Risk factors for neck pain among forklift truck operators: a retrospective cohort study.

BACKGROUND: No previous research has been performed into neck pain among forklift operators. This is a common complaint among these workers, who number around 150,000 in Sweden and six million in Europe. The aim of the study was to examine long-term exposure to unnatural neck positions among forklift operators as a risk factor for neck pain. METHODS: A retrospective cohort study was conducted of all eligible employees at a high-level warehouse. Forklift operators and office workers answered an 18-page questionnaire comprising questions about joint pain, work tasks, work postures and year of start for all items. By using person years in the exposed and less-exposed groups before start of neck pain we were able to calculate Incident Rate ratios for various exposures. RESULTS: Forty nine percent of the forklift operators reported having experienced neck pain compared to 30 % of office workers. Being a forklift operator was associated with an increased risk of neck pain (OR = 5.1, 95% CI 1.4-18.2). Holding the head in an unnatural position resulted in significantly increased risks for neck pain, irrespective of type of position. The risks for neck pain remained after taking other ergonomic exposures and psychosocial aspects into consideration. CONCLUSIONS: This is the first published study showing that forklift operators have an increased risk of neck pain. The results are therefore of significance for improving work schedules, the adjustment of work tasks for these workers and the design of the vehicles.

Protein profiles of nasal lavage fluid from individuals with work-related upper airway symptoms associated with moldy and damp buildings.

Upper airway irritation is common among individuals working in moldy and damp buildings. The aim of this study was to investigate effects on the protein composition of the nasal lining fluid. The prevalence of symptoms in relation to work environment was examined in 37 individuals working in two damp buildings. Microbial growth was confirmed in one of the buildings. Nasal lavage fluid was collected from 29 of the exposed subjects and 13 controls, not working in a damp building. Protein profiles were investigated with a proteomic approach and evaluated by multivariate statistical models. Subjects from both workplaces reported upper airway and ocular symptoms. Based on protein profiles, symptomatic subjects in the two workplaces were discriminated from each other and separated from healthy controls. The groups differed in proteins involved in inflammation and host defense. Measurements of innate immunity proteins showed a significant increase in protein S100-A8 and decrease in SPLUNC1 in subjects from one workplace, while alpha-1-antitrypsin was elevated in subjects from the other workplace, compared with healthy controls. The results show that protein profiles in nasal lavage fluid can be used to monitor airway mucosal effects in personnel working in damp buildings and indicate that the profile may be separated when the dampness is associated with the presence of molds.

The risk for multiple sclerosis in female nurse anaesthetists: a register based study.

BACKGROUND: Previous studies have suggested that exposure to organic solvents, including volatile anaesthetic agents, may be a risk factor for multiple sclerosis (MS), possibly in combination with genetic and other environmental factors. AIMS: To further investigate the role of volatile anaesthetic agents having similar acute toxic effects to other organic solvents. METHODS: Female nurse anaesthetists, other female nurses, and female teachers from middle and upper compulsory school levels were identified and retrieved from the 1985 census, Statistics Sweden. By means of the unique personal identity number in Sweden, these individuals were linked with the disability pension registers at The National Social Insurance Board and also with data on hospital care 1985-2000 at The National Board of Health and Welfare. RESULTS: The cumulative incidence rate ratio of MS was found to be increased in female nurse anaesthetists in relation to other nurses (statistically not significant) and teachers (statistically significant), respectively. CONCLUSIONS: These findings give some support to previous findings of an increased risk for MS in nurse anaesthetists. This is interesting in the context of previous observations of organic solvents in general as a potential risk factor in MS.

Multiple sclerosis, solvents, and pets. A case-referent study.

The effect of potential risk factors for multiple sclerosis was evaluated in a case-referent study that encompassed 83 cases and 467 randomized referents. Information on exposure was obtained by questionnaires that were mailed to the subjects. Mantel-Haenszel rate ratios were increased for males for occupational exposure to solvents and welding and for females for leisure time contact with dogs and caged birds. For both sexes, x-ray film examination occurred more frequently among cases than referents, possibly as an effect of early symptoms from the disease itself.

A comment on the reference series with regard to multiple exposure evaluations in a case-referent study.

Case-referent (case-control) studies permit multiple exposures to be considered within the same series of cases and referents (controls) with regard to the etiologic contribution to a certain disease. Specific aspects of validity should be considered however, one being the utilization of an adequate reference series. Should the exposure cause, prevent, or otherwise have a certain relationship to disorders other than the one being studied, individuals with such other disorders cannot be uncritically included in the reference series if obtained from a hospital register, a register of causes of deaths, or some other source of subjects with relations to the individuals' health status. If a general population register is utilized, this problem is avoided since individuals obtained from such a register would adequately reflect the exposure frequency of the source population of the cases. These aspects are well illustrated by a consideration of the use of drugs among cases and, on one hand, referents with some sort of disorder as compared to referents (whether healthy or not) obtained from a population register on the other hand. Studies of industrial exposures seem to be somewhat less sensitive to bias of this type however, since industrial exposures are not primarily disorder-related, whereas drug exposures are.

