Undervalued essential work and lacking health literacy as determinants of COVID-19 infection risks: a qualitative interview study among foreign-born workers in Sweden

OBJECTIVES

To investigate work and living conditions as determinants of COVID-19 infection risks in foreign-born workers in non-healthcare occupations.

DESIGN

Data were collected according to a qualitative design, using semistructured interviews. Verbatim transcripts of these interviews were analysed according to systematic text condensation.

PARTICIPANTS

We recruited foreign-born workers (n=15) and union representatives (n=6) among taxi drivers, bus and tram drivers, pizza bakers, cleaners and property caretakers, all indicated as risk occupations during COVID-19 in Sweden.

RESULTS

Four overarching themes were found: 'virus exposure at work', 'aspects of low status and undervalued work', 'lack of access to information' and 'foreign-born persons' position'. Virus exposure was frequent due to many social interactions over a workday, out of which several were physically close, sometimes to the point of touching. The respondents fulfilled important societal functions, but their work was undervalued due to low job status, and they had little influence on improving safety at work. Lack of health literacy limited foreign-born workers to access information about COVID-19 infection risks and protection, since most information from health organisations and employers was only available in Swedish and not adapted to their living conditions or disseminated through unknown channels. Instead, many turned to personal contacts or social media, through which a lot of misinformation was spread. Foreign-born persons were also subjected to exploitation since a Swedish residency permit could depend on maintaining employment, making it almost impossible to make demands for improved safety at work.

CONCLUSIONS

Structural factors and a lack of adapted information manifested themselves as fewer possibilities for protection against COVID-19. In a globalised world, new widespread diseases are likely to occur, and more knowledge is needed to protect all workers equally. Our results are transferable to similar contexts and bring forth aspects that can be tried in quantitative studies or public health interventions.Cite Now.

Occupational noise exposure, noise annoyance, hearing-related symptoms, and emotional exhaustion - a participatory-based intervention study in preschool and obstetrics care

A participatory-based intervention was performed in Sweden, aimed at improving the sound environment in one preschool (n = 20) and one obstetric ward (n = 50), with two controls each (n = 28, n = 66). Measured sound levels, and surveys of noise annoyance, hearing-related symptoms and emotional exhaustion were collected before, and three and nine months after the interventions, comparing intervention and control groups over time. The results of this first implementation in a limited number of workplaces showed significantly worsening of hyperacusis, sound-induced auditory fatigue, emotional exhaustion and increased sound levels in the preschool, and worsening of noise annoyance in both intervention groups. Increased risk awareness, limited implementation support and lack of psychosocial interventions may explain the worsening in outcomes, as might the worse baseline in the intervention groups. The complexity of the demands in human-service workplaces calls for further intervention studies.

Psychosocial work conditions and prediabetes risks: a cross-sectional study in middle-aged men and women

Prediabetes is a condition between diabetes and normoglycemia, and is a state of major health concern, as a large proportion of people with prediabetes are likely to develop diabetes which is associated with high mortality and morbidity. The purpose of this study was to investigate whether adverse psychosocial work conditions, based on the Job Demand-Control-social support model, increases risk for early dysregulated glucose metabolism in 50-64-year-old men and women. Job conditions were measured with the Swedish Demand-Control-Support questionnaire. Impaired glucose metabolism was assessed by an oral glucose tolerance test. Differences between groups were analyzed with Chi-square test and one-way ANOVA with Bonferroni post-hoc test. Odds ratios (OR) and 95% confidence intervals (95% CI) between Job Demand-control-support and prediabetes outcome were calculated with multiple logistic regression. Results from an adjusted logistic regression model showed that in men and woman separately, an active work situation (high demands-high control) was associated with significantly lower prediabetes risk (OR 0.657, 95% CI 0.513-0.842). This finding is consistent through all logistic regression models with different levels of adjustments. Further, the current study does not lend support for the hypothesis that work conditions characterized by high demands-low control were associated with dysregulated glucose metabolism in men nor women despite accumulation of many life-style related risk factors in the high strain group. In conclusion, we could show that men and women assessing their work conditions as active, had lower risk for prediabetes.

COVID-19 in people aged 18-64 in Sweden in the first year of the pandemic: Key factors for severe disease and death

Background

Studies on risk factors for severe COVID-19 in people of working age have generally not included non-working persons or established population attributable fractions (PAFs) for occupational and other factors.

Objectives

We describe the effect of job-related, sociodemographic, and other exposures on the incidence, relative risks and PAFs of severe COVID-19 in individuals aged 18-64.

Methods

We conducted a registry-based study in Swedish citizens aged 18-64 from 1 January 2020 to 1 February 2021 with respect to COVID-19-related hospitalizations and death.

Results

Of 6,205,459 persons, 272,043 (7.5%) were registered as infected, 3399 (0.05%) needed intensive care, and 620 (0.01%) died, with an estimated case fatality rate of 0.06% over the last 4-month period when testing was adequate. Non-Nordic origin was associated with a RR for need of intensive care of 3·13, 95%CI 2·91-3·36, and a PAF of 32·2% after adjustment for age, sex, work, region and comorbidities. In a second model with occupation as main exposure, and adjusted for age, sex, region, comorbidities and origin, essential workers had an RR of 1·51, 95%CI, 1·35-1·6, blue-collar workers 1·18, 95%CI 1·06-1·31, school staff 1·21, 95%CI 1·01-1·46, and health and social care workers 1·89, 95%CI 1·67-2·135) compared with people able to work from home, with altogether about 13% of the PAF associated with these occupations. Essential workers and blue-collar workers, but no other job categories had higher risk of death, adjusted RRs of 1·79, 95%CI 1·34-2·38 and 1·37, 95%CI 1·04-1·81, with adjusted PAFs of altogether 9%.

Conclusion

Among people of working age in Sweden, overall mortality and case fatality were low. Occupations that require physical presence at work were associated with elevated risk of needing intensive care for COVID-19, with 14% cases attributable to this factor, and 9% of deaths.

Severe COVID-19 in people 55 and older during the first year of the pandemic in Sweden

BACKGROUND

Exposure to many contacts is the main risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, while risk of serious disease and death is chiefly determined by old age and comorbidities. Relative and population-attributable fractions (PAFs) of multiple medical and social exposures for COVID-19 outcomes have not been evaluated among older adults.

OBJECTIVES

We describe the effect of multiple exposures on the odds of testing positive for the virus and of severe disease (hospital care or death) and PAFs in Swedish citizens aged 55 years and above.

METHODS

We used national registers to follow all citizens aged 55 years and above with respect to (1) testing positive, (2) hospitalization, and (3) death between 31 January 2020 and 1 February 2021.

RESULTS

Of 3,410,241 persons, 156,017 (4.6%, mean age 68.3 years) tested positive for SARS-CoV-2, while 35,999 (1.1%, mean age 76.7 years) were hospitalized or died (12,384 deaths, 0.4%, mean age 84.0 years). Among the total cohort, the proportion living without home care or long-term care was 98.8% among persons aged 55-64 and 22.1% of those aged 95 and above. After multiple adjustment, home care and long-term care were associated with odds ratios of 7.9 (95% confidence interval [CI] 6.8-9.1) and 22.5 (95% CI 19.6-25.7) for mortality, with PAFs of 21.9% (95% CI 20.9-22.9) and 33.3% (95% CI 32.4-34.3), respectively.

CONCLUSION

Among Swedish residents aged 55 years and above, those with home care or long-term care had markedly increased risk for COVID-19 death during the first year of the pandemic, with over 50% of deaths attributable to these factors.

Psychosocial job stressors and risk of suicidal behavior - an observational study among Swedish men

OBJECTIVE

This study aimed to explore the relationship between psychosocial job stressors and suicidal behavior (fatal and non-fatal) among Swedish men while controlling for potential confounders.

