Long-Term Trajectory and Risk Factors of Healthcare Workers' Mental Health during COVID-19 Pandemic: A 24 Month Longitudinal Cohort Study

BACKGROUND

Research has shown the substantial impact of the COVID-19 pandemic on healthcare workers' (HCWs) mental health, however, it mostly relies on data collected during the early stages of COVID-19. The aim of this study is to assess the long-term trajectory of HCWs' mental health and the associated risk factors.

METHODS

a longitudinal cohort study was carried out in an Italian hospital. At Time 1 (July 2020-July 2021), 990 HCWs took part in the study and completed the General Health Questionnaire (GHQ-12), the Impact of Event Scale (IES-R), and the General Anxiety Disorder (GAD-7)questionnaire. McNemar's test measured changes in symptoms' trajectories, and random effects models evaluated risk factors associated with scores above the cut-off.

RESULTS

310 HCWs participated to the follow-up evaluation (Time 2; July 2021-July 2022). At Time 2, scores above cut-offs were significantly lower (p < 0.001) than at Time 1 for all scales (23% vs. 48% for GHQ-12; 11% vs. 25% for IES-R; 15% vs. 23% for GAD-7). Risk factors for psychological impairment were being a nurse (IES-R: OR 4.72, 95% CI 1.71-13.0; GAD-7: OR 2.82, 95% CI 1.44-7.17), a health assistant (IES-R: OR 6.76, 95% CI 1.30-35.1), or having had an infected family member (GHQ-12: OR 1.95, 95% CI 1.01-3.83). Compared to Time 1, gender and experience in COVID-19 units lost significance with psychological symptoms.

CONCLUSIONS

data over more than 24 months from the pandemic onset showed improvement of HCWs' mental health; our findings suggested the need to tailor and prioritize preventive actions towards healthcare workforce.

Psychometric Evaluation of GHQ-12 as a Screening Tool for Psychological Impairment of Healthcare Workers Facing COVID-19 Pandemic

BACKGROUND

The General Health Questionnaire (GHQ) is a widely used tool, both in clinical and research settings, due to its brevity and easy administration. Researchers often adopt a dichotomous measurement method, considering a total score above or below a certain threshold. This leads to an extreme simplification of the gathered data and therefore to the loss of clinical details. In a multi-step evaluation study aimed at assessing health care workers' mental health during the Covid-19 pandemic, GHQ-12 proved to be the most effective tool to detect psychological distress compared to other scales adopted. These results led to deepen the understanding of GHQ-12 properties through a statistical study by focusing on items' properties and characteristics.

METHODS

GHQ-12 responses were analyzed using Item Response Theory (IRT), a suitable method for scale assessment. Instead of considering the single overall score, in which each item accounts equally, it focuses on individual items' characteristics. Moreover, IRT models were applied combined with the latent class (LC) analysis, aiming to the determination of subgroups of individuals according to their level of psychological distress.

RESULTS

GHQ-12 was administered to 990 health-care workers and responses were scored using the binary method (0-0-1-1). We applied the two-parameter logistic (2-PL) model, finding that the items showed different ways of responses and features. The latent class analysis classified subjects into three sub-groups according to their responses to GHQ-12 only: 47% of individuals with general well-being, 38% expressing signs of discomfort without severity and 15% of subjects with a high level of impairment. This result almost reproduces subjects' classification obtained after administering the six questionnaires of the study protocol.

CONCLUSIONS

Accurate statistical techniques and a deep understanding of the latent factors underlying the GHQ-12 resulted in a more effective usage of such psychometric questionnaire - i.e. a more refined gathering of data and a significant time and resource efficiency. We underlined the need to maximize the extraction of data from questionnaires and the necessity of them being less lengthy and repetitive.

Psychosocial safety climate (PSC) at middle management level in the healthcare sector: A contribution to the Italian validation of psychosocial safety climate-4

Introduction

Psychosocial safety climate (PSC) refers to workers' shared perceptions of organizational policies, practices and procedures for the protection of psychological health and safety. PSC offers a multilevel organizational approach that expands traditional models of workplace stress, giving a more comprehensive understanding of occupational health and safety issues. Although considerable research on psychosocial risks in the healthcare sector has been conducted, few studies have explored the role of PSC among healthcare workers at middle management level. Additionally, no validated version of PSC is available in Italian language. The aim of this study is to contribute to the validation of the Italian 4-item version of the PSC and to explore this theory within the Job Demands-Resources model (JD-R) among a sample of Italian healthcare workers by testing PSC at the middle management level.

Methods

We used cross-sectional data from 276 employees working in 17 different wards in a large Italian hospital. Intra-class coefficient (ICC) coefficient and agreement index were used to test PSC as a climate construct (data nested to hospital ward level). We performed hierarchical linear models to test mediation and moderation effects.

Results

The Italian version of PSC-4 proved to have good psychometric properties and confirmed its role as a group-level construct (α = 0.84; ICC = 0.16). Multilevel random coefficient models showed PSC was associated with Job demands (Effort: B = -0.36, SE = 0.07; Emotional demands: B = -0.03, SE = 0.01) and Job resources (Reward: B = 1.16, SE = 0.01; Physical work environment: B = 0.06, SE = 0.01). Results confirmed the indirect effect of PSC on Psychological (Burnout) and Occupational health (Job satisfaction) outcomes supporting the role of Job resources and Job demands as mediators. The multilevel analysis did not find a significant interaction terms between PSC and Job demands on Burnout therefore the moderation hypothesis was not supported.

Discussion

The Italian version of PSC-4 is a valid tool to evaluate PSC. These findings sustain the multilevel framework of PSC and the significant role played by mid-leaders in both the health impairment and motivational path. Further studies should explore the buffering effect of PSC at higher baseline levels as well as the adoption of PSC as a target for occupational health intervention the Italian context.

Immunogenicity and effectiveness of BNT162b2 COVID-19 vaccine in a cohort of healthcare workers in Milan (Lombardy Region, Northern Italy)

OBJECTIVES

to evaluate immunogenicity and effectiveness of BNT162b2 COVID-19 vaccine in a cohort of healthcare workers (HCWs).

DESIGN

cohort study.

