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Emergency department cesarean section for placental abruption is an uncommon surgical procedure that requires anticipation in the prehospital environment as well as preemptive recognition of impending fetal demise by the emergency physician. The presence of an obstetrician ready to perform immediate cesarean section on an unstable patient with placental abruption may be lifesaving for both the mother and the fetus. However, there are no specific guidelines for prehospital recognition of patients with placental abruption that require emergency cesarean section. While the emergency department is not the optimum surgical theatre for an emergency cesarean section, placental abruption often deteriorates so quickly that even a few minutes of delay can have catastrophic consequences for both mother and fetus. We describe a case of placental abruption following moderate motor vehicular trauma in an eight month pregnant woman whose only complaint was moderate abdominal pain. The emergency physician’s suspicion based on the mechanism of injury caused her to mobilize the obstetrician, who was ready to perform an emergency department cesarean section with successful delivery of the fetus. Subsequent managing of the mother’s surgical incision and coagulopathy was performed in the operating room. This case highlights the importance of vigilance that prehospital providers, emergency department physicians, and obstetricians should have for a pregnant patient involved in a motor vehicle crash.

Mental health is a fundamental component of good health. The World Health Organization (WHO) defines mental health as ‘a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’. Consequently, mental health problems range from the worries we all experience as part of everyday life to serious long-term conditions. The WHO pyramid Framework for mental health1 pleads for a comprehensive care offer and continuity of care. From a policy viewpoint every government needs to evaluate whether its mental health care system is effective and efficient and provides easy access for every civilian. Also for Belgium this exercise is important, especially in the light of recent social and political phenomena. In past decades the organisation of mental health care in Belgium underwent several reform waves with the main aim to further orient mental health care towards a reduction of residential hospital care in favour of recovery and reintegration treatment in the community. In order to attaint this objective, policies to promote five core foundations (i.e. deinstitutionalisation, inclusion, decategorisation, intensification, and consolidation)2 were developed. In 2016, the inter-cabinet working group (IKW – GTI) ‘task force on Mental Health care’ asked the KCE to look at the provision of mental health care services and the needs of the population. The current study focused on an in-depth analysis of the organisation of mental health services in Belgium with a need to clearly visualize the present care offer and to evaluate the organisation and continuity of care for the future decade. The objective of this study was to describe the Belgian mental health care offer in order to take into account possible gaps and overlaps between existing services and to assess the Belgian landscape against internationally defined frameworks. The results of this report should assist policy-makers in setting priorities and making strategic decisions regarding the organisation of mental health care. The study gives an overview of the Belgian mental health care landscape for adults including: (1) the care offer (the different organisations and service providers), (2) the identification of gaps and overlaps between service providers and how they may affect the five core foundations of the mental health care reform, 3) benchmark the Belgian situation in relation to the internationally developed frameworks for the provision of mental health care services for adults, and 4) the acceptability of future organisational measures/changes

In uitvoering van de Kaderrichtlijn Water bereidt de Coördinatiecommissie Integraal Waterbeleid het tweede stroomgebiedbeheerplan voor. In functie daarvan werden voor de Vlaamse overgangswateren en zoetwatergetijdenwateren maatlatten opgesteld voor de biologische kwaliteitselementen en voor hydromorfologie. In dit advies worden de Ecologische Kwaliteitscoëfficiënten ‘Hydromorfologie’ en ‘Macrobenthos’ berekend voor een aantal waterlichamen van de Zeeschelde en wordt de Ecologische Kwaliteitscoëfficiënt ‘Hydromorfologie’ berekend voor het waterlichaam ‘Havengeul IJzer’. In uitvoering van de Kaderrichtlijn Water bereidt de Coördinatiecommissie Integraal Waterbeleid het tweede stroomgebiedbeheerplan voor. In functie daarvan werden voor de Vlaamse overgangswateren en zoetwatergetijdenwateren maatlatten opgesteld voor de biologische kwaliteitselementen en voor hydromorfologie. In dit advies worden de Ecologische Kwaliteitscoëfficiënten ‘Hydromorfologie’ en ‘Macrobenthos’ berekend voor een aantal waterlichamen van de Zeeschelde en wordt de Ecologische Kwaliteitscoëfficiënt ‘Hydromorfologie’ berekend voor het waterlichaam ‘Havengeul IJzer’.

