[Deprivation indices in small-area studies of environment and health in Italy]

The use of deprivation indices in small-area studies of environment and health is described, with particular reference to the Italian context. Deprivation indices can represent a proxy for individual deprivation and/or contextual deprivation. In Italy, deprivation indices have been constructed using Census variables. They are applied at census tract level in studies with a local basis; in national based studies, they can be used at municipality level. In SENTIERI Project (Mortality study of residents in Italian polluted sites) an ad hoc deprivation index at municipal level was used (DI SENTIERI). Its strength and weaknesses are discussed. In addition, suggestions about the use of socioeconomic indices in small area studies of environment and health are given. For a description of SENTIERI, refer to the 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI Project.

[Global burden of mortality in Italian polluted sites]

SENTIERI Project has assessed the overall mortality profile in all the IPSs combined, and performed IPS-specific analyses. The epidemiological evidence of the causal association between cause of death and exposure was classified into one of these three categories: Sufficient (S), Limited (L) and Inadequate (I). The procedures and results of the evidence evaluation have been presented in a 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI. Mortality for causes of death with a priori Sufficient or Limited evidence of association with the environmental exposure exceeds the expected figures, with a SMR of 115.8 for men (90%CI 114.4-117.2; 2 439 extra deaths) and 114.4 for women (90% CI 112.4-116.5; 1 069 extra deaths). These excesses are also observed when analysis is extended to all the causes of death (i.e. with no restriction to the ones with a priori Sufficient or Limited evidence): for a total of 403 692 deaths (men and women combined), an excess of 9 969 deaths is observed, with an average of around 1 200 extra deaths per year. Most of these excesses are observed in IPSs located in Southern and Central Italy. The distribution of the causes of deaths shows that the excesses are not evenly distributed: cancer mortality accounts for 30%of all deaths, but is 43.2%of the excess deaths (4 309 cases of 9 969). Conversely, the percentage of excesses in non cancer causes, 19%, is lower than their share of total mortality (42%). Consistently with previous studies, the results suggest that the health status of populations living in the IPSs is worse than what regional averages show. Compared to previous studies, the analysis of the causes selected in SENTIERI, on the basis of a priori Sufficient or Limited evidence of association with the environmental exposures, provides additional information on their role, though some limitations, due to methodology and data used, should be considered.

[Mortality results in SENTIERI Project]

SENTIERI Project (Mortality study of residents in Italian polluted sites) studies mortality of residents in 44 sites of national interest for environmental remediation (Italian polluted sites, IPS). The epidemiological evidence of the causal association between causes of death and exposures was a priori classified into one of these three categories: Sufficient (S), Limited (L) and Inadequate (I). In these sites various environmental exposures are present. Asbestos (or asbestiform fibres as in Biancavilla) has been the motivation for defining six sites as IPSs (Balangero, Emarese, Casale Monferrato, Broni, Bari-Fibronit, Biancavilla). In five of these, increases in malignant neoplasm or pleura mortality are detected; in four of them, results are consistent in both genders. In six other sites (Pitelli, Massa Carrara, Aree del Litorale Vesuviano, Tito, "Aree industriali della Val Basento", Priolo), where other sources of environmental pollution in addition to asbestos are reported, mortality from malignant neoplasm of pleura is increased in both genders in Pitelli, Massa Carrara, Priolo, "Litorale vesuviano". In the time span 1995-2002, a total of 416 extra cases of malignant neoplasm of pleura are detected in the twelve asbestos-polluted sites. Asbestos and pleural neoplasm represent an unique case. Unlike mesothelioma, most causes of death analyzed in SENTIERI have multifactorial etiology; furthermore, in most IPSs multiple sources of different pollutants are present, sometimes concurrently with air pollution from urban areas: in these cases, drawing conclusions on the association between environmental exposures and specific health outcomes might be complicated. Notwithstanding these difficulties, in a number of cases an etiological role could be attributed to some environmental exposures. The attribution could be possible on the basis of increases observed in both genders and in different age classes, and the exclusion of a major role of occupational exposures was thus allowed. For example, a role of emissions from refineries and petrochemical plants was hypothesized for the observed increases in mortality from lung cancer and respiratory diseases in Gela and Porto Torres; a role of emissions from metal industries was suggested to explain increased mortality from respiratory diseases in Taranto and in Sulcis-Iglesiente-Guspinese. An etiological role of air pollution in the raise in congenital anomalies and perinatal disorders was suggested in Falconara Marittima, Massa-Carrara, Milazzo and Porto Torres. A causal role of heavy metals, PAH's and halogenated compounds was suspected for mortality from renal failure in Massa Carrara, Piombino, Orbetello, "Basso bacino del fiume Chienti" and Sulcis-Iglesiente-Guspinese. In Trento-Nord, Grado and Marano, and "Basso bacino del fiume Chienti" increases in neurological diseases, for which an etiological role of lead, mercury and organohalogenated solvents is possible, were reported. The increase for non-Hodgkin lymphomas in Brescia was associated with the widespread PCB pollution. Mortality for causes of death with a priori Sufficient or Limited evidence of association with the environmental exposure exceeds the expected figures, with a SMR of 115.8% for men (90% IC 114.4-117.2; 2 439 extra deaths) and 114.4% for women (90% CI 112.4-116.5; 1 069 extra deaths). These excesses are also observed when analysis is extended to all the causes of death (i.e. with no restriction to the ones with a priori Sufficient or Limited evidence): for a total of 403 692 deaths (both men and women), an excess of 9 969 deaths is observed, with an average of about 1 200 extra deaths per year. Most of these excesses are observed in IPSs located in Southern and Central Italy. The procedures and results of the evidence evaluation are presented in a 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI.

