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Dit rapport geeft een tussentijds overzicht van ‘state of the art’ kennis uit lopend onderzoek van het consortium ‘Climate Proof Fresh Water Supply’ (CPFWS) dat in het kader van het onderzoeksprogramma Kennis voor Klimaat wordt uitgevoerd. De focus van dit onderzoek naar een klimaatbestendige zoetwatervoorziening ligt op lokale en regionale oplossingen in Laag Nederland voor land- en tuinbouw en natuur. De zoetwatervoorziening van dit gebied wordt naast droogte vooral bedreigd door verzilting van grond- en oppervlaktewater. In zes samenhangende werkpakketten wordt geanalyseerd hoe dit gebied meer zelfvoorzienend kan worden én hoe aanpassingen in het (hoofd)watersysteem kunnen bijdragen aan de watervoorziening van het gebied. Centraal in de aanpak zijn een 3-tal casestudies in de Hotspots Haaglanden, Rotterdam Regio en Zuidwestelijke delta.

OBJECTIVE : To study the effectiveness and safety of induction of labour with a Foley catheter compared with vaginal prostaglandin E2 gel in full term pregnant women. DESIGN : Multicentre, randomised, open-label trial in 12 hospitals in the Netherlands between February 2009 and May 2010. METHODS : Women scheduled for induction of labour at full term singleton pregnancy in cephalic presentation, intact membranes, and an unripe cervix (Bishop score < 6) were enrolled by means of an on-line system. Participants were randomly allocated to induction of labour with a transcervical Foley catheter or vaginal prostaglandin E2 gel. The primary outcome was caesarean section rate. Secondary outcomes were maternal and neonatal morbidity and time from induction to birth. RESULTS : A total of 824 women were allocated to induction of labour with a Foley catheter (n = 412) or prostaglandin E2 (n = 412). Caesarean section rates were comparable (23% versus 20%, RR 1.13, 95% CI 0.87 to 1.47). In the Foley catheter group fewer instrumental deliveries for foetal distress were performed (12% versus 18%, RR 0.68, 95% CI 0.49 to 0.95). Time to delivery (median hours (IQR)) was longer (29 (15-35) versus 18 (12-33)). Fewer mothers had suspected intrapartum infection (2% versus 4%, RR 0.41, 95% CI 0.17-0.98). Significantly fewer neonates were admitted toaneonatal ward after induction with a Foley catheter (12% versus 20%, RR 0.60, 95% CI 0.43 to 0.83). CONCLUSION : In women with an unripe cervix at term, induction of labour with a Foley catheter does not reduce caesarean section rates, but there are fewer side-effects

Since the clinical diagnosis of pulmonary embolism is unreliable, various objective diagnostic methods (or combinations thereof) are advocated. Pulmonary angiography is the accepted reference method but is considered less suitable for initial screening due to its invasive nature. Therefore, at least nine different diagnostic management strategies employing invasive and noninvasive diagnostic tests are used in clinical practice. We assessed the cost-effectiveness of these strategies to help identify the optimal approach. Based on assumptions derived from published data, we calculated mortality, morbidity, adequacy for the indication of anticoagulant therapy, and associated diagnostic and therapeutic costs using a decision analytic model. Additionally, a cost-effectiveness analysis was performed using incremental costs per additional life saved. The analysis identified three separate categories of diagnostic management strategies: (1) Treatment of all patients (or of those with an abnormal perfusion scan) results in the lowest mortality and morbidity rates but the highest costs due to inappropriate treatment of 55% to 70% of patients. (2) Pulmonary angiography strategies with or without prior perfusion-ventilation lung scintigraphy and ultrasonography of the legs have comparable low mortality and morbidity rates, costs savings of approximately 40%, and inappropriate treatment in fewer than 5% of patients. (3) Use of perfusion-ventilation scintigraphy with or without ultrasonography results in unacceptably high mortality rates. At present, the optimal diagnostic management strategy should include pulmonary angiography. Use of perfusion-ventilation lung scintigraphy and ultrasonography results in a 40% to 50% reduction in the number of patients requiring pulmonary angiography and is cost-effective

Recent scenario studies on water management focus on one or two projection years and the effects on the water system and functions. The future is however more complex and dynamic. Therefore, we analyse transient scenarios in order to evaluate the performance of water management strategies. Current available simulation tools are not suitable for this purpose. Therefore, we have developed and used a tool to simulate 50-100 year long time series and that is good and fast enough to simulate the effects of these scenarios and strategies on the water system and the interaction with the human system. We present the first step by means of a case study.

