III Italian Consensus Conference on Malignant Mesothelioma of the Pleura. Epidemiology, Public Health and Occupational Medicine related issues.

The III Italian Consensus Conference on Pleural Mesothelioma (MM) convened on January 29th 2015. This report presents the conclusions of the 'Epidemiology, Public Health and Occupational Medicine' section. MM incidence in 2011 in Italy was 3.64 per 100,000 person/years in men and 1.32 in women. Incidence trends are starting to level off. Ten percent of cases are due to non-occupational exposure. Incidence among women is very high in Italy, because of both non-occupational and occupational exposure. The removal of asbestos in place is proceeding slowly, with remaining exposure. Recent literature confirms the causal role of chrysotile. Fibrous fluoro-edenite was classified as carcinogenic by IARC (Group 1) on the basis of MM data. A specific type (MWCNT-7) of Carbon Nanotubes was classified 2B. For pleural MM, after about 45 years since first exposure, the incidence trend slowed down; with more studies needed. Cumulative exposure is a proxy of the relevant exposure, but does not allow to distinguish if duration or intensity may possibly play a prominent role, neither to evaluate the temporal sequence of exposures. Studies showed that duration and intensity are independent determinants of MM. Blood related MM are less than 2.5%. The role of BAP1 germline mutations is limited to the BAP1 cancer syndrome, but negligible for sporadic cases. Correct MM diagnosis is baseline; guidelines agree on the importance of the tumor gross appearance and of the hematoxylin-eosin-based histology. Immunohistochemical markers contribute to diagnostic confirmation: the selection depends on morphology, location, and differential diagnosis. The WG suggested that 1) General Cancer Registries and ReNaM Regional Operational Centres (COR) interact and systematically compare MM cases; 2) ReNaM should report results presenting the diagnostic certainty codes and the diagnostic basis, separately; 3) General Cancer Registries and COR should interact with pathologists to assure the up-to-date methodology; 4) Necroscopy should be practiced for validation. Expert referral centres could contribute to the definition of uncertain cases. Health surveillance should aim to all asbestos effects. No diagnostic test is recommended for MM screening. Health surveillance should provide information on risks, medical perspective, and smoking cessation. The economic burden associated to MM was estimated in 250,000 Euro per case.

Tracheostomy decannulation in severe acquired brain injury patients: The role of flexible bronchoscopy.

INTRODUCTION AND OBJECTIVES: Subjects with severe acquired brain injury (sABI) require long-term mechanical ventilation and, as a consequence, the tracheostomy tube stays in place for a long time. In this observational study, we investigated to what extent the identification of late tracheostomy complications by flexible bronchoscopy (FBS) might guide clinicians in the treatment of tracheal lesions throughout the weaning process and lead to successful decannulation. SUBJECTS AND METHODS: One hundred and ninety-four subjects with sABI admitted to our rehabilitation unit were enrolled in the study. All subjects received FBS and tracheal lesions were treated either by choosing a more suitable tracheostomy tube, or by laser therapy, or by steroid therapy, or by a combination of the above treatments. RESULTS: Overall, 122 subjects (63%) were decannulated successfully. Our subjects received 495 FBSs (2.55 per subject) and as many as 270 late tracheostomy complications were identified. At least one complication was found in 160 subjects (82%). In only 11 subjects, late tracheostomy complications did not respond to the treatment and were the cause of decannulation failure. CONCLUSIONS: In conclusion, in sABI patients FBS is able to guide successful tracheostomy weaning in the presence of late tracheostomy complications that could get in the way decannulation.

Motor features of voluntary cough following partial laryngectomy for glottal carcinoma.

