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IntroductionPolice officers are frequently exposed to potentially traumatic events at work that increases risk of developing mental health problems, in particular post-traumatic stress disorder (PTSD). Individual and organisational factors may influence the detrimental effects of cumulative exposure to traumatic events. Occupational stress and lack of organisational support are associated with increased risk of PTSD among police officers. The Are You All right? (AYA) project is a prospective cohort study investigating the cumulative effect of traumatic events at work on mental health problems and absenteeism among police officers. The study also investigates whether potential risk and protective factors modify the association of traumatic events at work with mental health problems and absenteeism.Method and analysisThe AYA-study includes the entire Danish police force. Prospective survey data are collected over a 3-year period beginning in the spring of 2021. Electronic surveys are sent out at baseline with 1-year, 2-year and 3-year follow-up. Further, short surveys are sent out every third month, covering exposure to traumatic events and current mental health status. The survey data are paired with workplace register data on sickness absence. Register data on sickness absence cover the period from 2020 to 2025.Ethics and disseminationThis study was presented for evaluation at the National Ethics Committee in Denmark (reference number: 20202000-216), but according to Danish legislation, survey studies do not require approval by official Danish scientific or ethical committees. Participation in the project is based on informed consent, and data are handled in accordance with the Danish data legislation (journal number: 20/41457). Results are published in scientific journals and disseminated at international conferences.

PURPOSE: No reference material exists on the scope of long-term problems in novel spinal pain opioid users. In this study, we evaluate the prevalence and long-term use of prescribed opioids in patients of the Spinal Pain Opioid Cohort.METHODS: The setting was an outpatient healthcare entity (Spine Center). Prospective variables include demographics, clinical data collected in SpineData, and The Danish National Prescription Registry. Patients with a new spinal pain episode lasting for more than two months, aged between 18 and 65 years, who had their first outpatient visit. Based on the prescription of opioids from 4 years before the first spine center visit to 5 years after, six or more opioid prescriptions in a single 1-year interval fulfilled the main outcome criteria Long-Term Opioid Therapy (LTOT).RESULTS: Overall, of 8356 patients included in the cohort, 4409 (53%) had one or more opioid prescriptions in the registered nine years period. Of opioid users, 2261 (27%) were NaiveStarters receiving their first opioid prescription after a new acute pain episode; 2148(26%) PreStarters had previously received opioids. The prevalence of LTOT in PreStarters/NaiveStarters was 17.2%/11.2% in their first outpatient year. Similar differences between groups were seen in all follow-up intervals. In the last follow-up year, LTOT prevalence in Prestarters/NaiveStarters was 12.5%/7.0%.CONCLUSIONS: Previous opioid treatment-i.e., before a new acute spinal pain episode and referral to a Spine Center-doubled the risk of LTOT 5 years later. The results underscore clinicians' obligation to carefully and individually weigh the benefits against the risks of prescribing opioid therapy.LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

The aims of this study were to explore muscle activity levels during different violin repertoires, quantify the general levels bilaterally in upper extremity muscles, and evaluate associations between muscle activity and anthropometrics characteristics. In 18 skilled violin players surface EMG was recorded bilaterally from trapezius (UT), flexor digitorum superficialis (FDS), extensor carpi ulnaris (ECU), extensor digitorum cummunis (EDC), and extensor carpi radialis (ECR) during A and E major scales played in three octaves and Mozart’s Violin Concerto no. 5. To compare side differences the static, median and peak levels of muscle activity were calculated from an amplitude probability distribution function (APDF). This study demonstrated that scales played as standardized tasks can be used to estimate the average muscle activity during violin playing. Comparing results from scales and the music piece revealed a similar muscle activity across all muscles in the music piece and E major scales. The static, median and peak EMG levels were higher in left than in right forearm muscles with left ECU presenting the highest peak load of 30 %MVE. Females demonstrated a higher muscle activity than males, but this was in accordance with differences in anthropometric measures.

