Validation of sun exposure and protection index (SEPI) for estimation of sun habits.

BACKGROUND: In both Sweden and Australia high incidence rates of skin cancer have become a major health problem. In prevention and risk communication, it is important to have reliable ways for identifying people with risky sun habits. In this study the validity and reliability of the questionnaire Sun Exposure Protection Index (SEPI), developed to assess individual's sun habits and their propensity to increase sun protection during routine, often brief, clinical encounters, has been evaluated. The aim of our study was to evaluate validity and reliability of the proposed SEPI scoring instrument, in two countries with markedly different ultraviolet radiation environments (Sweden and Australia). METHOD: Two subpopulations in Sweden and Australia respectively were asked to fill out the SEPI together with the previously evaluated Readiness to Alter Sun Protective Behaviour questionnaire (RASP-B) and the associated Sun-protective Behaviours Questionnaire. To test reliability, the SEPI was again filled out by the subjects one month later. RESULTS: Comparison between SEPI and the questions in the Sun-protective Behaviours Questionnaire, analyzed with Spearman's Rho, showed good correlations regarding sun habits. Comparison between SEPI and RASP-B regarding propensity to increase sun protection showed concurrently lower SEPI mean scores for action stage, but no difference between precontemplation and contemplation stages. The SEPI test-retest analysis indicated stability over time. Internal consistency of the SEPI, assessed with Cronbach's alpha estimation showed values marginally lower than the desired >0.70 coefficient value generally recommended, and was somewhat negatively affected by the question on sunscreen use, likely related to the classic "sunscreen paradox". There were some differences in the performance of the SEPI between the Swedish and Australian samples, possibly due to the influence of "available" sunlight and differing attitudes to behaviour and protection "at home" and on vacation. CONCLUSIONS: SEPI appears to be a stable instrument with an overall acceptable validity and reliability, applicable for use in populations exposed to different UVR environments, in order to evaluate individual sun exposure and protection.

Parental sun-protective regimens and prevalence of common melanocytic naevi among 7-year-old children in Sweden: changes over a 5-year period.

BACKGROUND: Common melanocytic naevi and cutaneous malignant melanoma share a common risk profile, influenced by ultraviolet radiation exposure. A high density of common melanocytic naevi correlates with an increased lifetime risk of developing cutaneous malignant melanoma. Effective strategies for sun protection, starting in early childhood, are considered of great importance to reduce the steadily rising melanoma trend. OBJECTIVES: To investigate the 5-year changes in sun tanning habits, sun-protective regimens and density of common melanocytic naevi between two age-standardized populations of children. METHODS: Population-based cross-sectional study performed among 7-year-old children in southern Sweden in 2002 and 2007. The parents answered a questionnaire and all children were examined by the same, trained research nurse. RESULTS: In total, 1190 children were enrolled: 681 in 2002 and 509 in 2007. The results showed that sun-protective regimens, such as use of sunscreen (+29%), clothing (+30%), staying in the shade (+123%) or indoors (+136%) during peak sun hours, had all increased significantly (P<0·0001). Travelling to sunny seaside holiday resorts abroad before the age of 2years had almost doubled (P<0·0001). The adjusted mean number of naevi per square metre body surface was significantly (P<0·0001) lower in 2007: 6·6 [95% confidence interval (CI) 5·6-7·6], compared with 11·0 (95% CI 10·0-12·0) in 2002. CONCLUSIONS: This study demonstrates increased self-reported parental actions for sun protection of young Swedish children in recent years; in consistency, lower numbers of common melanocytic naevi were observed. Results support the use of common melanocytic naevi as an objective measure of sun exposure in children.

Factors related to participation in a cervical cancer screening programme in urban Sweden.

Fifty-six per cent of invited women aged 25-60 attended the Population-based Cervical Cancer Screening Programme (PCCSP) in Stockholm, Sweden in 1994-1996. The objective of this study was to explore factors related to participation in this PCCSP. Registry data on all women aged 25-60 invited to the PCCSP from 1994 to 1996 (n=307,552) was matched with a national longitudinal population database. Women in the youngest age group (25-29 years old) were found to be less likely to participate in the PCCSP than women in older age groups. Married women or widows attended the programme more often (OR 1.32, 95% confidence interval (95% CI) 1.29-1.34 and OR 1.36, 95% CI 1.27-1.45, respectively) than did single women. Women in the labour force were more likely to participate than those who were not in the labour force (OR 1.82, 95% CI 1.78-1.87). The participation rate was not lower for immigrant women from developing countries than for those born in Sweden. We found that age, marital status and being in the labour force or not are factors associated with participation in the cervical cancer screening programme.

