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Background: Specific vaccines are indicated for immunocompromised patients (ICPs) due to their vulnerability to infections. Recommendation of these vaccines by healthcare professionals (HCPs) is a crucial facilitator for vaccine uptake. Unfortunately, the responsibilities to recommend and administer these vaccines are not clearly allocated among HCPs involved in the care of adult ICPs. We aimed to evaluate HCPs’ opinions on directorship and their role in facilitating the uptake of medically indicated vaccines as a basis to improve vaccination practices. Methods: A cross-sectional survey was performed among in-hospital medical specialists (MSs), general practitioners (GPs), and public health specialists (PHSs) in the Netherlands to assess their opinion on directorship and the implementation of vaccination care. Additionally, perceived barriers, facilitators, and possible solutions to improve vaccine uptake were investigated. Results: In total, 306 HCPs completed the survey. HCPs almost unanimously (98%) reported that according to them, the primary treating physician is responsible for recommending medically indicated vaccines. Administering these vaccines was seen as a more shared responsibility. The most important barriers experienced by HCPs in recommending and administering were reimbursement problems, a lack of a national vaccination registration system, insufficient collaboration among HCPs, and logistical problems. MSs, GPs and PHSs all mentioned the same three solutions as important strategies to improve vaccination practices, i.e., reimbursement of vaccines, reliable and easily accessible registration of received vaccines, and arrangements for collaboration among the different HCPs that are involved in care. Conclusion: The improvement in vaccination practices in ICPs should focus on better collaboration among MSs, GPs, and PHSs, who should know each other’s expertise; clear agreement on responsibility; reimbursement for vaccines; and the availability of c

The region around Tolkamer (Province of Gelderland, the Netherlands) has traditionally been an area where and where several Orobanche species occur and where broomrapes grow in large numbers. Since the beginning of this century, a new species can be added to the species list of Tolkamer, namely Orobanche amethystea. This article discusses the features of this species and its occurrence in the Netherlands and Europe. It also presents extensive habitat data and vegetation relevés from the site at Tolkamer.

In de Green Deal Grondstoffen heeft STOWA met het Rijk afgesproken dat zij in 2015 een Onderzoeksprogramma Grondstoffen opstelt dat inzicht biedt in, en een overzicht geeft van het geheel van onderzoek en ontwikkeling op het gebied van grondstoffenwinning in de waterketen. Deze rapportage geeft ter voorbereiding op zo'n onderzoeksprogramma een beknopt overzicht van de binnen de Energie- en Grondstoffenfabriek onderscheiden onderzoeksvelden en van de daarbinnen lopende projecten, projecten in voorbereiding en nieuwe ideeën.

In de Green Deal Grondstoffen heeft STOWA met het Rijk afgesproken dat zij in 2015 een Onderzoeksprogramma Grondstoffen opstelt dat inzicht biedt in, en een overzicht geeft van het geheel van onderzoek en ontwikkeling op het gebied van grondstoffenwinning in de waterketen. Deze rapportage geeft ter voorbereiding op zo'n onderzoeksprogramma een beknopt overzicht van de binnen de Energie- en Grondstoffenfabriek onderscheiden onderzoeksvelden en van de daarbinnen lopende projecten, projecten in voorbereiding en nieuwe ideeën.

Planbureau voor de Leefomgeving (PBL), Centraal Planbureau (CPB), KNMI en Wageningen UR, LEI publiceren onder leiding van Deltares de ‘Deltascenario’s voor 2050 en 2100 – nadere uitwerking 2012-2013’. Deze scenario’s bouwen voort op de in 2011 gepubliceerde Deltascenario’s. Ze zijn gebaseerd op meer óf minder economische groei in combinatie met matige óf grote klimaatverandering. De vier scenario’s hebben de namen: RUST (resultaat van matige klimaatverandering en lage groei van economie en bevolking); DRUK (matige klimaatverandering, sterke groei); WARM (snelle klimaatverandering, lage groei); STOOM (snelle klimaatverandering, sterke groei). Aan de hand van elk van de uitgewerkte scenario’s toont het consortium voor welke uitdagingen Nederland in de toekomst kan komen te staan als het gaat om zoetwatervoorziening, de ruimtelijke inrichting van stad en land en bescherming tegen overstromingen.

