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author:("wickman, Anna")
1.  Marital status and survival after oesophageal cancer surgery: a population-based nationwide cohort study in Sweden 
BMJ Open  2014;4(6):e005418.
Objectives
A beneficial effect of being married on survival has been shown for several cancer types, but is unclear for oesophageal cancer. The objective of this study was to clarify the potential influence of the marital status on the overall and disease-specific survival after curatively intended treatment of oesophageal cancer using a nationwide population-based design, taking into account the known major prognostic variables.
Design
Prospective, population-based cohort.
Setting
All Swedish hospitals performing surgery for oesophageal cancer during 2001–2005.
Participants
This study included 90% of all patients with oesophageal or junctional cancer who underwent surgical resection in Sweden in 2001–2005, with follow-up until death or the end of the study period (2012).
Primary and secondary outcome measures
Cox regression was used to estimate associations between the marital status and the 5-year overall and disease-specific mortality, expressed as HRs with 95% CIs, with adjustment for sex, age, tumour stage, histological type, complications, comorbidities and annual surgeon volume.
Results
Of all 606 included patients (80.4% men), 55.1% were married, 9.2% were remarried, 22.6% were previously married and 13% were never married. Compared with the married patients, the never married (HR 1.02, 95% CI 0.77 to 1.35), previously married (HR 0.90, 95% CI 0.71 to 1.15) and remarried patients (HR 0.79, 95% CI 0.55 to 1.13) had no increased overall 5-year mortality. The corresponding HRs for disease-specific survival, and after excluding the initial 90 days of surgery, were similar to the HRs for the overall survival.
Conclusions
This study showed no evidence of a better 5-year survival in married patients compared with non-married patients undergoing surgery for oesophageal cancer.
doi:10.1136/bmjopen-2014-005418
PMCID: PMC4054621  PMID: 24907248
Oesophageal Cancer; Marital Status; Survival
2.  Intentional and unintentional non-adherence to medications following an acute coronary syndrome: A longitudinal study 
Journal of Psychosomatic Research  2014;76(5):430-432.
Objective
Non-adherence to medication is common among coronary heart disease patients. Non-adherence to medication may be either intentional or unintentional. In this analysis we provide estimates of intentional and unintentional non-adherence in the year following an acute coronary syndrome (ACS).
Method
In this descriptive prospective observational study of patients with confirmed ACS medication adherence measures were derived from responses to the Medication Adherence Report Scale at approximately 2 weeks (n = 223), 6 months (n = 139) and 12 months (n = 136) following discharge from acute treatment for ACS.
Results
Total medication non-adherence was 20%, 54% and 53% at each of these time points respectively. The corresponding figures for intentional non-adherence were 8%, 15% and 15% and 15%, 52% and 53% for unintentional non-adherence. There were significant increases in the levels of medication non-adherence between the immediate discharge period (2 weeks) and 6 months that appeared to stabilize between 6 and 12 months after acute treatment for ACS.
Conclusion
Unintentional non-adherence to medications may be the primary form of non-adherence in the year following ACS. Interventions delivered early in the post-discharge period may prevent the relatively high levels of non-adherence that appear to become established by 6 months following an ACS.
doi:10.1016/j.jpsychores.2014.02.007
PMCID: PMC4005033  PMID: 24745787
Adherence; Acute coronary syndrome; Psychological; Intention
3.  Education level and survival after oesophageal cancer surgery: a prospective population-based cohort study 
BMJ Open  2013;3(12):e003754.
Objectives
This study aimed to investigate whether a higher education level is associated with an improved long-term survival after oesophagectomy for cancer.
Design
A prospective, population-based cohort study.
Setting
Sweden—nationwide.
Participants
90% of all patients with oesophageal and cardia cancer who underwent a resection in Sweden in 2001–2005 were enrolled in this study (N=600; 80.3% male) and followed up until death or the end of the study period (2012). The study exposure was level of education, defined as compulsory (≤9 years), moderate (10–12 years) or high (≥13 years).
Outcome measures
The main outcome measure was overall 5-year survival after oesophagectomy. Cox regression was used to estimate the associations between education level and mortality, expressed as HRs with 95% CIs, with adjustment for sex, age, tumour stage, histological type, complications, comorbidities and annual surgeon volume. The patient group with highest education was used as the reference category.
Results
Among the 600 included patients, 281 (46.8%) had compulsory education, 238 (39.7%) had moderate education and 81 (13.5%) had high education. The overall 5-year survival rate was 23.1%, 24.4% and 32.1% among patients with compulsory, moderate and high education, respectively. After adjustment for confounders, a slightly higher, yet not statistically significantly increased point HR was found among the compulsory educated patients (HR 1.08, 95% CI 0.80 to 1.47). In patients with tumour stage IV, increased adjusted HRs were found for compulsory (HR 2.88, 95% CI 1.07 to 7.73) and moderately (HR 2.83, 95% CI 1.15 to 6.95) educated patients. No statistically significant associations were found for the other tumour stages.
