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Jerjes W, Harding D. De-prescribing in primary care: the clinical, ethical and psychological considerations. J Prim Health Care 2024; 16:96-98. [PMID: 38546783 DOI: 10.1071/hc23118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/31/2024] [Indexed: 04/02/2024] Open
Affiliation(s)
- Waseem Jerjes
- North End Medical Centre, Hammersmith and Fulham Partnership, London, UK; and Research and Development Unit, Hammersmith and Fulham Primary Care Network, London, UK; and Faculty of Medicine, Imperial College, London, UK
| | - Daniel Harding
- North End Medical Centre, Hammersmith and Fulham Partnership, London, UK
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2
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Ibrar M, Peddie N, Agnew S, Diserholt A, Fleming L. Breast Cancer Survivors' Lived Experience of Adjuvant Hormone Therapy: A Thematic Analysis of Medication Side Effects and Their Impact on Adherence. Front Psychol 2022; 13:861198. [PMID: 35602711 PMCID: PMC9120958 DOI: 10.3389/fpsyg.2022.861198] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Side effects from Hormone Therapy (HT) impact medication adherence in breast cancer survivors. Understanding the most distressing HT side effects and their impacts may inform the development and implementation of interventions to alleviate these side effects and maximise HT adherence. This study aimed to explore the lived experience of adjuvant HT and understand the impact of HT side effects on adherence in a sample of breast cancer survivors. Methods Twenty-five female breast cancer survivors who were currently taking adjuvant HT participated in the study. One-to-one, online, semi-structured interviews were conducted to explore (i) specific side effects from HT and (ii) the impact of these side effects on HT adherence. Data were analysed using Thematic Analysis. Results The most commonly reported side effects were sleep disturbance, hot flashes, anxiety, and joint pain. Data exploring the impacts of these side effects on HT adherence were thematically synthesised into four analytical themes: "A bitter pill to swallow," "Seeking relief," "Taking control," and "The only way out is through." These themes encompass 14 sub-themes that encapsulate participants' daily struggle with HT side effects and the coping strategies developed to manage these. Conclusion Adverse side effects from HT, such as sleep disturbance, hot flashes, pain and anxiety, impair quality of life and increase the likelihood of participants' becoming non-adherent to HT medication. In order to maximise HT adherence and reduce breast cancer mortality, HT side effects should be closely monitored to identify individuals who would benefit from targetted intervention strategies aimed at alleviating these side effects.
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Affiliation(s)
- Maryam Ibrar
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, United Kingdom
| | - Nicola Peddie
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, United Kingdom
| | - Sommer Agnew
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, United Kingdom
| | - Amanda Diserholt
- School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom
| | - Leanne Fleming
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, United Kingdom
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Kalim RA, Cunningham CJ, Ryder SA, McMahon NM. Deprescribing Medications that Increase the Risk of Falls in Older People: Exploring Doctors' Perspectives Using the Theoretical Domains Framework (TDF). Drugs Aging 2022; 39:935-947. [PMID: 36409404 PMCID: PMC9676799 DOI: 10.1007/s40266-022-00985-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Falls can lead to hospitalisation and death in older people. Polypharmacy is a major risk factor, and deprescribing fall-risk increasing drugs (FRIDs) is one of several possible important preventive measures. The objective of this study was to explore the factors that influence doctors when deprescribing FRIDs in a hospital setting. METHOD Semi-structured interviews were conducted with consultant geriatricians and hospital doctors experienced in dealing with patients aged 65 years or older, at a large academic teaching hospital (~ 1000 beds), Dublin, Ireland. The interviews were directed by an interview guide and audio recorded and transcribed verbatim, with subsequent thematic analysis in NVivo 12 software. RESULTS A total of 18 participants were interviewed. Barriers to deprescribing included: insufficient time, incomplete patient records, changing medications initiated by other specialists and difficulties following up patients after discharge. Facilitators included: enhanced documentation through electronic patient records, the support of other healthcare professionals such as clinical pharmacists, and patients' engagement, which is considered essential for the success of the deprescribing process's outcome. CONCLUSION Deprescribing FRIDs in older adults in the hospital setting is challenging. Implementation of the process in practice requires combined effort from stakeholders to tackle everyday work environment challenges. Future studies are required examining the clinical effect of the suggested interventions and exploring patients' involvement in deprescribing decisions.