Water managers in the Rhine basin are increasingly confronted with information on the impact of climate change and climate variability on the discharge regime of their river system. The river Rhine has a long history of flooding events that caused casualties and severe damage. The question remains whether measures that are currently implemented upstream in Germany have either positive or negative effects on peak water levels downstream. Adaptation can significantly reduce impacts of climate change and is seen as an important part of societal response to global climate change. Planned adaptation implies decisions and measures within society that help to anticipate to climate related risks. The overall aim of ACER is to investigate the impact of climate change and to explore adaptation strategies for the Rhine basin under climate change, for both basin wide as well as regional water managers. The ACER project follows a so-called scenario analysis whereby solution trajectories are analyzed and compared, under the assumption of various long-term climate change and socio-economic scenarios. At the core of the ACER scenario approach are a group of stakeholders representing water managers at different levels in the Rhine basin. The results can be grouped in two themes: 1) Modeling processes - a trade-off. Instead of creating an overall new "Rhine model" for this project, we realized there is a trade-off between model complexity and the ability to run long time series and/or large ensembles of climate change scenarios. Considering model performance, focus and scale of the problem, a unique model set-up had to be optimized for each project objective. We coupled two complex models to simulate and investigate land surface - atmosphere feedback mechanisms. However, to simulate the combined effect of climate change and flood management measures, another model was developed that can be forced with output from a rainfall generator (10.000 year series of meteorological daily data).

Floods are extreme events that can have large impacts on human societies and ecosystems. They arise from a multitude of causes and can have very different consequences depending on regional and local circumstances. Floods are part of the natural hydrological cycle, but adverse impacts arise when water masses inundate infrastructures and land that cannot cope with the excessive water. Major flood disasters in Europe have caused loss of lives and economic loss that amount to billions of euro, but aggregated over large areas small local floods also produce significant losses. Analyses of trends of past flood events suggest flood hazard may have increased in parts of Europe. Available evidence suggests high flows have been increasing in northern Europe, especially in western Britain and coastal Scandinavia. Regional patterns are, however, diverse, with many weak negative trends occurring in northern Europe as well, and a very mixed pattern in central Europe. Across most of the continent, however, urbanisation and the accumulation of assets in flood prone areas have led to increasing trends in the damages and economic consequences of floods. Global warming may reduce flood hazard in areas that are dominated by annual snowmelt floods, except in those regions where a sharp increase in winter snowfalls outweighs the effects of a warmer and shorter snow season. In other parts of Europe there is greater uncertainty in how flood hazard will change due to climate change. Increases in extreme river flows have, however, been predicted in several studies and may occur over relatively short time spans. Flood risk management is a demanding task that requires careful analysis of flood hazards and their causes, assessments of the magnitude of the risks, systematic planning to reduce risks and adaptation in the face of possible change. Dam safety is a major issue in dealing with flood risks. Flood risk management requires appropriate institutions, technical solutions and functioning go

Het algemene doel van het ACER project is om de gevolgen van klimaatverandering en adaptatie strategieën te onderzoeken voor het Rijnstroomgebied, zowel grensoverschrijdend in Duitsland en Frankrijk als voor het regionale waterbeheer in Nederland. ACER gebruikt een scenario analyse om effecten en oplossing te analyseren en vergelijken, onder de veronderstelling van verschillende klimaatverandering en sociaal-economische scenario’s voor 2050. Aan de basis van deze scenario aanpak staat een internationale groep van belanghebbenden en waterbeheerders uit verschillende bestuurslagen in het Rijnstroomgebied. Het is de vraag of de maatregelen die momenteel stroomopwaarts in Duitsland worden uitgevoerd positieve of negatieve effecten op de piekavoeren benedenstrooms hebben

This report describes floods in a European context with the purpose of highlighting factors that contribute to the occurrence and adverse consequences of floods, and possibilities to reduce flood risks from inland waters and rainfall. It includes a discussion on changes in flood patterns and illustrates how different scenarios for climate change may affect vulnerability to floods and flood risks. The report provides illustrative examples of flood risk management from the local to European level.