Background: High workload seems to increase the risk of patient-initiated workplace violence (patient-initiated violence). However, the temporal association between workload and violence remains uncertain. Understanding the interplay of factors in the psychosocial working environment and patient-initiated violence is important to future preventive initiatives. Aim: To assess whether a high workload increases the risk of patient-initiated violence, and whether intraorganizational relationships based on trust, reciprocity, justice and collaboration, known as workplace social capital, moderate this risk. Method: Baseline survey data on 1823 social educators was collected followed by 12 monthly surveys on patient-initiated violence exposure. Poisson regressions, in mixed models, were conducted to assess the risk of violence at four levels of workload. Further, moderation analyses were conducted to assess the moderating effects of three sub-types of workplace social capital. Results: High and very high workload increased the risk of patient-initiated violence: RR = 1.5 [1.4–1.6], p (co-worker): F (3, 16,712) = 3.4, p =.017, Workload*Workplace social capital (local management): F (3, 16,748) = 11.9, p (general management): F (3, 16,556) = 5.5, p (co-workers) reduced the risk of violence at all levels of workload. Workplace social capital (general management) reduced the risk of violence at high, medium and low workload, and Workplace social capital (local management) reduced the risk of violence at medium and low workload. Conclusion: High workload clearly increases the risk of patient-initiated violence. A high workplace social capital appears to be a viable protective factor and should be investigated further in studies of patient-initiated violence prevention.

PURPOSE: Burnout and workplace violence (WPV) have been associated in cross-sectional studies, but longitudinal studies with solid methods and adequate sample sizes are lacking. This study investigates whether WPV increases burnout symptoms during a 12-month period.METHODS: Questionnaire data were collected on 1823 social educators at baseline and 12-month follow-up, coupled with additionally 12 monthly text-message surveys on exposure to WPV. Using general linear modelling for repeated measures, we estimated change over time in burnout symptoms in three WPV exposure groups (none, low, high).RESULTS: A time by exposure to WPV interaction existed for development of burnout; F(2) = 7.2, p = 0.001 η2 = 0.011. Burnout increased significantly within the group of low exposure; F(1) = 6.8, p = 0.01 and high exposure; F(1) = 6.7 p = 0.001, but not within the non-exposed F(1) = 2.1 p = 0.15. At follow-up, both the low exposed and high exposed had significantly higher levels of burnout compared to the non-exposed.CONCLUSION: Exposure to WPV increases level of burnout within a 12-month period. We propose that assessment of burnout in future studies should utilize instruments capable of detecting small changes. We further propose that prevention against employee burnout could be improved using monitoring targeted at employees exposed to WPV.

Background: Several rating scales assessing stress-related symptoms of exhaustion have emerged in recent years. However, more knowledge is needed about the performance of these rating scales in patients with stress-related disorders as well as in other patient groups. With the recently developed Karolinska Exhaustion Disorder Scale (KEDS), we compared symptoms of exhaustion in different patient groups that were sorted according to diagnosis. Methods: Patients were sampled consecutively from departments of occupational medicine (DOM) at three Danish hospitals. The total study group comprised 698 care-seeking patients (487 women). Patients with stress-related diagnoses (n = 217; the International Classification of Diseases [ICD]-10 code F43: reaction to severe stress and adjustment disorder) were compared to a diverse group of patients with a range of somatic diagnoses (n = 338) and to patients with other psychiatric diagnoses (n = 143), including subgroups with major depression disorder (n = 34; F32 and F33) and problems related to employment and unemployment (n = 99; Z56). The data were analysed using linear mixed models with the SPSS statistical program. Results: The mean KEDS sum score in patients with stress-related diagnoses (29.3; SD = 8.0) was significantly higher than in patients with other psychiatric diagnoses (25.9; SD = 9.5) and in patients with somatic diagnoses (17.6; SD = 10.8). The subgroup with a major depression disorder had high mean KEDS sum scores (31.4, SD = 8.1), similar to patients with stress-related diagnoses, while the mean KEDS sum score in patients with problems related to employment and unemployment (Z56) was 23.5 (SD = 9.0). Young and old patients scored similarly on KEDS, but in patients with somatic diagnoses, female patients scored significantly higher than male patients. Conclusion: The symptoms of exhaustion measured with KEDS were higher in patients with stress-related diagnoses and major depression disorder than in patients with somatic diagnoses. The intermediate level of the symptoms of exhaustion that were associated with problems related to employment and unemployment, (Z56) compared to the lower level of the symptoms with somatic diagnoses, suggests that KEDS might be useful in detecting mild, prodromal states of exhaustion. This needs further investigation.