SETTING AND PARTICIPANTS

in a hospital in Milan (Lombardy Region, Northern Italy) HCWs without ("negative cohort") and with ("positive cohort") history of SARS-CoV-2 infection or elevated serum antibody before the vaccination campaign (27.12.2020) were included. Data collection and follow-up covered the period 27.12.2020-13.05.2022.

MAIN OUTCOMES MEASURES

1. serum anti-spike-1 (anti-S1) antibody levels after vaccination; 2. vaccine effectiveness (VE) against SARS-CoV-2 infections (either symptomatic or not) in the negative cohort. Data on infections were extracted from multiple sources (laboratory, accident reports, questionnaires). Vaccination was treated as a time-dependent variable. Using unvaccinated person-time as reference, hazard ratios (HR) of infections and 95% confidence intervals (95%CI) were calculated with a Cox regression model adjusted for gender, age, and occupation. VE was calculated as (1 - HR)×100.

RESULTS

5,596 HCWs were included, 4,771 in the negative and 825 in the positive cohort. In both cohorts, serum anti-S1 antibodies were high one months after the second dose, halved after six months, and returned to high levels after the third dose. In the negative cohort, 1,401 SARS-CoV-2 infections were identified. VE was 70% (95%CI 54-80; 46 infected) in the first four months after the second dose and later declined to 16% (95%CI 0-43; 97 infected). After the third dose, VE increased to 57% (95%CI 35-71; 61 infected) in the first month but rapidly declined over time, particularly after three months (24% in the fourth month and 1% afterwards). The number of infections avoided by vaccination was estimated to be 643 (95%CI 236-1,237).

CONCLUSIONS

in spite of rapidly declining effectiveness, vaccination helped to avoid several hundred infections in the considered hospital.

One Year Facing COVID. Systematic Evaluation of Risk Factors Associated With Mental Distress Among Hospital Workers in Italy

INTRODUCTION

Italy was the first Western country affected by the COVID-19 pandemic that still constitutes a severe challenge for healthcare workers (HCWs), with a deep impact on their mental health. Several studies confirmed that a considerable proportion of HCW developed adverse psychological impairment (PsI). To focus on preventive and rehabilitation measures, it is fundamental to identify individual and occupational risk factors. We systematically assessed possible PsI among all employees in a large university hospital in Italy, using validated psychometric scales in the context of occupational health surveillance.

METHODS

In the period of July 2020 to July 2021, we enrolled 990 HCWs. For each subject, the psychological wellbeing was screened in two steps. The first-level questionnaire collected gender, age, occupational role, personal and occupational COVID-19 exposure, general psychological discomfort (GHQ-12), post-traumatic stress symptoms (IES-R), and anxiety (GAD-7). Workers showing PsI (i.e., test scores above the cutoff in at least one among GHQ-12, IES-R, and GAD-7) have been further investigated by the second-level questionnaire (psycho-diagnostic) composed by PHQ-9, DES-II, and SCL-90 scales. If the second-level showed clinically relevant symptoms, then we offered individual specialist treatment (third level).

RESULTS

Three hundred sixteen workers (32%) presented signs of PsI at the first-level screening questionnaire. Women, nurses, and subjects engaged in the COVID-19 area and with an infected family member showed significantly higher PsI risk. PsI prevalence was strongly associated with the pandemic trend in the region but sensibly decreased after January 2021, when almost all workers received the vaccination. A proportion of subjects with PsI presented clinically relevant symptoms (second-level screening) on PHQ-9 (35%), DES (20%), and SCL-90 (28%). These symptoms were associated neither to direct working experience with patients with COVID-19 nor to COVID-19 experience in the family and seemed not to be influenced by the pandemic waves or workers vaccination.

CONCLUSIONS

The evaluation of psychological wellbeing of all hospital workers, directly or indirectly exposed to pandemic consequences, constitutes a unique condition to detect individual, occupational, and non-occupational risk factors for PsI in situations of high stress and/or disasters, as well as variables associated with symptom chronicization.

Identification of a new potential plasmatic biomarker panel for the diagnosis of malignant pleural mesothelioma

BACKGROUND

Malignant pleural mesothelioma (MPM) is a rare highly aggressive tumor strongly associated with asbestos exposure and characterized by poor prognosis. Currently, diagnosis is based on invasive techniques, thus there is a need of identifying non-invasive biomarkers for early detection of the disease among asbestos-exposed subjects. In the present study, we measured the plasmatic concentrations of Mesothelin, Fibulin-3, and HMGB1 protein biomarkers, and of hsa-miR-30e-3p and hsa-miR-103a-3p Extracellular-Vesicles- embedded micro RNAs (EV-miRNAs). We tested the ability of these biomarkers to discriminate between MPM and PAE subjects alone and in combination.

METHODS

the study was conducted on a population of 26 patients with MPM and 54 healthy subjects with previous asbestos exposure (PAE). Mesothelin, Fibulin-3, and HMGB1 protein biomarkers were measured by the enzyme-linked immunosorbent assay (ELISA) technique; the levels of hsa-miR-30e-3p and hsa-miR-103a-3p EV-miRNAs was assessed by quantitative real-time PCR (qPCR).

RESULTS

the most discriminating single biomarker resulted to be Fibulin-3 (AUC 0.94 CI 95% 0.88-1.0; Sensitivity 88%; Specificity 87%). After investigating the different possible combinations, the best performance was obtained by the three protein biomarkers Mesothelin, Fibulin-3, and HMGB1 (AUC 0.99 CI 95% 0.97-1.0; Sensitivity 96%; Specificity 93%).

CONCLUSIONS

the results obtained contribute to identifying new potential non-invasive biomarkers for the early diagnosis of MPM in high-risk asbestos-exposed subjects. Further studies are needed to validate the evidence obtained, in order to assess the reliability of the proposed biomarker panel.

Side effects among healthcare workers from a large Milan university hospital after second dose of BNT162b2 mRNA COVID-19 vaccine

BACKGROUND

In Italy, healthcare workers (HCWs) were among the first to receive COVID-19 vaccination. Aim of the present study is to evaluate frequency and severity of adverse events (AEs) following the second dose of BNT162b2 vaccine among HCWs of a large university hospital in Milan, Italy.

