Emerging problems and novel skills: a qualitative analysis on the role of occupational physicians.

INTRODUCTION: The thorough changes in the world of employment, together with regulatory changes, have made the role of occupational health physicians increasingly complex, with an extension of the prescribing component, linked to the operational aspects of the role, as well as a greater complexity in the discretionary sphere, which also requires a number of "non-technical" skills. OBJECTIVES: This work investigates how occupational physicians experience and represent their role, with special attention paid to the person-context relationship, so as to offer reflections and useful tools for supporting this role within the participatory health and safety system in the workplaces. METHODS: Using a qualitative approach, the survey has been carried out through semi-structured interviews to a sample of 22 Italian occupational health physicians who were asked to talk about their professional experience with regard to the legislative reforms, critical factors in their work, their relationship with other players in the safety system, and satisfaction with Continuous Medical Training (ECM). The interviews were analyzed using content statistics analysis software. RESULTS: Faced with the various context constraints, occupational physicians often remain confined to their healthcare role and in their relationship with the patient-worker. This causes difficulties in intervening as overall health and safety consultants for workers in a preventive context. Traditional technical expertise, delivered through ECM Training and guidelines, is not enough to make a substantial change in practising the profession, but other types of intervention are necessary to facilitate reflection about problems and one's own actions.

[DIFFERENT APPROACHES FOR CHEMICAL RISK ASSESSMENT IN LABORATORIES]. / Rischio chimico nei laboratori: confronto tra diversi approcci alla valutazione.

The aim of this study was to compare the different approaches used for chemical risk assessment, in relation to the perception of riskfor operators, in some research laboratories of a hospital in Rome. All information regarding the chemicals used for the application of three algorithmic models for chemical risk assessment ("Movarisch", "Inforisk", "Archimede") were collected. An environmental and biological monitoring and a study on the combined exposure to multiple chemicals using the World Health Organization proposed steps were carried out. A questionnaire was prepared for the identification of risk perception. An estimation of chemical risk with algorithms was compared with data from monitoring: findings showed that estimated risk was higher than those identified with airborne or urine concentrations, always under their limit values. The study of multiple exposure showed a possible cumulative risk, in some cases, but the conditions of use (volume and time) often bring to a reduced one. The perception of risk attributed to the monitored hazardous substances showed a correct perception in all laboratories and for all workers, with regard to the substances manipulated.

[Study of the application of the guidelines for the handling of citotoxic drugs in some health facilities]. / Studio dell'applicazione delle linee guida per la manipolazione dei farmaci antiblastici in alcune strutture sanitarie.

AIM: A survey in 5 Roman hospital was carried out to have a deep understanding of guidelines application and existing regulations regarding health professionals' protection in handling antiblastic drugs. METHODS: A questionnaire was administered to 122 nurses, working in oncology units, about the main points required by guidelines for safe handling of antiblastic drugs. RESULTS: Results show that attention to collective protection equipment and working practices is evident, nevertheless other elements are still partly applied, first the lack of staff training, which not involved all health professionals and the frequency which does not fit guidelines. The use of Personal Protective equipment, where provided, is sometimes ignored, a situation which can be connected to the lack of specific training of personnel. CONCLUSIONS: Greater attention must be taken to ensure that required training for nurses involved in the preparation and administration of antiblastic drugs, this is the starting point for the proper use of Personal Protective equipment and of appropriate procedures in each work phase. Increased control by the institutional bodies to confirm compliance with the rules and regulations for the protection of workers' health is desiderable.

[The organization and management of First Aid in the workplace: critical issues and innovations to be introduced]. / L'organizzazione e la gestione del Prime Soccorso nei luoghi di lavoro: aspetti critici e innovazioni da introdurre.

