Healthcare utilization and unmet needs of patients with antisynthetase syndrome: An international patient survey

Antisynthease syndrome (ASSD) is a rare, complex and understudied autoimmune disease. Internet-based studies can overcome barriers of traditional on-site research and are therefore very appealing for rare diseases. The aim of this study was to investigate patient-reported symptoms, diagnostic delay, symptoms, medical care, health status, working status, disease knowledge and willingness to participate in research of ASSD patients by conducting an international web-based survey. The multilingual questionnaire was created by an international group of rheumatologists and patients and distributed online. 236 participants from 22 countries completed the survey. 184/236 (78.0%) were female, mean age (SD) was 49.6 years (11.3) and most common antisynthetase antibody was Jo-1 (169/236, 71.6%). 79/236 (33.5%) reported to work full-time. Median diagnostic delay was one year. The most common symptom at disease onset was fatigue 159/236 (67.4%), followed by myalgia 130/236 (55.1%). The complete triad of myositis, arthritis and lung involvement verified by a clinician was present in 42/236 (17.8%) at disease onset and in 88/236 (37.3%) during the disease course. 36/236 (15.3%) reported to have been diagnosed with fibromyalgia and 40/236 (16.3%) with depression. The most reported immunosuppressive treatments were oral corticosteroids 179/236 (75.9%), followed by rituximab 85/236 (36.0%). 73/236 (30.9%) had received physiotherapy treatment. 71/236 (30.1%) reported to know useful online information sources related to ASSD. 223/236 (94.5%) were willing to share health data for research purposes once a year. Our results reiterate that internet-based research is invaluable for cooperating with patients to foster knowledge in rare diseases.

Psychological Symptoms in Late Adolescence and Long-Term Risk of Suicide and Suicide Attempt

Mental disorders in the general population are associated with increased risk of suicidality, but less is known about the independent predictive ability of self-reported psychological symptoms. We followed 49,321 screened and interviewed Swedish conscripts through 36-year follow-up to test whether psychological symptoms predicted suicide and hospitalization for suicide attempts. There were 619 suicides and 1,230 suicide attempts during the follow-up period. After excluding subjects with any psychiatric diagnoses (n = 5,691, 12%) and controlling for other psychological symptoms, severe symptoms of anger, trouble falling asleep, and feeling down predicted suicide. Similarly anger, headaches, feeling down, and nervousness predicted suicide attempt. Self-reported psychological symptoms may have a predictive value beyond psychiatric diagnosis.

Conditions during childhood and adolescence as explanations of social class differences in disability pension among young men

Aims: This study investigates whether conditions present or established in youth and adolescence among young men contribute to the differences in the risk of an early disability pension (DP) among social classes. Methods: The study is based on data from a nationwide survey of the 49,285 Swedish males born between 1949 and 1951 who were conscripted into military service between 1969 and 1970. Data on socioeconomic groups were based on information of occupation and educational level reported in the census of 1975 held by Statistics Sweden. Potential psychosocial and behavioural risk factors were linked to records from the Swedish Social Insurance Board up until 1993. The analyses were based upon those 33,609 conscripts with information on all background variables who reported an occupation and who were not granted a DP in 1975. Results : The strongest social class difference in the distribution of risk indicators was found for low ranking on the psychometric tests and for having been in a remedial class. In the univariate analyses, the highest odds ratios were noted for unskilled manual workers. In the multivariate model, with all the background variables included, the increased risk ratios for lower socioeconomic groups decreased considerably for a DP irrespective of diagnosis, and diminished for a DP with an alcohol-related diagnosis. Conclusion: It is concluded that conditions present or established in youth and adolescence are of major importance to understand the strong social class gradient in disability pensions among young men. It is suggested that the increased risks for skilled and unskilled manual workers compared with non-manual employees might be interpreted according to the concept of unfavourable life careers.

Sickness absence at a young age and later sickness absence, disability pension, death, unemployment and income in native Swedes and immigrants

Background: Sickness absence with cash benefits from the sickness insurance gives an opportunity to be relieved from work without losing financial security. There are, however, downsides to taking sickness absence. Periods of sickness absence, even short ones, can increase the risk for future spells of sickness absence and unemployment. The sickness period may in itself have a detrimental effect on health. The aim of the study was to investigate if there is an association between exposure to sickness absence at a young age and later sickness absence, disability pension, death, unemployment and income from work. Methods: Our cohort consisted of all immigrants aged 21–25 years in Sweden in 1993 (N = 38 207) and a control group of native Swedes in the same age group (N = 225 977). We measured exposure to sickness absence in 1993 with a follow-up period of 15 years. We conducted separate analyses for men and women, and for immigrants and native Swedes. Results: Exposure to ≥60 days of sickness absence in 1993 increased the risk of sickness absence [hazard ratio (HR) 1.6–11.4], unemployment (HR 1.1–1.2), disability pension (HR 1.2–5.3) and death (HR 1.2–3.5). The income from work, during the follow-up period, among individuals with spells of sick leave for ≥60 days in 1993 was around two-thirds of that of the working population who did not take sick leave. Conclusions: Individuals on sickness absence had an increased risk for work absence, death and lower future income.

Lack of adjustment latitude at work as a trigger of taking sick leave-a Swedish case-crossover study

OBJECTIVES

Research has shown that individuals reporting a low level of adjustment latitude, defined as having few possibilities to temporarily adjust work demands to illness, have a higher risk of sick leave. To what extent lack of adjustment latitude influences the individual when making the decision to take sick leave is unknown. We hypothesize that ill individuals are more likely to take sick leave on days when they experience a lack of adjustment latitude at work than on days with access to adjustment latitude.

