Mirror therapy in children with hemiplegia: a pilot study.

Mirror therapy, which provides the visual illusion of a functional paretic limb by using the mirror reflection of the non-paretic arm, is used in the rehabilitation of hemiparesis after stroke in adults. We tested the effectiveness and feasibility of mirror therapy in children with hemiplegia by performing a pilot crossover study in ten participants (aged 6-14 y; five males, five females; Manual Ability Classification System levels: one at level I, two at level II, four at level III, three at level IV) randomly assigned to 15 minutes of daily bimanual training with and without a mirror for 3 weeks. Assessments of maximal grasp and pinch strengths, and upper limb function measured by the Shriner's Hospital Upper Extremity Evaluation were performed at weeks 0 (baseline), 3, 6 (intervention), and 9 (wash-out). Testing of grasp strength behind the mirror improved performance by 15% (p=0.004). Training with the mirror significantly improved grasp strength (with mirror +20.4%, p=0.033; without +5.9%, p>0.1) and upper limb dynamic position (with mirror +4.6%, p=0.044; without +1.2%, p>0.1), while training without a mirror significantly improved pinch strength (with mirror +6.9%, p>0.1; without +21.9%, p=0.026). This preliminary study demonstrates the feasibility of mirror therapy in children with hemiplegia and that it may improve strength and dynamic function of the paretic arm.

A PERCEÇÃO DE QUALIDADE DE SERVIÇO DOS CLIENTES EMPRESAS: O CASO BCA

O objetivo do presente trabalho foi estudar a perceção que os clientes empresas têm em relação a qualidade de serviço prestado por um Banco em Santiago, Cabo Verde. Procurou-se saber se existe gap entre as expetativas dos clientes e a perceção do serviço recebido. No estudo utilizou-se um dos modelos muito usado nos serviços de marketing, o SERVQUAL, desenvolvido por Parasuraman et al. (1985 e 1988). O modelo é baseado na perceção de gaps entre a qualidade de serviço recebido e esperado amplamente adotado para explicar a perceção da qualidade dos serviços pelos consumidores. No estudo utilizou-se um questionário estruturado com perguntas fechadas. Uma amostra de 90 empresas constitui o número de inquiridos. A pesquisa foi conduzida na ilha de Santiago, República de Cabo Verde. Cinco caraterísticas da qualidade de serviços foram analisadas: Tangibilidade, Confiabilidade, Atendimento, Segurança e Empatia. Ficou evidente que existe gap entre as expetativas e perceções das empresas inquiridas. A limitação do estudo prende-se com o tamanho da amostra e de estar restrito à ilha de Santiago, pertencente ao grupo de Sotavento do arquipélago de Cabo Verde.

Effect of compaction on microbial activity and carbon and nitrogen transformations in two oxisols with different mineralogy

The use of machinery in agricultural and forest management activities frequently increases soil compaction, resulting in greater soil density and microporosity, which in turn reduces hydraulic conductivity and O2 and CO2 diffusion rates, among other negative effects. Thus, soil compaction has the potential to affect soil microbial activity and the processes involved in organic matter decomposition and nutrient cycling. This study was carried out under controlled conditions to evaluate the effect of soil compaction on microbial activity and carbon (C) and nitrogen (N) mineralization. Two Oxisols with different mineralogy were utilized: a clayey oxidic-gibbsitic Typic Acrustox and a clayey kaolinitic Xantic Haplustox (Latossolo Vermelho-Amarelo ácrico - LVA, and Latossolo Amarelo distrófico - LA, respectively, in the Brazil Soil Classification System). Eight treatments (compaction levels) were assessed for each soil type in a complete block design, with six repetitions. The experimental unit consisted of PVC rings (height 6 cm, internal diameter 4.55 cm, volume 97.6 cm³). The PVC rings were filled with enough soil mass to reach a final density of 1.05 and 1.10 kg dm-3, respectively, in the LVA and LA. Then the soil samples were wetted (0.20 kg kg-1 = 80 % of field capacity) and compacted by a hydraulic press at pressures of 0, 60, 120, 240, 360, 540, 720 and 900 kPa. After soil compression the new bulk density was calculated according to the new volume occupied by the soil. Subsequently each PVC ring was placed within a 1 L plastic pot which was then tightly closed. The soils were incubated under aerobic conditions for 35 days and the basal respiration rate (CO2-C production) was estimated in the last two weeks. After the incubation period, the following soil chemical and microbiological properties were detremined: soil microbial biomass C (C MIC), total soil organic C (TOC), total N, and mineral N (NH4+-N and NO3--N). After that, mineral N, organic N and the rate of net N mineralization was calculated. Soil compaction increased NH4+-N and net N mineralization in both, LVA and LA, and NO3--N in the LVA; diminished the rate of TOC loss in both soils and the concentration of NO3--N in the LA and CO2-C in the LVA. It also decreased the C MIC at higher compaction levels in the LA. Thus, soil compaction decreases the TOC turnover probably due to increased physical protection of soil organic matter and lower aerobic microbial activity. Therefore, it is possible to conclude that under controlled conditions, the oxidic-gibbsitic Oxisol (LVA) was more susceptible to the effects of high compaction than the kaolinitic (LA) as far as organic matter cycling is concerned; and compaction pressures above 540 kPa reduced the total and organic nitrogen in the kaolinitic soil (LA), which was attributed to gaseous N losses.

