Multimodal Plan Research Articles

Prospective pilot study of Merkel cell carcinoma.

e19005 Background: Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine skin cancer. The annual incidence for MCC, based on SEER database, was 0.6 cases per 100,000 in 2006 (0.15 cases per 100,000 in 1986), with slightly more males affected (60%). Due to its rarity, data on its clinico-pathological features and impact of therapy are limited. Aim: To characterize MCC based on immunohistochemical (IHC) features and serum levels of biochemical markers such as chromogranin A (CgA) and serotonin and select treatment options. Methods: This prospective pilot study included 7 patients (pts) since 2009 and their age, sex, primary site, IHC features and serum levels of biochemical markers, progression-free-survival (PFS) were recorded. Median of overall survival was not achieved. Results: Pts characteristics were: age 44–67 years (mean 57), male–female ratio = 4:3. Most common primary sites were extremities (5pts), lymphnode metastases from unknown primary (1pt) and genitals (1pt). IHC showed diffuse positivity for CgA (6pts), dot-like staining for cytokeratin 20 (7pts), synaptophysin (6pts), Ki-67 (40%-1pt, 50%-1pt, 60–70%-5pts). The tumors did not express vimentin, TTF1. Serum levels of Cg A (2pts) and serotonin (1pt) were above normal. Treatment: Local disease – surgery, either alone (1pt) or as part of multimodality plan (2pts); Locoregional disease – surgery plus chemotherapy (2pts) and chemotherapy alone (1pt); Distant disease – chemotherapy plus surgery (1pt). Median of PFS was 16 months.Two patients with improvement of biochemical markers continue to receive maintenance therapy with somatostatin (SST) analogues for 16 and 24 months with complete remission. Conclusions: SST analogues facilitates treatment of MCC without reducing quality of life and increase PFS in patients with high CgA serum level. In spite of recent advances in understanding the biology of MCC, many molecular mechanisms that influence behavior stills are unknown.

Traffic modelling and simulation for regional multimodal evacuation analysis

History has shown that evacuation planning has been based largely on lessons learned from prior events. While it yields incremental improvements, this approach also results in plans that tend to address failures 'of past evacuations', while leaving vulnerabilities to unforeseen conditions. Traffic simulation is a tool that can be used to evaluate evacuation plans and test contingencies not yet experienced or imagined. This paper discusses an effort to develop and test an agent-based travel demand and simulation model of the New Orleans regional multimodal evacuation plan. It is among the first to integrate a multimodal evacuation process into a regional traffic model with over a million vehicles, covering thousands of square miles, over two days and the first to use field recorded evacuation data for calibration and validation. The result of the model were used to quantitative and qualitative assess speed, volume, density, and congestion formation and recovery throughout the evacuation network.

Evaluating State Multimodal Transportation Policy Responses

Using Virginia’s statewide multimodal plan as a case study, this paper outlines an approach to evaluating policies that coordinate the transportation-related efforts of individual agencies. The approach entails identification of seven potentially promising multimodal policies, a case study quantification of impacts for two such policies, and recommended steps for implementation. The case policies evaluated were (1) using cost per kilogram of emissions eliminated to select among eight alternatives and (2) increasing density to reduce CO2 emissions. The case study demonstrates the feasibility of the outlined approach: Policy 1 increases efficacy by a factor of up to 3.7, and Policy 2 reduces annual CO2 by 1.5 million metric tons, showing that a comparison of diverse multiagency policies at a sketch planning level is productive. The paper shows that a multimodal planner’s role includes explicit identification of assumptions and quantitative methods that enable a comparison of diverse transportation investments given the typical lack of hard data early in the transportation planning process.

