Challenges for Creating and Sustaining A Green Revolution in Africa

Research and Development/Tech Change/Emerging Technologies,

The socio-technical organisation of community pharmacies as a factor in the Electronic Prescription Service Release Two implementation: a qualitative study

Background The introduction of a new method of transmitting prescriptions from general practices to community pharmacies in England (Electronic Prescription Service Release 2 (EPS2)) has generated debate on how it will change work practice. As EPS2 will be a key technical element in dispensing, we reviewed the literature to find that there were no studies on how social and technical elements come together to form work practice in community pharmacies. This means the debate has little point of reference. Our aim therefore was to study the ways social and technical elements of a community pharmacy are used to achieve dispensing through the development of a conceptual model on pharmacy work practice, and to consider how a core technical element such the EPS2 could change work practice. Method We used ethnographic methods inclusive of case-study observations and interviews to collect qualitative data from 15 community pharmacies that were in the process of adopting or were soon to adopt EPS2. We analysed the case studies thematically and used rigorous multi-dimensional and multi-disciplinary interpretive validation techniques to cross analyse findings. Results In practice, dispensing procedures were not designed to take into account variations in human and technical integration, and assumed that repetitive and collective use of socio-technical elements were at a constant. Variables such as availability of social and technical resources, and technical know-how of staff were not taken into account in formalised procedures. Yet community pharmacies were found to adapt their dispensing in relation to the balance of social and technical elements available, and how much of the social and technical elements they were willing to integrate into dispensing. While some integrated as few technical elements as possible, some depended entirely on technical artefacts. This pattern also applied to the social elements of dispensing. Through the conceptual model development process, we identified three approaches community pharmacies used to appropriate procedures in practice. These were ‘technically oriented’, ‘improvising’ or ‘socially oriented’. Conclusion We offer a model of different work approaches community pharmacies use to dispense, which suggests that when adopting a core technical element such as the EPS2 system of dispensing there could be variations in its successful adoption. Technically oriented pharmacies might find it easiest to integrate a similar artefact into work practice although needs EPS2 to synchronise effectively with existing technologies. Pharmacies adopting an improvising-approach have the potential to improve how they organise dispensing through EPS2 although they will need to improve how they apply their operating procedures. Socially oriented pharmacies will need to dramatically adapt their approach to dispensing since they usually rely on few technical tools

Atmospheric Composition Change: Climate-Chemistry Interactions

Chemically active climate compounds are either primary compounds such as methane (CH4), removed by oxidation in the atmosphere, or secondary compounds such as ozone (O3), sulfate and organic aerosols, formed and removed in the atmosphere. Man-induced climate-chemistry interaction is a two-way process: Emissions of pollutants change the atmospheric composition contributing to climate change through the aforementioned climate components, and climate change, through changes in temperature, dynamics, the hydrological cycle, atmospheric stability, and biosphere-atmosphere interactions, affects the atmospheric composition and oxidation processes in the troposphere. Here we present progress in our understanding of processes of importance for climate-chemistry interactions, and their contributions to changes in atmospheric composition and climate forcing. A key factor is the oxidation potential involving compounds such as O3 and the hydroxyl radical (OH). Reported studies represent both current and future changes. Reported results include new estimates of radiative forcing based on extensive model studies of chemically active climate compounds such as O3, and of particles inducing both direct and indirect effects. Through EU projects such as ACCENT, QUANTIFY, and the AEROCOM project, extensive studies on regional and sector-wise differences in the impact on atmospheric distribution are performed. Studies have shown that land-based emissions have a different effect on climate than ship and aircraft emissions, and different measures are needed to reduce the climate impact. Several areas where climate change can affect the tropospheric oxidation process and the chemical composition are identified. This can take place through enhanced stratospheric-tropospheric exchange of ozone, more frequent periods with stable conditions favouring pollution build up over industrial areas, enhanced temperature-induced biogenic emissions, methane releases from permafrost thawing, and enhanced concentration through reduced biospheric uptake. During the last 510 years, new observational data have been made available and used for model validation and the study of atmospheric processes. Although there are significant uncertainties in the modelling of composition changes, access to new observational data has improved modelling capability. Emission scenarios for the coming decades have a large uncertainty range, in particular with respect to regional trends, leading to a significant uncertainty range in estimated regional composition changes and climate impact

