Certification and prescription in the diabetology field: occupational and medico-legal aspects.

Abstract: Diabetes mellitus is an ever-increasing disease and is defined as a "social disease" due to the significant economic damage it causes to the affected individuals and the community involved in its care. This paper presents the process of certification of diabetic disease and the application for invalidity in order to obtain welfare and economic benefits provided by law; it, also, describes the prescription process and the appropriateness of therapeutic prescription for the diabetic patient in terms of clinical-prescriptive appropriateness and economic-prescriptive appropriateness. Finally, it reports on the side effects of the most common antidi-abetics, the off-label use of metformin and the physician's responsibili-ties in the light of the Gelli-Bianco law.

High body mass index and night shift work are associated with COVID-19 in health care workers.

OBJECTIVE: To assess the magnitude of COVID-19 spread and the associated risk factors among health care workers (HCWs), we conducted an in-hospital survey in a central Italian COVID Hospital. METHODS: Participants underwent nasopharyngeal swab and/or serum collection for SARS-CoV-2 IgG examination. We divided participants according to working status, into rotating-night shift workers (r-NSW) and day-workers. RESULTS: We found 30 cases of COVID-19 infection in a total of 1180 HCWs (2.5%). Most COVID-19-positive hospital employees were r-NSWs with significantly higher BMI than that of individuals who tested negative. After adjustment for covariates, night work and BMI > 30 were associated with a markedly greater risk of COVID-19 diagnosis (OR 3.049 [95%CI 1.260-7.380] and OR 7.15 [95%CI 2.91-17.51], respectively). CONCLUSIONS: Our results describe a low prevalence of COVID-19 infection among HCWs at a central Italian COVID Hospital. COVID-19 infection risk appears to be associated with obesity and night shift work, thus supporting the need for careful health surveillance among frontline HCWs exposed to COVID-19.

Monthly fluctuations in 25-hydroxy-vitamin D levels in day and rotating night shift hospital workers.

PURPOSE: Epidemiological studies have suggested that indoor hospital employees, either day or night shift workers, are at high risk of metabolic and cardiovascular diseases. Interestingly, previous reports have also described a higher prevalence of vitamin D (25OHD) deficiency among these workers. However, few studies have determined the monthly variations in 25OHD levels in indoor hospital employees. METHODS: To address this lack of knowledge, in 2018, during the periodic health surveillance checks at the Service of Occupational Medicine, we measured 25OHD levels in a group of indoor hospital workers (88 rotating night shift workers vs 200 day workers). Each participant received a single annual health surveillance check. RESULTS: The mean levels of 25OHD were consistently below the lower limit of the normal range in both groups throughout the year. Only in the summer, day workers but not rotating night shift workers (mean 25.9 ± 11.3 ng/ml vs 23.1 ± 9.1 ng/ml; p = 0.042) showed levels significantly higher than those in the other seasons. This difference remained statistically significant even after correction for study covariates [ß = -  1.649 (CI - 0.283/- 3.482), p = 0.039]. A cosinor analysis confirmed that the difference in the 25OHD levels between groups was present later in the year. CONCLUSIONS: We found that relatively young healthy hospital workers, especially those with rotating night shifts, in the absence of significant metabolic risk factors, have a high risk of 25OHD deficiency/insufficiency. Because 25OHD deficiency may lead to a progression to more severe conditions such as osteoporosis or bone fractures, our results should be verified in larger cohorts including different ancestries.

Pulmonary functionality among workers of a Central Italy waste-to-energy plant: a retrospective study.

BACKGROUND: We are observing a growing trend towards the use of waste incineration in waste-to-energy (WTE) plants in Italy. Various authors started to investigate their potential health effects, but without univocal outcomes. The aim of this study is to assess whether or not main pulmonary function indexes could be decreased in a group of workers employed in a municipal solid WTE plant located in Central Italy, and if there's a correlation between the levels of exposure to airborne pollutants and alterations in the pulmonary apparatus. METHODS: The study was conducted with a retrospective cohort approach. We reviewed data from clinical records of 58 waste-to-energy plant workers undergoing annual health surveillance in the period 2010-2015. We considered the exposure to airborne dust and the main parameters of respiratory function (FVC, FEV1, Tiffeneau Index and FEF 25-75%) at time zero and after a period of 5 years. We divided our study population into two groups: low (< 1 mg/m3) and high (> 1 mg/m3) exposure. We estimated odds ratios (OR) with 95% confidence interval (95% CI) adjusted for potential confounders. RESULTS: We observed a decrease in lung function parameters both in high and in low exposure group after a five-years exposure period. FEV1, FEV1/VC ratio and FEF 25-75% were worst in more exposed group, even if this difference resulted not significant at Wilcoxon test. CONCLUSIONS: Active employee in WTE plants is associated to a non-significant worsening in the main parameters of lung function after 5 years exposure. Clinical significant of these variations need to be assessed.

