File:R10.01 Brücke Möckern, ET piojos.paranix.eu
At the time it was built, this was one of the world's largest privately funded rail construction schemes. The system is based primarily on Japan's. Most intermediate stations on the line lie outside the cities served; however, a variety of transfer options, such as free shuttle buses, conventional rail, and metros have been constructed to facilitate transport connections. Ridership initially fell short of forecasts, but grew from fewer than 40,000 passengers per day in the first few months of operation to over 129,000 passengers per day in June 2013. Daily passenger traffic reached 130,000 in 2014, well below the forecast of 240,000 daily passengers for 2008. The system carried its first 100 million passengers by August 2010 and over 200 million passengers had taken the system by December 2012, followed by 400 million by December 2016. The government also extended the rail concession from 35 years to 70 years and terminated the company's build-operate-transfer business model. The idea of a new high-speed rail line arose in the 1970s, and informal planning began in 1980. In 1987 the executive branch of Taiwan's government, the , instructed the to launch a feasibility study for a high-speed rail line in the western Taiwan corridor, which was completed in 1990. The study found that in a comparison of potential solutions to traffic problems in the corridor, a high-speed rail line would offer the highest transit volume, lowest land use, highest energy savings, and least pollution. However, controversy arose during rolling-stock selection. Four additional stations were added in 2014 and 2015. On 10 September 2019, the announced that the railway would be expanded to. Although lowest in cost, the option was met with criticism regarding its economic benefits. On 25 October 2019, the Railway Bureau published an assessment report to extend the line from Taipei to , cutting travel time to 13 minutes. This marked the first time Shinkansen technology was exported to a foreign country. Customization was focused on adapting to Taiwan's climate and geography, and the nose shape was optimized for tunnels wider than those in Japan. The 12 cars of a 700T train are grouped in three traction units with three power cars and one trailer each, providing 10. The train is 304 m 997 ft long and has a mass of 503 554 when empty. The trains have a passenger capacity of 989 seats in two classes: 66 seats in 2+2 configuration in the single Business Car and 923 seats in 2+3 configuration in the eleven Standard Cars. The per capita energy consumption of a fully loaded 700T train is 16% of that of private cars and half that of buses; emissions are 11% of private cars and a quarter that of buses. All driver candidates must spend 8 months completing 1,326 hours of professional training and pass the National Certification before they can drive the train. In addition, after becoming a certified high-speed train driver, they undergo further on-the-job training at least three times each year in order to guarantee they can drive the train safely. This system consists of a network of sensors installed along the rail route to detect unexpected situations such as earthquakes, strong winds, heavy rainfall, floods, landslides, and intrusions. One operating train was slightly derailed in , and six trains were stopped on the track. In spite of the temporary suspension of operations, there was no damage or casualties. All 2,500 affected passengers were evacuated in two hours without injury. Such a record was well noted, and provided valuable experience in operational safety to the global railway industry. In April 2010, it was reported that had been observed during construction on a 6 km 3. The subsidence continued, reaching up to 55 cm 22 in over seven years. By 2010 subsidence had slowed, which was ascribed to the closure of some deep wells operating in the region. On 25 July 2011, the government announced plans to close almost 1,000 wells in and counties, reducing the amount of water pumped from deep wells by 210,000,000 tonnes 2. Most southbound trains originate from and most northbound trains originate from ; however, a few trains operate just between Nangang and or between Taichung and Zuoying. Southbound trains are designated by odd train numbers, and northbound trains by even train numbers. Each train consists of 1 business car car 6 and 11 standard cars including reserved seats and non-reserved seats. Since July 2010, non-reserved seats are available in cars 10 through 12 some trains available in cars 9 through 12. Car 7 of each train is fitted with 4 wheelchair accessible chairs and a disabled-friendly restroom. Business and standard car reserved ticket reservations are available 28 days prior to the date of departure including the departure day. A group discount is offered for groups of 11 or more. A group discount cannot be used in combination with other discount offers and does not include non-reserved seats. Passengers eligible for multiple discounts can only choose one discount offer. Since 1 July 2010, a system has provided frequent travelers with multi-ride eight trips or periodic tickets. Only adult tickets are available in this format, and cannot be used for rides between Banqiao and Taipei. After purchasing or adding value to a multi-ride card, the card balance is valid for 45 days counted from the day of first use. The ticket is good for 8 rides. The multi-ride card provides a discount of about 21% off the full fare of a reserved Standard Seat. Since November 2012, an Early Bird discount of 35% has been offered for a limited number of tickets sold no later than 8 days before the departure date. If the 35% off tickets sell out before the deadline, tickets with a discount of 20% off are offered. If these tickets sell out before the deadline, tickets with a discount of 10% off are offered. If all early bird tickets are sold out, then full fare tickets are offered. In view of a 50% drop in airline passengers in the wake of the , forecasts were revised downwards. The final initial ridership estimate was 140,000 passengers per day. Actual initial ridership did not match these projections. In the second year, passenger numbers almost doubled. In the third year, average daily ridership continued to grow to 88,000 