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.

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.

Work participation and health-related characteristics of sickness absence beneficiaries with multiple somatic symptoms.

OBJECTIVES: The primary aim was to study whether high levels of multiple symptoms influenced sick-listed individuals' employment status or desire to return to work (RTW) and whether this was associated with social relations at work. STUDY DESIGN: A cross-sectional study nested in a clinical trial. METHODS: In 2011-2012, 736 (34%) of 2172 sick-listed individuals completed a posted questionnaire and were included. Main outcome was self-reported employment status. The Symptom Check List (SCL-SOM)'s sum score (0-48) was categorized in high (>18) and low (≤18) levels. Previous employment, sick-listing, and use of health care were register-data. Multivariate logistic regression analyses with adjustments were performed. RESULTS: Beneficiaries with high SCL-SOM score (n = 218, 33%) reported poorer health, job satisfaction, a lower desire to RTW and more problems with supervisors. The risk of being unemployed was higher for this group than for those with a low score. Adjusting for general health reduced the association between symptoms and unemployment, whereas problems with social relations only affected it marginally. CONCLUSIONS: Sick-listed individuals reporting high levels of symptoms were more often unemployed and less frequently desired to RTW than those with few symptoms. The association could not be explained by problems with social relations at work. TRIAL REGISTRATIONS: ISRCTN43004323, and ISRCTN51445682.

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.

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.

Premature awakening and underuse of neuromuscular monitoring in a registry of patients with butyrylcholinesterase deficiency.

BACKGROUND: Patients with butyrylcholinesterase (BChE) deficiency can experience prolonged paralysis after receiving suxamethonium or mivacurium. We hypothesized that patients suspected of BChE deficiency had a higher risk of being awakened while paralysed and having respiratory complications if neuromuscular monitoring was not applied before awakening. METHODS: We retrospectively included patients referred to the Danish Cholinesterase Research Unit between 2004 and 2012 on suspicion of BChE deficiency. We collected data on genotype, BChE activity, neuromuscular blocking agents administered, neuromuscular monitoring, and postoperative respiratory complications, defined as arterial oxygen desaturation <90%, assisted ventilation, reintubation of the trachea, and pulmonary aspiration. Patients were classified as prematurely awakened if anaesthesia had been terminated while the patient was still paralysed. RESULTS: We included 123 patients. Neuromuscular monitoring was applied before awakening in 48 (39%) patients. A nerve stimulator was never used or only after attempted awakening in the remaining 75 (61%) patients. Premature awakening occurred in 75 (100%) and 14 (29%) of the unmonitored and monitored patients, respectively (P<0.001, Fisher's exact test). In 11 of the monitored patients, the results of neuromuscular monitoring were interpreted as equipment failure or were disregarded. Respiratory complications occurred in 19 (25%) and five (10%) of the unmonitored and monitored patients, respectively (P=0.06). CONCLUSIONS: Patients with BChE deficiency are at higher risk of being awakened while paralysed if neuromuscular monitoring is not applied or used; neuromuscular monitoring is recommended whenever a neuromuscular blocking agent is administered.

Use of neuromuscular monitoring to detect prolonged effect of succinylcholine or mivacurium: three case reports.

Mutations in the butyrylcholinesterase gene can lead to a prolonged effect of the neuromuscular blocking agents, succinylcholine and mivacurium. If the anaesthesiologist is not aware of this condition, it may result in insufficient respiration after tracheal extubation. However, this can be avoided with the use of objective neuromuscular monitoring if used adequately. Three case reports of prolonged effect of succinylcholine or mivacurium were presented to illustrate the importance of neuromuscular monitoring during anaesthesia. In the first case, continuous intraoperative neuromuscular monitoring allowed a prolonged neuromuscular blockade to be discovered prior to tracheal extubation of the patient. The patient was extubated after successful reversal of the neuromuscular blockade. On the contrary, neuromuscular monitoring was not used during anaesthesia in the second patient; hence, the prolonged effect of the neuromuscular blocking agent was not discovered until after extubation. In the third patient, the lack of response to nerve stimulation was interpreted as a technical failure and the prolonged effect of succinylcholine was discovered when general anaesthesia was terminated. Both patients had insufficient respiration. They were therefore re-sedated, transferred to the intensive care unit and the tracheas were extubated after full recovery from neuromuscular blockade. We recommend the use of monitoring every time these agents are used, even with short-acting drugs like succinylcholine and mivacurium.

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.

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.