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Posts Tagged concussion
[REVIEW ARTICLE] Blood Biomarkers for Traumatic Brain Injury: A Quantitative Assessment of Diagnostic and Prognostic Accuracy – Full Text
Posted by Kostas Pantremenos in Uncategorized on April 29, 2019
Blood biomarkers have been explored for their potential to provide objective measures in the assessment of traumatic brain injury (TBI). However, it is not clear which biomarkers are best for diagnosis and prognosis in different severities of TBI. Here, we compare existing studies on the discriminative abilities of serum biomarkers for four commonly studied clinical situations: detecting concussion, predicting intracranial damage after mild TBI (mTBI), predicting delayed recovery after mTBI, and predicting adverse outcome after severe TBI (sTBI). We conducted a literature search of publications on biomarkers in TBI published up until July 2018. Operating characteristics were pooled for each biomarker for comparison. For detecting concussion, 4 biomarker panels and creatine kinase B type had excellent discriminative ability. For detecting intracranial injury and the need for a head CT scan after mTBI, 2 biomarker panels, and hyperphosphorylated tau had excellent operating characteristics. For predicting delayed recovery after mTBI, top candidates included calpain-derived αII-spectrin N-terminal fragment, tau A, neurofilament light, and ghrelin. For predicting adverse outcome following sTBI, no biomarker had excellent performance, but several had good performance, including markers of coagulation and inflammation, structural proteins in the brain, and proteins involved in homeostasis. The highest-performing biomarkers in each of these categories may provide insight into the pathophysiologies underlying mild and severe TBI. With further study, these biomarkers have the potential to be used alongside clinical and radiological data to improve TBI diagnostics, prognostics, and evidence-based medical management.
Traumatic brain injury (TBI) is a common cause of disability and mortality in the US (1) and worldwide (2). Pathological responses to TBI in the CNS include structural and metabolic changes, as well as excitotoxicity, neuroinflammation, and cell death (3, 4). Fluid biomarkers that may track these injury and inflammatory processes have been explored for their potential to provide objective measures in TBI assessment. However, at present there are limited clinical guidelines available regarding the use of biomarkers in both the diagnosis of TBI and outcome prediction following TBI. To inform future guideline formulation, it is critical to distinguish between different clinical situations for biomarker use in TBI, such as detection of concussion, prediction of positive and negative head computed tomography (CT) findings, and prediction of outcome for different TBI severities. This allows for comparisons to determine which biomarkers may be used most appropriately to characterize different aspects of TBI.
The identification of TBI severity has become a contentious issue. Currently, inclusion in TBI clinical trials is primarily based on the Glasgow Coma Scale (GCS), which stratifies patients into categories of mild, moderate, and severe TBI. The GCS assesses consciousness and provides prognostic information, but it does not inform the underlying pathologies that may be targeted for therapy (5, 6). Furthermore, brain damage and persistent neurological symptoms can occur across the spectrum of TBI severity, limiting the use of GCS-determined injury severity to inform clinical management. Biomarkers in TBI have the potential to provide objective and quantitative information regarding the pathophysiologic mechanisms underlying observed neurological deficits. Such information may be more appropriate for guiding management than initial assessments of severity alone. Since the existing literature primarily focuses on applications of biomarkers in either suspected concussion, mild TBI (mTBI), or severe TBI (sTBI), we will discuss biomarker usage in these contexts.
Concussion is a clinical syndrome involving alteration in mental function induced by head rotational acceleration. This may be due to direct impact or unrestrained rapid head movements, such as in automotive crashes. Although there are over 30 official definitions of concussion, none include the underlying pathology. Missing from the literature have been objective measures to not only identify the underlying pathology associated with the given clinical symptoms, but also to indicate prognosis in long-term survival. Indeed, current practices in forming an opinion of concussion involve symptom reports, neurocognitive testing, and balance testing, all of which have elements of subjectivity and questionable reliability (7). While such information generally reflects functional status, it does not identify any underlying processes that may have prognostic or therapeutic consequences. Furthermore, because patients with concussion typically present with negative head CT findings, there is a potential role for blood-based biomarkers to provide objective information regarding the presence of concussion, based on an underlying pathology. This information could inform management decisions regarding resumption of activities for both athletes and non-athletes alike.
Blood-based biomarkers have utility far beyond a simple detection of concussion by elucidating specific aspects of the injury that could drive individual patient management. For example, biomarkers may aid in determining whether a mTBI patient presenting to the emergency department requires a CT scan to identify intracranial pathology. The clinical outcome for a missed epidural hematoma in which the patient is either discharged or admitted for routine observation is catastrophic; 25% are left severely impaired or dead (8). The Canadian CT Head Rule (9) and related clinical decision instruments achieve high sensitivities in predicting the need for CT scans in mild TBI cases. However, they do this at specificities of only 30–50% (10). Adding a blood biomarker to clinical evaluation may be useful to improve specificity without sacrificing sensitivity, as recently suggested (11). In addition, given concern about radiation exposure from head CT scans in concussion cases, particularly in pediatric populations, identification of patients who would be best assessed with neuroimaging is crucial. Thus, the use of both sensitive and specific biomarkers may serve as cost-effective tools to aid in acute assessment, especially in the absence of risk factors for intracranial injury (12). S-100B, an astroglial protein, has been the most extensively studied biomarker for TBI thus far and has been incorporated into some clinical guidelines for CT scans (13, 14). However, S-100B is not CNS-specific (15, 16) and has shown inconsistent predictive capacity in the outcome of mild TBI (17, 18). Given that several other promising biomarkers have also been investigated in this context, it is important to evaluate and compare the discriminative abilities of S-100B with other candidate blood-based biomarkers for future use.
Blood biomarkers also have the potential to help predict unfavorable outcomes across the spectrum of TBI severity. Outcome predication is difficult; in mTBI, existing prognostic models performed poorly in an external validation study (19). Identifying biomarkers that best predict delayed recovery or persistent neurological symptoms following mTBI would help with the direction of resources toward patients who may benefit most from additional rehabilitation or prolonged observation. In sTBI, poorer outcome has often been associated with a low GCS score (20). However, factors such as intoxication or endotracheal intubation may make it difficult to assess GCS reliably in the acute setting (21, 22). The addition of laboratory parameters to head CT and admission characteristics have improved prognostic models (23). Thus, prognostic biomarkers in sTBI could help determine whether patients are likely to benefit from intensive treatment. Several candidate biomarkers that correlate with various pathologies of mild and severe TBI have been studied (24), but their relative prognostic abilities remain unclear.
Existing reviews on biomarkers in TBI have provided valuable insight into the pathologic correlates of biomarkers, as well as how biomarkers may be used for diagnosis and prognosis (25–31). However, there has been no previous quantitative comparison of the literature regarding biomarkers' discriminative abilities in specific clinical situations. Here, we compare existing studies on the discriminative abilities of serum biomarkers for four commonly studied clinical situations: detecting concussion, predicting intracranial damage after mTBI, predicting delayed recovery after mTBI, and predicting adverse outcome after sTBI.[…]
Continue —-> Frontiers | Blood Biomarkers for Traumatic Brain Injury: A Quantitative Assessment of Diagnostic and Prognostic Accuracy | Neurology
Figure 2. Anatomical locations of potential TBI biomarkers. The biomarkers included in this schematic all rated as "good" (AUC=0.800.89) or better for any of the four clinical situations studied (detecting concussion, predicting intracranial damage after concussion, predicting delayed recovery after concussion, and predicting adverse outcome after severe TBI). Biomarkers with a pooled AUC <0.8 are not shown. 1Also found in adipose tissue; 2synthesized in cells of stomach and pancreas; may regulate HPA axis; 3found mostly in pons; 4also found extracellularly; 5lectin pathway of the complement system; 6also found in endothelial cells. BBB, blood brain barrier. ECM, Extracellular matrix. Image licensed under Creative Commons Attribution-ShareAlike 4.0 International license. https://creativecommons.org/licenses/by-sa/4.0/deed.en. See Supplementary Material for image credits and licensing.
biomarker, Biomarkers, concussion, diagnosis, mTBI, Prognosis, TBI, Traumatic Brain Injury
[BLOG] Lash & Associates' Award-Winning Blog site
Posted by Kostas Pantremenos in Uncategorized on March 22, 2019
TBI, ABI, PTSD, Stroke, Concussion Blog Posts!
Lash & Associates'
Award-Winning Blog Site
Is Well Worth A Look
Our large variety of blog articles are keyword searchable, and offer help & encouragement.
Click here to go the our blog site!
No matter what your situation – as a survivor, a clinician, a caregiver, or a family member, our blog site provides a great reference point. Check it out – we've got something for most any situation regarding the greater TBI Community!
via Lash & Associates' Award-Winning Blog site
ABI, blog, concussion, Lash & Associates, PTSD, Stroke, TBI
[Abstract] Rehabilitation of Cognitive Dysfunction Following Traumatic Brain Injury – Epilepsy Society
Posted by Kostas Pantremenos in Cognitive Rehabilitation on November 22, 2018
This article outlines key principles and considerations in the rehabilitation of cognitive challenges following mild, moderate, and severe traumatic brain injuries, with a focus on the needs of the service member and veteran population. The authors highlight specific evidence-based strategies and interventions and provide functional examples to support implementation. By emphasizing the array of tools and resources that have been designed to address cognitive challenges in the service member and veteran population, they focus on optimizing cognition to support successful community reintegration and the resumption of a full and meaningful life.
via Rehabilitation of Cognitive Dysfunction Following Traumatic Brain Injury – Physical Medicine and Rehabilitation Clinics
cognitive, concussion, Moderate, REHABILITATION, Service members, severe, Traumatic Brain Injury, Veterans
[ARTICLE] Clinical Findings in a Multicenter MRI Study of Mild TBI
Posted by Kostas Pantremenos in REHABILITATION on October 24, 2018
Background: Uncertainty continues to surround mild traumatic brain injury (mTBI) diagnosis, symptoms, prognosis, and outcome due in part to a lack of objective biomarkers of injury and recovery. As mTBI gains recognition as a serious public health epidemic, there is need to identify risk factors, diagnostic tools, and imaging biomarkers to help guide diagnosis and management.
Methods: One hundred and eleven patients (15–50 years old) were enrolled acutely after mTBI and followed with up to four standardized serial assessments over 3 months. Each encounter included a clinical exam, neuropsychological assessment, and magnetic resonance imaging (MRI). Chi-square and linear mixed models were used to assess changes over time and determine potential biomarkers of mTBI severity and outcome.
Results: The symptoms most frequently endorsed after mTBI were headache (91%), not feeling right (89%), fatigue (86%), and feeling slowed down (84%). Of the 104 mTBI patients with a processed MRI scan, 28 (27%) subjects had white matter changes which were deemed unrelated to age, and 26 of these findings were deemed unrelated to acute trauma. Of the neuropsychological assessments tested, 5- and 6-Digit Backward Recall, the modified Balance Error Scoring System (BESS), and Immediate 5-Word Recall significantly improved longitudinally in mTBI subjects and differentiated between mTBI subjects and controls. Female sex was found to increase symptom severity scores (SSS) at every time point. Age ≥ 25 years was correlated with increased SSS. Subjects aged ≥ 25 also did not improve longitudinally on 5-Digit Backward Recall, Immediate 5-Word Recall, or Single-Leg Stance of the BESS, whereas subjects < 25 years improved significantly. Patients who reported personal history of depression, anxiety, or other psychiatric disorder had higher SSS at each time point.
Conclusions: The results of this study show that 5- and 6-Digit Backward Recall, the modified BESS, and Immediate 5-Word Recall should be considered useful in demonstrating cognitive and vestibular improvement during the mTBI recovery process. Clinicians should take female sex, older age, and history of psychiatric disorder into account when managing mTBI patients. Further study is necessary to determine the true prevalence of white matter changes in people with mTBI.
Mild traumatic brain injury (mTBI) is defined as a traumatically induced physiological disruption of brain function (1). Although mTBI accounts for at least 75% of traumatic brain injuries and imposes an excessive societal burden (2, 3), mTBI diagnosis continues to lack objective clinical and imaging biomarkers. As of now, the best marker for severity and recovery is a subjective assessment of acute symptom burden (4). Uncertainty continues to surround mTBI diagnosis, symptoms, prognosis, and outcome for physicians and patients as reliable biomarkers remain elusive. As injury rates increase and mTBI becomes a serious public health epidemic (5), there is an increasing role for identification of potential imaging biomarkers, specific neuropsychological assessments, and validated risk factors to help guide prognoses and return to play decisions.
Given the current subjective nature of symptom burden assessment, there is a role for neuropsychological assessments in evaluating the cognitive impairment of patients after injury. The sport concussion assessment tool (SCAT) has been demonstrated as an effective tool to differentiate between mTBI subjects and controls in non-athlete populations and is widely used in mTBI studies (6–8). Tests of memory, balance, and cognition are incorporated into the SCAT (9, 10), but research has not demonstrated their effectiveness as longitudinal assessments (11). Separately, 3-word recall is commonly employed in patients with mTBI to assess memory function (12). This test is usually normal and is probably inadequate for assessing these patients.
The risk factors for mTBI severity are debated in the literature. Demographic factors commonly explored include sex, age, previous concussions, learning disability, psychiatric history, and migraine/headache history (13). Although each of these preinjury characteristics has been studied in numerous protocols, a consensus has not been reached. Further research is needed to establish the risk factors for mTBI severity so that they may be incorporated into clinical care.
Moreover, routine imaging techniques are limited in their value of serving as biomarkers of severity or prognosis in the mTBI population, and the extent of incidental magnetic resonance imaging (MRI) findings in mTBI patients also remains unclear. Conventional structural MR imaging is felt to be limited in its yield of disease severity or prognosis. Further research is necessary to investigate the anatomical characteristics of the mTBI population that present to medical attention. Better characterization of the specific abnormalities in anatomic imaging in this population is necessary.
The aim of this study was to incorporate patient history, clinical exams, imaging, and multiple neurological assessments into a prospective longitudinal study of patients presenting with an acute mild traumatic brain injury to provide guidance for hypothesis generation and future study design of mTBI research. Traditional neuropsychological assessments were developed to further attempt to detect abnormalities in patients with mTBI. Although MR imaging is not routinely performed for acute mTBI, recent advances in MRI based techniques have allowed researchers to incorporate imaging into mTBI trials. This study specifically investigated the presence of white matter hyperintensities on structural imaging. This combination of assessments and time points provided a more comprehensive and detailed assessment of symptoms and outcomes of mTBI patients than found in previous studies. This allows for identification of previously elusive potential risk factors which may influence outcome measures for mTBI populations.[…]
Continue —> Frontiers | Clinical Findings in a Multicenter MRI Study of Mild TBI | Neurology
Age, concussion, gender, IMAGING, Mild traumatic Brain Injury, mTBI, neuropsychological assessments, Risk factors, white matter hyperintensities
[Poster] Repetitive Transcranial Magnetic Stimulation (rTMS) application in cognitive deficits after Traumatic Brain Injury (TBI)/concussion
Posted by Kostas Pantremenos in Cognitive Rehabilitation, tDCS/rTMS on May 28, 2018
Objective: The objective of this study is to review current literature for the efficacy of Repetitive Transcranial Magnetic Stimulation (rTMS) treatment for cognitive deficits after Traumatic Brain Injury (TBI)/concussion.
Background: TBI is a major public health problem and can cause substantial disability. TBI can lead to Post Concussive Syndrome (PCS) which consists of neuro-motor, cognitive, behavioral/affective, and emotional symptoms. Cognitive deficits can significantly impact functionality. The outcome of neuropsychopharmacological treatment is limited, with risk for side effects. TMS is a form of non-invasive neuromodulation which is FDA-approved for treatment-resistant depression. However, there is limited understanding about its application in addressing cognitive deficits after TBI. We therefore sought to examine current research pertaining to the application of TMS in post-TBI cognitive deficits.
