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Purpose There is conflicting evidence on the association between asbestos exposure and bladder cancer. We performed a systematic review and meta-analysis to provide evidence on occupational asbestos exposure and the risk of mortality and incidence of bladder cancer. Methods We searched three relevant electronic databases (Pubmed, Scopus, and Embase) from inception to October 2021. The methodological quality of included articles was evaluated using the US National Institutes of Health tool. Standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) for bladder cancer, as well as respective 95% confidence intervals (CIs), were extracted or calculated for each included cohort. Main and subgroup meta-analyses according to first year of employment, industry, sex, asbestos type, and geographic region were performed. Results Fifty-nine publications comprising 60 cohorts were included. Bladder cancer incidence and mortality were not significantly associated with occupational asbestos exposure (pooled SIR: 1.04, 95% CI: 0.95–1.13, P = 0.000; pooled SMR: 1.06, 95% CI: 0.96–1.17, P = 0.031). Bladder cancer incidence was higher among workers employed between 1908 and 1940 (SIR: 1.15, 95% CI: 1.01–1.31). Mortality was elevated in asbestos workers cohorts (SMR: 1.12, 95% CI: 1.06–1.30) and in the subgroup analysis for women (SMR: 1.83, 95% CI: 1.22–2.75). No association was found between asbestos types and bladder cancer incidence or mortality. We observed no difference in the subgroup analysis for countries and no direct publication bias evidence. Conclusion There is evidence that workers with occupational asbestos exposure have a bladder cancer incidence and mortality similar to the general population.

Hodgkin lymphoma (HL) is today one of the most curable pediatric cancers. Despite survival rates now exceeding 90%, survivors of pediatric HL are still at higher risk to develop late effects of cancer therapy. Premature aging has been proposed as a paradigm to explain the onset of long-term complications in these subjects. High levels of advanced glycation end products (AGEs), together with chronic inflammation and oxidative unbalance, have been shown to be among the main factors contributing to aging. The present study aims to evaluate glycoxydation, inflammatory status, and oxidative stress in plasma and peripheral blood mononuclear cells (PBMC) obtained from 20 adult survivors of pediatric HL and 40 age- and sex-matched healthy controls. After the isolation of PBMC and the collection of plasma, we performed the analyses of gene expression by qRT-PCR and measured inflammatory and oxidative-stress markers. AGEs plasma levels, expressed as Nϵ-carboxymethyl-lysine and methylglyoxal hydroimidazolone, were markedly higher in HL survivors than in healthy subjects. HL survivors also showed a condition of higher oxidative stress, as demonstrated by an increased expression of NADPH oxidase on PBMC. Antioxidant defenses, evaluated in terms of alpha-tocopherol, GSSG/GSH ratio and catalase plasma levels, were strongly impaired in survivors. This pro-oxidative condition led to the over-expression of both NLRP3 and NFkB genes in PBMC and, consequently, to increased plasma levels of interleukin(IL)-1β and IL-6. Finally, the expression of the receptors for AGEs in PBMC confirmed the dysregulated AGE pathways. Data show AGEs accumulation in survivors of pediatric HL. The consequent activation of the receptor for AGEs leads to the persistent activation of intracellular signaling toward inflammation. These results suggest that the co-existence of AGEs accumulation, unbalanced oxidative status, and inflammation could play a role in the onset of late complications in HL survivors.

