Performance Measures for Iowa Transportation Systems, 2006

The purpose of performance measures in planning operations is to identify and track meaningful, quantifiable measures that reflect progress toward the goals of the plan. The Iowa Department of Transportation (DOT) has already adopted performance measures in a number of operational areas, including highway maintenance, highway safety, public transportation, and aeronautics. This report is an initial effort to utilize performance measures for transportation system planning. The selected measures provide a cross-section of system performance indicators across three selected transportation planning goals (safety, efficiency, and quality of life) and five transportation modes (highways/bridges, public transit, railroads, aviation, and pedestrian/bicycle). These performance measures are exploratory in nature, and constitute a first attempt to apply performance measures in the context of a statewide, multimodal transportation plan from the Iowa DOT. As such, the set of performance measures that the Iowa DOT uses for planning will change over time as more is learned about the application of such measures. The performance measures explained in this document were developed through consultation with Iowa DOT modal staff (aviation, railroads, highways, public transportation, and pedestrian/bicycle) and the Office of Traffic and Safety. In addition, faculty and staff at the Iowa State University Center for Transportation Research and Education were consulted about performance measurement and data within their areas of expertise.

Prognostic value of cortically induced motor evoked activity by TMS in chronic stroke: caveats from a very revealing single clinical case

Background: We report the case of a chronic stroke patient (62 months after injury) showing total absence of motor activity evoked by transcranial magnetic stimulation (TMS) of spared regions of the left motor cortex, but near-to-complete recovery of motor abilities in the affected hand. Case presentation: Multimodal investigations included detailed TMS based motor mapping, motor evoked potentials (MEP), and Cortical Silent period (CSP) as well as functional magnetic resonance imaging (fMRI) of motor activity, MRI based lesion analysis and Diffusion Tensor Imaging (DTI) Tractography of corticospinal tract (CST). Anatomical analysis revealed a left hemisphere subinsular lesion interrupting the descending left CST at the level of the internal capsule. The absence of MEPs after intense TMS pulses to the ipsilesional M1, and the reversible suppression of ongoing electromyographic (EMG) activity (indexed by CSP) demonstrate a weak modulation of subcortical systems by the ipsilesional left frontal cortex, but an inability to induce efficient descending volleys from those cortical locations to right hand and forearm muscles. Functional MRI recordings under grasping and finger tapping patterns involving the affected hand showed slight signs of subcortical recruitment, as compared to the unaffected hand and hemisphere, as well as the expected cortical activations. Conclusions: The potential sources of motor voluntary activity for the affected hand in absence of MEPs are discussed. We conclude that multimodal analysis may contribute to a more accurate prognosis of stroke patients.

La incidència de l'estrés en el cos docent

Aquest article ofereix una visió actualitzada de l’alarmant incidència de l’estrès en el col·lectiu docent, aprofundint en el seu diagnòstic, multicausalitat i diversifi cada repercussió. Així, doncs, es posa de manifest l’elevada subjectivitat en l’aparició de l’estrès, com també altres causes vinculades amb les dimensions personal, organitzativa i social. També es descriuen tant els indicadors de risc, com els factors de protecció més signifi catius envers la seva gènesi. Finalment, es presenta una proposta d’intervenció integradora i multimodal, de caràcter preventiu i pal·liatiu, constituïda per dinou programes que engloben la totalitat de les àrees implicades en aquesta patologia. Paraules clau: Estrès laboral docent, Burnout, Indicadors de Risc laboral, Factors de Protecció laboral, Programes preventius i palliatius d’estrès.

Mouse Grueneberg ganglion neurons share molecular and functional features with C. elegans amphid neurons.

The mouse Grueneberg ganglion (GG) is an olfactory subsystem located at the tip of the nose close to the entry of the naris. It comprises neurons that are both sensitive to cold temperature and play an important role in the detection of alarm pheromones (APs). This chemical modality may be essential for species survival. Interestingly, GG neurons display an atypical mammalian olfactory morphology with neurons bearing deeply invaginated cilia mostly covered by ensheathing glial cells. We had previously noticed their morphological resemblance with the chemosensory amphid neurons found in the anterior region of the head of Caenorhabditis elegans (C. elegans). We demonstrate here further molecular and functional similarities. Thus, we found an orthologous expression of molecular signaling elements that was furthermore restricted to similar specific subcellular localizations. Calcium imaging also revealed a ligand selectivity for the methylated thiazole odorants that amphid neurons are known to detect. Cellular responses from GG neurons evoked by chemical or temperature stimuli were also partially cGMP-dependent. In addition, we found that, although behaviors depending on temperature sensing in the mouse, such as huddling and thermotaxis did not implicate the GG, the thermosensitivity modulated the chemosensitivity at the level of single GG neurons. Thus, the striking similarities with the chemosensory amphid neurons of C. elegans conferred to the mouse GG neurons unique multimodal sensory properties.

