One year of surgical mask testing at the University of Bologna labs: Lessons learned from data analysis.

The outbreak of SARS-CoV-2 pandemic highlighted the worldwide lack of surgical masks and personal protective equipment, which represent the main defense available against respiratory diseases as COVID-19. At the time, masks shortage was dramatic in Italy, the first European country seriously hit by the pandemic: aiming to address the emergency and to support the Italian industrial reconversion to the production of surgical masks, a multidisciplinary team of the University of Bologna organized a laboratory to test surgical masks according to European regulations. The group, driven by the expertise of chemical engineers, microbiologists, and occupational physicians, set-up the test lines to perform all the functional tests required. The laboratory started its activity on late March 2020, and as of the end of December of the same year 435 surgical mask prototypes were tested, with only 42 masks compliant to the European standard. From the analysis of the materials used, as well as of the production methods, it was found that a compliant surgical mask is most likely composed of three layers, a central meltblown filtration layer and two external spunbond comfort layers. An increase in the material thickness (grammage), or in the number of layers, does not improve the filtration efficiency, but leads to poor breathability, indicating that filtration depends not only on pure size exclusion, but other mechanisms are taking place (driven by electrostatic charge). The study critically reviewed the European standard procedures, identifying the weak aspects; among the others, the control of aerosol droplet size during the bacterial filtration test results to be crucial, since it can change the classification of a mask when its performance lies near to the limiting values of 95 or 98%.

The effect of a multimodal group programme in hospital workers with persistent low back pain: a prospective observational study.

BACKGROUND: Low Back Pain (LBP) is a very common disorder in hospital workers. Several studies examined the efficacy of multimodal interventions for health care providers suffering from LBP; nevertheless their results did not appear to be consistent. OBJECTIVE: The aim of the study was to determine the effect of a multimodal group programme (MGP) on pain and disability in a sample of hospital workers with persistent LBP. METHODS: A prospective cohort study was conducted to compare baseline measurements with changes over an eight-month period. The study focused on 109 workers suffering from persistent LBP with or without radiating pain. 62 nurses and 47 blue collars not involved in health care. The MGP consisted of six group sessions including supervised exercises, an at-home programme and ergonomic advice. The primary outcome measurement was the level of disability recorded with the Roland & Morris Disability Questionnaire, while the secondary outcome measurement was the evaluation of lumbar physical discomfort with the Visual Analogue Scale. Data were analyzed using the Multiple Imputation method for dropouts. RESULTS: At the short-term follow-up participants showed a statistically significant reduction (from baseline) of all outcome measurements, particularly for the nurses group. Moreover, about a third of the subjects showed clinically significant improvement. No significant reduction in pain and disability (from baseline) was observed at the mid-term follow-up in either group. CONCLUSIONS: An MGP dedicated to hospital workers seems to be partially useful only for short-term follow-up, particularly for health care providers.

Biological monitoring of occupational exposure to antineoplastic drugs in hospital settings.

BACKGROUND: In view of the evidence of cytotoxicity of chemotherapic antineoplastic drugs (AD), current guidelines recommend the evaluation of the health risks of hospital personnel exposed to these compounds. Biological monitoring is the main tool to evaluate all possible drug intake and measure workers' real risk. OBJECTIVES: The aim of this study was to assess occupational exposure toAD in a large hospital in Northern Italy in order to verify the effectiveness of the structural and procedural improvements carried out over the last decade. METHODS: Three biological monitoring campaigns were performed using LC-MS/MS analysis of cyclophosphamide (CP) and metotrexate (MTX) as biomarkers of internal dose in the urine of hospital workers. In the first two campaigns, 50 and 81 workers respectively were monitored during AD preparation operations. The last campaign, concerning AD administration activity, was performed after a centralized preparation unit had been set up. Two environmental monitoring campaigns were carried out as well, to complete AD exposure assessment. RESULTS: During the first monitoring campaign we found positive urinary samples in all the wards studied (total positivity 36%), whereas in the second campaign 11% of the samples were positive and four departments showed negative results in all urine samples. The last campaign showed all urinary CP and MTX levels below the detection limit of the analytical method CONCLUSION: Exposure of oncology ward nurses considerably decreased due to the centralization of AD preparation operations together with training and education of workers. The last biological monitoring results were reassuring; nevertheless, surface contamination still occurred and safety measures should be further improved in order to achieve the lowest reasonably possible contamination levels.

