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Vincristine induced peripheral neuropathy is the most common type of toxicity in patients using vincrstine. Vincristine is chemotherapeutic agent used in a diverse range of pediatric oncology treatment protocols. In this thesis we take a multidimensional view on the topic of vincristine induced peripheral neuropathy. We describe a validation study reporting on the validity of the Dutch translated version of the pediatric-modified total neuropathy score (ped-mTNS). Furthermore we report on the effects of vincristine induced peripheral neuropathy on quality of life during treatments. This showed that children with cancer and vincrstine induced peripheral neuropathy report a lower quality of life than children with cancer without vincristine induced peripheral neuropathy. Furthermore we report the outcomes of a randomized clinical trial studying the effect of administration duration (push injections versus one-hour infusions) of vincristine on the development of vincristine induced peripheral neuropathy. This trial reported no overall effect, but showed that when vincristine in concomitantly used with azole antifungals (which is generally avoided to their drug-drug interaction leading to an increase in vincristine induced peripheral neuropathy) in case of an invasive fungal infection requiring treatment next to vincristine, one-hour administration resulted in a significant reduced peripheral neuropathy compared to push injections. We also report on the outcomes of pharmacokinetics of vincrstine related to administration duration and describes genetic single nucleotide polymorphisms related to vincristine induced peripheral neuropathy. Finally, we describe the research protocol of an dose escalation trial with close toxicity monitoring in pediatric oncology patients in Kenyan patients.

Bakgrund: Ländryggssmärta är en av de vanligaste typerna av muskuloskeletal smärta och den ledande formen av nedsatt funktion världen över. Styrketräning (ST) är en av de vanligaste formerna av konservativ behandling vid kronisk ospecifik ländryggssmärta (CNSLBP). Det saknas rekommendationer för dosering av ST och effekten av olika doseringar är oklar. Syfte: Syftet med denna systematiska litteraturstudie var att kartlägga rapporterade träningsdoseringar vid CNSLBP samt att jämföra effekten av olika doseringar. Metod: En systematisk granskning av randomiserade kontrollerade studier publicerade de fem senaste åren genomfördes efter sökningar i databaserna MEDLINE, CINAHL och PEDro. En kvalitetsbedömning av studierna genomfördes och träningsdosering av styrketräning som behandling vid CNSLBP kartlades och kategoriserades. I inkluderade studier där liknande träningsupplägg med olika dosering jämförts, utvärderades doseringarnas effekt avseende smärtintensitet och funktion. Resultat: Totalt inkluderades sex artiklar. Risken för systematiska fel bedömdes som genomgående låg till medelhög. Träningsdoseringarna kategoriserades som moderata till medelhöga. Enbart en av de sex inkluderade studierna jämförde olika träningsdosering där komponenten intensitet varierats i två grupper. Högintensiv styrketräning uppvisade signifikanta förbättringar avseende funktion och små ickesignifikanta förbättringar avseende smärtintensitet jämfört med den medelintensiva träningsgruppen. Slutsats: Den här litteraturstudien visade att få studier anger träningsdosering av styrketräning som behandling för patienter med CNSLBP. De kartlagda träningsdoseringarna var moderata till medelhöga och liknar doseringarna som rekommenderas för motionärer. Inga slutsatser kunde dras avseende doseringarnas effekt. Framtida kliniska studier med träning som intervention bör definiera styrketräningsdosering vilket anses relevant för såväl forskare som fysioterapeuter i praktiken. Background: Low back pain is one of the most common musculoskeletal disorders and the leading cause of disability worldwide. Resistance training (RT) is an effective therapeutic modality for the treatment of patients with chronic non-specific low back pain (CNSLBP). However, recommendations of RT dosages is lacking and the effects of different dosages remains unclear. Objective: The objective of this review was to map and evaluate the effectiveness of reported RT dosages for the treatment of CNSLBP. Method: A systematic search for literature was conducted in the databases MEDLINE, CINAHL and PEDro. Dosages were mapped and categorized. Effect sizes of pain intensity and disability were extracted from articles with comparisons between dosages. The risk of bias was judged for the articles, respectively. Results: A total of six articles were included. The dosages were categorized as moderate to medium high. Comparison between dosages was made in one of the included articles. Significant improvements in pain intensity and non-significant improvements in disability in favour of a high intensity group compared to a low intensity training group was found. The risk of bias was consistently judged as low or moderate. Conclusion: This study showed a lack of correctly reported RT dosages. The mapped dosages where corresponding to the recommendations for a healthy population. No conclusions could be drawn upon the effect of different dosages. A clear definition of the RT dosage in future trials is of importance to further investigate the effect of RT as an intervention for the treatment of CNSLBP.

