The efficacy and safety of a third anti-TNF monoclonal antibody in Crohn's disease after failure of two other anti-TNF antibodies.

BACKGROUND: Adalimumab (ADA) and certolizumab pegol (CZP) have demonstrated efficacy in Crohn's disease (CD) patients previously treated with infliximab (IFX). AIM: To assess the efficacy and tolerability of a third anti-TNF in CD after failure of and/or intolerance to two different anti-TNF antibodies. METHODS: Crohn's disease patients who received ADA or CZP after loss of response and/or intolerance to two anti-TNF agent were included in this retrospective study. Data were collected using a standardized questionnaire. Clinical response, duration, safety and reasons for discontinuation were assessed. RESULTS: Sixty-seven patients treated with CZP (n = 40) or ADA (n = 27) were included. A clinical response was observed in 41 (61%) at week 6 and 34 patients (51%) at week 20. The probability of remaining under treatment at 3 months, 6 months and 9 months was 68%, 60% and 45%, respectively. At the end of follow-up, the third anti-TNF had been stopped in 36 patients for intolerance (n = 13), or failure (n = 23). Two deaths were observed. CONCLUSIONS: The treatment with a third anti-TNF (CZP or ADA) agent of CD patients, who have experienced loss of response and/or intolerance to two anti-TNF antibodies, has favourable short-term and long-term efficacy. It is an option to be considered in patients with no other therapeutic options.

Impacts on Safety of Left-Turn Treatment at High Speed Signalized Intersections, HR-347, 1994

Left-turning traffic is a major source of conflicts at intersections. Though an average of only 10% to 15% of all approach traffic turns left, these vehicles are involved in approximately 45% of all accidents. This report presents the results of research conducted to develop models which estimate approach accident rates at high speed signalized intersections. The objective of the research was to quantify the relationship between traffic and intersection characteristics, and accident potential of different left turn treatments. Geometric, turning movement counts, and traffic signal phasing data were collected at 100 intersections in Iowa using a questionnaire sent to municipalities. Not all questionnaires resulted in complete data and ultimately complete data were derived for 63 intersections providing a database of 248 approaches. Accident data for the same approaches were obtained from the Iowa Department of Transportation Accident Location and Analysis System (ALAS). Regression models were developed for two different dependent variables: 1) the ratio of the number of left turn accidents per approach to million left turning vehicles per approach, and 2) the ratio of accidents per approach to million traffic movements per approach. A number of regression models were developed for both dependent variables. One model using each dependent variable was developed for intersections with low, medium, and high left turning traffic volumes. As expected, the research indicates that protected left turn phasing has a lower accident potential than protected/permitted or permitted phasing. Left turn lanes and multiple lane approaches are beneficial for reducing accident rates, while raised medians increase the likelihood of accidents. Signals that are part of a signal system tend to have lower accident rates than isolated signals. The resulting regression models may be used to determine the likely impact of various left turn treatments on intersection accident rates. When designing an intersection approach, a traffic engineer may use the models to estimate the accident rate reduction as a result of improved lane configurations and left turn treatments. The safety benefits may then be compared to any costs associated with operational effects to the intersection (i.e., increased delay) to determine the benefits and costs of making intersection safety improvements.

The Economics of Reducing the County Road System: Three Case Studies in Iowa - Executive Summary, HR-242, 1986

This Executive Summary presents a brief summary of the main research report, "The Economics of Reducing the County Road System: Three Case Studies in Iowa" (DOT/OST/P-34/86-035). The case studies are described, as well as the analytic methodology and research findings.

