Lars Brandt

Does computer use pose an occupational hazard for forearm pain; from the NUDATA study

Aims: To determine the occurrence of pain conditions and disorders in the forearm and to evaluate risk factors for forearm pain in a cohort of computer workers. Methods: A total of 6943 participants with a wide range of computer use and work tasks were studied. At baseline and at one year follow up participants completed a questionnaire. Participants with relevant forearm symptoms were offered a clinical examination. Symptom cases and clinical cases were defined on the basis of self reported pain score and palpation tenderness in the muscles of the forearm. Results: The seven days prevalence of moderate to severe forearm pain was 4.3%. Sixteen of 296 symptom cases met criteria for being a clinical forearm case, and 12 had signs of potential nerve entrapment. One year incidence of reported symptom cases was 1.3%; no subjects developed new signs of nerve entrapment. Increased risk of new forearm pain was associated with use of a mouse device for more than 30 hours per week, and with keyboard use more than 15 hours per week. High job demands and time pressure at baseline were risk factors for onset of forearm pain; women had a twofold increased risk of developing forearm pain. Self reported ergonomic workplace factors at baseline did not predict future forearm pain. Conclusion: Intensive use of a mouse device, and to a lesser extent keyboard usage, were the main risk factors for forearm pain. The occurrence of clinical disorders was low, suggesting that computer use is not commonly associated with any severe occupational hazard to the forearm.

A Systematic Overview of Chemotherapy Effects in Indolent Non-Hodgkin's Lymphoma

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 evaluation the scientific literature are described separately (Acta Oncol 2001; 40: 155-65). This synthesis of the literature on chemotherapy for indolent non-Hodgkins lymphoma (NHL), predominantly follicular lymphoma, is based on 108 scientific reports including 31 randomised studies, 38 prospective studies and 18 retrospective studies. These studies involve 8,699 patients. The conclusions reached can be summarized into the following points: In initially localized disease-- The addition of chemotherapy to radiotherapy as primary treatment has not convincingly prolonged remission duration or survival. In initially advanced disease-- Alkylating agents are useful palliative treatment options which can result in improved well-being for most patients, often for long periods. Combinations of chemotherapy have not convincingly resulted in more or longer remissions. There is no proof that initial combination chemotherapy will prolong survival in comparison with single drugs. The addition of interferon to initial combination chemotherapy may increase the response rate, significantly prolong remission duration, but prolonged survival has not been unequivocally proven. In the absence of disease-related symptoms, treatment can safely be deferred. For patients with relapsed lymphoma-- Patients may repeatedly respond to alkylating agents or combinations containing an alkylating agent, although the proportion responding decreases with each relapse. Patients relapsing after or who are refractory to treatment with alkylating agents often respond to treatment with combinations containing an anthracycline. Responses are also often seen in patients treated with purine analogues alone or in combination with other drugs. High dose chemotherapy followed by autologous or allogeneic reestablishment of bone marrow function can induce long-term remissions but it is not proven whether they are more frequent or of longer duration than with conventionally dosed therapy. The impact of the novel treatment strategies including high-dose therapy on overall survival is still uncertain. A monoclonal antibody, rituximab, is a new active substance for patients with relapsed lymphoma. It can induce remissions also in chemoresistant patients.

A systematic overview of chemotherapy effects in Hodgkin's disease

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 Hodgkins disease (HD) is based on 113 scientific 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 field 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 field 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 field radiotherapy. However, this conclusion remains to be better documented in the literature. At advanced stages, chemotherapy or a combination of chemotherapy and limited field 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.

A Systematic Overview of Chemotherapy Effects in B-cell Chronic Lymphocytic Leukaemia

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.

