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The paper reports 9 cases of mesothelioma diagnosed by means of histology or cytology that were observed among women resident in the Veneto Region, Northern Italy, whose only activity that could involve exposure to asbestos was as rag sorter. These cases are part of a group of about 260 subjects with mesothelioma whose entire working and residential history has been collected. The women worked as rag sorters between the 1940's and 1960's in textile recycling (8 cases) or (one case) at a paper mill where cotton was used for paper production. The work as rag sorter helps to explain the high proportion of mesotheliomas among women with an occupational exposure to asbestos.

The statistical methods used in occupational health studies were evaluated by analyzing the papers published from 1986 to 1990 in the proceedings of the annual meetings of the Italian Society of Occupational Medicine and Industrial Hygiene, in order to calculate the degree of understanding of the readers provided with only one-sided knowledge of statistical subjects and to improve the educational objectives in postgraduate schools of occupational health. Almost 70% of the 1151 articles reviewed contained some kind of statistical analysis: methods more complicated than descriptive statistics were used in about 35%. Student's t test (15%) and chi square (12%) were the most common methods. Other methods were less frequently used, so that it was possible to estimate that the learning of any new method would improve the understanding of about 1-2% of the articles. A wider use of statistical methods in data analysis is recommended; the attainment of a higher level of statistical knowledge should be a priority target in occupational health training.

Introduction: In a previous paper on acceleration of failure time we highlighted the difficulties of the application to the case of mesothelioma of the methodology proposed by Berry. In this contribution we elaborate further on the concept of anticipation/acceleration, taking into account the content of the III Italian Consensus Document., Methods: We analyzed the ways in which the concept of anticipation/acceleration has been proposed and interpreted in the III Consensus Document., Results: We show that the concept of anticipation of the III Consensus Document has to do with incidence (frequency) in a population (and not with acceleration of the pathological process in an individual case), and is a measure which is alternative to other measures of frequency effects. In addition, we show that the same epidemiological result is compatible with causal models where no cases, all the cases, or some of the cases are anticipated., Discussion: This paper suggests that the concept of anticipation measurable through epidemiologic data has to do exclusively with the anticipation of a frequency indicator (more occurrencies and anticipated occurrencies are indistinguishable and alternative concepts) but not with the acceleration of the biological process in individual cases. In causal terms, without a biological support it is not possible to infer from the epidemiologic results if a causal model is in action with no, all, or some of cases anticipated.

Background: In the last few years, the incidence of upper limbs tendon injuries has seen a dramatic increase among workers. Conservative treatment is the first choice to relieve symptoms, allowing a safe return to work. However, the scientific evidence of its  efficacy is widely debated., Objective and Methods: Research and literature review on the efficacy of conservative treatment of upper limbs tendon injuries in occupational settings., Results: A total of 271 references were found on Medline and Embase up to May 2015. 116 papers were excluded, 155 articles were included and the full text read., Conclusions: After a timely diagnosis, a prompt start of the rehabilitation programme and a limitation of complete rest are useful to relieve pain, increase functionality and reduce work absenteeism in the long term. Conservative treatment combinations, such as manual therapy, specific exercises focused on increasing flexibility and muscle strength and specific-gesture training, achieves more significant results than a single isolated treatments. Currently, there is no strong scientific evidence to support prolotherapy and Platelet-Rich Plasma (PRP). However, current promising results will encourage further studies. Awareness among both employers and employees about prevention and risk factors should be enhanced.

Introduction: Taking a publication by Berry in 2007 (3) as a cue, this paper presents in didactic form the topic of acceleration of events as a consequence of a harmful exposure and extends the proposed approach to the case of the asbestos-mesothelioma relationship., Methods: Berry's approach was applied to lung cancer and mesothelioma data., Results: The effects of the acceleration of events are presented as a function of age at onset in exposed subjects, relative risk, scale factor, in addition to age and geographical variability of the relationship between age and mesothelioma rates., Discussion: The discussion regards the general characteristics of the method of acceleration, its meaning and interpretation, and the difficulties associated with its application in the context of diseases with low occurrence; the conditions, applicability constraints, and specific results in the case of mesothelioma; the epidemiologic meaning of acceleration and the difficulties of its extension to individual subjects.

Introduction: In the period 1957/1995 more than 200,000 tons of asbestos arrived at the Port of Livorno. This paper attempts to reconstruct the levels of exposure of the dockers during this period, given the absence of any environmental investigations., Methods: The estimates were calculated using the quantities unloaded annually, the number of dockers, the duration and frequency of the unloading operations, the type of packaging and the background pollution. The Time Weighted Average annual exposure allows calculation of a range of cumulative exposure for each worker with a known period of employment. The working methods were reconstructed interviewing employees and the levels of pollution used in the calculations were partly obtained from published data., Results: Significant doses were accumulated by dockers who worked at the port in the 60's and 70's. Non-coincidence of the period with the highest imports with that of highest exposure is worth highlighting. Since 1980 the annual average exposure levels were well below the level required for granting insurance compensation benefits. This suggests caution in the use of lists of beneficiaries for epidemiological purposes since the statistical power would be very low., Conclusions: The strongest point of the research is the estimated annual TWA exposure that, regardless of the accuracy of the data, does however allow an epidemiological analysis of the cohort for subgroups with different exposure. The twenty-three cases of mesothelioma already recorded in this cohort were first employed before 1966. This method can be used to estimate exposure in other ports, where basic information is available.

Sleep disorders and related diseases are becoming increasingly relevant for the health and wellbeing of the general and working populations. Sleep disorders affect all aspects of health, showing a bi-directionality with health conditions and comorbidity with several diseases. Consequently, sleep disorders may have severe negative consequences both for the individual and the enterprise, as well as for society on the whole, in terms of health, productivity and social costs. When considering the disturbances of the sleep/wake cycle, it is important to distinguish between those connected with endogenous biological factors from those related to socio-environmental conditions, including work, and those associated with mental and physical diseases, that are often associated and interact with each other. Many sleep disorders are still underestimated and under-valued in clinical practice and, to a much greater extent, in workers' health surveillance. The present paper is aimed at drawing the attention of the occupational health physician to some key issues, particularly regarding excessive daytime sleepiness, obstructive sleep apnea syndrome and shift and night work, as well as their implications in terms of health and occupational consequences. Information on the main aspects of clinical diagnosis and health surveillance, as well as risk management and prevention at the workplace, are provided.

Introduction: This paper presents an innovative device for measuring artificial optic radiations (AOR). AOR are required to be measured in accordance with both Italian and European regulations. The traditional measurement methods do not provide a quantitative measurement of the energy affecting the retina and in particular the fovea. Hence, they are not suitable to assess the real risk to the eye. Furthermore traditional methods are not even able to measure the exposure time (in relation to the position of the head with respect to the source)., Materials and Methods: The device permits the acquisition of essential information about AOR source direction and position so as to obtain an evaluation of the relative impact on worker's everyday activity. The device acts as both a wearable personal dosimeter and an instantaneous radiance detector. The main components are: a colour light sensor mounted at the centre of a pair of safety goggles (placed on the same line of the worker's sight) used to determine AOR intensity; an inertial/position sensor used for measuring head position/movement, and lastly a video camera to localize emission sources and generate the background in augmented reality visualization. The device is connected by means of a thin, flexible cable to a datalogger and/or netbook? for recording data., Results: the experiments were carried out in order to evaluate AOR sources during work activity; the results obtained and duly processed are presented in the paper., Conclusion: the aims are to achieve work place safety zoning so as to distinguish unsafe from safe areas, and not only specific dangerous areas, via analysis and integration of the overlapping pieces of information obtained with the proposed device.