Use of Three-Dimensional Ultrasound in the Detection of Breast Tumor Bed Displacement During Radiotherapy

To evaluate the feasibility and usefulness of a three-dimensional ultrasound (3D-US) image-guided system in identifying and tracking the tumor bed (TB) for planning and daily localization before radiation delivery for breast cancer. Twenty breast cancer patients underwent two CT scans at the time of simulation and just before their boost. Three-dimensional ultrasound images were acquired immediately after the CT scans, to which the images were automatically fused. Three-dimensional ultrasound images were also acquired immediately before treatment. Spatial and temporal TB differences between CT and US were evaluated. The TB was not visible on US and CT in 1 subject who had and 1 subject who had not received chemotherapy before whole-breast radiotherapy. The mean (SD) TB volume overlap was 78% (14%). The mean centroid position of the TB on CT vs. US differed by 0.1, 0.2, and 0.4 mm in the anterior-posterior, left-right, and superior-inferior directions. The mean (SD) absolute radial displacement of the TB on each fraction from the treatment plan was 10.8 (6.3) mm. The TB was well visualized by US for the majority of patients. Clinically insignificant differences in the displacements calculated by paired CT vs. paired US demonstrate the feasibility of using 3D-US. The present study suggests that a 10-mm planning target volume margin could result in undercoverage of the clinical target volumes in 50% of treatments. Multimodality planning and image-guided radiotherapy with US potentially offers an accurate and non-ionizing solution for the daily definition of the TB position during partial-breast irradiation and boost treatments.

P65 A multi-modality peri-operative care plan for radical cystectomy and urinary intestinal diversion. Comparison of results and complications in patients aged less than 75 years, and 75 years and older

Purpose of the study: To compare the results and complications in radical cystectomy patients younger than 75 years of age and 75 and older treated within a multi modality perioperative plan aimed at reducing, or preventing, the incidence of post operative ileus. Method(s): The core measures intended to prevent post-operative ileus consisted in the abolition of mechanical bowel preparation and fasting before surgery, the administration of opiod-sparing general, and combined thoracic epidural anaesthesia, prevention of hypovolemia, substitution of saline with dextrose, protracted post-operative epidural analgesia, and early provision of nutrients. Time to return of bowel movements, time to reinstitution of a regular diet, presence and duration of postoperative ileus, incidence and nature of complications, constituted the study endpoints. Result(s): From Jan 2003 to Dec 2008 a total of 107 consecutive patients underwent radical cystectomy with some form of intestinal urinary reconstruction that were evaluable for results and complications 66 were aged 74 years or younger, median age 64.3, and 41 were 75, or older, median age 78.9. Bowel movements returned after a median time of 2 days, range 1 to 6, and the median time to re-institution of a regular diet was 4 days, range 3 to 9, in both groups. POI was observed in 17.7%. The overall complication rate was 24.2%, mortality rate 3.4%. Conclusion(s): Short time to resumption of normal intestinal function and low incidence of post operative ileus were attained in both age groups by applying a peri-operative plan aimed at enhancing the post-operative recovery of intestinal function. Further studies on peri-operative regimens are needed.

A multimodal public transport planning guidance for sustainable transport in developing countries

Many chaotic public transport systems in developing countries remain unchanged. The question is why we do not have faith in changing the system of public transport in terms of services and performance? Because many local governments think that modern system of public transport is difficult to start with, or it needs much money that they could not afford to support, or, as usual – it is no need to hurry up changing the system. This concept is misleading. In fact if the guidance to improve the public transport system is available then sustainable transport can be achieved and unnecessary expenses caused by pollution and deteriorating city can be avoided. Sustainable transport can be achieved by reducing fuel used for transportation for example reduce car use and switch to public transport use, decrease the excessive public transport to the efficient and effective public transport, switch unimodal to multimodal public transport system. Many examples can be adapted, but they still need adjustment, which might take longer than previously doing the complete survey. Therefore, it is desirable to write guidance for the initiative of establishing the multimodal public transport (MMPT) system.

