Optimising drug therapy in older patients. Exploring different approaches across the patient pathway

Background - Drug therapy contributes to healthy aging but has a key duality: It prolongs and can improve quality of life, but drugs can also cause serious harm. Harm from drugs include falls, cognitive decline, lowered quality of life, hospitalisation, and death. Older patients are especially at risk for harm from drug therapy, therefore optimising drug therapy is imperative for this group. Aim - To generate new knowledge of drug therapy optimisation for older patients by exploring the impact of drug burden and investigating different approaches to optimise drug therapy across the patient pathway. Methods - This thesis used data from The Norwegian patient registry, The Norwegian Prescription Database and data collected in a randomised controlled trial (RCT). Observational data of the delivery of the RCT-intervention was included. In Paper I the association between anticholinergic (AC) and sedative (SED) drug burden and post-discharge institutionalisation (PDI) was assessed using multiple regression. Paper II described an RCT investigating the effect of an in-hospital pharmacist intervention. Paper III presented the fidelity and process outcomes of the intervention (Paper II). In Paper IV, an observational tool was developed and time distribution for the pharmacists running the RCT examined. Results - Number of drugs used before hospitalisation was mean 7.11 (SD 4.09) and at hospitalisation median 6.0 (range 4-9). Prevalence of AC/SED drugs was 45.5%. All measures of AC/SED drug burden was significantly associated with PDI. The number of AC drugs were most sensitive (OR 1.13, per AC drug), and the DBI most challenging to apply. The clinical pharmacist contributed to identify and solve discrepancies for 72% of the patients (median 1) and DRPs for 94.6% of the patients (median 4), and the acceptance rate was 67%. Intervention fidelity at admission was 100%, and 57% overall. The pharmacists advanced communication of drug therapy across the patient pathway. About 41% of pharmacist time was spent on administrative RCT-tasks and the estimated intervention time was >3.5 hours/patient. Conclusions - The drug burden is high in older patients acutely admitted to hospital in Norway and assessing AC/SED drug use can reduce the risk of PDI. The in-hospital pharmacist intervention contributed to drug therapy optimisation and facilitated communication across the patient pathway. These measures can contribute to optimisation of drug therapy but are time consuming and costly. It is essential to establish models for drug therapy optimisation across the pathway, including primary care

Baby Booming Inequality? Demographic Change and Earnings Inequality in Norway, 1967-2000

In this paper, we demonstrate how age-adjusted inequality measures can be used to evaluate whether changes in inequality over time are due to changes in the age structure. To this end, we use administrative data on earnings for every male Norwegian during 1967-2000. We find that the substantial rise in earnings inequality over the 1980s and into the early 1990s, is to some extent driven by the fact that the large baby boom cohorts are approaching the peak of the age-earnings profile. We further demonstrate that the impact of age adjustments on the trend in inequality during the period from 1993-2000 is highly sensitive to the method used: while the most widely used age-adjusted inequality measure indicates little change in inequality over this period, a new and improved age-adjusted measure suggests a decline in inequality.inequality trend, age structure, age-earnings profile, Gini coefficient

Secondary charging effects due to icy dust particle impacts on rocket payloads

We report measurements of dust currents obtained with a small probe and a larger probe during the flight of the ECOMA-4 rocket through the summer polar mesosphere. The payload included two small dust probes behind a larger dust probe located centrally at the front. For certain phases of the payload rotation, the current registered by one of the small dust probes was up to 2 times the current measured with the larger probe, even though the effective collection area of the larger probe was 4 times that of the small one. We analyze the phase dependence of the currents and their difference with a model based on the assumption that the small probe was hit by charged dust fragments produced in collisions of mesospheric dust with the payload body. Our results confirm earlier findings that secondary charge production in the collision of a noctilucent cloud/Polar Summer Mesospheric Echo (NLC/PMSE) dust particle with the payload body must be several orders of magnitude larger than might be expected from laboratory studies of collisions of pure ice particles with a variety of clean surfaces. An important consequence is that for some payload configurations, one should not assume that the current measured with a detector used to study mesospheric dust is simply proportional to the number density of ambient dust particles. The higher secondary charge production may be due to the NLC/PMSE particles containing multiple meteoric smoke particles

Nanodust shedding and its potential influence on dust related phenomena in the mesosphere

We explore the possibility that some meteoric smoke particles that collide with larger nanoparticles near the mesopause can escape from the larger particles by capturing surface electrons. If the process were sufficiently efficient, under certain conditions it would influence the responses of polar mesospheric summer echoes to artificial heating in a manner that is compatible with observations that are unexplained with previous models. The process would have a number of other possible consequences for nanoparticles near the mesopause

