[Medical and risk records]

Aim of this report is to outline the importance of personal medical records collected from the occupational health surveillance practice. The Italian law D.Lgs. 81/08 puts a great emphasis on a national information system built up by health monitoring results in workplace as far as individual and general prevention is concerned. Private and public roles and duties are discussed.

[The occupational and active research, diagnosis and reporting of occupational diseases]

The Occupational Doctor plays a key role on the protection of workers safety and prevention of occupational and work-related disease. His training and his need of updating, due to the constant transformation of work, the evolution of technology and the medical progress, set him in the center of all activities carried out to protect health in workplaces. The Occupational Doctor should devote special attention to the working anamnesis as well as to the pathological anamnesis both close and remote. He should also pay attention to semeiotics. Another important element is the relationship between the Occupational Doctor and the Doctor of General Medicine (MMG); this synergy is of vital importance in protecting health and in investigating diseases whether occupational or not. D.Lgs. 81/08 emphasizes this synergy, in fact name and phone number of Doctor of General Medicine is compulsory in Case History. Major source of information for all form of prevention is the survey of occupational disease which is a tool for epidemiological control. The use of a systematic collection of data, of protocols, of guidelines and of scientific evidence is the basis for identifying occupational diseases, their diagnosis and subsequent denunciations. This is the line suggested in MAL PROF informative system, made for registration of work-related diseases, and which is important, with other instruments, in realizing an integrated informative system for prevention in workplace. The Covenant for the Protection of Health and Prevention in Workplaces (DPCM 17/12/2007) indicates the strategic objectives of the National Health System for the consolidation and development of the existing system and of the programs promoting health and safety. These include the growth of the culture of prevention and of the epidemiological control of occupational diseases. The Occupational Doctor has an important role because he can identify the early onset of diseases during the working age and start all forms of prevention and health promotion. In the case of diagnosis of a suspected professional disease the Occupational Doctor has three distinct obligations. The first is to report to the legal authority (C.P.P. art. 365). The second requirement is the declaration of the occupational disease (D.P.R. 1124/65 art. 139) and the third is to issue the first certificate of occupational disease for compensation insurance (D.P.R. 1124/65 artt. 53, 251).

[Chemical resistance of latex gloves]

Dermal chemical risk is represented by the chemicals with irritant, caustic and sensitization properties or that can produce toxic effects after penetration through the skin. During the last few years the interest for the effective protecting ability of gloves progressively is increased in parallel with their use. Penetration of chemicals through the protecting material does not always turn out visible. That has led to the development of test standardizes. In 1989 the EC adopted two Directives in the field of the characteristics of protection devices defining certification procedures (89/686/EEC) and characteristics demanded for the use of protection devices at the workplace (89/656/EEC). When the European Standards are accepted from the CEN they exist in rough draft shape (prEN), losing the prefixed one pr- when they are approved by all the EC member Countries. A number of EN for protection gloves have been proposed by CEN/TC 162 regarding methods for testing the resistance to penetration/permeation of chemicals and other characteristics. However in these protocols some limitations were found, since not necessarily they represent the real using conditions. In general an ideal protecting material against the chemicals does not exist because what is effective to a specific compound does not effectively protect from an other. Latex is not commonly considered a very chemical resistant material and therefore its use in such sense is limited However the low cost and the spread of latex gloves in particular in Public Health often make them easy available at workplace and therefore used in several situations.

Advanced glycation end products and sorbitol in blood from differently compensated diabetic dogs

Canine diabetes mellitus (DM) is a common metabolic disorder with long term complications, most of which are caused by glycosylation of structural proteins, decreases in antioxidant concentrations, altered osmotic balance and hypoxia due to impaired oxygen transport. Previous studies have demonstrated that under hyperglycemic conditions canine erythrocytes undergo swelling, probably due to activation of the polyol pathway. The present work aimed to assess the plasma concentration of advanced glycation end (AGE) products, stable Amadori-products generated by non-enzymatic glycosylation of proteins and the intracellular concentration of sorbitol, produced by the activation of polyol pathway in 34 blood samples from diabetic dogs and in 14 controls. AGE products were significantly higher (p<0.01) in plasma from diabetic dogs compared with control animals. The sorbitol concentration in erythrocytes was also significantly higher in diabetic dogs and, in particular, in poorly compensated animals and in dogs with ketonuria. In five cases that were analysed before and after clinical improvement, sorbitol concentration was found to correlate with improvement. These results suggest that non-specific glycosylation is increased and that the polyol pathway is activated in diabetic dogs in a manner that is proportionate to the severity of disease. Moreover, the concentration of AGE products and sorbitol may be useful for monitoring the onset of diabetic complications and assessing the most appropriate therapeutic approaches for management of canine DM.

