Employment status in cancer patients the first five years after diagnosis-a register-based study

PURPOSE

Work is important for identity formation, social status, and economic independency. Although some evidence within the field of work and cancer survivorship exists, no study has so far investigated employment status across all cancer diagnoses. Thus, the aim of the present study was to investigate the impact of all cancer diagnoses on employment status.

METHODS

Danish cancer patients aged 20-60 years, diagnosed between 2000 and 2015, were identified through Danish registers and matched 1:5 with cancer-free controls. Logistic and linear regression was performed separately in 11 cancer types to assess and compare work status and work participation between cancer patients and cancer-free controls one, three, and five years after diagnosis.

RESULTS

A total of 111,770 cancer patients and 507,003 cancer-free controls were included. All cancer types had lower chances of working one year after diagnosis (ORs between 0.05 and 0.76), with lung, colorectal, upper gastrointestinal, and blood cancer patients having the lowest chances. After three years, 10 of 11 cancer types had lower chances (ORs between 0.39 and 0.84). After five years, there were minimal differences between cancer patients and controls among most cancer types (ORs between 0.75 and 1.36).

CONCLUSION

Most cancer patients had lower chances of working compared with the general population until five years after diagnosis. However, patients with certain cancer types experienced lower chances of working all years, despite improvement over time.

IMPLICATIONS FOR CANCER SURVIVORS

The knowledge will help increase awareness on challenges regarding work-life after cancer. Furthermore, the distinguishing between diagnoses can inform to more targeted vocational rehabilitation.

Cardiac rehabilitation: pedagogical education strategies have positive effect on long-term patient-reported outcomes

This study examined whether patients attending cardiac rehabilitation (CR) based on the pedagogical strategy learning and coping (LC) led to improved health-related quality of life (HRQL), reduced symptoms of anxiety and depression and improved self-management 6 and 12 months after the completion of CR compared with patients attending CR based on the pedagogical strategy 'Empowerment, Motivation and Medical Adherence' (EMMA). A pragmatic cluster-controlled trial of two pedagogical strategies, LC and EMMA, including 10 primary health care settings and 555 patients diagnosed with ischaemic heart disease and referred to CR between August 2018 and July 2019 was conducted. In total, 312 patients replied to the questionnaires collected at baseline, 12 weeks, 6 months and 12 months after completing CR. Linear regression analyses adjusted for potential confounder variables and cluster effects were performed. We found clinically relevant and statistically significant improvements in HRQL, anxiety, depression and self-management after completing CR. The improvements were sustained at 6 and 12 months after the completion of CR. We found no differences between the two evidence-based patient education strategies. In conclusion, this study supports the use of evidence-based patient education strategies, but there is no evidence to suggest that one pedagogical strategy is superior to the other.

"To have and then lose the safety net" - Female cancer survivors' experiences of the process of becoming ready to return to work

BACKGROUND

Validation studies have not been able to confirm the stage-specific understanding as operationalised in the readiness for return to work (RRTW) questionnaire.

OBJECTIVE

To explore retrospectively how working female cancer survivors experienced the process of becoming ready to RTW during and beyond participation in an occupational rehabilitation intervention and thereby expand the understanding of the RRTW construct.

METHODS

A qualitative research design was employed. Thirteen female cancer survivors were included for semi-structured interviews one to two years after they had completed active treatment and returned to work. The RRTW construct guided data generation and analysis. Content analysis was performed in four analytical steps that combined a concept-driven and a data-driven analytic strategy.

RESULTS

Three themes were identified; "To have and then lose the safety net", "Realise a changed life situation", "Strive to balance work and everyday life". In a time span of approximately one to two years (from receiving treatment, being enrolled in an intervention and to gradually returning to work); the identified themes were interdependent of each other as one theme gradually evolved to the next theme in the process of engaging in sustained work participation.

CONCLUSIONS

The present study points towards continuous development of the RRTW construct and whether the addition of a preparedness dimension would improve validity.

Waking Up in Pain: a prospective unselected cohort study of pain in 3702 patients immediately after surgery in the Danish Realm

BACKGROUND

Acute and persistent pain after surgery is well described. However, no large-scale studies on immediate postoperative pain in the operating room (OR) exist, hindering potential areas of research to improve clinical outcomes. Thus, we aimed to describe the occurrence and severity of immediate postoperative pain in a large, unselected cohort.

METHODS

This was a prospective cohort study, encompassing all procedures in 31 public hospitals in the Danish Realm, during a 5-day period including the weekend. Data on procedures and anesthesia were collected and the main outcome was occurrence of moderate or severe pain in the OR. Secondary outcomes included pain, sedation and nausea in the OR or during the first 15 min in the postanesthesia care unit (PACU) including relevant risk factors. Descriptive and logistic regression statistics were used.

RESULTS

A total of 3675 procedures were included for analysis (87% inclusion rate). Moderate or severe pain occurred in 7.4% (95% CI 6.5% to 8.3%) of cases in the OR immediately after awakening, rising to 20.2% in the OR and/or PACU. Large intraprocedure and interprocedure variations occurred (0.0%-37.5%), and in 20% of cases with epidural-general anesthesia patients experienced moderate or severe pain. Independent risk factors were female sex, younger age, preoperative pain, daily opioid use and major surgical procedures.