Pesticide use, erythrocyte acetylcholinesterase level and self-reported acute intoxication symptoms among vegetable farmers in Nepal: a cross-sectional study

BackgroundAs pesticide use is increasing and proper handling training is lacking, exposure to pesticides and intoxications are an important public health problems among farmers in developing countries. This study describes pesticide use among farmers and compares symptoms of possible acute intoxication and Erythrocyte Acetylcholinesterase(AChE) levels among vegetable farmers with a control group of blood donors in Nepal.MethodsA cross-sectional study was carried out among 90 pesticide-exposed farmers and a control group of 90 blood donors. Participants were randomly selected and data were gathered through questionnaires, observation and blood test. Chi-square test, logistic regression and Student’s t-test were used for data analysis to describe pesticide use and compare symptoms and AChE levels between the two groups. This study was approved by Nepal Health Research Council.ResultsThe majority of pesticides used were WHO class II, classified as moderately hazardous. The mean numbers of personal protective equipment used by farmers were 2.22 (95% CI: 1.89; 2.54). Out of five hygienic practices asked, farmers followed 3.63 (95% CI: 3.40; 3.86) hygienic practices on the average. Farmers reported more symptoms of possible pesticide intoxication in the past month than did controls, mean 5.47 (95% CI: 4.70; 6.25) versus 2.02 (95% CI: 1.63; 2.40) (p < 0.05). The mean haemoglobin-adjusted AChE(Q) was significantly lower among farmers compared to controls, 28.92 (95% CI: 28.28; 29.56) U/g versus 30.05 (95% CI: 29.51; 30.60) U/g, (p = 0.01). The risk of a farmer having lower Q level was about 3 times (OR = 2.95; 95% CI: 1.16; 7.51) greater than controls.ConclusionNepalese farmers exposed to pesticides have significantly more symptoms of possible pesticide intoxication than a control group of healthy individuals. A lower mean haemoglobin- adjusted AChE level was seen among farmers compared to the controls. The use of highly toxic pesticides, inadequate use of personal protective equipment and poor hygienic practices might explain the reason for symptoms of pesticide intoxication and a lower AChE level among farmers. Education and information of farmers should be undertaken to remediate these problems.

Relation between occupational exposure to organic solvents and chromosome aberrations in non-Hodgkin's lymphoma.

Chromosome analysis of lymphoma cells was performed in 54 untreated patients with non‐Hodgkins lymphoma (NHL). 10 patients had a history of daily occupational handling of organic solvents for at least 1 year (exposed group) and 44 patients had never (or only for shorter periods) worked with solvents (unexposed group). There were no differences between exposed and unexposed patients regarding age, clinical stage or histologic malignancy grade. The patients were assigned to three categories: Patients with 0–4, 5–9, or ≥ 10 cytogenetic events producing clonal aberrations of the lymphoma cells. The proportions of exposed patients in these categories were 2/26 (8%), 5/20 (25%) and 3/8 (38%); respectively, i.e. with increasing numbers of events there was an increasing probability of previous exposure to solvents (p = 0.035; trend analysis). 5 of 7 exposed patients (71%) with intermediate or high‐grade lymphomas displayed translocations involving the band 14q32. Such 14q+ markers were found in only 5 out of 28 unexposed patients (18%) with lymphomas of comparable malignancy grade (p = 0.01). Among unexposed patients with intermediate or high‐grade lymphoma the most common clonal aberration was 6q‐ which occurred in 10 out of 28 patients (36%). This abnormality was not observed in the exposed patients with lymphomas of corresponding malignancy grades (p = 0.08). It thus appears that the number of clonal chromosome aberrations is especially large in NHL patients with a history of occupational exposure to organic solvents. Moreover, such exposure may be associated with characteristic cytogenetic changes in the lymphoma cells.

Gender and Time Differences in Initial Location and Histological Grade of Non-Hodgkin's Lymphomas in Southern Sweden

