Commuting and sick leave: a retrospective longitudinal study among a Belgian military population.

OBJECTIVES: In a military context, people often have to deal with long commuting distance. The aim of the current study is to investigate to what extent commuting distances predict sickness absence among a military population. METHODS: The present study is based on a dynamic cohort of active-duty military personnel of the Belgian Defence. A proportional hazard Andersen-Gill model was used to determine the effect of commuting distance on the recurrence of sickness absence, considering relevant covariates. In a second model, an interaction term for commuting and traffic congestion was introduced. RESULTS: Higher commuting distances led to higher risk of recurring sickness absence, which was 9%, 15%, 8% and 11% higher, respectively, for distances of 5-14 km, 15-29 km, 30-59 km or >60 km compared with a distance of <5 km.A commuting distance of 30-59 km increased the risk with 47%, 33%, 35% and 76% if the reported traffic congestion was, respectively, 5-20%, 20-40%, 40-70% and 70-100% compared with a commuting distance of <5 km and a reported traffic congestion of 0-5%. A commuting distance of >60 km increased the risk with 25% and 76%, respectively, for a reported traffic congestion of 5-20% and 70-100% compared with a commuting distance of <5 km and a reported traffic congestion of 0-5%. CONCLUSIONS: These findings support measures to reduce the distance and frequency of commuting in order to reduce sickness absence, considering for example remote working, a more responsible geographical distribution of the offices or a revision of the employees' job-changing policies.

Creating realistic nerve agent victim profiles for computer simulation of medical CBRN disaster response.

In the last decades, Chemical, Biological, Radiological and Nuclear (CBRN) threats have become serious risks prompting countries to prioritize preparedness for such incidents. As CBRN scenarios are very difficult and expensive to recreate in real life, computer simulation is particularly suited for assessing the effectiveness of contingency plans and identifying areas of improvement. These computer simulation exercises require realistic and dynamic victim profiles, which are unavailable in a civilian context. In this paper we present a set of civilian nerve agent injury profiles consisting of clinical parameters and their evolution, as well as the methodology used to create them. These injury profiles are based on military injury profiles and adapted to the civilian population, using sarin for the purpose of illustration. They include commonly measured parameters in the prehospital setting. We demonstrate that information found in military sources can easily be adjusted for a civilian population using a few simple assumptions and validated methods. This methodology can easily be expanded to other chemical warfare agents as well as different ways of exposure. The resulting injury profiles are generic so they can also be used in tabletop and live simulation exercises. Modeling and simulation, if used correctly and in conjunction with empirical data gathered from lessons learned, can assist in providing the evidence practices for effective and efficient response decisions and interventions, considering the contextual factors of the affected area and the specific disaster scenario.

SIMEDIS: a Discrete-Event Simulation Model for Testing Responses to Mass Casualty Incidents.

It is recognized that the study of the disaster medical response (DMR) is a relatively new field. To date, there is no evidence-based literature that clearly defines the best medical response principles, concepts, structures and processes in a disaster setting. Much of what is known about the DMR results from descriptive studies and expert opinion. No experimental studies regarding the effects of DMR interventions on the health outcomes of disaster survivors have been carried out. Traditional analytic methods cannot fully capture the flow of disaster victims through a complex disaster medical response system (DMRS). Computer modelling and simulation enable to study and test operational assumptions in a virtual but controlled experimental environment. The SIMEDIS (Simulation for the assessment and optimization of medical disaster management) simulation model consists of 3 interacting components: the victim creation model, the victim monitoring model where the health state of each victim is monitored and adapted to the evolving clinical conditions of the victims, and the medical response model, where the victims interact with the environment and the resources at the disposal of the healthcare responders. Since the main aim of the DMR is to minimize as much as possible the mortality and morbidity of the survivors, we designed a victim-centred model in which the casualties pass through the different components and processes of a DMRS. The specificity of the SIMEDIS simulation model is the fact that the victim entities evolve in parallel through both the victim monitoring model and the medical response model. The interaction between both models is ensured through a time or medical intervention trigger. At each service point, a triage is performed together with a decision on the disposition of the victims regarding treatment and/or evacuation based on a priority code assigned to the victim and on the availability of resources at the service point. The aim of the case study is to implement the SIMEDIS model to the DMRS of an international airport and to test the medical response plan to an airplane crash simulation at the airport. In order to identify good response options, the model then was used to study the effect of a number of interventional factors on the performance of the DMRS. Our study reflects the potential of SIMEDIS to model complex systems, to test different aspects of DMR, and to be used as a tool in experimental research that might make a substantial contribution to provide the evidence base for the effectiveness and efficiency of disaster medical management.

Utstein-style template for uniform data reporting of acute medical response in disasters.

BACKGROUND: In 2003, the Task Force on Quality Control of Disaster Management (WADEM) published guidelines for evaluation and research on health disaster management and recommended the development of a uniform data reporting tool. Standardized and complete reporting of data related to disaster medical response activities will facilitate the interpretation of results, comparisons between medical response systems and quality improvement in the management of disaster victims. METHODS: Over a two-year period, a group of 16 experts in the fields of research, education, ethics and operational aspects of disaster medical management from 8 countries carried out a consensus process based on a modified Delphi method and Utstein-style technique. RESULTS: The EMDM Academy Consensus Group produced an Utstein-style template for uniform data reporting of acute disaster medical response, including 15 data elements with indicators, that can be used for both research and quality improvement. CONCLUSION: It is anticipated that the Utstein-style template will enable better and more accurate completion of reports on disaster medical response and contribute to further scientific evidence and knowledge related to disaster medical management in order to optimize medical response system interventions and to improve outcomes of disaster victims.

