Manual handling of loads: the point of view of experts involved in the application of EC Directive 90/269

This paper illustrates the viewpoint of a group of Italian research workers who have been directly involved in providing criteria and guidelines for application of EC Directive 90/269, Manual handling of loads. The problems posed by application of the Directive in Italy and which are mainly related to exposure assessment, health surveillance and risk management (work and workplace redesign) are thoroughly examined. Major questions still to be solved include defining methods for assessment of multiple and complex load handling tasks, identifying data sources on 'health effect' trends as investigated in a working population with low exposure or in the general population in order to fix action levels, and setting up a data bank of technical and organizational solutions and products accessible to experts and users.

[Transurethral incision of the prostate]

In this paper the Authors present the preliminary results of an investigation of a series of a patients with BPH who have undergone TUIP by modified monolateral incision. Post-operative complications, hospital stay and short-term urine flow values have been assessed. From June '94 to April '96 at the Department of Urology of the Hospital of Matera, 56 patients with BPH-induced cervico-urethral obstruction undergone TUIP. Their average age was 66; the average follow up was 9.5 months. Thirty-one of them ha bladder catheters. The patients were selected by ultrasonographically measured prostatic volume (< or = 30 gr). The operation was almost in all cases conducted under spinal anaesthesia. A 5-10 mm-long monolateral incision was made medial to the right urinary meatus, starting just behind the trigonal bar and going up to the pre-spyncteric region, laterally to the veru montanum. The incision was made up to the section of the muscle fibres of the trigone and those of the prostate capsule, exposing the fat. Post-operative assessment included a urine culture after 15 days as well as a urine flow measurement every three months. The operative took an average of 10.3 minutes. The catheter was removed on average after 2 days. Post-operative hospitalization lasted on average 3.9 days. No post-operative complications were encountered. Only in 3 cases in which a catheter with no Coudè tip was used, was it difficult to insert. In no case was a blood transfusion necessary. Six patients with normal pre-operative sexual activity maintained their normal ejaculation. Of the 29 patients that had got through the 3-months' follow-up, seven who had been catheterized before the operation, showed, along with an average volume of urine of 236.7 cc, a maximum flow value of 10.8 ml/sec., an average flow of 6.8 ml/sec. and a bladder emptying time of 36.8 sec. The other 22 patients had an average maximum flow speed of 20.5 ml/sec. (+121.5%), an average flow of 10.3 (123.9%), an emptying time of 33 sec. (-8.8%) with an average volume of urine of approximately 300 cc (+58.9%). Thus, in view of the noteworthy post-operative improvement in the symptomatology, both in subjective and objective terms, as well as the low rate of complications and the considerably reduced costs, TUIP may be considered a valid surgical alternative for treatment of BPH with adenomas weighing < or = 30 gramis in selected patients.

[Epidemiology of musculoskeletal disorders caused by biomechanical overload (WMSDs)]

The link between occupation and musculo-skeletal disorders has been focused on in numerous research projects, ranging from those simply observing the different pathological findings reported among workers performing particular tasks, down to the latest studies actually quantifying the "exposure" of workers to physical and psycho-social stimuli, Recently, Hagberg et al (11) carried out a critical review of the literature concerning the upper limbs. For some disorders and certain tissues, the authors reported that specific types of work-related exposure are associated with the development of musculo-skeletal pathologies, and that the relative risks for certain types of occupational exposure can be extremely high. This has been proven in relation to tendinitis of the shoulder and hand-wrist, carpal tunnel syndrome, and tense neck syndrome, as well as several localised aspecific musculo-skeletal symptoms, such as pain. For other pathologies, the study reported contradictory results. This is the case for lateral epicondylitis, narrow chest syndrome and cervical radiculopathy. Associations have moreover been observed between several groups of disorders and certain psycho-social factors (e.g. workload, degree of discretionality).