Characterization of a Clinical Cohort of 87 Women with Interstitial Cystitis/Painful Bladder Syndrome

To provide a characterization of a cohort of women with interstitial cystitis/painful bladder syndrome (IC/PBS) by describing their historical and clinical characteristics. This was reported with the National Institutes of Health chronic prostatitis cohort, but a literature review did not reveal a similar study for women with IC/PBS. A total of 87 women with IC/PBS were referred to the Beaumont Women's Initiative for Pelvic Pain and Sexual Health program. A certified nurse practitioner took a comprehensive history and performed a pelvic exam for each. Data were analyzed using descriptive statistics to describe this cohort. Most women experienced constant pain for 5 or more years (mean Visual Analog Scale = 5 out of 10). A total of 94.2% had levator pain. More than 50% had vulvar pain with exam. More than half reported a history of abuse, often in more than one life stage. A total of 28% had cesarean births and 76% had a history of miscarriage, stillbirth, or abortion. Women averaged 4 lifetime pelvic surgeries, and 48% had hysterectomies, two-thirds of which were done before IC/PBS diagnosis. Premenstrual women reported pain throughout the menstrual cycle. As many as 12% had chlamydia previously, which was higher than the national average. Common comorbidities were pelvic pain (93%), allergies (86%), and sexual dysfunction (72%). This population of women with unrelieved chronic pain, frequency, and urgency is in desperate need of care. Researchers should continue to search for the etiology, prevention, and treatment interventions that are effective in dealing with IC/PBS. It may be most therapeutic to develop a multimodal plan of care that includes physical therapy, oral and intravesical therapies, neuromodulation, and cognitive-behavioral therapies.

Urban Services Localization and Optimal Traffic Distribution: Users Oriented System

This technical note discusses the applications of a users oriented system devised to define the localization of urban services based on traffic distribution. The system, urban location interactive system for services (ULISSE), created by the writers, uses a static model of the network and solves an optimization problem oriented to minimize the global access cost (in term of time) faced by clients to a predefined service location, as well as the number of vehicles in the considered road network, which is strictly related to the global traffic pollution. With a client-server structure and a friendly user interface, ULISSE is a tool for interactive applications and decision support systems. As examples, some results are here presented relevant to the field of service allocation and of multimodal transport system planning.

Measuring community-based case management performance: strategies for evaluation.

Case management services are not implemented uniformly or with the same levels of intensity. Case managers serve in diverse settings, have varied training and experiences, and individualize care at the patient level. The flexible characteristics of case management services pose challenges to, and accentuate the need for, successful ongoing evaluation. The purpose of this article is to describe a multimodal evaluation planning strategy that was applied to case management services delivered to pediatric Medicaid recipients within an enhanced primary care case management delivery system. The evaluation planning steps included describing the organization and case management program, identifying barriers to evaluation, outlining evaluation questions, specifying data needs, identifying sources of data, and selecting evaluation methods. The evaluation plan utilized a combination of case studies, monitoring, surveys, and trend analysis. The approaches outlined in this article are likely to be applicable to evaluating diverse case management programs and services.

Coordinating Self-interested Planning Agents

We consider planning problems where a number of non-cooperative agents have to work on a joint problem. Such problems consist in completing a set of interdependent, hierarchically ordered tasks. Each agent is assigned a subset of tasks to perform for which it has to construct a plan. Since the agents are non-cooperative, they insist on planning independently and do not want to revise their individual plans when the joint plan has to be assembled from the individual plans. We present a general formal framework to study some computational aspects of this non-cooperative coordination problem and we establish some complexity results to identify some of the factors that contribute to the complexity of this problem. Finally, we illustrate our approach with an application to coordination in multi-modal logistic planning.