[Scientific collaboration between Istituto Superiore di Sanità and Italian Association of Cancer Registries for the study of cancer incidence in Italian polluted sites]

The collaborative study between Istituto superiore di sanità and Associazione italiana registri tumori (ISS-AIRTUM) aims at investigating cancer incidence in polluted sites for adults and for children (0-14 years) and adolescents (15-19 years) to comment the study results in the light of a set of a priori hypotheses. On the whole, 141 out of 298 municipalities included in SENTIERI Project are served by a Cancer Register participating to the AIRTUM network. For a description of SENTIERI, refer to the 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI Project. The time window of the study is the period 1996-2005. The number of expected cases in each polluted site will be estimated by applying incidence rates of the national pool of cancer registries and of the pool of the geographic macroarea in which each site is located: Northern, Central, Southern Italy and Islands. Cancer incidence in children and adolescents is one of the main priorities of international public health institutions, because of the need to protect childhood health from involuntary exposure to environmental risk factors. Standardized incidence ratios (SIRs) will be computed using expected figures derived from the national pool of cancer registries.

[The contribution of cancer registries in environmental health studies]

Cancer incidence is an outcome of interest in studies assessing the health impact of polluted sites, for which an example is represented by SENTIERI Project. Incidence data are characterized by better diagnostic quality and are not influenced by survival factors, furthermore they allow the investigation of high-survival neoplasms (i.e. childhood cancer) and rare malignancies. Furthermore, the study of incidence is more informative than mortality for non-lethal tumours, therefore it represents an advancement in respect to the study of mortality completed in SENTIERI Project. In the last decade in Italy some environmental epidemiology studies used cancer register data, for example the Biancavilla (Sicily) investigation on fluoro-edenite related mesothelioma and the study in an area of Naples Province where hazardous waste was extensively dumped. In this frame, ISS planned some collaborative studies with Siracusa, Mantua and Ferrara cancer Registries, where three major polluted sites are located. Following these pilot studies an ISS-AIRTUM (Italian Association of Cancer Registries) collaborative study has been planned. For a description of SENTIERI, refer to the 2010 supplement of Epidemiology & Prevention, devoted to the Project.

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.

Impaired decision-making in opiate-dependent subjects: effect of pharmacological therapies

Cognitive dysfunction is a major feature of drug addiction. In the present paper, we compared the decision-making ability using the Iowa gambling task of methadone- and buprenorphine-maintained individuals to non opiate-dependent drug-free controls. Buprenorphine-maintained individuals performed better than methadone-maintained individuals, and not differently than non opiate-dependent controls. In addition, methadone-maintained individuals had more perseverative errors on the Wisconsin card sorting task (WCST) as compared with non opiate-dependent drug-free controls whereas buprenorphine-maintained individuals had intermediate scores. Scores on Weschler adult intelligence scale (WAIS-R) were similar for methadone- and buprenorphine-maintained individuals whereas drug-free controls had significantly higher scores. In addition, both opiate-dependent groups performed more poorly than drug-free controls on the Benton visual retention test (BVRT). The results suggest that buprenorphine in contrast to methadone improves decision-making, and thus may be more effective in rehabilitation programs of opiate-dependent subjects and this improvement may be related to its distinct pharmacological action as a k antagonist.

