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1.  Occupational and leisure time physical activity: risk of all-cause mortality and myocardial infarction in the Copenhagen City Heart Study. A prospective cohort study 
BMJ Open  2012;2(1):e000556.
Objectives
Men with low physical fitness and high occupational physical activity are recently shown to have an increased risk of cardiovascular disease and all-cause mortality. The association between occupational physical activity with cardiovascular disease and all-cause mortality may also depend on leisure time physical activity.
Design
A prospective cohort study.
Setting
The Copenhagen City Heart Study.
Participants
7819 men and women aged 25–66 years without a history of cardiovascular disease who attended an initial examination in the Copenhagen City Heart Study in 1976–1978.
Outcome measures
Myocardial infarction and all-cause mortality. Occupational physical activity was defined by combining information from baseline (1976–1978) with reassessment in 1981–1983. Conventional risk factors were controlled for in Cox analyses.
Results
During the follow-up from 1976 to 1978 until 2010, 2888 subjects died of all-cause mortality and 787 had a first event of myocardial infarction. Overall, occupational physical activity predicted all-cause mortality and myocardial infarction in men but not in women (test for interaction p=0.02). High occupational physical activity was associated with an increased risk of all-cause mortality among men with low (HR 1.56; 95% CI 1.11 to 2.18) and moderate (HR 1.31; 95% CI 1.05 to 1.63) leisure time physical activity but not among men with high leisure time physical activity (HR 1.00; 95% CI 0.78 to 1.26) (test for interaction p=0.04). Similar but weaker tendencies were found for myocardial infarction. Among women, occupational physical activity was not associated with subsequent all-cause mortality or myocardial infarction.
Conclusions
The findings suggest that high occupational physical activity imposes harmful effects particularly among men with low levels of leisure time physical activity.
Article summary
Article focus
Men with low physical fitness and high occupational physical activity are recently shown to have an increased risk of cardiovascular disease and all-cause mortality.
It is unknown if the association between occupational physical activity with cardiovascular disease and all-cause mortality also depends on leisure time physical activity.
Key messages
This study shows that men with high occupational physical activity have an increased risk of all-cause mortality.
Leisure time physical activity was found to modify the positive association between occupational physical activity and risk of all-cause mortality. High occupational physical activity imposes harmful effects particularly among men with low levels of leisure time physical activity.
Strengths and limitations of this study
Study strengths include the long follow-up time, repeated assessment of the occupational physical activity, objective measures of several covariates from clinical examinations, information on outcomes obtained from valid registers, and participation of both sexes. Some limitations are the lack of control for psychosocial work factors and the self-reported exposures.
doi:10.1136/bmjopen-2011-000556
PMCID: PMC3282285  PMID: 22331387
2.  Risk factors for ischaemic heart disease mortality among men with different occupational physical demands. A 30-year prospective cohort study 
BMJ Open  2012;2(1):e000279.
Objectives
Men with high physical work demands have elevated cardiovascular strain, which may lead to enhanced atherosclerosis. Theoretically, the impact of risk factors for ischaemic heart disease (IHD) may thus depend on physical work demands. The authors investigated this hypothesis.
Design
Prospective 30-year follow-up.
Setting
The Copenhagen Male Study.
Participants
5249 gainfully employed men aged 40–59 years; 311 men with cardiovascular disease/diabetes were excluded.
Primary and secondary outcome measures
IHD and all-cause mortality.
Results
579 men (11.8%) died due to IHD and 2628 (53.7%) from all-cause mortality. Similarities and differences in risk predictors were found between men with low (n=1219), medium (n=2636) and high (n=846) physical work demands. After control for potential confounders, high physical fitness conferred a reduced risk of IHD mortality only among men with high physical work demands (HR: 0.48, 95% CI 0.24 to 0.96), a moderate/high level of leisure-time physical activity was associated with reduced risk of IHD mortality only among men with moderate and high physical work demands. High systolic blood pressure and smoking were risk factors in all groups. Similar, but less pronounced differences in risk factors for all-cause mortality between groups were found.