[Risk assessment of biomechanical overload of limbs and spine in workers employed on stone paving roads, using a combination of different methods]. / Valutazione del rischio da sovraccarico biomeccanico agli arti e rachide negli addetti alla pavimentazione lapidea stradale: applicazione integrata di diversi metodi.

BACKGROUND: Few data exist on the risk of musculoskeletal disorders in road paving workers, in addition methods for risk assessment of biomechanical overload of the lower limbs and the spine are also lacking. OBJECTIVES: The aim of this study was to assess the risk from biomechanical overload for the whole musculoskeletal system and manual handling involved in the activity of stone paving of roads. METHODS: In accordance with the guidelines of the Italian Society of Occupational Medicine and Industrial Hygiene various risk assessment methods were used. RESULTS: The Washington State checklist revealed the presence of biomechanical overload of the spine in flexion. The Turin checklist showed a risk score higher than the acceptable limit for the cervical and lumbar spine and limbs (risk level similar to that obtained from the OCRA checklist for the upper limbs). The assessment of risk from manual handling of loads carried out using the NIOSH method provided a synthetic risk index whereas evaluation conducted using the Washington State method was acceptable. CONCLUSIONS: Biomechanical risk assessment showed the presence of risk for use of force and awkward postures of the wrist and elbow, which agrees with literature data. The division of tasks among workers and the distribution of breaks helped to reduce the risk to an acceptable level for limbs. All methods however showed a risk for the spine. Health surveillance showed disorders of the spine in 28% of the workers and no disorders of the upper limbs, which agrees with the risk assessment.

[Risk assessment of biomechanical overload of the limbs and spine in workers paving roads with stones]. / Valutazione del rischio da sovraccarico biomeccanico agli arti e rachide negli addetti alla pavimentazione lapidea stradale.

Aim of this study is to assess the risk from biomechanical overload for the whole musculoskeletal system and manual handling involved in the activity of stone paving of the road. According to the guidelines of the Italian Society of Occupational Medicine and Industrial Hygiene various risk assessment methods have been used: Washington State checklist, checklist of Turin and OCRA checklist to assess the risk from biomechanical overload for the upper limb and NIOSH method with the method provided by the State of Washington to assess the risk from manual handling of loads.

[Lesser validity of urinary benzene than S-phenylmercapturic acid for measuring occupational and environmental exposure to very low concentrations of benzene]. / Minore validità del benzene urinario rispetto all'acido S-fenilmercapturico nel rilevare l'esposizione occupazionale ed ambientale a concentrazioni molto basse di benzene.

AIM: To study the validity of urinary benzene as a biomarker of low and very low exposure to this toxicant, as compared with t,t-muconic acid (t,t-MA) and S-phenylmercapturic acid (SPMA), also taking into account the influence of cigarette smoking and co-exposure to toluene on the urinary excretion of benzene. MATERIALS AND METHODS: The results obtained in two different studies were compared: in the first, workers occupationally exposed to low concentrations of benzene (18 fuel tanker drivers and 23 filling station attendants) were compared with 31 controls and in the second, workers exposed to very low concentrations of benzene (the same 23 filling station attendants) were compared with the 31 controls. Exposure to airborne benzene and toluene was monitored with passive personal samplers (Radiello). Then the urine collected at the end of the work shift was analyzed for t,t-MA, SPMA and urinary benzene. All participants also filled out a questionnaire about their lifestyle habits. RESULTS: There were no differences among the three groups in terms of age and smoking habit. Occupational exposure to benzene and toluene and the urinary concentrations of t,t-MA, SPMA and urinary benzene were higher in the fuel tanker drivers than the filling station attendants and higher in the latter than in the controls. Cigarette smoking was found to be associated with urinary excretion of t,t-MA, SPMA and urinary benzene at both low and very low exposure to benzene. The biomarkers t,t-MA, SPMA and urinary benzene were almost always correlated, for both low and very low exposure to benzene. Notably, for low exposure to benzene a dependency relation was found with the levels of t,t-MA, SPMA and urinary benzene on both cigarette smoking and airborne benzene, whereas for very low exposure to benzene there was a dependency relation of SPMA on cigarette smoking and airborne benzene, of urinary benzene only on cigarette smoking and of t,t-MA on none of the variables considered. CONCLUSIONS: For occupational exposure to low concentrations of benzene, urinary benzene and SPMA showed a comparable validity, while for exposure to very low concentrations of this toxicant the validity of SPMA was confirmed while urinary benzene was found to be less useful. Cigarette smoking was the main factor conditioning the excretion of all the biomarkers of benzene in conditions of both low and very low exposure to the toxicant, so for the analysis of occupational exposure to benzene it is best to recommend abstention from smoking at least in the hours immediately before urine collection.

