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The EX-FRAIL CKD trial: a study protocol for a pilot randomised controlled trial of a home-based EXercise programme for pre-frail and FRAIL, older adults with Chronic Kidney Disease
http://orcid.org/0000-0002-4093-6204Andrew Christopher Nixon1,2,3,
Theodoros M Bampouras4,5,
Helen J Gooch3,6,
Hannah M L Young7,8,
Kenneth William Finlayson9,
Neil Pendleton10,
Sandip Mitra11,12,
Mark E Brady1,
Ajay P Dhaygude1
1Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
2Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
3Centre for Health Research and Innovation, NIHR Lancashire Clinical Research Facility, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
4Lancaster Medical School, Lancaster University, Lancaster, Lancashire, UK
5The Centre for Ageing Research, Lancaster University, Lancaster, Lancashire, UK
6Core Therapies Department, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
7Department of Respiratory Sciences, University of Leicester, Leicester, UK
8John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
9Research in Childbirth and Health Unit, University of Central Lancashire, Preston, Lancashire, UK
10Division of Neuroscience and Experimental Psychology, The University of Manchester, Manchester, UK
11Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
12Devices for Dignity, NIHR MedTech & In-vitro Diagnostics Co-operative, Sheffield, UK
Correspondence to Dr Andrew Christopher Nixon; andrew.nixon3{at}nhs.net
Introduction Frailty is highly prevalent in adults with chronic kidney disease (CKD) and is associated with adverse health outcomes including falls, poorer health-related quality of life (HRQOL), hospitalisation and mortality. Low physical activity and muscle wasting are important contributors to physical frailty in adults with CKD. Exercise training may improve physical function and frailty status leading to associated improvements in health outcomes, including HRQOL. The EX-FRAIL CKD trial aims to inform the design of a definitive randomised controlled trial (RCT) that investigates the effectiveness of a progressive, multicomponent home-based exercise programme in prefrail and frail older adults with CKD.
Methods and analysis The EX-FRAIL CKD trial is a two-arm parallel group pilot RCT. Participants categorised as prefrail or frail, following Frailty Phenotype (FP) assessment, will be randomised to receive exercise or usual care. Participants randomised to the intervention arm will receive a tailored 12-week exercise programme, which includes weekly telephone calls to advise on exercise progression. Primary feasibility outcome measures include rate of recruitment, intervention adherence, outcome measure completion and participant attrition. Semistructured interviews with a purposively selected group of participants will inform the feasibility of the randomisation procedures, outcome measures and intervention. Secondary outcome measures include physical function (walking speed and Short Physical Performance Battery), frailty status (FP), fall concern (Falls Efficacy Scale-International tool), activities of daily living (Barthel Index), symptom burden (Palliative care Outcome Scale-Symptoms RENAL) and HRQOL (Short Form-12v2).
Ethics and dissemination Ethical approval was granted by a National Health Service (NHS) Regional Ethics Committee and the NHS Health Research Authority. The study team aims to publish findings in a peer-reviewed journal and presents the results at relevant national and international conferences. A summary of findings will be provided to participants, a local kidney patient charity and the funding body.
Trial registration number ISRCTN87708989.
adult nephrology
end stage renal failure
Strengths and limitations of this study
A validated frailty assessment will be used to determine suitability for randomisation ensuring that only prefrail and frail participants receive the intervention.
The exercise programme is delivered in a graded and progressive manner with the use of weekly participant telephone calls to review progress.
A nested qualitative study will explore the acceptability of the randomisation procedures, outcome measures and intervention to participants.
Semistructured interviews will be completed by a researcher involved in delivery of the study intervention.
Patients who decline study enrolment will not be offered the opportunity to participate in the qualitative study.
Frailty is the consequence of a cumulative decline in multiple physiological systems associated with ageing.1 This results in a state of increased vulnerability to disproportionate changes in health status when exposed to seemingly minor insults, such as an infection or fall.1 Frailty, and its precursor prefrailty, is associated with an increased risk of falls, hospitalisation, worsening disability and death.2 The pathophysiological process inherent to chronic kidney disease (CKD), including, though not limited to, uraemia, anabolic hormone dysregulation, increased inflammatory burden, metabolic acidosis and cellular senescence, appears to hasten the decline from fitness to frailty.3 This is to such an extent that the prevalence of frailty in CKD, particularly by the time of dialysis initiation, is considerably greater than in the community-dwelling older adult population.4 5 Importantly, as in the general older population, patients with CKD and frailty have worse outcomes than their non-frail counterparts. Frailty is independently linked with adverse clinical outcomes in all stages of CKD, including an increased risk of worse health-related quality of life (HRQOL),6 7 falls,8 hospitalisation and mortality.9–11
Low physical activity and associated muscle wasting are important contributors to physical frailty.3 Physical activity is low in patients with advanced CKD12, and muscle wasting is pronounced prior to the commencement of dialysis.13 Increased physical activity levels in those with CKD and prefrailty/frailty may mitigate this muscle wasting. Exercise training has been shown to improve physical fitness and HRQOL in CKD populations.14 15 However, patients living with frailty are typically poorly represented in interventional studies, often due to concerns that drop-out rates, adverse events or intervention tolerability may be affected.16 17 Studies that have explored the use of exercise training in frail older adults have demonstrated benefits in terms of 'falls, mobility, balance, functional ability, muscle strength and body composition'.18 However, the optimum exercise programme has not been established.18 Regardless, exercise programmes that are effective for frail older adults may not meet the needs of patients living with frailty and CKD, who are more likely to be frail at a younger age,10 report considerable symptom burden19 and have high healthcare utilisation.20
Many exercise programmes used in studies involving participants with CKD have been performed under supervision within hospital or other facilities,14 15 circumstances that can be challenging to implement in clinical practice considering financial and staffing constraints. Furthermore, travel for exercise sessions may be onerous for frail individuals with CKD who often report higher levels of fatigue.6 Home-based exercise programmes may be less burdensome and more convenient, allowing patients to incorporate physical activity into their daily lives leading to longer term adoption and maintenance of increased physical activity.21 There is evidence in the gerontology literature that home-based exercise interventions may improve disability in older people with frailty.22 However, research is needed to evaluate the benefits of a pragmatic, progressive home-based exercise programme tailored to the needs of people living with frailty and CKD.
As recommended by the Medical Research Council guidance for developing and evaluating complex interventions,23 pilot studies should be used to address key uncertainties prior to the definitive evaluation of complex interventions. Given the previously described uncertainties, a pilot randomised controlled trial (RCT) of a home-based exercise programme for prefrail and frail older adults with CKD is necessary. This will inform the design of a large-scale RCT that investigates the effect of a home-based exercise intervention on physical function, frailty status, fall concern, activities of daily living, symptom burden and HRQOL in prefrail and frail older adults with CKD. The 2013 Standard Protocol Items: Recommendations for Interventional Trials guidelines24 25 will be used as the framework for reporting the EX-FRAIL CKD trial protocol.
A pilot RCT will be performed that aims to:
Evaluate rate of participant recruitment, intervention adherence, outcome measure completion and attrition.
Qualitatively explore the acceptability of the randomisation procedure, outcome measures and, in the intervention arm, a progressive home-based exercise programme and identify areas requiring adaptation for a definitive RCT.
Estimate the SD of walking speed in prefrail and frail patients with CKD to allow sample size estimation for a definitive RCT.
The EX-FRAIL CKD trial is a two-arm parallel group pilot RCT. Outcome assessments will be performed at baseline and 12 weeks' post randomisation. A nested qualitative study will be performed following completion of 12-week follow-up visits to explore participant perceptions of the study and, where applicable, the study intervention.
Study setting
Participants will be recruited from outpatient clinics at Lancashire Teaching Hospitals National Health Service (NHS) Foundation Trust (LTHTR), East Lancashire Teaching Hospitals NHS Trust and Blackpool Teaching Hospitals NHS Foundation Trust. The regional nephrology service operates a 'hub-and-spoke' model, accordingly participants attending clinics at sites other than LTHTR are still under the care of the LTHTR nephrology service.
Patients aged ≥65 years old with CKD G3b-5 (not receiving dialysis or received a kidney transplant) identified as at least 'vulnerable' using the Clinical Frailty Scale (score ≥4) are eligible for participation.26 The Clinical Frailty Scale is a 9-point scale that provides definitions for levels of frailty and has good diagnostic accuracy for identifying patients with advanced CKD at risk of frailty.26 27 It has been adopted as a frailty screening measure within usual care at LTHTR and is used by clinicians and clinical nurse specialists in outpatient clinics. Using a Clinical Frailty Scale score ≥4 within the inclusion criteria will maximise the likelihood of prefrail and frail patients being approached for study involvement. Patients must also be able to give informed consent.
In accordance with the American College of Sport's Medicine28 :
Unstable Angina or recent (within the last 3 months) myocardial infarction.
Uncontrolled arrhythmias.
Persistent uncontrolled hypertension (systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg).
Recent (within the last 3 months) stroke or transient ischaemic attack.
Registered blind.
Unable to mobilise independently.
Receiving palliative care for advanced terminal cancer.
Recently (within the last 12 months) enrolled in a structured exercise programme (eg, cardiac rehabilitation) prescribed by a health professional.
Anticipated to commence dialysis or receive a renal transplant within the next 3 months.
Insufficient understanding of the English language to complete study questionnaires or follow advice within the exercise programme guidebook.
Clinical and/or research team consider participation in the exercise programme unsafe.
Figure 1 illustrates the participant flow through the study. Patients will be screened by members of the clinical team (based on age, CKD stage and Clinical Frailty Scale score). Patients aged ≥65 years with CKD G3b-5 and a Clinical Frailty Scale score ≥4 will be given a participant information sheet. Patients will then be telephoned to establish if they are interested in participating and to ensure eligibility. Patients will be offered an appointment with the Chief Investigator, at least 24 hours following the telephone call, to obtain written informed consent to participate in the study.
Study flow diagram.
Our previous study demonstrated that a Clinical Frailty Scale score ≥4 had a sensitivity and specificity for identifying frailty of 1.00 and 0.55, respectively.27 Given the risk of false positives, we considered it prudent to perform a more objective frailty assessment to ensure that only patients with prefrailty or frailty underwent randomisation. The Frailty Phenotype (FP) is a well-studied method to diagnose physical frailty in CKD populations.2 5 The FP includes five components, as detailed in table 12 . Frailty is diagnosed if an individual is assessed as having three components and prefrailty if an individual has one or two components.2 The FP is not routinely performed in clinical practice and, therefore, can only be performed following study consent. Participants will have an FP assessment prerandomisation and will be withdrawn from the study if they are categorised as robust (ie, not prefrail or frail). This eventuality will be explained to patients prior to study consent. Participants categorised as prefrail or frail will complete all outcome assessments as detailed in table 2, and then be randomised to exercise or usual care groups. Follow-up outcome assessments will be performed 12 weeks post randomisation. A group of participants will be invited to participate in semistructured interviews following 12-week follow-up assessments (or following a participant's decision to stop the exercise programme).
The Frailty Phenotype
Schedule of assessments
We aim to recruit 40 participants to allow for a dropout rate (that includes participants categorised as robust using the FP) of up to 50% and still provide sufficient data to assess study feasibility and estimate the SD of walking speed to inform the sample size calculation for a definitive RCT.18 22 29 30 Semistructured interviews will be conducted with a purposively selected group of participants, from both study arms, considering age, gender and frailty status. A pragmatic sample size of 12–14 participants will be recruited to this nested qualitative study.
Allocation and blinding
Participants will be randomised in a 1:1 ratio to either the intervention or usual care. A central, concealed web-based randomisation process (www.sealedenvelope.com) will be performed in blocks of 4. Stratification will be limited to one factor, FP status, leaving two strata, that is, prefrailty and frailty.31 This will ensure that both groups contain similar proportions of prefrail and frail participants. Participants cannot be blinded to the outcome of randomisation due to the nature of the intervention. Furthermore, outcome assessors will not be blinded to the outcome of randomisation as this pilot study does not aim to evaluate intervention effectiveness. Blinding of outcome assessors will be performed if a definitive RCT is considered feasible.
Intervention development
The EX-FRAIL CKD exercise programme is a 12-week progressive, multicomponent home-based exercise programme. It was developed through review of international guidance and systematic reviews that evaluated exercise interventions in CKD and older adult populations. A 2014 systematic review demonstrated that exercise training is associated with improved health outcomes in adults with CKD.15 However, most studies evaluated interventions in adults with dialysis-dependent CKD and mostly aerobic exercise interventions.15 The authors recommended further evaluation in non-dialysis populations and further analysis of resistance training and multicomponent interventions.15 Several systematic reviews have demonstrated that frail older adults benefit from exercise programmes and reported multicomponent exercise programmes (involving combinations of strength, aerobic and balance training) were often effective.18 32 33 A 2012 Cochrane review determined that both multicomponent group exercise and home-based exercise reduce the rate of falls in older adults.34 Furthermore, a systematic review of home-based exercise programmes suggested that there is preliminary evidence that home-based exercise interventions may improve disability in older adults with moderate frailty.22 The American College of Sports Medicine and American Heart Association Guidelines highlight the importance of physical activity being increased gradually in older adults, particularly those who are very deconditioned.35 Additionally, the guidelines recommend that older adults who reduce their sedentary behaviour, even if not to the level recommended, still attain health benefits.35
Intervention description
Participants randomised to the intervention will receive an individual exercise education session delivered by a physiotherapist experienced in exercise prescription. Participants will be provided information about the potential benefits of physical activity for their general health and well-being. They will subsequently receive instruction on how to complete the exercises within the exercise programme safely and effectively. The exercises will be demonstrated to participants by a physiotherapist. The participants will then be asked to practice the exercises under supervision to ensure appropriate technique. If a participant is unable to perform a specific exercise, for example due to a functional limitation, an alternative will be provided that focuses on the same muscle groups. Furthermore, if a participant is unable to complete the proposed number of repetitions, the participant will be advised to perform a lower number of repetitions initially. This approach reflects exercise prescription in clinical practice and should increase the feasibility and safety of the exercise programme.
Table 3 demonstrates the six exercises within the programme and details the progressions for each exercise. Participants categorised as frail will initially be advised to perform each exercise at level 1, whereas participants categorised as prefrail will be advised to perform each exercise at level 2, unless the physiotherapist determines that it would be unsafe for an individual participant to perform a specific exercise at this level. Participants will receive education on how to use the Borg rating of perceived exertion36 and will be advised to perform exercise 1 at a light intensity (Borg score <12) and exercises 2–6 at a moderate intensity (Borg score 12–16). Participants will be asked to gradually increase physical activity levels so that they ultimately perform three exercise sessions at home per week, with each session lasting approximately 30–45 min. Participants will be provided an exercise guidebook comprising written guidance on each exercise with accompanying photographs of models demonstrating the exercises.