Floods are extreme events that can have large impacts on human societies and ecosystems. They arise from a multitude of causes and can have very different consequences depending on regional and local circumstances. Floods are part of the natural hydrological cycle, but adverse impacts arise when water masses inundate infrastructures and land that cannot cope with the excessive water. Major flood disasters in Europe have caused loss of lives and economic loss that amount to billions of euro, but aggregated over large areas small local floods also produce significant losses. Analyses of trends of past flood events suggest flood hazard may have increased in parts of Europe. Available evidence suggests high flows have been increasing in northern Europe, especially in western Britain and coastal Scandinavia. Regional patterns are, however, diverse, with many weak negative trends occurring in northern Europe as well, and a very mixed pattern in central Europe. Across most of the continent, however, urbanisation and the accumulation of assets in flood prone areas have led to increasing trends in the damages and economic consequences of floods. Global warming may reduce flood hazard in areas that are dominated by annual snowmelt floods, except in those regions where a sharp increase in winter snowfalls outweighs the effects of a warmer and shorter snow season. In other parts of Europe there is greater uncertainty in how flood hazard will change due to climate change. Increases in extreme river flows have, however, been predicted in several studies and may occur over relatively short time spans. Flood risk management is a demanding task that requires careful analysis of flood hazards and their causes, assessments of the magnitude of the risks, systematic planning to reduce risks and adaptation in the face of possible change. Dam safety is a major issue in dealing with flood risks. Flood risk management requires appropriate institutions, technical solutions and functioning go

Water managers in the Rhine basin are increasingly confronted with information on the impact of climate change and climate variability on the discharge regime of their river system. The river Rhine has a long history of flooding events that caused casualties and severe damage. The question remains whether measures that are currently implemented upstream in Germany have either positive or negative effects on peak water levels downstream. Adaptation can significantly reduce impacts of climate change and is seen as an important part of societal response to global climate change. Planned adaptation implies decisions and measures within society that help to anticipate to climate related risks. The overall aim of ACER is to investigate the impact of climate change and to explore adaptation strategies for the Rhine basin under climate change, for both basin wide as well as regional water managers. The ACER project follows a so-called scenario analysis whereby solution trajectories are analyzed and compared, under the assumption of various long-term climate change and socio-economic scenarios. At the core of the ACER scenario approach are a group of stakeholders representing water managers at different levels in the Rhine basin. The results can be grouped in two themes: 1) Modeling processes - a trade-off. Instead of creating an overall new "Rhine model" for this project, we realized there is a trade-off between model complexity and the ability to run long time series and/or large ensembles of climate change scenarios. Considering model performance, focus and scale of the problem, a unique model set-up had to be optimized for each project objective. We coupled two complex models to simulate and investigate land surface - atmosphere feedback mechanisms. However, to simulate the combined effect of climate change and flood management measures, another model was developed that can be forced with output from a rainfall generator (10.000 year series of meteorological daily data).

In Europe, water management is moving from flood defence to a risk management approach, which takes both the probability and the potential consequences of flooding into account. It is expected that climate change and socio-economic development will lead to an increase in flood risk in the Rhine basin. To optimize spatial planning and flood management measures, studies are needed that quantify future flood risks and estimate their uncertainties. In this paper, we estimated the current and future fluvial flood risk in 2030 for the entire Rhine basin in a scenario study. The change in value at risk is based on two land-use projections derived from a land-use model representing two different socio-economic scenarios. Potential damage was calculated by a damage model, and changes in flood probabilities were derived from two climate scenarios and hydrological modeling. We aggregated the results into seven sections along the Rhine. It was found that the annual expected damage in the Rhine basin may increase by between 54% and 230%, of which the major part (∼ three-quarters) can be accounted for by climate change. The highest current potential damage can be found in the Netherlands (110 billion €), compared with the second (80 billion €) and third (62 billion €) highest values in two areas in Germany. Results further show that the area with the highest fluvial flood risk is located in the Lower Rhine in Nordrhein-Westfalen in Germany, and not in the Netherlands, as is often perceived. This is mainly due to the higher flood protection standards in the Netherlands as compared to Germany. © 2011 Author(s).

