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Summary Background Endovascular renal denervation reduces blood pressure in patients with mild-to-moderate hypertension, but its efficacy in patients with true resistant hypertension has not been shown. We aimed to assess the efficacy and safety of endovascular ultrasound renal denervation in patients with hypertension resistant to three or more antihypertensive medications. Methods In a randomised, international, multicentre, single-blind, sham-controlled trial done at 28 tertiary centres in the USA and 25 in Europe, we included patients aged 18–75 years with office blood pressure of at least 140/90 mm Hg despite three or more antihypertensive medications including a diuretic. Eligible patients were switched to a once daily, fixed-dose, single-pill combination of a calcium channel blocker, an angiotensin receptor blocker, and a thiazide diuretic. After 4 weeks of standardised therapy, patients with daytime ambulatory blood pressure of at least 135/85 mm Hg were randomly assigned (1:1) by computer (stratified by centres) to ultrasound renal denervation or a sham procedure. Patients and outcome assessors were masked to randomisation. Addition of antihypertensive medications was allowed if specified blood pressure thresholds were exceeded. The primary endpoint was the change in daytime ambulatory systolic blood pressure at 2 months in the intention-to-treat population. Safety was also assessed in the intention-to-treat population. This study is registered with ClinicalTrials.gov , NCT02649426 . Findings Between March 11, 2016, and March 13, 2020, 989 participants were enrolled and 136 were randomly assigned to renal denervation (n=69) or a sham procedure (n=67). Full adherence to the combination medications at 2 months among patients with urine samples was similar in both groups (42 [82%] of 51 in the renal denervation group vs 47 [82%] of 57 in the sham procedure group; p=0·99). Renal denervation reduced daytime ambulatory systolic blood pressure more than the sham procedure (−8·0 mm Hg [IQR –16·4 to 0·0] vs –3·0 mm Hg [–10·3 to 1·8]; median between-group difference –4·5 mm Hg [95% CI –8·5 to –0·3]; adjusted p=0·022); the median between-group difference was –5·8 mm Hg (95% CI –9·7 to –1·6; adjusted p=0·0051) among patients with complete ambulatory blood pressure data. There were no differences in safety outcomes between the two groups. Interpretation Compared with a sham procedure, ultrasound renal denervation reduced blood pressure at 2 months in patients with hypertension resistant to a standardised triple combination pill. If the blood pressure lowering effect and safety of renal denervation are maintained in the long term, renal denervation might be an alternative to the addition of further antihypertensive medications in patients with resistant hypertension. Funding ReCor Medical.

Introduction: Data remains scarce on which telestroke related sub-events (component parts/time intervals) are associated with delays in door-to-needle (DTN) time and goals for each telestroke sub-event. We aimed to assess the telestroke sub-events that contribute to DTN. After establishing set goals for each sub-event, we further evaluated the odds of DTN within 45 minutes if sub-event goals were achieved. Methods: We retrospectively analyzed prospectively collected data from a hub-and-spoke model telestroke network from January 2017 to September 2019. To determine which sub-events significantly contributed to DTN time, a sequential multiple regression analysis was performed. We entered covariates (age, sex, time of telestroke [day or night], NIHSS, average number of telestroke consults at a given site) in the first block followed by sub-events (door-to-telestroke request, door-to-CT, request-to-page, stroke physician response time, telestroke phone-to-video, video duration prior to needle and video completion-to-needle) in the second block. Logistic regression models were performed to estimate the odds of achieving a DTN within 45 minutes if sub-event goals were achieved. Results: During the study, 3361 telestrokes were completed and 306 (9.1%) patients received IV thrombolytics. After exclusions, 253 patients treated with IV thrombolytics were included. Five sub-events contributed to DTN time above and beyond the nuisance variables: door-to-telestroke request, stroke physician response time, telestroke phone-to-video, video duration prior to needle, and video completion-to-needle; each p Conclusions: Telestroke sub-events involving door-to-telestroke request, stroke physician response, telestroke phone-to-video, video duration prior to needle, and video completion-to-needle significantly contribute to DTN time. Successful achievement of sub-event goals was related to greater likelihood of administration of thrombolytic therapy within 45 minutes.

