Kenji Inaba, MD, FRCSC, PhD, FACS

• Program Director, Surgical Critical Care Fellowship,
• University of Southern California? Keck School of
• Medicine, CA, USA

Settings of Care Since palliative care is not setting-specific erectile dysfunction obesity purchase super viagra 160mg with amex, palliative care principles and practices are applicable throughout the course of a serious illness vegetable causes erectile dysfunction buy super viagra 160mg overnight delivery. Palliative care is available across and between care settings erectile dysfunction options 160 mg super viagra, thereby Clinical Practice Guidelines for Quality Palliative Care erectile dysfunction zinc super viagra 160 mg otc, 4th edition v Foreword improving continuity and coordination of care and, as a consequence, decreasing expenses related to duplicative or non-beneficial interventions or waste. While hospital-based palliative care and hospice are widely available in the United States, access to palliative care in other settings is often unavailable. Reliable access to palliative care in community-based settings is essential to the delivery of expert care and symptom management, as well as psychological, practical, and social support, helping patients and families remain safely in their care setting of choice. New community-based palliative care models are meeting the needs of those with a serious illness who are neither hospitalized nor hospice-eligible, through provision of care in patient homes, physician offices/ clinics, cancer centers, dialysis units, assisted and long-term care facilities, and other community settings. Community-based palliative care services are delivered by clinicians in primary care and specialty care practices (such as oncologists), as well as home-based medical practices, private companies, home health agencies, hospices, and health systems. Domain 3: Psychological and Psychiatric Aspects Domain 3 clarifies and strengthens the responsibilities of the social worker and all palliative care clinicians regarding the mental health assessment and treatment in all care settings, either directly, in consultation, or through referral to specialist level psychological and/or psychiatric care. Grief and bereavement are described separately to reflect the distinction between the two concepts; bereavement is now in Domain 7, which focuses on care nearing the end of life. Domain 4: Social Aspects of Care Domain 4 describes an assessment of social supports, relationships, practical resources, and safety and appropriateness of the care environment. Flexible approaches to ensuring adequate spiritual support of patients and families are described. Domain 6: Cultural Aspects of Care Specific elements of a cultural assessment are outlined in Domain 6. The influence of culture within families is delineated, with specific attention to the role of the child or adolescent in treatment decisions. Domain 7: Care of the Patient Nearing the End of Life the title of this domain was changed from "Care of the Patient at the End of Life" to reflect the importance of attending to the changing needs of patients and families in the final days and weeks of life. Systematic Review of Key Research Evidence A systematic review was conducted, synthesizing evidence for each domain. The review included evidence published as of April 2018, was guided by 10 key questions, and was supported by a panel of technical experts. As with all clinical practice guidelines, evidence from research is combined with consensus of experts in the field to support recommendations for care. The methods, literature flow, evidence tables, critical appraisal, and summary of findings and quality of evidence assessment are published online in the Journal of Pain and Symptom Management (doi: 10. While any clinician can apply palliative care principles and practices, specialist palliative care teams are interdisciplinary, and the team members have certification or specialty-level competency to provide specialist palliative care. It is defined as a dynamic and intrinsic aspect of humanity through which individuals seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Primary palliative care providers can integrate the knowledge and skills within the criteria and in the Essential Palliative Care Skills Needed by All Clinicians section of each domain. Individual professionals, teams, and organizations will benefit from reading this entire document. While it may be tempting for professionals to focus on the guideline that aligns most closely with their discipline, each Domain reflects a team-based approach to palliative care. The project also received essential input from subject matter experts who offered their support, experience, and thoughtful comments throughout the revision process. Martha Twaddle for their leadership as co-chairs of the National Consensus Project Steering Committee and the co-chairs of the Writing Workgroup, Stacie Sinclair and Dr. We also thank every member of the Steering Committee and the Writing Workgroup for their invaluable contributions to this work. The members of the Writing Workgroup and Steering Committee did not disclose any relationships constituting a conflict of interest. National Coalition for Hospice and Palliative Care American Academy of Hospice and Palliative Medicine. Half of Older Americans Seen in Emergency Department in Last Month of Life; Most Admitted to Hospital, and Many Die There. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Palliative care begins with a comprehensive assessment and emphasizes patient and family engagement, communication, care coordination, and continuity of care across health care settings. Guideline 1 1 Interdisciplinary Team Since palliative care is holistic in nature, it is provided by a team of physicians, advanced practice registered nurses, physician assistants, nurses, social workers, chaplains, and others based on need. The palliative care team works with other clinicians and community service providers supporting continuity of care throughout the illness trajectory and across all settings, especially during transitions of care. Primary care and other clinicians work with interdisciplinary colleagues to integrate palliative care into routine practice. Physicians focus on the illness trajectory, prognosis, and medical treatments, making patient visits or providing supervision in collaboration with advanced practice registered nurses or physician assistants (see Domain 2: Physical Aspects of Care). Nurses provide direct patient care, serving as patient advocate, care coordinator, and educator. Nurses are at the center of the immediate assessment and reassessment of patient needs (see Domain 2: Physical Aspects of Care). Advanced practice providers (physician assistants and advanced practice registered nurses) expand the capacity to deliver complex care and provide direct care (see Domain 2: Physical Aspects of Care). Social workers attend to family dynamics, assess and support coping mechanisms and social determinants of health, identify and facilitate access to resources, and mediate conflicts (see Domain 3: Psychological and Psychiatric Aspects of Care and Domain 4: Social Aspects of Care). Clinical Practice Guidelines for Quality Palliative Care, 4th edition 1 Domain 1 Domain 1: Structure and Processes of Care f. The patient and family have access to palliative care staff 24 hours a day, seven days a week by phone or telehealth applications. Policies and procedures are in place for prioritizing and promptly responding to referrals and ongoing patient and family care needs. The setting of care or reimbursement may further dictate which clinician must be certified. Guideline 1 2 Comprehensive Palliative Care Assessment An interdisciplinary comprehensive assessment of the patient and family forms the basis for the development of an individualized patient and family palliative care plan. Clinical Practice Guidelines for Quality Palliative Care, 4th edition 2 Domain 1: Structure and Processes of Care 1. Patient and family understanding of the serious illness, goals of care, treatment preferences, and a review of signed advance directives, if available b. A determination of decision-making capacity or identification of the person with legal decision-making authority c. A physical examination including identification of current symptoms and functional status d. A thorough review of medical records and relevant laboratory and diagnostic test results. A review of the medical history, therapies, recommended treatments, and prognosis f. Social determinants of health, including financial vulnerability, housing, nutrition, and safety i. Social and cultural factors and caregiving support, including caregiver willingness and capacity to meet patient needs Patient and family emotional and spiritual concerns, including previous exposure to trauma k. The ability of the patient, family, and care providers to communicate with one another effectively, including considerations of language, literacy, hearing, and cultural norms l. Clinical Practice Guidelines for Quality Palliative Care, 4th edition 3 Domain 1 Domain 1: Structure and Processes of Care Criteria: 1. The care plan is updated and reviewed at regular intervals and when the patient experiences a significant change in status; changes are based on the evolving needs of the patient and family, with recognition of complex, competing, and shifting priorities in goals of care. New medications, medical equipment, tests, and therapies are authorized by payers c. The patient and family can safely and effectively manage and administer medications 1. Treatment and care setting alternatives are documented and communicated to the patient and family to promote informed shared decision-making. Re-evaluation of treatment efficacy, patient-family goals, and choices are documented. Supports the surrogate with education related to signs and symptoms of psychological and psychiatric distress, and techniques to help alleviate distress c. Patients and families receive an explanation of the palliative care services and, depending upon the setting of care, a written consent for services is signed by the patient and/or health care surrogate.