METHODS

One month after having received the second dose of vaccine, HCWs filled-in a form about type, severity, and duration of post-vaccination local and systemic symptoms. We calculated the overall frequency of AEs and used multivariable Poisson regression models (adjusted for sex, age, BMI, smoking, allergy history, previous SARS-CoV-2 infection, anti-hypertensive therapy, and occupation) to calculate risk ratios (RR) and 95% confidence intervals (CI) of AEs according to selected variables.

RESULTS

We included 3659 HCWs. Overall, 2801 (76.6%) experienced at least one local event, with pain at injection site being the most frequent (2788, 76.2%). Systemic events were reported by 2080 (56.8%) HCWs, with fatigue (52.3%), muscle pain (42.2%), headache (37.7%), joint pain (31.9%), and fever (26.2%) being the most frequent. Risks of systemic events were associated with female gender (RR=1.14, CI: 1.06-1.23), age (strong decrease with increasing age, p-trend<0.001), allergy history (RR=1.13, CI: 1.05-1.20), and current smoking (RR=0.90, CI: 0.84-0.97). HCWs with previous SARS-CoV-2 infection (even if symptomatic) were not at increased risk.

CONCLUSIONS

Both local and systemic acute effects after second dose of BNT162b2 vaccine were frequently reported. However, symptoms were mostly light/mild and of short duration. Thus, our findings support the safety of COVID-19 vaccination in adults in relatively good health.

Increased Risk of Urticaria/Angioedema after BNT162b2 mRNA COVID-19 Vaccine in Health Care Workers Taking ACE Inhibitors

Urticarial eruptions and angioedema are the most common cutaneous reactions in patients undergoing mRNA COVID-19 vaccinations. The vasoactive peptide bradykinin has long been known to be involved in angioedema and recently also in urticaria. Bradykinin is mainly catabolized by angiotensin-converting enzyme (ACE), which is inhibited by ACE inhibitors, a commonly employed class of antihypertensive drugs. We evaluated the risk of developing urticaria/angioedema after inoculation with the BNT162b2 mRNA COVID-19 vaccine in a population of 3586 health care workers. The influences of ACE inhibitors and selected potential confounding variables (sex, age, previous SARS-CoV-2 infection, and allergy history) were evaluated by fitting univariate and multivariable Poisson regression models. The overall cumulative incidence of urticaria/angioedema was 1.8% (65 out of 3586; 95% CI: 1.4–2.3%). Symptoms were mild, and no subject consulted a physician. Subjects taking ACE inhibitors had an adjusted three-fold increased risk of urticaria/angioedema (RR 2.98, 95% CI: 1.12–7.96). When we restricted the analysis to those aged 50 years or more, the adjusted RR was 3.98 (95% CI: 1.44–11.0). In conclusion, our data indicate that subjects taking ACE inhibitors have an increased risk of urticaria/angioedema after vaccination with the BNT162b2 mRNA COVID-19 vaccine. Symptoms are mild and self-limited; however, they should be considered to adequately advise subjects undergoing vaccination.

Hospital workers mental health during the COVID-19 pandemic: methods of data collection and characteristics of study sample in a university hospital in Milan (Italy)

BACKGROUND

The COVID-19 pandemic is currently a severe challenge for healthcare workers, with a considerable impact on their mental health. In order to focus preventive and rehabilitation measures it's fundamental to identify risk factors of such psychological impairment. We designed an observational longitudinal study to systematically examine the psychological wellbeing of all employees in a large University Hospital in Italy, using validated psychometric scales in the context of the occupational physician's health surveillance, in collaboration with Psychiatric Unit.

METHODS

The study started after ethical approval in August 2020. For each worker, the psychological wellbeing is screened in two steps. The first level questionnaire collects sociodemographic characteristics, personal and occupational COVID-19 exposure, worries and concerns about COVID-19, general psychological discomfort (GHQ-12), post-traumatic stress symptoms (IES-R) and anxiety (GAD-7). Workers who score above the cut-off in at least one scale are further investigated by the second level questionnaire composed by PHQ-9, DES-II and SCL-90. If second level shows psychological impairments, we offer individual specialist treatment (third level). We plan to follow-up all subjects to monitor symptoms and possible chronicization; we aim to investigate potential risk factors through univariate analysis and multivariate logistic regressions.

RESULTS

Preliminary results refer to a sample of 550 workers who completed the multi-step evaluation from August to December 2020, before vaccination campaign started. The participation rate was 90%. At first level screening, 39% of the subjects expressed general psychological discomfort (GHQ-12), 22% post-traumatic stress symptoms (IES-R), and 21% symptoms of anxiety (GAD-7). Women, nurses, younger workers, subjects with COVID-19 working exposure and with an infected family member showed significantly higher psychological impairment compared to colleagues. After the second level screening, 12% and 7% of all workers showed, respectively, depressive and dissociative symptoms; scorings were significantly associated with gender and occupational role. We are currently extending sample size and evaluating subjects over a period of further 12 months.

CONCLUSIONS

The possibility to perform a systematic follow-up of psychological wellbeing of all hospital workers, directly or indirectly exposed to pandemic consequences, constitutes a unique condition to detect individual, occupational, and non-occupational risk factors for psychological impairment in situations of prolonged stress, as well as variables associated with symptoms chronicization.

SARS-CoV-2 tests in occupational settings: what you look for is what you get

During the last month of 2019, a new Coronavirus from China started to spread all around the world causing a pandemic emergency still ongoing. The outbreak made imperative the need for diagnostic and screening tests that could identify the current and past infection state of an individual. Occupational medicine is facing a very demanding challenge, as the pandemic set off the need to re-evaluate many aspects of workplace safety. A fundamental role has been played by tests used to diagnose COVID-19 and to isolate infected asymptomatic subjects, with a view to the viral evolution and the emerging variants. However, the need for the urgent set-up of new methods for assessing both new and past infections has resulted in a large number of methods, not always comparable with each other, in terms of laboratory techniques, viral antigens used for detection, and class of antibodies detected. These factors make it difficult to understand the serological test results and their possible application. In this paper, we reviewed the types of assays currently available, to address some key aspects that characterize each technique, and might have an impact on results interpretation.

