Occupational asbestos exposure and ovarian cancer: updated systematic review

BACKGROUND

The association between asbestos exposure and ovarian cancer has been questioned given the possible misdiagnosis of peritoneal mesothelioma as ovarian cancer.

AIMS

To update a systematic review on ovarian cancer risk in women occupationally exposed to asbestos, exploring the association with the time since first exposure and the duration of exposure.

METHODS

We searched PubMed from 2008 onwards, screened previous systematic reviews, combined standardized mortality ratios (SMR) using random effect models and quantified heterogeneity using the I2 statistic. To assess tumour misclassification, we compared the distribution of observed excess ovarian cancers (OEOC) to that expected (EEOC) from the distribution of peritoneal cancers in strata of latency and exposure duration.

RESULTS

Eighteen publications (20 populations), including a pooled analysis of 21 cohorts, were included. The pooled SMR was 1.79 (95% confidence interval 1.38-2.31), with moderate heterogeneity between studies (I2 = 42%), based on 144 ovarian cancer deaths/cases. The risk was increased for women with indirect indicators of higher exposure, longer duration and latency, and lower for chrysotile than for crocidolite exposure. The effect of duration and latency could not be completely disentangled, since no multivariate analysis was available for time-related variables. The dissimilarity index between OEOC and EEOC for the time since first exposure was small suggesting a similar pattern of risk.

CONCLUSIONS

While some misclassification between ovarian and peritoneal cancers cannot be excluded, the observed excess risk of ovarian cancer should be added to the overall disease burden of asbestos.

Allergic reaction and metal hypersensitivity after shoulder joint replacement

PURPOSE

Metal ion release may cause local and systemic effects and induce hypersensitivity reactions. The aim of our study is first to determine if implant-related hypersensitivity correlates to patient symptoms or not; second, to assess the rate of hypersensitivity and allergies in shoulder arthroplasty.

METHODS

Forty patients with shoulder replacements performed between 2015 and 2017 were studied with minimum 2-year follow-up; no patient had prior metal implants. Each patient underwent radiographic and clinical evaluation using the Constant-Murley Score (CMS), 22 metal and cement haptens patch testing, serum and urine tests to evaluate 12 metals concentration, and a personal occupational medicine interview.

RESULTS

At follow-up (average 45 ± 10.7 months), the mean CMS was 76 ± 15.9; no clinical complications or radiographic signs of loosening were detected; two nickel sulfate (5%), 1 benzoyl peroxide (2.5%) and 1 potassium dichromate (2.5%) positive findings were found, but all these patients were asymptomatic. There was an increase in serum aluminum, urinary aluminum and urinary chromium levels of 1.74, 3.40 and 1.83 times the baseline, respectively. No significant difference in metal ion concentrations were found when patients were stratified according to gender, date of surgery, type of surgery, and type of implant.

CONCLUSIONS

Shoulder arthroplasty is a source of metal ion release and might act as a sensitizing exposure. However, patch test positivity does not seem to correlate to hypersensitivity cutaneous manifestations or poor clinical results. Laboratory data showed small constant ion release over time, regardless of gender, type of shoulder replacement and implant used.

LEVELS OF EVIDENCE

Level II.

Lung Asbestos Bodies and Pulmonary Cancer in Subjects without Occupational Exposure

Lung asbestos bodies were searched for in 65 subjects with pulmonary cancer and without occupational exposure and in 65 matched controls. No significant association between the presence of asbestos bodies and occurrence of lung cancer was found. Nevertheless, adenocarcinoma was significantly associated with the presence of lung asbestos bodies in men. The latter result suggest that, even in non-professionally exposed subjects, the possibility of relationships between asbestos exposure and lung cancer cannot be excluded.

Cancer mortality in cohorts of workers in the European rubber manufacturing industry first employed since 1975

BACKGROUND

Increased cancer risk has been reported among workers in the rubber manufacturing industry employed before the 1960s. It is unclear whether risk remains increased among workers hired subsequently. The present study focused on risk of cancer mortality for rubber workers first employed since 1975 in 64 factories.

PATIENTS AND METHODS

Anonymized data from cohorts of rubber workers employed for at least 1 year from Germany, Italy, Poland, Sweden, and the UK were pooled. Standardized mortality ratios (SMRs), based on country-specific death rates, were reported for bladder and lung cancer (primary outcomes of interest), for other selected cancer sites, and for cancer sites with a minimum of 10 deaths in men or women. Analyses stratified by type of industry, period, and duration of employment were carried out.

RESULTS

A total of 38 457 individuals (29 768 men; 8689 women) contributed to 949 370 person-years. No increased risk of bladder cancer was observed [SMR = 0.80, 95% confidence interval (CI) 0.46; 1.38]. The risk of lung cancer death was reduced (SMR = 0.81, 95% CI 0.70; 0.94). No statistically significant increased risk was observed for any other cause of death. A reduced risk was evident for total cancer mortality (SMR = 0.81, 95% CI 0.76; 0.87). Risks were lower for workers in the tyre industry compared with workers in the general rubber goods sector. Analysis by employment duration showed a negative trend with SMRs decreasing with increasing duration of employment. In an analysis of secondary end points, when stratified by type of industry and period of first employment, excess risks of myeloma and gastric cancer were observed each due, essentially, to results from one centre.