The EX-FRAIL CKD exercise programme
Participants will be encouraged to complete an exercise diary. The diary prompts participants to document each exercise session including when they exercised, if they completed all exercises, the duration to complete the full exercise session and their Borg rating of perceived exertion for each exercise completed. Participants randomised to the intervention will receive weekly telephone calls from the physiotherapist or a specialist trainee in renal medicine who has clinical and research experience with patients living with frailty and CKD. To enhance intervention fidelity, a telephone pro forma will be used that prompts a review of the participants exercise diary, exercise technique, any problems (including symptoms, falls and healthcare episodes), an exploration of any participant uncertainties about the exercise programme and goal-setting for the following week. The physiotherapist and specialist trainee will discuss the outcomes of telephone calls, as a further safeguard of intervention fidelity. The telephone calls will be used to provide ongoing encouragement and to advise on exercise progression. If participants can perform exercises 2–6 comfortably (Borg score <12), the physiotherapist or specialist trainee will discuss exercise progression with the participant. If required, participants will be offered additional educational sessions during the 12-week intervention period to ensure safe exercise technique when progressing to more difficult exercise levels. Figure 2 illustrates the Exercise Intervention Logic Model and table 4 summarises the intervention using the Template for Intervention Description and Replication checklist.37
Exercise Intervention Logic Model.
TIDier checklist
Patient and public involvement
The study was presented to the LTHTR Research Development Group, which includes lay members. Feedback from this meeting led to the adoption of a study design that included a nested qualitative interview study. The proposed study was also presented to members of a local kidney patient charity, discussed in a patient focus group, supported by funding received from National Institute of Health Research (NIHR) Design Service, and with the LTHTR Lay Research Group, which is a group of local lay representatives. The study team was encouraged by positive feedback received on proposed study visits, outcome assessments and the exercise programme, including the burden of the intervention.
Primary feasibility outcome measures
Primary feasibility outcome measures will be assessed as recommended by the Consolidated Standards of Reporting Trials (CONSORT) randomised pilot and feasibility trial guidelines.38 The proportion of patients attending nephrology clinics who are eligible for study consent and the proportion of eligible patients subsequently recruited will be recorded. Reasons for ineligibility and non-consent will be recorded. In the intervention arm, adherence will be assessed by telephoning participants weekly to review the preceding week's exercise activity and by reviewing participant exercise diaries at the end of the study period. Reasons for non-adherence will be documented. The proportion of participants who complete all outcome measures and who are lost to follow-up will be assessed. Reasons for failure to complete outcome measures and for study withdrawal will be recorded.
Using a predetermined topic guide, the specialist trainee will conduct semistructured face-to-face interviews with participants. The interviews aim to explore the acceptability of the randomisation procedure, outcome measures and, in the intervention arm, a progressive home-based exercise programme. Perceived safety and barriers to participation will be explored. The interviews will be conducted in a private environment at the NIHR Lancashire Clinical Research Facility. Interviews will be audio recorded using a digital recorder with the participant's consent and will last approximately 30–60 min. Interviews will be transcribed verbatim.
A 'stop', 'change' and 'go' approach to progression criteria will be used as described in the literature,39 with qualitative data used to identify areas for adaptation for a definitive RCT, if required. Table 5 details the study progression criteria.
Progression criteria
Secondary outcome measures
Physical function
Walking speed is independently associated with all-cause mortality in adults with CKD.40 Walking speed will be assessed using infrared timing gates (Brower Timing System 2012, Brower Timing Systems, Draper, Utah, USA). Participants will be asked to walk 15 feet at their normal walking pace on two occasions, using their usual walking aid if applicable. The fastest of the two assessments will be used for analysis. A meaningful change in walking speed has been described as 0.05 m/s.41 42
The Short Physical Performance Battery (SPPB) comprises a group of measures of lower extremity function that together can be used to generate a composite score between 0 and 12.43 SPPB score is associated with mortality in adults with CKD.44 A minimally significant change in SPPB has been reported as 0.5 points.41 42 The measures included in the SPPB are:
Five chair stands: timed standing from a chair at a standardised height five times as quickly as able.
Balance testing: stand in three positions with increasing difficulty (standing with feet side by side, in a semitandem position and in a full tandem position) for 10 s in each position.
Walking speed: timed walking 8 feet at usual pace.
As described earlier and detailed in table 1, the FP can be used to diagnose prefrailty and frailty,2 which are associated with adverse outcomes in CKD populations.6–11 Studies have not evaluated the change in frailty status following exercise interventions in CKD populations. However, McAdams-DeMarco et al demonstrated an improvement in FP score of 0.3 points following transplantation.45
The Barthel Index evaluates independence with 10 activities of daily living to generate a score between 0 and 100.46 Higher scores indicate greater independence.
The Falls Efficacy Scale-International tool will be used to assess fall concern.47 48 It is a self-report questionnaire that asks individuals to rate their fall concern for 16 situations on a 4-point scale. The answers are totalled to provide a cumulative score between 16 and 64. A score between 16 and 19 indicates low fall concern, between 20 and 27 moderate fall concern and between 28 and 64 high fall concern. The number of falls within the preceding 6 months will also be recorded.
Symptom burden
The Palliative care Outcome Scale-Symptoms RENAL (POS-S RENAL) will be used to assess symptom burden.49 The POS-S RENAL questionnaire asks individuals to report 17 symptoms that may have affected them over the preceding week and to indicate to what extent. Each symptom is scored and scores totalled to create a symptom burden score with higher scores representing greater symptom burden.
HRQOL
The Short Form-12v2 (SF-12) comprises 12 questions that are used to assess HRQOL.50 51 The answers are used to produce an 8-scale profile of health and well-being and to generate physical and mental health summary measures. Higher SF-12 scores represent better HRQOL. The proposed minimal important difference for SF-12 summary scales is 3 T-score points.52
All electronic study data will be recoded on a secure, password-protected database on the LTHTR server. The server will only be accessible using password-protected user profiles on LTHTR computers. Participant names and hospital identification numbers will not be recorded on this database; participants will be identified by a study-specific participant number. There will not be a formal data monitoring committee. However, data will be managed in accordance with the LTHTR Information Governance Policy.
Analysis plan
As recommended by the 2010 CONSORT guidelines,38 feasibility quantitative outcome measures will be reported descriptively with 95% CIs. This will include the proportion of eligible patients and recruited participants, participants who adhere to the intervention, participants who complete all outcome assessments and participants who are lost to follow-up. Secondary outcome measures will also be reported descriptively with 95% CIs. The SD of walking speed will be estimated for both trial arms to inform the sample size calculation for a definitive RCT. SPSS software (V.25, IBM Corp) will be used for statistical analysis.
Qualitative data will be analysed using thematic analysis whereby narrative segments will first be coded, and then translated into more abstract themes in an iterative manner.53 NVivo software (V.12.5.0, QSR International) will be used to support analysis. Two members of the researcher team will compare themes to ensure all codes are represented. Qualitative and quantitative findings will be linked using a triangulation approach as described by Farmer et al54 to provide a more comprehensive understanding of trial and intervention acceptability.
Serious adverse events are defined as any episode during the study period that requires inpatient hospitalisation, results in persistent/significant disability, is life-threatening or results in death. All adverse events will be discussed with the medically trained Chief Investigator who will assess seriousness and causality. All adverse events will be reported to the study sponsor and all suspected unexpected serious adverse reactions reported to the regional ethics committee. The trial will be stopped prematurely if three or more suspected unexpected serious adverse reactions occur.
Study steering committee
A study steering committee will provide scientific, ethical and financial oversight of research activity. The committee comprises clinicians, physiotherapists, academics, a study sponsor representative and a patient representative. Meetings will be held during before, during and on completion of the study. The patient representative will be remunerated as recommended by INVOLVE.
Ethics and dissemination
Study ethical approval has been granted by the North West Greater Manchester East Research Ethics Committee (reference 18/NW/0211) and the NHS Health Research Authority (project reference 244772). The LTHTR Centre for Health Research and Innovation accepted the role and responsibilities of study sponsorship. The study is subject to the LTHTR Internal Research and NIHR audit programmes to ensure all research activities are performed in accordance with the international standards of Good Clinical Practice, United Kingdom clinical trials legislation and trust policies. Protocol amendments approved by the Research Ethics Committee/NHS Health Research Authority will be communicated with the study sponsor, study team and, where necessary, the trial registry.
The study data set will not be made publicly available as it may be possible to identify participants from interview transcripts and as this pilot study does not aim to use quantitative data to demonstrate intervention effectiveness. The study team aims to publish the findings in a peer-reviewed journal and presents the results at national and international conferences. A summary of findings will be provided to participants, a local kidney patient charity and the funding body.
To our knowledge, the EX-FRAIL CKD trial is the first pilot RCT of a progressive home-based exercise intervention specifically designed for prefrail and frail older adults with CKD. Given the uncertainties around recruitment rates, intervention adherence and outcome measure acceptability, it is necessary to perform a pilot study prior to proceeding with a full-scale trial. These uncertainties have been considered during study design, though amendments may be required to maximise the success of a multicentre RCT.
This study's strengths include the use of a validated frailty screening measure27 to assist participant recruitment and, during baseline assessment, the use of the reference standard for diagnosing physical frailty, that is, the FP,2 to determine suitability for randomisation. This methodology will minimise the number of robust individuals approached for study consent and ensure that only prefrail and frail participants receive the intervention, thereby strengthening any conclusions that can be made following study completion. Furthermore, the nested qualitative study will complement quantitative data analysis by exploring the acceptability of the randomisation procedures, outcome measures and intervention, thus identifying areas for adaptation in a definitive RCT. An acknowledged limitation is that semistructured interviews will be completed by a researcher involved in delivery of the study intervention, which may influence participant responses. However, the participants will be encouraged to give honest responses by reinforcing that the study objectives include to explore the acceptability of the study and identify areas requiring adaptation for a definitive RCT. For pragmatic reasons, patients who decline to participate in the study will not be invited to participate in an interview. However, participants who decide to stop exercising earlier than planned will be invited to participate in an interview to explore their experience of the study. Furthermore, participants' rationale and motivation for enrolling in the study will be explored during interviews.
Home-based exercise programmes have been performed safely in frail older adults;22 however, perceived safety concerns (eg, fall concerns) may influence participant adherence to the exercise programme. Participants randomised to the intervention arm will receive exercise education from a physiotherapist experienced in exercise prescription. Moreover, the exercise programme will be delivered in a graded and progressive manner with the use of weekly telephone calls that ensure safe exercise practices, explore participant uncertainties and provide ongoing support. We hope that the above will minimise participant concerns; therefore maximising participant adherence to the exercise programme.
The EX-FRAIL CKD trial aims to inform the design of a definitive multicentre RCT that explores the benefits of a progressive, multicomponent home-based exercise programme. If a definitive RCT demonstrates improvements in the physical function of participants, associated improvements in mobility, fall concern, independence, symptom burden and HRQOL are anticipated, supporting the case for a home-based exercise programme within routine clinical care.
Trial status
The study opened in August 2018 and the first participant was recruited in November 2018. Data collection was completed in December 2019.
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. Symptom burden in patients with chronic kidney disease not requiring renal replacement therapy. Clin Kidney J 2017;10:788–96.doi:10.1093/ckj/sfx057pmid:http://www.ncbi.nlm.nih.gov/pubmed/29225808
Khan SS,
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Ashworth NL,
Chad KE,
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. Home versus center based physical activity programs in older adults. Cochrane Database Syst Rev 2005:CD004017.doi:10.1002/14651858.CD004017.pub2pmid:http://www.ncbi.nlm.nih.gov/pubmed/15674925
Clegg AP,
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. Do home-based exercise interventions improve outcomes for frail older people? findings from a systematic review. Rev Clin Gerontol 2012;22:68–78.doi:10.1017/S0959259811000165pmid:http://www.ncbi.nlm.nih.gov/pubmed/27226701
Craig P,
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. Developing and evaluating complex interventions: the new medical Research Council guidance. BMJ 2008;337:a1655.doi:10.1136/bmj.a1655pmid:http://www.ncbi.nlm.nih.gov/pubmed/18824488
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. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489–95.doi:10.1503/cmaj.050051pmid:http://www.ncbi.nlm.nih.gov/pubmed/16129869
. Diagnostic accuracy of frailty screening methods in advanced chronic kidney disease. Nephron 2019;141:147–55.doi:10.1159/000494223pmid:http://www.ncbi.nlm.nih.gov/pubmed/30554199
pp Pescatello L, Arena R, Riebe D, et al. Exercise prescription for patients with cardiovascular and cerebrovascular disease; American college of sports medicine's guidelines for exercise testing and prescription 2013:236–59.
Julious SA
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. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res 2011;2011:569194doi:10.4061/2011/569194pmid:http://www.ncbi.nlm.nih.gov/pubmed/21584244
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. Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: a meta-analysis. Ageing Res Rev 2012;11:136–49.doi:10.1016/j.arr.2011.11.002pmid:http://www.ncbi.nlm.nih.gov/pubmed/22101330
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. Functional evaluation: the BARTHEL index. Md State Med J 1965;14:61–5.pmid:http://www.ncbi.nlm.nih.gov/pubmed/14258950
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. The falls efficacy scale international (FES-I). A comprehensive longitudinal validation study. Age Ageing 2010;39:210–6.doi:10.1093/ageing/afp225pmid:http://www.ncbi.nlm.nih.gov/pubmed/20061508
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Twitter @DrAndyNixon, @drtheobampouras, @hmlyoungphysio
Contributors All authors contributed to the research idea and study design. ACN, TMB, HJG and HMLY were involved in the development of the EX-FRAIL CKD exercise programme. ACN and HMLY developed the study progression criteria. ACN, TMB and HMLY contributed to the quantitative analysis plan. HMLY and KWF contributed to the qualitative analysis plan. MEB, NP, APD and SM were involved in supervision/mentorship. ACN drafted the manuscript. Each author contributed important intellectual content during manuscript revision and accepts responsibility for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.
Funding The EX-FRAIL CKD Trial is supported by a grant from Kidney Research UK (IN_013_20180306), which has funded equipment costs and HJG's study-related activity. ACN and HJG receive non-financial support from the NIHR Lancashire Clinical Research Facility. HMLY is supported by a grant from the NIHR (DRF-2016-09-015). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care. The funders had no role in the study design; collection, analysis and interpretation of the data; writing the report; and the decision to submit the report for publication.
Competing interests Unrelated to this body of work, APD has received lecture fees from speaking at the invitation of MSD and received travel support from Pharmacosmos.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.


