[Health education on occupational risks: a target not yet achieved? Workers' opinions collected via a questionnaire]. / Informazione sui rischi presenti nell'ambiente di lavoro: un obiettivo non ancora conseguito? L'opinione di un campione di lavoratori.

INTRODUCTION: This study collected the opinions of sample of workers, sent to the Department of Occupational Medicine of Brescia Civil Hospital, on the contents and the methods used for carrying out information programs on the occupational risks in their workplaces. METHODS: A questionnaire including three sections has been prepared: in the first section demographic data and information on the job were collected, in the second section the contents of programs on the prevention of occupational risks were evaluated, the third section investigated how these programs have been performed. RESULTS: 250 workers have been examined; 16 self-employed workers have been excluded. Mean length of employment was sixteen years. 29% of workers reported to have received information about the role of the main actors of the prevention in the workplaces according to the Italian legislation; overall 41.8% of workers have been informed both on occupational risks in their factory and specific job-related risks, potential occupational diseases and working procedures to prevent these risks. 7.2% of workers did not receive any information on occupational risks. 24% of subjects referred the involvement of the occupational physician in the information meetings. 55% of these meetings lasted more than 60 minutes and included frontal lectures and the delivery of information leaflets; learning assessment was referred by 50% of the workers and 77.9% considered the information (contents and quality) at least sufficient. DISCUSSION: This study, even if preliminary and based on anamnestic data, pointed out that, at this moment, careful information on occupational risks in the workplaces seems a target not yet achieved. It is desirable to verify in the future the improvement of the quality of information given to workers, following the entry into force of the recent Italian legislation concerning this topic.

Occupational diseases due to allergic and toxic chemicals in health care workers: fitness for work.

The purpose of this review is to suggest job fitness criteria for health care workers exposed to sensitizing or chemical agents. These recommendations are derived from a comparison between previous documents on prevention and management of allergic and chemical risks in health care settings and updated evidence; the job fitness criteria and the main documents on these topics are summarized in tables. Glove allergy, in particular latex allergy, is still a significant problem but we should remember that a wide choice of alternative materials is now easily available; many different alternative health products are also currently available when an allergy to disinfectants or detergents is diagnosed. Hence the prevention of allergic diseases is mostly based on an appropriate choice and use of the gloves and health products according to the specific tasks and possible individual susceptibility; this meets the requirements of the "good health care organization", which translates into lower costs, if possible, as well as the best protection of worker's health. Concerning chemical risk, it should be remembered that during the last 20 years the improvements made in work environments have profoundly changed the mode and the levels of exposure to chemical substances and the current recommendations concerning the management of workers exposed to anesthetic gases, antineoplastic agents and sterilizers/disinfectants significantly differ from those of early 1990s. However, the past prudential guidelines are still valid for formaldehyde.

[Management of occupational dermatitis. Nine years' experience]. / Dermatiti occupazionali: problematiche gestionali. Nove anni di esperienza.

OBJECTIVES: To evaluate management problems concerning 301 workers with occupational dermatitis (OD) referred to the Occupational Health Institute of Brescia in the period 2000-2008. METHODS: We considered gender, age, job, referring physicians, diagnosis, latency between the onset of symptoms and the etiological diagnosis, examinations and tests performed before referral to our Institute. RESULTS: We diagnosed 168 cases of allergic contact dermatitis, 101 cases of irritant contact dermatitis and 32 other forms of dermatitis. 51.8% of the workers had been referred by general practitioners and 45.9% by occupational physicians. The mean latency between onset of symptoms and etiological diagnosis was 36 months and was significantly longer for construction workers (60 months). General practitioners referred workers to dermatologists or allergists and prescribed appropriate treatment more frequently than occupational physicians. We performed specific allergological tests in 292 workers (97%): in 48 subjects the correlation between symptoms and occupational exposure was unclear and was verified more than once, in 29 workers we requested a dermatological consultation due to severe skin lesions. Frequently it was necessary to collect further detailed information on occupational exposure, thereby postponing the diagnosis by about 3-10 weeks. CONCLUSIONS: Management of OD is still not satisfactory due to inadequate information to workers on occupational risks, limited presence of occupational physicians in the workplaces, low quality health surveillance, underestimation of occupational risks by general practitioners who are frequently the main referents for workers, poor collaboration between all physicians involved in OD management.