Methods: We searched the PubMed research database with the specific terms "TMS in cognitive deficits after TBI", "rTMS" and "post concussive syndrome." We assessed clinical trials where cognition was measured either as a primary or secondary variable. Case studies/reports were excluded.
Results: One non-controlled, pilot study was found that assessed cognition after TMS as a secondary variable in TBI. The aim of the study was to assess safety, tolerability and efficacy of repetitive TMS for treatment of PCS after mild TBI (mTBI). Patients who had sustained mTBI over three months prior and had a PCS Symptom Scale score of over 21 were selected. Repetitive TMS (rTMS) was used as the intervention with 20 sessions of rTMS using a figure-8 coil attached to MagPro stimulator. Cognitive symptoms were assessed using subjective self-report scales and objective tests for attention and speed of processing domains. Neuropsychological tests that were used include Trails A & B, Ruff's 2 & 7 Automatic speed test, Stroop test, Language test for phonemic, and category fluency, Rey AVLT test. The study showed a reduction in overall severity of PCS symptoms but no significant changes on the cognitive symptoms questionnaire or on the majority of neuropsychological test scores.
Conclusion: Despite the limitation in this study with the lack of a control group, there appears to be a good signal for the clinical application of TMS for post-concussive syndrome after TBI/concussion. A more robust, large well-controlled study may be very reasonable approach in the future to evaluate efficacy of rTMS.
1. Koski L1, Kolivakis T, Yu C, Chen JK, Delaney S, Ptito A. Noninvasive brain stimulation for persistent postconcussion symptoms in mild traumatic brain injury. J Neurotrauma. 2015 Jan 1;32(1):38-44. https://doi.org/10.1089/neu.2014.3449.
2. Bashir S1, Vernet M, Yoo WK, Mizrahi I, Theoret H, Pascual-Leone A. Changes in cortical plasticity after mild traumatic brain injury. Restor Neurol Neurosci. 2012;30(4):277-82. https://doi.org/10.3233/RNN-2012-110207.
3. Demirtas-Tatlidede A1, Vahabzadeh-Hagh AM, Bernabeu M, Tormos JM, Pascual-Leone A.Noninvasive brain stimulation in traumatic brain injury. J Head Trauma Rehabil. 2012 Jul-Aug;27(4):274-92. https://doi.org/10.1097/HTR.0b013e318217df55.
4. Neville IS, Hayashi CY, El Hajj SA, Zaninotto AL, Sabino JP, Sousa LM Jr, Nagumo MM, Brunoni AR, Shieh BD, Amorim RL, Teixeira MJ, Paiva WS. Repetitive Transcranial Magnetic Stimulation (rTMS) for the cognitive rehabilitation of traumatic brain injury (TBI) victims: study protocol for a randomized controlled trial. Trials. 2015 Oct 5;16:440. https://doi.org/10.1186/s13063-015-0944-2.
via Repetitive Transcranial Magnetic Stimulation (rTMS) application in cognitive deficits after Traumatic Brain Injury (TBI)/concussion – Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation
Cognitive deficits, concussion, repetitive transcranial magnetic stimulation, rTMS, TBI, Traumatic Brain Injury
[WEB SITE] Learning stress-reducing techniques may benefit people with epilepsy
Posted by Kostas Pantremenos in Epilepsy on March 18, 2018
Learning techniques to help manage stress may help people with epilepsy reduce how often they have seizures, according to a study published in the February 14, 2018, online issue of Neurology®, the medical journal of the American Academy of Neurology.
"Despite all the advances we have made with new drugs for epilepsy, at least one-third of people continue to have seizures, so new options are greatly needed," said study author Sheryl R. Haut, MD, of Montefiore Medical Center and the Albert Einstein College of Medicine in the Bronx, NY, and member of the American Academy of Neurology. "Since stress is the most common seizure trigger reported by patients, research into reducing stress could be valuable."
The study involved people with seizures that did not respond well to medication. While all of the 66 participants were taking drugs for seizures, all continued to have at least four seizures during about two months before the study started.
During the three-month treatment period all of the participants met with a psychologist for training on a behavioral technique that they were then asked to practice twice a day, following an audio recording. If they had a day where they had signs that they were likely to have a seizure soon, they were asked to practice the technique another time that day. The participants filled out daily electronic diaries on any seizures, their stress level, and other factors such as sleep and mood.
Half of the participants learned the progressive muscle relaxation technique, a stress reduction method where each muscle set is tensed and relaxed, along with breathing techniques. The other participants were the control group-;they took part in a technique called focused attention. They did similar movements as the other group, but without the muscle relaxation, plus other tasks focusing on attention, such as writing down their activities from the day before. The study was conducted in a blinded fashion so that participants and evaluators were not aware of treatment group assignment.
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Before the study, the researchers had hypothesized that the people doing the muscle relaxing exercises would show more benefits from the study than the people doing the focused attention exercises, but instead they found that both groups showed a benefit-;and the amount of benefit was the same.
The group doing the muscle relaxing exercises had 29 percent fewer seizures during the study than they did before it started, while the focused attention group had 25 percent fewer seizures, which is not a significant difference, Haut said. She added that study participants were highly motivated as was shown by the nearly 85 percent diary completion rate over a five-month period.
"It's possible that the control group received some of the benefits of treatment in the same way as the 'active' group, since they both met with a psychologist and every day monitored their mood, stress levels and other factors, so they may have been better able to recognize symptoms and respond to stress," said Haut. "Either way, the study showed that using stress-reducing techniques can be beneficial for people with difficult-to-treat epilepsy, which is good news."
Haut said more research is needed with larger numbers of people and testing other stress reducing techniques like mindfulness based cognitive therapy to determine how these techniques could help improve quality of life for people with epilepsy.
Source: https://www.aan.com/AAN-Resources/Details/press-room/current-press-release/
via Learning stress-reducing techniques may benefit people with epilepsy
Alzheimer's disease, concussion, Drugs, Epilepsy, Migraine, multiple sclerosis, muscle, neurology, neuroscience, Parkinson's disease, Sclerosis, seizure, sleep, Stress, Stroke
[BLOG POST] Study: Transcranial e-stim beneficial in mild traumatic brain injury
Posted by Kostas Pantremenos in tDCS/rTMS on October 3, 2017
Researchers from the University of California San Diego and from the Veterans Affairs San Diego Healthcare System have improved neural function in a group of people with mild traumatic brain injury using low-impulse electrical stimulation to the brain, according to a study published in Brain Injury.
Although little is understood about the pathology of mild TBI, the team of researchers noted that previous work has shown that passive neuro-feedback, low-intensity pulses applied to the brain through transcranial electrical stimulation, has promise as a potential treatment.
The team's pilot study enrolled six people with mild TBI who were experiencing post-concussion symptoms. Researchers used a form of LIP-tES combined with concurrent electroencephalography monitoring and assessed the treatment's effect using a non-invasive functional imaging technique, magnetoencephalography, before and after treatment.
"Our previous publications have shown that MEG detection of abnormal brain slow-waves is one of the most sensitive biomarkers for mild traumatic brain injury (concussions), with about 85 percent sensitivity in detecting concussions and, essentially, no false-positives in normal patients," senior author Dr. Roland Lee said in prepared remarks. "This makes it an ideal technique to monitor the effects of concussion treatments such as LIP-tES."
Researchers reported that the brains in all six patients had abnormal slow-waves at the time of initial scans. After treatment, MEG scans showed reduced abnormal slow-waves and the study participants reported a significant reduction in post-concussion scores.
"For the first time, we've been able to document with neuroimaging the effects of LIP-tES treatment on brain functioning in mild TBI," first author Ming-Xiong Huang added. "It's a small study, which certainly must be expanded, but it suggests new potential for effectively speeding the healing process in mild traumatic brain injuries."
Source: Study: Transcranial e-stim beneficial in mild traumatic brain injury – MassDevice
concussion, electroencephalography, LIP-tES, magnetoencephalography, Mild traumatic Brain Injury, mTBI, tDCS
[WEB SITE] TBI Basics – BrainLine
Posted by Kostas Pantremenos in Caregivers, TBI on August 29, 2017
A TBI can happen to anyone, whether it happens while playing sports, at work, or just slipping on an icy sidewalk. Injuries can range from "mild" to "severe", with a majority of cases being concussions or mild TBI. The good news is that most cases are treatable and there are several ways to help prevent injury.
What You'll Find Here
Interactive Brain
Take an interactive journey to see how the brain works and what impact an injury can have
Read more about Interactive Brain
What Is a TBI?
Top resources about brain injury, the types of brain injury, brain anatomy, and TBI statistics.
Read more about What Is a TBI?
Do I Have a Concussion?
When to go to the hospital, what to expect at the ER, and common tests and procedures.
Read more about Do I Have a Concussion?
Newly Diagnosed. Now What?
Our best resources for starting down the road to recovery and rehabilitation.
Read more about Newly Diagnosed. Now What?
See how others are navigating their post-TBI lives. Check out personal stories and "life after TBI" blogs, or join the conversation with our Facebook community.
Source: TBI Basics | BrainLine
brain injury, concussion, TBI
[WEB SITE] 9 1/2 Need-to-Know Facts About Traumatic Brain Injury
Posted by Kostas Pantremenos in Educational on June 25, 2017
An estimated 5.3 million Americans — about 2 percent of the U.S. population — currently have a long-term or lifelong need for help with everyday activities due to traumatic brain injury (TBI). (1) Many believe this number to be low as it only takes into account the number of reported injuries to hospital emergency rooms and by health care professionals. We've compiled the top 9 1/2 things to know about traumatic brain injury, it would have been 10 but the last 1/2 was left off because memory is often affected by traumatic brain injury.
Learn why prevention is crucial when it comes to kids. Dr. James Kelly Talks About Children, Helmets, and Concussion
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A traumatic brain injury is a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. You do not need to lose consciousness to sustain a concussion.
1.7 million people sustain a TBI each year in the United States. By the numbers, every American has more than a 1:300 chance of sustaining a traumatic brain injury each year. (2)
The three groups at highest risk for traumatic brain injury are children (0-4 year olds), teenagers (15-19 year olds), and adults (65 and older). (2)
Estimates peg the number of sports-related traumatic brain injuries as high as 3.8 million per year. (2)
Using a seatbelt and wearing a helmet are the best ways to prevent a TBI.
Males are almost twice as likely as females to sustain a TBI.
A concussion is a mild brain injury. The consequences of multiple concussions can be far more dangerous than those of a first TBI. (3)
The area most often injured are the frontal lobes that control thinking and emotional regulation.
A blow to one part of the brain can cause damage throughout.
9 1/2. Most people do make a good recovery from TBI.
If you found this useful, please share with family and friends or leave a comment below if you think we've left something off.
Centers for Disease Control. http://www.cdc.gov/traumaticbraininjury/pdf/BlueBook_factsheet-a.pdf
Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006.
Cifu, David, MD. eMedicine.com. www.emedicine.com/sports/TOPIC113.HTM.
Source: 9 1/2 Need-to-Know Facts About Traumatic Brain Injury
concussion, TBI, Traumatic Brain Injury
[ARTICLE] Role of Interleukin-10 in Acute Brain Injuries – Full Text
Posted by Kostas Pantremenos in Pharmacological on June 19, 2017
Interleukin-10 (IL-10) is an important anti-inflammatory cytokine expressed in response to brain injury, where it facilitates the resolution of inflammatory cascades, which if prolonged causes secondary brain damage. Here, we comprehensively review the current knowledge regarding the role of IL-10 in modulating outcomes following acute brain injury, including traumatic brain injury (TBI) and the various stroke subtypes. The vascular endothelium is closely tied to the pathophysiology of these neurological disorders and research has demonstrated clear vascular endothelial protective properties for IL-10. In vitro and in vivo models of ischemic stroke have convincingly directly and indirectly shown IL-10-mediated neuroprotection; although clinically, the role of IL-10 in predicting risk and outcomes is less clear. Comparatively, conclusive studies investigating the contribution of IL-10 in subarachnoid hemorrhage are lacking. Weak indirect evidence supporting the protective role of IL-10 in preclinical models of intracerebral hemorrhage exists; however, in the limited number of clinical studies, higher IL-10 levels seen post-ictus have been associated with worse outcomes. Similarly, preclinical TBI models have suggested a neuroprotective role for IL-10; although, controversy exists among the several clinical studies. In summary, while IL-10 is consistently elevated following acute brain injury, the effect of IL-10 appears to be pathology dependent, and preclinical and clinical studies often paradoxically yield opposite results. The pronounced and potent effects of IL-10 in the resolution of inflammation and inconsistency in the literature regarding the contribution of IL-10 in the setting of acute brain injury warrant further rigorously controlled and targeted investigation.
Stroke and traumatic brain injury (TBI) are devastating acute neurological disorders that can result in high mortality rates or long-lasting disability. Approximately 87% of strokes are ischemic and 13% are hemorrhagic, with 10 and 3% of the latter representing intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), respectively (1). Stroke is the fourth most common cause of death in the United States, and ischemic stroke (IS) in particular is the seventh most frequent emergency department presentation (2, 3). TBI and concussions have over twice the incidence of all strokes combined (4), with more than three million people in the United States alone living with long-term disability as a result of TBI (5). Collectively, stroke and TBI have very few treatments, and despite advances in clinical management of these disorders, they are still associated with significant disability and mortality (6, 7).
Inflammation plays a central role in the pathophysiology of stroke and TBI and can have both protective and harmful effects on brain tissue (8–15). Although there are some distinct differences in the inflammatory cascades following the various types of acute brain injury, there are also numerous commonalities. Acute neuroinflammation is characterized by the activation of resident central nervous system (CNS) immune surveillance glial cells that release cytokines, chemokines, and other immunologic mediators, which facilitate the recruitment of peripheral cells such as monocytes, neutrophils, and lymphocytes (8, 9, 12, 15). Collectively, this initial response is helpful in the clearance of toxic entities and the restoration and repair of damaged tissue. However, during the resolution phase, with an uncontrolled and prolonged inflammatory response, secondary damage results from overactivation of this inflammatory surge and release of additional factors that led to breakdown of the blood–brain barrier (BBB), cerebral edema, cerebral hypertension, and ischemia.
Interleukin-10 is generally known as an anti-inflammatory cytokine that exerts a plethora of immunomodulatory functions during an inflammatory response and is particularly important during the resolution phase. Expression of IL-10 in the brain increases with CNS pathology, promoting neuronal and glial cell survival, and dampening of inflammatory responses via a number of signaling pathways (16). IL-10 was originally described as cytokine synthesis inhibitory factor and in addition to attenuating the synthesis of proinflammatory cytokines, IL-10 also limits inflammation by reducing cytokine receptor expression and inhibiting receptor activation (16). Furthermore, IL-10 has potent and diverse effects on essentially all hematopoetic cells that infiltrate the brain following injury. For example, IL-10 reduces the activation and effector functions of T cells, monocytes, and macrophages, ultimately ending the inflammatory response to injury (17). The structure, function, and regulation of IL-10 have been extensively reviewed elsewhere, including a review of IL-10 in the brain (16–20), although not in the context of the various forms of acute brain injury. Please refer to the aforementioned reviews for additional details, including the potential cellular sources, target cells, signal transduction, and mode of action of IL-10.
Given the intriguing multifactorial role of IL-10 in the resolution of inflammatory cascades that are important for promoting neurologic recovery from acute brain injury, here we present a comprehensive literature review of preclinical and clinical studies in this area. We focus on the contribution of IL-10 in modulating various important parameters and pathophysiologic processes important for IS, SAH, ICH, and TBI outcomes, and whether IL-10 has therapeutic or biomarker potential. A better understanding of the many functions of IL-10 in the brain after injury, particularly in the resolution phase of inflammatory processes, will promote our knowledge of the pathophysiology of these debilitating disorders and guide future development of novel therapeutic approaches.[…]
Continue —> Frontiers | Role of Interleukin-10 in Acute Brain Injuries | Neurology
concussion, endothelium, intracerebral hemorrhage, Ischemia, Stroke, subarachnoid hemorrhage, Traumatic Brain Injury, vasculature