Background There is conflicting evidence on the association between asbestos exposure and prostate cancer (PCa). Two recent meta-analyses have claimed that exposure is associated with increased PCa incidence and mortality, but they suffer from some methodological flaws. Given the potential importance of this research question, we aimed to perform a methodologically sound systematic review and meta-analysis to investigate the association between occupational asbestos exposure and the incidence of and mortality from PCa. Methods We followed PRISMA guidelines to systematically search for pertinent articles in three relevant electronic databases: Pubmed, Scopus, and Embase, from their inception to July 2020. The methodological quality of included articles was evaluated using the US National Institutes of Health tool. Standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) for PCa, as well as respective 95% confidence intervals (CIs), were extracted or calculated for each included cohort. Main and subgroup meta-analyses according to first year of employment, industry, asbestos type, and geographic region were performed. Results Sixty-five articles comprising 68 cohorts were included. PCa incidence and mortality were not significantly associated with occupational asbestos exposure (pooled SIR: 1.06, 95% CI: 1.00-1.13, P = 0.062; pooled SMR: 1.03, 95% CI: 0.99-1.06, P = 0.115). PCa incidence was higher among workers employed after 1960 (SIR: 1.10, 95% CI: 1.01-1.20). Pooled SIR was elevated in European (SIR: 1.09, 95% CI: 1.01-1.18) and UK cohorts (SIR: 1.05, 95% CI: 1.02-1.09). Mortality was elevated in North American cohorts (SMR: 1.06, 95% CI: 1.02-1.10). Studies of lower methodological quality appeared to yield elevated SIRs or SMRs. Conclusions This systematic review and meta-analysis provides evidence that men with occupational asbestos exposure have a PCa incidence and mortality similar to that of the general population. Temporal and geographical variables seem to be related to higher SMR or SIR.

Late effects of cancer and its treatments during childhood or adolescence can impact work placement and increase the risk of unemployment. The aim of this study is to describe the work placement and the perceived job and economic satisfaction of long-term childhood cancer survivors (CCS). Jobs have been categorized according to the International Standard Classification of Occupations version 08 (ISCO-08), and satisfaction has been evaluated through the Satisfaction Profile (SAT-P). Out of 240 CCS (female = 98) included: 53 were students, 46 were unemployed and 141 were employed. Within unemployed survivors, 89.13% were affected by late effects (n = 41). The presence of at least one severe late effect was significantly associated with the probability of unemployment (OR 3.21; 95% CI 1.13–9.12, p < 0.050), and having any late effect was inversely related to the level of satisfaction of the financial situation of unemployed CCS (b −35.47; 95% CI −59.19, −11.74, p = 0.004). Our results showed that being a survivor with severe comorbidities has a significantly negative impact on occupation and worsens the perception of satisfaction of economic situations. Routinary follow-up care of CCS should include the surveillance of socioeconomic development and provide interventions, helping them to reach jobs suitable for their health.

Background: This study aims at investigating the association between personal protection equipment (PPE) use and SARS-CoV-2 infection among healthcare workers (HCWs) during the first wave of the COVID-19 pandemic. Methods: We analyzed occupational surveillance contact forms notified between March and September 2020 by Italian HCWs, which were followed by a PCR test. The odds ratios (ORs) and 95% confidence intervals (CIs) for positive PCR test based on characteristics of HCWs and contacts, including self-reported symptoms and PPE use, were calculated through multivariable logistic regression models. Results: Overall, 4,883 contacts reported by 2,952 HCWs, were included in the analysis. A total of 224 contacts (4.6%) among 144 HCWs (4.9%) resulted in a positive PCR test. No difference was found based on sex, age, employment in a COVID-19 unit, or job title, except for an OR of 0.30 (95% CI 0.11-0.78) for resident physicians, compared to administrative staff. The ORs for use of surgical mask were 0.59 (95% CI=0.40-0.86) for use only by HCW, 0.49 (95% CI=0.22-1.07) for use only by the infected person, and 0.40 (95% CI=0.27-0.60) for use by both, compared to use by neither. Use of other PPEs was not associated with infection, while the OR for hand sanitation was 0.61 (95% CI=0.40-0.93). HCW reporting fever, cough, and asthenia had a higher risk of infection. Conclusions: Use of surgical masks was associated with a 40-60% lower risk of infection, especially when both HCW and the infected individual used it. Our results quantify the role played by mask use and hand sanitation in preventing SARS-CoVARSV-2 transmission in high-risk circumstances in the hospital setting.