Cancer risk in offspring of male pesticide applicators in agriculture in Sweden.

AIMS: To explore cancer risk from date of birth until 1994 in children, born 1958 or later, of Swedish male pesticide applicators. METHODS: Records of male pesticide applicators licensed 1965-76 were linked to the Multigeneration Register. The records of their offspring were then linked to the Swedish Cancer Registry and the Cause of Death Register. RESULTS: In total 51 cases of cancer were observed, which is significantly lower than the expected 73.0 (standardised incidence ratio (SIR) 0.70, 95% CI 0.52 to 0.92). Tumours of the nervous system was most common, amounting to 20 cases, 39% of all cancer cases (SIR 1.01, 95% CI 0.62 to 1.56). A statistically significant reduced risk for leukaemia was found (SIR 0.43, 95% CI 0.19 to 0.86). For non-Hodgkin's lymphoma, three cases were observed and 4.8 expected (SIR 0.63, 95% CI 0.13 to 1.83). For Hodgkin's disease, five cases were observed versus 3.7 expected (SIR 1.36, 95% CI 0.44 to 3.17). Two cases of testicular cancer were observed and 1.7 expected (SIR 1.19, 95% CI 0.13 to 4.28). CONCLUSIONS: None of the a priori hypotheses of increased risk of tumours of the nervous system, kidney cancer, leukaemia, lymphoma, soft tissue sarcoma, and testicular cancer in children of male pesticide applicators could be confirmed.

Contacts with animals and humans as risk factors for adult brain tumours. An international case-control study.

While numerous studies have addressed the possible role of farming and related exposures as risk factors for brain tumours in adults, few of them have examined the potential effect of exposure to farm animals or pets. In an international multicentre case-control study, we investigated whether residence on a farm, contact with animals, or working in occupations with a high degree of potential contact with animals or humans were associated with brain tumours. Using a common questionnaire, 1177 cases of glioma, 330 with meningioma and 2478 controls from eight centres were interviewed about the exposures and, in particular, about their contacts with nine species of animals: dairy cattle, beef cattle, pigs, horses, sheep, goats, poultry, dogs and cats. Living or working on a farm was not a risk factor, for either glioma or meningioma. Except in some centres, there was no relationship between having contacts with farm animals or pets and the risk of brain tumour, for either type of tumour or either sex. In relation to seven industrial groups involving frequent human and/or animal contacts, no association was apparent for either glioma or meningioma. In relation to 25 occupational groups with potential frequent contact with humans and/or animals, for glioma there was a reduced risk for biological technicians (Odds Ratio (OR)/=0, P=0.01), and general farm workers (OR=0.66, 95% Confidence Interval (CI): 0.5-0.9). For meningioma, there was an increased risk for cooks (OR=2.0; CI: 1.2-3.4). With some exceptions, these results indicate no association between either the type of brain tumour and contacts with animals, or with occupations that include a high level of contact with animals or a high level of contact with humans.

Tanning habits and sunburn in a Swedish population age 13-50 years.

As part of a skin cancer control programme, we studied the occurrence of self-reported outdoor tanning, sunbed use and ultraviolet (UV)-induced erythema in an urban area. A cross-sectional questionnaire study of 6000 adolescents aged 13-19 years, and 4000 adults aged 20-50 years was applied. Non-response was analysed for outdoor tanning and sunbed use. Results, in general, did not differ between responders and non-responders. Females aged 17-29 years tanned outdoors most frequently. Sunbed use and related erythema was twice as common in young females. In males, outdoor tanning was not age-related. In the past 12 months, 55% reported sunburn and/or burn from sunbed use, one-third were burned in Sweden, one-quarter on sunny resorts abroad. Sunburn occurs frequently. Compliance with recommendations for sunbed use is poor, especially among adolescents and young adults. To reduce the occurrence of erythema, the influence of risk settings upon behaviours is a critical issue for exploration.

Dental radiography after age 25 years, amalgam fillings and tumours of the central nervous system.