Carotid artery dissection: three cases and a review of the literature.

Carotid artery dissections are potentially disabling, probably underdiagnosed, and mainly affect young-aged and middle-aged people. We present three consecutive cases illustrating different clinical presentations and thereby emphasizing the diagnostic challenge of carotid artery dissections for the emergency physician. Neck and facial pain, headache, unilateral pulsatile tinnitus, partial Horner's syndrome (or oculosympathetic palsy), amaurosis fugax, retinal infarction, and anterior circulation brain ischemia may all occur in isolation or in various combinations. Medical imaging plays a pivotal role in making the right diagnosis. Clinical vigilance is of utmost importance as early diagnosis and timely treatment favor long-term prognosis and even prevent ischemic complications. We review the literature and discuss the pathophysiology, etiology, clinical presentation, diagnosis, imaging techniques, treatment, and prognosis of carotid dissections.

Aetiology of unsuccessful prehospital witnessed cardiac arrest of unclear origin.

OBJECTIVES: To determine, by means of autopsy, the cause of death following unsuccessful cardiopulmonary resuscitation of patients with a witnessed prehospital cardiac arrest of unclear origin. METHOD: Observational study of all prehospital-witnessed cardiac arrest of unclear origin over a period of 19 months in the emergency medical service region of a tertiary care hospital. RESULTS: During the study period, 211 prehospital cardiopulmonary resuscitation attempts were recorded. In 144 study participants, cardiopulmonary resuscitation was not successful: there was no return of spontaneous circulation. Cardiac arrest of traumatic or other clear origin was not considered, nor were paediatric cases. Thirty out of the 114 remaining patients underwent an autopsy (26.3%). The main aetiology of cardiac arrest in this selected population was ischaemic heart disease in 16 out of 30 patients (53.3%) followed by pulmonary embolism in four patients (13.3%) and vascular disease other than coronary disease in two patients (6.7%). Other causes consisted of hypertrophic obstructive cardiomyopathy (one patient) (3.3%) and poisoning (one patient) (3.3%). The cause of death could not be identified in six cardiac arrest victims (20%). CONCLUSIONS: Ischaemic heart disease and pulmonary embolism account for 66.6% of all witnessed cardiac arrest with no return of spontaneous circulation.

The effect of anti-L-selectin (aselizumab) in multiple traumatized patients--results of a phase II clinical trial.

OBJECTIVE: The objectives of this study were to evaluate safety (primary) and clinical efficacy (secondary) of the humanized monoclonal anti-L-selectin antibody aselizumab in severely injured patients. DESIGN: Prospective phase II, parallel group, double-blind, randomized, placebo-controlled clinical trial. SETTING: Fourteen medical intensive care units or trauma units in level I trauma centers in Belgium, Germany, and Poland. PATIENTS: Eighty-four patients with a sustained trauma due to a blunt or penetrating injury and a total Injury Severity Scale score of > or =25. INTERVENTIONS: Patients received either aselizumab at dosages of 0.5, 1, or 2 mg/kg or placebo within 6 hrs of the traumatic event and were followed for 6 wks. MEASUREMENTS AND MAIN RESULTS: The number of expeditable adverse events increased dose dependently over the aselizumab groups compared with placebo. There were no statistically significant differences between all groups regarding leukopenia and risk of infection. No immunologic response following infusion of aselizumab was noted. The number of patients with multiple organ failure, defined as a median value of the total Goris Multiple Organ Failure score of > or =5 on > or =2 consecutive days within 14 days, was not significantly different for the 0.5 mg/kg, 1 mg/kg, 2 mg/kg, and placebo groups. There were no statistically significant differences in time of mechanical ventilation, length of stay in an intensive care unit, and total duration of hospitalization between treatment groups. CONCLUSIONS: Aselizumab was associated with a higher rate of infections and leucopenia; however, this difference was not significantly different compared with placebo. For all efficacy variables, aselizumab presented no significant trends but only a few scattered statistically significant differences between groups.

What do we know about patients dying in the emergency department?

OBJECTIVE: To determine our knowledge in terms of cause of death and quality of death certification about patients who die in the emergency department. To establish the role of autopsy in this matter. METHODS: Retrospective chart review of all patients dying in an academic emergency department (ED) of a tertiary hospital over a period of 1 year. RESULTS: One hundred and ninety-six patients died in the ED in 1998. In 141/196 patients the cause of death could be determined on clinical grounds. In 53/196 patients, the antemortem clinical diagnosis was unknown. Twenty-nine out of 53 patients underwent autopsy. In all but one patient autopsy revealed the cause of death. After retrospective analysis of all patient data (notes, biology, radiology and pathological investigation), the major causes of death were cardiac (19.4%), cerebral (non-traumatic) (16.8%), trauma (15.3%) and unknown (13.3%). In the patient group with sudden cardiac arrest of unclear origin, the postmortem cause of death was identified as cardiac (51.7%), non-traumatic bleeding (10.3%), infectious (10.3%) and pulmonary embolism (3.4%). In the group of patients with a clinically clear cause of death, who underwent autopsy, 14 class II findings according to the Goldman's classification of autopsy diagnoses (i.e. major diagnosis whose detection would not have altered therapy nor outcome) were found in 16 patients. No class I findings (i.e. major diagnosis whose detection would have altered therapy or outcome) were noted. Altogether, major discrepancies between the antemortem presumed cause of death according to the notes and the real cause of death was found in 15.3%. CONCLUSIONS: Autopsy remains a very important tool to establish the cause of death in patients dying in ED. The concordance between the antemortem presumed cause of death recorded in the patient notes and the real cause (all patient data) is poor.