Clinically decisive (dis)agreement in multidisciplinary team assessment of esophageal squamous cell carcinoma; a prospective, national, multicenter study.

BACKGROUND: Decisions regarding tumor staging, operability, resectability, and treatment strategy in patients with esophageal cancer are made at multidisciplinary team (MDT) conferences. We aimed to assess interobserver agreement from four national MDT conferences and whether this would have a clinical impact. METHODS: A total of 20 patients with esophageal cancer were included across all four upper gastrointestinal (GI) cancer centers. Fully anonymized patient data were distributed among the MDT conferences which decided on TNM category, resectability, operability, curability, and treatment strategy blinded to each other's decisions. The interobserver agreement was expressed as both the raw observer agreement and with Krippendorff's α values. Finally, a case-by-case evaluation was performed to determine if disagreement would have had a clinical impact. RESULTS: A total of 80 MDT evaluations were available for analysis. A moderate to near-perfect observer agreement of 79.2%, 55.8%, and 82.5% for TNM category was observed, respectively. Substantial agreement for resectability and moderate agreement for curability were found. However, an only fair agreement was observed for the operability category. The treatment strategies had a slight agreement which corresponded to disagreement having a clinical impact in 12 patients. CONCLUSIONS: Esophageal cancer MDT conferences had an acceptable interobserver agreement on resectability and TM categories; however, the operability assessment had a high level of disagreement. Consequently, the agreement on treatment strategy was reduced with a potential clinical impact. In future MDT conferences, emphasis should be on prioritizing the relevant information being readily available (operability, T & M categories) to minimize the risk of disagreement in the assessments and treatment strategies, and thus, delayed or suboptimal treatment.

Perceived stress and risk of adult-onset asthma and other atopic disorders: a longitudinal cohort study.

BACKGROUND: Psychological stress can affect airway inflammatory response to irritants and allergens, but the importance of stress in the etiology of adult-onset respiratory and dermatologic allergic disorders remains unclear. We aim to address the relationship between perceived stress and the risk of adult-onset asthma, allergic rhinitis, atopic dermatitis, and asthma/bronchitis medication. METHODS: Participants (n = 9785) from the Copenhagen City Heart Study, Denmark, free of atopic disorders at baseline in 1981-1983 were asked questions on stress intensity and frequency. They were followed for first-time asthma hospitalization in nationwide registers until 2010, with < 0.1% loss to follow-up. Objective measures of lung function allowed for thorough adjustment for confounding and prevented ambiguity between diagnosis of asthma and chronic obstructive lung disease. Daily intake of asthma/bronchitis medication and incidence of asthma, allergic rhinitis, and atopic dermatitis were assessed by self-report after 10 years of follow-up in 5648 persons. RESULTS: Perceived stress was associated with atopic disorders in a dose-dependent manner (P(trend)  < 0.001). High vs low stress was associated with higher risk of self-reported asthma incidence (OR = 2.32; 95% CI: 1.47-3.65), daily intake of asthma/bronchitis medication (OR = 2.26; 95% CI: 1.42-3.58), first-time asthma hospitalization (HR = 2.01; 95% CI: 1.41-2.86), allergic rhinitis (OR = 1.64; 95% CI: 0.99-2.72), and atopic dermatitis (OR = 1.75; 95% CI: 1.11-2.77). The associations were similar for smokers and nonsmokers. CONCLUSIONS: Stress is strongly associated with asthma incidence and hospitalization, use of asthma medication as well as with allergic rhinitis and atopic dermatitis in adults.

Perceived stress as a risk factor for changes in health behaviour and cardiac risk profile: a longitudinal study.

