Management of children with non-acute abdominal pain and diarrhea in Dutch primary care:a retrospective cohort study based on a routine primary care database (AHON)

Objective: To describe the testing, prescription, referral, and follow-up management by general practitioners (GPs) for children presenting with non-acute abdominal pain and/or diarrhea in primary care. Design: Retrospective cohort study with one-year follow-up. Setting: Registry data from a Dutch primary care database (AHON) between 2015 and 2019. Subjects: Children aged 4–18 years old who presented by face-to-face consultation in primary care for non-acute abdominal pain and/or diarrhea (&gt;7 days). Main outcome measures: We recorded the proportions of children who received (1) diagnostic testing, medicine prescriptions, follow-up consultations, and referrals at their first visit and (2) repeat consultations and referrals by one-year of follow-up. Results: Among the 2200 children (median age, 10.5 years; interquartile range, 7.0–14.6) presenting to a GP with non-acute abdominal pain and/or diarrhea, most reported abdominal pain (78.7%). At the first visit, GPs performed diagnostic testing for 32.2%, provided a prescription to 34.5%, and referred 2.5% to secondary care. Twenty-five percent of the children had a follow-up consultation within four weeks and 20.8% had a repeat consultation between four weeks and one year. Thirteen percent of the children were referred to secondary care by one year. However, only 1% of all children had documentation of an organic diagnosis needing management in secondary care. Conclusion: One-third of children received diagnostic testing or a medicine prescription. Few had a follow-up consultation and &gt;10% was referred to pediatric care. Future research should explore the motivations of GPs why and which children receive diagnostic and medical interventions.</p

Management of children with non-acute abdominal pain and diarrhea in Dutch primary care:a retrospective cohort study based on a routine primary care database (AHON)

Objective: To describe the testing, prescription, referral, and follow-up management by general practitioners (GPs) for children presenting with non-acute abdominal pain and/or diarrhea in primary care. Design: Retrospective cohort study with one-year follow-up. Setting: Registry data from a Dutch primary care database (AHON) between 2015 and 2019. Subjects: Children aged 4–18 years old who presented by face-to-face consultation in primary care for non-acute abdominal pain and/or diarrhea (&gt;7 days). Main outcome measures: We recorded the proportions of children who received (1) diagnostic testing, medicine prescriptions, follow-up consultations, and referrals at their first visit and (2) repeat consultations and referrals by one-year of follow-up. Results: Among the 2200 children (median age, 10.5 years; interquartile range, 7.0–14.6) presenting to a GP with non-acute abdominal pain and/or diarrhea, most reported abdominal pain (78.7%). At the first visit, GPs performed diagnostic testing for 32.2%, provided a prescription to 34.5%, and referred 2.5% to secondary care. Twenty-five percent of the children had a follow-up consultation within four weeks and 20.8% had a repeat consultation between four weeks and one year. Thirteen percent of the children were referred to secondary care by one year. However, only 1% of all children had documentation of an organic diagnosis needing management in secondary care. Conclusion: One-third of children received diagnostic testing or a medicine prescription. Few had a follow-up consultation and &gt;10% was referred to pediatric care. Future research should explore the motivations of GPs why and which children receive diagnostic and medical interventions.</p

Greenhouse gas emission factors associated with rewetting of organic soils

Drained organic soils are a significant source of greenhouse gas (GHG) emissions to the atmosphere. Rewetting these soils may reduce GHG emissions and could also create suitable conditions for return of the carbon (C) sink function characteristic of undrained organic soils. In this article we expand on the work relating to rewetted organic soils that was carried out for the 2014 Intergovernmental Panel on Climate Change (IPCC) Wetlands Supplement. We describe the methods and scientific approach used to derive the Tier 1 emission factors (the rate of emission per unit of activity) for the full suite of GHG and waterborne C fluxes associated with rewetting of organic soils. We recorded a total of 352 GHG and waterborne annual flux data points from an extensive literature search and these were disaggregated by flux type (i.e. CO2, CH4, N2O and DOC), climate zone and nutrient status. Our results showed fundamental differences between the GHG dynamics of drained and rewetted organic soils and, based on the 100 year global warming potential of each gas, indicated that rewetting of drained organic soils leads to: net annual removals of CO2 in the majority of organic soil classes; an increase in annual CH4 emissions; a decrease in N2O and DOC losses; and a lowering of net GHG emissions. Data published since the Wetlands Supplement (n = 58) generally support our derivations. Significant data gaps exist, particularly with regard to tropical organic soils, DOC and N2O. We propose that the uncertainty associated with our derivations could be significantly reduced by the development of country specific emission factors that could in turn be disaggregated by factors such as vegetation composition, water table level, time since rewetting and previous land use history

