Effectiveness of multimodal exercises integrated with cognitive-behavioral therapy in working patients with chronic neck pain: protocol of a randomized controlled trial with 1-year follow-up

Background

The etiology of neck pain is multifactorial and includes personal and work-related factors such as age, sex, wrong postures, and repeated strains. Studies based on bio-psychosocial model also link chronic neck pain to psychological factors. Over time, the use of multidisciplinary interventions for chronic neck pain has grown in order to improve disability, pain, and adaptive cognitions and behaviors towards patients’ problems. The objective is to evaluate the effectiveness of an individual-based multidisciplinary rehabilitation program that integrates cognitive-behavioral therapy focused on kinesiophobia with specific exercises in the treatment of patients with chronic neck pain, employed in different working activities.

Methods

A randomized, parallel-group superiority-controlled trial will be conducted with 1-year follow-up. One hundred seventy patients engaged in several working activities (blue collar and white collar workers) will be randomly allocated to either the experimental (receiving a multidisciplinary rehabilitation program combining multimodal exercises with psychologist-lead cognitive-behavioral therapy sessions) or the control group (receiving general care physiotherapy). Both groups will follow individual-based programs once a week for 10 weeks. The main outcome measures will be the Neck Disability Index, the Tampa Scale for Kinesiophobia, the Pain Catastrophizing Scale, a pain numerical rating scale, the Short-Form Health Survey, and the Work Ability Index. Participants will be evaluated before, after training, and after 12 months.

Discussion

Findings may provide empirical evidence on the effectiveness of an individual-based multidisciplinary rehabilitation program on inducing clinically significant and long-term improvements in the disability, pain, psychological factors, and quality of life of workers with chronic neck pain and that these would be maintained in the long term. Hence, this trial might contribute towards refining guidelines for good clinical practice and might be used as a basis for health authorities’ recommendations.

Trial registration

ClinicalTrials.gov NCT04768790. Registered on 24 February 2021

P229 IMPROVED CLINICAL–INSTRUMENTAL OUTCOMES IN PATIENTS WITH CHRONIC DILATED HYPERTENSIVE / ISCHEMIC HEART DISEASE, UNDERGOING CCM, CARRIER OF CRTD WITH PERSISTENT SEVERE LEFT VENTRICULAR DYSFUNCTION

A 62–year–old man repeatedly subjected to PTCA + stent with severe left ventricular dysfunction and estimated FE 15%. After some hospitalizations for heart failure in 2015 he underwent an AICD implant Biventricular. Followed up in our clinics dedicated to heart failure, the patient did not present the characters of the CRT responder presenting a constant high end–systolic volume (224 ml) and none FE improvement of 15%. There was also an asthenia and tendency to inactivity and elevated NT Pro BNP levels despite optimal medical therapy even with entresto 24/26 mg x 2 / day. It has been decided to submit the patient enrolled in the cardiac transplant and / or VAD implantation lists to an implantation procedure of CCM system (cardiac contractility modulation). After two active fixation placement leads on the interventricular septum and connection to the CCM system housed in the subcutaneous pocket right contralateral to the biventricular AICD, the patient was monitored. We have noticed since the first days conditions of hemodynamic stability. Scheduled CCM therapy delivery for 10 hours a day. Following subsequently in the follow up at 3 – 6 – 12 – 18 months the patient showed an improvement of minneshota quality of life questionnaire in heart failure: MLWHFQ (44 at baseline, 17 at two months, 15 to six months, 10 to 12 months and 3 to 18 months), an increase in FE from 15 to 23 up to 26%, a reduction of the NTPROBNP from 13444 to 1178 then climbed back to 5549 and 3712 at 18 months for atrial fibrillation, without any requires re–hospitalization, an increased physical activity of the patient detected by the sensors of the two devices

Fetal programming of atherosclerosis: may the barker hypothesis explain the susceptibility of a subset of patients to develop stroke or cardiac infarct?