Applicability of urinary benzene to biological monitoring of occupational and environmental exposure to very low benzene concentrations.

OBJECTIVE: To verify whether urinary benzene is an applicable biomarker of occupational exposure to very low concentrations of benzene, considering the influence of cigarette smoke and benzene-toluene co-exposure. MATERIALS AND METHODS: 23 filling station attendants with occupational exposure to benzene and 31 controls were analyzed. Occupational and environmental exposure was monitored and t,t-muconic acid (t,t-MA), S-phenylmercapturic acid (SPMA), urinary benzene and creatinine in the urine samples were tested. RESULTS: Occupational exposure to benzene and toluene was significantly higher in the filling station attendants than in the controls, whereas t,t-MA, SPMA and urinary benzene were not different in the two groups. Instead, the smoker group showed significantly higher values for the above biomarkers than the non-smoker group, each of which included both exposed workers and controls. SPMA was dependent on airborne benzene and cigarette smoking, and urinary benzene only on cigarette smoking, while t,t-MA was not dependent on either of these variables. CONCLUSIONS: At very low concentrations of occupational exposure to benzene, urinary benzene is less valid than SPMA as a biomarker, even if both are strongly influenced by smoking habit. Abstention from smoking should therefore be recommended for at least two hours before urine collection.

[Influence of non-occupational sources on the levels of biomarkers of internal dose for use in biological monitoring of occupational exposure to extremely low concentrations of benzene]. / Ruolo dei fattori non occupazionali nel condizionare i livelli di indicatori di dose interna utilizzati per monitorare l'esposizione occupazionale a concentrazioni molto molto basse di benzene.

OBJECTIVES: To study how traditional (t,t-muconic acid--t,t-MA and S-phenylmercapturic--SPMA) and new (urinary benzene) urinary biomarkers of internal dose can contribute to exclude an occupational source of exposure to extremely low concentrations of benzene, also analyzing the influence that non-occupational sources of exposure, such as cigarette smoking and urban pollution, can have on the levels of these biomarkers. MATERIALS AND METHODS: Assessment was made of 6 workers employed at a groundwater purification plant polluted by benzene (exposed) and 6 administrative clerks employed at the same plant (controls); both groups included smokers and non-smokers. Environmental monitoring (fixed and personal samplings lasting 8 hours) and biological monitoring (determinations of t,t-MA, SPMA, urinary benzene, and urinary creatinine so as to apply suitable adjustments) were performed in exposed workers on 10 successive days, including also rest days (background exposure), and in controls only once. RESULTS: Airborne benzene always resulted lower than the limit of detection of the analytical method in both fixed and personal samplings done on exposed workers and controls during working days, while personal samplings done on exposed workers during rest days showed benzene concentrations even higher than 5 microg/m3, that is the limit value for ambient air quality. Concentrations of t,t-MA, SPMA and urinary benzene did not show differences between exposed workers, regardless of whether they were studied on working or rest days, and controls and appeared to be largely within the reference value range for the Italian population. All biomarkers of internal dose examined in the study showed significantly higher values in smokers than non-smokers. In the latter, SPMA was always below the limit of detection, while urinary benzene resulted higher than the limit of detection in 60.0% and 87.5% of the determinations done on working and on rest days, respectively. CONCLUSIONS: In situations of occupational exposure to extremely low doses of benzene or of absence of exposure, the application of an integrated environmental--biological monitoring approach, involving the determination of SPMA and/or urinary benzene, together with a careful evaluation of those factors determining non-occupational exposure to the toxicant, seems indispensable in order to be able to exclude the presence of occupational exposure. In these particular situations of occupational exposure to benzene, the interpretation of the results of environmental and biological monitoring should not only consider the TLV or BEI, but also the limit value for ambient air quality and the reference value for the general population, since benzene is able to determine genotoxic carcinogenic effects even at exposure to extremely low concentrations of the toxicant.

