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Purpose: To study respiratory effects of exposure to soft paper dust exposure, a relationship that is rarely studied., Methods: Soft tissue paper mill workers at a Swedish paper mill were investigated using a questionnaire and lung function and atopy screening. Spirometry without bronchodilation was performed with a dry wedge spirometer, and forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV 1 ) were obtained and expressed as percent predicted. Exposure to soft paper dust was assessed from historical stationary and personal measurements of total dust, in addition to historical information about the work, department, and production. The impact of high exposure to soft paper dust (> 5 mg/m 3 ) vs. lower exposure ≤ 5 mg/m 3 , as well as cumulative exposure, was analyzed using multiple linear regression models. Multivariate models were adjusted for smoking, atopy, gender, and body mass index., Results: One hundred ninety-eight current workers (124 male and 74 female) were included. There were significant associations between both cumulative exposure and years of high exposure to soft paper dust and impaired lung function. Each year of high exposure to soft paper dust was associated with a 0.87% decrease in FEV 1 [95% confidence interval (CI) - 1.39 to - 0.35] and decreased FVC (- 0.54%, 95% CI - 1.00 to - 0.08) compared to the lower exposed workers., Conclusions: The present study shows that occupational exposure to soft paper dust (years exceeding 5 mg/m 3 total dust) is associated with lung function impairment and increased prevalence of obstructive lung function impairment.

Objective: To elucidate whether occupational noise exposure increases the mortality from ischemic heart disease (IHD) and stroke, and if exposure to paper dust modified the risks., Methods: We studied 6686 workers from soft paper mills, with occupational noise exposure, < 85 dBA, 85-90 dBA and > 90 dBA, and high (> 5 mg/m 3 ) exposure to paper dust. Person-years 1960-2019 were stratified according to gender, age, and calendar-year. Expected numbers of deaths were calculated using the Swedish population as the reference and standardized mortality ratios (SMR) with 95% confidence intervals (95% CI) were assessed., Results: SMR for IHD was 1.12 (95% CI 0.88-1.41) for noise < 85 dBA, 1.18 (95% CI 0.90-1.55) for 85-90 dBA, and 1.27 (95% CI 1.10-1.47) among workers exposed > 90 dBA. Joint exposure to high noise exposure and high exposure to paper dust resulted in slightly higher IHD mortality (SMR 1.39, 95% CI 1.15-1.67). SMR for ischemic stroke was 0.90 (95% CI 0.37-2.15) for noise < 85 dBA, 1.08 (95% CI 0.45-2.59) for 85-90 dBA, and 1.48 (95% CI 0.99-2.00) among workers exposed > 90 dBA. High noise exposure and high exposure to paper dust resulted in higher ischemic stroke mortality (SMR 1.83, 95% CI 1.12-2.98)., Conclusion: Noise levels > 90 dBA was associated with increased IHD mortality. Combined exposures of noise and paper dust may further increase the risks. Our results do not provide support for a causal relationship for ischemic stroke. Residual confounding from smoking has to be considered. Workers need to be protected from occupational noise levels exceeding 90 dBA., (© 2023. The Author(s).)

Purpose: Associations between various malignancies and work in the pulp and paper industry have been reported but mostly in analyses of mortality rather than incidence. We aimed to study cancer incidence by main mill pulping process, department and gender in a Swedish cohort of pulp and paper mill workers., Methods: The cohort (18,113 males and 2,292 females, enrolled from 1939 to 1999 with >1 year of employment) was followed up for cancer incidence from 1958 to 2001. Information on the workers' department and employment was obtained from the mills' personnel files, and standardized incidence ratios (SIRs) were calculated using the Swedish population as reference., Results: Overall cancer incidence, in total 2,488 cases, was not increased by work in any department. However, risks of pleural mesothelioma were increased among males employed in sulphate pulping (SIR, 8.38; 95 % CI, 3.37-17) and maintenance (SIR, 6.35; 95 % CI, 3.47-11), with no corresponding increase of lung cancer. Testicular cancer risks were increased among males employed in sulphate pulping (SIR, 4.14; 95 % CI, 1.99-7.61) and sulphite pulping (SIR, 2.59; 95 % CI, 0.95-5.64). Female paper production workers showed increased risk of skin tumours other than malignant melanoma (SIR, 2.92; 95 % CI, 1.18-6.02)., Conclusions: Incidence of pleural mesothelioma was increased in the cohort, showing that asbestos exposure still has severe health consequences, and highlighting the exigency of strict asbestos regulations and elimination. Testicular cancer was increased among pulping department workers. Shift work and endocrine disruptors could be of interest in this context.