Unsatisfactory outcomes in myasthenia gravis: influence by care providers.

Myasthenia gravis (MG) can be difficult to treat despite an available therapeutic armamentarium. Our aim was to analyze the factors leading to unsatisfactory outcome (UO). To this end we used the Myasthenia Gravis Foundation of America classification system. Forty one patients with autoimmune MG were followed prospectively from January 2003 to December 2007. Outcomes were assessed throughout follow-up and at a final visit. 'Unchanged', 'worse', 'exacerbation' and 'died of MG' post-intervention status were considered UOs. During follow-up, UO rates reached 54% and were related to undertreatment (41%), poor treatment compliance (23%), infections (23%), and adverse drug effects (13%). The UO rate at final study assessment was 20%. UO during follow-up was significantly (P = 0.004) predictive of UOs at final assessment. When care was provided by neuromuscular (NM) specialists, patients had significantly better follow-up scores (P = 0.01). At final assessment UO rates were 7% and significantly better in patients treated by NM specialists, compared to other physicians where UO rates reached 27%. UO was a frequent finding occurring in more than half our patients during follow-up. Nearly two-thirds of the UOs could have been prevented by appropriate therapeutic adjustments and improved compliance. The differential UO rates at follow-up, their dependency on the degree to which the management was specialized and their correlation with final outcomes suggest that specialized MG care improves outcomes.

Comparison between detailed digital and conventional soil maps of an area with complex geology

Since different pedologists will draw different soil maps of a same area, it is important to compare the differences between mapping by specialists and mapping techniques, as for example currently intensively discussed Digital Soil Mapping. Four detailed soil maps (scale 1:10.000) of a 182-ha sugarcane farm in the county of Rafard, São Paulo State, Brazil, were compared. The area has a large variation of soil formation factors. The maps were drawn independently by four soil scientists and compared with a fifth map obtained by a digital soil mapping technique. All pedologists were given the same set of information. As many field expeditions and soil pits as required by each surveyor were provided to define the mapping units (MUs). For the Digital Soil Map (DSM), spectral data were extracted from Landsat 5 Thematic Mapper (TM) imagery as well as six terrain attributes from the topographic map of the area. These data were summarized by principal component analysis to generate the map designs of groups through Fuzzy K-means clustering. Field observations were made to identify the soils in the MUs and classify them according to the Brazilian Soil Classification System (BSCS). To compare the conventional and digital (DSM) soil maps, they were crossed pairwise to generate confusion matrices that were mapped. The categorical analysis at each classification level of the BSCS showed that the agreement between the maps decreased towards the lower levels of classification and the great influence of the surveyor on both the mapping and definition of MUs in the soil map. The average correspondence between the conventional and DSM maps was similar. Therefore, the method used to obtain the DSM yielded similar results to those obtained by the conventional technique, while providing additional information about the landscape of each soil, useful for applications in future surveys of similar areas.

Iowa Department of Corrections Presentation to Transportation, Infrastructure, Capitals Appropriations Subcommittee, February 2008

An update of the following: Status of capital projects from prior year appropriations, appropriation from RIIF, and other other projects, current prison population, expected growth and over population, overview of revised classification system and how it affects bed planning, timeline for construction, 2009 funding, plan for the governor recommended $500,000 for project management and other infrastructure priorities.

