Contextualisation of patient-centred care: A comparative qualitative study of healthcare professionals' approaches to communicating with seriously ill patients about their dependent children.

Patients' family relations play an important part in the provision of patient-centred cancer care, not least when healthcare professionals encounter seriously ill patients with dependent children. Little is known about how children are perceived and dealt with in clinical encounters. In this qualitative comparative study, we explore the influence of medical contexts in three Danish hospital wards, haematology, oncological gynaecology and neuro-intensive care, on communication with patients about their children. In exploring the degree to which the inclusion of children in clinical encounters is dependent on context, we took a comparative approach based on fieldwork in wards either exclusively focusing on cancer treatment or partially involved in critical phases of cancer treatment. We conducted 49 semi-structured, in-depth interviews with doctors and nurses, and 27 days of participant observation. The thematic analysis was based on Bateson's conceptualisation of communication. We found that healthcare professionals' approach to children in clinical encounters and the ways in which children were positioned on each ward were influenced by aspects specific to the ward, including the diagnosis and treatments that related specifically to the patient. Our findings suggest the need to explore further the influence of medical contexts on the inclusion of children in patient communication.

Occupational exposure to chemical agents in the paper industry.

As part of an International Agency for Research on Cancer (IARC) international epidemiological study of workers in the pulp and paper industry, previously unpublished exposure measurements were assembled in a database. This article summarizes the results of 3,873 measurements carried out in the production departments of paper and paperboard mills and recycling plants in 12 countries. In the paper and paperboard mills, most of the agents were measured in the pulping and refining departments and in on-machine coating and winding of paper/paperboard. Exposures to asbestos, carbon monoxide, formaldehyde, fungal spores, bacteria, nitrogen dioxide, minerals dusts, paper dust, sulphuric acid and different solvents sometimes exceeded exposure limit values. In the re-pulping and de-inking departments of recycling plants high exposures to formaldehyde, fungal spores, bacteria and paper dust were observed. High exposures to asbestos, bioaerosols, carbon monoxide and paper dust were found in many departments; ammonia, formaldehyde, mineral and paper dust and solvents were found in coating machines; and diphenyl and polychlorobiphenyls (PCBs) were found in some special circumstances. Measurements in the newsprint and uncoated paper machine departments revealed only a few elevated exposures. In nearly all departments, measurements of epichlorohydrin, PCBs, sulphur dioxide, hydrogen sulphide and mercaptans tended to be low, often even below their detection limits. In spite of some uncertainties in the measurement data, the study provides new insights into the level and variation of occupational exposures of production workers in the paper and paperboard industry.

[Metaphors and power. A qualitative study of metaphorical thinking among Danish cancer patients]. / Metaforer og kraeft. En kvalitativ underøgelse af metaforisk taenkning hos danske kraeftpatienter.

The use of metaphors concerning cancer was investigated by interviewing nine Danish cancer patients, aged 30-85 years. Metaphors about the disease were widely used, e.g. personification metaphors. Most patients considered their cancer as a metaphor for a physical and psychological imbalance in the period before the disease. Some patients felt responsible for the disease. The metaphors of cancer patients should be considered when communicating with cancer patients.

Hodgkin's disease, pharyngeal cancer, and soft tissue sarcomas in Danish paper mill workers.

Several studies have indicated an increased cancer risk among paper mill workers, based on rather few cancer cases. The authors studied cancer incidence in a large historical cohort of 14,362 Danish paper mill workers, employed at any time between 1943 and 1990, and followed up until December 31, 1993. Men had an increased risk of pharyngeal cancer (15 observed (obs), standardized incidence ratio (SIR) 1.99, 95% confidence interval (CI) 1.11-3.29). With two additional cases among women, 11 of 17 cases were located in the tonsils. Men also had an increased risk of Hodgkin's disease (18 obs, SIR 2.01, 95% CI 1.19-3.18). Women had an increased risk of soft tissue sarcomas (nine obs, SIR 2.33, 95% CI 1.06-4.43), with a high risk among female paper sorters (eight obs, SIR 3.98, 95% CI 1.71-7.84). The study thus supports some studies' observations of an increased risk of Hodgkin's disease in paper mill workers. The detailed reporting of cancer cases in paper mill workers have furthermore revealed a risk of pharyngeal cancer together with a risk of soft tissue sarcomas in paper sorters.

Risk of cancer among paper recycling workers.