Introduction: Obesity is often particularly burdensome for subjects at work and leads to hypertension and diabetes preceded by a low grade of inflammation. Measures to promote health at the workplace can be achieved through periodic health surveillance. Simple parameters such as height, weight, body mass index (BMI), waist circumference (CV), blood pressure (BP), as well as taking into account the type of work and tasks, shift work and smoking, are in fact sufficient to identify the most significant features of the working population so as to adequately design the type of intervention required. The paper describes how a health promotion programme aimed at preventing overweight and obesity was implemented based on analysis of the health surveillance data routinely collected by the occupational physician in an engineering plant in northern Italy., Subjects and Methods: Data on weight, height and BMI were collected for 301 workers with different jobs and shifts in an engineering plant; 32 of these workers, (mean age 44+/-8.4) agreed to undergo a diagnosis and treatment programme at the Obesity and Work Centre of the Clinica del Lavoro in Milan., Interventions and Results: A higher incidence of overweight and obesity was found compared to the national average for similar age classes, therefore meetings were organized at the plant on awareness and information on correct lifestyle and diet targeted for shift workers. The workers who had followed the diagnosis and treatment programme had a mean BMI of 32.6 (SD 2.7) and, considering the parameters investigated, the presence of metabolic syndrome was found in a greater proportion of subjects (62.5%) than the average in our practice (46%) and particularly in workers with three day shifts. CONCLUSIONSThe intervention programme began with assessment of the information obtained in the course of routine periodic health surveillance according to the occupational hazards under study. On the basis of this information it was possible to implement the first awareness campaigns. On completion of the multidisciplinary intervention, which was conducted in collaboration with the occupational physician, two major initiatives were taken: one in the canteen with the aim of improving the nutritional content and type of meals offered to suit the dietary needs of overweight or obese workers, and the other consisted of an agreement with local gyms so as to motivate workers to exercise more. A prerequisitefor this type of initiative is the willingness and understanding of the management to recognize the health of the worker as a priority value.

Introduction: Recently, the National University Council (CUN) recognized the importance of bibliometric indicators in assessing scientific output and the Ministry of Education, University and Research established that the selection committees' decision must be guided by internationally recognized metrics including the impact factor (IF)., Aim: To analyse methods and tools of metrics to assess scientific performance in Occupational Medicine by examining some critical aspects for entry-level positions and academic promotion in the Universities., Methods: By means of different databases (Web of Knowledge, Scopus, SCImago), the h-index was studied to assess the scientific output in the field of Occupational Medicine. The h-index was used as an index of both output and quality of overall output of researchers, disciplines, journals, and countries., Results: Italian scientific output in the Public, Environmental & Occupational Health subject category (h-index = 62) was lower than almost the total of other medical disciplines and, at an international level, is ranked at 12th place (other disciplines ranked 3rd to 9th). Output was 32% compared to that of the USA (other disciplines ranged from 42% and 61%). However, it should be noted that most scientific papers of Occupational Medicine researchers are published mainly in journals of different disciplines (with a higher IF) rather than in journals of Public, Environmental & Occupational Health (with a lower IF)., Conclusion: Assuming that selection committees' decisions will be guided by metrics and will respect the minimum standard proposed by CUN, Occupational Medicine researchers aiming at academic promotion will have good reason to ask themselves not only which journals are most useful but also which journals have the greatest impact. This fact could have profound implications for the future of the discipline.

Introduction: The recently introduced Italian law on the protection of workers' health states that the occupational health physician (competent physician) is required to act according to the Code of Ethics of the International Commission on Occupational Health (ICOH)., Aim: This paper aims at examining the articles of legislative decree 81/2008 dealing with informed consent and confidentiality compared with the corresponding points of the ICOH Ethics Code., Results: Analysis of the relationship between articles 25 and 39 (informed consent) and 18, 20 and 39 (confidentiality) of the decree shows that there are some points of disagreement between the legal requirements and the Code of Ethics, in particular concerning prescribed health surveillance, consent based on appropriate information (points 8, 10 and 12 of the Code) and some aspects of confidentiality (points 10, 20, 21, 22 and 23 of the Code)., Conclusion: Although the competent physician is required to act according to the law, the decisional process could lead to a violation of workers' autonomy.

Background: Training is a key tool to improve prevention and safety management at the workplace. Few studies have aimed at assessing quality of training and its outcomes., Objectives and Methods: This paper describes the rationale, design, content, and evaluation of an ongoing randomized controlled trial aimed at assessing the effectiveness of a training programme designed to reduce the risk of occupational injuries among employees of the wood processing industry., Discussion and Conclusions: Well designed, targeted training programmes could represent a feasible means of reducing work injuries by improving employers' behaviour and attitudes towards safety; nevertheless, these kinds of interventions have a considerable impact both in terms of human resources and in terms of cost. For these reasons, assessment of effectiveness and knowledge-sharing should be considered as essential phases of injury prevention programmes.

Background: In the dynamic context of occupational medicine an increasing number of occupational health problems requires a high-quality standard practice supported by decisions consistent both with ethics and legislation., Objectives: This paper examines the relationship between legal requirements, ethical values and scientific evidence issues in occupational health practice., Results: i) Legal requirements. Italian law states that practice must be evidence-based and comply with the code of ethics for occupational health professionals of the ICOH. ii) Ethical values. The code itself emphasizes that practice should be relevant, knowledge-based, sound and appropriate to occupational risks. Furthermore, the objectives and methods of health surveillance and biological monitoring must be clearly defined and indicator must be chosen according to their relevance and predictive value. Any dilemma arising from the practice should be dealt with according to the ethical principles of health benefit, independence and justice. iii) Scientific evidence. Both the law and the code of ethics require that practice be based on available evidence., Conclusions: Decisions made on the basis of a comprehensive process founded on scientific evidence should result in effective and high-quality outcomes that respect both the law and the rights of individuals and society.

Introduction: A new Italian law aiming at improving and supporting research productivity establishes that evaluation of academic products is a requisite for accessing research funds,for acting as examiner for recruitments and for individual financial benefits., Aim: To analyse the scientific products of full professors of Occupational Medicine in Italian Universities in order to provide a framework for discussing a standard of productivity with objective metric parameters., Population and Methods: Research products of the 40 full professors of Occupational Medicine indexed in the National Library of Medicine PubMed database were identified. By means of l0 different indicators, including the total number of papers, the papers published in journals included in the Journal Citation Reports (JCR), total Impact Factor (IF), the individual productivity of the last 5 years was measured., Results: In the last 5 years 503 scientific products were published, 231 of which in JCR-indexed journals, with a mean individual IF = 16.741. The total number of papers indexed in PubMed, the number of papers included in JCR-indexed journals and the number of papers included in JCR-indexed journal of Public, Environmental & Occupational Health were associated with the overall number of authors (p < 0.001). This observation accounts for the relevance of the research group as a resource predicting qualitative and quantitative outputs. The total number of papers is inversely associated with age (p < 0.03)., Conclusion: High productivity authors have an elevated number of products both in JCR-indexed journals (targeted to a small number of specialists in the field) and in PubMed-indexed journal (addressed to the broad audience of occupational health professionals). The productivity standard of academics of Occupational Medicine should take into account the overall research products within the Public Health field. In addition, the standard should be shared with that of academics of Hygiene and of Forensic medicine in order to address the recruitment policy in the Public Health field