METHODS

Population-based Swedish longitudinal cohort study of male conscripts without previous self-harm (N=1 483 310) enlisting 1968-2002. Conscription examinations included measures of IQ, stress resilience and psychiatric diagnoses. Job demand-control (JDC) exposure was assessed using the Swedish Job Exposure Matrix linked to specific occupations. Suicidal behavior among men aged 30-64 was identified in the National Hospital Register (non-fatal self-harm) and Swedish Cause of Death Register (suicide) during follow-up 2002-2014. Cox regression models were used to estimate associations between JDC category and suicidal behavior.

RESULTS

In fully adjusted models, passive jobs (low demand-low control) showed the highest risk of suicidal behavior [hazard ratio (HR) 1.33, 95% confidence interval (CI) 1.25-1.43] compared to those with low strain (low demand-high control), followed by high strain (high demand-low control) (HR 1.12, 95% Cl 1.03-1.22). A lower risk of suicidal behavior was found in the active category, where levels of both demand and control are high (HR 0.64, 95% Cl 0.60-0.70). Separate analyses for suicide as outcome revealed a lower risk of suicide in persons with active jobs (high demands-high control). The passive category showed a higher risk for suicide, but the association did not remain after adjustment for stress resilience and IQ.

CONCLUSIONS

These results show that psychosocial job stressors among men are associated with risk for suicidal behavior. Improving job control has the potential to decrease suicidal behavior for this group.

Nurses’ and preschool teachers’ experiences of taking part in a participatory intervention project in communication-intense working environments

BACKGROUND: Noise is a common workplace problem that can affect health and performance. High sound levels have been found in sectors that largely has been overlooked in noise research such as health care and education. In these communication-intense environments the work requires speech communication, thus making it difficult to wear hearing protection. OBJECTIVE: To explore nurses’ and preschool teachers’ experiences of taking part in a participatory intervention project aiming to improve the sound environment and the psychosocial work environment. METHODS: One preschool and one obstetrics ward took part in the study, and a qualitative design was used to evaluate the experience of the participatory intervention approach. RESULTS: Five main themes were found in the analysis: Awareness, Taking control of the sound environment, Influence of the building and interior design, Circumstances influencing the intervention process and Motivation to maintain change. CONCLUSIONS: Despite demanding working situations and lack of financial resources, preschool and obstetrics staff described being creative in planning and implementing several different solutions to improve the sound environment at their workplaces, while interventions specifically improving the psychosocial work environment were fewer. Hence, our study suggest that a participatory intervention approach may facilitate participation and motivation, but resources and support are needed for a comprehensive and effective implementation.

Psychosocial job conditions and biomarkers of cardiovascular disease: A cross-sectional study in the Swedish CArdioPulmonary bioImage Study (SCAPIS)

AIMS

The aim of this study was to investigate associations between psychosocial work exposure and the presence of biological and imaging biomarkers of cardiovascular disease.

METHODS

This cross-sectional study was conducted in a sub-cohort of the Swedish CArdioPulmonary bioImage Study (SCAPIS). Psychosocial exposure was evaluated with the job demand-control model, and analysed according to the standard categorization: high strain, active, passive and low strain (reference). Biomarkers (blood pressure, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, coronary artery calcification (CAC) and metabolic syndrome) were measured, or derived through measurements, from clinical examinations. Gender-specific prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated with regression models and adjusted for age, education, smoking, physical activity, general life stress and body mass index (BMI).

RESULTS

The analyses included 3882 participants (52.5% women). High strain (high demands-low control) was linked to increased PR for low HDL cholesterol in women, adjusted for all covariates (PR 1.76; 95% CI 1.25-2.48). High strain was also related to moderately increased PR for metabolic syndrome in men, after adjustments for all covariates except BMI (PR 1.25; 95% CI 1.02-1.52). In addition, passive work (low demands-low control) was associated with diastolic hypertension in women (fully adjusted: PR 1.29; 95% CI 1.05-1.59). All relationships between psychosocial factors and LDL cholesterol or CAC (both genders), or hypertension (men), were non-significant.

CONCLUSIONS

Poor psychosocial job conditions was associated with the presence of low HDL cholesterol and diastolic hypertension in women, and metabolic syndrome in men. These findings contribute to the knowledge of potential pathways between stressful work and coronary heart disease.

Psychosocial job exposure and risk of coronary artery calcification

Purpose

The aim was to examine potential associations between psychosocial job exposures, evaluated with the Job Demand-Control-model, and presence of coronary artery calcium.

Methods

We performed a cross-sectional study using the Swedish CArdioPulmonary bioImage Study,(SCAPIS)pilot study. Coronary artery calcium was assessed through computed tomography of the coronary arteries and with coronary artery scoring, CACS. Main outcome was CACS ≥100 compared to CACS 0. Job demand and control was analysed according to the standard categorization of the two variables into: high strain, active, passive and low strain (reference). Associations between these variables and CACS were calculated with prevalence ratios (PR) using Cox regression with robust variance, 95% confidence intervals (CI) and adjusted for age, smoking, education, socioeconomic area and metabolic syndrome.

Results

In total 777 participants were used in our analyses, for which 20% of the men and 5% of the women had CACS ≥100, respectively. The PR of having CACS ≥100 was non-significantly elevated for men in high strain jobs 1.54 (95% CI 0.88–2.69) and in active jobs 1.67 (95% CI 0.92–3.06), adjusted for covariates. For women there was no association between exposure to high strain and having CACS ≥100 PR 1.02 (95% CI 0.24–4.31). Among women reporting passive job, the PR was non-significantly elevated, 2.40 (95% CI 0.83–6.92), adjusted for covariates.

Conclusion

The statistical power of the study was limited, but our results suggests the possibility that exposure to a high strain or an active job situation may increase the risk of CACS in men, while in women, it may rather be exposure to passive job.

Industry mobility and disability benefits in heavy manual jobs: A cohort study of Swedish construction workers

Objectives:

This study aimed to investigate whether change from the construction industry to work in other industries at age 45–55 years lowered risks of disability benefits (DB) later in life (60–64 years of age). We hypothesized that risks would be lowered the most among those changing from the heaviest occupations.

Methods:

The study included men employed in the construction industry during 1971–1993. We selected workers from the largest occupational groups in heavy (concrete workers and painters) and less heavy (drivers, electricians and foremen) occupations. The occurrence of DB in 1990–2015 was retrieved from national registers. Regression analyses were used to calculate relative risks (RR) of DB at 60–64 years, comparing those working in other industries to those still in the construction industry at the age of 45, 50 and 55 years.

Results:

Mobility away from the construction industry was related to lowered DB risks at 60–64 years in all selected occupations. Effects were most pronounced among those who, at 55 years of age, worked in an industry other than construction, with significantly reduced RR for DB among concrete workers [RR 0.63, 95% confidence interval (CI) 0.51–0.77], electricians (RR 0.61, 95% CI 0.47–0.77) and foremen (RR 0.78, 95% 0.63–0.96).

Conclusions:

Risks for DB at 60–64 years of age were reduced among those who changed from construction work to other industries. Notable reductions were observed among workers originating from both heavy and less heavy occupations, and future studies should explore other factors, in addition to heavy workload, as motivators for leaving the construction industry.

Cardiovascular mortality in a Swedish cohort of female industrial workers exposed to noise and shift work

PURPOSE

The aim was to study mortality due to cardiovascular disease as well as total mortality, among female industrial workers, and the association to occupational noise and shift work.

METHODS

Women from cohorts of soft tissue paper mills (N = 3013) and pulp and paper mills (N = 1483) were merged into one cohort. Job exposure matrices were developed and used for classification of shift work and noise exposure. Every year was classified as shift work excluding nights or shift work including nights. Noise was classified into seven 5 dB(A) bins from < 75 to ≥ 100 dB(A). Mortality from cardiovascular diseases and total mortality during 1956-2013 was calculated as a standardized mortality ratio (SMR) with 95% confidence interval (CI) using the female general population as a reference.