Develop an effective First Aid's system in workplaces is significantly important to the outcomes of accidents at work, thus contributing positively to create healthy and safe environments, improving responsible attitude and risk perception by workers. The italian regulation (D. Lgs. 81/08; DM 388/03) gives an important role to First Aid within the system for managing health and safety in workplaces and requires the employers to designate and train workers and organize facilities in the workplace. However, to ensure that First Aid's system actually contributes to increasing health and safety in workplaces, it's necessary to verify its effectiveness, beyond the law compliance. The article stands to evaluate the critical issues and related innovations to be introduced in this context, by analyzing data from literature and field experiences involving actors in the prevention system. The goal is to provide suggestions and action proposals to improve first aid's system in workplaces, paying particular attention to the aiders training (selection, motivation, teaching methods, retraining), as well as introduce to innovations to allow an immediate and timely emergency response (company equipments, other useful devices). On this last aspect, it has given particular emphasis to the introduction of semi-automatic defibrillator (AED), which is essential in case of sudden cardiac arrest with ventricular fibrillation, and special aiders training by means of BLSD (Basic Life Support and Defibrillation) courses based on international guidelines.

Sex Difference and Benzene Exposure: Does It Matter?

Sex-related biological differences might lead to different effects in women and men when they are exposed to risk factors. A scoping review was carried out to understand if sex could be a discriminant in health outcomes due to benzene. Studies on both animals and humans were collected. In vivo surveys, focusing on genotoxicity, hematotoxicity and effects on metabolism suggested a higher involvement of male animals (mice or rats) in adverse health effects. Conversely, the studies on humans, focused on the alteration of blood parameters, myeloid leukemia incidence and biomarker rates, highlighted that, overall, women had significantly higher risk for blood system effects and a metabolization of benzene 23-26% higher than men, considering a similar exposure situation. This opposite trend highlights that the extrapolation of in vivo findings to human risk assessment should be taken with caution. However, it is clear that sex is a physiological parameter to consider in benzene exposure and its health effects. The topic of sex difference linked to benzene in human exposure needs further research, with more numerous samples, to obtain a higher strength of data and more indicative findings. Sex factor, and gender, could have significant impacts on occupational exposures and their health effects, even if there are still uncertainties and gaps that need to be filled.

A Case-Control Study on the Effects of Plasticizers Exposure on Male Fertility.

Male infertility is a serious concern for public health, and the possible role of exposure to plasticizers such as phthalates and bisphenol A in contributing to the condition is widely debated. We have herein enrolled 155 infertility cases attending an infertility center and 211 controls (fathers of a spontaneously conceived newborn) to investigate this issue. The urinary levels of seven phthalates and BPA were analyzed through HPLC/MS/MS. All data were statistically elaborated considering information about clinical situation, life habits, occupational activity, and, for cases, semen parameters (volume, sperm concentration, total count of spermatozoa, and sperm motility). Results showed significantly higher urinary concentrations for all the phthalates in cases compared to controls, except for monoethylphthalate and BPA. In total, 90.07% of cases had sperm motility lower than the WHO reference value (2010), while 53.69%, 46.31%, and 16.56% had sperm total number, concentration, and volume, respectively, out of the reference range. Regarding the possible source of exposure, the use of scents seems to be a significant source of DEP (diethylphthalate). When considering occupational settings, industrial workers, dental technicians, artisans, and farmers using chemicals showed higher risk (OR = 2.766, 95% CI 1.236-6.185), particularly in relation to DnBP (di-n-butyl phthalate) and DEHP (di-ethyl-hexyl phthalate) exposure. No clear quantitative correlation between specific plasticizers and sperm parameters could be demonstrated but these findings call for future studies about the risks associated with exposure to their mixture.

Phthalate Exposure and Biomarkers of Oxidation of Nucleic Acids: Results on Couples Attending a Fertility Center.

Phthalates are substances used as plasticizing agents and solvents that can increase the risk of infertility and that appear to induce oxidative stress. The aim of the study was to show the possible relationship between urinary concentrations of phthalates metabolites, namely MEP, MBzP, MnBP, MEHP, MEHHP, and MnOP and biomarkers of nucleic acids oxidation, methylation, or protein nitroxidation. The oxidative stress biomarkers measured in human urine were 8-oxo-7,8-dihydroguanine, 8-oxo-7,8-dihydroguanosine, 8-oxo-7,8-dihydro-2'-deoxyguanosine, 3-nitrotyrosine, and 5-methylcytidine. Two hundred and seventy-four couples were enrolled, undergoing an assisted reproduction technology (ART) treatment, urine samples were analyzed in HPLC/MS-MS, and then two sub-groups with urinary concentration > 90th or <10th percentile were identified, reducing the sample size to 112 subjects. The levels of oxidative stress biomarkers were measured in both groups, reduced to 52 men and 60 women. A statistically significantly difference for 8-oxoGuo and 3-NO2Tyr between men and women, with higher levels in men, was found. The levels of oxidative stress biomarkers were directly correlated with some phthalate concentrations in both sexes.

