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Cardiovascular diseases (CVDs) are a global burden that requires attention. For the detection and diagnosis of CVDs, the 12-lead ECG is a key tool. With technological advancements, ECG devices are becoming smaller and available for home use. Most of these devices contain a limited number of leads and are aimed to detect atrial fibrillation (AF). To investigate whether a four-electrode arrangement could provide enough information to diagnose other CVDs, further research is necessary. At the University Medical Center Utrecht in a multidisciplinary team, we developed the miniECG, a four-electrode ECG handheld system for scientific research in clinical environments (TRL6). This paper describes the process followed during the development of the miniECG. From assembling a multidisciplinary team, which includes engineers, cardiologists, and clinical physicians to the contribution of team members in the design input, design, and testing for safety and functionality of the device. Finally, we detail how the development process was composed by iterative design steps based on user input and intended use evolution. The miniECG is a device compliant for scientific research with patients within Dutch Medical Centers. We believe that hospital-based development led to a streamlined process, which could be applied for the design and development of other technologies used for scientific research in clinical environments. [ABSTRACT FROM AUTHOR]

Antithrombotics require careful monitoring to prevent adverse events. Safe use can be promoted through so-called antithrombotic stewardship. Clinical decision support systems (CDSSs) can be used to monitor safe use of antithrombotics, supporting antithrombotic stewardship efforts. Yet, previous research shows that despite these interventions, antithrombotics continue to cause harm. Insufficient adoption of antithrombotic stewardship and suboptimal use of CDSSs may provide and explanation. However, it is currently unknown to what extent hospitals adopted antithrombotic stewardship and utilize CDSSs to support safe use of antithrombotics. A semi-structured questionnaire-based survey was disseminated to 12 hospital pharmacists from different hospital types and regions in the Netherlands. The primary outcome was the degree of antithrombotic stewardship adoption, expressed as the number of tasks adopted per hospital and the degree of adoption per task. Secondary outcomes included characteristics of CDSS alerts used to monitor safe use of antithrombotics. All 12 hospital pharmacists completed the survey and report to have adopted antithrombotic stewardship in their hospital to a certain degree. The median adoption of tasks was two of five tasks (range 1–3). The tasks with the highest uptake were: drafting and maintenance of protocols (100%) and professional's education (58%), while care transition optimization (25%), medication reviews (8%) and patient counseling (8%) had the lowest uptake. All hospitals used a CDSS to monitor safe use of antithrombotics, mainly via basic alerts and less frequently via advanced alerts. The most frequently employed alerts were: identification of patients using a direct oral anticoagulant (DOAC) or a vitamin K antagonist (VKA) with one or more other antithrombotics (n = 6) and patients using a VKA to evaluate correct use (n = 6), both reflecting basic CDSS. All participating hospitals adopted antithrombotic stewardship, but the adopted tasks vary. CDSS alerts used are mainly basic in their logic. [ABSTRACT FROM AUTHOR]

Background: A strong increase in mental health emergency consultations and admissions in youths has been reported in recent years. Although empirical evidence is lacking, gender differences in risk of admission may have contributed to this increase. A clearer understanding of the relationship, if any, between gender and various aspects of (in)voluntary care would help in more evidence-based service planning. Methods: We analysed registry data for 2008–2017 on 3770 outpatient emergencies involving young people aged 12 to 18 years from one urban area in the Netherlands, served by outreaching psychiatric emergency services. These adolescents were seen in multiple locations and received a psychosocial assessment including a questionnaire on the severity of their problems and living conditions. Our aims were to (a) investigate the different locations, previous use of mental health service, DSM classifications, severity items, living conditions and family characteristics involved and (b) identify which of these characteristics in particular contribute to an increased risk of admission. Results: In 3770 consultations (concerning 2670 individuals), more girls (58%) were seen than boys. Boys and girls presented mainly with relationship problems, followed by disruptive disorders and internalizing disorders. Diagnostic differences diminished in hospitalisation. More specifically, disruptive disorders were evenly distributed. Suicide risk was rated significantly higher in girls, danger to others significantly higher in boys. More girls than boys had recently been in mental health care prior to admission. Although boys and girls overall did not differ in the severity of their problems, female gender predicted admission more strongly. In both boys and girls severity of problems and lack of involvement of the family significantly predicted admission. Older age and danger to others significantly predicted admission among boys, whereas psychosis, suicidality and poor motivation for treatment predicted admission among girls. Conclusion: There are different pathways for youth admission, which can partly be explained by different psychiatric classifications as well as gender-specific differences with regard to age, suicide risk, danger to others and the influence of motivation for treatment. Finally, for both genders, family desire for hospitalisation is also an important predictor. [ABSTRACT FROM AUTHOR]

The horizontal time-of-flight neutron reflectometer at the reactor of the Delft University of Technology, The Netherlands, has been completely renewed, relocated, and upgraded and allows for the study of air/liquid, solid/liquid, and solid/air interfaces. Innovations in the redesign include (i) a completely flexible double disk chopper system allowing to choose the optimal wavelength resolution with exchangeable neutron guide sections between the chopper disks to increase intensity, (ii) a movable second diaphragm just before the sample position to better control the beam footprint on the sample and effectively decrease counting times, and (iii) guides along the entire flight path of the neutron reflectometer. The performance of the renewed reflectometer is illustrated with measurements of hydrogen sensing materials. [ABSTRACT FROM AUTHOR]

Building with Nature (BwN), is a concept that has been applied in various projects around the world in the broader context of nature based solutions for climate resilience and adaptation. Most of these projects are regional or local in nature and are implemented on a smaller scale. Larger scale projects are more rare. The aim of this article is to highlight a number of large‐scale projects that have been completed or are in the developing stage. The focus will be on coastal regions, from temperate locations in the Netherlands and from developing countries in the tropics including Bangladesh. The value of implementing the principle of BwN for a sustainable future is underlined and described. Certain aspects of governance are highlighted to point out the differences and challenges, but also similarities, of carrying out such projects in different parts of the world. [ABSTRACT FROM AUTHOR]

In Team Based Learning (TBL), it is, based on theory, assumed that knowledge development in each phase contributes to the subsequent phase and to learning performance. However, there is no empirical evidence for this assumption. In order to find support for the relation between TBL and the underlying theory, we determined to what extent each phase of TBL is associated with the knowledge development in the next phase and with the total learning performance. We measured the scientific concepts recalled by 56 second-year undergraduate medical students before TBL, after each of the three phases and after TBL. We used multivariate regression analysis to determine the statistical association between the phases as well as the total learning performance. Results showed that in each phase, students produced new concepts in addition to those previously recalled. Regression models showed statistically significant explained variance ranging from 0.19 to 0.26, between the three phases and the total learning performance. Each phase of the TBL is significantly associated with knowledge development in the subsequent phase and with the total learning performance, and therefore matters. This study contributes to the scientific underpinning of TBL and offers leads to more elaborate research and interventions to improve TBL. [ABSTRACT FROM AUTHOR]