Objectives: To clarify whether occupational exposure to paper-dust is associated with an increased risk of non-infectious rhinitis., Methods: Thirty-seven workers exposed to paper-dust in a soft-paper mill were compared with 36 unexposed controls. The study was performed under normal working conditions during the non-pollen season. Medical and occupational history was taken down in a comprehensive questionnaire and nasal symptoms were scored on a visual analogue scale (VAS). Pulmonary and nasal function was assessed by spirometry, acoustic rhinometry and peak nasal inspiratory flow. Nasal lavage was analysed for interleukin-8 (IL-8) and nasal transit time was monitored with the saccharine test. Concentrations of inhalable dust for each exposed subject during the day of the clinical study were measured with personal sampling devices., Results: There was an increased prevalence of nasal blockage and crust formation among the exposed workers. However, there was no difference with regard to acoustic rhinometry, nasal transit time or nasal peak inspiratory flow. In the whole population, IL-8 in nasal lavage was higher among men than among women, 193 ng/l vs 132 ng/l, P = 0.006. There was also a positive trend (P = 0.01) with increasing nasal IL-8 going from non-smokers (122 ng/l), ex-smokers (126 ng/l) to current smokers (235 ng/l)., Conclusions: We have found that occupational exposure to paper-dust is associated with symptoms of nasal blockage and nasal crusting. We find no objective signs of nasal inflammation, even among the subgroup with the highest current exposure.

The aim of the present cross-sectional study was to investigate whether long-term exposure to soft paper dust causes impairment of lung function. Exposed workers (n = 287) and referents (n = 79) were investigated, using spirometry and questionnaires. Personal samplings of total dust showed that the actual mean concentrations did not exceed 3 mg/m3. The exposed subjects were divided into three categories according to historical and present exposure to paper dust; low exposure, moderate exposure and high exposure. The study did not show any lung function impairment due to exposure to paper dust. However, the exposed subjects had a significantly increased prevalence of symptoms from both the upper and lower airways as well as an increased prevalence of reported asthma. On the basis of our study, we conclude that lung function impairment does not occur among workers exposed to mean levels of soft paper dust below 5 mg/m3.

Juvenile zebrafish (Danio rerio) were exposed to different dilutions (0, 0.67, 2.5, 10, and 50%) of effluent water from a Swedish pulp mill that previously has been reported to be androgenic to fish. Exposure was performed between days 10-38 days post-hatch. Fish were sampled for whole-body vitellogenin concentrations at day 38 post-hatch and for histological examination of gonads at day 60 post-hatch. In fish exposed to the highest concentration of pulp mill effluent, elevated concentrations of vitellogenin were measured. The androgenicity of the pulp mill water was confirmed by the increased number of males recorded at 60 days post-hatch. Image analysis of testes indicated stimulation of spennato genesis. Intersex fish were observed in all exposure groups. An androgenic activity equivalent to 5.6 ng/L dihydroxytestosterone was measured using the yeast androgen screen (YAS) assay. The present study demonstrates that both androgenic and estrogenic effects can be detected when exposing zebrafish during the juvenile period to complex mixtures of chemicals.