[Consensus Document. Update on latex exposure and use of gloves in Italian health care settings]. / Documento di Consenso. Aggiornamenti in tema di esposizione a latice e impiego di guanti in ambito sanitario.

This consensus document was prepared by an Italian working group including occupational health professionals involved for many years in the management of glove- and latex-related problems in health care settings. The aim of this document was to address the most significant technical, epidemiological, clinical, environmental and prevention problems related to the use of gloves and latex. The group's recommendations are based on scientific evidence and practical experience but they cannot be considered as final. These topics need to be periodically revised. The following points should be taken into account: glove quality seems to have improved considerably but the information on glove features provided by the manufacturers is often still inaccurate or incomplete; the regulations in force provide that the manufacturers perform tests to supply evidence for the quality of the products but they do not indicate which analytical method should be used and they do not require that the results be reported in the technical data sheets. Thus the manufacturers have only to declare that their products are "in accordance with the rules"; therefore, purchasers should require the manufacturing companies to supply detailed information and verify their reliability. Moreover, the rules should be adapted to higher quality standards; occupational physicians must be involved for the correct choice and purchase of protective gloves; the use of gloves (in particular latex gloves) and latex devices in health care settings should be based on specific criteria: procedures must be available stating which kind of gloves are suitable for specific tasks. When exposure to latex cannot be avoided it is necessary to choose products that have good biocompatibility (e.g., powder free-gloves with low allergen content); once and for all latex powdered gloves should no longer be commercially available! labels for latex devices (including gloves) should report the extractable latex allergen content. Limit values for extractable latex allergens should be established; the use of synthetic rubber gloves should be encouraged since some materials (e.g., neoprene and nitrile rubber) appear to have physical properties and protective efficacy similar to latex, plus good biocompatibility; more studies should be promoted to verify the protective efficacy of new synthetic materials; health care workers should be informed about the advisability and usefulness of using materials other than latex; health care services should not cause additional risks but rather highlight the advantages for workers and patients if the use of latex gloves and devices is minimized.

[Latex exposure and gloves' use in health settings: old and new issues]. / Esposizione a latice e impiego di guanti in ambito sanitario: vecchie e nuove problematiche.

The diffusion of the "universal precautions", promoted in 1987 by the Center for Disease Control and Prevention, dramatically increased the use of latex glove in health care settings for protection against the HIV and HBV. The increased demand caused an increased production of gloves, a reduction in processing time and a different chemical treatment of rubber trees which lowered the glove quality, that means high levels of antigens and high powder content. This situation caused an increase of frequency of allergic (type I and type IV) and irritant reactions to latex gloves in health care workers. Recommendations and guidelines for the prevention of latex allergy in health care settings were available from 1995 both in Italy and in other countries. When properly applied, the preventive effectiveness of these suggestions has been demonstrated, but unfortunately the guidelines are not widely adopted as we could think and the frequency of latex allergy and sensitization in health care workers is not as reduced as it could be expect. This could be due also to the fact that some practical issues are still open, for example: the possibility of assessing the real glove quality and the reliability of information provided by manufacturers that often are inaccurate and incomplete; the necessity to update the regulations in force to higher quality standards; the availability of procedures for the selection, purchase and use of gloves in relation to specific tasks within health care setting; the involvement of occupational physicians in the management of these procedures; clear indications of limit values for extractable latex allergens in medical and common latex devices; the assessment of the real protective efficacy against chemicals and biological agents of new synthetic rubber gloves. An Italian working group of occupational health professionals, involved for a long time in the management of glove and latex related problems in health care settings,finalized a consensus document with practical suggestions and possibly answers to the above mentioned questions.

[Old and new types of sanitary gloves: what has improved?]. / Vecchie e nuove tipologie di guanti in commercio e possibili implicazioni clinico-preventive: materiali e patologie, qualcosa è migliorato?