Massive haemobilia after percutaneous liver biopsy in a patient with POEMS syndrome successfully treated by arterial embolization

A 65-year-old woman with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes) developed severe upper right quadrant colic with jaundice, massive haematemesis and melaena following an apparently uncomplicated percutaneous liver biopsy performed for suspected liver involvement. Symptom onset occurred about 18 hours after the procedure. Haemobilia was diagnosed on endoscopic retrograde cholangiopancreatography. An arteriovenous fistula in the third hepatic segment was demonstrated by transfemoral arteriography and successfully embolized using Gelfoam pledgets mixed with Ivalon fragments. A review of percutaneous liver biopsy related haemobilia is presented.

[Evaluation of the socioeconomic status in epidemiological surveys: hypotheses of research in the Brianza area MONICA project]

Socio-economic status (SES) has been reported as a causative factor of increasing health inequalities in industrialized countries. The phenomenon has been particularly investigated for job related diseases, including cardiovascular disease and risk. The group of occupational medicine specialists in the world wide MONItoring program of CARdiovascular disease (WHO-MONICA Project) is now producing a number of hypotheses about the application of internationally defined criteria and tools for SES evaluation in the Italian area of the Project, Area Brianza. After a short review of some main conceptual and methodological problems, a proposal is presented of an SES index, derived from the pooled data of two population surveys carried out in this area. From a randomized sample of 3200 residents, 25-64 years old, stratified by sex and age decade, 1731 subjects, 594 females and 1137 males, employed at the time of the screening were extracted. Four variables were considered: age, education, occupational level and job-strain (according to the Karasek-Theorell model) by which each subject was classified in three levels--high, medium, low--of education and occupation, whose combination was used to obtain as many levels of socio-economic status. This a method of building an SES index is based on a sequence of approximations following two essential criteria: limitation of the variables to be surveyed, through standardized procedures; ability to identify the "low" SES category, presumably more at risk for disease.

[Primary carcinoid of the umbilicus. Description of the 1st case]

A 78-year old male came to our observation presenting and enlargement of bilateral inguinal lymph nodes and a tumor of the mesogastric abdominal wall. Three years before the patient had been operated on for a primary tumor of the umbilicus with concomitant longstanding diarrhea. No histological examination was performed at that time. We performed a lymph node biopsy which demonstrated carcinoid metastasis. We went on to perform radical resection of the abdominal wall, regional lymphadenectomy and right hemicolectomy for malignant villous adenoma of the right colon. The abdominal defect was repaired by using Goretex mesh. Cyclic adjuvant alpha-interferon therapy was continued for more than 1 year, followed by long term therapy with longastatin. Twenty months after the operation the patient is in good clinical conditions and disease-free. On the basis of literature review our case appears to be the first primary carcinoid of the umbilicus.

[Primary lymphomas of the gastrointestinal tract: clinical picture]

Approximately 5% of all lymphomas are located in the gastrointestinal tract. These lesions may be secondary manifestations of systemic lymphomatous disease, but there are also primary lesions that are not associated with superficial lymph node enlargement mediastinal adenopathy, liver and spleen involvement or hematologic alterations. Primary lymphomas may arise in the stomach or intestine. Small intestinal lesions may or may not be preceded by other types of intestinal pathology, such as celiac or inflammatory disease. The former cases are characterized by persistent diarrhea, malabsorption and weight loss. Abdominal pain and later nausea and/or vomiting are the most common presenting symptoms of lesions that arise in an already diseased bowel, palpable abdominal masses are present in approximately one third of these cases. Gastric lymphomas often presents with non-specific symptoms: cramp-like epigastric pain, anorexia and weight loss.

