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PubMed2026

Association between Kidney Tubular Secretory Clearance with Cognitive Function among Adults with CKD in the Systolic Blood Pressure Intervention Trial.

BACKGROUND: Persons with CKD are disproportionally affected with cognitive impairment, yet the pathophysiology linking the two conditions is unclear. Because kidney tubule secretion is essential for clearance of medications, uremic toxins, and metabolites, we hypothesized that worse tubular secretion would be associated with reduced cognitive function in CKD. METHODS: The Systolic Blood Pressure Intervention Trial tested a systolic blood pressure target <120 mmHg vs. <140 mmHg in hypertensive individuals at high cardiovascular risk. In paired blood and urine specimens from 1,937 participants with eGFR <60 ml/min/1.73m2, we measured 10 endogenous tubule-secreted metabolites and calculated a urine/plasma ratio for each, then averaged these to generate a summary secretion score. We used unadjusted and multivariable-adjusted linear regression and mixed models to evaluate cross-sectional and longitudinal associations of the secretion score with the Montreal Cognitive Assessment, Digit Symbol Coding, and Logical Memory immediate and delayed tests-measured at baseline and months 24 and 48 of follow-up. Multivariable Cox regression evaluated associations with incident probable dementia and mild cognitive impairment, adjudicated by prespecified criteria. RESULTS: Mean age was 73 ± 9 years, 41% were women, mean eGFR was 48.2 ± 11.4 ml/min/1.73m2, median albuminuria was 14.8 [7.1-48.6] mg/g. Lower secretion score was associated with a 0.06 higher adjusted logical memory delayed score (95% CI: 0.02, 0.11) but not with other cognitive tests at baseline or longitudinal cognitive decline. After a median 4.1 years of follow-up, 118 developed probable dementia and 187 developed mild cognitive impairment. Each 1-SD lower secretion score was associated with lower risk of probable dementia (HR 0.78, 95% CI: 0.63, 0.98) but not mild cognitive impairment. CONCLUSIONS: Among Systolic Blood Pressure Intervention Trial participants with CKD, lower estimated tubular secretion was not associated with worse cognition at baseline or during longitudinal follow-up.

Journal Article↗

PubMed2026

Longitudinal comparison of treat-to-target states and clinical outcomes in patients with late-onset versus early-onset systemic lupus erythematosus.

OBJECTIVE: We compared demographic and clinical characteristics between patients with late-onset (LO) and early-onset (EO) systemic lupus erythematosus (SLE) and examined their longitudinal associations with treatment targets and long-term outcomes, irreversible organ damage accrual and health-related quality of life (HRQoL). METHODS: We analyzed prospectively collected data from patients enrolled in the Asia Pacific Lupus Collaboration cohort. Patients diagnosed with SLE at age >50 years were classified as LO-SLE and compared with those diagnosed at age ≤50 years (EO-SLE). Longitudinal associations with treatment targets (LLDAS and DORIS remission), organ damage accrual (SLICC/ACR Damage Index), and HRQoL (SF36v2 physical and mental component summary (PCS and MCS) scores) were examined using multivariable multilevel logistic, recurrent-event survival, and linear mixed-effects models, respectively. Disease activity, flares, medication exposure, and other clinical characteristics were also compared between groups. RESULTS: Among 3,917 patients studied, 346 (8.8%) had LO-SLE. Compared with EO-SLE, patients with LO-SLE had lower disease activity, lower glucocorticoid and immunosuppressant exposure, and higher attainment of treatment targets; LO-SLE was associated with higher odds of attaining LLDAS (OR: 2.33 (1.66, 3.28)) and DORIS remission (OR: 2.22 (1.45, 3.38)). However, they were at a greater risk of damage accrual (HR:1.82 (1.50, 2.21)) and lower PCS scores, meaning poorer physical health (regression coefficient (RC) = -3.63 (-4.58, -2.68)) but not MCS (RC= 0.68 (-.50, 1.86)). CONCLUSION: Despite higher attainment of treatment targets, patients with LO-SLE experienced greater damage accrual and poorer physical health, suggesting that disease activity targets alone may not fully capture outcome risk in LO-SLE.

Journal Article↗

PubMed2026

The Effectiveness of Passive Half-Time Interventions on Simulated Second-Half Performance in Elite Youth Soccer Players.