From Environmental to Possible Occupational Exposure to Risk Factors: What Role Do They Play in the Etiology of Endometriosis?

Endometriosis is a gynecological disorder characterized by the presence of endometrial stroma and glands outside the uterine cavity. A systematic review of the literature was conducted to clarify, starting from environmental exposure data, whether possible occupational risk factors may correlate with the onset of the disease. The guidelines for reporting systematic reviews of the "PRISMA" statement were followed and two databases, Scopus and PubMed, were used. Of the 422 studies selected with specific keywords, 32 publications were eligible, 28 of which referred to chemical agents and 4 related to night work. Conflicting data emerged among these studies. Although some compounds seemed to be more involved than others in the onset of endometriosis. Association with exposure to organochlorine compounds is the most supported by the epidemiological data, while other pesticide exposure did not show any clear correlation. Likewise, the hypothesis of a correlation with perfluoroalkyls exposure is not currently supported by data. The involvement of metals as risk factors has not been confirmed, while the role of night work, in the case of long service, seems to play an etiological role. In order to clarify the potential occupational risk of endometriosis development, well-designed studies are needed to evaluate the potential association between chemical compounds and disease etiology.

Female Reproductive Health and Exposure to Phthalates and Bisphenol A: A Cross Sectional Study.

The xenoestrogenicity of some plasticisers (phthalates and bisphenol A) is documented in the literature and may pose a risk to female reproductive health. The aim of this study was to assess exposure to six phthalates. This was achieved by measuring their respective metabolites (mono-ethylphthalate (MEP); mono-n-butylphthalate (MnBP); mono-n-ottylphthalate (MnOP); and monobenzylphthalate (MBzP)), as well as the sum of two of the diethyl-hexyl phthalate metabolites-(∑DEHP) and bisphenol A (BPA) in a female population with infertility problems, and by conducting a correlation analysis between infertility factors, work activities, and lifestyle habits, in order to formulate a causal hypothesis. A cross-sectional epidemiological study was carried out and women under 43 years of age were recruited from an assisted reproduction technology (ART) center; the sample of 186 women was given a specific questionnaire and a spot urine sample was collected. Phthalate metabolites and urinary BPA were analyzed by HPLC/MS/MS. The results showed significantly higher mean values for MEP in women with recurrent pregnancy loss (RPL) (820.5 ± 1929.5 µg/g of creatinine) and idiopathic infertility (230.0 ± 794.2 µg/g of creatinine) than in women with other infertility factors (76.9 ± 171.8 µg/g of creatinine). Similarly, for MnOP levels, women with idiopathic infertility (2.95 ± 3.44 µg/g of creatinine) showed significantly higher values than women with the other infertility factors taken together (1.35 ± 2.05 µg/g of creatinine). Women with tubal factors of infertility, RPL, and endocrine dysfunctions show higher values of DEHP (p = 0.032). Considering occupations, women working in commerce showed more than twice as much urinary BPA levels (1.10 ± 0.48 µg/g of creatinine) compared to women working in other industries (0.45 ± 0.35 µg/g of creatinine). The presence of significantly higher values of certain phthalates, DEHP in particular, especially in women with RPL and idiopathic infertility, suggests a possible involvement of these compounds as competing factors in reproductive issues. The study of sources of exposure suggested that the working activity in trade, as a casher in particular, represents a major one for BPA (p = 0.015).

Saliva as an analytical matrix: state of the art and application for biomonitoring.