Introduction: Prior studies have demonstrated the importance of measuring and monitoring telestroke sub-events of door-to-needle time (DTN) such as door-to-telestroke request, but there is limited data on educational efforts to reduce sub-events contributing to DTN. We educated spoke coordinators, nurses and physicians at our telestroke sites on tips to reduce sub-events of DTN, developed a reference pocket card and reviewed sub-event metrics during monthly telestroke quality meetings with spoke sites. We aimed to evaluate if our educational activities and monthly data review affected door-to-telestroke request within 10 minutes of arrival, completion-of-video to needle within 1 minute and DTN within 60 minutes. Methods: Prospectively collected data was analyzed retrospectively from a hub-and-spoke model telestroke network. Education of the spokes was completed between January 2019 and April 2019. We compared data for one year prior to education (January 2018 - December 2018) and one year after education (May 2019 - April 2020). Logistic regression analyses were performed to determine the odds of achieving a door-to-telestroke request within 10 minutes, DTN within 60 minutes and completion-of-video to needle within 1 minute in treated patients. We entered possible confounding variables (EMS arrival; NIHSS; posterior symptoms) in the first block followed by the pre/post education groups in the second block. Results: Overall, telestroke was requested 2574 times during the study (1338 pre-education; 1236 post-education). A Chi square test suggested a trend towards more thrombolytic and thrombectomy treatments occurred after education compared to before education (14.6% vs. 12%), OR = 1.25 (95%CI 0.99 - 1.56), p=0.06. Door-to-telestroke request Conclusions: Education and regular review of sub-events data reduced door-to-telestroke request and door-to-needle time in our telestroke network.

Myopericarditis has been observed among individuals receiving the BNT162b2-mRNA and mRNA-1273 COVID-19 vaccines.1,2 In this case series, we describe the initial experience with myopericarditis following COVID-19 vaccination across the largest healthcare system in Connecticut.

In this selection from Bourgeois Utopias: The Rise and Fall of Suburbia (1987), urban historian Robert Fishman argues that “the suburban ideal” was, in the final analysis, yet another form of utopia, the utopia of the urban middle class. The ideal was to create a perfect synthesis of urban sophistication and rural virtue. Here was a conception as utopian as that of any visionary social reformer but with an important difference: “Where other modern utopias have been collectivist,” writes Fishman, “suburbia has built its vision of community on the primacy of private property and the individual family.” Fishman describes how America and Europe took different paths towards suburbia. When both the American Frederick Law Olmsted and the French Cesar Daly visited England in the early 1850s, they saw that increasing numbers of the urban middle class were moving out of the central city into suburbs on the urban periphery so as to preserve and protect middle-class domesticity – not just safety and calm surroundings for their families but for the idea of the sanctity of the family as well. Many of these new suburbs were simply clusters of houses built on the outskirts of cities. Others were planned communities. Olmsted returned to America and designed the romantic suburb of Riverside outside of Chicago. Daly returned to Paris where he promoted the idea of building similar suburban places for the French middle class only to be frustrated by “Haussmannization,” the massive rebuilding of Paris carried out by Baron Georges-Eugene Haussmann. In America, local real estate markets created suburbs for the middle class outside of the cities. In France, national taxes created options for the middle class within the city. As a result, while America chose suburbanity, France chose urbanity.

Urban design history and theory courses are a key element of urban design curricula across the globe. These courses take a pause from the high paced decision-making environment of the design studio to reflect on the theoretical underpinning of cities, and their conscious and subconscious transformation in the past, present and future. The contemplative nature of history and theory courses can create a perceived disconnect between ‘theory’ and ‘practice’, and ‘lecture’ and ‘studio’ – often undeservedly. This paper discusses various methods of situated learning in urban design history and theory pedagogy that bridge these false dichotomies. The two case studies presented in this paper engage students in real-world applications of historical and theoretical research, convincing them that pasts and paradigms strongly influence their everyday and future environments. Both cases have energised students by demonstrating that theories from the past and present inform the practice and lived experience of the urban environment. Furthermore, the cases use techniques typically taught in studios, such as mapping, collage imagery and three-dimensional modelling, to analyse non-traditional topics. The bridging of theory, practice, past and present can further integrate history and theory pedagogically into the growing field of urban design education.

