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Gunnarsson, Lars-GunnarORCID iD iconorcid.org/0000-0002-4192-8273
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Gunnarsson, L.-G. & Bodin, L. (2019). Occupational Exposures and Neurodegenerative Diseases: A Systematic Literature Review and Meta-Analyses. International Journal of Environmental Research and Public Health, 16(3), Article ID 337.
Open this publication in new window or tab >>Occupational Exposures and Neurodegenerative Diseases: A Systematic Literature Review and Meta-Analyses
2019 (English)In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 16, no 3, article id 337Article, review/survey (Refereed) Published
Abstract [en]

Objectives: To carry out an integrated and stratified meta-analysis on occupational exposure to electromagnetic fields (EMFs), metals and pesticides and its effects on amyotrophic lateral sclerosis (ALS) and Parkinson's and Alzheimer's disease, and investigate the possibility of publication bias.

Methods: In the current study, we updated our recently published meta-analyses on occupational exposures in relation to ALS, Alzheimer's and Parkinson's disease. Based on 66 original publications of good scientific epidemiological standard, according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines, we analysed subgroups by carrying out stratified meta-analyses on publication year, statistical precision of the relative risk (RR) estimates, inspection of the funnel plots and test of bias.

Results: Based on 19 studies the weighted RR for occupational exposure to EMFs was 1.26 (95% confidence interval (CI) 1.07-1.50) for ALS, 1.33 (95% CI 1.07-1.64) for Alzheimer's disease and 1.02 (95% CI 0.83-1.26) for Parkinson's disease. Thirty-one studies concerned occupational exposure to pesticides and the weighted RR was 1.35 (95% CI 1.02-1.79) for ALS, 1.50 (95% CI 0.98-2.29) for Alzheimer's disease and 1.66 (95% CI 1.42-1.94) for Parkinson's disease. Finally, 14 studies concerned occupational exposure to metals and only exposure to lead (five studies) involved an elevated risk for ALS or Parkinson's disease and the weighted RR was 1.57 (95% CI 1.11-2.20). The weighted RR for all the non-lead exposures was 0.97 (95% CI 0.88-1.06).

Conclusions: Exposure to pesticides increased the risk of getting the mentioned neurodegenerative diseases by at least 50%. Exposure to lead was only studied for ALS and Parkinson's disease and involved 50% increased risk. Occupational exposure to EMFs seemed to involve some 10% increase in risk for ALS and Alzheimer's disease only.

Place, publisher, year, edition, pages
MDPI, 2019
Keywords
epidemiology, metals, pesticides, electromagnetic fields, ALS, Parkinson's disease, Alzheimer's disease
National Category
Environmental Sciences Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:oru:diva-73127 (URN)10.3390/ijerph16030337 (DOI)000459113600043 ()30691095 (PubMedID)2-s2.0-85060621765 (Scopus ID)
Available from: 2019-03-14 Created: 2019-03-14 Last updated: 2019-03-14Bibliographically approved
Gunnarsson, L.-G. & Bodin, L. (2018). Alzheimer’s Disease and Occupational Exposures: A Systematic Literature Review and Meta-Analyses. In: Alzheimer's Disease & Treatment: . Open Access ebooks
Open this publication in new window or tab >>Alzheimer’s Disease and Occupational Exposures: A Systematic Literature Review and Meta-Analyses
2018 (English)In: Alzheimer's Disease & Treatment, Open Access ebooks , 2018Chapter in book (Refereed)
Abstract [en]

Six systematic literature reviews together with meta-analyses have been published on the associations between Alzheimer’s disease and occupational risk factors. Our meta-analyses were based only on studies fulfilling good standards of scientific quality. We scrutinized the 54 relevant original publications found using a checklist proposed by the MOOSE-group together with a new elaborated protocol. Thus our results are not hampered by bias from studies of lower scientific quality. Thirty publications fulfilled good scientific standards and were thus used in our meta-analyses. Exposures to electromagnetic fields were concerned in 12 publications. The weighted relative risk estimate was 1.35 (95% confidence interval: 1.08-1.70). Exposure to pesticides or other chemicals resulted in the statistically significant relative risk 1.5 while exposure to metals involved no increase of risk. A high degree of work complexity (especially in relation to people) and long education were both protective against Alzheimer’s disease. Based on ten studies the weighted relative risk was 0.47 (95% CI: 0.35-0.63). Both work-related risk factors and protective factors are discussed in relation to possible pathophysiological mechanisms.