passengers per day, jumping to over 120,000 passengers per day in 2012. The 10-millionth passenger was carried after 265 days of operation on 26 September 2007, while the 100-millionth passenger was carried after 1,307 days on 3 August 2010, and 200-millionth by December 2012. The next single-day record was reached on 25 January 2012, also the third day of Chinese New Year's celebration, at 191,989 passengers. The most recent record is 212,000 passengers transported on 1 January 2013. Total domestic air traffic was expected to be halved from 2006 to 2008, and actually fell from 8. In June 2012, officials announced the discontinuation of the last remaining commercial flight between Taipei and Kaohsiung. The share for conventional rail between Taipei and Kaohsiung fell from 9. Construction of the system took more than 2,000 professional engineers from 20 countries and over 20,000 foreign and domestic workers six years to complete. Construction work was broken into several specialized lots that were contracted separately. One group of contracts was for civil works, covering the construction of the superstructure of open line sections. Stations and depots were the subject of separate groups of construction lots. A fourth group of lots was for track work. Track laying began in July 2003. The signalling and train control system was laid out for bi-directional operation according to European specifications. Each track section has a checkpoint, and an automatic control system ensures that trains are spaced at least 1 km 0. After four months of delays, trial runs using the first trains began on 27 January 2005, on the Tainan—Kaohsiung section. The section between Taipei and Kaohsiung opened to the public on 5 January 2007. About 251 km 156 mi or 73% of the line runs on , mostly spans, the first of which was put in place in October 2001. It was the second in the world as of 2017. Viaducts were designed to be to allow for trains to stop safely during a seismic event and for repairable damage following a maximum design earthquake. Bridges built over known were designed to survive fault movements without catastrophic damage. About 61 km 38 mi or 18% of the line is in tunnels, including 14 km 8. Forty-two of the tunnels included a total of 39,050 m 24. The finished interior cross-sectional area of 90 m 2 970 sq ft , set according to wider European standards, provides space for two tracks with safety walkways. The pheasant-tailed Jacana population in Tainan, Taiwan, which at one point numbered less than 50, has increased to over 300. The temple established beside the old tree is the belief center of the people there. Advertising spots on trains and station platforms have also been sold. Revenues grew along with ridership over the first three years, but ridership remained below expectations. Revenues first exceeded this level, thus generating a positive , in the fourth month of operation April 2007. As a result, the balance of operating revenues and costs showed a high loss in the first year of operation, which was only reduced as revenues grew in the second year. In 2011, the Company continued to pursue sustainable growth aligned with the interests of shareholders and society, achieving record profits even amid a challenging economic environment. The interest cost is another major item of this company's financing. In the first few years of operation, interest rates were well above market rates. Interest rates fell in the first half of 2009, reducing interest expenses and contributing to a reduced. In comparison with the terms and conditions of previous loans, the newly signed refinancing debts carried lower interest rates and longer tenors up to 22 years. The Company's financial burden is therefore largely reduced. The company was put under new management in September 2009 with the aim of turning around the company's finances with government help in arranging refinancing of the loans. The government took majority control of the company after the election of its new board on 10 November 2009. The government also approved the company's new variable depreciation charge. The train was stopped at and all of the passengers were evacuated. Later, it was determined the luggage contained an unidentified liquid in cans, alarm clock and white particulate matter. The items were dismantled by the bomb squad and taken for further investigation. Two legislators, and , were on board. The traffic control center decided to evacuate passengers after the train stopped at Taoyuan station at 9:45 am. More than 600 people were asked to disembark and continue their journey on another train. Two bomber suspects were arrested in a hotel in Zhongshan City, Guangdong Province, China on 15 April and repatriated to Taiwan on 17 April 2013. Part of the tracks near were badly damaged during the on 6 February 2016. All high-speed rail services south of were suspended until 7 February 2016. On 10 May 2017, a non-passenger carrying train headed the opposite direction of the track from Zuoying to Tainan for 1 km due to human negligence. The switch to reserved seats only aims to reduce crowding. On public display was an enormous 2 meter tall by 3 meter wide calligraphy sculpture created by Ms. Dong using naturally weathered wood from Taiwan. This is the first calligraphy sculpture in Taiwan that allows the spirit of calligraphy and the connotation of words to transcend the constraints of the writing brush, and its cultural and artistic significance enriched Taichung Station as well as the journeys of passengers transiting through the station. The performances were well received by passengers, with fans even forming groups to catch a glimpse of the musicians at various stations. It also continues to actively conduct experience sharing with its fellow railway transportation operators to enhance the quality of public transportation and create better planning, design and service. In of the internationally aired reality television game show , which was watched by 11. International Journal of Business and Management. Canadian Center of Science and Education. The Taiwan-Japan Workshop on the Earthquake Early Warning System abstract. Taiwan High Speed Rail Corporation. Ministry of Transportation and Communications stat. Proceedings of the 13th World Conference on Earthquake Engineering.