Introduction: Ethical behaviour consists ofindividual choices inspired by knowledge and professional experience derived from the universally acknowledged ethical principles of beneficience/nonmaleficience, autonomy and justice. However, in spite of the unanimous consent on their universal importance, such principles do not usually have the strength of a law., Aim: The recently introduced Italian law on the protection of workers' health represents a novelty because it gives the Ethics Code of the International Commission on Occupational Health legal strength. This paper aims at examining article 25 of legislative decree 81/2008 by comparing the points of the Ethics Code and the Deontology Code of the Italian medical profession., Results: The relationships between the 12 points of paragraph 1 of article 25, the 26 points ofthe Code ofEthics and the 75 articles of the Deontology Code are described with regard to the occupational health physician's duties (i) of collaboration with other occupational health professionals, (ii) of organization and execution of health surveillance, (iii) of recording, securing, transmitting of medical files on workers' health and (iv) of employee and employer information on the importance and meaning of health surveillance.

Background: Statistics on occupational injuries published by INVAIL (National Insurance Institute for Occupational Accidents and Diseases) are not useful to plan appropriate preventive actions in local manufacturing sectors., Methods: The injury surveillance system, developed by Viareggio Local Health Unit, collects data on all occupational injuries that occurred in the Versilia area, by enterprise, worksite and manufacturing sector. Enterprises operating in particular sectors (e.g. shipyards, construction) are classified differently than in the national injury surveillance system. After trend analysis and interpretation of injury data, the main results are available both in electronic and paper format., Results and Conclusions: Surveillance data are used by the Local Health Unit to promote and formulate specific preventive actions, such as: research and development of safer tools, promotion and control of safer use of specific tools, promotion and enforcement of good practices, control programmes in high risk manufacturing sectors and jobs.

Background: Workplace accident investigations place a heavy, time-consuming load on Italian Occupational Health and Safety Units of the National Health Service. Such investigations entail preventative measures, legal proceedings and likely penalties for enterprises. Staff shortages induce Units to reduce investigations in order to implement other preventive goals., Methods and Results: This paper reports the actions that the Veneto Region performed to achieve a uni form treatment by all Units (inter-unit comparison and a new set of guidelines). We also describe a "short questionnaire-based investigation" aimed at encouraging enterprises to make preventive efforts, thereby enabling our staff to manage more events., Conclusions: We suggest and discuss effectiveness indicators for both practices.

Background: Latex allergy is an important medical issue, particularly for some occupationally exposed categories (healthcare personnel). The increase in the number of cases reported, occurred as a consequence of the diffusion of latex use, prompted several scientific and institutional organisms, both on a local and international level, to create guidelines for risk management in healthcare environment., Objectives: To review and compare, more than ten years after the first official guidelines, the directives on latex allergy currently used in different countries and in the Italian regions., Methods: We used the references contained in the relevant literature and in the regulations concerning prevention of latex allergy., Results: Epidemiologic data, together with the recent decrease of the number of papers on latex allergy, suggest a relevant, but still unsatisfactory reduction of the problem., Conclusions: In the light of a recent study performed by National Health Service (NHS) in UK, we point out the need for a critical evaluation of the real application of the existing guidelines, which are often formally present but left unattended in the daily hospital practice.

Background: Road traffic injuries constitute one of the main causes of death and disability in Italy and in the European Union. Occupational medicine should pay special attention to the field of road transport because every year a large number of road accidents occur with fatal outcomes. Via health surveillance the occupational physician can play an important role in the prevention of such events., Objectives: The aim of the article is to summarize the results of the most recent studies on the main risk factors for road transport safety and discuss possible strategies of health surveillance, according to the recent indications of the European Agency for Safety and Health at Work, Bilbao., Methods: A review of the literature was made., Results and Conclusions: The scientific literature provides a large amount of interesting information on the most important risk factors for road accidents, such as drinking and drug abuse, sleepiness and other medical conditions, or excessive speed. The presence of numerous and varied hazards for road transport safety requires, as suggested by the Bilbao Agency, the adoption of occupational health measures, including risk assessment, health education, technical and environmental prevention, health surveillance and clinical interventions (diagnosis and rehabilitation of occupational accidents). Moreover, the paper stresses the need to strengthen collaboration between occupational health physicians and other medical specialists.

Background: Italian law requires that occupational physicians for workers exposed to ionizing radiations consider carefully increased sensitivity to cancer in order to define fitness for work. Cancer risk from radiation is proportional to radiation dose, consistent with the so-called linear no-threshold hypothesis., Objectives: The aim of this paper was to estimate the annual dose limit for ionizing radiation exposure in workers hypersensitive to cancer so that the occupational risk of cancer is the same as that of reference workers., Methods: Relative risks of developing cancer in several situations are multiplied by radiation-induced cancer nominal risk coefficients (ICRP Recommendations) to give cancer sensitivity predictions. It is then possible to estimate the annual dose limit reduction., Results: Examples of annual dose limit (personalized dose limit) were estimated in several situations in which individuals are prone to cancer or are cancer survivors., Conclusions: personalized dose limits makes it possible to define fitness for work and avoid exclusion of these individuals from work.

Background: The biotechnology industry has expanded greatly in the last 20-30 years and has led to a number of applications in different sectors of work, i.e., medical and pharmaceutical, agricultural, chemical, energetic and others. Nowadays hundreds of thousands of workers worldwide are employed in biotechnology plants. Health and safety issues related to such working activities are considered as relevant to workers as well as to the general public. In particular, when compared to traditional biotechnology, modern methods of processing microrganisms have given rise to public concern that they might generate hazards to human beings and to the environment., Objectives and Methods: After summarizing the most important products and fields of application, the paper sets out to detail potential adverse effects for the health of biotechnology workers; in addition, an analysis of the literature highlights the various concepts of primary and secondary prevention., Results and Conclusion: Along with occupational risk factors common to other working activities (i.e. the well-known physical and chemical hazards), the peculiarity of handling microrganisms and/or different biologic systems may induce infections, immunological alterations or non-infective and non-immunologic toxic reactions in the workers involved The need is emphasized for an accurate risk assessment, careful control by means of the current monitoring strategies and implementation of the confinement measures, taking into account the criteria set by Italian legislation for occupational biological risk. Lastly, attention is focussed on examinations for the medical surveillance of workers at risk.

Background: Mount Reventino, a massif located in the Calabria Region of Italy, has several ophiolite outcrops of greenstone. These deposits are an important economical resource in the surrounding area. Some rock layers contain tremolite, a type of asbestos fibre., Objectives: The aim of this paper was to analyze the chemical and physical structure of the outcrops of Mount Reventino, and to assess and reduce the risk to workers associated with exposure to airborne fibres., Methods: Personal and environmental samples were collected and analysed by Scanning Electron Microscopy equipped with energy-dispersive X-ray analysis., Results: The analysis of samples showed a difference in mineralogical features not only between the quarries under study, but also between the two opposite sides of the mountain. Exploitation of the quarries produces a fibre dispersion that is higher than the natural emission. Occupational exposure to asbestos fibres during greenstone transformation was confirmed by by the results of analysis of the collected samples., Conclusions: This study made it possible to identify working activities with highest exposure to asbestos and establish the correct procedures to abate fibre dispersion, in order to reduce the correlated risk. Environmental samples collected in the urban area surrounding the quarries showed that the asbestos fibre concentrations were very low, however, further studies are needed in order to confirm these findings.