The risk stratification of young adults between subjects who will develop a mild form of atherosclerosis and subjects who will undergo a severe disease remains inaccurate. In the eighties of the previous century, David JP Barker has demonstrated the relationship between fetal conditions and occurrence of pathologies in adulthood. In this paper, the multiple evidence that might explain the increased susceptibility to severe forms of atherosclerosis, including stroke and cardiac infarct, in subjects who underwent intrauterine growth restriction (IUGR) will be analyzed. Specifically, we will review those inter-connected data indicating an association between a low weight at birth and an adult phenotype which might favor a severe outcome of atherosclerosis. Young and adult subjects born too small (IUGR) or too early (pre-terms) might represent a subgroup of "at risk subjects", more susceptible toward severe forms of atherosclerosis. Given that low birth weight (LBW) may be considered a surrogate of IUGR, this phenotypic feature could be considered among those indispensable clinical data collected in every patient presenting with atherosclerosis, irrespectively of age. According to the hypothesis that structural arterial changes might represent the link between LBW and susceptibility to atherosclerosis later in life, we suggest that the prevention of atherosclerosis should begin at birth. Regenerative and physiological substances such as thymosin Beta-4 could be challenged for a new "arterial regenerative medicine" in the perinatal period. The goal of this new approach should be the reinforcement of the structure of the arterial wall, allowing LBW newborns to avoid the most severe complications of atherosclerosis later in life: a dream that our research could contribute to bringing to life.

Characterization of hand forces exerted during non-powered hospital bed pushing and pulling tasks

Accurate assessment of biomechanical risk associated with pushing/pulling tasks represents a challenging issue, especially in the health system where personnel are often required to maneuver beds and carts. Most studies in this field have been carried out in the laboratory, while few data have been collected under actual working conditions. This study aims to characterize the forces exerted during non-powered hospital bed maneuvering. Twenty participants were required to move a bed (equipped with a customized handlebar to measure exerted forces) along an actual hospital path including straight, turn and maneuver phases. The results show that higher forces are associated with the initial phase (peak and mean values 222 and 68 N) while the straight, turn and maneuvering phases required similar (lower) efforts. The combined effect of left, right and transversal forces suggests that the trunk of the operator might experience axial rotation, thus calling for further investigations of this aspect.

Risk for Depression, Burnout and Low Quality of Life Among Personnel of a University Hospital in Italy is a Consequence of the Impact One Economic Crisis in the Welfare System?

BACKGROUND

Research literature suggests that burnout, depression, and a low mental quality of life (QOL) are common among health care workers. Economic crisis might have increased the burden of burnout, depression and low QOL in health care workers.

OBJECTIVES

To identify depression risk, burnout levels, and quality of life in a sample of workers of an Italian university hospital.

METHOD

Cross sectional study with comparison with two community surveys database results (n = 2000 and 1500, respectively). Overall, 522 workers accepted to take part in the study, representing a 78% response rate (out of 669 individuals).

RESULTS

The frequency of positivity at the screener for Major Depressive Disorder among health care workers was more than double than that in the standardized community sample (33.3% vs 14.1%, p<0.0001). All professionals, except the administrative staff and technicians (i.e. those who do not have contact with patients), showed a statistically higher frequency of positivity for depressive episodes compared to the controls. Among the medical staff, the highest risk was found in the surgeon units, while the lowest one was in the laboratories. Surgeons also were those most exposed to high risk of burnout, as measured by the Maslach Burnout Inventory.

CONCLUSION

Since burnout is linked to patient safety and quality of patient care, and contribute to medical errors, dedicated interventions aimed at reducing poor mental health and low quality of life in medical staff are indicated.

Assessing hand hygiene compliance among healthcare workers in six Intensive Care Units

INTRODUCTION

Healthcare associated infections (HAIs) are a cause of high morbidity, disability and reduced quality of life, as well as mortality and rising costs for health systems. Preventing the HAI risk by planning and implementing effective preventive strategies is important to safeguard patient health.

METHODS

The study aimed to evaluate the presence of procedures and protocols for infection control, to assess the adhesion to the different aspects of hand hygiene (HH) and hand washing technique by healthcare workers in six ICUs. A perspective observational study was conducted in six ICUs. In each ICU, the adherence by health care workers to both hand hygiene practices and standard precautions was assessed, as well as the presence of procedures and written protocols.

