Occupational hypersensitivity pneumonitis: an EAACI position paper.

The aim of this document was to provide a critical review of the current knowledge on hypersensitivity pneumonitis caused by the occupational environment and to propose practical guidance for the diagnosis and management of this condition. Occupational hypersensitivity pneumonitis (OHP) is an immunologic lung disease resulting from lymphocytic and frequently granulomatous inflammation of the peripheral airways, alveoli, and surrounding interstitial tissue which develops as the result of a non-IgE-mediated allergic reaction to a variety of organic materials or low molecular weight agents that are present in the workplace. The offending agents can be classified into six broad categories that include bacteria, fungi, animal proteins, plant proteins, low molecular weight chemicals, and metals. The diagnosis of OHP requires a multidisciplinary approach and relies on a combination of diagnostic tests to ascertain the work relatedness of the disease. Both the clinical and the occupational history are keys to the diagnosis and often will lead to the initial suspicion. Diagnostic criteria adapted to OHP are proposed. The cornerstone of treatment is early removal from exposure to the eliciting antigen, although the disease may show an adverse outcome even after avoidance of exposure to the causal agent.

EAACI Position Paper on assessment of cough in the workplace.

Cough is a nonspecific and relatively common symptom that can present difficulties in diagnosis and management, particularly when it is reported to be associated with the workplace. The present consensus document, prepared by a taskforce of the Interest Group on Occupational Allergy of the European Academy of Allergy and Clinical Immunology by means of a nonsystematic review of the current literature, is intended to provide a definition and classification of work-related chronic cough (WRCC) to assist the daily practice of physicians facing with this symptom. The review demonstrates that several upper and lower airway work-related diseases may present with chronic cough; hence, the possible link with the workplace should always be considered. Due to the broad spectrum of underlying diseases, a multidisciplinary approach is necessary to achieve a definite diagnosis. Nevertheless, more epidemiological studies are necessary to estimate the real prevalence and risk factors for WRCC, the role of exposure to environmental and occupational sensitizers and irritants in its pathogenesis and the interaction with both upper and lower airways. Finally, the best management option should be evaluated in order to achieve the best outcome without adverse social and financial consequences for the worker.

Monitoring of occupational and environmental aeroallergens-- EAACI Position Paper. Concerted action of the EAACI IG Occupational Allergy and Aerobiology & Air Pollution.

Exposure to high molecular weight sensitizers of biological origin is an important risk factor for the development of asthma and rhinitis. Most of the causal allergens have been defined based on their reactivity with IgE antibodies, and in many cases, the molecular structure and function of the allergens have been established. Significant information on allergen levels that cause sensitization and allergic symptoms for several major environmental and occupational allergens has been reported. Monitoring of high molecular weight allergens and allergen carrier particles is an important part of the management of allergic respiratory diseases and requires standardized allergen assessment methods for occupational and environmental (indoor and outdoor) allergen exposure. The aim of this EAACI task force was to review the essential points for monitoring environmental and occupational allergen exposure including sampling strategies and methods, processing of dust samples, allergen analysis, and quantification. The paper includes a summary of different methods for sampling and allergen quantification, as well as their pros and cons for various exposure settings. Recommendations are being made for different exposure scenarios.

EAACI position paper: irritant-induced asthma.

The term irritant-induced (occupational) asthma (IIA) has been used to denote various clinical forms of asthma related to irritant exposure at work. The causal relationship between irritant exposure(s) and the development of asthma can be substantiated by the temporal association between the onset of asthma symptoms and a single or multiple high-level exposure(s) to irritants, whereas this relationship can only be inferred from epidemiological data for workers chronically exposed to moderate levels of irritants. Accordingly, the following clinical phenotypes should be distinguished within the wide spectrum of irritant-related asthma: (i) definite IIA, that is acute-onset IIA characterized by the rapid onset of asthma within a few hours after a single exposure to very high levels of irritant substances; (ii) probable IIA, that is asthma that develops in workers with multiple symptomatic high-level exposures to irritants; and (iii) possible IIA, that is asthma occurring with a delayed-onset after chronic exposure to moderate levels of irritants. This document prepared by a panel of experts summarizes our current knowledge on the diagnostic approach, epidemiology, pathophysiology, and management of the various phenotypes of IIA.

EAACI consensus statement for investigation of work-related asthma in non-specialized centres.

