Furnace for in situ and simultaneous studies of nano-precipitates and phase transformations in steels by SANS and neutron diffraction.

Interphase precipitation occurring during solid-state phase transformations in micro-alloyed steels is generally studied through transmission electron microscopy, atom probe tomography, and ex situ measurements of Small-Angle Neutron Scattering (SANS). The advantage of SANS over the other two characterization techniques is that SANS allows for the quantitative determination of size distribution, volume fraction, and number density of a statistically significant number of precipitates within the resulting matrix at room temperature. However, the performance of ex situ SANS measurements alone does not provide information regarding the probable correlation between interphase precipitation and phase transformations. This limitation makes it necessary to perform in situ and simultaneous studies on precipitation and phase transformations in order to gain an in-depth understanding of the nucleation and growth of precipitates in relation to the evolution of austenite decomposition at high temperatures. A furnace is, thus, designed and developed for such in situ studies in which SANS measurements can be simultaneously performed with neutron diffraction measurements during the application of high-temperature thermal treatments. The furnace is capable of carrying out thermal treatments involving fast heating and cooling as well as high operation temperatures (up to 1200 °C) for a long period of time with accurate temperature control in a protective atmosphere and in a magnetic field of up to 1.5 T. The characteristics of this furnace give the possibility of developing new research studies for better insight of the relationship between phase transformations and precipitation kinetics in steels and also in other types of materials containing nano-scale microstructural features.

Bariatric surgery trends in Belgium. The health insurer's view.

Strict regulation of bariatric surgery based upon objective needs for this therapy could create in Belgium an important reduction in--actually overused--surgical gastric banding procedures especially among the female population 18-50 year not corresponding with Class III obesity or with Class II + comorbidities in the near future. With the progressive popularity of the gastric bypass procedure that can also be carried out laparoscopically in specialised obesity centres and better reflecting the prevalence of obesity eligible for surgery in the male population and among the older age groups, the number of bypass interventions will probably increase without compensating for the diminishing number of interventions with adjustable gastric band. Short-term projections without the above mentioned regulation of bariatric surgery and with ongoing constant increase of obesity prevalence indicate that the annual number of interventions based on the latest data of the national health insurance will know a 60% growth in 2006 and could reach 20.000 procedures in 2007.

Pharmacoeconomics of immunisation: a review.

The effects of immunisation programmes that have existed for several decades in developed countries are demonstrated by the decrease and even eradication of smallpox, poliomyelitis, measles, mumps and hepatitis B. Cost, health policy and spontaneous evolution in the incidence of communicable diseases have a decisive influence on the use of a vaccine. Investment in vaccination policy has to be encouraged to maintain this progress made in the control of infectious diseases and to meet new challenges. Studies re-evaluating ongoing immunisation programmes are scarce. Nevertheless, it can be concluded that for vaccination against hepatitis B in professionally exposed at-risk populations, arguments for positive returns are consistent. The same holds for vaccination against S. pneumoniae and for influenza virus in the elderly. The results of the economic evaluation of revaccination against measles, when insufficient coverage exists, are inconclusive. Universal vaccination of children against Haemophilus influenzae type b (Hib) and of children of hepatitis B-positive mothers against hepatitis may require costs to be paid in order to gain extra health benefits.

Socio-economic impact of chronic venous insufficiency. An underestimated public health problem.

BACKGROUND: Disease of the venous system is an underestimated public health problem affecting all Western industrialised countries. The prevalence of venous disease of the lower limb in the adult population is estimated at 40-50% for men and 50-55% for women, whereas visible varicose veins and chronic venous insufficiency are, respectively, present in 10-15% and 2-7% of the male population and 20-25% and 3-7% of the female population. In France the costs of venous disease represented 2.6% of the total health care budget in 1995, thus confirming other data from European studies and an early health survey in the USA. To evaluate the socio-economic impact of chronic venous insufficiency by measuring the health care cost. METHODS: Detailed information on diagnostic and therapeutic procedures for venous disease was obtained from the billing data of the compulsory health insurance system in Belgium. Total ambulatory and intramural treatment costs are calculated for varicose veins of the lower limb and for haemorrhoids during the 1988-1995 period. RESULTS: Medical care costs for chronic venous disease amount to 10 billion BEF, which is 2-2.5% of the 1995 total health care budget. Annual spending on venotropic drugs with 11.5 mean daily doses per 1,000 inhabitants amounted to one billion BEF in 1995 for ambulatory treatment only. CONCLUSIONS: In view of the major medical, social and economical consequences of venous pathology, research and prevention efforts are required in this area as part of a well-targeted and effective health policy.

Cost-effectiveness in surgery. The insurers' point of view.

