Haemodynamic significance of extrinsic outflow graft stenoses during HeartMate 3™ therapy.

Aims: The HeartMate 3 (HM3) implantable left ventricular assist device connects the left ventricle apex to the aorta via an outflow graft. Extrinsic obstruction of the graft (eOGO) is associated with serious morbidity and mortality and recently led to a Food and Drug Administration Class 1 device recall of HM3. This study aimed to provide a better understanding of the haemodynamic impact of extrinsic stenoses. Methods and results: Computed tomography (CT) images of two retrospectively identified patients with eOGO (29 and 36% decrease in cross-sectional area, respectively, by radiological evaluation) were acquired with a novel photon-counting CT system. Numerical evaluations of haemodynamics were conducted using a high-fidelity 3D computational fluid dynamics approach on both the patient-specific graft geometries and in two virtually augmented stenotic severities and three device flows. Visual analysis identified increased velocity, pressure, and turbulent flow in the outer anterior curvature of the outflow graft; however, changes in graft pressure gradients were slight (1-9 mmHg) across the range of stenosis severities and flow rates tested. Conclusion: Evidence of eOGO during HM3 support and the recent device recall can provoke clinical apprehension and interventions. The haemodynamic impact of a stenosis detected visually or by quantification of cross-sectional area reduction may be difficult to predict and easily overestimated. This numerical study suggests that, for clinically encountered flow rates and stenosis severities below 61% in cross-sectional area decrease, eOGO may have low haemodynamic impact. This suggests that patients without symptoms or signs consistent with haemodynamically significant obstruction might be managed expectantly.

Experiences and actions of part-time firefighters' family members: a critical incident study.

OBJECTIVES: The purpose of this study was to describe the experiences and actions of part-time firefighters' family members in rural areas in Sweden. DESIGN: The study had an inductive descriptive design and used the critical incident technique. SETTING: Rural areas, primarily served by a part-time fire station, across Sweden. PARTICIPANTS: The study included 25 participants (21 females and 4 males) with experiences of being a family member of a part-time firefighter. Family members who themselves served as firefighters were excluded. RESULTS: Being a part-time firefighter's family member was described into three main areas of experiences: 'affecting everyday life', 'dealing with uncertainty' and 'being in this together'. Actions taken were divided into two main areas: 'pursuing adaptations' and 'alleviating difficulties'. CONCLUSIONS: Family members of part-time firefighters faced increased responsibility at home, managing personal inconvenience and frustration. They offered emotional support for the firefighter, however, expressing a need for guidance on handling firefighters' emotions and mental health after call-outs. Despite their crucial role, they often felt unrecognised by the fire and rescue service. Nonetheless, they took pride in their firefighter's contribution to the community and noted positive impacts on the family.

An East Antarctic, sub-annual resolution water isotope record from the Mount Brown South Ice core.

We report high resolution measurements of the stable water isotope ratios (δ18O, δD) from the Mount Brown South ice core (MBS, 69.11° S 86.31° E). The record covers the period 873 - 2009 CE with sub-annual temporal resolution. Preliminary analyses of surface cores have shown the Mount Brown South site has relatively high annual snowfall accumulation (0.3 metres ice equivalent) with a seasonal bias toward lower snowfall during austral summer. Precipitation at the site is frequently related to intense, short term synoptic scale events from the mid-latitudes of the southern Indian Ocean. Higher snowfall regimes are associated with easterly winds, while lower snowfall regimes are associated with south-easterly winds. Isotope ratios are measured with Infra-Red Cavity Ring Down Spectroscopy, calibrated on the VSMOW/SLAP scale and reported on the MBS2023 time scale interpolated accordingly. We provide estimates for measurement precision and internal accuracy for δ18O and δD.

Self-determination in older patients: Experiences from nurse-dominated ambulance services.

