IMPORTANCE UV radiation (UVR) exposure is the primary environmental risk factor for developing cutaneous malignant melanoma (CMM). OBJECTIVE To measure changes in sun behavior from the first until the third summer after the diagnosis of CMM using matched controls as a reference. DESIGN, SETTING, AND PARTICIPANTS Three-year follow-up, observational, case-control study performed from May 7 to September 22, 2009, April 17 to September 15, 2010, and May 6 to July 31, 2011, at a university hospital in Denmark of 21 patients with CMM and 21 controls matched to patients by sex, age, occupation, and constitutive skin type participated in the study. Exposure to UVR was assessed the first and second summers (n=20) and the first and third summers (n=22) after diagnosis. Data from 40 participants were analyzed. MAIN OUTCOMES AND MEASURES Exposure to UVR was assessed by personal electronic UVR dosimeters that measured time-related UVR in standard erythema dose (SED) and corresponding sun diaries (mean, 74 days per participant each participation year). RESULTS Patients' daily UVR dose and UVR dose in connection with various behaviors increased during follow-up (quantified as an increase in daily UVR dose each year; all days: mean, 0.3 SED; 95% CI, 0.05-0.5 SED; days with body exposure: mean, 0.6 SED; 95% CI, 0.07-1.2 SED; holidays: mean, 1.2 SED; 95% CI, 0.3-2.1 SED; days abroad: 1.9 SED; 95% CI, 0.4-3.4 SED; and holidays with body exposure: mean, 2.3 SED; 95% CI, 1.1-3.4 SED). After the second year of follow-up, patients' UVR dose was higher than that of controls, who maintained a stable UVR dose. No difference was found between groups in the number of days with body exposure or the number of days using sunscreen in the second and third years of follow-up. CONCLUSIONS AND RELEVANCE Our findings suggest that patients with CMM do not maintain a cautious sun behavior in connection with an increase in UVR exposure, especially on days with body exposure, when abroad, and on holidays.
The study aimed to explore changes in the prevalence of psychological distress and co-occurring psychological symptoms among 19-34 years old Finnish university students between the years 2000 and 2012.
The prevalence of perceived frequent psychological symptoms was compared in four nationwide cross-sectional student health surveys with random samples (N=11,502) in the following years: 2000 (N=3,174), 2004 (N=3,153), 2008 (N=2,750), and 2012 (N=2,425).
In the time phase from 2000 to 2012, the overall psychological distress (12-item General Health Questionnaire, GHQ-12) increased from 22% to 28%, while there was also an increase in the frequently experienced psychological symptoms (depressiveness from 13% to 15%, anxiety from 8% to 13%, concentration problems from 12% to 18%, and psychological tension from 13% to 18% with a peak prevalence observed in 2008). The co-occurrence of different psychological symptoms increased as well. Psychological distress was more common in females and in older students.
The findings suggest an increasing trend of frequent psychological distress among Finnish university students over the years from 2000 to 2012, with the peak prevalence occurring in 2008, which may reflect the growing multifaceted environmental demands.
A cohort of 839 young girls at the ages of 14 and 15 years was screened for total antibodies to herpes simplex virus (HSV) and, if positive, for specific antibodies to HSV-2, by means of a sensitive, enzyme-linked immunosorbent assay (ELISA). The cohort was followed from 1972-1987. Blood samples were obtained on six occasions during these 16 years. In total, 2270 blood samples were taken. The number of sero-converting girls was studied in relation to calendar time. Two methods were constructed for the statistical analyses. The first of these gave an estimate of the sero-prevalence at different points in time. This analysis showed that the sero-prevalence which was 23% against HSV-1 in 1972 had increased to 36% in 1976. At the end of the study in 1987, 50% of the cohort had sero-converted against HSV-1. The proportion of girls who had sero-converted against HSV-2 was 0.4% in the 14-15-year-olds and had reached 22% by the end of the study. The second statistical method used all the available information implicit in the observations so as to obtain a maximum-likelihood (ML) estimate of the prevalence. The ML estimates were slightly more precise, but the two estimates did not differ significantly. The observations were further analysed by the Mantel-Haenszel test in order to see if there was any dependence between positivity to HSV-1 and HSV-2 respectively but none was found.