Earthquake site response is an essential part of seismic hazard assessment, especially in densely populated areas. The shallow geology of the Netherlands consists of a very heterogeneous soft sediment cover, which has a strong effect on the amplitude of ground shaking. Even though the Netherlands is a low- to moderate-seismicity area, the seismic risk cannot be neglected, in particular, because shallow induced earthquakes occur. The aim of this study is to establish a nationwide site-response zonation by combining 3D lithostratigraphic models and earthquake and ambient vibration recordings. As a first step, we constrain the parameters (velocity contrast and shear-wave velocity) that are indicative of ground motion amplification in the Groningen area. For this, we compare ambient vibration and earthquake recordings using the horizontal-to-vertical spectral ratio (HVSR) method, borehole empirical transfer functions (ETFs), and amplification factors (AFs). This enables us to define an empirical relationship between the amplification measured from earthquakes by using the ETF and AF and the amplification estimated from ambient vibrations by using the HVSR. With this, we show that the HVSR can be used as a first proxy for site response. Subsequently, HVSR curves throughout the Netherlands are estimated. The HVSR amplitude characteristics largely coincide with the in situ lithostratigraphic sequences and the presence of a strong velocity contrast in the near surface. Next, sediment profiles representing the Dutch shallow subsurface are categorised into five classes, where each class represents a level of expected amplification. The mean amplification for each class, and its variability, is quantified using 66 sites with measured earthquake amplification (ETF and AF) and 115 sites with HVSR curves. The site-response (amplification) zonation map for the Netherlands is designed by transforming geological 3D grid cell models into the five classes, and an AF is assigned to most of the classes. This site-response assessment, presented on a nationwide scale, is important for a first identification of regions with increased seismic hazard potential, for example at locations with mining or geothermal energy activities. [ABSTRACT FROM AUTHOR]

Earthquake site-response is an essential part of seismic hazard assessment, especially in densely populated areas. The shallow geology of the Netherlands consists of a very heterogeneous soft sediment cover, which has a strong effect on seismic wave propagation and in particular on the amplitude of ground shaking, resulting in significant damage on structures despite the fact that the events are of small magnitude. Even though it is a low-to-moderate seismicity area, the seismic risk cannot be neglected, in particular, because shallow induced earthquakes occur. The aim of this study is to establish a nationwide site-response zonation by using the lithostratigraphy, earthquake- and ambient vibration recordings. In the first step, we constrain the parameters (velocity contrast and shear-wave velocity) that are indicative of ground-motion amplification in the Groningen area. For this, we combine ambient vibration and earthquake recordings using resp. the horizontal-to-vertical spectral ratio method (HVSR), borehole empirical transfer functions (ETFs) and amplification factors (AFs). This enables us to define an empirical relationship between measured earthquake amplification from the ETF and AF, and amplification estimated with the HVSR derived from the ambient seismic field. Therewith, we show that the HVSR can be used as a first proxy for amplification. Subsequently, HVSR curves throughout the Netherlands are estimated. The resulting peak amplitudes largely coincide with the in-situ lithostratigraphic sequences and the presence of a strong velocity contrast in the near-surface. Next, sediment profiles representing the Dutch shallow subsurface are categorized into five classes, where each class is representing a level of expected amplification. The mean amplification for each class, and its variability, is quantified using 66 sites with measured earthquake amplification (ETF and AF) and 115 sites with HVSR curves. The site-response (amplification) zonation map for the Netherlands is designed by transforming published geological 3D grid cell models into the five classes and an AF is assigned to most of the classes. This presented site-response assessment on a national scale is important for a first identification of regions with increased seismic hazard potential, for example at locations with mining or geothermal energy activities. [ABSTRACT FROM AUTHOR]

For seismic hazard assessment and earthquake hypocentre localization, detailed shear-wave velocity profiles are an important input parameter. Here, we present a method to construct a shear-wave velocity profiles for a deep unconsolidated sedimentary layer by using strong teleseismic phases and the ambient noise field. Gas extraction in the Groningen field, in the northern part of the Netherlands, is causing low-magnitude, induced seismic events. This region forms an excellent case study due to the presence of a permanent borehole network and detailed subsurface knowledge. Instead of conventional horizontal-to-vertical spectral ratios (H/V ratios) from amplitude spectra, we calculate power spectral densities and use those as input for H/V calculations. The strong teleseisms provide resonance recordings at low frequencies, where the seismic noise field is too weak to be recorded well with the employed geophones and accelerometers. The H/V ratios of the ambient noise field are compared with several forward modelling approaches to quality check the teleseism-based shear-wave velocity profiles. Using the well-constrained depth of the sedimentary basin, we invert the H/V ratios for velocity profiles. A close relationship is observed between the H/V spectral ratios from the ambient noise field, shear-wave resonance frequencies and Rayleigh-wave ellipticity. By processing only five teleseismic events, we are able to derive shear-wave velocities for the deeper sedimentary sequence with a 7 % bias in comparison with the existing detailed velocity model for the Cenozoic sediments overlying the Groningen gas field. Furthermore, a relation between resonance frequency and unconsolidated sediment thickness is derived, to be used in other areas in the Netherlands, where detailed depth maps are not available. [ABSTRACT FROM AUTHOR]

For hazard assessment and earthquake hypocentre localisation, detailed shear-wave velocity profiles are an important input parameter. Here we present a method to construct a shear-wave velocity profiles for a deep unconsolidated sedimentary layer by using strong teleseismic phases and the ambient noise field. Gas extraction in the Groningen field, in the northern part of the Netherlands, is causing low-magnitude, induced seismic events. This region forms an excellent case study due to the presence of a permanent borehole network and detailed subsurface knowledge. Instead of conventional horizontal-to-vertical spectral ratios (H/V ratios) from amplitude spectra, we calculate power spectral densities and use those as input for H/V calculations. The strong teleseisms provide resonance recordings at low frequencies, where the seismic noise field is too weak to be recorded well with the employed geophones and accelerometers. The H/V ratios of the ambient noise field are compared with several forward modeling approaches to quality check the teleseism-based shear-wave velocity profiles. A close relationship is observed between the H/V spectral ratios from the ambient noise field, shear-wave resonance frequencies and Rayleigh-wave ellipticity. Using the well-constrained depth of the sedimentary basin, we invert the H/V ratios for velocity profiles. By processing only five teleseismic events, we are able to derive shear-wave velocities for the deeper sedimentary sequence with a 7% bias in comparison with the existing detailed velocity model for the Cenozoic sediments overlying the Groningen gas field. Furthermore, a relation between resonance frequency and unconsolidated sediment thickness is derived, to be used in other areas in the Netherlands, where detailed depth maps are not available. [ABSTRACT FROM AUTHOR]

For more than five hundred years the southern part of the Netherlands belonged to the Roman Empire, more particularly to the province of Germania inferior (Lower Germany). The left bank of the river Rhine served as the external boundary of this province, once the ambition to annex the Germanic territories across the river had been abandoned. Although the Lower German Limes is only a modest part of the whole frontier system of the Roman Empire, it can boast of various distinctive characteristics, the most important of which is the outstanding preservation of timber buildings, ships and other organic remains in the water-logged conditions of the Rhine delta. This paper presents a brief history of this frontier section and addresses a few general issues, as an introduction to a series of papers discussing a variety of aspects of the frontier and of life in a frontier zone. [ABSTRACT FROM AUTHOR]