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Affiliation(s)
- Reham A Kalim
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Conal J Cunningham
- St James's Hospital, James's Street, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Sheila A Ryder
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
| | - Niamh M McMahon
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
- St James's Hospital, James's Street, Dublin, Ireland
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Cairo Notari S, Sader J, Caire Fon N, Sommer JM, Pereira Miozzari AC, Janjic D, Nendaz M, Audétat M. Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research. Int J Clin Pract 2021; 75:e14187. [PMID: 33783098 PMCID: PMC8459259 DOI: 10.1111/ijcp.14187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/25/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow-up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term. METHODS A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed-methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool. RESULTS A total of 2 165 abstracts and 362 full-text articles were assessed. Thirty-two studies met the inclusion criteria. Results showcased that GPs' clinical reasoning during the long-term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients' constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient. CONCLUSIONS Although the challenges GPs are facing in the long-term follow-up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs' clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.
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Affiliation(s)
- Sarah Cairo Notari
- Primary Care UnitFaculty of MedicineUniversity of GenevaGenevaSwitzerland
- Faculty of Psychology and Educational SciencesUniversity of GenevaGenevaSwitzerland
| | - Julia Sader
- Unit of Development and Research in Medical EducationFaculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Nathalie Caire Fon
- Department of Family Medicine and Emergency MedicineFaculty of MedicineUniversité de MontréalMontrealQCCanada
| | | | | | - Danilo Janjic
- Primary Care UnitFaculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Mathieu Nendaz
- Unit of Development and Research in Medical EducationFaculty of MedicineUniversity of GenevaGenevaSwitzerland
- Department of Internal MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - Marie‐Claude Audétat
- Primary Care UnitFaculty of MedicineUniversity of GenevaGenevaSwitzerland
- Unit of Development and Research in Medical EducationFaculty of MedicineUniversity of GenevaGenevaSwitzerland
- Department of Family Medicine and Emergency MedicineFaculty of MedicineUniversité de MontréalMontrealQCCanada
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Warmoth K, Day J, Cockcroft E, Reed DN, Pollock L, Coxon G, Heneker J, Walton B, Stein K. Understanding stakeholders’ perspectives on implementing deprescribing for older people living in long-term residential care homes: the STOPPING study protocol. Implement Sci Commun 2020. [DOI: 10.1186/s43058-020-00067-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Older people with multimorbidity often experience polypharmacy. Taking multiple medicines can be beneficial; however, some older adults are prescribed multiple medicines when they are unlikely to improve clinical outcomes and may lead to harm. Deprescribing means reducing or stopping prescription medicines which may no longer be providing benefit. While appropriate deprescribing may usually be safely undertaken, there is a lack of guidance about how to implement it in practice settings such as care homes. Implementing deprescribing in care homes is often challenging, due to differing concerns of residents, staff, clinicians, friends/family members and carers along with differences in care home structures. The STOPPING study will support the development of better deprescribing practice in care homes, considering different views and environments. This paper aims to introduce the research protocol.
Methods
We will use qualitative approaches informed by the widely accepted Consolidated Framework for Implementation Research (CFIR) to aid analysis. To understand the barriers, facilitators, and contextual factors influencing deprescribing in care homes, we will employ individual interviews with care home residents and family members, focus groups with care home staff and healthcare professionals, and observations from care homes. Then, we will examine acceptability, feasibility, and suitability of existing deprescribing approaches using cognitive interviews with care home staff and healthcare professionals. Lastly, we will use narrative synthesis to integrate findings and develop guidance for implementing a deprescribing approach for care homes.
Discussion
This research will support the development of implementable approaches to deprescribing in care homes. The insights from this project will be shared with various stakeholders: care home residents, staff, pharmacists, general practitioners, nurses, and other health professionals, carers, researchers, and the public. This work will support deprescribing to be implemented effectively in care homes to benefit residents and the wider health economy.