AIM: To describe ambulance clinicians' experiences of self-determination in older patients. DESIGN: The study had an inductive and explorative design, guided from a life-world perspective. METHODS: Thirty-two Swedish ambulance clinicians were interviewed in six focus groups in November 2019. The data were analysed with content analysis, developing manifest categories and latent themes. FINDINGS: The ambulance clinicians assessed the older patients' exercise of self-determination by engaging in conversation and by being visually alert, to eventually gain an overall picture of their decision-making capacity. This assessment was used as a platform when informing older patients of their rights, thus promoting their participation in care. Having limited time and narrow guidelines counteracted ambulance clinicians' ambitions to support older patients' general desire to avoid hospitalization, which resulted in an urge to displace their responsibility to external decision-makers. CONCLUSION: Expectations that older patients with impaired decision-making ability will give homogeneous responses mean an increased risk of ageist attitudes with a simplified view of patient autonomy. Such attitudes risk the withholding of information about options that healthcare professionals do not wish older patients to choose. When decision-making is difficult, requests for expanded guidelines may paradoxically risk alienation from the professional nursing role. IMPLICATIONS AND IMPACT: The findings show ambulance clinicians' unwillingness to shoulder their professional responsibility when encountering older patients with impaired decision-making ability. In assuming that all older patients reason in the same way, ambulance clinicians tend to adopt a simplistic and somewhat ageist approach when it comes to patient autonomy. This points to deficiencies in ethical competence, which is why increased ethics support is deemed suitable to promote and develop ethical competence. Such support can increase the ability to act as autonomous professionals in accordance with professional ethical codes. REPORTING METHOD: This study adhered to COREQ guidelines. PATIENT AND PUBLIC CONTRIBUTION: None.

Voluntary first responders' experiences of being dispatched to suspected out-of-hospital cardiac arrest in rural areas: an interview study.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a leading cause of death, and survival outcomes vary across countries and regions. To improve survival, the European Resuscitation Council Guidelines encourage the implementation of technologies like smartphone applications to alert voluntary first responders (VFRs) who are near a suspected OHCA. VFRs are of great importance in the ´chain of survival´, but there is still a lack of knowledge about their experiences; especially of those operating in rural areas. Understanding those experiences is crucial in developing appropriate interventions to train, encourage, and safeguard VFRs in their mission. Therefore, the aim of this study was to describe VFRs´ experiences of being dispatched to suspected OHCA in rural areas. METHODS: The study used an inductive design. The data were collected using individual interviews with 16 VFRs and analysed using qualitative content analysis. RESULTS: The results are presented in terms of six generic categories ''Being motivated and prepared'', ''Having strategies to undertake the mission'', ''Collaborating with others'', ''Being ethically aware'', ''Supporting the family members'', and ''Coping with the mission'', which formed the basis of the main category 'Desire to save lives and help others'. The findings showed that VFRs had a genuine desire to contribute to save lives in this rural area. Regardless of the circumstances, they were prepared to leave everything and act to the best for the victim and their family members. In theirs' missions they collaborated with others at the scene and were guided by ethics while they acted in complex circumstances. CONCLUSIONS: VFRs dispatched in rural areas express a desire to save lives. In their missions, they acted in complex situations and experienced both emotional and ethical challenges. The design, implementation, and evaluation of support interventions directed at VFRs should be prioritised, especially in rural areas, as it can contribute to more people becoming and remaining VFRs, which in turn could contribute to sustainable development.

Nurses' use of an advisory decision support system in ambulance services: A qualitative study.