The half-time period in soccer provides a potentially important window to implement short-duration interventions aimed at maintaining second-half performance. However, passive rest has been associated with a decline in subsequent physical and technical performance. While re-warm-up strategies are well studied, little is known about the efficacy of technology-based, passive recovery modalities, device-supported interventions that require minimal active movement or physical exertion from the athlete, during half-time intervals. This study examined whether percussive therapy, electrical muscle stimulation, and pneumatic compression can mitigate second-half performance decline in male adolescent soccer players. Forty-three academy-level players (17.5 ± 0.6 years) completed a simulated soccer protocol including the Loughborough Soccer Pass Test (LSPT), repeated 20-meter sprints, and completed Total Quality of Recovery (TQR) assessments before and after half-time. Participants were randomized into one of four intervention groups during the 15-minute half-time interval: Passive Rest (CON), Percussive Therapy (Theragun Pro; TG), EMS (PowerDot; PD), and Pneumatic Compression (RecoveryAir; COMP). Linear mixed-effects models assessed Time × Condition interactions for performance and recovery outcomes. Passive half-time rest led to significant deterioration in technical skill, sprint performance, and perceived recovery (p < .05) for the control group. TG and PD significantly improved technical performance (LSPT scores) compared to the control group (d = 0.65 and 0.72, respectively; p < .01). Furthermore, TG and COMP were effective at maintaining 20-meter sprint times (d = 0.58 and 0.49; p < .01), whereas the control group experienced significant slowing. Perceived recovery (TQR) scores significantly declined in the CON group from First Half to Second Half (16.5 ± 2.2 to 11.1 ± 2.3. However, this decline was significantly attenuated in all intervention groups: TG (17.5 ± 1.9 to 14.2 ± 1.9), PD (17.3 ± 1.9 to 15.1 ± 1.9), and COMP (17.6 ± 1.9 to 15.9 ± 2.0). Short-duration passive interventions during half-time can mitigate performance decline in adolescent soccer players. TG and EMS appear most effective for preserving technical skills, while COMP may support perceived recovery. These findings highlight practical strategies for optimizing in-game performance and inform evidence-based half-time protocols.

Humans↗

PubMed2006

Effects of sibutramine treatment in obese adolescents: a randomized trial.

BACKGROUND: Increased prevalence of adolescent obesity requires effective treatment options beyond behavior therapy. OBJECTIVE: To see whether sibutramine reduced weight more than placebo in obese adolescents who were receiving a behavior therapy program. DESIGN: 12-month, 3:1 randomized, double-blind trial conducted from July 2000 to February 2002. SETTING: 33 U.S. outpatient clinics. PARTICIPANTS: 498 participants 12 to 16 years of age with a body mass index (BMI) that was at least 2 units more than the U.S. weighted mean of the 95th percentile based on age and sex, to the upper limit of 44 kg/m2. INTERVENTIONS: Site-specific behavior therapy plus 10 mg of sibutramine or placebo. Blinded study medication dose was uptitrated to 15 mg or placebo at month 6 if initial BMI was not reduced by 10%. MEASUREMENTS: Body mass index, waist circumference, body weight, fasting lipid and glycemic variables, safety, and tolerability. RESULTS: Seventy-six percent of patients in the sibutramine group and 62% of patients in the placebo group completed the study. The estimated mean treatment group difference at month 12 (linear mixed-effects model) favored sibutramine for change from baseline in BMI (-2.9 kg/m2 [95% CI, -3.5 to -2.2 kg/m2]) and body weight (-8.4 kg [CI, -9.7 to -7.2 kg]) (P < 0.001 for both). The sibutramine group had greater improvements in triglyceride levels, high-density lipoprotein cholesterol levels, insulin levels, and insulin sensitivity (P < or = 0.001 for all). The rate of tachycardia was greater with sibutramine vs. placebo (12.5% vs. 6.2%; difference, 6.3 percentage points [CI, 1.0 to 11.7 percentage points]) but did not lead to increased withdrawal (2.4% vs. 1.5%; difference, 0.9 percentage point [CI, -1.7 to 3.5 percentage points]). LIMITATIONS: The 1-year study duration precluded assessment of long-term weight maintenance and putative health benefits and harms, and 24% and 38% of the sibutramine and placebo groups, respectively, did not complete follow-up. CONCLUSIONS: Sibutramine added to a behavior therapy program reduced BMI and body weight more than placebo and improved the profile of several metabolic risk factors in obese adolescents.