Through a Glass, Darkly:The CIA and Oral History

This article broaches the thorny issue of how we may study the history of the CIA by utilizing oral history interviews. This article argues that while oral history interviews impose particular demands upon the researcher, they are particularly pronounced in relation to studying the history of intelligence services. This article, nevertheless, also argues that while intelligence history and oral history each harbour their own epistemological perils and biases, pitfalls which may in fact be pronounced when they are conjoined, the relationship between them may nevertheless be a productive one. Indeed, each field may enrich the other provided we have thought carefully about the linkages between them: this article's point of departure. The first part of this article outlines some of the problems encountered in studying the CIA by relating them to the author's own work. This involved researching the CIA's role in US foreign policy towards Afghanistan since a landmark year in the history of the late Cold War, 1979 (i.e. the year the Soviet Union invaded that country). The second part of this article then considers some of the issues historians must confront when applying oral history to the study of the CIA. To bring this within the sphere of cognition of the reader the author recounts some of his own experiences interviewing CIA officers in and around Washington DC. The third part then looks at some of the contributions oral history in particular can make towards a better understanding of the history of intelligence services and the CIA

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation.

OBJECTIVES: To provide an accurate, web-based tool for stratifying patients with atrial fibrillation to facilitate decisions on the potential benefits/risks of anticoagulation, based on mortality, stroke and bleeding risks. DESIGN: The new tool was developed, using stepwise regression, for all and then applied to lower risk patients. C-statistics were compared with CHA2DS2-VASc using 30-fold cross-validation to control for overfitting. External validation was undertaken in an independent dataset, Outcome Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). PARTICIPANTS: Data from 39 898 patients enrolled in the prospective GARFIELD-AF registry provided the basis for deriving and validating an integrated risk tool to predict stroke risk, mortality and bleeding risk. RESULTS: The discriminatory value of the GARFIELD-AF risk model was superior to CHA2DS2-VASc for patients with or without anticoagulation. C-statistics (95% CI) for all-cause mortality, ischaemic stroke/systemic embolism and haemorrhagic stroke/major bleeding (treated patients) were: 0.77 (0.76 to 0.78), 0.69 (0.67 to 0.71) and 0.66 (0.62 to 0.69), respectively, for the GARFIELD-AF risk models, and 0.66 (0.64-0.67), 0.64 (0.61-0.66) and 0.64 (0.61-0.68), respectively, for CHA2DS2-VASc (or HAS-BLED for bleeding). In very low to low risk patients (CHA2DS2-VASc 0 or 1 (men) and 1 or 2 (women)), the CHA2DS2-VASc and HAS-BLED (for bleeding) scores offered weak discriminatory value for mortality, stroke/systemic embolism and major bleeding. C-statistics for the GARFIELD-AF risk tool were 0.69 (0.64 to 0.75), 0.65 (0.56 to 0.73) and 0.60 (0.47 to 0.73) for each end point, respectively, versus 0.50 (0.45 to 0.55), 0.59 (0.50 to 0.67) and 0.55 (0.53 to 0.56) for CHA2DS2-VASc (or HAS-BLED for bleeding). Upon validation in the ORBIT-AF population, C-statistics showed that the GARFIELD-AF risk tool was effective for predicting 1-year all-cause mortality using the full and simplified model for all-cause mortality: C-statistics 0.75 (0.73 to 0.77) and 0.75 (0.73 to 0.77), respectively, and for predicting for any stroke or systemic embolism over 1 year, C-statistics 0.68 (0.62 to 0.74). CONCLUSIONS: Performance of the GARFIELD-AF risk tool was superior to CHA2DS2-VASc in predicting stroke and mortality and superior to HAS-BLED for bleeding, overall and in lower risk patients. The GARFIELD-AF tool has the potential for incorporation in routine electronic systems, and for the first time, permits simultaneous evaluation of ischaemic stroke, mortality and bleeding risks. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF (NCT01090362) and for ORBIT-AF (NCT01165710)

Two-year outcomes of patients with newly diagnosed atrial fibrillation: results from GARFIELD-AF.

AIMS: The relationship between outcomes and time after diagnosis for patients with non-valvular atrial fibrillation (NVAF) is poorly defined, especially beyond the first year. METHODS AND RESULTS: GARFIELD-AF is an ongoing, global observational study of adults with newly diagnosed NVAF. Two-year outcomes of 17 162 patients prospectively enrolled in GARFIELD-AF were analysed in light of baseline characteristics, risk profiles for stroke/systemic embolism (SE), and antithrombotic therapy. The mean (standard deviation) age was 69.8 (11.4) years, 43.8% were women, and the mean CHA2DS2-VASc score was 3.3 (1.6); 60.8% of patients were prescribed anticoagulant therapy with/without antiplatelet (AP) therapy, 27.4% AP monotherapy, and 11.8% no antithrombotic therapy. At 2-year follow-up, all-cause mortality, stroke/SE, and major bleeding had occurred at a rate (95% confidence interval) of 3.83 (3.62; 4.05), 1.25 (1.13; 1.38), and 0.70 (0.62; 0.81) per 100 person-years, respectively. Rates for all three major events were highest during the first 4 months. Congestive heart failure, acute coronary syndromes, sudden/unwitnessed death, malignancy, respiratory failure, and infection/sepsis accounted for 65% of all known causes of death and strokes for <10%. Anticoagulant treatment was associated with a 35% lower risk of death. CONCLUSION: The most frequent of the three major outcome measures was death, whose most common causes are not known to be significantly influenced by anticoagulation. This suggests that a more comprehensive approach to the management of NVAF may be needed to improve outcome. This could include, in addition to anticoagulation, interventions targeting modifiable, cause-specific risk factors for death. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Overvåkning av rømt oppdrettslaks i Trøndelag etter rømminger fra lokalitetene Geitryggen og Austvika i 2018