[Work related mesothelioma: analysis of cases discovered at the Section for Occupational Medicine and Toxicology of Siena University during the years 2000-2007]

This study focuses on the spread of mesothelioma in Siena. The population consisted of 30 patients. The diagnosis was made through histopathological and immunoistochemical or cytological and immunoistochemical analysis. The association between malignant masothelioma and exposure to asbestos was deduced by the occupational history. The mesothelioma was noted both in traditional industries and other jobs such as the chain of manifacture, plumbers, electricians, carpenters, installers of asbestos insulation and construction workers. Thus it is possible to find other malignant and nonmalignant asbestos-related diseases more frequently than mesothelioma. There is an evident risk in rebuilding, so the development of new cases due to these exposures is expected.

[Estimate of the previous exposure to asbestos through mineralogical examination of the bronchoalveolar lavage (BAL) fluid in a population working in a sugar industry]

In this study the past professional exposure and the health state of sugar refinery workers in Arezzo (Italy) are reviewed. The medical examinations, confirmed by chest CT, showed asbestos pleural thickening and one asbestosis case. Mineralogical analysis of bronchoalveolar lavage fluid (BALF) was carried out in this population to measure the pulmonary burden. Total fiber's concentration was not different in either subjects with or without asbestos-related disease. Notably, comparison between total fiber's concentration in sugar refinery workers and subjects employed in other industries, revealed a lower professional exposure of the former with respect to shipyard workers and electric plants. In other groups of Italian sugar refinery workers, a concentration of asbestos fibers higher than in the studied population was found. Thus, the study highlights the necessity to develop standardized methodologies to carry out health intervention programmes in workers previously exposed to asbestos.

Measurement of asbestos fibre concentrations in fluid of repeated bro-choalveolar lavages of exposed workers

OBJECTIVES

The aim of this study was to assess the reliability of asbestos fibre concentration in bronchoalveolar lavage fluid (BALF) by carrying out the mineralogical analysis of BALF at different times in the same patient and comparing the results.

METHODS

Twenty two patients underwent diagnostic fibreoptic bronchoscopy twice: the first was to assess the past asbestos exposure and the second for different clinical reasons. Mineralogical analysis of BALF was carried out.

RESULTS

In 16 patients (72.7%), a reduction of concentration in BALF of all asbestos fibres was observed. The concentrations of both chrysotile and amphiboles in the first bronchoalveolar lavage (BAL) were related to their concentrations in the second BAL and the observed differences were not statistically significant. A significant decrease in asbestos body concentration between the first and the second BAL was found (Wilcoxon test, P < 0.01).

CONCLUSIONS

The reliability of the fibre concentration in BALF as a marker of past asbestos exposure seems quite good. In most cases, it allows us to distinguish workers in different classes of exposure and gives useful information on the pattern of exposure. Uncertainties related in general to lung residues and in particular to mineralogical analysis of BALF (mainly due to the high coefficient of variation (CV) at low fibre concentrations and the results of the statistical analysis on total fibres) suggest that this biomarker is more likely suitable for a qualitative/categorical approach to exposure assessment than a quantitative one.

Biological monitoring of exposure to chlorpyrifos-methyl by assay of urinary alkylphosphates and 3,5,6-trichloro-2-pyridinol

The results of biological monitoring by assay of urinary 3,5,6-trichloro-2-pyridinol and alkylphosphates (DMP, DMTP) in groups of 9 and 2 workers exposed to chlorpyrifos-methyl during vine spraying and manual leaf thinning 5-11 d after spraying, respectively, are reported. The results are compared with those of a control group of 46 subjects not occupationally exposed to organophosphate insecticides. Significantly higher urinary excretion of metabolites (Mann-Whitney U-test) was found in both groups than in controls. Levels of 3,5,6-trichloro-2-pyridinol (mean +/- SD) were 15.9 + 10.6 nmol/g creatinine (n = 33) for controls, 92.4 + 162.5 nmol/g creatinine (n = 20) for manual workers, and 675.5 + 1110.8 nmol/g creatinine (n = 48) for workers spraying and mixing the insecticide. Levels of DMP (mean +/- SD) were 63.8 + 100.1 nmol/g creatinine (n = 42), 123.0 + 79.0 nmol/g creatinine (n = 20), and 577.2 + 1003.2 nmol/g creatinine (n = 61), respectively, for the same 3 groups. Levels of DMTP (mean +/- SD) were 153.4 + 164.4 nmol/g creatinine (n = 43), 489.3 + 288.3 nmol/g creatinine (n = 20), and 297.6 + 215.4 nmol/g creatinine (n = 61), respectively, for the same 3 groups. Good correlations were found between urinary excretion of 3,5,6-trichloro-2-pyridinol and DMP (r = .776 for manual workers; r = .775 for workers mixing and spraying the insecticide) or DMTP (r = .558 and r = .746, respectively for the same 2 groups). The peak of excretion of the three metabolites was found in urine samples collected the night after the spraying or leaf thinning operations.

