[Medical visits before return to work, after a long lasting absence, above 60 days, for injuries or common diseases in a public transport company. Analysis and discussions of utility and consequences in term of evaluation of fitness to specific job]. / La visita al rientro da una malattia/infortunio di durata superiore a 60 giorni: analisi critica di una casistica relativa ad una grande azienda di trasporti.

The aim of this study is to evaluate the opportunity to do medical visits before return to work, after a long continuous absence, above 60 days, for injuries (occupational and non-occupational) or common diseases. We have examined medical records of 403 workers, in 2010 and 2011, occupied in a public transport company, in order to control the following variables: job, age, clinical conditions related to the absences, classification of the absence as injuries or common disease and conclusions about medical fitness to specific job. Our findings have shown an equal percentage of causes of absences in term of injuries or common diseases. The main cause of absence and of non fit to specific job, after medical evaluation, is depending on orthopaedic post-traumatic diseases. This evidence support the importance to do medical visits after long-lasting absence from work, particularly in case of jobs (bus, tram, subway drivers) at risk for other people.

Interferons and their receptors in human papillomavirus lesions of the uterine cervix.

PURPOSE OF INVESTIGATION: In this study we analyzed the immunohistochemical expression of specific types of interferon (IFN) in human papillomavirus (HPV) associated cervical lesions. METHODS: Reactivity to anti-IFN-alpha,-beta and -gamma and to anti-IFN-alpha/beta- and gamma-receptors was tested in 33 cervical punch biopsies from 24 HPV-infected women and nine healthy controls. The HPV-infected cases were subdivided into low-risk and high-risk groups, according to the known "oncogenic" potential of the HPV-types detected by PCR. RESULTS: Cervical epithelium and stroma in HPV-negative as well as low-risk HPV-positive samples were diffusely stained by anti IFN-alpha, beta and gamma antibodies. In contrast, a significantly lower percentage of high-risk HPV-infected tissues was immunoreactive to IFN-beta in the stroma and IFN-gamma in the epithelium. There were no relevant differences between control and HPV cases in the expression of IFN-receptors. CONCLUSION: We show that a decreased production of some specific classes of IFN is associated with high-risk-type HPV lesions suggesting an important role of IFN distribution patterns in the pathogenesis of HPV lesions.

[The occupational risks and pathologies due to the manual lifting of patients in Italian legislation]. / I rischi e le patologie professionali da movimentazione manuale dei pazienti nella legislazione Italiana.

Current Italian legislation establishes all necessary details of intervention procedures aimed at elimination or substantial reduction of risk due to manual lifting of patients. Chapter V of Law No 626/94, which was a thoroughly innovative step in the field of safety, hygiene and prevention at the workplace, in 3 articles and one annex incorporated Community Directive 269/90 into Italian legislation. The model to approach manual load handling, whose definition can in all respects be transferred to health facilities where load means patients who are not self-sufficient in movement, sets out a precise strategy of actions. The first action is automation of the "production process", which is inapplicable in the health care sector; the second action is to provide "aids", which is perfectly applicable to the health care sector. A further action foreseen by the regulations that should be taken into consideration in addressing the problem of manual patient handling from the point of view of prevention is found in the Law (Presidential Decree) of 14/1/97 concerning criteria of accreditation of health facilities, which also refers to the regulations contained in Law 626/94. As regards the insurance coverage of acute or chronic impairment due to manual handling of loads/patients, these aspects are still not contemplated in any regulations. This contradiction became even more evident with the introduction of Law No 626/94 where in Chapter V reference is made to "dorsal-lumbar lesions". Although these lesions are recognized legally in the acute form (accidents), there are also degenerative diseases with chronic development, and the latter are not given any protection apart from the theoretical recognition contained in the Constitutional Court Sentence 179/88. It is to be hoped that the review process of the list of compensable occupational diseases will address this problem, too, so that it can be solved as soon as possible.

[The assessment of the risk due to the manual lifting of patients: the initial descriptive and analytical results on exposure levels]. / Valutazione del rischio da movimentazione manuale di pazienti: primi risultati descrittivi e analitici sui livelli di esposizione.