Purpose: The aim was to study mortality due to cardiovascular disease as well as total mortality, among female industrial workers, and the association to occupational noise and shift work., Methods: Women from cohorts of soft tissue paper mills (N = 3013) and pulp and paper mills (N = 1483) were merged into one cohort. Job exposure matrices were developed and used for classification of shift work and noise exposure. Every year was classified as shift work excluding nights or shift work including nights. Noise was classified into seven 5 dB(A) bins from < 75 to ≥ 100 dB(A). Mortality from cardiovascular diseases and total mortality during 1956-2013 was calculated as a standardized mortality ratio (SMR) with 95% confidence interval (CI) using the female general population as a reference., Results: Fatal myocardial infarctions (N = 144) were increased in the total cohort, SMR 1.20 (95% CI 1.01-1.41) but not total mortality. The SMR for myocardial infarction for women exposed to noise ≥ 90 dB(A) for > 10 years was 1.41 (95% CI 1.02-1.89) and for those exposed to night shifts > 10 years, 1.33 (95% CI 0.91-1.89). Shift workers without nights ≤ 65 years, with noise exposure ≥ 90 dB(A), had SMR 2.41 (95% CI 1.20-4.31) from myocardial infarction. There was no increased mortality from cerebrovascular disease., Conclusions: Female paper mill workers had an increased mortality from acute myocardial infarction, especially before retirement age, when exposed to noise ≥ 90 dB(A) and with long-time employment. Exposure to shift work and noise usually occurred concurrently.

We estimate the price sensitivity in health care among adolescents and young adults, and assess how it varies across income groups and gender, using a regression discontinuity design. We use the age differential cost-sharing in Swedish primary care as our identification strategy. At the 20th birthday, the copayment increases from €0 to approx. €10 per primary care physician visit and close to this threshold the copayment faced by each person is distributed almost as good as if randomized. The analysis is performed using high-quality health care and economic register data of 73,000 individuals aged 18-22. Our results show that the copayment decreases the average number of visits by 7%. Among women visits are reduced by 9%, for low-income individuals by 11%, and for low-income women by 14%. In conclusion, modest copayments have significant utilization effects, and even in a policy context with relatively low income inequalities, the effect is substantially larger in low-income groups and among women.

Objectives: To query the experience of oral surgeons concerning referral routines and preferences for radiographic imaging modality before surgical removal of mandibular third molars and investigate factors that influence imaging modality preferences., Materials and Methods: Members of the Swedish Association of Oral and Maxillofacial Surgeons (n = 280) were invited to participate in a web-based digital survey concerning their experiences and use of three imaging modalities in pre-surgical assessment of mandibular third molar removal. The survey comprised multiple-choice questions and four cases depicted in images; respondents reported whether they would supplement the cases with other images and, if so, from which modality., Results: The response rate was 64%. Panoramic radiographs were most commonly used in pre-surgical planning (response options: always or often), significant difference between professions (p = 0.039), and considered to facilitate treatment planning (87%), as was CBCT (82%); for 51%, CBCT reduced post-operative complications. Preferred modality for localizing the mandibular canal was fairly evenly distributed and for non-complex case, significant difference between subgroups of OMFS surgeons was found (p = 0.003) as to preference for intraoral radiographs., Conclusions: A majority of respondents received a report within 2 weeks of their referral for CBCT and would read the report and view the images before surgery. Image modality preference differed depending on case complexity, with a greater perceived need for CBCT. Profession and practical experience affected choice., Clinical Relevance: Choice of imaging modality in mandibular third molar assessment is also important from dose delivery and social economy standpoints., (© 2021. The Author(s).)

Objectives: The aim of the study was to examine the associations between heavy physical workload among middle-aged and older workers and disability pension due to any diagnosis, as well as musculoskeletal, psychiatric, cardiovascular or respiratory diagnoses. The population-based design made it possible to examine dose-response and potential gender differences in the associations., Methods: About 1.8 million men and women aged 44-63 years and registered as living in Sweden in 2005 were followed regarding disability pension during 2006-2016, until ages 55-65 years. Mean values of physical workload and job control, estimated through gender-specific job-exposure matrices (JEMs), were assigned to individuals through their occupational titles in 2005. Exposure values were ranked separately for women and men and divided into quintiles. Associations were analyzed with Cox proportional-hazards regression., Results: The analyses showed robust, dose-response associations between physical workload and disability pension with a musculoskeletal diagnosis in both genders: the adjusted hazard ratio and 95% confidence interval for those with the heaviest exposure was 2.58 (2.37-2.81) in women and 3.34 (2.83-3.94) in men. Dose-response associations were also seen in relation to disability pension with a cardiovascular or a respiratory diagnosis, though the hazard ratios were smaller. Physical workload was not associated with disability pension with a psychiatric diagnosis after adjustment for job control., Conclusion: This study of the entire Swedish population of middle-aged and older workers suggests that higher degrees of physical workload may increase the risk of disability pension overall, and specifically with musculoskeletal, cardiovascular or respiratory diagnosis, in both women and men., (© 2021. The Author(s).)