The aim of this research was to gain insight into the experiences and perspectives of individual members of a Medical Research Ethics Committee (MREC) regarding their individual roles and possible tensions within and between these roles. We conducted a qualitative interview study among members of a large MREC, supplemented by a focus group meeting. Respondents distinguish five roles: protector, facilitator, educator, advisor and assessor. Central to the role of protector is securing valid informed consent and a proper risk-benefit analysis. The role of facilitator implies that respondents want to think along with and assist researchers in order to help medical science progress. As educators, the respondents want to raise ethical and methodological awareness of researchers. The role of advisor implies that respondents bring in their own expertise. The role of assessor points to contributing to the overall evaluation of the research proposal. Various tensions were identified within and between roles. Within the role of protector, a tension is experienced between paternalism and autonomy. Between the role of protector and facilitator tensions occur when the value of a study is questioned while risks and burdens for the subjects are negligible. Within the role of assessor, a tension is felt between the implicit nature of judgments and the need for more explicit formulations. Awareness of various roles and responsibilities may prevent one-sided views on MREC work, not only by members themselves, but also by researchers. Tensions within and between the roles require reflection by MREC members. [ABSTRACT FROM AUTHOR]

Aims: The Paediatric Urology Guidelines Panel reports initial experience with patient involvement in spina bifida patient groups to gather information on their awareness of the guidelines and reflection of guideline recommendations. Methods: The survey was delivered to spina bifida patients/parents via the national society groups in Turkey, Germany, and The Netherlands. Questions included demographic features, medical status, awareness, and agreement on the recommendations given in the guidelines and future expectations. Results: A total of 291 patients from 3 countries responded to the survey. Mean age was 13.9 ± 12.2 years, male/female ratio 138/151, 75% of all surveys were completed by the caregivers. The medication was taken by 78% of patients (64% anticholinergics). Complete dryness rates for urine and stool were 24% and 47%, respectively. The agreement rates on the recommendations regarding urodynamics, intermittent catheterization, anticholinergics drug use, bowel management, and life‐long follow‐up were 97%, 82%, 91%, 77%, and 98%, respectively. Only 8% of responders were aware of the European Association of Urology/European Society for Pediatric Urology guidelines. The priorities of patients for future expectations were as the following: quality of life (QoL), surgical techniques, development of new medications and sexuality/fertility issues. Male spina bifida patients preferred new medications and sex/fertility issues more, whereas females favored QoL issues improvement more. Conclusions: Although the native language of the involved patients was different from English, awareness of guidelines was 8%. The general approval of the recommendations given in the guidelines is quite high. The national society groups showed a great interest to get involved in the creation of the guidelines to improve health care for spina bifida patients. [ABSTRACT FROM AUTHOR]

Introduction: Thiamine is an essential cofactor in carbohydrate metabolism, and deficiency can therefore cause various organ dysfunctions. Little is known about the prevalence and possible worsening of thiamine deficiency in critically ill patients. In this study, we investigated the prevalence of thiamine deficiency at admission to the intensive care unit (ICU) and hypothesized that intensive insulin therapy, aimed at regulating glucose levels, increases thiamine utilization and therefore might cause or worsen deficiency in patients with limited thiamine stores. Materials and Methods: An observational prospective cohort study was carried out in a medical–surgical ICU in a general teaching hospital in Apeldoorn, the Netherlands. All adults who were treated during that time with intensive insulin therapy were included. Deficiency was defined as a thiamine level <100 nmol/L. No thiamine supplementation was administered except for normal amounts present in standard enteral feeding. Results: A total of 58 patients were available for analysis. Median thiamine level at admission was 111 nmol/L. Deficiency was present in 39.7% of patients and was significantly associated with the presence of gastrointestinal pathology and with recent surgery. Thiamine levels increased a median of 14 nmol/L in 48 hours. Only 3.4% of patients showed a predefined relevant decline in thiamine levels. Conclusion: Intensive insulin therapy does not appear to cause or worsen thiamine deficiency. However, based on the high prevalence of deficiency at admission, it might be warranted to supplement thiamine in all patients admitted to the ICU, especially when there is an underlying gastrointestinal disease or recent surgery. [ABSTRACT FROM AUTHOR]

Background: Loneliness is highly prevalent among older people, has serious health consequences and is an important predictor of mortality. Loneliness and depression may unfavourably interact with each other over time but data on this topic are scarce.Aims: To determine whether loneliness is associated with excess mortality after 19 years of follow-up and whether the joint effect with depression confers further excess mortality.Method: Different aspects of loneliness were measured with the De Jong Gierveld scale and depression with the Centre for Epidemiologic Studies Depression Scale in a cohort of 2878 people aged 55-85 with 19 years of follow-up. Excess mortality hypotheses were tested with Kaplan-Meier and Cox proportional hazard analyses controlling for potential confounders.Results: At follow-up loneliness and depression were associated with excess mortality in older men and women in bivariate analysis but not in multivariate analysis. In multivariate analysis, severe depression was associated with excess mortality in men who were lonely but not in women.Conclusions: Loneliness and depression are important predictors of early death in older adults. Severe depression has a strong association with excess mortality in older men who were lonely, indicating a lethal combination in this group. [ABSTRACT FROM AUTHOR]

Background: Moral case deliberation is increasingly becoming part of various Dutch healthcare organizations. Although some evaluation studies of moral case deliberation have been carried out, research into the results of moral case deliberation within aged care is scarce. Research questions: How did participants evaluate moral case deliberation? What has moral case deliberation brought to them? What has moral case deliberation contributed to care practice? Should moral case deliberation be further implemented and, if so, how? Research design: Quantitative analysis of a questionnaire study among participants of moral case deliberation, both caregivers and team leaders. Qualitative analysis of written answers to open questions, interview study and focus group meetings among caregivers and team leaders. Participants and research context: Caregivers and team leaders in a large organization for aged care in the Netherlands. A total of 61 moral case deliberation sessions, carried out on 16 care locations belonging to the organization, were evaluated and perceived results were assessed. Ethical considerations: Participants gave informed consent and anonymity was guaranteed. In the Netherlands, the law does not prescribe independent ethical review by an Institutional Review Board for this kind of research among healthcare professionals. Findings: Moral case deliberation was evaluated positively by the participants. Content and atmosphere of moral case deliberation received high scores, while organizational issues regarding the moral case deliberation sessions scored lower and merit further attention. Respondents indicated that moral case deliberation has the potential to contribute to care practice as relationships among team members improve, more openness is experienced and more understanding for different perspectives is fostered. If moral case deliberation is to be successfully implemented, top-down approaches should go hand in hand with bottom-up approaches. Conclusion: The relevance of moral case deliberation for care practice received wide acknowledgement from the respondents. It can contribute to the team’s cohesion as mutual understanding for one another’s views is fostered. If implemented well, moral case deliberation has the potential to improve care, according to the respondents. [ABSTRACT FROM AUTHOR]