text:
Kinsella Weitzman Iser Kump & Aldisert LLP
Media & Entertainment: Litigation
4 ranked lawyersBand 3CaliforniaUSA 2021 View ranking table
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Chambers Research is conducted by 200 Research Analysts, across 200 jurisdictions and provides nearly 6,000 rankings tables. Annually we collect hundreds of thousands of responses from clients, the majority via in-depth interview. Learn more about our methodology.
What the team is known for
Highly respected litigators serving an enviable list of corporate and individual clients, with extensive experience representing well-known recording artists and their estates. Capable of handling the full range of contractual and intellectual property disputes and also adept at handling profit participation and vertical integration litigation.
A source states: "The firm does an incredibly high level of work, and is especially good with high-profile cases. The team provides a stellar service."
Represented the Duke and Duchess of Sussex in an invasion of privacy case filed in Los Angeles County Superior Court against unnamed paparazzi and media outlets who, in violation of California law, took photographs of their son playing in their private yard.
Notable practitioners
Dale Kinsella has a thriving entertainment practice, which sees him regularly representing film and TV producers and studios in high-stakes litigation. His expertise includes profit participation, intellectual property and breach of contract claims.
"Dale is one of the most talented lawyers I know. He is superb."
Howard Weitzman is best known for his representation of recording artists. His vast experience includes intellectual property and estate law disputes.
Lawrence Iser 's media and entertainment practice sees him handle complex copyright and contractual disputes.
Michael Kump continues to represent high-profile individuals as well as entertainment companies in intellectual property and contractual disputes.
"He is absolutely terrific."
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redpajama_set_name: RedPajamaCommonCrawl


