Developing a Training in Motivational Counselling to Promote Return to Work: An Intervention Mapping Approach.

PURPOSE: Due to the Belgian health insurance system's controlling nature, work-disabled claimants can feel forced to return to work (RTW), increasing their risk of relapse. RTW out of interest or importance is considered more sustainable. Such autonomous motivation for RTW can be promoted through 'motivational counselling', an integration of self-determination theory and motivational interviewing. To adopt this, health insurance practitioners need training, which can be designed through intervention mapping as an evidence-based planning tool. This paper reports on the development of a motivational counselling training for health insurance practitioners. METHODS: Intervention mapping's six steps guided the formulation of programme goals and learning outcomes, matching the context. We then identified change methods which were translated into practical components. Together with the health insurances' input, this resulted in a concrete training programme with an implementation and evaluation plan. RESULTS: The training was designed to increase practitioners' knowledge, skills, and beliefs relevant for learning motivational counselling, which also requires solution-focused strategies. Methods like guided practice were translated into built-in exercises, feedback, and information, which were implemented through an online training format of five sessions including one follow-up. CONCLUSION: Reporting about training development increases understanding of its effectiveness and implementation, which will be evaluated via pre- and post-training data collection amongst practitioners. Future trainings can benefit from this by accounting for health insurances' organizational barriers or building on the training's evidence-based backbone whilst only requiring specific adaptations for other stakeholders and contexts. Further research should evaluate motivational counselling's impact on claimants' RTW trajectories.

Process Evaluation of a Motivational Interviewing Intervention in a Social Security Setting: A Qualitative Study among Work-Disabled Patients.

Purpose Return to work (RTW) may be facilitated by motivational interviewing (MI), a counseling style designed to increase motivation towards behavior change. MI's relevance in a RTW context remains however unclear. Exploring how, for whom and in what circumstances MI works is therefore necessary. Methods Eighteen people (29-60 years; sick leave > 12 weeks) with low back pain (LBP) or medically unexplained symptoms (MUS) participated in a semi-structured interview after one MI consultation. We conducted a realist-informed process evaluation to explore MI's mechanisms of impact, its outcomes and how external factors may influence these. Data were coded using thematic analysis. Results Main mechanisms were supporting autonomy, communicating with empathy and respect, facilitating feelings of competence and focusing on RTW solutions instead of hindrances. Competence support was more salient among LBP patients, whereas MUS patients benefited more from empathy and understanding. External factors were mentioned to have impacted MI's effectiveness and/or the further RTW process, being personal (e.g. acceptance of the condition), work-related (e.g. supervisor support) and societal (e.g. possibility of gradual RTW). Conclusions These results stress the importance of self-determination theory's support for autonomy, relatedness and competence, together with a solution-focused approach when stimulating patients' engagement regarding RTW. These mechanisms' instalment during RTW counseling and their long-term impact depends on both personal and system-like external factors. Belgium's social security system's premise, based on control, might actually hinder RTW instead of facilitating it. Further longitudinal research could explore MI's long-term effects as well as its complex interaction with external factors.

Reassessing the Carotid Artery Plaque "Rim Sign" on CTA: A New Analysis with Histopathologic Confirmation.

BACKGROUND AND PURPOSE: The CTA "rim sign" has been proposed as an imaging marker of intraplaque hemorrhage in carotid plaques. This study sought to investigate such findings using histopathologic confirmation. MATERIALS AND METHODS: Included patients had CTA neck imaging <1 year before carotid endarterectomy. On imaging, luminal stenosis and the presence of adventitial (<2-mm peripheral) and "bulky" (≥2-mm) calcifications, total plaque thickness, soft-tissue plaque thickness, calcification thickness, and the presence of ulcerations were assessed. The rim sign was defined as the presence of adventitial calcifications with internal soft-tissue plaque of ≥2 mm in maximum thickness. Carotid endarterectomy specimens were assessed for both the presence and the proportional makeup of lipid material, intraplaque hemorrhage, and calcification. RESULTS: Sixty-seven patients were included. Twenty-three (34.3%) were women; the average age was 70.4 years. Thirty-eight (57.7%) plaques had a rim sign on imaging, with strong interobserver agreement (κ = 0.85). A lipid core was present in 64 (95.5%) plaques (average, 22.2% proportion of plaque composition); intraplaque hemorrhage was present in 52 (77.6%), making up, on average, 13.7% of the plaque composition. The rim sign was not associated with the presence of intraplaque hemorrhage (P = .11); however, it was associated with a greater proportion of intraplaque hemorrhage in a plaque (P = .049). The sensitivity and specificity of the rim sign for intraplaque hemorrhage were 61.5% and 60.0%, respectively. CONCLUSIONS: The rim sign is not associated with the presence of intraplaque hemorrhage on histology. However, it is associated with a higher proportion of hemorrhage within a plaque and therefore may be a biomarker of more severe intraplaque hemorrhage, if present.