METHODS

A case-crossover design was applied to 546 sick-leave spells, extracted from a cohort of 1 430 employees at six Swedish workplaces, with a 3-12 month follow-up of all new sick-leave spells. Exposure to lack of adjustment latitude on the first sick-leave day was compared with exposure during several types of control periods sampled from the previous two months for the same individual.

RESULTS

Only 35% of the respondents reported variations in access to adjustment latitude, and 19% reported a constant lack of adjustment latitude during the two weeks prior to the sick-leave spell. Among those that did report variation, the risk of sick leave was lower on days with lack of adjustment latitude, than on days with access (Odds Ratio 0.36, 95% Confidence Interval 0.25-0.52).

CONCLUSIONS

This is the first study to show the influence of adjustment latitude on the decision to take sick leave. Among those with variations in exposure, lack of adjustment latitude was a deterrent of sick leave, which is contrary to the à priori hypothesis. These results indicate that adjustment latitude may not only capture long-lasting effects of a flexible working environment, but also temporary possibilities to adjust work to being absent. Further studies are needed to disentangle the causal mechanisms of adjustment latitude on sick-leave.

Work and health among immigrants and native Swedes 1990-2008: a register-based study on hospitalization for common potentially work-related disorders, disability pension and mortality

Background

There are many immigrants in the Swedish workforce, but knowledge of their general and work-related health is limited. The aim of this register-based study was to explore whether documented migrant residents in Sweden have a different health status regarding receipt of a disability pension, mortality and hospitalization for lung, heart, psychiatric, and musculoskeletal disorders compared with the native population, and if there were variations in relation to sex, geographical origin, position on the labor market, and time since first immigration.

Methods

This study included migrants to Sweden since 1960 who were 28–47 years old in 1990, and included 243 860 individuals. The comparison group comprised a random sample of 859 653 native Swedes. These cohorts were followed from 1991 to 2008 in national registers. The immigrants were divided into four groups based on geographic origin. Hazard ratios for men and women from different geographic origins and with different employment status were analyzed separately for the six outcomes, with adjustment for age, education level, and income. The influence of length of residence in Sweden was analyzed separately.

Results

Nordic immigrants had increased risks for all investigated outcomes while most other groups had equal or lower risks for those outcomes than the Swedes. The lowest HRs were found in the EU 15+ group (from western Europe, North America, Australia and New Zealand). All groups, except Nordic immigrants, had lower risk of mortality, but all had higher risk of disability pension receipt compared with native Swedes. Unemployed non-Nordic men displayed equal or lower HRs for most outcomes, except disability pension receipt, compared with unemployed Swedish men. A longer time since first immigration improved the health status of men, while women showed opposite results.

Conclusions

Employment status and length of residence are important factors for health. The contradictory results of low mortality and high disability pension risks need more attention. There is great potential to increase the knowledge in this field in Sweden, because of the high quality registers.

Unemployment at a young age and later sickness absence, disability pension and death in native Swedes and immigrants

Background: Youth unemployment is an increasing problem for societies around the world. Research has revealed negative health effects of unemployment, and this longitudinal register-based cohort study examined the relationship between unemployment and later sickness absence, disability pension and death among youth in Sweden. Method: The study group of 199 623 individuals comprised all immigrants born between 1968 and 1972 who immigrated before 1990 (25 607) and a random sample of native Swedes in the same age-range (174 016). The baseline year was 1992, and the follow-up period was from 1993 to 2007. Subjects with unemployment benefit in 1990–91, disability pension in 1990–92, severe disorders leading to hospitalization in 1990–92 and subjects who emigrated during follow-up were excluded. Results: Those who were unemployed in 1992 had elevated risk of ≥60 days of sickness absence (OR 1.02–1.49), disability pension (HR 1.08–1.62) and all except native Swedish women had elevated risk of death (HR 1.01–1.65) during follow-up compared with non-unemployed individuals. The risk of future sickness absence increased with the length of unemployment in 1992 (OR 1.06–1.54), and the risk of sickness absence increased over time. A larger part of the immigrant cohort was unemployed at baseline than native Swedes. Selection to unemployment by less healthy subjects may explain part of the association between unemployment and the studied outcomes. Conclusion: Unemployment at an early age may influence the future health of the individual. To a society it may lead to increased burdens on the welfare system and productivity loss for many years.

Demands, skill discretion, decision authority and social climate at work as determinants of major depression in a 3-year follow-up study

PURPOSE

The psychosocial work environment may be a determinant of the development and course of depressive disorders, but the literature shows inconsistent findings. Thus, the aim of this study is to determine longitudinal effects of the job demands-control-support model (JDCSM) variables on the occurrence of major depression among working men and women from the general population.

METHODS

The sample comprised 4,710 working women and men living in Stockholm, who answered the same questionnaire twice, 3 years apart, who were not depressed during the first wave and had the same job in both waves. The questionnaire included JDCSM variables (demands, skill discretion, decision authority and social climate) and other co-variables (income, education, occupational group, social support, help and small children at home, living with an adult and depressive symptoms at time 1; and negative life events at time 2). Multiple logistic regressions were run to calculate odds ratios of having major depression at time 2, after adjustment for other JDCSM variables and co-variables.

RESULTS

Among women, inadequate work social climate was the only significant risk indicator for major depression. Surprisingly, among men, high job demands and low skill discretion appeared as protective factors against major depression.