Background The objective of this prospective cohort study was to assess whether the 45-minute prehospital limit for ambulance transfer is met in case of postpartum hemorrhage ( PPH) after midwifery-supervised home birth in The Netherlands and evaluate the process of ambulance transfer, maternal condition during transfer, and outcomes in relation to whether this limit was met. Methods Using ambulance report forms and medical charts, ambulance intervals, urgency coding, clinical condition (using the lowest Revised Trauma Score, [ RTS]), and maternal outcomes were collected. From April 2008 to April 2010, midwives reported 72 cases of PPH. Associations between duration of the ambulance transfer, maternal condition during ambulance transfer and outcomes were analyzed. The main outcome measures were duration of ambulance transfer, RTS, blood loss, surgical procedures, and blood transfusions. Results Seventy-two cases were reported, 18 (25%) were excluded: 54 cases were analyzed. In 63 percent, the 45-minute prehospital limit was met, 75.9 percent received a RTS of 12, indicating optimal Glasgow Coma Scale, systolic blood pressure, and respiratory frequency. In 24.1 percent a decrease in systolic blood pressure was found ( RTS 10 or 11). We found no difference in outcomes between women with different RTS or in whom the 45-minute prehospital limit was or was not met. Conclusions We found no relation between the duration of ambulance transfer and maternal condition or outcomes. All women fully recovered. The low-risk profile of women in primary care, well-organized midwifery, and ambulance care in The Netherlands are likely to contribute to these findings. [ABSTRACT FROM AUTHOR]

The most suitable candidates for subsurface storage of CO 2 are depleted gas fields. Their ability to retain CO 2 can however be influenced by the effect which impurities in the CO 2 stream (e.g. H 2 S and SO 2 ) have on the mineralogy of reservoir and seal. In order to investigate the effects of SO 2 we carried out laboratory experiments on reservoir and cap rock core samples from gas fields in the northeast of the Netherlands. The rock samples were contained in reactor vessels for 30 days in contact with CO 2 and 100 ppm SO 2 under in-situ conditions (300 bar, 100 °C). The vessels also contained brine with the same composition as in the actual reservoir. Furthermore equilibrium modeling was carried out using PHREEQC software in order to model the experiments on caprock samples. After the experiments the permeability of the reservoir samples had increased by a factor of 1.2–2.2 as a result of dissolution of primary reservoir minerals. Analysis of the associated brine samples before and after the experiments showed that concentrations of K, Si and Al had increased, indicative of silicate mineral dissolution. In the caprock samples, composed of carbonate and anhydrite minerals, permeability changed by a factor of 0.79–23. The increase in permeability is proportional to the amount of carbonate in the caprock. With higher carbonate content in comparison with anhydrite the permeability increase is higher due to the additional carbonate dissolution. This dependency of permeability variations was verified by the modeling study. Hence, caprock with a higher anhydrite content in comparison with carbonate minerals has a lower risk of leakage after co-injection of 100 ppmv SO 2 with CO 2 . [ABSTRACT FROM AUTHOR]

Context: In temperate Europe, warming, summer droughts, and increased winter precipitation are predicted to have profound effects on vegetation performance and composition. Especially groundwater dependent vegetation will be affected. These impacts within the landscape may negatively affect the connectivity within ecological networks. Objectives: With an integrated surface- and groundwater model and a climate robust traits-based vegetation model, we simulated the implementation of water conservation measures in a stream valley catchment in the Netherlands. Methods: We assessed the impacts of conservation measures on groundwater levels, seepage flux, and vegetation composition for the current climate and two climate scenarios, with a global temperature increase of 2 °C and an increase (+6 %) or decrease (−2 %) in annual precipitation. Results: Our model showed that water conservation measures on average increased groundwater levels, although there were large spatial differences. At the same time, water conservation decreased the seepage flux in the stream valley, thereby decreasing the supply of nutrient-poor groundwater. These negative impacts on seepage flux will be amplified in a future climate. Semi-terrestrial vegetation along the streams will benefit from water conservation measures and increasingly so in a future climate. Other vegetation types showed a wide array of responses depending on spatially-differentiated changes in groundwater level and seepage fluxes. Conclusion: Our results highlight the importance of integrating spatially-explicit hydrology-vegetation interactions into models that evaluate climate adaptation measures. Customized water conservation measures can contribute to minimize negative effects of climate change on groundwater dependent vegetation and ensure the robustness of ecological networks. [ABSTRACT FROM AUTHOR]

Background Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress. Methods This study is an international qualitative interview study involving interviews with physicians, nurses, and relatives of deceased patients in the UK, The Netherlands and Belgium (the UNBIASED study) about a case of continuous sedation at the end of life they were recently involved in. All interviews were transcribed verbatim and analysed by staying close to the data using open coding. Next, codes were combined into larger themes and categories of codes resulting in a four point scheme that captured all of the data. Finally, our findings were compared with others and explored in relation to theories in ethics and sociology. Results The participants' responses can be captured as different dimensions of 'closeness', i.e. the degree to which one feels connected or 'close' to a certain decision or event. We distinguished four types of 'closeness', namely emotional, physical, decisional, and causal. Using these four dimensions of 'closeness' it became possible to describe how physicians, nurses, and relatives experience their involvement in cases of continuous sedation until death. More specifically, it shined a light on the everyday moral reasoning employed by care providers and relatives in the context of continuous sedation, and how this affected the emotional impact of being involved in sedation, as well as the perception of their own moral responsibility. Conclusion Findings from this study demonstrate that various factors are reported to influence the degree of closeness to continuous sedation (and thus the extent to which carers feel morally responsible), and that some of these factors help care providers and relatives to distinguish continuous sedation from euthanasia. [ABSTRACT FROM AUTHOR]

Abstract: We analyze the decision-making process of the abandonment of a Carbon Capture Storage (CCS) initiative in the Northern-Netherlands. We investigate the social acceptance of the Northern-Netherlands CCS initiative using the results from a survey among the key stakeholders. We find that local opposition can only be held partially responsible for the abandonment of the CCS project. This result differs from the broadly accepted notion “no local public acceptance, no CCS”. Our study finds that the views from key stakeholders regarding the prospects of the CCS initiative were conflicting and this played a role in abandoning the initiative. We conclude that the way in which responsibilities between key stakeholders were arranged has had a dominant impact on the level of acceptance. We recommend that future policy and policy instruments for subsurface activities, like CCS, should be designed in accordance with the object, subject and inter-subject dimension of the decision-making process. In addition there should be a strategic framework, which accounts for the interaction between social-political, market and community acceptance. [Copyright &y& Elsevier]

Objective. To study the impact of generalized joint hypermobility (GJH) in professional dancers on physical fitness, musculoskeletal complaints and psychological distress.Methods. Thirty-six professional dancers were recruited and compared with control subjects (mean age 20.1, range 17–27). Height, weight, Beighton score, physical fitness (walking distance, muscle strength, estimated VO2max), musculoskeletal complaints (pain, fatigue) and psychological distress (anxiety, depression) were measured.Results. Univariate analysis revealed, in between-group analysis, that dancers (with and without GJH) had higher physical fitness [the six-minute walk test (6MWT): ΔD = +8.4%, P = 0.001; VO2max: ΔD = +12.8%, P = 0.01], fatigue (checklist individual strength: ΔD = +80.3%, P < 0.0001) and greater psychological distress (Hospital Anxiety and Depression Scale: ΔD = +115.0%, P < 0.0001). When comparing dancers and control subjects with GJH to those without GJH, lower levels of physical fitness (muscle strength: ΔD = −11.3%, P < 0.0001; 6MWT: ΔD = −9.9%, P < 0.0001), more fatigue (checklist individual strength: ΔD = +84.4%, P < 0.0001) and greater psychological distress (Hospital Anxiety and Depression Scale: ΔD = +79.6%, P < 0.0001) were observed in subjects with GJH. Multivariate analysis showed that dancers have higher levels of physical fitness (6MWT, P = 0.001; VO2max, P = 0.020); however, when taking GJH into account, this advantage disappeared, indicating lower levels of physical fitness in comparison with control subjects (6MWT, P = 0.001; muscle strength, P < 0.0001; VO2max, P = 0.040). Dancers experienced more fatigue (P = 0.001) and psychological distress (P < 0.0001). This was associated with even more fatigue (P = 0.010) and psychological distress (P = 0.040) when GJH was present.Conclusion. Dancers with GJH seem more vulnerable to musculoskeletal and psychological complaints. In addition, GJH was also associated with lower physical fitness, despite training. Caregivers for professional dancers should monitor closely the physical capabilities and the amount of psychological strain. [ABSTRACT FROM PUBLISHER]