CONCLUSION

No consistent increased risk of cancer death was observed among rubber workers first employed since 1975, no overall analysis of the pooled cohort produced significantly increased risk. Continued surveillance of the present cohorts is required to confirm the absence of long-term risk.

Responses of hematological parameters, beta-endorphin, cortisol, reactive oxygen metabolites, and biological antioxidant potential in horses participating in a traditional tournament

Several concerns have been raised over the health of animals used in equestrian games that have their origins in historical or religious events and are currently held in many countries. This study investigated physiological stress response and health status of horses participating in the Sartiglia, a historical horse tournament held in the city of Oristano, Italy, which is principally based on the attempts of masked horsemen at a gallop to run a sword through a hole in a suspended silver star. Blood samples were collected from 21 horses the day before the tournament (D0), during the tournament (D1), and the day after the tournament (D2). Samples were analyzed for complete blood count and biochemical, hormonal, and oxidative stress assays. Data were analyzed using the mixed effect model with sampling session as one of the fixed effects. On the whole, blood parameters evidenced an optimal health status of horses at D0. Significant dehydration and increase of circulating glucose, enzymes, cortisol, and β-endorphin were registered at D1 (P < 0.001) with a complete recovery of physiological values just at D2. The reactive oxygen metabolites (d-ROM), from which the prooxidant activity can be evaluated, showed an increase from D0 to D1 and D2. Concentration of biological antioxidant potential, which measured the antioxidant capacity, was characterized by the maximum level registered during the tournament and counteracted the simultaneous increase of d-ROM. It can be hypothesized that the tournament played an important role in causing high levels of oxidant markers not only because of the physical exercise represented by the gallop but also because the emotional stressors. In conclusion, the tournament caused significant changes of most parameters, which rapidly recovered to baseline values within the day after. These data will certainly be useful for a future implementation of tests in equine medicine and for the improvements of knowledge of changes of blood parameters and health of horses in similar tournaments.

Return to work after organ transplantation: a cross-sectional study on working ability evaluation and employment status

INTRODUCTION

Organ transplantation has increased in Italy over the last decade. Thus, an increasing number of workers may face the problem of returning to work. The aim of this study was to provide an assessment of working ability of transplant recipients in comparison with their actual employment status.

METHODS

This study was based on 150 patients who underwent transplantation since 1994 and who underwent periodic post-transplantation examination during 2012. Fifty patients who had undergone heart transplantation (HT), 50 liver transplantation (LT), and 50 kidney transplantation (KT) and survived at least 12 months after surgery were eligible for this study. All patients underwent the International Classification of Functioning, Disabilities and Health (ICF) questionnaire; ten questions were further applied to those who were employed at the time of the study. X(2) statistics were used to compare working ability evaluation and employment status and for internal comparison among different organ recipients.

RESULTS

The employment status was as follows: 92 (61%) patients were in paid employment, 6 (4%) were students or housewives, 36 (24%) were unemployed, and 17 (11%) were retired because of invalidity benefits. According to our fitness evaluation only 4% to 10% of the patients were unfit for any job. When we excluded retired subjects, the X(2) statistics for correlated observations showed a highly significant statistical difference (P < .0001) between unemployed and unfit. As a result of the ICF questionnaire administration, there was a marked difference, although not statistically significant, in the fitness for previously performed jobs between KT and LT recipients (62% and 58%, respectively) and HT recipients (42%).

DISCUSSION AND CONCLUSION

In this cross-sectional study we found a relatively high rate of unemployment as compared with the working ability evaluation by ICF questionnaire and other questions. This may be due to several factors including health status and the possibility of gaining an adequate job. The ICF questionnaire proved to be a useful framework that can be used for research but also by occupational physicians in their usual practice after specific training.

[The evaluation of biological effects of exposure to respirable crystalline silica in building industry]

The building industry entails the exposure to Respirable Crystalline Silica (RCS), though there is a large variability among different sectors. The environmental values reported for the current conditions seem to be relatively low. For example the mean exposure estimated by IOM for all industrial sectors in the EU is 0.07 mg/m3. There are few studies in the building sector which show similar values. This is obviously not representative of past exposure. Moreover, the problems of sampling and analysis techniques are still at issue. The well known effect of RCS exposure is silicosis. The carcinogenicity of RCS is still under debate, especially regarding the question of whether RCS is carcinogenic "per se" or whether the risk of developing lung cancer is mediated by silicosis. Although the IARC includes RCS in the Group I (human carcinogen), the reference should be the CLP regulation, of which carcinogen definition criteria allow to state that today there are not sufficient data to classify RCS as a carcinogen and that it seems more appropriate to include RCS in different STOT.RE categories. This is valid for building industry as well as for the other industrial sectors. In Italy the recommended exposure limit is the ACGIH value of 0.025 mg/m3. At EU level it is still debated which is the best choice, based on cost/benefits evaluation, among the following limit values: 0.2, 0.1 and 0.05 respectively. The authors obviously believe that the most protective value should be adopted.