Place, publisher, year, edition, pages
Open Access ebooks, 2018
Keywords
Epidemiology; Electromagnetic fields; Pesticides; Chemicals, Metals; Work complexity; Education.
National Category
Medical and Health Sciences Neurology Occupational Health and Environmental Health
Identifiers
urn:nbn:se:oru:diva-70399 (URN)978-93-87500-26-6 (ISBN)
Available from: 2018-11-30 Created: 2018-11-30 Last updated: 2018-12-05Bibliographically approved
Gunnarsson, L.-G. & Bodin, L. (2018). Amyotrophic Lateral Sclerosis and Occupational Exposures: A Systematic Literature Review and Meta-Analyses. International Journal of Environmental Research and Public Health, 15(11), Article ID 2371.
Open this publication in new window or tab >>Amyotrophic Lateral Sclerosis and Occupational Exposures: A Systematic Literature Review and Meta-Analyses
2018 (English)In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 15, no 11, article id 2371Article in journal (Refereed) Published
Abstract [en]

Objectives: We conducted a systematic literature review to identify studies fulfilling good scientific epidemiological standards for use in meta-analyses of occupational risk factors for amyotrophic lateral sclerosis (ALS). 

Methods: We identified 79 original publications on associations between work and ALS. The MOOSE (Meta-analysis Of Observational Studies in Epidemiology) and GRADE (Grading of Recommendations, Assessment, Development and Evaluations) guidelines were used to ensure high scientific quality, and reliable protocols were applied to classify the articles. Thirty-seven articles fulfilled good scientific standards, while 42 were methodologically deficient and thus were excluded from our meta-analyses. 

Results: The weighted relative risks for the various occupational exposures were respectively; 1.29 (95% confidence interval (CI): 0.97⁻1.72; six articles) for heavy physical work, 3.98 (95% CI: 2.04⁻7.77; three articles) for professional sports, 1.45 (95% CI: 1.07⁻1.96; six articles) for metals, 1.19 (95% CI: 1.07⁻1.33; 10 articles) for chemicals, 1.18 (95% CI: 1.07⁻1.31; 16 articles) for electromagnetic fields or working with electricity, and 1.18 (95% CI: 1.05⁻1.34; four articles) for working as a nurse or physician. 

Conclusions: Meta-analyses based only on epidemiologic publications of good scientific quality show that the risk of ALS is statistically significantly elevated for occupational exposures to excessive physical work, chemicals (especially pesticides), metals (especially lead), and possibly also to electromagnetic fields and health care work. These results are not explained by publication bias.

Place, publisher, year, edition, pages
MDPI AG, 2018
Keywords
chemicals, electromagnetic fields, epidemiology, metals, physical activity
National Category
Probability Theory and Statistics
Identifiers
urn:nbn:se:oru:diva-70388 (URN)10.3390/ijerph15112371 (DOI)000451640500045 ()30373166 (PubMedID)2-s2.0-85055616670 (Scopus ID)
Funder
AFA Insurance
Note

Funding Agency:

Department of Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden

Available from: 2018-11-30 Created: 2018-11-30 Last updated: 2018-12-17Bibliographically approved
Vihlborg, P., Bryngelsson, I.-L., Lindgren, B., Gunnarsson, L.-G. & Graff, P. (2017). Association between vibration exposure and hand-arm vibration symptoms in a Swedish mechanical industry. International Journal of Industrial Ergonomics, 62, 77-81
Open this publication in new window or tab >>Association between vibration exposure and hand-arm vibration symptoms in a Swedish mechanical industry
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2017 (English)In: International Journal of Industrial Ergonomics, ISSN 0169-8141, E-ISSN 1872-8219, Vol. 62, p. 77-81Article in journal (Refereed) Published
Abstract [en]

