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Meyers AR, Wurzelbacher SJ, Krieg EF, Ramsey JG, Crombie K, Christianson AL, Luo L, Burt S. Work-Related Risk Factors for Rotator Cuff Syndrome in a Prospective Study of Manufacturing and Healthcare Workers. HUMAN FACTORS 2023; 65:419-434. [PMID: 34148475 PMCID: PMC8685298 DOI: 10.1177/00187208211022122] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE This prospective study assessed the risk of developing rotator cuff syndrome (RCS) with separate or specific combinations of biomechanical exposures measures, controlling for individual confounders. BACKGROUND Compared with other musculoskeletal disorders, rates of work-related shoulder musculoskeletal disorders have been declining more slowly. METHOD We conducted up to 2 years of individual, annual assessments of covariates, exposures, and health outcomes for 393 U.S. manufacturing and healthcare workers without RCS at baseline. Task-level biomechanical exposures assessed exposure to forceful exertions (level, exertion rates, duty cycles), vibration, and upper arm postures (flexion, abduction). Hazard ratios (HRs) were calculated with Cox proportional hazard models. RESULTS We observed 39 incident RCS cases in 694 person-years (incidence rate = 5.62 per 100 person-years). Adjusting for confounders, we found increased risk of incident RCS associated with forceful hand exertions per minute for three upper arm posture tertiles: flexion ≥45° (≥28.2% time, HR = 1.11, CI [1.01, 1.22]), abduction ≥30° (11.9-21.2%-time, HR = 1.18, CI [1.04, 1.34]), and abduction >60° (≥4.8% time, HR = 1.16, CI [1.04, 1.29]). We failed to observe statistically significant effects for other interactions or any separate measures of biomechanical exposure. CONCLUSION This study highlights the importance of assessing combinations of exposure to forceful repetition and upper arm elevation when developing interventions for preventing RCS. APPLICATION Based on these results, interventions that reduce exposure to forceful repetition (i.e., lower force levels and/or slower exertion rates) may reduce the risk of RCS, especially when upper arm elevation cannot be avoided.
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Affiliation(s)
- Alysha R Meyers
- National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
| | | | - Edward F Krieg
- National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
| | - Jessica G Ramsey
- National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
| | | | | | - Lian Luo
- ATTAIN, LLC, Cincinnati, Ohio, USA
| | - Susan Burt
- formerly National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
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Seidler A, Romero Starke K, Freiberg A, Hegewald J, Nienhaus A, Bolm-Audorff U. Dose-Response Relationship between Physical Workload and Specific Shoulder Diseases-A Systematic Review with Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17041243. [PMID: 32075183 PMCID: PMC7068556 DOI: 10.3390/ijerph17041243] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/09/2020] [Accepted: 02/10/2020] [Indexed: 11/16/2022]
Abstract
Several epidemiological studies have found an association between shoulder-loaded work activities and specific shoulder diseases. No study has derived the dose-response relationship and resulting doubling dose, important for the recognition of occupational diseases. This systematic review is an update of the van der Molen et al. (2017) review. Based on its methodologies, we identified new studies published up to November 2018. The dose-response relationship between physical occupational demands (hands at/above shoulder level, repetitive movements, forceful work, hand-arm vibrations) and specific shoulder diseases (defined as ICD-10 M 75.1-5: rotator cuff syndrome, bicipital tendinitis, calcific tendinitis, impingement, and bursitis) was derived. No evidence for sex-specific differences in the dose-response relationship was found. If there were at least two studies with comparable exposures, a meta-analysis was carried out. The pooled analysis resulted in a 21% risk increase (95% CI 4–41%) per 1000 h of work with hands above shoulder level. A meta-analysis was not possible for other occupational burdens due to the low number of studies and differing exposure measurements; an estimate of the doubling dose was made based on the cohort study of Dalbøge et al. (2014). To conclude, the present systematic review with meta-analysis contributes to knowledge of the level of exposure at which specific shoulder diseases—particularly rotator cuff lesions—should be recognized as an occupational disease.
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Affiliation(s)
- Andreas Seidler
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (K.R.S.); (A.F.); (J.H.)
