[Guidelines for occupational exposures to mechanical vibration.] / I valori guida nella valutazione del rischio da vibrazioni meccaniche.

OBJECTIVES: In this study, the daily exposure action values (EAV) and the daily exposure limit values (ELV) for hand-transmitted vibration (HTV) and whole-body vibration (WBV), established by the EU Directive 2002/44/EC and the Italian Decree 81/2008, and expressed in terms of 8-hr frequency weighted r.m.s. acceleration magnitude, are discussed upon consideration of the findings of experimental and epidemiological studies. METHODS: There is some epidemiological support for the EAV A(8) of 2.5 ms-2 r.m.s. and the ELV A(8) of 5 ms-2 r.m.s. for HTV, at least for the vascular component (secondary Raynaud's phenomenon) of the hand-arm vibration syndrome. RESULTS: There is some experimental evidence for the EAV A(8) of 0.5 ms-2 r.m.s. for WBV, while there is neither biodynamic nor epidemiological validation for the ELV A(8) of 1.15 ms-2 r.m.s. for WBV, this latter lowered to 1 ms-2 r.m.s. in the Italian legislation.

A double-blind, randomized, placebo-controlled crossover trial of the α2C-adrenoceptor antagonist ORM-12741 for prevention of cold-induced vasospasm in patients with systemic sclerosis.

OBJECTIVES: Our primary purpose was to evaluate the efficacy of the high-potency α2C-adrenoceptor antagonist ORM-12741 in the attenuation of a cold-induced reduction in finger blood flow and temperature in patients with RP secondary to SSc. Secondary objectives were to assess safety and tolerability. METHODS: This was a phase IIa, randomized, double-blind, crossover, single-dose, placebo-controlled, single-centre study. Patients attended five times: initial screening, treatment visits 1-3 (each at least 1 week apart) and 1-2 weeks after the last treatment. At each treatment visit, each subject received a single oral dose of 30 mg or 100 mg of ORM-12741 or placebo. Thirty minutes later the subject underwent a cold challenge. Blood flow to the fingers was assessed by three methods [temperature by probe, laser Doppler imaging (LDI) and infrared thermography] performed before, during and after the cold challenge. RESULTS: Twelve patients (10 female, mean age 58 years) were included. The area under the rewarming curve (LDI) of the right index finger (arbitrary flux units × time) was lower for both 30 mg (P = 0.043) and 100 mg (P = 0.025) of ORM-12741 compared with placebo, indicating delayed reperfusion. The time to 70% temperature recovery (middle finger probe) was longer with active than placebo treatment: mean (s.d.) values for placebo, 30 mg of ORM-12741 and 100 mg of ORM-12741 were 21.4 min (12.4), 25.7 min (12.2) and 26.9 min (13.9), respectively. Overall ORM-12741 was well tolerated. CONCLUSION: ORM-12741 did not expedite recovery from a cold challenge in the fingers of patients with SSc. TRIAL REGISTRATION: https://www.clinicaltrialsregister.eu/; no. 2010-024005-13.

Worldwide Expert Agreement on Updated Recommendations for the Treatment of Systemic Sclerosis.

OBJECTIVE: To evaluate agreement of the updated European League Against Rheumatism and European Scleroderma Trials and Research group (EUSTAR) recommendations for treatment of systemic sclerosis (SSc) among international experts. In addition, to determine factors that might influence agreement. METHODS: Level of agreement (10-point scale: 0 = not at all, 10 = completely agree) and local drug availability (yes/no) were assessed using an online survey. The Web link to the survey was shared with 481 unique e-mail addresses and SSc networks (Scleroderma Clinical Trials Consortium, Australian Scleroderma Interest Group, International Systemic Sclerosis Inception Cohort). Level of agreement was compared between subgroups stratified for participant characteristics. RESULTS: In total, 263 experts participated, of whom n = 209 (79%) completed each single item. The majority were rheumatologists (n = 200, 76%) working in Europe (n = 185; 71%); 59% (n = 156) were EUSTAR members; and 57% (n = 151) had > 10 years of clinical experience. Overall level of agreement was high (mean 8.0, SD 2.5). The 3 highest mean agreements included (1) angiotensin-converting enzyme inhibitors for scleroderma renal crisis (9.2, SD 2.1); (2) blood pressure control in SSc-patients treated with corticosteroids (9.0, SD 2.2); (3) proton pump inhibitors to prevent reflux complications (9.0, SD 2.2). The 3 lowest mean agreements included (1) fluoxetine for Raynaud phenomenon (RP; 4.6, SD 2.8); (2) hematopoietic stem cell transplantation (HSCT) for severe SSc (7.1, SD 2.9); (3) phosphodiesterase inhibitors 5 for RP (7.3, SD 2.7). Agreement differed between Europe and non-Europe for the use of iloprost, bosentan, methotrexate, HSCT, and cyclophosphamide. Treatment availability could partially explain differential agreement for iloprost, bosentan, and HSCT. CONCLUSION: In general, worldwide expert agreement on updated recommendations for treatment of SSc is high, supporting their value. Differences in agreement are partially explained by geographical area and treatment availability.