The Economics of Reducing the County Road System: Three Case Studies in Iowa, HR-242, 1986

This research project looked at the economic benefits and costs associated with alternative strategies for abandoning low volume rural highways and bridges. Three test counties in Iowa were studied, each 100 square miles in size: Hamilton County having a high agricultural tax base and a high percentage of paved roads and few bridges; Shelby County having a relatively low agricultural tax base, hilly terrain and a low percentage of paved road and many bridges; and Linn County having a high agricultural tax base, a high percentage of paved roads and a large number of non-farm households. A questionnaire survey was undertaken to develop estimates of farm and household travel patterns. Benefits and costs associated with the abandonment of various segments of rural highway and bridge mileages in each county were calculated. "Benefits" calculated were reduced future reconstruction and maintenance costs, whereas "costs" were the added cost of travel resulting from the reduced mileage. Some of the findings suggest limited cost savings from abandonment of county roads with no property access in areas with large non-farm rural population; relatively high cost savings from the abandonment of roads with no property access in areas with small rural population; and the largest savings from the conversion of public dead-end gravel roads with property or residence accesses to private drives.

Roadway Lighting on Secondary Roads in Iowa, HR-251, 1984

There are approximately 800 installations of destination lighting at secondary road intersections in Iowa. Approximately 90% of these have only a single luminaire. The other installations have two luminaires. No warrants currently exist for justifying the use of this type of lighting. Previous research has examined the safety benefits from full lighting of rural intersections that generally serve substantially higher traffic volumes than secondary road intersections in Iowa. However, the safety benefit of destination lighting at intersections carrying relatively low volumes has not been the subject of previous research. The research reported here, sponsored by the Iowa Department of Transportation, was undertaken to identify locations where destination lighting could be expected to improve highway safety. If destination lighting were shown to reduce accident frequency, warrants for its use on secondary roads could be developed. An inventory of secondary road lighting installations in Iowa was assembled. From this inventory, two samples were constituted that would permit two separate comparisons of the accident experience with and without destination lighting. Before and after comparisons were made for the same locations if accident records were available for at least one full year both preceding and following the installation of destination lighting. Accident records for this purpose were available from a statewide computerized record system covering the period from 1977 through 1982. The accident experience at locations having destination lighting installed before 1978 was compared with a sample of comparable locations not having destination lighting. The sample of secondary road intersections used for the before and after comparison included 91 locations. The sample of continuously lighted locations included 102 intersections. Accident experience at these locations was compared with the experience at 102 intersections that were not lighted. The intersections included in these samples averaged only 0.31 accidents per year. The accident rate at secondary road intersections that had destination lighting did not differ significantly from the accident rate at intersections that were not lighted. This conclusion was derived from both comparisons, the before and after experience and the comparison of experience at intersections that were continuously lighted with that at unlighted locations. Furthermore, no significant differences were noted between lighted and unlighted locations in the proportion of accidents that occurred at night. The distribution of accidents by type also did not differ between unlighted intersections and those having destination lighting. It was not possible to formulate warrants for destination lighting since analyses directed toward identifying specific characteristics of an intersection that could be correlated with highway safety did not yield any useful relationships. However, it was noted that the average damages for night accidents that occurred at lighted intersections were lower than for accidents at unlighted intersections. Even in the absence of a more definitive demonstration of beneficial effects, destination lighting is perceived by officials in most of the counties having such installations as yielding desirable effects and is recognized as helpful to motorists in performing the guidance function in driving. Given this benefit and a relatively low cost (an average of $74 per year for one luminaire), and given that the subjective criteria that have been used in the past to justify the installation of destination lighting have led to a high degree of public acceptance and satisfaction, it is recommended that the same subjective criteria continue to be used in lieu of definitive warrants.

Perception and Interpretation of Advance Warning Signs on County Roads, HR-256, 1984

This research consisted of five laboratory experiments designed to address the following two objectives in an integrated analysis: (1) To discriminate between the symbol Stop Ahead warning sign and a small set of other signs (which included the word-legend Stop Ahead sign); and (2) To analyze sign detection, recognizability, and processing characteristics by drivers. A set of 16 signs was used in each of three experiments. A tachistoscope was used to display each sign image to a respondent for a brief interval in a controlled viewing experiment. The first experiment was designed to test detection of a sign in the driver's visual field; the second experiment was designed to test the driver's ability to recognize a given sign in the visual field; and the third experiment was designed to test the speed and accuracy of a driver's response to each sign as a command to perform a driving action. A fourth experiment tested the meanings drivers associated with an eight-sign subset of the 16 signs used in the first three experiments. A fifth experiment required all persons to select which (if any) signs they considered to be appropriate for use on two scale model county road intersections. The conclusions are that word-legend Stop Ahead signs are more effective driver communication devices than symbol stop-ahead signs; that it is helpful to drivers to have a word plate supplementing the symbol sign if a symbol sign is used; and that the guidance in the Manual on Uniform Traffic Control Devices on the placement of advance warning signs should not supplant engineering judgment in providing proper sign communication at an intersection.

