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Occupational injuries (OI) are a relevant issue in workplaces, being responsible for a range of individual and socio-economic consequences, with an enormous toll paid by workers, enterprises and society. Despite all these issues, OI prevention has not received significant field research attention, with studies mainly addressed to reporting data a posteriori instead of evaluating the effectiveness of prevention programs. In addition, the role of occupational physician (OP) seems to be largely underplayed. OP may and should be involved in OI prevention and control, in respect of codes of ethics, current legislation and scientific evidence. A multifaceted intervention in foundries, which showed effectiveness in reducing OI rates and improving quantitative and qualitative outcomes, gave us the opportunity to highlight OP's key role in implementing good occupational health and safety practices in workplaces.

To assess the role of Occupational Medicine in the promotion of workers'health over the last forty years, the author studied the evolution of this discipline from a clinical-diagnostic approach to the current emphasis on prevention. However, it is stressed that in Occupational Medicine even preventive measures are based on clinical methodology, as for example in health surveillance, where the main tasks are the identification of individual hyper-susceptibility and the assessment of early and reversible health effects due to occupational risks. Moreover, the traditional clinical-diagnostic approach is still of utmost importance. In fact, the classical occupational diseases do not present with the specific clinical features of the recent past. Instead, today it is necessary to evaluate whether occupational risk factors play a concomitant role in the origin of diseases that affect the general population. Moreover, new occupational diseases are emerging, due to the continuous changes in manufacturing processes and work organization. To assess the role that Occupational Medicine has played in the binomial expression "disease-health", topics which particularly suit the Author's cultural background are considered and are used as "indicators" of the various scientific, cultural, social, economic, and legislative aspects that contribute to the professional development of Occupational Physicians. Important results have been achieved over the last 40 years, however Occupational Physicians face new problems that impose a continuous updating process, not only on medical topics but also on the development of technological processes. The laws and the recommendations of the most prestigious national and international organizations and the principles of the ICOH Code of Ethics should guide Occupational Physicians in their profession and their actions must imply full professional independence. They must acquire and maintain the necessary competence for their duties and adequate conditions to carry out their tasks according to good practice and professional ethics.

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.

Objectives: To highlight the role of occupational physician (OP) in occupational injuries (OI) prevention and management. To suggest an approach beyond traditional focus on descriptive epidemiology, engineering interventions, administrative aspects of OI prevention. To promote a person- and enterprise-tailored approach, entailing greater attention to human factors and to practical problems of the specific workplace, with a call to a leading role played by OP., Methods and Results: Analysis of the literature on the broader topic of OI prevention revealed thousands of publications; however, only a handful of them mention or describe the participation of OP in OI prevention. While recognizing that literature search is not the proper and only way to appreciate the current role of OP in this field, therefore, it seems necessary to call OP to a stronger effort in prevention and management of OI, through the context of a comprehensive intervention in cooperation with managers, supervisors, safety personnel and workers, focusing on specific needs of each enterprise. The following areas of OP intervention were examined: risk assessment, health surveillance, management, scientific research and health education. Within each of these topics, possible contributions, methodologies, instruments available for the OP were discussed, taking into account the relevant literature. Pathways for practical applications were illustrated, e.g., OI data generation and analyses, predictors of OI, fitness for work, case management, team work, educational issues, first aid, suggestion for OP contribution in specific research questions., Conclusions: OI continue to take a remarkable toll from individuals and society. New multidisciplinary interventions are needed to prevent OI. Focused activities at the single worksite with a central role from OP are definite options. OP is an effective interface between workforce and management and may offer, through a proactive approach, valuable practical and cultural contributions, while respecting technical and ethical guidelines of occupational health professionals.

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.

Background: Firm scientific evidence supports the causal association between malignant mesothelioma (MM) and occupational exposure to asbestos. Risk attributable to occupation varies from 30 to 80% across different populations. The existence of a threshold level below which there is no risk of MM is still debated. A prompt and thorough assessment of exposure is essential to evaluate and manage MM cases, from diagnostic and epidemiological points of view., Objectives and Methods: To highlight the multiple areas of intervention by Occupational Physicians (OP) in MM evaluation and management, to describe an experience of OP in the province of Brescia., Results: The main areas of interest of the OP are exposure assessment, diagnosis (clinical, etiological), medico-legal issues, social consequences, preventive strategies, risk communication, scientific dispute/uncertainties. By means of an active search, the Brescia MM registry, managed by OP belonging to the local health authority observed 309 MM from 1977 to 2003; the local Institute of Occupational Health, hosted in a hospital of national relevance, evaluated about 200 MM in the last decade. The main outcomes of OP activity are the high percentage of direct interviews, individual case management, expert exposure assessment, etiological diagnosis, counselling, medico-legal assistance, better knowledge of occupational risks, enhanced cooperation among health professionals (oncologists, pathologists, surgeons, pneumologists, general practitioners and OP), important contribution to Registries and to epidemiology (estimates of attributable risks, incidence, survival rates), with positive social and scientific consequences (insurance agencies, trade union organizations, public events, teaching opportunities)., Conclusions: This experience highlights the multifaceted role of OP in active research and evaluation of MM cases, in the context of a multidisciplinary approach.