Work with vibrating tools is common in many industries. Exposure to hand-arm vibrations is associated with a risk of hand injury in the form of: Vascular disorders, nerve malfunction, and effects on the musculoskeletal system. The aim of this study was to investigate the prevalence of hand-arm vibration symptoms among employees at a mechanical company, as well as to follow-up with patients presenting symptoms and evaluate the effects of certain proposed measures. We found that 21% of the employees were judged to have vibration-related problems even though the exposure to vibrations was judged to be relatively low. There seems to be an over-representation of Carpal tunnel syndrome among participants; this may suggest that ergonomic conditions at the investigated company, such as grinding with flexed wrists, are unfavorable.

Relevance to industry: Regular screening for early signs of vibration-related damage, even if workers are subject to only moderate vibration exposure, is an important part of preventing the aggravation of health problems.

Place, publisher, year, edition, pages
Elsevier, 2017
Keywords
Hand-arm vibration, Hand-arm vibration syndrome, Quantitative sensory testing, Carpal tunnel syndrome, Vibration exposure
National Category
Occupational Health and Environmental Health
Identifiers
urn:nbn:se:oru:diva-62842 (URN)10.1016/j.ergon.2017.02.010 (DOI)000414879600010 ()2-s2.0-85014872924 (Scopus ID)
Note

Funding Agency:

Region Örebro County 

Available from: 2017-11-27 Created: 2017-11-27 Last updated: 2019-03-04Bibliographically approved
Gunnarsson, L.-G. & Bodin, L. (2017). Parkinson's disease and occupational exposures: a systematic literature review and meta-analyses. Scandinavian Journal of Work, Environment and Health, 43(3), 197-209, Article ID 3641.
Open this publication in new window or tab >>Parkinson's disease and occupational exposures: a systematic literature review and meta-analyses
2017 (English)In: Scandinavian Journal of Work, Environment and Health, ISSN 0355-3140, E-ISSN 1795-990X, Vol. 43, no 3, p. 197-209, article id 3641Article in journal (Refereed) Published
Abstract [en]

Objectives: We conducted a systematic literature review to identify studies fulfilling good scientific epidemiological standards for use in meta-analyses of relevant risk factors for Parkinson's disease.

Methods: Our search identified 103 original publications on associations between work and Parkinson's disease. GRADE guidelines were used to ensure high scientific quality, and reliable guidelines were applied to classify the papers. Of the 103 articles, 47 fulfilled good scientific standards while 56 were methodologically deficient and thus excluded from our meta-analyses.

Results: A total of 23 publications concerned work exposure to pesticides. The weighted relative risk estimate was 1.67 (95% confidence interval 1.42-1.97). A funnel plot and bias test indicated that some publication bias concerning smaller studies might have been present. The risk estimate was not influenced by study design (case-control, cohort, or cross-sectional study) or gender. Higher estimates were found when there was a hereditary taint or onset below age 60. Studies on exposure to metals or electromagnetic fields did not show increased risk.

Conclusions: Using an elaborated quality protocol, there is now strong evidence that exposure to any pesticide involves a ≥50% increased risk for developing Parkinson's disease.

Place, publisher, year, edition, pages
Nordic Association of Occupational Safety and Health, 2017
Keywords
chemical; electromagnetic field; epidemiology; metal; pesticide; systematic review; welding
National Category
Occupational Health and Environmental Health
Research subject
Occupational and Environmental Medicine
Identifiers
urn:nbn:se:oru:diva-57338 (URN)10.5271/sjweh.3641 (DOI)000400705700002 ()28379585 (PubMedID)2-s2.0-85018371645 (Scopus ID)
Funder
AFA Insurance
Note

Funding Agencies:

Department of Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg 

Available from: 2017-05-30 Created: 2017-05-30 Last updated: 2018-07-31Bibliographically approved
Nilsagård, Y., Rådman, L., Jakobsson, K. & Gunnarsson, L.-G. (2017). Symtom efter strömgenomgång. In: Kjell Torén, Lars-Gunnar Gunnarsson, Sara Thomée och Kristina Jakobsson (Ed.), Elolyckor i arbetet: (pp. 21-26). Göteborg, Sweden: Göteborgs universitet
Open this publication in new window or tab >>Symtom efter strömgenomgång
2017 (Swedish)In: Elolyckor i arbetet / [ed] Kjell Torén, Lars-Gunnar Gunnarsson, Sara Thomée och Kristina Jakobsson, Göteborg, Sweden: Göteborgs universitet, 2017, p. 21-26Chapter in book (Other academic)
Abstract [sv]

523 elektriker som hade varit med om minst en elolycka med strömgenomgång besvarade en fördjupad enkät med fokus på frågor om symtom från perifera och centrala nervsystemet och muskulatur.

 Nio av tio som varit med om högspänningsolycka hade sökt akut sjukvård. Endast två av tio hade sökt vård efter lågspänningsolycka.

 Besvär framför allt i form av smärta och nedsatt känsel efter strömgenomgång var relativt vanligt, men för de allra flesta blev inte dessa besvär bestående.

 Symtom från nervsystem och hjärna var betydligt vanligare hos de som hade varit utsatta för högspänningsolyckor eller fastnat vid strömkällan på grund av muskelkramp.

Place, publisher, year, edition, pages
Göteborg, Sweden: Göteborgs universitet, 2017
Series
Arbete och Hälsa, ISSN 0346-7821 ; 51(2)
National Category
Neurology Occupational Therapy
Identifiers
urn:nbn:se:oru:diva-67168 (URN)978-91-85971-59-6 (ISBN)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2010-0561
Available from: 2018-06-05 Created: 2018-06-05 Last updated: 2019-03-22Bibliographically approved
Rådman, L., Nilsagård, Y., Jakobsson, K., Ek, Å. & Gunnarsson, L.-G. (2016). Electrical injury in relation to voltage, "no-let-go" phenomenon, symptoms and perceived safety culture: a survey of Swedish male electricians. International Archives of Occupational and Environmental Health, 89(2), 261-270
Open this publication in new window or tab >>Electrical injury in relation to voltage, "no-let-go" phenomenon, symptoms and perceived safety culture: a survey of Swedish male electricians
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2016 (English)In: International Archives of Occupational and Environmental Health, ISSN 0340-0131, E-ISSN 1432-1246, Vol. 89, no 2, p. 261-270Article in journal (Refereed) Published
Abstract [en]

Professional electricians are highly subjected to electrical injuries. Previous studies describing symptoms after electrical injury have not included people with less severe initial injuries. The purpose of the present study was to describe symptoms at different time points after electrical injury, the impact of "no-let-go" phenomenon and different electrical potential [high voltage (HV) vs. low voltage (LV)], and the safety culture at the workplace.

A retrospective survey was conducted with 523 Swedish electricians. Two questionnaires were issued: the first to identify electricians who had experienced electrical injury and the second to gain information about symptoms and safety culture. Self-reported symptoms were described at different time points following injury. Symptoms for HV and LV accidents were compared. Occurrence or nonoccurrence of "no-let-go" phenomenon was analysed using two-tailed Chi-2. Safety culture was assessed with a validated questionnaire.

Nearly all reported having symptoms directly after the injury, mainly paraesthesia and pain. For the first weeks after injury, pain and muscle weakness dominated. The most frequently occurring symptoms at follow-up were pain, muscle weakness and loss of sensation. HV injuries and "no-let go" phenomenon were associated with more sustained symptoms. Deficiencies in the reporting routines were present, as well as shortage of preventive measures.

The results indicate that symptoms are reported also long time after an electrical injury and that special attention should be paid to HV injuries and "no-let go" accidents. The workplace routines to reduce the number of work-related electrical injuries for Swedish electricians can be improved.