AIM: To illuminate from the perspective of nurses in ambulance services the experiences of using a web-based advisory decision support system to assess care needs and refer patients. DESIGN: Inductive and descriptive approaches. METHOD: Thirteen semi-structured interviews were conducted in the spring of 2020. The data were analysed through the reflexive thematic analysis. RESULTS: The Swedish web-based advisory decision support system (ADSS) was found to strengthen nurses' feelings of security when they assess patients' care needs, promote their competence and professional pride, and help them manage stress. However, the system also generated difficulties for nurses to adjust to the dynamic ambulance team and revealed a discrepancy between their professional roles and responsibilities to refer patients and provide self-care advice. The nurses thought that the support system facilitated their increased participation and helped them understand patients and significant others by offering transparency in assessment and decision making. Thus, the support system provides nurses with an opportunity to strengthen patients' independence through information and education. However, in the care relationship, nurses worked to overcome patients' expectations. CONCLUSION: Nurses using the ADSS increased their security while performing assessments and referrals and found new opportunities to provide information and promote understanding of their decisions. However, nursing care values can be threatened when new support systems are introduced, especially as ambulance services become increasingly protocol-driven. IMPLICATIONS FOR PROFESSION AND/OR PATIENT CARE: These findings have implications for nurses' work environments and help them maintain consistency in making medical assessments and in providing equivalent self-care advice when referring patients to the different levels of care. The findings will also impact researchers and policymakers who formulate decision support systems. REPORTING METHOD: Consolidated criteria for reporting qualitative research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: None.

Advising parents when their child has a fever: a phenomenographic analysis of nurses' perceptions when working at a telephone helpline, at primary care or at a paediatric emergency department in Sweden.

OBJECTIVES: To describe nurses' perceptions of advising parents when their child has a fever. DESIGN/METHOD: Inductive, descriptive study with a qualitative, phenomenographic approach. PARTICIPANTS AND SETTING: A purposive sampling was used. To be included, the 24 online interviewed nurses had to have experience advising parents of febrile children between birth and 5 years of age. They were recruited from three different parts of the healthcare system from four regions in the south of Sweden. RESULTS: The nurses described advising parents when their child has a fever as four different kinds of balancing acts: balancing between the parents' story and objective assessment, balancing between listening and teaching, balancing between self-confidence and trust in the expert, and balancing between independence and having someone by one's side. CONCLUSIONS: Giving advice to parents when their child has a fever is a process where the nurse needs to listen, assess and give advice based on the situation. This requires a correct assessment that depends on the parents' story. Creating a trusting relationship is perceived as necessary for parents to assimilate the advice that is provided. What dominates are the nurses' perceptions of the inner qualities required to achieve a balance in the process, for example, the importance of experience and security in their professional role, while it is also necessary to get support from colleagues.

Response times in rural areas for emergency medical services, fire and rescue services and voluntary first responders during out-of-hospital cardiac arrests.

Aim: To increase survival in out-of-hospital cardiac arrests (OHCA), great efforts are made to improve the number of voluntary first responders (VFR). However, evidence of the potential utility of such efforts is sparse, especially in rural areas. Therefore, the aim was to describe and compare response times for emergency medical services (EMS), fire and rescue services (FRS), and VFR during OHCA in relation to population density. Methods: This observational and comparative study was based on data including positions and time stamps for VFR and response times for EMS and FRS in a region in southern Sweden. Results: In total, 285 OHCAs between 1 July 2020 and 31 December 2021 were analysed. VFR had the shortest median response time in comparison to EMS and FRS in all studied population densities. The overall median (Q1-Q3) time gain for VFR was 03:07 (01:39-05:41) minutes. A small proportion (19.2%) of alerted VFR accepted the assignments. This is most problematic in rural and sub-rural areas, where there were low numbers of alerted VFR. Also, FRS had shorter response time than EMS in all studied population densities except in urban areas. Conclusion: The differences found in median response times between rural and urban areas are worrisome from an equality perspective. More focus should be placed on recruiting VFR, especially in rural areas since VFR can potentially contribute to saving more lives. Also, since FRS has a shorter response time than EMS in rural, sub-rural, and sub-urban areas, FRS should be dispatched more frequently.

Millennial-scale variability of Greenland dust provenance during the last glacial maximum as determined by single particle analysis.