Bakgrund: Skelettscintigrafi är en nuklearmedicinsk undersökning. Undersökningen är den mest använda nukleardiagnostiska metoden och den genomförs ofta som en helkroppsundersökning. För att undersökningen ska kunna erhålla sin diagnostiska kvalitet, samt följa strålsäkerhetsmyndighetens rekommendationer behövs det mer kännedom till hur optimeringen ska följa as low as reasonably achievable (ALARA). Studiens syfte var att optimera patientstråldos samt att undersöka hur injicerad aktivitet kan anpassas efter patientens specifika parametrar. Metod: Studiegruppen bestod av 85 patienter som genomgick skelettscintigrafier vid Central sjukhuset i Karlstad, från perioden februari-april 2020. Resultat: Visade att både ålder och vikt är patientspecifika variabler som borde tas till betraktning vid bestämning av injicerad strålningsdos. Konklusionen: För att optimera undersökningen för varje patient bör injicerad aktivitet anpassas efter både kroppsvikt och ålder. Fler studier där andra parametrar undersöks måste genomföras., Background: Bone scintigraphy is a nuclear medicine procedure. It is the most used nuclear diagnostic method and provides the opportunity to perform a full-body examination. For the method to retain its diagnostic quality, and to follow the recommendations of the Radiation Safety Authority, more knowledge is required on how the optimization should follow as low as reasonably achievable (ALARA). The purpose of the study was to optimize patient radiation dose and to investigate how the injected activity can be adapted to patient-specific parameters. Method: The study group consisted of 85 patients who underwent bone scintigraphy at the Central Hospital in Karlstad, from the period February-April 2020. Result: Showed that age and weight are patient-specific variables that should be considered when determining injected radiation dose. Conclusion: To optimize the examination for each patient, injected activity should be adjusted according to the patient’s body weight and age. More studies in where other parameters are investigated must be carried out.

Bakgrund: Det kan vara svårt att få i sig tillräcklig mängd D-vitamin för att upprätthålla en normal D-vitamins nivå under vinterhalvåret. Med normal nivå i blodet menas en D-vitaminstatus på omkring 50 nmol/l där risken för benskörhet och dödlighet minskar. Ny forskning talar för att D-vitamin har stor betydelse, inte bara för skelettet, utan också för vårt immunsystem och andra sjukdomar. Syfte: Denna studies syfte var att klargöra några av de hälsoeffekter som D-vitamin har på immunförsvaret. Metod: En litteraturstudie som baserades på tio tidigare utförda studier. Resultat: I resultatet framkom fem områden. Dessa är: Dosering för normala D-vitamin nivåer, D-vitamin effekter på hjärt- och kärlsjukdomar, D-vitamin effekter på cancersjukdomar, D-vitamins effekter på metabolt syndrom och diabetes och D-vitamins effekter på luftvägsinfektioner. Diskussion: Olika studier har forskat på vilka hälsoeffekter D-vitamin har på människans hälsa. Tillskott av D-vitaminhar visat sig ha skyddande effekter och kan även bidra till lägre dödlighet hos utsatta grupper. Effekterna av doseringsregimen för att avgöra vilka nivåer i blod som speglar ett optimalt D-vitaminstatus diskuteras. Konklusion: D-vitaminhar stor betydelse, inte bara för skelettet, utan också för vårt immunsystem. Tillskott av D-vitamin har visat skyddande effekter på ett flertal sjukdomar likt infektioner, typ 2 diabetes, bröstcancer och olika hjärt-kärlsjukdomar. Background: It may be difficult to get enough D-vitamin to maintain a normal D-vitamin level during the winter months. A normal level in the blood means a D-vitamin status of about 50 nmol/ l, where the risk of osteoporosis and mortality is reduced. New research shows that D-vitamin is of high importance not only for the skeleton, but also for our immune system and other diseases. Purpose: The purpose of this study was to clarify some of the health effects D-vitamin has on the immune system. Method: A literature study based on ten previous studies. Result: There was five areas in the result. These are: Dose for normal D-vitamin levels, D-vitamin effects on cardiovascular disease, D-vitamin effects on cancerous diseases, D-vitamin effects on metabolic syndrome and diabetes and D-vitamin effects on respiratory infections. Discussion: Various studies have researched the health effects D-vitamin has on the human health. Supplements of D-vitamin have been shown to have protective effects and can also contribute to lower mortality in vulnerable groups. The effects of the dosage regimen to determine which levels in blood reflect an optimal D-vitamin status are discussed. Conclusion: D-vitamin is of great importance not only for the skeleton, but also for our immune system. Supplements of D-vitamin have been shown to have protective effects on a variety of diseases like infections, type 2 diabetes, breast cancer and various cardiovascular diseases.

