INTRODUCTION:While point-of-care (POC) high-sensitivity cardiac troponin (hs-cTn) testing has the potential to reduce emergency department (ED) length of stay (LOS), evidence of real world effectiveness is lacking. Our objective was to examine factors that influence the real world effectiveness of POC hs-cTn-based accelerated diagnostic protocols (ADPs) in reducing ED LOS. METHODS:This is a post hoc analysis from the "Aiming towards evidence-based interpretation of cardiac biomarkers in patients presenting with chest pain using POC testing" (WESTCOR-POC) study which included 1494 consecutive patients with suspected acute coronary syndrome presenting to the ED at a moderately sized hospital in Norway. Patients were randomised to receive hs-cTn measurements at admission and after 1 hour either by POC or central laboratory testing. This post hoc analysis examines factors affecting the effectiveness of a POC-based ADP and predictors of non-ADP-concordant disposition. Both outcomes were assessed using regression models, with significance level set at p<0.05. RESULTS:Overall, 36.1% of patients met the ADPs' early discharge criteria, of which 66% were discharged. In effect-modification analyses, the effect of POC testing on ED LOS differed by concordance with ADP recommendations (interaction p=0.011), with a reduction among patients with ADP-concordant disposition (-14 min 95% CI -26 to -3), but no corresponding reduction among patients with discordant disposition (13.5 min, 95% CI -4.5 to 31.4). Factors predicting hospital admission despite ADP-recommended discharge were: age >60 years (OR 2.3, 95% CI 1.4 to 3.7, p=0.001), high triage category (OR 1.9, 95% CI 1.2 to 3.0, p=0.003) and suspected serious differential diagnosis (OR 5.9, 95% 3.5 to 9.9, p<0.001). CONCLUSION:Our findings highlight the need for implementation strategies that support ADP concordant disposition decisions and ensure appropriate patient selection to realise the efficiency potential of POC hs-cTn testing in the ED.

BACKGROUND:Anxiety and depression impose substantial clinical and economic burdens worldwide, with high prevalence, impaired functioning, and elevated health care costs. Digital self-help interventions offer scalable and potentially cost-effective strategies; however, evidence from rigorously controlled economic evaluations remains sparse. OBJECTIVE:This trial aims to evaluate the effectiveness and cost-effectiveness of 2 Norwegian mental health apps: Tankevirus (cognitive behavioral therapy-based) and Grubl (metacognitive therapy-based), compared with a digital placebo in reducing anxiety and depression symptoms, improving health-related quality of life, and generating quality-adjusted life years. METHODS:The Mental Health Intervention With Digital Applications (MIND-APP) trial is a 3-arm randomized controlled trial (1:1:1 allocation) conducted fully remotely via a bespoke smartphone research platform. A total of 1000 Norwegian residents aged 16 years or older with mild to moderate symptoms of anxiety and/or depression will be recruited through national digital outreach. Coprimary outcomes are changes in anxiety (Generalized Anxiety Disorder-7) and depression (Patient Health Questionnaire-9) scores from baseline to postintervention (2-4 weeks). Secondary outcomes include health-related quality of life (EQ-5D-5L), quality-adjusted life years accrued over 6 months, functional impairment (Work and Social Adjustment Scale), health care resource use, and adverse events. Incremental cost-effectiveness ratios for Tankevirus and Grubl relative to placebo will be estimated from the perspective of public health services. RESULTS:Funding was secured in April 2025, with ethical approvals, licensing, and app development planned through 2026. Recruitment will commence in 2027, with follow-up through 2027 and early 2028. An extension of the timetable has been approved by the funding agent to allow inclusion of an updated version of the Tankevirus app, which will be ready for testing around May 2027. Results are expected to be published in autumn 2028 and will provide robust evidence on the clinical and economic value of scalable app-based interventions for common mental health disorders. CONCLUSIONS:This trial will be among the first large-scale registered reports to combine rigorous clinical and economic evaluation of digital mental health interventions. Findings will inform health policy and resource allocation by determining whether low-cost, app-based programs represent cost-effective solutions for reducing the burden of anxiety and depression. TRIAL REGISTRATION:ClinicalTrials.gov NCT07627204; https://clinicaltrials.gov/study/NCT07627204. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):PRR1-10.2196/84096.