text:
Home Affairs to open refugee office in Maitland
New applicants to be served in Cape Town again
26 January 2019 - 10:14 By Tariro Washinyira
Queues at the Department of Home Affairs on the Foreshore. A new refugee office is to be opened in Maitland.
Image: Tariro Washinyira
The Department of Home Affairs intends to open the new Cape Town Refugee Reception Office in June 2019 on new premises in Maitland.
In a progress report to the Legal Resources Centre (LRC), Home Affairs said vacant land in Maitland had been identified by the Department of Public Works and the proposed date of occupation of the office was 1 June 2019.
Home Affairs decided in 2012 to stop processing new applicants at the Cape Town Refugee Reception Office.
In a judgment on 30 August 2012, the Western Cape High Court ordered Cape Town Home Affairs to start serving new applicants again. The judge said the cost to Home Affairs of assisting newcomers was negligible compared to the harm done to them.
He said that delaying implementation of the court order would cause grievous harm to asylum seekers. While undocumented, they would be subject to arrest and deportation.
But the office was not re-opened. The LRC took Home Affairs to court on behalf of the Scalabrini Centre and the Somali Association, and in September 2017 the Supreme Court of Appeal ruled that Home Affairs must "reopen and maintain a fully functional refugee reception office in or around the Cape Town Metropolitan Municipality, by Friday 31 March 2018." Home Affairs sought leave to appeal from the Constitutional Court but this was refused. This means the SCA ruling is final.
Asked to confirm the opening of the new office in Maitland, a Home Affairs spokesperson referred GroundUp to the Department of Public Works. Contacted on 21 January, Public Works spokesperson Lunga Mahlangu promised to respond but had not done so at the time of publication.
This article was first published in GroundUP.

