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Over the last two decades, rituximab (RTX) has played an important role in the treatment of some lymphoproliferative malignancies and immune-mediated diseases. RTX administration is generally safe and well-tolerated, but side effects including late-onset neutropenia, hypogammaglobulinemia, hepatitis B reactivation and rare cases of progressive multifocal leukoencephalopathy have been observed after its administration. Although there are no absolute contraindications regarding its use in people living with HIV (PLWH), the prescription of this drug has been principally limited in patients with oncohematological diseases. In this report, we described the outcome of four PLWH who underwent RTX therapy after the diagnosis of immune-mediated renal disease. The main RTX-associated adverse effects were leukopenia, late-onset neutropenia and decline of CD4+ and CD8+ T-cell counts. In addition, two of the four patients experienced pneumonia requiring hospitalization within six months from the last RTX infusion. We suggest that RTX should be used with caution in PLWH until further evidence emerges on its safety profile in this vulnerable population.

This study investigated the impact of the fourth COVID-19 pandemic wave on dialysis patients of Romagna territory, assessing the associations of vaccination status with infection risk, clinical severity and mortality. From November 2021 to February 2022, an epidemiological search was conducted on 829 patients under dialysis treatment for at least one month. The data were then analyzed with reference to the general population of the same area. A temporal comparison was also carried out with the previous pandemic waves (from March 2020 to October 2021). The epidemiological evolution over time in the dialysis population and in Romagna citizens replicated the global trend, as the peak of the fourth wave corresponded to the time of maximum diffusion of omicron variant (B.1.1.529). Of 771 prevalent dialysis patients at the beginning of the study, 109 (14.1%) contracted SARS-CoV-2 infection during the 4-month observation period. Vaccine adherence in the dialysis population of the reference area was above 95%. Compared to fully or partially vaccinated subjects, the unvaccinated ones showed a significantly higher proportion of infections (12.5% vs. 27.0% p = 0.0341), a more frequent need for hospitalization (22.2% vs. 50.0%) and a 3.3-fold increased mortality risk. These findings confirm the effectiveness of COVID-19 vaccines in keeping infectious risk under control and ameliorating clinical outcomes in immunocompromised patients.

Background and Aims Many studies are available that reported a higher risk of COVID-19 disease among patients on dialysis or with kidney transplantation, and the poor outcome of COVID-19 in these patients. Patients in conservative therapy for chronic kidney disease (CKD) have received lower attention, therefore little is known about how COVID-19 may affect this population. The aim of this study was to analyse the COVID-19 incidence and mortality in CKD patients followed up in an integrated healthcare program, living in a small area of Northern Italy. Method The study population included CKD patients from the Emilia-Romagna Prevention of Progressive Renal Insufficiency (PIRP) project, followed up in the 4 nephrology units (Ravenna, Forlì, Cesena and Rimini) of AUSL Romagna (Italy) and alive at 1.01.2020. All patients were in conservative therapy and none of them had initiated dialysis or received kidney transplantation. The hospital discharge database was used to identify patients hospitalized with COVID-19 up to 31.07.2020, and the mortality database was used to assess mortality among patients with COVID-19 at the same date. Multivariable logistic regression was used to identify predictors of COVID-19 disease, and Kaplan-Meier survival analysis to identify predictors of COVID-19 mortality. Excess mortality of 2020 compared to mortality in 2015-19 in the PIRP cohort was also estimated. Results COVID-19 incidence among CKD patients was 4.09% (193/4716 patients), while in the general population it was 0.46% (5,195/1,125,574). COVID-19 was more likely in CKD patients with older age (Odds Ratio=1.038), cardiovascular comorbidities (OR=2.217), COPD (OR=1.559) and less likely in patients living in the province of Ravenna (OR=0.468), that was hit later by the first wave of pandemic compared to the other areas of AUSL Romagna. Baseline eGFR was lower in CKD patients with COVID-19 (31.7 vs. 35.8 ml/min/1.73 m2), but this difference did not reach statistical significance (p=0.066). As of 31.07.2020, the crude mortality rate among CKD patients with COVID-19 was 44.6% (86/193), compared to 4.7% (215/4523) in CKD patients without COVID-19 and to 14.5% (4289/29670) in the general population with COVID-19 of the Emilia-Romagna region. Factors associated with mortality of CKD patients with COVID-19 were older age (p=0.034) and the period of COVID-19 onset (p=0.003). The highest crude mortality rate (71.4%) was found in CKD patients for whom COVID-19 onset occurred between 8 and 21 March. The excess mortality of January-July 2020 with respect to the average mortality of January-July 2015-19 in the PIRP cohort was +17.7%, corresponding to 77 excess deaths. March-April was the period with the highest excess mortality (+69.8%), while in January-February a 15.9% lower mortality was observed with respect to the corresponding months of the five previous years. Conclusion In our study, including a cohort of regularly followed up CKD patients, the risk of COVID-19 disease and of COVID-19 related mortality was comparable, or even somewhat higher, to that observed in patients on dialysis and those who received kidney transplantation. The incidence of COVID-19 in CKD patients was higher in the areas of AUSL Romagna earlier affected by the pandemic wave, whereas mortality rates were similar across all areas. CKD patients represent a population very vulnerable to COVID-19 disease, and their protection should be highly prioritized in the models of care and prevention measures.