CONCLUSION

Moderate or severe pain in the immediate postoperative phase occurred in 20% of all cases with procedure and anesthesiological technique variations, suggesting a need for identification of relevant procedure-specific risk factors and development of preventive treatments.

TRIAL REGISTRATION NUMBER

RoPR ID 43191.

Cardiac rehabilitation for patients with heart failure: a national Danish register-based study of predictors of referral and outcomes

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation

Background

 Heart failure (HF) places a large burden on patients and society as a major cause of morbidity, mortality and healthcare costs. Participation in exercise-based cardiac rehabilitation (CR) in people with HF is a clinically and cost-effective strategy and recommended in international clinical guidelines.

Purpose

The aims of this study were to: (1) examine the temporal trends and predictors of national CR referral, and (2) compare the risk of hospital readmission and mortality in those referred for CR compared to no referral.

Methods

All patients in Denmark with incident HF were identified by the Danish Heart Failure Register in the period 2010 to 2018 (n = 33,257) and CR referral assessed within 120 days of hospital admission. Multivariable logistic regression models were used to evaluate the association between CR referral and predictors and to compare risk of hospital readmission and mortality until 1 year between referred and not referred patients.

Results

Overall, 45.0% of HF patients were referred to exercise-based CR, increasing from 31.7% in 2010 to 52.2% in 2018. Factors independently associated with higher CR referral were: NYHA functional class II, LVEF <50%, diagnosis of myocardial infarction and use of ACE inhibitor. Male gender, older age, region, unemployment, retirement, living alone, non-Danish ethnic origin, lower educational level, NYHA class IV, treatment for hypertension, existing chronic obstructive lung disease and stroke were associated with lower CR referral. CR referral was associated with lower risk of readmission (adjusted odds ratio: 0.90;95%CI: 0.85-0.95), HF-specific mortality (0.61; 0.39-0.95) and all-cause mortality (0.61; 0.55-0.69) as compared to no referral.

Conclusions

Although CR referral has increased over time, only some 1 in 2 diagnosed HF patients in Denmark are referred to exercise-based CR. CR referral is associated with lower risk in readmissions and mortality. Strategies to promote CR referral including healthcare professional education on the benefits of CR and alternative methods of CR delivery are urgently needed to improve access to CR, especially for high-risk groups.

Short- and long-term effects of the patient education strategy-learning and coping-in cardiac rehabilitation: a randomized controlled trial (LC-REHAB)

The objectives were to assess the short- and long-term effect of the patient education strategy 'Learning and Coping' (LC) in cardiac rehabilitation (CR) on health-related quality of life, patient education impact, cardiac risk factors and lifestyle. In total, 825 patients hospitalized with ischaemic heart disease or heart failure were randomized to either LC-CR or standard CR at three Danish hospitals. Teaching approach in LC-CR was situational, inductive and reflective, with experienced patients as co-educators and supplemental interviews. Teaching approach in standard CR was structured and deductive. Outcomes were assessed immediately after CR, and after 3 months (short term), and after 3 years (long term). Between-arm differences in favour of LC-CR were SF-12 'role emotional' (3.7, 95% CI: 0.6-6.8) and MDI depression score (0.9, 0.1-1.8) immediately after CR, exercise capacity (4 W, 1-9) at 3 months and SF-12 'role physical' (4.6, 0.1-9.0) (long term). Between-arm differences in favour of controls were waist circumference (-1.7 cm, -2.3 to -1.0) immediately after CR and HeiQ domain 'Constructive attitudes and approaches' (0.11, 0.04-0.18), triglycerides (-0.12 mmol/l, -0.21 to -0.02), systolic blood pressure (-3.12 mmHg, -5.66 to -0.58) at 3 months. Adding LC strategies to CR provides inconsistent short-term results but improves 'role physical' long term.

Effects of the patient education strategy 'Learning and Coping' in cardiac rehabilitation on readmissions and mortality: a randomized controlled trial (LC-REHAB)

We assessed the effects of the patient education strategy 'Learning and Coping' (LC) in cardiac rehabilitation (CR) on mortality and readmissions by exploring results from the LC-REHAB trial. In all, 825 patients with ischaemic heart disease or heart failure were randomized to the intervention arm (LC-CR) or the control arm (standard CR) at three hospitals in Denmark. LC-CR was situational and inductive, with experienced patients as co-educators supplemented with two individual interviews. Group-based training and education hours were the same in both arms. Outcomes were time to death or readmission, length of stay and absolute number of deaths or readmissions. No between-arm differences were found in time to death, first readmission, or length of stay. Within 30 days after completion of CR, the absolute number of all-cause readmissions was 117 in the LC arm and 146 in the control arm, adjusted odds ratio 78 (95% CI: 0.61-1.01), P = 0.06. This trend diminished over time. Adding LC strategies to standard CR showed a short term but no significant long-term effect on mortality or readmissions. However, the study was not powered to detect differences in mortality and morbidity. Thus, a risk of overseeing a true effect was present.