Stress is one of the greatest burdens of our society and often implies impairments in cognitive and emotional functions. Here, we hypothesise that changes in the brain's dopamine (DA)-based mesocorticolimbic projec-tions in patients with work-related stress (adjustment disorder) will manifest themselves as altered glucose metabolism in relation to neural activity, and as altered DA radiotracer binding potentials at the relevant receptors.Subjects and healthy controls undergo neuropsychiatric tests and PET/MRI with three tracers: 18F-fluorodeoxyglucose to measure glucose metabolism as a marker of neural activity, 11C-raclopride to explore binding potentials in the striatum, and 11C-FLB 457 to study possibly impaired mesocortical dopaminergic transmission in the cortex. To demonstrate differences of glucose metabolism, more than 2 × 41 patients/controls are needed. We expect to find that symptoms of cognitive and motivational reward deficits are attributable to changes in the frontal lobe and striatal glucose metabolism in the majority of patients, and that changes of D2-receptor availability and impaired dopaminergic transmission in the striatum and prefrontal cortex are contributing factors.This project is designed to generate entirely new and objective evidence of stress-induced cerebral illness, and to provide a basis for in-depth research and for a more rational management of this strenuous disorder.Private, industrial and public funds.Clinicaltrails.gov/NCT03334045.

This study investigated whether factors related to bodily contact between health care workers and patients were associated with patient-initiated violence. This cross-sectional study surveyed 496 Danish health care workers measuring patient-initiated violence, use of assistive devices, body mass index, physical exertion, frequency of patient transfers, psychosocial work environment, gender, age, and seniority. Associations were modeled using logistic regression analyses using patient-initiated violence as the outcome. Twenty-five percent of the respondents had experienced physical or verbal violence during the past year. Infrequent use of assistive devices, high physical strain, and severe obesity all significantly increased the risk of physical violence (risk ratio [RR] = 1.18, RR = 1.18, and RR = 1.16, respectively), whereas only the lack of assistive device use significantly increased the risk of verbal violence (RR = 1.13 and RR = 1.08). Consistent use of assistive devices appears to reduce the risk of patient-initiated violence. Managers should require the use of assistive devices when designing work processes for patient transfers.

Introduction The present study is to provide an understanding of the motivational factors and barriers that influence compliance with physical exercise during working hours that are aimed at reducing musculoskeletal disorders, for employees at a hospital laundry. Methods This study used a semideductive, thematic, and structured in-depth interview that was nested in an ongoing project with 140 laundry employees at a hospital laundry with 3 different geographic locations, that have been physical active at work since January 2015. The interviews was conducted 72 weeks within the main project among 22 informants with diverse field of laundry work, where the majority participated in the resistance band training at the workplace for 5 min, three times per week. The following factors, organisational, implementational, and individual motives and barriers were explored. Result The results indicates that there should be attention to the interaction between management, the employees and the aim of the intervention, since the main barrier for compliance in this study is internal working culture. The results emphasised a certain need of clear connexion between the management’s intentions of the implementation of physical exercise at work and the actual implementation. There was also a strong correlation between the employee’s motivation and participation in relation to the manager’s participation at the daily physical exercise at the workplace. Additionally the results emphasise the importance of ensuring the cooperation among manager’s, participants and colleagues in order to ensure compliance regarding the intervention. Discussion Our recommendations from this study suggest a thorough pre-evaluation in order to analyse the organisational and implementation factors before the implementation of physical exercise at work.

Background No previous studies have examined if genetic factors interacts in the relationship between occupational risk factors and hip and knee osteoarthritis (OA). Objective To examine occupational risk factors for Hip and Knee OA leading to Total Joint Arthroplasty, and if gene-exposure interaction, affect the risk factor-outcome relationship. Material and methods In October 2012 all twin pairs alive in the Danish Twin Register (DTR) with at least one in the pair registered in the Danish Hip or the Danish Knee Arthroplasty Registers (DHA/DKA) with a diagnosis of primary OA were sent a detailed questionnaire regarding previous occupation, related exposures and complementary environmental factors. The analyses included cumulated exposures, McNemar`s X 2 tests, and conditional logistic regression including gene-exposure-interaction variables. Results 1181 twins responded (rate 58.9%). Responder analyses did not display any significant difference with non-responders with respect to diagnosis, zygosity and sex. We found a gene-exposure effect modification in hip OA-lifting and lifting-walking with OR`s 17.7 (1.1–280.2) and 10.4 (1.00–107.1), respectively, and a clear dose-response relationship between hip OA and prolonged standing-walking. Significant occupational risk factor in knee OA was kneeling, but no gene-kneeling interaction was detectable. Conclusion Gene-exposure effect modification may be important in the development of hip OA in particular exposures to lifting and lifting-walking, but not in knee OA.