Patients at risk for long-term sick leave because of low back pain.

BACKGROUND CONTEXT: Ten percent of patients with low back pain (LBP) are not able to resume work within 3 months of sick leave, accounting for 90% of all medical and indemnity costs. PURPOSE: To quantify the relative contribution of sociodemographic, clinical, occupational, and psychological risk factors in determining the non-return to work after 3 months of compensated LBP and to develop a screening tool to identify patients who require further guidance and rehabilitation. STUDY DESIGN/SETTING: A 6-month prospective cohort study of disabled workers applying for compensation benefit because of LBP during a 6-month period in the Belgian compulsory health insurance system. PATIENT SAMPLE: Three hundred and forty-six patients. OUTCOME MEASURES: Patients unable to resume work within 3 months of sick leave were classified as bad outcomes. METHODS: Consecutively, injured workers applying for income replacement benefits between October 2003 and March 2004 because of LBP were followed 6 months after the start of the sick leave period. All subjects underwent a standardized physical examination and completed a battery of 12 self-report questionnaires. RESULTS: Forty-seven percent of the population had not resumed work 3 months after the start of the sick leave period. The risk factors for sickness absence more than 3 months were Oswestry disability index (odds ratio for each point increase: 1.04; 95% confidence interval: 1.02-1.06), fear of avoidance severity score (odds ratio for each point increase: 1.05; confidence interval: 1.02-1.09), blue collar worker (odds ratio: 2.18; confidence interval: 1.21-3.92), LBP for less than 12 weeks before sick leave (odds ratio: 0.32; confidence interval: 0.17-0.64), and pain behavior (odds ratio for each point increase: 1.72; confidence interval: 1.25-2.39). A multivariate screening test based on five questions identified 80% of the patients unable to resume work after 3 months of sick leave (specificity: 56.6; cut off: 0.4). CONCLUSIONS: A questionnaire comprising a limited set of items allows a practical screening of LBP patients unlikely to resume work.

Changes in hand and generalised bone mineral density in patients with recent-onset rheumatoid arthritis.

OBJECTIVES: To evaluate changes in bone mineral density (BMD) in the hands, hip and spine after 1 and 2 years of follow-up, in relation to antirheumatic and antiresorptive therapies and disease and demographic variables in patients with recent-onset rheumatoid arthritis (RA). METHODS: Changes in BMD measured in metacarpals 2-4 by digital x-ray radiogrammetry and in the hip and spine by dual energy x-ray absorptiometry were assessed at baseline and after 1 and 2 years of follow-up in 218 patients with recent-onset RA from the BeSt study, who received one of four treatment strategies: sequential monotherapy (group 1); step-up combination therapy (group 2); initial combination therapy with tapered high-dose prednisone (group 3); or initial combination therapy with infliximab (group 4). RESULTS: After 1 and 2 years, there was significant BMD loss in all locations, with significantly greater BMD loss in the hands than generalised BMD loss in the hip and spine. Initial combination therapy with prednisone or infliximab were associated with less hand BMD loss compared with initial monotherapy after 1 and 2 years (-0.9 and -1.6%, -0.6 and -1.4%, -1.7 and -3.3%, and -2.6 and -3.6% for group 4-1 after 1 and 2 years, overall p = 0.001 and p = 0.014, respectively). Progression in erosions was independently associated with increased BMD loss both in the hands and hip after 1 year. The use of bisphosphonates protected only against generalised BMD loss in the hip and spine. CONCLUSIONS: The association between joint damage progression and both hand and generalised BMD loss in RA suggests common pathways between these processes, with hand BMD loss occurring earlier in the disease course than generalised BMD loss.