Reintegrating Employees Undergoing Cancer Treatment into the Workplace: A Qualitative Study of Employer and Co-worker Perspectives

Purpose The purpose of this study was to explore how employers and co-workers experience the return to work (RTW) process of employees undergoing cancer treatment. Methods Sixteen semi-structured individual interviews and participant observations at seven workplaces took place, involving seven employers and nine co-workers with different professions. A phenomenological-hermeneutic analytic approach was applied involving coding, identification of themes, and interpretation. Results We identified three employer themes: call for knowledge, Making decisions, and Feeling helpless. Also, three co-worker themes were identified: understanding and sympathy, extra work and burden, and Insecurity about future work tasks. Early initiated RTW, e.g. less work hours and work accommodations, did neither constitute challenges for employers nor co-workers in the beginning of the RTW process. However, when the RTW process was prolonged employers encountered difficulties in finding suitable work tasks, whereas co-workers were burdened by extra work. Conclusions Overall, cancer survivors' RTW process was welcomed and encouraged at the workplace level. However, employer and co-worker experiences suggested that RTW initiation parallel with cancer treatment raised challenges at the workplace level, when the RTW process was extended beyond the initial RTW plan; increased workload and difficulties in balancing the needs of the cancer survivor and co-workers. Mechanisms that support cancer survivors' RTW without introducing strain on co-workers should be investigated in future research. Furthermore, support for employers in their RTW management responsibilities needs to be addressed in general and in particular in future RTW interventions.

Social inequality in cancer survivors' health behaviours-A Danish population-based study

The aim of this study was to compare health behaviours (smoking, alcohol consumption, physical activity and diet), to explore social inequality in these behaviours among cancer survivors and individuals with no history of cancer, respectively, and to study the impact of time since diagnosis on cancer survivors' health behaviours. Data from the Danish National Health Survey from 2013 were linked with data from the Danish Cancer Registry to identify all cancer diagnoses among the respondents during the period 1945-2012. In total, 11,166 cancer survivors and 151,117 individuals with no history of cancer were included. Cancer survivors smoked less and had a more sedentary lifestyle than individuals with no history of cancer. In relation to alcohol and dietary habits, no differences were found between the groups. Wide variations in health behaviours were seen across cancer sites, and in particular lung, bladder and oral cancer survivors had poor health behaviours. We found a clear social gradient in cancer survivors' health behaviours which reveals the need for greater focus on socially differentiated initiatives within prevention and patient education for cancer survivors. Our study revealed rather blurred results in relation to identifying the optimal timing for health-related behavioural interventions in cancer survivors.

Return-to-work intervention during cancer treatment - The providers' experiences

To explore in-depth understanding of providers' experiences when involved in a return-to-work (RTW) intervention offered during cancer treatment. Semi-structured individual interviews and participant observations at a hospital department and two municipal job centers were carried out, including ten providers (physicians, nurses and social workers). A phenomenological-hermeneutic approach was applied, involving coding, identification of themes and interpretation of findings. Three major themes were identified: Treatment first, Work as an integrated component in cancer rehabilitation, and Challenges in bringing up work issues. Differences in providers' experiences of the RTW intervention offered to cancer patients were found: in the hospital setting RTW was a second priority, whereas in the municipality job centers it was an integrated component. Further studies are needed to investigate how and when occupational rehabilitation services can be implemented across sectors to support cancer patients' RTW. In the future, work issues ought to be systematically presented by providers across sectors as early as possible to support cancer patients' RTW. Cancer patients' individual needs and thoughts about RTW are to be identified by both health care providers during treatment and social workers at the municipality level and shared across sectors.

Screening instruments for predicting return to work in long-term sickness absence

Background

Multiple somatic symptoms are common and may cause prolonged sickness absence (SA) and unsuccessful return to work (RTW).

Aims

To compare three instruments and their predictive and discriminative abilities regarding RTW.

Methods

A longitudinal cohort study of participants recruited from two municipal job centres, with at least 8 weeks of SA. The instruments used were the Symptom Check List of somatic distress (SCL-SOM) (score 0-48 points), the Bodily Distress Syndrome Questionnaire (BDSQ) (0-120 points) and the one-item self-rated health (SRH) (1-5 points). The instruments' predictive value was explored in a time-to-event analysis. Different cut-points were analysed to find the highest number of correctly classified RTW cases, identified in a register on public transfer payments.

Results

The study involved 305 subjects. The adjusted relative risk regarding prediction of RTW was 0.89 [95% confidence interval (CI) 0.83-0.95], 0.89 (95% CI 0.83-0.95) and 0.78 (95% CI 0.70-0.86) per 5-, 10- and 1-point increase in the SCL-SOM, BDSQ and SRH, respectively. After mutual adjustment for the three instruments, only the prediction of RTW from SRH remained statistically significant 0.81 (95% CI 0.72-0.92). The highest sensitivity (86%) was found by SRH at the cut-point ≤5, at which 62% were correctly classified.