Tá cónaí ar Bhríd Ní Mhóráin ar an gCam in Oirthear Duibhneach agus í ag oibriú mar scríbhneoir cónaitheach le hOidhreacht Chorca Dhuibhne, le tacaíocht Ealaín na Gaeltachta, i nGaeltacht Chorca Dhuibhne ó 2003. I measc na leabhar atá foilsithe aici tá Ceiliúradh Cré (Coiscéim, 1992), Fé Bhrat Bhríde (An Sagart, 2002), Síolta an Iomais (Cló Iar-Chonnachta, 2006), An Cosán Bán/The White Path (Oidhreacht Chorca Dhuibhne, 2008)agus Pietas (An Sagart, 2010). Foilsíodh dánta dá cuid ar líne in Connotation Press, 2011 agus Poetry International Poetry Rotterdam, 2013.
- ba leasc liom scaoileadh le haon ruainne.
Ach a scaoileann tú uait.
Le breis is dhá scór de bhlianta.
Ar imeall leamh na léachtaí.
Candide-Il faut cultiver notre jardin.
Ní raibh deireadh leis an Feng Shui fós.
Sara scaoilfí leo go buan.
Grian is teas san aer, péacann.
Móide beannú fileata ó gharnóir mo chroí.
A phearsan bhí caoin, dea-mheabhrach.
Ar a chéile ar staitse na síoraíochta.
A d'iompair fuil na beatha tamall.
Go n-éirí bhur slí libh.
A bhéarfadh fómhar an tsuaimhnis aigne.
Is scamall ar an bpaiste talún.
'Múscail do mhisneach arís eile.
Chomh tairbheach le saothrú an ghairdín.
Is úlla na cailliúna, gréas an fháis is athfháis.
Níl aon cheannchúrsa ach timpeall i bhfáinne.
An scol is binne ó lon dubh na héigse.