[Epidemiological survey on smoking habit among young students in Sardinia. A cross sectional study]

The study reports the prevalence of cigarette smoking among 11401 high school Sardinian students. The prevalence of smokers (40.2%) significantly differs between gender (41.1% males and 38.4% females). Males have an early initiation of smoking with an evident addictive effect by age. 54.3% are daily smokers and 21.4% smoke 15 or more cigarettes per day. More than 50% smoke to look grown-up and to be accepted by the group. Besides age (OR=1.10; 95%CI: 1.06-1.15), other factors are associated with smoke: low education level of father (OR=1.08; 95%CI: 1.02-1.15), no maternal support (OR = 1.73; 95%CI: 1.17-2.54), to have at least one smoker cohabitant (OR=1.66; 95%CI: 1.54-1.80) and alcohol drinking (OR=3.46; 95%CI: 3.04-3.93). The smokers' knowledge on smoke topics significantly differ from non smokers. Our results suggest the need of community preventive interventions, diversified for specific target populations, to modify the students' behaviours so that they respect their own health and that of their fellow citizens.

[Cohort study of mortality among leather tanners in the Lower Valdarno area]

BACKGROUND

Epidemiological studies of tanners have shown increased risk for a number of cancer sites, namely: lung, bladder, kidney and urinary organs as well as stomach, intestine, pancreas, nose and nasal cavities, together with leukemias and soft tissue sarcomas.

OBJECTIVE

To study cause specific mortality of leather tanners in Tuscany (Valdarno Inferiore area).

METHODS

The cohort included 4874 workers (4150 males and 724 females) employed in 92 tanneries operating in 1996 (Valdarno Inferiore Tanneries Census) which were also operating on 31-12-1970. Ascertainment of vital status was completed for all individuals on 31-12-1998 (end of follow-up), and the cause of death was known for all deceased subjects. Demographic and work history data were obtained from factory payrolls. Regional mortality rates were used for comparison to calculate SMR (Standardised Mortality Ratio) and 90% Confidence Intervals (CI). In addition to the overall cohort analysis, for men only separate analyses were completed for finishers, chrome tanners and vegetable tanners.

RESULTS

The study showed an increased mortality from lung cancer among finishers, Standardised Mortality Ratio (SMR) 145, 19 observed (obs) (90% Confidence Intervals, 90% CI 95-212), from bladder cancer in the overall cohort (SMR 134, 9 obs, 90% CI 70-233) and among finishers (SMR 125, 2 obs, 90% CI 22-393) and from pancreatic cancer among finishers (SMR 120, 2 obs, 90% CI 21-379). Mortality from lymphoemopoietic cancer is above expected, and the increase is mainly due to myeloid leukaemia, both in males (SMR 208, 5 obs, 90% CI 82-437) and females (SMR 599, 2 obs, 90% CI 106-1887). No deaths from soft tissue sarcoma were observed. A new finding of the study was the increased mortality from cancer of the endocrine glands (SMR 566, 4 obs, 90% CI 194-1297), psychiatric disorders (SMR 195, 6 obs, 90% CI 85-385) and blood diseases (SMR 329, 4 obs, IC 90% 112-752).

CONCLUSIONS

The observations of increased lung cancer mortality among finishers, of bladder cancer in the overall cohort and among finishers, as well as an increase in pancreatic cancer among the latter, confirm previous epidemiological findings among tanners. The increase in myeloid leukemia mortality for both males and females, and the absence of deaths from cancer of the connective tissue, which includes soft tissue sarcomas, are worthy of note. The results should be valued with caution, given the small number of cases and the novelty of some observations.

Update of the follow-up of mortality and cancer incidence among European workers employed in the vinyl chloride industry

Although vinyl chloride is an established cause of liver angiosarcoma, the evidence is inconclusive on whether it also causes other neoplastic and nonneoplastic chronic liver diseases as well as neoplasms in other organs. Furthermore, the shape of the dose-response relation for angiosarcoma is uncertain. We have extended for approximately 8 years the mortality and cancer incidence follow-up of 12,700 male workers in the vinyl chloride industry in four European countries. All-cause mortality was lower than expected, whereas cancer mortality was close to expected. A total of 53 deaths from primary liver cancer (standardized mortality ratio 2.40, 95% confidence interval = 1.80-3.14) and 18 incident cases of liver cancer were identified, including 37 angiosarcomas, 10 hepatocellular carcinomas, and 24 liver cancers of other and unknown histology. In Poisson regression analyses we observed a marked exposure response for all liver cancers, angiosarcoma, and hepatocellular carcinoma. The exposure-response trend estimated for liver cancer in analyses restricted to cohort members with cumulative exposures of <1,500 parts per million-years was close to that estimated for the full cohort (relative risk of 2.0 per logarithmic unit of cumulative dose). No strong relation was observed between cumulative vinyl chloride exposure and other cancers. Although cirrhosis mortality was decreased overall, there was a trend with cumulative exposure.