OBJECTIVE: The aim of this study was to evaluate the long-term effects of stress on changes in health behaviour and cardiac risk profile in men and women. DESIGN: A prospective cohort study. SETTING: The Copenhagen City Heart Study, Denmark. SUBJECTS: The analyses were based on 7066 women and men from the second (1981-1983) and third (1991-1993) wave of the Copenhagen City Heart Study. All participants were asked questions on stress and health behaviour and they had their weight, height, blood pressure and level of blood lipids measured by trained personnel. MAIN OUTCOME MEASURES: Changes in health behaviour (smoking, physical activity, alcohol consumption, overweight) and cardiac risk profile (cholesterol, HDL cholesterol, blood pressure, diabetes). RESULTS: Individuals with high levels of stress compared to those with low levels of stress were less likely to quit smoking (OR = 0.58; 95% CI: 0.41-0.83), more likely to become physically inactive (1.90; 1.41-2.55), less likely to stop drinking above the sensible drinking limits (0.43; 0.24-0.79), and stressed women were more likely to become overweight (1.55; 1.12-2.15) during follow-up. Men and women with high stress were more likely to use antihypertensive medication (1.94; 1.63-2.30), and stressed men were more than two times as likely to develop diabetes during follow-up (2.36; 1.22-4.59). CONCLUSION: This longitudinal study supports a causal relation between stress and cardiovascular diseases mediated through unfavourable changes in health behaviour and cardiac risk profile.

Safety and feasibility of preoperative exercise training during neoadjuvant treatment before surgery for adenocarcinoma of the gastro-oesophageal junction.

Background: Neoadjuvant chemotherapy or chemoradiotherapy is used widely before tumour resection in cancer of the gastro-oesophageal junction (GOJ). Strategies to improve treatment tolerability are warranted. This study examined the safety and feasibility of preoperative exercise training during neoadjuvant treatment in these patients. Methods: Patients were allocated to a standard-care control group or an exercise group, who were prescribed standard care plus twice-weekly high-intensity aerobic exercise and resistance training sessions. The primary endpoint was the incidence of serious adverse events (SAEs) that prevented surgery, including death, disease progression or physical deterioration. Preoperative hospital admission, postoperative complications, changes in patient-reported quality of life and pathological treatment response were also recorded. In the exercise group, adherence to exercise and changes in aerobic fitness, muscle strength and body composition were measured. Results: The incidence of SAEs was not increased in the exercise group. The risk of failure to reach surgery was 5 versus 21 per cent in the control group (risk ratio (RR) 0·23, 95 per cent c.i. 0·04 to 1·29), the risk of preoperative hospital admission was 15 versus 38 per cent respectively (RR 0·39, 0·12 to 1·23) and the risk of postoperative complications was 58 versus 57 per cent (RR 1·06, 0·61 to 1·73). The exercise group attended a mean of 17·5 sessions, and improved fitness, muscle strength and Functional Assessment of Cancer Therapy - Esophageal (FACT-E) total score compared with the baseline level. Conclusion: Preoperative exercise training during neoadjuvant treatment in patients with GOJ cancer is safe and feasible, with improvements in fitness, strength and quality of life. Preoperative exercise training may be associated with a lower risk of critical SAEs that preclude surgery or result in hospitalization.

Perceived stress and risk of colorectal cancer in men and women: a prospective cohort study.

OBJECTIVE: We aim to assess the relationship between stress and risk of primary colorectal cancer in men and women. DESIGN: A prospective cohort study. SETTING: The Copenhagen City Heart Study, Denmark. SUBJECTS: A total of 6488 women and 5426 men were included in the study. The participants were asked about intensity and frequency of stress at baseline in 1981-1983 and were followed until the end of 2000 in the Danish Cancer Registry. Less than 0.1% was lost to follow-up. MAIN OUTCOME MEASURES: First time incidence of primary colorectal cancer. RESULTS: During follow-up 162 women and 166 men were diagnosed with colorectal cancer. Women with moderate and high stress intensity had a hazard ratio of 0.60 (95% CI: 0.37-0.98) and 0.52 (0.23-1.14) for colorectal cancer, respectively, compared to women with no stress. For colon cancer, a one-unit increase on a seven-point stress-score was associated with an 11% lower incidence of the disease (HR = 0.89, 95% CI: 0.81-0.99) amongst women. There was no consistent evidence of an association between stress and colorectal cancer in men. CONCLUSION: Perceived stress was associated with lower risk of particularly colon cancer in women, whilst there was no clear relationship between stress and colorectal cancer in men.

Burnout as a predictor of self-reported sickness absence among human service workers: prospective findings from three year follow up of the PUMA study.

