Difficulties associated with outpatient management of drug abusers by general practitioners. A cross-sectional survey of general practitioners with and without methadone patients in Switzerland.

BACKGROUND: In Switzerland, general practitioners (GPs) manage most of the patients receiving methadone maintenance treatment (MMT). METHODS: Using a cross-sectional postal survey of GPs who treat MMT patients and GPs who do not, we studied the difficulties encountered in the out-patient management of drug-addicted patients. We sent a questionnaire to every GP with MMT patients (556) in the French-speaking part of Switzerland (1,757,000 inhabitants). We sent another shorter questionnaire to primary care physicians without MMT patients living in the Swiss Canton of Vaud. RESULTS: The response rate was 63.3%. The highest methadone dose given by GPs to MMT patients averaged 120.4 mg/day. When asked about help they would like to be given, GPs with MMT patients primarily mentioned the importance of receiving adequate fees for the care they provide. Secondly, they mentioned the importance of better training, better knowledge of psychiatric pathologies, and discussion groups on practical cases. GPs without MMT patients refuse to treat these patients mostly for emotional and relational reasons. CONCLUSION: GPs encounter financial, relational and emotional difficulties with MMT patients. They desire better fees for services and better training.

New considerations on the management of osteoporosis in Central and Eastern Europe (CEE): summary of the "3rd Summit on Osteoporosis-CEE", November 2009, Budapest, Hungary.

INTRODUCTION: In November 2009, the "3rd Summit on Osteoporosis-Central and Eastern Europe (CEE)" was held in Budapest, Hungary. The conference aimed to tackle issues regarding osteoporosis management in CEE identified during the second CEE summit in 2008 and to agree on approaches that allow most efficient and cost-effective diagnosis and therapy of osteoporosis in CEE countries in the future. DISCUSSION: The following topics were covered: past year experience from FRAX® implementation into local diagnostic algorithms; causes of secondary osteoporosis as a FRAX® risk factor; bone turnover markers to estimate bone loss, fracture risk, or monitor therapies; role of quantitative ultrasound in osteoporosis management; compliance and economical aspects of osteoporosis; and osteoporosis and genetics. Consensus and recommendations developed on these topics are summarised in the present progress report. CONCLUSION: Lectures on up-to-date data of topical interest, the distinct regional provenances of the participants, a special focus on practical aspects, intense mutual exchange of individual experiences, strong interest in cross-border cooperations, as well as the readiness to learn from each other considerably contributed to the establishment of these recommendations. The "4th Summit on Osteoporosis-CEE" held in Prague, Czech Republic, in December 2010 will reveal whether these recommendations prove of value when implemented in the clinical routine or whether further improvements are still required.