BACKGROUND: Aspiration and respiratory tract infections are commonly observed in patients following conservative laryngeal surgery such as supracricoid laryngectomy with cricohyoidopexy (CHP). Since laryngeal closure is important for cough effectiveness, we hypothesised that CHP reduced cough intensity by affecting the cough motor pattern. METHODS: In ten male patients with laryngeal cancer eligible for CHP, we assessed the intensity of maximum voluntary cough (MVC) prior to and 2 months after surgery. Cough intensity was indexed in terms of both the peak amplitude of the integrated electromyographic activity of abdominal muscles (IEMGp) and the ratio of IEMGp to the duration of the expiratory ramp during cough (TEC), i.e. the rate of rise of IEMG activity (IEMGp/ TEC). For each cough effort, the duration of the compressive phase (CP), the cough peak flow (CPF), the time elapsed from the onset of cough to CPF (TTP) and their ratio, i.e. the volume acceleration (VA), were also evaluated. RESULTS: CHP did not affect IEMG-related variables; in contrast, it reduced (p < 0.01) CPF, CP and lengthened (p < 0.05) TTP values. In consequence, cough VA values after CHP were consistently lower than in control condition. CONCLUSIONS: Supracricoid laryngectomy with CHP alters the intensity of voluntary cough as indexed by flow-related variables. This may reduce cough efficiency and facilitate the onset and/or persistence of chest infections (Tab. 2, Fig. 1, Ref. 22).

Application of socio-economic-health deprivation index, analysis of mortality and influenza vaccination coverage in the elderly population of Tuscany.

OBJECTIVE: The aim of this paper is to describe the results obtained from the application of a specific local deprivation index, to general and cause-specific mortality and influenza vaccination coverage among elderly people in the municipality of Florence. METHODS: General and cause-specific mortality data (2009-2013) and influenza vaccination coverage data (2015/16 and 2016/17) were collected for subjects aged ≥ 65 years residing in the municipality of Florence (Tuscany), at the 2011 Census section level. A Socio-Economic and Health Deprivation Index (SEHDI) was constructed and validated by means of socio-economic indicators and mortality ratios. RESULTS: Half of the population of Florence belonged to the medium deprivation group; about 25% fell into the two most deprived groups, and the remaining 25% were deemed to be wealthy. Elderly people mostly belonged to the high deprivation group. All-cause mortality and cause-specific mortality (cancer and respiratory diseases) reached their highest values in the high deprivation group. Influenza vaccination coverage (VC) was 54.7% in the 2015/16 and 2016/17 seasons, combined. VC showed a linear rising trend as deprivation increased and appeared to be correlated with different factors in the different deprivation groups. CONCLUSIONS: As socio-economic deprivation plays an important role in health choices, application of the SEHDI enables us to identify the characteristics of the main sub-groups of the population with low adherence to influenza vaccination. The results of the present study should be communicated to General Practitioners, in order to help them to promote influenza vaccination among their patients.

What happened in Italy? A brief summary of studies conducted in Italy to evaluate the impact of the smoking ban.

The aim of this short report is to give a brief summary of the studies conducted in Italy in order to evaluate the impact of the ban on smoking in enclosed public places that came into force on 10 January 2005. Support of Italians for the smoking ban increased once the policy was introduced, and is still increasing. Surveys conducted among the Italian population and owners of hospitality premises report that the ban is generally respected. After the ban, environmental nicotine concentrations in four pubs and three discos in Florence and concentrations of particulate matter with diameter <2.5 microm in 50 hospitality premises in Milan, Trieste and Rome dropped to 70-97% of the concentrations recorded before the ban. In 2005 total sales of cigarettes in Italy decreased by 6.1% in comparison to 2004, from 98.8 to 92.8 million kg. In 2006 sales increased by 1.1% in comparison to 2005, partly attributed to the covered outdoor smoking places available in many restaurants and bars from the winter of 2005-2006. Smoking prevalence decreased from 2004 to 2006 by 7.3%, from 26.2% to 24.3%.

[Fatal home accidents in Tuscany in 2001-2002]. / Incidenti mortali domestici in Toscana negli anni 2001-2002.

In the last years in Italy deaths due to accidents were more than 26.000/year. One of the most frequent places in which they occurred was at home, with more than 8.000 deaths/year. Due to the lack of studies related to this field, in Tuscany a specific study of fatal home accidents has been done. The cases studied, occurred in Tuscany in 2001-2002, have been extracted from the electronic database of the Regional Mortality Registry of Tuscany. Information about the modality of the accidents was collected by administering a questionnaire to the closest available relative of the victim. A total of 284 cases were studied, the majority of whom were female, over 75 years of age, with low educational level, pensioners, often with more than three pathologies. The accidents happened mostly in the bedroom or on the stairs due to accidental falls. The dynamics of fatal accidents showed great differences if compared to the nonfatal accidents. This suggests the need of different approaches for fatal injury surveillance and for the implementing of preventive strategies.