RESULTS

Fatal myocardial infarctions (N = 144) were increased in the total cohort, SMR 1.20 (95% CI 1.01-1.41) but not total mortality. The SMR for myocardial infarction for women exposed to noise ≥ 90 dB(A) for > 10 years was 1.41 (95% CI 1.02-1.89) and for those exposed to night shifts > 10 years, 1.33 (95% CI 0.91-1.89). Shift workers without nights ≤ 65 years, with noise exposure ≥ 90 dB(A), had SMR 2.41 (95% CI 1.20-4.31) from myocardial infarction. There was no increased mortality from cerebrovascular disease.

CONCLUSIONS

Female paper mill workers had an increased mortality from acute myocardial infarction, especially before retirement age, when exposed to noise ≥ 90 dB(A) and with long-time employment. Exposure to shift work and noise usually occurred concurrently.

Gendered lived experiences of marriage and family following exposure to chemical warfare agents: content analysis of qualitative interviews with survivors in Halabja, Kurdistan-Iraq

OBJECTIVE

To study gendered experiences of the long-term effects of a chemical warfare agent (CWA; sulfur mustard).

DESIGN

Qualitative face-to-face semi-structured in-depth interview study using content analysis approach with thematic analysis and anthropological inquiries.

SETTING

The city of Halabja in the Kurdistan Region of Iraq.

PARTICIPANTS

Survivors of CWA (n=16, female:male 10:6, mean age 45.5 years (range 34 to 67)) with lung damage diagnosis and with a range of sociodemographic variables.

RESULTS

Latent content was expressed as: To get or not to get married? Two categories-social abandonment and uncertain marriage-emerged as expressions of the manifest content. The majority of the participants showed uncertainty as a central concern that affects all decision-making in their private and social life. Uncertainty over marriage and family were huge, corresponding to their fear of giving birth to children with congenital birth defects. Exposure to CWAs was conceptualised in terms of stigmatised illnesses, and consequently resulted in loneliness and social isolation, leading to negative impacts on other aspects of professional and social life. The results demonstrated a gendered pattern: CWA-exposed women were more affected psychosocially than CWA-exposed men. More CWA-exposed women were unemployed, divorced or single, or lived under vulnerable circumstances compared with men.

CONCLUSION

Survivors of CWA exposure have developed a sense of gendered uncertainty around getting married and building a family. Sulfur mustard-exposed women, in particular, long to be desired in the community as they face social exclusion. Survivors should be provided evidence-based consultancy to optimise their decision-making around marriage and other social and family challenges.

Phenotypic features of vascular calcification in chronic kidney disease

BACKGROUND

Patients with chronic kidney disease stage 5 (CKD5) are predisposed to vascular calcification (VC), but the combined effect of factors associated with VC was sparsely investigated. We applied the relaxed linear separability (RLS) feature selection model to identify features that concomitantly associate with VC in CKD5 patients.

METHODS

Epigastric arteries collected during surgery from living donor kidney transplant recipients were examined to score the histological extent of medial VC. Sixty-two phenotypic features in 152 patients were entered into RLS model to differentiate between no-minimal VC (n = 93; score 0-1) and moderate-extensive VC (n = 59; score 2-3). The subset of features associated with VC was selected on the basis of cross-validation procedure. The strength of association of the selected features with VC was expressed by the absolute value of 'RLS factor'.

RESULTS

Among 62 features, a subset of 17 features provided optimal prediction of VC with 89% of patients correctly classified into their groups. The 17 features included traditional risk factors (diabetes, age, cholesterol, BMI and male sex) and markers of bone metabolism, endothelial function, metabolites, serum antibodies and mitochondrial-derived peptide. Positive RLS factors range from 1.26 to 4.05 indicating features associated with increased risk of VC, and negative RLS factors range from -0.95 to -1.83 indicating features associated with reduced risk of VC.

CONCLUSION

The RLS model identified 17 features including novel biomarkers and traditional risk factors that together concomitantly associated with medial VC. These results may inform further investigations of factors promoting VC in CKD5 patients.

Mortality in persons with disability pension due to common mental disorders: A cohort study of Swedish construction workers

Aims: This study investigated mortality in disability pensions due to common mental disorder, and variation over time after first receiving disability pension. Methods: Objectives were explored in 301,863 construction workers (97.2% men) recruited through healthcare examinations from 1971-1993. By linking with the Swedish National Insurance Agency registers, disability pensions until 2014 were identified. Common mental disorder was defined as disability pension diagnosis due to anxiety, stress-related disorders or moderate depression. Mortality was calculated in all-psychiatric diagnosis and diagnostic sub-groups, and compared to persons without disability pensions, using Poisson regression. Additional analyses were stratified by age at follow-up. Results: In total 6030 subjects received disability pensions based on psychiatric diagnoses, and 2624 constituted common mental disorder. Analyses in an all-psychiatric diagnosis displayed increased mortality risks in men (relative risk 3.6; 95% confidence interval 3.3-3.9) and women (relative risk 2.1; 95% confidence interval 1.6-2.6). Common mental disorder was associated with mortality, especially in men (relative risk 2.5; 95% confidence interval 2.2-2.8). Increased relative risks in alcohol and substance abuse were also observed. Results in analyses stratified by age at follow-up displayed persistent high relative risks for mortality in older ages (75-89 years) in men in all-psychiatric disability pensions diagnosis (relative risk 2.8; 95% confidence interval 2.1-3.7) and common mental disorder diagnosis (relative risk 2.6; 95% confidence interval 1.8-3.6), compared to men without disability pensions. Similar results were found in women, but few cases lowered the precision of estimates. Conclusions: This study shows that disability pension based on common mental disorders, often regarded as a 'lighter' psychiatric diagnosis, is a risk for early mortality in construction workers, even several years after first receiving disability pension.

Working in preschool increases the risk of hearing-related symptoms: a cohort study among Swedish women

PURPOSE

To assess whether working in preschools increases the risk of hearing-related symptoms and whether age, occupational noise, and stressful working conditions affect the risk.

METHODS

Questionnaire data on hearing-related symptoms were analysed in women aged 24-65 (4718 preschool teachers, and 4122 randomly selected general population controls). Prevalence and risk ratio (RR) of self-reported hearing loss, tinnitus, difficulty perceiving speech, hyperacusis and sound-induced auditory fatigue were assessed by comparing the cohorts in relation to age and self-reported occupational noise and stressful working conditions (effort-reward imbalance and emotional demands). RR was calculated using log-binomial regression models adjusted for age, education, income, smoking, hearing protection, and leisure noise. Incidence rates and incidence rate ratios (IRR) were calculated for retrospectively reported onset of all symptoms except sound-induced auditory fatigue.

RESULTS

Compared to the controls, preschool teachers had overall more than twofold RR of sound-induced auditory fatigue (RR 2.4, 95% confidence interval 2.2-2.5) and hyperacusis (RR 2.3, 2.1-2.5) and almost twofold for difficulty perceiving speech (RR 1.9, 1.7-2.0). Preschool teachers had a threefold IRR of hyperacusis (IRR 3.1, 2.8-3.4) and twofold for difficulty perceiving speech (IRR 2.4, 2.2-2.6). Significantly although slightly less increased RR and IRR were observed for hearing loss and tinnitus. RR and IRR were generally still increased for preschool teachers when stratified by age and occupational exposure to noise and stress.

CONCLUSIONS

This large cohort study showed that working as preschool teacher increases the risk of self-reported hearing-related symptoms, indicating a need of preventative measures.

Longitudinal study of occupational noise exposure and joint effects with job strain and risk for coronary heart disease and stroke in Swedish men

OBJECTIVES

The aims were to investigate whether occupational noise increased the risk for coronary heart disease (CHD) and stroke and to elucidate interactions with stressful working conditions in a cohort of Swedish men.

DESIGN

This is a prospective cohort study on CHD and stroke in Swedish men followed until death, hospital discharge or until 75 years of age, using Swedish national registers on cause of death and hospital discharges. Baseline data on occupation from 1974 to 1977 were used for classification of levels of occupational noise and job demand-control. Cox regression was used to analyse HRs for CHD and stroke.