Conclusions
The risk factors for IHD and all-cause mortality, low physical fitness and low leisure-time physical activity are not identical for men with different physical work demands. Preventive initiatives for IHD should be tailored to the physical work demands.
Article summary
Article focus
Men with high physical work demands have elevated cardiovascular strain and risk of ischaemic heart disease (IHD).
Unknown if established risk factors for IHD impose divergent risk for IHD mortality among men with different levels of occupational physical activity.
Key messages
Risk factors for IHD and all-cause mortality are not identical for men with different physical work demands.
Low physical fitness and leisure-time physical activity particularly increase the risk of IHD mortality among men with high physical work demands.
Preventive initiatives for IHD ought not to be general but tailored to the physical work demands of employees.
Strengths and limitations of this study
Study strengths are the 30-year follow-up on objective outcomes, inclusion of several objectively measured risk factors for IHD and mortality and exclusion of workers with pre-existing cardiovascular disease at baseline.
Study limitations are that physical work demands were based on self-assessment and lacking repeated measures of exposure during the relatively long follow-up period.
doi:10.1136/bmjopen-2011-000279
PMCID: PMC3253417  PMID: 22218719
3.  Inter-examiner reproducibility of clinical tests and criteria used to identify subacromial impingement syndrome 
BMJ Open  2011;1(1):e000042.
Introduction
A specific algorithm has been proposed for classifying impingement related shoulder pain in athletes with overhead activity. Data on the inter-examiner reproducibility of the suggested clinical tests and criteria and their mutual dependencies for identifying subacromial impingement symptoms (SIS) are not available.
Objective
To test the inter-examiner reproducibility of selected tests and criteria suggested for classifying SIS and the mutual dependencies of each of the individual tests and SIS.
Method
A standardised three-phase protocol for clinical reproducibility studies was followed, consisting of a training, an overall agreement and a study phase. To proceed to the study phase, an overall agreement of 0.80 was required. In total 10, 20 and 44 subjects were included in the three phases, respectively. The case prevalence in the study phase was 50%. The inclusion criterion for cases was ≥3, and for controls ≤1 positive test out of four. Cohen's κ statistics were used for calculating agreement.
Results
In the overall agreement phase, an agreement of 0.90 was obtained, while in the study phase it was 0.98 with a κ of 0.95 for SIS. κ Values for the individual tests varied between 0.60 and 0.95. Mutual dependencies between each test and SIS showed Neer's test with anterior pain to be most often used to determine SIS.
Conclusions
Inter-examiner reproducibility was moderate to almost perfect for the selected tests and criteria for SIS. The next challenge will be to establish reproducibility in clinical practice, as well as the validity of the tests and criteria for SIS.
Article summary
Article focus
This study examines the inter-tester reproducibility of Hawkins', Neer's, Jobe's and Apprehension tests, included in a recent clinical reasoning algorithm, both as individual tests and as performed as a battery of tests for screening for subacromial impingement symptoms (SIS) in overhead athletes.
Furthermore, the mutual dependency of each individual test and SIS was determined.
Key messages
Overall, the reproducibility was almost perfect for tests and criteria for SIS when following a standardised test protocol for reliability and validity studies.
Mutual dependency was highest for Neer's test with anterior pain and SIS, implying that this was the test most often used to determine SIS.
Strengths and limitations of this study
The strength of the study is the strict adherence to a standardised study protocol for reproducibility and validity studies, with a training and an overall agreement phase, including the requirement of a 0.50 prevalence of SIS, before performing the study phase. Since the study population consisted of overhead athletes, for whom the algorithm is intended, data can be generalised to the target population.
The limitation of the study is that the current mutual dependencies may have been deceptively high because of a possible bias due to the inclusion criteria used in this algorithm, since subjects with two out of four positive test responses are not included. However, this limitation has not biased the high reproducibility of the tests and criteria for SIS.
doi:10.1136/bmjopen-2010-000042
PMCID: PMC3191397  PMID: 22021736

Results 1-3 (3)