The European Water Framework Directive came into effect December 2000 in all member states. According to this directive, all European waters should reach ‘good status’ by the end of 2015. In order to assess the ecological status of their surface waters, member states have to act in concordance to a well-established step-wise plan and have to develop monitoring programs and valuation systems for a number of biological quality elements, which have been specified for each water category.This report deals with step 3 (delimitation of a reference) and step 4 (development of a score system). Subsequently, the ecological status is assessed. Assessed biological quality elements are phytoplankton, other aquatic flora, benthic invertebrates and fish. Hydromorphological status, as a supporting element for the biological quality elements, isalso assessed. Earlier studies served as a baseline to extend this research to all Flemish transitional water bodies within the Schelde basin (Van Damme et al., 2003; Brys et al., 2005) and results and insights gained from the conservations goals for the estuary where used (Adriaensen et al, 2005). While this report primarily deals with the tidal tributaries of the Zeeschelde (Flemish part of the Schelde River that has tidal regime), we tried to fill the gaps left by Brys et al. (2005), in order to obtain a comprehensive view at the entire estuary.All Flemish transitional waters have been identified as heavily modified water bodies. Therefore, maximum and good ecological potential (MEP/GEP) set the reference goals, not pristine conditions. These MEP and GEP were defined from an ecosystem perspective as an optimal functioning estuarine ecosystem. Thus, the ecological potential is conceived as the potential for natural physical, chemical and biological processes to deploy as good as possible within certain (achievable) boundaries. Attaining this potential requires an approach that surpasses the local level and individual quality elements. Therefore, an integrated, hierarchical and scale-dependent approach was chosen to establish the reference framework, including essential habitat characteristics besides the biological quality elements.At the ecosystem level, habitat area was considered, as it is a parameter relevant to all biological quality elements. Surface area of salt marsh, mudflat and shallow subtidal is also used to assess the hydromorphological status of the transitional waters. To obtain the MEP, a hydromorphological approach was used. Threshold band width was calculated as a quantifier for the space that is needed to maintain typical estuarine habitats (mudflats, salt marshes and shallow subtidal areas) in a sustainable and dynamic equilibrium of sedimentation and erosion. Along the estuary, this ‘equilibrium band width’ is proportional to the elevation range difference between the channel bottom and the mean high tide level (MHW) and the mean highest high water level (MHHW). The GEP for mudflats and salt marshes originates from the conservations goals set for the Schelde estuary: the minimum surface area of mudflat providing sufficient carrying capacity for macrobenthos, serving as (sufficient) food source for fish and birds (given good water quality). Salt marshes act as a source of dissolved silica. The minimal area of salt marshes, needed to provide sufficient amounts of silica for primary production of diatoms, is used to calculate the GEP for these marshes. The Zeeschelde and her tidal tributaries are, as a single ecosystem, in poor status, regarding the hydromorphological conditions. Dijle, Zenne, Getijdenetes and the upper Zeeschelde (Zeeschelde I) are in bad hydromorphological status. Zeeschelde II,III and Durme are also of poor status and Zeeschelde IV is in moderate status.To assess the phytoplankton of Durme and Rupel, the Flemish metric was used (Van Damme et al., 2003; Brys et al., 2005; Van Wichelen et al., 2005): chlorophyl a-concentration linked to the broader context of light climate, nutrient cycling and run-off time. The other tributaries were assessed by means of a German method (Mischke & Behrendt, 2007) comprising submetrics for phytoplankton biomass and species composition. Durme and Rupel were classified as ‘bad’, Dijle and Zenne as ‘moderate’ and the Getijdenetes as ‘good’.The macrobenthos metric consists of parameters at two scale levels:- habitat level: mudflat and shallow subtidal area- community level: application and evaluation of a number of available methods (AeTV, Dutch method, IOBS)These submetrics are subsequently integrated into a single indicator value (score). All fresh Schelde water bodies were scored ‘bad’.The macrophyte metric contains three levels:- ecosystem level: total salt marsh area- water body level: total salt marsh area and average quality of indivual marshes per water body- individual marsh level: (i) current area versus desired area (GEP) required for a sustainable development and conservation of the existing salt marshes, (ii) vegetation diversity, (iii) species richness and (iv) floristic quality index (FQI).These submetrics are subsequently integrated into a single indicator value (score), whereas the submetric values allow specific identification of bottlenecks and mitigating measures. The tributary macrophytes are scored as ‘poor’ or ‘bad’.In the fish assessment, species were selected per water body based on their discriminating power. According to their ecological demands, these species were grouped into guilds. From these guilds, relevant metrics were selected, based on their sensitivity towards anthropogenic pressures. Determination of class boundary values is based on the GEP reference list, providing the number of species per guild (metric). This number was used within each zone in order to calculate the maximum number of species and relative percentage in the total number of species for the selected guilds. Validation of the new index was based on catch data. The obtained score for the fish fauna within the studied tidal water bodies ranged from ‘bad to ‘poor’.Applying the WFD principle ‘one out, all out’, all of the 7 tidal water bodies of the Zeeschelde basin scored ‘bad’. Improvement is possible by means environmental measures which improve water and soil quality, as well as measures that provide sufficient amounts of space to the estuary, in order to allow natural functions and processes to develop naturally. Analysis of the impact of execution of the Most Desirable Alternative of the updated Sigma Plan, shows clear improvement for almost all of the considered water bodies and 3 of those 7 would rise above the GEP level boundary for the habitat area parameter.

