[Assessment of efficacy and economic impact of an influenza vaccination campaign in the personnel of a health care setting]

INTRODUCTION

Although vaccination against influenza is a well-established practice among the elderly in rest homes, in community-dwelling elderly people and in persons with underlying medical conditions associated with a high risk of complications, vaccination of workers is not always considered cost-effective, even though influenza is high on the list of diseases of public health importance. The aim of this study was to evaluate the efficacy and the cost-benefit ratio of an influenza vaccination campaign in health care workers (HCW) of a teaching hospital.

METHODS

A group of 423 HCW vaccinated against influenza during the 2002-2003 winter season was compared with a group of subjects not vaccinated, matched for sex and working area. The following outcomes were considered: (i) prevalence of influenza-like illness (ILI); (ii) days of absence from work due to ILL The cost-benefit ratio was calculated with a model using the following indices. indirect benefits (IB), indirect non medical costs (IC) and direct costs (DC).

RESULTS

The prevalence of ILI in the non vaccinated group (102 cases out of 423 subjects, 24%) was significantly increased (p < 0.001) compared with vaccinated subjects (64 cases out of 423, 15%). Working days lost for ILI were 516 in the non-vaccinated group versus 315 reported in the vaccinated group. Economic impact evaluation showed a cost of Euro 35,786.88 in vaccinees and of Euro 57,759.52 in the non-vaccinees. The resulting IB was Euro 21,078.64. The DC and IC for vaccination were Euro 2,463.29 and Euro 2,172.53 respectively. The overall cost-benefit ratio (IB/DC+IC) was 4.5.

DISCUSSION

The study shows that the influenza vaccination campaign was effective in preventing the influenza syndrome in HCW The economic impact assessment shows a cost-saving with an important cost-benefit ratio. This study suggests that a continuous effort should be recommended to increase the compliance of HCW with vaccination practice both to reduce their chance of becoming infected and for the economic benefits for healthy working adults.

[Ethical analysis of the decision-making process in occupational health practice]

BACKGROUND

Changes in workplaces and work organizations represent a challenge for governments, social partners and occupational health professionals whose aim is to appropriately satisfy emerging requirements and needs. An increasing number of occupational health problems requires a high-quality standard practice supported by ethically consistent decisions. The ethical aspect of the practice is strictly linked to that of appropriateness, involving requirements of effectiveness, efficiency and respect of ethical principles of the individual, community and society.

OBJECTIVES AND METHODS

The paper aims at focusing the ethical components of the quality of an occupational health program by taking a systematic approach to the ethical problems. The approach consists of a 2-step process. The first step consists of appraising the basic ethical principles of the dilemma ("to do good": to prevent or to remove evil and to do or to promote good; "not to do evil", implying not to inflict evil; to do no harm; autonomy implying respect of other's freedom and self-determination; justice implying equity, solidarity and non discrimination). The second step consists of detecting the stakeholders involved or interested in the decision. The alternatives are discussed according to the assessment of ethical costs (violating the consistentprinciple) and ethical benefits (fulfilment of the consistent principle) for the stakeholders.

RESULTS

Systematic analysis of the ethical components of the dilemma according to ethical principles and their discussion within a framework involving different stakeholders makes it possible to recognise ethical costs and ethical benefits of the alternative decisions. The decisions may have different costs and benefits, which should be considered and weighed to take a proper decision. Although there is no certainty about the suitability of the decision, the assessment of the ethical components may be a valuable tool in decision-making based on the awareness that any ethical aspect has been considered.

CONCLUSION

Occupational health professionals are requested to act with respect for general ethical principles and preferences of the individual, groups and setting. A high-quality practice will take into account the ethical content and the ethical conduct and any intervention will include analysis of ethical principles to compare alternative decisions and their consequences for the different stakeholders. This approach guarantees a practice based on, in addition to scientific evidence, the assessment of ethical costs and ethical benefits to favour decisions preventing conflicts.

Practising evidence-based occupational health in individual workers: how to deal with a latex allergy problem in a health care setting

BACKGROUND

Natural rubber latex, mainly contained in disposable medical gloves, is an important cause of occupational allergy in health care workers. Management of latex allergy includes education, reduction of cutaneous or mucosal contact with rubber products and minimization of exposure to latex allergens in the work environment.