Introduction: Perfusion based imaging aids in patient selection for endovascular therapy (EVT). Appropriate selection of patients for EVT is an important component of telestroke programs. Thus, telestroke sites could be ideal locations for perfusion imaging. Despite the advantages of perfusion imaging, there is the concern that advanced imaging may delay door to needle time (DTN). We implemented CT perfusion (CTP) using RAPID software at three large primary stroke centers within our telestroke network in December 2017. We aimed to evaluate the proportion of transfers for EVT, door in door out time (DIO) and DTN at telestroke sites before and after CTP implementation. Methods: Data was prospectively collected and retrospectively analyzed as part of our telestroke quality database. We compared data for one year before and one year after implementing CTP at the telestroke sites. We hypothesized that the addition of CTP would not delay DTN. Additionally we hypothesized that a greater proportion of transfers for possible EVT would receive a stroke thrombectomy and that DIO would be reduced after utilizing CTP. Results: Five hundred and forty patients were evaluated via telestroke and completed CT head and/or CT angiography head and neck imaging prior to CTP implementation. Seven hundred and thirteen telestroke patients received CT head, CTA head and neck and CTP imaging after CTP implementation. Of the 1253 patients, 101 (8.1%) were transferred for a possible EVT. Patients receiving CTP had a significantly shorter DIO time (median 109 minutes) compared to patients without CTP (median 122 minutes), U = 425, p = 0.04, r = 0.26. There was no difference in DTN in the 63 IV alteplase treated patients without CTP (median 66 minutes) and 58 IV alteplase treated patients who received CTP (median 63 minutes), U = 1672, p = 0.42, r = 0.07. There was no significant difference in the proportion of patients transferred for a possible EVT that received a stroke thrombectomy in the patients without CTP 28 (74%) compared to patients with CTP 38 (84%), p = 0.23. Conclusions: In conclusion, automated perfusion maps and calculated ischemic penumbra size in CTP allowed telestroke physicians to make quicker transfer decisions, without delaying DTN.

Background Rapid arterial occlusion evaluation (RACE) scale is a valid prehospital tool used to predict large vessel occlusion of major cerebral arteries in patients with suspected acute stroke. RACE scale administered by Emergency medicine services (EMS) technicians in the prehospital setting correlates well with NIH Stroke Scale score after patient arrival at a hospital. Despite this, the RACE scale is often characterized as too difficult for EMS technicians to accurately utilize. There are no data examining RACE scale accuracy in the prehospital setting comparing EMS technicians with neurologists. We sought to examine agreement between RACE scores calculated by EMS technicians and stroke neurologists in the prehospital setting during telestroke consultation. Methods Data for this observational cohort study were prospectively collected and retrospectively analyzed. EMS technicians in person and stroke specialized neurologists via televideo connection independently assessed suspected stroke patients and calculated RACE scores in the prehospital setting. We used a linearly weighted Cohen's kappa (kw) to estimate the extent of agreement for RACE score between EMS technicians and stroke neurologists. Results Thirty-one patients with stroke symptoms were independently examined and assessed with the RACE scale by EMS technicians and stroke neurologists in the prehospital setting. Exact agreement on the RACE score was found in 24 of 31 (77%) patients. We found very good agreement between EMS technicians and stroke neurologists, kw = .818 (95% CI, .677-.960), P Conclusions EMS technicians provide reliable RACE assessments in patients with suspected stroke, with agreement similar to stroke specialized neurologists in the prehospital setting.

Introduction: Timeliness of a response to page by telestroke physicians is an important component in a telestroke network. Accrediting organizations such as the Joint Commission require telemedicine to be available within 20 minutes of the request. We implemented a secure messaging system to improve physician communication. We hypothesized that implementation of a secure messaging system would improve communication, reduce telestroke physician response to page and reduce door-to-needle (DTN) times compared to the previous pager-based system. Methods: We reviewed data collected as part of our telestroke quality program. We compared response to page times for one year before and after initiation of the secure messaging system. Additionally, we compared DTN times during the same epochs. Results: Seven hundred and sixty-five telestroke consults were completed in the year prior to implementation of the secure messaging system and 941 telestroke consults were completed in the year following implementation. Telestroke response to page time decreased significantly between pre ( mean rank 1005; median 4 min) and post ( mean rank 731 ; median 2 min) implementation of the secure messaging system ( U = 244,240 , p < .001, r = .28). A significantly greater percentage of telestroke neurologist response times occurred within 20 minutes when using secure messaging 936/941 (99.5%) compared to pagers, 751/765 (98.2%), χ 2 (1, N = 1706) = 6.46, p = .01, φ = .06. DTN was lower when using secure messaging (64 min) compared to the prior paging system (66 min), but this difference was not statistically significant ( p = .74). Conclusions: In conclusion, implementation of a secure messaging system improved communication in our telestroke network and reduced telestroke response to page compared to our prior paging system. Implementation of the secure messaging system did not significantly reduce DTN times.

