[Filters on diesel cars. Desirability of imposing exhaust filters on diesel cars in the Netherlands]

SAMENVATTING De centrale vraagstelling De reden voor de NVMM om de vraag te stellen, of het wetenschappelijk verantwoord is om te besluiten filters voor dieselauto’s verplicht te gaan stellen, kwam voort uit het actieplan van Duitse, Zwitserse en Oostenrijkse milieugroeperingen. Deze groeperingen wilden het dieselfilter bij hun overheden onder de aandacht brengen met de leuze: “Kein Diesel ohne Filter”. Onderzocht diende te worden of een dergelijke bewering wetenschappelijk onderbouwd kan worden. Uiteindelijk moet de vraag beantwoord worden, of het nodig is dat dieselfilters in Nederland verplicht gesteld worden. Hierover zullen we een advies geven. Nagenoeg alle beschouwde informatie van milieugroeperingen bevatte een uiteenzetting over de gezondheidseffecten van PM10 (fijn stof). Dit komt doordat filters zich juist richten op het wegvangen van deze stoffen uit de uitlaatgassen. Hoewel dieseluitstoot duizenden componenten bevat, concentreert men, om bovenstaande reden, de aandacht nagenoeg volledig op de PM10-uitstoot. In dit rapport is bovendien een uitgebreide literatuurstudie verricht naar andere mogelijk verdachte componenten van de dieseluitstoot. De resultaten van deze literatuurstudie zijn in dit rapport opgenomen. Benodigde informatie om tot een standpunt te komen Om een tot een antwoord op de centrale vraagstelling te komen, is deze opgesplitst in verschillende deelvragen. Door beantwoording van de deelvragen is getracht een zo breed en duidelijk mogelijk beeld te schetsen omtrent dieselfilters. In de hoofdstukken van het rapport worden de verschillende aspecten, die komen kijken bij dieselfilters, besproken. In de inleiding wordt een schets gegeven van het wagenpark in Nederland en de daar uit voortkomende verontreiniging. In hoofdstuk 4 wordt in een overzicht gegeven van luchtverontreiniging als gevolg van dieselemissies. In hoofdstuk 5 worden gezondheidseffecten besproken, die het gevolg zijn van blootstelling aan luchtverontreiniging, met name fijn stof. In hoofdstuk 6 wordt een overzicht gegeven van de normstelling op nationaal en internationaal vlak. Hoofdstuk 7 is geheel gewijd aan het technisch aspect van het dieselfilter. Hoofdstuk 8 gaat over de effecten op de immissie, die het invoeren van het dieselfilter met zich meebrengt. In hoofdstuk 9 wordt getracht een kosten-baten analyse van het invoeren van dieselfilters uiteen te zetten. Na deze stappen worden in hoofdstuk 10 conclusies getrokken en aanbevelingen gedaan. Het uiteindelijke standpunt Na bestudering van de literatuur zijn wij tot de conclusie gekomen dat dieseluitstoot reden geeft tot bezorgdheid. Hoewel vele verdachte stoffen aangetoond zijn in dieselemissies, hebben studies naar de gezondheidseffecten laten zien dat effecten pas optreden bij concentraties, die veel malen hoger liggen dan gemiddelde concentraties in de atmosfeer. Epidemiologisch onderzoek heeft echter aangetoond dat er een waarneembaar verband bestaat tussen toename van de PM10-blootstelling en verhoging van het sterftecijfer. Dieselvoertuigen blijken daarin een belangrijke rol te spelen. Door de Europese Unie zijn al normen met betrekking tot dieselemissies ingevoerd. Per 1 oktober 2005 zal de Euro 4 norm van kracht zijn. Deze zal onder andere de maximaal toegestane PM10-emissie van nieuwe dieselvoertuigen met een factor 5 omlaag stellen. De nieuwe normstelling zal niet haalbaar zijn zonder extra voorzieningen, zoals bijvoorbeeld het dieselfilter. De conclusie is dat het huidige wagenpark dieselvoertuigen niet voldoet aan de toekomstige eisen, waardoor filtering of andere voorzieningen een onontkoombaar gevolg zullen zijn. Het advies dat wij geven naar aanleiding van dit rapport is het toepassen van dieselfilters te stimuleren. De kosten van filters zijn nu nog hoog: circa 6000 euro. Bij grootschalige toepassing, door onder andere stimulerende maatregelen van de overheid, kunnen de kosten een factor 10 dalen. Een wenselijke maatregel is het verplicht stellen van dieselfilters per 1 oktober 2005. Vooral voor auto’s tot 5 jaar oud is dit van belang, aangezien deze groep nog de langste verwachte levensduur heeft. Een tweede maatregel die wij adviseren is om alle auto’s die voldoen aan de Euro 4 norm, korting te bieden op de dieseltoeslag in de wegenbelasting. Dat zou tot gevolg kunnen hebben dat ook oudere auto’s gestimuleerd worden tot het monteren van een filter