次の
Archivfund: 01 1102
Number: 0016 Policy Aetna considers any of the following injections or procedures medically necessary for the treatment of back pain; provided, however, that only 1 invasive modality or procedure will be considered medically necessary at a time. These may be performed bilaterally during the same session for a total of up to six injections. A second diagnostic facet injection intraarticular and medial branch block is considered medically necessary to confirm the validity of the clinical response to the initial facet injection when it is administered at the same level as the initial facet injection, and where the initial facet injection produced a positive response i. If the initial injection did not produce a positive response, a second diagnostic injection is considered not medically necessary. Diagnostic facet joint injections are considered experimental and investigational for neck and back pain with untreated radiculopathy. Facet joint injections are considered experimental and investigational as therapy for back and neck pain and for all other indications because their effectiveness for these indications has not been established. Facet joint injections intra-articular and medial branch blocks containing corticosteroids are considered therapeutic injections. Aetna considers diagnostic facet joint injections not medically necessary where radiofrequency facet neurolysis is not being considered. Additional sets of facet injections or medial branch blocks at the same levels and side are considered experimental and investigational because they have no proven value. Aetna considers ultrasound guidance of facet injections experimental and investigational because of insufficient evidence of its effectiveness. Trigger point injections are considered experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established. A trigger point is defined as a specific point or area where, if stimulated by touch or pressure, a painful response will be induced. A set of trigger point injections means injections in several trigger points in one sitting. It is not considered medically necessary to repeat injections more frequently than every 7 days. Up to 4 sets of injections are considered medically necessary to diagnose the origin of a patient's pain and achieve a therapeutic effect; additional sets of trigger point injections are not considered medically necessary if no clinical response is achieved. Once a diagnosis is established and a therapeutic effect is achieved, it is rarely considered medically necessary to repeat trigger point injections more frequently than once every 2 months. Repeated injections extending beyond 12 months may be reviewed for continued medical necessity. Sacroiliac joint injections are considered experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established. Up to 2 sacroiliac injections are considered medically necessary to diagnose the patient's pain and achieve a therapeutic effect. It is not considered medically necessary to repeat these injections more frequently than once every 7 days. If the member experiences no symptom relief or functional improvement after 2 sacroiliac joint injections, additional sacroiliac joint injections are not considered medically necessary. Once the diagnosis is established, it is rarely medically necessary to repeat sacroiliac injections more frequently than once every 2 months. Repeat injections extending beyond 12 months may be reviewed for continued medical necessity. Ultrasound guidance of sacroiliac joint injections is considered not medically necessary. Member has failed to improve after 4 or more weeks of conservative treatments e. Interlaminar epidural injections of corticosteroid preparations, with or without added anesthetic agents, are considered experimental and investigational for all other indications e. Initially, the individual may receive the first three injections at intervals of no sooner than two weeks. If the initial interlaminar epidural injections are unsuccessful, additional interlaminar epidural injections are considered not medically necessary. If the member experiences less than 50% relief of pain after three interlaminar epidural injections, additional epidural injections are not considered medically necessary. After the initial three injections, repeat epidural injections more frequently than every two months are not considered medically necessary. Additional interlaminar epidural injections per region per rolling 12-month period are considered experimental and investigational because they have no proven value. Aetna considers ultrasound guidance of epidural injections experimental and investigational because of insufficient evidence of its effectiveness. Percutaneous lumbar diskectomy is considered experimental and investigational for all other indications because its effectiveness for indications other than the one listed above has not been established. Note: Clinical studies have not established any clinically significant benefit of use of a laser over use of a scalpel for percutaneous lumbar diskectomy. Non-pulsed radiofrequency facet denervation is considered experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established. Provided that greater than 50% pain relief is obtained for at least twelve weeks, further facet denervation procedures should be at intervals of at least six months per level per side, at a maximum of twice per rolling calendar year. Only 1 treatment procedure per level per side is considered medically necessary in a 6-month period. Spine cages are otherwise not considered medically necessary for cervical fusion because they have not been proven more effective than bone graft for this indication. Spine