Greenland ice core records exhibited 100-fold higher dust concentrations during the Last Glacial Maximum (LGM) than during the Holocene, and dust input temporal variability corresponded to different climate states in the LGM. While East Asian deserts, the Sahara, and European loess have been suggested as the potential source areas (PSAs) for Greenland LGM dust, millennial-scale variability in their relative contributions within the LGM remains poorly constrained. Here, we present the morphological, mineralogical, and geochemical characteristics of insoluble microparticles to constrain the provenance of dust in Greenland NEEM ice core samples covering cold Greenland Stadials (GS)-2.1a to GS-3 (~ 14.7 to 27.1 kyr ago) in the LGM. The analysis was conducted on individual particles in microdroplet samples by scanning electron microscopy with energy dispersive X-ray spectroscopy and Raman microspectroscopy. We found that the kaolinite-to-chlorite (K/C) ratios and chemical index of alteration (CIA) values were substantially higher (K/C: 1.4 ± 0.7, CIA: 74.7 ± 2.9) during GS-2.1a to 2.1c than during GS-3 (K/C: 0.5 ± 0.1, CIA: 65.8 ± 2.8). Our records revealed a significant increase in Saharan dust contributions from GS-2.1a to GS-2.1c and that the Gobi Desert and/or European loess were potential source(s) during GS-3. This conclusion is further supported by distinctly different carbon contents in particles corresponding to GS-2.1 and GS-3. These results are consistent with previous estimates of proportional dust source contributions obtained using a mixing model based on Pb and Sr isotopic compositions in NEEM LGM ice and indicate millennial-scale changes in Greenland dust provenance that are probably linked to large-scale atmospheric circulation variabilities during the LGM.

Ethics rounds in the ambulance service: a qualitative evaluation.

BACKGROUND: It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians' ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance service context. Thus, the aim of this study was to describe ambulance clinicians' experiences of participating in ethics rounds. METHODS: This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteen interviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis. RESULTS: Two themes describe the participants' experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue. CONCLUSION: Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service.

Clinical Outcomes in Patients With Refractory Anemia With Excess Blasts (RAEB) Who Receive Hypomethylating Agents (HMAs).

BACKGROUND: We sought to understand the clinical effectiveness associated with use of hypomethylating agents (HMAs) azacitidine (AZA) and decitabine (DEC) for patients with refractory anemia with excess blasts (RAEB; an established proxy for higher-risk myelodysplastic syndromes/neoplasms) in contemporary and representative real-world settings. PATIENTS AND METHODS: We used the Surveillance, Epidemiology and End Results (SEER)-Medicare database, a linkage of cancer registry and Medicare claims data, to identify patients aged ≥ 66 years diagnosed with RAEB, between 2009 and 2017 in the United States, and who received AZA or DEC as first-line therapy. Outcomes measured were overall survival (OS), event-free survival (EFS), and incidence of progression-related acute myeloid leukemia (AML). RESULTS: Of 973 eligible patients, 738 (75.8%) received AZA and 235 (24.2%) received DEC; 6.4% received hematopoietic cell transplantation during follow-up. In the overall population, median OS was 13.9 months (95% confidence interval [CI]: 12.9-15.0), median EFS was 5.2 months (95% CI: 4.9-5.7), and 38.0% of patients progressed to AML. Incidences of AML progression and death were 25.6% and 29.9%, respectively, at Year 1, and 34.3% and 44.8%, respectively, at Year 2. There were no significant differences in clinical benefits between AZA and DEC. CONCLUSION: Median OS with both HMAs remained significantly shorter than in the AZA-001 clinical trial, highlighting how patient outcomes vary between clinical and real-world settings. Further research is required to understand why these disparities exist.

Support in acute situations when a community health nurse is called: experiences of older patients, their significant others, and involved healthcare professionals- a qualitative interview study.

