling individuals. Results HCWs want to actively contribute to the prevention of ED visits among clients but observe many barriers that hinder them from doing so. Barriers refer to care organisation such as availability to primary care staff and information transfer; perceived attitudes towards HCWs as co-workers; and client-related factors. Participants suggest that improved communication and collaboration with primary care and discharge information from the ED to homecare services could overcome barriers. Furthermore, they ask for support and geriatric education from primary care nurses which may result in increased respect towards them as competent staff members. Conclusions HCWs feel that they have an important role in the health management of older individuals living at home. Still, they feel as an untapped resource in the prevention of ED visits. They deem that improved coordination and communication between primary care, ED, and homecare organisations as well as proactive care would enable them to add significantly to the prevention of ED visits.

Abstract Background Older adults with home care (HC) often have complex disease patterns and use healthcare extensively. Increased understanding is necessary to tailor their care. To our knowledge, this is the first study to describe patterns of morbidity and hospitalizations among community-dwelling older HC recipients nationwide and in subgroups defined by age, sex, and amount of HC, and to compare patterns to community-dwelling older adults without HC. Methods Nationwide register-based cohort study in community-dwelling adults aged 70 and older receiving publicly funded HC in Sweden on January 1st 2019 and an age-and-sex matched comparison group (“non-HC recipients”). Using register data from inpatient and specialized outpatient care, we assessed the prevalence of sixty chronic diseases, frailty, multimorbidity and hospitalizations, calculated incidence rates and explored reasons for hospitalizations during two years of follow-up. Results We identified 138,113 HC recipients (mean age 85, 66% women, 57% ≥5 chronic diseases). The most prevalent diseases were hypertension (55%) and eye conditions (48%). Compared to non-HC recipients, HC recipients had a higher prevalence of almost all diseases, with an overrepresentation of neurological (26.1 vs. 9.5%) disease and dementia (9.3 vs. 1.5%). 61% of HC recipients were hospitalized at least once during two years, which was 1.6 times as often as non-HC recipients. One third of HC recipients´ hospitalizations (37.4%) were due to injuries, infections, and heart failure. Hospitalizations for chronic obstructive pulmonary disease, confusion, infections, and breathing difficulties were 3–5 times higher among HC recipients compared to non-HC recipients. Conclusion Compared to non-HC recipients, HC recipients more often live alone, have higher degrees of frailty, suffer from more chronic diseases, especially neurological disease, and are hospitalized almost twice as often. The results provide a thorough description of HC recipients, which might be useful for targeted healthcare interventions including closer collaboration between primary care, neurologists, and rehabilitation.

Abstract Aims In patients with chronic heart failure with reduced ejection fraction (HFrEF), myocardial ketone metabolism is increased and short‐term treatment with the ketone body 3‐hydroxy butyrate (3‐OHB) has beneficial haemodynamic effects. In patients with HFrEF, we investigated whether the level of circulating 3‐OHB predicted all‐cause mortality and sought to identify correlations between patient characteristics and circulating 3‐OHB levels. Methods and results We conducted a cohort study in 218 patients with HFrEF. Plasma 3‐OHB levels were measured using high‐performance liquid chromatography tandem mass spectrometry. Data on all‐cause mortality were obtained by reviewing the patients' medical records, which are linked to the national ‘Central Person Registry’ that registers the timing of all deaths in the country. Mean left ventricular ejection fraction was 35 ± 8.6%, mean age was 67 ± 10 years, 54% were New York Heart Association II, and 27% had type 2 diabetes mellitus. Median follow‐up time was 7.3 (interquartile range 6.3–8.4) years. We observed large variations in 3‐OHB levels between patients (median 59 μM, range: 14–694 μM). Patients with 3‐OHB levels above the median displayed a markedly increased risk of death compared with those with low levels {hazard ratio [HR]: 2.1 [95% confidence interval (CI): 1.3–3.5], P = 0.003}. In a multivariate analysis, 3‐OHB predicted mortality independently of known chronic heart failure risk factors [HR: 1.004 (95% CI: 1.001–1.007), P = 0.02] and with a similar statistical strength as N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) [HR: 1.0005 (95% CI: 1.000–1.001), P = 0.02]. For every 100 μmol increase in plasma 3‐OHB, the hazard of death increased by 49%. The following factors significantly predicted 3‐OHB levels in the univariate analysis: free fatty acids (FFAs) [β: 238 (95% CI: 185–292), P 0.001]. Conclusions In patients with HFrEF, circulating 3‐OHB was a strong predictor of all‐cause mortality independently of NT‐proBNP. Circulating FFAs were the best predictor of 3‐OHB levels.

