STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail Adults with Limited Life Expectancy): Consensus Validation

Background: To validate STOPPFrail, a list of explicit criteria for potentially inappropriate medications (PIMs) in frailer older adults with limited life expectancy. A Delphi consensus survey of an expert panel (n = 17) comprising specialists in geriatric medicine, clinical pharmacology, palliative care, psychiatry of old age, clinical pharmacy and general practice.
Methods: STOPPFrail criteria was initially created by the authors based on clinical
experience and appraisal of the available literature. Criteria were organised according to physiological system. Each criterion was accompanied by an explanation. Panellists ranked their agreement with each criterion on a 5-point Likert scale and invited to provide written feedback. Criteria with a median Likert response of 4/5 (agree/strongly agree) and a 25th centile of ≥4 were included in the final criteria.
Results: Three Delphi rounds were required. All panellists completed all rounds. Thirty criteria were proposed for inclusion; 26 were accepted. No new criteria were added. The first two criteria suggest deprescribing medications with no indication or where compliance is poor. The remaining 24 criteria include lipid-lowering therapies, alpha-blockers for hypertension, anti-platelets, neuroleptics, proton pump inhibitors, H-2 receptor antagonists, anti-spasmodics, theophylline, leukotriene antagonists, calcium supplements, bone anti-resorptive therapy, selective oestrogen receptor modulators, non-steroidal antiinflammatories, corticosteroids, 5-alpha reductase inhibitors, alpha-1 selective blockers, muscarinic antagonists, oral diabetic agents, ACE-inhibitors, angiotensin receptor blockers, systemic oestrogens, multivitamins, nutritional supplements and prophylactic antibiotics. Anticoagulants and anti-depressants were excluded. Despite incorporation of panellists’ suggestions, memantine and acetyl-cholinesterase inhibitors remained inconclusive.
Conclusion: STOPPFrail comprises 26 criteria, which have been judged by broad consensus, to be potentially inappropriate in frailer older patients with limited life expectancy. STOPPFrail may assist in deprescribing medications in these patients.

Time-limited home-care reablement services for maintaining and improving the functional independence of older adults

Background: Reablement, also known as restorative care, is one possible approach to home-care services for older adults at risk of functional decline. Unlike traditional home-care services, reablement is frequently time-limited (usually six to 12 weeks) and aims to maximise independence by offering an intensive multidisciplinary, person-centred and goal-directed intervention. Objectives:Objectives To assess the effects of time-limited home-care reablement services (up to 12 weeks) for maintaining and improving the functional independence of older adults (aged 65 years or more) when compared to usual home-care or wait-list control group. Search methods:We searched the following databases with no language restrictions during April to June 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (OvidSP); Embase (OvidSP); PsycINFO (OvidSP); ERIC; Sociological Abstracts; ProQuest Dissertations and Theses; CINAHL (EBSCOhost); SIGLE (OpenGrey); AgeLine and Social Care Online. We also searched the reference lists of relevant studies and reviews as well as contacting authors in the field.Selection criteria:We included randomised controlled trials (RCTs), cluster randomised or quasi-randomised trials of time-limited reablement services for older adults (aged 65 years or more) delivered in their home; and incorporated a usual home-care or wait-list control group. Data collection and analysis:Two authors independently assessed studies for inclusion, extracted data, assessed the risk of bias of individual studies and considered quality of the evidence using GRADE. We contacted study authors for additional information where needed.Main results:Two studies, comparing reablement with usual home-care services with 811 participants, met our eligibility criteria for inclusion; we also identified three potentially eligible studies, but findings were not yet available. One included study was conducted in Western Australia with 750 participants (mean age 82.29 years). The second study was conducted in Norway (61 participants; mean age 79 years). We are very uncertain as to the effects of reablement compared with usual care as the evidence was of very low quality for all of the outcomes reported. The main findings were as follows. Functional status: very low quality evidence suggested that reablement may be slightly more effective than usual care in improving function at nine to 12 months (lower scores reflect greater independence; standardised mean difference (SMD) -0.30; 95% confidence interval (CI) -0.53 to -0.06; 2 studies with 249 participants). Adverse events: reablement may make little or no difference to mortality at 12 months’ follow-up (RR 0.97; 95% CI 0.74 to 1.29; 2 studies with 811 participants) or rates of unplanned hospital admission at 24 months (RR 0.94; 95% CI 0.85 to 1.03; 1 study with 750 participants). The very low quality evidence also means we are uncertain whether reablement may influence quality of life (SMD -0.23; 95% CI -0.48 to 0.02; 2 trials with 249 participants) or living arrangements (RR 0.92, 95% CI 0.62 to 1.34; 1 study with 750 participants) at time points up to 12 months. People receiving reablement may be slightly less likely to have been approved for a higher level of personal care than people receiving usual care over the 24 months’ follow-up (RR 0.87; 95% CI 0.77 to 0.98; 1 trial, 750 participants). Similarly, although there may be a small reduction in total aggregated home and healthcare costs over the 24-month follow-up (reablement: AUD 19,888; usual care: AUD 22,757; 1 trial with 750 participants), we are uncertain about the size and importance of these effects as the results were based on very low quality evidence. Neither study reported user satisfaction with the serviceAuthors’ conclusions:There is considerable uncertainty regarding the effects of reablement as the evidence was of very low quality according to our GRADE ratings. Therefore, the effectiveness of reablement services cannot be supported or refuted until more robust evidence becomes available. There is an urgent need for high quality trials across different health and social care systems due to the increasingly high profile of reablement services in policy and practice in several countries. 