[New data on pumice's structure and biological effects among miners and millers]

Pleural plaques among pumice workers on Lipari Island have been described and the Authors have suggested the hypothesis that such biological effect could be related to the particles' morphology characterized by the presence of elements similar to fibers. Analysis on compact bulk materials and on dust samples from different sites of the Island have been performed to obtain information on the chemical composition of such materials. The Scan Electron Microscopy (SEM) analyses confirm the presence of fibrous particles with a chemical structure similar to the Refractory Ceramic Fibers (RCF) composition. These results could explain the presence of plural plaques among the workers and new clinical and epidemiological evaluations of the potential effects associated to this exposure are needed.

The opinion of the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII) on silica-exposure and lung cancer risk

BACKGROUND

The Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII) began a thorough overview of the silica-silicosis-lung cancer question starting in 2005.

METHODS AND RESULTS

The body of informa tion obtained from a number of epidemiological studies, meta-analyses and reviews following the decision of the IARC to classify Respirable Crystalline Silica (RCS) as a human carcinogen (Group 1) led to different conclusions, which can be summarized as follows: basically an increased risk of developing lung cancer is demonstrated and generally accepted for silicotics; the association of lung cancer and exposure to silica per se is controversial, with some studies in favour of an association and some leading to contrary conclusions. Due to methodological problems affecting most studies and the difficulty in identifying the mechanism of action, we agree that the silica-lung cancer association is still unclear. The UE approach is more practical than scientific, in that it recommended the use of "good practices" subject to an agreement with the social partners, without any need to classify RCS as a human carcinogen. However, in 2008 the UE asked the Institute of Occupational Medicine (IOM) in Edinburgh to assess, as a primary objective, the impact of introducing a system for setting Occupational Exposure Limits (OELs) based on objective risk criteria.

CONCLUSION

In the present state of the art SIMLII's conclusions are: a) There is no need to label RCS with phrase H350i (ex R.49); b) It is of utmost importance to enforce compliance with current OELs; c) Future guidelines specific for silicosis risk should include adequate health surveillance; d) For legal medicine purposes, only lung cancer cases with an unquestionable diagnosis of silicosis should be recognised as an occupational disease.

[Alimentation, health promotion and work: a strategy for alimentary education and food quality promotion]

As health promotion activity have been started two alimentary education projects for CTO Turin Hospital and LntesaSanpaolo bank group employers. Both projects have been co-ordinated by structure of Occupational Health of CTO Hospital and Turin University. The first step of the projects provided information and formation by using a brochure containing good alimentation tips. In the next step each participant at projects registered daily the food choice on specific software. At the end of observational period (six months) each participant received a final report containing quali-quantitative evaluation on the food choice uprightness. At the same time in IntesaSanpaolo bank group it have been proceeded, following Slow Food indication, on introducing a new menu based on using localfood products.

[Early lung cancer detection in an occupational asbestos exposed population: clinical impact of low-dose computed tomography screening]

Lung cancer is the primary cause of cancer mortality in developed countries. Early detection and surgical resection is essential for the treatment of lung cancer. The introduction of low-dose spiral computed tomography (LDCT) is considered one of the most promising clinical research developments in early diagnosis of lung cancer. Our study is aimed at the evaluation of spiral CT in a cohort of subjects with a past occupational exposure to asbestos at high risk of developing lung cancer. 149 subjects were enrolled between 2007 and 2009 (the criteria for enrollment were date of birth between 1930-1961, no previous cancer and general good health, latency from the beginning of exposure > 10 years, exposure duration > 1 year, possibility to undergo to surgery). A helical low-dose CT (LDCT) of the chest was performed yearly and an evaluation protocol derived from IEO with a morphological analysis of nodules have been adopted. 13 nodules were diagnosed in the first CT, 7 in the second and 3 in the third but no invasive procedures have been taken and no lung cancer have been detected. Our early follow-up data aren't able yet to evaluate the effect of screening with LDCT on mortality but have do not confirm some of the literature initial results such as the Increase in cases of overdiagnosis (false positive) due to the high prevalence of benign lesions.

[The diagnosis of diseases due to occupation]

Occupational diseases are essentially defined by aetiological characteristics, and not by nosological characteristics, because the latter in most cases are not specific. This is particularly so for "work-related" diseases but still stays true for most "occupational" diseases. This implies that the diagnostic path for occupational diseases must include one additional step as compared to the standard procedure typical of non occupational medicine. The last is satisfactory after a suitable history and clinical-instrumental phase and thus a nosological definition are completed. The former includes an additional mandatory third phase, the one defining a reliable causal relationship taking into account a reasonable relationship between, on one side, the qualitative, quantitative and temporal aspects of the specific risk, and, on the other side, the observed "effect". These items must be systematically looked for (unless they are practically unobtainable) if a correct diagnosis of an occupational disease has to be reached.

[IARC evaluations: how are they conducted and what suggestions are derived therefrom?]