cages are considered experimental and investigational for indications other than fusion because their effectiveness for indications other than those listed above has not been established. Expandable cages are considered medically necessary for persons who meet criteria for fusion in. Expandable cages are considered experimental and investigational for all other indications. For intercostal nerve blocks, see. Microscope and endoscope : Use of a microscope or endoscope is considered an integral part of the spinal surgery and not separately reimbursable. Background Epidural Steroids An epidural steroid finjection is an injection of long lasting steroid in the epidural space -- that is the area which surrounds the spinal cord and the nerves coming out of it. An epidural steroid injection is used to help reduce radicular spinal pain that may be caused by pressure on a spinal nerve root as a result of a herniated disc, degenerative disc disease or spinal stenosis. This treatment is most frequently used for low back pain, though it may also be used for cervical neck or thoracic midback pain. A combination of an anesthetic and a steroid medication is injected into the epidural space near the affected spinal nerve root with the assistance of fluoroscopy which allows the physician to view the placement of the needle. This approach is commonly used to treat lumbar radiculopathy after prior surgery in the low back post-laminectomy pain syndrome. Also called translaminar, this method accesses the large epidural space overlying the spinal cord, and is the most commonly used approach for cervical, thoracic, and lumbar epidural injections. Medication is delivered to the nerve roots on both the right and left sides of the inflamed area at the same time. The goal of this treatment is to reduce inflammation and block the spinal nerve roots to relieve radicular pain or sciatica. It can also provide sufficient pain relief to allow the individual to progress with their rehabilitation program. The efficacy of epidurally administered steroids has been demonstrated without adverse consequence in a large number of patients with reproducible results. In a large number of studies, long-term relief of pain greater than 3 months can be achieved in at least 10 to 30 % of patients, while short-term relief less than 1 month can be achieved in 60 to 100 % of patients. Results for cervical pain are somewhat lower than those for lumbar pain. Such therapy is considered under accepted guidelines to be indicated in patients with low back and cervical pain that has not resolved after only a short period of more conservative measures since studies have shown a better response to therapy in patients whose pain is of shorter duration. Even if pain relief is temporary, it may have long-term benefit because it allows initiation of physical therapy or other rehabilitative measures at an earlier stage. Most authors indicate that a limit on number of injections is appropriate, and that most patients will respond with 3 or fewer injections. The average magnitude of effect is small, and the generalizability of the observation is limited by the small number of studies, limited to highly selected patient populations, the few techniques and doses studied, and variable comparison treatments. Data on use of epidural steroid injections to treat cervical radicular pain are inadequate to make any recommendation Level U. Guidelines from the American Pain Society Chou et al, 2009 questioned the clinical value of epidural injection for long-term use or for use of non-radicular back pain. A recommendation for epidural steroid injection for patients with symptomatic spinal stenosis was not offered based on insufficient or poor evidence. Trigger points have also been treated with dry needling. Dry needling is not to be confused with traditional Chinese acupuncture, even though it does make use of acupuncture-type needles. Acupuncture follows the principles of energy flow as a guide to where the needles will be inserted; in dry needling, needles are inserted directly into a myofascial trigger point, in an attempt to inactivate it, thereby decreasing the associated pain. Dry needling, even though it targets a trigger point, also differs from a trigger point injection, as there is no injection of medication or fluid. When palpated, these hyper-irritable areas cause pain in distant areas, or referred pain zones, which are specific for each trigger point. Trigger point injection, or direct wet needling, involves injection of fluid directly into the trigger point located in the taut muscle band. The main objective of trigger point injection is fast pain relief and elimination of muscle spasm in order to break the pain cycle. This facilitates physical therapy aimed at reducing muscle contracture and increasing range of motion. Thus, treatment may also include patient education, psychosocial support, oral medications, and physical therapy to improve the strength and flexibility of the affected musculoskeletal systems. An assessment conducted by the Alberta Heritage Foundation for Medical Research Scott and Guo, 2005 found that the evidence for the effectiveness of trigger point injections when used as the sole treatment for patients with chronic head, neck, and shoulder pain and whiplash syndrome was inconclusive, regardless of whether sterile water, saline, or botulinum toxin is injected. The assessment found that the combined use of dry needling and trigger point injection with procaine offers no obvious clinical benefit in the treatment of chronic craniofacial pain, while the effectiveness of trigger point injection for the treatment of cervicogenic headache is unknown. In contrast, the assessment