METHODS

This paper reports a case study dealing with the latex allergy health problem of an operating theatre nurse. The examination was required because of a recent onset rhino-conjunctivitis crisis and asthma during usual working activities. The case was investigated and a solution provided according to the evidence-based medicine (EBM) paradigm using the PICO model.

RESULTS

The literature search was conducted using Medline and the Cochrane Library. Twenty-one papers were considered to offer appropriate solutions. Two main types of interventions were suggested: (i) changing the work setting, (ii) limiting the work activities. The evidence obtained was discussed with the nurse, who was considered unfit to continue her work in the operating theatre where her colleagues used latex gloves. The resident proposed that she could relocate to a work environment where only non-latex gloves were used and latex medical devices were not present.

CONCLUSION

The case study shows that, as for other clinicians, the occupational physician can use the EBM paradigm according to the PICO model as a tool for providing appropriate solutions for the individual worker.

[Association between relational and organizational factors and occurrence of musculoskeletal disease in health personnel]

INTRODUCTION AND OBJECTIVES

Even if work musculo-skeletal disorders represent a serious and commonly observed health problem among health care workers, few data are available about physical therapists. This study aims to compare the musculoskeletal disorders prevalence over two different health care populations and

MATERIALS AND METHODS

Two populations have been studied: (i) 100 nurses working in the teaching hospital Azienda Policlinico di Modena and (ii) 100 physical therapists working in different hospitals in Modena and Reggio Emilia. The ergonomic risk assessment has been made according to the Ergo Web questionnaire. A self-reported questionnaire [partly built according to Outil de Repérage et d'Evaluation des Gestes (OREGE) method] has been used to collect data about physiological factors, musculo-skeletal symptoms of the upper limb and spine, stress indexes and psychosocial indexes.

RESULTS

The two populations are comparable as far as the data of physiological and working anamnesis. The physical therapists have an higher prevalence of neck pain (p<0.01), whereas the nurses have an higher prevalence of low back pain (p<0.01). Furthermore, the physical therapists have an higher index of pain (involving prevalence, number of occurrences and intensity of the disorder) of right upper limb too. The nurses have higher working strain (p=0.00), attention need at work (p=0.00), poor autonomy (p<0.01) indexes than physical therapists. The indexes' analysis shows that musculo-skeletal disorders are associated to stress and psychosocial factors in both populations.

Practising evidence-based occupational healthin workers' groups: how to prevent sickness absence caused by influenza

BACKGROUND

Influenza remains a major cause of disease and death. In addition to its recognized health effects, influenza has socio-economic consequences, in particular sickness absence. Managing influenza in working populations remains a relevant topic.

METHODS

This paper reports a case study dealing with the problem of sickness absence due to influenza-like illness epidemics in health care workers (HCWs) in a health care setting. The case was investigated and the solution was provided according to the evidence-based medicine (EBM) paradigm using the PICO model.

RESULTS

The investigation was carried out by using firstly the Cochrane Library and secondly Medline. Nine papers were considered to find appropriate solutions. Two main types of interventions were suggested: (i) influenza vaccination or (ii) antiviral M2 protein inhibitors and neuraminidase inhibitors. As the latter intervention is not yet completely validated, the immunization intervention was considered. The evidence obtained was reported to the general manager and it was proposed to undertake an annual programme of vaccination for all the health care professionals.

CONCLUSION

The case study shows that, as for other clinicians, the occupational physician can use the EBM paradigm according to the PICO model as a tool for providing appropriate solutions for the group of workers.

[Experimental validation of the Evidence-Based Occupational Health paradigm and of the PICO model in the decision making process applied by occupational health physicians]

BACKGROUND

Health care organizations are increasingly aware of the need to apply quality assurance principles to serve their mission and there is an increasing pressure on health professionals to ensure that the practice is based on evidence of appropriateness. Medical specialists of different disciplines, including occupational health, are presently required to shift from habitual practices to evidence-based practices, and have began to use an approach based on the paradigm of Evidence-Based Medicine and of Evidence-Based Occupational Health (EBOH).