Relevance of KIR gene matching in unrelated hematopoietic stem cell transplantations.

The aim of this collaborative study was to evaluate the impact of killer cell immunoglobulin-like receptor (KIR) gene disparities on unrelated hematopoietic stem cell transplantations (HSCT) outcome. To address this question, we have determined the presence or absence of 14 functional KIR genes in HLA-matched (n= 164) or HLA-mismatched (n= 100) donor/recipient pairs and investigated whether KIR gene disparities had an impact on both the occurrence of acute graft-vs-host-disease incidence and overall survival. In a univariate analysis, our preliminary results suggest a detrimental effect of a few KIR gene disparities on patient survival that should be avoided in unrelated HSCT.

Carbon monoxide load in indoor carting.

Personal experience and reports of colleagues made the authors aware of a possible problem of carbon monoxide exposure in indoor carting arenas. Symptoms such as nausea, headache and altered coordination are not uncommon. This prompted us to register carbon monoxide levels in 15 healthy volunteers in a recreational carting event in a random arena. After two sessions of 10 min and a finale of 20 min we measured a clear increase in carboxyhaemoglobin levels, up to a 16.5-fold increase. The mean rise in the carboxyhaemoglobin level (expressed as a percentage) was 2.06 (mean start carboxyhaemoglobin 0.49%, mean end carboxyhaemoglobin 2.55%). Nausea was noted in 53% of the drivers, headache and altered coordination in 33%, and 13% had a vague abdominal pain. The effects of carbon monoxide exposure during indoor carting should thus not be underestimated, and healthcare workers should be aware of the possible risks.

Impairment and return to work after intra-articular fractures of the calcaneus.

Intra-articular fractures of the calcaneus typically occur in individuals working on ladders, scaffolding or roofs. Male individuals in their productive age are most at risk. The functional problems that frequently persist are a well-known risk since they may obstruct a safe resumption of the former job. According to the data of the National Institute for Sickness and Invalidity Insurance the number of calcaneal fractures in Belgium have stabilised over the last ten years. These figures indicate the necessity for a better prevention policy. Scientific literature about the problem of impairment and disability in these cases is rare and lacks uniformity. A retrospective study was therefore performed on 65 private insurance compensation patients who were treated for intra-articular calcaneal fractures. The mean period of work incapacity was 260.5 days and the mean percentage of impairment was 12.3%. A large group (86.2%) were able to resume their former activities including the height workers. More than half of the patients (57%) needed a supportive device. Working at heights and falls from a height were a significant risk factor for long-term work incapacity. The figures are compared with the limited literature and further discussed.

Prostate-specific antigen screening coverage and prostate cancer incidence rates in the Belgian province of Limburg in 1996-1998.

According to the 1996-1998 cancer incidence report of the cancer registry of the Belgian province of Limburg (LIKAR), prostate cancer is the most common cancer in men with a crude invasive cancer incidence rate of 123.7 per 100000 person-years (125.4 and 81.8 after standardization for the European and the world standard population). In a study on geographical differences between the occurrence of cancers in municipalities, prostate cancer standardized incidence rates (SIRs) were significantly higher in a number of municipalities, with mean relative risks of 1.2 and 1.3 after full Bayesian smoothing. We hypothesized that prostate cancer incidence rates are largely influenced by the prostate-specific antigen (PSA) screening policy of local physicians and that differences between municipalities are more informative about local screening habits then about real differences in cancer occurrence. The aim of this study was to test this hypothesis by relating local prostate cancer SIRs to the PSA screening coverage of the population of men in each municipality. The SIRs of prostate cancer in 1996-1998 for each municipality were provided by LIKAR. They related to all histologically or cytologically proven new invasive prostate cancers during these years. For each municipality, PSA coverage data were provided by the largest sick fund of the region. Coverage was defined as the proportion of men above the age of 40 that was tested at least once within the registration period. The SIR of each municipality (dependent variable) was related to the age-standardized corresponding coverage (independent variable) by linear regression and was adjusted for the number of inhabitants per municipality: log (standardized incidence rate) = 164 + 602 * (standardized PSA coverage), = 0.12. The model explained 6% of the variance in incidence. In conclusion, in this study no statistically significant relationship was identified between PSA coverage and prostate cancer incidence rate per municipality. This could result from no such relationship existing or from low statistical power.