Retrospective mortality cohort study of Italian workers compensated for silicosis.

OBJECTIVES: To estimate cause specific mortality in a large cohort of Italian workers compensated for silicosis. METHODS: The cohort included 14 929 subjects (14,098 men and 831 women) compensated for silicosis between 1946 and 1979, alive on 1 January 1980, and resident in Tuscany (a region of central Italy with 3,547,000 inhabitants). Mortality follow up ranged from 1980 to 1999. Vital status and the causes of death were determined by linkage with the regional mortality registry and with the national mortality database. The cohort mortality rates were compared to the rates of the local reference population. SMRs and their 95% confidence intervals were computed assuming a Poisson distribution of the observed deaths. Specific SMR analyses were performed according to the level of disability, the year of compensation assignment, and the job type. RESULTS: A significant excess mortality was observed in male silicotics for cancer of the lung, trachea, and bronchus and cancer of the liver, respiratory diseases (silicosis, asbestosis, antracosilicosis, and other pneumoconiosis), and for tubercolosis. Statistically significant mortality excess was observed in female silicotics for respiratory diseases (specifically silicosis and other pneumoconiosis) and tuberculosis. Analyses for period of compensation assignment showed a twofold increased SMR for biliary tract cancer among female workers and for liver cancer among male workers compensated before 1970. CONCLUSIONS: The excess mortality from respiratory tract cancers and respiratory tract diseases detected in Italian compensated silicotics are in agreement with previous epidemiological studies. Although the twofold increased risk for liver cancer among males is suggestive of a possible association with silica dust exposure, the finding needs to be confirmed.

Survival of malignant pleural mesothelioma cases in the Tuscan Mesothelioma Register, 1988-2000: a population-based study.

This study analyses survival of Tuscan residents (Italy, 3.5 million population) diagnosed by histological examination with malignant pleural mesothelioma (MPM) during the period 1988-2000, and recorded in the Tuscan Malignant Mesothelioma Register. The aim was to establish the prognostic role of demographic, diagnostic and asbestos exposure variables. During 1988-2000, 381 MPM cases were recorded (318 men; 63 women). Vital status was ascertained up to 31 December 2002. No cases were lost to follow-up. Median survival of certain MPM was 324 days (11 months; 95% CI 297-366); 45.7% (95% CI 40.6-50.6%) survived more than 1 year; 24.2% (95% CI 20.0-28.5%) more than 2 years. In univariate and multivariate analyses survival was associated with histological subtype (epithelioid subtype had the longest survival). Gender, age, period of diagnosis, hospital of diagnosis and asbestos exposure did not show significant effects. Therapeutic information was available for patients of the period 1997-2000. There was no significant difference in survival between treated versus untreated patients. In conclusion, no advance in prognosis at the population level in the most recent period can be suggested on the basis of the data available to the Tuscan Malignant Mesothelioma Register.

Oncogenic risk in a chemical plant: a methological approach and preliminary results.

One of the major problems that occupational medicine has to deal with is cancer risk assessment. Recent Italian legislation requires the evaluation of occupational exposure to carcinogens in all workplaces, but a standardized method to be used in the environmental and biological criteria is generally lacking. The objective of this report is to identify a multidisciplinary approach to the research on this topic. The study is based on a chemical plant that produces pitch. The multidisciplinary approach is based on risk- and health-damage assessments. Ethical aspects are also taken into account, and the research design incorporates an informed consent for all employees. Some preliminary results are available. From the environmental point of view, all parameters provide an airborne concentration value below threshold limit values (TLVs), but biological monitoring demonstrates an increased urinary excretion of 1-OH-pyrene in all tested subjects. In conclusion, the first objective of our study is to demonstrate the carcinogenic risk of employees, searching for an agreement between environmental analysis, biological monitoring, and health effect data. A close collaboration between different professions is necessary.