Early Adoption In the 1980s impotence treatments natural super viagra 160 mg generic, most of the activity was focused on teleradiology xylometazoline erectile dysfunction order super viagra 160 mg otc, the quintessential form of "store-and-forward" telemedicine impotence restriction rings order 160mg super viagra. The first teleradiology systems were characterized by inefficiency erectile dysfunction doctors in coimbatore generic 160mg super viagra fast delivery, poor quality, limited scalability, and high cost. Photos or videos of hard copy radiology films were digitized for image transfer, enabling radiologists outside the hospital to provide remote and after-hours readings. Despite the potential benefits of these systems, the secondary digitization process was cumbersome and time-consuming because images had to be handled one at a time. They consist of an imaging modality, a secure network for data transmission, computer-based workstations for image interpretation, and archives for image storage and retrieval. For example, telepsychiatry-the delivery of psychiatric services using live interactive videoconferencing-emerged as an alternative to faceto-face treatment. Similar technology is being employed by neurologists to manage both acute and chronic neurologic conditions, such as stroke, epilepsy, and movement disorders, particularly in patients who live in rural areas and have limited ability to travel. A 2002 survey of teleconsultation activity (excluding teleradiology) in the United States reported that over 85,000 teleconsultations were performed by more than 200 programs in 30 specialties. In particular, the switch from analog to digital technology and the decreasing cost of information transmission have played a major role in fueling the expansion of telemedicine. In addition, the creation of the Internet, computer networks, and web-based applications have enabled a variety of real-time telemedicine applications that would have been technically impossible a generation ago. Barriers Regulatory Barriers Perhaps the most formidable barrier to expanding telemedicine today is the current system of medical licensure regulation. In our federal system of government, the states have the authority to ensure the quality of medical care provided to their residents. State-level regulation worked well for many years when medical care was almost exclusively delivered on a face-to-face basis. However, it presents challenges to physicians who want to practice telemedicine across state borders. Currently, all state medical licensing boards require that a physician engaging in telemedicine hold a medical license in the state where the patient is located. The standards mirror existing state laws by asserting that physicians providing official interpretations through teleradiology should maintain licensure in both the initiating and receiving states. But they are sufficiently burdensome to make telemedicine infeasible in most instances. Also, there are no data to support the need for these requirements or to prove that their addition provides the desired margin of safety. Case study 8: telemedicine 115 the need for physicians to obtain licensure across multiple states-and even credentials at each individual hospital-serves as a major barrier to the expansion of telemedicine. As a result, few physicians are legally credentialed to provide telemedical care to patients in remote or underserved areas. Until a solution to this problem is found, the potential benefits of telemedicine will not be fully realized, despite needy patients, willing providers, and the requisite enabling technology. Create a federal medical licensure and regulation system (modeled after that used by the Federal Aviation Administration for licensure of civilian airline pilots). Maintain a state-level medical licensure and regulation system without the requirement that practitioners of telemedicine be licensed in the state in which the patient resides. Instead, the state in which the provider is located would have regulatory authority over the licensing and activities of the provider. Grant functional licensure, which would supersede state requirements, in defined circumstances. This act would provide an exemption from the need to obtain multiple state licenses to U. Create a system of mutual recognition and portability of medical licenses between states (modeled after that used for issuing drivers licenses). Legislation designed to foster a voluntary national medical licensure system is currently being drafted by Sen. Tom Udall of New Mexico, who represents a state with substantial rural and frontier areas. The proposed system would provide a uniform set of standards and application process for national medical licensure and create a comprehensive data exchange system for primary source verification of credentials. Physicians holding a valid state medical license would be eligible to apply for a national license. The combination of the two would enable a physician to practice telemedicine across state lines. Chief among these is the still-substantial cost of the technology and insufficient reimbursement for telemedicine services. For example, restrictive Medicare reimbursement policies leave substantial gaps in coverage. Furthermore, reimbursement is contingent upon the patient being physically present in a "medical facility". This provision preempts one of the principal benefits of telemedicine: providing expert care to mobility-impaired patients and those who live in remote settings. Because Medicaid is a joint federal and state program, the states can decide whether to cover telemedicine services. States may choose which services to cover, where in the state telemedicine can be provided, what types of providers are covered, how much providers will be reimbursed, and other terms. Currently, there is no widely accepted standard among private plans for reimbursing telemedicine providers, so their approaches are highly