- Correspondence: ; Tel.: +49-351-3177-441
| | - Karla Romero Starke
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (K.R.S.); (A.F.); (J.H.)
| | - Alice Freiberg
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (K.R.S.); (A.F.); (J.H.)
| | - Janice Hegewald
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (K.R.S.); (A.F.); (J.H.)
| | - Albert Nienhaus
- Department of Occupational Medicine, Public Health and Hazardous Substances, Statutory Accident Insurance and Prevention in the Health and Welfare Services, 22089 Hamburg, Germany;
- Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany
| | - Ulrich Bolm-Audorff
- Division of Occupational Health, Department of Occupational Safety and Environment, Regional Government of South Hesse, 65197 Wiesbaden, Germany;
- Institute and Outpatient Clinic for Occupational and Social Medicine, University Medical Center Gießen, Justus-Liebig-University, 35392 Gießen, Germany
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Mikkelsen S, Pedersen EB, Brauer C, Møller KL, Alkjaer T, Koblauch H, Simonsen EB, Thygesen LC. Knee osteoarthritis among airport baggage handlers: A prospective cohort study. Am J Ind Med 2019; 62:951-960. [PMID: 31452223 DOI: 10.1002/ajim.23044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/12/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Knee osteoarthritis is a common and often disabling disorder, which has been related to knee-straining work. However, exposure response relations are uncertain and there are few prospective studies. We studied prospectively if incident knee osteoarthritis is associated with cumulative exposure as an airport baggage handler, lifting on average 5000 kg/d. METHODS The study is based on the Copenhagen Airport Cohort, a historical cohort of male baggage handlers and a reference group of unskilled men from the greater Copenhagen area, followed from 1990 to 2012. Cumulative years of employment as a baggage handler was based on information from company employment and union registers. Outcome was first hospital admission with a discharge diagnosis of knee osteoarthritis and/or knee replacement, ascertained from the Danish National Patient Register. RESULTS The cohort contained 3442 baggage handlers and 65 511 workers in the reference group. The unadjusted incidence rate ratio (IRR) of knee osteoarthritis increased steeply with cumulative years as a baggage handler. Although the exposure-response pattern became weaker and statistically nonsignificant (P ≈ .10) when adjusting for age, the risk of knee osteoarthritis was still increased in baggage handlers at the highest exposure level. Additional analyses showed that the association between age and osteoarthritis was stronger for baggage handlers (IRR = 2.09; 95% CI: 1.68-2.60) than for referents (IRR = 1.58; 95% CI: 1.53-1.63), indicating that knee osteoarthritis occurred at a younger age among baggage handlers than in the reference group. CONCLUSIONS The results of this prospective cohort study support that long-term heavy lifting increases the risk of knee osteoarthritis.
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Affiliation(s)
- Sigurd Mikkelsen
- Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Ellen B Pedersen
- Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Charlotte Brauer
- Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Karina L Møller
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Tine Alkjaer
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen N, Denmark
- The Department of Physical and Occupational Therapy, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Henrik Koblauch
- Department of Neuroscience, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Erik B Simonsen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen N, Denmark
- Department of Neuroscience, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Lau C Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Occupational lifting predicts hospital admission due to low back pain in a cohort of airport baggage handlers. Int Arch Occup Environ Health 2019; 93:111-122. [PMID: 31451926 PMCID: PMC6989598 DOI: 10.1007/s00420-019-01470-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 08/14/2019] [Indexed: 11/12/2022]
Abstract
Purpose To examine if occupational lifting assessed as cumulative years as a baggage handler is associated with first-time hospital diagnosis or treatment for low back disorders. Methods This study is based on the Copenhagen Airport Cohort consisting of male baggage handlers performing heavy lifting every day and a reference group of unskilled men from the greater Copenhagen area during the period 1990–2012. We followed the cohort in the National Patient Register and Civil Registration System to obtain information on diagnoses, surgery, mortality, and migration. The outcomes were first-time hospital diagnosis or surgery for (1) lumbar disc herniation or (2) low back pain (LBP). Results Baggage handlers (N = 3473) had a higher incidence rate of LBP, but not of lumbar disc herniation, compared to the reference group (N = 65,702). Baggage handlers with longer employment had a higher incidence of LBP compared to baggage handlers with shorter employment. The linear association of cumulative years as a baggage handler on LBP was significantly increased with an incidence rate ratio of 1.16 (95% CI 1.07–1.25) for a 5-year increase of employment as baggage handler. Conclusions In this large cohort study, we found an increased incidence of LBP among baggage handlers compared to the reference group with indications of a dose–response relationship between years of employment and the outcome. For baggage handlers working on the apron, the incidence was particularly increased before introduction of technical lifting equipment, suggesting that preventive measures to reduce cumulative work load may have a positive effect.