The Netherlands Center for River Research (NCR) in its first 10 years of existence has focused its activities on flooding. Climate change might cause that droughts will become as important as or even more important than floods. The dry year 2003 in Europe has shown the huge socio-economic impacts of droughts. New concepts are emerging on how to deal with droughts. This key-note addresses the issues of droughts and scarcity and makes a plea to include more drought research in NCR.

Background\ud \ud Ultrasound (US) has largely replaced contrast venography as the definitive diagnostic test for deep vein thrombosis (DVT). We aimed to derive a definitive estimate of the diagnostic accuracy of US for clinically suspected DVT and identify study-level factors that might predict accuracy.\ud \ud Methods\ud \ud We undertook a systematic review, meta-analysis and meta-regression of diagnostic cohort studies that compared US to contrast venography in patients with suspected DVT. We searched Medline, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, the ACP Journal Club, and citation lists (1966 to April 2004). Random effects meta-analysis was used to derive pooled estimates of sensitivity and specificity. Random effects meta-regression was used to identify study-level covariates that predicted diagnostic performance.\ud \ud Results\ud \ud We identified 100 cohorts comparing US to venography in patients with suspected DVT. Overall sensitivity for proximal DVT (95% confidence interval) was 94.2% (93.2 to 95.0), for distal DVT was 63.5% (59.8 to 67.0), and specificity was 93.8% (93.1 to 94.4). Duplex US had pooled sensitivity of 96.5% (95.1 to 97.6) for proximal DVT, 71.2% (64.6 to 77.2) for distal DVT and specificity of 94.0% (92.8 to 95.1). Triplex US had pooled sensitivity of 96.4% (94.4 to 97.1%) for proximal DVT, 75.2% (67.7 to 81.6) for distal DVT and specificity of 94.3% (92.5 to 95.8). Compression US alone had pooled sensitivity of 93.8 % (92.0 to 95.3%) for proximal DVT, 56.8% (49.0 to 66.4) for distal DVT and specificity of 97.8% (97.0 to 98.4). Sensitivity was higher in more recently published studies and in cohorts with higher prevalence of DVT and more proximal DVT, and was lower in cohorts that reported interpretation by a radiologist. Specificity was higher in cohorts that excluded patients with previous DVT. No studies were identified that compared repeat US to venography in all patients. Repeat US appears to have a positive yield of 1.3%, with 89% of these being confirmed by venography.\ud \ud Conclusion\ud \ud Combined colour-doppler US techniques have optimal sensitivity, while compression US has optimal specificity for DVT. However, all estimates are subject to substantial unexplained heterogeneity. The role of repeat scanning is very uncertain and based upon limited data.\ud \ud

Water resources contribute greatly to human well being, both directly and indirectly. Water resources are irreplaceable natural resources, and are limited. However, due to a growing population and related economic development, the water demand from urban, industry and agriculture has increased dramatically. Water shortage has become one of the most severe problems of the Yellow River basin, and has become a major constraint for the social and economic development of the region. It is well known that water demand management methods aim at applying economic incentives to reduce the consumption of water and to encourage conservation and protection of water resources. Water pricing, an important part of demand management, has been identified as a major solution to deal with water scarcity. Water is widely recognized to be, an economic good. But, in many cases the existing price for consumers is much less than the cost of production. Because these subsidies have traditionally been in place, the water price has never been connected to the actual cost by the government or local authorities. Consequently Water pricing reforms are strongly recommended in the Yellow River basin. One of the most important issues of water pricing reform is to set a rational price. Alot of discussion is going on about how to calculate the water price and which factors should be taken into account. There are many factors playing an important role in the economic valuation of water. Besides water supply cost and operation and maintenance cost, it has to take into account such factors as the intrinsic value of water, environment effects, sustainabihty, affordability of consumers, and so on. Based on above principles, the following topics were analyzed systemically in this study. These topics included: (1) water demand management and the role of water pricing, (2) the present situation of water price system and existing problems in Yellow River basin, (3) the value of water - theory and applications in other countries, (4) full cost recovery and analysis of factors effecting the water price, (5) WRM principles and consequences for water pricing, (6) a case study on a water supply project in the Lower Yellow River, (7) legal and institutional procedures for water pricing, and finally, providing a conclusion and recommendations. This study has set up the concept of Full Cost Recovery for the pricing of water supply. Putting forward Full Cost Water Pricing should include three parts: resource cost, engineering cost and environmental cost. A theoretical framework was developed to solve the problems of the calculation of full cost water price. This theoretical framework has been applied to a case study for irrigation district on the lower Yellow River. Due to limitations of data availability, different assumptions have been made during the case study, which should be further improved and refined. With detailed field studies and data analysis, this study could be helpful for the development of the water pricing reform for the Yellow River and support YRCC in this aim to come to a more integrated management of the water resources in the basin.