Conclusions

All three instruments predicted RTW, but only SRH remained a significant predictor after adjustment for the SCL-SOM and BDSQ. The SRH provides an efficient alternative to more time-consuming instruments such as SCL-SOM or BDSQ for estimating the chances of RTW among sickness absentees.

Returning and staying connected to work after long-term sickness absence

BACKGROUND

Returning to work (RTW) after long-term sickness absence is a challenge for convalescent workers, co-workers, managers and organizations. Few studies have investigated the post-return phase after long-term sickness absence.

AIMS

To investigate the RTW process as experienced by returning workers, co-workers and managers at an emergency care service and a waste disposal company, exploring various perspectives related to early RTW before full recovery and changes in the returning workers' work positions.

METHODS

An ethnographic field work design was employed. Returning workers with musculoskeletal disorders, co-workers and managers at two different workplaces participated in individual and group interviews and underwent participant observation over 5 months. These were repeated in a 2-week period after a 4-month interval. Grounded theory analysis was used to identify themes of importance.

RESULTS

Four main themes were identified: (1) return before full recovery, (2) changes in work tasks, (3) changes in work position and (4) individual responsibility.

CONCLUSIONS

Our results illustrate how returning workers, co-workers and managers at two workplaces experienced the RTW process. The results highlight some of the challenges that occur when returning at an early stage before full recovery is obtained leading to changes in the returning worker's work position.

Awareness during emergence from anaesthesia: significance of neuromuscular monitoring in patients with butyrylcholinesterase deficiency

BACKGROUND

Butyrylcholinesterase deficiency can result in prolonged paralysis after administration of succinylcholine or mivacurium. We conducted an interview study to assess whether patients with butyrylcholinesterase deficiency were more likely to have experienced awareness during emergence from anaesthesia if neuromuscular monitoring had not been applied.

METHODS

Patients referred during 2004-2012 were included. Data on the use of neuromuscular monitoring were available from a previous study. Interviews, conducted by telephone, included questions about awareness and screening for post-traumatic stress disorder. Reports of panic, hopelessness, suffocation, or a feeling of being dead or dying resulted in the experience being classified further as distressful. Patients were categorized as aware or unaware by investigators blinded to use of neuromuscular monitoring.

RESULTS

Ninety-five patients were eligible to be interviewed. Of the 70 patients interviewed, 35 (50%) were aware while paralysed during emergence. Of these, 28 (80%) were not monitored with a nerve stimulator when awakened, compared with 17 (49%) of the 35 unaware patients (P=0.012, Fisher's exact test). Thirty (86%) aware patients reported distress compared with seven (20%) unaware patients (P<0.001). The aware patients scored higher in screening for post-traumatic stress disorder (P=0.006, Mann-Whitney U-test).

CONCLUSIONS

Butyrylcholinesterase deficiency is a major risk factor for distressing awareness during emergence. Lack of neuromuscular monitoring increases the risk significantly. Neuromuscular monitoring should be applied even when using short-acting neuromuscular blocking agents.

Understanding male cancer patients' barriers to participating in cancer rehabilitation

The aim was to describe male cancer survivors' barriers towards participation in cancer rehabilitation as a means to guiding future targeted men's cancer rehabilitation. Symbolic Interactionism along with the interpretive descriptive methodology guided the study of 35 male cancer survivors representing seven cancer types. Data were generated through a 5-month fieldwork study comprising participant observations, semi-structured individual interviews and informal conversations. The analyses revealed two overarching findings shedding light on male cancer survivors' barriers to rehabilitation: 'Fear of losing control' and 'Striving for normality'. While 'Fear of losing control' signified what the men believed rehabilitation would invoke: 'Reduced manliness', 'Sympathy and dependency' and 'Confrontation with death', 'Striving for normality' was based on what the men believed rehabilitation would hinder: 'Autonomy and purpose', 'Solidarity and fellowship' and 'Forget and move on'. This study of male cancer survivors' and cancer rehabilitation documents how masculine ideals may constitute barriers for participation in rehabilitation and provides insights about why men are underrepresented in rehabilitation. The findings can guide practice to develop research-based rehabilitation approaches focused on preserving control and normality. Further empirical evidence is needed to: (1) explore the conduct of health professionals' towards male cancer patients and (2) address gender inequalities in cancer rehabilitation.

Effect of strength training in addition to general exercise in the rehabilitation of patients with non-specific neck pain. A randomized clinical trial

BACKGROUND

The optimal type of exercise protocol in the physical rehabilitation of non-specific neck pain has not yet been established. Furthermore, the role of fear-avoidance belief in the maintenance of pain and disability has been highlighted. Research indicates that exercise may be a means to reduce fear-avoidance belief, but evidence is scarce.

AIM

To compare the effect of two different exercise programs on pain, strength and fear-avoidance belief.

DESIGN

Randomized clinical trial.

SETTING

A specialized outpatient hospital clinic in Denmark.

POPULATION

Twenty-three men and 60 women on sick leave due to non-specific neck pain.