Background and objectives Renin-angiotensin system (RAS) inhibitors reduce cardiovascular morbidity and mortality in patients with CKD. We evaluated the cardioprotective effects of the angiotensin-converting enzyme inhibitor ramipril in patients on maintenance hemodialysis. Design, setting, participants, & measurements In this phase 3, prospective, randomized, open-label, blinded end point, parallel, multicenter trial, we recruited patients on maintenance hemodialysis with hypertension and/or left ventricular hypertrophy from 28 Italian centers. Between July 2009 and February 2014, 140 participants were randomized to ramipril (1.25–10 mg/d) and 129 participants were allocated to non-RAS inhibition therapy, both titrated up to the maximally tolerated dose to achieve predefined target BP values. The primary efficacy end point was a composite of cardiovascular death, myocardial infarction, or stroke. Secondary end points included the single components of the primary end point, new-onset or recurrence of atrial fibrillation, hospitalizations for symptomatic fluid overload, thrombosis or stenosis of the arteriovenous fistula, and changes in cardiac mass index. All outcomes were evaluated up to 42 months after randomization. Results At comparable BP control, 23 participants on ramipril (16%) and 24 on non-RAS inhibitor therapy (19%) reached the primary composite end point (hazard ratio, 0.93; 95% confidence interval, 0.52 to 1.64; P=0.80). Ramipril reduced cardiac mass index at 1 year of follow-up (between-group difference in change from baseline: −16.3 g/m2; 95% confidence interval, −29.4 to −3.1), but did not significantly affect the other secondary outcomes. Hypotensive episodes were more frequent in participants allocated to ramipril than controls (41% versus 12%). Twenty participants on ramipril and nine controls developed cancer, including six gastrointestinal malignancies on ramipril (four were fatal), compared with none in controls. Conclusions Ramipril did not reduce the risk of major cardiovascular events in patients on maintenance hemodialysis. Clinical Trial registry name and registration number: ARCADIA, NCT00985322 and European Union Drug Regulating Authorities Clinical Trials Database number 2008–003529–17.

Many studies reported a higher risk of COVID-19 disease among patients on dialysis or with kidney transplantation, and the poor outcome of COVID-19 in these patients. Patients in conservative management for chronic kidney disease (CKD) have received attention only recently, therefore less is known about how COVID-19 affects this population. The aim of this study was to provide evidence on COVID-19 incidence and mortality in CKD patients followed up in an integrated healthcare program and in the population living in the same catchment area. The study population included CKD patients recruited in the Emilia-Romagna Prevention of Progressive Renal Insufficiency (PIRP) project, followed up in the 4 nephrology units (Ravenna, Forlì, Cesena and Rimini) of the Romagna Local Health Authority (Italy) and alive at 1.01.2020. We estimated the incidence of COVID-19, its related mortality and the excess mortality within this PIRP cohort as of 31.07.2020. COVID-19 incidence in CKD patients was 4.09% (193/4,716 patients), while in the general population it was 0.46% (5,195/1,125,574). The crude mortality rate among CKD patients with COVID-19 was 44.6% (86/193), compared to 4.7% (215/4,523) in CKD patients without COVID-19. The excess mortality of March-April 2020 was +69.8% than the average mortality of March-April 2015–19 in the PIRP cohort. In a cohort mostly including regularly followed up CKD patients, the incidence of COVID-19 among CKD patients was strongly related to the spread of the infection in the community, while its lethality is associated with the underlying kidney condition and comorbidities. COVID-19 related mortality was about ten times higher than that of CKD patients without COVID. For this reason, it is urgent to offer a direct protection to CKD patients by prioritizing their vaccination.

BACKGROUND Muscle weakness, incorrect body water distribution and reduced exercise tolerance are the main characteristics found in renal transplant recipients after surgical treatment. Regular physical supervised exercise programs, at moderate intensity, have been promoted to contrast these aspects, while few data are available for long-term unsupervised mixed exercise plans. Bioelectrical impedance vector analysis (BIVA) provides a semi-quantitative evaluation of body cell mass and body water. This study aims to approach the role of the BIVA analysis in the follow-up of Renal Transplant Group (RTG) and analyze the impact of unsupervised exercise program. METHODS Thirteen male RTG and ten healthy subjects, adherent to a tailored exercise program, at moderate intensity and prescribed in an unsupervised way, have been followed up for one year. Every six months all the subjects have been submitted to the ergometric test, echocardiographic exam and an analysis of body composition by bioimpedance. They were compared to a healthy control group (HG). RESULTS A significant reduction of the BMI was observed at the end of the study in the RTG group (T0 24.8±3.2, T12 24.2±3.2 kg/m2; P