Analysis of three genetic markers in IgA nephropathy patients from a single region.

BACKGROUND: IgA nephropathy (IgA-N) is the most common glomerular disease. Various genetic factors have been suspected to influence the disease, but they never have been studied in the same cohort of patients. METHODS: In 125 IgA-N biopsy-proven cases, we studied by DNA techniques the allele distribution of 3 polymorphic loci: the angiotensin-converting enzyme (ACE) gene, the specific HLA-DQB1 gene and the hs1,2 enhancer of the alpha1 gene of the IgH locus. Patients were classified as progressive and non-progressive based on a creatininemia above 150 microl/ml or/and a deterioration of the clearance greater than 3 ml/min/year. We analyzed the influence of the polymorphism on the development and the progression of the disease. The control group consisted of 83 heathly subjects. RESULTS: The frequency of HLA-DQB1*0602 was decreased in IgA-N patients (3.6% vs 10.2%, Pc = 0.04, RR = 0.36), suggesting a protective effect of this allele for IgA-N. Kaplan-Meyer analysis with the Cox-proportional hazard model revealed a shorter time between diagnosis and renal failure in patients with the B allele for the al gene hs1,2 enhancer (p = 0.04). ACE polymorphism did not influence the development or the progression of the disease. CONCLUSION: Genes controlling the immune response, such as HLA DQB1 and the alpha1 transcriptional enhancer gene, may influence the development and/or the progression of IgA-N nephropathy. Patients who develop an IgA-N nephropathy have a higher risk of severe evolution if they have a profile of high IgA humoral responder.

Complications of cardiac catheterization in the current era: a single-center experience.

Consecutive cardiac catheterization procedures done over a 2-yr period (April 1996 to March 1998) were prospectively analyzed to determine and characterize procedure-related complications (in-hospital and 1-mo follow-up), as they occur at present. During the study period, 11,821 procedures (7,953 diagnostic and 3,868 therapeutic) were performed. The majority of procedures (> 60%) were done in high-risk patients. Stents were implanted in 33% of patients, and adjunctive abciximab was used in 6.6% of therapeutic procedures. The overall complication rate was 8% (3.6% of diagnostic procedures and 15.1% of therapeutic procedures). The procedure-related mortality rates were 0.2%, 0.1%, and 0.5% for total, diagnostic, and therapeutic procedures, respectively. Cardiac complications were seen in 3.9% (1.5% of diagnostic and 9% of therapeutic procedures). Emergency cardiac surgery was required in 0.05% of the diagnostic procedure group and 0.3% of the therapeutic procedure group (total, 0.1%). Despite marked changes in patient population and practice, the complication rates of cardiac catheterization remain very low.

The depletion of T cells from haematopoietic stem cell transplants.

OBJECTIVE: In our laboratory, we have developed an immunorosette technique for the depletion of T cells from bone marrow transplants. Tetrameric complexes of monoclonal antibodies are able to form very stable immunorosettes, which are efficiently depleted with the aid of a blood cell separator. Major improvements over the original sheep red blood cell depletion are the use of human (patient or donor derived) erythrocytes instead of sheep-derived cells, and the possibility of using a closed system for separation in a cell separator. In contrast to bone marrow, mobilized haematopoietic stem cell transplants obtained after leucocytapheresis contain higher numbers of T cells. Therefore, a different approach is necessary. METHOD: We have used two CD34 selection systems (Isolex 300SA and the Clinimacs) to perform T-cell depletions from peripheral blood stem cell (PBSC) transplants. RESULTS: Immunorosette T-cell depletion, with CD2/CD3 tetrameric complexes, of bone marrow transplants resulted in a mean 2.5 log depletion of T cells with a yield of 50% of the CD34+ cell population. Stem cell selection of PBSC transplants using one of the CD34 selection procedures resulted in a 4.5 log depiction of T cells for both systems, but with different results for the recovery of CD34+ cells. An increased yield of CD34+ cells was obtained with the Clinimacs procedure (57.9+/-9.0%) in comparison to the Isolex procedure (40.1+/-12.5%). CONCLUSION: Our own immunorosette depletion technique and the two tested CD34 selection methods for stem cell transplants both resulted in a very efficient T-cell depletion with the recovery of 40-60% of the CD34 haematopoietic stem cells present in the transplant.