Background: Knowledge of the results of studies on effectiveness of preventive interventions is a fundamental requirement in occupational medicine., Objectives: The aim of this review was to identify Italian scientific production regarding this issue in the proceedings of the Italian Society of Occupational Medicine and Industrial Hygiene congresses over the last fifteen years., Methods: An initial selection of the communications on intervention effectiveness studies was performed on the basis of titles, aims, tables and figures of each single presentation. A further selection was made via full reading of the previously selected communications. The selected articles were classified by type of strategy discussed, production sector, study design and several other criteria., Results: 108 studies were selected out of the 3215 papers (3.4%) published in the congress proceedings examined (1989-2003). More than half of these discussed technical control strategies. In the vast majority of cases, the study design was a pre- and post-evaluation of effectiveness, and the 6 (non-randomised) trials concerned vaccination programmes. Almost a quarter of the studies on accident prevention regarded the effectiveness of training programmes. Only 5 studies could be detected in Medline as articles later published in international journals., Conclusions: On the basis of the Italian Society of Occupational Medicine congress proceedings over the last 15 years, the percentage of communications concerning effectiveness of preventive interventions in occupational health was 3.4%. Intervention effectiveness papers published in congress proceedings seem to reveal a quite unexpected production of effectiveness evaluation studies. Nonetheless, recommendations need to be made to improve study design and to promote effective prevention and control strategies.

Background: In Italy, almost one thousand deaths due to occupational accidents are usually registered by INAIL each year. Case registration by INAIL has merely administrative purposes and therefore it is necessary to use other sources for case ascertainment in order to better estimate the real number of deaths related to occupational accidents, as shown also by previous papers., Objectives: Evaluation of the contribution of another data source, namely the Tuscany Regional Mortality Registry, to obtain the correct figure for occupational accident deaths through the use of a place-of-occurrence notation on the death certificate., Methods: Cases that occurred in residents in Tuscany in 2000-2001 were considered. They were identified from : a) the Tuscany Regional Mortality Registry (RMR) using the E code of the ICD LX code of death, the year and place of occurrence; b) the INAIL archive using the year of event, the type of definition and management., Results: The INAIL source was without doubt the most informative but was only 51% complete, whereas the RMR source, although less informative, was more complete (82.4%) and allowed identification of cases not registered by INAIL, that had occurred for instance in the Armed Forces and in the National Railway Company. However, the vast majority of RMR extra-cases occurred in subjects aged 65+, in agriculture and in the building industry., Conclusion: It is currently possible to plan a systematic linkage of the two sources due to the new possibilities that are available: the place-of-occurrence in the death certificate and the availability of individual data in the INAIL source.

Introduction: The Italian Occupation and Safety Act (d.lgs 626/94) provided for the establishment of a nationwide occupational cancer registry, under the National Institute for Occupational Health and Safety (ISPESL), with the aim of detecting cancer cases of occupational origin and estimating the influence of occupation in cancer causation., Methods: Information on cancer cases, drawn from six Italian population-based cancer registries (CRs of Friuli Venezia Giulia Region, Genoa Town and Genoa Province, Macerata Town, Umbria Region, Varese Town, Veneto Region), and on a random sample of population controls selected in each CRs area were linked with data on subjects employed in private enterprises that have been available in electronic form since 1974 at the National Institute for Social Security (INPS). In this way, both for cases and controls, the occupational histories of past employment were collected. A population-based case-control study covering the period 1990-1998 was carried out with the aim of estimating occupational cancer risk in the private sector by site and economic category in each area. Since one of the major drawbacks of this approach is the difficulty in distinguishing true occupational hazards from incidental findings derived from multiple comparisons, an extensive research of occupational literature was carried out, independently of the study results, to compare our results with existing knowledge on occupational risks., Results: Pooled analysis of the most recent incidence data based on 36,379 cases and 29,572 controls was performed; 34 "statistically significant" associations were found for 11 economic categories. Using our literature review, 10 associations were supported by more than 5 publishedpapers, 14 by a number of papers between 1 and 5, and 10 associations had not been previously reported., Conclusions: This system appears suitable for assessing existing occupational cancer risks and can eventually lead to detecting occupational hazards in many areas of Italy. The system can also provide a list of cases suitable for in-depth search for past occupational exposures.

Background: For a few years now in Italy there has been wide discussion on the advisability of developing health surveillance programmes for workers who were exposed to occupational carcinogens in the past (incompliance with Italian D.Lgs. 626/94, art. No. 69). The purpose of the present paper was to contribute to the discussion on operative guidelines for public or private Occupational Health Services intending to address this issue., Methods: A cross-sectional survey was undertaken on former workers of a glass factory located in Leghorn, Italy. Six hundred and seventy-seven workers discharged in the period 1/1/1942 - 30/6/1992, with at least 1 year of service, resident in the area of Leghorn, were identified from the personnel records of the company and invited to medical examination at the local public Occupational Health Service. A structured questionnaire was developed in order to standardize the collection of occupational and health histories., Results: 370 subjects were examined and for each of them occupational and health histories were collected. Occupational exposure to carcinogens in the factory in the last decades was reconstructed using the workers' occupational histories and the available plant records: 3 periods with different production activities (1942/49, 1950/69, 1970/92), and 4 main carcinogens (asbestos, PAH, silica and glass fibres) were identified. Thirty cancers were recorded and 10 of these were occupationally related., Conclusions: The health survey allowed occupational exposures to carcinogens to be defined in a factory where historical environmental data were not available. It was also possible to assess individual past occupational risk and provide information to each former worker on his risk, on available preventive measures, and on possible diagnostic, therapeutic and insurance procedures available in relation to diseases related to the different hazards. Via this survey it was also possible to identify and notify the Italian Institute of Insurance against Occupational Diseases and Accidents of 6 cases of bladder cancer, i.e., cancers with long survival that would be impossible to identify via current health data bases.

Background: It was considered appropriate to update of the significance and use of the different mercury exposure indicators., Objective: The aim of the this paper was to correctly select biological media and sampling time and to understand the toxic kinetics of mercury for assessment of accurate biological monitoring., Results: It was confirmed that mercury in blood (B-Hg) is a good indicator of recent exposure, while urinary mercury (U-Hg) indicates current exposure when mercury reaches the renal steady state. B-Hg values are greatly influenced by fish consumption, while the variables influencing U-Hg values are amalgam fillings, commercial gamma-globulin preparations, vaccines, topical remedies, environmental pollution and hobbies, occupational exposure and, partly, fish consumption. The speciation of mercury (Hg0, Hg++, methylmercury and ethylmercury) in biological media, should provide additional and important information in evaluating mercury toxicity., Conclusion: It was stressed that the appropriate choice of exposure indicators has to take account of the different variability factors and the characteristics of the toxic kinetics of mercury. The results of biological monitoring must be compared with references values, which are generally in the order of several micrograms/g creatinine, and limit values such as ACGIH BEI (U-Hg 35 micrograms/g creatinine and B-Hg 15 micrograms/l) or the DFG BAT (U-Hg 100 micrograms/l and B-Hg 25 micrograms/l).

