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.

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.

Vitamin D and cartilage. I. In vitro metabolism of 25-hydroxycholecalciferol by cartilage.

In the present work, the capacity of cartilage to metabolize 25-hydroxycholecalciferol was investigated. Cartilage preparations from growth plate, articular surface, rib, scapula, and ear were isolated from 3-week-old normal rabbits and chickens. Each tissue was separately incubated with tritiated 25-hydroxycholecalciferol (, x 10(-9) M) for 1-24 h. Incubations of kidney and muscle were performed simultaneously for comparison. Similarly, cultured chondrocytes isolated from rabbit growth plate and articular cartilage were incubated for 1 or 20 h in medium free of fetal calf serum. After methanol-chloroform extraction of tissues, cells, and their respective media, chloroform phases were chromatographed on Sephadex LH-20 columns. The results show that kidney and cartilage are able to convert 25-hydroxycholecalciferol into a derivative which migrates in the 24,25-dihydroxycholecalciferol region. Cartilage tissue previously boiled is unable to metabolize 25-hydroxycholecalciferol. The conversion of 25-hydroxycholecalciferol occurs with all types of cartilage and is also observed in incubations of cultured chondrocytes. In the latter, the polar 25-hydroxycholecalciferol derivative is detected as early as 1 h after addition of 25-hydroxycholecalciferol. Two findings suggest that the polar derivative of 25-hydroxycholecalciferol produced by cartilage is 24,25-dihydroxycholecalciferol: 1) the cartilage derivative and 24,25-dihydroxycholecalciferol (synthetic and biosynthetic) comigrate during Sephadex LH-20 and high liquid pressure chromatography; and 2) both the cartilage derivative and 24,25-dihydroxycholecalciferol are sensitive to periodate treatment.

Levels of emotional awareness and the degree of right hemispheric dominance in the perception of facial emotion.

To examine correlates of individual differences in the degree of right hemispheric dominance in the perception of facial emotion, 51 medical students completed the Levy Chimeric Faces Test and an independent measure of differentiation and complexity in the processing of emotional information, the Levels of Emotional Awareness Scales. A strong positive correlation was observed between the two measures, especially when variance due to verbal ability was removed and native English speakers only were included. These results suggest that as right hemisphere dominance in the perception of facial emotion increases, the ability to perceive complexity during the processing of emotional information increases.

Cell proliferation after ischemic infarction in gerbil brain.

In order to study cell proliferation after ischemic infarction, a model of bilateral common carotid artery occlusion in the gerbil was developed. A comparison of survival rates after 15, 30, 45 and 60 min of occlusion revealed that 45 min was the maximum duration of ischemia after which most (72%) of the gerbils were alive at 1 week. The administration of pentobarbital (single dose, 30 mg/kg) postoperatively to badly seizing animals increased survival to 100%. Large, well-demarcated infarcts were present in posterior thalamus or midbrain in 62% of gerbils subjected to 45 min bilateral occlusion. In 60% of these animals the infarcts were unilateral; in 40% they were bilateral. To quantitate cell proliferation in the infarcts from 12 h to 25 days after ischemia, gerbils were injected with [3H]thymidine 4 h prior to sacrifice, and autoradiographs were prepared from sectioned brains. Proliferation took place from 2 to 7 days after occlusion, with a maximum of 24% labeled cells at 6 days.

Angiogenesis in developing rat brain: an in vivo and in vitro study.

Brain capillary proliferation in postnatal rats was measured in vivo by [3H]thymidine autoradiography. Maximal capillary proliferation occurred between 5 and 9 postnatal days, and was 40 times greater than in the adult. To test the hypothesis that soluble angiogenesis factors play a role in this developmental vascularization of brain, we prepared extracts from the brains of 6-day-old rats at the peak of proliferative activity, and from adults when it was lowest. We assayed them using an in vitro growth system measuring [3H]thymidine incorporation into cultured brain capillary endothelial cells. Extracts prepared from either 6-day or adult rats and containing 150 micrograms/ml protein caused more than a 4-fold stimulation of the endothelial cells, increasing to 8-fold at a concentration of 1500 micrograms/ml. The presence of growth-promoting activity in brain extracts from both adult and immature rats suggests that soluble angiogenesis factors may be present in the brain throughout life, but are unavailable for stimulation of in vivo capillary growth unless released or activated by an appropriate stimulus.

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.

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.

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.

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.

Fitness for work after laparoscopic and open cholecystectomy.