Abstract Aims Although cardiopulmonary exercise testing (CPET) is the gold standard to assess exercise capacity, simpler tests (i.e., 6‐min walk test, 6MWT) are also commonly used. The aim of this study was to evaluate the relationship between cardiorespiratory parameters during CPET and 6MWT in a large, multicentre, heterogeneous population. Methods We included athletes, healthy subjects, and heart failure (HF) patients of different severity, including left ventricular assist device (LVAD) carriers, who underwent both CPET and 6MWT with oxygen consumption measurement. Results We enrolled 186 subjects (16 athletes, 40 healthy, 115 non‐LVAD HF patients, and 15 LVAD carriers). CPET‐peakV̇O2 was 41.0 [35.0–45.8], 26.2 [23.1–31.0], 12.8 [11.1–15.3], and 15.2 [13.6–15.6] ml/Kg/min in athletes, healthy, HF patients, and LVAD carriers, respectively (P

Anthropogenic aerosols mask the climate warming caused by greenhouse gases (GHGs). In the absence of observational constraints, large uncertainties plague the estimates of this masking effect. Here we used the abrupt reduction in anthropogenic emissions observed during the COVID-19 societal slow-down to characterize the aerosol masking effect over South Asia. During this period, the aerosol loading decreased substantially and our observations reveal that the magnitude of this aerosol demasking corresponds to nearly three-fourths of the CO2-induced radiative forcing over South Asia. Concurrent measurements over the northern Indian Ocean unveiled a ~7% increase in the earth's surface-reaching solar radiation (surface brightening). Aerosol-induced atmospheric solar heating decreased by ~0.4 K d-1. Our results reveal that under clear sky conditions, anthropogenic emissions over South Asia lead to nearly 1.4 W m-2 heating at the top of the atmosphere during the period March-May. A complete phase-out of today's fossil fuel combustion to zero-emission renewables would result in rapid aerosol demasking, while the GHGs linger on.

Sodium–glucose cotransporter 2 inhibitors (SGLT-2i) are now recommended in the current European Society of Cardiology/American College of Cardiology guidelines for the treatment of heart failure (HF) across the spectrum of left ventricular ejection fraction (LVEF) and several large trials have documented the beneficial effects of this drug class on cardiovascular outcomes. Although the clinical efficacy of SGLT-2 inhibition in HF is now well recognised, research is still ongoing to better understand the underlying mechanistic effects of this drug class. In this paper we assess the haemodynamic effects following SGLT-2i treatment in HF patients by reviewing the current literature. We focus our review on preload of the LV in terms of filling pressure and pulmonary artery pressure, cardiac output and afterload. We discuss these variables stratified according to HF with reduced LVEF (HFrEF) and HF with preserved LVEF (HFpEF). Finally, we examine the evidence of LV remodelling in the setting of SGLT-2i-related changes in haemodynamics.

IntroductionAccess to evidence-based psychological therapy for posttraumatic stress disorder (PTSD) is limited. Blended Trauma-focused Cognitive Therapy (bTF-CT), merging internet-modules with a few therapy sessions, may be a pathway to enhance treatment access while maintaining the benefits of face-to-face therapy.ObjectivesThis study aimed to evaluate the feasibility, acceptability, and preliminary effectiveness of bTF-CT for PTSD in routine care, as well as the feasibility of assessments and data collection.MethodA single-arm design was adopted. bTF-CT was provided to 17 participants across two psychiatric and one primary care clinic. Assessments were conducted pre, during, post and 6-months following treatment. We assessed feasibility and acceptability via self-report questionnaires, retention, and attrition rates. To estimate preliminary treatment effectiveness the PTSD Symptom Checklist (PCL-5) was used to assess PTSD symptom severity.ResultsTreatment satisfaction was high with a mean score of 28.7 out of 32 on the Client Satisfaction Questionnaire (SD = 3.5). The dropout rate was low, with 88% treatment retention. Program adherence was satisfactory, with scores ranging from 2.13 to 3.13 out of 4 on the internet intervention patient adherence scale. On the PCL-5, 88% made a reliable change, 64% demonstrated a clinically significant change, and the mean change from pre to post was 24 points (d = 2.13). Some negative effects were reported, such as unpleasant memories, feelings, and disrupted sleep, but these were temporary according to symptom scales.ConclusionsbTF-CT appears to be acceptable, feasible, and potentially effective when delivered in routine care. A large-scale non-inferiority trial to assess effectiveness compared to a gold-standard treatment is warranted.Clinical Trial RegistrationClinicaltrials.gov, identifier NCT04881643.