Centralized and Decentralized Multimodal Statewide Transportation Planning

Statewide multimodal transportation planning may be centralized through a single office or decentralized through separate modal agencies (e.g., aviation, transit, highway, port, rail, and toll agencies). To determine the value of each approach, representatives from 41 states were surveyed by questionnaire or telephone about the usefulness of centralized versus decentralized planning. Each approach offers benefits. Centralization provides consistency of modal plans, better modal coordination (including detection of modal conflicts earlier in the process), an ability to examine the entire transportation system holistically, collective attention brought to smaller modes that otherwise might be overlooked, economies of scale for service delivery and employee development, and a greater likelihood that long-range planning will be performed rather than eliminated by more immediate tasks. Decentralization, however, provides greater ease in obtaining modal support for a long-range plan (since the planners and implementers are in the same functional unit), greater ease of tapping mode-specific expertise, and an ability to focus on the most critical mode. External factors that may override the importance of either approach are mode-specific funding requirements, the increasing relevance of metropolitan planning organizations, and the fact that modal location in the same office is not synonymous with coordination. A subset of the free responses to the survey indicated that centralized multimodal planning can be beneficial but only if four constraints are met: modal staff work collaboratively, the centralized unit has funding or other authority, necessary mode-specific planning is not eliminated, and there is a clear linkage between this unit and the agencies that perform mode-specific planning such that the latter can implement the recommendations of the former.

Centralized and Decentralized Multimodal Statewide Transportation Planning: Survey of States

Statewide multimodal transportation planning may be centralized through a single office or decentralized through separate modal agencies (e.g., aviation, transit, highway, port, rail, and toll agencies). To determine the value of each approach, representatives from 41 states were surveyed by questionnaire or telephone about the usefulness of centralized versus decentralized planning. Each approach offers benefits. Centralization provides consistency of modal plans, better modal coordination (including detection of modal conflicts earlier in the process), an ability to examine the entire transportation system holistically, collective attention brought to smaller modes that otherwise might be overlooked, economies of scale for service delivery and employee development, and a greater likelihood that long-range planning will be performed rather than eliminated by more immediate tasks. Decentralization, however, provides greater ease in obtaining modal support for a long-range plan (since the planners and implementers are in the same functional unit), greater ease of tapping mode-specific expertise, and an ability to focus on the most critical mode. External factors that may override the importance of either approach are mode-specific funding requirements, the increasing relevance of metropolitan planning organizations, and the fact that modal location in the same office is not synonymous with coordination. A subset of the free responses to the survey indicated that centralized multimodal planning can be beneficial but only if four constraints are met: modal staff work collaboratively, the centralized unit has funding or other authority, necessary mode-specific planning is not eliminated, and there is a clear linkage between this unit and the agencies that perform mode-specific planning such that the latter can implement the recommendations of the former.

Subthalamic Nucleus Stimulation for Advanced Parkinson's Disease: How to Find a Far Medial STN

In a patient with advanced Parkinson's disease, an anatomically deviant far medial subthalamic nucleus (STN) posed problems in the placement of DBS electrodes for chronic high frequency (HF) stimulation despite the use of multimodal targeting with 1) statistical atlas data, 2) T (2)-weighted (T (2)W) magnetic resonance imaging (MRI), 3) microelectrode recording, and 4) clinical testing with macro stimulation. Diagnostic T (2)W MRI suggested that the patient's STN was in a typical location and seemed to confirm the statistical atlas-based planning. Intraoperatively, cell activity recording (MER) with five parallel electrodes could not reveal any STN typical activity profile and electrical stimulation was not able to disclose a medial or lateral displacement of the electrodes. The operation was discontinued and postoperative stereotactic CT confirmed that the correct target area had been approached during the operation. Postoperative T (2)W MRI now disclosed a left STN which was 2 mm medial of the initial target and lead to a further medial target definition and finally to a successful DBS placement. In conclusion, finding a deep seated DBS target like the STN can be difficult in cases with an extremely deviant anatomy even if reiterative sophisticated multimodal planning is used. In the presented case we applied the integrated information from intraoperative MER, macrostimulation and postoperative imaging work-up and were able to complete DBS implantation successfully.