AIM: To investigate whether burnout predicts sickness absence days and sickness absence spells in human service workers. METHOD: A total of 824 participants from an ongoing prospective study in different human service sector organisations were eligible for the three year follow up analysis. Burnout was measured with the work related burnout scale of the Copenhagen Burnout Inventory. Sickness absence was measured with self-reported number of days and spells during the last 12 months before the baseline and the follow up survey. A Poisson regression model with a scale parameter was used to account for over dispersion. A linear regression model was used for analysing changes in burnout and absence between baseline and follow up. RESULTS: Burnout was prospectively associated with both sickness absence days and sickness absence spells per year. Differences in sickness absence days varied from a mean of 5.4 days per year in the lowest quartile of the work related burnout scale to a mean of 13.6 in the highest quartile. An increase of one standard deviation on the work related burnout scale predicted an increase of 21% in sickness absence days per year (rate ratio 1.21, 95% CI 1.11 to 1.32) after adjusting for gender, age, organisation, socioeconomic status, lifestyle factors, family status, having children under 7 years of age, and prevalence of diseases. Regarding sickness absence spells, an increase of one standard deviation on the work related burnout scale predicted an increase of 9% per year (rate ratio 1.09, 95% CI 1.02 to 1.17). Changes in burnout level from baseline to follow up were positively associated with changes in sickness absence days (estimate 1.94 days/year, SE 0.63) and sickness absence spell (estimate 0.34 spells/year, SE 0.08). CONCLUSION: The findings indicate that burnout predicts sickness absence. Reducing burnout is likely to reduce sickness absence.

Work-family conflict as a risk factor for sickness absence.

OBJECTIVES: (1) To study both cross-sectional and prospective relationships between work-family conflict and sickness absence from work; (2) to explore the direction of the relationships between the different types of conflict (work-home interference and home-work interference) and sickness absence; and (3) to explore gender differences in the above relationships. METHODS: Data from the Maastricht Cohort Study were used with six months of follow up (5072 men and 1015 women at T6). Work-family conflict was measured with the Survey Work-Home Interference Nijmegen (SWING). Sickness absence was assessed objectively through individual record linkage with the company registers on sickness absence. RESULTS: In the cross-sectional analyses, high levels of work-family conflict, work-home interference, and home-work interference were all associated with a higher odds of being absent at the time of completing the questionnaire, after controlling for age and long term disease. Differences in average number of absent days between cases and non-cases of work-home interference were significant for men and most pronounced in women, where the average number of absent days over six months follow up was almost four days higher in women with high versus low-medium work-home interference. CONCLUSIONS: A clear relation between work-family conflict and sickness absence was shown. Additionally, the direction of work-family conflict was associated with a different sickness absence pattern. Sickness absence should be added to the list of adverse outcomes for employees struggling to combine their work and family life.

The Danish SF-36 Health Survey: translation and preliminary validity studies.

This article reports on the Danish translation of SF-36 and discusses the procedures used for translation improvement, translation evaluation, and scale evaluation. We followed the standard procedures of the International Quality of Life Assessment (IQOLA) Project including forward and backward translation, independent assessment of translation quality, assessment of response-choice weighting through visual analogue scale (VAS) investigations, and psychometric testing of the translated questionnaire. We found that backward translation, independent quality assessment, and VAS studies provided useful information for translation improvement. The Danish SF-36 received a favorable translation evaluation by independent rating; however, interrater agreement was low. Preliminary validity studies generally supported the internal consistency and homogeneity of the Danish SF-36, and the questionnaire performed satisfactorily in distinguishing depressive patients from nonpatients. On the basis of this and other studies, we recommend use of the Danish SF-36 in research.

Trends in mortality, incidence and case fatality of ischaemic heart disease in Denmark, 1982-1992.

