Initiation and persistence with dual antiplatelet therapy after acute myocardial infarction:a Danish nationwide population-based cohort study

OBJECTIVES: The study investigated dual antiplatelet therapy (DAPT) patterns over time and patient characteristics associated with the various treatments in a myocardial infarction (MI) population. DESIGN: A registry-based observational cohort study was performed using antecedent data. SETTING: This study linked morbidity, mortality and medication data from Danish national registries. PARTICIPANTS: All 28 449 patients admitted to a Danish hospital with a first-time MI and alive at discharge from 2009 through 2012 were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was initiation of DAPT and secondary outcomes comprised persistence in DAPT treatment and switches between DAPT treatments. RESULTS: The overall proportion of patients prescribed DAPT increased from 68% (CL 95% 67–69%) to 73% (CL 95% 72–74%) from 2009 to 2012. For treatment of patients with and without percutaneous coronary intervention (PCI), the corresponding numbers were from 87% (CL 95% 86–88%) to 91% (CL 95% 90–92%) and from 49% (CL 95% 47–50%) to 52% (CL 95% 51–54%), respectively. Non-PCI patients had a higher cardiovascular risk compared with PCI patients. Among PCI patients, age>75 years, atrial fibrillation, diabetes and peripheral arterial disease were associated with a higher risk of treatment breaks for DAPT. Among patients without PCI, ticagrelor treatment was associated with an increased risk of treatment breaks during the first 12 months compared with clopidogrel treatment. CONCLUSIONS: From 2009 to 2012, there was an increase in the proportion of patients with MI receiving DAPT, and a longer duration of DAPT. Still, a large proportion of patients without PCI are discharged either without DAPT or with a short DAPT duration. These findings may indicate the need for more careful attention to DAPT for patients with MI not undergoing PCI in Denmark

Papers, Please and Critical Literacy Skills

Denne oppgaven er en teoretisk gjennomgang av hvordan dataspillet Papers, Please kan brukes i undervisning for å utvikle critica literacy ferdigheter. Dette gjøres gjennom en kulturll analyse av dataspillet Papers, Please satt i sammenheng med den norske lærerplanen (LK20). Spillet ble toket som en tekst, basert på definisjonen i LK20. I konklusjonen er det beskrevet flere faktorer som må på plass for at elevene skal utvikle critical literacy ferdigheter ved å bruke dataspill. De trenger språk/terminologi og flere verktøy for å analysere dataspillet, og forhånds kunnskap om den historiske konteksten og ideologien som relaterer til spillet. Det er viktig å anerkjenne elevenes identitet når man jobber med dataspillet, fordi andre mennesker og samfunnet kan innvirke på hvilke valg elevene tar når de spiller spillet. Konstruktivisme er valgt som læringsteori fordi den passer godt i et klasserom der diskusjonen er knyttet opp til faktorer som at elevene har fått forskjellige endinger på spillet og at elever har ulike livserfaringer. Dataspillet i seg selv er godt egnet til å utvikle critical literacy på grunn av de relevante ideologiske temaene, på grunn av at det har ulike endinger avhening av hvilke valg man gjør underveis, og elevene støter på mange ulike dilemmaer gjennom hele spillet.This thesis is a theoretical review of how the video game Papers, Please can be employed in education to develop critical literacy skills. This is done through a cultural analysis of the video game Papers, Please in relation to the Norwegian curriculum (LK20). The video game was viewed as a text, based on the definition of text in LK20. The conclusion shows that there are several factors that needed to be in place for the pupils to develop critical literacy skill in relation to video games. They need language/terminology and tools to analyse the video game, and previous knowledge about the historical context and ideology that relate to the video game. The pupil’s identity is also important to acknowledge when working with the video game, because of how others around them and society can influence the choices the pupils make throughout the game. Constructivism was chosen as a learning theory, because it suits well in a classroom where the discussion realies on the factors of people getting different endings in the game and have different lived experiences. The game itself is well suited to develop critical literacy because of the relevant ideological theme, the several endings in the game they can have as consequence of the choices they make, and the different dilemmas the pupils will meet throughout the game