Place, publisher, year, edition, pages
Springer, 2016
Keywords
Electrical injury, Low-voltage injury, High-voltage injury, Safety management, Neurological symptoms, Pain
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:oru:diva-48474 (URN)10.1007/s00420-015-1069-3 (DOI)000368806500008 ()26186954 (PubMedID)2-s2.0-84955733403 (Scopus ID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2010-0561
Note

Funding Agency:

Örebro Research Committee

Available from: 2016-02-23 Created: 2016-02-23 Last updated: 2019-03-22Bibliographically approved
Rådman, L., Gunnarsson, L.-G., Nilsagård, Y. & Nilsson, T. (2016). Neurosensory findings among electricians with self-reported remaining symptoms after an electrical injury: A case series. Burns, 42(8), 1712-1720
Open this publication in new window or tab >>Neurosensory findings among electricians with self-reported remaining symptoms after an electrical injury: A case series
2016 (English)In: Burns, ISSN 0305-4179, E-ISSN 1879-1409, Vol. 42, no 8, p. 1712-1720Article in journal (Refereed) Published
Abstract [en]

Purpose: Symptoms described in previous studies indicate that electrical injury can cause longstanding injuries to the neurosensory nerves. The aim of the present case series was to objectively assess the profile of neurosensory dysfunction in electricians in relation to high voltage or low voltage electrical injury and the "no-let-go phenomenon".

Methods: Twenty-three Swedish male electricians exposed to electrical injury were studied by using a battery of clinical instruments, including quantitative sensory testing (QST). The clinical test followed a predetermined order of assessments: thermal perceptions thresholds, vibration perception thresholds, tactile gnosis (the Shape and Texture Identification test), manual dexterity (Purdue Pegboard Test), and grip strength. In addition, pain was studied by means of a questionnaire, and a colour chart was used for estimation of white fingers.

Results: The main findings in the present case series were reduced thermal perceptions thresholds, where half of the group showed abnormal values for warm thermal perception and/or cold thermal perception. Also, the tactile gnosis and manual dexterity were reduced. High voltage injury was associated with more reduced sensibility compared to those with low voltage.

Conclusion: Neurosensory injury can be objectively assessed after an electrical injury by using QST with thermal perception thresholds. The findings are consistent with injuries to small nerve fibres. In the clinical setting thermal perception threshold is therefore recommended, in addition to tests of tactile gnosis and manual dexterity (Purdue Pegboard).

Place, publisher, year, edition, pages
Oxford, United Kingdom: Elsevier, 2016
Keywords
Voltage, thermal perception, vibration perception thresholds, manual dexterity, tactile gnosis, small fibre neuropathy
National Category
Dermatology and Venereal Diseases Surgery
Identifiers
urn:nbn:se:oru:diva-50950 (URN)10.1016/j.burns.2016.05.017 (DOI)000391073900012 ()27317339 (PubMedID)2-s2.0-85005942729 (Scopus ID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2010-0561
Note

Funding Agencies:

Örebro Research Committee

Department of Occupational and Environmental Medicine, Örebro University Hospital

Available from: 2016-06-20 Created: 2016-06-20 Last updated: 2019-03-22Bibliographically approved
Gunnarsson, L.-G. & Bodin, L. (2015). Epidemiologiskt undersökta samband mellan Alzheimers sjukdom och faktorer i arbetsmiljön. Göteborg: Göteborgs universitet
Open this publication in new window or tab >>Epidemiologiskt undersökta samband mellan Alzheimers sjukdom och faktorer i arbetsmiljön
2015 (Swedish)Report (Refereed)
Abstract [en]

Epidemiological evidence on associations between work environment and Alzheimers disease

Lars-Gunnar Gunnarsson, assistant professor at School of Medicine, Örebro University, Sweden and

Lennart Bodin, professor emeritus, Department of Statistics, Örebro University, Sweden and senior researcher at Institute of Environmental Medicine, Karolinska Institute, Sweden.

In this systematic literature review we identified 50 original publications on associations between work and Alzheimer’s disease. GRADE guidelines were used to secure high scientific quality and reliable guidelines were applied to classify the papers. Thirty-one papers fulfilled high quality standards while 19 were methodologically deficient and thus were excluded from our meta-analyses.

Twenty-seven studies concerned exposure to electromagnetic fields and two published meta-analyses indicated a weighted relative risk (RR) reaching 2.0. Our meta-analysis was only based on twelve high quality publications and the weighted relative risk included statistically over chemicals was evaluated in seven studies and the weighted RR was 1.55 (95% confidence interval 1.19-2.02). Only some few publications concerned pesticides and other chemicals and the weighted RR indicated increased risk.