Population dynamics and zonation of the amphipods Bathyporeia pilosa and B. sarsi, co-occurring on some beaches, were studied through monthly sampling of eight cross-shore transects along the Belgian coast (October 2003-October 2004). Their biomass and production were assessed for the first time. Abundance and biomass of B. pilosa were ten times higher along western ultra-dissipative transects than along slightly more reflective, eastern transects. For B. sarsi (less prominent), differences between the two westernmost transects (2-5x higher) and all others were observed, whereas P/B ratio was comparable for all. B. pilosa could reach two times higher abundance and biomass and higher levels of production (max B. sarsi = 7,580 g m-2 y-1; max B. pilosa = 16,040 g m-2 y-1), while the species was nearly absent from the eastern transects. Continuous reproduction and recruitment with three relative peaks of the latter (February, July, October) were observed. Fecundity showed parallel temporal variation for both species, peaking in February and September-October. Interestingly, the July relative "recruitment" peak could not be explained by relative abundance of gravid females or fecundity, but was probably caused by adult mortality. Both species displayed comparable gonad production (B. pilosa: Pg = 0.73 mg/ind year; B. sarsi: Pg = 0.71 mg/ind year), but B. pilosa produced fewer yet larger embryos. Peak abundances were found at 436 +/- 25 SD cm (B. pilosa) and 357 +/- 40 SD cm (B. sarsi) above MLLWS, corresponding to a 40-62 m cross-shore distance between the peaks of both species. The occupied cross-shore range was larger for B. sarsi than for B. pilosa (35-54 m), for females than for males (15-23 m), and for adults than for juveniles of B. pilosa (5-8 m). Both species displayed many comparable life history features. Differences in abundance and biomass may be related to beach morphodynamics and zonation.

This paper provides a comprehensive overview of the available knowledge on sedimentology and hydrodynamics and five major ecosystem components - microphytobenthos, vascular plants, terrestrial arthropods, zoobenthos (macrobenthos, meiobenthos, hyperbenthos and epibenthos) and avifauna - of Belgian sandy beaches (from foredunes to foreshore). An ecosystem overview is presented for this specific geographically delimited shoreline, instead of dealing with a single component only. Belgian beaches are (ultra-)dissipative, macrotidal and wide beaches with a cross-shore average median grain size of 160-380 μm. Sediment becomes coarser, slopes steeper, tidal range smaller towards the east. Especially eastern beaches have been reshaped frequently through human action (e.g. beach nourishment). Belgian beaches are characterised by the presence of highly adapted organisms. It is demonstrated that even a highly recreational and heavily populated coastline like the Belgian coast provides valuable yet threatened habitats to several beach-dependent species, which may reach high numbers. Vascular plants of the drift line, dry beach and embryonic dunes are mostly short-lived and thalassochorous. Most common species are sea rocket (Cakile maritima), prickly saltwort (Salsola kali subsp. kali) and sea sandwort (Honckenya peploides). Terrestrial arthropods inhabiting the same general area are highly diverse, comprising halobiontic, halophilous and haloxene species. Prominent members of this fauna are sandhopper (Talitrus saltator) and dipterans (flies). Microphytobenthos is an important primary producer on Belgian beaches, mainly consisting of diatoms. Very little is known about this group of organisms. Belgian beaches also have a specific zoobenthic fauna in both meiofauna and macrofauna, e.g. the typical upper intertidal Scolelepis squamata-Eurydice pulchra community. Also epi- and hyperbenthic animals depend on the beach, e.g. as nursery grounds. Nowadays no nesting of birds occurs on the beach itself. Nevertheless, Belgian beaches are important for resting and foraging (e.g. sanderling Calidris alba). Little is know about biological interactions on Belgian beaches. Human actions associated with several aspects of recreation, beach management and fisheries, are endangering all the discussed biota, and are specified.