found that trigger point injection with lidocaine may be useful in the treatment of joint pain caused by osteoarthritis Scott and Guo, 2005. The assessment found no proof that triggers point injection is more effective than other less invasive treatments, such as physical therapy and ultrasound, in achieving pain relief, and there is some suggestion that the only advantage of injecting anesthetic into trigger points is that it reduces the pain of the needling process Scott and Guo, 2005. A number of trigger points may be injected in 1 session, but rarely more than 5. Repeated injections in a particular muscle are not recommended if 2 or 3 previous attempts have been unsuccessful Alvarez and Rockwell, 2002; Sanders et al, 1999. The pain relief may last for the duration of the anesthetic to many months, depending on the chronicity and severity of the trigger points and the concomitant treatment of perpetuating factors. According to available guidelines, use of trigger point injections should be short-term and part of a comprehensive rehabilitation program. Botwin and colleagues 2008 noted that myofascial pain is defined as pain that originates from myofascial trigger points in skeletal muscle. It is prevalent in regional musculoskeletal pain syndromes, either alone or in combination with other pain generators. The myofascial pain syndrome is one of the largest groups of under diagnosed and under treated medical problems encountered in clinical practice. Trigger points are commonly seen in patients with myofascial pain which is responsible for localized pain in the affected muscles as well as referred pain patterns. Correct needle placement in a myofascial trigger point is vital to prevent complications and improve efficacy of the trigger point injection to help reduce or relieve myofascial pain. In obese patients, these injections may not reach the target tissue. In the cervico-thoracic spine, a misguided or misplaced injection can result in a pneumothorax. These researchers described an ultrasound-guided trigger point injection technique to avoid this potential pitfall. Office based ultrasound-guided injection techniques for musculoskeletal disorders have been described in the literature with regard to tendon, bursa, cystic, and joint pathologies. For the interventionalist, utilizing ultrasound yields multiple advantages technically and practically, including observation of needle placement in real-time, ability to perform dynamic studies, the possibility of diagnosing musculoskeletal pathologies, avoidance of radiation exposure, reduced overall cost, and portability of equipment within the office setting. A palpable trigger point in the cervico-thoracic musculature was localized and marked by indenting the skin with the tip of a plastic needle cover. The skin was then sterile prepped. Then, using an ultrasound machine with sterile coupling gel and a sterile latex free transducer cover, the musculature in the cervico-thoracic spine where the palpable trigger point was detected was visualized. Then utilizing direct live ultrasound guidance, a 25-gauge 1. This guidance helped confirm needle placement in muscle tissue and not in an adipose tissue or any other non-musculature structure. The technique was simple to be performed by a pain management specialist who has ultrasound system training. The authors concluded that ultrasound-guided trigger point injections may help confirm proper needle placement within the cervico-thoracic musculature. The use of ultrasound-guided trigger point injections in the cervico-thoracic musculature may also reduce the potential for a pneumothorax by an improperly placed injection. Despite current treatments with physical therapy, analgesics, anti-depressants and trigger-point injections, myofascial pain remains a challenging chronic pain condition in clinical practice. Active trigger points are associated with referred pain and greatly impact many aspects of activities of daily living, mood, and health status. The literature referenced was obtained via a computer search with Google Scholar, PubMed, Medline and Embase. Additional references were retrieved from the reference list of the reports found via this search. Open-label studies, case reports, and other non-randomized studies were excluded. A total of 8 trials were found according to the above criteria. The main drawback of this study was its relatively small sample. Shinomiya et al 2016 examined if differences in corticosteroid injection site influence the therapeutic effect on trigger finger and thickness of local structures such as the A1 pulley and flexor tendons. Symptom remission and recurrence rates and recurrence timing did not significantly differ between the groups. Ultrasonography revealed mean standard deviation pre-injection A1 pulley thicknesses of 1. One month after injection, these decreased to 0. Furthermore, mean standard pre-injection flexor digitorum tendon thickness was 4. However, the difference at each time-point between the 2 groups was not statistically significant. The authors concluded that true intra-sheath injection offered no apparent advantage over extra-sheath injection for treating trigger fingers because both have the same effect on local structures. Lumbar Laminectomy with or without Fusion Laminectomy and laminotomy involve removal of a small part of the bony arches of the spinal canal, called the lamina, which increases the size of the spinal canal. A laminectomy or laminotomy is most commonly performed for a diagnosis of spinal stenosis. During a laminectomy the entire lamina is removed while only a portion of the lamina is removed in a laminotomy. If conservative therapy fails to relieve symptoms of sci.
次の