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study

Background The mental health of children and young people (CYP) is a major UK public health concern. Recent policy reviews have identified that service provision for CYP with mental health needs is not as effective, responsive, accessible or child-centred as it could be. Following on from a previous National Institute for Health Research (NIHR) study into self-care support for CYP with long-term physical health needs, this study explored self-care support’s potential in CYP’s mental health. Objectives To identify and evaluate the types of mental health self-care support used by, and available to, CYP and their parents, and to establish how such support interfaces with statutory and non-statutory service provision. Design Two inter-related systematic literature reviews (an effectiveness review with meta-analysis and a perceptions review), together with a service mapping exercise and case study. Setting Global (systematic reviews); England and Wales (mapping exercise and case study). Participants (case study) Fifty-two individuals (17 CYP, 16 family members and 19 staff) were interviewed across six sites. Main outcome measures (meta-analysis) A measure of CYP’s mental health symptomatology. Data sources (literature reviews) MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, All Evidence-Based Medicine (EBM) Reviews, Applied Social Sciences Index and Abstracts (ASSIA) and Education Resources Information Center (ERIC). Review methods Titles and abstracts of papers were screened for relevance then grouped into studies. Two independent reviewers extracted data from studies meeting the inclusion criteria. A descriptive analysis and meta-analysis were conducted for the effectiveness review; descriptive analyses were conducted for the perceptions review. These analyses were integrated to elicit a mixed-methods review. Results Sixty-five of 71 included studies were meta-analysable. These 65 studies elicited 71 comparisons which, when meta-analysed, suggested that self-care support interventions were effective at 6-month [standardised mean difference (SMD) = −0.20; 95% confidence interval (CI) −0.28 to −0.11] and 12-month (SMD = −0.12; 95% CI −0.17 to −0.06) follow-ups. However, judged against Cochrane criteria, the studies were mostly low quality. Key elements of self-care support identified in the perceptions review were the acquisition of knowledge and skills, peer support and the relationship with the self-care support agent; CYP also had different perceptions from adults about what is important in self-care support. The mapping exercise identified 27 providers of 33 self-care support services. According to the case study data, effective self-care support services are predicated on flexibility; straightforward access; non-judgemental, welcoming organisations and staff; the provision of time and attention; opportunities to learn and practise skills relevant to self-care; and systems of peer support. Conclusions Mental health self-care support interventions for CYP are modestly effective in the short to medium term. Self-care support can be conceptualised as a process which has overlap with ‘recovery’. CYP and their families want choice and flexibility in the provision of such interventions and a continued relationship with services after the nominal therapy period. Those delivering self-care support need to have specific child-centred attributes. Future work Future work should focus on under-represented conditions (e.g. psychosis, eating disorders, self-harm); the role of technology, leadership and readiness in self-care support; satisfaction in self-care support; the conceptualisation of self-care support in CYP’s mental health; and efficacy and cost-effectiveness

“PHC Leadership: Are Health Centres in Good Hands?Perspectives from 3 districts in Malawi”

The study aimed to document the kinds of leadership styles are practiced at health centres (H/C) and how these styles can be explained by the contexts, characteristics of the health centre in charge (IC) and subordinate trained health staff (STHS).MethodsA well-researched leadership style model was applied, which included task, relation and change styles. This is a cross-sectional study using self-administered questionnaires in 47 H/C in 3 districts. 347 STHSs (95%) and 46 ICs (98%) responded. Questions explored background data and perceived leadership behaviour. Style items were factor analysed, and bivariate analyses and hierarchical regressions determined how styles could be explained.ResultsTwo leadership styles were revealed: “Trans”style contained all relation and the majority of task and change items; “Control” style focused on health statistics (Health Management Information System), reporting and evaluation. STHS and IC had a median age/median work experience of 34/5 years and 38,5/2 years, respectively. 48% of IC reported having no management training. CHAM H/Cs had the lowest score on “Control” style. Distance to referral hospital had no impact on style scores. No contexts or STHS characteristics predicted any leadership styles. For ICs, young age and increasing work experience were significant predictors for both styles, while Nurse ICs were negative predictors for “Control style”. Management training was not a significant predictor for any style.ConclusionFrontline PHC leadership may be forced by situation and context to use a comprehensive style which could lack the diversity and flexibility needed for effective leadership. The missing associations between staff characteristics and leadership styles might indicate that this group is not sufficiently considered and included in leadership processes in the PHC organization. Leadership competency for the ICs seems not to be based on formal training, but substituted by young age and work experience. Health centre organization could also influence the options for leadership behaviour. In conclusion this calls for a reassessment of H/C leadership and formal leadership training