Management of radiation induced coronary heart disease (RICHD) presents a unique challenge to clinicians. A 66 year old male with a history of radiation treated Hodgkin's lymphoma and coronary artery calcium score of 8 four years prior presents with ongoing chest pain. ECG showed inferior ST

Introduction: Implementation of telestroke in community hospitals and primary stroke centers has resulted in reduced door to needle times. Mobile stroke units equipped with CT scanners, also utilizing telestroke have demonstrated a further reduction in door to needle times. Despite the benefits of mobile stroke units, the cost of producing and maintaining these units may be a limiting factor in system-wide adoption of the concept. There is little data examining continuous telestroke support provided by neurologists in the EMS setting. We tested this lower-cost alternative, by providing 24/7 telestroke access to two local EMS providers. We hypothesized that telestroke in the EMS setting would be safe, feasible and reduce door to needle times. Methods: Stroke-specialized neurologists provided continuous (24/7) video-based telestroke access to two local EMS agencies from December 2015 through May 2017 as part of the REACHOUT project. Data were prospectively collected and retrospectively analyzed. Intravenous (IV) tPA door to needle times were compared between patients who were assessed via EMS telestroke to patients assessed by hospital based telestroke in one of the nine hospitals within our telestroke network, during the same time period. Results: Fifty-eight telestroke requests were registered with 52 (89.7%) successful consultations during the study period. The initial telestroke impression in 42/52 (80.8%) cases was a possible acute stroke or TIA. There were 142 patients treated with IV tPA via hospital based telestroke encounters and 4 patients were treated with IV tPA after being evaluated via EMS telestroke. A comparison of door to needle times suggested shorter door to needle times in the EMS telestroke group (mean rank 12.8; median 39.5 min) compared to the hospital based telestroke group (mean rank 74.2; median 65.5 min), U = 41, p = .004, r = .24. Conclusions: Despite isolated connectivity issues, we found EMS based telestroke encounters to be safe and feasible. Pre-hospital evaluation of patients by a stroke-specialized neurologist provided a comprehensive clinical picture to emergency department physicians upon arrival to the hospital. Reduced door to needle times were reported in EMS based telestroke compared to hospital based telestroke.

Transcatheter aortic valve replacement (TAVR) has evolved from the use of the Medtronic first generation CoreValve to the second generation Evolut R valve. Most studies have showed comparable if not improved performance of the Evolut R. However, individual trials are based on single center

The Death and Life of Great American Cities hit the world of city planning like an earthquake when it appeared in 1961. Streets in cities serve many purposes besides carrying vehicles, and city sidewalks, the pedestrian parts of the streets, serve many purposes besides carrying pedestrians. The ballet of the good city sidewalk never repeats itself from place to place. To keep city safe is a fundamental task of a city's streets and its sidewalks. The bedrock attribute of a successful city district is that a person must feel personally safe and secure on the street among all the strangers. Today barbarism has taken over many city streets, or people fear it has, which comes to much the same thing in end. The sidewalk must have users on it fairly continuously, both to add to the number of effective eyes on the street and to induce the people in buildings along the street to watch the sidewalks in sufficient numbers.

In the 1920s, Lewis Mumford correctly predicted that the rest of the century would be dominated by a “Fourth Migration” from the central cities to their suburbs. In this article I argue that we are...

The American metropolis at century's end is vastly different than what many expected just 50 years ago. At mid‐century, seers envisioned a clean, rationally planned city of the future, free of long‐standing problems such as traffic and poverty. The reality is more complex. We built a new metropolis that addressed some major problems while simultaneously creating a host of new ones. The next 50 years will undoubtedly contain similar surprises. In conjunction with the 1999 Annual Housing Conference, which looked at the legacy of the 1949 Housing Act, the Fannie Mae Foundation commissioned a survey that asked urban scholars to rank the key influences shaping the past and future American metropolis. The “top 10” lists that resulted are the focus of this article.