[Fit for work judgment and ionizing radiation: discussion of clinical cases]

Introduction. The formulation of the suitability for risk assessment from exposure to ionizing radiation in workers diagnosed with malignant tumor disease entails important implications of a professional, human, social, but also medical-legal, nature. By now, the management of such situations is an event anything but infrequent in the activity of the Authorized Physician: the increase in the number of people staying in wore and the rise in the incidence and prevalence of malignant neoplastic diseases in the working-age population make the problem more relevant than ever. This is not only because of the improvement of the diagnostic and treatment capacity but also for the increased survival that follows from them. The result is therefore an increase in the cases that can potentially reach the antention of the Authorized Physician/Competent Physician who - in compliance with the provisions of current legislation - will be thus called to express the suitability assessment for the specific task by applying criteria that respect the highest and current scientific evidence in this field. Materials and Methods. Through the guided illustration of two clinical cases, it is intended to propose here a - practical and reasoned - path towards the formulation of the assessment on the occupational reintegration of the worker with diagnosis of neoplastic disease. This methodology is applied and developed through the systematic recourse to objective and specific orientation criteria, able to guide the decision-making process of the Authorized Doctor/Competent Doctor. Results. The proposed criteria were applied to workers operating in the healthcare sector and assigned to different types of activities who were at risk from exposure to ionizing sources. Conclusions. The proposed evaluation path is intended to represent a clinical and rational methodology of approach and management to the problem of assessing the suitability of workers with previous neoplastic diseases, all that by fully safeguarding the decision-making autonomy - variable from case to case - which is characteristic of the activity of the Authorized Physician/Competent Physician.

COVID-19: What happened to the healthcare workers of a research and teaching hospital in Milan, Italy?

The paper wants to present the data of infection of the Health Care Workers of a research and teaching hospital in Milan, Italy. The majority (2554, 55.9%) of 4572 HCWs were tested for SARS-CoV-2 and 8.8% were found positive. Most of the tested workers were women, but we found higher relative frequency of positivity for men, even after adjustment for age, working area, and occupation. The higher frequency of positive tests in the medicine area is probably explained by the higher concentration in that area of COVID-19 patients. Conversely, the low frequency of positive HCWs in intensive care units is  probably explained by the diffuse and continuous use of PPD. Our results show that HCWs in a research and teaching hospital in the most hit Region in Italy had a similar pattern of infection as all other HCWs all over the world. The problem of SARS-CoV-2 infections among the hospital personnel HCWs should remind us  the concerns about hospital acquired infections both for patients and HCWs.

[Monoclonal gammopathy of uncertain significance (MGUS) and occupational risk factors: criteria to carry out the health surveillance]

Monoclonal gammopathy of uncertain significance (MGUS) identifies a clinically asymptomatic and laboratory-based situation characterized by a modest monoclonal component (MC). In a limited percentage of cases, on a probabilistic basis, the asymptomatic genepremalignant stage could lead to multiple myeloma (MM). Materials and Methods. Based on literature data and available Guidelines on the subject, the diagnostic criteria and a methodological path are here suggested to the Occupational Physician to formulate a judgment of suitability for the task with exposure risk to RI or pesticides. Results. Some studies have evaluated the prevalence of MGUS in subjects exposed professionally to pesticides. Numerous other studies conducted on the survivors of the atomic bombing of Hiroshima and Nagasaki have highlighted a possible association with exposure to ionizing radiation (IR). The guidelines relating to the diagnosis and management of MGUS cases (with respect to the potential evolution in MM allow) to draw important operational indications for the competent/authorized physician. Conclusions. The routinely use of laboratory tests for subjects exposed to the studied risk factors is generally indicated starting from the worker's 50 years of age. The finding of a MGUS in the absence of further laboratory alterations represents the situation most frequently and does not require further measures, other than those of foreseeing even blood controls at least every two years. In this situation, there are no justified restrictions on work activities with exposure risks to IR or pesticides. If alterations suggestive for an increased risk of evolution in a neoplastic way could be identified, a close periodicity - every 3-6 months - of haematological checks is recommended. In these cases, it appears justified an abstention from activities involving exposure to ionizing radiation for a period of time that will be evaluated based on the evolution of the framework and by the progress of laboratory tests in the monitored period.

PM10 exposure is associated with increased hospitalizations for respiratory syncytial virus bronchiolitis among infants in Lombardy, Italy

Respiratory syncytial virus (RSV) is the primary cause of acute lower respiratory infections in children, bronchiolitis in particular. Airborne particulate matter (PM) may influence the children's immune system and foster the spread of RSV infection. We aimed to verify whether PM10 exposure is associated with hospitalization due to RSV bronchiolitis. We selected hospital discharge records (HRD) with ICD-9-CM code 466.11 of infants < 1 year of age, occurring in the epidemic seasons of two years (2012-2013) in Lombardy, Italy. Cases were assigned daily PM10 and apparent temperature levels of the capital city of their residential province. Different exposure windows were considered: single days preceding hospitalization (lag 0 to 30), their average estimates (lag 0-1 to 0-30), and the four weeks preceding hospitalization (week 1 to 4). Negative binomial regression models adjusted for apparent temperature and season were applied to the daily counts of hospitalizations in each province. Results were expressed as incidence rate ratios (IRR) and 95% confidence intervals (95%CI) per 10 µg/m³ increase in PM10 concentration. Random effects meta-analyses of province-specific IRR were performed to obtain regional estimates. 2814 HRD met our inclusion criteria; males represented about 55% of the cases. A 6% increased risk of hospitalization (95%CI: 1.03-1.10) was found at lag 0 and an almost overlapping 7% increase at lag 1. IRR ranged from 1.03 to 1.05 between lags 2 and 11. No increased risk was observed from lag 12. When considering averaged daily lags, risk estimates gradually increased in the two weeks preceding hospitalization from 1.08 (1.04-1.12) at lag 0-1 to 1.15 (1.08-1.23) between lags 0-11 and 0-13. Analyses on weekly lags showed a risk increase of 6% (1.01-1.12) during week 1 and of 7% (1.02-1.13) during week 2. Our study found a clear association between short- and medium-term PM10 exposures and increased risk of hospitalization due to RSV bronchiolitis among infants.

[Stochastic effects of ionizing radiations]

OBJECTIVES

Stochastic effects induced by exposure to ionizing radiation rapresent a relevance radioprotection aspect.