SETTING

Swedish men born in 1915-1925.

PRIMARY AND SECONDARY OUTCOME MEASURES

CHD and stroke.

PARTICIPANTS

The participants of the study were men from the Primary Prevention Study, a random sample of 10 000 men born in 1915-1925 in Gothenburg. Subjects with CHD or stroke at baseline or were not employed were excluded. The remaining subjects with complete baseline data on occupation, weight, height, hypertension, diabetes, serum cholesterol and smoking constituted the study sample (5753 men).

RESULTS

There was an increased risk for CHD in relation to noise levels 75-85 dB(A) and >85 dB(A) compared with <75 dB(A) (HR 1.15, 95% CI 1.01 to 1.31, and HR 1.27, 95% CI 0.99 to 1.63, respectively). Exposure to noise peaks also increased the risk for CHD (HR 1.19, 95% CI 1.03 to 1.38). Among those with high strain (high demands and low control) combined with noise >75 dB(A), the risk for CHD further increased (HR 1.80, 95% CI 1.19 to 2.73). There was no significantly increased risk for stroke in any noise category.

CONCLUSIONS

Exposure to occupational noise was associated with an increased risk for CHD and the risk further increased among those with concomitant exposure to high strain. None of the analysed variables were related to increased risk for stroke.

Cause-specific mortality in Swedish males diagnosed with non-psychotic mental disorders in late adolescence: a prospective population-based study

BACKGROUND

While risk of premature death is most pronounced among persons with severe mental illness, also milder conditions are associated with increased all-cause mortality. We examined non-psychotic mental (NPM) disorders and specific causes of natural death in a cohort of late adolescent men followed for up to 46 years.

METHODS

Prospective cohort study of Swedish males (n=1 784 626) who took part in structured conscription interviews 1968-2005. 74 525 men were diagnosed with NPM disorders at or prior to conscription. Median follow-up time was 26 years. HRs for cause-specific mortality were calculated using Cox proportional hazards models.

RESULTS

Risks in fully adjusted models were particularly elevated for death by infectious diseases (depressive and neurotic/adjustment disorders (HR 2.07; 95% CI 1.60 to 2.67), personality disorders (HR 2.90; 95% CI 1.96 to 4.28) and alcohol-related and other substance use disorders (HR 9.02; 95% CI 6.63 to 12.27)) as well as by gastrointestinal causes (depressive and neurotic/adjustment disorders (HR 1.64; 95% CI 1.42 to 1.89), personality disorders (HR 2.77; 95% CI 2.27 to 3.38) and alcohol-related/substance use disorders (HR 4.41; 95% CI 3.59 to 5.42)).

CONCLUSION

Young men diagnosed with NPM disorders had a long-term increased mortality risk, in particular due to infectious and gastrointestinal conditions. These findings highlight the importance of early preventive actions for adolescents with mental illness.

Cardiovascular fitness in late adolescent males and later risk of serious non-affective mental disorders: a prospective, population-based study

BACKGROUND

Cardiovascular fitness in late adolescence is associated with future risk of depression. Relationships with other mental disorders need elucidation. This study investigated whether fitness in late adolescence is associated with future risk of serious non-affective mental disorders. Further, we examined how having an affected brother might impact the relationship.

METHOD

Prospective, population-based cohort study of 1 109 786 Swedish male conscripts with no history of mental illness, who underwent conscription examinations at age 18 between 1968 and 2005. Cardiovascular fitness was objectively measured at conscription using a bicycle ergometer test. During the follow-up (3-42 years), incident cases of serious non-affective mental disorders (schizophrenia and schizophrenia-like disorders, other psychotic disorders and neurotic, stress-related and somatoform disorders) were identified through the Swedish National Hospital Discharge Register. Cox proportional hazards models were used to assess the influence of cardiovascular fitness at conscription and risk of serious non-affective mental disorders later in life.

RESULTS

Low fitness was associated with increased risk for schizophrenia and schizophrenia-like disorders [hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.29-1.61], other psychotic disorders (HR 1.41, 95% CI 1.27-1.56), and neurotic or stress-related and somatoform disorders (HR 1.45, 95% CI 1.37-1.54). Relationships persisted in models that included illness in brothers.

CONCLUSIONS

Lower fitness in late adolescent males is associated with increased risk of serious non-affective mental disorders in adulthood.

Impact of changes in welfare legislation on the incidence of disability pension. A cohort study of construction workers

Aims: Study objectives were to investigate how changes in social insurance legislation influenced the incidence of disability pension. Methods: The study included 295,636 male construction workers who attended health examinations between 1971 and 1993, aged 20-60 years and without previous disability pension. Via the Swedish National Insurance Agency national register we identified 66,046 subjects who were granted disability pension up until 2010. The incidence rates were calculated and stratified according to age and diagnosis. Results: The incidence rate of disability pension was fairly stable until the 1990s when large variations occurred, followed by a strong decreasing trend from the early 2000s to 2010. Trends in incidence rates, stratified by age and diagnosis, showed a consistent decrease in cardiovascular disease for all age groups. In subjects aged 30-49 years there was a high peak around 2003 for musculoskeletal diseases and psychiatric diseases. For the age group 50-59 years, musculoskeletal diagnosis, the most common cause of disability pension, had a sharp peak around 1993 and then a decreasing trend. In the 60-64 age group, the incidence rate for psychiatric diagnosis was stable, while incidence rates for musculoskeletal diagnosis varied during the 1990s. Conclusions: There are considerable variations in the incidence rate of disability pension over time, with different patterns depending on age and diagnosis. Changes in social insurance legislation, as well as in administration processes, seem to influence the variation.

Future marginalisation and mortality in young Swedish men with non-psychotic psychiatric disorders and the resilience effect of cognitive ability: a prospective, population-based study

OBJECTIVE

Large-scale studies examining future trajectories of marginalisation and health in adolescents with mental illness are scarce. The aim of this study was to examine if non-psychotic psychiatric disorders (NPDs) were associated with future indicators of marginalisation and mortality. We also aimed to determine whether these associations might be mediated by education level and attenuated by high cognitive ability.

DESIGN

This is a prospective cohort study with baseline data from the Swedish Conscription register.

SETTING

The study was carried out in Sweden from 1969 to 2005.

PARTICIPANTS

All of the participants were 18-year-old men at mandatory conscription in Sweden between 1969 and 2005 (n=1 609 690).

MEASURES

NPDs were clinically diagnosed at conscription. Cognitive ability was measured by a standardised IQ test at conscription. National register data covered information on welfare support, long-term unemployment, disability pension (DP) and mortality over a period of 1-36 years.

RESULTS

NPD at the age of 18 years was a predictor of future welfare support, OR 3.73 (95% CI 3.65 to 3.80); long-term unemployment, OR 1.97 (95% CI 1.94 to 2.01); DP, HR 2.95 (95% CI 2.89 to 3.02); and mortality, HR 2.45 (2.33-2.52). The adjusted models suggested that these associations were not confounded by fathers' educational level, cognitive ability had only a minor attenuating effect on most associations and the mediating effect of own educational level was small.

CONCLUSIONS

The present study underlines a higher prevalence of future adversities in young men experiencing NPDs at the age of 18 years. It also indicates that higher cognitive ability may work as a potential resilience factor against future marginalisation and mortality.

Job strain and resting heart rate: a cross-sectional study in a Swedish random working sample

Background

Numerous studies have reported an association between stressing work conditions and cardiovascular disease. However, more evidence is needed, and the etiological mechanisms are unknown. Elevated resting heart rate has emerged as a possible risk factor for cardiovascular disease, but little is known about the relation to work-related stress. This study therefore investigated the association between job strain, job control, and job demands and resting heart rate.

