Improving tetanus prophylaxis in the emergency department: a prospective, double-blind cost-effectiveness study.

BACKGROUND: The choice of tetanus prophylaxis for patients with wounds depends on obtaining their vaccination history, which has been demonstrated to be unreliable. Use of a rapid immunoassay (Tétanos Quick Stick, the TQS), combined with knowledge of certain demographic characteristics, may improve the evaluation of tetanus immunity and thus help to avoid inadequate prophylactic measures and reduce costs. OBJECTIVES: To evaluate the contribution of the TQS in the choice of tetanus prophylaxis and to perform a cost-effectiveness analysis. The final aim was to define the place of the TQS in a modified algorithm for assessment of tetanus immunity in the emergency department. METHOD: In this Belgian prospective, double-blind, multicentre study, 611 adult patients with a wound were included; 498 (81.5%) records were valid. The TQS test was performed by a nurse before the vaccination history was taken and the choice of prophylaxis was made, using the official algorithm (Belgian Superior Health Council), by a doctor who was unaware of the TQS result. RESULTS: The prevalence of protective anti-tetanus immunity was 74.1%. Immunity was lower in older patients and in female patients. The TQS was a cost-effective tool for patients presenting with a tetanus-prone wound and considered from the vaccination history to be unprotected. Use of the TQS would have improved management in 56.9% (95% CI 47.7% to 65.7%) of patients by avoiding unnecessary treatments, leading to a reduction in the mean cost per patient (10.58 euros/patient with the TQS versus 11.34 euros/patient without). The benefits of the TQS use were significantly greater in patients <61 years old: unnecessary treatment would have been avoided in 76.9% (95% CI 65.8% to 85.4%) of cases and the mean cost per patient reduced to 8.31 euros. CONCLUSION: In selected patients, the TQS is a cost-effective tool to evaluate tetanus immunity. An algorithm is proposed for ED assessment of tetanus immunity integrating age and the TQS result

How to Improve Assessment of Tetanus Immunity in the Emergency Room: A Prospective Cost-Effectiveness, Double Blind Study

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Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume–pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference

Searching for consensus among physicians involved in the management of sick-listed workers in the Belgian health care sector: a qualitative study among practitioners and stakeholders

Background In Belgium, the management of sick leave involves general practitioners (GPs), occupational health physicians (OPs) and social insurance physicians (SIPs). A dysfunctional relationship among these physicians can impede a patient’s ability to return to work. The objective of this study was to identify ways to improve these physicians’ mutual collaboration. Methods Two consensus techniques were successively performed among the three professional groups. Eight nominal groups (NGs) gathered 74 field practitioners, and a two-round Delphi process involved 32 stakeholders. Results From the results, it appears that two areas (reciprocal knowledge and evolution of the legal and regulatory framework) are objects of consensus among the three medical group that were surveyed. Information transfer, particularly electronic transfer, was stressed as an important way to improve. The consensual proposals regarding interdisciplinary collaboration indicate specific and practical changes to be implemented when professionals are managing workers who are on sick leave. The collaboration process appeared to be currently more problematic, but the participants correctly identified the need for common training. Conclusions The three physician groups all agree regarding several inter-physician collaboration proposals. The study also revealed a latent conflict situation among the analysed professionals that can arise from a lack of mutual recognition. Practical changes or improvements must be included in an extended framework that involves the different determinants of interdisciplinary collaboration that are shown by theoretical models. Collaboration is a product of the actions and behaviours of various partners, which requires reciprocal knowledge and trust; collaboration also implies political and economic structures that are led by public health authorities.Partnershi