Neurofeedback (NFB) research has reported improved concentration and attention in children with attention deficit/hyperactivity disorder (ADHD) and progress maintained over time. Would that also apply to children with an IQ between 50 and 70 (mild mental retardation [MMR]) and an IQ between 70 and 85 (borderline retardation [BR]) with characteristics of ADHD? To our knowledge this is the first NFB treatment study with long-term follow-up in this particular group. Ten adolescents with MMR and BR and ADHD received 30 sessions of quantitative electroencephalogram (QEEG)-based NFB. QEEG differences with a gender- and age-matched group without mental handicap and ADHD (data provided by BRAINnet) were investigated, at pre- and posttreatment and at 6-month follow-up. Neuropsychological functioning was tested administering the Bourdon-Vos, and the Amsterdam Neuropsychological Testing Program subscales SA DOTS and SSV. Pretreatment eyes-closed EEGs were not statistically different in the children with MMR compared to the controls. With eyes open higher amplitudes were found in the lower frequencies in the children with MMR, normalizing over time. The neuropsychological tests improved for reaction times and errors. On the complex tasks in the SSV a number of errors remained. The subjects perceived an improvement in ADHD and increasingly enjoyed the study. After NFB treatment, attention and concentration in children with MMR and BR have improved. Task span and effort also increased, although impulse control remained weak. This may be explained by a limited working memory capacity. The subjective reports may have been affected by situational factors and should be interpreted with caution. This study is limited by its nonrandomized design. [ABSTRACT FROM PUBLISHER]

Reliably predicting vegetation distribution requires habitat distribution models (HDMs) that are ecologically sound. Current correlative HDMs are increasingly criticized because they lack sufficient functional basis. To include functional information into these models, we integrated two concepts from community ecology into a new type of HDM. We incorporated: 1) species selection by their traits in which only those species that pass the environmental filter can be part of the community (assembly theory); 2) that the occurrence probability of a community is determined by the extent to which the community mean traits fit the required traits as set by the environment. In this paper, our trait-based HDM is presented and its predictive capacity explored. Our approach consists of two steps. In step 1, four plant traits (stem-specific density and indicator values for nutrients, moisture and acidity) are predicted from four dominant environmental drivers (disturbance, nutrient supply, moisture supply and acidity) using regression. In step 2, these traits are used to predict the occurrence probability of 13 vegetation types, covering the majority of vegetation types across the Netherlands. The model was validated by comparison to the observed vegetation type for 263 plots in the Netherlands. Model performance was within the range of conventional HDMs and decreased with increasing uncertainty in the environment-trait relationships and with an increasing number of vegetation types. This study shows that including functionality into HDMs is not necessarily at the cost of model performance, while it has several conceptual advantages among including an increased insight in the functional characteristics of the vegetation and sources of unpredictability in community assembly. As such it is a promising first step towards more functional HDMs. Further development of a trait-based HDM hinges on replacing indicator values by truly functional traits and the translation of these relationships into mechanistic relationships. [ABSTRACT FROM AUTHOR]

Objectives and design This study describes a randomized controlled trial which aimed to evaluate whether 16 sessions of psychotherapy combined with pharmacotherapy is more effective in relieving depression and improving social functioning than 8 sessions of psychotherapy combined with pharmacotherapy. Methods. Randomized controlled trial comparing two treatment conditions with different psychotherapy dosages in out-patients with major depression. All patients studied had a baseline score of at least 14 points on the 17-item Hamilton Depression Rating Scale (HDRS). The two conditions consisted of 8- or 16-session short psychodynamic supportive psychotherapy, both in combination with pharmacotherapy. Efficacy was assessed using the 17-item HDRS, the clinical global impression of severity and of improvement, the depression subscale of the Ninety Symptom Checklist, the Quality of Life Depression Scale, and the Groningen Social Disability Schedule. Results. Social functioning improved significantly in both groups. No significant differences were found between 8 and 16 sessions with regard to social functioning. A significant advantage is found for patients in remission on 5 of the 11 dimensions in social functioning over patients not in remission. Conclusions. At the end of treatment, no clear differences are found between 8 or 16 sessions of psychotherapy - both combined with pharmacotherapy - with regard to severity of depression and social functioning. It is thus still unknown if patients with major depression show more improvement in social functioning and less symptoms of depression after 16 sessions of combined therapy than after 8 sessions. Currently, it seems that for major depression 8 sessions of combined therapy are equally effective as 16 sessions. [ABSTRACT FROM AUTHOR]

To identify which patient groups can be safely discharged early after high dose chemotherapy. Until recently, the standard of care for patients with haematological malignancies who have been treated with high dose chemotherapy has been to hospitalise them until neutrophil recovery and clinical improvement. Over the past years, a more liberal approach has resulted in a tendency to discharge patients earlier. However, currently it is unclear which clinical variables are important and which patient groups are most suitable to be discharged early. Prospective cohort study. The study group of 55 patients underwent 82 admission periods for a total of 2269 patient days, which could be classified into four categories: induction treatment, consolidation treatment and autologous or allogeneic stem cell transplantation. Different clinical variables potentially interfering with early discharge were subsequently analysed for their association with each treatment group. The median duration of admission was 27 days. The incidence of fever (82·9%) and use of intravenous antibiotics (79·3%) was high in all treatment groups. The only statistically significant differences between groups were found for performance status and mucositis. In the patient group undergoing consolidation chemotherapy for acute myeloid leukaemia, the performance status was better and mucositis was less severe. The decline in performance status and the severity of mucositis were as expected most obvious 10-14 days after the start of chemotherapy. Patients undergoing consolidation chemotherapy appear to be the most suitable candidates for early discharge, especially in the first-week postchemotherapy treatment. Early discharge can also be considered in patients with a good performance status in the autologous stem cell transplantation group, directly after transplantation. An important factor in developing an early discharge programme is a good infrastructure, both at home and in the hospital. [ABSTRACT FROM AUTHOR]