The IARC Monographs on the Evaluation of Carcinogenic Risks to Humans are considered by several Institutions a point of reference for the prevention of adverse effects (namely cancer) of occupational exposures. The conclusions which lead to the Classification of a substance or an industrial process are the results of a vote within a Working Group of experts and are expressed in terms of "evidence" based on both epidemiological and experimental data or "other relevant data". Several points are discussed which include the methods of identification of the experts, the criteria of evaluation of the available data, the meaning of some definitions and finally the impact of IARC conclusions and Classification on Public Health regulations and secondarily on compensation procedures or trial decisions. Three recent examples regarding the Classification of Free Crystalline Silica, Shift-Work and Vinyl Chloride Monomer, which cannot be accepted as such without some criticism, are reported. In conclusion the Authors appreciate the effort of the IARC to provide a source of information which "may assist national and international authorities in making risk assessments and in formulating decisions concerning any necessary preventive measures". However, they suggest that the IARC "overall evaluation" should not be taken as confidently as if no doubt at all would exist on the final statement and the consequent Classification. Some suggestions as to the solution of the question are also provided.

First and subsequent asbestos exposures in relation to mesothelioma and lung cancer mortality

We analysed data from a cohort of 1966 subjects (889 men and 1077 women) employed by an Italian asbestos (mainly textile) company in the period 1946–1984, who were followed-up to 2004. A total of 62 025 person-years of observation were recorded. We computed standardised mortality ratios (SMR) for all causes and selected cancer sites using national death rates for each 5-year calendar period and age group. There were 68 deaths from mesothelioma (25 men and 43 women, 39 pleural and 29 peritoneal) vs 1.6 expected (SMR=4159), and 109 from lung cancer vs 35.1 expected (SMR=310). The SMRs of pleural/peritoneal cancer were 6661 for subjects exposed only before 30 years of age, 8019 for those first exposed before 30 and still employed at 30–39 years of age and 5786 for those first exposed before 30 and still employed at 40 or more years of age. The corresponding SMRs for lung cancer were 227, 446 and 562. The SMR of mesothelioma was strongly related to time since first exposure. The SMR of lung cancer, but not of mesothelioma, appeared to be related to subsequent exposures.

Formaldehyde and cancer risk: a quantitative review of cohort studies through 2006

BACKGROUND

Occupational exposure to formaldehyde has been associated with excess risk of nasopharyngeal and selected other cancers.

PATIENTS AND METHODS

We reviewed and pooled the results of cohort studies published through February 2007.

RESULTS

There were 5651 deaths from all cancers observed in six cohorts of industry workers and six of professionals, with a pooled relative risk (RR) of 0.95 for industry workers and of 0.87 for professionals. Nine deaths from nasopharyngeal cancer in three cohorts of industry workers yielded a pooled RR of 1.33, which declined to 0.49 after excluding six cases from one US plant. The pooled RR for lung cancer was 1.06 in industry workers and 0.63 in professionals. Corresponding values were 1.09 and 0.96 for oral and pharyngeal, 0.92 and 1.56 for brain, 0.85 and 1.31 for all lymphatic and hematopoietic cancers, and 0.90 and 1.39 for leukemia.

CONCLUSIONS

Comprehensive review of cancer in industry workers and professionals exposed to formaldehyde shows no appreciable excess risk for oral and pharyngeal, sinonasal or lung cancers. A non-significantly increased RR for nasopharyngeal cancer among industry workers is attributable to a cluster of deaths in a single plant. For brain cancer and lymphohematopoietic neoplasms there were modestly elevated risks in professionals, but not industry workers.

[In vitro study of genotoxic and oxidative effects induced on human pulmonary cells by exposure to PAHs extracted from airborne particulate matter collected in a coke plant]

Genotoxic and oxidative effect of airborne particulate matter collected in a coke plant were evaluated on lung epithelial cells (A549). We aimed to clarify the mechanism of action of complex mixtures of PAHs and to identify biomarkers of effect of lung cancer. Particulate matter was analysed by GC/MS. Genotoxic and oxidative effects induced by the exposure to the extract were evaluated by Fpg comet assay. The cells were exposed for 30 min, 2h and 4h to 0.01%, 0.02% and 0.05% of the extract. We evaluated comet percentage and analysed tail moment values of exposed and unexposed cells treated with Fpg enzyme (TMenz) and untreated (TM) that indicate respectively oxidative and direct DNA damage. We found 0.328 ng/m3 of pyrene, 0.33 ng/m3 of benzo(a)anthracene, 1.073 ng/m3 of benzo(b)fluoranthene, 0.22 ng/m3 of benzo(k)fluoranthene, 0.35 ng/m3 of benzo(a)pyrene, 0.079 ng/m3 of dibenzo(a,h)anthracene and 0.40 ng/m3 of benzo(g,h,i)perylene. A dose-dependent increase, although not significant, of TM and TMenz in the exposed cells in respect to controls was found that indicates a slight increase of both direct and oxidative damage in exposed cells. A slight increase of comet percentage was found at the highest dose. We show the high sensibility of comet assay to measure early DNA damage also at low doses suggesting the use of such test on A549 to evaluate on target organ the effects of complex mixtures of genotoxic substances.

[The role of occupational physician in the application of the 2006 "agreement on workers' health protection through the good handling and use of crystalline silica and products containing it": the experience in mining sector]

The 2006 "Agreement on Workers' Health Protection Through the Good Handling and Use of Crystalline Silica and Products Containing it" between social parts defines a standardization of exposition control methods and medical surveillance. The Occupational Physician is integral part in exposition evaluation process and risk stratification in which derives the medical surveillance program. This study presents a first application of the European agreement in mining sector and the role of Occupational Physician in the evaluation of the risk to define methods of prevention. In particular it will be precised the choice of homogenous groups, the classification of exposed workers from results of workplace monitoring, the choice of technical prevention and individual protection equipments, and then the strategy of medical surveillance.