Higher education and work complexity were evaluated in eleven publications and our meta-analysis show a reduced the risk for Alzheimer’s disease. The weighted RR was 0.47 (95% confidence interval 0.35-0.63). Both factors were independently and additively protective.

There are indications of an association between ALS and exposure to heavy muscle work especially in combination with muscle trauma, i.e. professional football players are reported to have an elevated risk. More studies are needed with more precise measures on these exposures.

Place, publisher, year, edition, pages
Göteborg: Göteborgs universitet, 2015. p. 58
Series
Arbete och Hälsa, ISSN 0346-7821 ; 49(3)
National Category
Other Medical Sciences not elsewhere specified Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:oru:diva-54878 (URN)978-91-85971-55-8 (ISBN)
Available from: 2017-01-20 Created: 2017-01-20 Last updated: 2017-10-18Bibliographically approved
Gunnarsson, L.-G. & Bodin, L. (2014). Epidemiologiskt påvisade samband mellan Parkinsons sjukdom och faktorer i arbetsmiljön. In: Lars-Gunnar Gunnarsson och Lennart Bodin (Ed.), Systematiska kunskapsöversikter: 6. Epidemiologiskt påvisade samband mellan Parkinsons sjukdom och faktorer i arbetsmiljön (pp. 11-79). Göteborg: Göteborgs universitet
Open this publication in new window or tab >>Epidemiologiskt påvisade samband mellan Parkinsons sjukdom och faktorer i arbetsmiljön
2014 (Swedish)In: Systematiska kunskapsöversikter: 6. Epidemiologiskt påvisade samband mellan Parkinsons sjukdom och faktorer i arbetsmiljön / [ed] Lars-Gunnar Gunnarsson och Lennart Bodin, Göteborg: Göteborgs universitet , 2014, p. 11-79Chapter in book (Refereed)
Abstract [en]

Epidemiological evidence on associations between work environment and Parkinson’s disease.

Lars-Gunnar Gunnarsson, assistant professor at School of Medicine, Örebro University, Sweden and

Lennart Bodin, professor emeritus, Department of Statistics, Örebro University, Sweden and senior researcher at Institute of Environmental Medicine, Karolinska Institute, Sweden.

In this systematic literature review we identified 93 original publications on associations between work and Parkinson’s disease (PD). GRADE guidelines were used to secure high scientific quality and reliable guidelines were applied to classify the papers. Forty-nine papers fulfilled high quality standards while 44 were methodologically deficient and thus were excluded from our meta-analyses.

Twenty five publications concerned work exposure to pesticides. The weighted relative risk (RR) estimate was 1.72 (95% confidence interval 1.46-2.04). A funnel plot and tests indicated that some publication bias concerning smaller studies might have been present. The risk estimate was not influenced by study design (case-control, cohort or cross section study) or gender. Higher estimates were found when there was a hereditary taint or onset below age 60.

In 15 publications exposure to electromagnetic fields was considered and there was no indication of risk, RR 1.07 (95% confidence interval 0.98-1.18).

Meta-analyses of ten studies on exposure for metals showed a statistically diminished risk estimate, RR 0.85 (95% confidence interval 0.82-0.89). A proposed explanation to this seemingly beneficial effect is hormesis meaning that exposures of a low-moderate dosage of toxic agents can induce neuroprotective mechanisms.

 

Place, publisher, year, edition, pages
Göteborg: Göteborgs universitet, 2014
Series
Arbete och Hälsa, Vetenskaplig skriftserie, ISSN 0346-7821 ; 48(1)
Keywords
Metaanalys
National Category
Medical and Health Sciences
Research subject
Epidemiology; Medicine; Medicine
Identifiers
urn:nbn:se:oru:diva-44192 (URN)978-91-85971-50-3 (ISBN)
Funder
AFA Insurance
Available from: 2015-04-09 Created: 2015-04-09 Last updated: 2017-10-17Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-4192-8273

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