The large variation in the relationships between environmental factors and plant traits observed in natural communities exemplifies the alternative solutions that plants have developed in response to the same environmental limitations. Qualitative attributes, such as growth form, woodiness, and leaf habit can be used to approximate these alternative solutions. Here, we quantified the extent to which these attributes affect leaf trait values at a given, resource supply level, using measured plant traits from 105 different species (254 observations) distributed across 50 sites in mesic to wet plant communities in The Netherlands. For each site, soil, total N, soil total P, and water supply estimates were obtained by field measurements and modeling. Effects of growth forms, woodiness, and leaf habit on relations between leaf traits (SLA, specific leaf area; LNC, leaf nitrogen concentration; and LPC, leaf phosphorus concentration) vs. nutrient and water supply were quantified using maximum-likelihood methods and Bonferroni post hoc tests. The qualitative attributes explained 8-23% of the variance within sites in leaf traits vs. soil fertility relationships, and therefore they can potentially be used to make better predictions of global patterns of leaf traits in relation to nutrient supply. However, at a given soil fertility, the strength of the effect of each qualitative attribute was not the same for all leaf traits. These differences may imply a differential regulation of the leaf economy traits at a given nutrient supply, in which SLA and LPC seem to be regulated in accordance to changes in plant size and architecture while LNC seems to be primarily regulated at the leaf level by factors related to leaf longevity. [ABSTRACT FROM AUTHOR]

In ecology, strategy schemes based on propositions about the selection of plant attributes are common, but quantification of such schemes in relation to nutrient and water supply is lacking. Through structural equation modeling, we tested whether plant strategies related to nutrient and water/oxygen supply are reflected in a coordination of traits in natural communities. Structural equation models, based on accepted ecological concepts, were tested with measured plant traits of 105 different species across 50 sites in mesic to wet plant communities in the Netherlands. For each site, nutrient and water supply were measured and modeled. Hypothesized cultivariate strategy models only partly reflected current theoretical schemes. Alternative models were consistent, showing that lack of consistency of the original models was because of (i) strong correlations among traits that supposedly belong to different strategy components; (ii) poor understanding of mechanisms determining the covariation of plant maximum height, leaf size, and stem density; and (iii) lack of integrative and long-term measures of nutrient supply needed to predict coordinated plant trait responses. Our main conclusion is that a combination of trade-offs (partly) across different plant organs and diverging effects of resource supply ultimately determines the coordination of plant traits needed to "make a living." [ABSTRACT FROM AUTHOR]

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Question: Is it possible to improve the general applicability and significance of empirical relationships between abiotic conditions and vegetation by harmonization of temporal data? Location: The Netherlands. Methods: Three datasets of vegetation, recorded after periods with different meteorological conditions, were used to analyze relationships between soil moisture regime (expressed by the mean spring groundwater level - MSLt calculated for different periods) and vegetation (expressed by the mean indicator value for moisture regime Fm). For each relevé, measured groundwater levels were interpolated and extrapolated to daily values for the period 1970-2000 by means of an impulse- response model. Sigmoid regression lines between MSLt and Fm were determined for each of the three datasets and for the combined dataset. Results: A measurement period of three years resulted in significantly different relationships between Fm and MSL, for the three datasets (F-test, p <0.05). The three regression lines only coincided for the mean spring groundwater level computed over the period 1970-2000 (MSLclimate) and thus provided a general applicable relationship. Precipitation surplus prior to vegetation recordings strongly affected the relationships. Conclusions: Harmonization of time series data (1) eliminates biased measurements, (2) results in generally applicable relationships between abiotic and vegetation characteristics and (3) increases the goodness of fit of these relationships. The presented harmonization procedure can be used to optimize many relationships between soil and vegetation characteristics. [ABSTRACT FROM AUTHOR]

Abstract: This paper reports findings from visits to palliative care settings and research units in the UK, Belgium and the Netherlands. The aim was to learn about clinicians’ (both nurses and doctors) and academic researchers’ understandings and experiences of palliative sedation for managing suffering at the end of life, and their views regarding its clinical, ethical and social implications. The project was linked to two larger studies of technologies used in palliative care. Eleven doctors, 14 nurses and 10 researchers took part in informal interviews. Relevant reports and papers from the academic, clinical and popular press were also collected from the three countries. The study took place in a context in which attention has been drawn towards palliative sedation by the legalisation of euthanasia in the Netherlands and Belgium, and by the re-examination of the legal position on assisted dying in the UK. In this context, palliative sedation has been posited by some as an alternative path of action. We report respondents’ views under four headings: understanding and responding to suffering; the relationship between palliative sedation and euthanasia; palliative sedation and artificial hydration; and risks and uncertainties in the clinician-patient/family relationship. We conclude that the three countries can learn from one another about the difficult issues involved in giving compassionate care to those who are suffering immediately before death. Future research should be directed at enabling dialogue between countries: this has already been shown to open the door to the development of improved palliative care and to enhance respect for the different values and histories in each. [Copyright &y& Elsevier]

Published trends and geographical differences in cryptorchidism rates are almost exclusively derived from hospital-based birth defect registers, which are sensitive to selection bias and incomplete reporting. This study aimed to accurately assess the cryptorchidism prevalence in the general population of Rotterdam. Of 7652 consecutive male live births, 7292 (95%) were examined for cryptorchidism at Child Healthcare Centres around the age of 1 month. In a subgroup of cases, the persistence of cryptorchidism was re-assessed during a follow-up examination by expert specialists. The cryptorchidism rate at the median age of 35 days was 1.2% (89/7292). In the re-examined subgroup (median age 95 days) 69% of the boys (24/35) had persistent cryptorchidism, of which 20 were unilateral and four bilateral. The population rate of 1.2% falls within the range of 0.9–9% reported by others. Differences in case ascertainment and population characteristics probably explain part of the differences between studies. Our cross-sectional design does not allow for analysis of a temporal trend, but provides a baseline for future trend studies. To study cryptorchidism rates, trends, and risk factors, a systematic case ascertainment is warranted. [ABSTRACT FROM AUTHOR]

Abstract Objective: To test the hypothesis that the use of an automated external defibrillator by police and fire fighters results in higher discharge rates for out of hospital cardiac arrest. Design: Controlled clinical trial with initial random allocation of automated external defibrillators to first responders in four of the eight participating regions; each region switched from control to experimental, and vice versa, every four months. Setting: Amsterdam and surroundings, the Netherlands. Participants: Patients with witnessed out of hospital cardiac arrests, identified by the emergency medical system between January 2000 and January 2002. Main outcomes measures: Survival to hospital discharge; return of spontaneous circulation; admission to hospital. Results: 243 patients (65% in ventricular fibrillation) were included in the experimental area and 226 patients (67% in ventricular fibrillation) in the control area. The median time interval between collapse and first shock was 668 seconds in the experimental area and 769 seconds in the control area (P < 0.001). 44 (18%) patients in the experimental area versus 33 (15%) patients in the control area were discharged (odds ratio 1.3 (95% confidence interval 0.8 to 2.2), P = 0.33), 139 (57%) experimental versus 108 (48%) control patients had return of spontaneous circulation (1.5 (1.0 to 2.2), P = 0.05), and 103 (42%) experimental versus 74 (33%) control patients were admitted (1.5 (1.1 to 1.6), P = 0.02). The median delay from receipt of call to dispatch of the ambulance was 120 seconds, and the delay to dispatch of the first responder was 180 seconds. Conclusions: Use of automated external defibrillators by first responders did not significantly increase survival to discharge from hospital, although it did improve return of spontaneous circulation and admission to hospital. Improved dispatch procedures should increase the success of programmes of first responders using external defibrillators. [ABSTRACT FROM AUTHOR]