This paper provides a short overview of cobalt-related diseases with particular reference to the potential carcinogenicity of cobalt compounds, and a review of a 10-year surveillance programme on plate painters exposed to cobalt in two Danish porcelain factories. Clinical experience and epidemiological studies have demonstrated that cobalt exposure may lead to severely impaired lung function, i.e. hard metal lung disease and occupational cobalt-related asthma, contact dermatitis and cardiovascular effects. However, the evidence for the carcinogenicity of cobalt and cobalt compounds is considered inadequate (IARC, 1991). Most frequently, exposure to cobalt occurs simultaneously with exposure to other elements known to pose a health risk, (e.g. nickel, arsenic, chromium, tungsten). The importance of cobalt as sole causal agent in hard metal lung diseases, cardiomyopathy and cancer are still a matter of controversy. In the two Danish porcelain factories, cobalt blue underglaze dyes have been used since 1888. In contrast to the exposure experience of hard metal factories, the exposure of plate painters occurs with only low trace levels of other potentially harmful compounds such as the carcinogenic metals nickel, arsenic and chromium. Consequently, the nearly-pure cobalt exposure makes the plate painters an attractive group for studies on the health effects of cobalt. During the period 1982-1992 the surveillance programme showed a profound reduction in the urine level of cobalt (Co-U) from 100-fold to 10-fold above the median level of the unexposed control subjects. In the same period, the airborne cobalt exposure declined from 1356 nmol/m3 to 454 nmol/m3, the Danish occupational exposure limit being 845 nmol/m3. In 1982, when the cobalt exposure was above the occupational exposure limit, the plate painters showed a chronic impaired lung function. The obstructive effects may be similar to some of the effects observed in hard metal workers. In 1988, a study on the effect of cobalt exposure at low levels revealed no inhibitory effects on thyroid function, but the ratio between T4 and T3 increased, indicating that low cobalt exposure may have an impact on the metabolism of thyroid hormones. Parallel studies were conducted on the metabolism and excretion of cobalt. The gastrointestinal uptake of soluble CoCl was considerably higher than the uptake of insoluble cobalt(II) oxide. In addition, it was demonstrated that ingestion of controlled amounts of the soluble cobalt compound resulted in significantly higher concentrations of cobalt in urine and blood (Co-B) from females compared with males (P
The burden of celiac disease (CD) is increasingly recognized as a global problem. However, whether this situation depends on genetics or environmental factors is uncertain. The authors examined these aspects in Sweden, a country in which the risk of CD is generally considered to be high. If environmental factors are relevant, CD risk in second-generation immigrant children should be related to maternal length of stay in Sweden before delivery.
Linking the Swedish Medical Birth Registry to other national registries, the authors investigated all singleton children (n = 792,401) born in Sweden between 1987 and 1993. They studied the risk of CD in children before age 6 as a function of the mother's geographical region of birth and length of stay in Sweden before delivery using Cox regression models.
In children whose mothers immigrated to Sweden from a country outside of Europe, a maternal length of stay in Sweden of more than 5 years increased the hazard ratio (HR) of CD (1.73, 95% confidence interval (CI) 1.06-2.81). The authors observed a similar result among children born to mothers from a Nordic country outside of Sweden (HR 1.57, 95% CI 0.89-2.75), but a non-conclusive protective effect was observed in second-generation immigrant children from a non-Nordic European country (HR 0.65, 95% CI 0.39-1.09).
The risk of CD among second-generation immigrants seems to be conditioned by maternal length of stay in Sweden before delivery, suggesting that environmental factors contribute to the variation in CD risk observed across populations.
To investigate occupational therapists', physiotherapists' and speech language pathologists' family-related rehabilitation practice post-stroke and its association with clinician and environmental variables.
A Canadian cross-sectional telephone survey was conducted on 1755 clinicians. Three case studies describing typical patients after stroke receiving acute care, in-patient rehabilitation, or community rehabilitation, and including specific descriptors regarding family stress and concern, were used to elicit information on patient management.