Toenail selenium status and the risk of Barrett’s esophagus: the Netherlands Cohort Study

Objective: To investigate the association between selenium and the risk of Barrett's esophagus (BE), the precursor lesion of esophageal adenocarcinoma. Methods: Data from the prospective Netherlands Cohort Study were used. This cohort study was initiated in 1986, when 120,852 subjects aged 55-69 years completed a questionnaire on dietary habits and lifestyle, and provided toenail clippings for the determination of baseline selenium status. After 16.3 years of follow-up, 253 BE cases (identified through linkage with the nationwide Dutch pathology registry) and 2,039 subcohort members were available for case-cohort analysis. Cox proportional hazards models were used to calculate incidence rate ratios (RR). Results: The multivariable-adjusted RR for the highest versus the lowest quartile of toenail selenium was 1.06 (95% CI 0.71-1.57). No dose-response trend was seen (p trend = 0.99). No association was found in subgroups defined by sex, smoking status, body mass index (BMI), or intake of antioxidants. For BE cases that later progressed to high-grade dysplasia or adenocarcinoma, the RR for a selenium level above the median vs. below the median was 0.64 (95% CI 0.24-1.76). Conclusions: In this large prospective cohort study, we found no evidence of an association between selenium and risk of BE. © 2010 The Author(s)

Treatment with curative intent of stage III non-small cell lung cancer patients of 75years: A prospective population-based study

AbstractBackgroundThere is little data on the survival of elderly patients with stage III non-small cell lung cancer (NSCLC).MethodsPatients with stage III NSCLC in the Netherlands Cancer Registry/Limburg from January 1, 2002 to December 31, 2008 were included.FindingsOne thousand and two patients with stage III were diagnosed, of which 237 were 75years or older. From 228 patients, co-morbidity scores were available. Only 33/237 patients (14.5%) had no co-morbidities, 195 (85.5%) had one or more important co-morbidities, 60 (26.3%) two or more co-morbidities, 18 (7.9%) three or more co-morbidities and 2 patients (0.9%) suffered from four co-morbidities. Forty-eight percent were treated with curative intent. No significant difference in Charlson co-morbidity, age or gender was found between patients receiving curative or palliative intent treatment. Treatment with curative intent was associated with increased overall survival (OS) compared to palliative treatment: median OS 14.2 months (9.6–18.7) versus 5.2months (4.3–6.0), 2-year OS 35.5% versus 12.1%, for curative versus palliative treatment.Patients who received only radiotherapy with curative intent had a median OS of 11.1months (95% confidence interval [95% CI] 6.4–15.8) and a 5-year OS of 20.3%; for sequential chemotherapy and radiotherapy, the median OS was 18.0months (95% CI 12.2–23.7), with a 5-year OS of 14.9%. Only four patients received concurrent chemo-radiation.InterpretationIn this prospective series treating elderly patients with stage III NSCLC with curative intent was associated with significant 5-year survival rates

Vegetables and fruits consumption and risk of esophageal and gastric cancer subtypes in the Netherlands Cohort Study

Prospective epidemiologic data on vegetables and fruits consumption and risk of subtypes of esophageal and gastric cancer are sparse. We studied the association between vegetables and fruits consumption and risk of esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), gastric cardia adenocarcinoma (GCA) and gastric noncardia adenocarcinoma (GNCA) in the Netherlands Cohort Study. In 1986, 120,852 Dutch men and women aged 55-69 filled out a questionnaire on diet and other cancer risk factors. After 16.3 years of follow-up, 101 ESCC, 144 EAC, 156 GCA, 460 GNCA cases and 4,035 subcohort members were available for case-cohort analysis using Cox proportional hazards models. Multivariable adjusted incidence rate ratios (RRs) were generally below unity. Total vegetable consumption was nonsignificantly inversely associated with EAC and ESCC risk, but not with GCA and GNCA risk. Significant inverse associations were observed for raw vegetables and EAC risk [RR per 25 g/day: 0.81, 95% confidence interval (CI) 0.68-0.98], and Brassica vegetables and GCA risk (RR per 25 g/day: 0.72, 95% CI 0.54-0.95). Total fruit consumption was associated with a nonsignificantly decreased EAC risk. Citrus fruits were inversely associated with EAC and GCA risk (RRs for highest vs. lowest intake: 0.55, 95% CI 0.31-0.98 and 0.38, 95% CI 0.21-0.69, respectively). Specifically for current smokers, vegetables and possibly also fruits intake was inversely associated with ESCC and EAC risk. Consumption of (specific groups of) vegetables and fruits may protect against subtypes of esophageal and gastric cancer. Copyright © 2011 UICC

