[Vocational integration of the worker suffering from ischemic heart disease: prognostic factors, occupational evaluation, and criteria for the assessment of their suitability for the specific task]

Ischemic heart disease, even if it has an incidence rate that increases with increasing age, can affect young people of working age. Remarkable progress in the treatment of acute coronary syndrome (ACS) and its complications, while it reduced the mortality due to myocardial infarction in both acute and later stages, on the other hand have contributed to increase prevalence, in people of working age, of ischemic heart disease and chronic conditions of post-ischemic left ventricular dysfunction in the outcomes of previous acute ischemic event. The first stage of the process of job placement is the study of worker health after acute coronary syndrome. After making all clinical and instrumental examinations, the first objective is risk stratification aimed to assess the prognosis of ischemic heart disease. The pathophysiological factors that allow risk stratification and thus constitute the determinants of prognosis after acute coronary event are: the presence of residual ischemia and inducibility of the same threshold; the left ventricular function; the presence of electrical instability and age. Only when the prognostic assessment has defined a low risk profile, an accurate study of work suitability, based both on hearth functional assessment and on work activity evaluation, becomes possible. Occupational assessment must consider, as a central factor (although not exclusive), measurement of energy expenditure required by work activity carried out through ergometric studies, but usually it occurs only in exceptional cases. However, although with some degree of approximation, energy expenditure of most occupational activities may be deducted from appropriate tables and should be regarded as a value "estimates". When the occupational physician has acquired, on the one hand all informations relating to the prognostic evaluation, risk stratification and clinical and instrumental analysis of residual work capacity, on the other hand all data pertaining to the evaluation (with models to "estimate") of energy expenditure of the specific task and data relating to occupational risk factors, he can compare the two groups of data. In the matching process, alongside the essential elements of judgment collected, criteria based on work physiology and on cardiac rehabilitation are necessary. It is assessed that a person is able to play for 6-8 hours continuous employment with consumption of oxygen equal to 35-40% (critical power - PCRIT) of maximum aerobic capacity (VO2 max) achieved in the ergospirometric test with peak values which must not exceed 2/3 of the maximal achieved. Return to work may be permitted and recommended if the patient's functional capacity is at least twice the energy demands of specific work activity.

[Metabolic syndrome and shift work: study of the relationship in workers of a chemical plant]

Metabolic syndrome is defined by several metabolic factors, related to one another, which induce atherosclerotic pathology. These factors are: visceral obesity, atherogenic dyslipidemia, high blood pressure, hyperglycemia, proinflammatory and prothrombotic state. Shift work is known to be related to a series of organic changes, including increased cardiovascular risk independent factors. The aim of our study is to assess if shift work might be a cofactor inducing metabolic syndrome. 119 workers of a chemical industry have been examinated and been divided in two groups: shift workers and daytime workers. We checked if workers were affected by metabolic syndrome, following the ATP III criteria. The results have been statistically compared. The prevalence of metabolic syndrome is significantly higher in night shift workers comparing to other workers. Among night shift workers metabolic syndrome was found in 28 out of 77 (36,36%); in daytime workers the syndrome was observed in 8 workers out of 42 (19,05%) (DR: 2, 43; 95% CI 0,99 - 5,98; p=0,049). This difference is stronger when only over 40 years old subjects were considered. Our results show an association between metabolic syndrome and night shift work. It is therefore necessary, as primary health safety measure, to verify the presence of metabolic syndrome in night shift workers. All aspects of the syndrome should be studied to prevent disease and its clinical complications. The primary prevention activity should be based on specific information and education programs, particulary aimed at learning about a correct lifestyle.

[Work integration of impaired workers in a type-B social cooperative]

This research aims to evaluate job occupation results of impaired workers in a type-B social cooperative, taking into consideration not only specific occupational risks' analysis and assessment, but also organisational, relational and psycho-social matters essential for their stable job occupation. The impaired workers involved were all those hired by a type-B social cooperative from Jan 1999 until Dec 2007, ie. 16 workers (M 8, F 8), equal to 40% of employees' total number. Every impaired worker has been submitted to preventive health surveillance in order to evaluate the degree of disability and residual job ability in relation to the job tasks suitable for him/her. In order to find available tasks which can be performed by disadvantaged workers, the personnel chart has been analyzed, and 10 of the 16 workers (equal to 62.5%) have been considered fit for the specific task without limitations. The other 6 (37.5%) have been considered capable of the specific task with limitations and/or prescriptions, and for 2 of them (12.5%) a tutorial supervision prescription was also necessary. Among those 6 workers with limitations and/or prescriptions, 4 were psychologically impaired (67%) and 2 were physically impaired (37%). The situation of these 16 impaired workers has been periodically verified and followed up for 8 years. Not only have the fifteen workers continued to perform the task initially considered suitable for their health status, but for some of them (5 workers), an increase in job performance, in both complexity and shift duration, has been observed. Moreover, with the only exception of a psychologically impaired worker who did alternate between good comfort times and occasional disease acute phases, all other workers have shown good and stable gains in psychological and physical health conditions, performing requested tasks not only with efficiency, but also with commitment and motivation. All workers have shown a remarkable improvement in their ability to form relationships, mainly within the work environment amongst colleagues and supervisors, but also in a social and family environment. A special mention is deserved in the case of the only worker hired in our research who left the cooperative after many years of work activity where, after having attended specific professional courses, steadily and successfully joined a company still in the social field but not exclusively dedicated to impaired workers. It may be observed that when one faces the work integration of impaired workers, the usual risk evaluation processes cannot be enough for the reason that these workers, due to their 'disability', find themselves in hypersusceptible conditions in respect to occupational risk factors which are generally acceptable for the other workers. In risk assessment it is therefore necessary to perform an accurate and all-round study in every aspect of the job duty, even around those considered irrelevant which, as a result, may show to be unsuitable to the worker's health status or might alter his/her often precarious psychological-physical condition. In conclusion, in the risk assessment process used prior to the work integration of impaired workers considered by our research, the organisational, relational and psycho-social aspects of work activity have often played a primary role in respect to traditional risk factors usually monitored and evaluated.

[Reactive anxiety crisis: a unique case of work injury]

The present study aims to describe a unique case in view of the disease diagnosed, the conditions of onset and the management by INAIL (Italian National Institute of Insurance for Injuries at Work and Occupational Diseases). A worker, after a verbal, animated dispute with some collegues, had an acute psychiatric agitation attack and went to the nearest emergency room, where he was investigated. No neuropsychiatric alteration was diagnosed, but based on anamnestic data, the physicians diagnosed an anxiety crisis reactive to work environment. A medical certificate for injury at work was produced and sent to the Insurance Board (INAIL). The worker was off work for 105 days diagnosed with a persistent anxious depressive syndrome, secondary to the traumatic event. INAIL reassessed the case later and confirmed only the first 30 days as due to work accident, while the following period was judged as related to affectivity disturbance due to common disease, not to work environment. Our case opens new perspective for the occupational physician in the assessment of ASD as work injury and of PTSD as professional disease, suggesting to give more attention to psychiatric health of workers.