[Methodology for assessing occupational dermal exposure]

BACKGROUND

Dermal risk assessment of exposure to chemicals is difficult due to the lack of standardisation of the methods used in exposure quantification; further limits concern the extent of skin contamination and especially dermal absorption of different substances. To solve these problems many authors proposed conceptual models founded on theoretical assumptions and experimental data, but their use in occupational settings revealed many difficulties. A possible alternative is the use of a check-list that permits evaluation of occupational dermal contamination hazards.

AIMS

To propose a simplified method for dermal risk assessment.

METHODS

Dermal contamination risk evaluation, chemical hazard quantification and duration of exposure are the basic features of the method. The first step assesses working conditions, use of protective devices, skin contamination directly observed, personal hygiene of workers: all information, collected by a trained observer, is scored according to literature data and/or to authors'personal experience. Chemical hazard quantfication is obtained from safety data sheet evaluation (R phrases classification and chemical-physical characteristics of the chemical in use). The method allows a preliminary dermal exposure assessment to be made, subdivided on hazard bands.

RESULTS

The method permits a rapid dermal exposure assessment to be made and suggests intervention measures to decrease dermal risk.

CONCLUSIONS

A check-list is proposed that can be a useful and easy method to assess dermal exposure to chemicals, particularly in small- and medium-sized enterprises.

[Echinococcosis: a persistent endemic]

Echinococcosis seems to be still endemic in Italy. Data from epidemiological studies in middle- south Italy indicates that this parasitosis is often a work- related disease. Our survey concerning findings among patients from surgical departments in Tuscany confirms the rsults of the studies. Echinococcosis is still endemic and dairy farming seems to be a risk factor.

In vitro predictions of skin absorption of caffeine, testosterone, and benzoic acid: a multi-centre comparison study

To obtain better insight into the robustness of in vitro percutaneous absorption methodology, the intra- and inter-laboratory variation in this type of study was investigated in 10 European laboratories. To this purpose, the in vitro absorption of three compounds through human skin (9 laboratories) and rat skin (1 laboratory) was determined. The test materials were benzoic acid, caffeine, and testosterone, representing a range of different physico-chemical properties. All laboratories performed their studies according to a detailed protocol in which all experimental details were described and each laboratory performed at least three independent experiments for each test chemical. All laboratories assigned the absorption of benzoic acid through human skin, the highest ranking of the three compounds (overall mean flux of 16.54+/-11.87 microg/cm(2)/h). The absorption of caffeine and testosterone through human skin was similar, having overall mean maximum absorption rates of 2.24+/-1.43 microg/cm(2)/h and 1.63+/-1.94 microg/cm(2)/h, respectively. In 7 out of 9 laboratories, the maximum absorption rates of caffeine were ranked higher than testosterone. No differences were observed between the mean absorption through human skin and the one rat study for benzoic acid and testosterone. For caffeine the maximum absorption rate and the total penetration through rat skin were clearly higher than the mean value for human skin. When evaluating all data, it appeared that no consistent relation existed between the diffusion cell type and the absorption of the test compounds. Skin thickness only slightly influenced the absorption of benzoic acid and caffeine. In contrast, the maximum absorption rate of testosterone was clearly higher in the laboratories using thin, dermatomed skin membranes. Testosterone is the most lipophilic compound and showed also a higher presence in the skin membrane after 24 h than the two other compounds. The results of this study indicate that the in vitro methodology for assessing skin absorption is relatively robust. A major effort was made to standardize the study performance, but, unlike in a formal validation study, not all variables were controlled. The variation observed may be largely attributed to human variability in dermal absorption and the skin source. For the most lipophilic compound, testosterone, skin thickness proved to be a critical variable.