Quantum-limited estimation of continuous spontaneous localization

We apply the formalism of quantum estimation theory to extract information about potential collapse mechanisms of the continuous spontaneous localisation (CSL) form.
In order to estimate the strength with which the field responsible for the CSL mechanism couples to massive systems, we consider the optomechanical interaction
between a mechanical resonator and a cavity field. Our estimation strategy passes through the probing of either the state of the oscillator or that of the electromagnetic field that drives its motion. In particular, we concentrate on all-optical measurements, such as homodyne and heterodyne measurements.
We also compare the performances of such strategies with those of a spin-assisted optomechanical system, where the estimation of the CSL parameter is performed
through time-gated spin-like measurements.

Effect of Earnings Volatility on Cost of Debt: The case of Swedish Limited Companies

The paper empirically tests the relationship between earnings volatility and cost of debt with a sample of more than 77,000 Swedish limited companies over the period 2006 to 2013 observing more than 677,000 firm years. As called upon by many researchers recently that there is very limited evidence of the association between earnings volatility and cost of debt this paper contributes greatly to the existing literature of earnings quality and debt contracts, especially on the consequence of earnings quality in the debt market. Earnings volatility is a proxy used for earnings quality while cost of debt is a component of debt contract. After controlling for firms’ profitability, liquidity, solvency, cashflow volatility, accruals volatility, sales volatility, business risk, financial risk and size this paper studies the effect of earnings volatility measured by standard deviation of Earnings Before Interest, Taxes, Depreciation and Amortization (EBITDA) on Cost of Debt. Overall finding suggests that lenders in Sweden does take earnings volatility into consideration while determining cost of debt for borrowers. But a deeper analysis of various industries suggest earnings volatility is not consistently used by lenders across all the industries. Lenders in Sweden are rather more sensitive to borrowers’ financial risk across all the industries. It may also be stated that larger borrowers tend to secure loans at a lower interest rate, the results are consistent with majority of the industries. Swedish debt market appears to be well prepared for financial crises as the debt crisis seems to have no or little adverse effect borrowers’ cost of capital. This study is the only empirical evidence to study the association between earnings volatility and cost of debt. Prior indirect research suggests earnings volatility has a negative effect on cost debt (i.e. an increase in earnings volatility will increase firm’s cost of debt). Our direct evidence from the Swedish debt market is consistent for some industries including media, real estate activities, transportation & warehousing, and other consumer services.