Paul Clemens has an important story to tell in this memoir,1 but it is not the story we expect. Born in Detroit in 1973, he grew up as part of a rapidly shrinking minority: white people in the Motor City. We anticipate a literate Eminem, but Clemens is honest enough to admit that his real contacts with the life and culture of black Detroit have been minimal. He had no love for the music the best locus for racial crossovers indeed almost no real contact with black Detroit, because he was educated in the still largely white Catholic parochial system. The real story in this memoir is the story of Clemens's father. He is the one genuinely "made in Detroit," born in 1944 when the city was truly "the arsenal of Democracy," a man who, in his son's words, "worshipped at the altar of the internal combustion engine." His work was making cars, and his only leisure was repairing and racing them. As Clemens observes, his father was part of

This United States Supreme Court brief argues that estate-paid professionals who are defending against objections to their fee applications should be able to get their defense fees paid from the estate if they substantially prevail on the defense of those fees.

New York ranks first among the handful of global cities where the economic future of the world is decided. But the majority of the region's 20 million people have few significant contacts with the New York that the world knows. In 1920, however, the core absolutely dominated the region, and the authors of the New York Regional Plan of 1929 also believed that the dominance of the core would and should continue. New York did not in fact develop in this fashion over the next fifty years. The Great Depression and the reform administration of Franklin D. Roosevelt introduced new government policies : housing policy, automobile policy, defense policy. These three policies favored the outer ring. Similarly, new systems of electronic communications, big social changes (growing black population, return of mothers to the paid work force) have negated the advantages of the core., New York est bien sûr la première «cité globale». Et chacun pense Manhattan, Broadway, le World Trade Center. Pourtant bien peu des 20 millions d'habitants de la région urbaine ont des rapports avec ces symboles de la centralité. La plupart vivent et travaillent dans la Suburbia, qui n'est plus la cité-dortoir d'il y a trente ou quarante ans, mais une nouvelle forme de ville de basse densité, qui unifie toutes les agglomérations américaines, de New York à Chicago, San-Francisco ou Los Angeles. Est-ce donc l'avenir des métropoles mondiales ? En fait, ce n'était pas le futur projeté pour New York, et notamment par le Schéma Directeur de 1929. En 1920, 9 millions des 11 millions de New-Yorkais d'alors vivent dans le noyau de l'agglomération ("core"), et près de 3 millions travaillent à Manhattan, au sud de Central Park. L'industrie la plus importante est celle de la confection, qui occupe dans une multitude d'ateliers urbains les immigrants juifs et italiens, tandis que Times Square concentre les théâtres. Le dessein des urbanistes d'alors est de conserver la suprématie de ce noyau aggloméré, en éloignant l'industrie dans un rayon de trente kilomètres autour de Lower Manhattan, et en construisant un réseau ferré rapide et interconnecté convergeant vers Manhattan, qui n'est pas sans rappeler le réseau RER de Paris d'aujourd'hui. La majorité de la population doit résider dans des immeubles collectifs construits sur des terrains libérés par le desserrement industriel, les maisons individuelles périurbaines restant l'exception, réservées aux cadres très supérieurs, que des trains rapides amèneraient à leurs bureaux de Manhattan. La réalité des années quatre-vingt-dix est loin de ce schéma. Sur 20 millions de «New-Yorkais», 54 % vivent en zone périurbaine («ring») et 51 % y travaillent. Pourquoi cet échec de la prévision urbanistique ? Incontestablement, c'est le résultat de l'impulsion de trois politiques instaurées par le New Deal de Roosevelt : une politique du logement individuel, pour relancer l'économie, une politique de l'automobile et des infrastructures routières, incarnées à New York par la figure emblématique de Robert Moses, une politique de dispersion de l'industrie militaire et stratégique, amplifiée parla deuxième guerre mondiale et la guerre froide. Les résultats dépassent l'intention, d'autant plus qu'elle montre des bouleversements technologiques importants (informatique, télécommunications) et des mouvements profonds de la société américaine : le rêve de ruralité, la montée des Noirs du Sud, qui paupérisent les anciens quartiers blancs proches du centre (Harlem), la progression des femmes actives qualifiées, qui veulent travailler près de chez elles, pour assurer leurs responsabilités familiales. L'auteur termine par l'évocation de l'exemple de Mount Laurel, entre New York et Philadelphie, pour illustrer cette ville hors la ville, faite de suburban dream houses, d'office parks, et de mails commerciaux., Fishman Robert. What is New York ?. In: Villes en parallèle, n°20-21, décembre 1994. Paris – New-York. pp. 108-122.