BACKGROUND: Care decisions for older patients in acute situations are challenging to make, and there is limited knowledge of support in home healthcare settings, where older patients receive ongoing health care from, for example, community health nurses. Therefore, this study aimed to describe the support for all involved in acute situations when a community health nurse was called, as experienced by older patients, their significant others and healthcare professionals involved. METHODS: The study was conducted using a phenomenological reflective lifeworld research approach, in which meanings of the study phenomenon were analyzed. The included participants were those who had been involved in acute situations. Twelve participants from four acute situations were interviewed. The participant included three older patients, one significant other, four community health nurses, one registered nurse student, one specialist in general practice, and two ambulance personnel, with one being a registered nurse and the other a specialist ambulance nurse. RESULTS: Support in decision-making was received from the knowledge of temporality, which provided a comprehensive understanding based on past and present knowledge of the older patient. The knowledge of temporality allowed for the early detection of new symptoms and facilitated care decisions tailored to the older patient. There was a dependency on pre-existing mutual interpersonal support, and confidence developed through relational, caring, and medical competence. CONCLUSIONS: The advantages of temporality, confidence and mutual interpersonal support in acute situations highlight the importance of enhancing relational continuity in home healthcare settings and establishing a structural collaboration among community health nurses, specialists in general practice, and ambulance personnel. This collaboration aims to provide support for making decisions regarding tailored care.

Ambulance clinicians' understanding of older patients' self-determination: A vignette study.

BACKGROUND: Older patients are often vulnerable and highly dependent on healthcare professionals' assessment in the event of acute illness. In the context of ambulance services, this poses challenges as the assessment is normally conducted with a focus on identifying life-threatening conditions. Such assessment is not fully satisfactory in a patient relationship that also aims to promote and protect patient autonomy. AIM: To describe ambulance clinicians' understanding of older patients' self-determination when the patient's decision-making ability is impaired. RESEARCH DESIGN: A qualitative design with an inductive approach, guided by descriptive phenomenology. PARTICIPANTS: In total, 30 ambulance clinicians, comprised of 25 prehospital emergency nurses, 1 nurse and 4 emergency medical technicians participated in 15 dyadic interviews. ETHICAL CONSIDERATIONS: The research was conducted in accordance with the Declaration of Helsinki, and permission was granted by the Swedish Ethical Review Authority. FINDINGS: The findings are presented in two themes: (1) Movement between explicit and implicit will; and (2) Contradictions about the patient's best interests. The clinicians' interpretations are based on an understanding of the patient's situation using substitute decision-making in emergency situations and conversations that reveal the patient's explicit wishes. Sometimes the clinicians collaborate to validate the patient's implicit will, while they at other times subordinate themselves to others' opinions. The clinicians find themselves in conflict between personal values and organisational values as they try to protect the patient's self-determination. CONCLUSION: The results indicate that older patients with an impaired decision-making ability risk losing the right to self-determination in the context of ambulance services. The clinicians face challenges that significantly affect their ability to handle the older patient's unique needs based on a holistic perspective and their ability to be autonomous.

Physicians' experiences and actions in making complex level-of-care decisions during acute situations within older patients' homes: a critical incident study.

BACKGROUND: Complex level-of-care decisions involve uncertainty in which decisions are beneficial for older patients. Knowledge of physicians' decision-making during acute situations in older patients' homes is limited. Therefore, this study aimed to describe physicians' experiences and actions in making complex level-of-care decisions during the assessment of older patients in acute situations within their own homes. METHODS: Individual interviews and analyses were performed according to the critical incident technique (CIT). In total, 14 physicians from Sweden were included. RESULTS: In making complex level-of-care decisions, physicians experienced collaborating with and including older patients, significant others and health care professionals to be essential for making individualized decisions regarding the patients' and their significant others' needs. During decision-making, physicians experienced difficulties when doubt or collaborative obstructions occurred. Physicians' actions involved searching for an understanding of older patients' and their significant others' wishes and needs, considering their unique conditions, guiding them, and adjusting care according to their wishes. Actions further involved promoting collaboration and reaching a consensus with all persons involved. CONCLUSION: Physicians strive to individualize complex level-of-care decisions based on older patients' and their significant others' wishes and needs. Furthermore, individualized decisions depend on successful collaboration and consensus among older patients, their significant others and other health care professionals. Therefore, to facilitate individualized level-of-care decisions, the health care organizations need to support physicians when they are making individualized decisions, provide sufficient resources and promote 24 - 7 collaboration between organizations and health care professionals.