METHODS

Actually most of the information about radiation-induced oncogenic risk arise from the follow-up of the atomic bombs survivors (Life Span Study, LSS); at this information sources have been added over the last decades also data derived from medical, occupational and environmental studies conducted in various parts of the world and their contribution about number of cases and duration of follow-up period is of great relevance. These sources of information, in fact, provide important data related to very different exposure models compared to the historical of the LSS and closer to those who characterize the employment context in the last decades.

RESULTS

Data from these studies seem to outline the evidence for which at the current occupational exposure levels significant ERR/Gy are observed only for lung cancer and for all haematological neoplasms with the exception of chronic lymphocytic leukemia.

[Oncological disease: dimensions of the phenomenon and role ionizing radiation]

OBJECTIVES

The continuous scientific advances against neoplastic diseases affecting all areas of oncology biomedical research. Age is an extremely important factor in cancer development, since the incidence of cancer increases significantly with age. Because of aging of the Italian population, although the incidence is kept constant, the number of cancer diagnosis is inevitably going to increase over time only to increasing age.

METHODS

Survival after the diagnosis of cancer is one of the main indicators that allow to evaluate the effectiveness of the health system against the cancer disease. The 5-year survival after diagnosis is a widely used indicator. If we consider the relative survival data after 5 years of diagnosis, for cancer cases diagnosed in subsequent three-year periods, from 1990-1992 to 2005-2007, it shows that the 5-year survival has increased significantly over time for both men and women. Many so-called patients "long-term survivors "are of working age and should return to work. This aims to ensure both the mental and social well-being of the worker, both industrial production. For the oncogenic risk assessment by ionizing radiation, the ICRP Publication 60 has referred to the mortality and cancer data collected from 1950 to 1985 by the RERF, Japan-US bi-national institution with headquarters in Hiroshima that leads the research program called Life Span study (LSS), that is the study of the long-term effects on survivors of the bomb A. For the thyroid, instead, reference is made to the data from medical irradiations, as well as for liver and bone, using in this case adapted data relating to exposure to alpha rays (thorium and radio). The interpretation model is the traditional one: the linear dose-effect assumptions without a threshold even at small doses (LNT theory) when epidemiological data are not more informative for statistical uncertainty, although we resort to radiobiological studies.

RESULTS

In transferring the risk among different populations ICRP in Publication 103 accommodates the idea that for each type of cancer is more suitable, from time to time, the additive or multiplicative model or a combination of the two.

CONCLUSIONS

To study the oncogenic role of occupational exposure to ionizing radiation in the onset of neoplastic disease, the probability of cause (PC), is a "reasonable way to address the problem of evaluation of the likelihood that previous exposure to ionizing radiation (IR) is responsible for an oncogenic event "(Committee on Radiation Protection and Measurements - NCRP - Statement N. 7 of 30/09/92).

Plasmatic extracellular vesicle microRNAs in malignant pleural mesothelioma and asbestos-exposed subjects suggest a 2-miRNA signature as potential biomarker of disease

Background

Malignant Pleural Mesothelioma (MPM) is an aggressive cancer mainly caused by asbestos exposure and refractory to current therapies. Specific diagnostic markers for early MPM diagnosis are needed. Changes in miRNA expression have been implicated in several diseases and cancers, including MPM. We examined if a specific miRNA signature in plasmatic extracellular vesicles (EV) may help to discriminate between malignant pleural mesothelioma patients (MPM) and subjects with Past Asbestos Exposure (PAE).

Methodology/Principal findings

We investigated 23 MPM patients and 19 cancer-free subjects with past asbestos exposure (PAE). We screened 754 miRNAs in plasmatic EVs by OpenArray and found 55 differential miRNAs using logistic regression models adjusted for age, sex, BMI, and smoking. Among the top-20 differential miRNAs chosen for validation by Real time PCR, 16 were confirmed. Using receiver operating characteristic (ROC) curve analysis, the most discriminating miRNA combination was given by miR-103a-3p + miR-30e-3p, which generated an AUC of 0.942 (95% CI 0.87–1.00), with a sensitivity of 95.5% and a specificity of 80.0%. Using multivariate Cox regression analysis including gender, age, BMI and smoking we found a Hazard Ratio for miR-103a-3p above the median of 0.37 (95%CI 0.13–1.13) and of 0.51 (95%CI 0.17–1.52) for miR-30e-3p.

Conclusions

This study suggests EV-associated miR-103a-3p and miR-30e-3p are able to discriminate MPM from PAE subjects. Larger and prospective studies are needed to confirm these two-miRNA signature alone or in combination with other biomarkers as diagnostic tools for MPM.

[A clinical case of occupational allergy to piperacilline. A novel diagnostic method: basophil activation test (BAT)]

BACKGROUND

Piperacillin, unlike other antibiotics, rarely causes immediate allergic reactions. Only two cases related to occupational exposure are reported in the literature.

OBJECTIVES

Adoption of new methods for diagnosis of occupational allergy to drugs.

METHODS

An atopic nurse, aged 30 years, was referred to our hospital for an allergic work-related reaction to piperacillin. The patient had suffered two successive episodes with immediate cutaneous reaction, angioedema and dyspnoea after preparing piperacillin. Almost four years previously she had suffered from similar symptoms after taking amoxicillin. She was submitted to a clinical examination and a routine allergic test, performing also specific IgE (Phadia Pharmacia ImmunoCap) and BAT (Basophil Activation Test) for Beta-lactam antibiotics.

RESULTS

A positive response to piperacillin was observed in our case using BAT a new non-invasive and safe method, that proved useful for diagnosis of allergy. Moreover, we observed a change from an allergic reaction for therapeutic use of amoxicillin to a work-related adverse reaction to another beta-lactam, piperacillin.

CONCLUSIONS

In previous clinical cases cutaneous and specific challenge tests were performed for diagnosis. At present, availability of an in vitro test, such as BAT may provide new diagnostic opportunities, and a useful tool for studying clinical cases other than, in perspective, monitoring exposed workers. Preventive measures were taken in the workplace to lower the risk of sensitization and allergic response. The nurse was transferred to a well controlled job.

[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]

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.