A potential role for imatinib and other small molecule tyrosine kinase inhibitors in the treatment of systemic and localized sclerosis.

Small molecule tyrosine kinase (TK) inhibitor, such as imatinib, is well established in the treatment of malignancy. Oral administration, high efficacy, and an excellent safety profile have made imatinib a drug of choice for several malignancies and benign conditions. Recent progress in the understanding of several benign conditions has led to the use of TK inhibitors in the treatment of hypereosinophilic syndrome and mastocytosis. Systemic sclerosis (SS) is a recalcitrant disease featuring multiorgan fibrosis and dysfunction. Molecular and biological evidence point to a central role for platelet-derived growth factor receptor, a TK-associated entity, in the pathogenesis of SS. The ability of several TK inhibitors, namely imatinib, to abrogate the activation of platelet-derived growth factor receptor-TK may entail their use in the treatment of SS and possibly more limited forms of sclerosis. Several human studies aiming to examine the use of imatinib in the treatment of SS are currently underway.

Conquering common breast-feeding problems.

Meeting mothers' personal breast-feeding goals depends on a number of factors, including the timely resolution of any problems she encounters. Nurses are often the first providers who interact with the mother during the perinatal period and are positioned to guide mothers through the prevention and solving of breast-feeding problems. Although many problems may be "common," failure to remedy conditions that cause pain, frustration, and anxiety can lead to premature weaning and avoidance of breast-feeding subsequent children. This article describes strategies and interventions to alleviate common problems that breast-feeding mothers frequently encounter.

Behaviour change interventions for the management of Raynaud's phenomenon: a systematic review protocol.

INTRODUCTION: Raynaud's phenomenon (RP) describes excessive peripheral vasospasm to cold exposure and/or emotional stress. RP episodes are associated with digital colour changes, pain and reduced quality of life. Pharmacological interventions are of low to moderate efficacy and often result in adverse effects such as facial flushing and headaches. Recommended lifestyle and behavioural interventions have not been evaluated. The objectives of the proposed systematic review are to assess the comparative safety and efficacy of behaviour change interventions for RP and identify what we can learn to inform future interventions. METHODS AND ANALYSIS: Studies eligible for inclusion include randomised controlled trials testing behaviour change interventions with a control comparator. A comprehensive search strategy will include peer review and grey literature up until 30 April 2017. Search databases will include Medline, Embase, PsychINFO and Cochrane. Initial sifting, eligibility, data extraction, risk of bias and quality assessment will be subject to review by two independent reviewers with a third reviewer resolving discrepancies. Risk of bias assessment will be performed using Cochrane risk of a bias assessment tool with quality of evidence assessed using Grading of Recommendations Assessment, Development and Evaluation(GRADE). A meta-analysis will be performed if there are sufficient data. Two subgroup analyses are planned: primary versus secondary RP outcomes; comparison of theoretically informed interventions with pragmatic interventions. ETHICS AND DISSEMINATION: This review does not require ethical approval as it will summarise published studies with non-identifiable data. This protocol complies with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. Findings will be disseminated in peer-reviewed articles and reported according to PRISMA. This review will make a significant contribution to the management of RP where no review of behaviour-change interventions currently exist. The synopsis and protocol for the proposed systematic review is registered in the International Prospective Register of Systematic Reviews (registration number CRD42017049643).

Influence on operator's health of hand-transmitted vibrations from handles of a single-axle tractor.