METHODS

Participants were randomized to either general physical activity (GPA group) or GPA and additional strength training of the neck and shoulder (SST group). The primary outcome was pain intensity. Secondary outcomes were muscle strength of the neck and shoulder and fear-avoidance belief.

RESULTS

Pain was significantly reduced within groups with a median of -1 (IQR: -3 to 0, P<0.001) in the SST group and -1 (IQR: -4 to 1, P=0.046) in the GPA group. The difference between groups was not significant. Changes in strength did not differ between groups. Both groups experienced significant increases in neck flexion strength of 14.7 N (IQR: -1 to 28.4, P=0. 001) in the SST group and 6.9 N (IQR: -4.9 to18.6, P=0.014) in the GPA group. Furthermore, the SST group achieved an increase of 18.6 N (IQR: -2.6 to 69.7, P=0.005) in neck extension. Fear-avoidance beliefs improved with 6 (IQR: 3 to 12, P<0.001) in the SST group, while the GPA group improved with 3 (IQR: 0 to 8, P=0.004). This between-group difference was significant (P=0.046).

CONCLUSION AND REHABILITATION IMPACT

This study indicates that in rehabilitation of subjects severely disabled by non-specific neck pain, there is no additional improvement on pain or muscle strength when neck exercises are given as a home-based program with a minimum of supervision. However, strength training of the painful muscles seems to be effective in decreasing fear-avoidance beliefs.

Men's reflections on participating in cancer rehabilitation: a systematic review of qualitative studies 2000-2013

This paper aims to report on a systematic review of qualitative studies on men's reflections on participating in cancer rehabilitation. Nine databases were systematically searched to identify qualitative papers published between 2000 and 2013. Papers were selected by pre-defined inclusion criteria and subsequently critically appraised. Key themes were extracted and synthesised. Fifteen papers were selected and represented. Four central themes were identified in the analytical process: 'changed life perspective', 'the masculinity factor', 'a desire to get back to normal' and 'the meaning of work'. Six peripheral themes were identified: 'the meaning of context', 'music', 'physical training', 'religion', 'humour' and 'the unmentionable'. The themes were synthesised into an integrative model representing men's reflections on participating in cancer rehabilitation. We conclude that existing qualitative literature offers insight into men's reflections on cancer rehabilitation and highlights the interrelationship between men's reflections on their changed life perspective, masculinity, orientation towards a normal life and getting back to work. Further research-based knowledge is needed to explore (1) the underlying causes and patterns of the men's needs, preferences and choices in rehabilitation; and (2) the health professional perspective on male cancer rehabilitation.

Factors associated with work outcome for survivors from haematological malignancies--a systematic literature review

Recent years have seen a growing number of survivors from haematological malignancies. As biology and treatment for these malignancies differ from other malignancies, we performed a systematic literature review of factors associated with work outcome for these survivors. A systematic literature search was conducted. Eight studies with different methodology and characteristics met the inclusion criteria. Three prospective studies agreed, to a high extent, on their findings, whereas results of five cross-sectional studies collectively were inconclusive. Overall, this review - like reviews on other cancer survivors - found no certain association of single factors with work outcome. However, based on possible explanations of the converging findings, this review pinpointed a number of issues that may inform future studies. The design should preferably be prospective, including comparison with age-paired cancer-free individuals. The role of co-morbidity and of differences between haematological diagnoses ought to be established, and work outcomes must be well defined and recorded with valid methods. To establish cause-effect relations, factors possibly associated to work outcome should be evaluated at an early time point after diagnosis. Such studies would assist identification of individuals at increased risk of encountering work-related problems and would hence help establish knowledge on which rehabilitation measures could rest.

Increased susceptibility of Atlantic salmon Salmo salar to infections with Gyrodactylus derjavini induced by dexamethasone bath treatment

Dexamethasone, a known immunosuppressant, was administered by bath or injection to Atlantic salmon Salmo salar (Conon stock) to study if this treatment could affect the susceptibility of fish to infections with a Danish strain of Gyrodactylus derjavini (Monogenea). Three groups of S. salar (Conon stock) were immersion treated either with 10, 60 or 240 microg dexamethasone l-1 water, respectively. In addition, one group (positive control) was treated intraperitoneally with 200 microg dexamethasone per fish and one negative control group was kept untreated. A single G. derjavini parasite was placed on the anal fin of each fish and the infection was subsequently monitored weekly for 6 weeks. An increase in parasite populations on the salmon was positively correlated with the amount of immunosuppressant used. Infection levels in the group immersion treated with dexamethasone (240 microg l-1 water) and in the i.p. treated positive control group were significantly higher compared to the untreated control group.