Objective: To report a case of fulminant shock and noncardiogenic pulmonary edema induced by intravenously administered dipyridamole. Case Summary: A 73-year-old woman presented to the office of her cardiologist for dipyridamole myocardial scintigraphy. Several minutes after administration of intravenous dipyridamole 0.57 mg/kg over 4 minutes she developed wheezing, followed by cardiovascular collapse and pulmonary edema requiring 100% oxygen and endotracheal intubation. She had never received dipyridamole before this, and no other medications or exposures were documented proximate to the collapse. On transfer to the hospital, she developed shock refractory to multiple vasopressors, which responded to continuous infusions of epinephrine. She also had severe pulmonary edema requiring invasive ventilation, 100% inspired oxygen, and 24 cm H2O positive end-expiratory pressure. An echocardiogram did not show new left-ventricular dysfunction and there were signs of right-heart underfilling, supporting a diagnosis of noncardiogenic pulmonary edema. Both shock and pulmonary edema resolved within 12 hours. Discussion: Dipyridamole-associated hypotension has been reported in a number of case series and registries. Detailed case descriptions, however, are not available in the literature to permit understanding of the mechanism of shock following hypotension resulting from dipyridamole myocardial scintigraphy. Our case is exceptional in that echocardiography results support a diagnosis of hypovolemic (rather than cardiogenic) shock. To our knowledge, this is the first case of severe (most likely noncardiogenic) pulmonary edema associated with intravenous infusion of dipyridamole. An objective causality assessment suggested that this patient's cardiopulmonary collapse was probably related to dipyridamole. Conclusions: While hypotension has been previously associated with intravenous use of dipyridamole, ours is the first report to suggest a noncardiogenic mechanism for shock. To our knowledge, this is the first reported case of noncardiogenic pulmonary edema following dipyridamole infusion.

Aims The Aerodose® inhaler is a novel, palm-sized, breath actuated device which requires little patient coordination. This study compared the dose–response of salbutamol delivered by the Aerodose® Inhaler (Aerogen Inc., Mountain View, USA) vs Pari LC Plus jet nebulizer (Pari LC Plus; Pari GmbH, Starnberg, Germany) and Ventolin™ Evohaler™ HFA pMDI (Evohaler; Allen & Hanburys [GlaxoSmithkline], Uxbridge, UK). Methods Twenty-two moderate to severe asthmatic patients, mean (s.d.) age: 44.7 (9.4), FEV1: 58.1 (12.0), received 4 cumulative doubling doses of salbutamol in a randomised, investigator blind, balanced crossover design. Spirometry and systemic safety variables (heart rate, blood pressure, T wave amplitude, QTc interval and potassium) were measured at baseline and after each dose. Results Parallel regression analysis revealed that microgram relative potency ratios for the Aerodose® Inhaler to be five times more efficient for FEV1 than either the Pari LC Plus (0.202, 90% CI: 0.189–0.216) or the Evohaler (0.202, 90% CI: 0.189–0.216), while there was no difference between Pari LC Plus vs Evohaler. Similarly, Aerodose® Inhaler vs. Pari LC Plus showed approximately five-fold greater potency for all systemic parameters, except blood pressure. As compared to the Evohaler, Aerodose® Inhaler had equivalent potency for plasma potassium and T wave amplitude, but demonstrated greater potency for heart rate and QTc interval. Conclusions This study has indicated therefore, that Aerodose® Inhaler is approximately five times as efficient as the Pari LC Plus and Evohaler in relative lung delivery of salbutamol in moderate to severe asthmatics.