OBJECTIVES: Studies in traditional paper mills have indicated an excess cancer risk, and mutagenic compounds have been identified in the industry. No studies have reported on risk of cancer in paper recycling. Therefore the cancer incidence in Danish paper recycling mills was investigated. METHODS: 5377 employees in five paper recycling plants were included in a historical cohort study. The workers had been employed in paper recycling in 1965-90, and the cohort was followed up until 31 December 1993. The expected number of cancer cases was calculated from national rates. RESULTS: There was significantly more pharyngeal cancer among male workers (seven observed (standardised incidence ratio (SIR) 3.33, 95% confidence interval (95% CI) 1.34 to 6.87)). There was slightly more lung cancer among male workers in production (39 observed, SIR 1.21, 95% CI 0.86 to 1.65). Risk of Hodgkin's disease was doubled in male production worker (four observed, SIR 1.90, 95% CI 0.51 to 4.85). CONCLUSIONS: The increased risk of pharyngeal cancer found in this study is interesting but may be influenced by confounders such as smoking and alcohol intake. This study also indicates an excess risk of Hodgkin's disease, which is in accordance with some studies in the traditional paper mills. As this is the first report on risk of cancer in paper recycling, further studies are needed.

[Exposure to endotoxins in the environment. Occurrence and health hazards]. / Eksponering for endotoksiner i det ydre miljø. Forekomst og helbredsrisiko.

Endotoxins are lipopolysaccharides from the outer cell wall of Gram-negative bacteria. Exposure to endotoxins can take place in industries where organic material is handled, in agriculture, in garbage handling, and sewage treatment. Byssinosis defined as Monday chest tightness and slight dyspnoea in the work place has been related to endotoxin exposure in cotton mills, but studies indicate that similar symptoms may be found in other work places. Other symptoms are: Headache, nausea, gastrointestinal symptoms and influenza-like symptoms. Several studies have shown a decrease in FEV1 following exposure to endotoxins. The relationship between exposure to organic dust, microorganisms, endotoxins and other chemicals in the work place and disease needs further research.

Cancer incidence of sulfite pulp workers in Denmark.

OBJECTIVES: Studies have indicated an excess risk of stomach cancer, pancreas cancer, and non-Hodgkin's lymphoma for sulfite pulp mill workers, and therefore cancer incidence was evaluated for 2 Danish sulfite mills. METHODS: Altogether 2238 workers employed in 1955--1990 were included in a historic cohort and followed until 31 December 1993. National cancer rates were used to calculate the expected number of cancer cases. RESULTS: The overall cancer risk was close to the expected, the standardized incidence ratio (SIR) being 1.01. The risk of stomach cancer was doubled [10 observed, SIR 1.99, 95% confidence interval (95% CI) 0.95--3.66], as was the risk of pancreatic cancer (7 observed, SIR 1.88, 95% CI 0.75-3.88). For the men with known pulp exposure, lung cancer was slightly increased (SIR 1.53, 95% CI 0.94-2.37). Other cancers with elevated risks were leukemia (7 observed, SIR 1.84) and soft-tissue sarcomas (4 observed, SIR 2.37). The risk of non-Hodgkin' s lymphoma was not increased. CONCLUSIONS: The excess risk of stomach cancer and pancreatic cancer found in this study was in accordance with that of other studies from sulfite pulp mills.

Industrial hygiene measurements in a new industry: the repulping and deinking of paper waste.

Six Danish paper recycling plants were included in an assessment of exposure to chemicals. A questionnaire on processes was completed, and in-plant industrial hygiene measurement data collected 1982-1994 were examined. The assessment of chemicals did not reveal a major use of possible carcinogens, but acrylamide may have been released in the work environment in one plant. A total of 197 hygiene measurements were recorded: 126 in the largest plant. Airborne concentrations of dust, microorganisms, and endotoxins varied widely between plants. High concentrations of dust were recorded in the paper machine area in one plant and in the repulping unit in another plant. In general, endotoxin levels were low, but endotoxin levels were increased in one plant when reuse of process water was intensified. Changes in procedures should be assessed by industrial hygiene measurements.

Cancer incidence in Danish health care workers.

Health care workers are exposed to various occupational hazards. In a register linkage study we investigated cancer incidence in health care personnel in Denmark. The overall cancer incidence was elevated in female general and dental practitioners. Male doctors had a risk of brain cancer twice as high as expected. Male dental practitioners, female hospital doctors and nurses had significantly high risks of melanomas of the skin. The breast cancer risk was elevated among female salaried dentists, hospital doctors, and nurses. Female cleaners had a significantly elevated risk of leukemia (31 cases, SIR 1.54). The lung cancer risk was low in several occupational groups. This indicates a change in risk behavior related to tobacco smoking. A high risk of skin melanomas may indicate that behaviour related to sunlight exposure has not changed.