[The epidemiologist in the court: requirements, professional standards, and deontologic considerations]

This paper examines two issues associated with the activity of epidemiologists who act as expert witness in courts: professional standards and deontologic codes. These issues are to be viewed in the light of the various roles the epidemiologist is called to play in court, as consultant for the prosecutor, the defendant and the plaintiffs. The criteria adopted in court should not differ from the ones usually followed in good epidemiologic practice. Potential conflict of interest that may occur when the personal interest of a researcher leads to introduce bias in his/her/witnes is another relevant issue. Another relevant point is how an epidemiologist deals with his/her colleagues in the courts: diversity in opinions and rigorous critics are acceptable but they must be adequately documented.

Buprenorphine: a controlled clinical trial in the treatment of opioid dependence

Clinical trials carried out to compare methadone and buprenorphine in the treatment of opioid dependence have generally employed an alcoholic solution of buprenorphine, which has a bioavailability superior to that of the tablets. Since the product available for large scale use is in tablet form, one intended to verify the efficacy of this formulation. In a multicentre randomised controlled double blind study, 72 opioid dependent patients were assigned to treatment with buprenorphine (8 mg/day) or methadone (60 mg/day) for a period of 6 months. The two compounds did not show any significant difference with regard to urinalyses: the average percentage of analyses proving negative was 60.4% for patients assigned to buprenorphine, and 65.5% for those assigned to methadone. With regard to retention, a non-significant trend in favour of methadone was observed. Patients completing the trial improved significantly in terms of psychosocial adjustment and global functioning, as ascertained by the DSM-IV-GAF and symptom checklist-90 (SCL-90) scales, and this was independent of the treatment group. Finally, in the case of buprenorphine, patients who dropped out differed significantly from those who stayed, in terms of a higher level of psychopathological symptoms, and a lower level of psychosocial functioning. The results of the study further support the utility of buprenorphine for the treatment of opioid dependence.

[Causality in epidemiology: populations, individuals, and alternative explanations]

The purpose of the present paper is to review issues concerning causal reasoning in epidemiology, with special emphasis on the relationship between observation at the individual and population level. The sequence of the three sections of the paper, causality in epidemiology, individual and population, alternative explanations, reflects the need to deal with issues of research methodology mainly derived from discussions in the frame of risk assessment, decision making, regulation and legal setting. In discussing the aforementioned topics, special attention is given to the attribution of causality to a single exposure in the presence of a plurality of potential causes. As a case study, data concerning the occurrence of hepatic and pulmonary tumors among subjects exposed to vinyl chloride are considered making reference to hearings on this topic which took place in Court.

Cohort mortality study of women compensated for asbestosis in Italy

BACKGROUND

The carcinogenic effect of asbestos is accepted for lung cancer and mesothelioma, while conflicting opinions exist for other cancer sites. The aim of the present investigation is to study cause-specific mortality of women compensated for asbestosis who had certainly been exposed to high levels of asbestos fibers.

METHODS

The cause-specific mortality of all Italian women compensated for asbestosis and alive December 31, 1979, was investigated through October 30, 1997. In the total cohort, which included 631 subjects, 277 deaths occurred. Cause-specific SMRs (Standardized Mortality Ratio) were computed using the national rates for comparison.

RESULTS

A significantly increased mortality for all diseases related to asbestos exposure was observed. Mortality for all causes, all neoplasms, lung cancer, uterine cancer, ovarian cancer, and non-neoplastic respiratory diseases was significantly increased. Separate analyses for textile (n = 276) and asbestos-cement (n = 278) workers were performed. Women employed in the textile industry, mainly exposed to chrysotile, who are compensated at a younger age, showed higher SMRs for lung cancer and asbestosis. Women in the asbestos-cement industry, mainly exposed to crocidolite containing asbestos mixtures, experienced higher mortality for pleural malignancies.

CONCLUSIONS

The role of asbestos exposure in the development of gastrointestinal and genital neoplasms is discussed.

Health and work among women in Italy: an overview of the epidemiological literature

The objective of this paper is to give an overview of the epidemiological studies completed in Italy during the past 25 years, about the role of occupational exposures on the development of adverse health effects on women. The implications for research developments are also discussed. The epidemiological investigations of selected categories of work-related health effects published in Italy in the years 1970-1995 were identified from the medical literature databases. The total number of studies is 142, including cohort mortality studies (n = 12), case-control studies of different neoplasms (n = 14), investigations of adverse reproductive effects (n = 8) and studies of occupational diseases different from the above (n = 94). In most investigations, women workers were not the main study objective and hence the number of females under study was small. The conclusions is that in Italy, given the dearth of studies of female workers and the preponderance of women in many economic sectors, i.e. the textile and shoe industry, health care, personal services and schools, there is a need to identify women workers in the above industries and occupations as priorities for epidemiological research and surveillance.