OBJECTIVE AND METHODS

The study was carried out to analyse how the paradigm of the EBOH could be implemented in the search, analysis and synthesis of the best available evidence to apply in the decision-making process in occupational health practice. Out of 464 medical examinations consecutively performed by 4 occupational health physicians, 6 cases were selected on the basis of their complexity and the need for further investigation. Each case was submitted to each of the 4 physicians, who were asked to make a decision according to the EBOH paradigm: i.e., (i) identification of the problem according to the PICO model, (ii) solution of the problem according to his/her internal evidence or experience (iii) search for scientific external evidence, (iv) critical appraisal of such evidence, (v) application of the evidence in the decision-making process, (vi) comparison between internal evidence and external evidence. Outcome measurements, including satisfaction of the physicians, were collected.

RESULTS

No differences were found between the decisions based on external evidence or on internal evidence in about 50% of the cases (13/24). In about 1/3 of the cases (7/24) no agreement was observed between the decisions taken on the basis of internal and external evidence. In some cases (5/24) no useful information was added for the purposes of decision-making. In about 50% of the cases the professionals were satisfied with the information found in databases, due to its usefulness both in increasing their knowledge and in improving their practice.

CONCLUSIONS

Due to their involvement in a corporate system, the participants were aware of the need to practice according to quality assurance principles and to relinquish ineffective and obsolete practices. They agreed with the need to search for the best available evidence with the aim of guaranteeing efficacious interventions. In spite of a number of obstacles to the application of the EBOH paradigm to occupational health practice, the study demonstrated that such approach can be successfully applied in this field and that it can be proposed for the search of appropriate solutions to the problems usually encountered in professional practice.

[Comments on Cogan's syndrome (congenital oculomotor apraxia) based on a case]

CASE

A 4-month-old girl was seen by a paediatrician for psychomotor delay and defective visual fixation. In order to shift gaze direction, she had to jerk her head in order to drag her eyes in the direction she wanted to look. She also showed non-specific pyramidal impairment. Herpes human virus type 6 (HHV-6) was amplified by PCR. No other findings could explain her troubles with fixation. She was diagnosed with congenital ocular motor apraxia (C.O.M.A.).

DISCUSSION

When C.O.M.A. is suspected, other causes of defective fixation and abnormal cephalic movements must be ruled out through the use of physical examination, electrophysiology and neuroimaging: troubles with ocular motility, poor vision or neurological processes. There have been cases associated with neurological misdevelopment, systemic diseases, metabolic deficits and chromosomic abnormalities.

[Health policy and occupational health: tools and methods to assure quality and appropriateness of interventions]

BACKGROUND

Although all health care organizations and professionals are encouraged to follow the explicit aim of reducing the burden of illness, accidents and disability, there is increasing pressure on health professionals to ensure that the practice be based on a quality standard and on evidence of appropriateness.

OBJECTIVES AND METHODS

The paper aims to focus on both the concept and dimensions of appropriateness (a complex issue with various dimensions and definitions) and on the different research and practice models aimed at search, analysis and synthesis of the best available evidence to be applied in the decision process of health and medical practice. Literature analysis has been carried out to find available tools and methods to identify, implement and monitor the evidence of efficacy in health care systems and services.

RESULTS

Most definitions of appropriateness address a number of requirements. An appropriate practice should be effective (based on sound evidence); efficient (providing that cost is considered) and consistent with the ethical principles and preferences of the relevant individual, community or society. Appropriateness is considered as the next frontier in the development of health care research: there is still limited knowledge, awareness, or research on this aspect. Health Technology Assessment consists of a multidisciplinary activity based on the systematic examination of technical performance, safety, clinical effectiveness and efficiency, including socio-economic, legal and ethical aspects. Evidence Based Medicine originates from an individual perspective and aims at using rigorous criteria to obtain the best available evidence in order to provide efficient interventions. The Clinical Practice Guidelines, based on both evidence and opinions of experts, are intended to assist clinical decisions for health professional and providers for the improvement of professional practices and system efficiency, taking into account local customers, health needs and preferences.