Provocation of electric hypersensitivity under everyday conditions.

OBJECTIVES: In most previous provocation studies subjects suffering from "electric hypersensitivity" have not been able to determine correctly whether or not they have been subjected to a sham or true provocation to magnetic or electric fields. However, an often-discussed weakness is that most of the earlier provocation studies have been performed in a laboratory situation, often with simulated fields, which may not be representative of conditions prevailing in the homes or workplaces of the patients. Criticism has also been put forth about neglect of the long latency period of symptoms. Therefore, a provocation study was performed in the homes or workplaces of the patients, where we also studied the symptoms and on-off answer 24 hours after the exposure. METHODS: Fifteen subjects selected as having fast and distinct reactions from electric equipment were provoked on 4 occasions: mainly 2 true and 2 sham provocations. The intervals between exposure were a few or more days in order to provide the subjects with an opportunity to recover before the next provocation. A control group of healthy subjects with normal hearing and vision verified that the provocations were performed in a blind manner. RESULTS: The patients suffering from "electric hypersensitivity" were no better than the control group in deciding whether or not they were exposed to electric and magnetic fields. CONCLUSIONS: Exposure to electric and magnetic fields per se does not seem to be a sufficient cause of the symptoms experienced by this patient group.

Bronchial asthma and air pollution at workplaces.

OBJECTIVES: This case-referent study was performed to investigate the possibility of nonspecific air pollution at workplaces increasing the risk of bronchial asthma for formerly healthy adults. METHODS: Seventy-nine cases of asthma, diagnosed at a lung clinic, among persons aged 20-65 years were compared with 304 referents drawn randomly from the population of the catchment area. Questionnaire information was obtained regarding occupation, exposure to suspect allergens, place of residence, smoking habits, and atopy. The subjects' occupations were categorized into four air pollution classes based on how the referents reported air pollution in their respective occupations. RESULTS: Three years or more of work in air-polluted occupations resulted in an odds ratio of 3.0 (OR) (95% confidence interval 1.5-6.1) in a comparison with work in occupations with slight or no air pollution. Stratification of the material for smoking habits or atopy did not alter the results. Nor did the exclusion of specific exposures to asthmatogenic agents such as ioscyanates, stainless steel welding, or aluminum salts change the effects of the nonspecific air pollution at workplaces. Smoking per se was associated with an almost doubled risk for asthma (OR 1.9, 95% confidence interval 1.1-3.4). CONCLUSION: The results of this study support an association between occupational exposure to nonspecific air pollution and the development of bronchial asthma.

Effects of low-dose radiation - a correlation study.

The effects of low-dose radiation have been a matter of controversy over the years, and the epidemiologic results have been conflicting. A couple of recent studies have indicated a possible impact on lung cancer mortality from exposure to indoor levels of radon and radon daughters. In this study, selected mortality rates, ie, lung cancer, pancreatic cancer, breast cancer (females only), leukemia, and multiple myeloma were correlated for the counties of Sweden with estimates of average background radiation exposure in these areas. Significant correlations were obtained for lung cancer (males, r = 0.46; females r = 0.55) and pancreatic cancer (males, r = 0.59; females, r = 0.40) , and there was a borderline correlation (r = 0.36; p = 0.04) for leukemia in males. In all, there were positive correlations for eight out of the nine computations made. Since background radiation correlates with urbanization and therefore with smoking, air pollution, etc, the correlations might be spurious due to confounding; on the other hand confounding is a reciprocal phenomenon which suggests that background radiation should to be taken into consideration when widespread risk factors like smoking, coffee drinking, general air pollution, etc, are studied.

Glutathione S-transferase M1 null genotype as a risk modifier for solvent-induced chronic toxic encephalopathy.