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Bergsten EL, Mathiassen SE, Kwak L, Vingård E. Daily Shoulder Pain Among Flight Baggage Handlers and its Association With Work Tasks and Upper Arm Postures on the Same Day. Ann Work Expo Health 2018; 61:1145-1153. [PMID: 29136416 PMCID: PMC6824525 DOI: 10.1093/annweh/wxx073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022] Open
Abstract
Objectives This study of flight baggage handlers aimed at examining the extent to which shoulder pain developed during single work shifts, and whether a possible development was associated with biomechanical exposures and psychosocial factors during the same shift. Methods Data were collected during, in total, 82 work shifts in 44 workers. Right and left shoulder pain intensity was rated just before and just after the shift (VAS scale 0–100 mm). Objective data on ‘time in extreme’ and ‘time in neutral’ upper arm postures were obtained for the full shift using accelerometers, and the baggage handlers registered the number of ‘aircrafts handled’ in a diary. During half of the shift, workers were recorded on video for subsequent task analysis of baggage handling. ‘Influence’ at work and ‘support’ from colleagues were measured by use of Copenhagen Psychosocial Questionnaire (COPSOQ). Associations between exposures and the increase in pain intensity during the shift (‘daily pain’) were analysed for the right and left shoulder separately using Generalized Estimating Equations (GEE). Results ‘Daily pain’ was observed in approximately one third of all shifts. It was significantly associated with the number of ‘aircrafts handled’ for both the right and left shoulder. In multivariate models including both biomechanical exposures and the psychosocial factors ‘influence’ at work and ‘support’ from colleagues, ‘aircrafts handled’ was still significantly associated with ‘daily pain’ in both shoulders, and so was ‘influence’ and ‘support’, however in opposite directions. Conclusions ‘Daily pain’ was, in general, associated with biomechanical exposures during the same shift and with general ‘influence’ and ‘support’ in the job. In an effort to reduce pain among flight baggage handlers, it may therefore be justified to consider a reduction of biomechanical exposures during handling of aircrafts, combined with due attention to psychosocial factors at work.
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Affiliation(s)
- Eva L Bergsten
- Department of Occupational and Public Health Sciences, University of Gävle, Centre for Centre for Musculoskeletal Research, Kungsbäcksvägen 47, Gävle 801 76, Sweden
| | - Svend Erik Mathiassen
- Department of Occupational and Public Health Sciences, University of Gävle, Centre for Centre for Musculoskeletal Research, Kungsbäcksvägen 47, Gävle 801 76, Sweden
| | - Lydia Kwak
- Unit of Intervention and Implementation Research for worker health, Institute of Environmental Medicine, Karolinska Institutet, Solnavägen 1, Stockholm 171 77, Sweden
| | - Eva Vingård
- Department of Medical Sciences, Occupational and Environmental Medicine, Eva Vingård, Uppsala University, Sjukhusvägen 7, Uppsala 753 09, Sweden
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Lu ML, Dufour JS, Weston EB, Marras WS. Effectiveness of a vacuum lifting system in reducing spinal load during airline baggage handling. APPLIED ERGONOMICS 2018; 70:247-252. [PMID: 29866315 DOI: 10.1016/j.apergo.2018.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 02/26/2018] [Accepted: 03/11/2018] [Indexed: 06/08/2023]
Abstract
Information on spinal loading for using lift assist systems for airport baggage handling is lacking. We conducted a laboratory study to evaluate a vacuum lift system for reducing lumbar spinal loads during baggage loading/unloading tasks. Ten subjects performed the tasks using the industry average baggage weight of 14.5 kg on a typical two-shelved baggage cart with or without using the lift system (i.e. lifting technique). Repeated measures analysis of variance (2 tasks × 2 shelf heights x 2 techniques) was used. Spinal loads were estimated by an electromyography-driven biomechanical model. On average, the vacuum lift system reduced spinal compressive forces on the lumbar spine by 39% and below the 3400 N damage threshold. The system also resulted in a 25% reduction in the anterior-posterior shear force at the L5/S1 inferior endplate level. This study provides evidence for the potential to reduce spinal loads when using a vacuum lift system.