During the last years, a significant technological and organisational evolution is taking place in the industrial activities, thanks to Advanced Manufacturing together with a more and more widespread use of Cloud Big Data Analytics. With special reference to the OSH (Occupational Safety and Health), these changes involve a new attention, both to the technological and employee's level. The paper discusses the characteristics, and the possible original use of a new methodology, based on virtual reality and digital checklist. This methodology can be used both to easily carry out surveillance activities and checks at workplaces, and to create a virtual itinerary of the area under investigation, in which checks and operative instructions can be virtually introduced for workers in charge of particular machinery or operations. The main results obtained thanks to the implementation of the methodology are: a reduction of the remedial actions' duration on non-compliances brought into evidence, and the deriving possible increase in the frequency and efficiency of inspections. Moreover, this approach intrinsically favors the involvement of workers and staff in charge of activities related to Prevention and Protection, supporting a process of continuous improvement and of general spread of the Culture of Safety in the Company.Negli ultimi anni si assistito in ambito industriale ad una sostanziale evoluzione tecnologica e organizzativa, resa possibile dalle Advanced Manufacturing associate ad un impiego sempre pi pervasivo di Cloud Big Data Analytics. Nell’ambito della Sicurezza e Salute del lavoro questi cambiamenti rendono essenziale una nuova attenzione, sia dal punto di vista tecnologico sia per quanto concerne il personale. Pertanto, in questo articolo, sono discusse le caratteristiche e le possibilit di impiego di una applicazione di una nuova metodologia, basata sulla realt virtuale e su una checklist digitale, utilizzabile per effettuare in modo semplice le attivit di sorveglianza e verifica nei luoghi di lavoro, consentendo di creare un percorso virtuale nell’area in esame, nel quale sono inseriti in maniera visuale gli accertamenti da eseguire e le istruzioni operative per addetti a particolari attrezzature od operazioni. I principali risultati ottenuti grazie all’applicazione sul campo della metodologia sono: riduzione del tempo di intervento su una non conformit e conseguente aumento della frequenza dei controlli e della loro efficacia. L’approccio favorisce intrinsecamente anche la partecipazione di lavoratori e preposti alle attivit legate a prevenzione e protezione, favorendo un processo di miglioramento continuo e di generale incremento nella disseminazione della cultura della sicurezza in azienda.

To update the analysis of mortality of a cohort of dyestuff workers, in Northern Italy, heavily exposed to carcinogenic aromatic amines.We updated to 2018 overall and cause-specific mortality in a cohort of 590 male workers heavily exposed to carcinogenic aromatic amines in a dyestuff factory from 1922 to 1972. Workers were censored at age 85. Expected cases for the period 1946-2018 were computed using Piedmont mortality rates and standardized mortality ratios (SMR) were computed.Between 1946 and 2018, 470 deaths were reported. The overall SMR was 1.59 (95% confidence interval [CI] 1.45-1.74) and SMR from all cancers was 2.05 (95% CI = 1.77-2.37); Compared to a previous report, there were 4 additional deaths from bladder cancer, for a total of 60 deaths compared with 4.0 expected (SMR 14.86, 95% CI 11.34-19.12).The SMR for bladder cancer increased with younger age at first exposure and longer duration of exposure, while it decreased with time since last exposure, albeit it was still 3.5, 30 or more years since last exposure. An increased risk was observed among workers exposed to fuchsine or ortho-toluidine (SMR=16.3; 95% CI = 6.0-35.5).This 73 year follow up confirms the results from previous analyses, with an increased overall mortality and, an increased mortality from all cancers and especially for bladder cancer. The excess risk of bladder cancer persisted several decades after stopping exposure.

Objective To update the analysis of mortality of a cohort of talc miners and millers in Northern Italy. Methods We analyzed overall mortality and mortality from specific causes of death during 1946–2020 of 1749 male workers in a talc mine where asbestos was not detected (1184 miners and 565 millers) employed during 1946–1995. Results The overall standardized mortality ratio (SMR) was 1.21 (95 % confidence interval [CI] 1.14–1.28); no deaths were observed from pleural cancer. Mortality from lung cancer was not increased (SMR = 1.02 95 % CI 0.82–1.27), while mortality from pneumoconiosis was (SMR 9.55; 95 % CI 7.43–12.08), especially among miners (SMR 12.74; 95 % CI 9.79–16.31). There was a trend in risk of pneumoconiosis with increasing duration of employment in the overall cohort, and the SMR for 25+ years of employment was 15.12 (95 % CI 10.89–20.43). Conclusions This uniquely long-term follow up confirms the results of previous analyses, namely the lack of association between exposure to talc with no detectable level of asbestos and lung cancer and mesothelioma. Increased mortality from pneumoconiosis among miners is related to past exposure to silica.