[Several aspects concerning the risk of biomechanical factors: an agenda for the SIMLII guidelines on manual load lifting]. / Alcuni aspetti critici relativi al rischio da fattori biomeccanici: un'agenda per le Linee Guida SIMLII sulla movimentazione manuale di carichi.

The Guidelines issued by SIMLII on manual material handling are being revised by an ad hoc working group. Different aspects must be reconsidered according to new data recently published: among these, risk assessment methods and exposure limits stand out as critical issues for a correct approach to this topic.

[Low back pain among video-terminal workers: ergonomic postural interventions]. / Efficacia di un intervento ergonomico sulla postura lavorativa e sul mal di schiena nei videoterminalisti.

BACKGROUND: Several studies report a high prevalence of low back pain (LBP) among video-terminal (VDT) workers. Targeted ergonomic interventions can help reduce the burden. OBJECTIVES: We investigated the long-term efficacy of an ergonomic postural intervention to address LBP among VDT workers. STUDY DESIGN: Non-randomized, crossover trial. POPULATION AND SETTING: Four hundred employees working in the administrative offices of the two main buildings of the town hall ofForlì who used VDTs for at least 20 hours a week; we randomly selected 100 participants from each building. INTERVENTION: Ergonomic adjustment of the VDT workstation design. OUTCOME MEASURES: Changes in prevalence of LBP and work-related posture. RESULTS: The ergonomic adjustment of the workstation improved work-related posture and reduced LBP in VDT operators who benefited from the intervention. CONCLUSIONS: A personalized ergonomic prevention intervention can improve work-related posture and LBP for VDT workers.

[The contribution of the Italian scientific community to efficacy studies in Occupational Health (1990-2006)]. / L'apporto della comunità scientifica Italiana alle prove di efficacia in medicina del lavoro.

INTRODUCTION: Evidence-based prevention (EBP) is gaining growing interest among the international scientific community in the field of Occupational Health. In order to ascertain the commitment that has been made in Italy to participation in EBPR, we conducted a systematic review of scientific publications on efficacy evaluations in Italy. METHODS: We hand-searched journals and interrogated the PubMed database to identify reports of studies evaluating interventions designed to improve workers' health in Italy between 1990 and 2006. The selected articles were classified by institutional category (of the first author), intervention methodology, study design, type of risk factor, and occupational sector. RESULTS: We found 23 eligible publications in the Italian language and 9 in English. The most frequent study-design was pre-/post-intervention evaluation; 3 studies were randomized trials. The interventions were aimed mainly at controlling the effects of chemical hazards and noise; health-care settings were the most frequent. We found only 2 studies (1 in English) evaluating the efficacy of interventions targeting injury prevention. DISCUSSION: The systematic approach of EBP can be applied to most occupational health interventions. These results may contribute to the debate on methodology and outcomes in the scientific community.

Incidence rates of surgically treated idiopathic carpal tunnel syndrome in blue- and white-collar workers and housewives in Tuscany, Italy.