Methods

We conducted a cross-sectional survey of randomly selected men and women in Västra Götalandsregionen, Sweden (West county of Sweden) (n = 1552). Information about job strain, job demands, job control, heart rate and covariates was collected during the period 2001–2004 as part of the INTERGENE/ADONIX research project. Six different linear regression models were used with adjustments for gender, age, BMI, smoking, education, and physical activity in the fully adjusted model. Job strain was operationalized as the log-transformed ratio of job demands over job control in the statistical analyses.

Results

No associations were seen between resting heart rate and job demands. Job strain was associated with elevated resting heart rate in the unadjusted model (linear regression coefficient 1.26, 95 % CI 0.14 to 2.38), but not in any of the extended models. Low job control was associated with elevated resting heart rate after adjustments for gender, age, BMI, and smoking (linear regression coefficient −0.18, 95 % CI −0.30 to −0.02). However, there were no significant associations in the fully adjusted model.

Conclusions

Low job control and job strain, but not job demands, were associated with elevated resting heart rate. However, the observed associations were modest and may be explained by confounding effects.

The association between job strain and atrial fibrillation in Swedish men

Objectives

The purpose of this study was to investigate whether psychosocial stress defined as high strain based on the job demand–control model increases risk for atrial fibrillation.

Methods

The present study comprised 6035 men born between 1915 and 1925 and free from previous coronary heart disease, atrial fibrillation and stroke at baseline (1974–1977). Work-related psychosocial stress was measured using a job-exposure matrix for the job demand–control model based on occupation at baseline. The participants were followed from baseline examination until death, hospital discharge or 75 years of age, using the Swedish national register on cause of death and the Swedish hospital discharge register for any registration for atrial fibrillation, resulting in the identification of 436 cases. Data were analysed with Cox regression models with atrial fibrillation as the outcome using high strain as the explanatory variable adjusted for age, smoking, body mass index, hypertension, diabetes and socioeconomic status.

Results

There was an increased risk for atrial fibrillation in relation to high strain (HR 1.32, 95% CI 1.003 to 1.75). When the four categories of the job-strain model were included and low strain was used as reference, the risk for high strain decreased (HR 1.23, 95% CI 0.84 to 1.82).

Conclusions

Exposure to occupational psychosocial stress defined as high strain may be associated with increased risk for atrial fibrillation. The observed increase in risk is small and residual confounding may also be present.

Psychosocial work environment, job mobility and gender differences in turnover behaviour: a prospective study among the Swedish general population

Background

Throughout the literature, substantial evidence supports associations between poor psychosocial work characteristics and a variety of ill-health outcomes. Yet, few reports strategies workers carry out to improve detrimental work conditions and consequently their health, such as changing jobs. The aim of this study was to examine if adverse psychosocial work exposure, as measured with the job demand-control and effort-reward imbalance models, could predict job mobility over a 5 years observation period.

Method

Participants were working men and women (n = 940; 54.3% women), aged 24–60 years from the population of Gothenburg and surrounding metropolitan area. Job demand-control and effort-reward variables were compared with independent t-tests and chi2-test in persons with and without job mobility. Multivariate logistic regression was used to analyse whether psychosocial factors could predict job mobility. All regression analyses were stratified by gender.

Results

Exposure to a combination of high demands-low control or high imbalance between effort and reward was related to increased odds of changing jobs (OR 1.63; CI 1.03-2.59 and OR 1.46; CI 1.13-1.89 respectively). When analysing men and women separately, men had a higher OR of changing jobs when exposed to either high demands-low control (OR 2.72; CI 1.24-5.98) or high effort-reward imbalance (OR 1.74; CI 1.11-2.72) compared to reference values. The only significant associations for women was slightly decreased odds for turnover in high reward jobs (OR 0.96; CI 0.92-0.99).

Conclusions

The results indicate that workers will seek to improve poor work environment by changing jobs. There were notable gender differences, where men tended to engage in job mobility when exposed to adverse psychosocial factors, while women did not. The lack of measures for mechanisms driving job mobility was a limitation of this study, thus preventing conclusions regarding psychosocial factors as the primary source for job mobility.

A longitudinal general population-based study of job strain and risk for coronary heart disease and stroke in Swedish men

OBJECTIVES

The aim was to investigate whether psychosocial stress based on the job-demand-control (JDC) model increased the risk for coronary heart disease (CHD) and stroke.

SETTING

Swedish men.

PARTICIPANTS

The Primary Prevention Study (PPS) comprises 6070 men born between 1915 and 1925 free from previous history of CHD and stroke at baseline (1974-1977). Psychosocial workplace exposure was assessed using a job-exposure matrix (JEM) for the JDC model based on occupation at baseline. The participants were followed from baseline examination, until death, until hospital discharge or until 75 years of age, whichever occurred first, using the Swedish national register on cause of death and the Swedish hospital discharge register for non-fatal and fatal stroke and CHD events. Cox regression models were used with stroke or CHD as the outcome, using JDC model and age as explanatory variables, as well as stratified models with regard to smoking, self-reported stress, socioeconomic status, obesity, hypertension and diabetes.

PRIMARY AND SECONDARY OUTCOME MEASURES

Risk for stroke and CHD.

RESULTS

There was an increased risk (HR) for CHD in relation to high strain (HR 1.31, 95% CI 1.01 to 1.70). The risk was further increased among ever-smokers and among blue-collar workers. There was a relation between low control and increased risk for CHD (HR 1.19, 95% CI 1.06 to 1.35). There was no increased risk for stroke in any of the JDC categories.

CONCLUSIONS

Exposure to occupational psychosocial stress defined as job strain or low control increased the risk for CHD, especially among smokers and blue-collar workers. There was no increased risk for stroke in any of the JDC categories.

Six iterative reconstruction algorithms in brain CT: a phantom study on image quality at different radiation dose levels

OBJECTIVE

To evaluate the image quality produced by six different iterative reconstruction (IR) algorithms in four CT systems in the setting of brain CT, using different radiation dose levels and iterative image optimisation levels.

METHODS

An image quality phantom, supplied with a bone mimicking annulus, was examined using four CT systems from different vendors and four radiation dose levels. Acquisitions were reconstructed using conventional filtered back-projection (FBP), three levels of statistical IR and, when available, a model-based IR algorithm. The evaluated image quality parameters were CT numbers, uniformity, noise, noise-power spectra, low-contrast resolution and spatial resolution.

RESULTS

Compared with FBP, noise reduction was achieved by all six IR algorithms at all radiation dose levels, with further improvement seen at higher IR levels. Noise-power spectra revealed changes in noise distribution relative to the FBP for most statistical IR algorithms, especially the two model-based IR algorithms. Compared with FBP, variable degrees of improvements were seen in both objective and subjective low-contrast resolutions for all IR algorithms. Spatial resolution was improved with both model-based IR algorithms and one of the statistical IR algorithms.

CONCLUSION

The four statistical IR algorithms evaluated in the study all improved the general image quality compared with FBP, with improvement seen for most or all evaluated quality criteria. Further improvement was achieved with one of the model-based IR algorithms.

ADVANCES IN KNOWLEDGE

The six evaluated IR algorithms all improve the image quality in brain CT but show different strengths and weaknesses.