Planten halen nutriënten normaal gesproken binnen via hun wortels. Het opname- en transportsysteem is daar volledig op ingericht. Bij bemesting via het blad is er niet zo’n gestroomlijnde route. Dat maakt het resultaat van bladbemesting erg wisselend. Immobiele elementen blijven snel steken bij de plek waar ze terecht zijn gekomen.

Het antibioticagebruik in de Nederlandse melkveehouderij daalde behoorlijk, volgens monitoring van WUR op ruim tachtig bedrijven. Landelijke cijfers bevestigen dit beeld, alhoewel een nieuwe rekenmethode voor nog lagere landelijke cijfers zorgt.

It used to be rare to come across plants that bind CO2 mainly at night: CAMplants. But it’s no longer an exception in the horticultural sector. Nowadays the best-selling pot plant in the Netherlands – phalaenopsis – belongs to this group. This then raises questions such as: When do CAM-plants behave according to the book and when don’t they? And when does it make sense to dose with CO2 and provide lighting?

Previous research has demonstrated that powdered activated carbon (PAC), when applied at very low dosages and long SRTs, reduces membrane fouling in membrane bioreactors (MBRs). This effect was related to the formation of stronger sludge flocs, which are less sensitive to shear. In this contribution the long-term effect of PAC addition was studied by running two parallel MBRs on sewage. To one of these, PAC was dosed and a lower fouling tendency of the sludge was verified, with a 70% longer sustainable filtration time. Low PAC dosages showed additional advantages with regard to oxygen transfer and dewaterability, which may provide savings on operational costs.

Melkveebedrijven, die stijgen in antibioticagebruik, zaten aanvankelijk op een heel laag niveau. Ze zijn meer droogzetters, middelen tegen mastitis en overige middelen gaan gebruiken. Dalende bedrijven doen het tegenovergestelde. Dalers zijn actiever in het aanpassen van de bedrijfsvoering, vooral huisvesting, het management rondom droogzetten en selectie van koeien. Stijgende bedrijven hebben een hoger celgetal dan de dalende bedrijven.

Voor de implementatie van een geïntegreerde geoptimaliseerde jaarrond beheersingsstrategie is nog veel operationele kennis over de aardappelziekte nodig.Duurzame beheersing van Phytophthora infestans is pas mogelijk als de complexe onderdelen voldoende op elkaar zijn afgestemd en worden vertaald naar geïntegreerde praktische oplossingen. Binnen dit thema van het Parapluplan Phytophthora worden de resultaten uit de andere thema's vertaald naar praktische oplossingen. In dit artikel wordt een aantal van de projecten uit de Toolbox toegelicht

This review aims to identify strategies to optimise radiography practice using digital technologies, for full spine studies on paediatrics focusing particularly on methods used to diagnose and measure severity of spinal curvatures. The literature search was performed on different databases (PubMed, Google Scholar and ScienceDirect) and relevant websites (e.g., American College of Radiology and International Commission on Radiological Protection) to identify guidelines and recent studies focused on dose optimisation in paediatrics using digital technologies. Plain radiography was identified as the most accurate method. The American College of Radiology (ACR) and European Commission (EC) provided two guidelines that were identified as the most relevant to the subject. The ACR guidelines were updated in 2014; however these guidelines do not provide detailed guidance on technical exposure parameters. The EC guidelines are more complete but are dedicated to screen film systems. Other studies provided reviews on the several exposure parameters that should be included for optimisation, such as tube current, tube voltage and source-to-image distance; however, only explored few of these parameters and not all of them together. One publication explored all parameters together but this was for adults only. Due to lack of literature on exposure parameters for paediatrics, more research is required to guide and harmonise practice