You must apply your current year capital losses from step 4 against (that is, deducted from) any capital gains you made during the year to determine your net capital gain or net capital loss.
Next, Kathleen notes her capital loss from collectables on her Capital gain or capital loss worksheet (PDF, 198KB) or on a separate piece of paper. Although she made a capital loss from collectables, she cannot reduce her other capital gains by this amount. However, she can carry this amount over so that if she makes a capital gain from collectables in the future, she can deduct this capital loss from her capital gain on a later tax return. If Kathleen has no other capital losses from the current year or earlier income years, she will now write the amount of $500 at V Net capital losses carried forward to later income years item 18 on her tax return (supplementary section).
Kathleen had bought these shares on 10 October 2011 and each has a reduced cost base of $4 (including incidental costs of acquisition and disposal).


HiHi! It is Deepavali tmr and everyone is on Holiday mood today even though it is Monday. It is the best Monday for most of us and in fact, most of the people are not wrking today, they took leave for the super long weekend.
I dont feel like blogging at all now. Just too 'nua' (lazy).
However, i want to share some pictures and thus…. haha.
Went for painting class yesterday with Gary and Seven. It is a 1 time class but i am falling in love with painting.
I also feel that i cant even paint or draw a decent image but i realised that painting and drawing is very personal. There is no right or wrong (of cos, the teacher will guide you on the strokes and brushes, usage of colors la, you wouldnt wana be too far off from professional right) and you can just draw whatever makes you happy!
To me, i feel better after painting because i painted my wishes, my visions and my desires. Upon completion, there is a sense of satisfaction and fulfilment.
I will get the details of the painting place and post it here. The teacher there is a young lady and her name is Jane. She is extremely helpful and nice. She is always encouraging me when i was feeling inferior of myself. The class was supposed to last for 2hrs and i took ard 3 hrs!
Haha. I spent too much time painting the sky and towards the end, i have to rush! My painting is more simple, direct, one can almost tell what i am painting about. I guess thats just me, i am not so deep to understand and i believe i am quite an open book.
Gary and Seven painted some abstract pieces and i asked Seven about her painting after guessing what she wanted to portray.
Gary's painting was very awesome too! I thought it is about life and the emotions in life, but he probably dont mean it tt way la. haha.
My painting of Peace,Hope and Love!
Laughter is also Healing , find out why in this sermon.
My 12hours fasting starts now, today (10 Oct 2012) is a church-wide fasting day for City Harvest Church. We are praying and fasting to be closer to God and also for unity among ourselves and also for CHC to reach a higher level through various trials.
Alright, thats all, let me conserve some energy and meanwhile, you folks enjoy the Word!
Special note to Seven and Gary, thank you guys. Both of you really really made me understand what is true friendship. I always thought that i am a good friend, you know, loyal, helpful and etc.
But, i didnt know how to love and be sensitive with my words and minimize the hurts when there are conflicts. Thank you for showing me unconditional love and still loving me despite me being mean sometimes.
Happy Birthday Singapore and the August babies!
Honestly, it is an eyesore for me to see people hating the Govt. I am not a Pro PAP person. I can be quite angry sometimes over the high living expenses, for the difficult times in SG, for the actions and decisions made (high amount of foreigners that jam the whole train, the high cost of buying a car, and the list goes on).
Honestly, i do not love the Govt, or rather, the PAP. But i am extremely thankful for them as well, i believe it is clear that, without them, we can never be proud of ourselves when we go overseas, we can never be the safest (i feel we are) country in South East Asia, or even Asia.
I thank the Govt for everything, i see how Singapore transform from a slump to a country of high standard now.
In short, we really have to give credit to the Govt, so we dont wake up to riots, we dont see drugs going around or people holding guns and etc.
Frankly, just 1 trip to our neighbour country and i am filled with thanks when i touch down back to my Home- Singapore.
I seriously feel that haters should stop hating, be better or go join the Govt to make Singapore a better place than just typing behind computer screens.
We Singaporeans should be proud of ourselves, why are there numerous haters hating and blaming? If you are poor, work harder!
I am not born rich, neither am i even consider rich now. but i do not blame the govt because they didnt make me poor, instead, they kinda motivate me to work harder. Thus i can tell people that are not from Singapore that "If i can survive in Singapore, i can survive anywhere".
When will haters stop hating? No idea, they blame the Govt, they curse my Pastor, they blame everything except for themselves and when i take a look at these people, these are usually the people who will never be contented with life or they are just the ones that are not achieving much that want to whine about everything in the world. Do something instead yo!
Practically, if you are so unhappy staying in SG with its Govt, migrate. Because the Govt is not gona change to please everyone, deal with it or just leave it.
Thus, Thank you Mr Lee Kwan Yew, i dont particularly love you but you deserve much thanks, and much appreciates goes to the Govt, PM Lee and his staff. Mr Tan Chuan Jin has also lent a great help to me and my family. So comon, i am not some rich, spoilt brat that speak up for the govt.
I believe the poor are suffering, my heart goes out to them, and i believe the Govt will try their best to help too, even if not the entire parliament, there will be help. Just hope, not whine.
Sad to say, nothing is fair in this world, even a beautiful country like France, they have beggers everywhere. Look at our neighbours ard SEA. Are they better off? Would you like to stay there? They are not countries that are difficult to live in, except that you might or might not have to face tons of riotings and drug trafficking.
No1 is perfect, no organization is perfect, accept it, be the best yourself and stop expecting. Love your country and even if you cant love the Govt, be thankful and fill yourself with gratitude.
Also, i would like to say Happy Birthday to my Dearest Mom. I love her so much. I will never be able to find a better Mummy other than her.
She is not the perfect Mum, but she is the best mum to me, EVER.
Mummy i love you so much, you are probably the only person other than Jesus, that loves me unconditionally and someone other than Jesus, i would give my heart and life to.
Happy 52! Long live Mummy! May God shower you His blessings of Love and bless you with Good Health and joy!
I know i havent been the best daughter, i know i am very rebellious during my younger days and i upset you aplenty. I hope is not too late to make up to you my dearest Mum.
Happy Birthday to Gary, a pal of mine, also, a belated HBD to my dearest 7. Thank you for being my friend, you both are awesome!


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redpajama_set_name: RedPajamaStackExchange


The SiT3921 is a highly flexible, differential DCXO with LVPECL and LVDS outputs. This programmable device supports any frequency, 1 to 220 MHz, along with any combination of voltage (1.8 V, 2.5 V-3.3 V), pull range (±25 ppm to ±200 ppm) and package (3225, 5032, 7050). It enables frequency tuning via a unique one-wire interface, eliminating frequency drift that is caused by board noise and simplifying PLL and clock synchronization design. It comes in 3 industry-standard 6-pin packages (3.2x2.5 mm, 5.0x3.2 mm, 7.0x5.0 mm).


text:
Sternosternus grouvellei is een keversoort uit de familie glanzende bloemkevers (Phalacridae). De wetenschappelijke naam van de soort werd in 1895 gepubliceerd door Guillebeau.

Glanzende bloemkevers

redpajama_set_name: RedPajamaWikipedia


Preaching has always been a significant moment in the church's worship. During the Middle Ages, preaching became almost completely irrelevant to the people as the consecration of the eucharistic elements became the sole focus of the liturgy. Fewer and fewer people could understand the Latin of the service. The mendicant preachers of the late Middle Ages began to restore preaching to the people, but the Reformation brought a new focus on preaching, often to the exclusion of the Eucharist. The current consensus views preaching as an essential part of the Service of the Word, which is balanced and completed by the Service of the Table. The following entries seek to provide resources for preaching while making no presumption of being exhaustive. The sections on styles and approaches in preaching delineate the essential methods of preaching while attempting to offer a glimpse into other more recent and creative trends in preaching. The history of preaching follows the natural divisions of Old Testament, New Testament, early church, fourth and fifth centuries, Middle Ages, Reformation, and modern era. First, the roots of biblical preaching are described in its Jewish background and later development by Jesus and Paul. The next three centuries of preaching are represented by Melito of Sardis, Origen, John Chrysostom, and Augustine, each with distinct methods and results. This history resumes, after a medieval lull, with the monastic Bernard of Clairvaux, the scholastic Thomas Aquinas, and the mystic John Tauler. Next we look at the preaching styles of the Reformers Martin Luther and John Calvin and conclude with the revivalistic style of John Wesley and George Whitefield.
Throughout the history of the church, preachers have developed different styles of proclaiming the Word. These styles of preaching are often related to the hermeneutics of the preacher. Broadly speaking, the preacher approaches the task of speaking with one of three starting points. The first of these starting points is the Bible. The preacher approaches the text with the question, What does it say? Sermons that fall into this general category are evangelistic preaching, expository preaching, liturgical preaching, narrative preaching, proclamatory preaching, prophetic preaching, and textual preaching. A second starting point may be that of a more systematized sort. It draws from creeds, catechesis, and Christian doctrines with the explicit intent of teaching the system of Christian faith. Such approaches to preaching include catechetical preaching and doctrinal preaching. A third approach to preaching which does not neglect the Scriptures or Christian doctrines is a view of preaching that begins with human need as the starting point. Such types of preaching include African-American preaching, confessional preaching, contextual preaching, lay preaching, life situational preaching, progressive-emotive preaching, and seeker-sensitive preaching. These styles are reviewed and discussed in the following section.
Approaches to preaching are as numerous as preachers themselves. In this section, however, only those approaches that seem most helpful to today's preacher have been included. This section begins with an overview of two approaches to preaching used throughout the church's history to guide the preacher in a selection of biblical texts-lectionary preaching and lectio continua (preaching through a biblical book). These two historical approaches to preaching are immediately followed by a more recent innovation, the involvement of the congregation through a study group in the preparation and evaluation of the sermon. This innovation is indicative of the trend in the modern church to regard the preacher less as an authority on Scripture and more as the gathered community's interpreter of the Bible. The next three entries outline two of the most popular approaches to contemporary preaching-story-formed preaching and seeker-centered preaching. Although story-formed preaching is as ancient as the Bible itself, as the entry about Jewish storytelling makes clear, only recently has the storytelling art been intensively applied to sermon construction. The how of that art is developed in an entry by a preacher who has discovered the revolutionary nature of preaching that is shaped by story. Yet, for all the popularity of story among modern preachers, both in the church and in seminary, a differing approach, seeker-centered preaching, is also gaining attention from contemporary preachers. In the entry by Bill Hybels, one will be able to discern the seeker-centered approach to preaching from one who has helped develop what might be considered the modern successor to the revivalistic approach to evangelistic preaching. Two other new approaches to preaching are described in this section. In both cases, it is not the approach that is new, but rather the people who are preaching. Today major shifts are occurring in both the Protestant and Roman Catholic world as those who have been silent for years bring both fresh voices and approaches to preaching. Two entries, one by a woman, and the other by a lay Roman Catholic, describe these shifts. Finally, two entries have been included to help preachers in their preaching. The first suggests ways in which the preacher may evaluate the sermon. The second entry is a sermon planner that may potentially help the preacher in organizing the biblical witness, outside materials, and their own personal contribution to faithfully proclaiming God's Word today.