A Discrete Event Simulation model to evaluate the treatment pathways of patients with Cataract in the United Kingdom

Background The number of people affected by cataract in the United Kingdom (UK) is growing rapidly due to ageing population. As the only way to treat cataract is through surgery, there is a high demand for this type of surgery and figures indicate that it is the most performed type of surgery in the UK. The National Health Service (NHS), which provides free of charge care in the UK, is under huge financial pressure due to budget austerity in the last decade. As the number of people affected by the disease is expected to grow significantly in coming years, the aim of this study is to evaluate whether the introduction of new processes and medical technologies will enable cataract services to cope with the demand within the NHS funding constraints. Methods We developed a Discrete Event Simulation model representing the cataract services pathways at Leicester Royal Infirmary Hospital. The model was inputted with data from national and local sources as well as from a surgery demand forecasting model developed in the study. The model was verified and validated with the participation of the cataract services clinical and management teams. Results Four scenarios involving increased number of surgeries per half-day surgery theatre slot were simulated. Results indicate that the total number of surgeries per year could be increased by 40% at no extra cost. However, the rate of improvement decreases for increased number of surgeries per half-day surgery theatre slot due to a higher number of cancelled surgeries. Productivity is expected to improve as the total number of doctors and nurses hours will increase by 5 and 12% respectively. However, non-human resources such as pre-surgery rooms and post-surgery recovery chairs are under-utilized across all scenarios. Conclusions Using new processes and medical technologies for cataract surgery is a promising way to deal with the expected higher demand especially as this could be achieved with limited impact on costs. Non-human resources capacity need to be evenly levelled across the surgery pathway to improve their utilisation. The performance of cataract services could be improved by better communication with and proactive management of patients.Peer reviewedFinal Published versio

Using big data from health records from four countries to evaluate chronic disease outcomes: a study in 114 364 survivors of myocardial infarction

Aims: to assess the international validity of using hospital record data to compare long-term outcomes in heart attack survivors. Methods and results: we used samples of national, ongoing, unselected record sources to assess three outcomes: cause death; a composite of myocardial infarction (MI), stroke, and all-cause death; and hospitalized bleeding. Patients aged 65 years and older entered the study 1 year following the most recent discharge for acute MI in 2002–11 [n = 54 841 (Sweden), 53 909 (USA), 4653 (England), and 961 (France)]. Across each of the four countries, we found consistent associations with 12 baseline prognostic factors and each of the three outcomes. In each country, we observed high 3-year crude cumulative risks of all-cause death (from 19.6% [England] to 30.2% [USA]); the composite of MI, stroke, or death [from 26.0% (France) to 36.2% (USA)]; and hospitalized bleeding [from 3.1% (France) to 5.3% (USA)]. After adjustments for baseline risk factors, risks were similar across all countries [relative risks (RRs) compared with Sweden not statistically significant], but higher in the USA for all-cause death [RR USA vs. Sweden, 1.14 (95% confidence interval 1.04–1.26)] and hospitalized bleeding [RR USA vs. Sweden, 1.54 (1.21–1.96)]. Conclusion: the validity of using hospital record data is supported by the consistency of estimates across four countries of a high adjusted risk of death, further MI, and stroke in the chronic phase after MI. The possibility that adjusted risks of mortality and bleeding are higher in the USA warrants further study