To address their role in promoting and/or maintaining observed cross-shore segregation of the co-occurring amphipods Bathyporeia pilosa and B. sarsi, sediment preferences and tolerances were investigated through lab experiments. Preferences were investigated in both allotopic and syntopic conditions, in order to investigate possible avoidance (as a proxy for interspecific competition). Selection of grain size showed no significant differences between the species, nor did the presence of the other species affect the selection. Both species avoided the finest (63-125 μm) and coarsest (>500 μm) grain sizes. Potential niche width with regard to grain size, as established from our experiments, was larger than the occupied width, as observed from field data. Selection of level of fines did not show any difference between species or condition (allo- vs. syntopy) either, while the highest abundance of B. pilosa occurred in 5% fines, whereas that of B. sarsi occurred in the absence of fines. Mortality of animals forced to survive in a single given sediment, was significantly higher in B. sarsi and both species had low mortality levels at a grain size best resembling natural beach sediment (255-350 μm). Thus, whereas preferences of both species are largely comparable, tolerances are not. Conclusively, no clear evidence for interspecific competition could be found, disallowing full explanation of observed segregation. Other possibly determining (abiotic and biotic) factors should be investigated to understand cross-shore segregation, as observed in these closely related yet coexisting species of sandy beach macrofauna.

Nowadays, beach nourishment is widely considered as a better alternative than the construction of hard structures to protect a coast against detrimental erosive effects, both from an ecological as from an engineering perspective. Most studies conducted on the ecological impact of beach nourishment are short-term, post hoc monitoring investigations of the benthic macrofauna. Little is known of the ruling biological processes during and after nourishment. To allow recolonisation after nourishment, habitat demands will have to match the characteristics of the nourished beach. The benthic habitat of the intertidal key polychaete Scolelepis squamata was investigated through lab experiments and field data analysis, aiming at guidelines for impact mitigation of beach nourishment. Survival, feeding frequency, burrowing time and grain size selection were investigated to assess tolerance and preference for sediment types varying in median grain size. Remarkable preference for very coarse sands contrasted with longer burrowing time. Feeding frequency was higher in coarser sands. Survival was total in all but very fine sands, where total mortality was observed. Data from five beaches were used to model Scolelepis abundance based on three environmental variables (elevation, median grain size and slope). Slope did not contribute significantly to any model. The selected model used median grain size, elevation and a second degree term of the latter. The degree of overdispersion remained large across models. Experimentally observed grain size preference seems to conflict with in situ distribution. High levels of overdispersion in our field data analysis suggest other additional factors (additional physical variables, interspecific and intraspecific interactions) determine Scolelepis abundance and post-nourishment recovery. For swift recolonisation of nourished beaches, we advocate nourishment to be executed in winter by means of foreshore nourishment in sections with alternation of nourished and unnourished stretches of beach. Concerning the fill quality, very fine sands and high concentrations of fines should be avoided, while also very coarse sands may hamper Scolelepis squamata populations. Factors explaining cross-shore and long-shore distribution of the species are still poorly known, as apparent from our field data analysis.

Beach nourishment is a widely applied means for coastal protection in Europe and North America. Nowadays, beach nourishment is widely considered as a better alternative than the construction of hard structures to protect a coast against detrimental erosive effects, both from an ecological as from an engineering perspective. Even though beach nourishment is considered as the more ecologically sound option, this form of beach restoration also brings about sizable changes in the sandy beach ecosystem. Most studies conducted on the ecological impact of beach nourishment are short-term, post hoc monitoring investigations of the benthic macrofauna. Little is known of long-term effects, recovery after nourishment, effects of repeated replenishment at the same site (cumulative effects) or what processes are of ecological importance during and after nourishment, to understand recovery. Therefore, little or no effort has been made to facilitate recovery by investigating the ecosystem prior to nourishment and drawing guidelines for impact mitigation. A methodological scheme is developed for pre-impact assessment of the ecological impact of beach nourishment. First, data needs on the physical and biological environment are specified. Secondly, methodological aspects of data collection are presented and a distinction is made between indispensable and less essential types of data. Cost-benefit considerations are made and options to cut costs are raised. Thirdly and finally, we applied the scheme to a case study on the intertidal macrobenthic fauna of Belgian beaches. We selected three key species (Scolelepis squamata, Bathyporeia pilosa and B. sarsi) and conducted field research on their population on Belgian beaches, as well as experiments on their habitat charactertistics. The results from this research allowed drawing guidelines for ecological impact reduction of beach nourishment. For the focal species, nourishment would preferably be executed by foreshore nourishment in winter (December-January). Desirable characteristics of the fill sediment are a good match with the natural sediment and especially low levels of fines. The applied methodology is proposed for use on other species, other ecosystem components and even other impact studies.