[An epidemiological study of workers exposed to vinyl chloride in the plants of Ferrara, Rosignano and Ravenna]

The aim of the present study is to investigate cause-specific mortality among male workers employed in vinyl chloride manufacture and polymerization in three Italian plants located in Ferrara, Rosignano and Ravenna. The cohorts include all workers hired between start of operation and, respectively 1985, 1978 and 1985, amounting to 418, 206 and 635 subjects followed up for mortality until 1996 (Ferrara and Rosignano) and 1997 (Ravenna). Cause specific SMRs (Standardized mortality ratios) were computed. Expected figures were obtained from mortality rates for the population resident in the region where the plant was located, for each SMR value a 90% confidence interval (CI) was calculated on the assumption of a Poisson distribution. The study detected an increased mortality for primary liver cancer in all three plants; SMR values were 444 in Ferrara (4 Obs. 90% CI 160-1069), 200 in Rosignano (1 Obs. 90% CI 10-869) and 375 in Ravenna (3 Obs. 90% CI 110-1038). In the pooled cohort liver cancer SMR was equal to 364 (8 Obs. 90% CI 108-390). In one plant, Ferrara, observed mortality was above the expected for lung cancer, SMR = 146 (14 Obs. 90% CI 89-229) and for larynx cancer, SMR = 500 (4 Obs. 90% CI 174-1167). One death from pleural cancer was observed in Rosignano (SMR = 1000 90% CI 47-4331). A non significant increase was detected for liver cirrhosis, in Ferrara (SMR 108, 6 Obs. 90% CI 73-332) and Rosignano (SMR 129, 3 Obs. 90% CI 35-332). The study results are confirming the carcinogenic action of vinyl chloride on the liver, they are pointing to its possible role in lung cancer development, as already shown for workers employed in Porto Marghera; an increased risk for larynx cancer is also shown.

Cancer mortality of art glass workers in Tuscany, Italy

OBJECTIVES

This study considers the cause-specific mortality from cancer among art glass workers employed in 17 industrial facilities in Tuscany, Italy.

METHODS

A cohort of 3390 workers, 3180 men and 210 women, employed at least 1 year, was taken from company payrolls. It was followed between the year each factory started operation, mostly the mid-1950s, and 31 December 1993. The cause-specific expected mortality from cancer was computed for men relative to Tuscany rates, specified for gender, 5-year age groups, and calendar year. Separate analyses were carried out for the job title of maker and former and for batch mixers.

RESULTS

For 3180 men, the observed mortality was above the expected for larynx [standardized mortality ratio (SMR) 166, 90% confidence interval (90% CI) 90-282], lung (SMR 123, 90% CI 100-151), stomach (SMR 105, 90% CI76-142), and brain (SMR 150, 90%CI 71-282) cancer. Increases for these causes were also found for the makers and formers. Mortality from larynx and lung cancer increased with latency, and significantly increased SMR values were observed for > or =21 years since first exposure. The increasing pattern was also present after adjustment for smoking.

CONCLUSIONS

The results showed consistently increased mortality from larynx and lung cancer in the overall cohort and among makers and formers. Stomach and brain cancer was also increased in the overall cohort and among the makers and formers.

Cohort study of art glass workers in Tuscany, Italy: mortality from non-malignant diseases

This investigation studies cause-specific mortality of art glass workers employed in 17 industrial facilities in Tuscany, Italy. A cohort of 3,390 workers employed for at least 1 year was enumerated from company payrolls. Follow-up was between the start of employment in each factory and 31 December 1993. The cause-specific expected mortality was computed relative to Tuscany rates and specified for gender, 5-year age groups and calendar year. Separate analyses were carried out for the jobs of makers and formers and for batch mixers. Among males (3, 180 individuals) observed mortality for non-cancer causes was higher than expected for hypertensive disease [standardized mortality ratio (SMR) = 178, 90% confidence interval (90% CI) = 96-301], pneumoconiosis (SMR = 200, 90% CI = 94-376) and diseases of the genitourinary system (SMR = 169, 90% CI = 95-279). Increases for the above causes were shown also among makers and formers: hypertensive disease (SMR = 182, 90% CI = 85-341), pneumoconiosis (SMR = 250, 90% CI = 109-493) and diseases of the genitourinary system (SMR = 224, 90% CI = 121-380). For batch mixers an increase was present for cerebrovascular disease. The observed mortality for cancer causes was above the expected for cancers of the larynx, lung, stomach and brain. This study points to the existence for Tuscan glass workers of health effects in addition to cancer; previously observed carcinogenic effects were also confirmed.