Determinants of Capital Structure of Swedish limited companies : Testing Trade-off Theory Against Pecking Order Theory

Research question- This thesis investigates the determinants of capital structure of the Swedish companies. In order to do so, the two dominant theories of the corporate structure are studied and their assumptions are tested. Thus, the study researches which one of the two theories is more appealing for the Swedish market. Methodology-The study follows a purely quantitative study, by conducting an econometric analysis. The data are collected from a secondary source and more particularly the "Retriever" database, which contains financial data of the Swedish companies. Findings- The findings indicate that the determinants of the corporate structure for the Swedish market do not differ from other studies which have been conducted in other countries. However, there is a difference when it comes to tax and non-tax shields. The results suggest that in most cases the Pecking Order Theory appears to be more representative for the Swedish market, since most of the coefficient appear to be in favour of it. Moreover, the significance of the effect of the industry for the financial leverage is confirmed.

A Finite Element to Perform 3D Shakedown Analysis for Limited Kinematic Hardening Materials

The use of the Design by Analysis (DBA) route is a modern trend in pressure vessel and piping international codes in mechanical engineering. However, to apply the DBA to structures under variable mechanical and thermal loads, it is necessary to assure that the plastic collapse modes, alternate plasticity and incremental collapse (with instantaneous plastic collapse as a particular case), be precluded. The tool available to achieve this target is the shakedown theory. Unfortunately, the practical numerical applications of the shakedown theory result in very large nonlinear optimization problems with nonlinear constraints. Precise, robust and efficient algorithms and finite elements to solve this problem in finite dimension has been a more recent achievements. However, to solve real problems in an industrial level, it is necessary also to consider more realistic material properties as well as to accomplish 3D analysis. Limited kinematic hardening, is a typical property of the usual steels and it should be considered in realistic applications. In this paper, a new finite element with internal thermodynamical variables to model kinematic hardening materials is developed and tested. This element is a mixed ten nodes tetrahedron and through an appropriate change of variables is possible to embed it in a shakedown analysis software developed by Zouain and co-workers for elastic ideally-plastic materials, and then use it to perform 3D shakedown analysis in cases with limited kinematic hardening materials

The Influence of Limited Kinematic Hardening in Shakedown Analysis

The use of the Design by Analysis concept is a trend in modern pressure vessel and piping calculations. DBA flexibility allow us to deal with unexpected configurations detected at in-service inspections. It is also important, in life extension calculations, when deviations of the original standard hypotesis adopted initially in Design by Formula, can happen. To apply the DBA to structures under variable mechanic and thermal loads, it is necessary that, alternate plasticity and incremental collapse (with instantaneous plastic collapse as a particular case), be precluded. These are two basic failure modes considered by ASME or European Standards in DBA. The shakedown theory is the tool available to achieve this goal. In order to apply it, is necessary only the range of the variable loads and the material properties. Precise, robust and efficient algorithms to solve the very large nonlinear optimization problems generated in numerical applications of the shakedown theory is a recent achievement. Zouain and co-workers developed one of these algorithms for elastic ideally-plastic materials. But, it is necessary to consider more realistic material properties in real practical applications. This paper shows an enhancement of this algorithm to dealing with limited kinematic hardening, a typical property of the usual steels. This is done using internal thermodynamic variables. A discrete algorithm is obtained using a plane stress, mixed finite element, with internal variable. An example, a beam encased in an end, under constant axial force and variable moment is presented to show the importance of considering the limited kinematic hardening in a shakedown analysis.