The operators of the single-axle tractors are especially exposed to hand-arm transmitted vibrations. These vibrations can cause the complex of vascular, neurological and musculoskeletal disorders, collectively named hand-arm vibration syndrome. Among these, the most common disorder is vibration-induced white finger (Raynaud's phenomenon). The vibration levels were measured in three tractor's working conditions, namely idling, transportation and soil tillage. The vibration level on the handles was measured and analysed and the frequency spectra for the chosen working conditions were obtained. The frequency-weighted acceleration, given in m/s2, was calculated and the obtained values are graphically presented. The measured vibration levels are then discussed with regard to the operator's daily exposure limits recommended by the ISO 5349. The vibration levels were much higher in the x and y directions than the z-direction in all working conditions. The vibration total values in idling, transportation and soil tillage were 3.37, 8.37 and 9.62 m/s2, respectively. Results showed that the 10% of workers are exposed to a risk of vibration-induced white finger disorder of the hands after relatively short periods (3-4 years), if the tractor is used 8 hour per day in soil tillage and transportation at full load. Considering the criteria of the ISO 5349, the daily working time with the single-axle tractor should be limited in order to protect the operator and work schedules should be arranged to include vibration-free periods.

Prevalence of Raynaud phenomenon in the adult population of South Carolina.

A prevalence estimate for Raynaud phenomenon among adult residents of South Carolina was based on data obtained from respondents in a statewide health survey, followed by face-to-face interviews and clinical screening for Raynaud phenomenon, using a screening procedure developed by the authors. The survey obtained 5246 personal interviews from a probability sample of over 3000 households, and 494 survey subjects participated in the clinical screening. The prevalence estimates and their standard errors were computed using survey case weights, design-based estimation, and logistic modelling techniques. The prevalence of Raynaud phenomenon among adult residents of South Carolina was determined to be 3.5%, with a standard error of 0.6%. Prevalence was higher for females (4.3%, SE = 0.7%) than for males (2.7%, SE = 0.6%). These figures are much lower than most estimates in the existing literature on Raynaud phenomenon.

Transmission of hand-arm vibration to the head.

A "tooth impression" was devised to measure head vibration. The vertical head vibration of four subjects was measured with the tooth impression during exposure of the hand to vertical sinusoidal vibration at acceleration levels of 3.15, 10.0, and 31.5 m/s2 root mean square in the range of 8-200 Hz. While in a standing position, the subjects pulled the vibrating handle upward at a force of 5 kg with the elbow joint stretched during the tests. The measurement was repeated twice. The difference between the two measurements was within 3 dB, a level which suggests that this method has good reproducibility. The vibration transmitted to the head was the greatest in the range of 12.5-16 Hz, and the attenuation was about 20 dB. Head vibration decreased by approximately 15 dB per octave at frequencies above 20 Hz as the frequency increased. When the excitation level was increased by 10 dB, the head vibration increased by about 8 dB.

Handlebar vibration of a motorcycle during operation on different road surfaces.

In Japan daily motorcycle mail deliverers have been exposed to vibration from the handlebars of their motorcycles. Handlebar vibration was measured during the operation of a motorcycle in order to evaluate the hazardous effects of vibration and to identify preventive measures against the vibration hazards. Tests were made on asphalted, unpaved, and packed-snow road surfaces. The tested motorcycles were selected from the many motorcycles in daily use. The test motorcycle was a 1-cylindered, 89-cm3, 4-cycle machine. The direction showing the maximum value of vibration acceleration was not always in the directions of X, Y, and Z proposed by the International Organization for Standardization (ISO). The maximum vibration acceleration level exceeded the exposure guideline of ISO, while its frequency corresponded to that of the engine speed during operation. Vibration of greater than 20 Hz was transmitted through the front forks from the road surface and tires.

Applications of hand-arm models in the investigation of the interaction between man and machine.

The mode of vibration of hand-held tools cannot be considered without knowledge of the influence of the operator's hand-arm system. Therefore some technical applications of hand-arm models were realized for drill hammers by the University of Dortmund. These applications are a software program to simulate the motion of machine components, a horizontal drilling jig, and a chucking device in a drilling rig.

Elaboration of a standard procedure for the measurement of vibration emitted by percussive tools--application to breakers.