[A cohort study of art glass workers in the Empoli area]

The investigation aimed at studying cause-specific mortality of art glass workers employed in 17 industrial facilities in Tuscany, Italy. A cohort of 3390 workers employed for at least 1 year was obtained from company payrolls. Follow-up was between the year each factory started operations, mostly in the mid-fifties, and the end of 1993. The cause specific expected mortality was computed relative to Tuscany rates, specified for gender, 5-year age groups and calendar year. Separate analyses were carried out for the job titles of makers, batch mixers and grinders. For males, 3180 individuals, the observed mortality for cancer causes was above the expected for the lung [standardized mortality ratio (SMR) 123, 10 observed (Obs)], larynx (SMR 166, 10 Obs), stomach (SMR 105, 30 Obs) and brain (SMR 150, 7 Obs). For non-cancer causes observed mortality was above expected for hypertensive diseases (SMR 178, 10 Obs) and diseases of the genitourinary system (SMR 169, 11 Obs). Increases for the above listed causes were shown also among makers. Mortality for larynx and lung cancer increased with time since first exposure and significantly increased SMRs were observed for 21 or more years since first exposure: this pattern was still present with smoking adjustment. The results showed consistently increased mortality for lung and larynx cancer in the overall cohort and among makers. Stomach cancer, brain cancer, hypertensive diseases and diseases of the genitourinary system were also increased in the overall cohort and among makers.

Asbestos-related lung cancer mortality in Piedmont, Italy

This study investigates the association between pleural neoplasm mortality, a possible proxy for asbestos exposure, and lung cancer mortality among males resident in Piedmont (northwestern Italy). Pleural neoplasm mortality was estimated in the 1,209 municipalities of the region for the period 1980-1992, applying Bayesian methods. The association with lung cancer mortality for municipalities was studied using Poisson regression. Urban/rural indicators and altitude were also included in the analysis. A positive, statistically significant association was found between pleural neoplasm and lung cancer mortality (beta = 0.025, P < 0.001); lung cancer risk was associated also with urban status (vs. rural, beta = 0.223, P < 0.001) and altitude (P = 0.01). The proportion of lung cancer deaths attributable to living in municipalities with increased pleural neoplasm mortality was 3.9% (95% confidence interval, 2.1-5.7%). The observed association and the presence of a dose-response relationship at the municipality level underscore the dangers of asbestos for human health.

Asbestos-related mortality in Italy: a geographical approach

The present contribution describes two studies of asbestos-related cancer mortality in Italy: an analysis of the geographical distribution of mortality from pleural neoplasms and an investigation into the relationship between pleural and lung cancer mortality in an Italian region, Piedmont. Mortality from malignant pleural neoplasms (ICD-IX Revision 163.0-163.9) has been studied in Italy in the 20 regions and the over 8000 municipalities for the years 1988-92: restriction of analysis to municipalities with at least three observed deaths and statistically significant increases led to identification of areas where occupational and/or environmental exposure to asbestos can have occurred. The analysis of pleural and lung cancer mortality was carried out for the years 1980-87 in Piedmont using an empirical Bayes method for small-area disease mapping; the results showed that the proportion of lung cancer mortality attributable to asbestos exposure was 5.6 and 5.7 percent respectively in men and women. While analyses of routinely collected data are no substitute for ad hoc individual based studies, notwithstanding the limitations of geographical approaches to the study of asbestos-related mortality, investigations carried out at the level of small area populations appear to provide informative results, which might be of value in terms of public health.

Aromatic amines and cancer

Epidemiological evidence on the relation between aromatic amines and cancer risk is reviewed. In particular, cancer risk in humans resulting from exposure to aromatic amines from occupational sources and tobacco smoking is assessed with reference to ecologic, cohort, and case-control studies. Seven arylamines have been classified by the International Agency for Research on Cancer: benzidine-based dyes and MOCA (4,4'-methylene bis 2-choloroaniline) were considered 'probably' carcinogenic, Group 2A, because of a high level of evidence in experimental animals; two occupational chemicals (2-naphthylamine and benzidine), one drug (Chlornaphazine), and two manufacturing processes (manufacture of auramine and magenta) were included in Group 1 on the basis of 'sufficient' evidence of carcinogenicity in humans. Occupational exposures to aromatic amines explain up to 25 percent of bladder cancers in some areas of Western countries; these estimates might be higher in limited areas of developing countries. Aromatic amines contaminate the ambient air as a component of environmental tobacco smoke. There is increasing evidence that the excess of bladder cancer in smokers is attributable to aromatic amines rather than to other contaminants of tobacco smoke such as polycyclic aromatic hydrocarbons (PAH). A modulating role in the risk of bladder cancer associated with exposure to aromatic amines is played by metabolic polymorphisms, such as the N-acetyltransferase genotype, raising important social and ethical issues. The consistent observation of a difference between men and women in bladder cancer risk, after allowing for known risk factors, suggests consideration of gender-related biological determinants for future investigation.