Ambulance nurses' experiences of pain management with Penthrox® in Swedish ambulance care: A mixed method study.

BACKGROUND: Methoxyflurane (MTX) is an inhalation agent that has several potential benefits for limiting various types of pain in ambulance care. AIM: To elucidate how ambulance nurses experience the characteristics of MTX in an ambulance care setting. METHOD: This cross-sectional study applied a mixed-methods approach, using a questionnaire together with complementary interviews. The questionnaire survey was analyzed using descriptive statistics (10-point Likert scale and question index values [Q-IV], range: 0-1.0). The interviews were analyzed using directed content analysis. Study results were reported following the STROBE statement. RESULTS: The ambulance nurses' overall general satisfaction with the MTX concept had a median of 7.0 (IQR 5-8), corresponding to a mean Q-IV of 0.84 (very good experience). The qualitative part was divided into three categories: sense of security, patient participation, and general usefulness. The results revealed varying experiences of usefulness, including pain-relieving effect and the possibility of patient participation. The perceived strong odor of MTX seemed to concern the ambulance nurses and their patients. CONCLUSION: In general, MTX was experienced as a safe and effective analgesic. However, the experiences of the overall usefulness varied, particularly since the product had a perceived strong odor. Increasing knowledge of using MTX, could likely increase the overall usefulness.

Tension between local, regional and national level in Norwegian handling of COVID-19.

INTRODUCTION: The initial phase of the COVID-19 pandemic can be described as a crisis - a threat that must be urgently addressed under conditions of deep uncertainty. We wanted to explore the tension between local, regional and national authorities evoked by some rural municipalities' decisions to impose local infection control measures during the first weeks of the COVID-19 pandemic in Norway. METHODS: Eight municipal chief medical officers of health (CMO) and six crisis management teams participated in semi-structured and focus group interviews. Data were analyzed with systematic text condensation. Boin and Bynander's interpretation of crisis management and coordination and Nesheim et al.'s framework for non-hierarchical coordination in the state sector inspired the analysis. RESULTS: Uncertainty in the face of a pandemic with unknown damage potential, lack of infection control equipment, patient transport challenges, vulnerable staff situation and planning of local COVID-19 beds were some of the reasons for rural municipalities imposing local infection control measures. Local CMOs' engagement, visibility and knowledge contributed to trust and safety. Differences in perspectives between local, regional and national actors created tension. Existing roles and structures were adjusted, and new informal networks arose. DISCUSSION: Strong municipal responsibility in Norway and the quite unique arrangement with local CMOs in every municipality with legal right to decide temporary local infection control measures seemed to facilitate a fruitful balance between top-down and bottom-up decision-making. The following dialogue and mutual adjustment of perspectives led to appropriate balance between national and local measures in Norway's handling of the COVID-19 pandemic.

Hepatic enhancement at computed tomography: is there a dependence on body weight past institutional contrast dosing limits?

BACKGROUND: Although described in product monographs, the maximum contrast media (CM) dose at computed tomography (CT) varies among institutions. PURPOSE: To investigate whether an upper limit of 40 g of iodine in women and 50 g in men is sufficient or if there is a body weight (BW) dependence of mean hepatic enhancement (MHE) beyond those thresholds. MATERIAL AND METHODS: At our institution, CM injection duration is fixed to 30 s and dosed 600 mg iodine/kg up to 40 g in women and 50 g in men. Pre- and post-contrast hepatic attenuation values (HU) were retrospectively obtained in 200 women and 200 men with glomerular filtration rate >45 mL/min undergoing 18-flurodeoxyglucose PET-CT (18F-FDG PET-CT) of which half weighed below and half above those dose thresholds using iodixanol 320 mg iodine/mL or iomeprol 400 mg iodine/mL. The correlation between BW and MHE was assessed by simple linear regression. RESULTS: Weight range was 41-120 kg in women and 47-137 kg in men. There was no significant relationship between MHE and BW in women receiving <40 g (r = -0.05, P = 0.63) or in men receiving <50 g (r = 0.18, P = 0.07). Above those thresholds there was an inverse relationship (r = -0.64, P<0.001 in women and r = -0.30, P<0.002 in men). There was no apparent upper limit where the dependence of hepatic MHE on BW decreased. Hepatosteatosis limited MHE. CONCLUSION: Adjusting CM to BW diminishes the dependence of MHE on BW. There was no apparent upper limit for the relationship between BW and MHE in heavier patients at CM-enhanced CT.

