Fetal Tachyarrhythmia - Part I: Diagnosis

Fetal tachycardia, first recognized in 1930 by Hyman et al1, is a condition occurring in approximately 0.4-0.6% of all pregnancies2. A subset of these cases with more sustained periods of tachycardia is clinically relevant. The necessity of therapeutic intervention in this condition is still a matter of discussion focused on the natural history of the disease. The spectrum of opinions varies from non-intervention3,4,5 based on a number of cases in which the tachycardia subsided spontaneously6, to aggressive pharmacotherapeutic intervention7,8 based on reports of deterioration of the fetal condition ultimately ending in significant neurological morbidity9,10,11, or fetal demise12,13,14. Prenatal treatment through indirect, maternally administered drug therapy seems to be the preference of most centers15,16,17,18,19,20,21. This matter will be discussed further in Fetal Tachyarrhythmia, Part II, Treatment

Fetal Tachyarrhythmia - Part II: Treatment

The decision to initiate pharmacological intervention in case of fetal tachycardia depends on several factors and must be weighed against possible maternal and/or fetal adverse effects inherent to the use of antiarrhythmics. First, the seriousness of the fetal condition must be recognized. Many studies have shown that in case of fetal tachycardia, there is a significant predisposition to congestive heart failure and subsequent development of fetal hydrops and even sudden cardiac death1,2,3 Secondly, predictors of congestive heart failure have been suggested in several studies, such as the percentage of time that the tachycardia is present, the gestational age at which the tachycardia occurs4, the ventricular rate5 and the site of origin of the tachycardia6. However, the sensitivity of these predictors is low and they are therefore clinically not very useful. In addition, hemodynamic compromise may occur in less than 24 - 48 hours as has been shown in the fetal lamb7 and in tachycardic fetuses8,9. On the other hand, spontaneous resolution of the tachycardia has also been described10. Thirdly, transplacental management of fetuses with tricuspid regurgitation11, congestive heart failure or fetal hydrops is difficult12,13, probably as a result of limited transplacental transfer of the antiarrhythmic drug14,15. In case of fetal hydrops, conversion rates are decreased and time to conversion is increased13. Treatment of sustained fetal tachycardia is therefore to be preferred above expectant management, although some centers oppose this regimen and suggest that in cases with (intermittent) fetal SVT not complicated by congestive heart failure or fetal hydrops, conservative management and close surveillance might be a reasonable alternative16,17,18

Fulmar Litter EcoQO Monitoring in the Netherlands 1979 - 2007 in relation to EU Directive 2000/59/EC on Port Reception Facilities

Operational and cargo related wastes from ships are an important source of litter in the marine environment in the southern North Sea and cause serious economical and ecological damage. Marine litter monitoring program using plastic abundance in stomachs of a seabird, the Northern Fulmar, was already operational in The Netherlands and was further developed also for international implementation by OSPAR as one of the 'Ecological Quality Objectives (EcoQOs)' for the North Sea (OSPAR 2008). Fulmars are purely oceanic foragers, ingest all sorts of litter from the sea surface, and do not regurgitate poorly degrading diet components, but slowly wear these down in the stomach. Accumulated hard plastic items in stomachs of beached Fulmars thus integrate marine litter levels encountered over a number of weeks in a particular area

Continuity of care for children with anorexia nervosa in the Netherlands:A modular perspective

Care provision for children with anorexia nervosa is provided by outpatient care teams in hospitals, but the way these teams are organized differs per hospital and hampers the continuity of care. The aim of this study is to explore the organization and continuity of care for children with anorexia nervosa in the Netherlands by using a modular perspective.We conducted a qualitative, exploratory case study and took the healthcare provision for children with anorexia nervosa, provided by outpatient care teams, as our case. We conducted nine interviews with healthcare professionals involved in outpatient care teams from six hospitals. A thematic analysis was used to analyze the data.The modular perspective offered insights into the work practices and working methods of outpatient care teams. We were able to identify modules (i.e. the separate consultations with the various professionals), and components (i.e. elements of these consultations). In addition, communication mechanisms (interfaces) were identified to facilitate information flow and coordination among healthcare professionals. Our modular perspective revealed gaps and overlap in outpatient care provision, consequently providing opportunities to deal with unnecessary duplications and blind spots.Conclusion: A modular perspective can be applied to explore the organization of outpatient care provision for children with anorexia nervosa. We specifically highlight gaps and overlap in healthcare provision, which in turn leads to recommendations on how to support the three essential parts of continuity of care: informational continuity, relational continuity, and management continuity

Developments in benthos and fish in gullies in an area closed for human use in the Wadden Sea : 2002-2016