The role of laparoscopic biopsies in lumbar spondylodiscitis.

Infection of an intervertebral disk is a serious condition. Diagnosis often is elusive and difficult. It is imperative to obtain appropriate microbiological specimens before initiation of treatment. The authors describe a 51-year-old woman with lumbar spondylodiscitis that was because of infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging confirmed the diagnosis, but computed tomography-guided fine needle biopsy did not provide adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of Propionibacterium acnes infection. The authors believe that this minimally invasive procedure should be performed when computed tomography-guided fine needle biopsy does not provide a microbiologic diagnosis in spondylodiscitis.

Entitat Metropolitana del Transport. Centre Operatiu d'Autobusos del Prat

El projecte contempla la resolució d’un Centre Operatiu d’Autobusos Metropolitans amb un programa que ha de donar cabuda a un mínim de 300 places d’aparcament de diferents mesures, tallers de manteniment, túnels de neteja, sortidors de repostatge, vestuaris, administració, oficines i serveis generals. L’emplaçament se situa en el barri de Sant Cosme del Prat de Llobregat, en un solar que esdevé la façana d’aquesta població a l’entrada a Barcelona des de l’aeroport. L’entorn el conformen els espais de protecció de les pistes que es perllonguen fins a tocar el Parc Natural del Delta del Llobregat, una zona humida protegida d’àmbit europeu. Al mateix temps, els requeriments del concurs sol•liciten mantenir un 50% de la superfície del solar com a parc urbà. Això comporta abordar la resolució d’un edifici extens, però de 3 alçades i mitja, per tal de poder encabir tot el programa. Tot i així, la proposta integra el gran volum de l’edificació en harmonia compositiva i cromàtica amb el canyissar i manté l’alçària en una cota similar a la dels edificis de l’entorn. L’àrea verda es concentra en la part de la parcel•la que té continuïtat directe amb el pati del nou Esplai del barri, per tal de optimitzar-ne l’ús. Al mateix temps, les àrees de circulació, neteja i manteniment dels autobusos se situen a la part posterior del solar, per fer-les compatibles amb la resta de requeriments funcionals i perquè la volumetria principal doni front a les vies d’entrada a l’àrea metropolitana. La cotxera està continguda en un únic volum lleugerament soterrat, per limitar l’alçària total. La construcció principal, de 120 x 55 x 14,5 metres, es troba configurada per una estructura regular que respecta les mesures i moviments dels autobusos, i per una pell consistent en una gelosia oberta en tres cares, i tancada en l’alçat nord. Aquest tancament es realitza amb prismes verticals de colors similars a la vegetació del entorn, separats harmònicament per tal de dissoldre lleument els contorns del volum. Com a contrapunt a la gran peça principal, es proposa un petit edifici vidriat que indica l’entrada a les oficines i conté les activitats administratives.Les àrees de funcionament es resumeixen en les següents:1. La circulació dels autobusos: el conjunt disposa de tres vies simultànies, una d’accés i dues de sortida, situades en línia amb dos punts de repostatge, aspiració interior i traspàs de dades i recaptacions, aptes per a ser utilitzades per tres vehicles alhora. També es disposen tres túnels de rentat previs a l’entrada a l’interior de la cotxera, amb pas per a tres carrils en by-pass. Es preveu una quarta via especial d’accés i sortida directes al taller, per situacions extraordinàries.2. La circulació dels vehicles de personal: tenen un accés i un recorregut independent al dels autobusos, amb control informatitzat. 3. La entrada peatonal de visites o personal: l’edifici disposa també d’una entrada peatonal que es produeix des de la porta principal, situada en el front del edifici administratiu.4. El edifici principal: consta de diferents nivells. El Nivell 0, a cota –1,3 m. es troba ocupat per la zona d’aparcament de vehicles privats (98 uts), l’aparcament de minibusos (20 uts), el taller d’autobusos (23 uts standard amb ITV, 2 uts articulats, 1 ut pintura articulat, 2 uts reparcions sostres), i l’àrea d’explotació i de dependències per conductors (vestidors, àrea de descans, cafeteria i espais habitables).El Nivell 1, a cota 2,4 m. està ocupat per l’aparcament de 47 autobusos de 13 m. de llarg i per 20 autobusos de 15 m.El Nivell 2, a cota 4,8 m. l’ocupen 22 places d’autobusos de 15 m., 6 places d’articulats i 37 de 13 m.El Nivell 3, a cota 7,2 m. és idèntic al Nivell 1.El Nivell 4, és idèntic al Nivell 2 i permet que la rampa continuï fins a un Nivell 5 de coberta, que excepcionalment pot convertir-se en aparcament descobert de 67 autobusos de més.La proposta contempla amb fermesa criteris de Sostenibilitat. Aquests es centren en primer lloc en la sobrietat del projecte que garanteix una organització clara en quan a circulacions i rendiment del espai i que, per tant, no malbarata més recursos dels necessaris. En segon lloc, s’aprofiten al màxim la llum i la ventilació naturals i, al mateix temps, es genera la pròpia energia per millorar la eficiència. També es resol el re-processament dels residus generats pel complex, es re-aprofiten les aigües utilitzades en els vestuaris i oficines pel rentat dels vehicles, i s’emmagatzemen les aigües pluvials per tal de complementar la generació d’energia i per escalfar amb el sol aigua calenta de neteja. En tercer lloc, es té especial cura en l’impacte ambiental del edifici, procurant adequar-lo a l’estructura urbana tant en alineacions com el alçària. També s’evita la contaminació acústica apantallant el so intern per tal de no enviar-lo a les àrees habitades, s’endrecen els accessos dels autobusos des de la rotonda de la via pública per alterar el mínim el trànsit dels veïns, i es concentra l’àrea verda en la zona on es té més contacte amb l’activitat veïnal comunitària: l’Esplai del barri.