RESULTS

The findings showed that in all the involved ICUs, 73 of 142 required protocols and procedures were available. Specifically, 59 of 79 were available for general measure of risk control, 12 of 15 for hand hygiene, and 24 of 48 for standard precautions and isolation measures. Also, the results showed highly variable levels of adherence to the best hygiene practices in all the ICUs involved in the study, with compliance rates ranging from 3% to 100%, and 73 of 142 required protocols were available at the study time.

CONCLUSIONS

Overall, the involved ICUs showed low levels of adherence to best hygiene practices. This suggests the need to implement immediate strategies for infection control in the ICUs. A multidisciplinary intervention could be effective in preventing and control the HAI risk.score was reached only by the third year students with regard to the proper HH. The level of knowledge about HAI was inadequate.A periodically check of nursing students' knowledge would be advisable in order to fill any gaps, improve training, reduce HAI and increase prevention measures compliance.

Teledermatology: An updated overview of clinical applications and reimbursement policies

Telemedicine is an emerging field in healthcare that provides services from different medical specialties to patients all around the world. One of the specialties in telemedicine, teledermatology, has grown exponentially as a cost-effective way to implement dermatological healthcare to underserved areas and populations. This article reviews the literature that pertains to the cost-effectiveness, reliability, public access, patient satisfaction, and reimbursement policies of teledermatology. Teledermatology was found to be cost-effective and reliable in reducing in-person visits and time away from work, and allows for the faster delivery of care. However, reimbursement policies for teledermatology services are rather new and vary significantly from state to state. As public interest in and access to teledermatology continue to grow, the future of teledermatology depends on the development of new technology as well as quality improvement strategies and the evolution of sustainable reimbursement policies.

Current preventive policies and practices against Vaccine-Preventable Diseases and tuberculosis targeted for workers from hospitals of the Sardinia Region, Italy

INTRODUCTION

Health care Workers are exposed to infectious diseases more than the general population. Many of these infections are preventable by vaccination. The objective in this study is to investigate whether, how, and which vaccination underwent Sardinia Health Care Workers (HCWs) and the variability of policies in different Hospital Health Managements of the whole region.

METHODS

In March 2013, we enrolled the Hospital Health Management of all the 32 Sardinia hospitals. We investigate on immunity against vaccine-preventable diseases and education campaigns about recommended vaccinations for HCWs. Flu, hepatitis B, measles-mumps-rubella, varicella and tuberculosis were the objects of our research.

RESULTS

In most of the hospitals, influenza vaccination coverage among HCWs is less than 6%. Hepatitis B antibody assay was performed in all the respondent hospitals but only 14 had available data as collected electronically. Most of the hospitals did not perform serological tests for the evaluation of antibodies against Varicella, Measles, Mumps and Rubella in their HCWs. In 30 hospitals Mantoux test was replaced or integrated by "in vitro" test for health surveillance protocols.

CONCLUSIONS

This method produced a large amount of data in small time and at a low cost. Sending back data to respective Hospital Health Management (HHM) we took a step towards greater awareness of the issue of biological risks of HCWs and of vaccine coverage.

SUMOylation regulates AKT1 activity

Serine threonine kinase AKT has a central role in the cell, controlling survival, proliferation, metabolism and angiogenesis. Deregulation of its activity underlies a wide range of pathological situations, including cancer. Here we show that AKT is post-translationally modified by the small ubiquitin-like modifier (SUMO) protein. Interestingly, neither SUMO conjugation nor activation of SUMOylated AKT is regulated by the classical AKT targeting to the cell membrane or by the phosphoinositide 3-kinase pathway. We demonstrate that SUMO induces the activation of AKT, whereas, conversely, down-modulation of the SUMO machinery diminishes AKT activation and cell proliferation. Furthermore, an AKT SUMOylation mutant shows reduced activation, and decreased anti-apoptotic and pro-tumoral activities in comparison with the wild-type protein. These results identify SUMO as a novel key regulator of AKT phosphorylation and activity.

Occupational exposure to trichloroethylene and risk of non-Hodgkin lymphoma and its major subtypes: a pooled InterLymph [correction of IinterLlymph] analysis

OBJECTIVES

We evaluated the association between occupational exposure to trichloroethylene (TCE) and risk of non-Hodgkin lymphoma (NHL) in a pooled analysis of four international case-control studies.