Work-related asthma (WRA) is a relevant problem in several countries, is cause of disability and socioeconomic consequences for both the patient and the society and is probably still underdiagnosed. A correct diagnosis is extremely important to reduce or limit the consequences of the disease. This consensus document was prepared by a EAACI Task Force consisting of an expert panel of allergologists, pneumologists and occupational physicians from different European countries. This document is not intended to address in detail the full diagnostic work-up of WRA, nor to be a formal evidence-based guideline. It is written to provide an operative protocol to allergologists and physicians dealing with asthma useful for identifying the subjects suspected of having WRA to address them to in-depth investigations in a specialized centre. No evidence-based system could be used because of the low grade of evidence of published studies in this area, and instead, 'key messages' or 'suggestions' are provided based on consensus of the expert panel members.

Occupational nonasthmatic eosinophilic bronchitis: current concepts.

BACKGROUND: Nonasthmatic eosinophilic bronchitis (NAEB) is an important cause of chronic cough, since it is present in 10-15% of patients referred for specialist investigation. The syndrome is considered a variant of occupational asthma when it develops as a consequence of occupational exposure, hence it should be considered in the spectrum of work-related airway diseases. OBJECTIVES AND METHODS: The aim of this paper was to update and expand the previous reviews on the clinical and pathophysiological features of NAEB and analyze available data on the occupational causes of the disease. Literature on the topic between the years 1990 and 2010 was reviewed with a Med Line search. RESULTS: The disease is probably underdiagnosed and an occupational origin was demonstrated only in isolated cases, probably due to the rarity of the disease and the lack of systematic evaluation of bronchial inflammation. CONCLUSIONS: In view of the current knowledge on this condition and the development of techniques to evaluate bronchial inflammation, occupational NAEB cannot be neglected any more and has been rightly included in the spectrum of occupational respiratory disorders.

EAACI position paper: prevention of work-related respiratory allergies among pre-apprentices or apprentices and young workers.

Apprenticeship is a period of increased risk of developing work-related respiratory allergic diseases. There is a need for documents to provide appropriate professional advice to young adults aiming to reduce unsuitable job choices and prevent impairment from their careers. The present document is the result of a consensus reached by a panel of experts from European and non-European countries addressed to allergologists, pneumologists, occupational physicians, primary care physicians, and other specialists interested in this field, which aims to reduce work-related respiratory allergies (rhinoconjunctivitis and asthma) among allergic or nonallergic apprentices and other young adults entering the workforce. The main objective of the document is to issue consensus suggestions for good clinical practice based on existing scientific evidence and the expertise of a panel of physicians.

Clinical and inflammatory features of occupational asthma caused by persulphate salts in comparison with asthma associated with occupational rhinitis.

BACKGROUND: The relationships between asthma and rhinitis are still a crucial point in respiratory allergy and have scarcely been analysed in occupational setting. We aimed to compare the clinical and inflammatory features of subjects with occupational asthma only (OA) to subjects with OA associated to occupational rhinitis (OAR) caused by persulphate salts. METHODS: The clinical charts of 26 subjects diagnosed in our Unit as respiratory allergy caused by ammonium persulphate (AP), confirmed by specific inhalation challenge (SIC), were reviewed. Twenty-two out of twenty-six patients underwent pre-SIC-induced sputum challenge test (IS) and 24/26 underwent nasal secretion collection and processing. RESULTS: Twelve out of twenty-six patients received a diagnosis of OA-only and 14/26 of OAR. Duration of exposure before diagnosis, latency period between the beginning of exposure and asthma symptom onset, basal FEV(1), airway reactivity to methacholine and asthma severity did not differ in the two groups. Eosinophilic inflammation of upper and lower airways characterized both groups. Eosinophil percentage in IS tended to be higher in OAR [11.9 (5.575-13.925)%] than in OA-only [2.95 (0.225-12.5)%] (P = 0.31). Eosinophilia in nasal secretions was present both in subjects with OAR [55 (46-71)%] and in subjects with OA-only [38 (15-73.5)%], without any significant difference. DISCUSSION: Our results indicate that OA because of ammonium persulphate coexists with occupational rhinitis in half of the patients. Unexpectedly, rhinitis did not seem to have an impact on the natural history of asthma. The finding of nasal inflammation in subjects with OA-only without clinical manifestations of rhinitis supports the united airway disease concept in occupational respiratory allergy as a result of persulphates.