Traitement de la douleur chronique: rôle de la stimulation transcrânienne du cortex moteur [Treatment of chronic pain: transcranial stimulation of the motor cortex?].

Chronic pain refractory to medical therapy poses a therapeutic challenge. The repetitive Transcranial Magnetic Stimulation (rTMS) and transcranial Direct Current Stimulation (tDCS) modulate brain activity offering a new approach. Current evidence suggests a potential therapeutic efficacy of motor cortex stimulation for the treatment of pain, but does not (yet) support their recommendation for clinical practice. These methods allow to deepen our knowledge in the pathophysiology of chronic pain while providing new therapeutic approaches.

Consolidation whole abdomen irradiation following adjuvant carboplatin-paclitaxel based chemotherapy for advanced uterine epithelial cancer: feasibility, toxicity and outcomes.

BACKGROUND: To evaluate feasibility and preliminary outcomes associated with sequential whole abdomen irradiation (WAI) as consolidative treatment following comprehensive surgery and systemic chemotherapy for advanced endometrial cancer. METHODS: We conducted a retrospective analysis of patients treated at our institution from 2000 to 2011. Inclusion criteria were stage III-IV endometrial cancer patients with histological proof of one or more sites of extra-uterine abdomen-confined disease, treated with WAI as part of multimodal therapy. Endpoints were feasibility, acute toxicity, late effects, recurrence-free survival (RFS) and overall survival (OS). Twenty patients were identified. Chemotherapy consisted of 3 to 6 cycles of a platinum-paclitaxel regimen in 18 patients. WAI was delivered using conventional technique to a median total dose of 27.5 Gy. RESULTS: No grade 4 toxicities occurred during chemotherapy or radiotherapy. No radiation dose reduction was necessary. Three patients developed small bowel obstruction, all in the context of recurrent intraperitoneal disease. Kaplan-Meier estimates and 95% confidence intervals for RFS and OS at one year were 63% (38-80%) and 83% (56-94%) and at 3 years 57% (33-76%) and 62% (34-81%), respectively. On univariate Cox analysis, stage IVB and serous papillary (SP) histology were found to be statistically significantly (at the p = 0.05 level) associated with worse RFS and OS. The peritoneal cavity was the most frequent site of initial failure. CONCLUSIONS: Consolidative WAI following chemotherapy is feasible and can be performed without interruption with manageable acute and late toxicity. Patients with endometrioid adenocarcinoma, especially stage FIGO III, had favorable outcomes possibly meriting prospective evaluation of the addition of WAI following chemotherapy in selected patients. Patients with SP do poorly and do not routinely benefit from this approach.

A prospective, randomized, and controlled study of fluid management in children with severe head injury: lactated Ringer's solution versus hypertonic saline.