Cost-effectiveness in surgery is only one example of a global health care policy by the Belgian social insurers aiming at optimal price-quality ratios for the offered care provision and within budgetary constraints. As a main partner in health care management the insurers' decision is guided by socio-economical evaluation of medical technology and care. This evaluation distinguishes respectively cost-benefit (CBA), cost-effectiveness (CEA) and cost-utility (CUA) analyses. In surgery the principles of cost-effective management are illustrated with examples for minor surgery in general practice, one day clinic, tympanostomy tube placement for recurrent otitis media, and laparoscopic vs. laparotomic cholecystectomy. Even if we need economic evaluation for policy making it can only be one instrument for making choices in the increasingly complex and expensive health care sector. To maintain the access, the quality and the actually fair cost-level in Belgium's compulsory health insurance system there is need for standardized indications, clinical guidelines, outcome evaluation and quality assurance by credentialing of providers and service centers.

Possibilities and limitations in the functional use of medical practice profiles.

The first use of medical practice profiles in the Belgian healthcare organization goes back to 1980 with the creation of practice pattern evaluation at the National Institute of Health and Invalidity Insurance (RIZIV). Since then, detailed information on the provision and on the utilization of healthcare has become increasingly important in the planning, budgeting and financing of the nation healthcare. The RIZIV uses practice profiling predominantly as a means to control aberrant prescription (e.g. clinical chemistry, medical imaging, pharmaceuticals) and provision of care (diagnostic tests). In 1991, the Federal Ministry of Health started using data on diagnosis and medical performance for hospital admissions in order to adapt the per diem price and the yearly quotum of admission days attributed to each hospital. At the level of the health insurer (sickness funds) there is growing interest to share the information derived from the extremely detailed patient claims for reimbursement of intramural and ambulatory care. These billing data allow the evaluation of medical care provision per physician, per hospital or provision center and per patient for a given period of time. The lack of specific diagnosis indication restricts mainly the use of these data as medical performance parameter to surgical procedures. The purpose of this profile information for the health insurer is to point to the physician the important medical practice variability in identical clinical situations in order to stimulate the design and implementation of practice guidelines and reduce aberrant differences in practice patterns. The use of medical practice profiles, in close collaboration of insurers and providers is considered extremely valuable as a means to improve the quality of healthcare provision.

[Primary inguinal hernia: Lichtenstein's ambulatory hernioplasty: early clinical results and economic implications. Study of the initial 130 surgical cases]. / Hernie inguinale primaire: hernioplastie ambulatoire selon Lichtenstein: premiers résultats cliniques et implications économiques. Etude des 130 premiers cas opérés.

The authors report their preliminary experience of 130 ambulatory treatment under local anesthesia of primary inguinal hernia. This method of treatment is very well accepted by the patients. There are few early recurrences. This method of treatment is very cost-effective.

Post-mortem vitreous ammonium concentrations in estimating the time of death.

On a total of 150 specimens of vitreous humor the post-mortem ammonia value was determined by diffusion method. The results established that there existed a regular ammonia increase after a sudden death and that deviating high or low vitreous ammonia values are strongly correlated with the cause of death and with environmental temperature. The ammonia content of the vitreous humor extracted from both eyes at the same and at different post-mortem intervals showed no differences in the concentrations between both specimens sampled at the same moment while an obvious variation in the individual rate of the vitreous ammonia increase is found, especially when hospital cases with antemortem existing disease are concerned.

Occupational exposure to dust and sinonasal cancer. An analysis of 386 cases reported to the N.C.C.S.F. Cancer Registry.

An analysis of 386 sinonasal cancer cases reported during the 1978-1994 period to the registry of the Christian Sickness Fund is presented. The relationship between this tumor and previous occupational exposure to carcinogens is investigated by a descriptive case study. Of 386 cases comprising 294 males and 92 females, 139 were adenocarcinomas which in 88 revealed an occupation as woodworker. In 169 sinonasal cancers the professional history indicates an exposure to dust of different origin, but mainly wood, textile, cereals, cement and leather. The primary tumor of 87 sinonasal adenocarcinomas in woodworkers was in 77% ethmoïdal, 12.2% maxillary, 6.8% nasal and 4-sphenoïdal. These findings confirm the results of previous reports on sinonasal cancer from other European countries.

[Cost analysis of inguinal hernia surgery in ambulatory and inpatient management]. / Kostenanalyse der Leistenhernienchirurgie bei ambulanter und stationärer Versorgung.