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D'Avanzo B, Agosti P, Reeve E, Pasina L, Sabbà C, Mannucci PM, Nobili A. Views of medical practitioners about deprescribing in older adults: Findings from an Italian qualitative study. Maturitas 2020; 134:29-33. [PMID: 32143773 DOI: 10.1016/j.maturitas.2020.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/07/2020] [Accepted: 01/18/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Even though increasing attention is given to deprescribing owing to the risks related to polypharmacy in older adults, deprescribing is not yet part of clinical culture. METHODS We conducted three focus groups with 25 internists, geriatricians and general practitioners to explore the factors influencing the implementation of deprescribing in the Italian context, and more specifically: i. to investigate the barriers to deprescribing; ii. to define strategies and actions to address these barriers; and iii. to identify skills and tools that may assist in implementing deprescribing in clinical practice. Thematic analysis was used. RESULTS Six themes were identified: Good reasons for deprescribing, Difficulties and doubts about deprescribing, System factors affecting polypharmacy and deprescribing, Perspectives on how to practically approach polypharmacy, Need for effective communication with patients and caregivers, Taking responsibility and starting action. Participants reported a willingness to challenge themselves by addressing the barriers to deprescribing through regular review of prescriptions and collaboration with colleagues and patients. CONCLUSIONS Italian internists, geriatricians and general practitioners reported many system-level barriers to deprescribing as well as some doubts about its necessity. Strategies to address the barriers to deprescribing include regular medication review and enhancing collaboration with colleagues and patients. Additionally, participants were willing to challenge themselves and use uncertainty as an impetus for deprescribing.
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Affiliation(s)
- Barbara D'Avanzo
- Laboratory of Quality Assessment of Geriatric Therapies and Services, Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa 19, 20156 Milan, Italy.
| | - Pasquale Agosti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, 20122 Italy
| | - Emily Reeve
- College of Medicine, University of Saskatchewan, Saskatoon, SK, S7N 5E5, Canada; NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, 5000, Australia; Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, NS, B3H 2E1, Canada
| | - Luca Pasina
- Laboratory of Quality Assessment of Geriatric Therapies and Services, Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa 19, 20156 Milan, Italy
| | - Carlo Sabbà
- Interdisciplinary Department of Medicine, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Pier Mannuccio Mannucci
- Scientific Direction, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, 20122 Milan, Italy
| | - Alessandro Nobili
- Laboratory of Quality Assessment of Geriatric Therapies and Services, Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa 19, 20156 Milan, Italy
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Byrne P, O’Donovan Ó, Smith SM, Cullinan J. Medicalisation, risk and the use of statins for primary prevention of cardiovascular disease: a scoping review of the literature. HEALTH RISK & SOCIETY 2019. [DOI: 10.1080/13698575.2019.1667964] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Paula Byrne
- National University of Ireland, Galway, Ireland
| | | | - Susan M Smith
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Weir K, Nickel B, Naganathan V, Bonner C, McCaffery K, Carter SM, McLachlan A, Jansen J. Decision-Making Preferences and Deprescribing: Perspectives of Older Adults and Companions About Their Medicines. J Gerontol B Psychol Sci Soc Sci 2019; 73:e98-e107. [PMID: 29190369 DOI: 10.1093/geronb/gbx138] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 10/16/2017] [Indexed: 01/27/2023] Open
Abstract
Objectives Polypharmacy in the older population is increasing-and can be harmful. It can be safe to reduce or carefully cease medicines (deprescribing) but a collaborative approach between patient and doctor is required. This study explores decision-making about polypharmacy with older adults and their companions. Method Semi-structured interviews were conducted with 30 older people (aged 75+ years, taking multiple medicines) and 15 companions. Framework analysis was used to identify qualitative themes. Results Participants varied considerably in attitudes towards medicines, preferences for involvement in decision-making, and openness to deprescribing. Three types were identified. Type 1 held positive attitudes towards medicines, and preferred to leave decisions to their doctor. Type 2 voiced ambivalent attitudes towards medicines, preferred a proactive role, and were open to deprescribing. Type 3 were frail, perceived they lacked knowledge about medicines, and deferred most decisions to their doctor or companion. Discussion This study provides a novel typology to describe differences between older people who are happy to take multiple medicines, and those who are open to deprescribing. To enable shared decision-making, prescribers need to adapt their communication about polypharmacy based on their patients' attitudes to medicines and preferences for involvement in decisions.