Purpose: The first objective was to contribute to a better understanding of the contrasting and paradoxical results in studies of work environment factors and sickness presence and sickness absence. A second objective was to examine if, and under what conditions, employees choose to replace sickness absence with sickness presence, i.e., so-called substitution., Methods: The study utilizes a large body of cross-sectional questionnaire data (n = 130,161) gathered in Sweden from 2002 to 2007 in connection with a comprehensive health promotion initiative. Health and motivation were analyzed as mediators of the effects of five job factors, job control, job support, job demand, role conflict and "work to family conflict" on sickness presence and absence., Results: The results concerning job demands indicate substitution in that increased job demands are associated with increased presenteeism and reduced absenteeism. The direct effect of higher job support was increased absenteeism, but via the health and motivation paths, the total effect of more social support was health-promoting and associated with a reduction in sickness absence and sickness presence. High job control emerged as the most pronounced health-promoting factor, reducing sickness presenteeism as well as absenteeism. More role conflicts and work-to-family conflicts were directly and indirectly associated with decreased health and increased absenteeism as well as presenteeism. earlier research., Conclusion: The mediation analyzes shed light on some of the paradoxes in research on sickness presenteeism and sickness absenteeism, especially regarding job demands and job support. The substitution effect is important for workplace policy and occupational health practice.

Objective: Previous studies have shown that high workload affects health negatively. However, studies are lacking among home care workers. The aim of this study is to examine the burden of perceived workload on health-related quality of life (HRQoL) among home care workers and to determine whether psychosocial factors modify such a relationship., Methods: A cross-sectional study was conducted in which 1162 (58% response rate) home care workers participated. The psychosocial factors were measured by QPSnordic. HRQoL was measured by EuroQol 5 dimensions, from which responses were translated into quality-adjusted life year scores (QALY). Propensity scores were used with absolute risk differences (RD). Stratified analysis was used to test the buffer hypothesis of the demand-control-support model., Results: Personnel with a high workload had a statistically significant 0.035 lower QALY than personnel with a normal workload. This difference was also statistically significant for the Visual Analogue Scale (RD 5.0) and the mobility (RD 0.033) and anxiety/depression scales (RD 0.20) dimensions of EQ-5D. For QALY, the effect of a high workload compared to a normal workload was higher, with low (RD 0.045, significant) compared with high (RD 0.015, non-significant) social support; while it was similar, and non-significant results, for low and high control., Conclusions: Our study shows that lowered work burden would be beneficial for home care personnel. Furthermore, our results suggest that interventions aimed at increasing social support could reduce work-related illness.

Many countries are adopting policies to create greater coordination and integration between acute and long-term care services. This policy is predicated on the assumption that these service areas have interdependent outcomes for patients. In this paper, we study the interdependencies between the long-term (home care) services and consultations with a primary care doctor, as used by people over 75 years. Starting with a model of individual's demand for doctor consultations, given supply, we formalize the hypothesis that exogenous increases to home care supply will reduce the number of consultations where these services are technical substitutes. Furthermore, greater coordination of public service planning and use of pooled budgets could lead to better outcomes because planners can account for these externalities. We test our main hypothesis using data from the British Household Panel Study for 1991-2009. To address potential concerns about endogeneity, we use a set of instrumental variables for home care motivated by institutional features of the social care system. We find that there is a statistically significant substitution effect between home care and doctor visits, which is robust across a range of specifications. This result has implications for policies that consider increased coordination between health care and social care systems.