Dynamics of small business internationalisation a European panel study

ABSTRACT Internationalisation has become part of the daily life of most small and medium sized enterprises (SME) in Europe. The internationalisation of enterprises is a dynamic phenomenon and is in this thesis studied as one specific example of change processes in the development of SMEs. Previous research on internationalisation has largely been explorative, most often without any modelling of causal relationships, and with insufficient definitions of concepts. The dominating dynamic models have been based on the assumption of un idirectional changes in small steps, and only cross sectional data have been used. The present research is one of the first where longitudinal date is available for studying the process of internationalisation. The data comes from a panel consisting of 1700 SMEs from 7 countries in Europe where each firm is observed 4 or 5 times in the period 1991-95. Around 47% ofthe enterprises in the panel exhibit development of their export quota which can be explained by an incremental change modeL. Importantly, an almost equally large proportion, 45% ofthe enterprises, exhibit fluctuations in their export quota which can not be explained by the incremental change models. Although variations have been found, the non-incremental change patterns are significantly represented in all countries, all size classes of enterprises and in all industry sectors; and can therefore be considered to be general features -- not patterns associated with specific sub groups of enterprises. The causal analyses of factors influencing export orientation were not able to identify a temporally stable regression model for export quota. The endogenous variable market extension has been found to be influenced by four composite measures: external interaction (+), available capacity (-), employment (+), and manager capabilities (+). Measured by growth in total sale, there is clear evidence that the non-regular change patterns of export quotas can not be regarded as indicators of failure. On the contrary, the results suggest that the non-regular change patterns identifY enterprises which successfully use adaptation and flexibility to their competitive advantage. An initial model was build on previous research where conceptualisation and relationships have mainly been tested with cross-sectional data. This model did not stand up to a test with longitudinal data. The discrepancy between cross sectional and longitudinal modelling indicates that there is a qualitative difference in what can be deduced from research based on one observation and multiple observations. The same conclusion can be derived from the fact that factor analyses as well as path analyses produced different results when the yearly data sets were analysed separately or concurrently

Forskningsbasert barnehagelærerutdanning?

Artikkelen skisserer et perspektiv på forskningsbasert barnehagelærerutdanning som i større grad enn tidligere legger til grunn det særegne ved yrkesfeltet og det potensialet studentaktive læringsformer har for profesjonskvalifisering. Dette perspektivet belyses så ved hjelp av fokusgruppeintervju med siste års barnehagelærerstudenter, etterfulgt av en diskusjon om muligheter og begrensninger ved forskningsbaseringen av fremtidens barnehagelærerutdannin

On the secondary charging effects and structure of mesospheric dust particles impacting on rocket probes

The dust probe DUSTY, first launched during the summer of 1994 (flights ECT–02 and ECT–07) from Andøya Rocket Range, northern Norway, was the first probe to unambiguously detect heavy charged mesospheric aerosols, from hereon referred to as dust. In ECT–02 the probe detected negatively charged dust particles in the height interval of 83 to 88.5 km. In this flight, the lower grid in the detector (Grid 2) measures both positive and negative currents in various regions, and we find that the relationship between the current measurements of Grid 2 and the bottom plate can only be explained by influence from secondary charge production on Grid 2. In ECT–07, which had a large coning, positive currents reaching the top grid of the probe were interpreted as due to the impact of positively charged dust particles. We have now reanalyzed the data from ECT–07 and arrived at the conclusion that the measured positive currents to this grid must have been mainly due to secondary charging effects from the impacting dust particles. The grid consists of a set of parallel wires crossed with an identical set of wires on top of it, and we find that if the observed currents were created from the direct impact of charged dust particles, then they should be very weakly modulated at four times the rocket spin rate ω<sub><I>R</I></sub>. Observations show, however, that the observed currents are strongly modulated at 2ω<sub><I>R</I></sub>. We cannot reproduce the observed large modulations of the impact currents in the dust layer if the currents are due only to the transfer of the charges on the impacted dust particles. Based on the results of recent ice cluster impact secondary charging experiments by Tomsic (2003), which found that a small fraction of the ice clusters, when impacting with nearly grazing incidence, carried away one negative charge −1<I>e</I>, we have arrived at the conclusion that similar, but significantly more effective, charging effects must be predominantly responsible for the positive currents measured by the top grid in ECT–07 and their large rotational modulation at 2ω<sub><I>R</I></sub>. <br><br> Since the secondary effect is dependent on the size of the impacting dust, this opens up for the possibility of mapping the relative dust sizes throughout a dust layer by comparing the observed direct and secondary currents