The paper reports the results of risk evaluation of patient lifting or moving obtained from a multicentre study on 216 wards, for both acute hospital patients and in geriatric residences. In all situations the exposure to patient lifting was assessed using a concise index (MAPO). Analysis of the results showed that only 9% of the workers could be considered as exposed to negligible risk (MAPO Index = 0-1.5); of these 95.7% worked in hospital wards and only 4.3% in geriatric wards. A further confirmation of the higher level of exposure of workers in long-term hospitalization was that 42.3% were exposed to elevated levels (MAPO Index > 5) compared with 27.7% observed in hospital ward workers. The mean values of the exposure index were 6.8 for hospital wards and 9.64 for geriatric residences and, although much higher in the latter, both categories showed high exposure. In the orthopaedic departments of the hospitals the values were higher than in the geriatric wards (MAPO Index = 10.1); medical and surgical departments showed values similar to the mean values observed in the geriatric wards. These high values were due to: severe shortage of equipment life lifting devices (95.5%) and minor aids (99.5%), partial inadequacy of the working environment (69.2%), poor training and information (96.1% lacking); only the supply of wheelchairs was adequate (65.8%). All of which points to an almost generalized non-observance of the regulations listed under Chapter V of Law No. 626/94. However, the proposed method of evaluation allows anyone who has to carry out prevention and improvement measures to identify priority criteria specifically aimed at the individual factors taken into consideration. By simulating an intervention for improvement aimed at equipment and training, 96% of the wards would be included in the negligible exposure class (MAPO Index 0-1.5).

[Clinical studies in health workers employed in the manual lifting of patients: methods for the examination of spinal lesions]. / Studi clinici negli operatori sanitari addetti alla movimentazione manuale di pazienti: metodi per la rilevazione delle affezioni del rachide.

To enable different research groups to make a standardized collection of clinical data on alterations of the lumbar region of the spine, protocols were used for the collection and classification of data that were proposed and thoroughly validated by the authors. The protocols include a clinical/functional examination of the spine, checking for positive anamnestic threshold, for pain on pressure/palpation of the spiny apophyses and paravertebral muscles, for painful movements, in order to classify 1st, 2nd and 3rd grade functional spondylarthropathy (for different regions of the spine). An ad hoc questionnaire was also prepared for the quantitative and qualitative study of true acute low back pain and the ingravescent low back pain controlled at the onset pharmacologically. The results of this questionnaire make it possible to calculate the incidence of acute low back pain (true and pharmacologically controlled).

[Initial epidemiological data on the clinical effects in health workers employed in the manual lifting of patients in wards]. / Primi dati epidemiologici sugli effetti clinici negli operatori sanitari addetti alla movimentazione manuale di pazienti nei reparti di degenza.

An investigation was carried out by teams from various centres coordinated by the EPM (Ergonomics of Posture and Movement) Research Unit on 54 different hospitals in various regions of northern and central Italy. The teams examined a total of 3341 health workers whose job involved manual handling of patients (553 male and 2788 females, 1568 working in hospitals and 1773 in geriatric residences). Numerous meetings were held to ensure that the methods of assessing the exposure indexes and spinal impairment were identical in the various teams. The final data were processed centrally at the EPM Research Unit. The sample analyzed may be considered as representative of the situation in hospitals in Italy, at least for northern and central Italy. The mean age was 36 years, mean length of service in the department 6 years and mean length of job duration not exceeding 10 years; staff turnover was high. Physical examination revealed that 8.4% of the workers had had at least one episode of acute low back pain in the previous 12 months: i.e., 4 times the values of the reference groups. Also in the case of clinical-functional spondyloarthropathies of the lumbosacral spine, in the females there was a significantly higher prevalence than in the reference groups. All disorders were more severe in sectors more at risk, i.e., old peoples homes, rehabilitation centres, orthopaedic and surgical departments, and in any case higher in old peoples homes and geriatric residences. The initial data concerning the ratio between presence of spinal disease and risk index were also positive.