variable. Because reimbursement is so variable and is often lower than care provided in a typical face-to-face encounter, the cost of acquiring the technology remains a barrier as well. Providers may be reluctant to invest the time and resources into learning and staying updated on new technology and telemedicine systems. Case study 8: telemedicine 117 Cost and Health Impact Telemedicine was created to expand access to care, improve quality of services provided to rural and underserved populations, promote health care equity, increase work efficiency, reduce health care costs, and improve inter-professional communications and information-sharing within the health care system. However, the extent to which these benefits have been documented in the medical literature is limited. One reason is that the adoption of telemedicine into clinical practice-and, therefore, the study of its clinical and economic outcomes-is relatively new. This creates a catch-22: Although telemedicine is technically feasible, its impact on costs and quality of care has not been demonstrated in a compelling way. But without adequate dissemination to conduct the evaluation, it is impossible to prove its potential impact. Second, the heterogeneity of the interventions makes it challenging to draw general conclusions about the overall effectiveness of telemedicine. Individual programs have demonstrated positive outcomes among patients, families, health care providers, and the health care system, including increased access to health care services, cost-effectiveness, enhanced educational opportunities, improved health outcomes, better quality of care, and enhanced social support. Included telemedicine programs used at least two communication media interactively, and the majority involved home care or patient self-monitoring for chronic disease. The review demonstrated feasibility and acceptability of the programs; however, the impact of telemedicine on clinical outcomes, including safety, was unclear. Furthermore, there was insufficient information to determine the cost-effectiveness of the interventions. Telemedicine asthma interventions used a range of technologies, including telephone, video conferencing, Internet, text messaging, and other networked systems. They found no difference in patient-reported quality of life and number of emergency department visits when comparing patients who were served by telemedicine and those who were not. However, there was a reduction in the rate of hospitalizations among patients who received the intervention. Outcomes of financial revenues, operating lead times, and customer satisfaction were examined. In the 12 months after information technology implementation, there was a 20- to 40-percent increase in revenues related to improvements in billing, an 80-percent reduction in turnaround time for generating final radiology reports (a marker of work efficiency), and a statistically significant increase in satisfaction among referring physicians. Craig and Patterson suggest that the outcomes of telemedicine programs should be evaluated on an individual basis. Health Care: Case studies of desired outcomes (feasibility, acceptability, cost, effectiveness, safety, and sustainability) will differ from program to program. In addition, they suggest that studies comparing telemedicine interventions with face-to-face patient care may not be relevant or appropriate if the intent of the intervention is not to replace face-to-face encounters or specialist referrals, but rather to enable provision of care in settings where conventional services are highly limited or nonexistent. If new drugs were required to show superiority over existing products on the market, few could meet that standard.

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Meets eligibility criteria for: Primary Disability: Secondary Disability: 02-Other Health Impairment 09-Speech Impairment Page 1 of 18 r4(A0 A+ D- Leander Independent School District 306 W erectile dysfunction pills for heart patients cheap super viagra 160 mg. She is averaging 90% for /1/ blends in words and sentences when given verbal prompts or placement cues erectile dysfunction doctors in memphis tn discount 160mg super viagra with amex. She is doing better in final word positions than in isolation or initial word positions erectile dysfunction doctor mumbai purchase super viagra 160 mg. We are averaging 50% in the final position of words and 25% in the initial position of words for /ch/ approximations tobacco causes erectile dysfunction generic super viagra 160 mg otc. Speech will continue with a focus on carryover of gliding in conversation and addressing Iji and /ch/ in words. Written Expression: 12/11/2019 writing skills are at the expected level for 1St grade. She may request frequent breaks to go to the rest room or visit the nurse that may or may not be related to need. This appears to be due related to frequent absences to address health needs, including hospitalizations and occurs frequently after she has been out ill. The district will implement its Code of Conduct with regard to all students, subject to and in compliance with the requirements of federal and state law pertaining to students with disabilities. Additional physical limitations comments: 12/2019 has restrictive lung disease and is out very frequently due to health issues. She is historically out during the brunt of flu/respiratory season (December-March) on homebound due to health risks. She may need extended time for meals as she has only been off of her g-tube for six months and is adjusting to eating some solid foods regularly. Explain: is able to access her education with the technology available to all students in the general education classroom. As of 12/11/2019, requires maximum verbal and visual prompts to achieve /j/ and /ch/approximations. Duration: 12/12/2019 to 12/11/2020 Language of Delivery: English Grade Level: Implementer: General Education Teacher Method