Background: Despite the benefits of physical activity on cardiovascular risk in kidney transplant recipients (KTRs), the long-term effects of exercise have been poorly investigated. This is a three-year observational study comparing graft function and cardiovascular risk factors in active KTRs (AKTRs) vs. sedentary KTRs (SKTRs). Methods: KTRs with stable renal function were assigned to active or sedentary group in relation to the level of daily physical activity based on World Health Organization (WHO) recommendations (&lt, 150 or &gt, 150 minutes/week, respectively). Complete blood count, renal function indices, lipid profile, blood pressure and anthropometric measures were collected yearly for an observation period of three years. The comparisons between the two groups were performed by repeated measures analyses of covariance (ANCOVAs), with age as a covariate. Results: Fifty-four subjects were included in the study. Thirty of them were identified as AKTRs (M/F 26/4, aged 45 &plusmn, 12 years) and 24 as SKTRs (M/F 18/6, aged 51 &plusmn, 14 years). Baseline characteristics were similar between the groups except body mass index (BMI) that was significantly higher in SKTRs (p = 0.043). Furthermore, over the three-year observation period, BMI decreased in AKTRs and increased in SKTRs (p = 0.006). Graft function was stable in AKTRs, while it showed a decline over time in SKTRs, as indicated by the rise in serum creatinine levels (p = 0.006) and lower eGFR (p = 0.050). Proteinuria, glucose and uric acid levels displayed a decrease in AKTRs and an increase in SKTRs during the three-year period (p = 0.015, p = 0.004 and p = 0.013, respectively). Finally, concerning lipid profiles, AKTRs had a significant reduction over time of triglycerides levels, which conversely showed a clinically relevant increase in SKTRs (p = 0.014). Conclusions: Our findings indicate that regular weekly exercise training may counteract the increased cardiovascular risks and also prevent graft function decline in KTRs.

Background Following the positive experience of the national project “A transplant...and now it’s time for sport,” the Transplant Reference Center of the Emilia-Romagna Region has pursued the promotion of pre- and post-transplant physical exercise by developing a network. Methods The path involved the transplant centers and operative units (UU.OO) who wanted to target transplant and waiting list patients, who are clinically stable, to perform personalized exercise through a program (supervised or not) prescribed by a specialist in sports medicine. With the collaboration of the Collective Prevention and Public Health Service, the network was established, consisting of the sports medicine centers and the gyms that promote health for adapted physical activity (PS-AMA). To implement the network, training courses for all the professionals involved (doctors, nurses, exercise specialists) and operational meetings in the transplant centers-nephrology units with patients’ associations have been organized. Results To date, there are 14 transplant centers and UU.OO, 9 sports medicine centers, and 45 PS-AMA involved in this network. Seven training courses were organized with the participation of 193 health professionals. Since January 2016, there have been 65 transplanted patients and 5 patients on the waiting list who practice the prescribed exercise. Of these, 45 carry out supervised exercise in PS-AMA; 25 perform autonomous exercise. Each patient is monitored every 6 months. No problems related to the exercise performance were recorded. Conclusions The development of a network of professionals and associations is the key element to raise awareness of physical activity among transplanted and waiting-for-transplant patients, reducing the pathologies associated with a sedentary lifestyle.

Background and aims Despite the excellent long-term outcomes in liver transplant (LT) recipients, several medical complications related to lifestyle still represent an issue. This study examined the effects of a 12-month supervised aerobic and strength training program on the aerobic capacity, muscle strength, metabolic profile, liver function, and quality of life of a cohort of LT recipients. Methods LT recipients with stable liver function were assigned to interventional exercise (group A) or usual care (group B). Aerobic capacity, muscle strength, metabolic profile, liver and kidney function, and health-related quality of life were assessed at baseline and after 6 and 12 months. Group A attended supervised training sessions 3 times per week for 12 months. Group B received general recommendations about home-based exercise. Results Forty patients from 6 Italian LT centers were randomized. Twenty-nine (72.5%, men-to-women ratio 23:6, mean age, 52 ± 8 years) LT recipients completed the study. Baseline characteristics were similar between groups except for body mass index and time from LT. No episode of acute rejection nor increase of transaminases occurred. Maximum workload and body mass index increased in both groups over time, but fasting glucose significantly decreased in group A (94.0 ± 15.0 mg/dL vs 90.0 ± 17.0 mg/dL; P = .037) and increased in controls (95.0 ± 24.0 mg/dL vs 102.0 ± 34.0 mg/dL, P = .04). Upper limb muscle strength increased only in supervised LT recipients. Vitality and general and mental health domains significantly improved after physical exercise. Conclusions Supervised combined training was safe and effective in increasing aerobic capacity, muscle strength, and quality of life and in improving glucose metabolism in stable LT recipients.