To date, there are heterogeneous studies related to childhood cancer survivors’ (CCS) employment rates. Given the importance of this topic, we aimed to perform a systematic review and meta-analysis to investigate the prevalence of employment among CCS and to examine its association with socio-demographic and clinical factors. We followed the PRISMA guidelines to search for pertinent articles in relevant electronic databases. Eighty-nine articles comprising 93 cohorts were included. The overall prevalence of employment was 66% (CI: 95% 0.63–0.69). Subgroup meta-analyses showed that lower rates were found for central nervous system tumor survivors (51%, CI: 95% 0.43–0.59), and for CCS treated with cranial-radiotherapy (53%, CI: 95% 0.42–0.64) or haematopoietic stem-cell transplantation (56%, CI: 95% 0.46–0.65). The studies conducted in Asia highlighted employment rates of 47% (CI: 95%, 0.34–0.60). Univariate meta-regressions identified the following socio-demographic factors associated with higher rates of employment: a female gender (p = 0.046), a higher mean age at the time of investigation (p = 0.00), a longer time since diagnosis (p = 0.00), a higher educational level (p = 0.03), and a married status (p = 0.00). In conclusion, this systematic review and meta-analysis provides evidence that two-thirds of CCS are employed worldwide. Identifying vulnerable groups of CCS may allow for the design of multidisciplinary support strategies and interventions to promote employment in this population.

Background To evaluate the prevalence of work-related musculoskeletal disorders (WRMSDs) in perioperative nurses and to explore their association with personal characteristics. Methods Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, Web of Science, Cochrane Library and Joanna Briggs Institute Database were systematically searched. A meta-analysis calculating event rates, and relative 95% Confidence Intervals (CI) was performed for each musculoskeletal body region. The contribution of perioperative nurses’ sex, age, and BMI was assessed through a meta-regression. Results Twenty-two studies, considering 3590 perioperative nurses, were included in the systematic review. The highest prevalence of WRMSDs was found for the lower-back (62%; 95% CI 0.54–0.70), followed by knee (47%; 95% CI 0.36–0.59), shoulder (44%; 95% CI 0.37–0.51), waist (42%; 95% CI 0.31–0.53), neck (39%; 95% CI 0.29–0.51), ankle-feet (35%; 95% CI 0.22–0.51), upper-back (34%; 95% CI 0.25–0.44), hand-wrist (29%; 95% CI 0.20–0.40), and elbow (18%; 95% CI 0.12–0.26). Meta-regression showed that sex, age, and BMI were not significant predictors of low-back disorders (p = 0.69; R2 = 0). Conclusions WRMSDs represent a high prevalence issue among perioperative nurses. Perioperative nurses, in general, are steadily exposed to both physical and temporal risk factors. Further studies should be addressed to identify specific interventions aimed at reducing the burden of WRMSDs including ergonomic education and physical rehabilitation. Our data could be used in future studies as a reference to assess the risk of WRMSDs in other health-care professionals’ population.

Limited information is available on carcinogenicity of asbestos on non-respiratory organs. We aimed at conducted an updated systematic review and meta-analysis of cohort studies on occupational exposure to asbestos and risk of kidney cancer. We searched through three databases, PubMed, Embase and Scopus for article published after 2000, and after eliminating duplicates and non-relevant studies, we identified 13 studies. We combined their results with those of 31 non-overlapping studies included in a previous review up to 2000. We conducted a meta-analysis based on random-effects models. The pooled relative risk of kidney cancer for asbestos exposure was 0.94 (95% confidence interval, 0.84–1.04), with no differences according to type of asbestos fiber, geographic region, period of exposure, or estimated quality of the study. Our results showed a lack of association between occupational asbestos exposure and risk of kidney cancer. Supplementary Information The online version contains supplementary material available at 10.1007/s10654-021-00769-x.

