Fibrin and fibrinogen degradation products in plasma : clinical and methodological studies using enzyme immuno assays

This thesis comprises studies with monoclonal antibody-based plasma assays for derivatives of fibrin and fibrinogen in patients with diseases and conditions characterized by an activated state of coagulation and fibrinolysi

Electronic Outbreak Surveillance in Germany: A First Evaluation for Nosocomial Norovirus Outbreaks

BACKGROUND: In Germany, surveillance for infectious disease outbreaks is integrated into an electronic surveillance system. For 2007, the national surveillance database contains case-based information on 201,224 norovirus cases, three-quarters of which are linked to outbreaks. We evaluated the data quality of the national database in reflecting nosocomial norovirus outbreak (NNO) data available in 19 Hessian local public health authorities (LPHAs) and the influence of differences between LPHA's follow-up procedures for laboratory notifications of Norovirus positive stool samples on outbreak underascertainment. METHODS: Data on NNO beginning in 2007 and notified to the 19 LPHAs were extracted from the national database, investigated regarding internal validity and compared to data collected from LPHAs for a study on NNO control. LPHAs were questioned whether they routinely contacted all persons for whom a laboratory diagnosis of norovirus infection was notified. The number of outbreaks per 1,000 hospital beds and the number of cases within NNOs for acute care and rehabilitation hospitals were compared between counties with and without complete follow-up. RESULTS: The national database contained information on 155 NNOs, including 3,115 cases. Cases were missed in the national database in 58 (37%) of the outbreaks. Information on hospitalisation was incorrect for an estimated 47% of NNO cases. Information on county of infection was incorrect for 24% (199/820) of cases being forwarded between LPHAs for data entry. Reported NNO incidence and number of NNO cases in acute care hospitals was higher in counties with complete follow-up (incidence-rate ratio (IRR) 2.7, 95% CI 1.4-5.7, p-value 0.002 and IRR 2.1, 95% CI 1.9-2.4, p-value 0.001, respectively). CONCLUSIONS: Many NNOs are not notified by hospitals and differences in LPHA procedures have an impact on the number of outbreaks captured in the surveillance system. Forwarding of case-by-case data on Norovirus outbreak cases from the local to the state and national level should not be required

The development of instruments to measure the work disability assessment behaviour of insurance physicians

<p>Abstract</p> <p>Background</p> <p>Variation in assessments is a universal given, and work disability assessments by insurance physicians are no exception. Little is known about the considerations and views of insurance physicians that may partly explain such variation. On the basis of the Attitude - Social norm - self Efficacy (ASE) model, we have developed measurement instruments for assessment behaviour and its determinants.</p> <p>Methods</p> <p>Based on theory and interviews with insurance physicians the questionnaire included blocks of items concerning background variables, intentions, attitudes, social norms, self-efficacy, knowledge, barriers and behaviour of the insurance physicians in relation to work disability assessment issues. The responses of 231 insurance physicians were suitable for further analysis. Factor analysis and reliability analysis were used to form scale variables and homogeneity analysis was used to form dimension variables. Thus, we included 169 of the 177 original items.</p> <p>Results</p> <p>Factor analysis and reliability analysis yielded 29 scales with sufficient reliability. Homogeneity analysis yielded 19 dimensions. Scales and dimensions fitted with the concepts of the ASE model. We slightly modified the ASE model by dividing behaviour into two blocks: behaviour that reflects the assessment process and behaviour that reflects assessment behaviour.</p> <p>The picture that emerged from the descriptive results was of a group of physicians who were motivated in their job and positive about the Dutch social security system in general. However, only half of them had a positive opinion about the Dutch Work and Income (Capacity for Work) Act (WIA). They also reported serious barriers, the most common of which was work pressure. Finally, 73% of the insurance physicians described the majority of their cases as 'difficult'.</p> <p>Conclusions</p> <p>The scales and dimensions developed appear to be valid and offer a promising basis for future research. The results suggest that the underlying ASE model, in modified form, is suitable for describing the assessment behaviour of insurance physicians and the determinants of this behaviour. The next step in this line of research should be to validate the model using structural equation modelling. Finally, the predictive value should be tested in relation to outcome measurements of work disability assessments.</p

Inter-doctor variations in the assessment of functional incapacities by insurance physicians

Abstract Background The aim of this study was to determine the - largely unexplored - extent of systematic variation in the work disability assessment by Dutch insurance physicians (IPs) of employees on long-term sick leave, and to ascertain whether this variation was associated with the individual characteristics and opinions of IPs. Methods In March 2008 we conducted a survey among IPs on the basis of the 'Attitude - Social norm - self-Efficacy' (ASE) model. We used the ensuing data to form latent variables for the ASE constructs. We then linked the background variables and the measured constructs for IPs (n = 199) working at regional offices (n = 27) to the work disability assessments of clients (n = 83,755) and their characteristics. These assessments were carried out between July 2003 and April 2008. We performed multilevel regression analysis on three important assessment outcomes: No Sustainable Capacity or Restrictions for Working Hours (binominal), Functional Incapacity Score (scale 0-6) and Maximum Work Disability Class (binominal). We calculated Intra Class Correlations (ICCs) at IP level and office level and explained variances (R2) for the three outcomes. A higher ICC reflects stronger systematic variation. Results The ICCs at IP level were approximately 6% for No Sustainable Capacity or Restrictions for Working Hours and Maximum Work Disability Class and 12% for Functional Incapacity Score. Background IP variables and the measured ASE constructs for physicians contributed very little to the variation - at most 1%. The ICCs at office level ranged from 0% to around 1%. The R2 was 11% for No Sustainable Capacity or Restrictions for Working Hours, 19% for Functional Incapacity Score and 37% for Maximum Work Disability Class. Conclusion Our study uncovered small to moderate systematic variations in the outcome of disability assessments in the Netherlands. However, the individual characteristics and opinions of insurance physicians have very little impact on these variations. Our findings provided no indications of other reasons for these variations. They may be related to different work routines or to different views on the workload of a 'normal' employee. If so, they could be reduced by well-developed and comprehensively implemented guidelines. Therefore, further research is needed.</p

Neighbourhood social inclusion from the perspective of people with intellectual disabilities: Relevant themes identified with the use of photovoice

Background: Earlier studies show that to gain more understanding of the concept of social inclusion, the views and experiences of people with intellectual disabilities are needed. The aim of this study was to investigate their perspective on neighbourhood social inclusion from an ecological point of view. Method: We carried out a photovoice study with 18 people with intellectual disabilities in three neighbourhoods in the Netherlands. Participants took photographs in their neighbourhood they considered relevant, and these photographs were discussed during an interview. Results: Six themes emerged from qualitative analysis: attractiveness of the neighbourhood, social contacts in the neighbourhood, activities in the neighbourhood, social roles in the neighbourhood, independence and public familiarity. Conclusions: As regards neighbourhood social inclusion, participants were often focused on small and informal activities and situations. Public familiarity proved very important. Framing the concept of neighbourhood social inclusion within an ecological approach may help to better understand processes of social inclusion