CONCLUSIONS

The results showed a strong relationship between inadequate social climate and major depression among women, while there were no certain effects for the remaining exposure variables. Among men, few cases of major depression hampered well-founded conclusions regarding our findings of low job demands and high skill discretion as related to major depression.

Psychiatric diagnosis in late adolescence and long-term risk of suicide and suicide attempt

OBJECTIVE

To investigate the associations between psychiatric diagnosis in late adolescence in an unselected population and subsequent suicide attempt and suicide during 36-year follow-up.

METHOD

A total of 49,321 Swedish men conscripted for compulsory military training in 1969/1970, born 1949-1951, were screened for psychiatric disorder and, if detected, diagnosed by a psychiatrist according to ICD-8. Data on suicides and suicide attempts 1971-2006 were collected in national registers.

RESULTS

At conscription examination, 11.7% of the cohort received a psychiatric diagnosis. Among those, increased risks of suicide 1971-2006 [HR = 2.7 (2.2-3.2), 624 cases] and suicide attempt 1973-2006 [HR = 3.5 (3.1-4.0), 1170 cases] were found. The increased relative risks persisted during the follow-up period 19-36 years after examination [1989-2006 suicide HR = 2.1 (1.6-2.7), 308 cases, and 1989-2006 suicide attempt HR = 2.6 (2.1-3.1), 484 cases]. The dominant diagnostic groups, neurosis and personality disorder, were significantly associated with suicide and suicide attempt in the early as well as the late follow-up period.

CONCLUSION

Psychiatric diagnoses made in late adolescence predicted subsequent suicide and suicide attempt over a 36-year follow-up period. The increased relative risks were not limited to young adulthood but were also evident 18-36 years after conscription examination.

Assessment of long-term and recent pesticide exposure among rural school children in Nicaragua

OBJECTIVE

This study assessed pesticide exposure of children in rural Nicaragua in relation to parental pesticide use, from around conception to current school age, as part of an epidemiological evaluation of neurodevelopment effects.

METHODS

We included 132 children whose parents were subsistence farmers or plantation workers, or had an agricultural history. As proxies for children's long-term exposures, we constructed cumulative parental pesticide-specific use indices for periods before and after the child's birth from data obtained using an icon-calendar-based questionnaire, of application hours (h) for plantation workers and subsistence farmers, and of kilograms of active ingredients (ai) only for subsistence farmers. Pesticide residues of TCPY, 3-PBA and 2,4-D were analysed in children's urine as indicators for current exposures.

RESULTS

Life-time indices were highest for the organophosphates chlorpyrifos (median 114 h (min 2; max 1584), 19.2 kg ai (min 0.37; max 548)) and methamidophos (84 h (6; 1964), 12.2 kg ai (0.30; 780)). The P50 values of children's urinary residues were 3.7 μg/g creatinine for TCPY, 2.8 for 3-PBA and 0.9 for 2,4-D; TCPY values are comparable with those in other countries, but 3-PBA and 2,4-D are considerably higher. The maximum levels for all three pesticides are the highest reported for children. Residues increased on days after application, but most high residue levels were unrelated to parental pesticide applications.

CONCLUSION

Urinary pesticide residues reveal high environmental exposure among children in rural Nicaragua. The quantitative parental pesticide use indices as proxies for children's exposures during different periods may be useful for the evaluation of developmental health effects.

Unemployment and mortality--a longitudinal prospective study on selection and causation in 49321 Swedish middle-aged men

BACKGROUND

Unemployment is associated with increased risk of mortality. It is, however, not clear to what extent this is causal, or whether other risk factors remain uncontrolled for. The aim of this study was to investigate the association between unemployment and all-cause and cause-specific mortality, adjusting for indicators of mental disorder, behavioural risk factors and social factors over the life course.

METHODS

This study was based on a cohort of 49321 Swedish males, born 1949/51, tested for compulsory military conscription in 1969/70. Data on employment/unemployment 1990-4 was based on information from the Longitudinal Register of Education and Labour Market Statistics. Information on childhood circumstances was drawn from National Population and Housing Census 1960. Information on psychiatric diagnosis and behavioral risk factors was collected at conscription testing in 1969/70. Data on mortality and hospitalisation 1973-2004 were collected in national registers.

RESULTS

An increased risk of mortality 1995-2003 was found among individuals who experienced 90 days or more of unemployment during 1992-4 compared with those still employed (all-cause mortality HR 1.91, 95% CI 1.58 to 2.31. Adjustment for risk factors measured along the life course considerably lowered the relative risk (all cause mortality HR 1.30, 95% CI 1.06 to 1.58). Statistically significant increased relative risk was found during the first 4 years of follow up (all-cause mortality, adjusted HR 1.57, 95% CI 1.13 to 2.18, but not the following 4 years (all cause mortality, adjusted HR 1.17, 95% CI 0.91 to 1.50).

CONCLUSION

The results suggest that a substantial part of the increased relative risk of mortality associated with unemployment may be attributable to confounding by individual risk factors.

Work-related psychosocial events as triggers of sick leave--results from a Swedish case-crossover study

BACKGROUND

Although illness is an important cause of sick leave, it has also been suggested that non-medical risk factors may influence this association. If such factors impact on the period of decision making, they should be considered as triggers. Yet, there is no empirical support available.The aim was to investigate whether recent exposure to work-related psychosocial events can trigger the decision to report sick when ill.