Tension between local, regional and national levels in Norway's handling of COVID-19.

AIMS: This study aimed to explore the tension between local, regional, and national authorities evoked by some rural municipalities' decisions to impose local infection-control measures during the first weeks of the COVID-19 pandemic in Norway. METHODS: Eight municipal Chief Medical Officers of Health (CMOs) participated in semi-structured interviews, and six crisis management teams participated in focus-group interviews. Data were analysed with systematic text condensation. Boin and Bynander's interpretation of crisis management and coordination and Nesheim et al.'s framework for non-hierarchical coordination in the state sector inspired the analysis. RESULTS: Uncertainty in the face of a pandemic with unknown damage potential, lack of infection-control equipment, patient transport challenges, vulnerable staff situation and planning of local COVID-19 beds were some of the reasons for rural municipalities imposing local infection-control measures the first weeks of the pandemic. Local CMOs' engagement, visibility and knowledge contributed to trust and safety. Differences in perspectives between local, regional and national actors created tension. Existing roles and structures were adjusted, and new informal networks arose. CONCLUSIONS: Strong municipal responsibility in Norway and the quite unique arrangement with local CMOs in every municipality with the legal right to decide temporary local infection-control measures seemed to facilitate a balance between top-down and bottom-up decision making. Tension between rural, regional and national actors that arose due to local infection-control measures, and the following dialogue and mutual adjustment of perspectives, led to a fruitful balance between national and local measures in Norway's handling of the COVID-19 pandemic.

Coupled atmosphere-ice-ocean dynamics during Heinrich Stadial 2.

Our understanding of climate dynamics during millennial-scale events is incomplete, partially due to the lack of their precise phase analyses under various boundary conditions. Here we present nine speleothem oxygen-isotope records from mid-to-low-latitude monsoon regimes with sub-centennial age precision and multi-annual resolution, spanning the Heinrich Stadial 2 (HS2) - a millennial-scale event that occurred at the Last Glacial Maximum. Our data suggests that the Greenland and Antarctic ice-core chronologies require +320- and +400-year adjustments, respectively, supported by extant volcanic evidence and radiocarbon ages. Our chronological framework shows a synchronous HS2 onset globally. Our records precisely characterize a centennial-scale abrupt "tropical atmospheric seesaw" superimposed on the conventional "bipolar seesaw" at the beginning of HS2, implying a unique response/feedback from low-latitude hydroclimate. Together with our observation of an early South American monsoon shift at the HS2 termination, we suggest a more active role of low-latitude hydroclimate dynamics underlying millennial events than previously thought.

Educational intervention in triage with the Swedish triage scale RETTS©, with focus on specialist nurse students in ambulance and emergency care - A cross-sectional study.

AIM: To determine the reliability of application of the RETTS© triage scale after an educational intervention using paper-based scenarios in emergency care education. BACKGROUND: Knowledge about and education in triage are important factors in triagescale implementation. Presenting students with a large number of triage scenarios is a common part of triage education. METHODS: In this prospective cross-sectional study at two universities students undergoing education in emergency care used RETTS© to assess triage level in 46 paper-based scenarios. RESULTS: 57 students in the study made 2590 final triage decisions. Fleiss Kappa for final triage was 0.411 which is in the lower range of moderate agreement. In 25 of 46 (53.4%) scenarios, final triage levels did not agree about whether the case was stable or unstable. CONCLUSION/IMPLICATIONS: Application of the RETTS© triage scale after an educational intervention with paper-based simulation in emergency care education resulted in moderate agreement about the final levels of triage.