This paper reviews the literature for lowering of dose to paediatric patients through use of exposure factors and additional filtration. Dose reference levels set by The International Commission on Radiological Protection (ICRP) will be considered. Guidance was put in place in 1996 requires updating to come into line with modern imaging equipment. There is a wide range of literature that specifies that grids should not be used on paediatric patients. Although much of the literature advocates additional filtration, contrasting views on the relative benefits of using aluminium or copper filtration, and their effects on dose reduction and image quality can vary. Changing kVp and mAs has an effect on the dose to the patient and image quality. Collimation protects adjacent structures whilst reducing scattered radiation.

Background: Computed tomography (CT) is one of the most used modalities for diagnostics in paediatric populations, which is a concern as it also delivers a high patient dose. Research has focused on developing computer algorithms that provide better image quality at lower dose. The iterative reconstruction algorithm Sinogram-Affirmed Iterative Reconstruction (SAFIRE) was introduced as a new technique that reduces noise to increase image quality. Purpose: The aim of this study is to compare SAFIRE with the current gold standard, Filtered Back Projection (FBP), and assess whether SAFIRE alone permits a reduction in dose while maintaining image quality in paediatric head CT. Methods: Images were collected using a paediatric head phantom using a SIEMENS SOMATOM PERSPECTIVE 128 modulated acquisition. 54 images were reconstructed using FBP and 5 different strengths of SAFIRE. Objective measures of image quality were determined by measuring SNR and CNR. Visual measures of image quality were determined by 17 observers with different radiographic experiences. Images were randomized and displayed using 2AFC; observers scored the images answering 5 questions using a Likert scale. Results: At different dose levels, SAFIRE significantly increased SNR (up to 54%) in the acquired images compared to FBP at 80kVp (5.2-8.4), 110kVp (8.2-12.3), 130kVp (8.8-13.1). Visual image quality was higher with increasing SAFIRE strength. The highest image quality was scored with SAFIRE level 3 and higher. Conclusion: The SAFIRE algorithm is suitable for image noise reduction in paediatric head CT. Our data demonstrates that SAFIRE enhances SNR while reducing noise with a possible reduction of dose of 68%.

Patients scheduled for a magnetic resonance imaging (MRI) scan sometimes require screening for ferromagnetic Intra Orbital Foreign Bodies (IOFBs). To assess this, they are required to fill out a screening protocol questionnaire before their scan. If it is established that a patient is at high risk, radiographic imaging is necessary. This review examines literature to evaluate which imaging modality should be used to screen for IOFBs, considering that the eye is highly sensitive to ionising radiation and any dose should be minimised. Method: Several websites and books were searched for information, these were as follows: PubMed, Science Direct, Web of Knowledge and Google Scholar. The terms searched related to IOFB, Ionising radiation, Magnetic Resonance Imaging Safety, Image Quality, Effective Dose, Orbits and X-ray. Thirty five articles were found, several were rejected due to age or irrelevance; twenty eight were eventually accepted. Results: There are several imaging techniques that can be used. Some articles investigated the use of ultrasound for investigation of ferromagnetic IOFBs of the eye and others discussed using Computed Tomography (CT) and X-ray. Some gaps in the literature were identified, mainly that there are no articles which discuss the lowest effective dose while having adequate image quality for orbital imaging. Conclusion: X-ray is the best method to identify IOFBs. The only problem is that there is no research which highlights exposure factors that maintain sufficient image quality for viewing IOFBs and keep the effective dose to the eye As Low As Reasonably Achievable (ALARA).