Analytical tests to measure chemicals in saliva can be employed for numerous analytes, endogenous compounds or xenobiotics. The objective was to determine which chemicals can be analysed with this matrix, which analytical methods are applicable, and what application is possible for biomonitoring. We reviewed the literature using three databases, MEDLINE, PubMed and Scopus, collecting articles on different kinds of analysis in saliva. Studies were principally about molecules of clinical interest, xenobiotics, especially drugs of abuse, and chemicals used at workplaces; some substances show no relevant correlation with exposure data while others seems to be of particular interest for systematic use for biomonitoring. Currently, saliva is used far less than other biological fluids but its use for biomonitoring of exposure to chemicals might open up new areas for research and would certainly simplify the collection of biological samples.

Cross Sectional Study on Exposure to BPA and Phthalates and Semen Parameters in Men Attending a Fertility Center.

Among the possible risk factors for male reproduction, exposure to phthalates and alkylphenols is widely documented. This study evaluated the possible association between chemical exposure and the quality of the seminal fluid of 105 subjects in a fertility clinic. The urinary levels of seven phthalate metabolites (monoethylphthalate, MEP; monobenzylphthalate, MBzP; mono n-butylphthalate, MnBP; mono-(2-ethylhexyl) phthalate, MEHP; mono(2-ethyl-5-hydroxyhexyl) phthalate, MEHHP; mono-n-octylphthalate, MnOP; mono-isononylphthalate, MiNP) and bisphenol A (BPA), were analysed by high performance liquid chromatography/tandem mass spectrometry HPLC/MS/MS. The regression analysis showed that the semen volume was positively associated with MnBP, MnOP and BPA levels while was negatively associated with MiNP levels. The sperm concentration had a significant inverse relationship with MEP levels. A negative association was found between the use of plastic containers for food storage (p = 0.037) and semen volume (3.06 vs. 2.30 mL as average values, never vs daily). A significant positive correlation emerged (p < 0.005) between the consumption of canned food and the levels of BPA (2.81 vs. 0.14 µg/g creat as average values, daily vs. never) and between the use of perfumes and levels of MEP (389.86 vs. 48.68 µg/g creat, as average values, daily vs. never). No further statistically significant associations were found, even considering the working activity. Some evidence emerged about the possible link between exposure and seminal fluid quality: further case/control or prospective studies will allow us to confirm this causality hypothesis.

Temporal Trends of Urinary Phthalate Concentrations in Two Populations: Effects of REACH Authorization after Five Years.

Phthalates are widely used in the industrial manufacture of many products. Some phthalates have shown reproductive toxicity in humans, acting as endocrine disruptors, so they were included in the authorization process defined in Reg. CE 1907/2006 (REACH). Two groups of population were recruited, before and after the inclusion of some phthalates in the authorization list in REACH: the first group of 157 volunteers was studied in 2011 and the second, 171 volunteers, in 2016. Each subject completed a questionnaire about personal lifestyle, working activities and use of chemical products. The main urinary metabolites of five phthalates were analyzed by HPLC/MS/MS: mono(2-ethylhexyl)phthalate (MEHP) and mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP) for di(2-ethylhexyl)phthalate (DEHP) exposure; monoethylphthalate (MEP) for diethylphtahate (DEP); monobenzylphthalate (MBzP) for butylbenzylphtahalate (BBP) and dibenzylphthalate (DBzP), mono-n-butylphthalate (MnBP) for butylbenzylphtahalate (BBP) and di-n-butylphthalate (DnBP). The results show a significant difference for all metabolites between the two periods, with the exception of MEP in women. The comparison of the two sets of results shows a decrease in urinary metabolites excretion from 2011 to 2016, statistically significant for the three phthalates included in Annex XIV of REACH. DEP, not currently included in the list for authorization, maintains a constant presence in the daily life of the population, particularly for women.

Bisphenol A and Metabolic Diseases: Challenges for Occupational Medicine.