METHODS

A case-crossover design was applied to 546 sick-leave spells, extracted from a Swedish cohort of 1430 employees with a 3-12 month follow-up of new sick-leave spells. Exposure in a case period corresponding to an induction period of one or two days was compared with exposure during control periods sampled from workdays during a two-week period prior to sick leave for the same individual. This was done according to the matched-pair interval and the usual frequency approaches. Results are presented as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Most sick-leave spells happened in relation to acute, minor illnesses that substantially reduced work ability. The risk of taking sick leave was increased when individuals had recently been exposed to problems in their relationship with a superior (OR 3.63; CI 1.44-9.14) or colleagues (OR 4.68; CI 1.43-15.29). Individuals were also more inclined to report sick on days when they expected a very stressful work situation than on a day when they were not under such stress (OR 2.27; CI 1.40-3.70).

CONCLUSIONS

Exposure to problems in workplace relationships or a stressful work situation seems to be able to trigger reporting sick. Psychosocial work-environmental factors appear to have a short-term effect on individuals when deciding to report sick.

Early-onset depression, anxiety, and risk of subsequent coronary heart disease: 37-year follow-up of 49,321 young Swedish men

OBJECTIVES

The purpose of this study was to investigate the long-term cardiac effects of depression and anxiety assessed at a young age, when reverse causation is not feasible.

BACKGROUND

Most prospective studies found a relatively strong association between depression and subsequent coronary heart disease (CHD). However, almost exclusively, only middle-age or older participants were examined, and subclinical atherosclerosis might contribute to the observed association. The prospective association between anxiety and CHD was less evident in previous studies and has been subjected to similar methodological concerns on the possibility for a reverse causation.

METHODS

In a nationwide survey, 49,321 young Swedish men, 18 to 20 years of age, were medically examined for military service in 1969 and 1970. All the conscripts were seen by a psychologist for a structured interview. Conscripts reporting or presenting any psychiatric symptoms were seen by psychiatrists. Depression and anxiety was diagnosed according to International Classification of Diseases-8th Revision (ICD-8). Data on well-established CHD risk factors and potential confounders were also collected (i.e., anthropometrics, diabetes, blood pressure, smoking, alcohol consumption, physical activity, socioeconomic position, family history of CHD, and geographic area). Participants were followed for CHD and for acute myocardial infarction for 37 years.

RESULTS

Multiadjusted hazard ratios associated with depression were 1.04 (95% confidence interval [CI]: 0.70 to 1.54), 1.03 (95% CI: 0.65 to 1.65), for CHD and for acute myocardial infarction, respectively. The corresponding multiadjusted hazard ratios for anxiety were 2.17 (95% CI: 1.28 to 3.67) and 2.51 (95% CI: 1.38 to 4.55).

CONCLUSIONS

In men, aged 18 to 20 years, anxiety as diagnosed by experts according to ICD-8 criteria independently predicted subsequent CHD events. In contrast, we found no support for such an effect concerning early-onset depression in men.

Non-participation in the second wave of the PART study on mental disorder and its effects on risk estimates

BACKGROUND

In epidemiological studies, analyses are needed to investigate the consequences of non-response.

AIMS

To analyse the consequences of attrition in the second wave of the population-based PART study, which was performed three years after the first wave.

METHODS

Potential determinants for non-participation obtained from population registers and the first wave were analyzed. The relationships between potential determinants and reduced well-being or depressive mood in the first wave questionnaire were investigated separately for participants and non-participants in the second wave. Samples of respondents to the second wave questionnaire with reduced or not reduced well-being were summoned for interview regarding determinants of distress and disorder. The occurrence of potential determinants was compared between participants and non-participants in both groups.

RESULTS

Low income, low education, non-Nordic origin, not being married and previous psychiatric diagnosis were associated with lower participation rates. These variables were similarly related to depressive mood and low psychological well-being in the first wave among participants and non-participants in the second wave. Potential determinants were not or only weakly related to participation in the interview groups.

CONCLUSION

Although the true prevalence of distress and disorder is underestimated, the true associations between potential determinants and the outcomes seem reasonably well reproduced.

Decreased kidney function of unknown cause in Nicaragua: a community-based survey

BACKGROUND

End-stage kidney disease overwhelms health services in Central America. We determined prevalences of decreased kidney function in distinct populations in the most affected region of Nicaragua.

STUDY DESIGN

Cross-sectional survey.

SETTING & PARTICIPANTS

Total populations aged 20-60 years of 5 villages in Northwest Nicaragua: mining/subsistence farming (elevation, 100-300 m above sea level), banana/sugarcane (100-300 m), fishing (0-100 m), services (0-100 m), and coffee (200-675 m); 479 men and 617 women (83% response).

PREDICTOR OR FACTOR

Village; participant sex, age, and occupation; conventional chronic kidney disease risk factors.

OUTCOMES

Serum creatinine (SCr) values greater than laboratory reference range for sex, estimated glomerular filtration rate <60 mL/min/1.73 m(2), proteinuria stratified in the low (dipstick protein excretion, 30-300 mg/dL) and high (>300 mg/dL) range.