redpajama_set_name: RedPajamaCommonCrawl


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text:
\section{Introduction}

The International Monetary Fund (IMF) was formed in 1944 at the Bretton Woods Conference. Currently
this international organization consists of 188 countries as members. Its highest decision-making body,
i.e., the \emph{Board of Governors},  makes its decisions by weighted voting. The weights are
composed of \emph{basic votes}, which are equal for each member and sum up to 5.502 percent of the total
votes, and one additional vote for each Special Drawing Right (SDR) of 100,000 of a member country's quota
(the IMF term for the country's financial stake, c.f.~\cite{leech2013new}). On January 26, 2016, the
conditions for the SDRs were increased at the Board Reform Amendment, which drastically changed the
corresponding voting weights. In general the weight of a country can be a poor proxy for its influence
in a weighted voting game.\footnote{Consider, e.g., a committee, where the weight shares are 49\%, 49\%,
and 2\%. For simple majority a least two out of the three committee members are needed in order to push
through a proposal, i.e., the influences are equal contrary to the voting weights.} To this
end, so-called power indices were introduced in order to measure the \emph{influence} or \emph{power}
of a committee member in a committee making its decisions via binary voting, i.e., each member can say
{\lq\lq}yes{\rq\rq} or {\lq\lq}no{\rq\rq} to a given proposal. As the idea of power and influence
is not defined unambiguously, several power indices were introduced in the literature. Arguably, the
Shapley-Shubik and the Banzhaf index are two of the most frequently applied power indices.
Unfortunately, the
evaluation of such a power index is a computational hard problem in general.\footnote{To be more precise,
the computation of the power indices treated in this paper is NP-hard in the sense of computational complexity
theory. We give a brief justification at the end of Section~\ref{sec_preliminaries}.} And indeed, we are not aware of
any paper, where either the Shapley-Shubik or the Banzhaf index of the IMF Board of Governors has been computed
exactly.  Approximation procedures were applied in \cite{leechms, leech2013new}. The \emph{Executive Board} was, e.g., studied
in \cite{aleskerov2008actual}. In this paper we will compute the exact numerical values of both
 power indices for the IMF Board of Governors corresponding to voting weights slightly after and before
the meeting on January 26, 2016. As the quota and voting shares will change as members pay their quota
increases, see \url{https://www.imf.org/external/np/sec/memdir/members.aspx}, we list the used voting weights
in tables~\ref{table_voting_weights_part1}-\ref{table_voting_weights_part4}.\footnote{The voting weights
were accessed at the official website \url{https://www.imf.org/external/np/sec/memdir/members.aspx}. The numbers
were retrieved on February 17, 2016 and on July 27, 2015, respectively.}

Algorithms for the efficient computation of power indices in voting games have been studied extensively
in the literature. By looping over all $2^n$ subsets of players, the Shapley-Shubik index of a fixed
player can be easily computed in $O(n\cdot 2^n)$ time. The straight-forward computation of the Banzhaf
index of a fixed player can be performed in $O(n^2\cdot 2^n)$ time. For weighted voting games these
computation complexities were reduced to $O\!\left(n\cdot \sqrt{2}^{\,n}\right)$ and $O\!\left(n^2\cdot \sqrt{2}^{\,n}\right)$ in
\cite{klinz2005faster}, respectively. Assuming that all weights are integers and taking the sum of voting
weights $C$ into account, more refined complexity results can be obtained. Several algorithms based on
generating functions were implemented in \texttt{Mathematica}, see \cite{tannenbaum1997power}. Those algorithms
are fast if the subsets of players attain only few different weight sums. The number of different weight sums
is clearly upper bounded by $C+1$. If almost all possible weight sums are attained, then one can use the related
but conceptually easier concept of dynamic programming, see \cite{matsui2000survey} for a survey.\footnote{Actually, the
only difference between the generating function and the dynamic programming approach is that the former
utilizes the fast-access data structures for polynomials with few coefficients implemented in computer algebra systems. The
generating function approach dates back at least to \cite{mann1962values}, where it was applied onto the
electoral college.}
With this, the Shapley-Shubik index of fixed player can be determined in $O(n^2 q)$ time and $O(nq)$ space, where
$q\le C$ denotes the \emph{quota} of a weighted voting game. The Banzhaf index of a fixed player can be computed
in $O(nq)$ time and $O(q)$ space. In \cite{uno2012efficient} these complexity bounds are maintained for the computation
of the respective power indices for all $n$ players. We slightly improve upon these complexity bounds by replacing
$q$ by $\min(q,C-q+1),$\footnote{For the IMF Board of Governors we have $q=0.85\cdot C$, so that we obtain an acceleration
of a factor of $0.85/0.15\approx 5.67$. The memory requirements are reduced by the same factor.} provide an easy to
understand description, and extend the analysis to further power indices. For practical efficiency we go into low-level
details of the algorithms and discuss their impact on the running time for the IMF example.

The remaining part of this paper is structured as follows. In Section~\ref{sec_preliminaries} we briefly introduce
simple games as models for voting systems and some related notation.
After introducing the defining equations for the power indices, we
consider algorithms for their computation in Section~\ref{sec_algorithms}. These are essentially based on counting the number
of coalitions per weights and size by dynamic programming techniques. After stating our computational results in
Subsection~\ref{subsec_computational_results} we draw a conclusion in Section~\ref{sec_conclusion}.
The weights of the considered voting games and the resulting power distributions are outsourced into an appendix due to their
large size.

\section{Preliminaries}
\label{sec_preliminaries}
Let $N=\{1,\dots,n\}$ be the set of players. A \emph{simple game} (on $N$) is a mapping $v:2^N\rightarrow\{0,1\}$
with $v(\emptyset)=0$, $v(N)=1$, and $v(S)\le v(T)$ for all $\emptyset\subseteq S\subseteq T\subseteq N$. A subset
$S\subseteq N$ is called \emph{coalition} and
represents the set of {\lq\lq}yes{\rq\rq}-voters. A coalition
$S$ is called \emph{winning} if $v(S)=1$ and \emph{losing} otherwise.
A simple game
$v$ is \emph{weighted} if there exist $q,w_1,\dots,w_n\in\mathbb{R}_{\ge 0}$ such that $v(S)=1$ iff $w(S)\ge q$
for all $S\subseteq N$, where $w(S):=\sum_{i\in S} w_i$. The $w_i$ are called \emph{weights} (for player~$i$) and
$q$ is called \emph{quota}. We write $v=[q;w_1,\dots,w_n]$ and remark that weights and quota are far from being unique, so that
we speak of a representation $(q,w)$ for $v$. A representation with $q\in \mathbb{N}$, $w\in\mathbb{N}_{\ge 0}^n$ is
called \emph{integer representation}. It is well known that each weighted game admits an integer
representation.\footnote{Let $(q,w)$ be a representation of $v$, let $\alpha$ the maximum weight of losing
coalition and $\beta$ the minimum weight of a winning coalition. Increase the weights by at most $(\beta-\alpha)/2n>0$
so that they become rational numbers. As quota chose an arbitrary rational number strictly between the
new minimum weight of a winning coalition and the new maximum weight of a losing coalition. Multiplication with the
common denominator yields an integer representation of $v$.} We speak of a \emph{minimum sum integer representation}
if the sum of weights is minimized within the class of all integer representations. Those representations need
not to be unique in general if the number of players is not too small, see e.g.~\cite{kurz2012minimum}.
If $v(S\cup\{i\})\ge v(S\cup\{j\})$ for all
$S\subseteq N\backslash \{i,j\}$ we write $i\succeq j$, which defines a partial order.  If this ordering is complete
we call the simple game $v$ \emph{complete} and remark that all weighted games are complete.
A player $i\in N$ is
called a \emph{null player} (in a simple game $v$), iff $v(S)=v(S\cup\{i\})$ for all $S\subseteq N\backslash\{i\}$.
Two players $i,j\in n$ are called \emph{equivalent}, denoted as $i\sim j$, if $i\succeq j$ and $j\succeq i$. If each
winning coalition contains a certain player $i$, she is called \emph{veto player}.