Primary angioplasty (PA) for acute myocardial infarction (AMI) has emerged as the standard of care in hospitals with cardiac interventional facilities. The benefits from the PA are time dependent, but recent data raise concerns regarding the timeliness of delivery of care in AMI and the level of benefit achieved by current standards. We assessed the effectiveness of an extensive multidisciplinary quality improvement initiative in reducing door-to-balloon (DTB) times in PA. The PA process was divided into six separate time periods, which were assessed individually. Subsequent quality initiatives resulted in a dramatic reduction in the mean DTB time (141.3 minutes preintervention compared to 95.1 minutes postintervention; P < 0.001).

The grandeur and the misery of the early twentieth-century industrial metropolis — the archetype of Patrick Geddes’ ‘megalopolis’ — was its seemingly unstoppable power to swallow up all the vital functions of its society. From the steel mill to the sweatshop, from the biggest department store to the most avant-garde art gallery the metropolis provided the inevitable location for success. Nowhere was metropolitan advantage more apparent than in the production and the consumption of culture. Whether in a centuries-old capital like Vienna or a brash new centre like Chicago, the metropolis alone possessed those great concentrations of population and wealth which supported theatres, concert halls, libraries, museums, metropolitan newspapers and journals; hence it offered a cornucopia of cultural consumption available only to those who lived within a streetcar ride of the core. For the producers of culture, the metropolis offered not only an unparalleled range of face-to-face contacts and opportunities to sustain their work, but, above all, the ‘urban experience’ which was at the heart of the modern movement in the arts.1

This paper argues that the late twentieth century has seen the emergence of a new kind of "network city:" neither urban, nor suburban, nor rural in the traditional senses, but combining elements of all three. Unlike an older city that occupied a definable space and had a clear center and periphery, the new city is defined by time rather than space. In the new city each citizen creates his or her own city out of the multitude of destinations that can be reached in a reasonable time by automobile. The new city thus corresponds to no particular space, but is formed by the overlapping journeys of the citizens. Moreover, there is no traditional center; instead, the urban functions are distributed among three overlapping networks: the household network composed of those destinations that support personal life; the "network of consumption" composed of shopping and leisure centers; and "network of production" where manufacturing and office services are performed. These networks do not sort themselves out into functional zones but juxtapose so that a huge corporate center might be bordered by small houses, and a massive "mega-mall set down next to corn fields. Having put forward a structure for the new city, I then consider whether this new urban form can attain the complexity, beauty and diversity of the great cities of the past, or whether it is doomed to be too dense to be efficient and too dispersed to be genuinely urban. I return to the great American prophets of decentralization from the 1930s, Frank Lloyd Wright and Lewis Mumford, for a vision of a decentralized city that is nevertheless capable of embodying the highest values of civilizations; and I attempt to show how the new city can be gradually re-built to reflect this vision., Cet article met en évidence l'émergence d'un nouveau type de "ville-réseau" à la fin du XXième siècle: ni urbain, ni suburbain, ni rural dans le sens traditionnel des termes, mais combinant les trois éléments. A l'inverse de la ville ancienne qui occupait un espace définissable et comprenait un centre et une périphérie, la nouvelle ville se définit par le temps plutôt que par l'espace. Dans la nouvelle ville, chaque habitant crée sa propre ville en dehors de la multitude de destinations atteintes en voiture, en un temps donné. Ainsi, la nouvelle ville ne correspond à aucun espace précis mais se construit à travers les chevauchements des parcours des habitants. En outre, il n'y a aucun centre traditionnel. Par contre, les fonctions urbaines se répartissent entre trois réseaux enchevêtrés: le réseau familial composé des destinations propres à la vie privée; le réseau de consommation composé des centres commerciaux et de loisirs; et le réseau de production, lieu d'exercice des services de fabrication et de bureaux. Ces réseaux ne s'ordonnent pas selon des zones fonctionnelles mais se juxtaposent, permettant à un immense centre corporatif d'être bordé de petites maisons et à un important "mega-mall" de longer des champs de maïs. Après avoir présenté la structure de la nouvelle ville, l'auteur s'interroge sur cène forme urbaine. Peut-elle atteindre la complexité, la beauté et la diversité des grandes cités du passé ou est-elle vouée à une trop grande densité pour être efficace et à une trop importante dispersion pour être vraiment urbaine? R. FISHMAN se réfère aux grands prophètes américains de la décentralisation des années 1930, Frank LLOYD WRIGHT et Lewis MUMFORD dont la vision de la ville décentralisée est néanmoins capable d'embrasser les plus grandes valeurs des civilisations; puis l'auteur tente de montrer que la nouvelle ville peut se reconstruire peu à peu pour refléter cette vision. le réseau familial composé des destinations propres à la vie privée; le réseau de consommation composé des centres commerciaux et de loisirs; et le réseau de production, lieu d'exercice des services de fabrication et de bureaux. Ces réseaux ne s'ordonnent pas selon des zones fonctionnelles mais se juxtaposent, permettant à un immense centre corporatif d'être bordé de petites maisons et à un important "mega-mall" de longer des champs de maïs. Après avoir présenté la structure de la nouvelle ville, l'auteur s'interroge sur cène forme urbaine. Peut-elle atteindre la complexité, la beauté et la diversité des grandes cités du passé ou est-elle vouée à une trop grande densité pour être efficace et à une trop importante dispersion pour être vraiment urbaine? R. FISHMAN se réfère aux grands prophètes américains de la décentralisation des années 1930, Frank LLOYD WRIGHT et Lewis MUMFORD dont la vision de la ville décentralisée est néanmoins capable d'embrasser les plus grandes valeurs des civilisations; puis l'auteur tente de montrer que la nouvelle ville peut se reconstruire peu à peu pour refléter cette vision., Fishman Robert. Metropolis unbound: the new city of the twentieth century. In: Flux, n°1, 1990. pp. 43-55.