METHODS

Overall, the pooled study population included 3788 NHL cases and 4279 controls. Risk of NHL and its major subtypes associated with TCE exposure was calculated with unconditional logistic regression and polytomous regression analysis, adjusting by age, gender and study.

RESULTS

Risk of follicular lymphoma (FL), but not NHL overall or other subtypes, increased by probability (p=0.02) and intensity level (p=0.04), and with the combined analysis of four exposure metrics assumed as independent (p=0.004). After restricting the analysis to the most likely exposed study subjects, risk of NHL overall, FL and chronic lymphocytic leukaemia (CLL) were elevated and increased by duration of exposure (p=0.009, p=0.04 and p=0.01, respectively) and with the combined analysis of duration, frequency and intensity of exposure (p=0.004, p=0.015 and p=0.005, respectively). Although based on small numbers of exposed, risk of all the major NHL subtypes, namely diffuse large B-cell lymphoma, FL and CLL, showed increases in risk ranging 2-3.2-fold in the highest category of exposure intensity. No significant heterogeneity in risk was detected by major NHL subtypes or by study.

CONCLUSIONS

Our pooled analysis apparently supports the hypothesis of an increase in risk of specific NHL subtypes associated with occupational exposure to TCE.

Regulation of the tumor suppressor PTEN by SUMO

The crucial function of the PTEN tumor suppressor in multiple cellular processes suggests that its activity must be tightly controlled. Both, membrane association and a variety of post-translational modifications, such as acetylation, phosphorylation, and mono- and polyubiquitination, have been reported to regulate PTEN activity. Here, we demonstrated that PTEN is also post-translationally modified by the small ubiquitin-like proteins, small ubiquitin-related modifier 1 (SUMO1) and SUMO2. We identified lysine residue 266 and the major monoubiquitination site 289, both located within the C2 domain required for PTEN membrane association, as SUMO acceptors in PTEN. We demonstrated the existence of a crosstalk between PTEN SUMOylation and ubiquitination, with PTEN-SUMO1 showing a reduced capacity to form covalent interactions with monoubiquitin and accumulation of PTEN-SUMO2 conjugates after inhibition of the proteasome. Moreover, we found that virus infection induces PTEN SUMOylation and favors PTEN localization at the cell membrane. Finally, we demonstrated that SUMOylation contributes to the control of virus infection by PTEN.

Biological monitoring of low-level exposure to benzene

INTRODUCTION

Conflicting opinions exist about the reliability of biomarkers of low-level exposure to benzene. We compared the ability of the urinary excretion of trans,trans-muconic acid (t,t-MA), s-phenilmercapturic acid (s-PAMA) and urinary benzene (U-Benz) to detect low level occupational and environmental exposure to benzene.

METHODS

We monitored airborne benzene by personal air sampling, and U-Benz, s-PMAI, t,t-MA and cotinine (U-Cotinine) in spot urine samples, collected at 8 am and 8 pm, in 32 oil refinery workers and 65 subjects, randomly selected among the general population of urban and suburban Cagliari, Italy. Information on personal characteristics, diet and events during the sampling day was acquired through in person interviews.

RESULTS

The median concentration of airborne benzene was 25.2 microg/m3 in oil refinery workers, and 8.5 microg/m3 in the general population subgroup. U-Benz in morning and evening samples was significantly more elevated among oil refinery workers than the general population subgroup (p = 0.012, and p = 7.4 x 10(-7), respectively) and among current smokers compared to non-smokers (p = 5.2 x 10(-8), and p = 5.2 x 10(-5) respectively). Benzene biomarkers and their readings in the two sampling phases were well correlated to each other. The Spearman's correlation coefficient with airborne benzene was significant for U-Benz in the evening sample, while no correlation was seen with t,t-MA and s-PMA readings in either samplings. The two benzene metabolites were frequently below limit of detection (LOD), particularly among the general population study subjects (17-9% and 39%, for t,t-MA and s-PMA respectively). Morning U-Cotinine excretion showed a good correlation with U-Benz in the morning and in the evening sampling (p < 0.001), and with s-PMA in the evening sample (p < 0.001), but not with t,t-MA in either samplings. t,t-MA in the evening sample was the only biomarker showing a moderate inverse correlation with BMI (p < 0.05). The multiple regression analysis adjusting by BMI and number of cigarettes smoked during the day confirmed the results of the univariate analysis.