BACKGROUND: Coping with regret has a substantial impact on wellbeing and mental health, but has rarely been investigated in an occupational setting.OBJECTIVE: To translate the Regret Coping Scale for Health-Care Professionals (RCS-HCP) and explore internal consistency, construct-, criterion- and predictive validity.METHODS: The instrument was translated using forward- back method. The qualities were evaluated with a sample of 2758 social educators using exploratory and confirmatory factor analysis as well as Cronbach's alpha, Pearson correlation, and multivariable regression.RESULTS: The translated instrument showed a trend similar to the original instrument. A 10-item version resulted from the research being reported. The reduced RCS-HCP showed improved fit (Full model, 15 items); CFI = 0.91, TLI = 0.89, RMSEA = 0.66, PClose = 0.000 and BIC = 1392 vs. (Reduced instrument, 10 items); CFI = 0.97, TLI = 0.96, RMSEA = 0.05, PClose = 0.499 and BIC 307. This instrument had acceptable internal consistency for short scales (Cronbach's alpha = 0.65, 0.69 and 0.84 respectively). The subscales correlated as expected with measures of health and occupational factors, coefficient ranging from 0.182 to 0.399. Also, the RCS-HCP predicted stress three month later ΔF[3,2747] = 15.1, p < 0.001, but with very small effect ΔR2 = 0.01, p≤0.001.CONCLUSIONS: The 10-item Danish version of the RCS-HCP is a valid instrument for measuring coping with regret in health related work.

Background Allergic reactions to the common house plant Hoya compacta (HC) have not previously been described. Aims To confirm HC as the cause of rhinoconjunctivitis in three horticultural workers. Methods Greenhouse working conditions were reproduced in our challenge chamber. Results All three cases developed rhinoconjunctivitis when working with HC plants. A control challenge was performed in two cases with iceberg lettuce causing no symptoms. Nasal volume measured by acoustic rhinometry (AR) fell after all three active challenges, but also after one of the control challenges. Conclusions Our study confirms that HC may cause occupational rhinoconjunctivitis and asthma through a Type I hypersensitivity reaction. Specific inhalation challenges, nasal nitric oxide measurement and AR may be useful additional tools in supporting such diagnoses for occupational physicians to consider.

Background: Farmers in developing countries use highly toxic organophosphate pesticides. Thus, the aim of this study was to compare plasma cholinesterase (PChE) enzyme activity before and after exposure to organophosphate pesticides in a real-life setting. Methods: This was a prospective study conducted on 25 farmers spraying organophosphate pesticide in their farm. The PChE level was measured and clinical signs and symptoms of toxicity were asked before and immediately after spraying. Results: The mean level of PChE before and after spraying was 1.41 and 1.29 IU/L, respectively (8.51% decreased). Farmers reported more clinical signs and symptoms of intoxication after spraying pesticides. Conclusions: Increase in acute intoxication signs/symptoms and decrease in PChE indicate a serious public health problem among farmers who use organophosphate pesticides. Appropriate training to the farmers is needed to reduce exposure to organophosphate pesticide.

Background Several research studies have during controlled conditions shown that physical training at work has a beneficial effect on work related musculoskeletal pain. The question is, whether the same effect can be obtained, when introducing physical training in a normal work setting. Aim To evaluate the effects of introducing elastic band exercise on a hospital laundry on upper extremity pain, sickness absence and job satisfaction among the laundry workers. Methods and material Elastic band exercise was introduced in a hospital laundry situated in 3 locations. A total of 151 laundry workers were included in an open cohort. Elastic band exercises for the upper extremities were performed once a day on working days and lasted 10 minutes per session. The workers completed a web base questionnaire at baseline before the training was introduced and at 1 year follow up. Questions concerned pain intensity (0–10 VAS scale) in the upper extremities during the last week, sickness absence due to pain in the upper extremities, and their training adherence. Results Questionnaire response rates at baseline and 1 year follow up were 94% and 89%, respectively. 21 workers left and 24 entered the cohort between baseline and 1 year follow-up. 114 participants completed the questionnaire both at baseline and at 1 year follow up. In average the participants performed the exercises 2.5 times per week. Pain intensity in the shoulders was reduced 1.05 point on the VAS scale (P Conclusions Upper extremity elastic band exercises at work,10 minutes per day at working days, reduces pain intensity in the upper extremities. There was no change in sickness absence.

Studies suggest that the psychological disorder arising after long-term stress differs from depression and anxiety disorders. In Sweden this stress-related condition is called exhaustion disorder (ED). ED is assigned the ICD-10 diagnostic code F43.8. The Karolinska Exhaustion Disorder Scale (KEDS) has been developed in order to assist in diagnosing patients with ED. KEDS is a short (9 items) questionnaire that addresses the core symptoms of ED: Problems with cognitive functioning, physical and mental stamina, sleeping problems, ability to recover, sensitivity to sensory impressions, reactions to demands, and feelings of irritability and anger. KEDS has been validated in Swedish ED patients and healthy individuals and showed good discriminatory power (A. Beser et al., Scandinavian Journal of Psychology, 2014, 55, 72–82). In response to the need to identify the health condition associated with long-term stress, we decided to translate KEDS into Danish, and to test it in a group of patients in occupational health clinics in Denmark. The purpose was to investigate to which extent KEDS is able to discriminate between stress-related disorders and other disorders. In the present paper we will present the translation process, the design of the test procedure, as well as preliminary test results.