AIMS:Available data on economic consequences of carrying an inherited familial hypercholesterolaemia (FH) genetic variant are sparse. This study aims to explore the hospital and pharmaceutical resource use and costs associated with cardiovascular disease (CVD) in patients with genetically verified FH compared with age- and sex-matched controls during the period 2010 through 2019. METHODS AND RESULTS:We included 5585 individuals with genetically verified FH from the Norwegian Unit for Cardiac and Cardiovascular Genetics registry and 111 483 age- and sex-matched controls from the general Norwegian population. Resource use and costs associated with CVD were collected from the Norwegian Patient Registry, the Cause of Death Registry, and the Norwegian Prescription Database. We estimated costs in European euros (EUR, €) based on diagnosis-related group (DRG) cost weights and pharmaceutical drug prices (Norwegian kroner 1 = EUR 0.1015). During 2010-19, patients with FH had CVD-related costs of €3911 per person for hospital care and €6119 for pharmaceuticals compared with €1498 and €514 among controls, respectively. The 10-year costs per person of percutaneous coronary interventions were €561 for FH and €140 for controls. The costs of CVD prescription drugs doubled in the FH population during 2010-19, largely due to the introduction of proprotein convertase subtilisin/kexin Type 9 inhibitors. Costs for prescription drugs increased in both the FH and control populations (P = 0.002 for FH and P = 0.005 for controls), while costs decreased for hospital care (P = 0. 0069 for FH and P = 0. 0943 for controls). CONCLUSION:Familial hypercholesterolaemia patients had about three times higher CVD-related hospital costs and more than 10 times higher pharmaceutical costs than age- and sex-matched controls during a 10-year follow-up. During the 10 years, costs for pharmaceuticals increased and costs for hospital decreased.

Post-COVID-19 condition is an ongoing public health concern, and the lack of established treatments increases health care utilization. Recent evidence suggests that cognitive and behavioral approaches reduce symptoms and improve functional capabilities. This study reports the cost-effectiveness of a brief outpatient cognitive-behavioral rehabilitation program compared to care as usual in non-hospitalized patients with post-COVID-19 condition. An economic evaluation based on a randomized clinical trial was conducted from a health care sector perspective. Health care utilization was charted using a self-developed questionnaire administered immediately after the intervention as well as 12 months after inclusion. Health-related quality of life was measured using the EQ-5D-5L inventory at inclusion and follow-ups and valued using the Norwegian tariff. We used multiple imputation with chained equations to impute missing data. To illustrate analysis of uncertainty, bootstrapping was performed. To account for correlation between costs and quality-adjusted life years (QALYs), we conducted seemingly unrelated regression. Costs and QALYs were summarized over the entire 12-month follow-up period. Over 12 months, analysis yielded an incremental QALY gain of 0.056 (95

Introduction: Patients with acute tachypnea pose diagnostic challenges in the emergency department (ED). Biomarkers such as N-terminal pro-B-type natriuretic peptide and cardiac troponin T improve diagnostic accuracy and risk stratification in patients with cardiovascular disease but may not be optimally assessed by clinicians in the ED. The aim of the Akershus Cardiac Examination 4 (ACE 4) study is to test whether early biomarker measurements with structured feedback in patients' electronic health records using a predetermined biomarker algorithm improve clinical outcomes in unselected patients hospitalized with tachypnea compared to standard care. The primary outcome is time to mortality or rehospitalization. Methods: The ACE 4 study is a single-center, pragmatic, non-pharmacological, randomized clinical trial including patients with acute tachypnea within 24 h of hospitalization. Patients will be randomized to either early biomarker measurements and feedback in the patient electronic medical health record using a predefined biomarker-based algorithm to assess the risk of heart failure (intervention group) or biomarker measurements without structured feedback (control group). We will preregister the study protocol and statistical analysis plan, and we will monitor data extraction and study execution. Conclusion: We hypothesize that early biomarker measurements and structured feedback in the patients' electronic health records using a predetermined biomarker algorithm will improve clinical outcomes in patients hospitalized with tachypnea compared to the standard of care. We will test this hypothesis in the ACE 4 study using a pragmatic, electronic health record-randomized controlled design, which enables inclusion of large patient groups in daily clinical practice.