RESULTS

Prevalences of abnormal SCr levels: 18% (of all men) and 5% (of all women); in the mining/subsistence farming village, 26% and 7%; banana/sugarcane, 22% and 6%; fishing, 13% and 4%; services, 0% and 1%; and coffee, 7% and 0%. Prevalences of estimated glomerular filtration rate <60 mL/min/1.73 m(2): 14% (of all men) and 3% (of all women); in the listed villages, 19% and 5%, 17% and 4%, 10% and 2%, 0% and 0%, and 7% and 0%, respectively. Proteinuria, predominantly in the low range, affected 14% and 11% of all men and women without marked differences between villages. By occupation, abnormal SCr levels occurred in 31% and 24% of male and female agricultural workers at 100-300 m above sea level, but not at higher altitudes, and also was high in male artisans (43%), construction workers (15%), and miners (14%). In logistic regression models, for the banana/sugarcane and mining/subsistence farming villages, high blood pressure and age were significant predictors of abnormal SCr levels in men, and for mining/subsistence farming, age in women.

LIMITATIONS

Causality is not addressed.

CONCLUSIONS

In some Nicaraguan villages and population segments, men in particular show a high prevalence of decreased kidney function of unknown origin, possibly environmental or occupational.

Low level of adjustment latitude--a risk factor for sickness absence

BACKGROUND

The prerequisite for obtaining sickness benefit is reduced work ability for medical reasons in combination with work demands which cannot be adjusted accordingly. The aim of this study was to investigate if low levels of adjustment latitude, defined as the possibility to temporarily adjust work demands in case of ill health, influence sickness absence.

METHODS

A prospective cohort study of 1420 employees (47% participation, aged 19-68; 56% women) was conducted at six Swedish workplaces. Exposure to two general and nine specific types of adjustment latitude was ascertained at baseline. Outcome was defined as the first new employer-reported sick-leave spell during a follow-up of 3-12 months. Hazard ratios (HR) of sick leave, with 95% confidence intervals (CI), were estimated by Cox proportional hazards regression.

RESULTS

The incidence of sickness absence was 2.85/1000 person-days. The self-reported reasons for sick leave were mainly minor complaints such as colds, influenzas and headaches. Employees lacking adjustment latitude had an adjusted HR of sickness absence of 1.51 (95% CI 1.08-2.11). Among specific adjustment latitude types, those not having the possibility to work from home generated an HR of 1.86 (95% CI 1.31-2.64). The effects of lack of adjustment latitude were similar for men and women but seemed to vary between different occupations.

CONCLUSION

A low level of adjustment latitude at work is a risk factor for sickness absence.

Early precursors and enabling skills of reading acquisition

Research on early linguistic precursors and enabling skills of reading acquisition among young children is reviewed. Language development starts early in infancy when the child learns to categorize the speech sounds according to the pattern typical of the mother tongue. Equipped with these sound categories the child is ready to learn to segment words from the sound stream and to understand and to use words. The precise phonological representation of words will facilitate the important development of phonological awareness, a basic prerequisite for reading acquisition. This paper reviews some of my longitudinal research and training studies indicating the causal direction of the relation between phonological awareness and reading and includes some ongoing studies, where gender differences, socio-economic factors, dose-response-effects and motivational factors are explored. Preventive and remedial implications of the findings are pointed out. Finally, the complexity of the causal relationships between different aspects of early language development, including genetic influences and later reading is pointed out.

Silica exposure among male current smokers is associated with a high risk of developing ACPA-positive rheumatoid arthritis

Objective

To study the association between silica exposure, separately as well as combined with smoking, and the risk of developing rheumatoid arthritis (RA) with or without the presence of antibodies against citrullinated peptide antigens (ACPA).

Methods

This Swedish population based case–control study analysed 577 incident RA cases and 659 randomly selected controls, all men aged 18–70 years, included during May 1996 to May 2006. Self-reported silica exposure, defined as exposure to stone dust, rock drilling or stone crushing and cigarette smoking was registered. ACPA status among cases was analysed.

Results

Silica-exposed subjects were found to have a moderately increased risk of ACPA-positive RA (odds ratio (OR) adjusted for age and residency=1.67 (95% CI 1.13 to 2.48), but not of ACPA-negative RA (OR=0.98 (95% CI 0.57 to 1.66)), compared with subjects unexposed to silica. Subjects exposed to rock drilling were found to have a somewhat more markedly increased risk of ACPA-positive RA (OR=2.34 (95% CI 1.17 to 4.68)). A high risk of developing ACPA-positive RA was observed among silica-exposed current smokers (OR=7.36 (95% CI 3.31 to 16.38)), exceeding the risk expected from the separate effects of silica exposure and current smoking, indicating an interaction between these exposures (attributable proportion due to interaction=0.60 (95% CI 0.26 to 0.95)).

Conclusion

Silica exposure combined with smoking among men is associated with an increased risk of developing ACPA-positive RA. These results suggest that different inhalation exposures may interact in the aetiology of ACPA-positive RA.

Studies on kidney function in subjects exposed to organic solvents. I. Excretion of albumin and beta-2-microglobulin in the urine

The urine of 134 subjects, exposed to different organic solvents, and 48 unexposed subjects has been analysed with reference to albumin and beta-2-microglobulin excretion. The exposed subjects excreted significantly larger quantities of albumin than the unexposed. Those exposed to styrene excreted the largest amounts. No significant difference in beta-microglobulin excretion could be demonstrated between the groups.

Problematic interpersonal relationships at work and depression: a Swedish prospective cohort study

OBJECTIVES

Studies have shown that interpersonal relations at work are important for several health related outcomes. The aim of the present study was to investigate whether low social support, serious conflict, exclusion by superiors or by co-workers at work may be determinants of depression.

