Results of the baseline assessment for NSL monitoring

Om de luchtkwaliteit in Nederland te verbeteren is het Nationaal Samenwerkingsprogramma Luchtkwaliteit (NSL) opgezet. In dit programma werken de Rijksoverheid en decentrale overheden samen om te zorgen dat Nederland overal tijdig aan de grenswaarden voor fijnstof en stikstofdioxide zal voldoen. Bij het NSL is ook een monitoringsprogramma opgezet om het bereiken van dit doel te waarborgen. Belangrijk onderdeel hiervan is een informatie- en rekensysteem (Monitoringtool) dat met een jaarlijks actualisatieproces het halen van de grenswaarden inzichtelijk moet maken. Voorafgaand aan de start van de monitoring heeft het RIVM een analyse (nulmeting) van dit systeem uitgevoerd. Vooral vanwege de consistente aanpak heeft de Monitoringtool veel potentie. Desondanks liggen er nog belangrijke verbeterpunten om het daadwerkelijk een robuust systeem te maken. Ondanks de consistente aanpak hebben de berekeningen voor toekomstige jaren een relatief grote onzekerheid, vooral doordat de kwaliteit van de invoergegevens niet bekend is. De kwaliteit van deze locatiespecifieke invoergegevens is primair de verantwoordelijkheid van lokale overheden die deze aanleveren. Thans zijn niet alle relevante onderbouwingen van deze gegevens in het monitoringstraject beschikbaar. Hierdoor is het moeilijk om de kwaliteit van deze gegevens en de daarop gebaseerde rekenresultaten te beoordelen. Met de nu voorliggende combinatie van de Monitoringstool en de bijbehorende invoergegevens kan het RIVM de kwaliteit van de monitoringsresultaten niet objectief vaststellen. Als gevolg hiervan kunnen in de monitoring van het NSL geen conclusies aan deze resultaten worden verbonden. In dit rapport worden aanbevelingen gedaan om de kwaliteit van de invoergegevens te vergroten en daarmee de onzekerheid van het eindresultaat te verkleinen. Bij het opstellen van de eerste Monitoringrapportage wordt in meer detail naar de kwaliteit van de resultaten van de Monitoring worden gekeken. De Monitoringtool vormt een belangrijke invulling van het Aarhus protocol waarin toegang van burgers tot milieugegevens wordt geregeld. Het rekeninstrument dat de kern vormt van het monitoringsprogramma is onder grote tijdsdruk tot stand gekomen en is deels nog in ontwikkeling. Het RIVM kan daardoor op dit moment alleen concluderen dat de gebruikte rekenmethoden voldoen aan de technisch-inhoudelijk en wettelijke regels om de luchtkwaliteit te berekenen. Het goed werken van het gehele rekeninstrument (inclusief volledige database en website) kon slechts beperkt worden getest. Een algemene uitspraak hierover, en dus ook over de kwaliteit van de monitoringsresultaten, is in deze nulmeting dan ook niet mogelijk.In order to improve the air quality in the Netherlands, the Ministry of Spatial Planning and the Environment (VROM) has authorised the establishment of The National Air Quality Cooperation Programme (NSL). Within the framework of this programme, the central government and local and regional authorities are collaborating to ensure that the Netherlands achieves timely compliance throughout the entire country with the limit values for particulate matter and nitrogen dioxide. The NSL includes a monitoring programme to ensure that this objective is achieved. One important part of this programme is an information and calculation system - i.e., a monitoring tool - that aims to guarantee compliance with the limit values through a yearly process of actualisation. The National Institute for Public Health and the Environment (RIVM) has performed a baseline assessment of this system prior to the start of monitoring. Due specifically to the consistency of its approach, the monitoring tool has great potential. However, there remain a number of important points for improvement before it will be a truly robust system. Despite the consistency of the approach, the prognostic calculations show a relatively high degree of uncertainty - mainly because the quality of the input data is unknown. The quality of the locality-specific input data is primarily the responsibility of local authorities, which provide the information. At the present time, these data are not subjected to further substantiation in the monitoring programme and, consequently, it is difficult to assess the quality of both the data and the calculated concentrations that are based on these data. Given the current limitations of this combination of monitoring tool and input data, it is not possible to draw any conclusion to the monitoring results. This report contains recommendations on how to improve the quality of the input data and thereby reduce the uncertainty of the end result. The quality of the monitoring results will be examined in more detail during the drafting of the first Monitoring Report. The monitoring tool constitutes an important supplement to the Aarhus protocol which ratifies public access to environmental information within the EU. The calculation instrument that forms the core of the monitoring programme was developed under great time pressure, and parts of it are still in the development stage. Therefore, at the present time, the only conclusion that can be drawn by the RIVM is that the calculation methods used satisfy the technical and statutory regulations for calculating air quality. It is not yet possible to comprehensively test whether the entire system (including the complete database and website) performs correctly. Consequently, it is also not possible to make a general pronouncement on either the system or the quality of the monitoring results in this baseline assessment.VRO