DISCUSSION

Our results suggest that unmetabolized U-Benz would allow a more reliable biomonitoring of low-level exposure to benzene than s-PMA and t,t-MA.

[Cancer risk among shift workers: a review]

INTRODUCTION

According to IARC, shift work resulting in disruption of circadian rhythm is a probable human carcinogen (Group 2A).

METHODS

We examined the scientific literature on the carcinogenic risk among shift workers for risk assessment purposes.

RESULTS

Clock genes polymorphisms might contribute with suppression of melatonin synthesis, immuno-suppression from sleep deprivation, individual habits associated with shift work, and low vitamin D levels, in increasing risk of breast cancer, prostate cancer and lymphoma among shift workers.

CONCLUSION

Although the epidemiological evidence seems scanty, the hypothesis that shift work-related sleep deprivation would contribute to increasing cancer risk seems based on solid ground.

[Pilot study for the assessment of perceived critical organizational aspects in a hospital of Local Health Authority of Cagliari, Italy]

INTRODUCTION

In Italy, the effectiveness of public health services must be assessed trhoug the assessment of efficency of employees.

OBJECTIVE

To acquire from this activity useful information to assess and promote the well being at work.

METHODS

During the assessment activities, a questionnaire was administered to assess the efficency of the management in manage perceived critical organizational aspects.

RESULTS

The 44-58% consider not sufficient the management efficency in manage perceived critical organizational aspects, exspecially for quality of services, communication, vocational training and risks for worker's health and safety.

CONCLUSIONS

The study provide useful suggestions to better assess and manage the risk of work-related stress and exploit the key consultant role of occupational physician in the organizational context.

[Risk of major lymphoma subtypes and use of mobile phones]

INTRODUCTION

We explored the association between use of mobile phones and lymphoma risk in a case-control study.

METHODS

We conducted unconditional logistic regression analysis in 322 lymphoma cases and 446 population controls, adjusting by age, gender and education.

RESULTS

Risk of lymphoma (all types; OR = 1.5; 95% CI 1.0 - 2.1), and chronic lymphocytic leukaemia (OR = 1.8; 95% CI 1.0 - 3.4) was elevated in subjects reporting use of mobile phones, but it decreased with duration of use, and years from first purchase.

CONCLUSIONS

Our contradictory findings would not support the aetiological nature of the observed associations.

[Occupational and environmental cancer in southern Sardinia: a survey on ten years of hospitalizations]

Based on hospital discharges in 1001-2010, we calculated risk of tumours with an elevated occupational and environmental etiological fraction by health district of residence within the Local Health Unit (LHU) N. 8 of Sardinia. With reference to the age and gender-specific hospitalization rates of the whole LHU, residents in the urban Cagliari health district showed an excess risk of haemolymphopoietic cancer (RR = 1.07; 95% CI 1.03-1.12) and bladder cancer (RR = 1.10; 95% CI 1.05-1.16); in both instances, risks were higher among female residents. The highest excess risk for lung cancer was observed among residents in the Quartu-Parteolla health district (RR = 1.13; 95% CI 1.05-1.21), and it was slightly higher among male residents. The results appear to confirm the role of urban factors in increasing cancer risk.

[Assessment of congenital malformation risk in the progeny of the military and civilian personnel of the Salto di Quirra military base: preliminary results]

INTRODUCTION

We evaluated the congenital malformation rate in the progeny of the personnel of the Salto di Quirra military base in Sardinia.

METHODS

During 2011, we gathered questionnaire information on the reproductive history of 389 employees, more then 99% of those eligible for routine health surveillance.

RESULTS

the observed congenital malformation rate (20.1 x 10(-3), 95% CI 6.3 - 33.8) was lower than that reported by the Italian Registries of Congenital Malformations, and it did not vary by exposure to radiofrequency, elf electromagnetic fields, and solvents, and by jobs associated with alleged exposure to nanoparticles or alpha radiation.