Background: The cardiovascular system can be the target organ of various occupational risk factors. Moreover, cardiovascular diseases of non-occupational origin may be aggravated and/or triggered by working activity., Objectives: To review the importance of cooperation between cardiologists and occupational health physicians, both in making an aetiological diagnosis and in job fitness evaluation., Methods: A review of the literature was carried out., Results and Conclusions: An early aetiological diagnosis allows therapy to be started, timely transfer of workers from the jobs involving risk and application for insurance compensation commensurate with the degree of impairment. The identification of a single worker with occupational cardiovascular disease may represent a "sentinel event" which will permit identification of other workers at risk and other subjects with occupational diseases. Specific job fitness assessment is the final act of risk evaluation and health surveillance. The principal aim is to protect the physical and psychological health status of the worker in relation to his job and to employ him in a job that takes account of his skills. A correct specific job fitness assessment is particularly important when the cardiologist and the occupational health physician work in close cooperation in the rehabilitation and occupational reintegration of the cardiopathic worker.

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.

Occupational medicine: a discipline in constant evolution among debates, didactics, research and clinics. Is the white coat still usefull? Occupational Medicine is a discipline in constant evolution: due to the changes in the technological processes and the prevention measures adopted, the classical Occupational diseases changed their pictures and new diagnostic problems emerge for the Occupational Physician. This specialist, even if he is more and more involved in preventive activities, cannot neglect a deep clinical preparation. In fact, when the Occupational Physician is involved in the field of health surveillance, he must express fitness evaluations that need careful diagnostic procedures. The debates and inside our discipline and between Occupational Health Physicians and other specialists have allowed to reach high level results in many fields of Occupational Medicine, educational, research, clinics, prevention.

Chromosome and biochemical studies were conducted for 18 healthy females occupationally exposed to lead in the manufacture of electrical storage batteries and in 12 comparable female controls. Biochemical indicators of dose (blood lead) and effect (erythrocyte protoporphyrin, delta-aminolevulinicacid dehydratase activity of red blood cells) were significantly different in the two groups. Cytogenetic studies were performed on lymphocytes cultured for 2 and 3 days with phytohemagglutinin to investigate the possible effect of culture time with respect to yield of chromosome aberrations. The results showed significantly increased rates of metaphases with chromatid and chromosome aberrations--excluding gaps--in the exposed vs. controls at both culture times. The yield of abnormal metaphases was higher in the 3-day than in the 2-day cultures, both in the exposed and controls; the difference was moderately significant for controls, while highly significant for those exposed. These results demonstrate the occurrence of increased numbers of abnormal metaphases also in women occupationally exposed to lead, as previously found in males.

The behaviour of blood lead (PbB) and of some indicators of effect (erythrocyte protoporphyrin IX (EP), delta-aminolaevulinic acid dehydratase activity of erythrocytes (ALAD), and urinary delta-aminolaevulinic acid (ALAU)) were studied in subjects who had ceased working with inorganic lead for at least one year. Relations between these indices and chelatable lead (PbU-EDTA (lead in urine after injection of CaNa2 EDTA 1 g intravenously)), a test that is used to evaluate the lead deposits in the body, were also analysed. As a comparison, a group of subjects currently exposed was studied. In the workers with past exposure the PbB values were significantly lower, at the same PbU-EDTA levels, than those found in subjects at work. The relation between EP and PbU-EDTA shows that, corresponding levels of chelatable lead, the values of the erythrocyte metabolite are identical in the two groups. Considering the EP-PbB relation, however, at the same PbB levels the protoporphyrin values appear distinctly more altered in the subjects with past exposure. Similar results were obtained from a study of the relations between ALAD and PbU-EDTA and between ALAD and PbB. The relation between ALAU and PbU-EDTA, however, shows that, at the same PbU-EDTA levels the urinary metabolic in past-exposed subjects is distinctly lower than in subjects at work, while the relation between ALAU and PbB shows that, for similar blood lead values, the ALAU levels are identical. On the basis of the results obtained it is concluded that in subjects with past exposure, EP and ALAD can be used in establishing the persistence and extent of an "active deposit" of lead in the organism, while PbB is of very limited use.

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