[Epidemiology of primary tumors of the pleura]. / Epidemiologia dei tumori primitivi della pleura.

The authors briefly reviewed the literature concerning the risk factors for primary pleural tumors in humans. The results from the most relevant studies emphasize the fact that the large majority of mesotheliomas are associated with exposure to asbestos or asbestiform fibers. Exposure to asbestos is mainly through industrial use, and mesotheliomas result from occupational, para-occupational, or environmental exposure. Fibers of crocidolite, amosite, and chrysotile appear to be, in descending order, more carcinogenic for pleural tissues. The authors summarize the available data on consumption of asbestos and asbestos-based products in Italy. The chrysotile-asbestos mine in Balangero (Piedmont) stimulated the industrial production of asbestos-cement; asbestos has been largely sprayed among shipyards and user for insulating railroad coaches and carriages. Italy had the greatest consumption of crocidolite in Europe, which was not banned until 1986. The authors discuss the major findings derived from descriptive epidemiological data presented in previous papers dealing with this issue. In addition, standardized mortality rates of primary pleural tumors for European countries are shown. A clearly increasing trend for mortality is observed in Italy, which has also the provinces with the highest mortality rates in Europe. Among Italian provinces, the mortality rates are consistent with the number of asbestosis cases receiving workman's compensation. The authors present the results of both cohort and case-control analytical studies performed in Italy, and provide suggestions for further research.

[Uncertainty: a parameter difficult of communicating through the risk message]. / L'incertezza: un parametro difficilmente comunicabile attraverso il mesaggio di rischio.

The theme of communicating uncertainty in messages of risk is examined in terms of the dominant goal of mobilizing action. Voluntary and involuntary "noises" compromise the efficiency of the communication process and are jointly responsible for several biases, at different levels, channels and agents, in messages of risk. A further source of confusion lies in how a message of risk is lived by the single individual--whether he/she identifies him/herself as the specific object of risk, or rather interprets risk as a mild probability diffused among a vast population.

[Estimate of underreporting of infectious diseases through a sentinel network of pediatricinas in the area of local health unit of Florence]. / Stima della sottonotifica di alcune malattie infettive attraverso una rete di pediatri sentinella nella ASL di Firenze.

The aim of this study was to evaluate the underreporting of some infectious diseases in the pediatric population in the Local Health Unit of Florence in the period 15.09.1997-14.09.1998. Data from the current notification system and from an a hoc sentinel network were used. Nine family pediatricians voluntarily participated in the sentinel network, notifying all cases of measles, mumps, pertussis, rubella, scarlet fever and chickenpox diagnosed in the population of children under their professional responsibility, in the period of the study. Chickenpox was the most frequent disease (2,043 cases equal to 73.5% of total notifications). The notification rate for chickenpox obtained with the sentinel network was 41.6 per 1,000 children, meanwhile the notification rate obtained with the current notification system was 23.7 per 1,000. The notification rate for scarlet fever was 24.1 per 1,000 with the sentinel network and 6.0 per 1000 with the current notification system. The underreporting for the two diseases was respectively 43% and 75%. Voluntary participation of physicians in sentinel network guarantees data of good quality, making these networks very useful tools for the epidemiologic evaluation of infectious diseases with benign prognosis.

[Course on smoking cessation organized by the Italian League against Cancer in Florence: determinants of cessation at the end of the course and after 1 year]. / Il corso per smettere di fumare organizzato dalla Lega Italiana per la Lotta contro I Tumori di Firenze: determinanti della cessazione alla fine del corso e dopo un anno.

