Adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with colon cancer at high risk of peritoneal carcinomatosis; the COLOPEC randomized multicentre trial

Background: The peritoneum is the second most common site of recurrence in colorectal cancer. Early detection of peritoneal carcinomatosis (PC) by imaging is difficult. Patients eventually presenting with clinically apparent PC have a poor prognosis. Median survival is only about five months if untreated and the benefit of palliative systemic chemotherapy is limited. Only a quarter of patients are eligible for curative treatment, consisting of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CR/HIPEC). However, the effectiveness depends highly on the extent of disease and the treatment is associated with a considerable complication rate. These clinical problems underline the need for effective adjuvant therapy in high-risk patients to minimize the risk of outgrowth of peritoneal micro metastases. Adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) seems to be suitable for this purpose. Without the need for cytoreductive surgery, adjuvant HIPEC can be performed with a low complication rate and short hospital stay. Methods/Design: The aim of this study is to determine the effectiveness of adjuvant HIPEC in preventing the development of PC in patients with colon cancer at high risk of peritoneal recurrence. This study will be performed in the nine Dutch HIPEC centres, starting in April 2015. Eligible for inclusion are patients who underwent curative resection for T4 or intra-abdominally perforated cM0 stage colon cancer. After resection of the primary tumour, 176 patients will be randomized to adjuvant HIPEC followed by routine adjuvant systemic chemotherapy in the experimental arm, or to systemic chemotherapy only in the control arm. Adjuvant HIPEC will be performed simultaneously or shortly after the primary resection. Oxaliplatin will be used as chemotherapeutic agent, for 30 min at 42-43 degrees C. Just before HIPEC, 5-fluorouracil and leucovorin will be administered intravenously. Primary endpoint is peritoneal disease-free survival at 18 months. Diagnostic laparoscopy will be performed routinely after 18 months postoperatively in both arms of the study in patients without evidence of disease based on routine follow-up using CT imaging and CEA. Discussion: Adjuvant HIPEC is assumed to reduce the expected 25 % absolute risk of PC in patients with T4 or perforated colon cancer to a risk of 10 %. This reduction is likely to translate into a prolonged overall survival

Environmental health guideline for Municipal Health Services. Assessment of air exchange and ventilation capacity in dwellings

Het RIVM heeft in samenwerking met GGD'en een richtlijn ontwikkeld die beschrijft hoe ventilatie en ventilatievoorzieningen van bestaande woningen beoordeeld kunnen worden. Voorbeelden zijn: hoeveel kubieke meter verse lucht komt er per uur een woning binnen en hoeveel binnenlucht wordt er afgevoerd? Hoeveel kan er hoogstens afgevoerd worden? Is dat voldoende om de binnenlucht gezond te houden en hoe valt dat te meten? De luchtverversing in woningen schiet vaak tekort, wat gevolgen kan hebben voor de kwaliteit van het binnenmilieu en voor de gezondheid. Het kabinet heeft plannen om de kwaliteit van het binnenmilieu te verbeteren. De richtlijn biedt GGD-medewerkers basisinformatie over ventilatie en ventilatievoorzieningen van woningen. Ook is beschreven welke relaties tussen ventilatie en gezondheidsrisico's er bekend zijn. Te weinig ventilatie kan leiden tot bijvoorbeeld vochtproblemen, en hoge concentraties van verbrandingsproducten en het gas radon. Dit kan gepaard gaan met onder andere geurhinder, verergering van astma of een verhoogde kans op longkanker. Daarnaast is op basis van de wettelijke voorschriften en andere maatstaven een selectie gemaakt van methoden, technieken en criteria die GGD'en kunnen hanteren om de ventilatiecapaciteit en de ventilatie te beoordelen. Om het instrumentarium compleet te maken zijn de methoden, technieken en criteria op onderdelen aangevuld. Hiermee zijn ze meer gericht op het aantal personen dat aanwezig is of doorgaans aanwezig is in de betreffende ruimten. Verder is beschreven wat de taken van de GGD'en zijn en hoe zij het beoordelingsproces van ventilatie en ventilatievoorzieningen kunnen indelen. De beoordeling kan plaatsvinden in de betreffende woning of vanaf de werkplek.The National Institute for Public Health and the Environment (RIVM) has drawn up a guideline, together with the Municipal Health Services (GGD) that describes how the air exchange rate and ventilation capacity of existing dwellings can be assessed. Examples of assessment points are: how many cubic metres of fresh air enter a dwelling per hour and how much indoor air is removed? What is the maximum volume flow that can be achieved? Is that flow sufficient to keep the indoor air at a healthy level and how can this be measured? Good ventilation in dwellings is often inadequate which can have consequences for the quality of the indoor environment and for people's health. Therefore, the Dutch government is planning to improve the indoor environmental quality. The guideline will provide GGD professionals with basic information regarding the air exchange rate and ventilation capacity of dwellings. It also outlines what is already known about the relationship between indoor air exchange and associated health risks. For example, too little ventilation can lead to dampness and high concentrations of combustion products and radon gas. This can cause: odour nuisance, exacerbation of asthma or even an increased risk of lung cancer. In addition, based on legal requirements and other standards, a selection of methods has been made of techniques and criteria that GGD departments can use to assess the ventilation capacity and air exchange rate of dwellings. In order to complete the range of instruments used, the methods, techniques and criteria have been supplemented wherever necessary. This change ensures more focus to be placed on the number of people actually present or usually present in the indoor area(s) concerned. In addition, the guideline outlines the specific tasks of the GGD departments as well as how they can approach the assessment process for air exchange rate and ventilation capacity. The assessment can take place in the dwelling itself or at the place of work.VW