Aggregation and errors in management accounting

Il est important pour les entreprises de compresser les informations détaillées dans des sets d'information plus compréhensibles. Au chapitre 1, je résume et structure la littérature sur le sujet « agrégation d'informations » en contrôle de gestion. Je récapitule l'analyse coûts-bénéfices que les comptables internes doivent considérer quand ils décident des niveaux optimaux d'agrégation d'informations. Au-delà de la perspective fondamentale du contenu d'information, les entreprises doivent aussi prendre en considération des perspectives cogni- tives et comportementales. Je développe ces aspects en faisant la part entre la comptabilité analytique, les budgets et plans, et la mesure de la performance. Au chapitre 2, je focalise sur un biais spécifique qui se crée lorsque les informations incertaines sont agrégées. Pour les budgets et plans, des entreprises doivent estimer les espérances des coûts et des durées des projets, car l'espérance est la seule mesure de tendance centrale qui est linéaire. A la différence de l'espérance, des mesures comme le mode ou la médiane ne peuvent pas être simplement additionnés. En considérant la forme spécifique de distributions des coûts et des durées, l'addition des modes ou des médianes résultera en une sous-estimation. Par le biais de deux expériences, je remarque que les participants tendent à estimer le mode au lieu de l'espérance résultant en une distorsion énorme de l'estimati¬on des coûts et des durées des projets. Je présente également une stratégie afin d'atténuer partiellement ce biais. Au chapitre 3, j'effectue une étude expérimentale pour comparer deux approches d'esti¬mation du temps qui sont utilisées en comptabilité analytique, spécifiquement « coûts basés sur les activités (ABC) traditionnelles » et « time driven ABC » (TD-ABC). Au contraire des affirmations soutenues par les défenseurs de l'approche TD-ABC, je constate que cette dernière n'est pas nécessairement appropriée pour les calculs de capacité. Par contre, je démontre que le TD-ABC est plus approprié pour les allocations de coûts que l'approche ABC traditionnelle. - It is essential for organizations to compress detailed sets of information into more comprehensi¬ve sets, thereby, establishing sharp data compression and good decision-making. In chapter 1, I review and structure the literature on information aggregation in management accounting research. I outline the cost-benefit trade-off that management accountants need to consider when they decide on the optimal levels of information aggregation. Beyond the fundamental information content perspective, organizations also have to account for cognitive and behavi¬oral perspectives. I elaborate on these aspects differentiating between research in cost accounti¬ng, budgeting and planning, and performance measurement. In chapter 2, I focus on a specific bias that arises when probabilistic information is aggregated. In budgeting and planning, for example, organizations need to estimate mean costs and durations of projects, as the mean is the only measure of central tendency that is linear. Different from the mean, measures such as the mode or median cannot simply be added up. Given the specific shape of cost and duration distributions, estimating mode or median values will result in underestimations of total project costs and durations. In two experiments, I find that participants tend to estimate mode values rather than mean values resulting in large distortions of estimates for total project costs and durations. I also provide a strategy that partly mitigates this bias. In the third chapter, I conduct an experimental study to compare two approaches to time estimation for cost accounting, i.e., traditional activity-based costing (ABC) and time-driven ABC (TD-ABC). Contrary to claims made by proponents of TD-ABC, I find that TD-ABC is not necessarily suitable for capacity computations. However, I also provide evidence that TD-ABC seems better suitable for cost allocations than traditional ABC.

Role of physical exercise in low back pain rehabilitation: a randomized controlled trial of a three-month exercise program in patients who have completed multidisciplinary rehabilitation.

STUDY DESIGN: Randomized controlled trial with 1-year follow-up. OBJECTIVE: To analyze the effects of an exercise program or routine follow-up on patients with chronic low back pain who have completed functional multidisciplinary rehabilitation. The short- and long-term outcome in terms of symptoms and physical and social functioning was compared. SUMMARY OF BACKGROUND DATA: Systematic reviews have shown that functional multidisciplinary rehabilitation improves physical function and reduces pain in patients with chronic low back pain. However, long-term maintenance of these improvements is inconsistent and the role of exercise in achieving this goal is unclear. METHODS: One hundred five chronic patients with low back pain who had completed a 3-week functional multidisciplinary rehabilitation program were randomized to either a 3-month exercise program (n = 56) or routine follow-up (n = 49). The exercise program consisted of 24 training sessions during 12 weeks. Patients underwent evaluations of trunk muscle endurance, cardiovascular endurance, lumbar spine mobility (flexion and extension range-of-motion, fingertip-to-floor distance), pain and perceived functional ability at the beginning and the end of functional multidisciplinary rehabilitation, at the end of the exercise program (3 months) and at 1-year follow-up. Disability was also assessed at the same time points except at the beginning of functional multidisciplinary rehabilitation. RESULTS: At the end of the functional multidisciplinary rehabilitation, both groups improved significantly in all physical parameters except flexion and extension range-of-motion. At the 3 month and 1 year follow-up, both groups maintained improvements in all parameters except for cardiovascular endurance. Only the exercise program group improved in disability score and trunk muscle endurance. No differences between groups were found. CONCLUSION: A favorable long-term outcome was observed after functional multidisciplinary rehabilitation in both patient groups. Patients who participated in an exercise program obtained some additional benefits. The relevance of these benefits to overall health status need to be further investigated.