of Evaluation: Teacher Observation, Data Collection. Student self-assessment Periodic reports on the progress the student is making toward meeting the annual goal will be provided (frequency): Concurrent with the issuance of report cards Page 6 of 18 (Leander Independent School District 306 W. Use of visual aids to provide feedback and reinforcement Alter Assignments or Testing Opportunity to make up missed work due to absences. Will the student be able to participate in district wide assessment without modification In-Class Support is individually determined with a focus on student independence, fading reliance on adults overtime. These services may include, but are not limited to , small group and individualized instruction, collaborative teaching, curricular and instructional accommodations, modifications, supplemental aids, materials and/or equipment. Will the student receive an educational benefit from participation in the general education setting (including nonacademic benefit) The student had a previously unsuccessful placement on a general education campus. The student has been confined to a home or hospital setting by physician or court order. Services received at school do not affect or compromise the type or amount of Medicaid services received outside of school. If the third party insurance denies a claim for an acceptable reason, no further action is taken. This information includes but is not limited to name, date of birth, Social Security number, Medicaid number, date of service, service type and service duration. This form has been provided in language understandable to the general public and in the native language or other mode of communication used by the parent, unless it is clearly not feasible to do so. Access to and Destruction of Records the special education department observes federal and state laws, state regulations and local policies pertaining to the confidentiality of student records. Parents (or an eligible student 18 years or older) may inspect and review records at any time. School officials with a legitimate educational interest have access to student records. If the student transfers to another school district, special education records will be sent to the receiving district without parental consent. Special education eligibility and educational records are maintained for five (5) years following the date of the last recorded action for each student served by the Special Education Department of Leander Independent School District. Records with personally identifiable information are located on the campus of the school which the student attends and the Special Education Services office at 306 W. She does show some work avoidance when she is in class and at times she is found wandering. She would like to propose some additional support when she is at school with her breaks being built in and continuing with support in the classroom. She would like to continue her speech time as 7, 30 minute sessions per 9 week grading period. Updated accommodations based on current needs Student required to take these assessments and accommodations are recommended. A copy of the procedural safeguards in understandable language, where feasible, must be given to the parents! A copy must also be given when an initial evaluation or a parent request for an evaluation occurs, upon receipt of the first due process, or State complaint during a school year, when the district decides to make a change in placement due to a discipline issue, and upon parent request. The notice was translated orally or by other means to the parent/adult student in his/her native language or other mode of communication on: by - El Parent/adult student verified to the translator that he/she understands the content of this notice. To obtain assistance in understanding this notice, you may call: Name: Stacy Laursen, M. Speech-Language Therapy: Group (not to exceed 4) 07/22/2020 - 08/20/2020 1 x Weekly 30 min. Date 11/20/2017 Learning Evaluation Report Marian Enny Evaluation/Report Evaluator Comments is a male aged 13-2 being evaluated to gather information to help determine educational supports. This examiner gave him a stress ball to squeeze to help focus on the task at hand. Throughout the evaluation directions were repeated and reworded for clarification. When was asked to focus on the task he would ask this evaluator if his teacher was going to be told that he was off task,or would ask if was being a good boy. In passage comprehension was able to read initial passages easily but appeared to struggle as the reading increased in difficulty. He had difficulty identifying some words correctly and then struggled with application of syntactic and semantic cues. An academic accommodation may be to incorporate visual and auditory stimulus for understanding of task completion. These results, in conjunction with all other assessments, will be used to determine eligibility for Special Education and Related Services. His cognitive abilities are understood best by examining his scores at the individual index level. These results in conjunction with other evaluations and input will be used to determine continued eligibility for Special Education and Related Services. Dorothy Pietrucha with Autism Spectrum Disorder and is a 13-year, 1-month old 7th grade student at Thompson Middle School. His goals focus on improving his visual motor/perceptual, sensory processing and self-care skills as they relate to the school environment. Scores from the standardized assessments should be interpreted with caution as it is unclear whether skill-level was measured accurately due to his decreased motivation and task persistence. He loves cleaning and cooking and always volunteers for jobs that include cleaning. Masotta 11/2019) Positive attitude Works well in class Will advocate when assistance is needed. They also said that he has a whole group of peers that he has grown up with and is looking to transition up with them.