METHODS

In a representative Swedish cohort study data were obtained in two waves three years apart. 4,040 women and men who did not change their jobs between the waves were chosen for the study. Exposure and confounders were obtained at Time 1 and outcome, depression according to Bech's MDI at Time 2. Previous depression was controlled for by adjusting for depression at Time 1. Data were analyzed using multiple logistic regression analyses.

RESULTS

Odds-ratios adjusted for possible confounders and depression at base-line showed significant effects for all four exposures on depression (adjusted OR, low social support 1.5 CI 95% 1.1-2.0, serious conflict 1.4 CI 95% 1.1-1.9, exclusion by superiors 1.6 CI 95% 1.2-2.1 and exclusion by co-workers 1.7 CI 95% 1.2-2.3).

CONCLUSIONS

The present results support the conclusion that problematic interpersonal relationships at work can be determinants of depression. These prospective findings may be of relevance for prevention and when rehabilitating depressed patients.

The Nicaraguan Pesticide Poisoning Register: constant underreporting

This study estimated the level of underreporting of acute pesticide poisonings (APP) in the pesticide surveillance system in Nicaragua in 2000. Data on pesticide exposure and health effects were assessed in a nationally representative cross-sectional survey of 3,169 persons aged 15 years and older. The authors found 1,369 cases of APP in the official register for 2000. Responses to questionnaires revealed 22 cases of APP in which individuals sought medical attention. Most of these cases involved agricultural workers who spray organophosphate pesticides, mostly class I. In 68 percent of cases, the mean out-of-pocket cost for treatment of one APP episode was $41, almost equivalent to one month's salary. Only 1 of the 22 cases (< 5%) in which the individual sought medical attention was reported to the national register. The authors estimate that, nationally, about 30,000 pesticide poisoning cases receiving medical treatment were not reported. Characterization of APP based only on official figures, without considering the underreported cases, leads to a constant inability to interpret and report acute pesticide health effects in a manner useful to policymakers. The pesticide surveillance system must be strengthened to improve registration routines, analysis and interpretation of data, health personnel training, and participation of private providers.

Components of the Illness Flexibility Model as Explanations of Socioeconomic Differences in Sickness Absence

The authors studied the social gradient in sickness absence in relation to components of the illness flexibility model, which highlights conditions affecting whether people attend work when they are ill. The conditions studied were: adjustment latitude, attendance requirements at work, stimulating work, and health. The population sample was part of a panel originating in 1994 when 15,154 inhabitants of Stockholm County were randomly selected to receive a questionnaire covering, among other things, health and psychosocial conditions. New questionnaires were sent to the respondents in 1998 and 2002. This article analyzes the 2002 data, for 1,634 women and 1,063 men. These respondents had reported being employed or on leave of absence. In this sample, a social difference was found in sickness absence of 31 days or more per year. For manual workers, women had an odds ratio (OR) of 2.8 and men an OR of 3.4 for such absence compared with nonmanual workers of both sexes in high socioeconomic positions. All single potential confounders decreased these ORs. Adding all characteristics decreased the OR by 78 percent for women and 67 percent for men. The results indicate that the social gradient in sickness absence is due to differences in health and in working conditions when one is ill.

To what extent may the association between immigrant status and mental illness be explained by socioeconomic factors?

BACKGROUND

Immigrants in Sweden have a higher rate of mental illness than the native Swedes. This study investigated to what extent the association between immigrant status and mental illness can be explained by a different distribution of known risk factors for impaired mental health between groups of immigrants and persons born in Sweden.

METHODS

The study is based on data from the Swedish PART-study, designed to identify risk factors for, and social consequences of, mental illness. The study population consists of a random sample of 10,423 Swedish citizens, whereof 1,109 were immigrants. The data was collected in the year 2000. The immigrants were divided into three groups based on country of origin (Scandinavians born outside Sweden, Europeans born outside Scandinavia, non-Europeans). The occurrence of mental illness among immigrants and native Swedes were compared not adjusting and adjusting for indicators of socioeconomic advantage/disadvantage (education, income, labour market position, etc). Mental illness was approximated with the WHO (ten) wellbeing index scale and depressive symptoms were measured with the major depression inventory scale (MDI).

RESULTS

Immigrants' excess risk for low subjective wellbeing was completely accounted for by adjustment for known risk factors in all the immigrant groups. However, social-economic disadvantages could not account for the non-European immigrants' higher prevalence of depression (MDI), although the increased relative risk found in univariate analyses was substantially reduced.

CONCLUSIONS

The findings in this study suggest that the association between immigrant status and mental illness appears above all to be an effect of a higher prevalence of social and economic disadvantage.

Mortality, morbidity and occupational exposure to airway-irritating agents among men with a respiratory diagnosis in adolescence

OBJECTIVES

To examine the influence of an airway diagnosis in adolescence on future health and occupation in Swedish men.

METHODS

Data were collected from the linkage of four Swedish national registers: the Military Service Conscription Register, the Population and Housing Censuses, the Inpatient Care Register and the National Cause of Death Register. A job-exposure matrix for airway-irritating substances was developed for application on the conscription cohort. The cohort included 49 321 Swedish men born 1949-51. Three groups-(1) healthy, (2) asthmatics (mild and severe asthma) and (3) subjects with allergic rhinitis without concurrent asthma-were identified at conscription and analysed for mortality, in-patient care and strategies for choice of occupation with emphasis on airway-irritating job exposure. Analyses were adjusted for smoking and childhood socioeconomic position.