Background: Symptomatic knee osteoarthritis is a highly age and sex associated complex disease. Little is known about the causes behind this age and sex associated increase, or if genetic and environmental factors impacts differently by gender. Our study examined the risk and heritability of primary knee osteoarthritis leading to total knee arthroplasty and whether these differences were attributable to sex and age differences in heritability. Methods: All twins of known zygosity from The Danish Twin Register alive in 1997 were examined in a nationwide population based follow-up study collecting information on all twins recorded in The Danish Knee Arthroplasty from 1997 to follow-up in 2010. Our main outcomes were the cumulative incidence, probandwise concordance rates, heritability, within pair correlations in monozygotic and dizygotic twin pairs and the genetic and environmental influence estimated in models taking into account that individuals may not have had a total knee arthroplasty at follow up. Results: 92,748 twins were eligible for analyses and 576 twins had a record of primary knee osteoarthritis in The Danish Knee Arthroplasty Register at follow-up comprising 358 female and 218 male twin cases. The risk increased particular after the age of 50years displaying significant sex differences in the elderly. In the sex stratified analyses a discrete genetic component was found in females, but in males no genetic component could be detected. In both genders common and unique environmental factors were highly significant. In the sex-adjusted analysis an additive genetic component of 18% (0; 62), a shared environmental component of 61% (25; 97) and an individual environmental component of 21% (6; 36) accounted for the variation in liability to primary total knee arthroplasty. Conclusion: The risk of primary total knee arthroplasty increases significantly after the age of 50years, in particular in females, displaying significant sex differences in the elderly. After sex-adjustment 82% of the variation in liability to primary total knee arthroplasty was attributable to common and unique environmental factors; the remaining 18% of this variation was attributable to additive genetic factors indicating a pivotal impact of environmental factors on this disease.

Chromosome analysis with fluorescent and Giemsa staining revealed trisomy G-21 in almost 100 % of the bone marrow cells in a case of adult acute myelomonocytic leukaemia with equal proportions of granulocytic and monocytic cells. The results indicate a common precursor cell for the two cell series.

The incidence of oxalate-induced radial-segmented (RS) nuclei in lymphocytes from peripheral blood correlated closely with the diameter of the cell and with the diameter of the nucleus; the majority of RS nuclei were found in large lymphocytes. This observation supports the basic hypotheses, that large lymphocytes from peripheral blood represent a later stage in the cell cycle than small lymphocytes, that the tubulin content of lymphocytes increases during the interphase and that the incidence of RS nuclei reflects the tubulin content of the cells within the various size classes.

A defective uptake of oxygen by peripheral blood granulocytes during phagocytosis, indicating a subnormal phagocytic capacity, has been found in a patient with regional enteritis complicated by pyoderma gangrenosum (PG). During administration of clofazimine and granulocyte function normalized and the skin lesions healed. It is possible that a defective granulocyte function may sometimes be involved in the pathogenesis of PG and that a clofazimine-induced improvement in the function will favour healing of the lesions. The result of treatment in our patient and in other cases recently published indicates that the drug may be worth trying in PG.

The proportions of myeloblasts (MB), promyelocytes (PMC) and myelocytes (MC) within the granulopoietic precursor pool of the bone marrow and a mitotic index of the precursor cells were determined in 43 patients with chronic myeloid leukaemia (CML) diagnosed in the chronic phase of the disease. There was a negative correlation between the percentages of MB + PMC and the mitotic indices, i.e. large proportions of MB + PMC were associated with low mitotic indices. With increasing proportions of MB + PMC at diagnosis, survival was significantly reduced. Furthermore, only 22 % of patients with MB + PMC above the median value (28 %) associated with a mitotic index below the mean value (1.02 %) survived for more than 2 years whereas 82 % of the patients with a percentage of MB + PMC below the median value combined with a mitotic index above the mean value survived for more than 2 years. It is concluded that the composition and mitotic activity of the granulopoietic precursor pool at diagnosis of CML has a prognostic significance. Successive accumulation of early granulocytic precursors with a low mitotic activity probably occurs in the bone marrow during the chronic phase of CML ending up in the final blast crisis characterized by a heavy predominance of such celis.