[Asbestosis and microfiber role]

Based on the predominant content of thin and short asbestos fibres in lung and mesothelioma tissues, it was recently stated (2005) that such fibres "appear to contribute to the causation of human malignant mesothelioma". In another study of the same year it was stated that fibres in the order of few microm length and 0.2 microm diameter are the sole able to induce mesothelioma. This scientific conclusions entail some implications from practical point of view. The enormous amount of information gained on asbestos in the last decades is based on the definition of a fibre as an alongated particle with an aspect-ratio of at least 3:1, a diameter < or = 3 microm and a length > or = 5 microm. These parameters were used up today to define occupational and in some case non-occupational limits. In which way can "reference" values be established if all lengths or only fibres shorter than 5 microm are considered? Nowadays we have no answer. Secondly, assuming a prevalent role of such fibres especially in mesothelioma cases, how can reliable estimates of past exposure obtained in a medico-legal context, since they have never been counted? Morever, how might he the employer responsibility assessed since short fibres were not measured by definition pathogenic, and this not measured, nor were there appropriate filtering systems up to the middle of the '80?

["The Italian decree 195/2006 on the protection of workers against risks arising from noise"]

The Italian decree 195/2006 incorporates the European Directive 2003/10/CE on the minimum health and safety requirements regarding the exposure of workers to the risks arising from physical agents (noise). It is rather different to previous decree 277/1991, particularly as regard of the new exposure limit value and the elimination of annex VI and VII. We discus here only two aspects that we consider relevant and quite critical: 1) The calculation of the exposure limit values as noise equivalent level: it is a method that underestimates the potential damage of impulsive noise, so the risk evaluation remains quite inaccurate. 2) To take account of the attenuation provided by the individual hearing protectors worn by the worker in determining the worker's effective exposure when applying the exposure limit values: this must not apply to the obligations of employer to control the risk at source avoiding or reducing exposure to the minimum. Furthermore the attenuation power of individual hearing protectors is difficult to measure because his variability during the time and among different subjects. Then we evaluate and discus the new duties of Occupational Physician in this matter. The daily exposure limit values and action values are in fact in part modified as well as the methodology for organize the programs of prevention, health surveillance, information and formation of workers. As support for his activity we proposed the guidelines that The Italian Society of Occupational Health and Industrial Hygiene (SIMLII) has published in 2003, which provides recommendations for the health surveillance for the prevention of noise induced hearing loss at the workplace.

Occupational silica exposure and lung cancer risk: a review of epidemiological studies 1996–2005

BACKGROUND

In 1997, a Monograph from the International Agency for Research on Cancer (IARC) classified occupational exposure to crystalline silica as carcinogenic to humans. Large amounts of epidemiological data have been published subsequently.

METHODS

We conducted a systematic review of epidemiological investigations on silica exposure and lung cancer risk published after the IARC Monograph, including 28 cohort, 15 case-control and two proportionate mortality ratio (PMR) studies. These were identified in the available literature.

RESULTS

The pooled RR of lung cancer, calculated using random effects models, from all cohort studies considering occupational exposure to silica was 1.34. The RRs were 1.69 in cohort studies of silicotics only, 1.25 in studies where silicosis status was undefined and 1.19 among non silicotic subjects. The pooled RR was 1.41 for all case-control studies. The RRs were 3.27 in case-control studies of silicotics only, 1.41 in studies where silicosis status was undefined and 0.97 among non silicotic subjects. The RR was 1.24 for PMR studies.

CONCLUSIONS

In this re-analysis, the association with lung cancer was consistent for silicotics, but the data were limited for non silicotic subjects and not easily explained for undefined silicosis status workers. This leaves open the issue of dose-risk relation and pathogenic mechanisms and supports the conclusion that the carcinogenic role of silica per se in absence of silicosis is still unclear.

[Training needs and role of general practitioners for preventing measures and medical surveillance of ex-exposed to occupational carcinogens]

The study was aimed at investigating in a sample of general medicine practitioners the level of epidemiologic and law knowledge as well as the degree of sensitivity to the topic of subjects formerly affected by occupational cancer. From the research, carried out on a sample of 745 practitioners from two northern Italy highly industrialized regions, come out the need for training and information on the problems associated with identification and management of subjects formerly exposed to professional cancer.

Cancer mortality in a cohort of asbestos textile workers

A cohort of 889 men and 1077 women employed for at least 1 month between 1946 and 1984 by a former Italian leading asbestos (mainly textile) company, characterised by extremely heavy exposures often for short durations, was followed up to 1996, for a total of 53 024 person-years of observation. Employment data were obtained from factory personnel records, while vital status and causes of death were ascertained through municipality registers and local health units. We observed 222 cancer deaths compared with 116.4 expected (standardized mortality ratio, SMR=191). The highest ratios were found for pleural (SMR=4105), peritoneal (SMR=1817) and lung (SMR=282) cancers. We observed direct relationships with duration of employment for lung and peritoneal cancer, and with time since first employment for lung cancer and mesothelioma. Pleural cancer risk was independent from duration (SMR=3428 for employment <1 year, 7659 for 1–4 years, 2979 for 5–9 years and 2130 for ⩾10 years). Corresponding SMRs for lung cancer were 139, 251, 233 and 531. Nonsignificantly increased ratios were found for ovarian (SMR=261), laryngeal (SMR=238) and oro-pharyngeal (SMR=226) cancers. This study confirms and further quantifies the central role of latency in pleural mesothelioma and of cumulative exposure in lung cancer.

