Background: Falls are a significant problem for older adults. Individuals who have sustained a fall come to the attention of health care providers and are at risk of further falls. To promote the highest quality of care and reduce variation in care, a practice guideline is needed. Summarization of evidence regarding falls may be useful to researchers in this field. Objectives: To provide evidence-based guidelines of assessment and treatment to prevent falls in older adults and to provide researchers with tables of risk factor studies and randomized controlled trials of falls prevention. Methods: A template for the development of practice guidelines from the Agency for Health Care Policy and Research was used. Evidence for risk factors was accepted from prospective studies with more than 80% follow-up. Potentially modifiable risk factors were selected and a schema for evaluating the importance of each risk factor was used. Evidence for interventions was examined from randomized controlled trials and strength of the evidence was graded. Recommendations for aspects of care where judgment was required were made by panel consensus. Results: Information was drawn from 46 risk factor studies and 37 randomized controlled trials to develop a practice guideline consisting of assessment items and recommended interventions for community-dwelling and institution-dwelling older adults separately. For clinicians, a check list is provided. Summary tables of the results of studies are given to substantiate the recommendations. Conclusions: For community-dwelling older adults, there is strong evidence for multi-factorial specific risk assessment and targeted treatment. Balance exercises are recommended for all individuals who have had a fall and there is evidence for a program of home physiotherapy for women over 80 years of age regardless of risk factor status. For institutional settings, the establishment of a falls program for safety checks, ongoing staff education and monitoring is substantiated by research. Residents who have fallen need to be assessed for specific risk factors and clinical indicators to determine relevant management options.
Approaches that root national climate strategies in local actions will be essential for all countries as they develop new nationally determined contributions under the Paris Agreement. The potential impact of climate action from non-national actors in delivering higher global ambition is significant. Sub-national action in the United States provides a test for how such actions can accelerate emissions reductions. We aggregated U.S. state, city, and business commitments within an integrated assessment model to assess how a national climate strategy can be built upon non-state actions. We find that existing commitments alone could reduce emissions 25% below 2005 levels by 2030, and that enhancing actions by these actors could reduce emissions up to 37%. We show how these actions can provide a stepped-up basis for additional federal action to reduce emissions by 49%—consistent with 1.5 °C. Our analysis demonstrates sub-national actions can lead to substantial reductions and support increased national action.
Abstract. This article proposes new terminology that distinguishes between different concepts involved in the discussion of the shelf life of pharmaceutical products. Such comprehensive and common language is currently lacking from various guidelines, which confuses implementation and impedes comparisons of different methodologies. The five new terms that are necessary for a coherent discussion of shelf life are: true shelf life, estimated shelf life, supported shelf life, maximum shelf life, and labeled shelf life. These concepts are already in use, but not named as such. The article discusses various levels of "product" on which different stakeholders tend to focus (e.g., a single-dosage unit, a batch, a production process, etc.). The article also highlights a key missing element in the discussion of shelf life-a Quality Statement, which defines the quality standard for all key stakeholders. Arguments are presented that for regulatory and statistical reasons the true product shelf life should be defined in terms of a suitably small quantile (e.g., fifth) of the distribution of batch shelf lives. The choice of quantile translates to an upper bound on the probability that a randomly selected batch will be nonconforming when tested at the storage time defined by the labeled shelf life. For this strategy, a random-batch model is required. This approach, unlike a fixedbatch model, allows estimation of both within-and between-batch variability, and allows inferences to be made about the entire production process. This work was conducted by the Stability Shelf Life Working Group of the Product Quality Research Institute.KEY WORDS: ICH method; quantile for distribution of batch shelf lives; random-batch model; shelf life terminology; stability.
Since 1989 in New Zealand, the work of the primary school principal has been transformed in official policy texts from that of leading professional to chief executive officer. Surveys document the changing nature of the role and the workload and other pressures that have resulted, particularly for principals with teaching responsibilities in smaller schools. There is a generally accepted crisis of preparation, recruitment, development and retention. Below the surface, however, are deeper-seated, structural difficulties: women comprise the majority of teachers, yet are a minority of principals and their career advancement is largely limited to small schools and those in poorer socioeconomic areas. This article reviews the situation and examines the reasons why dominant images of the primary school principalship may be both partial and counterproductive.
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