[Psychotropic substances and driving]

Consumption of psychotropic substances (alcohol, drugs, medication) has a major impact on complex activity performance such as driving. This issue is of relevant social interest for the high number of potentially involved subjects and the often fatale outcomes, and affects also occupational physicians because of the high number of people whose job is driving. There are still few studies trying to assess the presence of a possible association between increased risk of accident/injury at work and consumption of psychotropic substances and results are not always in agreement. In spite of such uncertainties and some Italian regulations still worth being amended by Legislator, the possible impact of consumption of psychoactive substances on driving is an issue to be still better defined for which occupational physicians may play a basic role in the field of prevention, clinics and rehabilitation.

Fitness for work in health care workers: state of the art and possible operational recommendations for its formulation and management in relationship to alcohol and drug addiction

Both chronic and acute alcohol or drug consumption have severe health consequences, alter the subject's cognitive functions and work performance and increase the risk of work-related accidents, for the worker and for third parties (e.g., co-workers and other people subject to negative impact of worker's actions). Limited scientific evidence has suggested that some working conditions present in the health care sector (e.g., high levels of responsibility, competitiveness, burnout, shiftwork, work-related stress) may favour alcohol and drug abuse. The aim of the present report is to describe the problem of alcohol and drug consumption among health care professionals and to evaluate the problem of related fitness for work. The magnitude of this problem remains unclear; recent estimates have reported alcohol abuse and addiction problems in 1-14% and psychotropic, illicit and non-illicit, substance abuse in 6-15% of health care workers. The prevalence of tranquilizer and sedative/hypnotic drug use is high, particularly among physicians. However, it remains unclear whether the incidence of workplace accidents and injuries is higher among drug abusers, and whether the statutory introduction of prevention programmes has led to actual control of this problem in the workplace. Italian legislation identifies the occupational physician as a key figure to prevent psychotropic substance abuse in some work activities, but some difficulties in its application remain. Legislators should issue simple norms that clearly define the responsibilities and skills of each actor involved in safeguarding workplace health and safety, as well as clearly outlining workplace monitoring procedures.

Asbestos-related diseases in entertainment workers

OBJECTIVES

To investigate asbestos exposure in 4 patients (3 cases of malignant mesothelioma and 1 case ofpleural plagues) previously employed in the entertainment business.

METHODS

The patients were seen at the Occupational Health Unit of the "Clinica del Lavoro Luigi Devoto" in Milan (Italy). Information regarding exposure to asbestos (occupational, environmental, and familial) was collected through a standardized questionnaire administered to the patients by an occupational physician.

RESULTS AND CONCLUSION

The presence of asbestos in the building structures and its use were described by all patients. The presence of asbestos in public buildings used for entertainment such as cinemas and theatres was in fact confirmed by the Occupational Health Services of the Local Heath Unit. An occupational aetiology was recognised in all the cases mentioned above, thus leading to the identification of an atypical occupational sector at risk in the past for asbestos exposure,

[Upgrade on alcohol abuse]

Problematic use of alcohol configures an element of interest in the context of preventive interventions aimed to ensuring the performance of any work in safety conditions. To contrast the acute alcohol abuse in the workplace the existing legislation provides alcoholimeters controls and prohibition of recruitment and administration of alcohol. Recent legislation (D.Lgs. 81/08) establishes health surveillance for alcohol dependence and appears still incomplete and difficult to apply. Clinical diagnostic tools available to the physician for alcohol dependence identification are well-defined and recently improved thanks to new laboratory markers with high sensitivity and specificity (CDT) and self-administered questionnaires. In this contest we are awaiting for legislative action to specify conditions and procedures for inspections in the workplace in order to face the problem of alcohol dependence without excessive bureaucracy and with more attention to preventive aspects.

[Systematic surveillance of occupational cancer: the Lombardy Sinonasal Cancer Registry]

BACKGROUND

Sinonasal cancer (SNC) includes uncommon tumours that are characterized by a high occupational etiologic component. For this reason they are an easy target for systematic surveillance by setting up a specific disease registry. The National Registry of these tumours is located at the Italian Institute for Occupational Safety and Prevention (ISPESL) and is based on data from Regional Operating Centres (ROCs). In the Lombardy Region a ROC was established in 2008 at the Clinica del Lavoro "Luigi Devoto" in Milan aimed at making surveillance systematic and thus provide adequate support for scientific research and prevention measures in the high risk work sectors.

OBJECTIVES

To estimate the incidence of SNC, to define different sources of occupational exposure both known (wood, leather, nickel, chromium) and unknown.

METHODS

The Registry collects all the new incident cases of epithelial SNC occurring among residents ofthe Lombardy Region. The Regional Registry is managed in accordance with the specific National Guidelines and uses the experience already acquired with the organizational and operational management of the Regional Mesothelioma Registry.

RESULTS

During the first period of activity (1.1.2008-30.9.2009) 556 cases of suspected SNC were reported to the Registry; only 62 (11.2%) of these actually complied with the inclusion criteria of the Registry and were mainly adenocarcinoma and squamous carcinoma. Occupational exposure to wood or leather dust was ascertained in 50% of cases.

CONCLUSION

Data collected up to now confirm that occupational exposure to wood and leather dusts are the most significant risk factors for SNC. The study of occupational sectors and job tasks in cases with as yet undefined exposure might suggest new etiologic hypotheses.

[Prevention and control of substance abuse in the workplace: a new and significant opportunity for the occupational physician]

OBJECTIVES

Substance abuse is nowadays a recurrent theme in the daily practice of occupational physicians (OP), mainly owing to recent legislation prescribing mandatory assessments for workers performing job tasks involving danger to third parties. While some degree of bureaucracy is inevitable and legislation seems to be inclined towards deterrence, it is recommended to take advantage of the opportunities offered for practical interventions which, in accordance with science and ethics, the OP can carry out in the workplace. Risk assessment, health surveillance, fitness for work, health promotion and cooperation in management issues are the areas of intervention required for the OP to fully accomplish his role in the practice of modern occupational health.

CONCLUSIONS

We propose specific activities for the OP so as to highlight roles and obligations, based on available scientific evidence and established codes of ethics. Lastly, we wish to emphasize the overall role of the OP in taking on responsibilities shared jointly with all the parties and in the approach to the substance abuse problem in all workplaces with the ultimate goal of acting for the benefit of workers, enterprises and society in general.

[Validity of carbohydrate-deficient transferrine (CDT) in assessing chronic abuse of ethyl alcohol in urban public transport workers]

OBJECTIVES

The aim of this study was to verify the ability of some chemical-clinical parameters, with particular emphasis on carbohydrate-deficient transferrin (CDT), in assessing chronic abuse of ethanol in a group of urban public transport workers.