Using the Giemsa technique the chromosome banding pattern was determined in bone marrow cells of 10 untreated patients with a recent diagnosis of acute myeloid leukaemia. 5 patients had a completely normal banding pattern whereas 5 patients had cells with karyotypic abnormalities. The latter group included one case with a pseudodiploid karyotype which would not have been detected by previous techniques. In the total material the karyotype analyses of the abnormal metaphases indicated a non random involvement of chromosomes nos. 8, 21 and the X chromosome.

Five out of 74 patients with adult coeliac disease (ACD) diagnosed from 1965 through 1977 developed intestinal lymphoma. The age at diagnosis of ACD was 54-63 years (mean 58) and in all patients an initial improvement was noted on a gluten-free diet. The interval between the diagnoses of ACD and lymphoma was 0.5-6 years (mean 3). In 4 patients the diagnosis of lymphoma was preceded by relapse of diarrhoea and loss of weight despite an adequate diet; 2 patients developed perforation of the bowel. In all patients who subsequently developed lymphoma a pronounced lymphocytopenia, 0.4-1.3 X 10(9)/l, was found at the diagnosis of ACD. It is suggested that ACD patients over 40 who have relapse of malabsorption symptoms despite an adequate diet should be investigated for the presence of an intestinal lymphoma. The suspicion of a malignant transformation may be especially strong if a previous, pronounced lymphocytopenia has been recorded. Three patients died 1-12 months after the diagnosis of lymphoma. However, 2 patients are in good condition 14 and 20 months, respectively, after laparotomy and removal of the tumour, indicating that an early diagnosis and treatment may have a reasonably palliative effect in some cases.

In 18 untreated adult patients (median age 62.5 yr) with advanced non‐Hodgkin's lymphoma of unfavourable histology, thymidine labelling indices (LIs) of the lymphoma cells were assessed. The patients were treated with combination chemotherapy and have been followed for 29–60 (median 52) months or until death. The survival curve had a steep fall during the first 2 yr. Between 2–5 yr after treatment there was a flattening of the curve and survival seemed to be similar to the survival expected for a Swedish population matched for age and sex. 11 patients died with 2 yr and 7 patients have survived for a longer period. Age, histopathologic classification and clinical stages were comparable in short‐term and long‐term survivors and treatment was not more aggressive for the long‐term survivors. The LIs were significantly higher (median 8.2) in short‐term survivors than in the long‐term survivors (median 1.4). Long‐term survival following combination chemotherapy of advanced NHL of unfavourable histology seems to be achieved mainly in patients with a low proliferative activity of the lymphoma cells. It is suggested that in NHL a high proliferative activity may facilitate the generation of new mutants and that some of these are spontaneously resistant to various chemotherapeutic drugs. (Less)

Purpose: A prospective comparison of three imaging techniques: thoracic CT, positron emission tomography (PET), and endoscopic ultrasonography (EUS) with fine needle aspiration (FNA), each performed under routine conditions, for the detection of metastatic lymph nodes metastases in patients with lung cancer considered for operative resection. Patients and methods: Following bronchoscopic evaluation, CT, PET, and EUS were performed to evaluate potential mediastinal involvement in 33 consecutive patients with bronchoscopic biopsy/cytology proven (n = 25) or radiologically suspected (n = 8) lung cancer prior to surgery. Surgical histology was used as “gold standard” to confirm the diagnosis of the primary tumor and the mediastinal status in all patients. Histology proved non-small cell lung cancer in 30 patients, neuroendocrine tumor in 1 patient, and benign disease in 2 patients. Results: The mean age of the study group was 61.5 years (range, 41 to 80 years; 23 male patients). CT, PET, and EUS detected mediastinal lymph nodes (size, 0.4 to 1.6 cm) in 15, 14, and 27 patients (21 of which were suspected to be malignant on EUS), respectively. With respect to the correct prediction of mediastinal lymph node stage, the sensitivities of CT, PET, and EUS were 57%, 73%, and 94%. Specificities were 74%, 83%, and 71%. Accuracies were 67%, 79%, and 82%. Results of PET could be improved when combined with CT (sensitivity, 81%; specificity, 94%; accuracy, 88%). The specificity of EUS (71%) was improved to 100% by FNA cytology (EUS-guided FNA), which gave a tissue diagnosis including tumor type, without complications. Conclusions: No single imaging method alone was conclusive in evaluating potential mediastinal involvement in apparently operable lung cancer and routine clinical conditions. A tissue diagnosis is extremely helpful. Because FNA can be performed at the same time as EUS, this combination emerged as the most useful technique in the evaluation of even very small mediastinal metastases of lung cancer. CT seems necessary additionally to evaluate the pretracheal region as well as the rest of the thorax, and PET may be valuable to detect distant metastases.