[Occupational Medicine Programme in the university degree on prevention techniques in living and working environments]

This document has been prepared by a working group of University Professors belonging to the Italian Society of Occupational Medicine and Industrial Hygiene, with the aim of defining the role of this discipline in the university course on Prevention Techniques in Working and Living Environments. The course trains health professionals to apply risk assessment techniques, preventive measures and legislative tools for safety and health in working and living environments, food and beverages hygiene, and Public Health. The document describes the organization and the structure of the course, general and specific learning objectives, occupational medicine teaching and other organization aspects. Also, training of non-graduate technicians working for local health authorities is discussed.

[New biomarkers of exposure]

In this paper we have defined the new biomarkers of exposure (NBE) as those biomarkers discovered in the last five years and, among previously validated biomarkers, also those applied in different ranges of doses or those determined in biological matrices which differ from matrices originally considered. We examined the results from the surveys carried out by the main Italian research units involved in biological monitoring, i.e. those from the Universities of Brescia, Milan, Naples, Padua, Parma, Pavia, Turin and Verona. The data were collected using a standardized model and included the following: type of element or organic compound, type of biomarker, analytical technique and method, their relationship with environmental monitoring data, their relationship with effect indicators or effects in general, improvement with respect to old biomarkers, reference values. Twenty two NBEs were identified: 14 elements and chemical compounds as such or as metabolites, 4 examples of mixtures, 3 of new matrices, one of speciation. Among the others, aspects such as interest in requiring NBE, quality assurance, availability, cost-benefit ratio were discussed. We conclude that development of this specific field of research appears to be a crucial point for future improvement in risk assessment and health surveillance procedures.

[Biological monitoring and risk assessment]

Risk assessment in occupational medicine is the part of risk analysis where physicians also contribute. A risk is the probability of an adverse health effect and derives from the hazard posed by a given chemical and from exposure characteristics. Due to the complexity of this process, models are used in occupational medicine, where risk factors are identified and exposure estimated, combined with an understanding of the severity of possible effects. Theoretically, the advantages of biological monitoring are obvious. However, the paucity of available data on biological monitoring limits its uses. Moreover, the utilization of data on biological monitoring requires evaluation of their significance. Examples are discussed to highlight advantages and limitations of biological monitoring data in both hazard and risk assessments. They include exposure to polycyclic aromatic hydrocarbons, benzene, other carcinogens, paraquat and polychlorinated biphenyls.

A new polymorphism (Ser362Thr) of the L-myc gene is not associated with lung adenocarcinoma risk and prognosis

The non-coding variation in the second intron of the L-myc gene, generating an EcoRI polymorphism, is associated with lung cancer risk and prognosis. We carried out sequence analysis of the L-myc gene in lung adenocarcinoma (ADCA) patients to identify functional polymorphisms and identified a new single nucleotide polymorphism (SNP) in the third exon of the gene causing a Ser362Thr conservative amino acid change in the C-terminus of the encoded protein. This polymorphism showed significant linkage disequilibrium with the L-myc EcoRI polymorphism located at 1751 bp distance. Genotyping of the Ser362Thr SNP in 220 Italian ADCA patients and in 230 general population controls revealed a similar low frequency (0.10-0.11) of the Thr allele in both groups. The multivariate odds ratio was 0.68 (95% confidence interval (CI) 0.38-1.22). In the ADCA patients, no significant association between the Ser/Thr polymorphism and survival was observed. Thus, the present results do not support candidacy of the L-myc Ser362Thr polymorphism for the functional polymorphism of the L-myc genomic region.

[Epidemiologic research on asbestos related disease in ENEL SpA electricity production plant maintenance]

Since many years research programs have been set up to study the relationship between asbestos occupational exposure and development of asbestos-related lung diseases in electricity production plants workers. In the year 2000 a new study of asbestos-related lung abnormalities prevalence in italian geothermal and idrothermal power plant maintenance workers was planned. The cohort comprised 3891 subjects. To meet the criteria, only workers in service for at least six months before 1990 and still in service at power plants in May 2000 were included in the study; chest X-rays were taken and made anonymous. Independent reading of X-rays was made by two groups of specialists, and a third reading of selected discordant readings X-rays was made by another group of specialists. A further diagnostic protocol (including HRCT) was planned when two out of three readings showed the presence of asbestos related lung abnormalities. The analysis was made on 3063 subjects (78.7% of the cohort). The number of asbestos-related abnormalities in two out of three X-ray readings was 122 (4%). The further diagnostic protocol, that included occupational and pathological anamnesis and HRCT, confirmed an asbestos-related occupational lung abnormalities in 41 cases (1.3% out of 3063 subjects). The prevalence of asbestos-related lung abnormalities among 3063 power plant maintenance workers was 1.3%. If all the cases of lung abnormalities so far detected (data are still provisional) had developed only in the power plant environment, and not in previous working activities, the prevalence of lung abnormalities would be extremely low. These data support the evidence of limited exposure levels to asbestos in this working environment And bears witness to the success of preventive measures to control this specific risk.