Patients scheduled for a magnetic resonance imaging (MRI) scan sometimes require screening for ferromagnetic Intra Orbital Foreign Bodies (IOFBs). To assess this, they are required to fill out a screening protocol questionnaire before their scan. If it is established that a patient is at high risk, radiographic imaging is necessary. This review examines literature to evaluate which imaging modality should be used to screen for IOFBs, considering that the eye is highly sensitive to ionising radiation and any dose should be minimised. Method: Several websites and books were searched for information, these were as follows: PubMed, Science Direct, Web of Knowledge and Google Scholar. The terms searched related to IOFB, Ionising radiation, Magnetic Resonance Imaging Safety, Image Quality, Effective Dose, Orbits and X-ray. Thirty five articles were found, several were rejected due to age or irrelevance; twenty eight were eventually accepted. Results: There are several imaging techniques that can be used. Some articles investigated the use of ultrasound for investigation of ferromagnetic IOFBs of the eye and others discussed using Computed Tomography (CT) and X-ray. Some gaps in the literature were identified, mainly that there are no articles which discuss the lowest effective dose while having adequate image quality for orbital imaging. Conclusion: X-ray is the best method to identify IOFBs. The only problem is that there is no research which highlights exposure factors that maintain sufficient image quality for viewing IOFBs and keep the effective dose to the eye As Low As Reasonably Achievable (ALARA).

Aim: Optimise a set of exposure factors, with the lowest effective dose, to delineate spinal curvature with the modified Cobb method in a full spine using computed radiography (CR) for a 5-year-old paediatric anthropomorphic phantom. Methods: Images were acquired by varying a set of parameters: positions (antero-posterior (AP), posteroanterior (PA) and lateral), kilo-voltage peak (kVp) (66-90), source-to-image distance (SID) (150 to 200cm), broad focus and the use of a grid (grid in/out) to analyse the impact on E and image quality (IQ). IQ was analysed applying two approaches: objective [contrast-to-noise-ratio/(CNR] and perceptual, using 5 observers. Monte-Carlo modelling was used for dose estimation. Cohen’s Kappa coefficient was used to calculate inter-observer-variability. The angle was measured using Cobb’s method on lateral projections under different imaging conditions. Results: PA promoted the lowest effective dose (0.013 mSv) compared to AP (0.048 mSv) and lateral (0.025 mSv). The exposure parameters that allowed lower dose were 200cm SID, 90 kVp, broad focus and grid out for paediatrics using an Agfa CR system. Thirty-seven images were assessed for IQ and thirty-two were classified adequate. Cobb angle measurements varied between 16°±2.9 and 19.9°±0.9. Conclusion: Cobb angle measurements can be performed using the lowest dose with a low contrast-tonoise ratio. The variation on measurements for this was ±2.9° and this is within the range of acceptable clinical error without impact on clinical diagnosis. Further work is recommended on improvement to the sample size and a more robust perceptual IQ assessment protocol for observers.

This review aims to identify strategies to optimise radiography practice using digital technologies, for full spine studies on paediatrics focusing particularly on methods used to diagnose and measure severity of spinal curvatures. The literature search was performed on different databases (PubMed, Google Scholar and ScienceDirect) and relevant websites (e.g., American College of Radiology and International Commission on Radiological Protection) to identify guidelines and recent studies focused on dose optimisation in paediatrics using digital technologies. Plain radiography was identified as the most accurate method. The American College of Radiology (ACR) and European Commission (EC) provided two guidelines that were identified as the most relevant to the subject. The ACR guidelines were updated in 2014; however these guidelines do not provide detailed guidance on technical exposure parameters. The EC guidelines are more complete but are dedicated to screen film systems. Other studies provided reviews on the several exposure parameters that should be included for optimisation, such as tube current, tube voltage and source-to-image distance; however, only explored few of these parameters and not all of them together. One publication explored all parameters together but this was for adults only. Due to lack of literature on exposure parameters for paediatrics, more research is required to guide and harmonise practice

Purpose: To determine whether using different combinations of kVp and mAs with additional filtration can reduce the effective dose to a paediatric phantom whilst maintaining diagnostic image quality. Methods: 27 images of a paediatric AP pelvis phantom were acquired with different kVp, mAs and additional copper filtration. Images were displayed on quality controlled monitors with dimmed lighting. Ten diagnostic radiographers (5 students and 5 experienced radiographers) had eye tests to assess visual acuity before rating the images. Each image was rated for visual image quality against a reference image using 2 alternative forced choice software using a 5-point Likert scale. Physical measures (SNR and CNR) were also taken to assess image quality. Results: Of the 27 images rated, 13 of them were of acceptable image quality and had a dose lower than the image with standard acquisition parameters. Two were produced without filtration, 6 with 0.1mm and 5 with 0.2mm copper filtration. Statistical analysis found that the inter-rater and intra-rater reliability was high. Discussion: It is possible to obtain an image of acceptable image quality with a dose that is lower than published guidelines. There are some areas of the study that could be improved. These include using a wider range of kVp and mAs to give an exact set of parameters to use. Conclusion: Additional filtration has been identified as amajor tool for reducing effective dose whilst maintaining acceptable image quality in a 5 year old phantom.