BACKGROUND: During the eighties a large increase in latex gloves production was observed because of the high demand of gloves in health care settings. In this period a low compliance to minimal quality standard was detected and the poor glove quality was associated with an increase of both irritant and allergic glove-related diseases. Since the second half of nineties health care workers and manufacturers paid more attention to these problems and a trend to a gradual, even if slow, quality improvement was observed. Most frequently powder-free gloves and synthetic gloves were offered on the market. OBJECTIVES: The aim of this study was to highlight what has improved about materials and types of sanitary gloves during the last ten years. METHODS: The information are based on a review of the scientific literature and practical experiences. RESULTS AND CONCLUSIONS: Today a large selection of gloves made of different materials are available and they should be addressed to specific tasks. The review of the scientific literature and the analysis of many technical sheets provided by the manufacturers pointed out a trend to a better latex gloves quality (less chemical additives and generally a lower total protein content); sometimes data about a lower extractable latex allergens content are also available. Unfortunately detailed information on glove composition are not usually provided by the manufacturers; purchasers should require the manufacturing company to give comprehensive information and verify their reliability. Moreover the regulation in force should be adapted to higher quality standards. Powder-free and synthetic gloves consumption has improved but the use of synthetic rubber gloves should be further enhanced since some materials (e.g. neoprene and nitrile rubber) have a good biocompatibility and seem to have physical properties and protective efficacy similar to latex. Moreover allergic reactions to synthetic gloves (some chemical additives) are only occasional.

[Interactions between alcohol and work exposure to chemical substances]. / Interazioni fra consumo di alcol ed esposizione lavorativa ad agenti chimici.

BACKGROUND AND OBJECTIVES: The quite diffused habit of a significant assumption of alcohol drinks, can interfere with the professional exposure to chemical substances. The interaction may result in increasing their toxicity and/or modifying the parameters of the biological monitoring. It may also act as a confounding factor, not only in epidemiologic researches but also at individual level when the assessment of the occupational exposure and/or the diagnosis of an occupational diseases, is under consideration. We review available references in the literature summarizing major scientific evidences. RESULTS: The interaction between the alcohol assumption and industrial chemicals may be toxicokinetic or toxicodynamic. Alcohol can interfere in the processes of biotransformation of xenobiotics and modify the doses and the effect indicators used for the biological monitoring, causing wrong interpretations of the results. The metabolism of ethanol can be altered by the exposures to toxic industrial materials, creating some clinical pictures of alcohol intolerance, like an "antabuse syndrome" or an "degreaser flush syndrome". Professional exposure to carbon sulfide or to dimethylformamides, trichloroethylene as well as to nitroglycerin and nitroglycole ethylenic can produce similar syndromes. Interactions are reported between alcohol and solvents: on toxicokinetic bases for methanol, isopropanol, glycol ether, trichloroethylene, methyl ethyl ketone and toluene; and on toxicodynamic bases for CNS. Also between alcohol and metals there can occur toxicokinetic interactions, like in the case of lead and mercury. Alcohol can also interfere with the biological monitoring of solvents, producing an over-estimation of the exposure. CONCLUSIONS: For the biological monitoring of reported chemical substances, it is suitable to evaluate the biologic indicators in the days in which there is not assumed alcohol. If this cannot be guaranteed, it is necessary to know at least the quantity of the alcohol consumed or at least if the subject is an alcohol abuser.

[Implementation of a health education programme in a sample of hairdressing trainees]. / Applicazione di un programma di educazione sanitaria in un campione di apprendisti acconciatori.

BACKGROUND: Skin and respiratory diseases and upper limb cumulative trauma disorders are common in practising hairdressers but unfortunately also in hairdressing trainees. Recent data showed that prevention by education in this working area is of fundamental importance. OBJECTIVES: The purpose of this study was to assess the knowledge that hairdressing trainees have of the risks present in their workplaces and to apply and verify, the efficacy of a specific educational programm METHODS: The programme was aimed at hairdressing trainees, aged from 15 to 21 years, attending 3 technical schools. The school training was part-time (1 day per week) and was completed in 3 years. Educational meetings were organized during the first year (154 students participated) and two years later at the end of the school training (only 83 students completed the training). The programme included a booklet and 3 self-administered questionnaires: one for the assessment of risks knowledge, work-related symptoms and preventive measures adopted, one for the assessment of long-term learning and one, after two years,for the assessment of changes in daily hairdressing practice, symptoms and preventive measures. RESULTS: At the beginning of the school training all the trainees were working as apprentices, only 76% reported using gloves (powdered latex gloves in 90% of cases) none used respiratory protective devices, 22.7% were atopic. 39% reported work-related skin lesions, 19.5% work-related rhinitis, 5.8% work-related conjunctivitis, 0.6% asthma, 9.1% work-related low back pain and 2.6% shoulder and/or elbow pain. At the end of school training most of the trainees were performing advanced procedures such as hair-drying and cutting instead of shampooing, dyeing and perming; almost all reported using gloves during technical activities and the use of non-latex gloves and skin care products increased; the percentage of work-related skin symptoms was significantly lower but the percentage of work-related musculoskeletal disorders was significantly higher. CONCLUSIONS: At the end of school training hairdressing trainees have a better knowledge of work-related risks and the importance of their prevention. Some changes in hairdressing practice (e.g use of gloves, barrier creams, skin care products) and procedures were evident and were associated with a decrease in work-related dermatitis; in this field the efficacy of specific educational programmes is significant. Nevertheless the increase in musculoskeletal disorders, probably related to the increase in performing advanced procedures (e.g. hair drying or cutting) often characterized by unsafe postures and few rest breaks, could be reduced only if employers too are involved and informed on practical aspects of prevention since, for these risk factors, changes in workplace and work organization are required.