[Professional eosinophilic bronchitis: considerations and new diagnostic methods in a clinical case]. / La bronchite eosinofila professionale: considerazioni e nuovi strumenti diagnostici a margine di un caso clinico.

Nonasthmatic eosinophilic bronchitis (NAEB) is a condition characterized by corticosteroid-responsive chronic cough, sputum eosinophilia and absence of symptoms or objective evidence of variable airflow obstruction and airway hyper-responsiveness. Like asthma, NAEB can be associated with exposure to occupational sensitizers and can be considered as being a variant of occupational asthma when it develops as a consequence of work exposure. Few case reports of NAEB caused by workplace exposure have been reported. Bakers are at high risk of developing occupational respiratory disorders and three cases of occupational NAEB have been described. We describe the first case of occupational NAEB due to storage mites in a baker in which the offending agent was identified by means of the basophil activation test (BAT), a new tool which has never been proposed in diagnostic procedures of occupational respiratory allergy. BAT's results allowed the recognition of the offending agent, that is mandatory for diagnosis.

The South American lungfish Lepidosiren paradoxa as a new host for Trichodina quelenii.

Recently, the South American lungfish Lepidosiren paradoxa is being found inside aquaculture ponds, and even though there are a few studies on their parasite fauna, there is still much to be reported. Thus, the objective of this study is to report parasitism by trichodinids in L. paradoxa, as these ciliate protozoa are related to injuries and mortality in fish farming. The lungfish were collected from experimental tanks, had their tegument scraped and the resultant mucus was analyzed under an optical microscope for morphological and morphometrical analyses in Giemsa and silver nitrate stained slides. The species found was identified as Trichodina quelleni. This is the first report of this parasite in L. paradoxa, and the second report in cultivated fish in Brazil.

[Exercise electrocardiography in the sanitary surveillance of workers with physical strain]. / Elettrocardiografia da sforzo nella sorveglianza sanitaria di lavoratori con impegnativo dispendio energetico.

To evaluate the opportunity of exercise electrocardiography (ECG) in the sanitary surveillance of workers with physical strain, we estimated the energy consumption of the duties of 22 electrical workers (males; age: 35-56 years). They subsequently underwent Treadmill exercise ECG, determining for each worker the maximal METs (multiples of basal metabolism) and the critical potency (P(CRIT)). In one subject, myocardial ischemia arose 9 minutes after the beginning of the test. The others interrupted the test after 7-13 minutes for tiring; 5 of them showed ventricular extra systoles, paired or isolated. Twelve subjects presented arterial hypertension, at rest and/or during exercise. Ergonomic analysis revealed that the occupational duties were between 1.5 and 8.0 METs. The energy consumption of the job on the whole was 4-6 METs (medium intensity). The maximal METs reached by the examined subjects were between 8.8 and 15.6; however, only 11 workers went reassuringly over the 4 METs required by duty analysis at P(CRIT). One subject was declared unfit for the job, and a judgement of partial idoneity was expressed for 3 workers. Preventive and therapeutic indications were given to 12 subjects. Aerobic training was suggested to 10 workers. The study indicates that an ergonomic evaluation is advisable for the most energy consuming occupational duties. In such cases, the sanitary surveillance should include a cardiologic assessment with exercise ECG, reproducing the physical strain of the specific job.

Diabetes and illness image: an analysis of diabetic early-adolescents' self-perception through the Draw-a-person test.

To study the self-projective representations expressed by diabetic children, aged between 10 and 15 yr., and to compare these with representations of a control group the Draw-a-person test associated with those for subsequent Draw-a-sick-person were administered to 23 children regularly checked by an Antidiabetic Centre. The diabetic subjects drew an image of "sick person" having projective elements with a regressive value and denoting a refuge in the past, together with depressive signs of retiring into themselves and of less consideration of the self. Also, the diabetic children seemed to be less prone to the cultural stereotype which requires a smiling and happy image of "the healthy person." At the same time there was also a transparent symbolic defense which allowed the diabetics to adapt variously and to move from their anxious state toward psychological recovery.