Environmental and agricultural benefits of a management system designed for sandy loam soils of the humid tropics

A sustainable management of soils with low natural fertility on family farms in the humid tropics is a great challenge and overcoming it would be an enormous benefit for the environment and the farmers. The objective of this study was to assess the environmental and agronomic benefits of alley cropping, based on the evaluation of C sequestration, soil quality indicators, and corn yields. Combinations of four legumes were used in alley cropping systems in the following treatments: Clitoria fairchildiana + Cajanus cajan; Acacia mangium + Cajanus cajan; Leucaena leucocephala + Cajanus cajan; Clitoria fairchildiana + Leucaena leucocephala; Leucaena leucocephala + Acacia mangium and a control. Corn was used as a cash crop. The C content was determined in the different compartments of soil organic matter, CEC, available P, base saturation, percentage of water saturation, the period of the root hospitality factor below the critical level and corn yield. It was concluded that alley cropping could substitute the slash and burn system in the humid tropics. The main environmental benefit of alley cropping is the maintenance of a dynamic equilibrium between C input and output that could sustain up to 10 Mg ha-1 of C in the litter layer, decreasing atmospheric CO2 levels. Alley cropping is also beneficial from the agricultural point of view, because it increases base saturation and decreases physical resistance to root penetration in the soil layer 0 - 10 cm, which ensures the increase and sustainability of corn yield.

Iowa Budget Book Fiscal Year 2011.

Our FY 2011 General Fund budget is balanced, fiscally conservative, and does not raise sales or income taxes. We have already proposed and signed three balanced state budgets and have demonstrated the leadership to ensure that the current year (FY 2010) budget is balanced in the face of dramatic and quick declines in state revenues last year that occurred as a result of the national recession.

Pedotransfer functions to estimate proctor test parameters under different tillage systems

The Proctor test is time-consuming and requires sampling of several kilograms of soil. Proctor test parameters were predicted in Mollisols, Entisols and Vertisols of the Pampean region of Argentina under different management systems. They were estimated from a minimum number of readily available soil properties (soil texture, total organic C) and management (training data set; n = 73). The results were used to generate a soil compaction susceptibility model, which was subsequently validated using a second group of independent data (test data set; n = 24). Soil maximum bulk density was estimated as follows: Maximum bulk density (Mg m-3) = 1.4756 - 0.00599 total organic C (g kg-1) + 0.0000275 sand (g kg-1) + 0.0539 management. Management was equal to 0 for uncropped and untilled soils and 1 for conventionally tilled soils. The established models predicted the Proctor test parameters reasonably well, based on readily available soil properties. Tillage systems induced changes in the maximum bulk density regardless of total organic matter content or soil texture. The lower maximum apparent bulk density values under no-tillage require a revision of the relative compaction thresholds for different no-tillage crops.

Safer Construction and Maintenance Safer Construction and Maintenance Practices to Minimize Potential Liability by Counties from Accidents, September 1979

Tort claims resulting from alleged highway defects have introduced an additional element in the planning, design, construction, and maintenance of highways. A survey of county governments in Iowa was undertaken in order to quantify the magnitude and determine the nature of this problem. This survey included the use of mailed questionnaires and personal interviews with County Engineers. Highway-related claims filed against counties in Iowa amounted to about $52,000,000 during the period 1973 through 1978. Over $30,000,000 in claims was pending at the end of 1978. Settlements of judgments were made at a cost of 12.2% of the amount claimed for those claims that had been disposed of, not including costs for handling claims, attorney fees, or court costs. There was no clear time trend in the amount of claims for the six-year period surveyed, although the amount claimed in 1978 was about double the average for the preceding five years. Problems that resulted in claims for damages from counties have generally related to alleged omissions in the use of traffic control devices or defects, often temporary, resulting from alleged inadequacies in highway maintenance. The absence of stop signs or warning signs often has been the central issue in a highway-related tort claim. Maintenance problems most frequently alleged have included inadequate shoulders, surface roughness, ice o? snow conditions, and loose gravel. The variation in the occurrence of tort claims among 85 counties in Iowa could not be related to any of the explanatory variables that were tested. Claims appeared to have occurred randomly. However, using data from a sub sample of 11 counties, a significant relationship was shown probably to exist between the amount of tort claims and the extensiveness of use of warning signs on the respective county road systems. Although there was no indication in any county that their use of warning signs did not conform with provisions of the Manual on Uniform Traffic Control Devices (Federal Highway Administration, Government Printing Office, Washington, D.C., 1978), many more warning signs were used in some counties than would be required to satisfy this minimum requirement. Sign vandalism reportedly is a problem in all counties. The threat of vandalism and the added costs incurred thereby have tended to inhibit more extensive use of traffic control devices. It also should be noted that there is no indication from this research of a correlation between the intensiveness of sign usage and highway safety. All highway maintenance activities introduce some extraordinary hazard for motorists. Generally effective methodologies have evolved for use on county road systems for routine maintenance activities, procedures that tend to reduce the hazard to practical and reasonably acceptable levels. Blading of loose-surfaced roads is an example of such a routine maintenance activity. Alternative patterns for blading that were investigated as part of this research offered no improvements in safety when compared with the method in current use and introduced a significant additional cost that was unacceptable, given the existing limitations in resources available for county roads.