Next we briefly introduce the used power indices.
The \emph{Shapley-Shubik} index of player $i$ is given by
\begin{equation}
  \label{eq_ssi}
  \operatorname{SSI}_i(v)=\frac{1}{n!}\cdot \sum_{S\subseteq N\backslash\{i\}} |S|!\cdot (n-|S|-1)!\cdot(v(S\cup\{i\})-v(S)).
\end{equation}
The \emph{absolute Banzhaf index} of player $i$ is given by
\begin{equation}
  \label{eq_absolute_bz}
  \operatorname{Bz}_i^{\text{a}}(v)=\frac{1}{2^{n-1}}\cdot \sum_{S\subseteq N\backslash\{i\}} v(S\cup\{i\})-v(S).
\end{equation}
If we call a coalition $S\subseteq N\backslash\{i\}$ an \emph{$i$-swing} if $S$ is losing and $S\cup\{i\}$ winning, then
$\operatorname{Bz}_i(v)$ is equal to the number of $i$-swings divided by the number of coalitions with(out) player~$i$.
Normalizing to sum $1$, we obtain the (relative) \emph{Banzhaf index} of player~$i$:
\begin{equation}
  \label{eq_bz}
  \operatorname{Bz}_i(v)=\operatorname{Bz}_i^{\text{a}}(v) / \sum_{j=1}^n \operatorname{Bz}_j^{\text{a}}(v).
\end{equation}

The two power indices have the property that they sum up to one and assign a value of zero to a player if and only
if she is a null player. Since it is NP-hard to decide whether a player is a null player in a given weighted game, see
e.g.~\cite{chalkiadakis2011computational}, the computation of the used power indices is at least NP-hard. We remark that
the equivalent players attain the same Shapley-Shubik or Banzhaf index.

\section{Algorithms}
\label{sec_algorithms}

Assume that we have a weighted game $v=[q;w]$ on $n$ players in integer representation, where we set $C=\sum_{i=1}^n w_i$.
As the complexity of our subsequent algorithms will depend on $\Delta:=\min(q,C-q+1)$ it would be beneficial to have a minimum
sum integer representation at hand. However, it is not clear if minimizing the integer representation pays off
for the computation of power indices, c.f.~\cite{mostly_sunny}, where this is proposed as a promising strategy. So, here we
propose to perform the following computationally cheap preprocessing steps at the very least. At first we reduce the weights that
are larger then the quota by setting $q'=q$ and $w_i'=\min(q,w_i)$ for all $i\in N$. Next we guarantee that the weights are not
too much larger than $C-q$. If $w_i>C-q$, then player $i$ is a vetoer and we set $w_i'=C-q+1$, $q'=q-w_i+w_i'$, and $w_j'=w_j$
for all $j\in N\backslash\{i\}$. Both operations can be performed in $O(n)$. The power indices used in this paper do not
only assign zero power to all null players but are \emph{null player preserving}, i.e., if $v'$ arises from $v$ by adding
null player $i$, then we have $\mathcal{P}_j(v')=\mathcal{P}_j(v)$ for all $j\neq i$. Nevertheless, it is NP-hard to detect
null players we can efficiently remove players with a zero weight, so that we can assume $1\le w_i\le \Delta$
in the following, i.e., we have $C\ge n$.

In the following subsections we present the algorithmic details how to compute the power indices efficiently.

\subsection{Counting coalitions per weight}
\label{subsec_coalitions_per_weight}
Let $c(x)$ denote the number of coalitions of a given weighted game $v$ attaining weight $x$. By
Algorithm~\ref{alg:coalitions_per_weight_forward} we can compute $c(x)$ for all $0\le x\le q$ in
$O(nq)$ time and $O(q+n)$ space, where we assume that we have precomputed the terms $\min\{q,\sum_{j=1}^i w_j\}$
for all $i\in N$.

\begin{algorithm}[htp]
\SetAlgoNoLine
\KwIn{$q$, $w$, $n$}
\KwOut{$c(x)$ for $0\le x\le q$}
$c(0)\gets 1$\;
\For{$1\le x\le q$}{
    $c(x)\gets 0$\;
    }
\For{$i$ from $1$ to $n$}{
   \For{$x$ from $\min\{q,\sum_{j=1}^i w_j\}$ to $w_i$}{
       $c(x)\gets c(x)+c(x-w_i)$\;
       }
   }
\caption{Forward counting of coalitions per weight}
\label{alg:coalitions_per_weight_forward}
\end{algorithm}

Similarly we can compute the respective counts starting from weight $C$, see Algorithm~\ref{alg:coalitions_per_weight_backward}
that needs $O(n\cdot(C-q+1))$ time and $O(C-q+1+n)$ space.

\begin{algorithm}[htp]
\SetAlgoNoLine
\KwIn{$q$, $w$, $n$}
\KwOut{$c(x)$ for $q\le x\le C$}
$c(C)\gets 1$\;
\For{$q\le x\le C-1$}{
    $c(x)\gets 0$\;
    }
\For{$i$ from $1$ to $n$}{
   \For{$x$ from $\max\{q+w_i,C-\sum_{j=1}^{i-1} w_j\}$ to $C$}{
       $c(x-w_i)\gets c(x)+c(x-w_i)$\;
       }
   }
\caption{Backward counting of coalitions per weight}
\label{alg:coalitions_per_weight_backward}
\end{algorithm}

For the ease of notation we assume that the basic arithmetic operations for integers not too much larger than $C$ can be performed
in $O(1)$ time and space. However, the values stored in $c(x)$ can grow very quickly, i.e., we have
$2^n\ge \max_{0\le x\le C} c(x)\ge 2^n/(C+1)$. So, we should count $\Theta(n)$ for each addition or subtraction. To avoid
technical complications in the exposition and in order to be comparable with the related literature we also assume that all
basic arithmetic operations for integers can be performed in constant time. From a practical point of view we have to deal with
the corresponding problems nevertheless. In our application of the IMF we have $n=188$, so that the values of $c(x)$ do not fit
into the  standard, simple data types on a 64-bit system. Since the overhead of a general-purpose arbitrary-precision arithmetic
is quite large, we directly implement the most frequently used  basic operations as follows. We choose different primes $p_1,\dots, p_l$,
such that all occurring numbers are between $0$ and $-1+\prod_{i=1}^l p_i$. During the computation we perform all basic operations modulo $p_i$
for all $1\le i\le l$. For the final result we can recover the real integers behind by applying the Chinese remainder theorem. For
our example of the IMF we choose $l=3$, $p_1=2^{63}-25$, $p_2=2^{63}-165$, and $p_3=2^{63}-259$.\footnote{Choosing primes of the form
$2^{63}-x$ for small $x$, has the advantage that the computations can be performed using the standard, simple data type \texttt{unsigned long}
in \texttt{C++}. Our choices are indeed the largest possibilities, see e.g.\ \url{https://primes.utm.edu/lists/2small/0bit.html}. We remark that
a na\"{\i}ve checking of the primality of the $p_i$ was performed in $41$~seconds. We implement $a=b+c\,\operatorname{mod}\,p$ as $a=b+c$ and
$\operatorname{if}\,a\ge p\,\operatorname{then}\,a-=p$.}

The number of losing coalitions is given by $\sum_{x=0}^{q-1} c(x)$ and the number of winning coalitions is given by
$\sum_{x=q}^{C} c(x)$. Since the total number of coalitions is $2^n$, both numbers can be determined in $O(n\Delta)$ time and $O(\Delta+n)$ space.

For the computation of the Banzhaf index we need to know either the number $c^w(x)$ of coalitions with weight sum $x$ that contain player~$i$
or the number $c^{wo}(x)$ of coalitions with weight sum $x$ that do not contain player $i$. For a fixed player $i$ we set
$c^{wo}(x)=0$ for $0\le x<w_i$. By looping from $w_i$ to $q-1$ we can recursively compute $c^{wo}(x)=c(x)-c^{wo}(x-w_i)$, so that
$\operatorname{Bz}_i^a (v)=\frac{1}{2^{n-1}} \sum_{x=q-w_i}^{q-1} c^{wo}(x)$. Alternatively, we set $c^w(x)=c(x)$ for all $C-w_i<x\le C$ and
recursively compute $c^w(x)=c(x)-c^w(x+w_i)$ by looping from $C-w_i$ to $q$, so that $\operatorname{Bz}_i^a (v)=\frac{1}{2^{n-1}}
\sum_{x=q}^{q+w_i-1} c^{w}(x)$.
\begin{Theorem}
  The number of winning, losing coalitions and the Banzhaf indices of all players of a weighted game $v$ can be
  computed in $O(n\Delta)$ time and $O(\Delta+n)$ space.
\end{Theorem}