CONCLUSIONS

Our findings suggest that the documented or alleged occupational exposures among the PISQ workforce did not increase the congenital malformation rate in the progeny.

[Results of a health surveillance program for health care workers exposed to a patient affected by tuberculosis]

A health surveillance program was implemented in 71 health care workers (HCW) exposed to a patient with active TB infection. A two-step tuberculin skin test (TST) was performed in all the exposed, and a QuantiFERON-TB Gold (QTF) test was scheduled for positive TST subjects. Clinical-radiological surveillance (CRS) was scheduled for subjects positive to TST and QTF or symptomatic. Thirty eight percent HCW were TST positive; 19% of them were also QTF positive and were referred to CRS. No clinical TB was observed among the exposed HCW. Comprehensive health surveillance allows to increase risk perception, compliance to HS and to reduce cost in respect to less cost-effective practices.

[Vaccinations for health care workers exposed to biohazard. Evidences and good medical practices]

Biohazard in healthcare settings is an issue for Occupational Physician (OP), owing to the potential relevant adverse effects for health care workers (HCW) and for the non complete effectiveness of primary prevention. Vaccination represents an effective tool to minimize risk of occupational and nosocomial transmission for many relevant communicable diseases. Implementation of vaccination campaigns may however present some critical aspects. The present study evaluates available scientific evidences and reports an Italian multicenter study (9 Hospitals, 3200 HCW), suggesting good medical practices in vaccination, while highlighting the role of the OP in a multidisciplinary context.

[Focus on risk assessment in health environments: results and perspectives of a multicenter working group]

The hospital risk assessment (VdR) is certainly a relevant issue concerning the activities of prevention for the health of healthcare workers in relation to biological risk. The aim of this paper is to provide an up-date of the issue, based on the suggestions of recent literature about the rules ratified by the new legislative decree and data supplied by the Group of 10 Hospitals participated in this multicenter study. From the analysis of data on healthcare settings (HCS) participating in the project the following considerations can be formulated: i) All HCS considered VdR from biological agents. The method recommended in the Guidelines SIMLII 2005 is the most followed ii) To grading the risk, the use of invasive procedures for carrying out the analysis results is a necessary element iii) the operators classified as exposed to biological risk, and therefore subject to health surveillance, represent almost all of workforce in 7 out of 10 HCS. The subgroup believes that VdR must be conducted in close collaboration with the occupational physician and should represent a worthwhile investment with spin-off character on prevention, decision making, empowering. The presence of environmental requirements and organizational procedures should be considered, so that HCS is enabled for an effective risk management, without which risk assessments cannot be performed. The method of VdR mentioned in the guidelines MLIS 2005, besides being the most widely used by the company participating in the study, still has practical reasons and opportunities to justify its use. The HCS group felt the need to propose an implementation of the definition of invasive procedures and EPP, together with individual assessment. Flexibility was suggested in identifying different levels of risk with the involvement of occupational physicians, especially in the presence of EPP, also in order to plan content and frequency of health surveillance.

[Exanthemic diseases (measles, chickenpox, rubella and parotitis). Focus on screening and health surveillance of health workers: results and perspectives of a multicenter working group]

BACKGROUND

Nosocomial transmission of varicella-zoster virus, certain paramixovirus and rubivirus might pose a risk of morbidity for varicella (V), rubella (R), mumps (Mu) and measles (Me) in health care workers (HCW), patients and coworkers. International literature and European legislation recommend preventive interventions to minimize the risk.

METHODS

A literature review and a seroprevalence study were carried out in 9 hospitals located in north and central Italy, in order to evaluate risk assessment, health surveillance and fitness for work of HCW exposed to V, R, Mu and Me. Antibodies (Ab) against V, R, Mu and Me were determined. For a subgroup of 4 hospitals; sociodemographic, occupational data and sera were collected and analyzed.

RESULTS

About 36000 tests on about 9000 HCW were analyzed. Differences in seroprevalence ratios (V 85.7-95.1%, R 47-96.8%, Me 71.4-97.8%, Mu 52.5-87.6%) were detected. In a subgroup, a relevant number of non immune HCW was also found among women infertile age and areas at higher risk. Statistically significant differences were detected only for selected variables and viruses.