Aronsen, T., Berntsen, H.H., Johansen, M.R., Moe K. & Næsje, T.F. 2019. Overvåkning av rømt oppdrettslaks i Trøndelag etter rømminger fra lokalitetene Geitryggen og Austvika i 2018. NINA Rapport 1636. Norsk institutt for naturforskning. På grunn av rømminger av totalt 106 700 oppdrettslaks fra Marine Harvest AS (nå Mowi Norway AS) sine oppdrettslokaliteter Geitryggen og Austvika i Trøndelag i februar 2018 ble det igangsatt ekstra overvåkning av rømt oppdrettslaks i elver i Trøndelag i 2018. Det ble i henhold til pålegget gitt av Fiskeridirektoratet utført overvåkning i følgende elver i 2018: Namsen (skjellprøver fra sportsfiske og høstfiske), Årgårdsvassdraget (skjellprøver fra sportsfiske og høstfiske), Aursunda (skjellprøver fra sportsfiske og høstfiske), Bogna (skjell-prøver fra sportsfiske og høstfiske), Oksdøla (forsøk på innsamling av skjellprøver fra sports-fiske og høstfiske), Steinsdalselva (skjellprøver fra sportsfiske og høstfiske), Salvassdraget (skjellprøver fra sportsfiske og høstfiske) og Norfolla (skjellprøver fra sportsfiske og høst-fiske). Det ble også gjennomført videoovervåkning I Årgårdsvassdraget, Steinsdalselva, Salvassdraget og Nordfolla som vil bli rapportert separat da dataene fra disse undersøkelsene ikke var klare ved utarbeidelse av denne rapporten. I tillegg ble visuell klassifisering av opp-drettslaks fra kilenotovervåkning i Namsfjorden og ved Kvaløya ved Vikna inkludert i overvåkningen. Det var vanskelige fiskeforhold i store deler av fiskesesongen i 2018 på grunn av lite nedbør i starten av sommeren. Det var også vanskelige forhold for undersøkelser om høsten 2018 på grunn av mye nedbør. Dette har mest sannsynlig gitt et lavt antall innsendte skjellprøver på grunn av lave fangster i de mindre vassdragene. 1.1 Andeler rømt oppdrettslaks i vassdrag 2018 Totalt ble det sendt inn skjellprøver fra 1685 laks og blant disse var det 131 rømte oppdrettslaks (7,8 %). I de fleste av vassdragene var andelene oppdrettslaks i samme størrelsesorden som i perioden 2014 ─ 2017. Av det totale antallet rømte oppdrettslaks ble 75 % fanget i Salvassdraget og Steinsdalselva. Andelen rømt oppdrettslaks blant innsendte skjellprøver i Namsen var 2,1 % (19 oppdrett av 917 laks) i skjellprøver fra sportsfiskefangstene og 3,2 % (6 oppdrett blant 187 laks) i høstfiskefangstene. Andelen under sportsfisket var i samme størrelsesorden som 2014 ─ 2017 (variasjon 1,2 ─ 3,8 %), mens andelen i høstfisket var lavere enn andelen i perioden 2014 ─ 2017 (variasjon 8,0 ─ 15,8 %). Hverken Bogna eller Aursunda hadde fangst av oppdrettslaks blant henholdsvis 10 og 29 innsendte skjellprøver av laks fra sportsfisket i 2018 eller blant henholdsvis 43 og 10 innsendte skjellprøver av laks fra høstfisket i Bogna og Aursunda i 2018. Vi har ikke data fra Oksdøla fra 2018 da vi ikke har skjellprøver av laks fra sportsfisket eller høstfisket, I Årgårdsvassdraget var andelen oppdrettslaks 4,8 % (fire oppdrett blant 84 laks) blant innsendte skjellprøver fra sportsfisket i 2018 og 6,3 % i høstfisket (en oppdrett blant 16 laks). Dette er høyere enn i perioden 2014 ─ 2017 (variasjon 0 ─ 0.6 % i sportsfisket og 0 ─ 3,8 % i høstfisket, men merk at det kun ble fanget fem oppdrettslaks til sammen i høstfisket og sportsfisket og at det var få prøver fra høstfisket (16 prøver av laks). I Norfolla var andelen rømt oppdrettslaks blant skjellprøver fra sportsfiskefangstene 11,8 % (to oppdrett blant 