The South American lungfish Lepidosiren paradoxa as a new host for Trichodina quelenii / O lungfish sul-americano Lepidosiren paradoxa como novo hospedeiro para Trichodina quelenii

Abstract Recently, the South American lungfish Lepidosiren paradoxa is being found inside aquaculture ponds, and even though there are a few studies on their parasite fauna, there is still much to be reported. Thus, the objective of this study is to report parasitism by trichodinids in L. paradoxa, as these ciliate protozoa are related to injuries and mortality in fish farming. The lungfish were collected from experimental tanks, had their tegument scraped and the resultant mucus was analyzed under an optical microscope for morphological and morphometrical analyses in Giemsa and silver nitrate stained slides. The species found was identified as Trichodina quelleni. This is the first report of this parasite in L. paradoxa, and the second report in cultivated fish in Brazil.

Resumo Recentemente, o peixe pulmonado sul-americano Lepidosiren paradoxa tem sido encontrado em tanques de cultivo da aquicultura e, embora existam alguns estudos sobre a fauna de parasitas neste hospedeiro, ainda há muito a ser relatado. Assim, o objetivo deste estudo é relatar o parasitismo por tricodinídeos em L. paradoxa, pois esses protozoários ciliados estão relacionados a lesões e mortalidade na piscicultura. Os peixes foram coletados de tanques experimentais, tiveram seu tegumento raspado e o muco resultante foi analisado sob um microscópio óptico para análises morfológicas e morfométricas em lâminas impregnadas com Nitrato de Prata e com Giemsa. Os espécimes encontrados foram identificados como Trichodina quelleni. Este é o primeiro registro deste parasita em L. paradoxa, e a segunda ocorrência de Trichodina quelenii em peixes cultivados no Brasil.

The South American lungfish Lepidosiren paradoxa as a new host for Trichodina quelenii

Abstract Recently, the South American lungfish Lepidosiren paradoxa is being found inside aquaculture ponds, and even though there are a few studies on their parasite fauna, there is still much to be reported. Thus, the objective of this study is to report parasitism by trichodinids in L. paradoxa, as these ciliate protozoa are related to injuries and mortality in fish farming. The lungfish were collected from experimental tanks, had their tegument scraped and the resultant mucus was analyzed under an optical microscope for morphological and morphometrical analyses in Giemsa and silver nitrate stained slides. The species found was identified as Trichodina quelleni. This is the first report of this parasite in L. paradoxa, and the second report in cultivated fish in Brazil.

Resumo Recentemente, o peixe pulmonado sul-americano Lepidosiren paradoxa tem sido encontrado em tanques de cultivo da aquicultura e, embora existam alguns estudos sobre a fauna de parasitas neste hospedeiro, ainda há muito a ser relatado. Assim, o objetivo deste estudo é relatar o parasitismo por tricodinídeos em L. paradoxa, pois esses protozoários ciliados estão relacionados a lesões e mortalidade na piscicultura. Os peixes foram coletados de tanques experimentais, tiveram seu tegumento raspado e o muco resultante foi analisado sob um microscópio óptico para análises morfológicas e morfométricas em lâminas impregnadas com Nitrato de Prata e com Giemsa. Os espécimes encontrados foram identificados como Trichodina quelleni. Este é o primeiro registro deste parasita em L. paradoxa, e a segunda ocorrência de Trichodina quelenii em peixes cultivados no Brasil.

Fenoldopam to prevent renal replacement therapy after cardiac surgery. Design of the FENO-HSR study.

INTRODUCTION: Acute kidney injury requiring renal replacement therapy is a serious complication following cardiac surgery associated with poor clinical outcomes. Until now no drug showed nephroprotective effects. Fenoldopam is a dopamine-1 receptor agonist which seems to be effective in improving postoperative renal function. The aim of this paper is to describe the design of the FENO-HSR study, planned to assess the effect of a continuous infusion of fenoldopam in reducing the need for renal replacement therapy in patients with acute kidney injury after cardiac surgery. METHODS: We're performing a double blind, placebo-controlled multicentre randomized trial in over 20 Italian hospitals. Patients who develop acute renal failure defined as R of RIFLE score following cardiac surgery are randomized to receive a 96-hours continuous infusion of either fenoldopam (0.025-0.3 µg/kg/min) or placebo. RESULTS: The primary endpoint will be the rate of renal replacement therapy. Secondary endpoints will be: mortality, time on mechanical ventilation, length of intensive care unit and hospital stay, peak serum creatinine and the rate of acute renal failure (following the RIFLE score). CONCLUSIONS: This trial is planned to assess if fenoldopam could improve relevant outcomes in patients undergoing cardiac surgery who develop acute renal dysfunction. Results of this double-blind randomized trial could provide important insights to improve the management strategy of patients at high risk for postoperative acute kidney injury.