DISCUSSION AND CONCLUSIONS

Data of multicenter study confirm literature evidences and allow to define good medical practices for manage and minimize the risk of nosocomial transmission of V, R, Me and Mu. Recommendation are issued about serologic screening on HCW exposed to all 4 viruses thorough the modern analytical techniques, in order to assess risk on individual a group basis and to select priorities for intervention. Vaccination should be prescribed for those HCW non immune, selecting areas and HCW according to priorities.

[Focus on health surveillance of health workers exposed to blood-transmissible biological agents: results and perspectives of a multicenter working group]

The biological risk from exposure to bloodborne pathogens in health care environments represents a frequent and widespread risk, involving a large number of exposed workers. On the basis of the available scientific innovations, the recent legislation regarding health and safety of workers and the experiences of SIMLII guidelines on health surveillance (HS) workers exposed to biological risk, a multicenter study was carried out, involving nine relevant hospitals and about 32 000 healthcare workers (HCW). A review of the literature was performed, with particular reference to the last 10 years. For each hospital, protocols of HS have been examined according to tasks and biological risk from bloodborne viruses (HBV, HDV, HCV, HIV) as well as management of HCW infected with this pathogens. Differences of risk management in the hospitals, in relationship also with recommendations of the literature have been evaluated. The literature supplies important indications for HS management of HCW exposed to bloodborne pathogens, with relevant information also for patient safety. Preventive examinations are in line with the recommendations of literature and similar across the hospitals for HCV and HIV, while they are different for HBV. Periodic surveillance was different for the frequency, among the hospitals and also as compared to national SIMLII guidelines. As for management, no differentiation among the hospitals was detected as referred to different risk of exposure, while differences were observed around definitions of restrictions. Finally, good medical practices to support occupational physicians in the prevention and management of HCWs' exposed to biological risks are suggested.

Rotavirus NSP5 orchestrates recruitment of viroplasmic proteins

Rotavirus genome replication and the first steps of virus morphogenesis take place in cytoplasmic viral factories, called viroplasms, containing four structural (VP1, VP2, VP3 and VP6) and two non-structural (NSP2 and NSP5) proteins. NSP2 and NSP5 have been shown to be essential for viroplasm formation and, when co-expressed in uninfected cells, to form viroplasm-like structures (VLS). In the present work, VLS formation was shown upon co-expression of NSP5 with the core protein VP2 despite the absence of NSP2, indicating a central role for NSP5 in VLS assembly. Since VP2 and NSP2 also induce NSP5 hyperphosphorylation, the possible correlation between VLS formation and the NSP5 phosphorylation status was investigated without evidence of a direct link. In VLS induced by NSP2, the polymerase VP1 was recruited, while the middle layer protein VP6 was not, forming instead tubular structures. On the other hand, VLS induced by VP2 were able to recruit both VP1 and VP6. More importantly, in VLS formed when NSP5 was expressed with both inducers, all viroplasmic proteins were found co-localized, resembling their distribution in viroplasms. Our results suggest a key role for NSP5 in architectural assembly of viroplasms and in recruitment of viroplasmic proteins. A new role for VP2 as an inducer of viroplasms and of NSP5 hyperphosphorylation is also described. These data may contribute to the understanding of rotavirus morphogenesis.

Parallel conduction of the phase I preventive and therapeutic trials based on the Tat vaccine candidate