\subsection{Counting coalitions per weight and size}
\label{subsec_coalitions_per_weight_and_size}
By $c(x,s)$ we denote the number of coalitions of weight $x$ and cardinality $s$ (for a given weighted game $v$).
Algorithm~\ref{alg:coalitions_per_weight_forward} and Algorithm~\ref{alg:coalitions_per_weight_backward} can be
easily adopted to this end. The running time and the memory requirements both increase by a factor of $n$, since
$0\le s\le n$. We remark $c(x,s)=0$ for $x>\sum_{j=1}^s w_j$ or $x<\sum_{j=n-s+1}^n w_j$, assuming
$w_1\ge \dots\ge w_n$.\footnote{The players can be sorted in $O(n+\Delta)$ time and space in a preprocessing step.}
These known values can be taken into account in the boundaries of the for-loops to save time and memory.  By extending the
definition and recursion for $c^{wo}(x)$, $c^{w}(x)$ to $c^{wo}(x,s)$, $c^{w}(x,s)$, we can state
$$
  \operatorname{SSI}_i(v)=\sum_{s=0}^{n-1} s!(n-s-1)!\cdot \!\!\!\sum_{x=q-w_i}^{q-1} c^{wo}(x,s)
\text{ and }
  \operatorname{SSI}_i(v)=\sum_{s=0}^{n-1} s!(n-s-1)!\cdot \!\!\!\sum_{x=q}^{q+w_i-1} c^{w}(x,s+1).
$$
Of course we can precompute the factorials and the product of the $n-1$ pairs of factorials.
In our fixed-precision arithmetic we first compute the sums over the $c^{wo}$ or $c^w$ and then
switch to arbitrary-precision arithmetic.\footnote{We remark $s!(n-s-1)!< 2^{n\log_2 n}$ for $n>1$.}

\begin{Theorem}
  The $\operatorname{SSI}$ indices of all players of a weighted game $v$ can be
  computed in $O(n^2\Delta)$ time and $O(n\Delta)$ space.
\end{Theorem}

\subsection{Intersections of weighted games}
Some real-world voting systems are expressed as the intersection of, say $k$, weighted voting games $v_1,\dots,v_k$, i.e.,
a coalition is winning if and only if it is winning in all sub-games $v_1,\dots,v_k$. Let $C_1,\dots,C_k$ be the weights sums
and $q_1,\dots,q_k$ be the quotas of the sub-games. By easily extending our counting functions $c(x)$ and $c(x,s)$ to
$c(x_1,\dots,x_k)$ and $c(x_1,\dots,x_k,s)$ we can go along the same lines as in the previous two subsections and
obtain algorithms with the same complexity bounds if we formally set $\Delta=\min\left\{ \prod_{i=1}^k q_i,\prod_{i=1}^k C_i-q_i+1\right\}$.
This number may grow very quickly even for moderate values of $k$, so that it may be crucial to choose a representation with a small
number $k$ of sub-games. We remark that the smallest possible integer $k$ (for a simple game) is called \emph{dimension}.

\subsection{Computational results}
\label{subsec_computational_results}
We have applied the described algorithms for the four weighted voting games arising from the two different sets of voting weights
of the IMF in 2015 and 2016, see tables~\ref{table_voting_weights_part1}-\ref{table_voting_weights_part4}, and quotas of either
85\% or 50\% of the respective weight sums.\footnote{According to the \textit{type} of the decision different values for $q$ are
used, see e.g.~\cite{leech2013new}.
All computations were performed on an Intel(R) Core(TM) i7-3720QM cpu with a clock speed of 2.60~GHz and 8~GB RAM. As a a general-purpose
programming language we have chosen C++ and used the CLN-library\footnote{CLN - Class Library for Numbers, available at
\url{http://www.ginac.de/CLN}.} for the arbitrary-precision arithmetic parts.

For 2016 and super-majority, i.e., $q=85\%$, Algorithm 1 needed 4.73 seconds and Algorithm 2 needed 0.67 seconds. The acceleration factor
for using the described tailored fixed-precision arithmetic over an arbitrary-precision arithmetic is slightly larger than $6$. Using
pointers instead of the STL class \texttt{vector} results in a speed-up of roughly $2$. The number of winning coalitions
is given by 4506727722110247822679513808100007271801182981184082. The entire Banzhaf computation, based on Algorithm 2,
for all players was performed in less than 3~seconds. The corresponding SSI computation took less than 7~minutes.

We have listed the power distributions for the years 2015 and 2016, the cases of super-majority and simple majority, the power indices
$\operatorname{Bz}$ and $\operatorname{SSI}$ in tables~\ref{table_voting_power_part1}-\ref{table_voting_power_part4} using a precision of
five decimal digits for the output. The power of a few countries seem to coincide, which is a numerical artefact, except for France ($i=58$)
and the United Kingdom ($i=179$). To be more precise, those two countries have the same weights in both 2015 and 2016, so that they are equivalent
for all values of the quota $q$. For super-majority and simple majority all other countries are inequivalent, which may be seen at the
exact values of either the Banzhaf or the Shapley-Shubik index. We have written out the exact integers $\operatorname{Bz}_i^a$ for the super-majority
case in tables~\ref{table_exact_bz_85_part1}-\ref{table_exact_bz_85_part4}. As predicted  by theory, all values have the same parity. For
the exact values of $n!\cdot \operatorname{SSI}_i$ we
have
\begin{eqnarray*}
  &\!\!\!& 7943491105336407342763365681397386123932473437094983074178260503548102866231696606 \\
  &\!\!\!& 6280159129991609891845042632480167905404863728522082305141284091873293991567044167 \\
  &\!\!\!& 8913841818287049871073575292808579836984419649634709080444217051613536750323984357 \\
  &\!\!\!& 7219072966973233208480541488235675648000000000000000000000000000000000000000000
\end{eqnarray*}
as an example for the United States in 2015 in the super-majority case. The remaining exact values can
be obtained from the author upon request.

Having a closer look at the different power distributions we observe that the choice of the power index or the quota as well as the
modified weights have a significant impact. The dominance of the United states has further increased from 2015 to 2016. Interestingly enough,
the Banzhaf power in the super-majority cases shows almost no difference to, e.g., Japan, which is different for the Shapley-Shubik index.
To obtain a more complete, but still compact, overview about the differences we have introduced
$\Delta P_y^q(I):=\sum_{i\in I} \left|\operatorname{Bz}_i(v_y^q)-\operatorname{SSI}_i(v_y^q)\right|$,
$\Delta \operatorname{Bz}^q(I):=\sum_{i\in I} \left|\operatorname{Bz}_i(v_{2015}^q)-\operatorname{Bz}_i(v_{2016}^q)\right|$, and
$\Delta \operatorname{SSI}^q(I):=\sum_{i\in I} \left|\operatorname{SSI}_i(v_{2015}^q)-\operatorname{SSI}_i(v_{2016}^q)\right|$,
where $q\in \{85\%,50\%\}$, $y\in\{2015,2016\}$, and $v_y^q$ denotes the corresponding weighted game of the IMF. We evaluate
those values on the entire set of countries $N$ and on all countries except the biggest five (United States, Japan, Germany, France,
United Kingdom) $\underline{N}$, see Table~\ref{table_differences}.

\begin{table}[htp!]
  \caption{Differences in power between years and power indices}{
  \begin{tabular}{rrrrrrrrr}
\hline
  set of countries $I$ & $\Delta P_{2015}^{85\%}$ & $\Delta P_{2016}^{85\%}$ & $\Delta \operatorname{Bz}^{85\%}$ & $\Delta \operatorname{SSI}^{85\%}$
  & $\Delta P_{2015}^{50\%}$ & $\Delta P_{2016}^{50\%}$ & $\Delta \operatorname{Bz}^{50\%}$ & $\Delta \operatorname{SSI}^{50\%}$ \\
\hline
$N$  & 54.33\% &         51.98\% &         19.90\% &         27.00\% &         9.46\% &         32.21\% &         46.52\% &       34.68\% \\
$\underline{N}$ & 28.48\% &         26.17\% &         18.45\% &         17.67\% &         2.68\% &         9.70\% &         18.35\% &        18.00\% \\
\hline
  \end{tabular}}
  \label{table_differences}
\end{table}

The stated running times can be easily extrapolated to other examples. If we assume a hypothetical IMF consisting of 1000 members whose weights
are of similar magnitude as in the 2016 example, then both $n$ and $\Delta$ increase by a factor of $1000/188$. Instead of three primes we would need
16 primes, so that the computation of the Banzhaf indices in the super-majority case would took approximately 8 minutes while
the SSI indices may be computed in 4 days.\footnote{In the latter case the memory requirements might become a serious issue if the computations
for the different primes are not performed consecutively. Computing the intermediate results for each prime in parallel is the better
option anyway. Using 16 computers (or cores) the mentioned times reduce to seconds and less than 7 hours, respectively.}

\begin{figure}[htp!]
\begin{center}
  \caption{Banzhaf power distribution of the IMF in 2015 for the five largest countries with variable quota}
  \label{fig_bz_2015_q}
  \includegraphics[width=12cm]{bz_2015_q.pdf}
\end{center}
\end{figure}

The minuscule running time for the Banzhaf index obviously allows more sophisticated applications where the power index computation is performed
several times. Trying to heuristically solve the inverse power index problem, where weights need to be found whose power distribution is close
to a given target distribution, is just an example. Here we have computed the Banzhaf power distribution of the IMF when the quota changes
from 0\% to 100\% in steps of 0.1\%, i.e., 1001 evaluations have been performed, as another possible application. In
figures~\ref{fig_bz_2015_q}-\ref{fig_bz_2016_q} we have depicted the corresponding power for the five most powerful countries
(United States $i=180$, Japan $i=82$, Germany $i=62$, France $i=58$, United Kingdom $i=179$). We can see that the respective Banzhaf indices
are rather volatile with respect to changes of the quota. The difference between the respective Banzhaf power shares is negligible for
Japan and Germany, while there is no difference between France and the United Kingdom, for all values of the quota $q$. For an extreme
quota of 0\% or 100\% all countries obtain exactly the same Banzhaf power share. For quotas
below 15\% or above 85\% there is almost no difference in power for the five largest countries. However, there is a critical interval,
say $q$ between 25\% and 75\%, where the relative power distribution between the five largest countries is very sensitive to changes of the quota.
The United States most intensive benefit from quotas around 50\%. In 2016 also the Banzhaf power share of Japan is very sensitive to changes
of the quota. Instead of 50\% a quota of roughly 65\% would be rather favorable for them.

\begin{figure}[htp!]
\begin{center}
  \caption{Banzhaf power distribution of the IMF in 2016 for the five largest countries with variable quota}
  \label{fig_bz_2016_q}
  \includegraphics[width=12cm]{bz_2016_q.pdf}
\end{center}
\end{figure}

\section{Conclusions}
\label{sec_conclusion}
Nevertheless the computation of both the Banzhaf and the Shapley-Shubik index is NP-hard for weighted voting games, we have
demonstrated that in practice it is not too hard to compute the exact values if the considered games are not \textit{too large}.
In the used sense, the current IMF voting system is definitely not too large since the Banzhaf indices can be computed in seconds
and the Shapley-Shubik indices can be computed in a few minutes. For weighted games of that magnitude no approximations to the
real values are necessary.

