Persistence of cognitive impairment and its negative impact on psychosocial functioning in lithium-treated, euthymic bipolar patients: a 6-year follow-up study.

BACKGROUND: Previous cross-sectional studies report that cognitive impairment is associated with poor psychosocial functioning in euthymic bipolar patients. There is a lack of long-term studies to determine the course of cognitive impairment and its impact on functional outcome. Method A total of 54 subjects were assessed at baseline and 6 years later; 28 had DSM-IV TR bipolar I or II disorder (recruited, at baseline, from a Lithium Clinic Program) and 26 were healthy matched controls. They were all assessed with a cognitive battery tapping into the main cognitive domains (executive function, attention, processing speed, verbal memory and visual memory) twice over a 6-year follow-up period. All patients were euthymic (Hamilton Rating Scale for Depression score lower than 8 and Young mania rating scale score lower than 6) for at least 3 months before both evaluations. At the end of follow-up, psychosocial functioning was also evaluated by means of the Functioning Assessment Short Test. RESULTS: Repeated-measures multivariate analysis of covariance showed that there were main effects of group in the executive domain, in the inhibition domain, in the processing speed domain, and in the verbal memory domain (p<0.04). Among the clinical factors, only longer illness duration was significantly related to slow processing (p=0.01), whereas strong relationships were observed between impoverished cognition along time and poorer psychosocial functioning (p<0.05). CONCLUSIONS: Executive functioning, inhibition, processing speed and verbal memory were impaired in euthymic bipolar out-patients. Although cognitive deficits remained stable on average throughout the follow-up, they had enduring negative effects on psychosocial adaptation of patients.

The Alcohol Use Disorders Identification Test (AUDIT) as a screening tool for excessive drinking in primary care: reliability and validity of a French version.

BACKGROUND: Excessive drinking is a major problem in Western countries. AUDIT (Alcohol Use Disorders Identification Test) is a 10-item questionnaire developed as a transcultural screening tool to detect excessive alcohol consumption and dependence in primary health care settings. OBJECTIVES: The aim of the study is to validate a French version of the Alcohol Use Disorders Identification Test (AUDIT). METHODS: We conducted a validation cross-sectional study in three French-speaking areas (Paris, Geneva and Lausanne). We examined psychometric properties of AUDIT as its internal consistency, and its capacity to correctly diagnose alcohol abuse or dependence as defined by DSM-IV and to detect hazardous drinking (defined as alcohol intake >30 g pure ethanol per day for men and >20 g of pure ethanol per day for women). We calculated sensitivity, specificity, positive and negative predictive values and Receiver Operator Characteristic curves. Finally, we compared the ability of AUDIT to accurately detect "alcohol abuse/dependence" with that of CAGE and MAST. RESULTS: 1207 patients presenting to outpatient clinics (Switzerland, n = 580) or general practitioners' (France, n = 627) successively completed CAGE, MAST and AUDIT self-administered questionnaires, and were independently interviewed by a trained addiction specialist. AUDIT showed a good capacity to discriminate dependent patients (with AUDIT > or =13 for males, sensitivity 70.1%, specificity 95.2%, PPV 85.7%, NPV 94.7% and for females sensitivity 94.7%, specificity 98.2%, PPV 100%, NPV 99.8%); and hazardous drinkers (with AUDIT > or =7, for males sensitivity 83.5%, specificity 79.9%, PPV 55.0%, NPV 82.7% and with AUDIT > or =6 for females, sensitivity 81.2%, specificity 93.7%, PPV 64.0%, NPV 72.0%). AUDIT gives better results than MAST and CAGE for detecting "Alcohol abuse/dependence" as showed on the comparative ROC curves. CONCLUSIONS: The AUDIT questionnaire remains a good screening instrument for French-speaking primary care.

Análisis de la evaluación única y continuada en Biofarmacia y Farmacocinética-I

La construcción del Espacio Europeo de Educación Superior (EEES) tiene como objetivo disponer de un espacio abierto en el que no existan obstáculos a la movilidad de estudiantes, titulados, profesores y personal de administración. El sistema se articula en torno al reconocimiento de titulaciones y otras calificaciones de educación superior, la transparencia (un sistema de titulaciones comprensibles y comparables organizado en tres ciclos) y la cooperación europea en la garantía de la calidad Ante este gran reto, la enseñanza universitaria ha tenido que reorganizarse y los planes de estudio de cada facultad han tenido que adaptarse a las nuevas exigencias del EEES. Además las metodologías docentes centran su interés en un seguimiento más tutorizado del alumno, para garantizar su aprendizaje, no sólo en la adquisición de conocimientos sino también de competencias.