One-third of the sample identified a family-related problem and offered a related intervention, but only 12/1755 clinicians indicated that they would typically use a standardized assessment of family functioning. Working in the community out-patient setting was associated (OR 9.16), whereas working in a rehabilitation in-patient setting was negatively associated (OR 0.58) with being a problem identifier, the reference group being acute care. Being a PT (OR 0.53) or an SLP (OR 0.49) vs an OT was negatively associated with being a problem identifier, whereas being older (OR 1.02 ) or working in Ontario (OR 1.58) was associated with being a problem identifier. To work in a community out-patient setting (OR 2.43), being older clinicians (OR 1.02) or not perceiving their work environment being supportive of an on-going professional learning (OR 1.72) was associated with being an intervention user,whereas being a PT (OR 0.50) was negatively associated with being a user.
For these 3 disciplines, the prevalence of a family-related focus is low post-stroke. Given the increasing evidence regarding the effectiveness of family-related interventions on stroke outcomes, it is imperative that best practice is implemented.
The APHEA 2 project investigated short-term health effects of particles in eight European cities. In each city associations between particles with an aerodynamic diameter of less than 10 microm (PM(10)) and black smoke and daily counts of emergency hospital admissions for asthma (0-14 and 15-64 yr), chronic obstructive pulmonary disease (COPD), and all-respiratory disease (65+ yr) controlling for environmental factors and temporal patterns were investigated. Summary PM(10) effect estimates (percentage change in mean number of daily admissions per 10 microg/m(3) increase) were asthma (0-14 yr) 1.2% (95% CI: 0.2, 2.3), asthma (15-64 yr) 1.1% (0.3, 1.8), and COPD plus asthma and all-respiratory (65+ yr) 1.0% (0.4, 1.5) and 0.9% (0.6, 1.3). The combined estimates for Black Smoke tended to be smaller and less precisely estimated than for PM(10). Variability in the sizes of the PM(10) effect estimates between cities was also investigated. In the 65+ groups PM(10) estimates were positively associated with annual mean concentrations of ozone in the cities. For asthma admissions (0-14 yr) a number of city-specific factors, including smoking prevalence, explained some of their variability. This study confirms that particle concentrations in European cities are positively associated with increased numbers of admissions for respiratory diseases and that some of the variation in PM(10) effect estimates between cities can be explained by city characteristics.
From the aDepartment of Public Health and Clinical Medicine, Division of Occupational and Environmental Medicine, Umeå University, Umeå, Sweden; bAgeing and Living Conditions Programme, Umeå University, Umeå, Sweden; cCentre for Population Studies, Umeå University, Umeå, Sweden; and dDepartment of Public Health and Clinical Medicine, Division of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
Climate change is projected to increase the frequency of extreme weather events. Short-term effects of extreme hot and cold weather and their effects on mortality have been thoroughly documented, as have epidemiologic and demographic changes throughout the 20th century. We investigated whether sensitivity to episodes of extreme heat and cold has changed in Stockholm, Sweden, from the beginning of the 20th century until the present.
We collected daily mortality and temperature data for the period 1901-2009 for present-day Stockholm County, Sweden. Heat extremes were defined as days for which the 2-day moving average of mean temperature was above the 98th percentile; cold extremes were defined as days for which the 26-day moving average was below the 2nd percentile. The relationship between extreme hot/cold temperatures and all-cause mortality, stratified by decade, sex, and age, was investigated through time series modeling, adjusting for time trends.
Total daily mortality was higher during heat extremes in all decades, with a declining trend over time in the relative risk associated with heat extremes, leveling off during the last three decades. The relative risk of mortality was higher during cold extremes for the entire period, with a more dispersed pattern across decades. Unlike for heat extremes, there was no decline in the mortality with cold extremes over time.
Although the relative risk of mortality during extreme temperature events appears to have fallen, such events still pose a threat to public health.