E-business is a concept that has been given many definitions in practice and in the literature. In general, e-business is used for improving the efficiency of established supply chains or for the creation of new (dynamic) supply chain networks with looser partnerships. However, because of this diversity in meanings the evaluation of the usefulness of a certain type of e-business for a specific supply chain situation is often indistinct. Based on a review of 16 prevailing electronic business-to-business initiatives in (mainly Dutch) food supply chains, this paper defines and develops a typology of e-business models to elucidate these discussions. The paper is concluded with proposed classifications and developments of e-business in food supply chains. [ABSTRACT FROM AUTHOR]

Dutch euthanasia and physician-assisted suicide stand on the eve of important legal changes. In the summer of 1999, a new government bill concerning euthanasia and physician-assisted suicide was sent to Parliament for discussion. This bill legally embodies a ground for exemption from punishment for physicians who conduct euthanasia or physician-assisted suicide and comply with certain requirements. On November 28, 2000, the Dutch parliament approved an adapted version of this bill. Since the approval by the Dutch Senate can be regarded as a formality, it is expected that the bill will come into force in the course of this year (2001). In this paper we discuss these new developments. [ABSTRACT FROM AUTHOR]

This contribution is a report of a two months' participant observation in a Dutch hospice. The goal of the observation was to gain an overview of moral decisions in a hospice in which euthanasia, a tolerated practice in the Netherlands, is not accepted as an option. In an introduction, the development of palliative care in the Netherlands will be briefly presented. Subsequently, various moral decisions that were taken during the participant observation are presented and analysed by means of case reports. Attention is especially drawn to decisions that directly or indirectly relate to euthanasia. These moral decisions will be clarified in the light of the philosophy behind the concept of palliative care as it has evolved since the foundation of St Christopher's Hospice, London in 1967. [ABSTRACT FROM AUTHOR]

The study examines the meaning of procedural justice to Dutch victims of crime. Using victimological research and the group-value or relational model or procedural justice developed by Lind and Tyler, a model for procedural justice judgments is developed and tested using the structural equation model Data used for the analysis consist of 221 interviews with victims regarding their experience with the police and 111 interviews with victims concerning their experience with the public prosecution. Although the emerging model differs from that of Lind and Tyler, results support Lind and Tyler's assertion that procedural justice judgments are normative and not instrumental Victims are particularly concerned about being treated with dignity and respect and are not interested in influencing the outcome of their case. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with hospitalized older adults.

Background: Extramuralisation in healthcare has influenced medical and nursing curricula internationally with the incorporation of themes related to primary/ community care. Despite this, students do not easily change their career preferences. The hospital is still favourite, leading to labour market shortages in extramural care. This study investigates how baccalaureate nursing students' perceptions of community care and placement preferences develop over time in a more 'community-care-oriented' curriculum, to gain insights on which curriculum elements potentially influence career choices. Methods: A nursing student cohort of a University of Applied Sciences in the Netherlands (n = 273) underwent a new four-year curriculum containing extended elements of community care. The primary outcome was assessed with the Scale on Community Care Perceptions (SCOPE). Data were collected each year of study. Descriptive statistics were used to investigate students' placement preferences and perceptions, and linear mixed model techniques (LMMs) for measuring how students' perceptions develop over time. Patterns of placement preferences at individual level were visualised. Results: Students' perceptions of community care, as measured with SCOPE, show a slight decrease between year 1 and 4, while items mutually differ substantially. In contrast, the preference of community care for a placement increases from 2.6% in year 1 tot 8.2% in year 4. The hospital is favourite in year 1 (79.8%), and remains most popular. At individual level, students often change placement preferences, although a preference for the hospital is more consistent. The LMMs indicates that, at the four time-points, the estimated marginal means of students' perceptions fluctuate between 6 and 7 (range 1–10). A placement in community care did not positively influence students' perceptions, and an intensive 1 week theoretical programme was only temporarily influential. Conclusions: Although interest for placement in community care increased substantially, it was not clear which curriculum elements stimulated this, nor did the curriculum positively influence students' perceptions. As most students do not look forward to the high responsibility of the field, other curricula with educational tracks for more mature students/ nurses with a vocational training may be an alternative contribution to solving the labour market problems in community care. [ABSTRACT FROM AUTHOR]

Background: The shift in healthcare to extramural leads to more patients with complex health problems receiving nursing care at home. However, the interest of baccalaureate nursing students for community nursing is moderate, which contributes to widespread labour-market shortages. This study investigates the effect of a more 'community-care-oriented' curriculum on nursing students' perceptions of community care. Methods: A quasi-experimental quantitative survey study with a historic control group (n = 477; study cohorts graduating in 2015, 2016, and 2017; response rate 90%) and an intervention group (n = 170; graduating in 2018; response rate 93%) was performed in nursing students of a University of Applied Sciences in a large city in the Netherlands. The intervention group underwent a new curriculum containing extended elements of community care. The primary outcome was assessed with the Scale on Community Care Perceptions (SCOPE). The control and intervention group were compared on demographics, placement preferences and perceptions with a chi-square or T-test. Multiple regression was used to investigate the effect of the curriculum-redesign on nursing students' perceptions of community care. Results: The comparison between the control and intervention group on students' perceptions of community care shows no significant differences (mean 6.18 vs 6.21 [range 1–10], respectively), nor does the curriculum-redesign have a positive effect on students' perceptions F (1,635) =.021, p =.884, R2 = <.001. The comparison on placement preferences also shows no significant differences and confirms the hospital's popularity (72.7% vs 76.5%, respectively) while community care is less often preferred (9.2% vs 8.2%, respectively). The demographics 'working in community care' and 'belonging to a church/religious group' appear to be significant predictors of more positive perceptions of community care. Conclusions: Graduating students who experienced a more 'community-care-oriented' curriculum did not more often prefer community care placement, nor did their perceptions of community care change. Apparently, four years of education and placement experiences have only little impact and students' perceptions are relatively static. It would be worth a try to conduct a large-scale approach in combination with a carefully thought out strategy, based on and tying in with the language and culture of younger people. [ABSTRACT FROM AUTHOR]

This paper (re)considers the question if chronic and diffuse heavy metal pollution (cadmium, copper, lead and zinc) affects the structure and functioning of terrestrial ecosystems of Biesbosch National Park, the floodplain area of rivers Meuse and Rhine. To reach this aim, we integrated the results of three projects on: 1. the origin, transfer and effects of heavy metals in a soil–plant–snail food chain; 2. the impact of bioavailability on effects of heavy metals on the structure and functioning of detritivorous communities; 3. the risk assessment of heavy metals for an herbivorous and a carnivorous small mammal food chain. Metal pollution levels of the Biesbosch floodplain soils are high. The bioavailability of metals in the soils is low, causing low metal levels in plant leaves. Despite this, metal concentrations in soil dwelling detritivores and in land snails at polluted locations are elevated in comparison to animals from ‘non-polluted’ reference sites. However, no adverse effects on ecosystem structure (species richness, density, biomass) and functioning (litter decomposition, leaf consumption, reproduction) have been found. Sediment metal pollution may pose a risk to the carnivorous small mammal food chain, in which earthworms with elevated metal concentrations are eaten by the common shrew. Additional measurements near an active metal smelter, however, show reduced leaf consumption rates and reduced reproduction by terrestrial snails, reflecting elevated metal bioavailability at this site. Since future management may also comprise reintroduction of tidal action in the Biesbosch area, changes in metal bioavailability, and as a consequence future ecosystem effects, cannot be excluded. [Copyright &y& Elsevier]