From clinical activities to didactics and research in occupational medicine.

BACKGROUND: The daily practice of Occupational Physicians in the mot industrialized countries suggests that the frequency of traditional occupational diseases is progressively lowering, their gravity is decreasing, and the etiological factors are changing. This trend should be quantitatively and qualitatively verified with ad hoc studies. The information is particularly relevant for Academic Institutions where medical students and residents in occupational medicine are trained. OBJECTIVES: To analyse the trends of clinical diagnoses and health surveillance activities conducted in the last 15 years by an Italian Institute of Occupational Health, and to gain information on the most relevant topics to be taught in academic program and to be addressed with future research. METHODS: Data sources were represented by the computerised registration of a) diagnostic activities and b) health surveillance programs, conducted by the Institute of Occupational Medicine of the University of Brescia, a highly industrialized area in Northern Italy. The observation period was from 1990 to 2005. The health surveillance programs regarded workers pulled from an iron foundry, a veterinary institute, a health departments for the assistance of elderly subjects, a nursery schools and a municipal department for road maintenance. RESULTS: Diagnostic activities were conducted on 9080 subjects, who had been referred for suspected occupational disease. The diagnosis of occupational disease was confirmed for 3759 cases. Multiple diseases were diagnosed in 1554 subjects, yielding the total number of 5721 occupational diseases. The most frequent diagnoses accounted for allergic skin disease (23.4%), followed by pneumoconiosis (20.4%), chronic obstructive pulmonary disease (15.9%), noise hearing loss (7.1%), musculoskeletal disorders (6.9%), respiratory allergies (6.9%), cancer (5.9%), miscellaneous (6.4%). When limited to the last quinquennium, the analysis showed a definite increase of muskuloskeltal disorders, cancer, and, although at a lesser extent, diseases due to psychosocial factors. The analysis of the health surveillance programs regarded 1207 workers, and showed that various non occupational diseases caused limitation to individual work fitness. The most frequent conditions were musculoskeletal disorders (65%) and skin diseases (14%). CONCLUSIONS: The results from these two investigations are important not only for the didactic program run by the Institute, but also because they indicate the most relevant topics to be addressed with future research, at least at a local level.

Fitness for work in difficult cases: an occupational medicine experience in a University Hospital.

BACKGROUND: Fitness for work (FW) in certain clinical cases poses significant professional challenges for Occupational Physicians (OPs). OBJECTIVES: to discuss the role of a public Institute of Occupational Medicine (IOM) in FW, thorough description of clinical cases. METHODS: the IOM at the University of Brescia is a public clinic available to general practitioners, OPs, other specialists, insurance companies, health authorities, employers, trade unions. IOM expert opinion on FW may be requested by OPs, employers or workers. In each case, occupational and clinical histories are taken, physical examinations, laboratory and instrumental tests might be performed, and technical and clinical documentation is acquired; expert opinions from other specialists might also be sought. Risk assessment (RA) stems from worksite inspections and information from company health and safety representatives, or health authorities. RESULTS: a few peculiar clinical cases are reported: tremors in a dental hygienist trainee, chorioretinitis in a welder, spasmofilia in a nursing aide, obstructive sleep apnoea in a steel worker, epilepsy in a metal engineering worker, as well as a number of cases fom the same workplace. CONCLUSIONS: FW judgement made by a IOM had several advantages from clinical and RA aspects. Work restrictions may not always be evidence based and it might be difficult to balance rights and duties of patients, employers and OPs; the IOM's wider experience, case discussion with the relevant parties, scientific and technical documentation of diagnostic and FW processes, strengthen the role of the IOM in dealing with difficult cases and as a guarantee from technical and ethical viewpoints.