OBJECTIVE: The aim of this study was to identify possible health effects caused by different cleaning agents used in graffiti removal. METHODS: In 38 graffiti removers working 8-h shifts in the Stockholm underground system, the exposure to organic solvents was assessed by active air sampling, biological monitoring, and by interviews and a questionnaire. Health effects were registered, by physical examinations, porta7ble spirometers and self-administered questionnaires. The prevalence of symptoms was compared with 49 controls working at the underground depots, and with 177 population controls. RESULTS: The 8-h time-weighted average exposures (TWA) were low, below 20% of the Swedish permissible exposure limit value (PEL) for all solvents. The short-term exposures occasionally exceeded the Swedish short-term exposure limit values (STEL), especially during work in poorly ventilated spaces, e.g. in elevators. The graffiti removers reported significantly higher prevalence of tiredness and upper airway symptoms compared with the depot controls, and significantly more tiredness, headaches and symptoms affecting airways, eyes and skin than the population controls. Among the graffiti removers, some of the symptoms increased during the working day. On a group basis, the lung function registrations showed normal values. However, seven workers displayed a clear reduction of peak expiratory flow (PEF) over the working shift. CONCLUSIONS: Though their average exposure to organic solvents was low, the graffiti removers reported significantly higher prevalence of unspecific symptoms such as fatigue and headache as well as irritative symptoms from the eyes and respiratory tract, compared with the controls. To prevent adverse health effects it is important to inform the workers about the health risks, and to restrict use of the most hazardous chemicals. Furthermore, it is important to develop good working practices and to encourage the use of personal protective equipment.
OBJECTIVE: To describe the sociomedical risk factors associated with episodes of acute otitis media (AOM), recurrent AOM (rAOM), and chronic otitis media (COM) in Greenlandic children and especially to point out children at high risk of rAOM (defined as > 5 AOM episodes since birth) and COM which are prevalent among Inuit children all over the Arctic. METHODS: The study design was cross-sectional and included 740 unselected children, 3, 4, 5, and 8-years-old, living in two major Greenlandic towns, Nuuk and Sisimiut. All children were otologically examined and the parents answered a questionnaire containing sociomedical variables including ethnicity, family history of OM, housing, insulation, crowding, daycare, passive cigarette smoking, breast feeding, type of diet, allergy, and chronic diseases. Historical data were cross-checked in medical records which also formed the basis for the drop-out analyses. Statistical analyses included frequency tests, calculation of odds ratio (OR), and multiple logistic regression. RESULTS: The attendance rate was 86%. Former episode of AOM was reported by 2/3 of the children, rAOM by 20%, and COM by 9%. The following variables were found significantly more often in children with AOM by simple frequency testing: Parental (OR = 1.83), sibling (OR = 1.62), and parental plus sibling (OR = 2.56) history of OM, crowding (OR = 5.55), long period of exclusive breast feeding ( > 4 months) (OR = 2.47), and recent acute disease (P = 0.034). The following variables were found significantly more often in children with rAOM or COM by simple frequency testing: Parental history of OM (OR = 1.60; OR = 2.11, respectively) and no recall of breast feeding (P = 0.005; P = 0.003, respectively). Also, COM was found significantly more often in children with two Greenlandic parents (OR = 3.07). A multiple logistic regression test denoted only parental history of OM (OR = 1.82) and long period of exclusive breast feeding (OR = 1.14) as significant predictors of AOM. CONCLUSIONS: Many of the risk factors usually associated with AOM could not be confirmed as risk factors in this survey. Parental history of OM and long period of exclusive breast feeding were the strongest factors associated with AOM in Greenlandic children and ethnicity was associated with COM. However, the study confirms that AOM is a multifactorial disease determined by a number of genetic and environmental factors.
Haptoglobin (Hp) which is synthesized in response to infection, inflammation, trauma or toxicological damage is known as a major acute phase protein in numerous species. Quantification of the circulating concentration of this protein can provide an objective measure of the health status, but there is a lack of investigations on harbour seals. We investigated the Hp concentration in samples of 123 seals (Phoca vitulina) from the German and Danish Wadden Sea to study physiological ranges of Hp levels. Hp levels between 2002, the end of the phocine distemper virus epidemic (PDV), and 2007 were considered, and Hp concentrations between animals of different sex, ages as well as living areas were compared. Furthermore, as a case study, six animals from the open sea isle Helgoland were investigated in 2006. Influences on the health status of the seal population e.g. the PDV epidemic were reflected by increased Hp levels in North Sea seals in 2002. The results of the Wadden Sea seals showed no significant age-, sex-, or geographical area-related differences. Interestingly, for the seals of the open sea isle Helgoland higher Hp values were measured compared to the Wadden Sea seals. The present study demonstrates that Hp can be used as a diagnostic tool to monitor the health status of harbour seals.