Engineering Study Automating Iowa's Speed Monitoring Program, HR-228, 1983

Excessive speed on State and County highways is recognized as a serious problem by many Iowans. Speed increases both the risk and severity of accidents. Studies conducted by the FHWA and NHTSA have concluded that if average speeds were increased by five MPH, fatalities would increase by at least 2,200 annually. Along with the safety problems associated with excessive speed are important energy considerations. When the national speed limit was lowered to 55 MPH in 1974, a tremendous savings in fuel was realized. The estimated actual savings for automobiles amounted to 2.2 billion gallons, an average of 20.75 gallons for each of the 106 million automobiles registered in 1975. These benefits prompted the Federal-Aid Amendment of 1974 requiring annual State enforcement certification as a prerequisite for approval of Federal-aid highway projects. In 1978, the United States D.O.T. recommended to Congress significant changes in speed limit legislation designed to increase compliance with the national speed limit. The Highway Safety Act of 1978 provides for both withholding Federal-aid highway funds and awarding incentive grants based on speed compliance data submitted annually. The objective of this study was to develop and make operational, an automatic speed monitoring system which would have flexible capabilities of collecting accurate speed data on all road systems in Iowa. It was concluded that the Automatic Speed Monitoring Program in Iowa has been successful and needed data is being collected in the most economical manner possible.

Solar Powered Highway Delineator System, HR-367, 1993

Currently, many drivers experience some difficulty in viewing the road ahead of them during times of reduced visibility, such as rain, snow, fog, or the darkness of night- Recent studies done by the National Safety Council provide a detailed contrast between fatal accidents occurring during the day and night. Revealed was that the motor vehicle night death rate (4.41 deaths per 100 million miles driven) was sharply higher than the corresponding death rate during daylight hours (1.21). By providing a delineating system powered by the natural resource of solar power, a constant source of visibility may be maintained throughout the evening. Along with providing enough light to trace the outline of the road, other major goals defined in producing this delineator system are as follows: 1. A strong and durable design that would protect the internal components and survive extreme weather conditions. 2. A low maintenance system where components need few repairs or replacements. 3. A design which makes all components accessible in the event that maintenance is needed, but also prevents vandalism. 4. A design that provides greater visibility to drivers and will not harm a vehicle or its passengers in the event of a collision. This solar powered highway delineator consists of an adjustable solar array, a light fixture, and a standard delineator pole. The solar array houses and protects the solar panels, and can be easily adjusted to obtain a maximum amount of sunlight. The light fixture primarily houses the battery, the circuit and the light assembly. Both components allow for easy accessibility and reduce vandalism using internal connections for bolts and wires. The delineator mounting pole is designed to extensively deform in the event of a collision, therefore reducing any harm caused to the vehicle and/or the passengers. The cost of a single prototype to be produced is approximately $70.00 excluding labor costs. However, these material and labor costs will be greatly reduced if a large number of delineators are produced. It is recommended that the Iowa Department of Transportation take full advantage of the research and development put into this delineator design. The principles used in creating this delineator can be used to provide an outline for drivers to follow, or on a larger scale, provide actual roadway lighting in areas where it was never before possible or economically feasible. In either event, the number of fatal accidents will be decreased due to the improved driver visibility in the evening.