AIM To evaluate the effect of a 12-mo supervised aerobic and resistance training, on renal function and exercise capacity compared to usual care recommendations. METHODS Ninety-nine kidney transplant recipients (KTRs) were assigned to interventional exercise (Group A; n = 52) and a usual care cohort (Group B; n = 47). Blood and urine chemistry, exercise capacity, muscular strength, anthropometric measures and health-related quality of life (HRQoL) were assessed at baseline, and after 6 and 12 mo. Group A underwent a supervised training three times per week for 12 mo. Group B received only general recommendations about home-based physical activities. RESULTS Eighty-five KTRs completed the study (Group A, n = 44; Group B, n = 41). After 12 mo, renal function remained stable in both groups. Group A significantly increased maximum workload (+13 W, P = 0.0003), V’O2 peak (+3.1 mL/kg per minute, P = 0.0099), muscular strength in plantar flexor (+12 kg, P = 0.0368), height in the countermovement jump (+1.9 cm, P = 0.0293) and decreased in Body Mass Index (-0.5 kg/m2, P = 0.0013). HRQoL significantly improved in physical function (P = 0.0019), physical-role limitations (P = 0.0321) and social functioning scales (P = 0.0346). No improvements were found in Group B. CONCLUSION Twelve-month of supervised aerobic and resistance training improves the physiological variables related to physical fitness and cardiovascular risks without consequences on renal function. Recommendations alone are not sufficient to induce changes in exercise capacity of KTRs. Our study is an example of collaborative working between transplant centres, sports medicine and exercise facilities.

The aim of the study was to investigate the effects of sport activity on health-related quality of life (HRQoL) of solid organ transplant recipients participating in sports competitions. A group of 168 sportive transplanted patients (STP), a group of 97 nonsportive transplanted patients (NSTP), and a group of 152 sportive healthy controls (SHC) were compared on the eight scales of the SF-36 questionnaire. STP and NSTP reported significantly lower scores than SHC on the physical functioning scale. STP did not differ from SHC in the Role-Physical, General Health, and Vitality scales, while NSTP reported significantly lower scores. STP obtained higher scores than NSTP and SHC on Mental Health. Among STP, the effect of quantity of sport activity was significant on General Health and Role Emotional, with more sport activity associated with higher HRQoL. Organ failure and post-transplant therapies may have negative consequences on HRQoL. Sports activities and participation in sports competitions can reduce this impact, improving general and psychological functioning of solid organ transplant recipients.

Background: This paper follows up on a project that was launched in 2008 and contributed to the development of the new Italian Society of Occupational Medicine (SIML) guidelines for the road haulage industry. Objective: To reach a better understanding of occupational illness amongst truck drivers, in order to define appropriate health monitoring protocols and promote a healthy life-style. Methods: We assessed 673 male drivers (mean age 43.85 years, SD 9.56; mean working seniority 27.28 years, SD 10.59), employed by 46 different companies. The drivers, who were gradually recruited in the study over the years, had a maximum of 8 re-assessments each, for a total of 2608 examinations. We applied a survey protocol consisting in a medical examination, questionnaires for the most common risks and instrumental and laboratory tests in compliance with SIML guidelines. Results: We identified a total of 44 work-related diseases: 22 cases of noise-induced hearing loss (NIHL) and 22 cases of lumbar degenerative disc disease. As regards metabolic disorders, we observed 28 cases of diabetes mellitus, in most cases (71.4%) as a first diagnosis or under poor therapeutic control. We observed poorly-controlled hypertension in 103 drivers, the majority of whom (54%) were diagnosed for the first time. Over 30% of the workers in our study were obese and approximately 40% were tobacco smokers. We identified just 9 individuals (1.3%) with a positive toxicological screening for use of recreational drugs. Our data confirm a high prevalence of occupational illness amongst truck drivers. Cardiovascular and metabolic conditions require close monitoring.

The aim of this multicenter, prospective study was to explore the possibility of carrying out routine sessions of post-dilution hemodiafiltration with a polyacrylonitrile membrane grafted with heparin (HeprAN) and reduced anticoagulation. Forty-four patients from eight centers were included in the study and treated by means of post-dilution on-line hemodiafiltration with automatic control of TMP, according to three different modalities tested consecutively: phase 1, polyethersulfone filter primed with heparinized saline and anticoagulated with continuous infusion of unfractionated heparin 1000/h; phase 2, HeprAN membrane filter primed with saline without heparin. Anticoagulation: a 1000-unit bolus of unfractionated heparin at the start of session followed by a second one at the end of the second dialysis hour; phase 3, same filter and priming procedure as in phase 2; anticoagulation with nadroparin calcium at the beginning of treatment. Partial or massive clotting of the dialyzer occurred in less than 1% of sessions in phase 1; 10% and 7% in phase 2; and 1% and 2% in phase 3. Clotting limited to the drip chambers was observed in 13%, 34% and 12%, respectively. The study of coagulation parameters showed a better profile when low-molecular weight heparin (LMWH) was used in association with HeprAN membrane, while the generation of TAT complexes did not differ from that observed with the standard anticoagulation modality used in phase 1. Our results suggest that the HeprAN membrane can be used safely in routine post-dilution hemodiafiltration with reduced doses of LMWH.