Multiple Geotechnological Tools Applied to Digital Mapping of Tropical Soils

ABSTRACT In recent years, geotechnologies as remote and proximal sensing and attributes derived from digital terrain elevation models indicated to be very useful for the description of soil variability. However, these information sources are rarely used together. Therefore, a methodology for assessing and specialize soil classes using the information obtained from remote/proximal sensing, GIS and technical knowledge has been applied and evaluated. Two areas of study, in the State of São Paulo, Brazil, totaling approximately 28.000 ha were used for this work. First, in an area (area 1), conventional pedological mapping was done and from the soil classes found patterns were obtained with the following information: a) spectral information (forms of features and absorption intensity of spectral curves with 350 wavelengths -2,500 nm) of soil samples collected at specific points in the area (according to each soil type); b) obtaining equations for determining chemical and physical properties of the soil from the relationship between the results obtained in the laboratory by the conventional method, the levels of chemical and physical attributes with the spectral data; c) supervised classification of Landsat TM 5 images, in order to detect changes in the size of the soil particles (soil texture); d) relationship between classes relief soils and attributes. Subsequently, the obtained patterns were applied in area 2 obtain pedological classification of soils, but in GIS (ArcGIS). Finally, we developed a conventional pedological mapping in area 2 to which was compared with a digital map, ie the one obtained only with pre certain standards. The proposed methodology had a 79 % accuracy in the first categorical level of Soil Classification System, 60 % accuracy in the second category level and became less useful in the categorical level 3 (37 % accuracy).

Case complexity and clinical outcome in diabetes mellitus. A prospective study using the INTERMED.

The aim of this study was to assess a population of patients with diabetes mellitus by means of the INTERMED, a classification system for case complexity integrating biological, psychosocial and health care related aspects of disease. The main hypothesis was that the INTERMED would identify distinct clusters of patients with different degrees of case complexity and different clinical outcomes. Patients (n=61) referred to a tertiary reference care centre were evaluated with the INTERMED and followed 9 months for HbA1c values and 6 months for health care utilisation. Cluster analysis revealed two clusters: cluster 1 (62%) consisting of complex patients with high INTERMED scores and cluster 2 (38%) consisting of less complex patients with lower INTERMED. Cluster 1 patients showed significantly higher HbA1c values and a tendency for increased health care utilisation. Total INTERMED scores were significantly related to HbA1c and explained 21% of its variance. In conclusion, different clusters of patients with different degrees of case complexity were identified by the INTERMED, allowing the detection of highly complex patients at risk for poor diabetes control. The INTERMED therefore provides an objective basis for clinical and scientific progress in diabetes mellitus. Ongoing intervention studies will have to confirm these preliminary data and to evaluate if management strategies based on the INTERMED profiles will improve outcomes.

Le Resident Assessment Instrument-Home-Care (RAI-Domicile): ce que le médecin de premier recours doit savoir [The Resident Assessment Instrument Home care: what primary care physician needs to know].

Following the decision of the Swiss Association for Home Care Services to adopt the Resident Assessment Instrument (RAI), the RAI-Home Care is gradually implemented in all home care services in Switzerland. Based on a comprehensive geriatric assessment, the RAI not only allows to establish an individualized plan of care, but also generates quality indicators and a case-mix classification system that helps financing and planning resources. This article describes the five steps of the RAI-Home Care process and discusses the strengths, future and limitations of the RAI.

Diagnostic algorithm for a validated displacement grading of pediatric supracondylar fractures.

Background: The first AO comprehensive pediatric long bone fracture classification system has been established following a structured path of development and validation with experienced pediatric surgeons. Methods: A follow-up series of agreement studies was applied to specify and evaluate a grading system for displacement of pediatric supracondylar fractures. An iterative process comprising an international group of 5 experienced pediatric surgeons (Phase 1) followed by a pragmatic multicenter agreement study involving 26 raters (Phase 2) was used. The last evaluations were conducted on a consecutive collection of 154 supracondylar fractures documented by standard anteroposterior and lateral radiographs. Results: Fractures were classified according to 1 of 4 grades: I = incomplete fracture with no or minimal displacement; II = Incomplete fracture with continuity of the posterior (extension fracture) or anterior cortex (flexion fracture); III = lack of bone continuity (broken cortex), but still some contact between the fracture planes; IV = complete fracture with no bone continuity (broken cortex), and no contact between the fracture planes. A diagnostic algorithm to support the practical application of the grading system in a clinical setting, as well as an aid using a circle placed over the capitellum was proposed. The overall kappa coefficients were 0.68 and 0.61 in the Phase 1 and Phase 2 studies, respectively. In the Phase 1 study, fracture grades I, II, III, and IV were classified with median accuracies of 91%, 82%, 83%, and 99.5%, respectively. Similar median accuracies of 86% (Grade I), 73% (Grade II), 83%(Grade III), and 92% were reported for the Phase 2 study. Reliability was high in distinguishing complete, unstable fractures from stable injuries [ie, kappa coefficients of 0.84 (Phase 1) and 0.83 (Phase 2) were calculated]; in Phase 2, surgeons' accuracies in classifying complete fractures were all above 85%. Conclusions: With clear and unambiguous definition, this new grading system for supracondylar fracture displacement has proved to be sufficiently reliable and accurate when applied by pediatric surgeons in the framework of clinical routine as well as research.