Adolescent↗

PubMed2006

Changes in the sonographic appearance of the uterus after discontinuation of tamoxifen therapy.

OBJECTIVE: The purpose of this study was to assess the duration of sonographically detected changes in the endometrium of women with a history of tamoxifen use. METHODS: Patients with breast cancer who had a history of tamoxifen use and documented pelvic sonographic studies were identified by means of clinic databases in both the Section of Gynecological Oncology and the Section of Obstetrical and Gynecological Ultrasound, University of Chicago, between January 1, 1996, and March 30, 2004. Of the 99 patients who met study criteria, 34 had discontinued tamoxifen use before the sonographic evaluation. Each patient's age, gravity and parity, weight, ethnicity, duration and dose of drug use, interval from drug discontinuation until sonographic evaluation, and uterine pathologic findings were reviewed. Endometrial thickness as assessed by pelvic sonography was examined in relation to duration of tamoxifen use and time from discontinuation of the drug. Statistical analysis was performed with linear regression and mixed effect linear regression models. RESULTS: Endometrial thickness increased with increasing duration of tamoxifen use at a rate of 0.75 mm/y. The mean endometrial thickness after approximately 5 years of tamoxifen use was 12 mm (range, 6-21 mm). After discontinuation of tamoxifen, endometrial thickness decreased by 1.27 mm/y. CONCLUSIONS: Endometrial thickness as measured by pelvic ultrasound examination increases with the duration of tamoxifen use. After discontinuation of the drug, the measured thickness decreases but at a very slow rate.

Antineoplastic Agents, Hormonal↗

PubMed1999

Response to health insurance by previously uninsured rural children.

OBJECTIVE: To examine the healthcare utilization and costs of previously uninsured rural children. DATA SOURCES/STUDY SETTING: Four years of claims data from a school-based health insurance program located in the Mississippi Delta. All children who were not Medicaid-eligible or were uninsured, were eligible for limited benefits under the program. The 1987 National Medical Expenditure Survey (NMES) was used to compare utilization of services. STUDY DESIGN: The study represents a natural experiment in the provision of insurance benefits to a previously uninsured population. Premiums for the claims cost were set with little or no information on expected use of services. Claims from the insurer were used to form a panel data set. Mixed model logistic and linear regressions were estimated to determine the response to insurance for several categories of health services. PRINCIPAL FINDINGS: The use of services increased over time and approached the level of utilization in the NMES. Conditional medical expenditures also increased over time. Actuarial estimates of claims cost greatly exceeded actual claims cost. The provision of a limited medical, dental, and optical benefit package cost approximately $20-$24 per member per month in claims paid. CONCLUSIONS: An important uncertainty in providing health insurance to previously uninsured populations is whether a pent-up demand exists for health services. Evidence of a pent-up demand for medical services was not supported in this study of rural school-age children. States considering partnerships with private insurers to implement the State Children's Health Insurance Program could lower premium costs by assembling basic data on previously uninsured children.

Arkansas↗

PubMedDate not supplied

Population pharmacokinetics of cisplatin in patients with advanced ovarian cancer during intraperitoneal hyperthermia chemotherapy.

The objective of this study was to determine the pharmacokinetic profile of total platinum administered by hyperthermic peritoneal perfusion (HPP) in 16 patients with ovarian cancer. The patients had a performance status of lIIalpha/b/c on the FIGO scale. They received 60, 80 or 100 mg of cisplatin. The percent of cisplatin remaining in the body after the peritoneum was emptied averaged 65% (41.7-85.4%). The average ratio between peritoneal drug concentrations and plasma concentrations was 73. A Bayesian estimation of individual phamacokinetic parameters was carried out using the non-linear mixed-effect modeling approach as implemented in the NONMEM computer program. A two-compartment model with an additional peritoneal cavity compartment was used to fit the data. Large interindividual variability of the pharmacokinetic parameters occurred The maximum platinum concentration in plasma was reached between 1 and 1.5 hours after the beginning of administration; it ranged from 0.37 to 1.7 microg/ml (1.9 to 8.72 microM). The elimination half-life was 80 hours (48-152 hours and the area under the plasma concentration time curve normalized to a 100 mg cisplatin dose was 79 mg/liter x hours. The simultaneous fit of perfusate and plasma concentrations allowed us to estimate the percent of cisplatin that reached the systemic circulation at about 20%. At time infinity, the urinary cisplatin recovery accounted for only 20% of the administered dose. The results in this study showed that a high proportion of the cisplatin dose was absorbed by target tumor cells. In spite of the advanced disease of patients at the time of HPP, 37.5% of them were still alive three years after HPP (ie., 3-6 years after cancer diagnosis) and 12.5%, 7 years after HPP (i.e., 8 years after cancer diagnosis).