The prevalence of metabolic diseases has markedly increased worldwide during the last few decades. Lifestyle factors (physical activity, energy-dense diets), together with a genetic predisposition, are well known factors in the pathophysiology of health problems. Bisphenol A (BPA) is a chemical compound used for polycarbonate plastics, food containers, epoxy resins coating metallic cans for food and beverage conservation. The ability of BPA to act as an endocrine disruptor-xenoestrogen in particular-is largely documented in literature, with numerous publications of in vivo and in vitro studies as well as epidemiological data on humans. Recently, different researchers studied the involvement of BPA in the development of insulin resistance; evidences in this way showed a potential role in etiology of metabolic disease, both for children and for adults. We review the epidemiological literature in the relation between BPA exposure and the risk of metabolic diseases in adults, with a focus on occupational exposure. Considering published data and the role of occupational physicians in promoting Workers' Health, specific situations of exposure to BPA in workplace are described, and proposals for action to be taken are suggested. The comparison of the studies showed that exposure levels were higher in workers than in the general population, even if, sometimes, the measurement units used did not permit rapid comprehension. Nevertheless, occupational medicine focus on reproductive effects and not metabolic ones.

Teaching Life-Saving Manoeuvres in Primary School.

Introduction. In the event of sudden cardiac arrest (SCA) early intervention provided by a layperson can be life-saving. Teaching first aid in primary school may increase the lifelong ability and motivation of young people to take action in an emergency. Objective. The aim of this article is to report a training experience on BLSD (Basic Life Support and Defibrillation) designed for a group of pupils in an Italian primary school, with assessment of its effectiveness at a distance. Methods. The assessment was carried out using a multiple choice questionnaire on a sample of 130 pupils aged 11-12, 62 trained in BLSD and 68 as a control group. The trained group also performed an emergency simulation to assess their learning of practical skills. Results. Using the t test, significant differences emerged in the questionnaire scores between the case-control group. The results of the skill test were positive, even for the most difficult manoeuvres such as opening airways, assessing breathing, or using an AED (Automated External Defibrillator). Conclusion. Although there are still some open questions regarding the ability to retain these skills in the medium/long term, the study shows that life-saving manoeuvres can be effectively taught to primary school pupils.

Exposure to Bisphenol a and Gender Differences: From Rodents to Humans Evidences and Hypothesis about the Health Effects.

Bisphenol A (BPA) interacts with the endocrine system and seems to produce different effects in relation to gender. The objective of the study was to clarify the possible health effects of exposure to BPA in relation to gender. A literature search was performed using three different search engines: Medline, PubMed and Scopus. Data on both animals and humans showed that BPA acts as a xenoestrogen and interacts with the androgens' metabolism, producing different outcomes: uterotropic effects, decreasing sperm production, stimulation of prolactin release. Gender difference plays a key role in understanding the real toxic effects, the BPA serum concentrations were, all the time, higher in male subjects, possibly due to the difference in androgen-related enzyme activity levels, compared with the healthly female subjects, to equal levels of exposure; while higher BPA levels in women have been associated with a variety of conditions including obesity, endometrial hyperplasia, recurrent miscarriages, and polycystic ovarian syndrome. The data collected are sufficiently robust to raise concerns about the potentially deleterious impact of BPA on humans, even with some methodological limitations; the different impact of BPA in men and in women is documented and of a certain interest. In toxicology it is necessary to assess effects in relation to gender differences, in order to set up prevention plans in the work environment targeting the specific risk.

[A series of cases of sinonasal cancer among shoemakers and tannery workers]. / Analisi di una serie di casi di neoplasie maligne delle fosse nasali e dei seni accessori nel settore conciario e delle calzature.

A series of cases of sinunasal cancer has been observed among shoe-makers (11 cases) and tannery workers (8 cases) in the leather production area in Tuscany in the period 1990-2002. We stress the possible etiologic role of tannins both in leather and in wood industry.

Urinary metabolite concentrations of phthalate metabolites in Central Italy healthy volunteers determined by a validated HPLC/MS/MS analytical method.