17 laks) og 14,3 % (en oppdrett blant syv laks) i høstfiskefangstene. Merk at antall skjellprøver var for lavt til å gi et godt estimat på andel oppdrett i vassdraget. Tre fangede oppdrettslaks, til tross for et lavt antall innsendte skjellprøver, gir allikevel grunn til å følge opp Norfolla med hensyn til rømt oppdrettslaks fremover. Det finnes imidlertid ikke tidligere data på rømt oppdrettslaks i fangster fra Nordfolla. Steinsdalselva hadde betydelige andeler og antall rømt oppdrettsfisk i fangstene i 2018. Blant innsendte skjellprøver fra sportsfisket var andelen 11,5 % (9 oppdrett blant 78 laks) og for høstfisket var andelen 35,6 % (37 oppdrett blant 104 laks). Andelen i sportsfisket var høyere enn tidligere registrert (1,2 % i 2015 og 4,4 % i 2017), mens andelen om høsten er den nest høyeste som er registrert (variasjon 9,8 ─ 43,1 % i perioden 2014 ─ 2017). Steinsdalselva er et vassdrag som også tidligere har tiltrukket seg mye rømt oppdrettslaks spesielt om høsten. Høstfisket foregår primært i nedre deler av vassdraget og er mest sannsynlig ikke representativt for andelen oppdrettslaks i hele vassdraget, men høstfisket har blitt utført på samme måte som tidligere år og vi kan dermed konkludere med at det var en høy andel og et høyt antall oppdrettslaks i fangstene i Steinsdalselva i 2018. Andelen oppdrettslaks i Salvassdraget var 29,8 % (50 oppdrett blant 168 laks) i sportsfiske-sesongen 2018 basert på skjellprøver fra fangster i nedre del av vassdraget og kilenotfiske i Salvatnet. Salvassdraget har også i tidligere år hatt høye andeler oppdrettslaks i sportsfisket. I perioden 2014 ─ 2017 var variasjonen 9,7 ─ 36 % og andelen i 2018 er da den nest høyeste sammenlignet med denne perioden. Det ble også utført et høstfiske med garn i Sakstjønna i Salvassdraget i 2018. Andelen oppdrettslaks i dette fisket var 14,3 % (to oppdrett blant 14 laks). Dette er lavere enn i tidligere år (2014, 2015 og 2016: variasjon 33 ─ 57 %) men merk at andelen er basert på et lavt antall prøver. 1.2 Andelen oppdrettslaks i sjøovervåkningen Andelen oppdrettslaks ble også undersøkt ved kilenotfiske i Namsfjorden og med kilenot/krokgarnfiske ved Kvaløya i Vikna kommune. Andelen oppdrettslaks basert på fiskerens vurdering av laksens utseende var 1,2 % (16 antatte oppdrett eller usikker oppdrett blant 1384 laks) i Namsfjorden, noe som er lavt i forhold til tidligere år (2013 ─ 2017: variasjon = 1,3 ─ 5,7%). Ved Kvaløya var andelen oppdrettslaks, basert på fiskerens vurdering av laksens utseende, 4,8 % (26 antatte oppdrett blant 544 laks) som er svært lavt i forhold til tidligere år (2011 ─ 2017: variasjon = 17 ─ 52%). Andelen rømt oppdrettslaks i fangstene er forventet å øke noe når skjellprøvene blir analysert. 1.3 Rømthistorikk for fanget oppdrettslaks med skjellprøve i 2018 Vekstmønsteret i skjellet kan gi informasjon om hvor lenge oppdrettslaksen har vært i sjøen etter rømming. Fravær av vintersoner med lav vekst i skjellene indikerer at oppdrettslaksen har rømt samme år som den ble fanget. Vekstmønsteret kan også fortelle oss om oppdretts-laksen har rømt på et tidlig stadium (smolt/postsmolt 30 cm og som hadde rømt i samme år som de ble fanget. Steinsdalelva og Salvassdraget var de eneste av de undersøkte vassdragene med høye andeler av oppdrettslaks som sannsynligvis hadde rømt inneværende år (> 80 %) og som potensielt kan ha rømt fra Geitryggen og Austvika) basert på skjellanalysen