Population-based study of morbidity risk associated with pathological complete response after chemoradiotherapy for rectal cancer

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer may induce a pathological complete response (pCR) but increase surgical morbidity due to radiation-induced fibrosis. In this study the association between pCR and postoperative surgical morbidity was investigated. METHODS: Patients in the Netherlands with rectal cancer who underwent nCRT followed by total mesorectal excision between 2009 and 2017 were included. Data were stratified into patients who underwent resection with creation of a primary anastomosis and those who had a permanent stoma procedure. The association between pCR and postoperative morbidity was investigated in univariable and multivariable logistic regression analyses. RESULTS: pCR was observed in 976 (12·2 per cent) of 8003 patients. In 3472 patients who had a primary anastomosis, the presence of pCR was significantly associated with surgical complications (122 of 443 (27·5 per cent) versus 598 of 3029 (19·7 per cent) in those without pCR) and anastomotic leak (35 of 443 (7·9 per cent) versus 173 of 3029 (5·7 per cent) respectively). Multivariable analysis also showed associations between pCR and surgical complications (adjusted odds ratio (OR) 1·53, 95 per cent c.i. 1·22 to 1·92) and pCR and anastomotic leak (adjusted OR 1·41, 1·03 to 2·05). Of 4531 patients with a permanent stoma, surgical complications were observed in 120 (22·5 per cent) of 533 patients with a pCR, compared with 798 (20·0 per cent) of 3998 patients with no pCR (adjusted OR 1·17, 0·94 to 1·46). CONCLUSION: Patients with a pCR in whom an anastomosis was created were at increased risk of developing an anastomotic leak

Quality of life and clinical outcomes in rectal cancer patients treated on a 1.5T MR-Linac within the MOMENTUM study

Background and purpose: This study assessed quality of life (QoL) and clinical outcomes in rectal cancer patients treated with magnetic resonance (MR) guided short-course radiation therapy (SCRT) on a 1.5 Tesla (T) MR-Linac during the first 12 months after treatment. Materials and methods: Rectal cancer patients treated with 25 Gy SCRT in five fractions with curative intent in the Netherlands (2019–2022) were identified in MOMENTUM (NCT04075305). Toxicity (CTCAE v5) and QoL (EORTC QLQ-C30 and -CR29) was primarily analyzed in patients without metastatic disease (M0) and no other therapies after SCRT. Patients who underwent tumor resection were censored from surgery. A generalized linear mixed-model was used to investigate clinically meaningful (≥10) and significant (P < 0.05) QoL changes. Clinical and pathological complete response (cCR and pCR) rates were calculated in patients in whom response was documented. Results: A total of 172 patients were included, of whom 112 patients were primarily analyzed. Acute and late radiation-induced high-grade toxicity were reported in one patient, respectively. CCR was observed in 8/64 patients (13 %), 14/37 patients (38 %) and 13/16 patients (91 %) at three, six and twelve months; pCR was observed in 3/69 (4 %) patients. After 12 months, diarrhea (mean difference [MD] −17.4 [95 % confidence interval [CI] −31.2 to −3.7]), blood and mucus in stool (MD −31.1 [95 % CI −46.4 to −15.8]), and anxiety (MD –22.4 [95 % CI −34.0 to −10.9]) were improved. Conclusion: High-field MR-guided SCRT for the treatment of patients with rectal cancer is associated with improved disease-related symptom management and functioning one year after treatment

Master protocol trial design for technical feasibility of MR-guided radiotherapy

The master protocol trial design aims to increase efficiency in terms of trial infrastructure and protocol administration which may accelerate development of (technical) innovations in radiation oncology. A master protocol to study feasibility of techniques/software for MR-guided adaptive radiotherapy with the MR-Linac is described and discussed. </p

Active afforestation of drained peatlands is not a viable option under the EU Nature Restoration Law

