Leren van Marker Wadden - Over het speelveld en governance opgaven

Dit rapport bestaat uit 5 hoofdstukken. In hoofdstuk 2 wordt de achtergrond van het ontstaan van de Marker Wadden beschreven. Hierin het ontstaan van de Marker Wadden toegelicht en de opgaven op het gebied van ecologie, gebiedsontwikkeling en innovatie. Hoofdstuk 3 presenteert de resultaten van de stakeholderanalyse, waarbij diverse elementen worden onderzocht: de rollen en belangen van betrokken partijen, de middelen waarover zij beschikking hebben en wat hun ambities en probleempercepties zijn. Hierbij wordt steeds onderscheid gemaakt tussen de initiatiefase, aanlegfase en beheerfase van de Marker Wadden. Hoofdstuk 4 schetst de beleidscontext en de financiering van de Marker Wadden. Hoofdstuk 5 richt zich op de governance opgaven die kunnen worden geïdentificeerd op basis van voorgaande hoofdstukken. Hier wordt onderzocht hoe de ontwikkelingen en interacties tussen de betrokken partijen kunnen worden geduid volgens bedrijfskundige theorieën. Het rapport wordt afgesloten met een conclusie en aanbevelingen in hoofdstuk 6

Nieuw stelsel agrarisch natuurbeheer : criteria voor leefgebieden en beheertypen

In het nieuwe stelsel Agrarisch Natuur en Landschapsbeheer (ANLb-2016) worden vier agrarisch leefgebieden onderscheiden en daarbinnen 10 beheertypen. Deze eenheden vormen de basiseenheden van het stelsel waarvan het beheer in zogenaamde gebiedsplannen zal worden uitgewerkt. Voor deze eenheden zijn op basis van ecologische kennis kwalitatieve en kwantitatieve criteria uitgewerkt. De criteria zijn bedoeld als hulpmiddel voor het opstellen en beoordelen van gebiedsplannen. De soortenfiches, soortenmaatregelen en de eerder genoemde leefgebiedenbeschrijving, opgesteld door Wouter van Heusden, zijn gebruikt als uitgangspunt

EULAR definition of difficult-to-treat rheumatoid arthritis

Background: Despite treatment according to the current management recommendations, a significant proportion of patients with rheumatoid arthritis (RA) remain symptomatic. These patients can be considered to have ‘difficult-to-treat RA’. However, uniform terminology and an appropriate definition are lacking. Objective: The Task Force in charge of the „Development of EULAR recommendations for the comprehensive management of difficult-to-treat rheumatoid arthritis” aims to create recommendations for this underserved patient group. Herein, we present the definition of difficult-to treat RA, as the first step. Methods: The Steering Committee drafted a definition with suggested terminology based on an international survey among rheumatologists. This was discussed and amended by the Task Force, including rheumatologists, nurses, health professionals and patients, at a face-to-face meeting until sufficient agreement was reached (assessed through voting). Results: The following three criteria were agreed by all Task Force members as mandatory elements of the definition of difficult-to-treat RA: 1) Treatment according to EULAR rec-ommendation and failure of ≥2 b/tsDMARDs (with different mechanisms of action) after failing csDMARD therapy (unless contraindicated); 2) presence of at least one of the follow-ing: at least moderate disease activity; signs and/or symptoms suggestive of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; RA symptoms that are causing a reduction in quality of life; 3) the management of signs and/or symptoms is perceived as problematic by the rheumatologist and/or the patient. Conclusions: The proposed EULAR definition for difficult-to-treat RA can be used in clinical practice, clinical trials and can form a basis for future research

EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis

Objective: To develop evidence-based European Alliance of Associations for Rheumatology (EULAR) points to consider (PtCs) for the management of difficult-to-treat rheumatoid arthritis (D2T RA). Methods: A EULAR Task Force was established comprising 34 individuals: 26 rheumatologists, patient partners and rheumatology experienced health professionals. Two systematic literature reviews addressed clinical questions around diagnostic challenges, and pharmacological and non-pharmacological therapeutic strategies in D2T RA. PtCs were formulated based on the identified evidence and expert opinion. Strength of recommendations (SoR, scale A-D: A typically consistent level 1 studies, D level 5 evidence or inconsistent studies) and level of agreement (LoA, scale 0-10: 0 completely disagree, 10 completely agree) of the PtCs were determined by the Task Force members. Results: Two overarching principles and eleven PtCs were defined concerning diagnostic confirmation of RA, evaluation of inflammatory disease activity, pharmacological and nonpharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to D. The mean LoA with the overarching principles and PtCs was generally high (8.4-9.6). Conclusions: These points to consider for D2T RA can serve as a clinical roadmap to support healthcare professionals and patients to deliver holistic management and more personalised pharmacological and non-pharmacological therapeutic strategies. High-quality evidence was scarce. A research agenda was created to guide future research

The comparative responsiveness of Hospital Universitario Princesa Index and other composite indices for assessing rheumatoid arthritis activity

Objective To evaluate the responsiveness in terms of correlation of the Hospital Universitario La Princesa Index (HUPI) comparatively to the traditional composite indices used to assess disease activity in rheumatoid arthritis (RA), and to compare the performance of HUPI-based response criteria with that of the EULAR response criteria. Methods Secondary data analysis from the following studies: ACT-RAY (clinical trial), PROAR (early RA cohort) and EMECAR (pre-biologic era long term RA cohort). Responsiveness was evaluated by: 1) comparing change from baseline (Delta) of HUPI with Delta in other scores by calculating correlation coefficients; 2) calculating standardised effect sizes. The accuracy of response by HUPI and by EULAR criteria was analyzed using linear regressions in which the dependent variable was change in global assessment by physician (Delta GDA-Phy). Results Delta HUPI correlation with change in all other indices ranged from 0.387 to 0.791); HUPI's standardized effect size was larger than those from the other indices in each database used. In ACT-RAY, depending on visit, between 65 and 80% of patients were equally classified by HUPI and EULAR response criteria. However, HUPI criteria were slightly more stringent, with higher percentage of patients classified as non-responder, especially at early visits. HUPI response criteria showed a slightly higher accuracy than EULAR response criteria when using Delta GDA-Phy as gold standard. Conclusion HUPI shows good responsiveness in terms of correlation in each studied scenario (clinical trial, early RA cohort, and established RA cohort). Response criteria by HUPI seem more stringent than EULAR''s