The main objective of this study was to determine the average concentrations for the metabolites of the four more common phthalates, industrial chemicals widely used in commercial products and potential endocrine disruptors, in the urine of a control population living in Central Italy. The study population consisted of 157 healthy subjects, not occupationally exposed to phthalates (74 males and 83 females). Urinary levels of the analytes were determined by liquid chromatography tandem mass spectrometry (LC-MS/MS) with isotopic dilution. The reference values (geometric mean) for males and females were estimated for each metabolite:. Females: for MEP was 72.94µg/g creatinine (CI 95% 3.63-149.51), for MEHP was 3.37µg/g creatinine (CI 95% 1.85-4.89), for MEHHP was 12.74µg/g creatinine (CI 95% 9.45-22.19), for MnBP was 20.26µg/g creatinine (CI 95% 8.17-28.43) and for MBzP was 14.74 (CI 95% 2.94-17.68). Males: for MEP was 56.35µg/g creatinine (CI 95% 2.32-110.39), for MEHP was 2.80µg/g creatinine (CI 95% 1.08-4.52), for MEHHP was 10.77µg/g creatinine (CI 95% 6.18-16.95), for MnBP was 17.59µg/g creatinine (CI 95% 5.72-29.45) and for MBzP was 16.44 (CI 95% 7.90-29.45). To obtain reference values for these chemicals is without doubt an important topic for evaluate the exposure of population and their possible health effects. Information from different geographical areas are important to understand the real different background concentrations.

Urinary phthalate monoesters concentration in couples with infertility problems.

The widespread use of phthalates results in human exposure: phthalates are rapidly metabolized to their respective monoesters and other oxidative products, which are glucuronidated and excreted through the urine and feces. Several in vivo studies showed that some phthalates, in particular diethyl-hexyl phthalate (DEHP), diethyl phthalate (DEP), di(n-butyl)phthalate (DnBP) and n-butylbenzylphthalate (BBzP), are able to interact with the human endocrine system, interfering with the reproduction ability. In this study, 56 couples were recruited from a centre of assisted reproduction. Spot urine samples were collected and five urinary metabolites of the above phthalates were determined using an HPLC/MS/MS analytical method with isotopic dilution. The results were compared with those of 56 couples of parents of one or more children and the statistical analysis revealed a significant difference between the two groups in terms of urinary concentrations of phthalates metabolites. A further step will be the correlation of these results with information on the life styles and working conditions collected through a specifically designed questionnaire.

Exposure to styrene in fiberglass-reinforced plastic manufacture: still a problem.

OBJECTIVE: The aim of the work is to define occupational exposure to styrene in fiberglass manufacture; the phase of stretching styrene resins needs some manual handling and leads workers to be exposed to styrene. METHODS: We surveyed 20 workers in two companies manufacturing fiberglass, checking environmental levels and urinary concentrations of mandelic acid (MA), and phenylglioxylic acid (PGA). Workers completed a questionnaire collecting their medical history. RESULTS: Environmental monitoring showed some styrene concentrations higher than the threshold limit value-time-weighted average. Biological monitoring confirmed these findings and four workers had levels of urinary PGA and MA concentrations higher than the Biological Exposure Indices of the American Conference of Governmental Industrial Hygienists. CONCLUSIONS: This picture confirms that, even though the risk is known and the manufacturing cycle is well-defined, workers nevertheless risk exposure. More research is needed to optimize the work processes and the protection systems to lower this risk.

Complete separation of urinary metabolites of xylene in HPLC/DAD using ß-cyclodextrin: application for biological monitoring.

To determine the biomarkers of exposure to xylene, urinary 2-, 3- and 4-methyl-hippuric acids, a new HPLC/DAD analytical method has been developed, which uses ß-cyclodextrin as an additive for elution; its complexing abilities are exploited to achieve complete chromatographic separation of the three isomers. The mobile phase was a 3% aqueous solution of ß-cyclodextrin, pH 3, and methanol, 80:20, in isocratic conditions, with a flow rate of 1 mL/min. To optimize quantitative analysis three wavelengths were employed for detection: λ=198 nm, λ=200 nm, and λ=202 nm. SPE was applied for the extraction from urine samples of analytes. Validation parameters show recoveries always above 82%; LOD was set at 1 µg/mL with an LOQ of 3 µg/mL. The linear dynamic range (from 4 to 100 µg/mL) showed excellent correspondence. This method is rapid and inexpensive and can be applied to several samples simultaneously using a manifold for SPE extraction. The analytes were separated completely and could be fully quantified. The method was used for the analysis of urine samples from 54 workers exposed to xylene in hospital laboratories and showed a good applicability while allowing quantification even at low doses.