Seasonal changes in serum metabolites in free-ranging alpine marmots (Marmota marmota)

Circannual changes in serum parameters and body mass were studied in free-ranging Marmota marmota that had been shot in Switzerland (Grisons) for management reasons in May, July, and September of 1995, 1996, and 1997; and in April 1996. Markers of lipid (triglycerides, cholesterol), protein (total protein, urea-nitrogen) and mineral (calcium, inorganic phosphate) metabolism were evaluated in 111 haemolysis-free serum samples; the effects of sex, age, reproductive status, season and year were tested. Mean body mass was higher in adult males than in adult females in July and September, and serum cholesterol concentrations were lower in adult males in May. Pregnant females had lower concentrations of total protein than non-pregnant females, and triglyceride concentrations were negatively correlated with the number of uterine ampullae. Inorganic phosphate decreased and total protein increased with age. In adults, triglycerides, cholesterol and urea-nitrogen increased mainly from May to July and decreased between September and May. Total protein, calcium and phosphate did not change throughout the year. This suggests that, during the active season, ingested lipids and amino acids were utilised for metabolic needs or lipid storage, while in winter, lipids were catabolised and protein was spared. Quantitative differences between years, observed for triglycerides and total protein during the active season, were probably due to different climatic conditions in each year.

[Assessment of asbestos exposure via mineralogical analysis of bronchoalveolar lavage fluid]

BACKGROUND

Mineralogical analysis of bronchoalveolar lavage fluid (BALF) by electron microscopy could be the most suitable method for assessing asbestos exposure. However, it has been claimed that there is not a standardized or systematic approach to the subject of mineralogical analysis.

OBJECTIVES

The aim of the study was to evaluate mineralogical analysis of BALF by transmission electron microscopy (TEM) as biomarker of asbestos fibre load.

METHODS

BALF was examined in 193 exposed workers (189 men and 4 women) and in 84 patients (65 men and 19 women) who underwent diagnostic fibreoptic bronchoscopy for various clinical purposes. Asbestos bodies (AB) in BALF were counted with a phase contrast microscope, while fibres were counted and analysed by TEM.

RESULTS

Fibre counting by TEM showed a significant difference in the two populations (two tailed Mann-Whitney U test, p=0.0044), since it was positive in all exposed subjects. Only 75.1% of the exposed population was positive for asbestos bodies (AB). Subjects who had been exposed over a long time period had higher concentrations of fibres than subjects who had been exposed more recently probably because of higher exposure in the past.

CONCLUSIONS

The study confirms the results of a previous study on a limited number of subjects. Fibre concentrations in BALF can be considered as a reliable biomarker of past asbestos exposure even after many years after cessation of exposure.

[Assessment of occupational skin exposure: proposal of a check-list]

The dermal risk assessment requires simplified methodologies to understand the role played by the skin. The conceptual models proposed to this aim are founded on theoretical assumptions and experimental data, but their use in occupational settings shows many difficulties. For this end we have drawn up a check-list that includes six sessions and allows to obtain a preliminary dermal exposure evaluation subdivided on hazard bands.

[Skin and respiratory allergic disease caused by polyfunctional aziridine]

BACKGROUND

Polyfunctional aziridine (PFA) hardener is increasingly used in water-based paints and inks as a replacement for organic solvents. Allergic contact dermatitis, contact urticaria, respiratory allergy in occupationally exposed patients with hypersensitivity to PFA are reported.

OBJECTIVES

The aim was to study a population of adhesive tape printers for occupational respiratory and skin sensitisation to PFA hardener. Also 2 cases of occupational asthma in workers exposed to PFA in tanneries are reported.

METHODS

A standard series prick and patch tests was carried out on 15 workers with skin symptoms out of 36 adhesive tape printers exposed to PFA. Prick tests with a 1% PFA water solution and patch tests with a dilution series (0.1-0.32-0.5-1%) of PFA in petrolatum were performed. Lung and nasal provocation tests with PFA hardener were also carried out on 4 subjects with skin and respiratory symptoms.

RESULTS

Skin sensitivity to PFA prick tests was demonstrated in 8.3% of the exposed population; 22.2% of the exposed workers suffered from allergic contact dermatitis due to PFA with positive patch tests for this compound. One case of occupational rhinitis due to PFA was diagnosed.

CONCLUSIONS

PFA is a strong sensitizer and the use of gloves and protective clothing appears to be insufficient to prevent occupational allergic diseases. Elimination of PFA from production processes is desirable.

[Evaluation of sources of mercury absorption through studying urinary mercury levels in the general population]

OBJECTIVES

The number of instances where mercury exposure is possible outside the workplace are numerous, with the main source being amalgam dental fillings and diet. It is also possible to envisage environmental exposure in subjects resident in areas where there is existing environmental contamination. This is probably what happened in Tuscany where past mining activity in the Monte Amiata area may have been the cause. This study estimated the concentration of urinary mercury (HgU) in non-occupationally exposed subjects from southern Tuscany, with the aim of evaluating the sources of mercury absorption in the general population.