METHODS

In the 512 subjects, public transport tram drivers, all males, who entered the study, information on the intake of alcoholic beverages was collected during the periodical health surveillance controls performed according to Italian legislation (DM88/99). In the study subjects the following clinical-chemical parameters were measured: CDT gamma-glutamyltransferase (GGT), mean corpuscular volume of erythrocytes (MCV), aspartate aminotransferase (AST), alanine aminotransferase (ALT).

RESULTS

The subjects were divided into five groups according to different levels of alcohol intake: non-drinkers, occasional drinkers, moderate drinkers, habitual drinkers and heavy drinkers. The median values of CDT GGT and MCV were higher in drinkers than in non-drinkers, with an increasing trend in proportion to the amount of ethanol ingested. The validity of each parameter in determining chronic abuse of ethyl alcohol was calculated taking as true the statement on alcohol intake made spontaneously by the subject. CDT was confirmed as the parameter with the best sensitivity and specificity: 90% and 98%, respectively, the negative predictive value was 99%, while the positive predictive power was 45%. The combination of CDT with GGT or MCV led to small improvements in the positive predictive ability, which reached 50% for CDT and MCV and 60% for CDT and GGT.

CONCLUSIONS

Our results confirmed that, also in the workplace, CDT is the most important parameter for the diagnosis of chronic abuse of alcohol intake, but also showed that the positivity of this marker cannot be taken as certainty of abuse. The adoption of further diagnostic tools is therefore proposed, such as a specific questionnaire to collect information on alcohol intake, and in case of positive CDT a second-level test with a high specificity.

[Acute and chronic alcohol abuse and work]

A not moderate alcohol consumption or its abuse have relevant consequences not only on the health of the general population but also on the possibility to carry out any work in safety conditions. These behaviours have focused the attention of the institutions, which have promoted in the last years a growing number of preventive and informative actions and have adopted specific laws that have significantly involved the figure of occupational physician. Over the clinical implications, in fact, those behaviours, in the employment context, are associated with an increased risk of injuries (from 10 to 30% of total), an increase in the number of absences from work, with greater precariousness, with the possible interaction and/or strengthening of other occupational toxics and with the progressive reduction of working capacity. Diagnostic tools available for the detection of alcohol abuse or dependency consist, in acute cases by direct measuring of alcohol on blood, saliva and exhaled air, while in the chronic situations in addiction to the more traditional indicators (AST, ALT, GGT, MCV) there are recently introduced marker (CDT)--or in validation (ethyl glucuronide)--that representing, also with specific questionnaires (AUDIT, MAST, MALT, CAGE), useful integrated tools in the clinical-diagnostic path. The role and contribution of occupational medicine in the management of alcohol related problems is vital and relevant. Must be clear however that these are problems associated with a particular behaviour of the person and not with risks present on work-site.

[Alcohol intake, complex ability and responsibility towards others: experience on a cohort of personnel employed to public transport services]

BACKGROUND

The excessive intake or the abuse of alcoholic substances represent an important hazard's source for the individual health and for the carrying out of any complex working activities, above all if characterized by elevated responsibility toward other people. In this context the recent Provision of 16 March 2006 of the Permanent Lecture for the Relationships among the State the Regions and the Autonomous Provinces of Trento and Bolzano, has individualized bus driver among the activities or tasks of which is forbidden the assumption of alcoholic drinks at work and can performed alcoholic controls by the competent physician (art. 15 of the Law March 30 th 2001, n. 125). Within the normative considering the DM 23 February 1999 n. 88s (Rule bringing norms dealing about the check and the control of the physical and psycho-aptitude ability of the personnel employed to public transport services), we introduced experience growing up in the period from January 2005 to August 2006, on about 1500 employees, for over 90% of men, employed in a public transport company of the Lombardy as bus driver or railwayman.

METHODS

In order to assess driver's alcoholic abuse the analytical determination of carbohydrate-deficient transferring (CDT) has been used as a marker of alcohol intake. Within the visits of hiring in service (equal to 10% of the total one of the effected visits) the determination of the CDT has always been performed, while in revision visits (equal to 90% of the total one) this analytical determination has been performed only if possible alcohol abuse has been hypothesized by elevated values of gamma-GT before the Provision March 16th 2006 (and eventually of MCV, AST and ALT) and of routine from April 2006.

CONCLUSIONS

This experience on this large population has confirmed the importance of a careful behaviours of abuse monitoring in workers with high responsibility toward other people. The CDT values reflect high alcoholic consumption, while is poorly remarkable the contribution furnished by anamnestic questionnaire.

[Health surveillance in workers with a previous exposure to asbestos: a method of retrospective evaluation of exposition]

The medical surveillance of the previously exposed to asbestos like method of retrospective appraisal of the exposure. The medical surveillance of the previously exposed to asbestos is effected on indication of the Competent Physician by the DL 257/2006. An aspect that often countersigns such typology of surveillance is the lack of relative data about past environmental asbestos exposure. There've been submitted to sanitary controls 140 subject employees in a steel metal company where in past activity of heavy carpentry has been developed. All the subjects have been submitted in the period 1998-2007 to medical visit, PFR with DLCO, radiography of the chest, in some cases TC and BAL. The past exposure has been resulted inclusive between 1962 and 1981. None of these workers has developed asbestosis, while the 10% of the subjects have showed bilateral pleural plaques. 12 subjects have been submitted to close examination through BAL for the determination of the internal dose of asbestos with comparison of middle values of 3.9 ca /ml. Four cases of pulmonary neoplasm and any case of mesothelioma have been diagnosed. This experience shows as the medical surveillance of a homogeneous group of workers can furnish useful data also to frame previous asbestos exposure in absence of environmental data.