Measles immunity in an Italian teaching hospital.

BACKGROUND: Healthcare workers (HCWs) have an increased exposure risk to measles, which can put them, their patients and their relatives at risk of infection. In Italy, 4617 cases of measles were reported in 2017; 302 involving HCWs. According to the Italian National Immunization and Prevention Plan, all HCWs should have demonstrable evidence of immunity to measles. AIMS: To evaluate measles immunization status in HCWs at a large Italian teaching hospital. METHODS: We analysed clinical records and measles-specific IgG antibody titres of HCWs undergoing occupational health surveillance between 1 January and 31 August 2017. RESULTS: Among the 1532 HCWs (mean age 32.7 ± 10.4 years) included in the study, 87% (1328) had protective antibody titres. The proportion of protective titres was highest in those born before 1982. No significant gender differences in mean measles-specific IgG antibody titres were detected. CONCLUSIONS: Our study shows non-protective measles IgG antibody titres in a substantial percentage of HCWs, especially those born in the 1980s and 1990s. Due to the increased risk of measles transmission in the hospital environment, increased prevention strategies are required, including rigorous screening and prompt vaccination of non-immune workers.

Managing the risk of bacterial meningitis among healthcare workers.

BACKGROUND: Meningococcal disease is generally caused by A, B, C, W and Y subgroups of Neisseria meningitidis. In 2015, the Italian mass media focused on this disease due to the death of two nurses. This generated alarm in the general population, especially in healthcare workers (HCWs). The Occupational Medicine department of the Foundation PTV Polyclinic Tor Vergata (PTV) offered free MenACWY vaccine to HCWs and to students of the University of Rome Tor Vergata. AIMS: To analyse the prevalence of N. meningitidis in PTV, a large teaching hospital, and to evaluate preventive measures offered to individuals at risk (i.e. HCWs and students). METHODS: The Hospital Informatic Service provided data about patients admitted to PTV from January 2012 to December 2016. Hospital Discharge Registers were analysed and all cases of meningitis were selected. MenACWY vaccine administered to HCWs and students of PTV in 2017 was analysed. RESULTS: There was just one case of meningococcal disease in 2016. Of the 117 MenACWY vaccines administered, 42% were given to students, 32% to doctors, 8% to nurses, 2% to clerks and 16% to other healthcare professionals. CONCLUSIONS: International guidelines recommend MenACWY vaccine for microbiologists exposed to N. meningitidis isolates. The Italian Legislative Decree 81/2008, however, states that occupational physicians can adopt special protective measures such as vaccination programmes for HCWs. The response rate highlights how perceived risk may influence behaviour even in populations with a higher background knowledge than the general population.

Incidence of metabolic syndrome among night-shift healthcare workers.

OBJECTIVE: Night-shift work is associated with ischaemic cardiovascular disorders. It is not currently known whether it may be causally linked to metabolic syndrome (MS), a risk condition for ischaemic cardiovascular disorders. The syndrome presents with visceral obesity associated with mild alterations in glucidic and lipidic homeostasis, and in blood pressure. The aim of this study was to assess whether a causal relationship exists between night-shift work and the development of MS. METHODS: Male and female nurses performing night shifts, free from any component of MS at baseline, were evaluated annually for the development of the disorder during a 4-year follow-up. Male and female nurses performing daytime work only, visited during the same time period, represented the control group. RESULTS: The cumulative incidence of MS was 9.0% (36/402) among night-shift workers, and 1.8% (6/336) among daytime workers (relative risk (RR) 5.0, 95% CI -2.1 to 14.6). The annual rate of incidence of MS was 2.9% in night-shift workers and 0.5% in daytime workers. Kaplan-Meier survival curves of the two groups were significantly different (log-rank test; p<0.001). Multiple Cox regression analysis (forward selection method based on likelihood ratio) showed that among selected variables (age, gender, smoking, alcohol intake, familiar history, physical activity, and work schedule) the only predictors of occurrence of MS were sedentariness (hazard ratio (HR) 2.92; 95% CI 1.64 to 5.18; p = 0.017), and night-shift work (HR 5.10; 95% CI 2.15 to 12.11; p<0.001). CONCLUSIONS: The risk of developing MS is strongly associated with night-shift work in nurses. Medical counselling should be promptly instituted in night-shift workers with the syndrome, and in case of persistence or progression, a change in work schedule should be considered.