To determine to what extent the 'non-diagnostic' lung scans made because of a clinical suspicion of pulmonary embolism enable further determination of the risk of pulmonary embolism. Retrospective. All non-diagnostic lung perfusion ventilation scans made in the Academic Medical Centre of Amsterdam in 1997 of 114 patients in succession (55 males and 59 females aged 27-85 years) were subjected to blind and independent re-evaluation by three observers (an experienced nuclear medicine expert, an experienced and an inexperienced intern) who, using a lung segment chart, estimated the risk of embolism as 75%. They did this first without and then with the chest X-ray. The findings were grouped on the basis of accordance or non-accordance with the pulmonary angiogram. The interobserver agreement was calculated by means of kappa statistics. Of 58 patients the lung scan could be compared with a chest X-ray and a pulmonary angiogram. In 43 patients with a normal angiogram the observers in an average of 50% of the scans estimated the risk of pulmonary embolism as 75% in 5%. In 15 patients with a deviant pulmonary angiogram, these figures were 22%, 38%, 20%, and 12%, respectively. The interobserver kappa for evaluation without chest X-ray was

BACKGROUND AND PURPOSE: Previous studies have shown that clinical localization of trigeminal nerve lesions is inaccurate as compared with MR imaging findings. The purpose of our study was to ascertain the added value of electromyographic (EMG) investigation of the trigeminal nerve reflexes for the improvement of lesion localization and for the preselection of patients for MR imaging. METHODS: We reviewed the EMG studies of the trigeminal reflexes and the MR imaging studies of 20 patients with unilateral symptoms and signs related to the trigeminal nerve (40 trigeminal nerves examined). The results of the two studies were compared to assess the value of EMG in predicting MR imaging outcome. Lesion localization as demonstrated by EMG was compared with localization at MR imaging. MR imaging was used as the standard of reference. RESULTS: Eight (40%) of 20 patients had MR imaging findings related to presenting trigeminal symptoms, including five brain stem lesions and three peripheral lesions. Fourteen (70%) of 20 patients had EMG abnormalities related to presenting symptoms and signs. For brain stem lesions, lesion localization as shown by EMG corresponded well with MR imaging findings. EMG yielded a sensitivity of 100%, a specificity of 81%, a positive predictive value of 57%, and a negative predictive value of 100% in predicting MR imaging results. Interobserver agreement was good for both the EMG reflex and MR imaging examinations. CONCLUSION: Our data suggest that EMG recordings of the trigeminal reflexes can be used to exclude structural lesions in patients with symptoms related to the trigeminal nerve. When a lesion is localized in the brain stem with EMG, a tailored MR imaging examination of this region may be sufficient

In contrast to the development of new drugs, strict guidelines for the development of new diagnostic methods do not exist. A diagnostic test can be made available without proper evaluation of its clinical utility, which can lead to its premature introduction and inappropriate use. In this review suggestions are made regarding the criteria that should be met during the various phases of development of new diagnostic techniques. It is suggested that a new diagnostic test should only be implemented in routine clinical use after all phases of development have been properly performed with good results. Several diagnostic tests for pulmonary embolism (pulmonary angiography, ventilation-perfusion scintigraphy, D-dimer assays, and spiral computed tomography), and the studies evaluating them, are thereafter reviewed. It is concluded that present pulmonary angiography and ventilation-perfusion scintigraphy are the only properly evaluated diagnostic tests for pulmonary embolism. Although new developments, such as D-dimer assays and the spiral computed tomographic scan are certainly promising, further studies are needed to determine their real value and safety in the diagnostic work-up of patients suspected of pulmonary embolism

To determine the clinical outcomes for patients with suspected pulmonary embolism, we studied 487 consecutive patients after they received appropriate diagnostic management and routine heparin and oral anticoagulant therapy. Pulmonary embolism was confirmed, excluded, or remained uncertain in 193, 242, and 51 patients, respectively. During the 6-month follow-up period, 7 patients (3.3%) bad serious bleeding complications, 2 of which were fatal. Recurrent pulmonary embolism was shown in 0.9% to 2.6% of patients in whom it was initially ruled out or confirmed. Overall mortality was 11% for patients without pulmonary embolism, 28% for those with an uncertain diagnosis, and 17% in those with a confirmed diagnosis. Death was related to pulmonary embolism in 5%.