[The role of ultrasonography in the diagnosis and staging of gastroenteric lymphoma]

Ultrasonography (US) plays an important role in the diagnosis, staging and follow-up of gastrointestinal lymphomas particularly when associated with complementary techniques such as echo-guided biopsy and endoscopic ultrasonography. Besides the well-known ultrasonographic "pseudo-kidney" image as sign of gastrointestinal pathology, the "spoke wheel" image is suggestive of gastroenteric lymphoma. This lesion is due to the lymphomatous infiltration of intestinal wall that looks ipoechoic compared to the iperechoic lumen. An early abdominal US study performed after clinical suspicion, should allow a presumptive identification of the enteric tract involved on the basis of the relationship between the "pseudokidney" image and the other abdominal organs. US study of the abdomen may be useful also to demonstrate enlarged retroperitoneal or visceral lymph nodes both in primary gastroenteric or systemic lymphomas. Fine needle biopsy (FNB) of deep lymph nodes is mandatory when superficial enlarged lymph nodes are not found showing a specificity and sensitivity of 100% and 66% respectively. The typical image of gastric wall on endoscopic US is constituted of five layers; the second one represents the lamina propria with the lymphatic tissue. The thickness increase of this layer suggest the diagnosis of gastric lymphoma. Therefore the endoscopic US examination is particularly important when the endoscopic features and the endoscopic biopsies are negative. Finally endoscopic US may be used to guide FNB of gastrointestinal tract lesions.

[Diseases of the dorsal-lumbar spine and manual handling of loads: guidelines for fitness assessment]

In occupational medicine, degenerative diseases and malformations of the spine are one of the main reasons for requests for fitness assessment for specific jobs, especially among workers involved in manual handling tasks. By means of a selected review of the specialised literature, the authors identify analysis procedures and precise criteria for assessing compatibility between the clinical condition of the spine and manual handling tasks. Attention is drawn in particular to the diseases caused or at least aggravated by mechanical overloading of the spine. For each of these a set of diagnostic criteria is established which could be useful in defining the various levels of severity. On another front, by using tried and tested methods and criteria to identify the weight limits that can be lifted by healthy subjects in various manual handling situations, an approach was developed that can be applied to establish the weight limits that can be lifted by subjects with spinal diseases. By combining the two factors, risk level and damage level, a set of disorders was established that correspond to three different fitness levels. At each level, manual load handling was only allowed up to certain weights and for handling conditions that became increasingly stringent as the severity of the disorder increased. The paper outlines the clinical protocols and the protocols for reconstructing work exposure. The procedural differences involved in the case of fitness assessments in the pre-employment stage are also briefly discussed.

Study of distribution and characteristics of spinal disorders using a validated questionnaire in a group of male subjects not exposed to occupational spinal risk factors

This article presents the content and the application criteria of a questionnaire intended for the study of spinal disorders in workers and the results of an investigation, carried out via this questionnaire, in a group of 1205 male workers not exposed to occupational risks for the spine either currently or in the past. The data, stratified into three age classes (26-35, 36-45, and 46-55 years) concern: cases of disc herniation, cases of acute lumbago, subjects with spinal disorders in the period before the last 12 months. In addition, for each spinal segment (cervical, thoracic, and lumbar) data are reported on cases classified as positive according to predefined criteria, cases with disorders of any degree, disability caused by disorders, absence from work, and recourse to treatment for disorders. These data constitute a reference for cross-sectional epidemiologic studies on the diffusion and features of spinal disorders in workers exposed to occupational risks for the spine, performed using the same questionnaire. The authors discuss selection criteria and criteria for use of the data in inferential analysis for the purposes of producing correct assumptions on the causal relationships between occupational risk and spinal disorders.

Criteria for the ergonomic evaluation of work chairs

On the basis of a critical overview of specialised ergonomics literature and of national and international standards on the subjects, this paper outlines the main ergonomic requirements and characteristics for work chairs. The main ergonomic requirements for work chairs are the following:

SAFETY

the chair should not be the source or cause of accidents. Adaptability: the chair's dimensions and control features should be such that they meet the anthropometric characteristics of at least 90% of the potential users. Comfort: the chair should be physiologically comfortable for the user. To this end, the following are all important features: seat-plane and backrest contours, backrest height and inclination adjustability, padding and covering materials that allow the body to breath. Practicality: the chair, and in particular the control features, should be practical and easy to control use. Durability: the chair should offer good wear and durability of its components and controls. Suitability for the job: the chair should be appropriately designed for the intended type of job and working environment. For each of these requirements single parameters are considered and for each parameter specific qualitative and/or quantitative data are given in order to class each single item as: "not acceptable", "acceptable" or "good", as regards standards and regulations, anthropometric parameters and intended uses. Criteria are given for a concise assessment of each of the six main requirements and for a comprehensive assessment of the "ergonomic quality" of the work chair.