OBJECTIVES: Exposure to organic solvents increases the risk of neuropsychiatric disability or chronic toxic encephalopathy (CTE). Polymorphisms in the biotransformation of xenobiotics and solvents may influence individual susceptibility to develop toxic effects. In this study the problem of whether there could be any association between the glutathione S-transferase M1 (GSTM1) null genotype and the risk for CTE, with regard to solvent exposure, was investigated. METHODS: Sixty patients referred to a clinic because of some degree of psychiatric or neurological symptoms, as well as exposure to solvents, were examined by means of a validated questionnaire and psychometric testing. The degree of exposure to solvents was assessed by a thorough interview. According to clinical findings, the patients were classified into three categories as those with solvent-induced CTE, those with incipient CTE, and those who were non-CTE patients. Afterwards, leukocyte DNA (deoxyribonucleic acid) was isolated and the GSTM1 null genotype was determined by an assay based on polymerase chain reaction, blindly with regard to both exposure and disease status. RESULTS: The relative proportion (RP) of GSTM1 null genotypes was significantly increased for patients with a diagnosed CTE when they were compared with non-CTE patients (RP 2.55, 95% confidence interval 1.0-6.2). Dichotomizing the patients by high and low exposure revealed an increased risk for both GSTM1 gene carriers and the GSTM1 null genotype in the high-exposure group, the relative risks (RR) being 4.5 and 7.9, respectively. The chi-square for the Mantel extension for trend was 6.2 (P = 0.025). CONCLUSIONS: The GSTM1 null genotype acts as a risk modifier for CTE among patients occupationally exposed to solvents. The risk seems to increase in a dose-dependent fashion.

A case-referent study on acute myeloid leukemia, background radiation and exposure to solvents and other agents.

The effect of potential risk factors for acute myeloid leukemia was evaluated in a case-referent study encompassing 42 cases and 244 referents, all deceased. Information on exposure was obtained with questionnaires mailed to the next of kin. Particularly the effect of background radiation was evaluated, as assessed with a gamma radiation index weighing the time spent outdoors and indoors and considering the building material (stone, wood, etc.) in the homes and the workplaces of the subjects. Especially between the ages of 20 and 49 a, to some extent also between 50 and 69 a but not above 70, there seemed to be an effect from background radiation and a trend suggesting an exposure-effect relationship. There was also about a sixfold increase in the rate ratio with regard to solvent exposure, which also seemed to modify the effect of background radiation. Other exposures were associated with relatively modest increases in the rate ratios and/or very small numbers of exposed individuals. It would be worthwhile to undertake further cancer epidemiologic studies of background radiation in which effective study designs are applied and a variety of potential confounders and modifiers of effect are identified and accounted for.

Are deficits in the equilibrium system relevant to the clinical investigation of solvent-induced neurotoxicity?

OBJECTIVES: The diagnosis of solvent-induced chronic toxic encephalopathy is commonly based on case histories of exposure to solvents, symptoms, and deficits on psychometric tests. It has previously been demonstrated that long-term solvent-exposed workers have disturbances of the equilibrium system. The correlation between these disturbances and the diagnosis of chronic toxic encephalopathy has been analyzed in the present study. MATERIAL AND METHODS: Sixty men, consecutively admitted due to the suspicion of this syndrome, were investigated and classified into 3 groups--solvent-induced chronic toxic encephalopathy, incipient chronic toxic encephalopathy and nonchronic toxic encephalopathy. They were all examined using an otoneurological test battery, including analysis of saccades, smooth pursuit, visual suppression of the vestibular ocular reflex, and dynamic posturography. RESULTS: Compared with healthy referents several of the subjects, even in the nonchronic toxic encephalopathy group, showed a reduced visual suppression ability, a prolonged latency of saccades, and pathological posturographic results. Some otoneurological tests correlated with the duration of exposure and the results of psychometric tests representing memory and perceptual skills. Nevertheless, there was no significant group correlation between the otoneurological findings and the diagnosis of chronic toxic encephalopathy. CONCLUSION: Disturbances revealed by an otoneurological investigation have so far not been considered in the diagnosis of chronic toxic encephalopathy. Our results indicate that an otoneurological test battery adds worthwhile information about lesions within the brainstem-cerebellar complex not revealed by a psychometric investigation.

Multiple sclerosis and exposure to solvents, ionizing radiation and animals.

Earlier studies have indicated an association between multiple sclerosis and environmental factors, especially occupational exposure to solvents. The present study examined such relationships further. From medical files of hospitals in Kalmar and Jönköping, 91 cases of multiple sclerosis, diagnosed in 1983-1988, were identified from population registers corresponding to the catchment areas of the hospitals, and 348 referents were randomly drawn. The cases and referents answered a questionnaire concerning occupational exposure and animal contacts. The men had significantly elevated risks, determined from logistic odds ratios, for solvent exposure, occupational contact with dogs or cats, and leisure-time contact with caged birds. X-ray treatment and previous diseases were risk indicators among the women. For the men and women together, solvent exposure, radiological work, and previous diseases were associated with clearly elevated risks. Although the study concerned rather few subjects, the findings indicate that several exogenous factors might contribute to the development of multiple sclerosis.

Incidence of neoplasms in ages 0-19 y in parts of Sweden with high 137Cs fallout after the Chernobyl accident.