Soil microbial biomass under different management and tillage systems of permanent intercropped cover species in an orange orchard

To mitigate soil erosion and enhance soil fertility in orange plantations, the permanent protection of the inter-rows by cover species has been suggested. The objective of this study was to evaluate alterations in the microbial biomass, due to different soil tillage systems and intercropped cover species between rows of orange trees. The soil of the experimental area previously used as pasture (Brachiaria humidicola) was an Ultisol (Typic Paleudult) originating from Caiuá sandstone in the northwestern part of the State of Paraná, Brazil. Two soil tillage systems were evaluated: conventional tillage (CT) in the entire area and strip tillage (ST) (strip width 2 m), in combination with different ground cover management systems. The citrus cultivar 'Pera' orange (Citrus sinensis) grafted onto 'Rangpur' lime rootstock was used. Soil samples were collected after five years of treatment from a depth of 0-15 cm, under the tree canopy and in the inter-row, in the following treatments: (1) CT and an annual cover crop with the leguminous species Calopogonium mucunoides; (2) CT and a perennial cover crop with the leguminous peanut Arachis pintoi; (3) CT and an evergreen cover crop with Bahiagrass Paspalum notatum; (4) CT and a cover crop with spontaneous Brachiaria humidicola grass vegetation; and (5) ST and maintenance of the remaining grass (pasture) of Brachiaria humidicola. Soil tillage and the different cover species influenced the microbial biomass, both under the tree canopy and in the inter-row. The cultivation of brachiaria increased C and N in the microbial biomass, while bahiagrass increased P in the microbial biomass. The soil microbial biomass was enriched in N and P by the presence of ground cover species and according to the soil P content. The grass species increased C, N and P in the soil microbial biomass from the inter-row more than leguminous species.