This paper, as a contribution for the centenary celebration of the establishment of the "Clinica del Lavoro Luigi Devoto" in Milan (Italy), presents a brief 30 year history of the activities of its Department of Occupational Epidemiology. Studies and methodological contributions that characterized the first decade of activity are presented and grouped under the heading of analysis of known health effects. The second decade was dominated by the studies and activities that originated from the Seveso accident (dioxin), with an initial interest towards molecular epidemiology, which became increasingly relevant during the third decade when we addressed topics like melanoma, lung cancer, and benzene, in addition to dioxin. More traditional occupational approaches were not dismissed and cohort mortality studies are currently under way (textile dyeing and finishing industry, sulfuric acid, tetrafluoroethylene). Pros and cons of the epidemiologic approach are discussed in the context of occupational health and the strength of its methodological apparatus is suggested as a fundamental tool for studying adverse occupational health effects. In contrast, it is stressed how occupational epidemiology has been poorly used in the application of law 626/94. Considering that contemporary epidemiology is much more inclined towards the discovery of new work-related risks (electromagnetic fields, air pollution) than the description of known health effects, the paper suggests that occupational epidemiology enlarge its interests: people and environment outside the factories might be good candidates for study.

Background: The Tuscany Mesothelioma Register (ARTMM) records pleural malignant mesothelioma cases of Tuscany residents, diagnosed by histological, cytological, or clinical (radiography or computerized tomography) examinations. The ARTMM began in 1988 and estimates mesothelioma incidence in Tuscany and collects information on past asbestos exposure of mesothelioma cases., Objectives: The aim of this paper was to describe the incidence of pleural mesothelioma cases in Tuscany and to analyse their possible past asbestos exposures., Methods: We considered pleural mesothelioma cases recorded in ARTMM in the period 1988-2000 and interviews collected for these cases. In order to identify past asbestos exposure in the occupational and non-occupational history of patients, interviews were carried out using a standardised questionnaire., Results: In the period 1988-2000, 494 pleural malignant mesothelioma cases were recorded in the ARTMM; 82% were males. In the periods 1988-1993, 1994-1997, 1998-2000 the incidence rates, standardised on the Italian population (per 100,000), were respectively 1.15, 1.57, 2.58 among males; 0.29; 0.27; 0.29 among females. Information on occupational history was collected for 418 mesothelioma patients (85% of recorded cases): 173 mesothelioma cases were directly interviewed; for 245 cases relatives or work colleagues were interviewed. Occupational asbestos exposure was ranked as certain, probable or possible in 72% of the interviewed cases (80% of males; 20% of females). Environmental and non-occupational asbestos exposure was identified in 1% of males, and 3% of females. In 24% of the interviewed cases (15% of males; 74% of females) no known asbestos exposure was identified. Occupational asbestos exposure occurred in maritime activities (shipyards, dock work, merchant and regular Navy), the building industry, railway carriage construction and maintenance, rail transport, textile industries (mainly rag sorting), electricity production, asbestos cement manufacture, chemical, iron and steel industries and in glass manufacturing. In Tuscany two areas are distinguished for their well-documented and massive use of asbestos: the coastal areas (Livorno and Massa Carrara) for maritime activities, and the areas of Pistoia and Arezzo for railway carriage construction and repair. Mesothelioma incidence rates in these areas are the highest in the whole region., Conclusions: Further investigation is needed in order to identify unknown asbestos uses and consequent exposure, in particular for females. Uncertainty as regards occurrence of asbestos exposure persists in the textile industries where the mesothelioma epidemics have not yet declined. Research hypotheses are addressed on the re-use of jute bags previously containing asbestos, therefore collection of further information on periods and methods of this recycling activity is essential.

The principal aims of the project financed by the Italian Ministry of University and Scientific and Technological Research were: to verify if at the current limit values early biological effects can be demonstrated; to identify the levels of internal dose that can cause early effects; to evaluate the non-occupational factors that can contribute to the levels of internal dose. In particular, the mercury intake derived from dental amalgams and fish consumption was considered. The internal dose was measured with the traditional biological indicators (urinary and blood mercury) and with the speciation of a large percentage of biological samples by ICP-MS. The central nervous system, neuroendocrine function, kidney and the immune system were considered as target organs and were examined using previously standardized indicators of effects. Two groups of subjects were included in the study: workers with occupational exposure to inorganic mercury in different industrial settings and control subjects identified from the general population. The first group was characterized by an exposure level to inorganic mercury clearly below the current limit values; whereas the HgU levels of a relevant number of control subjects were similar to those measured in the exposed subjects. The in vitro studies covered several issues: the percutaneous absorption of mercury using skin derived from human post-mortem samples in a standardized model; the release of the metal from dental amalgams in different physiological conditions of the oral cavity; the effects of increasing doses of mercury chloride on tubular renal cells. The project was realized with the cooperation of seven Research Units from six Italian Universities. Researchers belonging to Departments of Occupational Medicine, Industrial Hygiene, General Pathology, Biochemistry, Odontology, and Biostatistics were involved to achieve a multidisciplinary approach. The results of this research project are described and discussed in the following papers.

Aims: This paper reviews the studies, both in vivo and in vitro, carried out for the project on low-dose effects of inorganic mercury, financed by the Italian Ministry of Universities and Scientific and Technological Research., Results, Comments and Proposal: The results offer both innovative aspects and potential practical applications. Particular attention is drawn to the reliability of biomarkers of exposure [mercury in urine (HgU) and blood (HgB), possibility of speciation] as well as to the availability of guidance values for risk assessment (reference value, action level, biological threshold value). In the general population, HgU and HgB levels are significantly related to the presence of dental amalgams and to fish consumption; nevertheless, such exposure levels do not elicit adverse health effects on renal, immune and nervous functions, according to the markers evaluated in the studies. The present biological threshold values for occupational exposure appear adequate to prevent health effects, considering the immune system, kidney and central nervous system as the target organs. However, possible effects of low doses of mercury on immune and neuroendocrine functions should be further examined; moreover, consideration should be given to the risk of consuming fish species with high Hg content, particularly concerning the renal and central nervous system effects. Finally, further studies should be planned on other potentially important effects, that could not be considered in this study, such as those on prenatal development, the cardiovascular system and the thyroid gland.

The compensation system concerning accidents at work and occupational diseases has been substantially modified by the Accidents at Work and Occupational Diseases Insurance (Amendment) Regulations 2000 which introduced compensation for biological damage. This kind of impairment is already a well known legal and medical concept in civil liability. Therefore, while in the past the generic working capacity was taken into account in order to obtain the impairment percentage, this kind of evaluation is now based on the damage to biological and relational capacities of the person. Thus, while the medical premise evaluated in percentage, i.e. the biological damage, unites INAIL's system with the ordinary system of civil liability, the economic evaluation highlights difference between the two compensation systems. The system as modified by the above mentioned Regulations provides, along with compensation for biological damage, compensation for financial losses caused by psycho-physical impairment, i.e. impairment of working capacity. The legal instruments provided by Parliament to implement the two kinds of compensation (biological damage and financial losses) were passed by the Secretary of State for Employment with Approval of Tables of Impairments, Biological Damage and Coefficients Regulations 2001. Three tables have been approved: the first with impairments in order to have a percentage evaluation of the biological damage; the second with the coefficients to obtain the percentage of impairment to working capacity; the third for the economic conversion of the impairment percentage evaluated with the first two tables. The paper goes over the framework of the new protection system, analyses the instruments for its implementation, i.e. the tables, and explains methods for their application.