Development and Implementation of an Expert System for Forecasting Fog on US Highway 30 in Cedar Rapids, Iowa, HR-357, 1996

Several accidents, some involving fatalities, have occurred on U.S. Highway 30 near the Archer Daniels Midland Company (ADM) Corn Sweeteners plant in Cedar Rapids, Iowa. A contributing factor to many of these accidents has been the large amounts of water (vapor and liquid) emitted from multiple sources at ADM's facility located along the south side of the highway. Weather and road closure data acquired from IDOT have been used to develop a database of meteorological conditions preceding and accompanying closure of Highway 30 in Cedar Rapids. An expert system and a FORTRAN program were developed as aids in decision making with regard to closure of Highway 30 near the plant. The computer programs were used for testing, evaluation, and final deployment. Reports indicate the decision tools have been successfully implemented and were judged to be helpful in forecasting road closures and in reducing costs and personnel time in monitoring the roadway.

Distributing State Road Use Tax Funds to Counties, HR-386, 1996

Iowa's county road system serves many critical functions in a changing environment. Many counties with very different social, economic, and demographic circumstances do not have adequate resources to provide the desired level of service on their secondary road systems. How the state's Road Use Tax Fund (RUTF) is distributed among counties is therefore of great importance. This report presents the results of a year-long study of how to distribute RUTF resources among Iowa's 99 counties. The project was undertaken at the request of county engineers who wish to replace the current method of allocation with one that is more stable, comprehensible, and predictable. This report describes the current allocation method, examines how other states distribute road funds to counties, and discusses potential allocation factors that could be included in a revised procedure. The process undertaken to narrow the range of possible formulas and determine the one to recommend is summarized. Finally, the report presents the allocation formula recommended by the project advisory committee, along with how it would operate.

Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data.

Background and Purpose-The safety and efficacy of thrombolysis in cervical artery dissection (CAD) are controversial. The aim of this meta-analysis was to pool all individual patient data and provide a valid estimate of safety and outcome of thrombolysis in CAD.Methods-We performed a systematic literature search on intravenous and intra-arterial thrombolysis in CAD. We calculated the rates of pooled symptomatic intracranial hemorrhage and mortality and indirectly compared them with matched controls from the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. We applied multivariate regression models to identify predictors of excellent (modified Rankin Scale=0 to 1) and favorable (modified Rankin Scale=0 to 2) outcome.Results-We obtained individual patient data of 180 patients from 14 retrospective series and 22 case reports. Patients were predominantly female (68%), with a mean +/- SD age of 46 +/- 11 years. Most patients presented with severe stroke (median National Institutes of Health Stroke Scale score=16). Treatment was intravenous thrombolysis in 67% and intra-arterial thrombolysis in 33%. Median follow-up was 3 months. The pooled symptomatic intracranial hemorrhage rate was 3.1% (95% CI, 1.3 to 7.2). Overall mortality was 8.1% (95% CI, 4.9 to 13.2), and 41.0% (95% CI, 31.4 to 51.4) had an excellent outcome. Stroke severity was a strong predictor of outcome. Overlapping confidence intervals of end points indicated no relevant differences with matched controls from the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register.Conclusions-Safety and outcome of thrombolysis in patients with CAD-related stroke appear similar to those for stroke from all causes. Based on our findings, thrombolysis should not be withheld in patients with CAD. (Stroke. 2011;42:2515-2520.)