OBJECTIVES: Resuscitation in severe head injury may be detrimental when given with hypotonic fluids. We evaluated the effects of lactated Ringer's solution (sodium 131 mmol/L, 277 mOsm/L) compared with hypertonic saline (sodium 268 mmol/L, 598 mOsm/L) in severely head-injured children over the first 3 days after injury. DESIGN: An open, randomized, and prospective study. SETTING: A 16-bed pediatric intensive care unit (ICU) (level III) at a university children's hospital. PATIENTS: A total of 35 consecutive children with head injury. INTERVENTIONS: Thirty-two children with Glasgow Coma Scores of <8 were randomly assigned to receive either lactated Ringer's solution (group 1) or hypertonic saline (group 2). Routine care was standardized, and included the following: head positioning at 30 degrees; normothermia (96.8 degrees to 98.6 degrees F [36 degrees to 37 degrees C]); analgesia and sedation with morphine (10 to 30 microg/kg/hr), midazolam (0.2 to 0.3 mg/kg/hr), and phenobarbital; volume-controlled ventilation (PaCO2 of 26.3 to 30 torr [3.5 to 4 kPa]); and optimal oxygenation (PaO2 of 90 to 105 torr [12 to 14 kPa], oxygen saturation of >92%, and hematocrit of >0.30). MEASUREMENTS AND MAIN RESULTS: Mean arterial pressure and intracranial pressure (ICP) were monitored continuously and documented hourly and at every intervention. The means of every 4-hr period were calculated and serum sodium concentrations were measured at the same time. An ICP of 15 mm Hg was treated with a predefined sequence of interventions, and complications were documented. There was no difference with respect to age, male/female ratio, or initial Glasgow Coma Score. In both groups, there was an inverse correlation between serum sodium concentration and ICP (group 1: r = -.13, r2 = .02, p < .03; group 2: r = -.29, r2 = .08, p < .001) that disappeared in group 1 and increased in group 2 (group 1: r = -.08, r2 = .01, NS; group 2: r = -.35, r2 =.12, p < .001). Correlation between serum sodium concentration and cerebral perfusion pressure (CPP) became significant in group 2 after 8 hrs of treatment (r = .2, r2 = .04, p = .002). Over time, ICP and CPP did not significantly differ between the groups. However, to keep ICP at <15 mm Hg, group 2 patients required significantly fewer interventions (p < .02). Group 1 patients received less sodium (8.0 +/- 4.5 vs. 11.5 +/- 5.0 mmol/kg/day, p = .05) and more fluid on day 1 (2850 +/- 1480 vs. 2180 +/- 770 mL/m2, p = .05). They also had a higher frequency of acute respiratory distress syndrome (four vs. 0 patients, p = .1) and more than two complications (six vs. 1 patient, p = .09). Group 2 patients had significantly shorter ICU stay times (11.6 +/- 6.1 vs. 8.0 +/- 2.4 days; p = .04) and shorter mechanical ventilation times (9.5 +/- 6.0 vs. 6.9 +/- 2.2 days; p = .1). The survival rate and duration of hospital stay were similar in both groups. CONCLUSIONS: Treatment of severe head injury with hypertonic saline is superior to that treatment with lactated Ringer's solution. An increase in serum sodium concentrations significantly correlates with lower ICP and higher CPP. Children treated with hypertonic saline require fewer interventions, have fewer complications, and stay a shorter time in the ICU.

Predicting neurological outcome after cardiac arrest.

Purpose of reviewTherapeutic hypothermia and aggressive management of postresuscitation disease considerably improved outcome after adult cardiac arrest over the past decade. However, therapeutic hypothermia alters prognostic accuracy. Parameters for outcome prediction, validated by the American Academy of Neurology before the introduction of therapeutic hypothermia, need further update.Recent findingsTherapeutic hypothermia delays the recovery of motor responses and may render clinical evaluation unreliable. Additional modalities are required to predict prognosis after cardiac arrest and therapeutic hypothermia. Electroencephalography (EEG) can be performed during therapeutic hypothermia or shortly thereafter; continuous/reactive EEG background strongly predicts good recovery from cardiac arrest. On the contrary, unreactive/spontaneous burst-suppression EEG pattern, together with absent N20 on somatosensory evoked potentials (SSEP), is almost 100% predictive of irreversible coma. Therapeutic hypothermia alters the predictive value of serum markers of brain injury [neuron-specific enolase (NSE), S-100B]. Good recovery can occur despite NSE levels >33 mu g/l, thus this cut-off value should not be used to guide therapy. Diffusion MRI may help predicting long-term neurological sequelae of hypoxic-ischemic encephalopathy.SummaryAwakening from postanoxic coma is increasingly observed, despite early absence of motor signs and frank elevation of serum markers of brain injury. A new multimodal approach to prognostication is therefore required, which may particularly improve early prediction of favorable clinical evolution after cardiac arrest.