Adult↗

PubMed2002

Percutaneous absorption of trihalomethanes, haloacetic acids, and haloketones.

Bathing in chlorinated drinking water causes significant exposure to potentially toxic disinfection by-products (DBPs). In the present studies, we measured the permeation coefficients (K(p)) of three important classes of DBPs, trihalomethanes (THMs), haloketones (HKs), and haloacetic acids (HAAs), in aqueous solution across human skin using in vitro diffusion chambers. Linear mixed-effects model was utilized to calculate the steady-state permeability coefficients. The permeability coefficients of THMs ranged from 0.16 to 0.21 cm/h when the donor solution was at 25 degrees C. Bromoform had the highest K(p) value, while chloroform was the least permeable through the skin. THMs were approximately 10 times more permeable than HKs, while the permeability of HAAs through the skin was very low (1 to 3 x 10(-3) cm/h, pH 7). The permeability of HKs tripled as the temperature was increased from room temperature (20 degrees C) to bathing temperature (40 degrees C). A direct relationship was found between the permeability of THMs, but not HKs and HAAs, and their octanol/water partition coefficients. The dermal dose from daily bathing activities was approximated for an average adult using U.S. EPA recommended methods and found to be 40-70% of the daily ingestion dose for the THMs, 10% of the ingestion dose for HKs, and an insignificant percentage of the ingestion dose for the HAAs. In addition to ingestion, dermal absorption is an important route of exposure to THMs and HKs and must be considered in models of risk assessment.

Acetates↗

PubMedDate not supplied

Assessment of an electronic goniometer designed to measure equinus contracture.

To achieve more objective and repeatable measurements of equinus contracture, we developed the equinometer, a device that allows the measurement of ankle range of motion under controlled torque conditions. This study assessed its accuracy across different subjects and examiners. Two examiners used the equinometer to measure the angle of ankle dorsiflexion at 15 N x m torque on five subjects. Accounting for variation in measurements because of subjects, examiners, and placement of device, we used linear mixed-effects models. Accounting for the variation because of subject, different placements of the equinometer within each subject and the adjustment for the effects of examiner and trial sequence, the standard deviation was 0.94 degrees, 95% confidence interval (0.79 degrees, 1.13 degrees). An upper standard deviation of 1.36 degrees is felt to be acceptable for clinical investigation.

Ankle Joint↗

PubMedDate not supplied

Intravenous cyclophosphamide therapy for systemic sclerosis. A single-center experience and review of the literature with pooled analysis of lung function test results.

OBJECTIVE: Oral cyclophosphamide (CYC) is a promising therapy for Systemic Sclerosis (SSc)-related interstitial lung disease (ILD). The use of intravenous (i.v.) pulses has been considered as an alternative route of drug administration, possibly associated with reduced toxicity. Our objectives were to re-evaluate our experience with i.v. CYC, to review the literature, and to pool our results with those available from other groups, improving the statistical power of the analysis. METHODS: 1) Retrospective analysis of our center experience on 16 patients with SSc and active alveolitis, treated with i.v. CYC 750 mg + 6-methylprednisolone 125 mg every 3 weeks. 2) Pooled analysis of papers published in peer-reviewed journals reporting detailed data on each patient treated with i.v. CYC. The end-point was modification in the results of lung function tests (LFT) after 6 months. Piecewise regression analysis was performed using a linear mixed-effects model adjusted for baseline values to evaluate the changes in LFT. RESULTS: Retrospective analysis. In the period before therapy there was a significant deterioration in FVC (in 6 months: -4.3%; p=0.0009) and DLCO (-2.1%; p=0.018). After 6 months of treatment there was a modest improvement in the FVC (+2.7% p=0.08) and DLCO (+2.2%; p=0.08). Pooled analysis. In 53 evaluable patients, the improvement in LFT reached conventional statistical significance (FVC: +2.85%; 95% confidence intervals: +0.04, +5.66%; p=0.04. DLCO: +4.4%; 95% confidence intervals: +1.2%, +7.5%; p<0.001). CONCLUSION: i.v. CYC for 6 months can achieve a small, but significant improvement of LFT in patients with SSc and active alveolitis.