Comparative susceptibility of two races of Salmo salar (Baltic Lule river and Atlantic Conon river strains) to infection with Gyrodactylus salaris

The susceptibility of various races of salmonids towards infections with the skin parasitic monogenean Gyrodactylus salaris Malmberg, 1957, differs markedly. Norwegian and Scottish salmon strains are known as extremely susceptible to infection, whereas Baltic salmon races such as the Neva strain (Russian origin) and the Indals river (Swedish origin) salmon have been characterized as relatively resistant. However, the status of the many other Baltic strains has remained unknown. The present study reports on the susceptibility of the Baltic salmon from the Swedish river Lule. It was shown that this strain is susceptible to infection but to a lesser extent than the Scottish salmon. Further studies showed that injection of immuno-suppressants (dexamethasone) greatly increased population growth of G. salaris on Scottish salmon but not on the Baltic salmon. Mucous cell density on fins differed between strains, and a general trend to decreased cell density on infected fish 8 wk post-infection, compared to uninfected fish, was observed. The largest decrease in mucous cell density following infection was seen in the most resistant fish. After administration of immuno-suppressants, this decrease in mucous cell density was inhibited in the Scottish salmon but not in the Baltic salmon. Thus, there seems to be a relationship between the fishes' ability to discard mucous cells and the ability to resist infections with Gyrodactylus salaris. Although the Lule salmon seems more susceptible to infection compared to previous reports on the Neva salmon, the results support the notion that Baltic salmon strains are generally more resistant than East Atlantic salmon.

Effect of early vocational intervention in a rheumatological outpatient clinic--a randomized study

This study aims to explore the effect of vocational intervention in a rheumatological outpatient clinic. The study is designed as a randomized study with intervention in 108 patients and with 93 patients serving as controls. The study population comprises patients referred for non-inflammatory diseases of the locomotor system who are all active members of the workforce and whose vocational status is threatened by their disease. Intervention consisted of sociomedical examination, multidisciplinary assessment and individual sociomedical rehabilitation plans. The study shows that intervention was an important instrument in the process of clarifying patients' future maintenance situation as assessed 1 year after intervention (relative risk (RR) = 1.2 (CI 1.0-1.5)). The effect was particularly prominent among well-educated women. A non-significant effect was established for vocational status in general (RR = 1.1 (CI 0.8-1.4)). This effect was significant and positive for well-educated patients with a short-term sick leave (maximum 6 months). The verified effect of early sociomedical intervention in the secondary healthcare sector warrants the permanency of routine intervention.

Fraunhofer diffraction of atomic matter waves: electron transfer studies with a laser cooled target

We have constructed an apparatus combining the experimental techniques of cold target recoil ion momentum spectroscopy and a laser cooled target. We measure angle differential cross sections in Li(+)+Na-->Li+Na(+) electron transfer collisions in the keV energy regime with a momentum resolution of 0.12 a.u. yielding an order of magnitude better angular resolution than previous measurements. We resolve Fraunhofer-type diffraction patterns in the differential cross sections. Good agreement with predictions of the semiclassical impact parameter method is obtained.

Host responses against the fish parasitizing ciliate Ichthyophthirius multifiliis

Recent studies have shown that fish are able to mount protective immune responses against various parasites. One of the best characterized parasite-host system in this context is the ciliate Ichthyophthirius multifiliis (Ich) parasitizing a range of freshwater fishes. Both specific and non-specific host defence mechanisms are responsible for the protection of fish against challenge infections with this ciliate. The specific humoral components comprise at least specific antibodies. The non-specific humoral elements included are the alternative complement pathway and probably lectins. Cellular factors involved in the specific response are B-cells and putative T-cells. The non-specific effector cells recognized are various leukocytes. In addition, goblet-cells and mast cells (EGC-cells) may have a function. The NCC-cell (suggested analogue to NK-cells in mammals) seems to play a role in the non-specific response. This well documented protective response in freshwater fishes against Ich has urged the development of anti-parasitic vaccines. Indeed, such products based on formalin killed parasites have been developed and found to offer the vaccinated host a satisfactory protection. However, the collection of parasites for vaccine production is extremely laborious. It involves keeping infected fish due to the fact that in vitro propagation of the parasite is still insufficiently developed. Gaining knowledge of amino acid sequences and its encoding DNA-sequences for the protective antigens (i-antigens) in the parasite was a major breakthrough. That achievement made it possible to produce a recombinant protein in E. coli and preliminary results indicated a certain protection of fish vaccinated with this product. Recent work has shown that the free-living and easily cultivated ciliate Tetrahymena can be transformed and express the i-antigen. This path seems to be promising for future development of vaccines against Ich. A novel approach in fish is the development of DNA-vaccines. Successful DNA-vaccination trials have been conducted in fish against viral infections and the technology also makes it possible to develop a DNA-vaccine against Ich. Other approaches to immuno-protection against Ich have been the use of heterologous vaccines. Thus, both bath and injection vaccination using live or killed (un-transformed) Tetrahymena has been reported to offer treated fish a certain level of protection. Such protection could be explained by non-specific reactions and the efficacy and duration of this vaccination type should be further evaluated.