A meta-analysis of acupuncture for chronic pain.

Results of 14 randomized controlled trials of acupuncture for chronic pain were pooled in a meta-analysis and analysed in three subgroups according to site of pain; and in two subgroups each according to type to trial, type of treatment, type of control, 'blindness' of participating agents, trial size, and type of journal in which results were published. While few individual trials had statistically significant results, pooled results of many subgroups attained statistical significance in favour of acupuncture. Various potential sources of bias, including problems with blindness, precluded a conclusive finding although most results apparently favoured acupuncture.

Rétablissement postopératoire optimisé, applique aux patients après cystectomie [Enhanced recovery after surgery applied to cystectomy patients].

Enhanced Recovery After Surgery (ERAS) is a multimodal concept combining pre, intra and postoperative evidence-based care elements to reduce surgical stress. ERAS pathways have been shown to significantly reduce morbidity, length of hospital stay and total costs when applied to colorectal surgery. It is therefore considered standard of care in this specialty. There can be no doubt that ERAS principles can be applied also in other major surgeries. However, uncritical application of the guidelines issued from colonic procedures seems inappropriate as the surgical procedures in pelvic cancer surgery differ considerably. This article reports on the first steps of an ERAS project and his introduction in urology.

Réhabilitation améliorée après chirurgie--L'ere de la prise en charge optimale du patient chirurgical [Enhanced Recovery After Surgery--optimal management of the surgical patient].

Enhanced Recovery After Surgery (ERAS) is a multimodal, standardized and evidence-based perioperative care pathway. With ERAS, postoperative complications are significantly lowered, and, as a secondary effect, length of hospital stay and health cost are reduced. The patient recovers better and faster allowing to reduce in addition the workload of healthcare providers. Despite the hospital discharge occurs sooner, there is no increased charge of the outpatient care. ERAS can be safely applied to any patient by a tailored approach. The general practitioner plays an essential role in ERAS by assuring the continuity of the information and the follow-up of the patient.

Expert clinical reasoning and pain assessment in mechanically ventilated patients: A descriptive study.

BACKGROUND: Pain assessment in mechanically ventilated patients is challenging, because nurses need to decode pain behaviour, interpret pain scores, and make appropriate decisions. This clinical reasoning process is inherent to advanced nursing practice, but is poorly understood. A better understanding of this process could contribute to improved pain assessment and management. OBJECTIVE: This study aimed to describe the indicators that influence expert nurses' clinical reasoning when assessing pain in critically ill nonverbal patients. METHODS: This descriptive observational study was conducted in the adult intensive care unit (ICU) of a tertiary referral hospital in Western Switzerland. A purposive sample of expert nurses, caring for nonverbal ventilated patients who received sedation and analgesia, were invited to participate in the study. Data were collected in "real life" using recorded think-aloud combined with direct non-participant observation and brief interviews. Data were analysed using deductive and inductive content analyses using a theoretical framework related to clinical reasoning and pain. RESULTS: Seven expert nurses with an average of 7.85 (±3.1) years of critical care experience participated in the study. The patients had respiratory distress (n=2), cardiac arrest (n=2), sub-arachnoid bleeding (n=1), and multi-trauma (n=2). A total of 1344 quotes in five categories were identified. Patients' physiological stability was the principal indicator for making decision in relation to pain management. Results also showed that it is a permanent challenge for nurses to discriminate situations requiring sedation from situations requiring analgesia. Expert nurses mainly used working knowledge and patterns to anticipate and prevent pain. CONCLUSIONS: Patient's clinical condition is important for making decision about pain in critically ill nonverbal patients. The concept of pain cannot be assessed in isolation and its assessment should take the patient's clinical stability and sedation into account. Further research is warranted to confirm these results.

Diagnosis and Management of Upper Tract Urothelial Carcinoma.

While UTUC is relatively uncommon, it has an aggressive natural history and poor prognosis, which has not substantially improved over the past two decades. Nevertheless, continued research has led to the discovery of risk factors improving the prevention and early detection of UTUC. Although RNU remains the standard treatment for localized invasive UTUC, nephron-sparing surgery for selected patients has made considerable progress in the recent years. The stagnation in the prognosis of UTUC over the past two decades highlights the necessity for incorporating multimodal approaches including refinements in systemic chemotherapy and radiotherapy to attain better outcomes for patients with UTUC.