The question of appropriate exposure standards for wood dust is addressed by reference to the major health effects, especially sino-nasal cancer, that have been investigated. A review of several key papers on wood dust exposure permits some associations to be made between exposure data and effects, particularly impaired/suppressed nasal mucociliary clearance, according to which it may be suggested, based on available evidence, that a standard of 1.5-2 mg/m3 of total suspended wood dust could reasonably protect against the observed effects. Moreover, data from the literature show that reducing personal wood dust exposures to below 2 mg/m3 is accomplished relatively easily, whereas reducing exposures to below 1 mg/m3 is considerably more difficult and expensive. The exposure level of 1.5-2 mg/m3 is suggested for all wood dusts; it does not seem reasonable at the present time to distinguish between hardwood and softwood because many of the important mortality studies report results based on patients with mixed exposures. The threshold exposure value of 5 mg/m3 for hardwood proposed from 1/1/2003 by Law 66/2000 is deemed to be too high as a health-based occupational exposure limit.

Working activities with exposure to biological agents have become a matter of discussion especially after the introduction in Italy of the Law 626/94, in conformity with the EU directive 90/679/EEC. There are many important biological agents that can have infectious, allergic, toxic or carcinogenic effects on the working population. Large occupational groups are exposed to these biohazards, both in agriculture and industry. Vaccination is one of the most beneficial medical practices, which has led to the eradication of such a devastating human disease as smallpox and the almost total elimination of poliomyelitis. Vaccination is also one of the most cost effective prevention measures applicable in this respect. This paper describes the possible vaccinations that employers should make available to employees exposed to biological risk, according to article 86 of Law 626/94.

The European Union (EU) has recently twice amended the framework Council Directive 90/394/CEE on the protection of workers from risks related to exposure to carcinogens at work: protective measures were extended to category 1 and 2 mutagens; a new carcinogenic agent was identified in "work involving exposure to hardwood dusts" and three exposure limit values were fixed for carcinogens. The EU Member States are required to incorporate amending Directives into national legislation not later than 29 April 2003. Italy acknowledged these directives by the Decree 66/00 of the 25/2/2000. In this paper the development and the evolution of European legislation in the twenty years from 1980 to 2000 are overviewed: first, occupational exposure limits were defined and introduced for harmful chemicals, then for occupational carcinogens and later three binding limit values for benzene, VCM and hardwood dusts were fixed. The paper attempts to identify the expected problems and advantages that incorporation of the amending Directives will have on the protection of workers from carcinogenic risk.

The paper proposes a model for health and safety organization in health care units and hospitals which takes account of the risk assessment procedures required by law and the quality assessment of the measures thus taken. A redefinition is given of the role of Medical Director and of the functions, aims and standards on which health and safety service and the services of an authorized occupational health physicians must be based.

Three hundred years after the first edition of Ramazzini's "De Morbis Artificum Diatriba", this paper reviews all the articles on the work of the great Master of Carpi that have been published over a century in the ninety volumes of "La Medicina del Lavoro". Since the first issue of the journal in 1901, many authors have submitted papers which revisited and commented on the work of Ramazzini, particularly in anniversary years (1914, the anniversary of his death, 1933 and 1983, anniversaries of his birth), but only Luigi Devoto was capable of fully understanding the methodology introduced by Ramazzini, transforming it into practical applications which he listed in ten fundamental actions. Mainly for this reason and considering that Ramazzini had been practically ignored for two centuries, it was decided to consider the Devoto period as the "true Ramazzini era". The death of the founder of the journal in 1935 marked the unexpected beginning of a long silence, lasting up to 1983, during which not one paper on Ramazzini was published in "La Medicina del Lavoro". It is concluded that a comparison between the diseases described by Ramazzini and those of to-day is of no practical use and that a tribute to Ramazzini is simply necessary in recognition of his contribution to the birth and development of occupational medicine, but is nonetheless insufficient. What is also needed, following in the footsteps of the founder of this journal and of the Clinica del Lavoro of Milan, is to reinterpret Ramazzini's methods in modern terms in the perspective of the ten actions he proposed, bearing in mind that possibilities exist to-day whereby his efforts can be completed and further enlarged in terms of practical applications.

In preparing this paper we considered the articles published in La Medicina del Lavoro from 1901, its first year of publication. This scientific journal was founded in Milan, when an animated debate arose in Italy on the necessity of treating and, above all, preventing occupational diseases. In the same city, the "Clinica del Lavoro" (i.e. Institute of Occupational Medicine) was inaugurated in 1910. Its founder, Professor Luigi Devoto, had to overcome numerous obstacles caused by the hostility of the Rector of the University of Pavia--the future Nobel prize winner Camillo Golgi--and the clinicians of the main hospital of Milan, founded by Francesco Sforza in the XV century. From reading a century of articles which appeared in La Medicina del Lavoro, it is clear that for occupational physicians lead is an exemplary topic by which to evaluate the evolution of research in the field of occupational diseases. The numerous pathological features of lead poisoning, the successive therapeutic responses of physicians, and the gradual development of preventive techniques constitute a paradigm that has subsequently been applied to all other fields of industrial toxicology. Reading the papers of 100 years gives a clear picture of the evolution of clinical syndromes over the decades. The pathological picture of lead poisoning gradually became less serious and progressively changed into aspecific, subclinical manifestations. The categories of workers in which lead poisoning had a high incidence changed over the years: painters, printers and munition makers had the highest incidence in the first three decades of this century; afterwards, those engaged in lead smelting, alloy production, painters, and in the last few decades those employed in battery, ceramic and PVC production. Prevention consisted mainly of early diagnosis of lead poisoning and instruction in proper hygiene measures. Later, in 1929, insurance of occupational diseases was made compulsory in Italy, and among the few risk factors covered by law were lead and its compounds. This law was a great advance not only in the diagnostic and insurance fields but also for prevention. Two aspects of occupational lead poisoning are particularly instructive: treatment on the one hand and the use of laboratory analysis on the other. In treatment, the initial approach was mainly empirical and physicians insisted on evacuation of the bowel. Laboratory analysis started in the 20's with analysis of erythrocytes with basophilic stippling and continued with the study of urinary porphyrins. This was followed by the determination of lead in blood and urine. These tests were used initially as diagnostic tools, and only since the 60's they have been used for biological monitoring of workers for preventive purposes. The identification of indicators of dose, of critical/subcritical effect, and of critical organ started with studies on lead poisoning. Since then, following this model, biological monitoring has been applied to numerous other metals, solvents, and pesticides. The evaluation of the Italian scientific literature on lead over one hundred years in La Medicina del Lavoro has been a very exciting experience. It suggests that knowledge of the evaluation of lead poisoning and lead exposure should be taught to medical students and young physicians, thereby stimulating them to put into practice the maxim that was engraved on the foundation stone of the Clinica del Lavoro: in aliis vivimus, movemur et sumus.