RESULTS

The prevalence of total asthma was 1.8%, severe asthma 0.45% and allergic rhinitis 2.7%. Mortality for all causes was significantly higher in total asthma, hazard ratio (HR) 1.49 (95% CI 1.00 to 2.23), and lower in allergic rhinitis, HR 0.52 (95% CI 0.30 to 0.91). Asthma was a risk factor for inpatient care while allergic rhinitis was associated with less in-patient care (odds ratio (OR) for total asthma 1.16 (95% CI 1.00 to 1.34), severe asthma 1.38 (95% CI 1.04 to 1.85), allergic rhinitis 0.92 (95% CI 0.82 to 1.03)). Those with asthma tended to avoid jobs with a high probability for airway-irritating exposure (OR 0.88, 95% CI 0.71 to 1.09), but not to the same extent as subjects with allergic rhinitis (OR 0.58, 95% CI 0.47 to 0.70) (ORs from 1990).

CONCLUSION

Subjects with asthma did not change their exposure situation to the same extent as subjects with allergic rhinitis. Further, asthmatics had an increased risk for morbidity and mortality compared to healthy subjects and subjects with allergic rhinitis.

Parental occupational exposure to pesticides and the risk of childhood leukemia in Costa Rica

OBJECTIVES

Parental exposure to pesticides and the risk of leukemia in offspring were examined in a population-based case-control study in Costa Rica.

METHODS

All cases of childhood leukemia (N=334), in 1995-2000, were identified at the Cancer Registry and the Children's Hospital. Population controls (N=579) were drawn from the National Birth Registry. Interviews of parents were conducted using conventional and icon-based calendar forms. An exposure model was constructed for 25 pesticides in five time periods.

RESULTS

Mothers' exposures to any pesticides during the year before conception and during the first and second trimesters were associated with the risk [odds ratio (OR) 2.4, 95% confidence interval (95% CI) 1.0-5.9; OR 22, 95% CI 2.8-171.5; OR 4.5, 95% CI 1.4-14.7, respectively] and during anytime (OR 2.2, 95% CI 1.0-4.8). An association was found for fathers' exposures to any pesticides during the second trimester (OR 1.5, 95% CI 1.0-2.3). An increased risk with respect to organophosphates was found for mothers during the first trimester (OR 3.5, 95% CI 1.0-12.2) and for fathers during the year before conception and the first trimester (OR 1.5, 95% CI 1.0-2.2 and OR 1.6, 95% CI 1.0-2.6, respectively), and benzimidazoles during the first, second, and third trimesters of pregnancy (OR 2.2, 95% CI 1.0-4.4; OR 2.2, 95% CI 1.0-5.0; OR 2.2, 95% CI 1.0-5.2, respectively). There was a suggestion of an exposure-response gradient for fathers as regards picloram, benomyl, and paraquat. Age at diagnosis was positively associated with fathers' exposures and inversely associated with mothers' exposures.

CONCLUSIONS

The results suggest that parental exposure to certain pesticides may increase the risk of leukemia in offspring.

Adolescent mental health predicts quitting smoking in adulthood: a longitudinal analysis

OBJECTIVES

Several studies have reported an association between cigarette smoking and psychiatric illness. A common finding is that the prevalence of psychiatric illness among former smokers is much lower than among current smokers and is often similar to that among never-smokers. There are two alternative causal explanations for this association: either improved mental well-being results from smoking cessation; or those with poorer mental well-being are less successful at smoking cessation. The objective was to analyse a unique longitudinal data set to shed light on the direction of causality and to distinguish between these alternative explanations.

METHODS

Information on smoking status and indicators of poor mental well-being from childhood and adolescence was collected at age 18 in 1969 from 49 321 men at compulsory conscription for military service. Follow-up data on smoking status were collected among a random subset (n = 694) who participated in one or more annual national Swedish Surveys of Living Conditions in 1981-2001.

RESULTS

Approximately half of the smokers at age 18 in 1969 had quit by the time they were resurveyed (1981-2002). Those who had not quit and who reported smoking more than 10 cigarettes/day at age 18 (called persistent heavy smokers), were more likely to have had childhood and adolescent indicators of poor mental health measured at age 18 in 1969 than non-smokers or quitters.

CONCLUSION

Our findings indicate that men who would subsequently be successful at smoking cessation reported better mental health and a lower prevalence of childhood mental health indicators at age 18 than persistent heavy smokers.

The association between cognitive ability measured at ages 18-20 and coronary heart disease in middle age among men: a prospective study using the Swedish 1969 conscription cohort

An association between childhood cognitive ability measured with IQ-tests and coronary heart disease (CHD) incidence has been reported recently. It is not clear from those studies to what extent the increased relative risk associated with lower cognitive ability may be explained by CHD risk factors. This study aims to investigate the association between cognitive ability measured at age 18-20 and incidence of CHD, acute myocardial infarction (AMI), and stroke among middle aged men adjusting for risk factors for CHD over the life course. Data on cognitive ability, and other risk factors for CHD (height, parental cardiovascular diseases (CVD) mortality, blood pressure, smoking, risky use of alcohol, BMI), were collected from 49,321 men, born in 1949-51, at conscription for compulsory military training in 1969/70 in Sweden. Information on socioeconomic factors in childhood (socioeconomic position and crowded housing) and adulthood (education, socioeconomic position, and income), as well as information on mortality and morbidity, was collected through national registers. Cognitive ability showed an inverse and graded association with CHD incidence. Adjustment for indicators of poor childhood circumstances, behavioural factors measured in late adolescence, and adult social circumstances strongly attenuated the increased risks of CHD and AMI. The contribution from adult social circumstances, after adjustment from all other factors, was very small. After adjustment for all risk factors no significantly increased relative risk was seen for stroke incidence. After adjustment for risk factors over the life course, the risk of CHD and AMI associated with cognitive ability decreased substantially, and was of borderline significance. Given the results from this study it is unlikely that cognitive ability is a risk factor on its own for CHD, AMI and stroke among men below 54 years of age.