Progress of the National Air Quality Cooperation Programme (NSL)

Om de luchtkwaliteit in Nederland te verbeteren is het Nationaal Samenwerkingsprogramma Luchtkwaliteit (NSL) opgezet. In dit programma werken de Rijksoverheid en decentrale overheden samen om te zorgen dat Nederland overal tijdig aan de grenswaarden voor fijnstof (2011) en stikstofdioxide (2015) zal voldoen. Om de voortgang te volgen is bij het NSL een monitoringsprogramma opgezet. Centraal onderdeel daarvan is een rekeninstrument waarvoor de overheden de brongegevens aanleveren. De daaruitvolgende rekenresultaten zijn vervolgens door het Bureau Monitoring (samenwerkingsverband RIVM en InfoMil) samengevoegd in voorliggende voortgangsrapportage. De prognoses voor 2011 en 2015 laten zien dat voor een groot deel van Nederland de resultaten onder de Europese grenswaarden voor PM10 (fijnstof) en NO2 liggen. Op een aantal plekken zijn er wel nieuwe of grotere overschrijdingen van de PM10- en NO2-grenswaarden zichtbaar. Bij de fijnstof (PM10) overschrijdingen gaat het hoofdzakelijk om locaties bij veehouderijen en een aantal industriele gebieden. Vooral nabij veehouderijen is op een aantal plekken nog sprake van grote overschrijdingen die lastig voor medio 2011 op te lossen zijn. De huidige prognose voor de concentraties stikstofdioxide in 2015 laat een minder gunstige ontwikkeling zien ten opzichte van wat is berekend in de vaststelling van het NSL. Dit komt voor een belangrijk deel door tegenvallende verkeersemissies wat heeft geleid tot een aantal nieuwe overschrijdingen. De nu in de prognoses berekende concentraties liggen op veel locaties net onder de grenswaarde. Met veel concentraties net onder de grenswaarde neemt het aantal overschrijdingen snel toe bij een tegenvaller in een van de gemaakte aannamen. In combinatie met een grote en deels onbekende onzekerheid in de rekenresultaten vormt dit een risico voor het behalen van de doelstelling van het NSL.The NSL has been put in place to improve air quality in the Netherlands and to ensure that the Netherlands meets the date of compliance with the EU limit values for particulate matter and nitrogen dioxide. Local, regional and national authorities work together within the framework of this programme to ensure that these goals are met. A monitoring programme, centred around a specially designed assessment tool, has been set up to monitor the progress. This tool uses data that the participating authorities are required to provide as part of the annual monitoring cycle. The results of the tool have been bundled by the Bureau Monitoring into this progress report. The prognosis for 2011 and 2015, based on the results obtained using the assessment tool, are that the concentrations of PM10 and NO2 fall below the EU limit values in most parts of the Netherlands. However, exceedances of the limit values do occur at specific locations. For PM10, these exceedances mostly occur close to a number of industrial sites and stock farms. Particularly high exceedances in the vicinity of these stock farms will make it difficult to meet the limit values by mid 2011 at these locations. The prognostications for NO2 show a less favourable decline in NO2 concentrations than was modelled at the establishment of the NSL. This is mostly due to the decline in traffic emissions falling short of expectations, resulting in new exceedances. At many locations, the calculated concentrations in the prognostications fall just under the limit value and, consequently, there will be a large increase in the number of exceedances when one or more of the premises become less favourable. This possibility, together with the large and partially unknown uncertainty in the calculation results, add up to a risk for not meeting the limit values by the date of compliance.VRO