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Affiliation(s)
- Ming-Lun Lu
- National Institute for Occupational Safety and Health, Taft Laboratories, 1150 Tusculum Ave. Cincinnati, OH 45226, USA.
| | - Jonathan S Dufour
- Spine Research Institute, The Ohio State University, Columbus, OH, USA; Department of Integrated Systems Engineering, The Ohio State University, Columbus, OH, USA
| | - Eric B Weston
- Spine Research Institute, The Ohio State University, Columbus, OH, USA; Department of Integrated Systems Engineering, The Ohio State University, Columbus, OH, USA
| | - William S Marras
- Spine Research Institute, The Ohio State University, Columbus, OH, USA; Department of Integrated Systems Engineering, The Ohio State University, Columbus, OH, USA
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Møller SP, Brauer C, Mikkelsen S, Alkjær T, Koblauch H, Pedersen EB, Simonsen EB, Thygesen LC. Risk of subacromial shoulder disorder in airport baggage handlers: combining duration and intensity of musculoskeletal shoulder loads. ERGONOMICS 2018; 61:576-587. [PMID: 28925318 DOI: 10.1080/00140139.2017.1382721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/14/2017] [Indexed: 06/07/2023]
Abstract
Musculoskeletal shoulder load among baggage handlers measured by combining duration and intensity based on biomechanical and epidemiological information may be a stronger predictor of subacromial shoulder disorders than baggage handler seniority. In 2012, a cohort of baggage handlers employed at Copenhagen Airport in 1990-2012, and a cohort of unskilled otherwise employed men answered a survey. Self-reported information on work tasks during employment in the airport in combination with work task specific biomechanically modelled forces in the shoulder joint was used to estimate shoulder load. Exposure measures were accumulated shoulder abduction moment, accumulated shoulder compression force, accumulated supraspinatus force and baggage handler seniority. The outcome was subacromial shoulder disorder registered in the Danish National Patient Register. When analyses were adjusted by all confounders except age, exposure variables showed close to significant associations with subacromial shoulder disorder. Results could not confirm our hypothesis that combined information on work task duration and shoulder load intensity was stronger associated with subacromial shoulder disorder than seniority. Practitioner Summary: In this study we sought to identify if the exposure to work-related musculoskeletal shoulder loading including duration and intensity among baggage handlers was associated with subacromial shoulder disorder. We found that there was an association but this was not stronger than that between baggage handler seniority and subacromial shoulder disorder.
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Affiliation(s)
- Sanne Pagh Møller
- a National Institute of Public Health, University of Southern Denmark , Copenhagen , Denmark
| | - Charlotte Brauer
- b Department of Occupational and Environmental Medicine , Copenhagen University Hospital , Copenhagen , Denmark
| | - Sigurd Mikkelsen
- b Department of Occupational and Environmental Medicine , Copenhagen University Hospital , Copenhagen , Denmark
| | - Tine Alkjær
- c Department of Biomedical Sciences , University of Copenhagen , Copenhagen , Denmark
- d The Department of Physical and Occupational Therapy , Copenhagen University Hospital Bispebjerg-Frederiksberg , Copenhagen , Denmark
| | - Henrik Koblauch
- e Center for Neuroscience , University of Copenhagen , Copenhagen , Denmark
| | - Ellen Bøtker Pedersen
- b Department of Occupational and Environmental Medicine , Copenhagen University Hospital , Copenhagen , Denmark
| | - Erik B Simonsen
- e Center for Neuroscience , University of Copenhagen , Copenhagen , Denmark
| | - Lau Caspar Thygesen
- a National Institute of Public Health, University of Southern Denmark , Copenhagen , Denmark
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Dalbøge A, Frost P, Andersen JH, Svendsen SW. Surgery for subacromial impingement syndrome in relation to intensities of occupational mechanical exposures across 10-year exposure time windows. Occup Environ Med 2017; 75:176-182. [DOI: 10.1136/oemed-2017-104511] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/17/2017] [Accepted: 07/28/2017] [Indexed: 02/06/2023]
Abstract
