[Quality improvement in workers health surveillance: the spirometry training courses experience]. / Miglioramento della qualità della sorveglianza sanitaria: l'esperienza dei corsi di spirometria.

The spirometry execution during workers health surveillance requires accurate and reproducible spirometric measurements, which should comply with the ATS/ERS guidelines. Low acceptability of spirometric manoeuvres has been reported in health surveillance. This may hamper the validity of the results and affect clinical decision making. Training and refresher courses may produce and maintain good-quality testing, promote the use of spirometric results in clinical practice and enhance the quality of interpretation. We evaluated (with PLATINO score) 239 spirometries from 23 occupational physicians recorded before and after a spirometry refresher course (16 hours) and we verified that only 4 physicians showed a very good improvement and others 4 a good improvement of score, while 9 showed a very slight improvement and 6 instead no improvement. It is worthy of note that in 2012 some spirometers not suitable to UNI EN 26782/2009 were still in use.

[Quality control of spirometry in workers' medical surveillance]. / Il controllo di qualità della spirometria nella sorveglianza sanitaria dei lavoratori.

Spirometry plays an important role in occupational respiratory health surveillance programs. However, when not performed correctly, the values obtained can be misleading, resulting in misclassification of the workers' health status. Studies carried out in Italy have shown that spirometries recorded by occupational physicians often do not comply with quality criteria for recording FEV1 and FVC, according to joint statements on lung function testing for the American Thoracic Society and the European Respiratory Society, issued in 2005. For this reason, they are useless for the purposes of their execution. Compliance with ATS/ERS statements is essential to assure that spirometry results are beneficial for the monitoring of workers' health.

[The activity of local health units in agriculture: promotion, prevention, control]. / Attività di promozione, prevenzione e controllo delle ASL/AUSL in ambito agricolo.

Agriculture shows an high proportion of injuries, mostly by machineries and instruments, and the highest proportion between fatal and total injuries. The Conference of Regions has adopted the National Agriculture and Forestry Prevention Plan, in application of the "Pact for health and safety in workplaces". The plan gives priority to actions improving the safety of agricultural machines, specially if more frequently involved in serious and fatal injuries. Goal is to achieve an homogenous intervention standard all over in the country, composed by a mix of information, support and control, addressed to farms and agricultural machines traders. Public prevention organizations of Local Health Units moreover will record homogenously the happen modality of fatal and serious accidents, will collaborate in joining prevention objectives with Rural Develop Plans and in drawing up good practices. At another level in some regions have been developed prevention activities for other risk factors: definition of exposition profiles of pesticides, development of professionally exposed workers formation, control of buildings and cattle breeding, medical and epidemiological periodic survey of employees.

[Effectiveness of measures to promote and control on the appropriateness of preventive measures taken on farms--health surveillance, surveys on damages associated with risk]. / Efficacia delle azioni di promozione e controllo sull'appropriatezza delle misure di prevenzione adottate nelle aziende agricole--la sorveglianza sanitaria, le indagini sui danni associati al rischio.

The agricultural activities have several issues in the management of safety and health of workers. The study of two ASL of Central Italy (VT and RMH) intended to check the risk conditions in order to highlight most critical points and define a prevention and surveillance plan. We moved in these directions: verification of workplaces and work practices; examination of machineries and equipment; active search of occupational diseases. We analyzed some peculiar aspects of the health surveillance of 75 workers such as risk from sun exposure, significantly underestimated by employers and competent doctors, despite sun exposure diseases are included in the list for which reporting is mandatory. Our study shows that a targeted campaign of prevention and control can lead to an improvement in safety management, on the other hand shows the necessity to bring occupational health physician to assess and manage also less valuated risks as the sun exposure.

[The surveillance of occupational risks. Problems and perspectives of the recent legislative framework after the national preliminary survey]. / I dati sanitari aggregati e di rischio dei lavoratori sottoposti a sorveglianza sanitaria. Risultati preliminari dello studio pilota nazionale sulle comunicazioni ex art. 40. D.lgs 81/2008.

BACKGROUND: Legislation in Italy concerning health, safety and prevention at the workplace recently established a new data communication standard OBJECTIVES: The findings are reported of a specific survey on 18 Local Health Units (ASL) over the entire Italian territory, aimed at identifying the critical points in data management and analyze the available information. METHODS: The occupational health physician for each company must collect and transmit information on the number of workers submitted to health surveillance protocols to the Local Health Unit. Information must be divided by risk factor and gender Local health Units then transmit the data to the Regions and finally to the Italian National Institute for Occupational Safety and Prevention (ISPESL). RESULTS: A sample of 22.977 companies was studied, providing information on about 410,009 workers undergoing health surveillance protocols. Carrying or moving heavy loads, exposure to noise, VDU and chemical substances were the most frequent risk factors. The difference between genders was significant in risk allocation, with exposures to VDU and biological agents prevalently among females. CONCLUSIONS: The information thus collected suffered from a lack of data organization and completeness in the sample under study, but nevertheless provides preliminary evidence of a map of occupational risks on a national basis, confirming the potential for the new law (D.Lgs 81/2008) to investigate health safety and prevention at the workplace.