The Association Française de Normalisation (AFNOR) is preparing a standard on the exposure assessment of vibration from percussive tools. Therefore, a test code was developed for the measurement of vibration from percussive tools under laboratory conditions. The handle vibration from six different breakers, among which three tools were of "antivibration design," was measured with the following energy absorption methods: hydraulic base, steel shot, actual breaking of concrete, AFNOR concrete block, pointed chisel embedded in concrete. The last four methods were applied with breakers held by three successive operators. In addition, the first two were used with tools mounted in a rig which held them vertically and loaded them with a vertical downforce. The results indicated that the steel shot method was preferable although it gave 20% lower vibration results than those recorded for the actual breaking of concrete. It has the advantages of yielding consistent results with low scatter and being simple and cheap. Since difficulties have been experienced during the use of a pneumatic rig with breakers of antivibration design conception, the shot method should be applied with human operators.

Accuracy of measuring impedance in the hand-arm system.

In an assessment of the accuracy with which impedance can be determined in the hand-arm system, two subjects were each tested six times at 28 frequencies between 10 and 800 Hz. In addition the effect of wearing an air cushion glove was investigated, and an attempt was made to develop a simple model of the glove. The results showed agreement with other recently published data for impedance in the hand-arm system at frequencies above about 25 Hz but not below. The mean values of the impedance for a single subject had standard errors of about 10%. When the subjects wore an air cushion glove, there was only a small change in impedance, and consequently in the total amount of energy dissipated in the hand-arm system. A simple mass-spring damper model of the glove predicted that the attenuation provided by the glove was minimal, except at the highest frequencies.

Effects of different weight loads on the body during motorcycle riding.

The authors examined the physiological changes of men riding motorcycles carrying different loads. Nine healthy professional riders were the subjects. They used professional Honda MD 90B-90CC motorcycles. Each subject made test rides with the loads of 0, 10, 15, and 20 kg, taken at random, on a concrete road for 20 min at a speed of 30 km/h. The environmental temperature at the time of the test, skin temperature, vibration sense threshold at a vibration level of 125 Hz, critical flicker fusion frequency, pinching power, grasping power, pulse rates, and blood pressure were measured. The pulse rates were significantly different for the rides with the four different loads, and the changes in pulse rate after the ride with the loads of 10 and 20 kg were comparatively higher than those before the ride. The changes of systolic blood pressure after the rides with the loads of 15 and 20 kg were significantly higher than those before the rides. The other changes observed were not significantly different.

Assessment of vibration levels associated with hand-held roadbreakers.

The hand-held roadbreaker plays a vital role in enabling the British gas distribution workforce to install gas supply pipework. Hence, any potential problem which could lead to a restriction of the use of this equipment would present pipework installation departments with serious operational problems. A test program was therefore set up to enable risks to operators to be quantified. The vibration levels measured exceeded proposed limits laid down in current guidelines for vibration exposure. If these limits were realistic, a high prevalence of vibration-induced white finger (VWF) would have been expected. However, a survey of the workforce using the roadbreakers indicated a VWF prevalence of 20 times less than that predicted by the guidelines. It was concluded that a possible explanation could be that the current frequency-weighting factors used in the guidelines are inappropriate for application to this type of equipment with dominant frequencies below 25 Hz. The application of the current weighting factors to the test data produced during the program led to high weighted acceleration values and unrealistic dose-response relationships. It is proposed that the application of the various guidelines to the use of this equipment be reconsidered.

Digital high-speed sampling of combined exposure to noise and vibration.

The digital high-speed sampling technique was applied to simultaneous measurements of exposure to noise and vibration among workers who used hand-held power tools in a shipyard. The transducers were two accelerometers and two microphones which measured the transmission of vibration acceleration from the handle of the tool to the wrist and the attenuation of noise by the earmuffs. The measurements were taken by a microcomputer-controlled digital multichannel sampling unit. An analogue-digital converter was used with a 100-kHz scanner for multichannel signal acquisition in the 10 kHz bandwidth. The sound pressure was A-weighted, and the vibration acceleration was both unweighted and weighted according to the guidelines of the International Organization for Standardization. Impulsiveness was determined as the difference between the peak and root-mean-square levels. The noise exposure was 81 dB during grinding and 85 dB during hammering. The earmuffs provided protection against impulse noise at least when the impulses contained high frequencies. The transmission loss of vibration acceleration between the tool handle and wrist was 45 dB for grinding and 29 dB for hammering. The transmission of noise and vibration was affected by the frequency content and impulsiveness of the signals.