Serum thymidine kinase activity compared with CA 15-3 in locally advanced and metastatic breast cancer within a randomized trial

The primary objective was to estimate serum thymidine kinase 1 (TK1) activity, reflecting total body cell proliferation rate including cancer cell proliferation, in women with loco regional inoperable or metastatic breast cancer participating in a prospective and randomized study. Secondary objectives were to analyze TK1 in relation to progression-free survival (PFS), overall survival (OS), therapy response and other tumour characteristics, including CA 15-3, widely used as a standard serum marker for disease progression. TK1 and CA 15-3 were analysed in 198 serum samples collected prospectively from women included in the randomized TEX trial between December 2002 and June 2007. TK1 activity was determined by the ELISA based DiviTum™ assay, and CA 15-3 analyses was generated with the electrochemiluminescence immunoassay Cobas Elecsys CA 15-3 II. High pre-treatment TK1 activity predicted shorter PFS (10 vs. 15 months p = 0.02) and OS (21 vs. 38 months, p < 0.0001), respectively. After adjustment for age, metastatic site and study treatment TK1 showed a trend as predictor of PFS (p = 0.059) and was an independent prognostic factor for OS, (HR 1.81, 95 % confidence interval (CI) 1.26-2.61, p = 0.001). There was a trend of shortened OS for women with high CA 15-3 (p = 0.054) in univariate analysis, but not after adjustment for the above mentioned covariates. Both TK1 (p = 0.0011) and CA 15-3 (p = 0.0004) predicted response to treatment. There were statistically different distributions of TK1 and CA 15-3 in relation to the site of metastases. TK1 activity measured by DiviTum™ predicted therapy response, PFS and OS in loco regional inoperable or disseminated breast cancer. These results suggest that this factor is a useful serum marker. In the present material, a prognostic value of CA 15-3 could not be proven.

A cross-sectional study of the relationship between job demand-control, effort-reward imbalance and cardiovascular heart disease risk factors

BACKGROUND

This cross-sectional study explored relationships between psychosocial work environment, captured by job demand-control (JDC) and effort-reward imbalance (ERI), and seven cardiovascular heart disease (CHD) risk factors in a general population.

METHOD

The sampled consists of randomly-selected men and women from Gothenburg, Sweden and the city's surrounding metropolitan areas. Associations between psychosocial variables and biomarkers were analysed with multiple linear regression adjusted for age, smoking, education and occupational status.

RESULTS

The study included 638 men and 668 women aged 24-71. Analysis between JDC and CHD risk factors illustrated that, for men, JDC was associated with impaired scores in several biomarkers, especially among those in high strain jobs. For women, there were no relationships between JDC and biomarkers. In the analysis of links between ERI and CHD risk factors, most associations tested null. The only findings were raised triglycerides and BMI among men in the fourth quartile of the ERI-ratio distribution, and lowered LDL-cholesterol for women. An complementary ERI analysis, combining high/low effort and reward into categories, illustrated lowered triglycerides and elevated HDL-cholesterol values among women reporting high efforts and high rewards, compared to women experiencing low effort and high reward.

CONCLUSIONS

There were some associations between psychosocial stressors and CHD risk factors. The cross-sectional design did not allow conclusions about causality but some results indicated gender differences regarding sensitivity to work stressors and also how the models might capture different psychosocial dimensions.

Obesity and nocturnal gastro-oesophageal reflux are related to onset of asthma and respiratory symptoms

Several studies have identified obesity as a risk factor for asthma in both children and adults. An increased prevalence of asthma in subjects with gastro-oesophageal reflux (GOR) and obstructive sleep apnoea syndrome has also been reported. The aim of this investigation was to study obesity, nocturnal GOR and snoring as independent risk factors for onset of asthma and respiratory symptoms in a Nordic population. In a 5-10 yr follow-up study of the European Community Respiratory Health Survey in Iceland, Norway, Denmark, Sweden and Estonia, a postal questionnaire was sent to previous respondents. A total of 16,191 participants responded to the questionnaire. Reported onset of asthma, wheeze and night-time symptoms as well as nocturnal GOR and habitual snoring increased in prevalence along with the increase in body mass index (BMI). After adjusting for nocturnal GOR, habitual snoring and other confounders, obesity (BMI >30) remained significantly related to the onset of asthma, wheeze and night-time symptoms. Nocturnal GOR was independently related to the onset of asthma and in addition, both nocturnal GOR and habitual snoring were independently related to onset of wheeze and night-time symptoms. This study adds evidence to an independent relationship between obesity, nocturnal gastro-oesophageal reflux and habitual snoring and the onset of asthma and respiratory symptoms in adults.

Phase II study of capecitabine in combination with paclitaxel in patients with anthracycline-pretreated advanced/metastatic breast cancer

The addition of oral capecitabine to docetaxel improves response rate, time to progression (TTP) and overall survival in anthracycline-pretreated metastatic breast cancer (MBC). This phase II study evaluates the efficacy and safety of a 21-day cycle of oral capecitabine (1000 mg m⁻² twice daily, days 1–14) plus i.v. paclitaxel (175 mg m⁻², day 1) in anthracycline-pretreated advanced/MBC. In all, 73 patients were enrolled at 13 Swedish and Spanish centres. The objective response rate was 52% (95% confidence interval (CI): 40–63%) in the intent-to-treat population, including complete responses in 11%. Disease was stabilised in a further 29%. The median time to disease progression (TTP) was 8.1 months and the median overall survival was 16.5 months. The combination was generally well tolerated with a predictable safety profile. The most common treatment-related nonhaematological adverse events were hand–foot syndrome (42%), alopecia (30%) and diarrhoea (26%). The only treatment-related Grade 3/4 adverse events occurring in >5% of patients were alopecia (22%) and hand–foot syndrome (11%). Grade 3/4 neutropenia and lymphocytopenia were reported in 12 and 14% of patients, respectively. Capecitabine plus paclitaxel is highly active with a favourable safety profile in anthracycline-pretreated MBC.

Different airway inflammatory responses in asthmatic and healthy humans exposed to diesel

Particulate matter (PM) pollution adversely affects the airways, with asthmatic subjects thought to be especially sensitive. The authors hypothesised that exposure to diesel exhaust (DE), a major source of PM, would induce airway neutrophilia in healthy subjects, and that either these responses would be exaggerated in subjects with mild allergic asthma, or DE would exacerbate pre-existent allergic airways. Healthy and mild asthmatic subjects were exposed for 2 h to ambient levels of DE (particles with a 50% cut-off aerodynamic diameter of 10 microm (PM10) 108 microg x m(-3)) and lung function and airway inflammation were assessed. Both groups showed an increase in airway resistance of similar magnitude after DE exposure. Healthy subjects developed airway inflammation 6 h after DE exposure, with airways neutrophilia and lymphocytosis together with an increase in interleukin-8 (IL-8) protein in lavage fluid, increased IL-8 messenger ribonucleic acid expression in the bronchial mucosa and upregulation of the endothelial adhesion molecules. In asthmatic subjects, DE exposure did not induce a neutrophilic response or exacerbate their pre-existing eosinophilic airway inflammation. Epithelial staining for the cytokine IL-10 was increased after DE in the asthmatic group. Differential effects on the airways of healthy subjects and asthmatics of particles with a 50% cut-off aerodynamic diameter of 10 microm at concentrations below current World Health Organisation air quality standards have been observed in this study. Further work is required to elucidate the significance of these differential responses.

Low-intensity conditioning and hematopoietic stem cell transplantation in patients with renal and colon carcinoma

We have evaluated whether allogeneic hematopoietic stem cell transplantation (HSCT) could induce an antitumor effect in patients with metastatic solid tumors. A total of 12 HLA-identical siblings and 6 HLA-A-, -B- and -DR beta 1-compatible unrelated grafts were used. Diagnoses were adenocarcinoma of kidney (n=10), colon (n=6), breast (n=1) and cholangiocarcinoma (n=1). Conditioning was fludarabine 30 mg/m(2)/day for 3 days and 2 Gy of total body irradiation. Recipients of unrelated HSCT were also given thymoglobuline and two additional days of fludarabine. The median CD34+ cell dose was 7.5 x 10(6)/kg. Immunosuppression was mycophenolate mofetil and cyclosporin. Among all, 12 patients became complete donor chimeras within a median of 28, 29 and 65 days for B, myeloid and T cells, respectively. Two patients rejected the grafts, one developed marrow aplasia and three were mixed chimeras. The probability of grades II-IV acute graft-versus-host-disease (GVHD) was 57%. Regression of all tumor metastases was seen in one patient with colon carcinoma. Another patient with colon and two with renal carcinoma had regression of lung metastases, but progression of metastases in the liver and/or bone. Necrosis of lung metastasis was found in one further patient with renal carcinoma who died of graft-versus-host-disease (GVHD). In all, 10 patients died; four of transplant-related complications, one of trauma and five of progressive disease. Thus, progression was common after allogeneic HSCT in unselected patients with advanced solid tumors. However, the regression of some metastases associated with GVHD provides suggestive evidence that the GVHD effect may occur in renal and colon adenocarcinoma using reduced intensity conditioning.