INTRODUCTION:Cisplatin-based chemotherapy (CBCT) is standard treatment for most men with metastatic testicular cancer (TC). The main objective was to evaluate changes in physical fitness and body composition from before to immediately after CBCT and 3 months after completion of CBCT. PATIENTS AND MATERIALS:The assessments included cardiorespiratory fitness (peak oxygen uptake [VO2 peak]), muscle strength (1 repetition maximum [1RM]) and muscular endurance in leg- and chest press, body composition (dual-energy X-ray absorptiometry), physical activity (PA) levels, and patient-reported outcomes (functional scales, global quality of life [QoL], mental health and fatigue). Twenty-eight patients were included, most with low-volume metastatic disease and all within the good prognosis risk group. RESULTS:From before the start of CBCT to immediately after the last CBCT cycle, there were significant reductions in VO2 peak by 24% (P < .001), 1RM leg press by 8% (P = .004), 1RM chest press by 17% (P = .001), chest press endurance by 22% (P = .005), total lean body mass by 2.2 kg (P < .001), PA level, physical-, role-, cognitive- and social functioning, and QoL; and significant increases in total and physical fatigue and symptoms of depression. There was a good correlation between reductions in VO2 peak and QoL during CBCT (r = 0.54, P = .016), whereas no correlation between reductions in VO2 peak and PA levels. Twelve weeks after CBCT, all variables had returned to baseline values except for PA levels and physical functioning. CONCLUSION:TC patients should be prepared for reductions in physical fitness and QoL during CBCT. The reduction in cardiovascular fitness is possibly independent of the PA level.

Background Urban areas often act as early epicentres of pandemics, yet transmission dynamics across regions with different demographic profiles remains poorly understood. We aimed to characterise COVID−19 transmission in Norway and assess how it interacted with infection control measures across urban and rural settings. Methods We analysed daily COVID−19 cases across three pandemic waves (Alpha, Delta, Omicron). For local trends, 36 sites in the Greater Oslo Region were grouped by infection trajectories using group-based trajectory modelling. For national trends, we examined the cities of Oslo, Bergen, Trondheim, Stavanger, Tromsø, and Akershus county. Infection trends were analysed using linear mixed models and lagged regression analyses and related to demographic characteristics. Results In the Greater Oslo Region, three distinct site groups—high, moderate, and low infection—were identified. The high infection group had the highest population density, largest proportion of crowded housing and immigrant population and preceded the moderate and low groups by 5–13 days during the Alpha wave. Nationally, Oslo’s infection rates peaked 11–24 days before other cities during the Alpha wave, with shorter lags during the Delta and Omicron waves. Despite similar control measures, infection rates differed substantially, with the high infection group and Oslo city consistently bearing the greatest burden. Conclusions Densely populated areas with crowded housing act as early warning signals, with infection growth preceding that in other areas by days to weeks. Systematic monitoring of such high-burden urban areas could provide valuable lead time for policymakers and support more targeted, timely responses in future pandemics.

STUDY OBJECTIVE:To compare the effectiveness of high-sensitivity cardiac troponin (hs-cTn) point-of-care testing to central laboratory hs-cTn measurements when investigating patients presenting to the emergency department (ED) with symptoms of acute coronary syndrome. METHODS:The WESTCOR point-of-care study was a single-center prospective randomized controlled trial where we randomized patients presenting with possible acute coronary syndrome in a 1:1 fashion to receive either 0/1-hour centralized hs-cTnT measurements (control) or 0/1-hour point-of-care hs-cTnI testing (intervention). We defined length of stay (LOS) in the ED as the primary endpoint and the minimum clinically meaningful difference as 15 minutes. RESULTS:We included 1,494 patients in the final analysis, 728 in the point-of-care group, and 766 in the control group. The median (interquartile range) age was 61 (22) years, and 635 (42.5%) were women. Median LOS in the ED was 174 (95% confidence interval [CI] 167 to 181) and 180 (95% CI 175 to 189) minutes in the point-of-care and control group, respectively, resulting in a reduction in median LOS of 6 minutes (95% CI -4 to 17). Acute myocardial infarction, death, or acute revascularization occurred in 83/728 (11.4%) of point-of-care and 72/766 (9.4%) of control patients. CONCLUSIONS:We found that implementing point-of-care hs-cTnI testing in the ED with a 0/1-hour diagnostic algorithm did not lead to a clinically meaningful reduction in ED LOS. We observed no difference in the incidence of myocardial infarction, acute coronary revascularization, or death during 30 days follow-up.