[The manual lifting of patients: the results of an assessment of exposure to the specific risk and of a clinical study in a rehabilitative institute]. / Movimentazione manuale pazienti: risultati della valutazione dell'espozione al rischio specifico e dell'indagine clinica in un istituto riabilitativo.

An investigation was carried out in a rehabilitation centre in the Province of Milan in order to quantify exposure to patient handling and assess impairment of the spine induced by this risk factor. Altogether 5 departments were analyzed, with different rehabilitation aims (cardiological, respiratory and neurological); 97 of the 104 exposed staff underwent physical examination by an occupational health physician. Both exposure assessment and identification of impairment were performed using the methods proposed by the EPM Research Group. The exposure indices (MAPO Index) were high in 4 departments (5.6, 6.75, 8.81 and 13.8) and only one department had an index of 2.95 which is considered low-medium. The prevalences of impairment of the lumbar region of the spine were also higher in this group of workers compared to those found in other hospitals. In particular, the disorders of the lumbar spine reported were 45.4% in the males and 62.6% in the females. Of these 13% showed a third grade SAP. About 11% of the workers who underwent physical examination reported episodes of acute low back pain in the previous 12 months with a frequency 4 times higher than that found in group of unexposed workers. Analysis of the rehabilitation centre drew attention to the need for improvement measures that took into account the particular nature of the care services involved as in some cases it is not always possible to use equipment and aids to assist certain manual handling. In these cases the solutions involve the organization aspects especially. The results of this study were used by the rehabilitation centre management in order to plan the interventions for improvement. On the whole it was shown that analysis of this risk factor and health surveillance of exposed workers in such particular structures as rehabilitation centres is of considerable importance.

[The assessment of exposure to and the activity of the manual lifting of patients in wards: methods, procedures, the exposure index (MAPO) and classification criteria. Movimientazione e Assistenza Pazienti Ospedalizzati (Lifting and Assistance to Hospitalized Patients)]. / Valutazione dell'esposizione ad attività di movimentazione manuale dei pazienti nei reparti di degenza: metodi, procedure, indice di esposizione (MAPO) e criteri di classificazione.

Since a method for quantifying exposure to patient handling in hospital wards is lacking, the authors describe and propose a model for identifying the main risk factors in this type of occupational exposure: presence of disabled patients, staff engaged on manual handling of patients, structure of the working environment, equipment and aids for moving patients, training of workers according to the specific risk. For each factor a procedure for identification and assessment is proposed that is easily applicable in practice. The authors also propose a formula for the calculation of a condensed exposure index (MAPO Index), which brings together the various factors. The exposure index, which requires further, detailed study and validation, makes it possible, in practice, to plan the preventive and health measures according to a specific order of priority, thus complying with the requirements of Chapter V of Law 626/94. From a practical point of view, in the present state of knowledge, it can be stated that for MAPO Index values between 0 and 1.5, risk is deemed negligible, average for values between 1.51 and 5, and high for values exceeding 5.

[The application of a synthetic index of exposure in the manual lifting of patients: the initial validation experiences]. / L'applicazione dell'indice sintetico di esposizione nella movimentazione manuale pazienti: prime esperienze di validazione.