This paper explores the relationship between the prolongation of working life and subjective health. Drawing on a unique combination of longitudinal data and the results of a postal survey in Sweden, we investigate the health consequences of extending working life beyond the normal retirement age of 65. To do this, we compare the health status of two groups of retired people: one group who left the labour market completely at the age of 65, and a second group who remained in employment after the age of 65. Using a standard linear probability model and controlling for a range of socio-economic variables as well as previous labour market experiences, perceived life expectancy, pre-retirement income and health, our estimations show that those continuing to work after 65 on average display a 6.8% higher probability of reporting better health during retirement than those leaving at the age of 65. However, we find that this positive correlation between the extension of working life and health is only transitory. After 6 years of retirement, the health advantage of working after the normal retirement age disappears. Furthermore, we did not find any evidence that working after the age of 65 is positively correlated with physical fitness, self-reported depressive symptoms or well-being.

Drawing on contemporary publications in German and Swedish/Scandinavian journals and biographies as well as conference proceedings of the German Society of Urology (DGU), this paper examines the Swedish impressions of the 1929 DGU meeting in Munich. It focusses on why the Swedish delegates visited the congress and how they evaluated their congress experiences for their Scandinavian peers. Finally, the article shows to what extent a knowledge transfer from the DGU Congress to Sweden took place.

In this paper we test the 'red herring' hypothesis for expenditures on long-term care (LTC). The main contribution of this paper is to assess the 'red herring' hypothesis by using the probability of dying as a measure for time-to-death (TTD). In addition, we implement models that allow for age-specific TTD effects on LTC utilization as well as sex-specific effects. We also focus on total, institutional and domiciliary LTC separately. For our analysis we use high quality administrative data from Sweden. Our analysis is based on fixed effects estimates. We use our findings to project future LTC expenditures and show that, although TTD is a relevant predictor, age itself remains the main driver of LTC expenditures.

Since the new millennium, a notion has developed in certain parts of society that environmental pollutants and their associated effects are under control. The primary objective of this investigation, performed in 2003, was to test whether this was actually the case in an industrialised region in the County of Västernorrland in northern Sweden with well-documented environmental pollution from past and present activities. This was performed by measuring a moderate battery of simple biomarkers in adult female perch at several stations. The point sources included sewage-treatment plants, pulp and paper mills, as well as other industries. The biomarkers included growth, somatic indices, gonad maturation status, gonad pigmentation, fin erosion, skin ulcers, and ethoxyresorufin-O-deethylase (EROD) activity in the liver. The results showed that the environmental pollutants and their associated effects were not under control. In fact, the health of the perch was impaired at all of the polluted stations. Many responses were unspecific with respect to underlying cause, whereas some effects on EROD activity and gonad maturation status were attributed to historical creosote pollution and current kraft pulp mill effluents, respectively. The data presented may also be used as reference values for future investigations of health effects in perch.

This paper presents a model for measuring the outcome of Worksite Health Promotion Programs through an application of Structural Equation Modeling with ordinal data. We model the function "being healthy" as a vector comprised of three latent or unobservable variables: Health Status, Lifestyle and Stress. Each variable can be measured only indirectly through a set of manifest or observable ordinal indicators. The objective is to derive and analyze the distributions, and changes in distributions over time, of the latent variables on an individual level. The model is analyzed empirically on data from three large Swedish manufacturing firms.

This paper examines how the unemployment rate is related to adolescent alcohol use and experience of binge drinking during a time period characterized by big societal changes. The paper uses repeated cross-sectional adolescent survey data from a Swedish region, collected in 1988, 1991, 1995, 1998, 2002 and 2005, and merges this with data on local unemployment rates for the same time periods. Individual level frequency of alcohol use as well as experience of binge drinking is connected to local level unemployment rate to estimate the relationship using multilevel modeling. The model includes municipality effects controlling for time-invariant differences between municipalities as well as year fixed effects controlling for municipality-invariant changes over time in alcohol use. The results show that the unemployment rate is negatively associated with adolescents' alcohol use and the experience of binge drinking. When the unemployment rate increases, more adolescents do not drink at all. Regular drinking (twice per month or more) is, on the other hand, unrelated to the unemployment rate. Examining gender-differences in the relationship, it is shown that the results are driven by behavior in girls, whereas drinking among boys does not show any significant relationship with changes in the unemployment rate.