Subsequent fracture rates and associated mortality were compared before and after the introduction of fracture liaison service (FLS). In 100,198 women and men, FLS was associated with 13

Background Poor cardiorespiratory fitness (CRF) is associated with a higher symptom burden and an increased prevalence of long-term treatment–related cardiovascular disease risk factors in cancer survivors. However, the magnitude of systemic therapy–related CRF impairment remains unclear. Objectives The aim of this study was to evaluate the effects of systemic anticancer treatment on CRF and identify physiological determinants underpinning CRF impairment. Methods A systematic literature search was performed in PubMed, Embase, CINAHL, SPORTDiscus, and the Cochrane Library. The primary endpoint was the change in CRF, measured by peak oxygen consumption (Vo2peak), from before to after systemic treatment. Secondary endpoints included post-treatment differences in Vo2peak between cancer survivors and noncancer control subjects, along with physiological determinants of Vo2peak. Two meta-regressions were conducted to examine the association between CRF and cardiac output and arteriovenous oxygen difference. Results A total of 44 studies were included, comprising 27 prospective trials (61%; n = 1,234 cancer survivors, median age 52.4 years) and 17 cross-sectional studies (39%; n = 1,372 cancer survivors, median age 54.0 years; n = 1,923 noncancer control subjects, median age 56.0 years). Systemic anticancer treatment was associated with a significant decrease in Vo2peak (weighted mean difference −2.13 mL·kg−1·min−1; 95% CI: −2.76 to −1.50 mL·kg−1·min−1). No significant differences were observed between patient subgroups (esophagogastric, breast, and colon or rectal cancers). At a median follow-up of 2 years (range: 6 weeks to 12 years) post-therapy, cancer survivors had a significantly lower Vo2peak (weighted mean difference −6.39 mL·kg−1·min−1; 95% CI: −7.60 to −5.18 mL·kg−1·min−1) compared with noncancer control subjects. Reduced arteriovenous oxygen difference was associated with lower Vo2peak (β = 2.55; 95% CI: 2.05-3.06; P < 0.001). Conclusions Systemic anticancer treatment leads to substantial and sustained impairments in CRF.

BackgroundHeadache-related sick leave is increasing in Norway. In cooperation with the Norwegian Labour and Welfare Administration we established the first Norwegian multidisciplinary headache clinic for patients with current or recurrent sick leave due to headaches. The primary objective of this study was to evaluate treatment effects on headache frequency and sick leave, and secondly to identify predictors for improvement and return-to-work.MethodsA team comprising neurologists, nurses, physiotherapists, psychologists, and job specialists treated patients aged 18-67 years with headache-related sick leave. Validated questionnaires and semi-structured interviews were conducted at baseline, 3, 6, and 12 months. Mixed effects linear and logistic regression was performed with headache days and sick leave as outcomes.ResultsOne hundred and one patients completed the 12-month follow-up. The median monthly headache days decreased from 24 (Interquartile range [IQR], 15.5-30) at baseline to 10 (IQR, 4-20) at 12 months (p < 0.001). Headache-related sick leave declined from 53.5% to 33.7% (p < 0.001). Migraine diagnosis and long-term sick leave at baseline negatively predicted for return-to-work, while female sex and low baseline headache frequency predicted favorable clinical outcomes.ConclusionMultidisciplinary treatment reduced headache frequency and increased work attendance. Our findings have potential implications for healthcare policy and resource allocation.