The kidney transplant recipients' population shows pronounced alterations of the lipidic profile, with hypercholesterolemia (total cholesterol, LDL, VLDL), normal HDL and hypertriglyceridemia. Multiple factors contribute to the development of dyslipidemia, towards these, immunosuppressive therapy plays an important role. The impact on cardiovascular outcomes is less well defined than in general population. This work is a revaluation of the clinical approach to dyslipidemia in kidney transplant based on the more recent Guide Lines and literature. The use of statins in an adult transplanted population (eventually associated with ezetimibe) is safe and is a good compromise in terms of a cost/benefit analysis. Other hypolipidemic drugs are not usually suggested for the high incidence of side effects. Lifestyle changes are taking more and more relevance, and in the pediatric population is the only therapeutic act suggested.

Diabetes is a disease with high social impact and it is important to consider how work may be influenced by it or whether work itself may promote or accelerate its course.The objective was to investigate the prevalence of diabetes in four critical categories of workers. The survey involved construction workers, truck drivers, bus drivers and shift workers in the manufacturing sector.In the years 2012-14 we investigated 2034 males workers, through personal history, physical examination, laboratory tests. The subjects with fasting glucose125 mg/dl underwent a second control and haemoglobin A1c determination. Positive cases were referred to specialist control. Expected prevalence and standardized prevalence ratio (SPR) were calculated using official data regarding diabetes prevalence in Italy.The prevalence of diabetes in 608 truck drivers was 4.4% (expected 2.6%, SPR 1.69, IC95% 1.08 to 2.31); in 860 construction workers 1.9% (expected 2.1%, SPR 0.90, IC95% 0.48 to 1.33); in 378 bus drivers 2.6% (expected 3.5%, SPR 0.74, IC95% 0.29 to 1.20); in 188 shift workers 3.2% (expected 2.1%, SPR 1.52, IC95% 0.33 to 2.71). In the age range 35-59 years the prevalence in 467 truck drivers was 5.1% (expected 2.4%, SPR 2.13, IC 95% 1.29 to 2.96).Diabetes was confirmed to be highly prevalent at working ages. The study highlighted an increased diabetes prevalence among truck drivers, whereas other jobs might represent protective factors; this hypothesis, however, needs further investigation.

Metformin is the first choice drug in type II diabetes. This drug has a renal excretion and its use requires caution in a setting of glomerular filtration rate reduction; an accumulation can be associated with a lactic acidosis, complication burden with a high rate mortality.In a user base of 390.000 people we reviewed all the cases of metformin-associated lactic acidosis treated at the First Aid in a 15 months period; we considered the patients characteristics, their risk factors and the outcome.We observed 11 cases (incidence 60/year/100.000 patients). 10 had an acute renal failure due to dehydration. None had absolute contraindications to metformin, but most of the patients had at least one risk factor for acute kidney injury. 10 patients had been treated with hemodialysis. The total mortality rate was 36%.In our experience we found a higher incidence compared to literature, probably because of the widespread use of this drug in more and more fragile patients. We confirm the need of a strict adherence to prescription with a specific attention, not only to renal function, but also to the concomitant presence of risk factors (age over 80, use of Ace-inhibitors, angiotensin receptor blockers and diuretics). We draw the attention to the importance of acute clinical events and we reaffirm the need of an adequate education of the patient and his relatives for a better management of the acute event.

The activity of the occupational physician (OP) in the enterprise has as its purpose the protection of the health of workers and consists of two main areas: health surveillance and risk assessment. Every day thle OP have to take into account both the results of clinical diagnostic investigation and the outcomes of the estimation of occupational exposure to risk factors by making a right mix between what is proven by scientific evidence and professional experience. He also knows that its effectiveness is closely linked to the contribution of other figures ofprevention in the company. In the scientific literature, the authors are unanimous in considering the effective actions to reduce exposure to risk, risk behaviors, injuries, occupational illnesses, disability, absenteeism. The use of indicators of effectiveness and / or appropriateness for the enhancement of its contribution, especially as a consultant in the field ofprevention and health protection in the compmany and then with anmt active role in corporate governance of prevention, are a must and no longer postponed, as well as the development of tools that document in formal terms, its contributioni (annual health report, the definition of risk profiles). I, this paper, by analyzing the results of specific experiences in the surveillance of construction workers, drivers and bakers, the authors want to emmphasize the contribution of the OP.