This paper develops a welfare theoretic foundation for cost-effectiveness analysis (CEA) when survival is not affected. With this foundation, all costs and their corresponding utility-terms should be included. A key question, though, is whether these utility-terms are consistent with quality-adjusted life year (QALY) (utility) theory or not. The results show that health care costs and changes in the utility of health should be included. However, as QALYs do not capture the utility of changes in consumption (as this utility must be independent of health, according to QALY theory), the corresponding changes in consumption costs should be excluded. Regarding the costs for changes in absence from work, these should only be included if the utility of changes in the amount of leisure is included. As no QALY theory has been developed that includes this utility, it is unclear how to handle these costs (even if there are arguments for excluding them). For changes in productivity at work, though, there are robust arguments for the inclusion of these costs. Overall, it seems difficult to provide a clear basis for CEA in economic welfare theory when also including non-medical goods such as consumption and leisure.

Terrestrial organic carbon is exported to freshwater systems where it serves as substrate for bacterial growth. Temporal variations in the terrigenous organic carbon support for aquatic bacteria are not well understood. In this paper, we demonstrate how the combined influence of landscape characteristics and hydrology can shape such variations. Using a 13-day bioassay approach, the production and respiration of bacteria were measured in water samples from six small Swedish streams (64 degrees N, 19 degrees E), draining coniferous forests, peat mires, and mixed catchments with typical boreal proportions between forest and mire coverage. Forest drainage supported higher bacterial production and higher bacterial growth efficiency than drainage from mires. The areal export of organic carbon was several times higher from mire than from forest at low runoff, while there was no difference at high flow. As a consequence, mixed streams (catchments including both mire and forest) were dominated by mire organic carbon with low support of bacterial production at low discharge situations but dominated by forest carbon supporting higher bacterial production at high flow. The stimulation of bacterial growth during high-flow episodes was a result of higher relative export of organic carbon via forest drainage rather than increased drainage of specific "high-quality" carbon pools in mire or forest soils.

This paper is an introduction to the study "The Burden of Rheumatoid Arthritis and Patient Access to Treatment". The objective of the study is to compare patient access to new drugs in Europe, North America and a selection of other countries, and to analyse the determinants of differences between countries, as basis for a discussion on how patients' access to new and effective treatments can be improved. There were few treatments available that could affect the progression of the disease prior to the introduction of the first TNF inhibitors in the late 1990s. Since the cost per patient treated with these biological drugs is high compared to previously available treatments, reimbursement through private and public insurance is an important determinant for access to treatment.

In this paper, we analyze exits from long-term sickness spells in Sweden. Using data for more than 2,500 people, the aim is to analyze the transition to different states: return to work, full disability pension, partial disability pension, and other exits from the labor force. Given the complexity of the exit decision, which encompasses both the individual's choice, the medical evaluation and the decision of the insurance adjudicator, we consider the outcome as being the result of two aspects of the exit process: one that governs the duration of a spell prior to the decision to exit, and another that governs the type of exit. Therefore, the analysis is done in two steps: first, we analyze the duration of the sickness spells, and then we analyze the process that governs the type of exit. The results indicate that both individual characteristics and push factors, such as regional unemployment, are important for both components of the decision process.

Today there is growing awareness among spine surgeons of the advantages in using registers to facilitate the analyses and reporting of treatment outcome. The Swedish Spine register is among the first to be used on a national scale and annual reports are published in international journals. In this paper we discuss our experiences and lessons learned from a paper-based version in 1993, to an online web-based solution in 2005. We emphasise the advantages of registers being owned by the national spine society, a support function available during working hours, online feedback to participating departments and professional assistance in designing a register program for web use. Hopefully, our experiences will be of help to colleagues who are planning to start registering.