METHODS

A questionnaire aimed at collecting specific information on factors which might influence the uptake of mercury was used. 164 subjects were studied: 82 subjects (41 males, 41 females) came from the Monte Amiata area and the other 82 (41 males, 41 females) from the Province of Siena. In this way it was possible to evaluate the elements associated with everyday life which may have influenced the presence of the metal in the urine. Since the distribution of the variables cannot be assumed multivariate normal as usual, a recently-proposed method based on a permutation procedure was adopted that allows the analysis of the variables as well as the single marginal analyses, without assuming any model for the distribution of variables.

RESULTS AND CONCLUSIONS

The results showed significantly lower levels of HgU in the subjects from the Monte Amiata area. Highly significant differences were demonstrated in the population which was sub-divided according to number and surfaces of amalgam fillings, use of contact lenses and type of water drunk (p < 0.001). Correlations between the levels of HgU and the investigated variables were not observed. It was confirmed that mercury uptake is simultaneously influenced by many factors. Probably the presence of higher levels of mercury in the environment in the Monte Amiata area is a factor of minor importance compared to others, especially the number of amalgam fillings, in determining mercury absorption in the general population.

[In vitro study of transcutaneous inorganic mercury absorption from solid soil]

OBJECTIVES

Skin is such an important route of absorption of mercury compounds that the ACGIH has assigned them a skin notation. Soil has been recognised as a potential source of exposure to chemical contaminants. It therefore seems advisable to establish maximum daily exposure levels for mercury in soil. In the past, areas adjacent to certain industries and smelters were heavily contaminated by mercury. For example, on Monte Amiata in Tuscany, which was an important mercury mining and production centre in the past, several areas have been polluted. To understand the dermal uptake of chemicals bound to soil and dust, information on the pure substance is helpful but does not seem sufficient. Other factors must be accounted for, that can easily be reproduced and controlled in in vitro experiments.

METHODS

Using an in vitro diffusion cell system and human skin, we studied percutaneous penetration of mercury chloride (HgCl2) at different concentrations, with particular emphasis on skin absorption from soil. The test apparatus consisted of a flow-through diffusion cell system. Dermotomed human cadaver skin was used as the membrane, while the receiving liquid was a saline solution with 6% PEG-20 oleyl-ether and gentamycin sulphate. Mercury chloride was applied at two different concentrations using a buffered solution and soil as vehicles.

RESULTS AND CONCLUSIONS

Increments of percentage of absorption at the different hours were found to be significantly lower in the cells where the higher concentration of mercury chloride was applied. In the receiving fluid of cells where soil was used as vehicle, the concentration of mercury was always below the detection limit. Skin contamination with soil containing inorganic mercury does not seem to be a dermal risk.

Dermal exposure assessment in occupational medicine

The importance of dermal exposure has increased during the last few years, mainly because of the reduction of respiratory exposure to toxicants. Pesticides, aromatic amines and polycyclic aromatic hydrocarbons are considered to be the chemicals at highest dermal risk. In the occupational exposure limit lists of the American Conference of Governmental Industrial Hygienists (ACGIH) and of many countries, compounds that can be absorbed through the skin are identified by a skin notation. However, a generally accepted criterion for assigning skin notation does not exist. The recent attempts to develop health-based dermal occupational exposure limits (DOELs) have not been accepted, thus in practice their use has remained limited. To predict the systemic risk associated with dermal exposure and to enable agencies to set safety standards, penetration data are needed. Moreover, there is a need for a practical risk assessment model, particularly for small and medium-sized enterprises.

[RISKOFDERM: European research project for assessment of occupational skin exposure to chemicals]

OBJECTIVES

RISKOFDERM is a research project whose aim is to develop instruments to assess and manage occupational dermal exposure to chemical substances.

METHODS

The research, funded by the European Commission, involves 15 Institutes from 10 member countries; it is a continuation of the Dermal Exposure Network experience and consists of four interrelated parts. The first phase (Qualitative survey) assumed that dermal exposure can be extrapolated from one compound to another when it is task-based: therefore six Dermal Exposure Operation units (DEOu) were defined that lead back to the variety of occupational dermal exposure conditions and an extensive Questionnaire was developed for on-site surveys to perform standard observations in selected working situations (scenarios).

RESULTS

The Italian group, participating in the research, obtained a set of observations relating to two "scenarios" in different working sectors: asphalt, ceramic and pottery workers, spectacle decorators and paint production: the aim was to verify the validity of the methodology in assessing the risk of percutaneous absorption, time, frequency and extension of skin exposure.

CONCLUSIONS

From the observations made it was shown that the perception of risk was poor; it is necessary to rationalise work organization, and train and inform the employees on the correct use of personal protection devices.