Addressing male sexuality: a perspective from Denmark.

PIP: Family planning associations (FPAs) in the Scandinavian countries know the importance of addressing the needs of male adolescents and young men. Even though sex education is part of school curricula in Denmark, many young men lack good and confident counsellors to give them advice about sexuality and reproduction. In Denmark, almost half of men aged 16-20 years never talk to their parents about sexuality. It should therefore not be surprising that more than two-thirds of callers to the Danish FPA's, and other European FPAs', anonymous sex counseling telephone line are male. Many of the questions asked by young men indicate insecurity about sexual activity and what is perceived to be sexually normal. FPAs can play a vital role in providing counselling to boys and young men. Male discussion groups can help identify the needs of boys and young. Involving adolescents and the importance of the male perspective are discussed.^ieng

Cancer in printing workers in Denmark.

OBJECTIVES: To study the cancer incidence in printing workers in Denmark. METHODS: The cohort of 15,534 men and 3593 women working in the printing industry in 1970 were followed up for death, emigrations, and incident cancer cases until the end of 1987. Their cancer incidence was compared with that of all economically active people in Denmark. The smoking and drinking habits reported by members of the printing trade unions at a survey in 1972 were compared with habits reported by members of other trade unions. RESULTS: Lung, bladder, renal pelvis, and primary liver cancers were in excess among the printing workers. The excess risks of lung cancer among the factory workers in newspaper and magazine production, of bladder cancer in typographers in printing establishments, of renal pelvis cancer in typographers and lithographers, and of primary liver cancer among lithographers and bookbinders exceeded those expected based on the reported smoking and drinking habits. CONCLUSION: Our results indicate, in line with a previous study from Manchester, that work with rotary letterpress printing was associated with an increased risk of lung cancer. The inconsistent results from studies on bladder cancer in printing workers may point to a risk confined to a certain subgroup. The sixfold risk of primary liver cancer in Danish lithographers warrants studies in other countries.

[Mandatory anonymous HIV-surveillance in Denmark. Experience with the new notification system]. / Lovpligtig anonym HIV-overvågning i Danmark. Erfaringer med det nye meldesystem.

A newly implemented mandatory, anonymous HIV surveillance system in Denmark is described. The system is based on a serially numbered form that is circulated among the laboratories, the physicians, and the national surveillance unit. All laboratories doing confirmatory tests for HIV antibodies must send a report form along with any positive test result. Before forwarding the form to the physician, the laboratory is to fill in the top part of the form with its own name, the name and address of the requesting physician and the date of testing. The back copy must be send to the surveillance unit. The Danish physicians are by law mandated to fill in the form with data on the patient and then send the original to the surveillance unit. The two copies are for the patient's file and for the physicians' own centralized filing system. After a revision of the system in 1992, a response rate of 95% was obtained during the first year. An increasing number and proportion of first-time identified HIV-infections in Denmark are acquired heterosexually, many of these infections are identified among foreigners. The newly developed mandatory HIV surveillance system is based on anonymous reporting but it allows routine evaluation of the completeness of reporting as well as nonresponding physicians to be reminded of their duty to report. Also, the system allows nested studies to be carried out among selected HIV-infected subpopulations of special research interest without compromising the anonymity of the patient.

[HIV testing in Denmark in 1993: were the tests relevant?]. / HIV-testning i Danmark i 1993: blev der testet relevant?

In order to describe HIV-testing activity among adults in Denmark, a cross-sectional study was designed using an anonymous questionnaire, which was forwarded with all HIV-test results in a given two-week period in 1993. Notified first-time identified HIV-positive cases were used for comparisons. The response rate was 50%. A total of 996 women and 834 men were included, among whom 68% of men and 62% of women were classified as having a behaviour that put them at increased risk for acquiring HIV, p < 0.02. Women were younger than men, p < 0.001. Around 1/3 of both men and women had previously been HIV-tested, a proportion that increased with increasing risk for HIV, p < 0.00001 for trend. HIV-tested adults were younger and less frequently living in the Copenhagen area than the first-time identified HIV-infected persons reported to the mandatory national HIV-surveillance system. The overall HIV prevalence was 0.3%, being 0.5% among men and 0.2% among women. Estimates showed that the yearly number of first-time identified HIV-infections among tested homo/bisexual men per 10(5) men were 100 times as high as among the heterosexual population. Also, 12% of Danish homo/bisexual men had an HIV test per year, a proportion that was 2.3% among adult women and 1.8% among adult heterosexual men without i.v. drug use. The yearly test-activity decreases with increasing age among both men and women. In conclusion, studies among the HIV-tested population along with results from systematic surveillance of first-time identified HIV-infections are useful in order to estimate the frequency and the relevancy of HIV testing in the entire population. Also, these results may help when planning national information campaigns.