Intermodal and Multimodal Freight Policy, Planning, and Programming at State Departments of Transportation: Review of the Decade Since the Intermodal Surface Transportation Efficiency Act

Intermodal and multimodal freight policy, planning, and programming in state agencies in the decade since passage of the Intermodal Surface Transportation Efficiency Act of 1991 (ISTEA) are summarized, providing a snapshot of state freight activities in the early 21st century and supplementing previous reports. Freight policy, planning, and programming requirements in ISTEA and the Transportation Equity Act for the 21st Century are reviewed. Freight efforts recently completed or under way in state agencies, primarily state transportation agencies, are summarized. The summary focuses on freight studies and plans, freight offices or programs, and selected information obtained from responses to a survey of state transportation agencies. The report may be useful to groups advocating freight agendas, developing freight outreach programs and future research ideas, or preparing recommendations for federal or state legislation.

Tool for Rural and Statewide Multimodal Transportation Planning

The Georgia Department of Transportation's Multi-modal Transportation Planning Tool (MTPT) facilitates multimodal planning in rural areas. Using open databases that are available agencywide, the to...

Conversion of Weight of Freight to Number of Rail Cars

Multimodal freight vehicle assignment models require numbers of vehicles to generate origin-destination matrices. Most current freight flow data are provided as total volume or value. Presented are the development and results of conversion models for converting weight to number of rail cars as one component of a multimodal planning activity. The 1992 rail waybill sample was used for developing the conversions. Only loaded cars were used for conversions. Therefore, empty cars are not included in the models. Evaluation of these conversions was performed by using 1993 Commodity Flow Survey data. On the basis of the evaluation, recommendations on conversion models are made.

Planning for Megacontainerships: Statewide Transportation Planning Approach

The emergence of the megacontainership, exceeding 5,000 twenty-foot equivalents (TEUs) in capacity, is of interest to shippers, logistics companies, port authorities, and those engaged in maritime planning. Where such ships unload, rather than transship, state transportation agencies responsible for multimodal planning and highway connectivity are affected by greater flows of containers passing through the load center. A planning process is described that can be applied at the state level to select a megacontainership site. It was developed as part of a Texas Department of Transportation research study into the effects of containerships on the state transportation system but is generic in structure and can be applied at port sites located in other parts of the United States.

Data and image processing for abdominal imaging.

Modern imaging techniques allow information from within the human body to be obtained by using noninvasive or minimally invasive means. This article is intended as a summary of the tools used for processing and displaying such datasets, with a focus on abdominal imaging. Although these tools and their applications are permanently evolving, their use for clinic and research is already recognized as essential. As an insight into the near future, advanced protocols such as multidimensional and multimodality diagnostic and therapy planning are also demonstrated with a few clinical examples.

Postoperative Pain Management

Postoperative pain can be effectively managed, even in the most complex oncologic procedures. Although the primary agents for treatment of severe pain continue to be opioids, routes of administration and dosing regimen have undergone a dramatic metamorphosis in the past 10 years. The intramuscular injection given every 4 hours has been replaced by patient-controlled analgesia and epidural techniques. Management of ancillary issues that contribute to an increased perception of pain (i.e., stress, depression, anxiety, and inflammation) must be included in an effective multimodal plan. Closer attention to the treatment of pain can obviate the consequences of poorly managed pain, which we are only beginning to understand. In this day of active consumerism in medicine, patients have come to expect improved pain management. Early outcome studies are beginning to confirm the belief that improved pain management translates into between outcomes and earlier dismissals. In the first century BC, Publilius Syrus, a Latin mime, wrote, "There are some remedies worse than the disease." For centuries, pain was inextricably linked to treatment. We may now be approaching a time in the development of medical care when this is no longer true.

Using constraint propagation in MAGPIE: a multi-agent approach

Multimodal presentation planning must solve the constraints imposed by the structure of the discourse. In this paper, we discuss a multi-agent implementation of the design and realization layers of the Standard Reference Model (SRM) for Intelligent Multimedia Presentation Systems (IMMPS), where design constraints for multimodal presentations are distributed over a number of agents. Thus, a constraint propagation mechanism is required so that the distributed constraints can be satisfied cooperatively by these agents.