BACKGROUND: In Denmark, as in many other Western countries, a decline in mortality from ischaemic heart disease (IHD) has been observed. The present study assesses whether the decline in IHD mortality is due to a decrease in incidence and/or case-fatality, and whether parallel changes occurred in the various manifestations of IHD requiring hospitalization. METHODS: The National Patient Register of hospital discharges and the Causes-of-Death Register were linked and all cases of first admission for IHD including AMI and fatal first manifestations of IHD since 1977 in the entire Danish population were identified. Cases of AMI and IHD were considered as incident cases if no admission for these diagnoses had occurred during the preceding 5 years. Sex-specific, age-standardized annual mortality, incidence and case-fatality rates of AMI (ICD8 code 410), narrowly defined IHD (NIHD, ICD8 codes 410-4) and broadly defined IHD (BIHD, ICD8 codes 410-4, 427 and 795-6) were calculated for the period 1982-1992. RESULTS: During the entire period the age-standardized mortality of AMI, NIHD and BIHD decreased in both men and women. The incidence of AMI and NIHD decreased, while the incidence of BIHD remained constant. Case fatality of AMI decreased in both men and women, while case fatality of NIHD and BIHD decreased in men and in women aged 0-64 years only. CONCLUSION: The declining mortality from IHD in Denmark may be partly due to declining incidence as well as declining case fatality, but changes in disease manifestation or diagnostic drift may also contribute because more broadly defined diagnostic groups showed less or no decline in incidence.

Impact of work environment on cardiovascular diseases in Denmark.

STUDY OBJECTIVE: The aim was to estimate the quantitative impact of working conditions on cardiovascular diseases in Denmark. DESIGN: The study was based on a review of recent epidemiological research publications in which relative risks were estimated and risk factor prevalences were determined. The impact of working conditions was quantified by means of aetiological fractions. SETTING: The aetiological fractions were estimated on the Danish population. MAIN RESULTS: 16% of the premature cardiovascular mortality in men and 22% in occupationally active women is avoidable through interventions in the work environment. If "sedentary" work is included in the occupational risk factors, the aetiological fractions reach 51% for men and 55% for women. Taken separately, the major aetiological fractions for cardiovascular risk factors at work are respectively (women in parentheses) 6% (14%) for monotonous high paced work, 7% (7%) for shift work, and 2% (2%) for passive smoking. CONCLUSIONS: The aetiological fractions show that working conditions play a considerable role in cardiovascular diseases. Furthermore they might widen the focus of preventive cardiology from interventions directed only at individual and lifestyle risk factors to interventions directed also at working conditions.

Self rated health as a predictor of coronary heart disease in Copenhagen, Denmark.

STUDY OBJECTIVE: To analyse the association between self rated health and the incidence of fatal and non-fatal coronary heart disease (CHD) in a Danish cohort followed up over 16 years. DESIGN: This was a prospective epidemiological follow up study. SETTING: A cohort from the County of Copenhagen, Denmark. PARTICIPANTS: The study included 1052 men and women born in 1936. During the 16 years' follow up 50 cases of CHD were registered in either the Danish register of deaths or the register of hospital admissions. MAIN RESULTS: Univariate analysis showed the following relative risks of CHD in the four self rated health groups: 'extremely good': 1.0, 'good': 4.0, 'poor': 5.8, 'miserable': 12.1 (p = 0.02). After control for the conventional CHD risk factors and a substantial number of other potential confounders the relative risks were: 1.0, 4.2, 6.5, and 18.6 (p = 0.02) respectively. CONCLUSIONS: Self rated health was an independent predictor of CHD in the present cohort. If confirmed, the association between self rated health and CHD may lead to new insight into psychosocial processes leading to this disease.

Sickness absence and work strain among Danish slaughterhouse workers: an analysis of absence from work regarded as coping behaviour.

This paper comprises two parts: a theoretical part in which a number of theoretical and methodological recommendations about research on absence are made on the basis of a review of selected literature, and an empirical part that contains analyses of absence from work in the Danish slaughterhouse industry. In the theoretical part it is asserted that sickness absence cannot be understood if it is viewed as a simple function of ill health or other individual factors, such as job dissatisfaction. Absence should rather be regarded as a coping behaviour that reflects an individual's perception of his/her health (illness) and is a function of a number of factors at different levels, primarily the combination of job demands and coping possibilities at the job (job strain). Several ideal methodological requirements regarding absence research are formulated on this basis. The empirical part presents an analysis of absence from work in the Danish slaughterhouse industry based on a study of 4407 slaughterhouse workers. It is shown that a number of factors at the company level, the job level and the individual level are associated with an individual's absence from work over a 12-month period. It is further shown that people with high job strain have a significantly higher absence rate, that there is a clear association between sickness absence and perceived health and that absence is part of a pattern along with other coping strategies which are directed against stressing working conditions and perceived ill health. Lastly, it is discussed whether absence from work is a functional coping strategy.