text:
Bohemian, DIY, Modern, Preppy, Retro, Whimsical, Alternative, Park, Rooftop, Country Club, Winter, Fall Wedding Photos
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College sweethearts Angela Gispert (26 and a graphic designer) and Christopher Church (26 and also a graphic designer) exchanged vows at the s...
A Preppy Mountain Wedding at Crowne Plaza Resort and Golf Club Lake Placid in New York
Sleek stripes and punchy polka dots put a playful, modern twist on Kate Preston and Katie DiFranco's fall wedding in Lake Placid, New York. Th...
A Modern Museum Wedding at California Academy of Sciences in San Francisco, California
Kalya Paradis (30 and an occupational therapist) met Mike Shahindoust (31 and a mechanical engineer) in Golden Gate Park in San Francisco, Cal...
A Modern, Multicultural Wedding the Greystone at Piedmont Park in Atlanta, Georgia
rn "We had a sort of traditional fall wedding with a twist," says Aparna Kumar (31 and a health care consultant). She wed K...
An Urban Rooftop Wedding at Plenty Mercantile in Oklahoma City, Oklahoma
Marissa Schultz (27 and a retail financial planner) and Scott Rader (31 and an environmental permit and compliance specialist) met at a colleg...
A Boho-Chic Wedding at Degage Jazz Cafe in Maumee, Ohio
Andi Teggart (26 and works in digital marketing) and Eric Burdullis (27 and works in customer experience) met at a music festival in Californi...
A Vibrant Fall Wedding at Indian Trail Club in Franklin Lakes, New Jersey
Since Jaclynn Hinz (27 and a teacher) and Matthew Hinz (27 and a New York state trooper) got married in the fall, they decided to run with a f...
A Rustic Outdoor Wedding at Holiday Inn Hotel & Suites Red Deer South in Edmonton, Alberta
Chantal Vautour (29 and a police officer) and Josh Matthies (30 and a police officer) are outdoorsy ...
A Fun Baseball Stadium Wedding at Target Field in Minneapolis, Minnesota
Kortney Spaeth (24 and a retail manager) and Logan Bratton (25 and a sales lead) met in college as part of the university programming committe...
A Modern Travel-Themed Wedding at the New Seabury Country Club in Mashpee, Massachusetts
Carrie Mackoff (25 and an accountant) and Josh LaQuerre (26 and a pilot) met briefly during their freshman year of college, but it wasn't unti...


Makeup products are the need of both girl and women because without them one can not suffer in this modern age. There are various best makeup brands that are working for the fashion industry of this world. They make their products in different shapes, colors, sizes, designs and patterns. Some cosmetics are suitable for all skin forms. But some items are specially made for sensitive, dry or oily skin type. All cosmetic companies want to give everlasting beauty to their customers with best and quality products. Because of these brands you can find countless things that we use in our makeup. They all are according to your choice and taste and depict the latest trends.
This article is about top 7 international makeup brands and I hope you will like this. I am also showing few pictures of them so that you can easily identify by name, color and size. There are many girls who cannot select a perfect product for their skin tones and because of this mistake they face many skin problems. When you purchase a cosmetic, first of all check those ingredients that are used in it. The name of brand is the most important thing that can affect you.
Another trustworthy brand of makeup is Nivea which is famous for its skin caring products. I would like to tell you that it was awarded in 2010 as the best international brand of this world. Its foundations are liked by everyone because they mix a special cream for sensitive skin.
This is the most favorite makeup brand of men as well as women in the whole global. This is famous for some particular cosmetics such as perfumes, shampoo, creams, foundations, lipstick etc. Mostly men like its hair gel and dye and other beauty products for men. No doubt it is getting popularity among people very rapidly. Estee Lauder is also competing with other companies and making you stylish and beautiful.
One of the biggest international brands Avon was founded in 1880 and since then it is serving both men and women. It is famous for cleansing lotions, eye shadows, liners, nail paint, concealer, moisturizers etc.
It was introduced in 1957 and it has got 7th position in the most famous cosmetics brands of this world. Both men and women are solving their all skin problem by its makeup equipments. Its shampoos and conditioners are useful for our hairs and they contain many essential elements. Its product are mostly used in makeup tips and other applications. Beauty soaps face wash, moisturizing creams & lotions some many other makeup accessories are included in Dove's production.
From 1950s Olay is providing heart winning and beneficial skin care makeup things. It is liked by everyone because of its skin tightening and anti ageing creams.
This brand is the first choice of high-class women especially models who want extra beauty and attraction at all times. All the beauty, hair and skin cosmetics of Neutrogena are made from natural elements. This is also called best lipstick color brand in the world. Its best products are sun block, scrubs, whitening creams, compacts, lip gloss, base coats etc.
These are the best Makeup Brands in the world according to our magazines point of view. For more information please visit on daily basis.


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Home » Blog » Canadian Immigration Programs Overview
Canadian Immigration Programs Overview
Mateo Pelletier
There are many ways to immigrate to the Great White North for those looking to resettle for a better life.
Several programs that the Canadian government offers have various requirements and needs that immigrants to Canada must address. Here are the main ones.
Express Entry
The federal government introduced Express Entry in 2015 for skilled workers to get permanent residency in Canada. It works through a pool system established by IRCC with three federal programs and some cases of Provincial Nominee Programs. Following are the groups for Express Entry immigration.
Federal Skilled Worker Class (FSWC)
Federal Skilled Trades Class (FSTC)
One part of the Provincial Nominee Program (PNP)
Who is eligible? In order to apply for PR through express entry, candidates must meet the eligibility criteria which encompasses age, education, experience, language tests and adaptability factors. All of these factors decide the Comprehensive Ranking System (CRS) score, on the basis of which you are selected to receive an Invitation to Apply (ITA).
How to apply? Candidates are selected through the express entry draw which takes place roughly two weeks apart. On receiving the ITA from the federal government, the candidate has 60 days to submit all required documents and complete the application for successful PR.
The Federal Skilled Worker (FSW) program is Canada's main economic immigration program, and is one of the most popular and preferred ways to gain permanent residency.
Who is eligible? Individuals with specific work skills and experience who can contribute to Canada's economic growth are eligible. The minimum score required: 67. Based on education, language, skillset, and work experience.
How to apply? Candidates must complete a profile under the Express Entry system in order to receive an Invitation to Apply (ITA). Through FSW, candidates can settle anywhere in Canada, except Quebec, which has its own skilled worker program.
Selected candidates must show proof of sufficient funds to support themselves (and/or family) in Canada until they are well settled and financially stable.
The CEC is a stream under the Express Entry program and is ideal for individuals who specifically have Canadian work experience and are seeking to become permanent residents.
Who is eligible? Individuals who can show at least one year of full time (or equal amount in part time) work experience in Canada while under temporary resident status. The work experience must be in managerial, professional or technical jobs and skilled trades. There is no educational requirement for the program.
How to apply? Candidates must have a profile in Express Entry. Periodically, invitations based on Comprehensive Ranking System (CRS) score, are sent out to eligible candidates inviting them to apply for permanent residency.
The Federal Skilled Trades Class (FSTC)
The Federal Skilled Trades Program is for people who are skilled in a trade listed in the NOC and have at least 2 years of recent full-time Canadian experience in the last 5 years.
Who is eligible? There's no points requirement to enter this program. Applicants have to demonstrate that they have a high level of English through a CIC-approved language test.
How to apply? Candidates can complete a profile under the Express Entry system in order to receive an Invitation to Apply (ITA), applying through the PNP and applying specific to Quebec.
The Provincial Nominee Programs
Specifically have Canadian work experience and seeking to become permanent residents. In some cases, a province or territory will decide to nominate a specific person for permanent residency, who has expressed an interest in living there. Each province or territory has its own individual PNP program. Many of these programs are aligned with the Canada Express Entry Program.
Express Entry vs. PNP
PNP is a very specific pathway of entry for potential immigrants. They have very inflexible eligibility criteria that one has to fall under, whereas express entry has broader eligibility criteria that allow a large influx of candidates to apply for permanent residency. Consequently, the pool of candidates for PNP are also much smaller as compared to Express Entry.
Furthermore, when one applies for PNP, their options are narrowed down to one particular province or territory after applying directly for that region. In contrast, Express Entry allows you to settle anywhere you please in Canada and relocate whenever you wish.
There are many benefits of becoming a permanent resident in Canada regardless of which immigration pathway you choose. Candidates can always improve their CRS scores to enhance their chances of being selected for ITA.
How to Avoid Canadian Immigration Scams?
How to Choose the Best Canadian Immigration Consultant
RCICreview is free due to affiliate relationships with some of the consultants mentioned here. Our directory lists all consultants—not just those that pay us - so that you can make the best-informed immigration decision possible.
©2019-2021 RCICreview.com. All rights reserved.