De Deltascenario's zijn mogelijke toekomstbeelden van de fysieke en sociaaleconomische omgeving die relevant zijn voor het Delta programma. Deze Deltascenario's zijn gebaseerd op de klimaatscenario's van het KNMI en de WLO-scenario's van de samenwerkende planbureaus, beide uit 2006. De Deltascenario's geven een indicatie van de mogelijke veranderingen in fysische omgevingsfactoren, zoals rivierafvoeren, de zeespiegel, bodemdaling en verzilting, en voor sociaaleconomische factoren, zoals groei of krimp van de bevolking en de economie en de mogelijke consequenties voor het gebruik van ruimte, land en water in Nederland op een termijn van 50 tot 100 jaar. Voor die zeer lange termijn zijn modelberekeningen op basis van de KNMI'06 scenario's gecombineerd met indicaties (doorkijken) van het ruimtegebruik in de tweede helft van de eeuw op basis van mogelijke sociaaleconomische ontwikkelingen. De Deltascenario's zijn ontworpen ter ondersteuning van de analyse van knelpunten en kansen en de strategieontwikkeling in het Deltaprogramma. De scenario's bestaan uit kwalitatieve en kwantitatieve informatie over klimaat en water- en ruimtegebruik in relatie tot de toekomstige problematiek rond veiligheid tegen overstroming en zoetwatervoorziening voor Nederland. De kwantitatieve informatie maakt de scenario's geschikt voor gebruik in het landelijk Deltamodel., Deltaprogramma

In Europe, water management is moving from flood defence to a risk management approach, which takes both the probability and the potential consequences of flooding into account. It is expected that climate change and socio-economic development will lead to an increase in flood risk in the Rhine basin. To optimize spatial planning and flood management measures, studies are needed that quantify future flood risks and estimate their uncertainties. In this paper, we estimated the current and future fluvial flood risk in 2030 for the entire Rhine basin in a scenario study. The change in value at risk is based on two land-use projections derived from a land-use model representing two different socio-economic scenarios. Potential damage was calculated by a damage model, and changes in flood probabilities were derived from two climate scenarios and hydrological modeling. We aggregated the results into seven sections along the Rhine. It was found that the annual expected damage in the Rhine basin may increase by between 54% and 230%, of which the major part (∼ three-quarters) can be accounted for by climate change. The highest current potential damage can be found in the Netherlands (110 billion €), compared with the second (80 billion €) and third (62 billion €) highest values in two areas in Germany. Results further show that the area with the highest fluvial flood risk is located in the Lower Rhine in Nordrhein-Westfalen in Germany, and not in the Netherlands, as is often perceived. This is mainly due to the higher flood protection standards in the Netherlands as compared to Germany. © 2011 Author(s).

De Deltascenario's zijn mogelijke toekomstbeelden van de fysieke en sociaaleconomische omgeving die relevant zijn voor het Delta programma. Deze Deltascenario's zijn gebaseerd op de klimaatscenario's van het KNMI en de WLO-scenario's van de samenwerkende planbureaus, beide uit 2006. De Deltascenario's geven een indicatie van de mogelijke veranderingen in fysische omgevingsfactoren, zoals rivierafvoeren, de zeespiegel, bodemdaling en verzilting, en voor sociaaleconomische factoren, zoals groei of krimp van de bevolking en de economie en de mogelijke consequenties voor het gebruik van ruimte, land en water in Nederland op een termijn van 50 tot 100 jaar. Voor die zeer lange termijn zijn modelberekeningen op basis van de KNMI'06 scenario's gecombineerd met indicaties (doorkijken) van het ruimtegebruik in de tweede helft van de eeuw op basis van mogelijke sociaaleconomische ontwikkelingen. De Deltascenario's zijn ontworpen ter ondersteuning van de analyse van knelpunten en kansen en de strategieontwikkeling in het Deltaprogramma. De scenario's bestaan uit kwalitatieve en kwantitatieve informatie over klimaat en water- en ruimtegebruik in relatie tot de toekomstige problematiek rond veiligheid tegen overstroming en zoetwatervoorziening voor Nederland. De kwantitatieve informatie maakt de scenario's geschikt voor gebruik in het landelijk Deltamodel., Deltaprogramma