First erectile dysfunction causes mental order 160 mg super viagra with amex, the per person) in alternatives analyses/major investment studies for all modes impotence trials france super viagra 160mg online. These densities apply for typical urban service in which riders stand less than a policy-specified length of time erectile dysfunction treatment injection generic super viagra 160 mg with amex, usually 20 to 30 minutes erectile dysfunction herbal treatment discount super viagra 160mg line. This standee density is an average over a typical peak hour within a typical peak period. The density (defining "crush" capacity) during the peak of the peak hour, usually 15 minutes, would be about 40% higher, or about 4. The number of seats is also very much influenced by the number and placement of doors and, on low-floor buses, intrusion into the vehicle interior of wheel wells, fuel tanks, and engines. When trip lengths are longer and people are likely (Photo Credit: New Flyer of Canada, Ltd. New Flyer conventional low-floor bus- 18-meter (60-foot) low-floor articulated bus (Vancouver 98 B-line). Second, having fewer seats provides a more open interior with better circulation characteristics. Seats installed perpendicular to vehicle walls not only reduce the area available for standees, but they also make circulation within the vehicle more difficult, especially near doors. The maximum capacities shown are approximations based on the vehicle dimensions shown in the table. Maximum capacities are computed as the number of seats plus a number of standees calculated using a standing area divided by a standing density. Doors When fares are collected off board (and even when they are not), the larger the number and the width of doors, the lower passenger service times will be. Multiple doors can also result in a better distribution of passengers within the vehicle, thus taking full advantage of available capacity. Each boarding and alighting stream using a double stream door should be allocated at least 51 centimeters (20 inches) or more of door width, with at least 76 centimeters (30 inches) for a single channel door. In markets with a significant amount of simultaneous boarding and alighting, the maximum number of double stream doors of at least a 1. The floor plan for the Las Vegas vehicle (shown in Figure 6-1), to be used in a dense urban corridor with significant turnover, illustrates the trade-off between the number of doors (4) and the number of seats (32). This can be compared with the schematic for the standard articulated bus shown in Figure 6-2, which is used on Ottawa Transitway system. The vehicle shown in Figure 6-2 has almost identical dimensions, but it has 54 seats and only 3 doors (2 double stream doors and 1 single door). Although both vehicles have essentially the same external dimensions, one has 7 boarding/alighting streams and 32 seats whereas the other has 5 streams and 54 seats. For dense corridors, in which significant boarding and alighting take place simultaneously, a larger number of passenger service streams in the same vehicle length may be warranted. A number of conventional buses and specialized vehicles are available with doors on either the left side. This is done to allow vehicles to use a center platform either exclusively, as in the South American systems, or in conjunction with side platform stations, as is planned in Cleveland. Center platform stations are popular for rapid-transit stations where right-ofway widths are tight at stations. Center platforms also reduce the need for multiple fare media vending machines and levelchange devices such as elevators and escalators, and they make it easier to provide security. The effects of door channels on boarding and alighting times are shown in Table 6-2. The vehicle features seven passenger service streams (three double doors, one single) for an 18-meter (60-foot) vehicle. Door Positions the major objective affecting door positioning is the need to ensure even loading and unloading across the length of the respective vehicles. For low-floor buses, reduce boarding times by 20%, front alighting times by 15% and rear alighting times by 25%. Irrespective of how fares are collected, doors should be positioned and configured so that no single door. Door Types Four basic types of doors are generally used for buses in North America: swing doors, bi-fold doors, plug doors, and pivot doors (sliding doors are used for buses in some other countries). These doors rotate around a vertical axis at the outer edge of the respective door panels and open outward to a position perpendicular to the vehicle at the outer edges of the respective door opening. These doors, which hinge in the middle as well as at the outside vertical edges, are simple and have traditionally been used on streetcars and buses on which