[Extended high frequency audiometry in the prevention of noise-induced hearing loss]. / Uso delle alte frequenze nella prevenzione precoce della ipoacusia da rumore.

An early detection of noise induced hearing loss (NIHL) may allow more effective protection measures. Our aim was to investigate the usefulness of high-frequency audiometry to evaluate the possibility of a future use of the high frequencies audiometry as an early indicator for noise induced hearing loss. A cross-sectional study was performed involving 204 industrial noise exposed and 100 non-industrial noise-exposed workers. Each subject was tested with both conventional-frequency (0.25-8 kHz) and high-frequency (9-18 kHz) audiometry during the annually health surveillance campaign conducted in two Italian cement factories. As expected, noise exposed workers were found to have significantly higher hearing thresholds (P < 0.05) at both conventional and extended high frequencies. Marked differences were found for EHFA. Moreover, significant differences at EHFA were detected also in the subgroup of noise-exposed workers with normal findings at conventional audiometry. Our finding indicate that the use of the extended high frequency test may represent a useful tool for detecting early changes of hearing impairment and that it could be used in addition to the conventional test to better prevent the progression of noise hearing loss.

[Metabolic syndrome in visual display units users]. / Sindrome metabolica e attività lavorativa al videoterminale.

BACKGROUND: Reports about medical consequences from sedentary work are contradictory. It might be associated with the metabolic syndrome (MS), a collection of cardiovascular risk factors including hypertension, dyslipidemia, insulin resistance and central obesity. No data are currently available on workers using visual display units (VDIU), a potential high risk group, given the sedentariness inherent in this work. PATIENTS AND METHODS: We evaluated MS prevalence in 1547 VDU users with a mean age of 29.7 years and in a control group of 892 individuals with a mean age of 30.2 years who performed non-sedentary work, selected on the basis of similar demographic data. Physical examination and laboratory tests useful for MS diagnosis were performed. RESULTS: MS prevalence was 3.10% in VDU users vs 2.01% in controls (OR 2.048, 95% CI 1.169 to 3.587, p = 0.012). Significance persisted after controlling for confounding factors (e.g, smoking and leisure activity) in a multivariate analysis (OR 1.555, 95% CI 1.03 to 2.690, p < 0.05). CONCLUSIONS: MS should carefully considered when performing health surveillance programmes in VDU users.

[Interaction between carbon nanotubes and cardiovascular autonomic nervous system regulation: proposal of an animal model and preliminary findings]. / Interazione tra nanotubi di carbonio e controllo cardiovascolare del sistema nervoso autonomo: presentazione di un modello sperimentale animale e risultati preliminari.

BACKGROUND: Altered autonomic cardiovascular regulation (ACR) may mediate the association between single-wall carbon nanotubes (SWCNT) exposure and adverse cardiovascular events. MATERIAL AND METHODS: 400 mg of SWCNT in 400 ml of phosphate buffer saline (PBS) or 400 ml of PBS were randomly given to 7 Wystar-Kyoto rats (400 g body wt) previously implanted in abdominal aorta with a telemetry transmitter for recordings of arterial pressure signals. Recordings were performed at baseline, 24 hours and two weeks after intratracheal instillation. The beat-by-beat time series of systolic arterial pressure (SAP) and PR interval were analyzed to identify sequences of three or more consecutive beats in which SAP and PR changed in the same (baroreflex sequences) or in the opposite direction (nonbaroreflex sequences). The mean individual slope of the sequences was calculated and taken as a measure of the baroreflex (BRS) and nonbaroreflex sensitivity for that period. RESULTS: The 24 hour BRS response showed a 100% increase (from 4.6 to 9.2 msec/mmHg) in controls, whereas it was blunted in cases (from 5.1 to 6.1 msec/mmHg) (p < 0.05). CONCLUSIONS: Our study demonstrates that this rat model is suitable to study the ACR during exposure to SWCNT and suggests a blunted BRS response after SWCNT instillation.