To determine the impact of the type of surgical intervention and medicosocial factors in the fitness for work after cholecystectomy, 2094 records of patients were reviewed. Subjects were Christian sickness fund recipients who underwent surgery from 1992 until 1994 with a follow-up period between 1 to 3 years. A work incapacity longer than 6 weeks was defined as a bad outcome. Data were analyzed using univariate statistics (chi2-test) and logistic regression. A laparoscopic cholecystectomy was significantly associated with an earlier fitness for work and a shorter period of hospital stay. In general, a bad outcome was also related to a longer period of work incapacity before the intervention, older age, longer hospital stay, employment as a blue collar worker and operation in a non-university medical center. These factors should be taken into account in the selection of patients for cholecystectomy, and in policies to improve patients recovery and fitness for work. Clear information about the duration of the postoperative recovery period and the incapacity for work should be given to the patients before the intervention. An unnecessary long time of sick leave without medical motive should be avoided.

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.

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.

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.

Subpopulations of cells in immature mouse mammary gland as detected by proliferative responses to hormones in organ culture.

Organ culture of immature mouse mammary gland was used to demonstrate the presence of different epithelial cell types in this tissue. Whole glands were cultivated for 10 days in various hormone combinations, and the proliferative responses of the epithelium were evaluated by [3H]thymidine autoradiography. It was found that different regions of the gland responded to hormones dissimilarly. The large, primary duct required no added hormones for either maintenance (viability according to histological criteria) or proliferation. Secondary and tertiary ducts required insulin for maintenance and proliferation and exhibited hyperplasia when a mineralocorticoid plus either growth hormone, prolactin, or placental lactogen were also present. End buds required the most complex hormone environment for maintenance in culture, and did not exhibit proliferative activity as intense as that which occurs in vivo, even in the optimum hormone combinations used.

Fitness for work after surgery for lumbar disc herniation: a retrospective study.

This report retrospectively evaluates fitness for work in 3956 cases of surgery for lumbar disc herniation between 1992 and 1994. Patient records were derived from a database including all interventions of the insured population of the largest Belgian sickness fund. The datafile consisted of 126 cases of percutaneous nucleotomy (nucleotomy group), 286 cases of lumbar disc surgery with fusion (fusion group) and 3544 cases of standard lumbar disc surgery (standard group). Fitness to resume work within 12 months after intervention was obtained in about 70% of the patients in the standard and nucleotomy groups but in only 45% of the patients in the fusion group. Ten medicosocial factors were related to fitness for work as outcome measure. Incapacity for work more than 12 months after intervention was defined as a bad outcome. Logistic regression was used to test the combined relative significance of the different variables. For the standard group a long duration of work incapacity before intervention, older age, lower benefit, employment as a blue-collar worker, a long duration of hospital stay and unemployment were significantly associated with a poor outcome. Related factors for the fusion group were a long duration of work incapacity before operation, a long duration of hospital stay and unemployment. For the nucleotomy group, no factor was significantly associated with a poor outcome. For the total group, discectomy combined with fusion was significantly related to a poor outcome whereas a standard discectomy and a percutaneous nucleotomy did not differ in their impact on fitness for work.

Cell proliferation after ischemic injury in gerbil brain. An immunocytochemical and autoradiographic study.

Tritiated thymidine autoradiography was used to measure cellular proliferation after ischemic injury in gerbil brain. Gerbils were subjected to bilateral occlusion of the common carotid arteries which resulted in areas of necrosis, or infarcts, in the posterior thalamus or midbrain. From 12 h to 10 days following the ischemia, gerbils were injected with 3H thymidine, sacrificed 4 h later, and the brains sectioned. In order to identify astrocytes and monocytes/macrophages, immunocytochemistry was performed prior to autoradiography, using antisera against glial fibrillary acidic protein and endothelial-monocyte reticuloendothelial antigen, respectively. Immunocytochemistry was also used to visualize microvessel laminin, myelin, and leakage of serum albumin. Lastly, a histochemical procedure for acid phosphatase activity was employed to verify cellular phagocytic activity in the wound. A reproducible sequence of reactions took place during the first 10 days after ischemia. Early changes included leakage of albumin and myelin breakdown, followed by arrival of monocytes at 2 days and their differentiation into macrophages by 5 days. These cells exhibited intense proliferation from 2 to 6 days post-ischemia. Microvessel endothelial cells were maximally labeled at 4 days post-ischemia. Hypertrophied astrocytes were apparent at 2 days and proliferated from 3 to 7 days post-ischemia, and by 10 days the wound was replaced by a "glial scar".