Climate change will increase winter precipitation, and in combination with earlier snowmelt it will cause a shift in peak discharge in the Rhine basin from spring to winter. This will probably lead to an increase in the frequency and magnitude of extreme floods. In this paper we aim to enhance the simulation of future low-probability flood peak events in the Rhine basin using different climate change scenarios, and downscaling methods. We use the output of a regional climate model (RCM) and a weather generator to create long, resampled time series (1000 years) of climate change scenarios as input for hydrological (daily) and hydrodynamic (hourly) modeling. We applied this approach to three parallel modeling chains, where the transformation method from different resampled RCM outputs to the hydrological model varied (delta change approach, direct output, and bias-corrected output). On the basis of numerous 1000 year model simulations, the results indicate a basin-wide increase in peak discharge in 2050 of 8%-17% for probabilities between 1/10 and 1/1250 years. Furthermore, the results show that increasing the length of the climate data series using a weather generator reduced the statistical uncertainty when estimating low-probability flood peak events from 13% to 3%. We further conclude that bias-corrected direct RCM output is to be preferred over the delta change approach because it provides insight into geographical differences in discharge projections under climate change. Also, bias-corrected RCM output can simulate changes in the variance of temperature and rainfall and in the number of precipitation days, as changes in temporal structure are expected under climate change. These added values are of major importance when identifying future problem areas due to climate change and when planning potential adaptation measures. Copyright 2010 by the American Geophysical Union.

Nederland bereidt zich voor op een sneller stijgende zeespiegel en een veranderend klimaat. Hiervoor is het Deltaprogramma gestart. Dit deltaprogramma voorziet een serie beslissingen die grote gevolgen zullen hebben voor het beheer van het water in Nederland. Om deze beslissingen zorgvuldig te nemen is informatie nodig over hoe het klimaat en de stijgende zeespiegel dit waterbeheer zullen beïnvloeden. De modellen die de gevolgen van klimaatverandering berekenen zullen daarom met dezelfde klimaat forcering en gekoppeld aan elkaar moeten worden gebruikt. In dit onderzoek is gekeken naar het linken van hydrologische en hydrodynamische modellen – en daaraan gekoppelde modellen die de ontwikkelingen in natuur en landgebruik modelleren -- die het gebied van de Alpen tot en met de Noordzee inclusief Nederland beschrijven.

Climate change will increase winter precipitation, and in combination with earlier snowmelt it will cause a shift in peak discharge in the Rhine basin from spring to winter. This will probably lead to an increase in the frequency and magnitude of extreme floods. In this paper we aim to enhance the simulation of future low-probability flood peak events in the Rhine basin using different climate change scenarios, and downscaling methods. We use the output of a regional climate model (RCM) and a weather generator to create long, resampled time series (1000 years) of climate change scenarios as input for hydrological (daily) and hydrodynamic (hourly) modeling. We applied this approach to three parallel modeling chains, where the transformation method from different resampled RCM outputs to the hydrological model varied (delta change approach, direct output, and bias-corrected output). On the basis of numerous 1000 year model simulations, the results indicate a basin-wide increase in peak discharge in 2050 of 8%-17% for probabilities between 1/10 and 1/1250 years. Furthermore, the results show that increasing the length of the climate data series using a weather generator reduced the statistical uncertainty when estimating low-probability flood peak events from 13% to 3%. We further conclude that bias-corrected direct RCM output is to be preferred over the delta change approach because it provides insight into geographical differences in discharge projections under climate change. Also, bias-corrected RCM output can simulate changes in the variance of temperature and rainfall and in the number of precipitation days, as changes in temporal structure are expected under climate change. These added values are of major importance when identifying future problem areas due to climate change and when planning potential adaptation measures. Copyright 2010 by the American Geophysical Union.