This thesis investigates the macrobenthic infauna from Belgian beaches and the impact of beach nourishment on unique sandy beach species of the upper intertidal Scolelepis squamata-Eurydice pulchra community. Whereas diversity and zonation describing research on this community is partially available, population studies of the key species are lacking. Furthermore, a process-directed approach of the impact of beach nourishment is lacking, as most studies present ‘just another case study’, often with methodological imperfections.

Population dynamics and zonation of the amphipods Bathyporeia pilosa and B. sarsi, co-occurring on some Belgian beaches, were studied through monthly sampling of eight cross-shore transects (October 2003-October 2004). Their biomass and production were assessed for the first time. Abundance and biomass of B. pilosa were ten times higher along western ultra-dissipative transects than along slightly more reflective, eastern transects. For B. sarsi, (less prominent) differences between the two westernmost transects (2-5x higher) and all others were observed, whereas P/B ratio was comparable for all. Bathyporeia pilosa could reach two times higher abundance and biomass and higher levels of production (max. B. sarsi = 7580 mg*m-2*y-1; max. B. pilosa = 16040 mg*m-2*y-1), while nearly absent along eastern transects. Continuous reproduction and recruitment with three relative peaks of the latter (February, July, October) were observed. Fecundity showed parallel temporal variation for both species, peaking in February and September-October. Interestingly, the July relative recruitment peak could not be explained by relative abundance of gravid females or fecundity, but is probably caused by adult mortality. Both species displayed comparable gonad production (B. pilosa: Pg = 0.73 mg/ind*year; B. sarsi: Pg = 0.71 mg/ind*year), but B. pilosa produced fewer yet larger embryos. Peak abundances were found at 436 + 25 SD cm (B. pilosa) and 357 + 40 SD cm (B. sarsi) above MLLWS, corresponding to a 40-62 m cross-shore distance between the peaks of both species. The occupied cross-shore range was larger for B. sarsi than for B. pilosa (35-54 m), for females than for males (15-23 m), and for adults than for juveniles of B. pilosa (5-8 m). Both species displayed many comparable life history features. Differences in abundance and biomass may be related to beach morphodynamics and zonation.

Though often regarded as biological deserts, sandy beaches provide a unique habitat for several species. Research was conducted by a consortium of experts with as a first objective to provide an integrated overview of the Belgian beach ecosystem and all its major components. A second objective comprised a review of available literature on the ecological impact of beach nourishment. To meet the first objective, an integrated overview of the Belgian sandy beach ecosystem based on spatial and temporal variation of fauna and flora of 11 sandy beaches is provided. The presented results corroborate the overlooked ecological significance of sandy beaches as a habitat. Besides sedimentology and hydrodynamics, five ecosystem components were taken into account: microphytobenthos, vascular plants, terrestrial arthropods, zoobenthos and avifauna. Nourishment of beaches is a large scale anthropogenic influence on sandy beach ecosystem. Sandy beaches are regarded as systems with a strong resilience towards such impacts. Nevertheless serious (short term) ecological effects can be expected. A review of prior studies indicates that the impact of nourishment is rather case-specific and that it is difficult to draw general conclusions. Short term impact is mostly large due to total mortality of benthic life. It seems very likely that potential recovery from the impact of nourishment will be limited to two essential, species specific pathways: (1) survival by resident organisms and (2) re-colonisation by immigrating individuals, the latter depending on both the dispersal capacities and habitat demands of the organisms. Further research is needed to explore possibilities for reducing detrimental ecological effects. Specific studies are needed towards the survival options, the dispersal capacities and habitat demands of the species present. These should allow for management guidelines to be drawn in terms of preferable nourishment sediment characteristics, timing and practice of the deposition of the sand.

Here we report on the combined observations of 10 years of opportunistic field work conducted during short visits to Sardinia, from 1999 to 2012. A total amount of 433 distribution records of 27 species were collected from 187 different localities covering 52 unique UTM squares. We report species presence in 157 new UTM squares and additionally reconfirm previous reported presence in 150 UTM squares. Overall, we produce a remarkable increase in the knowledge of the Sardinian herpetofauna. Notes and observations on ecology, taxonomy and conservation are provided.

Marine biological valuation provides a comprehensive concept for assessing the intrinsic value of subzones within a study area. This paper gives an update on the concept of marine biological valuation as described by Derous et al. (2007). This concept was based on a literature review of existing ecological valuation criteria and the consensus reached by a discussion group of experts during an international workshop in December 2004. The concept was discussed during an ENCORA-MARBEF workshop in December 2006, which resulted in the fine-tuning of the concept of marine biological valuation, especially with respect to its applicability to marine areas.