Introduction It is widely accepted that the risk of malignancies is significantly increased among patients with end-stage kidney disease (ESKD) and after kidney transplantation compared with the general population. Only a few data are available on kidney transplantation waiting list patients. The aim of this study was to investigate solid organ cancer incidence among subjects on the waiting list at a single center. Materials and Methods We retrospectively reviewed the records of all patients enrolled on our kidney transplantation waiting list between August 1, 2008 and July 31, 2010, seeking to evaluate the causes of withdrawal from the list, incidence of cancer, type of neoplasm, and its correlation with clinical features. We estimated the ratio of observed to expected numbers of cancers, the standardized incidence ratio (SIR). Results Among 1184 patients, we excluded 569 patients from the waiting list including 26 (4.56%) who displayed malignancies. The overall incidence of cancer was 0.11 events/person-months and the overall prevalence of cancer was 2.2%. In 97% of patients, the malignant disease was confined to the primitive organ of origin without secondary dissemination. We observed a prevalence of cancers related to ESKD (17; 65.38%). The SIR for all cancer types in our population compared with the general population was 2.22. The SIR for native kidney and thyroid cancers among our population compared with the general population was >10. Conclusion The incidence of cancer was significantly increased among kidney transplantation waiting list patients compared with the general population. Our study highlighted the importance of a careful, targeted neoplastic screening. It could be particularly important for ESKD-related malignancies like native kidney tumors or thyroid cancers.

Occupational Physician has a marginal role in the Risk Assessment (RA). He is rarely involved and generally he only reads the documentation of RA made by other specialists in the prevention and safety. The law obliges him to work with the Employer, not only for the planning of health surveillance but also for the preparation of measures for the protection of the health and psycho-physical integrity of workers. But it is mainly for the content and methodology of the RA that it is necessary the contribution of the occupational physician. The RA is in fact a multi-stage and multi-disciplinary activity carried out in close collaboration with industrial hygienists, ergonomists, safety experts, psychologists. The occupational physician for his studies and education is the most appropriate professional to evaluate the quality of the data and to make an integration between indicators of environmental contamination and biological indicators of internal dose and effect or damage. We agree with the Italian Society of Occupational Health and Industrial Hygiene that is necessary to proceed to the recognition of the role of occupational physician as a "consultant" of the company about health and safety in the workplace and involved in RA even when it is not necessary the health surveillance.

Background/Aims: The role of physical activity in transplanted patients is often underestimated. We discuss the Italian National Transplant Centre experience, which started in 2008 studying transplanted patients involved in sports activities. The study was then developed through a model of cooperation between surgeons, sports physicians and exercise specialists. Methods: A multicentre study was realized in 120 transplanted patients of which 60 treated with supervised physical activity (three sessions/week of aerobic and strengthening exercises) and 60 controls. We present the results of the first 26 patients (16 males, 10 females; 47.8±10.0 years; 21 kidney, 5 liver transplanted; time from transplant 2.3±1.4 years) who completed 12 months of supervised physical activity. Results: Data showed an increase of peak aerobic power (t=4.535; PConclusion: These preliminary results confirm the positive effects of supervised physical exercise. It can be considered as an input to promote other detailed exercise protocols.

The maintenance of an adequate of quality of life (QoL) represents a critical issue in the management of patients in haemodialysis and is also used to assess the effectiveness of health care programmes. The Consumer Direction Theory of Empowerment (CDTE) implies that greater patient direction in policy formulation and services delivery, together with an increased community integration, endorses a process which leads to a better QOL. The aim of the study was to test a contextualized version of CDTE in an ambulatory for patients in haemodialysis. Sixty-nine patients completed a questionnaire measuring the following variables: Patient direction, family integration, self-efficacy in managing the disease, mental and physical health. The results showed that patient direction and family integration have an indirect effect on QoL, through self-efficacy in managing the disease. The hypotheses were thus confirmed, providing support for the potential of CDTE in the context of health services for haemodialysis patients. Implications for the implementation of health programmes aimed at improving QoL of patients in haemodialysis are discussed, including interventions focused on psychological and contextual factors.