In 2008 is Woodsia ilvensis (L.) R.Br. voor het eerst in Nederland gevonden. Het enige exemplaar groeide op een 60 jaar oud laag bakstenen muurtje in Doetinchem. De dichtst nabij gelegen groeiplaats van deze kleine varensoort ligt in de Harz in Duitsland op zo’n 330 km afstand van deze stad. In 2008 Woodsia ilvensis (L.) R.Br. was recorded for the first time in the Netherlands. The single plant was growing on a 60 years old low brick garden wall in the Doetinchem, Province of Gelderland. The nearest known locality of this small fern species is located in the Harz Mts, Germany, at c. 330 km distance from this Dutch town.

Due to the growing wish and necessity to simulate the possible effects of climate change on the discharge regime on large rivers such as the Rhine in Europe, there is a need for well performing hydrological models that can be applied in climate change scenario studies. There exists large variety in available models and there is an ongoing debate in research on rainfall-runoff modelling on whether or not physically based distributed models better represent observed discharges than conceptual lumped model approaches do. In addition, it is argued that Land Surface Models (LSMs) carry the potential to accurately estimate hydrological partitioning, because they solve the coupled water and energy balance. In this paper, the hydrological models HBV and VIC were compared for the Rhine basin by testing their performance in simulating discharge. Overall, the semi-distributed conceptual HBV model performed much better than the distributed land surface model VIC (E=0.62, r2=0.65 vs. E=0.31, r2=0.54 at Lobith). It is argued here that even for a well-documented river basin such as the Rhine, more complex modelling does not automatically lead to better results. Moreover, it is concluded that meteorological forcing data has a considerable influence on model performance, irrespectively to the type of model structure and the need for ground-based meteorological measurements is emphasized.

Untill 2001 Circaea x intermedia was merely known from a single locality in the Netherlands, viz. in a decidious forest along the brook of Ratum near Winterswijk (prov. of Gelderland). A close inspection learned, however, that it (now) occurs along the whole length of that brook. The authors warn that “winged petioles” arise only during drying material for the herbarium.

Euphorbia platyphyllos was not found in the Netherlands for almost twenty years. The plant was rediscovered in 1999 on four new locations in the province of Gelderland on sandy, light clay soils near the river Linge. The plants were growing in dry ditches, a meadow and on a clayheap.

Bij een vlindervriendelijk beheer kunnen er op een kleine oppervlakte midden in een agrarisch gebied toch veel vlinders voorkomen. Dit blijkt uit het voorbeeld van ‘de Maandag’, een voormalige boerderij in de Gelderse Achterhoek. In totaal zijn er al 26 soorten gezien.

Before considering particularly the treatment of carcinoma of the neck, it is necessary to briefly refer to methods of diagnosis and classification process in several stages. Our interpretation of the diagnosis and classification has a very important role in our choice of treatment in each individual case influence. As developed cn use of cytology and biopsy, many early cases can be discovered, which had not been recognized ten or more years ago. Some of these are in the preinvasive stage when the disease is still curable 100%., Antes de considerar particularmente el tratamiento del carcinoma del cuello, es necesario referirnos brevemente a los métodos de diagnóstico y la clasificación del proceso en varias etapas. Nuestra interpretación del diagnóstico, así como su clasificación tiene una influencia muy importante en nuestra elección del tratamiento en cada caso individual. Cn el uso tan desarrollado de la citología y la biopsia, muchos casos tempranos pueden ser descubiertos, los cuales no hubieran sido reconocidos diez o más años atrás. Algunos de estos están en la etapa preinvasiva cuando la enfermedad es todavía curable en un 100%.