wide door openings were required. The downside of this arrangement is that bi-fold doors may protrude outside the vehicle, limiting how close to platform edges a particular vehicle may come. Through a relatively complex hinge arrangement, plug doors swing outward and end up flush with the sides of the vehicle. They work well with wide door openings, which is why they are frequently used on airport apron passenger shuttle vehicles. They are frequently used in contemporary buses because of their relative simplicity. These doors are generally only used for rail rapid-transit vehicles in the United States, although they are routinely used on buses carrying high loads in Japan and in other Asian countries that use Japanese buses. Irrespective of running gear intrusion into the vehicle, when there is 2+2 perpendicular seating, aisle width cannot be greater than approximately 60 centimeters (24 inches). Floor Height There are three options for floor height: high, 100% low, and partial low. Floors in high-floor vehicles are typically 61 centimeters (25 inches) to 89 centimeters (35 inches) above the pavement on over-the-road coaches and older buses with the engine under the floor. Vehicles that are 100% low floor have the great advantage of low boarding and alighting times and the ability to have a door behind the rear axle. However, 100%-low-floor designs also typically lose between four and eight seats to wheel wells intruding into the vehicles, even when relatively small wheel and tire sizes are used. Another disadvantage of 100%low-floor designs is that mechanical and electrical equipment and fuel tanks must either be stored inside the vehicle, where they take up space, or be put on the roof, where they are difficult to service. A final disadvantage is the difficulty of packaging conventional mechanical drive trains consisting of an engine, a hydraulic-mechanical transmission, connecting drive shafts, a differential, and an axle. In 100%-low-floor vehicles, this type of drive train can also lose up to four seats or the Figure 6-5. Aisle Width, Floor Height, and Floor Flatness Aisle width, floor height, and floor flatness also influence vehicle capacity. Most conventional low-floor vehicles, even those with a step up to the rear portion of the vehicle, have a minimum aisle width between the rear wheel wells (second and third axle on articulated vehicles) of about 60 centimeters (24 inches). This arrangement, along with perimeter seating, allows for a wider aisle (minimum width of 87 centimeters [34 inches]), which in turn permits easier in-vehicle circulation, lower passenger service times, and reduced station dwell times. Larger aisle width, in addition to no-step boarding and alighting, is one of the reasons (Illustration Credit: North American Bus Industries) Figure 6-6. As noted, low-floor vehicles make passenger boarding and alighting faster and more convenient. Corresponding reductions for front- and rear-door alighting were, respectively, 20 and 25%. These time reductions can result in higher ridership and revenue and greater capacity without increasing the number of vehicles or operating and maintenance expenditures. The passenger service times shown in Table 6-2 are for conventional, steered buses with a gap between the edge of the stop or station platform and the vehicle. Guidance systems on these vehicles- whether magnetic, optical, or mechanical-allow the vehicle to be precisely "docked" at stations. Stations served by these guided, low-floor vehicles will have slightly raised platforms (about 11 to 14 inches high instead of the roughly 6-inch normal curb height) to permit platform-tofloor, no-step, direct boarding and alighting. This, combined with wide aisles, can significantly reduce passenger service times for these customers and thus improve schedule reliability. As noted above, another way that the advantages of a guided, low-floor vehicle can be obtained without the disadvantages of 100%-low-floor designs is to use a high-floor vehicle with a rapidly deployed ramp, bridge, or door flap in conjunction with high-platform stations. The disadvantage of this approach (usually used with left-hand doors to support center-median platforms) is an inability to service offline stations that are not configured with high platforms and center platforms. This disadvantage could be overcome by having doors on both sides of vehicles and steps feeding some of them, but this would reduce seating capacity, and the system would suffer from increased dwell times at the off-line stations. The major disadvantage of 100%-low-floor vehicles when compared with partially low-floor vehicles is the loss of space caused by the intrusion of wheel wells and the drive train and the use of internal space for fuel tanks, batteries, and other devices that otherwise would be under the floor.