[The contribution of science to health promotion in the workplace]

An imposing amount of knowledge has been produced during the course of three hundred years of research in the field of occupational medicine and in other specialisations that in the last fifty years developed as branches of this discipline (industrial hygiene, industrial toxicology, respiratory physiopathology, etc). Part of this scientific heritage has been used to the full to plan and carry out prevention measures that have led to improved working conditions in many sectors of industry. Examples are the successes obtained in the prevention of pneumoconioses, aplastic anaemia and leukemia due to benzene, cancer caused by aromatic amines, and diseases occurring in pesticide users and consumers of agricultural products treated with such products. More recently, through original research programmes, with particular reference to the "Clinica del Lavoro" of Milan, a theoretical revision was made of the conception and method for analysing the relationship between organised work and health, resulting in an organic arrangement of the variables and procedures for the analysis of working conditions for the purposes of prevention. Other ways and areas where scientific bio-medical knowledge can be used are: a) planning of prevention measures on a vast social scale; b) variables and indicators for planning and assessing services designed for diagnosis and prevention of occupational risks and diseases; c) development of training programmes. In spite of these positive results, European Community statistics show that still too many occupational accidents and work-related diseases occur all over the world, especially in the developing countries, because the amount of scientific knowledge used is still much smaller than what is already available. The causes of this situation are many, among which those of a cultural nature. The author proposes the setting up of an "International Network for the History of Occupational and Environmental Prevention", and furnishes a detailed illustration of the aims and foreseeable initial actions.

Advanced non-small-cell lung cancer (NSCLC) treated with folinic acid (F), fluorouracil (FU), vincristine (O), and mitomycin-C (Mi), (F-FOMi)

Thirty-one patients with advanced non-small-cell lung cancer (NSCLC) were treated with a combination of folinic acid, fluorouracil, vincristine, and mitomycin (F-FOMi). Eight partial responses (26%), eight stable disease (26%), and 15 progressive disease (48%) were obtained. Patients with performance status (PS) 0-1 had a significantly better response rate than those with PS 2-3. Overall actuarial survival was 10 months. Toxicity was mild and mainly gastrointestinal with mucositis and diarrhea. F-FOMi seems to be comparable to regimens more widely used in the treatment of NSCLC.

Antipyrine metabolism in patients with liver metastases from colorectal cancer

BACKGROUND

The influence of cancer on antipyrine metabolism is under debate.

METHODS

To assess the functional activity of a liver with solid metastases from primary colorectal cancer, antipyrine metabolism was studied after the drug was administered orally (18 mg/kg body weight) to 55 healthy volunteers, 62 patients with well-compensated cirrhosis, and 42 patients with small (Class A) or massive (Class B) metastatic liver involvement.

RESULTS

In patients with cancer, antipyrine clearance (0.472 +/- 0.177 ml/min/kg) was similar to that in healthy volunteers (0.456 +/- 0.198 ml/min/kg) and significantly higher than in those with cirrhosis (0.259 +/- 0.17 ml/min/kg, P less than 0.001). There was no difference in antipyrine pharmacokinetics between Class A and B involvement. In the entire population, antipyrine clearance was correlated with serum albumin levels (r = 0.294, P = 0.0002) and prothrombin activity (r = 0.416, P = 0.001). This positive correlation was not present when only the neoplastic group was considered. No correlation was found between antipyrine clearance and alkaline phosphatase levels. In patients with cancer, no relationship was found between antipyrine clearance and carcinoembryonic antigen and lactic dehydrogenase levels.

CONCLUSIONS

These results show that patients with livers largely replaced by solid metastases are able to metabolize antipyrine to the same extent as healthy subjects.