[Kidney retransplantation: indications and limits]. / Il ritrapianto renale: indicazioni e limiti.

Whether or not to consider a uremic patient for retransplantation remains a matter of debate. Donor shortage and putative poor outcomes are the main cons, improved results in the last decade and a better survival (HR 0.50) with retransplantation than dialysis stand as pros. The percentage of patients waitlisted for retransplantation or already having been retransplanted is increasing (up to 20-30%) and the absolute contraindications are limited to rare conditions (loss of previous transplant due to anti-glomerular basement antibodies in Alport's syndrome, early recurrence of GNF or hemolytic uremic syndrome). When retransplantation is considered, however, careful screening for risk factors is mandatory, whether they are related to the previous graft or to the recipient's clinical features or the donor's demographics and immunological status. In the last decade the clinical outcomes of retransplantation have significantly improved. No difference in patient survival at the fifth year has been reported between first, second and third grafts. The kidney survival at the same interval is above 70% for the second graft and 65% for the third graft. Nephrectomy of a previous graft is not necessary if not for clinical reasons. As far as the maximum number of retransplants is concerned, most transplant centers (69%) set no clear-cut limit. In conclusion, also taking into account that many patients after graft failure ask for readmission to the waiting list (75% in our experience), we think the retransplantation option should always be evaluated.

[Smoke habit in a population of apprentices in middle of Italy]. / Abitudine al fumo in una popolazione di apprendisti dell'Italia centrale.

This study assessed the smoking habit in 7,159 apprentices (females: 53.3%) in central Italy. In the period 1996-2006, each apprentice underwent a compulsory health examination to assess fitness for work carried out by specialists in Occupational Medicine. Demographic data and information on schooling, smoking habit, alcohol and coffee intake were collected by a questionnaire. Overall, 51.9% of apprentices were smokers. Smokers were fewer among female apprentices than among the males (48.3% vs 55.9%; chi-square test, p < 0.001). No decrease in the prevalence of smokers was evident during the study period. Low educational level, and daily intake of alcohol and coffee significantly increased the risk of being a smoker. Finding a high percentage of smokers among Italian apprentices with a low educational level who are employed in jobs for which few qualifications are required indicates the need for work-place activities against tobacco smoking habit. Specialists in Occupational Medicine who perform regular health surveillance of workers could play a role in the anti-smoking campaign by integrating their routine work with brief counselling sessions aimed at preventing smoking in young workers and helping smokers to stop and by collaborating in work-place health promotion programmes.

[Good practice for medical surveillance by occupational physicians]. / La buona pratica nella sorveglianza sanitaria del medico competente.

Society--employers, workers, trade unions, public--demands the highest standards of professional competence and ethical conduct from occupational physicians. However, defining what exactly constitutes good medical practice and acceptable standards of professional competence and conduct is not so easily done. Good practice in occupational medicine should be aimed not only at improving the effectiveness of preventive action in the strict sense, but also at constantly adopting rigorous methodologies based on evidence and procedures breaking loose from rigid formats, which must be as uniform as possible throughout the country. It's essential, therefore, to develop consensus documents on workers' health surveillance, meeting with approval of occupational health physicians both operating in a free market context or within the framework of public sector health service.

[Silica in ceramic industry: exposition and pulmonary diseases]. / Esposizione a silice cristallina nel comparto ceramico di Civita Castellana (Viterbo) ed evidenze radiologiche e spirometriche di danno polmonare.

Since 1990, a cohort survey has been carried out among workers employed in pottery workers by the Local Health Unit of Viterbo, Latium (Italy). Cumulative exposure to silica containing dust has been assessed for 808 workers, who were also screened with a questionnaire on respiratory symptoms, chest radiography and lungfunction tests. The prevalence of small opacities 1/0 and 1/1+ was 3.0% and 4.1% respectively and the prevalence increased with the cumulative exposure. A close relationship has been found between silica dose and decrease in lung function.

A case-referent study on nasal cancer and exposure to wood dust in the province of Siena, Italy.