This paper aims to illustrate the conditions selected at the Clinica del Lavoro of the University of Milan to prepare and analyze a large number of fine dust samples produced over a period of about 50 years, that were initially used for studies within the Clinic performed in its own facilities, and since 1956 were sent to other Italian and overseas laboratories (Luxembourg, UK, Germany, Norway, Sweden, South Korea, USA). The total quantity of material distributed (with maximum size 7-10 microns) was about 2 kg and consisted of the following mineral and artificial compounds: quartz, HF-treated quartz, tridymite, HF-treated tridymite, cristobalite, chromite, anthracite, quartz sand for foundry moulds, sand from the Lybian desert, vitreous silica, pumice, cement, as well small quantities of metallic oxides, organic resins, chrysotile, crocidolite, fibres (vitreous, cotton and polyamidic). About half of the entire quantity of dusts produced consisted of partially HF-treated tridymite. Initially, research on the etiology of silicosis used quartz dust samples, simply sieved or ventilated (consisting of classes finer than 0.04 mm, containing a 15-20% respirable fraction). From 1956 to 1960 the dusts were produced by manual grinding in an agate mortar, below about 10 microns, starting from quartz from Quincinetto (near Ivrea, Province of Turin), containing about 99.5% quartz: particle size and composition were checked using an optical-petrographic technique, with identification of the free and total silica content. Subsequently, the dusts used for biological research were obtained by grinding coarse material with a cast iron pestle and planetary mills, agate and corundum jars. The grinding products were sized by means of centrifugal classification, using the selector developed by N. Zurlo, ensuring control of dust size both optically and by means of wet levigators and hydraulic classifiers (in cooperation with the Institute of Mines of Turin Polytechnic School). After 1990 pestles and rotating drum mills with autogenic grinding load were used for grinding: the size of the treated samples was reduced to 0.05 mm and an extremely fine fraction was extracted, smaller than 7-10 microns, which was used for pneumoconioses research. The characterization of the dust produced was in any case achieved by means of preliminary examination under the optical microscope (polarized light, sometimes supplemented with phase contrast), followed by quantitative analysis using chemical/petrographic, chemical diffraction or, more commonly, petrographic/diffraction techniques. Microscopic examination, if necessary supplemented with photo-micrography, was also used for particle size control, for numerical counting and subsequent reference to weight proportion. For all operational procedures the essential data on instruments and methods are reported. During studies on production, separation of fine dusts and their characterization, partly performed with support from the European Community (EEC/European Coal and Steel Commission), the following topics in particular were addressed: connections between particle size and free silica content in the measurable dust size fraction of the grinding products and in airborne dusts; characteristics of the dusts and risk indices in Italian iron and pyrite mines; possibility of abatement of the ultrafine classes of airborne dusts in pneumatically filled stopes by the addition of salts; comparison of the latest dust selectors used within the European Community; influence of the grinding methods on the results of fibrous and soft mineral measurement using X-ray diffraction analysis.

The paper reports the results of risk evaluation of patient lifting or moving obtained from a multicentre study on 216 wards, for both acute hospital patients and in geriatric residences. In all situations the exposure to patient lifting was assessed using a concise index (MAPO). Analysis of the results showed that only 9% of the workers could be considered as exposed to negligible risk (MAPO Index = 0-1.5); of these 95.7% worked in hospital wards and only 4.3% in geriatric wards. A further confirmation of the higher level of exposure of workers in long-term hospitalization was that 42.3% were exposed to elevated levels (MAPO Index > 5) compared with 27.7% observed in hospital ward workers. The mean values of the exposure index were 6.8 for hospital wards and 9.64 for geriatric residences and, although much higher in the latter, both categories showed high exposure. In the orthopaedic departments of the hospitals the values were higher than in the geriatric wards (MAPO Index = 10.1); medical and surgical departments showed values similar to the mean values observed in the geriatric wards. These high values were due to: severe shortage of equipment life lifting devices (95.5%) and minor aids (99.5%), partial inadequacy of the working environment (69.2%), poor training and information (96.1% lacking); only the supply of wheelchairs was adequate (65.8%). All of which points to an almost generalized non-observance of the regulations listed under Chapter V of Law No. 626/94. However, the proposed method of evaluation allows anyone who has to carry out prevention and improvement measures to identify priority criteria specifically aimed at the individual factors taken into consideration. By simulating an intervention for improvement aimed at equipment and training, 96% of the wards would be included in the negligible exposure class (MAPO Index 0-1.5).

The paper reports the results of a study carried out in four hospitals in northern Italy to assess exposure to patient handling and the consequent risks for the lumbar region of the spine. The methods proposed by the EPM Research Unit were used. Altogether, in the four hospitals there were 148 wards and 5596 staff. Of these, 34 wards and 510 workers were examined. The results of exposure assessment showed that the obstetrics departments had negligible risk (MAPO Index 0-1.5), urology and general surgery departments an intermediate risk (MAPO Index 1.51-5.0), while the departments of medicine, orthopaedics, neurology and rehabilitation had high risks (MAPO Index > 5.0). Of the 510 workers who underwent physical and anamnestic assessment for spinal disorders, 44% worked in the departments of medicine, which are known to have a high risk The prevalence of subjects who reported episodes of acute low back pain in the last 12 months (11.4%) was 5 times that of a group of workers not exposed to manual load handling (2.3%). Analysis of the same disorder referred to each job showed higher prevalences in the non-nursing staff (technical 25%, general 27%). The frequency of degenerative disorders of the lumbar spine was slightly lower than the figure for the country as a whole (6.7%). It is clear that measures for improvement of the environment are required aimed particularly at installing aids and staff training (for the specific risk factor), also so as to better manage the reallocation of workers judged unfit for patient handling who, in the group under study, were 5%.

The paper reports the results of a study carried out by a Prevention and Safety of Working Environments Service in checking the application of Law 626/94, especially Chapter V, in hospital environments. Via the study it was possible to identify the risks due to manual handling of patients and therefore to manage compliance with the requirements and obligations of the said Law, as regards health surveillance of exposed subjects (programme to ascertain specific job fitness) and development of plans aimed at reducing the specific risks. The project proposed by the EPM Research Unit was submitted to the health administrations via the control service (Prevention and Safety in Working Environments Service) with the aim of experimenting a new method of assessment of risk due to patient handling. In this context, the control service combined enforcement with a more influential role of safety consultant, thereby playing a more modern role of encouraging employers to undertake preventive measures, alongside the traditional role of safeguarding workers' health.

A fundamental part of the prevention strategies aimed at reducing risk due to manual handling of patients is the use of appropriate aids. This paper defines the basic types of aids for hospital wards: patient lifting devices, aids for hygiene and minor aids; and also proposes a procedure for choice of the type of aid: the procedure uses a specific protocol and also analyzes work organization and the environmental features of the ward. The proposed criteria for choice concern in the first place the fundamental requirements of the equipment: safety for operator and patient, simplicity of use and comfort for the patient. Secondly the basic determinants for choice of the type of aid are the type of disabled patient usually present in the ward and the analysis of the movements made in handling patients. On this basis, for each type of aid, the specific features are defined which direct the choice of supply for the various wards that will be adequate and effective both in reducing risk due to manual handling of patients and in improving the comfort of the patients.

This paper is aimed at describing the state of the art with respect to the application of law 626/94, particularly with reference to the activities connected with the use of carcinogens at the workplace. To understand what is going on and what practical activities have been established we found it useful to look for practical examples in the field of carcinogenic risk assessment. We interviewed many colleagues and experts in a non-random sample of situations, and this paper briefly describes the methodological problems encountered and some specific results emerging from eight experiences. The examples described regard both large and small factories, in different fields of activity (chemical and pharmaceutical industries, transport, power production, ...), with different attitudes and traditions with regard to carcinogenic risk assessment, and also with different specific results in terms of risk evaluation. Two among the eight examples reported directly involved the activities performed by private consultants or territorial Public Services active in the field of prevention. The paper concludes with the indication of the problems encountered in the collection of information and with the suggestion that such experiences should be freely presented in the literature, thus offering an opportunity of public discussion and evaluation.