2011 Road Use Tax Fund (RUTF) Study A report to the Iowa Legislature, per 2011 Iowa Code Section 307.31

The transportation system is in demand 24/7 and 365 days a year irrespective of neither the weather nor the conditions. Iowa’s transportation system is an integral and essential part of society serving commerce and daily functions of all Iowans across the state. A high quality transportation system serves as the artery for economic activity and, the condition of the infrastructure is a key element for our future growth opportunities. A key component of Iowa’s transportation system is the public roadway system owned and maintained by the state, cities and counties. In order to regularly re-evaluate the conditions of Iowa’s public roadway infrastructure and assess the ability of existing revenues to meet the needs of the system, the Iowa Department of Transportation’s 2006 Road Use Tax Fund (RUTF) report to the legislature included a recommendation that a study be conducted every five years. That recommendation was included in legislation adopted in 2007 and signed into law. The law specifically requires the following (2011 Iowa Code Section 307.31): •“The department shall periodically review the current revenue levels of the road use tax fund and the sufficiency of those revenues for the projected construction and maintenance needs of city, county, and state governments in the future. The department shall submit a written report to the general assembly regarding its findings by December 31 every five years, beginning in 2011. The report may include recommendations concerning funding levels needed to support the future mobility and accessibility for users of Iowa's public road system.” •“The department shall evaluate alternative funding sources for road maintenance and construction and report to the general assembly at least every five years on the advantages and disadvantages and the viability of alternative funding mechanisms.” Consistent with this requirement, the Iowa Department of Transportation (DOT) has prepared this study. Recognizing the importance of actively engaging with the public and transportation stakeholders in any discussion of public roadway conditions and needs, Governor Terry E. Branstad announced on March 8, 2011, the creation of, and appointments to, the Governor’s Transportation 2020 Citizen Advisory Commission (CAC). The CAC was tasked with assisting the Iowa DOT as they assess the condition of Iowa’s roadway system and evaluate current and future funding available to best address system needs. In particular the CAC was directed to gather input from the public and stakeholders regarding the condition of Iowa’s public roadway system, the impact of that system, whether additional funding is needed to maintain/improve the system, and, if so, what funding mechanisms ought to be considered. With this input, the CAC prepared a report and recommendations that were presented to Governor Branstad and the Iowa DOT in November 2011 for use in the development of this study. The CAC’s report is available at www.iowadot.gov/transportation2020/pdfs/CAC%20REPORT%20FINAL%20110211.pdf. The CAC’s report was developed utilizing analysis and information from the Iowa DOT. Therefore, the report forms the basis for this study and the two documents are very similar. Iowa is fortunate to have an extensive public roadway system that provides access to all areas of the state and facilitates the efficient movement of goods and people. However, it is also a tremendous challenge for the state, cities and counties to maintain and improve this system given flattening revenue, lost buying power, changing demands on the system, severe weather, and an aging system. This challenge didn’t appear overnight and for the last decade many studies have been completed to look into the situation and the legislature has taken significant action to begin addressing the situation. In addition, the Iowa DOT and Iowa’s cities and counties have worked jointly and independently to increase efficiency and streamline operations. All of these actions have been successful and resulted in significant changes; however, it is apparent much more needs to be done. A well-maintained, high-quality transportation system reduces transportation costs and provides consistent and reliable service. These are all factors that are critical in the evaluation companies undertake when deciding where to expand or locate new developments. The CAC and Iowa DOT heard from many Iowans that additional investment in Iowa’s roadway system is vital to support existing jobs and continued job creation in the state of Iowa. Beginning June 2011, the CAC met regularly to review material and discuss potential recommendations to address Iowa’s roadway funding challenges. This effort included extensive public outreach with meetings held in seven locations across Iowa and through a Transportation 2020 website hosted by the Iowa DOT (www.iowadot.gov/transportation2020). Over 500 people attended the public meetings held through the months of August and September, with 198 providing verbal or written comment at the meetings or through the website. Comments were received from a wide array of individuals. The public comments demonstrated overwhelming support for increased funding for Iowa’s roads. Through the public input process, several guiding principles were established to guide the development of recommendations. Those guiding principles are: • Additional revenues are restricted for road and bridge improvements only, like 95 percent of the current state road revenue is currently. This includes the fuel tax and registration fees. • State and local governments continue to streamline and become more efficient, both individually and by looking for ways to do things collectively. • User fee concept is preserved, where those who use the roads pay for them, including non¬residents. • Revenue-generating methods equitable across users. • Increase revenue generating mechanisms that are viable now but begin to implement and set the stage for longer-term solutions that bring equity and stability to road funding. • Continue Iowa’s long standing tradition of state roadway financing coming from pay-as-you-go financing. Iowa must not fall into the situation that other states are currently facing where the majority of their new program dollars are utilized to pay the debt service of past bonding. Based on the analysis of Iowa’s public roadway needs and revenue and the extensive work of the Governor’s Transportation 2020 Citizen Advisory Commission, the Iowa DOT has identified specific recommendations. The recommendations follow very closely the recommendations of the CAC (CAC recommendations from their report are repeated in Appendix B). Following is a summary of the recommendations which are fully documented beginning on page 21. 1. Through a combination of efficiency savings and increased revenue, a minimum of $215 million of revenue per year should be generated to meet Iowa’s critical roadway needs. 2. The Code of Iowa should be changed to require the study of the sufficiency of the state’s road funds to meet the road system’s needs every two years instead of every five years to coincide with the biennial legislative budget appropriation schedule. 3.Modify the current registration fee for electric vehicles to be based on weight and value using the same formula that applies to most passenger vehicles. 4.Consistent with existing Code of Iowa requirements, new funding should go to the TIME-21 Fund up to the cap ($225 million) and remaining new funding should be distributed consistent with the Road Use Tax Fund distribution formula. 5.The CAC recommended the Iowa DOT at least annually convene meetings with cities and counties to review the operation, maintenance and improvement of Iowa’s public roadway system to identify ways to jointly increase efficiency. In direct response to this recommendation, Governor Branstad directed the Iowa DOT to begin this effort immediately with a target of identifying $50 million of efficiency savings that can be captured from the over $1 billion of state revenue already provided to the Iowa DOT and Iowa’s cities and counties to administer, maintain and improve Iowa’s public roadway system. This would build upon past joint and individual actions that have reduced administrative costs and resulted in increased funding for improvement of Iowa’s public roadway system. Efficiency actions should be quantified, measured and reported to the public on a regular basis. 6.By June 30, 2012, Iowa DOT should complete a study of vehicles and equipment that use Iowa’s public roadway system but pay no user fees or substantially lower user fees than other vehicles and equipment.