Even more, an efficient computation does not rely on sophisticated algorithms but low-level details in order to gain speed-up factors.
For $C\ll 2^n$, which should be the case for all non-tiny real--world examples, the use of generating function approaches yields
no benefit, although being a common topic in the literature. The used underlying idea of counting coalitions per weight and size by
a simple recursion was just enhanced  by allowing the reverse direction starting from the weight sum $C$ for quotas larger than 50\%.
There is a single small insight that allows to recover those counts for the cases where a certain player is either assumed to be part
or not to be part of the counted coalitions more efficiently than a direct enumeration. Using this approach the complexity for
computing the considered indices are (up to a small constant) the same for a single player and all players.

For our real--world example of the IMF, the resulting power distributions are rather different from the weight shares and between
diverse power indices like the Banzhaf and the Shapley-Shubik index. We suspect that this is not a numerical artefact of this specific
example, so that it might be a good idea to compute several power indices to get a more comprehensive view whenever the considered
committee has some non-negligible impact.

The distribution of the Banzhaf power shares is rather sensitive to changes of the quota and there are clear incentives
for the few largest countries to alter them in their sense. The conclusion that may be drawn from that fact is debatable and the
choice of the quota should indeed obtain more consideration.

redpajama_set_name: RedPajamaArXiv


text:
Mesa, AZ – Two Severely Injured in Rollover Crash on US 60 at Greenfield Rd
Accident News AZ - Two Severely Injured in Rollover Crash on US 60 at Greenfield Rd, Injury Rollover Accidents in Arizona, Rollover wreck involving officer in Mesa
Mesa, AZ (August 11, 2020) – Two people were left critically injured after an accident occurred on US 60 eastbound near Greenfield Road on Tuesday.
Per officers with the Mesa Police Department, the accident occurred after the driver of a black Cadillac SUV rear-ended a fully marked Mesa police cruiser. Authorities say that the impact of the crash caused the SUV to roll and that it forced that police department officer's car all the way on the right shoulder. Both vehicles sustained severe damage, according to Sgt. Kameron Lee of the Department of Public Safety.
Fire rescue crews had to extract the officer from his car and said that he was in and out of consciousness.
Authorities say the wreck occurred just before 11:00 a.m. and occurred shortly after the Arizona Department of Public Safety received a call about a ladder in the center lane of US 60 eastbound near Higley Road. The officer involved in the accident came across the debris before the troopers and stopped in the travel lane to remove the debris from the road. At that time, the black Cadillac Escalade rear-ended that officer's patrol car.
The Mesa police officer, who is said to be in his 30s, was transported to an area hospital in critical condition. The woman who was driving the SUV is also in serious condition at a local medical center.
DPS is taking over the investigation and has not released further details about the crash.
Our thoughts are with the injured victims and their families at this time. We hope for their full recovery.
Injury Rollover Accidents in Arizona
The Arizona Department of Transportation published its most recent crash report, which showed almost 35,000 accident injuries statewide in 2018. Of last year's nearly 55,000 total accidents, more than half involved more than one injured victim and several of those accidents were reported as rollover wrecks. Oftentimes, victims may even succumb to their injuries after a rollover wreck, leaving grieving families to pick up the pieces in the aftermath of a serious accident.
Serious injuries, astronomical medical costs, and even job loss may plague victims and their families after a wreck. But those affected can contact a Phoenix accident lawyer for help, and in some cases, seek fair compensation from a personal injury or wrongful death lawsuit.
When it comes to supporting those affected by injury crashes, our Arizona accident attorneys at ELG have years of experience. We know what it takes to fight for victims and their families, and seek the fair compensation you deserve after a crash.
Our skilled Arizona injury attorneys at ELG have helped families affected by these accidents for decades, ensuring they're able to safeguard their legal rights after losing a loved one as a result of negligent parties' actions.
At ELG, when we represent a client and an adverse insurance company asks us to allow for a recorded statement from our client, 99% of the time the answer is a definitive no. Our recommendation is to tell them you will seek out counsel first, then call us at ELG.
We will gladly review the facts of your case and tailor our advice to match the specific needs of your case. Plus, every consultation is free and there is no obligation to retain us. So at worst, you get free advice. We won't cut corners or use intake specialists to talk or meet with you. At ELG, we guarantee your consultation will be with one of our experienced injury attorneys that only handle accident matters. That means that you can feel confident and rest assured that we will answer all of your questions.
Contact us for more information at (623) 321-0566, and learn more about your legal options after a car crash with a free consultation today. We're here to help you in your time of need.
Phoenix, AZ – 2-Car Crash Causes Injuries on I-10 at L-101
Phoenix, AZ (April 6, 2020) – A two-car crash caused injuries on eastbound Interstate 10 near Loop 101 on... read more
Phoenix, AZ (July 27, 2020) – Deputies from the Phoenix Police Department responded to a multi-vehicle crash on I-10... read more
Mesa, AZ – Charges Dropped Against DUI Driver in Fatal Crash at Alma School Rd
Mesa, AZ (November 27, 2019) – The Maricopa County Attorney's Office MCAO is dropping charges on a deadly crash... read more
Mesa, AZ – Injury Wreck on US 60 at L-101
Mesa, AZ (June 18, 2020) – A two-car accident blocked the left lanes of US 60 at Loop 101... read more
Phoenix, AZ – Injurious Crash Reported on I-17 NB at Camelback Rd
Phoenix, AZ (July 17, 2020) – Officers from the Phoenix Police Department are investigating a serious multi-vehicle crash on... read more
Flagstaff, AZ – Wrong-Way Collision on I-40
Flagstaff, AZ (November 14, 2019) – A wrong-way collision was responsible for the closing of the eastbound lanes of... read more
Scottsdale, AZ – Serious Injuries Reported in Multi-Vehicle Crash on L-101 at Indian School Rd
Scottsdale, AZ (February 20, 2020) – A multi-vehicle accident blocked all lanes at Indian School Road on Loop 101... read more
Phoenix, AZ – 3 Hospitalized After Head-on Collision at 48th St & Broadway Rd
Phoenix, AZ (October 16, 2019) – Local authorities responded to a two-vehicle wreck near 48th Street and Broadway Road... read more
Chandler, AZ – Rosario Ortiz Killed in Pedestrian Accident at Arizona Ave
Chandler, AZ (May 24, 2020) – One woman is dead after a vehicle struck her in Chandler on Saturday. Per... read more
Phoenix, AZ – Injuries Reported in Rear-End Crash on L-101 at McDowell Rd
Phoenix, AZ (June 8, 2020) – Officers from the Phoenix Police Department said that injuries were reported in a... read more


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The Department of Education reported a mistake in Pell Grant application forms that could result in tens of thousands of students losing their financial aid status.
A mistake in the Free Application for Federal Student Aid (FAFSA) application forms could cost tens of thousands of students their financial aid.
The Department of Education told The Associated Press that a change in the Free Application for Federal Student Aid (FAFSA) form, resulted in many students incorrectly entering their personal income levels. They estimate up to 200,000 people were wrongly declared eligible and others were incorrectly denied.
For example, an applicant with an Income Earned from Work value of $5,000.19 who, as a result of entering both the dollars and cents would have, instead of the correct value of $5,000, a value of $500,019 used in the calculation of the applicant's Expected Family Contribution (EFC).
Many academic institutions reported the glitch, but the DOE is recommending that many applicants' paperwork be reviewed before subsidized Title IV aid is disbursed for the 2014-2015 award year. "If such aid has already been disbursed the institution may need to change awards and return (or have the student return) any overawarded funds," the instructions read.
According to the Education Department, the maximum Federal Pell Grant for the 2014-2015 school year is $5,730, although the amount given depends on personal and family financial need, veteran or disability status, and the cost of attendance.


You're a go-getter with a can-do work ethic and a gusto for collaborating. You like a chill office vibe that's dog-friendly and has half-day Fridays. You like to work hard, have fun and your social knowledge would make Mark Zuckerberg take notice. You''ll develop social media strategies, campaigns and digital projects for clients and guide clients and teams through the process. You love working with creative teams on engaging storytelling, imaginative thinking and new ways to grow a brand's following and other metrics.
If you have 4-6 years experience, are a self-starter and comfortable working independently, yet collaboratively, Thorburn is your next home. You'll be our social guru, but you'll also be part of a team driving broader marketing initiatives from naming and identity to print, video and TV campaigns.