The characteristics and pre-hospital management of blunt trauma patients with suspected spinal column injuries: a retrospective observational study

Background Pre-hospital spinal immobilisation by emergency medical services (EMS) staff is currently the standard of care in cases of suspected spinal column injuries. There is, however, a lack of data on the characteristics of patients who received spinal immobilisation during the pre-hospital phase and on the adverse effects of immobilisation. The objectives of this study were threefold. First, we determined the pre-hospital characteristics of blunt trauma patients with suspected spinal column injuries who were immobilised by EMS staff. Second, we assessed the choices made by EMS staff regarding spinal immobilisation techniques and reasons for immobilisation. Third, we researched the possible adverse effects of immobilisation. Design A retrospective observational study in a cohort of blunt trauma patients. Study method Data of blunt trauma patients with suspected spinal column injuries were collected from one EMS organisation between January 2008 and January 2013. Coded data and free text notes were analysed. Results A total of 1082 patients were included in this study. Spinal immobilisation was applied in 96.3 % of the patients based on valid pre-hospital criteria. In 2.1 % of the patients immobilisation was not based on valid criteria. Data of 1.6 % patients were missing. Main reasons for spinal immobilisation were posterior midline spinal tenderness (37.2 % of patients) and painful distracting injuries (13.5 % of patients). Spinal cord injury (SCI) was suspected in 5.7 % of the patients with posterior midline spinal tenderness. A total of 15.8 % patients were immobilised using non-standard methods. The reason for departure from the standard method was explained for 3 % of these patients. Reported adverse effects included pain (n = 10, 0.9 %,); shortness of breath (n = 3, 0.3 %); combativeness or anxiety (n = 6, 0.6 %); and worsening of pain when supine (n = 1, 0.1 %). Conclusion/recommendation Spinal immobilisation was applied in 96.3 % of all included patients based on pre-hospital criteria. We found that consensus among EMS staff on how to interpret the criterion 'distracting injury' was lacking. Furthermore, the adverse effects of spinal immobilisation were incompletely documented in pre-hospital care reports. To provide validated information on potential symptoms of SCI, a uniform EMS scoring system for motoric assessment should be developed

Irrigation water quality and the threat it poses to crop production: evaluating the status of the Crocodile (West) and Marico catchments, South Africa

Ensuring food security is becoming increasingly difficult due to limited freshwater resources. Low-quality irrigation water also poses a severe threat to crop yield and quality. The aim of this study was to evaluate the water quality associated with the Crocodile (West) and Marico catchments, which represent one of South Africa’s most developed regions. Sources of irrigation water include the hypertrophic Hartbeespoort Dam, as well as the heavily impacted Crocodile (West) River. Analysis of historical irrigation water quality data (from January 2005 to December 2015) revealed that the Hartbeespoort and Crocodile (West) irrigation schemes were exposed to calcium sulfate enrichment, likely as a result of extensive mining activities in the Bushveld Igneous Complex. Also, significant differences in water quality parameters occurred between these irrigation schemes and the reference system (Marico-Bosveld Irrigation Scheme), while important salt (chloride and sodium) and nutrient (inorganic nitrogen and orthophosphate (as phosphorus)) concentrations exceeded threshold values provided by irrigation water quality guidelines. The Hartbeespoort and Crocodile (West) irrigation schemes also presented distinctive temporal (long-term and seasonal) patterns in water quality. Seasonal variation in pH levels at the Hartbeespoort Irrigation Scheme is likely caused by excessive algae growth and cyanobacteria blooms (Mycrocystis sp.), which also pose an important threat to human and animal health. Despite mitigation efforts by government and other stakeholders, some of South Africa’s major irrigation schemes remain highly impacted as a result of water quality deterioratio