Development of Updated Specifications for Roadway Rehabilitation Techniques, May 2011

As our nation’s highway system continues to age, asphalt maintenance and rehabilitation techniques have become increasingly important. The deterioration of pavement over time is inevitable. Preventive maintenance is a strategy to extend the serviceable life of a pavement by applying cost-effective treatments that slow the deterioration of pavement and extend its usable life. Thin maintenance surfaces (TMSs) are preventive maintenance techniques that can effectively prolong the life of pavement when applied at an opportune time. Common TMSs include bituminous fog seal, bituminous seal coat, slurry seal, cold in-place recycling (CIR), and micro-surfacing. This research project investigated ways to improve Iowa Statewide Urban Design and Specifications (SUDAS) and Iowa Department of Transportation (DOT) documents regarding asphalt roadway maintenance and rehabilitation. Researchers led an effort to review and help ensure that the documents supporting proper selection, design, and construction for asphalt maintenance and rehabilitation techniques reflect the latest research findings on these processes: seal coating, slurry sealing, micro-surfacing, and fog sealing. Full results of this investigation are included in this report and its appendices. This report also presents a summary of the recommendations based on the study results.

Low Water Stream Crossing: Design and Construction Recommendations, December 2001

Most counties have bridges that are no longer adequate, and are faced with large capital expenditure for replacement structures of the same size. In this regard, low water stream crossings (LWSCs) can provide an acceptable, low cost alternative to bridges and culverts on low volume and reduced maintenance level roads. In addition to providing a low cost option for stream crossings, LWSCs have been designed to have the additional benefit of stream bed stabilization. Considerable information on the current status of LWSCs in Iowa, along with insight of needs for design assistance, was gained from a survey of county engineers that was conducted as part of this research (Appendix A). Copies of responses and analysis are included in Appendix B. This document provides guidelines for the design of LWSCs. There are three common types of LWSCs: unvented ford, vented ford with pipes, and low water bridges. Selection among these depends on stream geometry, discharge, importance of road, and budget availability. To minimize exposure to tort liability, local agencies using low water stream crossings should consider adopting reasonable selection and design criteria and certainly provide adequate warning of these structures to road users. The design recommendations included in this report for LWSCs provide guidelines and suggestions for local agency reference. Several design examples of design calculations are included in Appendix E.

Carbon balance and crop residue management in dynamic equilibrium under a no-till system in Campos Gerais

The adoption of no-tillage systems (NT) and the maintenance of crop residues on the soil surface result in the long-term increase of carbon (C) in the system, promoting C sequestration and reducing C-CO2 emissions to the atmosphere. The purpose of this study was to evaluate the C sequestration rate and the minimum amount of crop residues required to maintain the dynamic C equilibrium (dC/dt = 0) of two soils (Typic Hapludox) with different textural classes. The experiment was arranged in a 2 x 2 x 2 randomized block factorial design. The following factors were analyzed: (a) two soil types: Typic Hapludox (Oxisol) with medium texture (LVTM) and Oxisol with clay texture (LVTA), (b) two sampling layers (0-5 and 5-20 cm), and (c) two sampling periods (P1 - October 2007; P2 - September 2008). Samples were collected from fields under a long-term (20 years) NT system with the following crop rotations: wheat/soybean/black oat + vetch/maize (LVTM) and wheat/maize/black oat + vetch/soybean (LVTA). The annual C sequestration rates were 0.83 and 0.76 Mg ha-1 for LVTM and LVTA, respectively. The estimates of the minimum amount of crop residues required to maintain a dynamic equilibrium (dC/dt = 0) were 7.13 and 6.53 Mg ha-1 year-1 for LVTM and LVTA, respectively. The C conversion rate in both studied soils was lower than that reported in other studies in the region, resulting in a greater amount of crop residues left on the soil surface.

Lenalidomide maintenance after stem-cell transplantation for multiple myeloma.