The EU Nature Restoration Law (NRL) is critical in restoring degraded ecosystems. However, active afforestation of degraded peatlands has been suggested by some as a restoration measure under the NRL. Here, we discuss the current state of scientific evidence on the climate mitigation effects of peatlands under forestry and its limitations, uncertainties and evidence gaps. Based on this discussion we conclude: Afforestation of drained peatlands, while maintaining their drained state, is not equivalent to ecosystem restoration. This approach will not restore the peatland ecosystem's flora, fauna, and functions. There is insufficient evidence to support the long-term climate change mitigation benefits of active afforestation of drained peatlands. Most studies only focus on the short-term gains in standing biomass and rarely explore the full life cycle emissions associated with afforestation of drained peatlands. Thus, it is unclear whether the CO2 sequestration of a forest on drained peatland can offset the carbon loss from the peat over the long term. In some ecosystems, such as abandoned or certain cutaway peatlands, afforestation may provide short-term benefits for climate change mitigation compared to taking no action. However, this approach violates the concept of sustainability by sacrificing the most space-effective carbon store of the terrestrial biosphere, the long-term peat store, for a shorter-term, less space-effective, and more vulnerable carbon store, namely tree biomass. Consequently, active afforestation of drained peatlands is not a viable option for climate mitigation under the EU Nature Restoration Law and might even impede future rewetting/restoration efforts. To restore degraded peatlands, hydrological conditions must first be improved, primarily through rewetting

Towards the development of a UK Peatland Code: Payments for Ecosystem Services (PES) Pilot Research Project

This Final Report describes research into the rationale and basis for the development of a UK Peatland Code. The development of the Code was supported by the latest relevant research evidence, via an international expert workshop, and by feedback from the Code’s Steering Group and 17 individuals/organisations from across the UK. The Code was launched in September 2013, at the start of an 18-month pilot phase of operation, in which the Code will be further developed, and is available online: http://www.iucn-uk-peatlandprogramme.org/peatland-code. There is growing interest in the creation of new markets to facilitate private investment in the provision of ecosystem services, and this was a key emphasis of Defra’s 2011 Natural Environment White Paper. The White Paper led to the formation of an Ecosystem Markets Taskforce to identify business opportunities in the natural environment that recommended the development of a UK Peatland Code in its report in March 2013. Subsequently in May 2013, Defra published an action plan for developing the potential for payments for ecosystem services in which it committed to work in partnership with the IUCN and others to support the testing, development and launch later in 2013 of a pilot UK Peatland Code. UK peatlands are a relevant place to explore the potential to pay for ecosystem services, given the range and importance of ecosystem services that they supply, and that fact that many of these service are not widely or fully paid for via agricultural support payments or by markets. This has led to the degradation of many peatlands through inappropriate burning, overWgrazing and drainage, leading to reductions in carbon storage, water quality and biodiversity. Investing in conserving and restoring peatlands is therefore a key tool to help deliver the UK’s climate change obligations, whilst helping meet other national and international obligations on biodiversity and water quality. Although there is growing interest from the private sector in paying for some of these ecosystem services, and there have been a small number of bilateral agreements to pay for peatland restoration via the Corporate Social Responsibility market, there is a need to develop guidance, frameworks and monitoring to provide sponsors with the confidence necessary to restore peatlands on any significant scale. This Payment for Ecosystem Service (PES) pilot research project therefore conducted the research necessary to develop and launch a UK pilot Peatland Code, designed to support markets that could pay for the restoration and reWwetting of degraded peatlands across the UK. The research project and subsequent Code drew significantly on Defra’s PES Best Practice Guide, first identifying a saleable ecosystem service and prospective buyers and sellers, based on previous work and new market research conducted as part of this project (Phase 1 in the PES Guide). The Code establishes the principles for a peatland PES scheme, and resolves a number of technical issues, to make it possible for buyers and sellers to work together for peatland restoration (Phase 2 in the PES Guide). The Code also provides guidance on contracts and monitoring (Phases 3 and 4 of the PES Guide), and takes a bundled approach to PES (a ‘premium carbon’ scheme that provides a range of coWbenefits), whilst not ruling out the possibility of layered schemes (e.g. using the Code to elicit payments for climate mitigation benefits on top of existing schemes that pay for water quality benefits) (Phase 5 of the PES Guide). The research offers a number of insights into the creation of markets for ecosystem services linked to peatland restoration. It also offers insights of more general relevance to the creation and implementation of new markets for ecosystem services, which may be of relevance to other habitats and ecosystems in the UK, and to the development of new PES schemes internationally