Selective nonoperative management of solid breast masses

A prospective study evaluated the hypothesis that, following consistent clinical and mammographic guidelines, many women with breast masses can be nonoperatively managed. One hundred eighty women with solid breast masses were assigned both a clinical and mammographic diagnosis by each a surgeon and radiologist. Immediate biopsy (n = 78) was recommended when either clinician thought that the mass was malignant (52 cancers). The remainder were offered a trial of observation, with interval biopsy performed upon patient preference or for increased clinical/mammographic concern. Of the 89 who consented to this, 70 received long-term follow-up (X = 22 months) with improvement in the characteristics of the mass. The diagnosis of invasive cancer was delayed in two women initially observed, with no apparent impact on survival. It is concluded that many women with solid breast masses can be safely observed. Biopsy remains warranted for any mass suspicious for malignancy on clinical/mammographic grounds, or if follow-up cannot be assured.

Hepatocarcinoma in cirrhosis. Is antithrombin III a neoplastic marker?

It has been reported that hepatoma (HCC) cells produce abnormal proteins such as erytropietin, fibrinogen, prothrombin, and, recently, antithrombin III (AT III). In a preliminary report, we reported increased AT III levels in patients bearing HCC independent of their clinical liver status. The present study was performed to assess antithrombin III levels and other serological data present in patients with cirrhosis and in patients with cirrhosis and clinical findings of neoplastic disease. In 70 well-matched patients (47 with cirrhosis and 23 with cirrhosis and proven HCC) serum total cholesterol, albumin, prothrombin, alkaline phosphatase, AFP, aminotransferases, and AT III were determined. Together with AFP and alkaline phosphatase, patients with HCC had higher values of AT III (88 +/- 7%) and total cholesterol (184 +/- 17 mg/100 ml), as compared with cirrhotic patients (AT III 56 +/- 3.6%; total cholesterol 113 +/- 5 mg/100 ml) (P less than 0.001). No difference was observed between these two groups for albumin, prothrombin, and aminotransferases. In HCC patients, AT III levels were related to the total cholesterol level (R2 = 0.317), whereas in the cirrhotic patients it correlated with the prothrombin level (R2 = 0.274). These data suggest that in HCC patients a greater rate of synthesis of AT III occurs, whereas in cirrhotic patients lower levels of AT III occur due to impaired synthesis or increased catabolism of the protein. The serial determination of AT III in cirrhotic patients as a means of detecting neoplastic transformation is suggested.

5-Fluorouracil (FU) and mitomycin C (MMC) in the management of colorectal carcinoma. Part II. In vitro activity of the two drugs in short-term tumor cultures

Eighty-seven colorectal adenocarcinomas from untreated patients were investigated by short term tumor cultures to test in vitro sensitivity to 5-fluorouracil and mitomycin C. This study reports the preliminary results of a multistep program aimed at the prospective clinical application of the assay. At present this in vitro experience was performed in parallel with a clinical trial carried out with the same drugs. The in vitro activity of the two anticancer agents is in agreement with the response rate reported in monochemotherapy; our data would suggest an increase of responses using the combination of fluorouracil and mitomycin in comparison to single drug therapy. A low cosensitivity rate and a high number of cases sensitive to one drug but resistant to the other, account for the use of this test as screening of active drugs in the individual patient.

Association of epirubicin, etoposide and cisplatin in gastric cancer. A phase II study

Cisplatin-based drug combinations are now currently investigated in an attempt to surpass the results obtainable by 5-FU alone or by 5-FU-containing regimens. We evaluated 29 patients with advanced and measurable gastric adenocarcinoma treated with etoposide, epirubicin and cisplatin. One patient had complete response (3 +/- 7%); 9 patients had partial response (31 +/- 17%); 5 patients (17 +/- 14%) were considered stable (S) and 14 (48 +/- 18%) were classified as progressive. The average survival time for the entire group was 11 months with 25% of the patients alive at 24 months. We feel that cisplatin-containing regimens are promising and deserve further investigations. To clearly explore the potential innovative role of these regimens randomized trials versus FAM or 5-FU alone are mandatory.