Prohibition of take-home dosages: negative consequences on methadone maintenance treatment

Patients on methadone maintenance were forewarned that a law prohibiting take-home dosages was to be enforced within 6 months. At the end of the 6-month period preceding the enforcement of the law the effect of the anticipated suppression of the take-home privilege was studied on a cohort of 211 methadone-maintained patients on take-home dosages. The outcome of the treatment of these patients was compared to that of a control group of 220 patients at the end of a 6-month period prior to the announcement of the new law. The outcome of the study suggests that the restrictive regulation is counterproductive for retaining patients in treatment.

Studying cancer among female workers: methods and preliminary results from a record-linkage system in Italy

In the context of a national program for occupational health surveillance, we examined cancer mortality among women from two study populations. The Torino Longitudinal Study includes 159,039 women, resident in Torino, northern Italy, 18 to 64 years old and economically active at the 1981 census. The Italian Cross-sectional Study includes 2,038 deaths among 6,073,071 Italian women, 18 to 64 years old and economically active at the 1981 census. Preliminary results indicate that women in higher socioeconomic classes showed excess overall cancer mortality. This excess was almost entirely explained by increased breast cancer among teachers, managers, and public officials. Metal, wood, and clothing manual workers showed a significantly increased risk of ovarian cancer. Some excesses of lung and digestive cancers were noticeable among women in the textile and clothing industry and in the restaurant, bar, and hotel trade. Further study is under way.

Cohort mortality study of rock salt workers in Italy

A cohort mortality study of rock salt workers was carried out in Volterra, Italy. The occupational risk factors identified during environmental hygiene surveys were high noise levels and exposure to dusts and to chrysotile asbestos. The cohort consists of 487 subjects (367 males and 120 females) employed in the mine between 1/1/1965 and 12/31/1989. At the end of follow-up, 387 individuals were alive (295 males and 92 females), and 100 were decreased (72 males and 28 females). For two decedents, the cause of death was unknown. Regional rates were used for the computation of standardized mortality ratios (SMRs). In the entire cohort, observed mortality for all causes was similar to expected (SMR = 98, 100 obs); SMR for all cancer was 127 (41 obs); for lung cancer, the SMR was 146 (10 obs). Two cases of pleural mesothelioma, both in males, resulted in a statistically significant elevation of this cause (SMR = 741, 90% confidence interval (CI) 131-2,332). Two malignant brain tumors were detected (SMR 328, 90% CI 58-1,032); one of these was identified as a secondary neoplasm with consideration of additional clinical information. Among males, mortality for all cancers was significantly increased (SMR = 140, 90% CI 106-192). The observed mortality for malignant tumors of the digestive and the respiratory systems was higher than expected. In women, two cases of malignant ovarian cancer were observed vs. 0.42 expected on the basis of the regional rates. Increased mortality from lung and pleural tumors was consistent with the exposure to asbestos, which has also been shown to play a role in the development of ovarian tumors. The main limitations of this study were the small number of subjects and the definition of exposure solely in terms of duration of employment. Further studies of rock salt workers are needed to elucidate our findings.

Gamma-hydroxybutyric acid for treatment of opiate withdrawal syndrome

In a double-blind placebo-controlled trial, gamma-hydroxybutyric acid (GHB) (25 mg/kg orally) suppressed most of the withdrawal symptomatology in 14 heroin addicts and 13 methadone-maintained subjects. The GHB effect was prompt (within 15 minutes) and persisted for between 2 and 3 hours. Subsequently, the same patients received GHB in an open study every 2 to 4 hours for the first 2 days and 4 to 6 hours for the following 6 days: most abstinence signs and symptoms remained suppressed and patients reported felling well. Urine analysis failed to detect any presence of opiate metabolites. No withdrawal symptomatology recurred after 8 days of treatment when GHB was suspended, and patients were challenged with an intravenous injection of 0.4 mg naloxone. The results indicate that GHB may be useful in the management of opiate withdrawal.

Nitrate and N-nitrosoproline excretion in two Italian regions with contrasting rates of gastric cancer: the role of nitrate and other factors in endogenous nitrosation

Exposure to nitrate and propensity for endogenous nitrosation were examined in 80 healthy males, aged 25-40 years, residing in areas of Italy with long-standing high (Florence) and low (Cagliari) rates of gastric cancer. Nitrate exposure was assessed by measurement of urinary nitrate excretion over 12 hr, and endogenous nitrosation was assessed using the N-nitrosoproline test (NPRO-test). Our hypothesis was whether the geographic variation in cancer rate correlated with nitrate exposure or nitrosating ability. Exposure to background sources of NPRO was significantly higher in the high-risk subjects (phi = 0.04) whereas no differences were found in exposure to nitrate or in urinary NPRO levels after L-proline loading (test NPRO levels). The regional difference in test NPRO was almost completely accounted for by background NPRO exposure. Examination of individual rather than grouped data revealed that exposure to nitrate was a major factor in NPRO formation. No other factors studied (age, dietary-questionnaire-assessed intake of anti-oxidant vitamins) had a significant effect. Geographical variation in gastric cancer risk did not, therefore, correlate with either nitrate exposure or propensity for endogenous nitrosation of L-proline.