The aim of the present study was to assess the risk of nasal cancer associated with exposure to dust in the wood and furniture industry in the province of Siena, Italy. Four to seven percent of the active male population is employed in this sector. A case-referent approach was used. The cases included male subjects seen at the Ear, Nose and Throat Clinic and the Radiotherapy Unit of Siena and diagnosed as having cancer of the nasal cavities or paranasal sinuses between 1963 and 1981. The referents were male patients admitted to the Medical Clinic of Siena for all causes except nasal neoplasia; they were matched 5:1 to the cancer patients for age and time of admission. Information was gathered (by postal questionnaires) on the occupational histories of all 36 of the cancer patients and 164 of the 180 referents. The odds ratio associated with exposure to wood dust was 5.4 (1.7-17.2) for all carcinomas, and 87.7 (19.8-407.3) for mucinous adenocarcinoma. The woods used by the exposed cancer patients were mainly oak, chestnut, poplar, and fir. The median duration of exposure was 40 years; no exposed cancer patient reported the presence of exhaust systems in their work environment.

Cancer among farmers in central Italy.

This case-referent study evaluated cancer risks among farmers in central Italy. Cancer cases (N = 1674, 17 sites) were selected from all deceased men aged 35-80 years; a random sample of 480 decedents formed the reference series. Farmers had a decreased risk of lung and bladder cancer and melanoma and nonsignificant excess risks for stomach, rectal, kidney, and nonmelanoma skin cancer. Stomach and kidney cancer were significantly increased among the farmers with > 10 years' experience, and stomach, rectal, and pancreatic cancer were increased among licensed pesticide users with > 10 years' experience. Possible relationships emerged between specific crops and cancer: fruit and colon and bladder cancer, wheat and prostate cancer, olives and kidney cancer, and potato and kidney cancer. The results regarding stomach, pancreatic, lung, bladder, and prostate cancer and melanoma congrue with earlier results. The kidney cancer excess, the association of colon and bladder cancer with orchard farming, and the excess of rectal cancer among licensed farmers are new and unexpected findings.

[Technical quality control of chest x-rays for the health surveillance of workers exposed to the risk of pneumoconiosis: proposal for a qualitative screening method]. / Controllo di qualità tecnica sui radiogrammi del torace effettuati per la sorveglianza sanitaria dei lavoratori esposti al rischio di pneumoconiosi: proposta di un metodo di screening qualitativo.

BACKGROUND: The necessity of a qualitative screening has arisen from the fact that good technical quality is of fundamental importance for evaluating initial pneumoconiosis, for reducing inter- and intra-reader variability, for effective secondary prevention and for forensic medicine purposes. OBJECTIVES: The authors report experience in use of a method to evaluate the quality of chest radiographs performed in health surveillance programs for workers at risk for development of pneumoconiosis. METHODS: 747 postero-anterior chest radiographs concerning employees of 21 ceramic factories in the Province of Viterbo were examined. A standardized pattern was created for this evaluation. The pattern considers the main factors that can influence the quality of chest radiographs and assigns points for each of them. That factors are: 1) reproduced image of the lung's vascular structure, chiefly in the peripheral portions; 2) reproduced image of heart border, aorta, diaphragm; 3) deep inspiration; 4) symmetric image of the chest; 5) position of the scapulae; 6) visualization of the costal-phrenic angles; 7) technical impairments. RESULTS: The application of the method revealed that half of the chest radiographs examined had poor image quality for a suitable reading, in conformity with the ILO 1980 guidelines. The critical points are poor visualization of the lung's vascular structure due to overexposure or underexposure, technical impairments, non-correct scapulae position. CONCLUSIONS: The authors believe that the suggested method can be a useful instrument for self-testing the quality of chest radiographs performed in radiology centers and for the National Health Service to test the quality of chest radiographs performed in health surveillance programs.

[Evaluation of training programs for purchasing and using pesticides]. / Valutazione dei corsi per l'abilitazione all'acquisto ed uso dei fitofarmaci.

Courses to enable farmers to use pesticides are an ideal opportunity to implement prevention programs. The aim of this study was to evaluate the efficacy of the courses and to define parameters to validate the teaching methods used. The population consisted of 307 individuals who followed the courses during 1991 in the province of Viterbo. A multiple choice questionnaire was administered before and after the course. A knowledge coefficient (KC) was considered as an indicator of knowledge improvement gained by the course. Wilcoxon's non-parametric test was used to compare pre- and post-test scores. A multivariate logistic model was designed to assess the effect of descriptive variables (age, educational level, years of work in agriculture, etc.) on KC. Post-test scores were significantly higher than pre-test scores and the mean KC was 60%, suggesting a general efficacy of the courses. A marked effect of age and educational level on KC was observed: KC values decreased with increase in age and with decrease in educational level. It is recommended to vary the courses according to age and educational level in view of the high proportion of older subjects and the low educational level (about 50%). Active learning methods should also be used as far as possible.

[Quality control of spirometric tests used in health surveillance for occupational exposure risk, in the province of Viterbo]. / Controllo di qualità delle prove spirometriche eseguite nell'ambito della sorveglianza sanitaria per esposizione a rischio lavorativo, in provincia di Viterbo.