CONCLUSIONS

Several models exist for measuring and evaluating the efficacy of health systems and health services. They can be adapted for evaluating and measuring public and occupational health practices. These tools support good practice through quality-standardized interventions aiming at the health protection of communities and individuals. These models, which are presented in a specific framework in which their outcomes and critical factors are evaluated, should be adapted to public and occupational health interventions to satisfy implicit and explicit needs of individuals and populations at risk thus assuring their quality and appropriateness.

Clinical and pressure-flow changes after long-term treatment with alfuzosin SR

OBJECTIVES

The aim of our study was to evaluate the symptomatic and urodynamic changes after 1-5 years of treatment with alfuzosin in patients with benign prostatic hyperplasia.

METHODS

Out of 255 patients with lower urinary tract symptoms observed from 1992 to 1997, who completed the International Prostatic Symptom Score (I-PSS) and underwent full urodynamic investigation, 161 were found to be obstructed (Schäfer classes 2-6). One hundred and two subsequently consented to a second clinical and urodynamic evaluation. Out of these, 46 underwent surgical treatment, 20 were elected for watchful waiting (WW) and 36 received a medical treatment. Twenty out of these, with a mean age of 65 years, a mean prostatic volume of 44 ml (20-70) a median Schäfer's obstruction class of 3 (range 2-5) were treated with slow release alfuzosin 5 mg twice a day. We re-evaluated these 20 patients with a second I-PSS and pressure-flow study after 1-5 years (mean: 2 years) of treatment. The patients in the WW group with comparable baseline characteristics were considered as controls. The Wilcoxon matched-pairs signed rank test and the Kruskal-Wallis test were used for statistical analysis.

RESULTS

In the group treated with alfuzosin, no differences were noted for I-PSS (14.9 +/- 6,8; 13.3 +/- 5); maximum flow (124 +/- 6; 14 +/- 6) and projected isometric pressure (105 +/- 36; 105 +/- 26). Statistically significant differences were noted for residual urine (103 +/- 100; 33 +/- 38, p = 0.02); detrusor pressure at maximum flow (64.4 +/- 23; 53 +/- 12, p = 0.04), minimum urethral opening pressure (36.5 +/- 9; 31 +/- 9, p = 0.02), Schäfer class (2.7 +/- 0.7; 2 +/- 0.8, p = 0.04); urethral resistance algorithm (34.7 +/- 11; 27 +/- 7, p = 0.02). Statistically significant differences between baseline and follow-up were noted for none of the clinical and urodynamic parameters in the WW group.

CONCLUSIONS

Patients with bladder outlet obstruction seem to remain clinically stable and to improve urodynamically when treated with alfuzosin for a long period of time.

[Effectiveness of interventions for the control and prevention of tuberculosis in health care facilities: a review of ATS,CDC, OSHA recommendations]

BACKGROUND

Health care workers (HCWs) are occupationally exposed to a multitude of biological hazards, and among these to the risk of tuberculosis (TB) infection, especially involving individuals working in specific workplace (TB and Chest divisions, Infectious Diseases wards, Microbiology laboratories) and performing thoracic endoscopy and "cough-inducing" procedures. According to national legislation (title VIII D.lgs. 626/94, 1998 Health Minister guide lines document) concerning the control and prevention of TB transmission among HCWs, health care facilities are required to (i) perform an accurate risk assessment and (ii) implement an exposure control plan and worker health surveillance program, thus involving the occupational health professionals.

OBJECTIVES

The aim of this paper is to provide a general view of the epidemiological and scientific evidence related to the effectiveness of health interventions in the prevention of occupational TB infection.

METHODS

Comparative evaluation and critical review of U.S. CDC (1994) guidelines, OSHA (1997) rules, and the most recent ATS and CDC (2000) "statement" documents.

RESULTS

In low risk groups TCT shows decreased positive predictive value, high variability, and can be confounded by other factors (age, BCG, MNT), thus reducing its diagnostic value for latent TB infection.

CONCLUSIONS

Recent recommendations on the control of TB infection in health care settings underline the need of implementing accurate risk evaluation in all hospital units, compared to the epidemiological profile in the community, and "targeted tuberculin testing" programs among high risk HCWs.