The Italian League against Cancer, section of Florence, organizes courses for smoking-cessation groups. Groups meet for 10 sessions throughout 6 weeks; sessions are managed by a psychologist with a cognitive-behavioral approach. In the 53 analyzed courses registered people (693 persons) are mainly women, aged 31-50, with a middle-high level of education. They are heavy smokers with a high level of nicotine dependence and they greatly trust in the course in spite of their previous quit attempts. At the end of the program 66% of registered people (69% of men; 63% of women; p > 0.05) asserts not to smoke anymore. One year later, phone interviews show that 33% of participants (41% of men; 28% of women; p < 0.01) are ex-smokers. After the end of the program the first three months are the higher risk period of relapsing. At the end of the program quitting-smoking predictors are: attendance at at least 7 sessions (OR = 4.26), no more than a high school educational level (OR = 1.71) and smoking less than 30 cig. a day before the course (OR = 1.56). One year later quitting-smoking predictors are: attendance at at least 7 sessions (OR = 2.08), scarce or medium nicotine dependence according to the Fagerström Tolerance Questionnaire (OR = 1.42) and male gender (OR = 1.40).

[The diffusion of information on the carcinogenicity of asbestos in the Italian scientific community before 1965]. / La diffusione delle informazioni sulla cancerogenicità dell'amianto nella comunità scientifica italiana prima del 1965.

The spreading of information on asbestos carcinogenicity within the Italian scientific community before 1965. The paper deals with the development of recognition of asbestos carcinogenicity within the Italian scientific community. This development was difficult in Italy as in other countries. Articles and other papers in handbooks and congress proceedings, by Italian authors, published in the period 1934-1965, were considered. The first cases of lung cancer in Italian workers exposed to asbestos were observed in 1955-56, the first cases of malignant mesothelioma in 1965. The cases observed were very few, but knowledge on asbestos carcinogenicity became widespread within the Italian scientific community during the fifties (from 1953 on wards) with the publication of several handbooks of occupational medicine.

The experience of the Mesothelioma Registry of Tuscany in assessing health hazard associated with asbestos exposure.

All cases of pleural malignant mesothelioma occurring in Tuscany were collected, backdated to 1980 (to 1970 for the provinces of Florence and Prato; to 1975 for the provinces of Pisa and Siena), in order to evaluate the incidence of occupational exposure to asbestos. The aim was to enhance primary prevention in those workplaces still at risk nowadays. To achieve information on the possible occupational, domestic or environmental exposure, an interview was conducted using a semi-structured questionnaire. An exposure classification was produced to focus preventive intervention. This surveillance system needs to be developed to contribute to epidemiological research, especially on the effects of low level exposures, and to primary prevention.

[Fatal occupational accidents: estimates based on more data sources]. / Infortuni lavorativi mortali: stime basate su più fonti informative.

The data reported by INAIL (Istituto Nazionale Assicurazione Infortuni sul Lavoro) on fatal occupational injuries have always been considered complete and reliable. The authors of this article verified the completeness of this information source crossing it with data bases existing in different registration systems (Regional Mortality Registry of Tuscany--RMR; registers and data of the Operative Units of Prevention, Hygiene and Safety in the Workplace--UOPISLL) for the period between 1992 and 1996. In the five years concerned, a total of 458 cases were reported. These cases could be considered fatal injuries at work without taking into account traffic accidents, which were not included in the present study. The results show that the most complete information source was RMR, reporting 80% of the total data, while INAIL reports only 62.2% of the total cases. On the contrary, the UOPISLL source is the least reliable. Using the capture/recapture method, the estimate of events in the period concerned (1992-1996) amounts to nearly 500 (499.8 LC 475.9-523.7), while the three sources systematically explored for the whole period (INAIL, RMR, UOSPILL) report 458 cases. An additional information source, the daily press, which could be systematically tested only two months for each of the five years, reports 10 additional cases, which were ignored by the 3 other sources, indirectly confirming in this way how reliable the performed estimate was. The main cases among the 157 fatal accidents reported by RMR, but not by INAIL, occurred among farmers (70), most of them already retired, but there were several fatal accidents reported in the construction sector (30). Other categories were included only in the RMR data because, in the period concerned, they were not covered by INAIL insurance (18 cases in the Army and Police, 7 on the railways). The survey that was carried out confirms the essential importance of INAIL data for the surveillance system applied to this phenomenon. This also confirms the need--which has been already stressed in the scientific literature--to combine INAIL's registration system at least with the mortality registries. In this way the knowledge and comprehension of the phenomenon could be integrated and completed especially for marginal work areas, where obligatory insurance may be evaded; and for groups of workers not covered by insurance. The relevance of an integrated system of registration of occupational fatal accidents is discussed.