Anticonvulsants in the treatment of aggression in the demented elderly: an update

Complex psychopathological and behavioral symptoms, such as delusions and aggression against care providers, are often the primary cause of acute hospital admissions of elderly patients to emergency units and psychiatric departments. This issue resembles an interdisciplinary clinically highly relevant diagnostic and therapeutic challenge across many medical subjects and general practice. At least 50% of the dramatically growing number of patients with dementia exerts aggressive and agitated symptoms during the course of clinical progression, particularly at moderate clinical severity. METHODS: Commonly used rating scales for agitation and aggression are reviewed and discussed. Furthermore, we focus in this article on benefits and limitations of all available data of anticonvulsants published in this specific indication, such as valproate, carbamazepine, oxcarbazepine, lamotrigine, gabapentin and topiramate. RESULTS: To date, most positive and robust data are available for carbamazepine, however, pharmacokinetic interactions with secondary enzyme induction limit its use. Controlled data of valproate do not seem to support the use in this population. For oxcarbazepine only one controlled but negative trial is available. Positive small series and case reports have been reported for lamotrigine, gabapentin and topiramate. CONCLUSION: So far, data of anticonvulsants in demented patients with behavioral disturbances are not convincing. Controlled clinical trials using specific, valid and psychometrically sound instruments of newer anticonvulsants with a better tolerability profile are mandatory to verify whether they can contribute as treatment option in this indication.

Improving Searching and Browsing Capabilities of Learning Object Repositories

Learning object repositories are a basic piece of virtual learning environments used for content management. Nevertheless, learning objects have special characteristics that make traditional solutions for content management ine ective. In particular, browsing and searching for learning objects cannot be based on the typical authoritative meta-data used for describing content, such as author, title or publicationdate, among others. We propose to build a social layer on top of a learning object repository, providing nal users with additional services fordescribing, rating and curating learning objects from a teaching perspective. All these interactions among users, services and resources can be captured and further analyzed, so both browsing and searching can be personalized according to user pro le and the educational context, helping users to nd the most valuable resources for their learning process. In this paper we propose to use reputation schemes and collaborative filtering techniques for improving the user interface of a DSpace based learning object repository.

The assessment of spirituality and religiousness in schizophrenia.

To assess religious coping in schizophrenia, we developed and tested a clinical grid, as no validated questionnaire exists for this population. One hundred fifteen outpatients were interviewed. Results obtained by 2 clinicians were compared. Religion was central in the lives of 45% of patients, 60% used religion extensively to cope with their illness. Religion is a multifaceted construct. Principal component analysis elicited 4 factors: subjective dimension, collective dimension, synergy with psychiatric treatment, and ease of talking about religion with psychiatrist. Different associations were found between these factors and psychopathology, substance abuse, and psychosocial adaptation. The high prevalence of spirituality and religious coping clearly indicates the necessity of addressing spirituality in patient care. Our clinical grid is suitable for this purpose. It proved its applicability to a broad diversity of religious beliefs, even pathological ones. Interjudge reliability and construct validity were high and specific training is not required.

The PsyCoLaus study: methodology and characteristics of the sample of a population-based survey on psychiatric disorders and their association with genetic and cardiovascular risk factors.