Limitations of Quantitative Blush Evaluator (QuBE) as myocardial perfusion assessment method on digital coronary angiograms

Background and Aim: Quantitative Blush Evaluator (QuBE) is a software application that allows quantifying myocardial perfusion in coronary angiograms after a percutaneous coronary intervention. QuBE has some limitations such as the application of a crude filter to remove large scale structures and the absence of correction for cardiac motion. This study investigates the extent of these limitations and we hypothesize that enhanced image analysis methods can provide improvements. Methods: We calculated QuBE scores of 117 patients from the HEBE Trial and determined its association with the Myocardial Blush Grade (MBG) score. Accuracy of large-structure removal is qualitatively assessed for various sizes of a median filter. The influence of cardiac motion was evaluated by comparing the blush curve and QuBE score of the native QuBE with manually motion-corrected QuBE for 40 patients. The effect of different kernel sizes and motion correction to a potential improvement of the association between QuBE score and MBG was studied. Results: In our population, there was no significant association between QuBE score and MBG (p = 0.14). Median filters of various kernel sizes were unable to remove large structure related noise. Variations in filters and cardiac movement correction did not result in an improvement in the association with MBG scores (observer 1: p = 0.66; observer 2: p = 0.72). Conclusions: There was no significant association of QuBE with MBG scores in our population, which suggests that QuBE is not suitable for a quantitative assessment of myocardial perfusion. Alternative kernel sizes for the large structure removal filter and cardiac motion correction did not improve QuBE performance. Relevance for patients: Further improvements of QuBE to overcome its inherent limitations are necessary in order to establish QuBE as a reliable myocardial perfusion assessment method

Two Decades of Research on Euthanasia from the Netherlands. What Have We Learnt and What Questions Remain?

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life

Deliberate termination of life of newborns with spina bifida, a critical reappraisal

Objects: Deliberate termination of life of newborns (involuntary euthanasia) with meningomyelocele (MMC) is practiced openly only in the Netherlands. 'Unbearable and hopeless suffering' is the single most cited criterion for this termination, together with the notion that 'there are no other proper medical means to alleviate this suffering'. In this paper, both (and other) statements are questioned, also by putting them in a broader perspective. Methods: First, a historical overview of the treatment of newborns with MMC is presented, concentrating on the question of selection for treatment. Second, a thorough analysis is made of the criteria used for life termination. Third, a case of a newborn with a very severe MMC is presented as a 'reference case'. Conclusion: 'Unbearable and hopeless suffering' cannot be applied to newborns with MMC. They are not 'terminally ill' and do have 'prospects of a future'. In these end-of-life decisions, 'quality of life judgments' should not be applied. When such a newborn is not treated, modern palliative care always will suffice in eliminating possible discomfort. There is no reason whatsoever for active life-termination of these newborns

Unbearability of suffering at the end of life: the development of a new measuring device, the SOS-V

AbstractBackgroundUnbearable suffering is an important issue in end-of-life decisions. However, there has been no systematic, prospective, patient-oriented research which has focused on unbearable suffering, nor is there a suitable measurement instrument. This article describes the methodological development of a quantitative instrument to measure the nature and intensity of unbearable suffering, practical aspects of its use in end-stage cancer patients in general practice, and studies content validity and psychometric properties.MethodsRecognizing the conceptual difference between unbearability of suffering and extent or intensity of suffering, we developed an instrument. The compilation of aspects considered to be of importance was based on a literature search. Psychometric properties were determined on results of the first interviews with 64 end-stage cancer patients that participated in a longitudinal study in the Netherlands.ResultsThe instrument measures five domains: medical signs and symptoms, loss of function, personal aspects, aspects of environment, and nature and prognosis of the disease. Sixty nine aspects were investigated, and an overall score was asked. In 64 end-stage cancer patients the instrument was used in total 153 times with an average interview time varying from 20-40 minutes. Cronbachs alpha's of the subscales were in majority above 0.7. The sum scores of (sub)scales were correlated strongly to overall measures on suffering.ConclusionThe SOS-V is an instrument for measuring the unbearability of suffering in end-stage cancer patients with good content validity and psychometric properties, which is feasible to be used in practice. This structured instrument makes it possible to identify and study unbearable suffering in a quantitative and patient-oriented way