Characterization of asbestos fibers in pleural tissue from 21 cases of mesothelioma.

Pleural biopsies from 21 patients with pleural mesothelioma and different asbestos exposure were analyzed by means of analytical electron microscopy with the aim of investigating the presence, quantity, types and sizes of asbestos fibers in pleural tissue. The majority of fibers found consisted of ultrathin (< 0.3 micron) and short (< 5 microns) fibers regardless of asbestos types and subject exposure. Concentrations appeared to be poorly related to the estimated exposure level. Fiber dimensions appeared to be the most important characteristic which determined their translocation in the pleural region.

[Tuscany mesothelioma registry (1988-2000): evaluation of asbestos exposure]. / La valutazione dell'esposizione ad amianto in Toscana attraverso i dati dell'Archivio Regionale Toscano dei Mesoteliomi Maligni (1988-2000).

BACKGROUND: The Tuscany Mesothelioma Register (ARTMM) records pleural malignant mesothelioma cases of Tuscany residents, diagnosed by histological, cytological, or clinical (radiography or computerized tomography) examinations. The ARTMM began in 1988 and estimates mesothelioma incidence in Tuscany and collects information on past asbestos exposure of mesothelioma cases. OBJECTIVES: The aim of this paper was to describe the incidence of pleural mesothelioma cases in Tuscany and to analyse their possible past asbestos exposures. METHODS: We considered pleural mesothelioma cases recorded in ARTMM in the period 1988-2000 and interviews collected for these cases. In order to identify past asbestos exposure in the occupational and non-occupational history of patients, interviews were carried out using a standardised questionnaire. RESULTS: In the period 1988-2000, 494 pleural malignant mesothelioma cases were recorded in the ARTMM; 82% were males. In the periods 1988-1993, 1994-1997, 1998-2000 the incidence rates, standardised on the Italian population (per 100,000), were respectively 1.15, 1.57, 2.58 among males; 0.29; 0.27; 0.29 among females. Information on occupational history was collected for 418 mesothelioma patients (85% of recorded cases): 173 mesothelioma cases were directly interviewed; for 245 cases relatives or work colleagues were interviewed. Occupational asbestos exposure was ranked as certain, probable or possible in 72% of the interviewed cases (80% of males; 20% of females). Environmental and non-occupational asbestos exposure was identified in 1% of males, and 3% of females. In 24% of the interviewed cases (15% of males; 74% of females) no known asbestos exposure was identified. Occupational asbestos exposure occurred in maritime activities (shipyards, dock work, merchant and regular Navy), the building industry, railway carriage construction and maintenance, rail transport, textile industries (mainly rag sorting), electricity production, asbestos cement manufacture, chemical, iron and steel industries and in glass manufacturing. In Tuscany two areas are distinguished for their well-documented and massive use of asbestos: the coastal areas (Livorno and Massa Carrara) for maritime activities, and the areas of Pistoia and Arezzo for railway carriage construction and repair. Mesothelioma incidence rates in these areas are the highest in the whole region. CONCLUSIONS: Further investigation is needed in order to identify unknown asbestos uses and consequent exposure, in particular for females. Uncertainty as regards occurrence of asbestos exposure persists in the textile industries where the mesothelioma epidemics have not yet declined. Research hypotheses are addressed on the re-use of jute bags previously containing asbestos, therefore collection of further information on periods and methods of this recycling activity is essential.

Mortality in the coke oven plant of Carrara, Italy.

A mortality study was undertaken on a cohort of 538 male workers employed at a coke plant in Carrara in the period 1960-1985. The follow-up period ranged from January 1 1960 to December 31 1990, with 10,665 person-years accumulated. A significant excess in mortality for lung cancer was observed: 19 observed deaths vs 10.02 expected deaths using national rates, SMR 190 (C.I. 95% = 114-296), and vs 11.19 expected deaths using regional rates, SMR 170 (C.I. 95% = 102-265). The results suggest the possible influence of this occupation on mortality from lung cancer, as was observed in previous studies performed on larger cohorts of coke oven workers.