The aim of the study was to investigate the importance of diagnostic dental radiography and amalgam fillings as risk factors for tumours of the central nervous system (CNS). This population-based case-control study included subjects aged 25-74 years, living in the catchment area of the Neurosurgery Department of Uppsala University Hospital in Sweden. A total of 192 cases of glioma, 99 cases of meningioma and 42 cases of acoustic neurinoma were identified between 1987 and 1990. A control group of 343 subjects was matched on age, gender and parish. Information about dental exposure was obtained by a self-administered questionnaire and from dental records. For those who had a dental radiography at least once a year after age 25 years, a relative risk of 2.1 (95% confidence interval (CI) 1.0-4.3) was seen for meningioma, while for other subgroups of CNS tumours the relative risk was close to unity. No association was observed between the number of amalgam fillings and CNS tumours. In conclusion, there was no clear evidence that dental radiography or amalgam fillings is related to the development of tumours of the CNS.

Occupational exposure to magnetic fields and brain tumours in central Sweden.

Occupations with exposure to magnetic fields were studied in a population-based case-control study of male glioma and meningioma in Central Sweden. The study included 84 cases of glioma, 20 cases of meningioma and 155 controls. Information about job titles was obtained by means of a questionnaire. Three different methods were used to classify exposure 1) 'electrical occupations', 2) assessment of magnetic fields by an electrical engineer, 3) job values based on magnetic field measurements at work sites for occupational groups. When analyses were based on 'electrical occupations' a relative risk (RR) of 1.0 (95% CI: 0.4-2.4) was seen for glioma and 1.8 (95% CI: 0.3-3.6) for meningioma. When analyses were based on measurements a relative risk of 1.9 (95% CI: 0.8-5.0) was seen for glioma and 1.6 (95% CI: 0.3-10.2) for those ever in an exposed job of an average mean value of > 0.4 microT. A larger number of individuals was classified as exposed, when exposure was based on measurements. Information was available regarding several potential confounders, but none of them seemed to be of any importance. Our conclusion is that the results based on magnetic field measurements give some support to the hypothesis that magnetic fields exposure may play a role in the development of brain tumours.

An international case-control study of adult glioma and meningioma: the role of head trauma.

BACKGROUND: Increased brain tumour risk after head trauma suggested by case reports and clinical series has been previously studied epidemiologically with mixed results. An international multicentre case-control study investigated the role of head trauma from injury or sports participation in adult brain tumour risk. METHODS: In all, 1178 glioma and 330 meningioma cases were individually or frequency matched to 2236 controls. Only exposures that occurred at least 5 years before diagnosis and head injuries that received medical attention were considered. RESULTS: Risk for ever having experienced a head injury was highest for male meningiomas (odds ratio [OR] = 1.5, 95% confidence interval [CI] : 0.9-2.6) but was lower for 'serious' injuries, i.e. those causing loss of consciousness, loss of memory or hospitalization (OR = 1.2, 95% CI: 0.6-2.3). Among male meningiomas, latency of 15 to 24 years significantly increased risk (OR = 5.4, 95% CI: 1.7-16.6), and risk was elevated among those who participated in sports most correlated with head injury (OR = 1.9, 95% CI: 0.7-5.3). Odds ratios were lower for male gliomas (OR = 1.2, 95% CI : 0.9-1.5 for any injury; OR = 1.1, 95% CI: 0.7-1.6 for serious injuries) and in females in general. CONCLUSIONS: Evidence for elevated brain tumour risk after head trauma was strongest for meningiomas in men. Findings related to sports should be interpreted cautiously due to cultural variability in our data and our lack of complete data on physical exercise in general which appeared to be protective.

Glioma and occupational exposure in Sweden, a case-control study.

OBJECTIVES: The aim of the study was to analyse whether any job titles, industrial codes, and certain occupational exposures were associated with an increased risk of glioma. METHODS: A population based case-control study of incident primary brain tumours in adults was carried out in Uppsala, Sweden in the period 1987-90. The study included 192 cases of glioma and 192 matched controls. It also included cases with other tumours of the central nervous system with matched controls. Information from all 343 controls was used in this study. Information was collected by means of a questionnaire that was sent to all subjects. An occupational hygienist reviewed the questionnaires for self reported exposures to substances and assessed whether these reported exposures were plausible or not in the corresponding occupation. RESULTS: The kappa coefficient for those classified by the two methods ranged between 0.46 and 0.88, and they were almost the same for cases and controls. For men exposed to solvents a relative risk (RR) of 2.6 (95% CI 1.3 to 5.2) was found. For men exposed to pesticides the RR was 1.8 (95% CI 0.6 to 5.1), and for plastic materials the RR was 3.6 (95% CI 1.0 to 12.4). For men employed in forestry and logging the RR was 2.2 (95% CI 0.9 to 5.3) and in basic metal industries 2.0 (95% CI 1.0 to 4.0). CONCLUSION: An increased risk of glioma was associated with use of solvents, pesticides, and plastic materials but this should be interpreted with some caution.