Via a multicentre study coordinated by the EPM research group carried out in 216 wards in a total of 56 hospitals, old peoples homes and geriatric departments, it was possible to quantify exposure to patient handling (classified in 4 classes: 0-1.5 negligible, 1.51-5 slight to average, 5.01-10 average to high, > 10 elevated), and at the same time identify the damage to the lumbosacral spine thus caused. Both assessment of exposure and identification of health impairment were carried out using homogeneous methods. Subjects with work seniority in the job of less than 6 months and subjects who had been transferred because of back trouble were excluded from the study. It was therefore possible to carry out two types of study to assess the association between exposure and impairment. In study A, covering 3021 subjects, an analysis was performed of the association between exposure index, positive response to the anamnestic threshold for lumbosacral disorders and acute low back pain using the method of logistic analysis to obtain the prevalence odds ratios. In study B, covering 418 subjects, the analysis of association was performed on the incidence rates of episodes of acute low back pain and pharmacologically controlled acute low back pain, assuming that exposure in the wards had remained constant. The technique used was Poisson regression, thereby calculating the relative incidence rate ratios. Both for PORs and IRRs the reference group consisted of the exposure class judged as negligible (exposure index 0-1.5). The results showed that the PORs calculated for positive lumbar threshold were significant for increasing exposure classes with a positive trend for the second and third exposure class but not for the last, presumably due to a healthy worker selection effect. Neither in Study A nor in Study B were any associations observed between exposure and acute low back pain occurring in the previous 12 months: this may be due to the fact that the impairment indicator does not appear to be appropriate in terms of latency period. A different result was obtained in Study B which showed a good association between exposure and incidence rates of episodes of acute low back pain and pharmacologically controlled acute low back pain according to department. The IRRs showed a positive trend both for acute episodes (IRR: 1.932, 2.439, 2.847) and for acute plus pharmacologically controlled acute episodes (1.798, 1.830, 4.523). On the basis of these results, even with the caution required for the reasons explained in the text, it seems to be possible to identify three grades of exposure which correspond to increasing probability of impairment of the lumbosacral region of the spine: the first where risk seems negligible corresponds to an exposure level between 0 and 1.5. The second, where the episodes of low back pain may occur with an incidence 3.8 times greater, corresponds to an exposure level between 1.51 and 5, and the third corresponds to exposure levels exceeding 5, where the episodes of low back pain may occur with an incidence up to 5.6 times greater than expected.

[Worker turnover because of spinal pathologies in the wards and outpatient clinics of the hospitals of Leno and Manerbo, Brescia]. / Il turn-over, per patologie del rachide, dei lavoratori nei reparti di degenza e negli ambulatori degli ospedali di Leno e Manerbio (BS).

A total of 306 employees of the hospitals of the Leno/Manerbio health area underwent clinical and anamnestic examination in order to ascertain the existence of degenerative diseases of the spine associated with "manual handling of loads" risk. The prevalences obtained for positive anamnestic threshold concerning the lumbosacral spine, the trend of total acute low back pain and of low back pain in the last year showed lower values compared to the entire national group and in any case lower or only slightly above the values for the reference group of non-exposed subjects. Therefore, in order to assess the real prevalences of disorders due to incorrect load handling in hospital environments, it is important to assess the presence of associated disorders of the spine also and especially in outpatients departments. In fact, unsuitable or unfit staff had recently been transferred from the wards to outpatients departments. 56 workers from outpatients departments underwent physical-anamnestic examination: 16 workers (4.5% of the entire group under study) from average-to-high risk wards were identified as suffering from degenerative disorders of the lumbosacral spine. Therefore the prevalence of unfit subjects from hospital wards, cancelling the effect of the turnover factor on outpatients departments, led to an almost twofold total frequency, which rose from 6.9% to 11.4%.

[Acute lumbago due to the manual lifting of patients in wards: prevalence and incidence data]. / La lombalgia acuta da movimentazione manuale di pazienti nei reparti di degenza: dati di prevalenza e incidenza.

The aim of the study was to measure the occurrence (prevalence and incidence) of episodes of acute low back pain (definite effect) in a wide sample of health workers assisting disabled patients. A questionnaire was used for the study both of true acute low back pain and of episodes of ingravescent low back pain controlled pharmacologically at the onset. The questionnaire identified overall acute and pharmacologically controlled episodes occurring in the previous 12 months, both in the course of work and over the whole life of the subject. Appropriately trained operators administered the questionnaire to 551 subjects; 481 valid answer cards were obtained from 372 females and 109 males working in medical, orthopaedic and geriatric departments. 75.4% of the sample had high exposure index levels for patient lifting. The prevalence of true acute low back pain was 9% in males and 11% in females referred to the previous 12 months. Taking acute true and pharmacologically controlled low back pain together the prevalences rose to 13.8% for males and 26.9% in females. Data from the reference populations showed that acute low back pain did not exceed 3% on average in the previous year. Since work seniority in the hospital wards was known, the incidences were calculated, giving 7.9% in females and 5.29% in males for acute low back pain, and 19% in females and 3.49% in males for pharmacologically controlled low back pain. Considering the number of episodes in 100 workers/year, acute low back pain alone reached prevalences of 13-14%. This therefore appears to confirm the positive ratio between episodes of low back pain and duties involving assistance to disabled patients.