Planten halen nutriënten normaal gesproken binnen via hun wortels. Het opname- en transportsysteem is daar volledig op ingericht. Bij bemesting via het blad is er niet zo’n gestroomlijnde route. Dat maakt het resultaat van bladbemesting erg wisselend. Immobiele elementen blijven snel steken bij de plek waar ze terecht zijn gekomen.

Aim: Optimise a set of exposure factors, with the lowest effective dose, to delineate spinal curvature with the modified Cobb method in a full spine using computed radiography (CR) for a 5-year-old paediatric anthropomorphic phantom. Methods: Images were acquired by varying a set of parameters: positions (antero-posterior (AP), posteroanterior (PA) and lateral), kilo-voltage peak (kVp) (66-90), source-to-image distance (SID) (150 to 200cm), broad focus and the use of a grid (grid in/out) to analyse the impact on E and image quality (IQ). IQ was analysed applying two approaches: objective [contrast-to-noise-ratio/(CNR] and perceptual, using 5 observers. Monte-Carlo modelling was used for dose estimation. Cohen’s Kappa coefficient was used to calculate inter-observer-variability. The angle was measured using Cobb’s method on lateral projections under different imaging conditions. Results: PA promoted the lowest effective dose (0.013 mSv) compared to AP (0.048 mSv) and lateral (0.025 mSv). The exposure parameters that allowed lower dose were 200cm SID, 90 kVp, broad focus and grid out for paediatrics using an Agfa CR system. Thirty-seven images were assessed for IQ and thirty-two were classified adequate. Cobb angle measurements varied between 16°±2.9 and 19.9°±0.9. Conclusion: Cobb angle measurements can be performed using the lowest dose with a low contrast-tonoise ratio. The variation on measurements for this was ±2.9° and this is within the range of acceptable clinical error without impact on clinical diagnosis. Further work is recommended on improvement to the sample size and a more robust perceptual IQ assessment protocol for observers.

Background: Computed tomography (CT) is one of the most used modalities for diagnostics in paediatric populations, which is a concern as it also delivers a high patient dose. Research has focused on developing computer algorithms that provide better image quality at lower dose. The iterative reconstruction algorithm Sinogram-Affirmed Iterative Reconstruction (SAFIRE) was introduced as a new technique that reduces noise to increase image quality. Purpose: The aim of this study is to compare SAFIRE with the current gold standard, Filtered Back Projection (FBP), and assess whether SAFIRE alone permits a reduction in dose while maintaining image quality in paediatric head CT. Methods: Images were collected using a paediatric head phantom using a SIEMENS SOMATOM PERSPECTIVE 128 modulated acquisition. 54 images were reconstructed using FBP and 5 different strengths of SAFIRE. Objective measures of image quality were determined by measuring SNR and CNR. Visual measures of image quality were determined by 17 observers with different radiographic experiences. Images were randomized and displayed using 2AFC; observers scored the images answering 5 questions using a Likert scale. Results: At different dose levels, SAFIRE significantly increased SNR (up to 54%) in the acquired images compared to FBP at 80kVp (5.2-8.4), 110kVp (8.2-12.3), 130kVp (8.8-13.1). Visual image quality was higher with increasing SAFIRE strength. The highest image quality was scored with SAFIRE level 3 and higher. Conclusion: The SAFIRE algorithm is suitable for image noise reduction in paediatric head CT. Our data demonstrates that SAFIRE enhances SNR while reducing noise with a possible reduction of dose of 68%.

De minimum effectieve dosering van een herbicide wordt bepaald door een complex van factoren zoals onkruidsoorten, onkruidgrootte, gewasstadium, weersomstandigheden, spuittechniek, formulering en hulpstoffen. In dit artikel wordt nader ingegaan op het Minimum Letale Herbicide Docering (MLHD) concept. MLHD is de laatste jaren ontwikkeld met als doel (vooral via sensingtechnieken) herbicidengebruik rationeler en duurzamer te maken