Trends in incidence of oesophageal and stomach cancer subtypes in Europe

Objective Time trend studies in the USA have shown that the incidences of adenocarcinomas of the oesophagus and gastric cardia have risen strongly since the 1970s, whereas the incidence of squamous cell carcinomas of the oesophagus has declined. Earlier, we found that the incidence of these adenocarcinomas also rose in some European countries until the early 1990s. The main goal of this study was to investigate more recent trends in the incidence of oesophageal and stomach cancer subtypes in the European countries. Methods Eurocim cancer incidence data of 23 cancer registries from 13 European countries were used to investigate the incidence trends in oesophageal and stomach cancer subtypes during the 1983-1997 period. We calculated estimated annual percentage changes (EAPCs) in European age-standardized incidence rates and 95% confidence intervals. Results The incidence of adenocarcinomas of the oesophagus and gastric cardia rose in most, but not all, registration areas (EAPCs were usually 1-7%), the strongest in the UK and Ireland. Oesophageal squamous cell carcinoma incidence rose mostly in Northern European and Slovakian men (EAPCs: 1-5%) and in women from all regions (EAPCs: 1-8%), but declined mostly in Southern and Western European men (EAPCs: -1 to -5%). Conclusion Our results are partly in line with earlier findings on adenocarcinomas of the oesophagus and gastric cardia. There was, however, substantial heterogeneity in trends of subtypes of these cancers within Europe. There may be different risk factors for these cancers, and the prevalence of these risk factors may differ among countries. Eur J Gastroenterol Hepatol 22:669-67

Substitution of outpatient care with primary care: a feasibility study on the experiences among general practitioners, medical specialists and patients

BACKGROUND: Reinforcing the gatekeeping role of general practitioners (GPs) by embedding specialist knowledge into primary care is seen as a possibility for stimulating a more sustainable healthcare system and avoiding unnecessary referrals to outpatient care. An intervention called Primary Care Plus (PC+) was developed to achieve these goals. The objective of this study is to gain insight into: (1) the content and added value of PC+ consultations according to stakeholders, and (2) patient satisfaction with PC+ compared to outpatient care. METHODS: A feasibility study was conducted in the southern part of the Netherlands between April 2013 and January 2014. Data was collected using GP, medical specialist and patient questionnaires. Patient characteristics and medical specialty data were collected through the data system of a GP referral department. RESULTS: GPs indicated that they would have referred 85.4 % of their PC+ patients to outpatient care in the hypothetical case that PC+ was not available. Medical specialists indicated that about one fifth of the patients needed follow-up in outpatient care and 75.9 % of the consultations were of added value to patient care. The patient satisfaction results appear to be in favour of PC+. CONCLUSION: PC+ seems to be a feasible intervention to be implemented on a larger scale, because it has the potential to prevent unnecessary hospital referrals. PC+ will be evaluated on a larger scale regarding the effects on health outcomes, quality of care and costs (Triple Aim principle)

A Prospective Cohort Study on Overweight, Smoking, Alcohol Consumption, and Risk of Barrett's Esophagus

Background: Barrett's esophagus (BE) is a precursor lesion of esophageal adenocarcinoma. Besides gastroesophageal reflux, possible risk factors for BE include overweight, cigarette smoking, and alcohol consumption. Our objective was to study these associations by using prospective data. Methods: The prospective Netherlands Cohort Study, initiated in 1986, consists of 120,852 men and women, aged 55 to 69 years at baseline. At baseline, all subjects completed a questionnaire on dietary habits and lifestyle. After 16.3 years of follow-up, 370 BE cases with specialized intestinal metaplasia and 3,866 subcohort members were available for case-cohort analysis. Cox proportional hazards models were used to calculate incidence rate ratios (RR) and 95% CIs. Results: Body mass index (BMI) at baseline was associated with risk of BE in women [multivariable adjusted RR per 1 kg/m2, 1.07 (1.03-1.11)] but not inmen [RR per 1 kg/m2, 0.99 (0.93-1.05)]. The association in women was not specifically due to abdominal overweight. Former cigarette smokers were at increased risk of BE (RR = 1.33, 95% CI: 1.00-1.77), but current smokers were not. Smoking duration showed a positive association with BE risk (Ptrend = 0.03). For alcohol consumption, the RR per 10 g ethanol/d was 0.95 (0.87-1.03). Conclusions: Increased BMI was a risk factor for BE in women but not in men. Several aspects of cigarette smoking were positively associated with BE risk. Alcohol consumption was not associated with an increased risk of BE. Impact: Future research should focus on risk factors both for development and for progression of BE to esophageal adenocarcinoma. ©2010 AACR