Social class and self-rated health: can the gradient be explained by differences in life style or work environment?

The purpose of the present paper is to describe differences in work environment and life style factors between social classes in Denmark and to investigate to what extent these factors can explain social class differences with regard to changes in self-rated health (SRH) over a 5 year period. We used data from a prospective study of a random sample of 5001 Danish employees, 18-59 years of age, interviewed at baseline in 1990 and again in 1995. At baseline we found higher prevalence in the lower classes of repetitive work, low skill discretion, low influence at work, high job insecurity, and ergonomic, physical, chemical, and climatic exposures. High psychological demands and conflicts at work were more prevalent in the higher classes. With regard to life style factors, we found more obese people and more smokers among the lower classes. The proportion with poor SRH increased with decreasing social class at baseline. The follow-up analyses showed a clear association between social class and worsening of SRH: The lower the social class, the higher the proportion with deterioration of SRH. There was no social gradient with regard to improved SRH over time. Approximately two thirds of the social gradient with regard to worsening of SRH could be explained by the work environment and life style factors. The largest contribution came from the work environment factors.

Do factors in the psychosocial work environment mediate the effect of socioeconomic position on the risk of myocardial infarction? Study from the Copenhagen Centre for Prospective Population Studies.

AIM: To investigate whether the effect of socioeconomic position on risk of myocardial infarction (MI) is mediated by differential exposure or differential susceptibility to psychosocial work environment. METHODS: Data were used from three prospective population studies conducted in Copenhagen. A total of 16 214 employees, 44% women, aged 20-75 years, with initial examination between 1974 and 1992 were followed until 1996 for incident (hospital admission or death) MI. Register based information on job categories was used. Psychosocial job exposures were measured indirectly by means of a job exposure matrix based on the Danish Work Environment Cohort Study 1990. RESULTS: During follow up, 731 subjects were diagnosed with an MI: 610 men and 121 women (35% fatal). The hazards by socioeconomic position showed a graded effect with a hazard ratio (HR) of 1.57 (95% CI 1.23 to 2.03) for unskilled workers compared to executive managers. Despite a strong and graded association in risk of MI related to decision authority and skill discretion, only skill discretion mediated the effect of socioeconomic position. The HR for unskilled workers was reduced to 1.47 (0.93 to 2.31) after adjustment for decision authority and other cardiovascular risk factors, and to 1.07 (0.72 to 1.60) after adjustment for skill discretion and cardiovascular risk factors. No sign of synergy was found. CONCLUSIONS: Decision authority and skill discretion were strongly related to socioeconomic position; and the effect on risk of MI was partially mediated by skill discretion. Improvements in psychosocial work environment, especially possibilities for skill discretion, might contribute to reducing the incidence of MI and social inequality in MI.

Cardiovascular diseases and the work environment. A critical review of the epidemiologic literature on nonchemical factors.

This is the first of two articles reviewing the epidemiologic research on cardiovascular diseases (CVD) and the work environment. It deals with a number of nonchemical factors, ie, physical inactivity at work, stressors at work, shift work, noise, cold, heat, and electromagnetic fields and waves. First the methodological quality of each of the empirical studies is assessed on the basis of epidemiologic criteria. Then the research literature on each of the aforementioned factors of the work environment is evaluated. It is concluded that the hypothesis of a causal relationship between physical inactivity at work and risk of CVD is substantially supported by the literature. As regards work stressors and shift work, several good studies have been published during the last 10 years strongly suggesting a causal relationship. Other studies have shown a relationship between noise and elevated blood pressure, but the quality of this literature is low. Heat and cold appear to have an acute effect on the incidence of CVD, but the possible chronic effect has seldom been investigated. Concerning electromagnetic fields and waves, it is concluded that more research is needed. The study of CVD and work ought to play a bigger role in research in the fields of occupational medicine and cardiovascular epidemiology in the future.