[Assessment criteria in the choice of aids for the lifting of patients]. / Criteri di valutazione nella scelta degli ausili per la movimentazione dei pazienti.

A fundamental part of the prevention strategies aimed at reducing risk due to manual handling of patients is the use of appropriate aids. This paper defines the basic types of aids for hospital wards: patient lifting devices, aids for hygiene and minor aids; and also proposes a procedure for choice of the type of aid: the procedure uses a specific protocol and also analyzes work organization and the environmental features of the ward. The proposed criteria for choice concern in the first place the fundamental requirements of the equipment: safety for operator and patient, simplicity of use and comfort for the patient. Secondly the basic determinants for choice of the type of aid are the type of disabled patient usually present in the ward and the analysis of the movements made in handling patients. On this basis, for each type of aid, the specific features are defined which direct the choice of supply for the various wards that will be adequate and effective both in reducing risk due to manual handling of patients and in improving the comfort of the patients.

Clinical trials among worker populations: the value and significance of anamnestic findings and clinical and instrumental tests for diagnosing work-related musculoskeletal disorders of the upper limbs (WMSDs).

The authors discuss the value and significance of symptoms in WMSDs, in view of the fact that the anamnestic threshold proposed in epidemiological investigations cannot be used as clinical and diagnosing criteria. Some useful clinical procedures are suggested for cases where there is a suspicion of musculoskeletal disorders of the cervical spine and upper limbs, bearing in mind that they are to be applied within the framework of health surveillance programmes undertaken by health care practitioners who are not specialists in orthopaedics, physiatrics or neurology. The recommendations for instrumental tests and specialist referrals are also discussed for the various disorders. The authors also provide flow charts for the diagnostic procedures pertaining to WMSDs. The appendix shows a sample patient chart illustrating the proposed procedures; it also permits the findings to be encoded so that they can be stored in a dedicated database. The codes for diagnosing WMSDs are also reported for the same epidemiological purposes.

Criteria for the health surveillance of workers exposed to repetitive movements.

In the light of the experience and guidelines developed by other countries and of Italian legislative and operational conditions, the authors outline a strategy for a health surveillance programme for work-related musculoskeletal disorders of the upper limbs. In particular, the paper defines the various aims of the health surveillance programme and identifies significant relevant criteria for its implementation (i.e. existence of risks or effects). A screening schedule is presented based on subsequent investigations (first and second level surveillance); the authors discuss the principal methods used for processing the results of the health surveillance programme, in collective (i.e. statistical comparisons, planning of periodical investigations) and individual terms (job fitness judgements, reporting of suspected occupational diseases).

[Clinical studies in working populations: value and significance of anamnestic findings, clinical tests and instrumental tests for the diagnosis of musculoskeletal disorders of the upper extremities]. / Studi clinici in popolazioni lavorative: valore e significato dei rilievi anamnestici, dei test clinici e degli esami strumentali per la diagnosi delle affezioni muscolo-scheletriche degli arti superiori (WMSDs).

The authors discuss the value and significance of symptoms in WMSDs, considering that the anamnestic threshold proposed in epidemiological investigations cannot be used as clinical and diagnosing criteria. Some useful clinical procedures are suggested for cases where there is a suspicion of musculo-skeletal disorders of the cervical spine and upper limbs, bearing in mind that they are to be applied within the framework of health surveillance programmes undertaken by health care practitioners who are not specialists in orthopaedics, physiatrics or neurology. The recommendations for instrumental tests and specialist referrals are also discussed for the various disorders. The authors also provide flow charts for the diagnostic procedures pertaining to WMSDs. The Appendix shows a sample patient chart illustrating the proposed procedures; it also permits the findings to be encoded so that they can be stored in a dedicated database. The codes for diagnosing WMSDs are also reported for the same epidemiological purposes.