ABSTRACT: BACKGROUND: The Psychiatric arm of the population-based CoLaus study (PsyCoLaus) is designed to: 1) establish the prevalence of threshold and subthreshold psychiatric syndromes in the 35 to 66 year-old population of the city of Lausanne (Switzerland); 2) test the validity of postulated definitions for subthreshold mood and anxiety syndromes; 3) determine the associations between psychiatric disorders, personality traits and cardiovascular diseases (CVD), 4) identify genetic variants that can modify the risk for psychiatric disorders and determine whether genetic risk factors are shared between psychiatric disorders and CVD. This paper presents the method as well as somatic and sociodemographic characteristics of the sample. METHODS: All 35 to 66 year-old persons previously selected for the population-based CoLaus survey on risk factors for CVD were asked to participate in a substudy assessing psychiatric conditions. This investigation included the Diagnostic Interview for Genetic Studies to elicit diagnostic criteria for threshold disorders according to DSM-IV and algorithmically defined subthreshold syndromes. Complementary information was gathered on potential risk and protective factors for psychiatric disorders, migraine and on the morbidity of first-degree family members, whereas the collection of DNA and plasma samples was part of the original somatic study (CoLaus). RESULTS: A total of 3,691 individuals completed the psychiatric evaluation (67% participation). The gender distribution of the sample did not differ significantly from that of the general population in the same age range. Although the youngest 5-year band of the cohort was underrepresented and the oldest 5-year band overrepresented, participants of PsyCoLaus and individuals who refused to participate revealed comparable scores on the General Health Questionnaire, a self-rating instrument completed at the somatic exam. CONCLUSIONS: Despite limitations resulting from the relatively low participation in the context of a comprehensive and time-consuming investigation, the PsyCoLaus study should significantly contribute to the current understanding of psychiatric disorders and comorbid somatic conditions by: 1) establishing the clinical relevance of specific psychiatric syndromes below the DSM-IV threshold; 2) determining comorbidity between risk factors for CVD and psychiatric disorders; 3) assessing genetic variants associated with common psychiatric disorders and 4) identifying DNA markers shared between CVD and psychiatric disorders.

Effectiveness of anti-psychotics and related drugs in the Huntington French-speaking group cohort.

PURPOSE: Huntington's disease is a rare condition. Patients are commonly treated with antipsychotics and tetrabenazine. The evidence of their effect on disease progression is limited and no comparative study between these drugs has been conducted. We therefore compared the effectiveness of antipsychotics on disease progression. METHODS: 956 patients from the Huntington French Speaking Group were followed for up to 8 years between 2002 and 2010. The effectiveness of treatments was assessed using Unified Huntington's Disease Rating Scale (UHDRS) scores and then compared using a mixed model adjusted on a multiple propensity score. RESULTS: 63% of patients were treated with antipsychotics during the survey period. The most commonly prescribed medications were dibenzodiazepines (38%), risperidone (13%), tetrabenazine (12%) and benzamides (12%). There was no difference between treatments on the motor and behavioural declines observed, after taking the patient profiles at the start of the drug prescription into account. In contrast, the functional decline was lower in the dibenzodiazepine group than the other antipsychotic groups (Total Functional Capacity: 0.41 ± 0.17 units per year vs. risperidone and 0.54 ± 0.19 vs. tetrabenazine, both p<0.05). Benzamides were less effective than other antipsychotics on cognitive evolution (Stroop interference, Stroop color and Literal fluency: p<0.05). CONCLUSIONS: Antipsychotics are widely used to treat patients with Huntington's disease. Although differences in motor or behavioural profiles between patients according to the antipsychotics used were small, there were differences in drug effectiveness on the evolution of functional and cognitive scores.

Nosturin tehonsyöttö rinnankytketyillä verkkovaihtosuuntaajilla

Taajuusmuuttajaohjatuissa nosturikäytöissä taakkaa laskettaessa syntyvä energia on muutettava lämmöksi jarruvastuksissa tai syötettävä takaisin sähköverkkoon esimerkiksi verkkovaihtosuuntaajalla. Verkkovaihtosuuntaajaa on tyypillisesti käytetty suurissa satamanostureissa, joiden tehontarve on yli 1000 kW. Työssä tutkitaan useista yhteiseen välipiiriin rinnankytketyistä nimellisteholtaan 250 kW:n verkkovaihtosuuntaajista koostuvan verkkoonjarrutuslaitteiston soveltuvuutta nosturikäyttöön. Lisäksi johdetaan yhtälöt verkkoonjarrutuslaitteiston virran laskemiseksi, kun nosturin mekaaniset arvot tunnetaan. Viidestä erityyppisestä nosturista esitellään esimerkkitoteutus rinnankytketyillä verkkovaihtosuuntaajilla. Aiemmin vastusjarruttavina toteutettujen nostureiden kustannuksia verrataan verkkovaihtosuuntaajilla toteutettuihin ratkaisuihin. Esimerkkinostureista esitetään nosturin työsykliin perustuva arvio verkkoonjarrutuksen tuomasta energian säästöstä. Tehtyjen mittausten perusteella käytetty menetelmä verkkovaihtosuuntaajien rinnan kytkemiseksi osoittautui nosturikäytössä toimivaksi. Kustannuslaskelmien perusteella verkkovaihtosuuntaajalla toteutetusta nosturista tulee materiaalikustannuksiltaan vastusjarruttavaa kalliimpi, vaikka paljon tilaa vievät vastuskaapit voidaankin jättää pois.