6-Amino-4-(4-chloro­phen­yl)-2-oxo-1,2-dihydro­pyridine-3,5-dicarbonitrile ethanol solvate

The title compound, C13H7ClN4O·C2H6O, was synthesized by the reaction of 4-chloro­benzaldehyde, malononitrile and 10% sodium hydroxide solution in an aqueous medium. In the crystal structure, the crystal packing is stabilized by inter­molecular N—H⋯N, O—H⋯O and N—H⋯O hydrogen bonds

High referral rates to secondary care by general practitioners in Norway are associated with GPs' gender and specialist qualifications in family medicine, a study of 4350 consultations

This article is part of Unni Ringberg's doctoral thesis which is available in Munin at http://hdl.handle.net/10037/7607Referral rates of general practitioners (GPs) are an important determinant of secondary care utilization. The variation in these rates across GPs is considerable, and cannot be explained by patient morbidity alone. The main objective of this study was to assess the GPs’ referral rate to secondary care in Norway, any associations between the referral decision and patient, GP, health care characteristics and who initiated the referring issue in the consultation. The probabilities of referral to secondary care and/or radiological examination were examined in 100 consecutive consultations of 44 randomly chosen Norwegian GPs. The GPs recorded whether the issue of referral was introduced, who introduced it and if the patient was referred. Multilevel and naive multivariable logistic regression analyses were performed to explore associations between the probability of referral and patient, GP and health care characteristics. Of the 4350 consultations included, 13.7% (GP range 4.0%-28.0%) of patients were referred to secondary somatic and psychiatric care. Female GPs referred significantly more frequently than male GPs (16.0% versus 12.6%, adjusted odds ratio, AOR, 1.25), specialists in family medicine less frequently than their counterparts (12.5% versus 14.9%, AOR 0.76) and salaried GPs more frequently than private practitioners (16.2% versus 12.1%, AOR 1.36). In 4.2% (GP range 0%-12.9%) of the consultations, patients were referred to radiological examination. Specialists in family medicine, salaried GPs and GPs with a Norwegian medical degree referred significantly more frequently to radiological examination than their counterparts (AOR 1.93, 2.00 and 1.73, respectively). The issue of referral was introduced in 23% of the consultations, and in 70.6% of these cases by the GP. The high referrers introduced the referral issue significantly more frequently and also referred a significantly larger proportion when the issue was introduced. The main finding of the present study was a high overall referral rate, and a striking range among the GPs. Male GPs and specialists in family medicine referred significantly less frequently to secondary care, but the latter referred more frequently to radiological examination. Our findings indicate that intervention on high referrers is a potential area for quality improvement, and there is a need to explore the referral decision process itself

GRIP - Gjenvinning, regulering og innovasjon i praksis En casestudie av NG Metall og sirkulær omstilling i bilgjenvinningsbransjen