Adult↗

PubMed2004

Does transient HAART during primary HIV-1 infection lower the virological set-point?

OBJECTIVES: To assess the influence of patient characteristics, treatment precocity (how early) and duration of sustained virological response to highly active antiretroviral therapy (HAART) on HIV RNA levels after withdrawal of treatment started during primary infection and to compare HIV RNA levels after HAART withdrawal with levels reached at the same time point during the natural history of infection in the pre-HAART era. DESIGN: HIV RNA was analysed using linear mixed-effects models for 58 patients from the PRIMO cohort (1996-2003) treated during primary infection (with sustained virological responses until HAART interruption) and 116 untreated patients enrolled in the SEROCO cohort within 6 months following infection (1988-1995). Viral loads were estimated in PRIMO patients 36 months after infection (12 months after treatment interruption) and were estimated for the SEROCO patients 36 months after infection, after adjustment for gender and age. RESULTS: HIV RNA levels 12 months after HAART interruption were independently associated with levels at HAART initiation and with the CD4 cell count at HAART interruption, but not with the precocity of HAART or the duration of virological response to HAART. Thirty-six months after infection, mean HIV RNA levels were 3.95 log10 copies/ml 12 months after stopping HAART and 4.11 log10 copies/ml in never-treated patients. CONCLUSION: Viral load 12 months after withdrawal of transient effective HAART started during primary infection is similar to viral load at the same time after infection in never-treated patients, suggesting that early HAART initiation does not lower the virological set-point.

Adult↗

PubMed2006

Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial.

BACKGROUND AND PURPOSE: In many physical therapy programs for subjects with adhesive capsulitis of the shoulder, mobilization techniques are an important part of the intervention. The purpose of this study was to compare the effectiveness of high-grade mobilization techniques (HGMT) with that of low-grade mobilization techniques (LGMT) in subjects with adhesive capsulitis of the shoulder. SUBJECTS: One hundred subjects with unilateral adhesive capsulitis lasting 3 months or more and a > or =50% decrease in passive joint mobility relative to the nonaffected side were enrolled in this study. METHODS: Subjects randomly assigned to the HGMT group were treated with intensive passive mobilization techniques in end-range positions of the glenohumeral joint, and subjects in the LGMT group were treated with passive mobilization techniques within the pain-free zone. The duration of treatment was a maximum of 12 weeks (24 sessions) in both groups. Subjects were assessed at baseline and at 3, 6, and 12 months by a masked assessor. Primary outcome measures included active and passive range of motion and shoulder disability (Shoulder Rating Questionnaire [SRQ] and Shoulder Disability Questionnaire [SDQ]). An analysis of covariance with adjustments for baseline values and a general linear mixed-effect model for repeated measurements were used to compare the change scores for the 2 treatment groups at the various time points and over the total period of 1 year, respectively. RESULTS: Overall, subjects in both groups improved over 12 months. Statistically significant greater change scores were found in the HGMT group for passive abduction (at the time points 3 and 12 months), and for active and passive external rotation (at 12 months). A statistically significant difference in trend between both groups over the total follow-up period of 12 months was found for passive external rotation, SRQ, and SDQ with greater change scores in the HGMT group. DISCUSSION AND CONCLUSION: In subjects with adhesive capsulitis of the shoulder, HGMTs appear to be more effective in improving glenohumeral joint mobility and reducing disability than LGMTs, with the overall differences between the 2 interventions being small.

Bursitis↗

PubMed1984

A patient mix model for hospital financial planning.

A linear programming model was formulated to examine the impact on hospital finances and resource use of changes in patient mix under current and proposed government reimbursement regulations. The model specifically incorporated the costs, revenues, and resource consumption patterns associated with patients drawn from different intensity level and payer class combinations. The necessary data were obtained from financial reports and other records, and the model was used in policy analysis at a major university teaching hospital.