A shortage of COVID-19 vaccines and reports of side-effects led several countries to recommend a heterologous regimen for second vaccine doses. This study aimed to describe the reasons behind individuals’ choices of a homologous or a heterologous second vaccination. This cross-sectional study enrolled individuals under 60 who had received a first dose of Vaxzevria and could choose between a homologous or heterologous regimen for their second dose. Quantitative (socio-demographic, clinical characteristics) and qualitative data were collected and analysed through a generalized linear model and thematic analysis, respectively. Of the 1437 individuals included in the analysis, the majority (76.1%) chose a heterologous second dose of the COVID-19 vaccination. More females chose a heterologous vaccination regimen (p = 0.003). Younger individuals also tended to choose heterologous vaccination (p < 0.001). The main motivation in favour of heterologous vaccination was to follow the Italian Ministry of Health recommendations (n = 118; 53.9%). This study showed that most individuals, mainly younger people and females, chose a heterologous dose of COVID-19 vaccination after their first viral vector vaccine. Heterologous vaccinations could be an effective public health measure to control the pandemic as they are a safe and efficient alternative to homologous regimens.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and its associated disease (COVID-19) represent a global health emergency that requires integrated and multidisciplinary intervention by international medical and scientific communities, in support of the national governments. In Italy many public health measures have been adopted to contain the transmission of the disease, which also involved occupational physicians. The regulatory path has had a rapid evolution due to the trend of infections and progressive scientific evidence: the most recent Circular from the Ministry of Labor and Social Policies and the Ministry of Health provides for the termination of the "exceptional health surveillance" activity, the management and protection of fragile individuals by activating the medical examination on request of the employee and excludes the old age, without comorbidities, as a specific condition of risk of serious complication of SARS-CoV-2 infection. For preventive and insurance purposes, COVID-19 usually represents a generic biological risk, for which the same measures must be adopted for the entire population. In the Inail Circular no. 13 of April 3, 2020, however, it is stated that professional categories that perform front office duties are considered exposed to a higher risk, as well as, health professionals, can be considered exposed to a specific risk. From January 1st to July 31st 2020, 51,363 cases of infection from SARS-CoV-2 were reported to INAIL as an accident. In the same period INAIL noticed a decrease in reports of accidents and occupational disease overall, correlated to the effects of lockdown and smart working.Il Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) e la malattia ad esso associata (COVID-19) hanno causato un’emergenza sanitaria, a livello mondiale, che richiede un intervento integrato e multidisciplinare da parte delle comunità medico-scientifiche internazionali, a supporto dei governi nazionali coinvolti. In Italia, per affrontare tale emergenza, sono state adottate misure di sanità pubblica a livello nazionale per contenere la trasmissione della malattia che hanno coinvolto anche i Medici Competenti. Il percorso normativo ha avuto una rapida evoluzione, in relazione all’andamento dei contagi e delle progressive evidenze scientifiche: la più recente Circolare del Ministero del Lavoro e delle Politiche sociali e del Ministero della Salute prevede la cessazione del concetto di “sorveglianza sanitaria eccezionale”, la gestione e tutela dei soggetti fragili mediante l’attivazione della visita su richiesta del lavoratore ed esclude l’elevata età anagrafica, in assenza di comorbidità, come condizione specifica di rischio di evoluzione in quadro grave dell’infezione da SARS-CoV-2. Per quanto concerne la tipologia di rischio, anche ai fini assicurativi, il COVID-19 rappresenta, solitamente, un rischio biologico generico, per il quale occorre adottare misure uguali per tutta la popolazione. Nella Circolare Inail n. 13 del 3 aprile 2020 si segnala, però, che per quelle categorie professionali che svolgono mansioni in costante contatto con il pubblico e con l’utenza, l’infezione da SARS-CoV-2 può rappresentare un rischio generico aggravato, così come, per gli operatori sanitari, può essere considerato un rischio specifico. Sulla base di tale interpretazione, nel periodo compreso tra il primo gennaio e il 31 luglio 2020 sono stati denunciati all’INAIL 51.363 casi di contagio da SARS-CoV-2 come infortunio, a fronte di un sensibile decremento delle denunce di infortunio e malattia professionale complessivi, correlabili agli effetti della sospensione delle attività lavorative considerate non essenziali e dell’incremento dell’attività di smart working.