Influence of different sling materials on connective tissue metabolism in stress urinary incontinent women

The aim of this study was to investigate the influence on the paraurethral connective tissue of different sling materials used in incontinence surgery. Biopsies from the paraurethral connective tissue were obtained intraoperatively from 16 women with stress urinary incontinence; all were operated on with the TVT procedure, 6 with Mersilene as the sling material and 10 with Prolene. Biopsies from 4 continent women with uterine bleeding irregularities, matched for age and parity, served as controls. New biopsies were obtained from all women after 2 years. The biopsies were examined histologically and analyzed for collagen concentration and solubility. An obvious inflammatory reaction with a significant increase in collagen extractability by pepsin was identified in patients where Mersilene was used as the sling material. A minimal inflammatory reaction without a significant change in collagen solubility was found in the Prolene group. In the control group no inflammatory reaction was seen. Mersilene gave rise to a significant foreign-body reaction in the paraurethral connective tissue after surgery. Such a reaction was not found with Prolene.

Bioelectric impedance analysis of acute body water changes in congestive heart failure

The body water changes indicated by bioelectric impedance analysis (BIA) and body weight were studied in 12 patients admitted to hospital for acute treatment of congestive heart failure (NYHA-class II-III). BIA was performed at the time of admittance and on the third day by using a multifrequency technique, which allows simultaneous estimation of the total body water (TBW) and the extracellular fluid (ECF) and intracellular fluid (ICF) volumes. The body weight at admittance was 85+/-20 kg. Body weight correlated with the body water compartments (r - 0.9, p<0.001). From day 1 to day 3, the body weight decreased by 2.9+/-1.7 kg. BIA estimated the corresponding reductions of the physiological body fluid spaces to 3.2+/-2.4 L (TBW), 2.7+/-1.6 L (ECF) and 0.5+/-3.2 L (ICF). These results indicate that diuretic treatment for acute congestive heart failure mainly lowers the ECF volume. However, changes in body weight correlated poorly with changes in TBW, r=-0.11. We conclude that, although BIA corresponded well to the weight changes at the group level, a poor correlation in individual patients suggests that BIA is not a suitable tool to monitor the fluid balance in patients with acute congestive heart failure undergoing diuretic treatment.

Use of monozygotic twins in search for breast cancer susceptibility loci

We have used Swedish monozygotic twins concordant for breast cancer to study genetic changes associated with the development of breast cancer. Because loss of heterozygosity (LOH) at a specific genomic region may reflect the presence of a tumour suppressor gene, loss of the same allele in both of the twins concordant for breast cancer may pinpoint a tumour suppressor gene that confers a strong predisposition to breast cancer. DNA samples extracted from the matched tumour and normal tissues of nine twin pairs were analysed for allelic imbalance using a set of microsatellite markers on chromosomes 1, 13, 16 and 17, containing loci with known tumour suppressor genes. The two main regions, where more twin pairs than expected had lost the same allele, were located at 16qtel', including markers D16S393, D16S305 and D16S413, and at 17p13, distal to the p53 locus. Our results show that the monozygotic twin model can be used to suggest candidate regions of potential tumour suppressor genes, even with a limited number of twin pairs.

Loss of heterozygosity in tumour-adjacent normal tissue of breast and bladder cancer

Normal tumour-adjacent breast tissue samples from 12 breast cancer patients forming six monozygotic twin pairs were analysed for loss of heterozygosity (LOH) on chromosomes 1, 13 and 17. 7 patients showed LOH at one or more markers. Each of them had a different LOH pattern. Only one twin pair showed LOH at the same locus, but the twins had lost a different allele. Multiple (n=1-13), histologically normal samples were collected from 6 bladder cancer patients and analysed for LOH on chromosomes 3 and 9. On chromosome 9, all 6 patients analysed showed LOH in at least one sample and one marker. Four of them also showed LOH on chromosome 3. Samples surrounding different tumours of a given patient resembled each other. More heterogeneity was seen between the patients, even though they shared some similarities in LOH clustering. The results demonstrate that tumour-adjacent normal tissues already harbour genetic changes typical for tumours. These alterations can reveal the earliest changes leading to tumorigenesis.

Allelic imbalance on chromosomes 13 and 17 and mutation analysis of BRCA1 and BRCA2 genes in monozygotic twins concordant for breast cancer

To study genetic changes associated with the development of breast cancer and the extent of its hereditary predisposition, paraffin-embedded tissue samples were obtained from monozygotic twin pairs concordant for breast cancer through the linked Swedish Twin and Cancer Registries. DNA samples extracted from the matched tumour and normal tissues of nine twin pairs were analysed for allelic imbalance using a series of microsatellite markers on chromosomes 13 and 17, containing loci with known tumour suppressor genes. Multiple losses of constitutional heterozygosity (LOH), consistent with a loss of large genomic region, the whole chromosome or chromosome arm, was found in at least three pairs of twins. One double mitotic crossover was identified in one tumour sample in a pair concordant for LOH at multiple loci on both chromosomes. Recombination breakpoints were mapped to regions delineated by D13S218 and D13S263, and D13S155 and D13S279, respectively. In general, no genetic effect of losing the same allele within a twin pair was found. However, for one marker at chromosome 13 (D13S328, between the BRCA2 and the RB-1 loci) and two markers on chromosome 17 (D17S786, distal to the p53 locus, and D17S855, an intragenic BRCA1 marker) the proportion of twin pairs with the same LOH was significantly higher than expected. These regions may reflect hereditary genomic changes in our sample set. In addition, tumour DNA samples from a subset of 12 twin pairs were analysed for BRCA1 and BRCA2 mutations using exon-by-exon single-strand conformation polymorphism analysis. Two unclassified BRCA2 variants, with a putative pathogenic effect, were identified, but no pathogenic alterations were found in the BRCA1 gene.

DNA copy number losses at 1p32-pter in monozygotic twins concordant for breast cancer

To find similarities that may possibly indicate novel mutations, we performed comparative genomic hybridization (CGH) analysis following degenerate oligonucleotide primed polymerase chain reaction (PCR) for DNA obtained from unique material of breast cancer that developed in monozygotic twin-pairs. Polymerase chain reaction amplification was successful in 12 samples for 11 patients, including 3 pairs. Six samples exhibited DNA copy number changes. Gains (76%) were more frequent than losses (24%). Gains or high-level amplifications in 8q were present in all but 1 of the abnormal cases. Frequent gains were detected with a minimal common overlapping region at 5p (4 cases), at 1q25-qter (3 cases), and at 20q12-qter (2 cases). The most frequent loss, detected in half of the abnormal cases, was at 1p32-pter. One twin-pair showed similar changes in 4 chromosomal locations involving loss of 1p32-pter and gains in 1q25-qter, 5, and 8q.

Efficacy of pamidronate in breast cancer with bone metastases: a randomized, double-blind placebo-controlled multicenter study

PURPOSE

To evaluate the efficacy of pamidronate 60 mg i.v. q 4 weeks in women with advanced breast cancer with skeletal metastases.

PATIENTS AND METHODS

404 woman with skeletal metastases from breast cancer in Sweden and Norway were included in a randomized, placebo-controlled, multicenter study. Except for the study medication, other palliative treatment was chosen at the discretion of the physician. Skeletal related events, i.e. increased pain, treatment of hypercalcemia, pathologic fractures of long bones or pelvis, paralyses due to vertebral compression, palliative radiotherapy for skeletal metastases, surgery on bone and change of antitumor therapy were recorded every third month as well as a self-estimated pain-score using visual Analog Scales and analgesic consumption.