Long duration response to levodopa in advanced Parkinson's disease patients treated with subthalamic deep brain stimulation

Résumé La levodopa (LD) est le traitement antiparkinsonien le plus efficace et le plus répandu. Son effet est composé d'une réponse de courte (quelques heures) et de longue durée (jours à semaines). La persistance de cette dernière dans les phases avancées de la maladie de Parkinson est controversée, et sa mesure directe n'a jamais été faite en raison des risques liés à un sevrage complet de LD. La stimulation du noyau sous-thalamique est un nouveau traitement neurochirurgical de la maladie de Parkinson, indiqué dans les formes avancées, qui permet l'arrêt complet du traitement médicamenteux chez certains patients. Nous avons étudié 30 patients qui ont bénéficié d'une telle stimulation, et les avons évalués avant l'intervention sans médicaments, et à 6 mois postopératoires, sans médicaments et sans stimulation. Chez 19 patients, la médication a pu être complètement arrêtée, alors qu'elle a dû être réintroduite chez les 11 patients restants. Au cours des 6 mois qui ont suivi l'intervention, le parkinsonisme s'est aggravé de façon significative dans le groupe sans LD, et non dans le groupe avec LD. Cette différence d'évolution s'explique par la perte de l'effet à long terme de la LD dans le groupe chez qui ce médicament a pu être arrêté. En comparant cette aggravation à la magnitude de l'effet à court terme, la réponse de longue durée correspond environ à 80 pourcent de la réponse de courte durée, et elle lui est inversement corrélée. Parmi les signes cardinaux de la maladie, la réponse de longue durée affecte surtout la bradycinésie et la rigidité, mais pas le tremblement ni la composante axiale. La comparaison du parkinsonisme avec traitement (stimulation et LD si applicable) ne montre aucune différence d'évolution entre les 2 groupes, suggérant que la stimulation compense tant la réponse de courte que de longue durée. Notre travail montre que la réponse de longue durée à la LD demeure significative chez les patients parkinsoniens après plus de 15 ans d'évolution, et suggère que la stimulation du noyau sous-thalamique compense les réponses de courte et de longue durée. Abstract Background: Long duration response to levodopa is supposed to decrease with Parkinson's disease (PD) progression, but direct observation of this response in advanced PD has never been performed. Objective: To study the long duration response to levodopa in advanced PD patients treated with subthalamic deep-brain stimulation. Design and settings: We studied 30 consecutive PD patients who underwent subthalamic deep-brain stimulation. One group had no antiparkinsonian treatment since surgery (no levodopa), while medical treatment had to be reinitiated in the other group (levodopa). Main outcome measures: motor Unified Parkinson's Disease Rating Scale (UPDRS). Results: In comparison with preoperative assessment, evaluation six months postoperatively with stimulation turned off for three hours found a worsening of the motor part of UPDRS in the no-levodopa group. This worsening being absent in the levodopa group, it most probably reflected the loss of the long duration response to levodopa in the no-levodopa group. Stimulation turned on, postoperative motor UPDRS in both groups were similar to preoperative on medication scores, suggesting that subthalamic deep-brain stimulation compensated for both the short and long duration responses to levodopa. Conclusions: Our results suggest that the long duration response to levodopa remains significant even in advanced PD, and that subthalamic deep-brain stimulation compensates for both the short and the long duration resposes to levodopa.