Automated Traffic/Truck Weight Monitoring Equipment (Weigh-in-Motion), HR-282, 1988

This report documents work undertaken in the demonstration of a low-cost Automatic Weight and Classification System (AWACS). An AWACS procurement specification and details of the results of the project are also included. The intent of the project is to support and encourage transferring research knowledge to state and local agencies and manufacturers through field demonstrations. Presently available, Weigh-in-Motion and Classification Systems are typically too expensive to permit the wide deployment necessary to obtain representative vehicle data. Piezo electric technology has been used in the United Kingdom and Europe and is believed to be the basic element in a low-cost AWACS. Low-cost systems have been installed at two sites, one in Portland Cement Concrete (PCC) pavement in Iowa and the other in Asphaltic Cement Concrete (ACC) pavement in Minnesota to provide experience with both types of pavement. The systems provide axle weights, gross vehicle weight, axle spacing, vehicle classification, vehicle speed, vehicle count, and time of arrival. In addition, system self-calibration and a method to predict contact tire pressure is included in the system design. The study has shown that in the PCC pavement, the AWACS is capable of meeting the needs of state and federal highway agencies, producing accuracies comparable to many current commercial WIM devices. This is being achieved at a procurement cost of substantially less than currently available equipment. In the ACC pavement the accuracies were less than those observed in the PCC pavement which is concluded to result from a low pavement rigidity at this site. Further work is needed to assess the AWACS performance at a range of sites in ACC pavements.

Embankment Quality: Phase III, TR-401, 2002

This report describes test results from a full-scale embankment pilot study conducted in Iowa. The intent of the pilot project was to field test and refine the proposed soil classification system and construction specifications developed in Phase II of this research and to evaluate the feasibility of implementing a contractor quality control (QC) and Iowa DOT quality assurance (QA) program for earthwork grading in the future. One of the primary questions for Phase III is “Was embankment quality improved?” The project involved a “quality conscious” contractor, well-qualified and experienced Iowa Department of Transportation field personnel, a good QC consultant technician, and some of our best soils in the state. If the answer to the above question is “yes” for this project, it would unquestionably be “yes” for other projects as well. The answer is yes, the quality was improved, even for this project, as evidenced by dynamic cone penetrometer test data and the amount of disking required to reduce the moisture content to within acceptable control limits (approximately 29% of soils by volume required disking). Perhaps as important is that we know what quality we have. Increased QC/QA field testing, however, increases construction costs, as expected. The quality management-earthwork program resulted in an additional $0.03 per cubic meter, or 1.6%, of the total construction costs. Disking added about $0.04 per cubic meter, or 1.7%, to the total project costs. In our opinion this is a nominal cost increase to improve quality. It is envisioned that future contractor innovations have the potential for negating this increase. The Phase III results show that the new soil classification system and the proposed field test methods worked well during the Iowa Department of Transportation soils design phase and during the construction phase. Recommendations are provided for future implementation of the results of this study by city, county, and state agencies.

Les fractures du pilon tibial. Etude rétrospective à long terme de 51 fractures traitées par réduction sanglante et ostéosynthèse [Fractures of the tibial pilon. Long-term retrospective study of 51 fractures treated with open reduction and osteosynthesis].