Costs and Cost Analysis↗

PubMed1982

Further evidence for the use of polyamines as biochemical markers for malignant tumors.

One hundred ninety patients with a variety of tumor presented within a specified time period and fit a specified protocol. Multiple serial urinary putrescine, spermidine, and spermine levels were obtained in these patients, and their disease activity over time, defined as either active or nonactive, was determined by clinical examination, the results of laboratory tests, and radiological criteria. Twenty-four-hr urine collections were used for analysis of polyamine levels. A linear mixed-effects model and the method of maximum likelihood estimation were used for statistical analysis. Statistically significant differences were found in polyamine levels between patients with active or nonactive disease for tumors of the breast, stomach, prostate, female genital tract, and a variety of metastatic carcinomas of unknown origin. There were 105 patients with these tumors; 319 polyamine determinations were obtained from this subset of patients. Our results suggest that serial determination of polyamine levels in urine may have clinical utility for monitoring the disease states for these tumors.

Breast Neoplasms↗

PubMed1998

On the analysis of mixed longitudinal growth data.

Mixed longitudinal growth data consists of several observations on a characteristic over a limited age range for each individual in a study. This data is then combined to model growth over the total age range of all individuals in the study. The limited data collected on each individual precludes a subject-specific approach to modelling so that a population-based approach must be used. Here we propose a method for the analysis of mixed longitudinal data using linear models constructed from cubic splines to model both the mean and variance curves of an observed characteristic. The method is illustrated on growth in height and head circumference for children in a recently collected mixed longitudinal data set concerning the growth of Victorian schoolchildren, where particular concern was the timing of growth spurts and increases in variability.

Adolescent↗

PubMed1991

Modelling hearing thresholds in the elderly.

This paper concerns a linear mixed-effects repeated measures model in the analysis of a large data set with over 17,000 observations in a longitudinal study of pure-tone hearing perception in the elderly. The repeated measurements are described by fixed and random components in the model. The fixed effects include the age at entry, time of follow-up, a quadratic component in natural logarithm of frequency, a component to allow for participants with hearing impairments, as well as interaction terms between age and frequency and between impairment and frequency. The random factors include a term for subject, a time component and a frequency component. The analysis shows that hearing impaired individuals have similar patterns of hearing loss over time but, on average, have higher hearing thresholds than normal individuals. Estimation of the random effects in the model by restricted maximum likelihood (REML) using the Newton-Raphson method made possible the analysis of this large data set with speed and efficiency.

Aged↗

PubMed2002

Complexities in ETS-domain transcription factor function and regulation: lessons from the TCF (ternary complex factor) subfamily. The Colworth Medal Lecture.

The ETS-domain transcription factor family can be divided into a series of subfamilies. Elk-1 represents the founding member of the ternary complex factor (TCF) subfamily. By focusing on the TCF subfamily, we can demonstrate the complexities that exist in the function and regulation of ETS-domain transcription factors. This article focuses on Elk-1 in detail and summarizes the functions of other TCFs. The key themes covered include the domain structure of the TCFs, the mechanisms of complex formation with serum response factor, regulation of TCFs by mitogen-activated protein kinase cascades, and transcriptional regulatory properties of the TCFs. Finally, the emerging role of the TCFs in vivo is discussed. A picture is developing indicating that, while these proteins exhibit significant sequence and functional conservation, key differences in their structure and regulation are being identified which may relate to unique functions of these proteins in vivo.

Amino Acid Sequence↗

PubMed2006

An inexact two-stage mixed integer linear programming method for solid waste management in the City of Regina.

In this study, an interval-parameter two-stage mixed integer linear programming (ITMILP) model is developed for supporting long-term planning of waste management activities in the City of Regina. In the ITMILP, both two-stage stochastic programming and interval linear programming are introduced into a general mixed integer linear programming framework. Uncertainties expressed as not only probability density functions but also discrete intervals can be reflected. The model can help tackle the dynamic, interactive and uncertain characteristics of the solid waste management system in the City, and can address issues concerning plans for cost-effective waste diversion and landfill prolongation. Three scenarios are considered based on different waste management policies. The results indicate that reasonable solutions have been generated. They are valuable for supporting the adjustment or justification of the existing waste flow allocation patterns, the long-term capacity planning of the City's waste management system, and the formulation of local policies and regulations regarding waste generation and management.

Canada↗