Adapting the Sherbrooke model to the Belgian situation

In Canada and the Netherlands, randomized controlled trials proved that the Sherbrooke model is an effective method to induce sustainable work resumption for patients off work over one month due to back problems. The model offered an individually tailored, workplace oriented, step-by-step multidisciplinary return to work strategy. Prior to implementing the model in Belgium, this study aimed at adapting it to the Belgian social security system and labour market needs. A qualitative study was conducted in 2011, with the support of the European Social Fund: discussion groups were organised with sickness absence benefit insurers; employers and workers unions; physicians, ergonomists, psychologists and nurses involved in disability management; and academic experts including the international group of trainees and mentors of the Strategic Training Program in Work Disability Prevention. The meetings aimed at collecting ideas and proposals for model adaptation. For the final model adaptation, the research team relied on a multidisciplinary expert group. To answer company’s requirements a tool was developed making co-workers co-responsible for the worker’s successful work resumption trajectory. To enhance the workers’ own responsibility in the return to work process, a patient return to work diary was designed. To take into account the rising trend in mental health reasons for prolonged sickness absence, the model was opened up to patients irrespectively of the cause of their sickness absence. Belgian employers having limited financial incentives for return to work initiatives when sickness absence periods exceed one month, it was decided to a) implement the model in sectors having difficulties finding suitable personnel due to the labour market scarcity, and b) ask participating companies to commit to fulfil 85% of multidisciplinary work resumption advices and to report in detail on non-followed advices. The Sherbrooke model was mirrored among the Belgian situation and adapted to Belgium’s specific needs. In 2012, the adapted model will be evaluated in a pilot study including five companies employing about 8000 workers in the Antwerp region of Belgium

The path to surgery in carcinoid heart disease: a retrospective study and a multidisciplinary proposal of a new algorithm

Background: Development of carcinoid heart disease (CHD) is the major negative prognostic factor in patients with the carcinoid syndrome. The only effective treatment is valve replacement. However, the selection of candidates and determination of optimal timing remain unclear. Considerable variability in local screening and treatment strategies exist. Methods: In this single-centre study, we retrospectively analysed the diagnostic process and outcome of all CHD patients who underwent valve surgery between 2000 and 2016. We propose a new CHD screening and management algorithm. Results: All patients (n = 15), mean age 64 ± 7, underwent tricuspid valve surgery. In 14 of them (93%) an additional valve was replaced. In only a minority of patients (27%) CHD diagnosis was established by screening. Survival after 1, 3, 12 and 24 months was 93%, 80%, 53% and 33%, respectively. Causes of death included infections and critical illness immediately postoperatively, and tumour progression and right heart failure in the longer term. There was a trend (p = .099) towards better preoperative right ventricular function in the patients who survived more than 12 months postoperatively (TAPSE 20 mm ± 4) compared to those who died between 3 to 12 months after surgery (TAPSE 16 mm ± 1). The former group had a shorter mean interval from diagnosis of the carcinoid syndrome to cardiac diagnosis than the latter (13 vs. 105 months, p = .014). Conclusion: Mortality after valve replacement for CHD remains high. A probably underestimated cause is late referral for cardiac surgery. We propose a systematic, multidisciplinary approach to all carcinoid syndrome patients.status: publishe

HR managers views and practices in SME's regarding return to work of sick listed employees

Background Little is known about the return to work (RTW) policies implemented in small and medium size enterprises (SME) which have limited resources to define and apply such policies. This study aimed at assessing the existing return to work practices in SME’s and exploring their view regarding the help they could receive from their occupational health service. Methods HR managers of 46 SME’s (23 in Flanders, 23 in Wallonia) employing 100 to 200 employees were contacted for an interview. The manager was asked to fill in a written questionnaire and to comment his/her answers in an open discussion with the researcher. The questionnaire involved three parts: 1°) describing existing rules or procedures when returning to work after sick leave, 2) assessing the manager knowledge of the RTW legal regulations within the occupational health care system, 3) assessing the occupational health physician (OP) involvement in RTW and the enterprise expectations for the future. Results Participation to the survey was accepted in 38 SME’s. In slightly more than half of them a sick leave related policy has been defined. While almost all SME’s have a well-defined procedure for the RTW examination by the OP, only 22 (out of 38) have defined procedures for maintaining a contact with the worker during the sick leave period, only 17 are informing their employees about the possibility to meet the OP during that period, and only 6 are systematically organising a worker-supervisor meeting when the worker comes back at work. Knowledge about RTW regulations is rather poor: 10 managers wrongly think that the OP may check the sick leave medical validity; only 14 managers know that the employer must inform the OP about any sick leave longer than 4 weeks; less than half of the managers have a good knowledge of the pre-return to work visit. Various expectations have been put forward as regard the role of the OH service: knowledge transfer about the regulations, coaching of the supervisors, training managers in carrying RTW talks with the worker, suggesting procedures, etc. Conclusions The lack of knowledge about RTW regulations underlines the need for information campaigns focused on the employers. The participating RH managers are awaiting a more proactive role from their OH service