Predictors for work incapacity continuing after disc surgery.

OBJECTIVES: This study was carried out to provide information on and identify factors about the fitness for work 12 months after disc herniation surgery. In addition a predictive tool for this outcome was developed. METHODS: A selected patient population (N = 177) operated on for lumbar disc herniation from September 1995 until May 1996 was evaluated by medical advisers of a sickness fund. The patients were submitted to a standardized interview about their personal, social, medical, professional, and psychological status. To assess the functional status of the lumbar spine, a standardized clinical examination was used. RESULTS: Eighty-five percent of the patients were employed 1 year after surgery. The most important predictors at 6 weeks after intervention were the estimation of pain according to a visual analogue scale, the patient's prediction of his possibilities to resume work, the Oswestry disability index score, and the Zung depression score. Of the clinical factors, nonorganic signs and sensory disturbances after surgery were negative prognosticators for long-lasting disability. Using the Oswestry score, the Zung score, the patient's own prediction, the score on the Social Readjustment Rating Scale, and the score on the Modified Somatic Perception Questionnaire, 86% of the poor outcomes could be correctly classified. CONCLUSIONS: The Oswestry disability scale and the Zung depression scale should be included in the routine postoperative assessment after disc surgery and the patient's own prediction of his possibility for fitness for work should be taken seriously. If a poor outcome is predicted, the patient is in need of rehabilitation and should be guided more intensely.

Return to work after surgery for lumbar disc herniation. A rehabilitation-oriented approach in insurance medicine.

STUDY DESIGN: An intervention study by the medical advisers of a social security sickness fund on a mandatorily insured patient population after open discectomy for herniated lumbar intervertebral disc. The medical advisers were randomized into two groups: a control group (n = 30) and an intervention group (n = 30). OBJECTIVES: To compare a rehabilitation-oriented approach in insurance medicine focused primarily on early mobilization and early resumption of professional activities with the usual claim-based practice. SUMMARY OF BACKGROUND DATA: This study included 710 patients, with a mean age of 39.2 years, who underwent surgery for herniated lumbar disc. METHODS: Medical advisers in the rehabilitation-oriented group examined the patients monthly, starting at 6 weeks after the surgical intervention. They used a newly developed protocol to motivate the patients and treating physicians toward social and professional reintegration. RESULTS: At 52 weeks, 10.1% of the patients guided by medical advisers from the rehabilitation-oriented group had not resumed work in contrast to 18.1% of the patients in the control group. It was statistically proven that this effect also holds during the follow-up period. CONCLUSIONS: A rehabilitation-oriented approach by the medical advisers of social security can increase the probability of a return to work for patients after lumbar disc herniation surgery.

Social insurance cost of standard discectomy and percutaneous nucleotomy. A retrospective study of 87 social insurance claim files of male blue collar workers.

A retrospective review of social insurance claim files of male blue collar workers was conducted to compare the social insurance costs of percutaneous lumbar nucleotomy with standard lumbar discectomy ; 29 percutaneous nucleotomy procedures were matched with 58 standard discectomies all carried out between January 1992 and December 1994. It was concluded that a standard discectomy procedure results in significantly higher costs during hospitalisation with respect to surgery, anaesthesia and hospital stay. A percutaneous nucleotomy leads to a significantly higher outpatient expenditure especially in radiology and medical devices. The relative proportion of outpatient practitioner's visits and hospital stay costs was significantly higher for the standard discectomy whereas medical devices had a relatively higher share in outpatient expenditure for the percutaneous nucleotomy. In this population of 87 compensation claimants, the average social insurance costs did not significantly differ between the percutaneous nucleotomy and the standard discectomy.