Ea games is very one the best, but now the popularity of Simcity Buildit is increasing tremendously. By it, the players are able to spend their free time without any type of issue. In the game, the players are required to create a city. The players are playing a role of Mayor in the city. They need to take all decision regarding the city and its residents. They are required to make sure that, the decisions are providing proper benefits to them or not.
In case you feel any decision is not suitable for the city then you should avoid the idea. Always try to choose the way which is beneficial for the city in all ways. In case any part of the city gets affected by it then it does not provide beneficial results.
Here the players should try to implement a proper strategy. In case the game plan is not proper or the city layout is not properly structured then the changes of unhappy Sims are increased. For all these things, the players should try to divide the whole into some parts.
How to prepare city layout?
Most of the beginners are asking what the perfect base for a good city layout is. For it, there are different types of ways available. When it comes to the placement at that time you should try to create groups. By it, you need to place all kinds of buildings together. In case of residential units and factory units, you should definitely implement it.
Another important thing about the city layout is that the players should try to keep factories far from the cities. It means you should create a group of factories and establish it as far as possible from sims. By it, they are able to breathe in fresh air and avoid lots of miss happenings.
It is a game but the activities are completely similar to the real world. The results of all types of activities are appearing as they are appearing in the real world. The industries are the biggest example of these types of things. As in real world, some industries are becoming a reason for pollution. Similarly, in the game's virtual world, the pollution is affecting the health status of characters and affects their mood.
Another example is related to the earnings. In the real world, the individuals are required to earn money for surviving and providing proper facilities to the family. Similar to it, the players need to use sims for earnings by providing a proper job. With SimCity Buildit Hack the players can earn lots of game money and spend it on the development of city.
Above mentioned things are helpful in setting-up coordination with city and the players' activities. These things are important but the players are required to focus in some basic things. They should put lots of efforts in order to achieve their objectives easily. The first and main motive of the players should be keeping the sims happy with smiley expressions. After that they should be focused on the upgrades or development.
In case from any type of upgrade or development step, the players are not happy then the efforts of players get wasted. If you want to do progress properly then you need to make decision wisely which is beneficial in development and keeping sims happy.
Well, you may have heard this name somewhere on TV or books or any other means. Harry Potter has been a great film series and a great novel written by J.K Rowling. This game is also based on this whole scenario as shown in the movies. You have to play a role of a girl whose brother is somehow disappeared and in this game. You have to find all the mystery behind the disappearing of your brother. Well, this game can be played anywhere with a stable internet connection and you can play this game on your google Android or iOS platform based Smartphone.
This can be somewhat hard when you have just started playing this RPG game. It will surely give you a hard time and you can use our guide to overcome these problems. So let's get started and make sure to read throughout the guide.
This can be very difficult and you have to be prepared to maintain your energy if you want to be a better player. All you need to do while playing is to manage your energy in order to never run out anytime while in the game. If you lose your energy in between the game then either you have to wait for your energy to refill or you have to spend gems or money to replenish it instantly. And there is no use of replenishing energy for a few minutes spending real cash or with Harry Potter Hogwarts Mystery Cheats.
There are many energy points hidden in the game where you can get free energy and try finding your house elves and these will replenish your energy to the full. If your energy bar is full then going to these hidden spots are of no use. Make sure you go there only when you need energy.
2. How to win House Cup?
House cup is one of the biggest events in Hogwarts School. You have to earn a point for your house to win and you'll come across many things that will make you lose many points. In order to earn more points try to attend more classes as this will offer you with currency, gems, and points. You'll get extra points attending these classes and earning starts can also give you extra points.
When you're sitting in a class, make sure you answer efficiently. All the questions asked by your professor will be tricky enough, so keep an eye on these questions and answer in a way that you get extra points. Read everything carefully and give a good response to everyone you're talking with.
These duels are fights and contest in the players you met in the game. Merula will give you a hard time while playing these duels as intend of being a good cousin you've to fight him and win these duels. So there will be two rounds while playing these duels which you've to go through in order to win.
Once you've moved to the action round then you'll be given two option to stance your round. Then you'll be needing potions and all in these rounds as to fight back easily.
Making friends is great in this game but don't trust anyone easily as you have to fight even your cousin in order to win. It will not be easy as it was in the tutorial of the game. You'll get to know about a hundred of people in this game and the handshake icon on the top of the person will let you hang out with him/her. You have to be careful enough while making friends as this will take up much of your coins and you'll be facing a hard time collecting them. Be careful while talking to your friends as you've to make your decisions according to their moods.
This game will make you dive into the gameplay and let you play freely in the early days. When you get deep into the gameplay then you'll come across many different and confusing things. To let you play with ease, we've come up with this guide for you all.
Pixel gun is one of the most famous games that are loved by the game lovers in facebook. It is a shooting based game where players have to kill the zombies as well as monsters in order to win. With the help of this, they can earn rewards in the form of in-game resources. These resources are also playing an important role because these can be used to buy the best weapons, gears, armor and much more things. After buying these entire items, players can easily survive in the battles and also kill the opponents with ease that is one of the amazing things.
You may also know about that it is really important for the beginners to focus on the gameplay so they can easily make progress faster, so they can read Pixel Gun 3d Review. They also need to play the game carefully which helps them to eliminate all the complications and issues that they are facing while playing the game. Most of the players are not focusing on the gameplay which also stops them to move further. They should put their best possible efforts in order to earn enough resources and also acquire the stars. Earning stars is not an easy task because, in order to acquire them, players need to complete some goals.
Well, they can earn one star by completing every goal at the different stages of the game. By killing the monsters will give them one star and if they kill them quickly without losing the time then they can get two stars. They can also earn total three stars after killing all the monsters quickly and also without having any damage. Most of the players can't earn the three stars because it is also one of the complicated tasks.
As along with the stars, the game currencies also have a great importance in the game. There are main two currencies but other resources are also important to consider. Players can earn coins by playing the game that is called as the primary currency. With the help of coins, they can buy various weapons from the game store. If you want to buy the premium weapons then you may need to spend the gems. Gems are also known as the premium currency that you can use to buy the various items that can't be purchased with coins. Players also need to spend the currency carefully in order to play the game without having tribulations.


If you pay tax and support a dependent relative, you could be eligible for significant tax breaks well in excess of all the tax credits touted in the latest federal budget.
Under the fairness provisions, assuming you are comfortable opening up previous years to audit, you could even be entitled to refunds for the past 10 years, refunds and tax credit entitlements that might be over $20,000 if there is a child with a disability.
Here's a rundown of the major support and medical deductions and credits now available.
Let's remember that for welfare purposes, support from anyone is cause for a clawback of benefits dollar for dollar. Bank accounts are monitored, and it is a requirement to report gifts of boots, coats, meals, and so on. Hence, requests for documentation for tax credits from the combination social welfare/medical clinic might be unwise.
The new Disability Savings Plan proposal in the federal budget discusses how the provinces must ease up on their income, means, and needs testing before such a plan could be implemented. The budget also proposes an Enabling Accessibility Fund for ramps and other projects.
Infirmity. "Infirmity" is what is required to claim the Infirm Over 18 or the Caregiver Credits. For purposes of the Income Tax Act, "infirmity" has no definition, relying instead on common usage, as do the terms "mental or physical handicap," "mental or physical impairment," "lack of normal physical development," all of which are used in the Income Tax Act in s.118.2(2), the medical expenses section. Often, doctors must certify a label that has no definition.
Disabled or impaired: what's in a label? The word "disability" is not the word used by our laws to describe what has been called the "Disability Tax Credit." The Income Tax Act provides for a credit for mental or physical impairment where an individual has one or more severe and prolonged impairments in physical or mental functions that markedly restrict an individual's ability to perform a basic activity (s.118.3). Note the positive use of "individual's ability" compared with "disability." Why do CanRev guides prefer to label people as "disabled" rather than "impaired"? See the revised 12-page application, Form 2201, issued in January 2007.
For a child, there is a Disability Supplement for Persons Under 18 that should reduce tax payable by a further $800 on top of the regular Disability Tax Credit, which reduces tax by about $1,400. The child disability supplement is clawed back by attendant care or childcare claims by anyone. The Child Disability Supplement is a supplement to the Disability Tax Credit (use Form 5000-D to calculate this supplement).
Note that the Disability Supplement is not the same as the Child Disability Benefit, which is a tax-free amount paid out to families along with their Child Tax Credit.
Refundable Medical Expense Supplement (RMES). For the working poor earning at least $2,919, this might provide for up to $1,000 of medical expenses reimbursement.
Transferable credits. Some tax credits are transferable if you provide support to your spouse or other dependent relative with a disability. These include tuition, education and textbook transfers from a child or grandchild or a spouse or partner.
Credits for dependent relatives. Dependent relatives over 18 who are infirm may not necessarily live with you. Check out Form TD1 and don't stop at the first few credits; read all the way to the bottom of number 11 on the form. Not only is this the form you use to ask your employer to reduce withholding tax at source, it is a great reference source for determining which credits you might be able to claim. For example, the Caregiver Credit was introduced in 1998 to provide an incentive for Canadians to care for their aging parents at home, but it is relatively underused.
Eligible Dependent (if you are single).
Infirm over 18 if the dependant's income is really low.
Caregiver credit if you have relatives living with you or you and your spouse/partner.
For the first time ever, CanRev lists about 123 medical expenses eligible to be claimed by those who qualify with the correct certification in writing or prescription or receipt, or a combination of all of those. In some cases, the Disability Tax Credit may also be available.
Extended health and dental premiums by payroll deduction or through a private plan plus the amount of medical expense paid directly qualify. For example, many plans require a copayment of 20% of drugs and 50% or more of dental costs, plus the excess over $200 for all those glasses. These qualify as medical expenses. There is no limit on your claims, only a threshold of the lower of 3% and $1,884.
Form T4002 contains more information about deducting your premiums as a business expense.
Request that your employer complete Box 85 on your T4 if you paid the premiums from your net pay. If you paid your premiums through your payroll plan at work, your T4 should have a box with a Code 85 containing the amount.
Now let's take a look at the math assuming annual earnings of $30,000. In this case, $30,000 x 3% is only $900, and your premiums were probably between $900 and $2,000 or maybe even more. There is a separate line on your medical expense tax form for those premiums for private health plans.
Claim medical expenses for you, your spouse or partner, and your children 18 and under on Line 330. Usually the most beneficial plan is to claim all of your family's medical expenses on the lower-income-spouse's return.
Medical expenses for dependent relatives over 18. If you pay for a dependant's medical expenses directly, claim what you paid up to $10,000 as a tax credit on Line 331. If Mom is in a care home and you are contributing directly by paying the bill, not by giving Mom money, you can claim. If your relatives also pay up to $10,000 for Mom's care, there is a CanRev ruling that each of you can claim $10,000. I wonder how long this will last.
Attendant care is usually considered an employer/employee relationship. Compliance with payroll, employment standards, and Worker's Compensation rules is in the family's best interest in spite of pressure from caregivers to pay cash. Accidents or injuries in the workplace bring out the best lawyers, funded by Employment Standards or Workers Compensation to represent the caregiver.
Gas tax refunds, both federal and provincial/territorial.
An HRDC fund called the Opportunities Fund for Persons with Disabilities.
Premium reduction on Provincial medical plans for persons with low income.
Assistance with vehicle insurance premiums for persons with disabilities.
Assistance with property taxes by way of grants and deferrals.
Remember, if you have not claimed these credits, you may be able to go back up to 10 years and request a reassessment under the fairness provisions. However, consult your accountant before you do, to ensure you don't open yourself to an audit.