BACKGROUND:Cancer treatment may impair physiological adaptations to exercise therapy, yet no study has directly compared exercise effects between cancer survivors and cancer-naive control subjects. OBJECTIVES:This study sought to examine the effects of aerobic exercise in anthracycline-treated long-term survivors of breast cancer (BCS) and to compare the effects to cancer-naive women. METHODS:The CAUSE (CArdiovascUlar Survivors Exercise) trial was a 2-arm randomized controlled trial in which long-term BCS were assigned to thrice-weekly nonlinear aerobic exercise for 5 months (BCS exercise) or usual care (BCS usual care). A third group of similarly aged cancer-naive women completed the same exercise intervention. The primary outcome was cardiorespiratory fitness (CRF) (measured as Vo2peak). Secondary outcomes included cardiovascular risk factors (cardiometabolic biomarkers and body composition) and patient-reported outcomes (subjective vitality and life satisfaction). RESULTS:Between October 2020 and February 2023, 140 BCS (aged 59.0 ± 6.4 years; 11 ± 1 years after treatment) and 69 cancer-naive women (aged 57.8 ± 4.9 years) were enrolled. From baseline to post-exercise intervention, Vo2peak increased by 1.2 ± 2.6 mL·kg-1·min-1 in the BCS exercise, by 0.01 ± 2.5 mL·kg-1·min-1 in the BCS usual care group (mean difference 1.3; 95% confidence interval [CI]: 0.5-2.1; P = 0.002), and by 2.6 ± 2.5 mL·kg-1·min-1 in non-cancer subjects (BCS exercise vs non-cancer subjects: mean difference -1.4; 95% CI: -2.2 to -0.5; P = 0.003). No changes in cardiovascular risk factors were observed. Compared with BCS usual care, the BCS exercise group reported improved subjective vitality (mean difference 2.56; 95% CI: 1.22-3.90; P < 0.001) and satisfaction with life (mean difference 1.68; 95% CI: 0.43-2.93; P = 0.009). CONCLUSIONS:Although aerobic exercise improves CRF in anthracycline-treated long-term BCS, the response was less than one-half that observed in cancer-naive subjects.

BackgroundThe coverage of influenza vaccination among older adults in Norway is insufficient, especially in some immigrant groups. To improve public health, there is a need for an intervention that can increase influenza vaccination coverage. Further, interventions tailored to reduce potential barriers among immigrants can reduce health inequities. ObjectiveInfluSMS aims to determine if SMS nudging increases vaccination coverage among those aged 65 years or older (1) in Norway’s general population; (2) among immigrants born in Poland; and (3) among immigrants born in Ukraine; and evaluate the impact of SMS nudging in Norwegian versus in the official language of the native country of immigrants born in Poland or Ukraine. MethodsInfluSMS is a pragmatic randomized controlled trial conducted among people aged 65 years or older residing in Norway. Influenza vaccination coverage is the main outcome, measured in control and intervention arms for each of the 3 populations listed earlier. In all 3 populations, the control arm is standard care, that is, no individual reminder for influenza vaccination. All populations have an intervention arm that will receive an SMS nudge in the Norwegian language. In addition, the Polish and Ukrainian immigrant populations include a second intervention arm that will receive an SMS nudge in Polish or Ukrainian, respectively. In the general population, at least 23,485 individuals will be randomized to the SMS intervention arm while the rest of the population constitutes the control arm. In each of the 2 immigrant populations, we will randomize all eligible individuals 1:1:1 into the 3 arms. The intervention will take place at the start of the 2025-2026 influenza season. All eligible individuals will be passively followed up through the National Immunisation Registry, SYSVAK, from which individual influenza vaccination status 3 months after the SMS nudge will be collected. Coverage rates between arms within each population and effect sizes between the populations will be compared. The cost-effectiveness of SMS nudging will also be assessed. ResultsThe inclusion of participants will start in the third quarter of 2025, and the registry data will be available in the first quarter of 2026. Coverage rates of each strategy and coverage differences between strategies will be presented. ConclusionsSMS nudging is a scalable, inexpensive, and nonintrusive intervention that could be integrated into the national influenza vaccination program if the trial shows it effectively increases influenza vaccination coverage among older adults. Further, the trial will establish whether language is a barrier to influenza vaccination uptake among recent immigrant groups that have low influenza vaccination coverage, and to what extent this potential barrier can be diminished by SMS nudging in the official language of their native country. Trial RegistrationClinicalTrials.gov NCT06486766; https://clinicaltrials.gov/study/NCT06486766 International Registered Report Identifier (IRRID)PRR1-10.2196/63938