Time series of daily administrative cardio-respiratory health and environmental information have been extensively used to assess the potential public health impact of ambient air pollution. Both series are subject to strong but unrelated temporal cycles. These cycles must be removed from the time series prior to examining the role air pollution plays in exacerbating cardio-respiratory disease. In this paper, we examine a number of methods of temporal filtering that have been proposed to eliminate such temporal effects. The techniques are illustrated by linking the number of daily admissions to hospital for respiratory diseases in Toronto, Canada for the 11 year period 1981 to 1991 with daily concentrations of ambient ozone. The ozone-hospitalization relationship was found to be highly sensitive to the length of temporal cycle removed from the admission time series, and to day of the week effects, ranging from a relative risk of 0.874 if long wave cycles were not removed at all to 1.020 for models which removed at least cycles greater than or equal to one month based on the interquartile pollutant range. The specific statistical method of adjustment was not a critical factor. The association was not as sensitive to removal of cycles less than one month, except that negative autocorrelation increased for series in which cycles of one week or less were removed. We recommend three criteria in selecting the degree of smoothing in the outcome: removal of temporal cycles, minimizing autocorrelation and optimizing goodness of fit. The association between ambient ozone levels and hospital admissions for respiratory diseases was also sensitive to the season of examination, with weaker associations observed outside the summer months.
Most epidemiologic studies use traffic at residential address as a surrogate for total traffic exposure when investigating effects of traffic on respiratory health. This study used GIS (Geographical Information Systems) to estimate traffic exposure, not only on residential, but also on workplace address, in addition to survey questions on time spent in traffic during commuting or other daily activities.The aim was to investigate 1) if there is an association between traffic exposure and prevalence of adult asthma and asthma symptoms, and 2) if so, does this association become stronger using more complete traffic exposure information.
This study was conducted in two stages: A first cross-sectional survey in Southern Sweden 2004 (n = 24819, 18-80 years, response rate 59%) was followed by a case-control study in 2005 to obtain more detailed exposure and confounder information (n = 2856, asthmatics and controls (1:3), 86% response rate). In the first survey, only residential address was known. In the second survey, questions about workplace addresses and daily time spent in traffic were also included. Residential and workplace addresses were geocoded and linked with GIS to road data and dispersion modelled outdoor concentrations of NOx (annual mean, 250 × 250 m resolution).
Living within 50 m of a road (measured by GIS) with traffic intensity of >10 cars/minute (compared with no road within this distance) was associated with an increased prevalence of asthma, (OR = 1.8, 95% CI = (1.1-2.8), and with asthma symptoms last 12 months. No statistically significant effects were seen for traffic exposure at workplace address, daily time spent in traffic, or commuting time to work, after adjustment for confounders. A combined total exposure estimate did not give a stronger association with asthma prevalence or asthma symptoms.
Traffic exposure at close proximity to residential address showed association with asthma prevalence and asthma symptoms last 12 months, among adults in southern Sweden. The associations were not stronger when accounting for total traffic exposure. This could reflect exposure misclassfication at workplace address and for other daily time in traffic, but also that residential address remains the main determinant for traffic exposure among adults.
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OBJECTIVES: This study examined certain occupational exposures and the risk for adult-onset asthma. METHODS: A nested case-referent study of adult-onset asthma was performed on a random population sample (N=15813), aged 21 to 51 years. Cases for the study included 2 groups: subjects reporting "physician-diagnosed" asthma (N=251) and a broader "asthma" group (N=362). The "asthma" group consisted of subjects with "physician-diagnosed" asthma (N=251) and subjects reporting asthma-like symptoms without having "physician-diagnosed" asthma (N=111). The referents (N=2044) were randomly selected from the whole population sample. The case-referent sample was investigated with a comprehensive questionnaire about occupational exposures, asthma, respiratory symptoms, smoking, and atopy. Odds ratios were calculated with stratification for gender, year of diagnosis, and birth year. RESULTS: The highest odds ratio for "physician-diagnosed" asthma was associated with exposure to flour dust [odds ratio (OR) 2.8, 95% confidence interval (95% CI) 1.5-5.2] and the occupational handling of resin-based paints (isocyanates) (OR 3.0, 95% CI 1.6-5.9). Exposure to welding fumes, textile dust, and work with glues containing acrylates was also associated with an increased odds ratio for "physician-diagnosed" asthma. Including persons with asthma-like symptoms (ie, the asthma group) showed similar results. CONCLUSION: This population-based case-referent study from Sweden indicates that occupational exposure to acrylate-based compounds and welding fumes is associated with increased risk for adult-onset asthma.