In the eastern Dutch Wadden Sea an area was closed for anthropogenic bottom-disturbing activities in 2005. The ‘natural’ development of the fauna in gullies located within this area was monitored and compared with the development in gullies outside the closed area. Emphasis was put on sampling the benthic fauna (every autumn). Eleven years after closure (2016) the fish population was sampled again and additional benthic samples were taken, the sea floor was mapped and the fishing pressures were calculated. Preliminary results show that throughout the investigated period the open gullies were subject to moderate shrimp fishing pressures and that the closed gullies were not fished. Closure of the gullies has not yet led to the formation of biogenic structures on the seafloor, but has led to an increase in the species richness of small benthic fauna and to subtle changes in benthic species composition. Due to the limited availability of data it was not possible to detect statistically significant differences in the fish population. Sinds november 2005 is een klein deel van de Nederlandse Waddenzee gesloten voor (potentieel) schadelijke menselijke activiteiten. Het gebied ligt ten zuiden van Rottumerplaat en Rottumeroog en beslaat zo’n 7400 hectare. Doel van de sluiting is om de ongestoorde ontwikkeling van de natuur in de Waddenzee te kunnen volgen. Dit rapport beschrijft de tussentijdse resultaten, 11 jaar naar sluiting. In het monitorprogramma is de nadruk gelegd op veranderingen in de bodemfauna die jaarlijks en vanaf 2002 in het najaar bemonsterd worden. In 2016 zijn aanvullende bemonsteringen uitgevoerd. In dat jaar is de visgemeenschap herbemonsterd, zijn additionele bodemmonsters genomen gericht op het bemonsteren van de wat grotere organismen, zijn de karakteristieken van het bodemoppervlak in kaart gebracht en is de visserijdruk in het gebied berekend. Voorlopige resultaten laten zien dat in de open geulen garnalenvisserij heeft plaatsgevonden gedurende de hier bestudeerde periode en dat in de gesloten geulen geen visserij heeft plaatsgevonden na 2005. Sluiting van de geulen heeft nog niet geleid tot vestiging van biogene structuren. Wel is de soortenrijkdom toegenomen en hebben er zich subtiele veranderingen in bodemdiersamenstelling voorgedaan. Vanwege de beperkte hoeveelheid gegevens was het niet mogelijk om uitspraken te doen over veranderingen in de vispopulatie

Fulmar Litter EcoQO Monitoring in the Netherlands 1982-2005 in relation to EU Directive 2000/59/EC on Port Reception Facilities

De belangrijkste veroorzaker van zerfvuil op zee is de scheepvaart, die afval dumpt. Gezien de rol van de scheepvaart en de tekortkomingen in afgifteprocedures in de havens heeft de EU de "Richtlijn betreffende havenontvangstvoorzieningen" ingevoerd, de zogenaamde HOI richtlijn. Het monitoren van de effecten van de HOI richtlijn is noodzakelijk. In Nederland worden de trends in zwerfafval op zee gebaseerd op op de hoeveelheid in magen van dood aangespoelde zeevogels: de Noordse Stormvogel. Deze graadmeter wordt verder ontwikkeld als één van de EcoQO's (ecologische kwaliteitsdoelstellingen

Is there a role for CT coronary angiography in patients with symptomatic angina? Effect of coronary calcium score on identification of stenosis

Present guidelines discourage the use of CT coronary angiography (CTCA) in symptomatic angina patients. We examined the relation between coronary calcium score (CS) and the performance of CTCA in patients with stable and unstable angina in order to understand under which conditions CTCA might be a gate-keeper to conventional coronary angiography (CCA) in such patients. We included 360 patients between 50 and 70 years old with stable and unstable angina who were clinically referred for CCA irrespective of CS. Patients received CS and CCTA on 64-slice scanners in a multicenter cross-sectional trial. The institutional review board approved the study. Diagnostic performance of CTCA to detect or rule out significant coronary artery disease was calculated on a per patient level in pre-defined CS categories. The prevalence of significant coronary artery disease strongly increased with CS. Negative CTCA were associated with a negative likelihood ratio of <0.1 independent of CS. Positive CTCA was associated with a high positive likelihood ratio of 9.4 if CS was <10. However, for higher CS the positive likelihood ratio never exceeded 3.0 and for CS >400 it decreased to 1.3. In the 62 (17%) patients with CS <10, CTCA reliably identified the 42 (68%) of these patients without significant CAD, at no false negative CTCA scans. In symptomatic angina patients, a negative CTCA reliably excludes significant CAD but the additional value of CTCA decreases sharply with CS >10 and especially with CS >400. In patients with CS <10, CTCA provides excellent diagnostic performance