Background: Secretoneurin, a member of the granin protein family, is associated with the risk of mortality in patients with acute and chronic heart failure. Secretoneurin may play an important role in cardiomyocyte calcium handling, suggesting that it may influence cardiac arrhythmia risk. We hypothesized that baseline and serial measurements of circulating secretoneurin are associated with the risk of incident ventricular tachyarrhythmias (VA) and death, and that serial measurement would provide prognostic information beyond baseline values. Methods: We measured circulating secretoneurin concentrations in blood samples obtained at 3-month intervals for one year in a prospectively enrolled cohort of ambulatory patients with left ventricular ejection fraction (LVEF) <= 35 % and a primary-prevention implanted cardioverter defibrillator (ICD). Associations between secretoneurin modeled as a time-dependent variable and the incidences of VA and death were assessed. Results: 154 patients (66 +/- 14 years, LVEF 23 +/- 8 %) were included in the analysis. During one-year follow-up, 26 (17 %) patients experienced VA, and 16 (10 %) died. Adjusting for age, sex, eGFR, and LVEF, baseline secretoneurin concentration was associated with the risk of death (hazard ratio (HR) per 10 pmol/L increase: 1.14 (95 % CI: 1.02-1.27), p = 0.020) but not VA (HR: 0.98 (0.81-1.19), p = 0.856). Using serial measurements at 3-month intervals, time-varying secretoneurin was associated with a similarly higher risk of death (HR: 1.14 (1.02-1.27), p = 0.017) but not of VA (HR: 0.97 (0.81-1.17), p = 0.776). Conclusion: In stable ambulatory patients with reduced LV systolic function and a primary prevention indication for ICD, secretoneurin concentration was associated with the risk of death but not ventricular tachyarrhythmia.

Cancer treatment may impair the physiological adaptations to exercise training according to earlier exercise training trials. Nonetheless, reduced exercise training response has not been systematically studied in cancer survivors. To examine the effects of aerobic exercise on cardiorespiratory fitness (CRF) and cardiovascular (CV) risk factors in anthracycline-treated long-term breast cancer survivors (BCSs) and compared these effects with women without cancer following the same exercise program. The CAUSE (CArdiovascUlar Survivors Exercise) trial was a two-armed randomized controlled trial, where long-term BCSs were assigned to five months of aerobic exercise training 3 times per week or to usual care. Similar-aged women without cancer underwent the same exercise program. CRF was assessed as peak oxygen consumption (V̇O2peak), and CV risk factors including cardiometabolic biomarkers and body composition were assessed at baseline and post-intervention. Patient-reported outcomes were assessed using the Subjective Vitality Scale (SVS) and the Satisfaction With Life Scale (SWLS). We included, 140 BCSs (aged 59.0±6.4 years), 11±1 years post-treatment, and 69 women without cancer (aged 57.8±4.9 years) between October 2020 and February 2023. Intervention adherence and loss to follow-up were similar between the exercise groups. VO2peak increased by 1.22±2.63 mL O2×kg-1×min-1 in BCSs after exercise training from baseline to post-intervention, 0.02±2.47 mL O2×kg-1×min-1 in BCSs after usual care [mean difference 1.32 (95% CI: 0.501; 2148), p=0.002] and 2.64±2.51mL in women without cancer after exercise training [BCSs exercise training VS. women without cancer: Mean difference -1.41, (95% CI: -2.267; -0.545), p=0.002]. There were no significant changes in CV risk factors from baseline to post-intervention between the groups. SVS [mean difference 2.56, (95% CI: 1.215; 3.897), p=<0.001] and SWLS [mean difference 1.68, (95% CI: 0.428; 2.932), p=0.009) significantly improved in BCSs after exercise training compared to BCSs after usual care, with greater changes in SWLS in BCSs after exercise training compared to women without cancer [mean difference 1.71, (95% CI: 0.262; 2.157), p=0.021]. A decade after anthracycline treatment, aerobic exercise training improves CRF in long-term BCSs. Importantly, however, the exercise training response was lower in BCSs compared to women without cancer.

