Early surgery prolongs professional activity in IDH mutant low-grade glioma patients: a policy change analysis

BackgroundUntil 2015, Dutch guidelines recommended follow-up and biopsy rather than surgery as initial care for suspected low-grade gliomas (LGG). Given evidence that surgery could extend patient survival, our center stopped following this guideline on January 1, 2010 and opted for early maximal safe resection of LGG. The effects of early surgery on the ability of patients to work remains little documented. MethodsA total of 104 patients operated on at our center between January 2000 and April 2013 and diagnosed with the WHO 2016 grade 2 astrocytoma, IDH mutant or oligodendroglioma, IDH mutant and deleted 1p19q were included. The clinical characteristics, survival, and work history of patients operated on before or after January 2010 were obtained from the patients' records and compared. The minimal follow-up was 8 years. ResultsAs per policy change, the interval between radiological diagnosis and first surgery decreased significantly after 2010. Likewise, before 2010, 25.8% of tumors were initially biopsied, 51.6% were resected under anesthesia, and 22.5% under awake conditions versus 14.3%, 23.8%, and 61.9% after this date (p < 0.001). The severity of permanent postoperative neurological deficits decreased after 2010. In total, 82.5% of the patients returned to work postoperatively before 2010 versus 100% after 2010. The postoperative control of epilepsy increased significantly after 2010 (74.4% vs. 47.9%). The median time from diagnosis to a definitive incapacity to work increased by more than 2 years after 2010 (88.7 vs. 62.2 months). ConclusionA policy shift towards early aggressive surgical treatment of IDH mutant LGG is safe and prolongs the patients' ability to work

Fractional flow reserve guided percutaneous coronary intervention optimization directed by high-definition intravascular ultrasound versus standard of care

Background Post percutaneous coronary intervention (PCI) fractional flow reserve (FFR) is a significant predictor of major adverse cardiac events (MACE). The rationale for low post procedural FFR values often remains elusive based on angiographic findings alone, warranting further assessment using an FFR pullback or additional intravascular imaging. It is currently unknown if additional interventions intended to improve the PCI, decrease MACE rates. Study design The FFR REACT trial is a prospective, single-center randomized controlled trial in which 290 patients with a post PCI FFR b0.90 will be randomized (1:1) to either standard of care (no additional intervention) or intravascular ultrasound (IVUS)-directed optimization of the FFR (treatment arm). Eligible patients are those treated with angiographically successful PCI for (un)stable angina or non-ST elevation myocardial infarction (MI). Assuming 45% of patients will have a post PCI FFR b0.90, approximately 640 patients undergoing PCI will need to be enrolled. Patients with a post PCI FFR ≥ 0.90 will be enrolled in a prospective registry. The primary end point is defined as a composite of cardiac death, target vessel MI and clinically driven target vessel revascularisation (target vessel failure) at 1 year. Secondary end points will consist of individual components of the primary end point, procedural success, stent thrombosis and correlations on clinical outcome, changes in post PCI Pd/Pa and FFR and IVUS derived dimensions. All patients will be followed for 3 years. Conclusion The FFR-REACT trial is designed to explore the potential benefit of HD-IVUS-guided PCI optimization in patients with a post PCI FFR b0.90 (Dutch trial register: NTR6711). (Am Heart J 2019;213:66-72.

The multi-layer safety approach and geodesign: exploring exposure and vulnerability to flooding

Lately, flood risk reducing measures can be assessed quicker and more precise due to increasing computing power and advanced conceptualization of geo-information and geodesign. For flood risk, the multi-layer safety approach is developed to support analysis and assessment of preventive and impact reducing measures. In this multi-layer safety approach, risk is calculated as probability of occurrence of a flood times the consequences of a flooding. The impact of a flooding equals the exposure of capital and people in the flood risk area times the vulnerability for flooding of capital and people. Complexity of flood risk reduction increases when flood risk managers incorporate these consequences. The use of geodesign to assess flood risk reducing measures in such a complex approach, is highly beneficial. We conceptualize flood risk consequences to illustrate the use of geodesign, and calculate inundation depth, velocity and timing of a flood at specific locations in the case ‘Rivierenland’. We assess evacuation possibilities, safety on first and second floors of health care institutions and effects of flood arrival times on evacuation capacity planning. Even the rough information provided by our case gives flood risk managers essential insight in the timing and impact of flooding events, and the possibilities to timely and effectively evacuate healthcare institutions. Advancement of geo-information and geodesign provides the opportunity to design more effective capacity planning schemes, to improve decisions about evacuation strategies and to a more robust design of buildings and critical (infra)structures with respect to flood risk

The replacement of hydraulic structures in light of tipping points

In many delta areas hydraulic structures are key elements in water management strategies for fresh water supply and flood risk management. Adaptation of delta areas to changing climatological and societal conditions will be in pace with the renovation and replacement of these hydraulic structures. Since hydraulic structures are prone to deterioration, their performance diminishes over time. Changes in society, the economy, and the physical environment can also alter the functionality of structures, or have an impact on their performance. Although faced with deterioration and exogenous changes, timing of replacement is essential because replacing too early leads to insufficient use of invested capital, while replacing too late leads to loss of societal benefits. This article explores the timing of replacement using adaptation tipping points. We indicate three drivers – deterioration, biophysical change, and socio-economic change – that determine the moment in time when replacement becomes necessary. Moreover, we conclude that for determining the moment of replacement, at the very least, the objectives, maintenance and operations of hydraulic structures need to be taken into account. This exploration is illustrated with the task of replacing seven hydraulic structures in the River Meuse.</p