Most of the difficulties when trying to realize the proposal to prescribe physical activity for transplantation patients come from patient attitudes and cultural beliefs that ignore the benefits of exercise, but there also are organizational aspects arising from the difficulties that these patients face in accessing supervised exercise facilities. To address these difficulties, the Italian study project "Transplant … and Now Sport" was developed based on a model of cooperation among transplantation specialists, sports physicians, and exercise specialists organized as a team combining their specific skills to effectively actuate the physical exercise programs. This preliminary report is based on 26 patients (16 male, 10 female; 47.8±10.0 years old; 21 kidney and 5 liver transplantations; time from transplantation 2.3±1.4 years) who performed prescribed and supervised exercises consisting of 3 sessions per week of aerobic and strengthening exercises for 1 year. Preliminary results show a significant decrease in body mass index (t=1.966; P

No abstract available

In this work the authors analyse the results of the clinical evaluation of patients affected by suspected work related musculo-skeletal disorders (WMSDs), observed throughout 2008-2009 in the specific ambulatory of Occupational Medicine Division of Ospedali Riuaniti di Bergamo. The aim is to illustrate the epidemiological relevance of upper limb (UL) WMSDs.We observed 430 patients (mean age 46,9 years, DS 9,3; mean working seniority 29 years, DS 10,4), investigating 600 disorders in diferent musculoskeletal segments. Most of the patients (66%) got to the division for a clinical consultation requested by general practitioners, 29,8% by occupational physicians, 4,2% by national insurance for occupational injuries and diseases (INAIL).Most of the patients (38,4%) were employed in construction industry. Among the 600 disorders investigated, 34,5% was at lumbar spine, 74,5% was at upper limb. The clinical diagnosis was already clear at the first consultation for 81,6% of subjects with low back pain and for 56,5% of patients with upper limb disorders; for the others was necessary to prescribe some instrumental exams or specialistic (neurologic, physiatric, orthopaedic) medical examination. We concluded for a diagnosis of WMSDs in 48,3% of the 600 cases: the percentage is 50,2% if we consider only disorders at lumbar spine and 52,5% among disorders at upper limb. The most frequent reason of refusing occupational aetiology, in the cases of low back pain, was the concomitant presence of other diseases at the segment; on the contrary, for the cases of upper limb disorders, was the lack of correlation between type of disease and professional exposure.All physicians demonstrate a high attention about upper limb disorders, topical subject of great epidemiological interest. General practitioners and occupational physicians have to take more advantage of diagnostic support and clinical evaluations offered by Occupational Medicine Divisions an Universities about WMSDs. In consideration of the dificulties to diagnose upper limb disorders and proving correlation with professional exposure is useful to promote specific courses for general practitioners and occupational physicians.

Introduction Evaluation of kidney transplant candidates is based on strict exclusion of major pathologies, such as neoplastic disease. The aim of this study is to evaluate epidemiological and clinical impact of tumor disease in an Italian renal transplant waiting list and to propose a screening schedule for neoplastic detection. Materials and methods We retrospectively observed data of patients enrolled on the Emilia-Romagna kidney transplant waiting list between 1st August 2008 and 31st December 2010, evaluating the different causes of getting out from the list, the histologic type and incidence of cancer and the correlation between cancer onset and clinical features. The ratio of observed to expected cancer numbers (standardized incidence ratio, SIR), was estimated. Results We observed 2345 patients; 1297 got out from the waiting list; 57 of them (4,4%) got out because the onset of tumor. The overall incidence rate of cancer was 1354.8 (x 100000 person-year) (1045.9 person-year in patients awaiting for first transplant(FT), 1851.5 person-year in patients awaiting for second transplant(ST)). The overall prevalence of cancer was 2,43% (2.2% in FT, 3.4% in ST) with a SIR of 1.8; In our population the prevalence of cancers related to ESKD was 52.6% with a SIR of 15.8. Conclusion Kidney transplant waiting list patients present a higher incidence and prevalence of cancer compared to general population; it could be important to evaluate them for ESKD related malignancies because of their high incidence.

A 55-year-old Caucasian man who had received a second kidney graft in July 1993, was switched from cyclosporine to tacrolimus in June 2000 due to deterioration of renal function. Thereafter, he began to complain of muscle cramps in both quadriceps with an increased CPK and EMG findings of polyneuropathy. A muscle biopsy demonstrated acute myositis. Prednisone was administered with amelioration of the patient's symptoms, but with persistently increased CPK and myoglobin levels. In February 2001, mycophenolate mofetil was introduced and tacrolimus tapered to 3 mg daily to seek a toxic role of this immunosuppressant, since there was no other cause of myositis. A sudden decrease in CPK was observed, but the complete normalization took place only after its withdrawal in September 2002. This case represents a tacrolimus-associated myositis.

Cobalt is regarded as being responsible for a form of myocardiopathy whose pathogenesis and clinical description must still find a specific place in the range of congestive myocardiopathies. In spite of this, epidemiological studies are not sufficient to prove the role of cobalt in inducing myocardiopathy in hard metal workers. This critical review intends to evaluate if hard metal exposure may induce toxic effects on the heart. In this context, the literature considered ranges from pioneer reports on 'beer drinkers' to the more recent papers concerning cases of patients occupationally exposed; subjects who, after a surgical operation died of fulminant heart failure and, lastly, hard metal workers who were examined for their cardiac function. Various pathogenetic mechanisms related to possible cardiac effects in hard metal workers have been analyzed. The most likely should be the inhibition of cellular respiration due to inhibition of the mitochondrial dehydrogenase.