OBJECTIVES: Rates of surgically treated carpal tunnel syndrome (CTS) among blue- and white-collar workers and housewives in the general population were compared. METHODS: Surgically treated cases of idiopathic CTS were investigated among 25-59-year-old residents of Tuscany, Italy, during 1997-2000, based on obligatory discharge records from all Italian public/private hospitals, archived according to residence on Tuscany's regional database. Population data were extracted from the 2001 census. RESULTS: After excluding repeat admissions, 8801 eligible cases were identified. Age-standardised rates (per 100 000 person-years) of surgical CTS were: "blue-collar women", 367.8; "white-collar women", 88.1; "housewives", 334.5; "blue-collar men", 73.5; and "white-collar men", 15.3. Compared with reference categories (same-sex white-collar workers): female blue-collar workers experienced a 4.2-fold higher standardised rate; housewives, a 3.8-fold excess; and male blue-collar workers, a 4.8-fold excess (all p<0.001). Male and female blue-collar workers showed approximately three to sevenfold higher age-specific rates compared to their white-collar counterparts (all p<0.001). Housewives' rates were similar to those of blue-collar female workers up to 40-44 years of age, after which they were significantly lower (p<0.002). At all ages, housewives' rates were much higher (p<0.001) than those of white-collar women. CONCLUSIONS: Surgically treated CTS was three to seven times more common (depending on age/gender) in blue-collar than in white-collar workers, which is difficult to explain by differences in body weight or other individual factors. Thus, occupational risk factors seem relevant throughout working life. The high rates for full-time housewives suggest that domestic chores should be investigated as a possible risk factor for CTS.

[Updating in occupational health for health care workers]. / Aggiornamenti in tema di tutela della salute occupazionale dei lavoratori della sanità.

The board of the Thematic Section on Preventive Medicine for Health Care Workers of the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII) programmed a national conference on occupational risks of health care workers to be held in late 2009. Main topics will be: a) biohazards; b) biomechanical risk; c) psychosocial factors. Three different working groups were established to tackle critical aspects and suggest practical recommendations to occupational health professionals. Preliminary issues are presented while final results will be presented at the conference on September 2009.

[Evidence based prevention and upper limb work-related musculoskeletal disorders]. / Evidence based prevention e rischio biomeccanico per l'arto superiore.

To evaluate interventions for primary prevention of Upper limb Work-related Musculoskeletal Disorders (UWMSD) we conducted a literature search from the biomedical database Medline and the Cochrane Collaboration Occupational Health Field. A total of 41 studies were selected: the majority investigated the effect of interventions among office workers, few involved industrial workplaces. Studies were characterized by a wide range of interventions (engineering, administrative, ergonomic training) and methodological heterogeneity (in the study design and outcome measures). Only four studies examine interventions for the prevention of specific outcomes (Carpal Tunnel Syndrome and Hand Arm Vibration Syndrome). At present, the multidimensional approach of interventions and the poor outcome definitions hamper the isolation of the potentially effective component of the intervention. Future intervention studies should be based on well defined risk assessment and outcome measures, rigorous and long-term study design. Only strong levels of evidence could be the base of policy recommendations.

Evaluation of an occupational therapy program for patients with spinal cord injury.

STUDY DESIGN: Clinical controlled trial. OBJECTIVES: To evaluate the effectiveness of an occupational therapy (OT) program combined with neuromotor rehabilitation, by assessing the degree of functional independence reached by patients with spinal cord injuries at first hospitalization. SETTINGS: Subjects selected from the Spinal Cord Unit of the Rehabilitation Institute of Montecatone (Imola, Italy). PARTICIPANTS: Thirty-six male patients below age 60, with complete paraplegia (ASIA-A) in thoracic-lumbar level, at first hospitalization. METHODS: Patients were divided into experimental and control groups. Subjects in the experimental group underwent neuromotor rehabilitation coupled with an OT program, whereas those in the control group followed neuromotor rehabilitation only. Increase in functional independence at discharge was evaluated by the Valutazione Funzionale Mielolesi (VFM) assessment scale. RESULTS: Patients in the experimental group showed a significant increase in the total VFM score, and in domains concerning transfers and wheelchair use. A significant improvement was observed in unmarried patients as compared to married ones. CONCLUSION: An OT service within a Spinal Cord Unit allows us to achieve a higher level of functional independence.