Childhood cancer among Swedish twins.

The risk of childhood cancer was evaluated among 35,582 twins born in Sweden between 1952 and 1967. Cancers were identified through linkage with national cancer and mortality registries. Overall, 59 childhood cancers and 41 deaths from cancer occurred before the age of 16. For both sexes combined, the cancer incidence was similar to that in the general population of primarily single-born children (number observed/number expected [O/E] = 1.0, 95 percent confidence interval [CI] = 0.7-1.2). For males under age five, cancer incidence was reduced significantly (O/E = 0.3, CI = 0.1-0.7). There was a substantial increase in all-cause mortality among twins (O/E = 3.7), attributable to a high mortality during the first year of life. Excluding this first year, the O/E for death (all causes) was 1.1 (CI = 1.0-1.3). For cancer mortality of both sexes, the O/E was 0.9 (CI = 0.6-1.2), with no significant reduction of risk in any sex-age group. We conclude that with the possible exception of males aged 0-4 years, the childhood cancer risk of twins appears similar to that of singletons.

Prenatal X-ray exposure and childhood cancer in Swedish twins.

The association between X-ray exposure in utero and childhood cancer was studied in a case-control study, nested in a national cohort of Swedish twin births. Records of the Swedish Twin Register for those born 1936-1967 (n = 83,316) were linked to the Swedish Cancer Register (1958-1983) and the Swedish Cause-of-Death Register (1952-1983). Ninety-five cases of childhood cancer before the age of 16 were identified. Two controls from the Twin Register were matched to each case by sex and year of birth. Maternal X-rays during pregnancy were documented for 41% of the cases and 36% of the controls. The crude relative risk of any childhood cancer associated with any prenatal X-ray was 1.2 (95% CI; 0.7-2.1). For the cases 64% of the X-rayed women had had abdominal X-rays, the numbers for the controls were 57%. Fifty-nine per cent of the X-rayed women had had abdominal X-rays, which were associated with a relative risk for all cancers of 1.4 (Cl; 0.8-2.5), leukemias 1.7 (Cl; 0.7-4.1) and tumors of the central nervous system 1.5 (Cl; 0.5-4.2). There was no apparent confounding by mother's age, drug use, obstetric complications, previous miscarriages, social class or length of pregnancy. The observed relative risks of cancer following prenatal X-ray exposure are consistent with previous studies, suggesting that the developing fetus may be more sensitive to the carcinogenic effects of ionizing radiation than are children irradiated post-natally.

Incidence of rheumatoid arthritis among patients with schizophrenia, affective psychosis and neurosis.

The aim of the study was to determine the incidence of hospital care with the diagnosis rheumatoid arthritis (RA) among patients with schizophrenia, affective psychosis and neurosis compared with that among hospitalized patients in general. By means of the in-patient register of Stockholm County, a cohort was formed comprising all patients discharged with the diagnoses schizophrenia, affective psychosis and neurosis in Stockholm County during 1971, and a sample of all patients discharged for any diagnosis during the same year. We followed the groups in the in-patient register through 1981 in order to identify hospital episodes with the diagnosis RA. Observed and expected incidences of RA in hospital care were obtained using all hospitalized patients as a reference group. For schizophrenia and affective psychosis the incidence of RA was around half the expected, whereas for neurosis it was close to the expected incidence. With reservation for small numbers of observed cases, the results support the hypothesis of a reduced incidence of RA among patients with schizophrenia. The finding regarding affective psychosis was based on a smaller number of cases and merits further investigations.

Mortality in rheumatoid arthritis, particularly as regards drug use.

239 persons with rheumatoid arthritis (RA), previously investigated in an epidemiological survey of RA in Stockholm, were monitored for 13 years with the aim of eliciting the cause(s) of the high mortality among persons with RA. All hospitalizations were identified through the in-patient register of Stockholm County. A study based on medical record information was performed on a group of 157 persons who had been hospitalized during the follow-up. Dead and surviving persons were compared with regard to characteristics at the start of the follow-up, drug use, and diseases other than RA during the follow-up. Male sex and high Steinbrocker functional grading were the factors most closely associated with an increased death risk. Neither drug use generally, nor use of any particular type of drug, contributory cause, the disease RA in itself--and particularly its severe forms--is the main cause of the high mortality among RA sufferers.