Need for focus on men's perspective in family planning.

PIP: An April 1994 workshop involving 13 men associated with European Family Planning Associations emphasized the need for greater male involvement in family planning and sex education. The redefinition of traditional sex roles currently underway in Europe provides a basis for men to discuss sexuality more openly and assume a more active part in family planning activities. This will not occur under existing family planning clinic models, however. Family planning associations must train male educators to train their counterparts and consider the establishment of special facilities to reach and meet the needs of men. In countries such as Sweden, Denmark, Holland, and Ireland, where male-specific services (e.g., sex education clinics for boys, courses on male sexuality for teachers and other role models, special educational materials) have been made available, the response has been overwhelming. Other suggested programs include peer-led boys' discussion groups, educational programs at sites such as sports clubs and army barracks, and open discussions of sensitive issues such as homosexuality, masturbation, and pornography. Also in need of revision is condom information. Such training should include advice to first try to masturbate with a condom and the experience of condom purchase. Realistic information on the difficulties of condom use should be offered, and young men should be given suggested phrases to use in situations when condom use is being negotiated with a partner.^ieng

Mandatory anonymous HIV surveillance in Denmark: the first results of a new system.

OBJECTIVES: This paper describes the principles and first results of the newly implemented anonymous mandatory human immunodeficiency virus (HIV) reporting system in Denmark. METHODS: The system is based on a serially numbered form that is circulated among the laboratories, the physicians, and the national surveillance unit. All laboratories doing confirmatory tests for HIV antibodies must send a report form along with any positive test results. Before forwarding the form, the laboratory is to fill in the top part with the name and address of the requesting physician and send the back copy to the surveillance unit. The physicians are mandated by law to fill in the form with data on the patient and to keep two copies for their own files before sending the original to the surveillance unit. RESULTS: After a revision of the system, a response rate of 95% was obtained. CONCLUSIONS: We have established an anonymous mandatory HIV surveillance system in Denmark that enables routine evaluation of the completeness of reporting and nonresponding physicians to be reminded of their duty to report. Also, the physicians can act as mediators between patients and researchers; therefore, nested studies can be done without breaking the anonymity of the patient.

Immunity from diphtheria, tetanus, poliomyelitis, measles, mumps and rubella among adults in Lithuania.

Health authorities have estimated a low immunity level against diphtheria, tetanus, poliomyelitis, measles, mumps and rubella among adults in Lithuania due to less than optimal vaccine quality. The aim of this study was to evaluate the level of immunity by blood sampling 100 young women, 50 young men and 50 middle-aged men and from the immunization history by questionnaire. Lack of protection against diphtheria was found in 0%, 2% and 46% of the young women, young men and middle-aged men respectively. The corresponding data for tetanus were 0%, 0% and 10%. It was found that 85% of the women had antibodies to all 3 types of polioviruses vs. 80% of the young men and 56% of the middle-aged men. A sub-protective antibody level against measles was found in 12% of the women, 22% of the young men, but in none of the middle-aged men. A protective titre of rubella antibodies was found among 94% of the young, pregnant women. It can be concluded that the level of immunity in Lithuania is comparable to that in Western Europe for the same age groups and that the launching of adult vaccination programs in Eastern Europe should be preceded by sero-epidemiological studies.

Danish ethics council rejects brain death as the criterion of death.

In Denmark, which alone in Western Europe has not accepted brain death as the criterion of death, the newly established Danish Council of Ethics has issued a report suggesting that in Denmark the criterion of death should still be the cessation of cardiac activity. The council bases its conclusion on the concept of death in everyday experience and its ethical implications.

[Medical ethics--various regulatory models in Europe]. / Medicinsk etik--nogle reguleringsmodeller i Europa.

Many European countries have set up bioethical committees. This article describes the organization and work of some of these committees. Advantages and disadvantages caused by different forms of organization are discussed.