In accordance with international data, non-Hodgkins lymphomas (NHL) in the Southern Health Care Region of Sweden were more common in men than in women and there was an inreasing incidence for both genders in the 1980s and 1990s. A study of the years 1983 and 1992, i.e. the beginning and the end of a 10-year period, was carried out. Case records for 94% of all adults diagnosed in 1983 and 1992 (220 men and 171 women) were reviewed. The sites of the lymphomas and malignancy grade (Kiel classification) were recorded. Comparisons were made between the genders and between the two years studied. Among 170 men with nodal lymphomas, 49 were localized (stage I-II) in lymphoid tissue regional to the respiratory tract, 18 were localized elsewhere and 103 were generalized (stage III-IV). The corresponding sites in 138 women were 28, 33 and 77, respectively (p = 0.002), implying a predominance of stage I-II lymphomas regional to the respiratory tract in men and a larger number of localized lymphomas elsewhere, mostly abdominal retroperitoneal with or without inguinal engagement in women. High-grade nodal lymphomas were more common in 1992 (54%) than in 1983 (34%, p = 0.01). suggesting an increasing number of mainly high-grade lymphomas. For extranodal lymphomas (50 in men and 33 in women), no clear differences were observed for gender and the years studied. Risk factors, e.g. occupational hazards, are probably different for men and women. The gender differences in initial nodal location suggest that initial lymphoma sites may be related to different risk factors. Epidemiologic studies where both malignancy grade and initial lymphoma locations are taken into account may be helpful in defining risk factors.In accordance with international data, non-Hodgkins lymphomas (NHL) in the Southern Health Care Region of Sweden were more common in men than in women and there was an inreasing incidence for both genders in the 1980s and 1990s. A study of the years 1983 and 1992, i.e. the beginning and the end of a 10-year period, was carried out. Case records for 94% of all adults diagnosed in 1983 and 1992 (220 men and 171 women) were reviewed. The sites of the lymphomas and malignancy grade (Kiel classification) were recorded. Comparisons were made between the genders and between the two years studied. Among 170 men with nodal lymphomas, 49 were localized (stage I-II) in lymphoid tissue regional to the respiratory tract, 18 were localized elsewhere and 103 were generalized (stage III-IV). The corresponding sites in 138 women were 28, 33 and 77, respectively (p = 0.002), implying a predominance of stage I-II lymphomas regional to the respiratory tract in men and a larger number of localized lymphomas elsewhere, mostly abdominal/retroperitoneal with or without inguinal engagement in women. High-grade nodal lymphomas were more common in 1992 (54%) than in 1983 (34%, p = 0.01), suggesting an increasing number of mainly high-grade lymphomas. For extranodal lymphomas (50 in men and 33 in women), no clear differences were observed for gender and the years studied. Risk factors, e.g. occupational hazards, are probably different for men and women. The gender differences in initial nodal location suggest that initial lymphoma sites may be related to different risk factors. Epidemiologic studies where both malignancy grade and initial lymphoma locations are taken into account may be helpful in defining risk factors.

Survival following combination chemotherapy in advanced high grade non‐Hodgkin's lymphomas: Relation to proliferative activity of the lymphoma cells

In 18 untreated adult patients (median age 62.5 yr) with advanced non‐Hodgkins 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.

The Regret Coping Scale for Health-Care Professionals (RCS-HCP): A validation study with Danish social educators

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 Cronbachs 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 (Cronbachs 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.

Prevalence of persons contacting general practice for psychological stress in Denmark

Abstract Objective: The prevalence of psychological stress has previously been estimated based on self-reported questionnaires. This study aimed to investigate the prevalence of persons who contact the general practitioner (GP) for psychological stress and to explore associations between psychological stress and characteristics relating to the patient, the GP, and area-specific socioeconomic factors. Design: Cross-sectional computer assisted journal audit. Setting: General practice in the Region of Southern Denmark. Subjects: Patients aged 18–65 years with a consultation during a six-month period that was classified with a stress-related diagnosis code. Main outcome measures: Six months prevalence of GP-assessed psychological stress and characteristics relating to the patient, the GP, and area-specific socioeconomic factors. Results: Fifty-six GPs (7% of the invited) identified 1066 patients considered to have psychological stress among 51,422 listed patients. Accordingly, a 2.1% six months prevalence of psychological stress was estimated; 69% of cases were women. High prevalence of psychological stress was associated with female sex, age 35–54 years, high education level and low population density in the municipality, but not with unemployment in the municipality or household income in the postal district. GP female sex and age <50 years, few GPs in the practice and few patients per GP were also associated with a higher prevalence of psychological stress. Conclusions: A total of 2% of the working-age population contacted the GP during a six-month period for psychological stress. The prevalence of psychological stress varies with age, sex and characteristics of both the regional area and the GP. Key points   Psychological stress is a leading cause of days on sick leave, but its prevalence has been based on population surveys rather than on assessment by health care professionals.   • This study found that during six months 2.1% of all working-age persons have at least one contact with the GP regarding psychological stress.   • The six months prevalence of psychological stress was associated with patient age and sex, GP age and sex, practices’ number of GPs and patients per GP, and area education and urbanization level.