[Contribution of ultrasonography in late maturation of native fistulae for chronic hemodialysis]

Early failure of arteriovenous fistulae for chronic hemodialysis can be avoided with early preoperative physical examination and complementary explorations. Nevertheless, insufficient development of the arteriovenous fistula after 3 months remains a frequent problem which is sometimes difficult to manage clinically. Duplex-Doppler is the fundamental exploration allowing distinction between pseudo-retard in maturation and true retard with low flow rate. In the first case, blood flow and venous and arterial caliber are normal but unfavorable anatomic conditions may result in superficialization. In the second case, blood flow is too with a true insufficiency in the venous caliber. An exhaustive exploration of the venous and arterial vessels allows accurate diagnosis of arterial strictures limiting inflow or venous strictures limiting dilatation to a diameter sufficient for puncture (6-7 mm). Different situations may occur: --anastomotic or justa-anastomotic strictures with a normal arterial and venous, suggesting the fistulae should be reoperated (excepting the rare situation resulting from intrinsic compression due to a postoperative hematoma); --focal stricture which generally requires interventional radiology on both the arterial and venous sides; --arterial strictures with diffuse calcification, requiring a new arterial site; --insufficient drainage via the elbow or a small or absent cephalic and/or basilary vein.

[Technique and results of duplex-Doppler for non-stenosing complications of vascular access for chronic hemodialysis: ischemia, steal, high flow rate, aneurysm]

Two factors increasing flow rate in arteriovenous fisulae (AVF) with the subsequent risk for cardiac function, are the site of the access and time since its creation. Cubital AVF and bypasses are less often involved. Mean flow rate in a distal fistula is 465 +/- 250 ml/min. For proximal fistulae, mean flow rate is 750 +/- 309 ml/min. Flow rate is measured by pulsed duplex-Doppler of the humeral artery or the axillary artery. If high flow rate is poorly tolerated, careful assessment should provide an orientation concerning appropriate correction: ligature of the proximal radial artery to limit arterial inflow to the AVF which is then comes solely from retrograde flow from the radial artery via the palmar arcades and the cubital artery; distal prolongation by radial bypass or transposition after checking the state of the forearm arteries. Vascular steal can lead to ischemia, which is greater for high flow proximal fistulae, with the risk of aggravating pre-existing arteritis. Continuous color-Doppler exploration of the distal vessels, with the fistulae open and closed with compression, is primordial to establish the positive diagnosis and the appropriate therapeutic approach. Flow rate must be determined accurately. If low flow rate is associated with signs of ischemia, angioplastic or surgical revascularisation may be required for identified and accessible areas of stenosis. If the flow rate is too high, reduction may be effective. If the distal Doppler signal is normal or minimally perturbed with the open AVF, the fistula may be the cause of the ischemia. If no flow can be detected when the AVF is closed, the distal artery is involved and may have to be closed. Venous ischemia is much more uncommon and may be caused by venous stenosis downstream from the fistula. Diffuse venous ectasia may result from a downstream obstruction due to stenosis or thrombosis, or to excessive flow. In the event of a false aneurysm, a pulsitile hematoma is visualized by color Doppler with one or more spurts, associated or not with images of mural thrombosis. Deterioration of the vessel walls at the point of puncture can lead to intra-capsular false aneurysm.

[Surgical treatment of nystagmus with horizontal torticollis]

PURPOSE

To study the effect of modified Anderson's procedure in nystagmus surgery with pure horizontal torticollis.

METHOD

Retrospective study of 8 patients with nystagmus and pure horizontal torticollis that were surgically treated in our hospital in a 4 years period. Mean age of the sample was 9 years, SD 8.6 (range 4-30). Large bilateral recessions were made in the yoke rectus muscles that are responsible for the versions to obtain the null position. The amount of surgery was variable according to the torticollis intensity and the association of strabismus. Follow-up length ranged from 15 to 45 months (average 31.14, SD 11.55).

RESULTS

Torticollis improved in all patients at the end of the study. A good result was achieved in 62.5% of the cases, with a residual torticollis inferior to 10 degrees. In two cases, severe torticollis improved to a moderate one (10-20 degrees ). Torticollis reversal occurred in one patient, who needed a second operation. Neither clinically significant ductions limitations, nor secondary strabismus were found.

