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.

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 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.

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.

Indoor climate, psychosocial work environment and symptoms in open-plan offices.

To study the indoor climate, the psychosocial work environment and occupants' symptoms in offices a cross-sectional questionnaire survey was made in 11 naturally and 11 mechanically ventilated office buildings. Nine of the buildings had mainly cellular offices; five of the buildings had mainly open-plan offices, whereas eight buildings had a mixture of cellular, multi-person and open-plan offices. A total of 2301 occupants, corresponding to a response rate of 72%, completed a retrospective questionnaire. The questionnaire comprised questions concerning environmental perceptions, mucous membrane irritation, skin irritation, central nervous system (CNS) symptoms and psychosocial factors. Occupants in open-plan offices are more likely to perceive thermal discomfort, poor air quality and noise and they more frequently complain about CNS and mucous membrane symptoms than occupants in multi-person and cellular offices. The association between psychosocial factors and office size was weak. Open-plan offices may not be suited for all job types. PRACTICAL IMPLICATION: Open-plan offices may be a risk factor for adverse environmental perceptions and symptoms.

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.

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.

Stress and life dissatisfaction are inversely associated with jogging and other types of physical activity in leisure time--The Copenhagen City Heart Study.

The associations between physical activity in leisure time with special focus on jogging and the level of mental stress and life dissatisfaction were studied in 12 028 randomly selected men and women aged 20-79 years. The associations were similar in men and women; thus, results are given for pooled data. The odds ratios (ORs) are presented as adjusted for sex, age, body mass index, smoking, alcohol consumption, education and income. With increasing physical activity in leisure time, there was a decrease in high level of stress, between sedentary persons and joggers, OR=0.30 (95% confidence interval (CI) from 0.16 to 0.56). With increasing physical activity there was also a decrease in life dissatisfaction, between sedentary persons and joggers, OR=0.30 (95% CI from 0.18 to 0.52). Although there was a dose-response effect between physical activity and psychosocial well-being the most pronounced difference with regard to the level of stress and dissatisfaction was seen between the group with low and the group with moderate physical activity, e.g., 2-4 h of walking per week. In conclusion, we recommend that increased well-being should be a key argument in future campaigns for increased leisure-time physical activity.

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.

Work schedules and fatigue: a prospective cohort study.

AIMS: (1) To describe the prevalence of fatigue among employees in different work schedules (day work, three-shift, five-shift, and irregular shift work); (2) to investigate whether different work schedules are related to increasing fatigue over time, while taking into account job title and job characteristics; and (3) to study fatigue among shift workers changing to day work. METHODS: Data from nine consecutive four-monthly self administered questionnaires from the Maastricht Cohort Study on Fatigue at work (n = 12 095) were used with 32 months of follow up. Day and shift workers were matched on job title. RESULTS: The prevalence of fatigue was 18.1% in day workers, 28.6% in three-shift, 23.7% in five-shift, and 19.1% in irregular shift workers. For three-shift and five-shift workers substantial higher fatigue levels were observed compared to day workers at baseline measurement. In the course of fatigue over the 32 months of follow up there were only small and insignificant differences between employees in different work schedules. However, among employees fatigued at baseline, fatigue levels decreased faster over time among five-shift workers compared to fatigued day workers. Shift workers changing to day work reported substantially higher fatigue levels prior to change, compared to those remaining in shift work. CONCLUSIONS: Substantial differences in fatigue existed between day and shift workers. However, as no considerable differences in the course of fatigue were found, these differences have probably developed within a limited time span after starting in a shift work job. Further, evidence was found that fatigue could be an important reason for quitting shift work and moving to day work. Finally, in the relation between work schedules and fatigue, perceived job characteristics might play an important role.

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.

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.

Workplace intervention studies.

The author reviews and discusses several intervention studies with implications for CVD or CV risk. The studies address chemical exposures. work schedules and working hours, and psychosocial factors at work. Effective strategies for prevention of CVD at the workplace are based on intervention research and integrate prevention at different levels.

Relation between job strain and myocardial infarction: a case-control study.

OBJECTIVES: To study the influence of different job related and socioeconomic factors for development of myocardial infarction (MI). METHOD: The study was a case-control study of 76 male wage earners who had been admitted to hospital with MI. As a control group 176 male wage earners not admitted to hospital who were residents of the same county were used. Both groups were interviewed with an extensive questionnaire on job related conditions. Several indices on job related psychosocial factors were established in accordance with Karasek's job strain model as well as the extension of the model, the isostrain model. RESULTS: The most significant findings were consistent with Karasek's job strain model in that mean with a high degree of demand combined with a low degree of control at work had a significantly increased odds ratio (OR) 95% confidence interval (95% CI) of 2.1 (1.2 to 3.8) for MI after adjustment for age compared with men with a low degree of demand and a high degree of control at work. Further adjustment for smoking, socioeconomic status, employment sector, job category, and social network did not affect the OR substantially (OR 2.3 (1.2 to 4.4)). Other factors significantly associated to MI were job category (blue collar workers v white collar workers, OR 2.8 (1.6 to 5.8)), and employment sector (private v public, OR 3.1 (1.8 to 6.1)). CONCLUSIONS: Thus, the study confirmed the job strain model as well as the well known association between socioeconomic status and risk of MI, whereas the finding of an increased risk among employees in the private sector has not previously been described.

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.

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.

[Self-rated health as a predictor of ischemic heart disease development]. / Selvvurderet helbred som praediktor for udvikling af iskaemisk hjertesygdom.

The study objective was to analyse the association between self-rated health and the incidence of fatal and non-fatal coronary heart disease in a Danish cohort followed up over 16 years. The study included 1052 men and women born in 1936. During the 16 years' follow-up 50 cases of coronary heart disease were registered either with the Danish register of deaths or the register of hospital admissions. Univariate analysis showed the following relative risks of coronary heart disease 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 coronary 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. Self-rated health was an independent predictor of coronary heart disease in this recent cohort. If confirmed, the association between self-rated health and coronary heart disease may lead to new insights into psychosocial processes leading to this disease.

Job strain and cardiovascular risk factors among members of the Danish parliament.

Sudden cardiovascular events among well-known politicians attract much attention--from the mass media and from the public. No previous studies have assessed the job strain profile and level of known cardiovascular risk factors among parliamentary politicians. The study was carried out within the frameworks of the Copenhagen City Heart Study. Some 102 members of the Danish parliament (70 men and 32 women) agreed to participate, giving a response rate of 55%. Three sex- and age-matched participants were drawn for each politician from the Copenhagen City Heart Study. In addition to the completion of large questionnaires on health and working conditions, all participants had a thorough examination, including measurements of height and weight and blood pressure and the drawing of a venous blood sample for the determination of serum lipids, ApolipoproteinA1 and ApolipoproteinB and fibrinogen. Job strain factors and established cardiovascular risk factors were the main outcome factors. Politicians reported much higher job demands, but also much more influence on their job than others. Politicians smoked less, consumed more wine, had higher levels of ApolipoproteinA1, and were taller. With respect to other major cardiovascular risk factors, serum lipids, blood pressure and physical activity, there was no difference between politicians and controls. Politicians had greater job demands, but also more control over their job than others, indicating that the job strain phenomenon should not increase their risk of cardiovascular disease. Other cardiovascular risk factors, job related or conventional, which were unevenly distributed between politicians and controls all favoured politicians. In conclusion, politicians had a more beneficial cardiovascular risk factor profile than a matched random sample from a comparable background population.