A systematic review of chemotherapy trials in several tumour types was performed by The Swedish Council of Technology Assessment in Health Care (SBU). The procedures for the evaluation of the scientiec literature are described separately (Acta Oncol 2001; 40: 155‐65). This synthesis of the literature on chemotherapy for Hodgkin’s disease (HD) is based on 113 scientiec reports including four meta-analyses, 44 randomised studies, 18 prospective studies and 40 retrospective studies. These studies involve 69 196 patients. The conclusions reached can be summarised into the following points: Chemotherapy is of utmost importance for the cure of HD. At early stages, extended e eld radiotherapy cures most patients. For the majority of patients with relapse after radiotherapy, chemotherapy is curative and the total proportion of cured early stage patients is 75‐90%. Chemotherapy in addition to extended e eld radiotherapy reduces recurrences but does not improve long-term survival. In early stage HD with a large mediastinal mass and:or with systemic symptoms, combined treatment with chemotherapy and radiotherapy is recommended. It is likely that chemotherapy will play a greater role in the future in the treatment also of early stage patients in order to reduce late consequences from extended eeld radiotherapy. However, this conclusion remains to be better documented in the literature. At advanced stages, chemotherapy or a combination of chemotherapy and limited eeld radiotherapy are effective treatment options and, using the regimens available 10‐20 years ago, 40‐50% of the patients are cured. Based upon more favourable short-term (three to eight years) results of more recently developed regimens, it can be expected that today a higher proportion of the patients will become long-term survivors. Several chemotherapy regimens containing four to eight drugs are effective in HD. The best regimen considering both antitumour activity and acute and late side-effects is not known. The choice of regimen is probably best done after considering various pre-treatment factors such as the number of poor prognostic signs, concomitant diseases and individual preferences. The results of chemotherapy are more favourable in young than in elderly patients. The development of less toxic but still effective treatment programmes is therefore particularly important for the elderly. High dose chemotherapy with stem cell support is presently often used in patients who are chemotherapy induction failures, who relapse after a short initial remission or after a longer initial remission and treated initially with seven or eight drugs, or who have had multiple relapses. However, this use is based on data from uncontrolled or small controlled studies, not being fully convincing with respect to effect on survival. Persistent side-effects of treatment are common among long-term survivors, although most patients have an apparently normal life. The relative contributions of chemotherapy and radiotherapy to the persistent effects are not well documented. SYSTEMATIC OVERVIEW ARTICLE

A systematic review of chemotherapy trials in several tumour types was performed by The Swedish Council of Technology Assessment in Health Care (SBU). The procedures for the evaluation of the scientific literature are described separately (Acta Oncol 2001; 40: 155-65). This synthesis of the literature on chemotherapy for B-cell chronic lymphocytic leukaemia (B-CLL) is based on data from 20 randomised controlled trials and one meta-analysis. Moreover, data from 19 prospective studies, one retrospective study and four other articles were used. Totally 44 scientific articles are included, involving 11,289 patients. The conclusions reached can be summarized into the following points: Primary treatment of patients with symptomatic B-CLL is recommended to be an oral alkylating agent such as chlorambucil. This drug induces tumour remission and symptomatic relief in a majority of patients with progressive disease. Response may be long-lasting, but cure is not obtained. Optimum dose and schedule of administration of chlorambucil or other alkylating agents have not been defined. It is recommended to defer initial therapy until required by disease progression. Large randomised trials have demonstrated that early treatment with chlorambucil in a continuous or an intermittent schedule does not prolong survival in B-CLL patients with low tumour burden (Binet stage A). The addition of corticosteroids to alkylator regimens has not been proven to give any benefit. Combination chemotherapy as primary treatment has not shown any advantage compared with single drugs. Early inclusion of anthracyclines to the therapy does not convincingly add to the activity of alkylating agents. The purine analogues fludarabine and 2-chlorodeoxyadenosine are active in B-CLL. However, like other drugs, they do not appear to be curative. In randomised multicentre trials a benefit from fludarabine as primary therapy compared with polychemotherapy (CHOP or CAP) has been observed in terms of tolerance and treatment response but not yet in survival. No randomised studies have been performed to show whether one of the purine analogues should be preferred. At relapse after single drug treatment, retreatment with the same drug often induces new remissions. However, the proportion of patients responding declines each time chlorambucil or any other single agent is readministered. At progression on single alkylating agents, the purine analogues or various combinations, mostly CHOP, frequently induce tumour remissions. For patients with advanced B-CLL failing to respond to fludarabine or CHOP, the prognosis is poor. None of the salvage regimens reported has produced durable remissions. High-dose chemo-radiotherapy with stem cell transplantation has been evaluated for young patients with B-CLL. A long survival has been shown in some patients following allogeneic and autologous transplantation. However, the risk of transplantation-related mortality is still high with allo-transplants and relapse is common after auto-transplantation. A benefit of purging autologous stem cells has been proposed but evidence is lacking. Thus, transplantation remains experimental; more patients and a longer follow-up are needed to assess if cure can be achieved. In the future an individual risk-adapted therapy will be required. The clinical heterogeneity of the disease has pointed to the necessity of new predictors for prognosis evaluated in prospective trials.