BACKGROUND: High-dose chemotherapy with autologous stem-cell transplantation is a standard treatment for young patients with multiple myeloma. Residual disease is almost always present after transplantation and is responsible for relapse. This phase 3, placebo-controlled trial investigated the efficacy of lenalidomide maintenance therapy after transplantation. METHODS: We randomly assigned 614 patients younger than 65 years of age who had nonprogressive disease after first-line transplantation to maintenance treatment with either lenalidomide (10 mg per day for the first 3 months, increased to 15 mg if tolerated) or placebo until relapse. The primary end point was progression-free survival. RESULTS: Lenalidomide maintenance therapy improved median progression-free survival (41 months, vs. 23 months with placebo; hazard ratio, 0.50; P<0.001). This benefit was observed across all patient subgroups, including those based on the β(2)-microglobulin level, cytogenetic profile, and response after transplantation. With a median follow-up period of 45 months, more than 70% of patients in both groups were alive at 4 years. The rates of grade 3 or 4 peripheral neuropathy were similar in the two groups. The incidence of second primary cancers was 3.1 per 100 patient-years in the lenalidomide group versus 1.2 per 100 patient-years in the placebo group (P=0.002). Median event-free survival (with events that included second primary cancers) was significantly improved with lenalidomide (40 months, vs. 23 months with placebo; P<0.001). CONCLUSIONS: Lenalidomide maintenance after transplantation significantly prolonged progression-free and event-free survival among patients with multiple myeloma. Four years after randomization, overall survival was similar in the two study groups. (Funded by the Programme Hospitalier de Recherche Clinique and others; ClinicalTrials.gov number, NCT00430365.).

Reforming the Iowa Civil Justice System, January 30, 2012

Executive Summary I. Survey The Task Force conducted a wide-ranging survey of more than 9,000 licensed Iowa attorneys and judges to obtain their input on a variety of civil justice system topics. The survey results helped inform the Task Force of problem areas in Iowa’s civil justice system. II. Two-Tier Justice System The Task Force recommends a pilot program based on a two-tier civil justice system. A two-tier system would streamline litigation processes—including rules of evidence and discovery disclosures—and reduce litigation costs of certain cases falling below a threshold dollar value. III. One Judge/One Case and Date Certain for Trial Some jurisdictions in Iowa have adopted one judge/one case and date certain for trial in certain cases. The assignment of one judge to each case for the life of the matter and the establishment of dates certain for civil trials could enhance Iowans’ access to the courts, improve judicial management, promote consistency and adherence to deadlines, and reduce discovery excesses. IV. Discovery Processes Reforms addressing inefficient discovery processes will reduce delays in and costs of litigation. Such measures include adopting an aspirational purpose for discovery rules to “secure the just, speedy, and inexpensive determination of every action,” holding discovery proportional to the size and nature of the case, requiring initial disclosures, limiting the number of expert witnesses, and enforcing existing rules. V. Expert Witness Fees The Task Force acknowledges the probable need to revisit the statutory additional daily compensation limit for expert witness fees. Leaving the compensation level to the discretion of the trial court is one potential solution. VI. Jurors Additions to the standard juror questionnaire would provide a better understanding of the potential jurors’ backgrounds and suitability for jury service. The Task Force encourages adoption of more modern juror educational materials and video. Rehabilitation of prospective jurors who express an unwillingness or inability to be fair should include a presumption of dismissal. VII. Video and Teleconferencing Options When court resources are constrained both by limited numbers of personnel and budget cuts, it is logical to look to video and teleconferencing technology to streamline the court process and reduce costs. The judicial branch should embrace technological developments in ways that will not compromise the fairness, dignity, solemnity, and decorum of judicial proceedings. VIII. Court-Annexed Alternative Dispute Resolution(ADR) Litigants and practitioners in Iowa are generally satisfied with the current use of private, voluntary ADR for civil cases. There is concern, however, that maintaining the status quo may have steep future costs. Court-annexed ADR is an important aspect of any justice system reform effort, and the Task Force perceives benefits and detriments to reforming this aspect of the Iowa civil justice system. IX. Relaxed Requirement of Findings of Fact and Conclusions of Law A rule authorizing parties to waive findings of fact and conclusions of law could expedite resolution of nonjury civil cases. X. Business (Specialty) Courts Specialty business courts have achieved widespread support across the country. In addition, specialty courts provide excellent vehicles for implementing or piloting other court innovations that may be useful in a broader court system context. A business specialty court should be and could be piloted in Iowa within the existing court system framework of the Iowa Judicial Branch. Appendix included as a separate document, is 176 pages.