Combining safety and nature: a multi-stakeholder perspective on integrated floodplain management.

In The Netherlands, river management strategies and land use of floodplains have changed drastically over the last two decades. Due to an integrated and participatory planning style, many agricultural fields in floodplains were transformed to nature. The idea of "self-regulating nature" in the floodplains and policies such as Room for the River and WaalWeelde created more multifunctional and natural floodplains. In this way, during the planning phase, win-win situations were created between flood protection and nature. It was only later that obstacles occurred with regard to the maintenance of floodplains, mainly because of different perspectives of the stakeholders on how to reconcile flood protection and nature. Therefore this study focuses on the opinions of persons involved with 'future' floodplain management strategies, which have been divided into five themes: ·visions of floodplain management; ·collaborators in floodplain management; ·visions of nature and self-regulating nature; ·realization of Natura 2000 goals in floodplains; ·feasibility of the Cyclic Floodplain Rejuvenation (CFR) strategy. We interviewed various persons involved in river and nature management along the Waal River. Based on our findings, it is concluded that an integrated planning approach has not been incorporated into the maintenance strategies and programs and, as a result, new, innovative management strategies such as CFR are proving to be incompatible with 'static' regulations such as Natura 2000's conservation goals and flood protection norms. However, by exploring the responders' visions of nature, we found that the majority of them preferred a dynamic vision of floodplains and, for this reason, they have advocated for more flexibility in current policies related to river and nature management. Additionally, the respondents emphasized the importance of multi-stakeholder collaboration to realize the goal of cost-efficient floodplain management.

Primary aortoenteric fistula: report of six new cases.

Primary aortoenteric fistula (PAEF) is defined as a communication between the native aorta and the gastrointestinal tract, in contrast to secondary fistulas, which arise between a suture line of a vascular graft and the intestine. Arteriosclerosis is the predominant cause of PAEF and accounts for more than two-thirds of the cases reported. The pathogenesis is usually based on direct adhesion of a segment of the gastrointestinal tract to an aortic aneurysm, followed by progressive erosion through the bowel wall. The clinical presentation is usually one of intermittent gastrointestinal haemorrhage resulting in lethal exsanguination. Pain in the abdomen, a pulsatile abdominal mass or fever may be present. The choice of various diagnostic procedures is often decided by the clinical presentation. Esophagogastroduodenoscopy, ultrasound and CT scan may be useful in the evaluation of these patients. Current recommendations for repair include debridement of the aneurysmal aorta, repair with an in situ graft and primary repair of the gastrointestinal tract, followed by aggressive antimicrobial therapy. We present six cases of PAEF surgically treated at the St. Radboud Hospital, the Canisius Wilhelmina Hospital in Nijmegen and the Lukas Hospital in Apeldoorn over a period of 15 years.

[Atrial fibrillations: daily occurrence possibly leading to embolism in an extremity]. / Boezemfibrilleren: alledaags, maar mogelijk leidend tot embolisatie naar een extremiteit.

A 64-year old woman had been tired and short of breath for the previous few months. During the past few days she had experienced disruptions in the movement and feeling of the right arm and both feet as well as a loss of strength and a heavy feeling in her right leg. Due to atrial fibrillation she had recently started using digoxin and due to possible arterial embolisms in the extremities she had recently started using acenocoumarol. Further investigations revealed one large thrombus in the left atrium, two large thrombi in the left auricle and a serious constriction in the right iliac artery. The thrombi were treated with heparin and oral anticoagulants; the ischaemia which probably occurred as a result of this was successfully treated with embolectomy. After the cardiac thrombi had disappeared, the patient was electrically converted to sinus rhythm. One month later, the patient was still in sinus rhythm and her clinical picture had improved. As she does not feel the atrial fibrillation, she will be permanently maintained on oral anticoagulants. In patients with atrial fibrillations, the possibility of an embolisation towards the extremities deserves serious consideration.

Wound infection after arterial surgical procedures.

During the period October 1983 to March 1987, 603 patients who underwent arterial surgical procedures were studied to determine the incidence and treatment of wound infections. Bypass procedures were performed in 395 patients (65.5%), in which autogenous vein was used for 158 grafts (26%), synthetic Dacron for 216 grafts (36%), and umbilical vein for 21 grafts (3.5%). Thrombo-endarterectomies, embolectomies and patch-grafts were performed in 208 patients (34.5%). An Infection Control Nurse examined and registered the wounds. The definition of wound infection used in our study is equivalent to Szilagyi grade II infection. Vascular surgery is classified as clean surgery, the clean wound infection rate being a useful measurement to evaluate preventative measures and surgical technique. Thirty-one patients (5.1%) developed a wound infection as a postoperative complication. The overall incidence of wound complications including haematoma and seroma following arterial reconstruction was 13%. The site of wound infection was predominantly the groin. The most common pathogen was Staphylococcus aureus which was found in 17 patients (2.8%). All infections resolved without further surgical intervention. The influence of possible aetiological factors is considered and the importance of prophylactic antibiotics and good surgical technique is stressed.

Bone lead in dialysis patients.

We measured lead and calcium in multiple bone biopsies from 11 cadavers without known excessive past exposure to lead. Paired iliac crest, transiliac and tibial bone biopsies from these cadavers indicated that in bone biopsy specimens the lead/calcium ratio is more reproducible than the absolute lead concentration. There were no significant differences between the lead/calcium ratios from the iliac crest, transiliac, or tibial specimens. Transiliac bone biopsies from 35 patients (13 patients showing symptoms of slight or moderate degree of renal failure, medical history of gout and/or arterial hypertension and 22 lead workers with chelatable lead in excess of 1000 micrograms) indicated that the lead and the lead/calcium ratio in bone biopsies reflect body lead stores as estimated by the EDT A test (r = 0.87 and 0.83, respectively). Chemical and histological studies of transiliac biopsies previously obtained from 153 dialysis patients (from 8 dialysis centers from Belgium, France and Germany) for studies of aluminum-induced bone disease showed that chronic renal failure and dialysis do not cause accumulation of lead in bone and elevated bone lead does not appear to alter trabecular bone histomorphometry. We found that in 5% of the hemodialysis population studied, bone lead concentrations approximated levels found in active lead workers.

Progressive pneumoperitoneum as preoperative preparation for large hernial repair in patients with severe chronic obstructive lung disease.

The results of operation in four patients with a large hernia associated with severe chronic obstructive lung disease show the advantages and limitations of a preparatory progressive pneumoperitoneum. If carefully employed, it seems possible to repair very large hernias in patients suffering from severe chronic obstructive lung disease.