A patient exposed to thorotrast angiography developed sarcoidosis 21 years after the injection and myelofibrosis 13 years later. On the latter occasion an extreme deficiency in circulating lymphocytes forming rosettes with sheep erythrocytes (T-cells) was observed and a large fraction of the cells had chromosomal aberrations. Acute leukaemia developed 1 year later. The multiple clinical symptoms may be related to radiation-induced destruction of bone marrow tissue, mutations in haemopoietic cells and depression of cell-mediated immunity.

Seamen constitute a special group of international travellers who may run an increased risk of contracting hepatitis, because of visits to foreign ports and the particular environment on board ship. The purpose of the survey was to assess the prevalence of serological markers for hepatitis A, B and C virus infection among seamen and to identify present and previous risk factors for infection. 515 seamen were studied. The prevalence of antibodies against hepatitis A was 0.3% in subjects below 40 years of age, increasing with age above 40 years, and highest among those who had sailed in international trade. The prevalence of antibodies against hepatitis B was 2.7% in subjects below 40 years of age, increasing to 35.7% in the group above 60 years of age. Hepatitis C antibodies occurred in 1.2%. Vaccination of sailors against hepatitis A should follow the same recommendations as to other travellers. The prevalence of hepatitis B was higher than in reference groups of non-seamen but, because hepatitis B is only one of many blood-borne diseases, prevention should be directed towards changes in behaviour rather than vaccination, except for special groups. Young seamen in international trade were found to be most at risk of contracting sexually transmitted diseases.

A retrospective cohort study was performed to analyze the mortality patterns of Danish merchant seamen in the period 1970-1985. The population census in 1970 in Denmark was the source of information on individual occupation, age, and marital status. All men aged 20-64 years and economically active in 1970 were included. Computerized linkage with the Danish Mortality Register gave information about the deceased persons' date and cause of death. An increased overall mortality among all groups of seamen was found, being highest for deck and engine crew members. The overall mortality was strongly dependent on age and marital status. The highest mortality rate ratios (MRR) were found among young seamen and unmarried seamen. MRRs of 1.90 and 2.47 for cancer of the respiratory system were found among engine officers and crew. The MRRs for accidents and suicide were increased for all seamen, and were highest for crew members, among whom the MRR from accidents was stable within age groups but fell for suicide with increasing age. The same pattern was found with cirrhosis of the liver, although this was positively associated with increasing age. Excess mortality from ischemic heart disease was only found among engine crew (MRR = 1.43). This study confirms earlier findings of high mortality among seafarers. Negative selection into the occupation, occupational environmental factors, and lack of health and safety promotion programs and education could be causes of the high mortality.

PURPOSE: To study how objectively recorded mouse and keyboard activity affects distal arm pain among computer workers. METHODS: Computer activities were recorded among 2,146 computer workers. For 52 weeks mouse and keyboard time, sustained activity, speed and micropauses were recorded with a software program installed on the participants' computers. Participants reported weekly pain scores via the software program for elbow, forearm and wrist/hand as well as in a questionnaire at baseline and 1-year follow up. Associations between pain development and computer work were examined for three pain outcomes: acute, prolonged and chronic pain. RESULTS: Mouse time, even at low levels, was associated with acute pain in a similar way for all the examined regions. There were no exposure-response threshold patterns. Keyboard time had no effect. Mouse and keyboard sustained activity, speed and micropauses were not risk factors for acute pain, nor did they modify the effects of mouse or keyboard time. Computer usage parameters were not associated with prolonged or chronic pain. A major limitation of the study was low keyboard times. CONCLUSION: Computer work was not related to the development of prolonged or chronic pain. Mouse time was associated with acute distal arm pain, but the impact was quite small.