[Criteria for the reintegration to their jobs of workers with musculoskeletal pathologies of the upper limbs based on preliminary practical experiences]. / Criteri per il reinserimento lavorativo di soggetti portatori di patologie muscolo-scheletriche degli arti superiori sulla base di prime esperienze applicative.

The report presents a preliminary study on the return to the workforce of employees with WMSDs of the upper limbs, and their reallocation to jobs with "low exposure". The study, which is still underway, involves a large engineering firm and includes some 100 workers affected by WMSDs. The trial envisages: providing a definition of the criteria for characterising "accommodating" jobs (i.e. frequency of action < or = 20 actions per minute; virtual absence of other risk factors such as force, posture, inadequate pauses, etc.); concretely identifying jobs meeting such criteria (or jobs which, with minimal modifications, could be made suitable); classifying WMSDs workers, according to the type and severity of the disorder; matching WMSDs workers with the jobs best suited to them; specific training for the workers and their supervisors; carrying out a follow-up of the return of WMSDs workers to the workforce in organisational terms (i.e. need for further modifications to equipment or procedures) and clinical terms (i.e. symptom patterns, acceptability of the condition). The preliminary results, 6-12 months after the start of the trial, are extremely encouraging, and show that when workers return to the workforce in jobs that fully meet defined criteria, a significant prevalence of "improvements" are reported among the involved workers. The investigation will need to be extended, but already it shows quite convincingly that it is possible for workers with what can be described as a "reduced working capacity" to remain "productive" (albeit in jobs featuring a lower exposure potential than the acceptable threshold for "healthy" workers).

First trimester human trophoblast expresses both interferon-gamma and interferon-gamma-receptor.

Interferon-gamma (IFN-gamma) is a lymphokine, produced by activated T lymphocytes, which plays a key regulatory role in the host immunological responses. In addition, IFN-gamma is expressed by human and porcine trophoblast. As IFN-gamma exerts its biological functions through specific cell surface receptors and a great number of IFN-gamma receptors (IFN-gamma R) have been purified from human placenta, we have examined the relative distribution of IFN-gamma and IFN-gamma R in human placental tissues at different stages of pregnancy. By using immunohistochemical analysis and monoclonal antibodies, it was found that IFN-gamma expression is intense in the first trimester but almost imperceptible at term, whereas the expression of IFN-gamma R is present at both stages of pregnancy. For both lymphokine and receptor, the most intense expression was observed in villous syncytiotrophoblast and in extravillous interstitial trophoblast. From these results it appears that the expression of IFN-gamma R in trophoblast is related to the presence of the lymphokine in the early phase of gestation but not later. On this basis, it can be argued that IFN-gamma exerts its functional role via an autocrine and/or a paracrine loop mainly during the first trimester.

[Health surveillance of workers]. / La sorveglianza sanitaria dei lavoratori.

The main purposes of the health surveillance of workers exposed to anaesthetic gases are: a) the finding of disorders either reliable to the exposure or incompatible with the activity in the operating theatre; b) the epidemiological evaluation of the late effects. Simple and rigorous methods to estimate the previous and the current risk are suggested. The main data to be collected during the medical examination are indicated. The registration of the data of the reproductive function by a protocol of recording is proposed. For the health surveillance of workers in Health Care Institution it's advisable to establish an interdisciplinary group, referring to a specialist on occupational medicine.

Multianalytic study on cervical HPV lesions.

Nowadays new sophisticated techniques of molecular biology based on the principles of hybridization between nucleic acids, allow a correct diagnosis of genital HPV infection. In the present paper, beside traditional diagnostic methods, we used In Situ Hybridization (ISH) and Polymerase Chain Reaction (PCR) to detect the presence of HPV types 6, 11, 16, 18, 31 and 33. We tested ten patients affected by cervical lesions of high histological atypias associated with HPV, who underwent surgical conization. Types 6 and 11, at low risk of evolution, are less frequent than 31 and 33, at medium grade of evolution, and than 16 and 18 which are at high risk of evolution.