Background: Because of the COVID-19 outbreak, the widespread use of Respiratory Protective Devices (RPD) is recommended to prevent the spread of infection. This recommendation involves not only healthcare workers but other category of workers and the general population as well, in public places, especially where social distancing is difficult to maintain. The use of facemasks should not cause physical impairment to individuals, especially for people suffering from lung and heart diseases. Objectives: To evaluate the impact of RPDs on the respiratory function in healthy and asthmatic subjects, in order to identify the fitness for use mainly, but not only for, occupational purposes during COVID-19 outbreak. Methods: Ten individuals were included, three of which affected by asthma and three current smokers. A Respiratory Functional Test (RFT) was performed at three times: at the beginning of the work shift 1) without wearing and 2) wearing surgical masks, and 3) after 4 hours of usual working activities wearing the masks. Arterial Blood Gas (ABG) samples were also tested before the first test and the third test. Results: Observed RFTs and ABG parameters did not suffer significant variations, but for Maximal Voluntary Ventilation (P=0.002). Data on asthmatic subjects and smokers were comparable to healthy subjects. Discussion: Our results suggest that wearing a surgical mask does not produce significant respiratory impairment in healthy subjects nor in subjects with asthma. Four hours of continuing mask-wearing do not cause a reduction in breathing parameters. Fitness for use in subjects with more severe conditions has to be evaluated individually. Our adapted technique for RFTs could be adopted for the individual RPDs fitness evaluation.

Background: Since the beginning of the coronavirus disease 2019 (COVID-19) outbreak, healthcare workers (HCWs) have been the workers most likely to contract the disease. Intensive focus is therefore needed on hospital strategies that minimize exposure and diffusion, confer protection and facilitate early detection and isolation of infected personnel. Methods: To evaluate the early impact of a structured risk-management for exposed COVID-19 HCWs and describe how their characteristics contributed to infection and diffusion. Socio-demographic and clinical data, aspects of the event-exposure (date, place, length and distance of exposure, use of PPE) and details of the contact person were collected. Findings: The 2411 HCWs reported 2924 COVID-19 contacts. Among 830 HCWs who were at ‘high or medium risk’, 80 tested positive (9.6%). Physicians (OR=2.03), and non-medical services resulted in an increased risk (OR=4.23). Patient care did not increase the risk but sharing the work environment did (OR=2.63). There was a significant time reduction between exposure and warning, exposure and test, and warning and test since protocol implementation. Hospital managers were the main source of infection due to the high number of interactions. Interpretation: A proactive system that includes prompt detection of contagious staff and identification of sources of exposure helps to lower the intra-hospital spread of infection. A speedier return to work of staff who would otherwise have had to self-isolate as a precautionary measure improves staff morale and patient care by reducing the stress imposed by excessive workloads arising from staff shortages. Funding Statement: This research was funded by University of Torino. Declaration of Interests: All the authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Ethics Approval Statement: All data were anonymized, and the hospital directorate approved data collection and analysis. The research followed ethical principles for medical research involving human subjects expressed by the Declaration of Helsinki.

This study aimed to evaluate the association between personal and job characteristics and the risk of upper limb work-related musculoskeletal disorders (WMSDs) among operating room nurses (ORNs). To this end, we collected data from 148 ORNs working at 8 Italian hospitals and measured any upper limb disabilities experienced in the previous year using the Italian version of the disabilities of the arm, shoulder and hand (DASH) questionnaire. The associations between personal and job characteristics and risk of upper limb WMSDs were estimated by unconditional logistic regression models. The prevalence of upper limb WMSDs was 45.9%. Multivariate analysis showed the &ldquo, female gender&rdquo, and &ldquo, monthly hours spent working as a scrub nurse&rdquo, to be directly associated with a higher DASH score (adjusted OR for gender = 5.37, 95% CI: 1.65&ndash, 17.51, p &lt, 0.01, adjusted OR for monthly hours as scrub nurse = 3.09, 95% CI: 1.33&ndash, 7.19, p &lt, 0.01). Overall, our findings indicate that a full-time job (&gt, 120 h/month) as a scrub nurse significantly increases the risk of developing upper limb WMSDs among female ORNs. Thus, to reduce such risk in this particularly sensitive population, we recommend urgent implementation of ergonomic interventions on surgical equipment alongside job rotation and medical surveillance programs.

No abstract available.