Background and purpose: Orthopedic trainees must be able to perform intraoperative fluoroscopy imaging to assess the surgical result after volar locking plate surgeries of distal radius fractures. Guided by Messick’s contemporary validity framework, the aim of our study was to gather evidence of validity for a test of proficiency for intraoperative imaging of a distal radius fracture using a novel immersive virtual reality simulator. Methods: 11 novices and 9 experienced surgeons employed at orthopedic departments completed 2 individual simulator sessions. At each session the participants performed 3 repetitions of an intraoperative fluoroscopic control of a distal radius fracture, consisting of 5 different fluoroscopic views. Several performance metrics were automatically recorded by the simulator and compared between the 2 groups. Results: Simulator metrics for 3 of the 5 fluoroscopic views could discriminate between novices and experienced surgeons. An estimated composite score based on these 3 views showed good test–retest reliability, ICC = 0.82 (confidence interval 0.65–0.92; P < 0.001). A discriminatory standard was set at a composite score of 6.15 points resulting in 1 false positive (i.e., novice scoring better than the standard), and 1 false negative (i.e., experienced surgeon scoring worse than the standard). Conclusion: This study provided validity evidence from all 5 sources of Messick’s contemporary validity framework (content, response process, internal structure, relationship with other variables, and consequences) for a simulation-based test of proficiency in intraoperative fluoroscopic control of a distal radius fracture fixated by a volar locking plate.

Interlinked water and climate impacts are increasingly crossing borders via global supply chains. A recent wave of supply chain regulations, based on human rights and environmental due diligence (HREDD), has emerged with the goal of holding companies accountable for adverse impacts throughout their supply chains. We develop an analytical framework to theorize how key factors grounded in domestic contexts shape how companies put HREDD in practice, focusing on water and climate risks. Our framework distinguishes between knowledge and transparency; domestic policies; and actor constellations and power. We apply this framework to study how large agricultural producers in Brazil (mal-)adapt to increasing water scarcity and climate change impacts, contributing to local water conflicts. Subsequently, we analyze how multinational companies have addressed these domestic factors in their HREDD systems. Our study provides a nuanced understanding of current trends and challenges of transnational business governance to effectively target cross-scalar climate and water risks.

Background and purpose: Parenting concerns can be a major source of distress for patients with cancer who are parents of dependent children; however, these are often not addressed in health care. The Parenting Concerns Questionnaire (PCQ) is an instrument designed to assess parents’ worries about the impact of cancer on their children and their ability to parent during this time. The Swedish version of the PCQ has, however, not been evaluated. This study therefore aimed to examine the psychometric properties of the PCQ in a sample of Swedish parents with cancer. Material and methods: A sample of 336 patients with cancer having dependent children (≤18 years) were included in a cross-sectional web-based survey. Participants completed questionnaires assessing parenting concerns, depression, anxiety, and stress symptoms (DASS); self-efficacy, family functioning (FAD-GF); and sociodemographic and clinical characteristics. Descriptive analyses, as well as reliability and validity analyses, were conducted followed by a confirmatory factor analysis of the factor structure proposed by the authors of the original version of the PCQ. Results: The majority were mothers (94.9%) with breast cancer (66.4%) aged 40–50 years (59.5%). The results showed evidence for convergent, criterion, and known group’s validity, but the original three-factor structure of the PCQ was not fully supported by confirmatory factor analysis. Interpretation: Evaluating parenting concerns may be an important step towards identifying patients who could benefit from targeted psychosocial interventions. However, the PCQ may require some further refinement to fully capture the breadth of parenting concerns in parents with cancer in different settings.