PURPOSE OF THE STUDY: Fracture of the tibial pilon is a rare injury and its treatment remains difficult. The aim of this study was to report the complications and long term results of internal fixation using a technique which respects soft tissues and in which little material was used. MATERIAL: From 1985 to 1990, 48 patients with 51 fractures of the tibial pilon were treated by open reduction and internal fixation. All patients were submitted to a clinical and radiological review. METHODS: Both the Rüedi/Allgöwer and the AO-classification were used and determined by standard X-rays. Surgical procedure was performed with a 2 or 3 1/3 tube AO-plates and the peroneus was always fixed if fractured. Intraoperative reconstruction was analyzed. Subjective and objective scoring were used according to Olerud and Molander and the ankle arthritis was scored according to the classification determined by the SOFCOT in 1992. RESULTS: A minimal follow-up of 1 year for all cases was obtained, based on our own files. Thirty-eight patients (40 fractures) were evaluated after an average period of 88 months (56 to 124 months). Five patients developed cutaneous infection, three developed deep infection and four developed superficial skin necrosis. One aseptic non-union necessitated reoperation after 14 months. Two ankles had joint fusion after 19 and 25 months respectively due to severe arthritis. In six cases infectious and non-infectious complications led to surgical revision. According to the Olerud and Molander score, 15 per cent of the results were excellent, 45 per cent were good, 30 per cent were fair and 10 per cent poor. DISCUSSION: Literature shows a wide range of results following this surgical procedure. This is due to the difference in the type of trauma, classification system used, material used for the internal fixation and method of evaluation. The classification system of Rüedi and Allgöwer is the most commonly used but has a rather subjective tendency, especially between type II and type III. Treatment is difficult, especially for comminutive fractures associated with soft tissue damage. In this case, open reduction and internal fixation could increase iatrogenic lesions. For this reason surgical procedure can be delayed for several days, little material is used and soft tissue manipulation is reduced to minimum. In other study reports, the use of external fixation with or without minimal internal fixation have produced less complications without improving long term results. CONCLUSION: Analysis and comparison of study reports are difficult because of the absence of consensus in classification system and evaluation methods. The AO-classification, apparently the most objective, will probably be more and more used in the future. Treatment must be adapted to the bony lesion and soft tissue damage. Open reduction and internal fixation must be reserved for a specific group of lesion.

Outcome at two years of age in a Swiss national cohort of extremely preterm infants born between 2000 and 2008.

BACKGROUND: While survival rates of extremely preterm infants have improved over the last decades, the incidence of neurodevelopmental disability (ND) in survivors remains high. Representative current data on the severity of disability and of risk factors associated with poor outcome in this growing population are necessary for clinical guidance and parent counselling. METHODS: Prospective longitudinal multicentre cohort study of preterm infants born in Switzerland between 24(0/7) and 27(6/7) weeks gestational age during 2000-2008. Mortality, adverse outcome (death or severe ND) at two years, and predictors for poor outcome were analysed using multilevel multivariate logistic regression. Neurodevelopment was assessed using Bayley Scales of Infant Development II. Cerebral palsy was graded after the Gross Motor Function Classification System. RESULTS: Of 1266 live born infants, 422 (33%) died. Follow-up information was available for 684 (81%) survivors: 440 (64%) showed favourable outcome, 166 (24%) moderate ND, and 78 (11%) severe ND. At birth, lower gestational age, intrauterine growth restriction and absence of antenatal corticosteroids were associated with mortality and adverse outcome (p < 0.001). At 36(0/7) weeks postmenstrual age, bronchopulmonary dysplasia, major brain injury and retinopathy of prematurity were the main predictors for adverse outcome (p < 0.05). Survival without moderate or severe ND increased from 27% to 39% during the observation period (p = 0.02). CONCLUSIONS: In this recent Swiss national cohort study of extremely preterm infants, neonatal mortality was determined by gestational age, birth weight, and antenatal corticosteroids while neurodevelopmental outcome was determined by the major neonatal morbidities. We observed an increase of survival without moderate or severe disability.

Defining risk thresholds for a 10-year probability of hip fracture model that combines clinical risk factors and quantitative ultrasound: results using the EPISEM cohort.

Using a large prospective cohort of over 12,000 women, we determined 2 thresholds (high risk and low risk of hip fracture) to use in a 10-yr hip fracture probability model that we had previously described, a model combining the heel stiffness index measured by quantitative ultrasound (QUS) and a set of easily determined clinical risk factors (CRFs). The model identified a higher percentage of women with fractures as high risk than a previously reported risk score that combined QUS and CRF. In addition, it categorized women in a way that was quite consistent with the categorization that occurred using dual X-ray absorptiometry (DXA) and the World Health Organization (WHO) classification system; the 2 methods identified similar percentages of women with and without fractures in each of their 3 categories, but the 2 identified only in part the same women. Nevertheless, combining our composite probability model with DXA in a case findings strategy will likely further improve the detection of women at high risk of fragility hip fracture. We conclude that the currently proposed model may be of some use as an alternative to the WHO classification criteria for osteoporosis, at least when access to DXA is limited.