The past half-century's radical transformation of American cities and regions has paradoxically stimulated our interest in older forms of cities and renewed our respect for the planning tradition that created them. Today, with everything urban and public perpetually in crisis, we turn attentively toward the figures who shaped our cities and left a magnificent legacy of public spaces, public transit, public parks, public libraries, public schools, public health, and public safety. The American Planning Tradition reevaluates those planners and their times in a series of essays by some of today's preeminent urbanists. These contributors view such antecedents as Albert Gallatin, Frederick Law Olmsted, Daniel Burnham, Edward Bennett, and Lewis Mumford not merely as precursors who prepared the way for the revelations of modern planning theory, but as contemporaries and even prophets who struggled with many of the same problems that afflict us, and responded with more vision, confidence, and hope than we seem to have today. Their chapters discuss principles proposed for American urban planning, cover a series of national efforts at planning for transportation, resources, and the environment, and describe recent experiences in New Orleans, Portland, Chicago, and Boston. The contributors are Robert Fishman, John Thomas, Michael J. Lacey, James Westcoat, Jr., Alan Brinkley, Margaret Weir, Arnold R. Hirsch, Carl Abbott, Judith A. Martin and Sam Bass Warner, Jr, and Anne Whiston Spirn.

ALTHOUGH I BELIEVE THAT MUCH OF THE ANALYSIS IN WILLIAM SHARPE'S and Leonard Wallock's vigorous polemic is seriously mistaken, I strongly agree with one fundamental point: the authors' profound concern for urbanity. They define urbanity as "diversity, cosmopolitanism, political culture, and public life," and they are right to be anxious about the present status and future survival of these crucial values. Unfortunately their anxieties have led them to adopt a literally reactionary analysis that seeks a return to the (supposedly) stirring days of yesteryear, when the clear binary opposition of city and suburb still held true. In the face of disturbing complexities, the authors cling to a vision of a simpler world where cities truly possess urbanity, suburbs do not, and upstanding cultural critics know exactly where they stand. The literary critic Diana Fuss has termed this insistence on preserving traditional dichotomies "policing the binaries." Sharpe and Wallock are particularly anxious to detect scholars who attempt to reconceptualize urban form and, thus (in their view), to subvert the special role of central cities. Not surprisingly, they prefer the critics of the 1950s-1970s who "attacked suburbia for its racial discrimination, patriarchal familism, political separatism, and geographical sprawl." By contrast, they indict more recent scholars (myself included) for "suburbanophilia." Yet the authors themselves acknowledge the truly revolutionary changes in urban and regional form that have transformed what they persist in calling "the suburbs" since 1945. Once bedroom communities-satellites