Long-term sickness absence - risk indicators among occupationally active residents of a Danish county

This study aims to identify risk factors and their prevalence in long-term sickness absence. The study is designed as a case-referent study which comprises 481 participants who have experienced a sickness absence lasting >10 weeks and a reference group of 1326 individuals in active employment. Multivariate analysis identified the following significant risk factors for men: (i) age >50 years [odds ratio (OR) = 2.4]; (ii) short period of education (OR = 2.3); (iii) unemployment within the last 3 years (OR = 1.7); (iv) heavy-duty work (OR = 2.1); (v) monotonous, repetitive work (OR = 1.7); (vi) lack of job satisfaction (OR = 2.1); and (vii) much back pain during the last 3 years (OR = 2.1). The following risk factors were identified for women: (i) leaving school without graduation (OR = 2.6); (ii) unemployment within the last 3 years (OR = 1.5); (iii) heavy-duty work (OR = 2.8); (iv) lack of influence on own job situation (OR = 2.1); and (v) much back pain within the last 3 years (OR = 1.8). It is concluded that the identification of working environment risk factors constitutes a case for improvement of the working environment which may be instrumental in reducing long-term sickness absence.

Prolonged in vitro cultivation of Ichthyophthirius multifiliis using an EPC cell line as substrate

The ciliate Ichthyophthirius multifiliis, which normally requires a fish host to develop from the theront stage to the trophont stage, was cultivated in vitro for part of its life cycle. Experiments were conducted using a laboratory strain of the parasite originally isolated from rainbow trout Oncorhynchus mykiss in a Danish trout farm. Theronts escaping from tomontocysts were kept in water, cell culture media (E-MEM or L-15), or cultures of EPC (Epithelioma Papulosum Cyprini) cells in plastic tissue culture dishes (Nunc multidish plates). In addition, a 2-compartment system, with water separated from tissue culture media by a monolayer of EPC cells on an Anopore Tissue Culture Insert (mimicking the fish epidermis) was tested as an experimental habitat for the parasite. Theronts transformed into trophonts in all treatments except in water alone. However, development was accelerated in wells containing EPC cells, and survival and growth of trophonts were significantly increased compared to water or tissue culture media alone. Further, the 2-compartment system allowed superior performance of the parasites (attachment of parasites to cells and growth from 36 to 46 microm). In all experiments it was found that the presence of host factors (mucus and serum) stimulated parasite development.

In vitro interactions between epithelial cells and Gyrodactylus derjavini

Skin responses of fish to various parasites have been shown to involve various immunologically competent cells producing factors which guide the reactions of epithelial cells. However, the present study has demonstrated that a monoculture of epithelial cells has the ability to encapsulate and partially degrade ectoparasites without involvement of leukocytes. The ectoparasitic monogeneanGyrodactylus derjavini was kept on a monolayer of Epithelioma Papulosum Cyprini (EPC) cells in 24-well multidishes supplied with tissue culture medium. Gyrodactylus derjavini did not reproduce but survived an incubation period of up to139h in the system. Due to sterile conditions, dead gyrodactylids were not subjected to microbial degradation and remained intact for several weeks. However, at 40 days G. derjavini was overgrown by EPC-cells and became partly degraded during the following 15 days. Analysis of enzyme reactivity in EPC-cells showed reactions for ten enzymes including esterases, amidases, phosphatases and phosphohydrolases. No marked differences for the ten enzymes between cell cultures with and without the ectoparasites were found but it cannot be excluded that some of these enzymes took part in parasite degradation. The study showed the in vitro capability of epithelial cells to interact, encapsulate and degrade G. derjavini without the involvement of leukocytes. This response probably is non-specific and will not exclude that various immunocompetent cells and their products normally optimize and accelerate elimination of invading parasites in vivo.

Age-dependent occurrence of the intestinal ciliate Balantidium coli in pigs at a Danish research farm

A cross sectional study of the prevalence and intensity of Balantidium coli in pigs was carried out on a Danish research farm. The prevalence of B. coli infection increased from 57% in suckling piglets to 100% in most pig groups > or = 4 weeks old. The mean number of cysts per gram faeces (CPG) of pigs aged 12 weeks and younger were < or = 206, whereas pigs aged 28 weeks and > 52 weeks had significantly higher counts of > or = 865 CPG. Although some lactating sows had very high CPG's, no significant differences in CPG could be detected between the intensities of pregnant sows, lactating sows and empty and dry sows. No human cases of B. coli infection have been published in Denmark though it is zoonotic.

[Sick leave for pregnant women in the municipality of Fjend 1987-1990]

All of 417 pregnancies in 1987-1990 in a rural community were retrospectively evaluated with emphasis on age, parity, previous spontaneous or induced abortion, occupation during pregnancy and sick leave from work. No difference was found in prevalence of sick leave between the employed women and the unemployed. Thirty-five percent of the women experienced sick leave at some time during pregnancy. The greatest single diagnostic group was pelvic insufficiency, which accounted for 33.5% of all days of sick leave up to the 32nd week of gestation. The incidence of pelvic insufficiency was high: 76 in 1000 deliveries. This may in part be due to a change in diagnostic criteria. Logistic regression analysis revealed that being a multipara was associated with a significantly higher risk of sick leave in the present pregnancy. Furthermore, being employed as a nurse, a shop assistant, a seamstress or a factory worker was associated with a significantly higher risk of sick leave during pregnancy in comparison with employment as a secretary. When investigating relationships between occupational conditions and the outcome of pregnancy, sick leave during pregnancy because of the same conditions may interfere significantly.