Radiaalikompressorin valinta hiilivetyteollisuudessa

Tutkimuksen tavoitteena oli selvittää hiilivetyteollisuudessa käytettävien radiaali-kompressorien ominaisuuksia, toimintaympäristöjä, turvallisuusasioita, etuja ja rajoitteita. Tämän lisäksi selvitettiin vaihtoehtoisia yleisesti käytettyjä menetelmiä radiaalikompressorien simuloimiseksi. Työssä tutkittiin myös kaupallisten mitoitusohjelmien soveltuvuutta laitesuunnittelun tueksi Neste Jacobs Oy:ssä. Työn kirjallisuusosassa käsiteltiin radiaalikompressorien toimintaympäristöjä, säätötapoja sekä näistäja muista tekijöistä aiheutuvia rajoitteita ja vaatimuksia. Kirjallisuustutkimuksen perusteella laadittiin tarkistuslista asioista, jotka tulee selvittää ennenvarsinaista radiaalikompressorien mitoittamista. Soveltuvaakaupallista kompressorien mitoitusohjelmaa ei tutkimuksessa löytynyt. Tämän vuoksi työn kokeellisessa osassa laadittiin Excel-laskentataulukko, joka perustuu yhteen kirjallisuusosassa esitettyyn mitoitustapaan. Laaditun laskentataulukon soveltuvuutta kompressorien esivalintaan testattiin vertailemalla ohjelman mitoituksia Neste Jacobs Oy:llä käytössä olevaan mitoitusohjelmaan ja toiseen työssä esitettyyn mitoitus-menetelmään. Lisäksi Excel-laskentataulukon ja Neste Jacobs Oy:n ohjelman mitoituksia verrattiin todellisen, käytössä olevan kompressorin suunnittelu- ja operointiarvoihin. Lisäksi tutkimuksessa arvioitiin laaditun laskentataulukon käytettävyyttä, rajoitteita ja kehitysmahdollisuuksia. Saatujen tulosten perusteella työssä laadittu laskentataulukko soveltuu sellaisenaan Neste Jacobs Oy:n radiaalikompressorien simulointiin.

Assessing catchment-scale erosion and yields of suspended solids from improved temperate grassland.

This paper quantifies the yields of suspended solids (SS) from a headwater catchment managed as improved temperate grassland, providing the first direct, catchment-scale evidence of the rates of erosion from this land-use in the UK and assessing the threat posed to aquatic ecosystems. High-resolution monitoring of catchment hydrology and the concentrations of SS and volatile organic matter (VOM) were carried out in the first-order channel of the Den Brook headwater catchment in Devon (UK) during the 2006-2007 hydrological season. The widely used 'rating curve' (discharge-concentration) approach was employed to estimate yields of SS, but as demonstrated by previous researchers, this study showed that discharge is a poor predictor of SS concentrations and therefore any yields estimated from this technique are likely to be highly uncertain. Nevertheless, for the purpose of providing estimates of yields that are comparable to previous studies on other land uses/sources, this technique was adopted albeit in an uncertainty-based framework. The findings suggest that contrary to the common perception, grasslands can be erosive landscapes with SS yields from this catchment estimated to be between 0.54 and 1.21 t ha(-1) y(-1). In terms of on-site erosion problems, this rate of erosion does not significantly exceed the commonly used 'tolerable' threshold in the UK ( approximately 1 t ha(-1) y(-1)). In terms of off-site erosion problems, it is argued here that the conventional expression of SS yield as a bulk annual figure has little relevance to the water quality and ecological status of surface waters and therefore an alternative technique (the concentration-frequency curve) is developed within this paper for the specific purpose of assessing the ecological threat posed by the delivery of SS into surface waters. This technique illustrates that concentrations of SS recorded at the catchment outlet frequently exceed the water quality guidelines, such as those of the EU Freshwater Fisheries Directive (78/659/EC), and pose a serious threat to aquatic organisms. It is suggested that failure to recognise improved temperate grasslands as a potential source of particulate material could result in the non-compliance of surface waters to water quality guidelines, deterioration of ecological status and failure of water quality remediation measures.