Prevention of latex allergy among health care workers and in the general population: latex protein content in devices commonly used in hospitals and general practice.

BACKGROUND: In this study the latex protein content in devices commonly used in hospitals and general practice were investigated. The main aim was to acquire information for preventing latex allergy in health care workers and in the general population. METHODS: About 22 different types of medical devices and 23 devices commonly used in general practice were examined evaluating the total allergenic potency by a modified RAST-inhibition assay and quantitative determination of single allergens (Hev b1, Hev b5 and Hev b6.02) by using commercial ELISA kit. RESULTS: A high level of inhibition was found in medical devices, such as elastic bandage (81.57%), tourniquet (74.09%), Foley urinary catheter (68.35%), Penrose drainage (67.25%) and taping (39.6%), and in common devices, such as rubber inner-sole (84.20%), toy balloon (78.62%), latex mattress (74.27%), household rubber gloves (49.10%), working gloves (38.25%), inflatable floating mattress (32.10%). Concentrations of latex extractable proteins and Hev b1, Hev b5 and Hev b6.02 antigens were high in some medical and general devices. CONCLUSIONS: Latex exposure sources were found in hospitals and the home. These findings, though only preliminary and far from conclusive, could enable sensitized persons to avoid risky exposures and prevent allergic reactions. From the point of view of prevention, the time may come when every natural rubber object could be systematically labelled as "containing latex" together with the warning that "this item may cause allergic reactions in sensitized subjects."

[Cardiopathy caused by physical or chemical agents]. / Cardiopatie da agenti chimici e fisici.

BACKGROUND: Occupational cardiovascular diseases do not possess any specific clinical and physiopathogenetic features. OBJECTIVES: The paper summarizes the results of the most recent studies on chemical and physical cardiovascular risks, and assesses the current degree of risk for occupational cardiovascular disease. METHODS: Scientific literature and medline databases on this topic were carefully considered. RESULTS AND CONCLUSION: The scientific literature often provides interesting information on the cardiotoxicity of chemical and physical agents in workplaces; however, a large amount of data refers to high-dose exposures. On the contrary, nowadays exposure conditions have progressively improved and toxic concentrations in air in most cases are below the environmental threshold limit values. In workplaces multiple exposures to different cardiovascular risks, both occupational and non-occupational, are often present simultaneously and these cardiovascular diseases have not been adequately studied in comparison to other occupational organic and systemic diseases. Moreover, possible interferences between occupational cardiotoxic substances and cardiological therapy are still poorly investigated, even though such situations frequently occur.

Prevention of latex allergy among health care workers: evaluation of the extractable latex protein content in different types of medical gloves.

BACKGROUND: Since the 1980s, there has been increased use of latex gloves by health care workers and a concomitant increase of irritant and allergic reactions. The total protein content and the latex allergenic protein content in different types of medical gloves commonly used in our hospital were evaluated to acquire information useful for preventing latex allergy in our hospital personnel. METHODS: The total protein content and the allergic latex protein contents were evaluated with Lowry modified method and RAST inhibition assay in samples and extracts of 29 different types of medical gloves. RESULTS: The highest concentrations of total proteins and allergenic latex proteins were found in examination powdered latex gloves and in surgical powdered latex gloves; a significant amount of latex proteins was found in some brands of nitrile gloves. CONCLUSIONS: The clear association between the total protein levels and the allergenic latex protein levels suggests that the gloves with highest total protein content have the greatest allergenic potential. Therefore, it is recommended that manufacturing companies should provide package inserts including the total protein contents and possibly allergenic latex protein levels. They should declare whether they have added latex to their nitrile glove formulation. RAST-inhibition assays directly on glove samples instead of glove extract seems to be a good reliable and faster alternative for the evaluation of the allergenic potential of latex gloves.