Reading, arithmetic, and task orientation--how are they related?

A sample of 60 children in Grade 3 was followed over one year. In the first year, an extensive battery of assessments was used including aspects of reading, arithmetic, and working memory. Teachers rated the children on 7-point scales on various motivational dimensions summarized to a total score tentatively called task orientation. In the follow-up assessment one year later, the testing and teacher ratings were repeated. The cross-sectional correlations between reading, arithmetic, and task orientation were all high (about +.70). The high correlation between reading and arithmetic decreased significantly when task orientation was partialed out, and it was further reduced when working memory as assessed by backward digit span was added to the controlling factors. Also, teacher ratings of cognitive ability and language development accounted for some of the common variance between reading and arithmetic. The correlation between task orientation and school achievement cannot be causally interpreted in cross-sectional designs. Some support for a "causal" hypothesis, however, was obtained in crosslagged correlation analyses indicating that task orientation in Grade 3 may have a causal impact on the level of performance in reading, and in arithmetic in Grade 4. Most likely, however, there is also a reciprocal relationship.

The demand control model and circadian saliva cortisol variations in a Swedish population based sample (The PART study)

Background

Previous studies of the relationship between job strain and blood or saliva cortisol levels have been small and based on selected occupational groups. Our aim was to examine the association between job strain and saliva cortisol levels in a population-based study in which a number of potential confounders could be adjusted for.

Methods

The material derives from a population-based study in Stockholm on mental health and its potential determinants. Two data collections were performed three years apart with more than 8500 subjects responding to a questionnaire in both waves. In this paper our analyses are based on 529 individuals who held a job, participated in both waves as well as in an interview linked to the second wave. They gave saliva samples at awakening, half an hour later, at lunchtime and before going to bed on a weekday in close connection with the interview. Job control and job demands were assessed from the questionnaire in the second wave. Mixed models were used to analyse the association between the demand control model and saliva cortisol.

Results

Women in low strain jobs (high control and low demands) had significantly lower cortisol levels half an hour after awakening than women in high strain (low control and high demands), active (high control and high demands) or passive jobs (low control and low demands). There were no significant differences between the groups during other parts of the day and furthermore there was no difference between the job strain, active and passive groups. For men, no differences were found between demand control groups.

Conclusion

This population-based study, on a relatively large sample, weakly support the hypothesis that the demand control model is associated with saliva cortisol concentrations.

Body mass index in late adolescence and its association with coronary heart disease and stroke in middle age among Swedish men

BACKGROUND AND OBJECTIVES

Body mass index (BMI) in adolescence may be of particular importance as a predictor of future risk of coronary heart disease (CHD). Associations measured either in childhood or in middle age have appeared to be weaker or non-existent. We investigated the association between BMI measured in adolescence and CHD, and also stroke, among middle aged Swedish men and controlled for potential confounders not included in previous studies.

METHODS

Data on BMI, smoking and blood pressure (diastolic and systolic) was collected from 49,321 Swedish males, born during 1949-1951, at conscription for military service in 1969/70. Census data on socioeconomic indicators in childhood and adulthood was linked to the cohort. The men were followed from 1991 through 2004 in national registers with regard to mortality and hospitalization from CHD and stroke.

RESULTS

A graded increase of CHD was seen in over six levels of BMI (BMI<18.5, hazard ratio (HR)=1.0, BMI=18.5-20.99 (reference category), BMI=21-22.99, HR=1.2; BMI=23-24.99, HR=1.5; BMI=25-29.99, HR=2.5; BMI > or =30, HR=4.3). A graded association between BMI and stroke was also found, although weaker. Adjustments for cardiovascular risk factors (smoking, diastolic and systolic blood pressure, and early cardiovascular mortality in parents) attenuated the relative risks to some extent, whereas adjustments for socioeconomic indicators in childhood and adulthood had minor effects.

CONCLUSION

The results strongly suggest that BMI in late adolescence is an important predictor of both CHD and stroke among men before age 55 years, independent of smoking, hypertension and early cardiovascular mortality in parents.

Return to work and adjustment latitude among employees on long-term sickness absence

INTRODUCTION

The aim was to study whether return to work (RTW) after long-term sickness absence is affected by adjustment latitude i.e. opportunities to adjust one's work to one's state of health by e.g. choosing among work tasks and deciding about work pace and working hours. We also studied whether the effect of adjustment latitude differed between those returning full-time and those returning part-time.

METHODS

Differences between men and women were also studied. A questionnaire was sent to 5,590 salaried employees who had been on sick leave for at least 90 days in 2000. The year after, 2001, they received a questionnaire which included questions about work status, working conditions, adjustment latitude and health.

RESULTS

The questionnaire was returned from 3056 persons. Among women 32% were fully back to work, 34% were partly back and 34% were still on sick leave. Comparable figures for men were 33%, 32% and 36%.

CONCLUSION

For both men and women the likelihood to RTW increased with increasing number of opportunities to adjust. Adjustment latitude increased returning to part-time as well as full-time work. The study indicates that work organisation is important for RTW.