[Risk assessment of biomechanical load for the upper limbs in housework]. / Valutazione del rischio da sovraccarico biomeccanico per l'arto superiore nei lavori femminili domestici.

BACKGROUND: There are few studies in the literature on work-related musculoskeletal disorders among housewives, also due to the difficulties encountered during risk assessment. OBJECTIVES: The aim of this study was evaluation of the biomechanical load for the upper limbs in housewives' tasks, using the different methods described in the literature. METHODS: A questionnaire was submitted to 104 women (aged 25-60 years), 62 of whom were housewives only. Twelve subjects accepted to be filmed on video-cameras while working, which was necessary for risk evaluation. A number of tasks were chosen to be evaluated (loading the dishwasher, cleaning kitchen work surfaces, sweeping, cleaning floors, using the vacuum cleaner, dusting, cleaning the bathroom, ironing, making beds) because they were more frequently performed over a day or a week and because they involved specific physical risk factors. The preliminary analysis was based on the search for such risks, identification of "caution zone" housework, and subsequent evaluation by advanced level tools. RESULTS: Biomechanical risk analysis showed that higher overloads were detected in ironing, cleaning floors and cleaning kitchen worktops but all housework analyzed in this study involved exposure to biomechanical risk when performed for four hours in a day. CONCLUSION: Housework involves exposure to several risk factors for the musculoskeletal system. Nevertheless, housewives are able to self-organise work and recovery times (even with the limits imposed by family demands) but their activities are characterised by repetitiveness and often by high hand/arm force associated with awkward postures.

Relationship between symptoms and instrumental findings in the diagnosis of upper limb work-related musculoskeletal disorders.

BACKGROUND: Upper limb work-related musculoskeletal disorders (UL-WRMSDs) are common among workers performing repetitive and forceful manual work. The diagnosis of UL-WRMSDs is mainly based on clinical features but its accuracy is further increased by physical examination and instrumental analysis. DISCUSSION AND CONCLUSIONS: In the occupational setting, several case definitions for UL-WRMSDs, based on different combinations of symptoms, physical examination findings and instrumental test results, have been proposed and published in the literature. Case definitions based on a combination of clinical history and instrumental findings would be preferred both for surveillance and epidemiological purposes. However, the use of instrumental tests introduces the issue of the poor level of agreement between symptoms and instrumental findings. Moreover, in the course of time both symptoms and instrumental findings tend to fluctuate and can be affected by several variables: exposure, individual factors, criteria used for data collection and time of examination in relation to work shift. As a paradigmatic example of UL-WRMSDs, the case of Carpal Tunnel Syndrome is discussed. In an improvement perspective, we suggest to focus on the following aspects: the monitoring of exposure assessment, the time of data collection in relation to work shift, the opportunity to collect clinical and instrumental data at the same time and the selection of normative data and of the best informative parameters for epidemiological studies.

Current issues in case definitions for common musculoskeletal disorders in workers for clinical practice and research.

BACKGROUND: Several reviews and attempts at meta-analysis have pointed out that comparisons between studies on work-related musculoskeletal disorders are problematic, since different studies use different case definitions. In a clinical setting, the case definition involves a detailed history, a physical examination, and laboratory testing. DISCUSSION AND CONCLUSIONS: When determining which tests should be included in a clinical examination, it is necessary to take into consideration the characteristics of clinical tests in terms of likelihood ratio for confirming and ruling out disease in addition to the pre-test probability of disease. If the different musculoskeletal symptoms and signs do not completely comply with the criteria for a disease, we recommend the choice of an ICD label (International Classification of Diseases - WHO) that focuses on the symptoms rather than the pathology. We suggest that the process for a new feasible case definition system for the neck and upper extremities should start with the creation of a consensus of criteria for diagnosis of common musculoskeletal disorders in primary care, developed by a panel consisting of researchers in the key disciplines. Furthermore, we suggest that in workers whose musculoskeletal function is crucial for employment, use of the International Classification of Function (ICF) may be one way to improve classification of health problems.