Masterstudien undersøker hvordan gjenvinningsbransjen innoverer i møte med regulatoriske endringer for sirkulær omstilling, med utgangspunkt i en casestudie av NG Metall AS i norsk bilgjenvinningsbransje. Den bygger på litteratur fra sirkulær økonomi, regulatorisk drevet innovasjon og systemtenkning, med en abduktiv tilnærming. Tidlig empiri og litteratur la grunnlag for fem antagelser brukt som analytisk linse for 15 dybdeintervjuer med bransjeaktører. Studien har bakgrunn i behovet for å redusere ressursbruk og avfall gjennom overgang til en mer sirkulær økonomi. EU har gjennom Green Deal og Circular Economy Action Plan etablert sirkulær omstilling som et sentralt virkemiddel, og det stilles økende krav til design, demontering og materialgjenvinning. Gjenvinningsbransjen står sentralt i denne omstillingen. Bilgjenvinning er særlig relevant som case fordi bilvrak er komplekse produkter med høy ressursverdi, tett regulering, og et etablert produsentansvarssystem. Studien viser at innovasjon i bransjen i stor grad skjer som enkeltstående, inkrementelle tiltak – ofte uten forankring i en helhetlig strategi. Manglende kapasitet, uklare ansvarsforhold og svak koordinering hemmer evnen til strategisk utvikling. Samtidig finnes det potensiale for teknologisk, organisatorisk og systemrettet innovasjon, særlig der samarbeid eller proaktiv tilpasning forekommer. Studien bidrar med praksisnær innsikt i hvordan reguleringer påvirker innovasjon i komplekse verdikjeder. Funnene peker på behov for tydeligere innovasjonsstrategier, felles strukturer og insentiver. For å lykkes med sirkulær omstilling må innovasjon forstås og organiseres som en felles oppgave i verdikjeden – ikke overlates til enkeltaktører alene.This master’s thesis explores how the recycling industry innovates in response to regulatory changes aimed at enabling a transition to circular economy, using a case study of NG Metall AS in the Norwegian vehicle recycling sector. The analysis draws on literature from circular economy, regulation-driven innovation and systems thinking, and follows an abductive research approach. Early empirical insights and literature informed five working assumptions, which were used as an analytical lens for 15 in-depth interviews with industry actors. The study is motivated by the growing need to reduce resource use and waste through a shift toward a more circulary economy. Through the Green Deal and the Circular Economy Action Plan, the EU has positioned circular transition as a key strategy, with increased demands on design, dismantling and material recovery. The recycling industry plays a crucial role in this shift. Vehicle recycling is a particularly relevant case due to end-of-life vehicles being complex products with high resource value, regulatory complexity and the existing producer responsibility system. Findings show that innovation largely occurs as isolated, incremental efforts, often without being anchored in broader strategies. Limited capacity, unclear responsibilities and weak coordination hinder strategic innovation. However, potential exists for technological, organizational and especially system-level innovation, particularly through collaboration and proactive adaptation. The study offers practice-based insight into how regulation shapes innovation in complex value chains, and highlights the need for clearer innovation strategies, shared structures and stronger incentives. In order to succeed with the transition to circular economy, innovation must be understood and organized as a shared responsibility across the value chain – not left to individual actors alone

A DNA Vaccine Encoding Multiple HIV CD4 Epitopes Elicits Vigorous Polyfunctional, Long-Lived CD4+ and CD8+ T Cell Responses

T-cell based vaccines against HIV have the goal of limiting both transmission and disease progression by inducing broad and functionally relevant T cell responses. Moreover, polyfunctional and long-lived specific memory T cells have been associated to vaccine-induced protection. CD4+ T cells are important for the generation and maintenance of functional CD8+ cytotoxic T cells. We have recently developed a DNA vaccine encoding 18 conserved multiple HLA-DR-binding HIV-1 CD4 epitopes (HIVBr18), capable of eliciting broad CD4+ T cell responses in multiple HLA class II transgenic mice. Here, we evaluated the breadth and functional profile of HIVBr18-induced immune responses in BALB/c mice. Immunized mice displayed high-magnitude, broad CD4+/CD8+ T cell responses, and 8/18 vaccine-encoded peptides were recognized. In addition, HIVBr18 immunization was able to induce polyfunctional CD4+ and CD8+ T cells that proliferate and produce any two cytokines (IFNγ/TNFα, IFNγ/IL-2 or TNFα/IL-2) simultaneously in response to HIV-1 peptides. For CD4+ T cells exclusively, we also detected cells that proliferate and produce all three tested cytokines simultaneously (IFNγ/TNFα/IL-2). The vaccine also generated long-lived central and effector memory CD4+ T cells, a desirable feature for T-cell based vaccines. By virtue of inducing broad, polyfunctional and long-lived T cell responses against conserved CD4+ T cell epitopes, combined administration of this vaccine concept may provide sustained help for CD8+ T cells and antibody responses- elicited by other HIV immunogens