Shakedown Analysis Considering Limited Kinematic Hardening Materials

In design or safety assessment of mechanical structures, the use of the Design by Analysis (DBA) route is a modern trend. However, for making possible to apply DBA to structures under variable loads, two basic failure modes considered by ASME or European Standards must be precluded. Those modes are the alternate plasticity and incremental collapse (with instantaneous plastic collapse as a particular case). Shakedown theory is a tool that permit us to assure that those kinds of failures will be avoided. However, in practical applications, very large nonlinear optimization problems are generated. Due to this facts, only in recent years have been possible to obtain algorithms sufficiently accurate, robust and efficient, for dealing with this class of problems. In this paper, one of these shakedown algorithms, developed for dealing with elastic ideally-plastic structures, is enhanced to include limited kinematic hardening, a more realistic material behavior. This is done in the continuous model by using internal thermodynamic variables. A corresponding discrete model is obtained using an axisymmetric mixed finite element with an internal variable. A thick wall sphere, under variable thermal and pressure loads, is used in an example to show the importance of considering the limited kinematic hardening in the shakedown calculations

The carrier’s exemption from liability in the Hague, Hamburg and Rotterdam Rules : an examination from the perspectives of fairness and clarity

Le commerce international est souvent relié au transport maritime. La poursuite des règles uniformes se rapportant à ce dernier avait débuté à la fin du XIXe siècle et a abouti à l’émergence des Règles de La Haye, des Règles de Hambourg et des Règles de Rotterdam. L’exonération du transporteur maritime, qui suscitait des controverses favorisant le développement des règles maritimes internationales, a été réglementée de trois façons différentes dans les trois Règles précitées. La question principale abordée dans la thèse présente est si elles sont suffisamment satisfaisantes. Une autre question, qui se pose s’il est prouvé qu’aucune d’entre elles ne l’est, est quelle serait une meilleure façon. Pour y répondre, deux critères, soit la justice et la clarté, ont été choisis. Les recherches effectuées dans le cadre de la thèse présente visent à donner une évaluation profonde des régimes existants en matière de réglementation de l’exonération du transporteur maritime ainsi que des suggestions d’amélioration à cet égard.

Shift Scheduling in Services When Employees Have Limited Availability: An L. P. Approach

This paper compares two linear programming (LP) models for shift scheduling in services where homogeneously-skilled employees are available at limited times. Although both models are based on set covering approaches, one explicitly matches employees to shifts, while the other imposes this matching implicitly. Each model is used in three forms—one with complete, another with very limited meal break placement flexibility, and a third without meal breaks—to provide initial schedules to a completion/improvement heuristic. The term completion/improvement heuristic is used to describe a construction/ improvement heuristic operating on a starting schedule. On 80 test problems varying widely in scheduling flexibility, employee staffing requirements, and employee availability characteristics, all six LP-based procedures generated lower cost schedules than a comparison from-scratch construction/improvement heuristic. This heuristic, which perpetually maintains an explicit matching of employees to shifts, consists of three phases which add, drop, and modify shifts. In terms of schedule cost, schedule generation time, and model size, the procedures based on the implicit model performed better, as a group, than those based on the explicit model. The LP model with complete break placement flexibility and implicitly matching employees to shifts generated schedules costing 6.7% less than those developed by the from-scratch heuristic.

US Highway 65 / IA-330 Improvements Polk and Jasper Counties, Iowa : Limited Phase I, Environmental Site Assessment, 1998

The Iowa Department of Transportation (IDOT) is currently considering improvements for US Highway 65 (US-65) and Iowa State Highway 330 (IA-330) in Polk and Jasper Counties, Iowa. As part of its project planning effort, IDOT is preparing an Environmental Assessment (EA) report which will include a section entitled "Hazardous Waste" to identify known sites in or near the proposed corridors that are, or could be, contaminated with hazardous or petroleum substances.

Time Delays on the Identification of the Need for CPR for Limited English Proficient 9-1-1 Callers

Thesis (Master's)--University of Washington, 2016-08

Characterizing bupropion metabolism, pharmacokinetics and drug-drug interaction liability

Thesis (Ph.D.)--University of Washington, 2016-06