[Biological effects of exposure to electromagnetic fields: introduction]

A widespread agreement on the presence, if any, of an association between non deterministic effects and exposure to electromagnetic fields (ELF and RF-MW) has not been reached yet. Some critical points of the pooled analyses of data that lead to the conclusion of the International Agency for Research on Cancer (IARC) are examined. While waiting for more well planned scientific studies, it seems important for scientific experts to give the most sober interpretation of current data, considering the widespread and growing attention of the general population for this subject.

[Exposure to low levels of solvents and noise, ear canal volume and audiometric pattern]

We described a case of a male worker, 62 years old, with a combined exposure to low noise levels (80-85 dB Leq,A) and organic solvents mixture for more than 30 years in the automobile industry as a painter. His ear canal has a diameter of more than 1.3 cm. and determine a peculiar pattern of hearing loss, similar to the noise induced one, but chiefly in the speech frequencies. According to experimental and human studies we speculate that in this patient the peculiar morphology of the audiogram, with the low or mean frequencies maximally affected, may been explained by a synergistic effect of solvents mixture in conjunction with noise exposure and a high ear canal volume.

[Aromatic amines with certain, probable, or possible carcinogenic action: reference values]

The aim of this work is to determine the amount of some aromatic amines in urine of non-exposed people in order to define a reference value. The literature examination has showed that only a small numbers of aromatic amines are usually determined in urine namely: aniline, benzidine, 2-naphtilamine, o-toluidine, 3,3'-dichlorobenzidine, 4-chloro-o-toluidine and 4-chlorobenzidine. On the basis of our experience the analytical method proposed by Lichtenstein is appropriate for obtaining reliable analytical results.

[Polychlorobiphenyls: reference values]

The purpose of this work is to compare the PCB values in blood, serum and adipose tissue of non-exposed people over the last twenty years of scientific literature in order to establish whether the determination of single congeners is better then the evaluation of the total PCB amount moreover an analytical strategy useful to define a reference value for non-exposed Italian population has been evaluated. In the literature very variable results were found for the determination of total PCBs in blood, in serum or adipose tissue. We suggest to determine only the amount of the most toxic congeners of PCBs (28, 52, 77, 101, 118, 126, 138, 153, 169, 180) by using the HRGC/ECD as analytical technique.

Study of ethmoidal mucosa in a population at occupational high risk of sinonasal adenocarcinoma

The occurrence of nasal adenocarcinomas was first described in 1965. Since 1988 these tumors have been accepted as an occupational disease for woodworkers in Italy. There are several underlying reasons why there is interest in studying the ways in which sinonasal adenocarcinomas occur. Often diagnosed at advanced stages of development because their symptoms are non-specific, these tumors are associated with a high mortality rate. A multidisciplinary study protocol was developed in this investigation. The aim was to identify the factors and conditions that promote sinonasal tumor growth in a population at risk due to occupational exposure to wood dust. Sixty-eight carpenters with a minimum of 10 years exposure to wood dust were studied. The control group comprised 81 volunteers. The patients underwent the following protocol: completion of a case report form, physical examination, evaluation of nasal cavity patency, clinical laboratory tests and histological study of the nasal mucosa. Our study provides significant evidence of the elevated incidence of pavimentous metaplasia in workers occupationally exposed to wood dust. In addition, it underscores a significant deficit of immunoglobulin A in such workers compared to the controls. However, we did not find, as reported elsewhere in the literature, a statistically significant difference between cases and controls as regards nasal symptoms and hyperemia of the nasal mucosa. Our study showed that, even in the absence of evident sinonasal lesions, it is still possible to determine an increased incidence of morphofunctional changes in subjects occupationally exposed to wood dust. Our findings may lead to the identification of occupational groups prone to elevated risk of the disease.

Occupational Mn parkinsonism: magnetic resonance imaging and clinical patterns following CaNa2-EDTA chelation

We report a case of occupational parkinsonism due to manganese exposure in which professional exposure has been documented both by the high blood and urinary levels of the metal and by its presence in the materials used. A strong relation was evident among chelating treatment, cessation of exposure and clinical improvement. MRI confirmed the evolution of clinical pattern by means of reduction of heavy metal deposition in basal ganglia. These findings also agree with the few experimental and human studies published. This case study points to the need for an accurate occupational history collection and suggests the possibility of useful chelating therapy with CaNa2EDTA.

Mortality among workers in the geothermal power plants at Larderello, Italy

BACKGROUND

Since the early 1990s various European electricity companies have set up a research program, named EURELEX, devoted to the development of a comprehensive and validated title-occupation--job-exposure matrix (i.e., an instrument to assess exposures from occupations and jobs), in order to estimate and quantify past exposure to a number of potentially carcinogenic agents plus a few selected other toxic substances. The EURELEX program was first applied in Italy to a cohort of geothermal workers in Larderello, Tuscany.