The fine folks at /Film found this great three-dimensional Dark Knight billboard in Los Angeles, specifically at the corner of Sunset and La Brea in Hollywood. (Hmm, who could have made that hole?) Now that's creative advertising!


An Act for regulating the Alienation of Crown Lands, 25 Vic., No. 1. 18 October, 1861.
2. On and after the passing of this Act the Orders in Council shall be repealed. Provided that nothing herein shall prejudice or affect anything already lawfully done or commenced or contracted to be done thereunder respectively or to prevent the several provisions of the said Orders in Council from being carried into effect with respect to lands under lease or promise of lease made previously to the twenty-second day of February one thousand eight hundred and fifty-eight during the currency of such leases as fully as if the same had not been hereby repealed.
21. Conditional purchasers of portions of Crown Lands under sections thirteen and fourteen of this Act not exceeding two hundred and eighty acres or their legal alienees may make additional selection of lands adjoining to the first selection or to each other but not otherwise and not exceeding in the whole three hundred and twenty acres and subject to all the conditions applicable to the original purchase except residence Provided that in the measurement of such additional selection of lands the frontage shall not exceed the extent which would be allowed to an original selection of three hundred and twenty acres Provided also that nothing herein contained shall prevent the sale of the adjoining lands to any other person before such further conditional purchase shall have been made.
22. Holders in fee simple of lands granted by the Crown in areas not exceeding two hundred and eighty acres who may reside on such lands may make conditional purchases adjoining such lands the areas of which shall not with that of the lands held in fee simple exceed three hundred and twenty acres and which shall not be subject to the condition of residence applicable to conditional purchases in other cases Provided that nothing herein contained shall prevent the sale of the adjoining lands to any other person before such further conditional purchase shall have been made.
23. Crown Lands intended to be sold without conditions for residence and improvement shall be put up for public auction in lots not exceeding three hundred and twenty acres-each at such places in the Police District in which the lands ate situated and at such times as the Minister shall direct to be notified by advertisement in the Gazette not less than one month nor more than three months before the day of sale And the upset prices per acre shall not be lower than for Town Lands eight pounds - Suburban Lands two pounds - other Lands one pound Provided that the upset prices may be respectively fixed at any higher amounts.
An Act for regulating the Occupation of Crown Lands. 25 Vic.
No. 2. 18 October 1861.
2. On and after the passing of this Act the Acts of Council eleventh Victoria number sixty-one and sixteen Victoria number twenty-nine and the Orders in Council shall be repealed Provided that nothing herein shall prejudice or affect anything already lawfully done or commenced or contracted to be done thereunder respectively or prevent the several provisions of the said Orders in Council from being carried into effect with respect to lands under lease or promise of lease made previously to the twenty-second day of February one thousand eight hundred and fifty-eight during the currency of such leases as fully as if the same had not been hereby repealed.
6. In cases in which two or more persons entitled to leases under the Orders in Council or under this Act may claim the same land the lease shall be granted to the person whose right thereto may have been or may be established after due inquiry to the satisfaction of the Governor or the Minister and in any such case in which the right of either claimant to a lease of the land in dispute shall not have been so established it shall be lawful for the Minister to require such right to be inquired into and determined by arbitration and the lease may be granted in accordance with the award of such arbitration.
(1) Lands shall not be let in portions of less than six hundred and forty acres or one square mile except in special cases hereinafter provided for.
(2) Every such lease shall be for the then current year and shall expire on the thirty-first day of December.
(3) Leases may be renewed annually by payment between the first and thirtieth day of September to the Land Agent of the district or to the Colonial Treasurer of rent for the ensuing year at the rate of two pounds per square mile or such higher rate as the lessee may pay for the current year, unless the lands be required for sale or for any public purpose or for the satisfaction of any pre-emptive lease claims in right of new purchases and leases not so renewed may be brought to sale by public auction.
(4) Leases under the regulations of twenty-ninth March one thousand eight hundred and forty-eight shall not be renewed under those regulations but may be converted into leases under this Act by payment to the Colonial Treasurer in Sydney or to the Land Agent of the district not later than two months from the publication in the Gazette of a notice to that effect of rent for the ensuing year at the rate of two pounds per square mile or such higher rate as the lessee may now pay unless the land be required for sale or for any public purpose or for the satisfaction of any pre-emptive lease claims which may arise under this Act.
(6) If there be two or more claimants under the last preceding condition of the same land the division of the land amongst them may be settled by arbitration Provided that if such land be of less extent than six hundred and forty acres it may on an award being made be forthwith occupied in accordance therewith and without further formal apportionment Provided also that if at the expiration of three months from the date of a notice in the Gazette announcing to the several claimants of portions not less than six hundred and forty acres the names of their competitors an award shall not have been arrived at and duly communicated to the proper officer the leases of the lands so circumstanced may be offered for sale by auction.
(7) All leases granted under pre-emptive right shall be notified in the Gazette and if within two months from the date of such notification the rent for the same shall not have been paid to the Colonial Treasurer or to the Land Agent of the district leases of the land shall be submitted for sale by auction.
(8) Crown Lands not previously under lease over which no preemptive right of lease shall have been exercised within one year from the passing of this Act may be put up to lease at auction at the Land Office of the district either on application or otherwise but no such sale of leases shall take place without one month's notice thereof having been given in the Gazette.
(9) The upset price of each lot shall be at the rate of one pound per section of six hundred and forty acres or of ten shillings if half of the current year sisal! have expired before the day of sale and the full price bid for each lot shall be paid at the time of sale.
(10) Any lease bid for but the price of which may not be forthwith paid shall thereupon be again offered for sale at auction.
(12) The sale conditional or otherwise of any portion of land under lease shall cancel so much of the lease as relates to the land so sold and to three times the area thereof adjoining thereto Leases may also be cancelled by the Minister for other sufficient reason and the balance of rent froth the date of such cancellation shall in either case be returned to the lessee Provided that the lessee of the lands from which such sale shall be made shall be at liberty either to retain the remaining portion thereof paying however the same amount of rent as for the whole section or surrender the same.
(1) Leases of runs shall be converted into leases for five years under this Act by payment to the Colonial Treasurer not later than two months from the date of a notice in the Gazette to that effect of rent to be determined by appraisement of the fair annual value for pastoral purposes of the lands comprised in such runs Provided that in estimating such value neither the construction of dams or reservoirs nor the laying down of grass nor the making of any other improvement by the occupier shall be taken into account Provided also that the rent shall in no case be less than ten pounds per annum Provided also that upon such conversion as aforesaid such runs shall cease to be liable to assessment under the Act twenty-second Victoria number seventeen.
(2) Leases of old runs may on their expiration be in like manner converted into leases for the term of five years under this Act.
(3) The rent shall be payable to the Colonial Treasurer in Sydney for each year after the first year on or before the thirty-first day of December of the year preceding Provided that a fine shall be payable for the whole time during which any rent due shall remain unpaid after that date at the rate of eight per centum on the amount if not more than three months in arrear and of ten per centum if more than three months And if the rent be not paid at or before the end of six months after such date together with such fine 'the lease shall then become forfeited.
(4) Leases shall not confer any right to purchase by pre-emption.