[The mortality among the makers of vinyl chloride in Italy]

A mortality study was performed on 5,946 vinyl chloride (VC)-polyvinyl chloride (PVC) workers of the nine Italian plants. The aims of the study were to investigate the cause-specific mortality of workers exposed to VC in production and polymerization stages and to ascertain whether exposure is associated with a higher risk of cancers other than liver angiosarcoma. An incident cohort was enumerated in five plants, a mixed cohort in two and a cross sectional one in the remaining two facilities. Cause-specific Standardized Mortality Ratios (SMR) were calculated for the six incidence cohorts with a sufficiently long follow-up period. Both Italian and regional rates were used for the comparison. A pooled analysis of six cohorts was performed. For deceased persons, information from death certificates was used in the mortality analysis. Additional clinical and pathological data were sought for all decreased individuals (Best Evidence = BE). The results of the study confirm the carcinogenic action of vinyl chloride on the liver but not on the other suggested target organs (i.e., lung, lymphopoietic tissues, brain). A deficit for all causes of death and cardiovascular disease was evident in most cohorts and in the pooled cohort. Analysis of BE data showed a broad spectrum of carcinogenic action of VCM on the liver as demonstrated by the occurrence of both angiosarcomas and other histotypes of tumours.

Nitrate and nitrite exposure in Italian populations with different gastric cancer rates

Exposure to nitrate and nitrite from dietary sources was estimated by questionnaire and measurement of salivary levels of the ions in residents of four regions of Italy with longstanding, contrasting, gastric cancer mortality rates. Whether using salivary levels or dietary questionnaire estimations no association was found between nitrate and nitrite exposure and gastric cancer mortality rates. For salivary nitrate and nitrite, the intra-provincial variation was greater than any inter-province difference. However, for dietary nitrate and nitrite intakes, there were significant differences between the regional groups (but not related to gastric cancer risk). Despite the limitations of the methods used, there was a weak positive association between salivary concentrations of nitrate and questionnaire assessment. Dietary factors are likely to play key roles at different stages of the gastric carcinogenic process. Nitrate may play a part but is unlikely to be a rate-limiting factor in all individuals or populations.

Mortality from liver disease among Italian vinyl chloride monomer/polyvinyl chloride manufacturers

The possible association in humans between nonangiosarcoma primary liver tumors (PLC-non-A), particularly hepatocellular carcinoma (HCC), and exposure to vinyl chloride monomer (VCM) is supported by both experimental and human data. This article presents a review of the information regarding 253 deaths that occurred in seven plants manufacturing VCM/PVC and one plant extruding PVC. The retrieval of clinical and pathological data, in addition to the information from death certificate, is referred to as "best evidence" (BE). BE has been carried out for 63 deaths. A total of 14 primary liver cancer (PLC) were detected: seven were angiosarcoma (PLC-A), and two of the remaining seven were hepatocellular carcinoma (HCC). In our series of 14 PLC cases, there was no significant difference between PLC-A and PLC-non-A as to length of exposure and latency. There was no noticeable difference in terms of job title between ASL and non-ASL cases. The list of longest held jobs shows the presence of various job titles, different from autoclave cleaner, for primary liver cancer, PLC-A and PLC-non-A. In conclusion, our observations show that VCM may have a broader carcinogenicity action on the liver and that exposure lower than that occurring in autoclave cleaning can cause primary liver cancer, both angiosarcoma and nonangiosarcoma.

A cohort study on vinyl chloride manufacturers in Italy: study design and preliminary results

A cohort mortality study of 5000 vinyl chloride manufacturers is ongoing in 9 Italian plants. They represent the entire workforce of those ever employed in the production of the monomer and its polymerization. The objectives of the study are to investigate the mortality of the exposed population and to clear up the carcinogenic spectrum of vinyl chloride. This article gives the results for 3 out of 9 plants, Rosignano, Ferrara and Ravenna, which represent about 25% of the total cohort. The expected deaths have been calculated using the mortality rates of the Italian population. For the deceased persons information from the death certificates were used in the analysis of mortality; additional clinical and pathological data were collected (best pathological evidence, b.p.e.). In Ferrara a statistically significant excess for all malignant tumors and lung cancer was detected. In Rosignano and Ravenna the number of observed deaths were small and therefore no comments can be made on cancer mortality. The cohort study is ongoing in the 6 remaining cohorts and the future analysis will consider duration and level of exposure and latency.