This article summarizes the present state of the art and some recommendations for solutions to problems identified by the European Congress on Cobalt and Hard Metal Disease on the basis of the papers and posters presented, as well as a round table discussion which produced several dominant questions and revealed areas of weakness and uncertainty. The round table discussion (chairman, Professor E. Capodaglio) focussed on the following aspects: (i) Monitoring (opinion leaders: R. Lauwerys, E. Sabbioni). (ii) Mechanisms of toxicity (opinion leaders: B. Nemery, N.L. Sprince, G. Scansetti). (iii) Health effects (opinion leaders: G. Nordberg, I.B. Andersen). (iv) Diagnosis/health surveillance (opinion leaders: G. Chiappino, S. Hernberg, S. Brown).

A study was carried out on cobalt (Co) excretion in the urine of 12 workers exposed to known cobalt concentrations in the stone cutting diamond wheel production and in six volunteers: four of these were exposed in the same work environment for a whole workshift and the other two were exposed to cobalt in a cabin under experimental conditions. The kinetics of the urinary excretion was multiphase: (i) a first stage of rapid elimination (T 1/2' = 43.9 h); (ii) a second phase of slower elimination (T 1/2'' = 10 days); (iii) a longer period of retention, of the order of years, in subjects with higher exposure. In the control group (4 subjects), the excretion proved to be much faster in the first stage (T 1/2' = 20 h). The different behaviour of the two groups could be related to the different body burden, of cobalt and/or to the possibility of different kinetics induced by continuous exposure to the metal. Moreover, 3 weeks after the removal of the workers from exposure the urinary cobalt concentrations were not within the normal limits of CoU for the general population, (even for workers exposed to cobalt levels of the same order as the TLV). The increase of CoU concentrations in the first 3 h after the end of exposure, stresses the problem of when urine samples for biological monitoring of the workers should be collected. The present study confirms the utility of CoU in discriminating between exposed and non-exposed subjects as well as in assessing high and low level exposure.

A method for the determination of inorganic and organically-bound cobalt in human urine has been developed and applied to the urine of hard metal workers. The development was based on the use of the radionuclides 57Co, 58Co and 60Co-labelled Co compounds such as Co-Vitamin B12 and CO2+ ions which allowed the study of their biotransformations in human and rat urine. The proposed procedure is based on the use of Chelex 100 resin which retains quantitatively the inorganic Co from the urine while the organic complexed form of the element is eluted. Cobalt is detected in both column and eluate by neutron activation analysis (NAA). The method has been applied to speciate inorganic and organically-bound Co in the urine of hard metal workers. There is a significant increase (P0.02) of the ratio inorganic/organic Co (2.3) in the urine of workers compared with controls (1.01), showing an increase of the inorganic fraction of Co in the urine of workers. The ratio was constant for the wide range of urinary Co analyzed (from 180 micrograms to 1254 micrograms Co/l). Therefore, the discrimination between inorganic and organic Co in urine should not represent progress in the biological monitoring of Co compared with the determination of total urinary Co. However, a large amount of organically-complexed Co is formed in the body of hard metal workers and excreted in urine, thus, investigations of the nature of the organo-cobalt compounds are of fundamental importance in establishing their possible clinical significance.

A sedentary lifestyle is an important risk factor leading to cardiovascular disease. Cardiovascular disease is particularly frequent in kidney transplant recipients, with a mortality rate of 38%. In this population, besides the classic risk factors (genetics, age, smoking, etc.) and disease-related factors (chronic renal failure, dialysis vintage) there are the side effects of immunosuppressive therapy such as diabetes and metabolic syndrome. Despite the general advice given on an appropriate lifestyle, most transplanted patients lead a sedentary life which may result in overweight. In this study the physiopathological effects of a sedentary lifestyle were analyzed with reference to the recent literature regarding the efficacy of physical activity in transplanted patients. Studies in the general population have demonstrated the beneficial effect of physical activity on the prevention of cardiovascular disease. There are only few studies within the kidney transplant population regarding regular physical activity and these studies were performed with heterogeneous protocols and different observation periods, and are therefore difficult to compare. Overall, positive results in terms of maximal aerobic capacity, muscle strength and perception of well-being have been obtained in the short and medium term (1 year). Further studies are necessary to verify the effect of physical activity on long-term patient and graft survival. In order to enhance physical activity in transplanted patients, local programs in collaboration with sports rehabilitation centers are to be recommended.

Viene fornito uno stato dell'arte riguardo ai principali schemi di terapia immunosoppressiva (terapia standard con schemi a duplice e triplice terapia, schema personalizzato con assenza di steroidi, minimizzazione calcineurina, senza inibitoro della calcineurina) per i pazienti trapiantati di rene. L'articolo fornisce inoltre le indicazioni sui livelli ematici efficaci dei farmaci immunosoppressori