Site characterization is key for seismic hazard analysis and risk mitigation but to obtain the subsurface properties is often a challenge. Over the last decades, increasing numbers of induced seismic events caused by gas production triggered the research on seismicity and site response in Groningen, the Netherlands. Waves are amplified within an approximately 800 m thick blanket of unconsolidated sediments at the surface. We have used both the ambient field and teleseismic arrivals to determine shear velocity profiles for this top soft sedimentary layer. Local shear wave velocity profiles are retrieved from H/V ratios of strong teleseismic events at 70 stations, each equipped with 1 accelerometer at the surface and 4 geophones at 50m depth intervals down to 200m. Using an existing shear velocity model for the top 200 meters, the body-wave H/V ratios are used to invert for the lower 600 meters of the soft sediments. Two borehole log datasets are used for calibration. From ambient noise data, we compute the probability density functions of the H/V ratios. Doing this for one month of data, results in stable mean H/V ratios. Based on the body- and surface wave forward modeling we find that the ambient field between 0.1 and 0.25 Hz is dominated by body waves, while at frequencies between 0.25 and 1.0 Hz, the higher mode Rayleigh waves are dominant. With this interpretation, a close relationship is observed between the H/V spectral ratios from the ambient field, S-wave resonance frequencies and the ellipticities of the Rayleigh waves. Furthermore, the good consistency between the earthquake and noise based models do confirm the robustness of the derived shear wave velocity profiles. The power of this study is the combination of body-and surface wave H/V ratios retrieved from multiple H/V approaches and the possibility to quality check the velocity profiles. These methods allow evaluation of the ambient seismic field. Furthermore, additional shallow impedance contrasts are determined. Such contrasts can cause additional wave amplification, which is important to take into account in site response modeling. [ABSTRACT FROM AUTHOR]

Abstract: Background: Tyrosine kinase inhibitors treatment in responding chronic myeloid leukaemia (CML) patients is generally continued indefinitely. In this randomised phase II trial, we investigated whether CML patients in molecular response4.5 (MR4.5, quantitative reverse-transcription polymerase chain reaction (RQ-PCR)) after previous combination therapy with imatinib and cytarabine may discontinue imatinib treatment safely. Patients and methods: Thirty-three patients from the HOVON 51 study with an MR4.5 for at least 2 years who were still on imatinib treatment were randomised between continuation of imatinib (arm A, n =18) or discontinuation of imatinib (arm B, n =15). Results: After a median follow up of 36 months since randomisation, 3 patients (17%) in arm A and 10 patients (67%) in arm B had a molecular relapse. All 3 relapsing patients in arm A had also stopped imatinib after randomisation. All but one relapsing patient relapsed within 7 months after discontinuation of imatinib. The molecular relapse rate at 12 and 24 months after randomisation was 0% and 6% (arm A) and 53% and 67% (arm B) respectively. As-treated analysis revealed 56% and 61% relapses at 1 and 2 years since cessation in patients who discontinued imatinib, in contrast to 0% of patients who continued imatinib. All evaluable patients remained sensitive to imatinib after reinitiation and regained a molecular response. Conclusion: Our data suggest that discontinuation of imatinib is safe in patients with durable MR4.5. [Copyright &y& Elsevier]

Abstract: The objective of this study was to compare the quick-and-easy undernutrition screening tools, ie, Short Nutritional Assessment Questionnaire and Malnutrition Universal Screening Tool, in patients undergoing cardiac surgery with respect to their accuracy in detecting undernutrition measured by a low-fat free mass index (FFMI; calculated as kg/m2), and secondly, to assess their association with postoperative adverse outcomes. Between February 2008 and December 2009, a single-center observational cohort study was performed (n=325). A low FFMI was set at ≤14.6 in women and ≤16.7 in men measured using bioelectrical impedance spectroscopy. To compare the accuracy of the Malnutrition Universal Screening Tool and Short Nutritional Assessment Questionnaire in detecting low FFMI sensitivity, specificity, and other accuracy test characteristics were calculated. The associations between the Malnutrition Universal Screening Tool and Short Nutritional Assessment Questionnaire and adverse outcomes were analyzed using logistic regression analyses with odds ratios and 95% confidence intervals (CI) presented. Sensitivity and receiver operator characteristic-based area under the curve to detect low FFMI were 59% and 19%, and 0.71 (95% CI: 0.60 to 0.82) and 0.56 (95% CI: 0.44 to 0.68) for the Malnutrition Universal Screening Tool and Short Nutritional Assessment Questionnaire, respectively. Accuracy of the Malnutrition Universal Screening Tool improved when age and sex were added to the nutritional screening process (sensitivity 74%, area under the curve: 0.72 [95% CI: 0.62 to 0.82]). This modified version of the Malnutrition Universal Screening Tool, but not the original Malnutrition Universal Screening Tool or Short Nutritional Assessment Questionnaire, was associated with prolonged intensive care unit and hospital stay (odds ratio: 2.1, 95% CI: 1.3 to 3.4; odds ratio: 1.6, 95% CI: 1.0 to 2.7). The accuracy to detect a low FFMI was considerably higher for the Malnutrition Universal Screening Tool than for the Short Nutritional Assessment Questionnaire, although still marginal. Further research to evaluate the modified version of the Malnutrition Universal Screening Tool, ie, the cardiac surgery–specific Malnutrition Universal Screening Tool, is needed prior to implementing. [Copyright &y& Elsevier]

This prospective cohort study evaluated the impact of the time-related elements of the “chain of survival” on the quality of life of patients, taking their characteristics into account. Between 1995 and 2002, consecutive, out-of-hospital cardiac arrest patients from Amsterdam and the surrounding areas were included in this study. A total of 227 patients (12%) survived to hospital discharge and 174 were definitive survivors who were available for assessment at 6 months. Quality of life was measured with the 136-item Sickness Impact Profile (SIP); cognitive functioning was assessed through the Mini Mental State Examination. SIP profiles were compared with profiles of an open Dutch population of the elderly and patients who experienced a stroke. Time intervals of the chain of survival were calculated from the estimated moment of collapse and related to outcome using regression analysis. The SIP profile of survivors was a little above the reference profile, indicating a slightly poorer quality of life, and below the profile of patients after stroke, indicating a better quality of life. Impaired cognitive function was associated with delay in the start of cardiopulmonary resuscitation (odds ratio 4.3, 95% confidence interval 1.0 to 19). Absence of the need for advanced cardiopulmonary life support was associated with better cognitive functioning (odds ratio 0.3, 95% confidence interval 0.1 to 0.9). Female gender and older age were associated with impaired physical functioning. Trends were found for better outcomes after early access, immediate resuscitation, early defibrillation, and early advanced care. [Copyright &y& Elsevier]