The incidence of neoplasms in childhood and adolescence in northern and central Sweden before and after the radioactive fallout from the Chernobyl accident was investigated in an ecologic study, 1978 to 1992. The study included all parishes in the six most contaminated counties classified after aerial mapping of ground radiation from 137Cs and investigated 746 cases of neoplasms in ages 0-19 y, diagnosed in the six counties. Incidence and relative risks of neoplasms were compared in areas with high, intermediate, and low contamination after versus before the Chernobyl accident in 1986. A continuous increase of brain tumor incidence in the ages 0-19 y during the period 1978-92 without clear relationship to the Chernobyl fallout was discovered. No clear relationship between the incidence of brain tumor and the exposure to varying levels of radiation from 137Cs was apparent. A somewhat decreased relative risk of acute lymphatic leukemia appeared in areas with increased exposure. Other neoplasms showed no changes in incidence over time or with regard to exposure. Until now, there is no indication that the Chernobyl accident has affected the incidence of childhood and adolescence neoplasms in Sweden, but it is still too early for any final conclusion about the effect of this event.

Acute myeloid leukemia and background radiation in an expanded case-referent study.

A case-referent study that investigated possible associations between environmental and occupational exposures and acute myeloid leukemia was performed on 86 cases and 172 referents, all of whom were living. Exposure information was obtained through a questionnaire mailed to each subject. An association was found between time spent in concrete buildings at home and work and leukemia morbidity. In addition, extensive x-ray examinations that occurred more than 5 y prior to diagnosis were more common among cases than referents.

Background radiation, electrical work, and some other exposures associated with acute myeloid leukemia in a case-referent study.

The effect of potential risk factors for acute myeloid leukemia was evaluated in a case-referent study encompassing 59 cases and 354 referents, all of whom were alive. Information on exposure was obtained through a questionnaire mailed to the subjects. The possible effect of background radiation was evaluated by means of a gamma radiation index, which accounted for the differences between cases and referents in this respect, i.e., in time spent in concrete buildings both at home and at work places. In the 20-54 yr old age group, there was an association between leukemia morbidity and index of background radiation. X-ray treatment and electrical work were also associated with increased rate ratios. With regard to solvents, only styrene appeared as a risk factor, but the number of exposed subjects was small. Other exposures were less clearly associated with increased risks.

Non-sensitising air pollution at workplaces and adult onset asthma.

OBJECTIVE: The aim of this study was to elucidate further whether occupational exposure to non-sensitising air pollution at workplaces increases the risk of adult onset asthma. METHODS: One hundred and twenty persons with asthma diagnosed by general practitioners, aged 20-65 years, were compared with 446 referents matched for age and gender and living in the same community as the cases. Information about occupation, exposure to specific allergens, smoking habits, dwellings and atopy was obtained from a postal questionnaire. The subjects' occupations were categorised as clean or polluted, based on the judgement of the referents on their respective occupations. RESULTS: Three years or more of work in air-polluted workplaces resulted in an odds ratio of 1.7 (95% confidence interval 1.0-2.7). Stratification of the material on smoking habits, gender or atopy did not alter the results, nor did exclusion of subjects exposed to specific allergens of statistical significance in this material, e.g. flour dust. Smoking per se did not bring any risk of asthma. Working in buildings affected by dampness and mould brought a fourfold significant risk. CONCLUSION: In this study occupational exposure to unspecific air pollution at workplaces was associated with an increased risk of adult-onset asthma.

Multiple myeloma and engine exhausts, fresh wood, and creosote: a case-referent study.

The effect of potential risk factors for multiple myeloma was evaluated in a case-referent study encompassing 131 cases and 431 randomized referents, all alive. Information on exposure was obtained with questionnaires mailed to the subjects. An analysis of the material by means of the Miettinen confounder score technique resulted in a few rate ratios significantly exceeding unity--namely, occupational exposure to engine exhausts, creosote, and fresh wood. In view of other studies that suggest ionizing radiation as a risk factor, it was somewhat surprising that low-level gamma radiation from background exposure was less common among the cases than the referents.

Neuropsychiatric effects of low exposure to styrene.

Workers exposed to styrene concentrations of about 50 mg/m3 at a plant manufacturing reinforced polyester boats were examined for neuropsychiatric symptoms both in close connection with exposure and also seven months after exposure had ceased. Physical workload is important for the uptake of styrene and was about 50 W at this plant. On the first occasion, after one week with no exposure, the workers reported a high frequency of neuropsychiatric symptoms such as fatigue, irritation, and forgetfulness whereas seven months later the frequency of these symptoms was low. These observations indicate that exposure to styrene at about 50 mg/m3 may induce reversible neuraesthenic symptoms. Even the relatively low Swedish standard (110 mg/m3 = 25 ppm) may, therefore, need revising.