[Assessment of the efficacy of limitations and indications issued by the occupational physician regarding the health of the staff working in public transportation vehicles]

In this study we assessed the evidence of some specific, "ad hoc", medical indications for city bus, tram and subway professional drivers. As known, professional drivers have very little chances of modifying shift organization and many chronic degenerative diseases (low back pain, diabetes type 2, cardiovascular diseases, ecc.) are difficult to manage according to job planning. In our study we observed a positive association between introduction of specific shift, in particular when shift is divided in two-piece, on morning "turno spezzato 1(0)/1(0)" or one on morning and the second part on afternoon "turno binato 1(0)/2(0)". Evidence of the real impact on professional drivers health conditions has been found from analysis of sickness leave during two, or in same case, one year before and after such medical indications intoduction. In our occupational drivers cohort a positive association, evidence based on real rates of two years sick absence before and after medical indications, was found between improvement of health general conditions and reduction of sickness leave rates correlated.

[The role of the occupational health physician in smoking cessation programmes: the experience of the "Clinica del Lavoro" of Milan]

<<The role of the occupational health physician in smoking cessation programmes: the experience of the "Clinica del Lavoro"of Milan>>.

BACKGROUND

The "Centre for the prevention, diagnosis and treatment of tobacco dependency", set up at the Occupational and Environmental Respiratory Diseases Section of the Clinica del Lavoro in Milan in September 2000, can count on multidisciplinary expertise, including occupational health physicians, pneumologists and clinical psychologists. Each step of the diagnostic and therapeutic process is based on an integrated approach that considers both the biological aspects of tobacco dependency and the psychological and behavioural aspects. The Centre, moreover, within the framework of "Health Promotion" programmes, offers advice to businesses as regards the new legislation that prohibits smoking at the workplace.

METHODS

The proposed treatment programme is based on psychological and motivational support (personal or team work), that can be associated with pharmacological therapy, either as an alternative or an addition. The drug preferred is slow-releasing buproprione, which has proved to be extremely effective compared to other drugs in increasing the probability of smoking cessation and decreasing side effects.

RESULTS

In an occupational population of more than 2000 workers, we succeeded in treating about 51% of the subjects, who had stopped smoking, after one year from the beginning of the programme. The best results were achieved using the association of psychological support and buproprione therapy (54%), compared with the other methods (psychological support alone: 42%; psychological support and free nicotine replacement therapy: 33%).

[Evaluation of the neurotoxic and nephrotoxic effects following long-term exposure to metallic mercury in employed at a chlorine/sodium-hydroxide plant]

OBJECTIVES

Within the frame work of a wide multicentre study, a sub-study was developed in order to explore the occurrence of early effects on the central nervous system, on the kidney and on the neuro-immune system in the workers of a chloro-alkali production plant exposed to metallic mercury at airborne concentration levels lower than 0.025 mg/m3 (TLV-TWA). They were compared to a control population of employees of the same huge petrochemical plant with different job that did not implicate exposure to mercury vapors. Specifically, the study aimed at revealing the occurrence of early effects on the central nervous system related with mercury exposure, as can be assessed through neurophysiological and neurobehavioral tests.

METHODS

The excretion of urinary mercury was measured by atomic absorption spectrometry. The study of renal function was assessed by measurement of the urinary excretion of some high and low molecular weight protein markers (albumin, beta 2-microglobulin, retinol-binding protein, fibronectin, specific proximal tubule brush border antigens, N-acetyl-beta-D-glucosaminidase). The neurobehavioral status of the study subjects was assessed by means of several test parameters (Simple Reaction Time, Color Word Vigilance Test, Symbol Digit, Finger Tapping, Mood Scale of Kjellberg and Iwanowski, Subjective symptoms questionnaire (QSS), Luria Nebraska Motor Scale, Branches Alternate Movement Task and Tremometry).

RESULTS

The values of urinary excretion averaged 12 +/- 8 micrograms Hg/g of creatinine for the exposed workers group (n = 38), while for the reference group (n = 34 cases) urinary excretion was statistically lower, averaging 4 +/- 6 micrograms Hg/g of creatinine. Neither the parameters selected for the assessment of renal functions, nor those chosen to probe the neurobehavioral status of the probands revealed statistically reliable differences between the group of exposed workers (length of exposure: range 1-34 years) and the control group. Nevertheless, some minor but still statistically reliable correlations were found between some neurobehavioral parameters and some demographic variables describing the whole group of tested workers, but not to the level of occupational exposure to mercury.

CONCLUSIONS

The results of the study confirm the lack of toxic effects of clinical importance on the central nervous system and on the kidney for values of mercury urinary excretion lower than the suggested index of biological exposure (IBE) of 35 micrograms Hg/gram of creatinine.

[Aging and work: health aspects in cleaners]

Over the last few years, studies on the relationship between ageing and work have attracted growing interest due to the increased probability among workers of developing major health problems as a consequence of ageing workers. Negative outcomes for health are possible when an age-related imbalance appears between physical workload and physical work capacity. Cleaning could be considered as a paradigm for studying the relationship between ageing and physically demanding jobs. Cleaning workers show a high proportion of ageing women who are at the bottom level of the social-status class and are generally poorly educated with low income and social support level. This study, particularly aimed at highlighting the presence of musculo-skeletal disorders, was conducted by means of standardized questionnaires and protocols for collecting anamnestic and clinical data. The results show an increased prevalence of disorders of elbow, wrist/hand and cervical spine which could be caused by work organization and non-ergonomic tools. On the basis of the experience gained it was possible to propose solutions for the ageing working population concerning the workload, health surveillance methods and the ergonomic measures as regards organization, work place and tools.

[The epidemiology of musculoskeletal changes due to biomechanical overload of the spine in the manual lifting of patients]

The painful lumbosacral symptoms associated with manual lifting by nursing staff constitutes an increasingly important problem in Occupational Health. This category of workers is in fact particularly exposed to risk situations involving the lumbar region of the spine, due especially to the extreme variability of work on the shift, the nature of what is lifted and not always sufficient knowledge and proper performance of the movements. On the basis of a review of a series of studies made on this topic, it was possible to assess the incidence and prevalence of low back pain in selected populations and identify the postural risk to which nursing staff are exposed at work, stressing also the importance of a correct knowledge of manual lifting techniques, frequency and mode of performing them, and the psychological aspects (perception of the intensity of tasks and osteoarticular strain). It was also observed that the data on painful lumbosacral symptoms were underestimated due to the type of epidemiological investigations carried out (mostly cross-sectional) and that comparison of the data proposed was often difficult due to the different criteria of evaluation used to classify the painful symptoms and also to the various epidemiological parameters used (incidence, cumulative incidence, prevalence).