Pre-Procedural Atorvastatin Mobilizes Endothelial Progenitor Cells: Clues to the Salutary Effects of Statins on Healing of Stented Human Arteries

OBJECTIVES: Recent clinical trials suggest an LDL-independent superiority of intensive statin therapy in reducing target vessel revascularization and peri-procedural myocardial infarctions in patients who undergo percutaneous coronary interventions (PCI). While animal studies demonstrate that statins mobilize endothelial progenitor cells (EPCs) which can enhance arterial repair and attenuate neointimal formation, the precise explanation for the clinical PCI benefits of high dose statin therapy remain elusive. Thus we serially assessed patients undergoing PCI to test the hypothesis that high dose Atorvastatin therapy initiated prior to PCI mobilizes EPCs that may be capable of enhancing arterial repair. METHODS AND RESULTS: Statin naïve male patients undergoing angiography for stent placement were randomized to standard therapy without Atorvastatin (n = 10) or treatment with Atorvastatin 80 mg (n = 10) beginning three days prior to stent implantation. EPCs were defined by flow cytometry (e.g., surface marker profile of CD45dim/34+/133+/117+). As well, we also enumerated cultured angiogenic cells (CACs) by standard in vitro culture assay. While EPC levels did not fluctuate over time for the patients free of Atorvastatin, there was a 3.5-fold increase in EPC levels with high dose Atorvastatin beginning within 3 days of the first dose (and immediately pre-PCI) which persisted at 4 and 24 hours post-PCI (p<0.05). There was a similar rise in CAC levels as assessed by in vitro culture. CACs cultured in the presence of Atorvastatin failed to show augmented survival or VEGF secretion but displayed a 2-fold increase in adhesion to stent struts (p<0.05). CONCLUSIONS: High dose Atorvastatin therapy pre-PCI improves EPC number and CAC number and function in humans which may in part explain the benefit in clinical outcomes seen in patients undergoing coronary interventions

Consequences of excessive glucosylsphingosine in glucocerebrosidase-deficient zebrafish

In Gaucher disease (GD), the deficiency of glucocerebrosidase causes lysosomal accumulation of glucosylceramide (GlcCer), which is partly converted by acid ceramidase to glucosylsphingosine (GlcSph) in the lysosome. Chronically elevated blood and tissue GlcSph is thought to contribute to symptoms in GD patients as well as to increased risk for Parkinson's disease. On the other hand, formation of GlcSph may be beneficial since the water soluble sphingoid base is excreted via urine and bile. To study the role of excessive GlcSph formation during glucocerebrosidase deficiency, we studied zebrafish that have two orthologs of acid ceramidase, Asah1a and Asah1b. Only the latter is involved in the formation of GlcSph in glucocerebrosidase-deficient zebrafish as revealed by knockouts of Asah1a or Asah1b with glucocerebrosidase deficiency (either pharmacologically induced or genetic). Comparison of zebrafish with excessive GlcSph (gba1-/- fish) and without GlcSph (gba1-/-:asah1b-/- fish) allowed us to study the consequences of chronic high levels of GlcSph. Prevention of excessive GlcSph in gba1-/-:asah1b-/- fish did not restrict storage cells, GlcCer accumulation, or neuroinflammation. However, GD fish lacking excessive GlcSph show an ameliorated course of disease reflected by significantly increased lifespan, delayed locomotor abnormality, and delayed development of an abnormal curved back posture. The loss of tyrosine hydroxylase 1 (th1) mRNA, a marker of dopaminergic neurons, is slowed down in brain of GD fish lacking excessive GlcSph. In conclusion, in the zebrafish GD model, excess GlcSph has little impact on (neuro)inflammation or the presence of GlcCer-laden macrophages but rather seems harmful to th1-positive dopaminergic neurons