Conclusions
This study provides limited evidence of an association between lower education and worse long-term survival after oesophagectomy for cancer.
doi:10.1136/bmjopen-2013-003754
PMCID: PMC3855588  PMID: 24302504
4.  Number and burden of cardiovascular diseases in relation to health-related quality of life in a cross-sectional population-based cohort study 
BMJ Open  2012;2(5):e001554.
Objectives
To clarify whether a greater number of cardiovascular diseases or a larger burden of disease are associated with poorer health-related quality of life (HRQoL) in an unselected general population.
Design
A population-based cross-sectional postal survey.
Settings
A random sample of the Swedish general population aged 40–79 years matched for national distributions of age, gender and region.
Participants
Out of 6969 eligible individuals, 4910 (70.5%) participated.
Primary and secondary measures
To create a reference database for HRQoL outcomes in the general population. To assess certain diseases and their relation to HRQoL.
Methods
Predefined cardiovascular diseases and HRQoL were assessed from validated questionnaires (EORTC QLQ-C30). Aspects of HRQoL included in the analyses were global quality of life, physical function, role function, emotional function, fatigue and dyspnoea. Individuals were categorised into: ‘good function’ versus ‘poor function’ and ‘no or minor symptoms’ versus ‘symptomatic’. Multivariable logistic regression calculated OR with 95% CI for poor HRQoL. The exposures were the number of cardiovascular diseases and the subjective disease burden.
Results
Out of the 4910 participants, 1358 (28%) reported having a cardiovascular disease and hypertension was most common. Reporting a greater number of cardiovascular diseases was associated with an increased risk of poor HRQoL, especially regarding dyspnoea. The OR for symptomatic dyspnoea was 1.37 (95% CI 1.08 to 1.74) for participants with one cardiovascular disease, 4.81 (95% CI 3.24 to 7.13) for two diseases and 4.18 (95% CI 2.24 to 7.80) for those with three or more cardiovascular diseases. Among the 271 participants who assessed their cardiovascular disease burden as major, the highest risk for poor HRQoL was found for physical function (OR 6.18, 95% CI 3.72 to 10.30).
Conclusions
Increased number of cardiovascular diseases and a greater burden of disease are generally associated with poorer HRQoL in people with cardiovascular disease from an unselected population.
doi:10.1136/bmjopen-2012-001554
PMCID: PMC3488712  PMID: 23100444
Epidemiology; Health Economics
5.  Physical activity, obesity and gastroesophageal reflux disease in the general population 
AIM: To clarify the association between physical activity and gastroesophageal reflux disease (GERD) in non-obese and obese people.
METHODS: A Swedish population-based cross-sectional survey was conducted. Participants aged 40-79 years were randomly selected from the Swedish Registry of the Total Population. Data on physical activity, GERD, body mass index (BMI) and the covariates age, gender, comorbidity, education, sleeping problems, and tobacco smoking were obtained using validated questionnaires. GERD was self-reported and defined as heartburn or regurgitation at least once weekly, and having at least moderate problems from such symptoms. Frequency of physical activity was categorized into three groups: (1) “high” (several times/week); (2) “intermediate” (approximately once weekly); and (3) “low” (1-3 times/mo or less). Analyses were stratified for participants with “normal weight” (BMI < 25 kg/m2), “overweight” (BMI 25 to ≤ 30 kg/m2) and “obese” (BMI > 30 kg/m2). Multivariate logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs), adjusted for potential confounding by covariates.
RESULTS: Of 6969 eligible and randomly selected individuals, 4910 (70.5%) participated. High frequency of physical activity was reported by 2463 (50%) participants, GERD was identified in 472 (10%) participants, and obesity was found in 680 (14%). There were 226 (5%) individuals with missing information about BMI. Normal weight, overweight and obese participants were similar regarding distribution of gender and tobacco smoking status, while obese participants were on average slightly older, had fewer years of education, more comorbidity, slightly more sleeping problems, lower frequency of physical activity, and higher occurrence of GERD. Among the 2146 normal-weight participants, crude point estimates indicated a decreased risk of GERD among individuals with high frequency of physical activity (OR: 0.59, 95% CI: 0.39-0.89), compared to low frequency of physical activity. However, after adjustment for potential confounding factors, neither intermediate (OR: 1.30, 95% CI: 0.75-2.26) nor high (OR: 0.99, 95% CI: 0.62-1.60) frequency of physical activity was followed by decreased risk of GERD. Sleeping problems and high comorbidity were identified as potential confounders. Among the 1859 overweight participants, crude point estimates indicated no increased or decreased risk of GERD among individuals with intermediate or high frequency of physical activity, compared to low frequency. After adjustment for confounding, neither intermediate (OR: 0.75, 95% CI: 0.46-1.22) nor high frequency of physical activity were followed by increased or decreased risk of GERD compared to low frequency among nonobese participants. Sleeping problems and high comorbidity were identified as potential confounders for overweight participants. In obese individuals, crude ORs were similar to the adjusted ORs and no particular confounding factors were identified. Intermediate frequency of physical activity was associated with a decreased occurrence of GERD compared to low frequency of physical activity (adjusted OR: 0.41, 95% CI: 0.22-0.77).