Cytogenetic assays in peripheral blood lymphocytes (PBL) have been used extensively in the last decades to survey human exposure to genotoxic agents. The conceptual basis for this approach has been the hypothesis that the extent of genetic damage in PBL reflects critical events for carcinogenic processes in target tissues. The predictive value of these tests for subsequent cancer risk has been recently evaluated by two cohort studies of cancer mortality and incidence carried out in Italy and in five North European countries. In this paper we report the update of both cohorts. In the new follow-up, a total of 64 cancer deaths out of 2019 subjects in the Italian cohort and 127 new cases of cancer out of 3182 subjects in the Nordic cohort were observed. The cytogenetic endpoints studied were CA (chromosomal aberrations), SCE (sister chromatid exchanges) and MN (micronuclei). In order to take into account the interlaboratory variation of absolute values, the results were trichotomized within each laboratory into three strata: low (1-33 percentile), medium (34-66 percentile), or high (67-100 percentile). The association between chromosomal damage and cancer risk was evaluated through SMR (standardized mortality ratio) for Italy and SIR (standardized incidence ratio) for the Nordic countries. National mortality/incidence cancer rates (age, sex and calendar-year specific) were used as reference. A linear trend of SMRs and SIRs according to CA level was found in both cohorts for the "All Cancers" cause (p < 0.01). In the Italian cohort it was also possible to analyze some specific cancer sites: a significant increase of SMR among subjects with a high level of CA with respect to the general population was found for lung cancers and lymphatic and hematopoietic tissue cancers. Contrariwise, no association between cancer mortality/incidence and SCE or MN frequency was observed. Findings from this study support the existence of an association between CA frequency and cancer risk.

The incorporation into Italian legislation of the European Community directives on the improvement of health and safety at work has promoted a vast effort in order to revise the surveillance approach in many facilities, including hospitals. At the S. Gerardo Hospital in Monza, the required risk evaluation was performed in 1995. The paper here reports the results of environmental and work organization inspection, literature review and the proposal of a surveillance program. S. Gerardo Hospital is a large facility with 2,547 employees. Major structural problems are associated with fire prevention and the continuous change required for the development of a modern hospital. Relevant risk in health care are: biological risk, in particular hepatitis B and AIDS virus, teratogenic viruses (rubella, cytomegalovirus and varicella-zoster) and the renewed possibility of tuberculosis infection, often multi-drug resistant; chemical hazards, in particular use and exposure to antineoplastic and antiviral agents, sterilants like ethylene oxide and formaldheyde; physical risk, well-known for ionizing radiations, but important also for non-ionizing radiations; manual lifting (patients in particular) which makes nurses one of the occupations most affected by low back pain; psycho-social risk, with particular reference to stress in emergency departments and everywhere a strong psychological engagement is required. Also the risk of non-health personnel, office areas, food preparation, housekeeping, maintenance, central supplies and laundry was assessed. Health surveillance programs for the exposed and preventive medicine programs according international standards for all workers are presented.

This paper reviews the assessments reported by the European Commission and the International Agency for Research on Cancer of evidence of carcinogenicity of agents. The aim was to identify the discrepancies in the classification of substances, jobs and occupational exposure situations considered by these two international bodies. This information can be of use in the risk evaluation of workers exposed to carcinogenic agents, as foreseen by Italian Decree No. 626/94.

The paper reports experience of the use of optical and electronic microscope methods for assessment of the concentration of airborne asbestos fibres and their respective identification. The results described are derived from the extensive experience of three Italian university institutes, which have used optical methods of observation for over 35 years (phase contrast technique, at times associated with the use of polarized light) and have examined altogether about 11,000 samples of airborne dust and fibres. After considering in more detail certain values of asbestos fibre concentrations in various environments, measured parallely with optical and electronic microscope, and assessing their basic comparability, attention is drawn to a number of ambiguities and contradictions contained in Law D.M. 6/9/1994, which tends to discourage the use of the optical microscope (especially using the phase contrast technique), without however taking into consideration the improved cost/benefit ratio in the assessment of respirable asbestos fibres present in working and living environments. On this topic, attention is drawn to the fact that the limits for occupational exposure to asbestos, proposed and/or adopted in the international scientific literature, are based on the numerical count of fibres with the optical microscope using the phase contrast technique (MOCF).

Vehicle exhausts are a well known source of aromatic hydrocarbon pollution in urban environments. The paper reports the results of environmental and biological monitoring of benzene exposure in traffic wardens carried out over a 5-hour workshift. Subjects (n = 131) were grouped according to smoking habits and job task as follows: group (A) 52 nonsmoking office workers, (B) 43 nonsmoking outdoor workers, subdivided into (B1) 36 working on foot and (B2) 7 cyclists; (C) 20 smokers office workers, (D) 16 smokers outdoor workers, subdivided into (D1) 11 working on foot and (D1) 5 cyclists. The median indoor environmental benzene concentration (26 micrograms/m3, n = 50) was significantly lower than the outdoor concentration (45 micrograms/m3, n = 43) (p < 0.01); median exposure value of cyclists was 78 micrograms/m3 (n = 12). For biological monitoring, urinary excretion of trans,transmuconic acid was determined in spot samples collected at 7:30 h (MAit) and 12:30 h (MAft). The MAftA median value (63 micrograms/l, range 2-242 micrograms/l) was not statistically different from MAftB (74 micrograms/l, range 15-216 micrograms/l), while the MAftB2 value of 96 micrograms/l was higher than both MAftB1 (71 micrograms/l) and MAftA. In group (B) there was a relationship between airborne benzene levels and MAftB excretion (y = 17.2 + 1.1x, r = 0.62, n = 35, p < 0.01). The influence of smoking on urinary MA excretion was studied by comparing the results obtained in all nonsmokers (AB) with smokers (CD). MAftCD (192 micrograms/l) was significantly higher than MAftAB (69 micrograms/l) (p < 0.01). In smokers, statistically significant relationships were observed between urinary excretion of MAft (y, microgram/l) and cotinine (x, microgram/l) (y = 83 + 0.08x, r = 0.73, n = 23, p < 0.01), and smoking (x, number cigarettes/day) (y = 87.4 + 4.4x, r = 0.53, n = 29, p < 0.01). Comparison between MAft and MAit median excretion values, calculated for each of the 6 exposure groups, showed that MAft was always higher than the corresponding MAit value. A rough estimate of the total dose of benzene ("index of exposure", EI) inhaled by each subject during the 5-hour working shift as a consequence of air pollution and smoking was also made. Considering the entire group of subjects, a significant association was observed between EI and MAft values (y = 43.4 + 0.39x, r = 0.65, n = 104, p < 0.01). Individual values of MA it were correlated with MAft according to the equation y = 43.6 + 0.82x (r = 0.62, n = 105; p < 0.01) and were also positively associated with EI values (y = 42.3 + 0.20x; r = 0.55; n = 74; p < 0.01). In conclusion, the results suggest that the measurement of urinary MA excretion is a poor indicator for assessing environmental benzene exposure at levels below 100 micrograms/m3, such as those seen in this study; MA can however be reliably used as a biomarker for higher exposures such as those, for example, due to smoking.