METHODS

The cohort mortality study comprised 4,237 men who had worked at the geothermal power plant between 1950 and 1990. Vital status and death certificates were obtained from registration offices in the municipality of birth or death. Particular attention was paid to neoplastic effects of exposure to asbestos, largely used in the past for pipeline insulating purposes. The matrix allowed the workers to be subdivided into several categories according to estimated absestos exposure. Smoking information was not available.

RESULTS

No excess mortality was found for all causes and total cancer mortality. A small excess of pleural cancer (2 obs. vs. 1.4 exp.) was not statistically significant. The effect of other agents included in the matrix was also examined: the small excess of leukemia among those exposed to solvents prior to 1963 (year of benzene ban in Italy) did not reach the level of statistical significance. No cases of leukemia were found among the workers presumed to have been exposed to important ELF electromagnetic fields.

CONCLUSION

The study provides reassuring information on a large cohort of a unique geothermal power plant since no significant excess mortality for asbestos related cancers was observed. Furthermore, it represents a useful application and validation of a comprehensive job-exposure matrix for the electric industry in Europe.

Cancer mortality among rice growers in Novara Province, northern Italy

Some excess of non-Hodgkin lymphomas (NHL) and soft tissue sarcomas (STS) was reported in the literature among agricultural workers, mainly in relation to exposure to phenoxyacids and chlorophenols. In this study, information was analyzed for a cohort of rice growers that comprised 1,493 subjects, and for a follow-up that was more than 99% complete with regard to both traced subjects and known causes of deaths. A total of 960 subjects (65%) died during the observation period (1957-1992). Lower than expected standardized mortality ratios (SMRs) were found for all causes, for cardiovascular diseases (especially ischemic heart disease) and for all cancers. Slightly increased SMRs were found for some cancer sites (oral cavity, esophagus, liver, intestines, pancreas, bladder, STS, and NHL), although none of these was statistically significant in the overall analysis. An excess risk of close to statistical significance was found for NHL among workers with longer exposure during the period when phenoxyacid herbicide was in use (1950-1992). Thus, a prolonged follow-up is advisable. At present the study should be evaluated in the context of the data set suggesting a tendency toward an increased risk of NHL among farmers.

Lung adenocarcinoma and indicators of asbestos exposure

A case-control study was carried out on 145 male lung-cancer patients diagnosed at autopsy and 178 controls, in order to investigate the relationship between asbestos exposure and the cell type of pulmonary carcinoma. Adenocarcinomas (AD) were individually matched with other cell types and with controls. The relative risk (RR) of developing AD in relation with lung asbestos body (AB) content as the exposure indicator was calculated by using logistic-regression analysis for matched sets. Two cutoff levels, 1,000 and 10,000 asbestos bodies per gram dry weight (AB/gdw), were used in the analysis. In addition, AB counts were treated as a continuous variable (log AB+I). A significant association was found between AD and asbestos exposure, using levels and logarithmic transformation. However, an association of asbestos exposure with cell types other than AD could not be ruled out.

What's new in managing health hazards in pathology departments

Health hazards related to activities performed in pathology departments have represented, in recent years, an increasing concern among pathologists and pathology technicians. The major occupational health problems encountered in pathology departments are reviewed. They include biological hazards (tuberculosis, hepatitis, HIV, other infectious diseases), chemical hazards (formaldehyde, xylene(s), aromatic amines, methacrylates, glutaraldehyde, latex) and physical hazards (cut injuries, accidental fires, radiation). Current data suggest that infections (particularly, tuberculosis and hepatitis) still represent the more relevant risk. Exposure to HIV and Creutzfeldt-Jakob agent may be highly harmful but containment measures have been proven to be effective. The actual adverse effects due to chemicals seem to be less alarming than was previously believed. Attaining a safe work environment is an inherent element of good quality assurance management. This task is largely a matter of information, education, organization and common sense. Well-designed premises, efficient equipment and well-trained personnel are the keys to preventing and minimizing hazardous exposures. In order to provide current information that may be used by pathology staff to implement the functional quality of the workplace, organizational and preventive measures are described.

[Carcinogenic risk of extremely-low-frequency electromagnetic fields: state of the art]

This paper summarizes the published literature and current problems relating to possible cancerogenic effects of occupational and residential exposure to ELF electromagnetic fields at levels slightly above ambient background. There are several suggestions that such an exposure may increase the risk of cancer, but these studies failed to provide conclusive indications. The present state of uncertainty led to a variety of recommendations and statements being made concerning restrictions to the exposure of people to ELF electromagnetic fields. Attempts to detect direct chromosomal damage from ELF electromagnetic fields have proven negative, while results on cancer promotion have been controversial. On the basis of several epidemiological studies on occupational exposure, an increased risk of leukemia, brain cancer and male breast cancer is apparent; the literature on residential exposure provides some evidence of an effect on childhood cancer, especially leukemia; however, when interpreting these results some major methodological concerns should be kept in mind. In conclusion, the public concern and potential public health impact of this environmental agent argue strongly for addressing further research in order to identify mechanisms of action on biological systems, to define the proper assessment of exposure and to obtain good epidemiological evidence.