CONCLUSION: Intermediate frequency of physical activity might decrease the risk of GERD among obese individuals, while no influence of physical activity on GERD was found in non-obese people.
doi:10.3748/wjg.v18.i28.3710
PMCID: PMC3406423  PMID: 22851863
Physical exercise; Gastroesophageal reflux disease; Population-based study; Risk factor; Body mass index; Obesity
6.  Anaemia and the development of depressive symptoms following acute coronary syndrome: longitudinal clinical observational study 
BMJ Open  2012;2(1):e000551.
Objective
Depressive symptoms are common following acute coronary syndrome (ACS) and predict subsequent cardiovascular morbidity. Depression in acute cardiac patients appears to be independent of clinical disease severity and other cardiovascular measures. One factor that has not been considered previously is anaemia, which is associated with fatigue and adverse cardiac outcomes. This study assessed the relationship between anaemia on admission and depressive symptoms following ACS.
Design
Longitudinal clinical observational study.
Setting
Coronary care unit.
Patients
223 patients with documented ACS.
Main outcome measures
Depressive symptoms measured with the Beck Depression Inventory 3 weeks after admission.
Results
Anaemia was defined with WHO criteria and was present in 30 (13.5%) patients. Anaemia predicted raised depression scores 3 weeks later independently of age, gender, marital status, educational attainment, smoking, Global Registry of Acute Cardiac Events (GRACE) risk scores, negative mood in hospital and history of depression (p=0.003). The odds of a Beck Depression Inventory score ≥10 among anaemic patients were 4.03 (95% CIs 1.48 to 11.00), adjusted for covariates. Sensitivity analyses indicated that effects were also present when haemoglobin was analysed as a continuous measure. Anaemia also predicted major adverse cardiac events over the subsequent 12 months.
Conclusions
Anaemia appears to contribute to depression following ACS and is associated with future cardiac morbidity. Studies evaluating the effects of anaemia management will help delineate the role of this pathway more precisely.
Article summary
Article focus
Depressive symptoms are common among survivors of acute myocardial infarction and other acute coronary syndromes (ACS) and predict a poor long-term outcome.
Depressive symptoms appear to be independent of clinical disease severity.
However, anaemia is common in ACS patients and has not previously been examined as a predictor of depressive symptoms.
Key messages
Anaemia on admission with ACS predicted depressive symptoms 3 weeks later, independently of covariates.
Anaemia also predicted major adverse cardiac events over the next 12 months.
Anaemia and haemoglobin levels should be considered as biological determinants of depressive symptoms following myocardial infarction and other ACSs.
Strengths and limitations of this study
This is the first study to investigate anaemia and subsequent depression in ACS patients using a prospective design.
The study was small scale and was not powered to investigate the impact of depression on long-term cardiac outcomes.
doi:10.1136/bmjopen-2011-000551
PMCID: PMC3274712  PMID: 22307099
7.  Quality of Life and Affective Well-Being in Middle-Aged and Older People with Chronic Medical Illnesses: A Cross-Sectional Population Based Study 
PLoS ONE  2011;6(4):e18952.
Background
There has been considerable research into the impact of chronic illness on health-related quality of life. However, few studies have assessed the impact of different chronic conditions on general quality of life (QOL). The objective of this paper was to compare general (rather than health-related) QOL and affective well-being in middle aged and older people across eight chronic illnesses.
Methods and Findings
This population-based, cross-sectional study involved 11,523 individuals aged 50 years and older, taking part in wave 1 of the English Longitudinal Study of Ageing. General QOL was assessed using the CASP-19, happiness was evaluated using two items drawn from the GHQ-12, and depression was measured with the CES-D. Analysis of covariance and logistic regression, adjusting for age, gender and wealth, were performed. General QOL was most impaired in people with stroke (mean 37.56, CI 36.73–38.39), and least in those reporting cancer (mean 41.78, CI 41.12–42.44, respectively), compared with no illness (mean 44.15, CI 43.92–44.39). Stroke (mean 3.65, CI 3.58–3.73) was also associated with the greatest reduction in positive well-being whereas diabetes (mean 3.81, CI 3.76–3.86) and cancer were least affected (3.85, CI 3.79–3.91), compared with no illness (mean 3.97, CI 3.95–4.00). Depression was significantly elevated in all conditions, but was most common in chronic lung disease (OR 3.04, CI 2.56–3.61), with more modest elevations in those with osteoarthritis (OR 2.08, CI 1.84–2.34) or cancer (OR 2.07, CI 1.69–2.54). Multiple co-morbidities were associated with greater decrements in QOL and affective well-being.
Conclusion
The presence of chronic illness is associated with impairments in broader aspects of QOL and affective well-being, but different conditions vary in their impact. Further longitudinal work is needed to establish the temporal links between chronic illness and impairments in QOL and affective well-being.
doi:10.1371/journal.pone.0018952
PMCID: PMC3084723  PMID: 21559485

Results 1-7 (7)