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Affiliation(s)
- Kristie Weir
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, New South Wales, Australia
| | - Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, New South Wales, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, New South Wales, Australia
| | - Vasi Naganathan
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, New South Wales, Australia
| | - Carissa Bonner
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, New South Wales, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, New South Wales, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, New South Wales, Australia
| | - Stacy M Carter
- Sydney Health Ethics, The University of Sydney, New South Wales, Australia
| | - Andrew McLachlan
- Centre for Education and Research on Ageing (CERA), Ageing and Alzheimer's Institute, Concord Hospital, The University of Sydney, New South Wales, Australia.,Faculty of Pharmacy, The University of Sydney, New South Wales, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, New South Wales, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, New South Wales, Australia
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Laursen J, Kornholt J, Betzer C, Petersen TS, Christensen MB. General Practitioners' Barriers Toward Medication Reviews in Polymedicated Multimorbid Patients: How can a Focus on the Pharmacotherapy in an Outpatient Clinic Support GPs? Health Serv Res Manag Epidemiol 2018; 5:2333392818792169. [PMID: 30246058 PMCID: PMC6144514 DOI: 10.1177/2333392818792169] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/09/2018] [Accepted: 07/09/2018] [Indexed: 11/20/2022] Open
Abstract
Purpose: The aim of this study was to explore whether general practitioners (GPs) experienced barriers toward medication reviews in polymedicated, multimorbid patients, and how a clinical pharmacologist with a focus on pharmacotherapy can support the GPs in an outpatient clinic. Design: The study was descriptive and exploratory and had a qualitative design with a phenomenological/hermeneutic orientation for the interviews. Participants: The study comprised 14 interviews with 14 different GPs from the Capital Region of Denmark. Results: Three themes emerged from the interviews: (1) The care of patients With polypharmacy is challenged by the lack of professional dialogue and collaboration between GPs and hospital-based clinical pharmacologists, (2) the relationship between the patients with polypharmacy and the GP is characterized by care and individual considerations, and (3) the culture encourages adding medication and inhibits dialogue about medication withdrawal even for patients with polypharmacy. Conclusion and implications for practice: This study found that the primary barriers toward multimorbid patients with polypharmacy were the need for communication and teamwork with specialists (cardiologists, neurologists, endocrinologists, etc). Often, GPs felt that the specialists at the hospitals were more concerned about following standards and guidelines regarding specific diseases instead of a more holistic patient approach. To improve management of polypharmacy patients, the GPs suggest that a joint force is necessary, a partner-like relationship with greater transparency regarding information transfer, feedback, and shared decision-making, but also more education in the pharmacological field is essential.
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Affiliation(s)
- Jannie Laursen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jonatan Kornholt
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Cecilie Betzer
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Tonny S Petersen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel B Christensen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
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Kriegbaum M, Liisberg KB, Wallach-Kildemoes H. Pattern of statin use changes following media coverage of its side effects. Patient Prefer Adherence 2017; 11:1151-1157. [PMID: 28744105 PMCID: PMC5513880 DOI: 10.2147/ppa.s133168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The media plays a role in shaping opinions about medical decisions, for example, whether to initiate or stop treatment. An association between negative media attention and statin discontinuation has been demonstrated, but it may differ depending on the reason for prescription and whether the user is new (incident) or long term (prevalent). AIM The aim of this study is to explore whether a Danish newspaper article featuring the side effects of statins affects statin discontinuation in incident versus prevalent users, with the reason for prescription also taken into account. METHODS The study relies on a quasi-experimental design and uses registry data on statin purchases to explore discontinuation and treatment duration. As a proxy for reason for prescription, data on filled prescriptions and hospital diagnoses from a Danish registry were used. We compared statin discontinuation in all statin users in Denmark in 2007 before the media event (n=343,438) and after it in 2008 (n=404,052). RESULTS Compared to 2007, statin discontinuation among prevalent users in 2008 increased by 2.97 percentage points (pp). The change in discontinuation varied with the indication for statin use. Those with myocardial infarction had the smallest increase (1.98 pp) and those with hypercholesterolemia or primary hypertension had the largest increase (3.54 pp). Incident statin users had a higher level of discontinuation and a larger difference in discontinuation between 2007 and 2008. Compared to 2007, more people (5.52 pp) discontinued statin treatment in 2008. Again, those with myocardial infarction had the smallest decrease in statin discontinuation (1.49 pp), while those with a potential atherosclerotic condition (7.05 pp) and hypercholesterolemia or primary hypertension (6.10 pp) had the largest increase. CONCLUSION Statin discontinuation increased in 2008 following a media event, but especially among individuals prescribed statins for primary prevention and among new statin users.
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Affiliation(s)
- Margit Kriegbaum
- Department of Public Health
- Correspondence: Margit Kriegbaum, Department of Public Health, University of Copenhagen, Oster Farimagsgade 5, 1014 Copenhagen, Denmark, Tel +45 35 33 73 26, Fax +45 35 32 76 29, Email
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