Tislauskolonnin varopurkauksen laskeminen dynaamisen simuloinnin avulla

Työn tavoitteena oli tutkia tislauskolonnin dynamiikkaa ja dynaamista mallintamista simulointien avulla. Dynaamisen simulointimallin avulla selvitettiin pentaanin erotuskolonnin toimintaa poikkeus- ja häiriötilanteissa. Lisäksi pyrittiin arvioimaan työssä käytettyjen simulointiohjelmistojen soveltuvuutta tislauksen dynaamiseen simulointiin. Työn kirjallisuusosassa käsiteltiin tislauskolonnindynamiikan mallintamista matemaattisten mallien avulla sekä tislauskolonnimallin rakentamista simulointiohjelmistoon. Kirjallisuusosassa esiteltiin myös tislauskolonnin häiriötilanteita ja niiden aiheuttamia varopurkaustapauksia. Tämän lisäksi kirjallisuusosassa käytiin läpi tislauskolonnin varoventtiilien mitoittamisen perusteita. Työn soveltavassa osassa muodostettiin tislauskolonnille dynaaminen simulointimalli Aspen HYSYS Dynamics ja PROSimulator-simulointiohjelmistolla. Mallien avulla tarkasteltiin erilaisten häiriöiden ja poikkeustilanteiden vaikutusta kolonnin käyttäytymiseen ja varopurkaus-tapauksiin. Työssä arvioitiin myös ohjelmistojen soveltuvuutta tislauksen dynaamiseen simulointiin. Työssä saatujen tulosten perusteella voidaan todeta, että dynaamisen simuloinnin avulla saadaan hyödyllistä tietoa tislauskolonnin toiminnasta häiriö- ja poikkeustilanteissa. Dynaamisen simuloinnin onnistuminen ja luotettavien tulosten saaminen edellyttää kuitenkin tarkasteltavan prosessin tuntemista ja ohjelmiston käytön hallintaa. Työssä käytetyn Aspen HYSYS Dynamics simulointiohjelmiston käytettävyydessä havaittiin puutteita ja ohjelmisto vaatii vielä kehitystyötä. Työssä käytetty PROSimulator-simulointiohjelmisto soveltui pienistä puutteista huolimatta hyvin tislauskolonnin häiriötilanteiden tutkimiseen.

Family Alliance as a Moderator of the Link Between Maternal Postpartum Depression and Child Symptoms Assessed by Both Parents

We investigated the moderating effect of family relationships on the links between maternal postpartum depression and child symptoms in a low-risk community sample of families with 3-month-old infants (n = 57). The level of maternal depression was assessed by the Montgomery-Asberg Depression Rating Scale from a clinical interview, child symptoms by the Symptom Check List completed by both parents, and family relationships by direct observation of father-mother-baby interactions (Lausanne Trilogue Play). Families were categorized as high coordination or low coordination from their overall coordination level throughout the play. Results showed no significant links between maternal depression level and child symptoms reported by both parents. Mothers with a high depressive level in high coordination families tended to report more symptoms in their child than did mothers with lower depressive scores, whereas this link was not found in low coordination families. Prevention perspectives and clinical implications of these results are discussed.

Laadullisten tekijöiden vaikutus yrityksen luottoluokitukseen -case Nordea Pankki Suomi Oyj

Tutkielman päätavoitteena oli analysoida, mitkä tekijät vaikuttavat pankin luottoluokituksissa laadullisten tekijöiden arviointiin ja mikävaikutus näillä tekijöillä on luottoluokitukseen. Tutkimuksessa myös arvioitiinlaadullisten tekijöiden vaikutusta pankin pääomavaatimukseen. Tutkimuksessa olimu-kana pankin 408 yritysasiakasta. Tutkimuksessa käytettiin tilastollista tut-kimusmenetelmää. Baselin pankkivalvontakomitean asettamat standardit ja rahoitusalan journaaleissa julkaistut tutkimukset muodostivat tutkimuk-sen teoreettisen viitekehyksen. Tutkimusten pohjalta asetettiin tutkimus-hypoteesit. Tutkimustulokset osoittivat, että laadullisten tekijöiden ja taloudellisten te-kijöiden arvioinnin erotukseen eivät vaikuta merkittävästi yrityksen ikä, ko-ko eikä asiakassuhteen kesto. Myöskään toimialalla ei ollut vaikutusta. Konttoreittain laadullisten tekijöiden arvioinnissa oli eroja. Laadullisia teki-jöitäarvioidaan keskimäärin positiivisemmin kuin taloudellisia tekijöitä mut-ta erotolivat koko otantajoukossa hyvin pieniä. Luottoluokitukset nousevat hieman laadullisten tekijöiden vaikutuksesta, jolloin tällä on pääomavaati-musta laskeva vaikutus. Laadullisten ja taloudellisten tekijöiden arvioinnin eroon voi kuitenkinolla olemassa perustellut syyt. Tutkimustulosten perusteellavoidaan todeta, että laadullisten tekijöiden arviointiin eivät vaikuta yksittäiset yrityskohtaiset tekijät. Luokittelijan sub-jektiivisten tekijöiden lisäksi taustalla saattaa vaikuttaa myös monet muut tekijät, joita ei ole tässä tutkimuksessa tutkittu.