The study investigated the risk of distal forearm fractures in adult Norwegian residents according to regions of birth. There were significant differences in fracture risk between the region of birth categories. Although the magnitude of the rates was different between the birth categories, similar sex and seasonal risk patterns were observed. Worldwide, distal forearm fractures (DFFs) are the most common fractures in adults. This study compared incidence rates of first DFFs in women and men in Norway by region of birth, age, and season. We included Norwegian residents aged 20 to 79 years with a first DFF between 2010 and 2020 using data from the Norwegian Patient Registry and population estimates from Statistics Norway. Three countries of birth groups were compared: Norwegian-born, Global North (most of Europe, North America, Australia, and New Zealand), and Global South (Asia, Africa, Latin America, Oceania). Compared to Norwegian-born residents in Norway, immigrants from Global North had 16

Objectives To investigate how doctors and self-managing older patients with heart failure (HF) discuss the patients’ potential or ongoing medication adherence problems, and how such discussions evolve as patients transition from hospital to home, with particular focus on: (1) doctors’ communicative actions aimed at addressing patient disclosures of adherence problems and (2) patients’ feedback indicating whether their doctor’s supportive actions were acceptable to them.Design Exploratory interaction-based observational cohort study. Inductive microanalysis of authentic patient–doctor consultations, audio recorded for each patient at: (1) first ward visit in hospital, (2) discharge visit from hospital and (3) follow-up visit with general practitioner (GP).Setting Hospital and primary care, Norway (2022–2023).Participants 25 patients with HF (+65 years) and their attending doctors (23 hospital doctors, 25 GPs).Results Analysis of 74 consultations revealed that 25 HF patients disclosed 23 practical adherence problems indicating risks of unintentional non-adherence (eg, limited resources to manage medications) and 39 perceptual problems indicating risks of intentional non-adherence (eg, worries, negative experience or stance). Doctors addressed 79% of patients’ disclosures by: (1) exploring the scope of the problem or (2) providing supportive actions to improve patients’ ability or motivation to adhere. We calculated nearly five times higher odds for doctors to address patients’ practical problems to their perceptual problems (OR 4.79, 95% CI 1.25 to 25.83). Unresolved problems included: (1) doctors addressed patients’ disclosures, but patients signalled the supportive actions were unsuitable (37%) and (2) doctors left disclosures unaddressed (21%).Conclusions In this explorative study, the doctors were more likely to address the patients’ adherence problems associated with unintentional non-adherence risks than those associated with intentional non-adherence risks. Even when doctors attempted to address HF patients’ medication adherence problems, half of the problems remained unresolved, usually because patients indicated that the doctor’s suggestion to improve their situation was against their preference.

BACKGROUND & AIM Understanding local vulnerability to heat and cold is crucial for public health planning, yet few studies have provided a nationwide analysis of temperature-related mortality across diverse communities. This study analyses the association between ambient air temperature and non-accidental mortality across mainland Norway, using a constrained hierarchical clustering algorithm to group municipalities with similar geographic, environmental, socioeconomic, and demographic patterns. METHODS This study analysed the association between ambient air temperature and non-accidental mortality across 356 Norwegian municipalities, using daily data from 1996 to 2018. We applied a case time series design with distributed lag non-linear models. A downscaling procedure assessed the effect of 21 vulnerability factors on temperature-related mortality risks, using Principal Components Analysis to explore heterogeneity across clusters. FINDINGS Cold temperatures contributed to an estimated 3,879 deaths per year (95% CI 3,718-4,130), while heat was associated with 44 deaths annually (95%CI: 29-58). The highest heat-related mortality risk occurred in the South-East, and the highest cold-related risk in the Central-East. Greater heat-related mortality correlated with medium- to sparsely-populated areas, while higher education levels were linked to reduced vulnerability to both heat and cold. INTERPRETATION By providing the first comprehensive assessment of temperature-related excess mortality and associated risk factors in Norway, our findings underscore the need for targeted, equitable health policies that integrate environmental and socioeconomic factors. These insights are essential to guide climate adaptation strategies, prioritising vulnerable rural communities and socioeconomically disadvantaged groups to mitigate future climate-related health impacts.