Development of Self-Cleaning Box Culvert Design – Phase II, TR-619, 2013

Culverts are common means to convey flow through the roadway system for small streams. In general, larger flows and road embankment heights entail the use of multibarrel culverts (a.k.a. multi-box) culverts. Box culverts are generally designed to handle events with a 50-year return period, and therefore convey considerably lower flows much of the time. While there are no issues with conveying high flows, many multi-box culverts in Iowa pose a significant problem related to sedimentation. The highly erosive Iowa soils can easily lead to the situation that some of the barrels can silt-in early after their construction, becoming partially filled with sediment in few years. Silting can reduce considerably the capacity of the culvert to handle larger flow events. Phase I of this Iowa Highway Research Board project (TR-545) led to an innovative solution for preventing sedimentation. The solution was comprehensively investigated through laboratory experiments and numerical modeling aimed at screening design alternatives and testing their hydraulic and sediment conveyance performance. Following this study phase, the Technical Advisory Committee suggested to implement the recommended sediment mitigation design to a field site. The site selected for implementation was a 3-box culvert crossing Willow Creek on IA Hwy 1W in Iowa City. The culvert was constructed in 1981 and the first cleanup was needed in 2000. Phase II of the TR 545 entailed the monitoring of the site with and without the selfcleaning sedimentation structure in place (similarly with the study conducted in laboratory). The first monitoring stage (Sept 2010 to December 2012) was aimed at providing a baseline for the operation of the as-designed culvert. In order to support Phase II research, a cleanup of the IA Hwy 1W culvert was conducted in September 2011. Subsequently, a monitoring program was initiated to document the sedimentation produced by individual and multiple storms propagating through the culvert. The first two years of monitoring showed inception of the sedimentation in the first spring following the cleanup. Sedimentation continued to increase throughout the monitoring program following the depositional patterns observed in the laboratory tests and those documented in the pre-cleaning surveys. The second part of Phase II of the study was aimed at monitoring the constructed self-cleaning structure. Since its construction in December 2012, the culvert site was continuously monitored through systematic observations. The evidence garnered in this phase of the study demonstrates the good performance of the self-cleaning structure in mitigating the sediment deposition at culverts. Besides their beneficial role in sediment mitigation, the designed self-cleaning structures maintain a clean and clear area upstream the culvert, keep a healthy flow through the central barrel offering hydraulic and aquatic habitat similar with that in the undisturbed stream reaches upstream and downstream the culvert. It can be concluded that the proposed self-cleaning structural solution “streamlines” the area upstream the culvert in a way that secures the safety of the culvert structure at high flows while producing much less disturbance in the stream behavior compared with the current constructive approaches.

Engineering Study for the Evaluation of Public Road Administration and Maintenance Alternatives, HR-265, 1985

Iowa's public road system of 112,000 miles is one of the largest and the best in the nation. It represents a considerable financial investment of taxpayer revenues over the years. And, it requires a sustained investment to preserve an economical level of transport service into the future. In 1982, a Governor's Blue Ribbon Transportation Task Force evaluated the effectiveness of Iowa's entire transportation system. Four important Task Force recommendations dealt with public road administrative issues in Iowa. These issues were related to: (1) Design criteria and levels of maintenance; (2) Consistency in the use of standards among jurisdictions; (3) Consolidation of maintenance operations at one jurisdiction level; and (4) Jurisdicational authority for roads; The issues formed the background for Research Project HR-265.

Snow Removal on Iowa's Secondary Roads, HR-267, 1984

Snow removal on the 90,000 mile Iowa secondary road system is a major concern of county engineers. Rural residents rely almost entirely on motor vehicles for travel. They have come to expect passable roads during all types of weather and as most county engineers know, the public is less tolerant of problems in snow removal than in any other highway department function. To avoid snow removal problems, maintenance personnel begin preparation before the winter maintenance season. The slide tape presentation, "Snow Removal on Iowa's Secondary Roads", was developed to assist in training and retraining maintenance personnel each year prior to winter. The program covers preparation for winter, snow and ice removal, and after storm care of equipment.

Test result-based sampling: an efficient design for estimating the accuracy of patient safety indicators.

OBJECTIVE: Accuracy studies of Patient Safety Indicators (PSIs) are critical but limited by the large samples required due to low occurrence of most events. We tested a sampling design based on test results (verification-biased sampling [VBS]) that minimizes the number of subjects to be verified. METHODS: We considered 3 real PSIs, whose rates were calculated using 3 years of discharge data from a university hospital and a hypothetical screen of very rare events. Sample size estimates, based on the expected sensitivity and precision, were compared across 4 study designs: random and VBS, with and without constraints on the size of the population to be screened. RESULTS: Over sensitivities ranging from 0.3 to 0.7 and PSI prevalence levels ranging from 0.02 to 0.2, the optimal VBS strategy makes it possible to reduce sample size by up to 60% in comparison with simple random sampling. For PSI prevalence levels below 1%, the minimal sample size required was still over 5000. CONCLUSIONS: Verification-biased sampling permits substantial savings in the required sample size for PSI validation studies. However, sample sizes still need to be very large for many of the rarer PSIs.