A quality control survey on spirometry assessments carried out in a number of factories in the province of Viterbo (Lazio Region) was made by the Local Health Unit in Viterbo, as required by law 626/94 on the promotion of workers health. The survey concerned 734 measurements concerning the same number of employees from 29 different factories. Each spirometry assessment was repeated in this study according to the quality standards defined in the literature and our own results were compared with the values which had been obtained over one year during the health surveillance program (ASP). A few main functional parameters were considered according to the following criteria: percentage of agreement (tolerance +/- 5%) between the two FVC, FEV1 and FEF25-75 measures or degree of discrepancy; for FEV1/FVC ratio, the occurrence of < 70 (suggestive of an obstructive lesion) and > 90 values (reflecting poor reliability in the measurement of the lung volumes) in the two sets of data. Further criteria concerned the comparison of the height of the individuals (tolerance range +/- 1 cm), and the comparison of the overall spirometry rating expressed as the number of tests rated normal or abnormal (during the first assessment as compared to the second). The results show poor agreement (11.4%) for FVC with as many as 85.8% underestimated values; 30.1% agreement and 64.2% underestimate for FEV1; 17% agreement and 53.5% overestimate for FEF25-75. There were 6.5% fewer < 70 FEV1/FVC ratios, and 18.3% more > 90 ratios in the tests carried out in the factories as compared to our own. There was 32.9% agreement on the height, with overestimation in 63.7% of the cases. There were 12.3% "false abnormal" and 2.6% "false normal" results in the overall rating of the spirometry (as carried out by the factories compared to our own). In conclusion, the survey revealed a trend in the measurements carried out by the factories to underestimate the volumes, overestimate the flows, improperly select the theoretical reference values because of a mistake in measuring the height, to overestimate restrictive abnormalities, and underestimate the obstructive ones.

Evaluation of skin and respiratory doses and urinary excretion of alkylphosphates in workers exposed to dimethoate during treatment of olive trees.

This article describes a study of exposure to dimethoate during spraying of olive trees in Viterbo province in central Italy. Airborne concentrations of dimethoate were in the range 1.5 to 56.7 nmol/m(3). Total skin contamination was in the range 228.4 to 3200.7 nmol/d and averaged 96.0% +/- 3.6% of the total potential dose. Cotton garments afforded less skin protection than waterproof ones, which were in turn associated with higher skin contamination than disposable Tyvek overalls. Total potential doses and estimated absorbed doses, including their maxima, were below the acceptable daily intake of dimethoate, which is 43.6 nmol/kg body weight (b.w.). Urinary excretion of alkylphosphates was significantly higher than in the general population, increasing with exposure and usually showing a peak in the urine sample collected after treatment. Metabolite concentrations were influenced by the type of individual protection used: minimum levels were associated with the closed cabin and maximum levels with absence of any respiratory or hand protection. Urinary alkylphosphates showed a good correlation with estimated absorbed doses and are confirmed as sensitive biologic indicators of exposure to phosphoric esters.

Mortality among male licensed pesticide users and their wives.

BACKGROUND: We evaluated the mortality pattern of male licensed pesticide users and their wives in central Italy. METHODS: The cohort consisted of 2978 male farmers licensed for buying and handling toxic pesticides during the period 1971-1973 and 2586 farmers' wives. The Standardized Mortality Ratio (SMRs) and their 95% Confidence Intervals (95% CI) were computed on the basis of regional death rates. RESULTS: We found a lower than expected overall and cancer mortality. Non-Hodgkin's lymphoma was increased among women (SMR = 2.29, 0.62-5.86) but not in male farmers (SMR = 0.90, 0.24-2.30), while both sexes were characterized by an increased risk of leukemia (men: SMR = 1.44, 0.69-2.64; women: SMR = 2.41, 1.04-4.76), mainly due to myeloid leukemia (men: SMR = 2.43, 0.98-5.00; women: SMR = 3.14, 1.02-7.33). CONCLUSIONS: Men and women tend to share the same mortality profile. The statistically significant increase of leukemia with a threefold increased risk of the myeloid subtype only among women suggests that different pattern of exposure or biological differences between genders should be considered in evaluating health risks in agricultural settings.

Evaluation of risk of Parkinson's disease in a cohort of licensed pesticide users.

In the last two years, the environmental theory on the aetiology of Parkinson disease has acquired new data. From an experimental point of view, a new model of parkinsonism induced by rotenone, a diffuse insecticide, has been proposed, and in vitro studies have provided proof that several pesticides stimulate the formation of alpha-synuclein fibrils (one of the principal constituents of Lewy bodies). Moreover, a meta-analysis of all case-control studies so far performed showed a positive, statistically significant association between pesticide exposure and PD. In this context, we are performing a cohort study on 5575 licensed pesticide users in the province of Viterbo. After 27 years of follow-up, 4788 subjects are still alive. The aim of this study is to measure the prevalence of Parkinson's disease in a large group of workers with theoretically increased risk.