Cardiovascular diseases and the work environment. A critical review of the epidemiologic literature on chemical factors.

This is the second of two articles reviewing the epidemiologic research on cardiovascular diseases (CVD) and the work environment. It deals with chemical factors, i.e., lead, cadmium, cobalt, arsenic, carbon monoxide, passive smoking, organic solvents, carbon disulfide, nitroglycerin, nitroglycol, and others. The epidemiologic literature relating to each is assessed on the basis of a number of methodological criteria, and the need for future research, the methodology of literature reviews, and preventive implications and perspectives are discussed. It is concluded that the causal relationship between two of the chemicals, carbon disulfide and nitroglycerin/nitroglycol, and CVD is very well documented. For lead and passive smoking a causal relation to CVD is likely. More research is needed concerning cobalt, arsenic, antimony, and other chemical compounds. Exposure to carbon monoxide increases the acute risk of CVD but has probably no lasting atherosclerotic effect. Cadmium and organic solvents are probably not causally related to CVD.

Challenges for research and prevention in relation to work and cardiovascular diseases.

The purpose of this paper is to discuss future challenges for research and prevention in the field of work environment and cardiovascular diseases (CVD). First, research on CVD and work during the last half of the 20th century is discussed. Second, the theories dominating the last 20 years are presented. Third, cardiovascular and occupational epidemiology are compared, and it is stressed that occupational epidemiology should avoid the individualistic bias of mainstream cardiovascular epidemiology. Finally, future challenges are discussed, and improvements are recommended concerning the use of intermediate end points, intervention research, theories about chemical and physical risk factors, the use of a unifying model for society, stress, and health, and the application of integrated prevention. It is concluded that research on CVD and work can play an important part in the development of integrated prevention strategies for the next century.

Lung cancer among butchers and slaughterhouse workers.

The following three questions are examined in this critical evaluation of the literature on lung cancer among butchers: (i) do butchers have an excess risk of lung cancer, (ii) if yes, is this excess possibly caused by exposures in the work environment, and (iii) if yes, what then are the possible etiologic exposures? It was concluded that butchers probably have an excess risk of lung cancer. This excess risk can be explained partly, but not entirely, by tobacco smoking. The following four possible etiologic exposures are introduced: human papilloma viruses, nitrite, incomplete combustion products, and fumes from meatpacking materials. Three of these possible explanatory factors (nitrite, combustion products and fumes from packing) are not, or only to a limited extent, substantiated by the empirical data. It was recommended that the hypothesis concerning human papilloma viruses and also the possible role of work stress be tested in future studies.

Standing at work and varicose veins.

OBJECTIVES: This study attempts to determine whether or not prolonged standing at work involves an excess risk for the occurrence of varicose veins. METHODS: A cohort of 1.6 million 20-to-59-year-old Danes gainfully employed in 1991 were followed for 3 years according to first hospitalization due to varicose veins of the lower extremities. The exposure data came from a representative sample of the baseline population. Altogether 5940 people were interviewed about occupational exposure and confounding factors. RESULTS: For men working mostly in a standing position, the risk ratio for varicose veins was 1.85 [95% confidence interval (95% CI) 1.33-2.36] in a comparison with all other men. The corresponding risk ratio for women was 2.63 (95% CI 2.25-3.02). The results were adjusted for age, social group, and smoking. CONCLUSIONS: Working in a standing position is associated with subsequent hospitalization due to varicose veins for both men and women.

Job stress and cardiovascular disease: a theoretic critical review.

During the last 15 years, the research on job stress and cardiovascular diseases has been dominated by the job strain model developed by R. Karasek (1979) and colleagues (R. Karasek & T. Theorell, 1990). In this article the results of this research are briefly summarized, and the theoretical and methodological basis is discussed and criticized. A sociological interpretation of the model emphasizing theories of technological change, qualifications of the workers, and the organization of work is proposed. Furthermore, improvements with regard to measuring the job strain dimensions and to sampling the study base are suggested. Substantial improvements of the job strain research could be achieved if the principle of triangulation were used in the measurements of stressors, stress, and sickness and if occupation-based samples were used instead of large representative samples.