CONCLUSIONS

The modified Anderson's procedure was effective for treating moderate horizontal torticollis with nystagmus. Severe torticollis were not totally corrected. Large muscle recessions were not associated with clinically significant ductions limitations. There was not secondary strabismus (Arch Soc Esp Oftalmol 2003; 78: 481-486).

[Evaluation of the efficacy of an influenza vaccine campaign among health personnel for the prevention of influenza-like illness (ILI)]

Aim of the study is to evaluate influenza vaccination effectiveness in health care workers. Results show: (i) a significant decrease of ILI-cases among vaccinated health care workers, (ii) a significant decrease of sickness absence among vaccinated workers, (iii) a favourable cost/benefit analysis.

[Assessment of appropriateness and verification of interventions in the professional practice of the occupational physician]

Evaluation of Occupational Health Practice is both an intriguing research field and an essential tool to assure the quality of intervention. The objectives of this paper are: (i) to define the principles of evaluation and the role of quality assurance of intervention, (ii) to define the principles of audit of professional practice, (iii) to outline the role of research in evaluating and improving intervention and other practice.

[The paradigm of evidence based medicine applied to occupational health: an intervention model]

The Evidence Based Medicine paradigm has been used for searching literature data to be used for solving workers' health problems. Results show that useful information has been found in 9 problems out of 17 selected cases.

Significance of selective carotid angiography during complete cardiac catheterization in patients candidates to combined aortic valve and carotid surgery

AIM

Association of aortic valve stenosis (AVS) with carotid artery disease (CD) constitutes a high risk clinical setting for combined surgery. Carotid angiography is still considered the gold standard for carotid artery imaging, but its use is confined in cases of dubious or inconclusive sonographic examination. Despite the widespread use of ultrasonography, selective angiography may be practical in patients undergoing complete routine cardiac catheterization for AVS due to characteristic abnormalities in flow velocity pattern due to aortic valve stenosis. The present retrospective study aims to estimate the feasibility and role of carotid angiography during complete routine cardiac catheterization in the assessment of CD associated with AVS in patients candidates for combined surgery, in whom Doppler ultrasonography was inconclusive.

METHODS

In agreement with cardiac and vascular surgeons, patients aged >60 years, presence of risk factors, and inconclusive Doppler ultrasonographic examination underwent selective carotid artery angiography during complete cardiac catheterization. The angiographic and clinical records of these patients were reviewed.

RESULTS

Sixty patients (male/female 28/32, mean age 64.5+/-10.6 years) underwent carotid angiography during left and right catheterization. Optimal visualization of carotid trunk anatomy and morphology was achieved in all patients. Forty-one patients (68.3%) had no carotid artery atherosclerotic involvement, whereas 4 (6.6%) had low grade CD. Fifteen patients (8.3%, male/female: 7/8, mean age 70+/-10.4 years) were diagnosed with critical stenosis of one (14 patients) or both (1 patients) internal carotid arteries. The mean lesion degree was 77.1+/-2.1%. Culprit plaques, bifurcation lesion and occlusion have been discovered in 6.6%, 20%, and 26.6% of patients, respectively. Two arterial spasms (3.3%), and no intrahospital complications were observed.

CONCLUSION

In highly selected patients with combined CD and AVS and inconclusive Doppler ultrasonographic examination, selective carotid angiography during heart catheterization is safe, acceptably time-consuming and it may give an optimal anatomical picture of CD.

[Criteria for the management of low back pain in health care workers]

Low back pain represents one of the most frequent health problems in several working populations and is an important problem for occupation health doctors. In fact, these professionals are often required to face with the specific management of this condition, also by participating with other professionals into the implementation of organizational and structural measures. This contribute describes a variety of interventions aimed at treating the syndrome and recovering the working ability of the patient-worker, including the initial clinical evaluation, the assessment of the casual relationship between work and the syndrome, the treatment, the formulation of proposals to modify the worker's physical and working activity, the ongoing heath surveillance and a more in-depth clinical and instrumental evaluation, including surgical treatment.