Recent interpretations of developmental gene expression patterns propose that the last common metazoan ancestor was segmented, although most animal phyla show no obvious signs of segmentation. Developmental studies of non-model system trochozoan taxa may shed light on this hypothesis by assessing possible cryptic segmentation patterns. In this paper, we present the first immunocytochemical data on the ontogeny of the nervous system and the musculature in the sipunculan Phascolion strombus. Myogenesis of the first anlagen of the body wall ring muscles occurs synchronously and not subsequently from anterior to posterior as in segmented spiralian taxa (i.e. annelids). The number of ring muscles remains constant during the initial stages of body axis elongation. In the anterior-posteriorly elongated larva, newly formed ring muscles originate along the entire body axis between existing myocytes, indicating that repeated muscle bands do not form from a posterior growth zone. During neurogenesis, the Phascolion larva expresses a non-metameric, paired, ventral nerve cord that fuses in the mid-body region in the late-stage elongated larva. Contrary to other trochozoans, Phascolion lacks any larval serotonergic structures. However, two to three FMRFamide-positive cells are found in the apical organ. In addition, late larvae show commissure-like neurones interconnecting the two ventral nerve cords, while early juveniles exhibit a third, medially placed FMRFamidergic ventral nerve. Although we did not find any indications for cryptic segmentation, certain neuro-developmental traits in Phascolion resemble the conditions found in polychaetes (including echiurans) and myzostomids and support a close relationship of Sipuncula and Annelida.

Objectives: The objective of this paper, was to direct attention to the diagnostic strategy and clinical approach necessary in the diagnosis of neuropathy in workers exposed to vibration. The purpose encompassed evaluation of selected aspects of bedside and electrodiagnostic examinations with respect to biological validity and the ability to distinguish between subjects with and without neuropathy., Methods: The neurological examinations viewed were restricted to those applicable to the upper extremity and neck system. A MEDLINE search was performed through the clinical queries service of PubMed searching for the following terms: nerve-conduction, Tinel's test, Phalen's test, tendon reflex, two-point discrimination test, abduction external rotation test, and Spurling test. Retrieved articles were discussed both in relation to the test accuracy and the validity aspects of the tests., Results: The evidence in support of the view that neurological tests can accurately distinguish between subjects with and without neuropathy specifically addressing hand-arm vibration syndrome was sparse. The initial number of diagnostic hypotheses could be reduced by progressively ruling out diseases based on negative results of highly sensitive tests. As the possible diagnostic alternatives become fewer, the use of positive results from highly specific tests are more effective. The information value of the various diagnostic tests is determined by the change in pre-test to post-test probability of target disorder, which depends on the prevalence of the disorder and the likelihood ratios of the tests. The review showed that target disease characteristics influence the test outcome as well as the choice of "gold standard" and the population domain of the studies., Conclusions: The selection of various bedside examinations and diagnostic electrophysiological tests should be dependent on the clinical context, the history and results from the successive diagnostic tests.

Objectives: The objective of the present paper is to study the relationship between the early sensorineural symptoms, classified according to the Stockholm scale, and the results of the main functional and sensory tests described in the literature, in subjects working with vibrating tools., Methods: Three groups of male workers were selected from industry: one group (69 subjects) exposed to hand-arm vibration in several workplaces, one group (62) performing heavy and repetitive hand and arm work but without exposure to vibration, and one control group (46) performing light and non-repetitive tasks without vibration. All the workers were interviewed by questionnaire, about their personal characteristics, their health status, their actual and past working conditions and the episodes of tingling at the level of the fingers. From these reported symptoms, the sensorineural stage of the hand-arm vibration was determined using the Stockholm scale. Based on the review of the literature, we selected six functional and sensory tests: maximum voluntary grip force, maximum angles of the wrist, pressure perception threshold test, vibration perception threshold test, distal sensory latency and the Purdue Pegboard test. Each test was performed by the workers in the three groups., Results: No main differences were observed between the personal characteristics of the three groups. According to the Stockholm scale, the sensorineural symptoms were mainly at stage SN1, with 9% at stage SN2 and none at stage SN3. These symptoms are associated with exposure to vibration, and had a prevalence of 40% in group 1, versus 20% in the two other groups. Furthermore, 25% of the workers exposed to vibration complained of symptoms at least once a week, compared with only 2% in the other groups. The multivariate logistic regression analysis showed an association between the existence of symptoms and a decrease in the maximum flexion angle of the wrist and an increase in the pressure perception threshold. This association, however, was too low to determine limit values with a sensitivity and specificity sufficiently high to make a reliable diagnosis., Conclusions: The sensorineural symptoms at stage N1 on the Stockholm scale, experienced occasionally by some 40% of the users of vibrating tools, could not be corroborated by the functional and sensory tests.