In Belgium 27,426 hernia repairs were performed in 1994 but only 1,451 (5.29%) were done on ambulatory basis, whereas in the U.S. over 50% of the yearly 600,000 hernia repairs are one day surgery procedures with interstate variation ranging from 6% to 89%. The mean treatment cost of inguinal hernia repair (doctors fees + hotel cost) was 53,704 BEF for inpatients vs. 30,510 BEF (general anesthesia) and 27,501 BEF (local anesthesia) for outpatients. Rates of complication and recurrence were not significantly different. This difference in total costs for hospital admission are determined by the mean length of stay and by the individual forfeitairy day price according to size of the hospital. Also the use of routine diagnostic procedures (clinical chemistry and medical imaging) - not necessarily essential for treatment - is higher at hospitalization. Even with 50% of all hernia repairs carried out in the one day clinic, total cost savings for treatment will hardly exceed 20% if the mean length of stay of the remaining inpatients will not decrease simultaneously. Supplementary and dramatic cost reductions however are possible by an earlier resumption of professional activities. The mean advised sick leave period of 4 weeks (+/- 2) still depends on irrelevant parameters as tradition, patients' preferences, job characteristics and type of insurance. Total costs for work incapacity add up to 2.5 billion BEF (vs. 1.4 billion BEF for total treatment costs) and can be cut by 50.18% via a mean 2 weeks earlier return to work. Since open primary hernia repair under local anesthesia can be easily carried out on outpatients resuming unrestricted daily activities in less than 1 week, the laparoscopic procedure with general anesthesia, higher treatment cost (endoscopic material) and still debated advantages in convalescence time and long-term outcome is not the gold standard for uncomplicated inguinal hernia.

Actual hazard of methyl bromide fumigation in soil disinfection.

Methyl bromide, a highly toxic and ready penetrating fumigant, is widely used against rodents, insects, mites, and a range of pathogenic organisms in soil, compost, and timber. To disinfect soil in greenhouses, methyl bromide is brought under pressure from outside by a vaporiser and blown on to ground under a polyethylene cover. The gas being three times heavier than air easily penetrates the ground. Depending on the local ventilation, a considerable amount of gas evaporates into the surrounding atmosphere, this emission being especially serious during the fumigation procedure and at the removal of the plastic cover. Previously, mechanical injection of methyl bromide on to the ground within closed areas was prohibited, since this technique exposed at least four disinfection workers at a time, who were provided with only a canister respirator, to gas concentrations of over 1000 ppm CH3Br. The present study established that fumigation with methyl bromide also carries risks for the well-protected worker inside, as well as for the one controlling the vaporiser. The concentration during application varies from 30 to 3000 ppm. Concentration in the air declines with time to 4 ppm CH3Br five days after application. Discarding the plastic sheet involves exposure to peak values as high as 200 ppm for a few seconds. On the ninth day after application, milling the soil can expose workers to up to 15 ppm; on the eleventh day no CH3Br concentration in the air could be found.

Dangerous concentrations of methyl bromide used as a fumigant in Belgian greenhouses.

In the disinfection of soil in greenhouses, methyl bromide can be applied to the soil by injection or by fumigation on the surface. The concentrations of methyl bromide in the air are measured, and the differences between each technique discussed. Concentrations during injection vary between 100 and 1,000 ppm with peaks up to 3,000 (10,000 in one case) ppm, but drop below 200 ppm if preventive measures are taken. During fumigation concentrations remain between 100 and 1,000 ppm. Large variations occur within a technique depending on the quality both of the material and operator.

Exposure of diamond polishers to cobalt.

Interstitial pulmonary fibrosis due to 'hard metal' exposure is well known, and the presence of cobalt has always been considered as the causative factor. Recently interstitial pulmonary fibrosis has been described in diamond polishing workers. In this study the dust composition in different polisher's workplaces where diamond disks are in use has been determined. Careful investigation showed that the exposure to respirable dust was comparable to that of 'hard metal' workers. The dust consists mainly of iron and cobalt particles and small amounts of silica. No 'hard metals' have been found, and other fibrogenic agents such as beryllium have been excluded. These observations lend support to the hypothesis that crystalline cobalt particles can be responsible for pulmonary fibrosis even in the absence of carbides.

The Belgian system to control indications for the implantable defibrillator: a model for other European countries?

OBJECTIVES: The purpose of this study was to assess the value of the Belgium system to control the indications for the implantable defibrillator. METHODS: We reviewed the answers of our official organization (Riijksinstituut voor Ziekte en Invaliditeitsverzekering-RIZIV) to our requests of implantable defibrillators in 49 patients in 1990, 1991 and the first months of 1992. In 1988 and in agreement with the RIZIV, 15 implants per year were allowed, but this number had been extended to 100 in 1992. RESULTS: There was an increasing first refusal rate from 1990 (0%) to 1991 (25%) and 1992 (42%), which was caused by: a) Difficulties to deal with indications for unusual diseases, particularly young patients with cardiac arrest and a structural normal heart; b) Possible distrust by the RIZIV towards the physician when the number of requests increases over time. However, all patients for whom a defibrillator was requested ultimately had it implanted. CONCLUSIONS: In the most ideal type of cooperation between official organisms and implanting physicians, such as the Belgian system, the official organization has to realize that uncommon patients with disputable indications exist. To avoid refusal of reimbursement in these cases, the decision taken by the treating physician can be accepted only on condition that the mutual relationship between both parties is based on open communication, mutual respect, and trust. The Belgian system provides care to all patients requiring a defibrillator with costs to society which are very acceptable. The Belgian system may be an excellent model for countries without clear regulations for reimbursement of implantable defibrillators.