Fetal growth, preterm birth and infant mortality in relation to work with video display terminals during pregnancy

Through register linkage between a trade union file and public health registers 24,352 pregnancy outcomes were selected from a source population of 214,108 commercial and clerical employees. In a case-base study including all recorded cases and a randomly selected base sample, the potential effect of video display terminal (VDT) use in pregnancy on the risk of low birthweight, preterm birth, light weight for delivery date, stillborn, perinatal death, and infant death was investigated. Data on VDT use and potential confounders were collected from postal questionnaires sent to 6312 women and 426 employers. The rate ratio for women exposed to any degree of use was 0.88 for low birthweight [95% confidence interval (95% CI) 0.67-1.16], 1.11 for preterm birth (95% CI 0.87-1.47), 0.99 for light weight for delivery date (95% CI 0.80-1.21), 0.73 for stillborn (95% CI 0.36-1.48), 1.10 for perinatal death (95% CI 0.62-1.94), and 0.20 for infant death (95% CI 0.04-1.03). In conclusion, this investigation did not show an increased risk of the studied adverse pregnancy outcomes among women with VDT use.

Fecundity and the use of video display terminals

The association between prolonged waiting time to pregnancy and the use of a video display terminal (VDT) was investigated among commercial and clerical employees in Denmark. Information on 24,352 pregnancies was obtained through register linkage with two national registers. A random sample of 2252 pregnancies was drawn, and the women were asked for information on waiting time to pregnancy, occupational exposures, and life-style factors. The overall exposure to a VDT indicated a slightly increased association with prolonged waiting time to pregnancy. The relative risks for waiting more than one year were 1.23, 0.77, and 1.61 for the women who worked with a VDT for 1-10, 11-20, and > or = 21 h per week, respectively. Only the last relative risk was statistically significant. The results could be explained by methodological shortcomings such as recall bias or confounding by alternative factors that might affect time to pregnancy, or simply by the lack of statistical power.

Job stress and adverse outcome of pregnancy: a causal link or recall bias?

A case-base study in a population of 214,108 commercial and clerical female workers in Denmark during the period 1983-1985 investigated whether increasing job stress, defined as increasing job demands and decreasing job control, increased the risk of an adverse outcome of pregnancy. Information on the cohort, the outcome of 24,362 pregnancies, was obtained by linkage with nationwide health registers. Six case groups were selected: 1) 2,248 spontaneous abortions, 2) 209 stillbirths or deaths within the first year of life, 3) 661 infants with congenital malformations, 3) 593 preterm deliveries, 4) 587 infants with term low birth weights, 5) 988 infants with light-for-date birth weights, and 6) a random sample of 2,252 pregnancies that constituted the reference group. Information on exposure was obtained by mailed questionnaire. When dichotomized scales on data concerning job demand and control were used, there was an increased relative risk of spontaneous abortion (odds ratio = 1.28, 95% confidence interval (CI) 1.05-1.57) and term low birth weight (odds ratio = 1.46, 95% CI 1.05-2.04) for women experiencing high job stress. For the other case groups, the odds ratios were as follows: congenital malformation, 1.23 (95% CI 0.93-1.63); preterm delivery, 1.03 (95% CI 0.77-1.39); light-for-date birth weight, 1.08 (95% CI 0.83-1.40); and stillbirth/death within the first year of life, 1.42 (95% CI 0.90-2.24). No substantial response bias was found. When occupational titles were used as an exposure matrix, no increased risk was found, except for term low birth weight. Recall bias is one possible explanation. Thus, the results must be interpreted with caution.

Congenital malformations among children of women working with video display terminals

In a case-base study among 214,108 commercial and clerical employees in Denmark the potential effect of the use of video display terminals on the risk of congenital malformations in pregnancy was investigated. The study base was identified by means of register linkage of the Medical Birth Register and the National Register of In-Patients. In the source population 24,352 pregnancy outcomes were registered, 661 of which with congenital malformations entered the case group, and a base sample of 2252 pregnancies was drawn. Data concerning the use of video display terminals, job stress, ergonomic factors, exposure to organic solvents, and life-style factors were obtained from postal questionnaires. The results of this study did not support the hypothesis that the use of video display terminals during pregnancy is associated with an increased risk of congenital malformations.

Spontaneous abortion among women using video display terminals

This case-base study with a source population of 214 108 commercial and clerical workers investigated the risk of adverse pregnancy outcome among women working with a video display terminal (VDT) in Denmark. A subpopulation was obtained by register linkage between a trade union membership file, the Medical Birth Register, and the National Register of In-Patients. In two years 24,352 pregnancy outcomes were registered, 2248 spontaneous abortions were recorded, and a base sample of 2252 pregnancies was randomly selected. Data on VDT use, job stress, ergonomic factors, and life-style factors were collected with questionnaires sent to 6212 women and 426 employers. There was no increased risk of medically verified spontaneous abortion among women with VDT use. The relative risk for women exposed to any degree of use was 0.94 (95% confidence interval 0.77-1.14). Ergonomic work load and job stress were not confounders.