RESULTS

There was a significantly increased time to progression of pain (p < 0.01), to hypercalcemic events (p < 0.05) as well as for the cumulative number of skeletal related events (p < 0.01) in favor for the pamidronate group. No statistically significant reduction of pathologic fractures of long bones or pelvis, or pareses due to vertebral compression occurred. No statistically significant differences were found for the need of radiotherapy and surgery on bone. The pamidronate group faired better regarding performance status (p < 0.05). There was a statistically not significant lower consumption of opioid analgesics in the pamidronate group (p = 0.14).

CONCLUSION

Pamidronate 60 mg i.v. q 4 weeks reduces skeletal events and improves the quality of life in women with bone metastases from breast cancer.

Sexual function in women suffering from aortoiliac occlusive disease

OBJECTIVE

To describe the sexual function in women suffering aortoiliac occlusive disease (AIOD) and in an age-matched reference group.

PATIENTS AND METHODS

Thirty-six women suffering from AIOD were included. Twenty were investigated before vascular intervention (untreated) and 16 different women after treatment (treated). Eighteen age-matched women served as a reference group. The patients answered a questionnaire including sexual, social and medical questions and a gynaecological examination was performed.

RESULTS

Untreated patients with AIOD have a significantly impaired physical well-being compared to the other groups (p < 0.001). A negative effect of the vascular disease and its treatment on sexual life was experienced by 69% of treated compared to 40% affected among untreated (p = 0.05). Vulval sensibility was impaired in 44% of treated, 11% of untreated and 22% of reference patients. Defective anal sphincter function was found in 33% of treated, 17% of untreated and 6% in the reference group. Those differences were not statistically significant.

CONCLUSIONS

Symptomatic AIOD in women is associated with a significantly impaired physical and sexual well-being. Though limited by size and methodology, the results indicate the possibility of iatrogenic nerve damage.

Persistent airway inflammation but accommodated antioxidant and lung function responses after repeated daily exposure to nitrogen dioxide

Nitrogen dioxide (NO2) is a common indoor and outdoor air pollutant that may induce deterioration of respiratory health. In this study the effects of repeated daily exposure to NO2 on airway antioxidant status, inflammatory cell and mediator responses, and lung function were examined. Healthy nonsmoking subjects were exposed under controlled conditions to air (once) and to 2 ppm of NO2 for 4 h on four consecutive days. Lung function measurements were made before and immediately after the end of each exposure. Bronchoscopy with endobronchial biopsies, bronchial wash (BW), and bronchoalveolar lavage (BAL) was carried out 1.5 h after the air exposure and after the last exposure to NO2. Repeated NO2 exposure resulted in a decrease in neutrophil numbers in the bronchial epithelium. The BW revealed a twofold increase in content of neutrophils (p < 0.05) and a 1.5-fold increase in myeloperoxidase (MPO) (p < 0.01) indicative of both migration and activation of neutrophils in the airways. After the fourth NO2 exposure, antioxidant status of the airway fluid was unchanged. Significant decrements in FEV1 and FVC were found after the first exposure to NO2, but these attenuated with repeated exposures. Together, these data indicate that four sequential exposures to NO2 result in a persistent neutrophilic inflammation in the airways, whereas changes in pulmonary function and airway antioxidants are resolved. We conclude that NO2 is a proinflammatory air pollutant under conditions of repeated exposure.

The effects of regular inhaled formoterol, budesonide, and placebo on mucosal inflammation and clinical indices in mild asthma

The present study was designed to observe the effects of 8 wk of treatment with formoterol (Foradil) 24 microgram, budesonide 400 microgram, and matched placebo inhaled twice a day on inflammatory indices in the bronchial mucosa of 64 patients with mild atopic asthma. Biopsies were obtained at the start and 1 wk before stopping a 9-wk period of treatment, and inflammatory cell numbers were assessed in the submucosa and epithelium by immunohistochemistry. Regular formoterol significantly reduced the number of submucosal mast cells, with a similar trend for eosinophils but not activated T cells. A subgroup analysis conducted in biopsies with >= 10 eosinophils per mm2 revealed a significant reduction in eosinophil numbers when compared with both pretreatment baseline (p < 0.01) and changes after placebo (p < 0.01). Parallel, but less pronounced, effects were observed on mast cell but not on CD25(+) T cell numbers. There was no effect of any of the three treatments on BAL levels of mast cell or eosinophil mediators. We conclude that regular treatment with inhaled formoterol reduces rather than increases inflammatory cells in the mucosa of asthmatic patients. It is possible that these cellular effects of formoterol may contribute to the therapeutic efficacy of this drug when used regularly in the treatment

High-dose chemotherapy with autologous stem cell support in patients with responding stage IV breast cancer

Ninety-four patients underwent high-dose chemotherapy with stem cell support for stage IV breast cancer. The high-dose chemotherapy consisted of the Stamp V regimen in all patients comprising cyclophosphamide, thiotepa and carboplatin (CTCb). Twenty-three patients received sequential high-dose therapies with the first consisting of high-dose melphalan and the second of Stamp V. Two patients died from chemotherapy-related complications resulting in a transplant-related mortality at 100 days of 2.2%. The progression-free survival at 3 years was 36% in patients with no evidence of disease at the first course of high-dose therapy compared with 17% in patients with remaining disease at time of the high-dose therapy (P = 0.03). There was no difference in overall survival between patients with no evidence of disease and other patients. The source of stem cells, single or double courses of high-dose therapy, positive selection of CD34+ cells, or number of involved sites had no influence on either progression-free survival or overall survival. Further studies of more intensive induction chemotherapy followed by high-dose therapy with stem cell support are indicated.

Multimodality treatment of 128 patients with locally advanced breast carcinoma in the era of mammography screening using standard polychemotherapy with 5-fluorouracil, epirubicin, and cyclophosphamide: prognostic and therapeutic implications

BACKGROUND

Locally advanced breast carcinoma is associated with a poor prognosis. With single treatment modalities, i.e., surgery and/or radiation therapy, results have been consistently dismal. However, several earlier reports have indicated improvement in survival with a combined modality approach, i.e., the utilization of systemic therapy.

METHODS

Between 1991 and 1994, 128 patients with locally advanced noninflammatory or inflammatory breast carcinoma (LABC) were treated with a combined modality strategy consisting of 4-6 courses of preoperative 5-fluorouracil (600 mg/m2), epirubicin (60 mg/m2), and cyclophosphamide (600 mg/m2) (FEC) every 3 weeks, followed by modified radical mastectomy or sector resection with axillary dissection in combination with postoperative radiotherapy and concomitant cyclophosphamide (850 mg/m2). Postoperatively, 3-5 adjuvant courses of FEC therapy were given. Nine percent of the patients received preoperative radiotherapy because the FEC therapy was not sufficiently effective. One-third of the patients were given tamoxifen (20 or 40 mg daily) at the end of the multimodal therapy.

RESULTS

Clinical responses were observed in 60% of the patients; 5% had complete responses (CR) and 55% had partial responses (PR). Stable disease (SD) was observed in 40%. No patient had progressive disease (PD) preoperatively. With a median follow-up of 37 months, the median disease free survival (DFS) and median overall survival (OS) were 29 and 54 months, respectively. The actuarial 5-year DFS and OS were 36% and 49%, respectively. The locoregional recurrence rate was 20%, and 53% of the patients experienced systemic relapse. Univariate analysis revealed a significant prognostic difference according to clinical stage of LABC in favor of less advanced stages. Clinical and biologic parameters linked to a significantly worse prognosis were the presence of inflammatory breast carcinoma and peau d'orange. There was a significant trend of worse prognosis for patients receiving below 60% and 75% of the intended dose intensity with reference to DFS and OS, respectively.

CONCLUSIONS

Standard dose preoperative and postoperative FEC therapy combined with surgery and radiotherapy in the era of mammography screening seem to yield results comparable to those achieved with other conventional strategies in the treatment of unscreened populations.