Shift work increases the frequency of duodenal ulcer in H pylori infected workers.

AIM: To evaluate whether shift work is associated with an increased rate of peptic ulcer in H pylori infected workers. METHODS: During a two year period, consecutive dyspeptic workers underwent non-invasive evaluation of H pylori status by means of urea 13C breath test or stool testing. Those testing positive were included in the study and divided into two main categories: day-time workers and shift workers. An upper gastrointestinal endoscopy was performed in all workers, and biopsy specimens were taken from the stomach to confirm the presence of H pylori infection (culture and histology). RESULTS: A total of 247 day-time workers and 101 shift workers were included. The prevalence of duodenal ulcer was significantly higher in shift workers than in day-time workers (29 of 101 v 23 of 247; OR = 3.92, 95% CI 2.13 to 7.21), and persisted after multivariate analysis, taking into account possible confounding factors (OR = 3.96, 95% CI 2.10 to 7.47). CONCLUSION: Shift work increases the ulcerogenic potential of H pylori infection and should be considered a risk factor for duodenal ulcer in infected shift workers. Treatment of infection in this high risk group may improve the health of workers and may reduce the economic impact of peptic ulcer.

Shift work and autoimmune thyroid disorders.

Stress induces autoimmune disorders by affecting the immune response modulation. Recent studies have shown that shift work stress may enhance the onset of the autoimmune Graves hyperthyroidism. On the other hand, the possible association between occupational stress and autoimmune hypothyroidism has not yet been investigated. In order to detect the possible association between shift work and subclinical autoimmune hypothyroidism we investigated the prevalence of isolated anti-peroxidase thyroid (TPO) autoantibodies in 220 shift workers and in 422 day-time workers. Subclinical autoimmune hypothyroidism was diagnosed by the concomitant presence of high anti-TPO values and TSH levels higher than 2.51 mU/l. Anti TPO antibodies were measured by chemiluminescent technology (Advia Centaur) (a value above 60 IU/l was considered altered). Subclinical autoimmune hypothyroidism was diagnosed in 7.7 percent shift workers and in 3.8 percent day-time workers with a statistically significant difference: Odds Ratio (OR) 2.12, 95 percent Confidence Interval (CI) 1.05 to 4.29; p=0.03. The difference persisted after multivariate analysis taking into account age, sex, smoking habits, alcohol intake, familial history of autoimmune thyroid disease and exposure to radiation as possible confounders: OR. 2.24, 95 percent CI.1.01 to 4.94, p 0.05. Altered anti- TPO autoantibodies were found in 13.6 percent shift workers and in 8.6 percent day-time workers OR. 1.64, 95 percent CI.1.03 to 2.74, p=0.05. The significant difference was still detectable after multivariate analysis: OR. 1.95, 95 percent CI. 1.09 to 3.48, p=0.02. Our data show a significant association between shift work and autoimmune hypothyroidism. This finding may have implications in the health surveillance programs.

Are thyroid dysfunctions related to stress or microwave exposure (900 MHz)?

In the last decade, numerous scientific evidence suggested possible adverse health effects from exposure to electromagnetic fields (EMF'S) and the use of mobile phones. According to some studies EMF induced changes of trans-membrane Ca++ flux may lead to altered metabolism and/or secretion of neurohormones including TSH, ACTH, GH, prolactin and melatonin. The aim of this research was to analyse the effects of mobile phone use on thyroid function and to evaluate the possible role of occupational stress. 2598 employees (1355 men and 1243 women) with different duties (vendors, operators and network technicians) were included in the study. Exposure to EMF'S, generated by mobile phones, was assessed both by submitting a questionnaire directly to the employees and acquiring data regarding conversation times. The workers were divided into three groups on the basis of their personal mobile phone use. Moreover, a group of 160 workers with TSH values below 0.4 UI/l was characterized. No statistically significant difference regarding TSH values below 0.4 UI/l was observed among workers with different duties but there was a greater prevalence of subjects with low SH values among 192 employees with more than 33 hrs./month conversation time; this difference was statistically significant (p<0.05). On the basis of our data, it is not possible to establish whether this result is determined by exposure to EMF'S from mobile phones of by the stress of using these instruments.