If you're in a hurry and don't have time to go through all the reviews and buying advice compiled by our researchers but you do want to find the best cordless electric hedge trimmers money can buy, this short paragraph should tell you everything you need to know. We have gathered a lot of information about the best cordless electric hedge trimmers on the market by looking at owner feedback, expert review sites, overall brand quality and even social media activity. Out of the products we have looked at the Black & Decker LHT2436 is the best because its 24 inch blade is capable of quickly trimming back overgrown hedges and can effortlessly cut through branches up to ¾" thick. It also comes with a long lasting 40V lithium ion battery that will give you the power you need to finish your yard chores. If the Black & Decker LHT2436 is not available, you could consider the Makita XHU02Z as it is the second best option.
If you have hedges or even just a couple of shrubs in your yard you know that they need to be trimmed periodically. Not only does this keep them looking neat and well maintained, it also helps to encourage healthy new growth. Cutting and shaping bushes can be time consuming, but it doesn't have to be with a cordless electric hedge trimmer. Before you rush out and buy the first model you see there are a few aspects to consider, and you can find the information you need in this buying guide.
According to the best cordless electric hedge trimmer reviews the first aspect to consider is the blade. There are several types of blades to choose from, though all are flat, constructed from metal and comes with serrated edges. Blades 16 inches and shorter are great for small and medium size hedges, while ones measuring 18 inches are ideal for trimming medium and large bushes. If you have several large bushes or a long row of hedges you will probably want a blade that is at least 20 inches long.
The blade on a hedge trimmer is sharp and accidents can happen if you are not careful. To ensure your safety there are a few features you might want to look for on the trimmers. Automatic shut off functions prevent the tool from running if you leave it unattended. Tooth extensions ensure that the blade is away from your arms and legs when you are working, and it is also a good feature to have if you are still learning how to control trimmer. Others come with shields on the front which can protect your hands and arms from loose twigs and branches.
Cordless electric shrub trimmers that come with wrap-around handles are usually more comfortable to use for extended periods of time, along with triggers that can be locked into place for continuous power. Long lasting batteries are another feature to consider, especially if you need to trim a large number of shrubs. Some models can even be used with an extender so you can easily trim and shape large privacy hedges.
If you want to keep your bushes looking their best then you might want to invest in a hedge trimmer. Convenient and easy to use, there is one that is perfect for your yard. While we can't choose the right one for you we can help you make an informed decision, which is why you can find the best electric hedge trimmers of 2019 showcased below.
With this cordless electric trimmer you can easily tackle long rows of hedges and still have plenty of time left to enjoy your day. It comes with a 40V lithium battery that is capable of supplying plenty of power for you to finish the job, without having to stop and recharge. In most cases it is capable of trimming up to 6,000 square feet on a single charge.
The 24 inch blade can easily tackle large hedges, and since it is "dual action" you will feel less vibrations when you are trimming. The powerful blade can easily cut through branches up to ¾ of an inch thick so even mature shrubs can be neatly trimmed. To ensure maximum comfort even at awkward angles this cordless electric hedge trimmer comes with a wrap-around handle.
There is very little not to like about this hedge trimmer from Makita. It comes with a powerful motor that is capable of up to 1,350 SPM so you can quickly cut and trim your bushes without any problems. The 22 inch blade ensures that everything is neatly trimmed, and it is even long enough to reach the tops of larger hedges.
The motor housing is specially designed to minimize vibrations for more comfort and control while you are working. You will also appreciate the small warning light that will let you know when the battery is running low on power. Your neighbors will love the fact that the XHU02Z is up to 25 percent quieter when running than similar models.
If you are looking for an affordable cordless electric hedge trimmer that can still give you the power and performance you need, you might want to look at this model from MLG. The 18V lithium battery ensures that you have the power you need to finish the job, and it also quickly recharges so it is ready to go when it is time to trim your shrubbery.
The dual action 18 inch blade is ideal for trimming medium and small hedges, and with the teeth spaced 14mm apart you can easily cut through woody overgrowth. Not only is the hedge trimmer easy and convenient to use, it is also designed to be comfortable. The 5 position handle ensures that you can safely and easily trim at an angle when necessary, and it can also make it easier to control.


text:
Q: How to insert a picture in the title so that numbering and page headers stay the same I am writing a book with amsbook document class.
I put a \title, an \author an\email and a \date and then after the \begin{document} I do a \maketitle. The result is ugly as the mail is not even centered ... But this personal taste set apart, the table of contents and the page numbering rea fine, pages headers as well. But this does not suit me as I want to include an eps in my title page. I came accross the custom solution (validated answer as of now from question How can I design a book cover?) that I used :
\documentclass[10pt]{amsbook}

\begin{document}

\clearpage
%% temporary titles
% command to provide stretchy vertical space in proportion
\newcommand\nbvspace[1][3]{\vspace*{\stretch{#1}}}
% allow some slack to avoid under/overfull boxes
\newcommand\nbstretchyspace{\spaceskip0.5em plus 0.25em minus 0.25em}
% To improve spacing on titlepages
\newcommand{\nbtitlestretch}{\spaceskip0.6em}
\pagestyle{empty}
\begin{center}
\bfseries
\nbvspace[1]
{\nbtitlestretch
First line of blah \\second line of blah}

\nbvspace[1]
\LARGE
The title
\nbvspace[1]
\bigskip
\bigskip
\bigskip
\bigskip

\nbvspace[2]

\begin{center}
\includegraphics[scale=1]{./path/to/the/figure.eps}
\end{center}

\nbvspace[4]
\normalsize\normalfont
First version : some date \\
This version : current date

\nbvspace[3]
\normalsize

{\sc First name Last Name}\\
\href{mailto:firstname.lastname@somemail.com}{\tt firstname.lastname@somemail.com}
\nbvspace[1]
\end{center}

%\frontmatter
%
%\pagenumbering{roman} % Start roman numbering
%
\tableofcontents
\setcounter{tocdepth}{3} % 2 pour les subsections
%
%
%\mainmatter
%\pagenumbering{arabic} % Switch to normal numbers

\part{...}

\chapter{...}

\section{...}

Alas this keeps the numbering of pages in the table of contents correct, but all pages numbering disappeared, as well as all headers in all pages ...
I would like to make my headers reappear, as well as the number in the pages as they were before, plus having roman numbers for the table of contents and arabic for all the rest. As show the commented lines in the above code, I tried various things without success.

A: The answer you linked completely bypasses \maketitle, i.e., the normal title page mechanism of amsbook. You can also use a more hybrid approach where you use the default elements of \maketitle and add some of your own. This approach preserves normal processing of headers, page numbers etc., or at least I think it does (you were not very specific on how the headers and page numbers should look).
For this approach the internal amsbook construct \g@addto@macro\addresses can be used, which (internally) adds things to the \addresses macro (unsurprisingly). \addresses is typeset by \maketitle. There are several redefinitions in effect for this macro, such as disabling line endings but also others, set by another internal macro \@setaddresses. Note that these macros have an @ symbol in the name, which informally means that the macros are internal. This also means that you need to use \makeatletter and \makeatother when you want to use of redefine the macros in your main document. The code below disables \@setaddresses and performs centering by redefining it to just \centering\addresses.
In the example code below there are four elements added to the title page: an e-mail address, a subtitle, date information, and an image. Each of these elements has an associated macro with two arguments, first an optional line spacing argument and then the contents (in case of the image there is a third argument for the scale). If the optional argument is not given then a default of 1cm vertical space is used.
The roman and arabic numbers are set using \pagenumbering as in the original code.
Note that the titlepage package option for amsbook is used to put the title on a separate page.
MWE:
\documentclass[10pt,titlepage]{amsbook}
\usepackage{graphicx}
\usepackage{lipsum}
\title{The title}
\author{First Name Last Name}
\makeatletter
\newcommand{\myemail}[2][1cm]{\g@addto@macro\addresses{\texttt{#2}\\[#1]}}
\newcommand{\subtitlelines}[2][1cm]{\g@addto@macro\addresses{#2\\[#1]}}
\newcommand{\datelines}[2][1cm]{\g@addto@macro\addresses{#2\\[#1]}}
\newcommand{\coverimage}[3][1cm]{\g@addto@macro\addresses{\includegraphics[scale=#2]{#3}\\[#1]}}
\def\@setaddresses{\centering\addresses}
\makeatother
\myemail[0.5cm]{firstname.lastname@somemail.com}
\subtitlelines{First line of blah\\Second line of blah}
\coverimage{0.6}{example-image}
\datelines{First version: some date\\This version: current date}

\begin{document}
\maketitle
\pagenumbering{roman}
\tableofcontents
\pagenumbering{arabic}
\part{First part}
\chapter{First chapter}
\section{First section}
\lipsum[1-10]
\end{document}

Result:


text:
Manchester Airport statement on TUI media reports
A statement from Manchester Airport relating to media reports that TUI are seeking compensation for operational disruption.
A Manchester Airport spokesperson said:
"The operational issues experienced by TUI at Manchester Airport in early June were the result of issues with TUI's own operation, including the ground handling services that are contracted directly by the airline.
"As such, we welcome TUI's confirmation that it will not seek compensation from Manchester Airport for the disruption its passengers experienced, contrary to some recent reports in the media.
"Manchester Airport has not enforced flight cancellations on any carrier, and we have been working closely with all our airlines to support them in operating their planned schedules.
"When individual airlines have taken the decision to reduce their schedules we have worked with them to facilitate that. This was the case in May when TUI opted to cut six flights per day from its June schedule, due to resource challenges experienced by the airline and its appointed ground handler, Swissport.
"We understand the disruption that flight cancellations cause to passengers, which is why we have worked hard with our airlines to avoid capacity reductions at Manchester Airport, and have sought regular assurances from all of our partners regarding their operational capacity."