International comparability of environmental tobacco smoke (ETS) exposure levels is difficult. This study assesses whether estimating children's exposure from information on adult smoking and exposure to ETS makes international comparisons more reliable.
The exposure among children was estimated using three different combinations (models) based on different sets of information on adult smoking, household composition or adult exposure to ETS at home in three cross-sectional nationally representative samples drawn from data sets from Estonia (n=2650), Finland (n=2829) and Latvia (n=5440) in the years 2002 and 2004. The first two models were based on adult smoking and the third also included ETS exposure.
The parental smoking rate was similar to the general smoking prevalence. ETS exposure in non-smoking parents ranged from 22% in Finland to 60% in Latvia. All models gave rather comparative ranges except in Latvia, where the proportion of children with exposure varied from 67% with the simplest model to 81% with the most complex one.
Adult exposure at home or adult smoking prevalence, preferably among people with children, could be used as a proxy for children's exposure to ETS. It is recommended that population questionnaires include detailed information on exposure and household composition.
INTRODUCTION/PURPOSE: Despite a large public health interest in physical activity and its role in obesity and other chronic diseases, only few reports to date have addressed total levels and trends of physical activity. We have studied in a cross-sectional setting with a retrospective recall of physical activity an association of levels of total physical activity and different types of activities with age and with calendar-time. METHODS: In a population-based study of 33,466 men aged 45-79 yr in central Sweden, information on physical activity and other lifestyle factors was collected through a self-administered questionnaire. Level of total activity at ages 15, 30, and 50 yr was assessed quantitatively, based on six questions on different activities: work/occupation, housework, walking/bicycling, exercise, inactive leisure time, and sleeping. The physical activity levels were measured as metabolic equivalents, MET-hours per days. RESULTS: Total daily physical activity decreased at age 30 yr (-1.6%, 95% CI: -1.7, -1.4) and at age 50 yr (-3.9%, 95% CI: -4.0, -3.7) compared with age 15 yr. Total physical activity decreased over a period of 60 yr in all three separate age groups (-9.1% among 15-yr-olds, 95% CI: -9.8, -8.5; -2.3% among 30-yr-olds 95% CI: -3.0, -1.6; and -2.9% among 50-yr-olds, 95% CI: -3.4, -2.5). CONCLUSION: These negative trends in physical activity observed by age and with time might explain the trends in increasing prevalence of obesity.
Studies from around the world indicate a trend toward younger ages of menarche. The extent of this trend in the Canadian population is unknown, and the relationship to later-life health indicators has not yet been fully elucidated. The objective of this study is to estimate the trend in age at menarche (AAM) in the Canadian population and evaluate the relationship between AAM and adult body mass index (BMI).
Our data source was a nationally representative survey (the Canadian Community Health Survey, 2.2), and analyses included 8080 women, aged 15 and older, who self-reported AAM. Height and weight were measured by the interviewers for the calculation of current BMI. We modeled the secular trend in AAM over time, and the relationship between current BMI and AAM.
We found a statistically significant decline in AAM in successive age cohorts, indicating a 0.73-year (8.8-month) decrease in AAM between the oldest and youngest age cohorts in the sample. A 1-year increase in AAM was associated with a decrease in mean BMI of approximately 0.5 kg/m(2), after adjustment for covariates. A current age-AAM interaction term was nonsignificant, indicating that the relationship was stable throughout increasing temporal separation from puberty.
The observed trend toward earlier menarche could be an indicator of a change in insulin-related metabolism, possibly mediated by behavioral and environmental variables. This study suggests that AAM may be an important clinical and public health indicator of susceptibility to overweight and obesity and attendant morbidity.