ObjectivesWe aimed to identify intensities of occupational mechanical exposures (force, arm elevation and repetition) that do not entail an increased risk of surgery for subacromial impingement syndrome (SIS) even after prolonged durations of exposure. Additionally, we wanted to evaluate if exposure to hand-arm vibration (HAV) is an independent risk factor.MethodsWe used data from a register-based cohort study of the entire Danish working population (n=2 374 403). During follow-up (2003–2008), 14 118 first-time events of surgery for SIS occurred. For each person, we linked register-based occupational codes (1993–2007) to a general population job exposure matrix to obtain year-by-year exposure intensities on measurement scales for force, upper arm elevation >90° and repetition and expert rated intensities of exposure to HAV. For 10-year exposure time windows, we calculated the duration of exposure at specific intensities above minimal (low, medium and high). We used a logistic regression technique equivalent to discrete survival analysis adjusting for cumulative effects of other mechanical exposures.ResultsWe found indications of safe exposure intensities for repetition (median angular velocity <45°/s), while force exertion ≥10% of maximal voluntary electrical activity and upper arm elevation >90° >2 min/day implied an increased risk reaching ORs of 1.7 and 1.5 after 10 years at low intensities. No associations were found for HAV.ConclusionsWe found indications of safe exposure intensities for repetition. Any intensities of force and upper arm elevation >90° above minimal implied an increased risk across 10-year exposure time windows. No independent associations were found for HAV.
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Møller KL, Brauer C, Mikkelsen S, Loft S, Simonsen EB, Koblauch H, Bern SH, Alkjær T, Hertel O, Becker T, Larsen KH, Bonde JP, Thygesen LC. Copenhagen Airport Cohort: air pollution, manual baggage handling and health. BMJ Open 2017; 7:e012651. [PMID: 28478397 PMCID: PMC5777468 DOI: 10.1136/bmjopen-2016-012651] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 01/15/2017] [Accepted: 01/20/2017] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Copenhagen Airport Cohort 1990-2012 presents a unique data source for studies of health effects of occupational exposure to air pollution (ultrafine particles) and manual baggage handling among airport employees. We describe the extent of information in the cohort and in the follow-up based on data linkage to the comprehensive Danish nationwide health registers. In the cohort, all information is linked to the personal identification number that also is used in Denmark Statistics demographic and socioeconomic databases and in the nationwide health registers. PARTICIPANTS The cohort covers 69 175 men in unskilled positions. The exposed cohort includes men in unskilled jobs employed at Copenhagen Airport in the period 1990-2012 either as baggage handlers or in other outdoor work. The reference cohort includes men in unskilled jobs working in the greater Copenhagen area. FINDINGS TO DATE The cohort includes environmental Global Positioning System (GPS) measurements in Copenhagen Airport, information on job function/task for each calendar year of employment between 1990 and 2012, exposure to air pollution at residence, average weight of baggage lifted per day and lifestyle. By linkage to registers, we retrieved socioeconomic and demographic data and data on healthcare contacts, drug subscriptions, incident cancer and mortality. FUTURE PLANS The size of the cohort and the completeness of the register-based follow-up allow a more accurate assessment of the possible health risks of occupational exposure to ultrafine particles and manual baggage handling at airports than in previous studies. We plan to follow the cohort for the incidence of ischaemic heart diseases, cerebrovascular disease, lung and bladder cancer, asthma and chronic obstructive pulmonary disease, and further for associations between heavy manual baggage handling and musculoskeletal disorders. TRIAL REGISTRATION number 2012-41-0199.
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Affiliation(s)
| | - Charlotte Brauer
- Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Sigurd Mikkelsen
- Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Steffen Loft
- Section of Environmental Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Erik B Simonsen
- Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Koblauch
- Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Stine Hvid Bern
- Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Tine Alkjær
- Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Ole Hertel
- Department of Environmental Science, Aarhus University, Roskilde, Denmark
| | - Thomas Becker
- Department of Environmental Science—Emission Modelling & Environmental Geography, Aarhus University, Roskilde, Denmark
| | - Karin Helweg Larsen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Jens Peter Bonde
- Department of Occupational and Environmental Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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