The native HIV-1 Tat protein was chosen as vaccine candidate for phase I clinical trials in both uninfected (ClinicalTrials.gov identifier: NCT00529698) and infected volunteers (ClinicalTrials.gov identifier: NCT00505401). The rationale was based on the role of Tat in the natural infection and AIDS pathogenesis, on the association of Tat-specific immune responses with the asymptomatic stage and slow-progression rate as well as on its sequence conservation among HIV clades (http://www.hiv1tat-vaccines.info/). The parallel conduction in the same clinical centers of randomized, double blind, placebo-controlled phase I studies both in healthy, immunologically competent adults and in HIV-infected, clinically asymptomatic, individuals represents a unique occasion to compare the vaccine-induced immune response in both the preventive and therapeutic setting. In both studies, the same lot of the native Tat protein was administered 5 times, every four weeks, subcute (SC) with alum adjuvant or intradermic (ID), in the absence of adjuvant, at 7.5 microg, 15 microg or 30 microg doses, respectively. The primary and secondary endpoints of these studies were the safety and immunogenicity of the vaccine candidate, respectively. The study lasted 52 weeks and monitoring was conducted for on additional 3 years. The results of both studies indicated that the Tat vaccine is safe and well tolerated both locally and systemically and it is highly immunogenic at all the dosages and by both routes of administration. Vaccination with Tat induced a balanced immune response in uninfected and infected individuals. In particular, therapeutic immunization induced functional antibodies and partially reverted the marked Th1 polarization of anti-Tat immunity seen in natural infection, and elicited a more balanced Th1/Th2 immune response. Further, the number of CD4 T cells correlated positively with anti-Tat antibody titers. Based on these results, a phase II study is ongoing in infected drug-treated individuals (http://www.hiv1tat-vaccines.info/).

[Prevention of occupational injuries in foundries: multidisciplinary intervention and evaluation of effectiveness]

BACKGROUND

There is a lack of field studies aimed at reducing occupational injuries (OI), particularly in foundries.

OBJECTIVES

To evaluate effectiveness of multidisciplinary intervention in foundries.

METHODS

The study was carried out in two foundries (cast-iron=A, non-ferrous=B). Since 1999-2000, a multidisciplinary intervention was developed, by a team managed by the occupational physician, including safety personnel and workers' representatives. Interventions regarded maintenance, protective equipment, procedures, training, health surveillance (HS), fitness for work, first aid. The desired outcome was a reduction in injury rates.

RESULTS

In foundries A and B, respectively 522 and 90 OI occurred in 1997-2007, accounting for 10,500 and 2,300 lost work days. Statistical analysis showed a significant decrease in incidence and frequency in both foundries. HS allowed for human factor and fitness for work evaluation, return-to-work management. Safety culture, behaviour and procedures positively changed.

CONCLUSIONS

The study was effective in reducing OI rates and improving a number of secondary outcomes. The same intervention, taking into account Evidence Based Prevention, is ongoing in about 50 foundries.

[Updating in occupational health for health care workers]

The board of the Thematic Section on Preventive Medicine for Health Care Workers of the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII) programmed a national conference on occupational risks of health care workers to be held in late 2009. Main topics will be: a) biohazards; b) biomechanical risk; c) psychosocial factors. Three different working groups were established to tackle critical aspects and suggest practical recommendations to occupational health professionals. Preliminary issues are presented while final results will be presented at the conference on September 2009.

[LBP and disability in nursing personnel performing manual handing of patients in a large Italian hospital]

Low back pain (LBP) has been recognized as a major cause of sickness and disability among health care workers (HCW) who perform handling of patients. A survey was carrying out to investigate risk factors for LBP and related absenteeism and disability in a group of HCW. 333 HCW were examined in 2003 and 2005 and data were collected on personal, occupational and clinical history and on risk factors for LBP and related absenteeism. Psychosocial factors and LBP related disability were evaluated by means of Karasek's Job Content questionnaire and Oswestry Low Back disability Index. Most of our study population were female (80%) and the prevalence of acute and chronic LBP was 37%. Subjects with chronic LBP referred a significantly higher level of disability as compared to acute LBP subjects. Moreover, a significantly relationship was found (p = 0.04) between high level of disability (group III e IV of ODI index) and high perceived job demand. The introduction of questionnaires to collect disability and psychosocial factors is highly recommended in periodic health surveillance program of HCW performing manual handling of patients.

[Susceptibility to varicella-zoster, measles, rosacea and mumps among health care workers in a Northern Italy hospital]

BACKGROUND

Nosocomial transmission of varicella (V), rubella (R), mumps (Mu) and measles (Me) may be a significant cause of morbidity in health care workers (HCW). Susceptible HCW might be a relevant part of the workforce.

METHODS

A seroprevalence study was performed in a public hospital. Antibodies (Ab) against V, R, Mu and Me were determined by ELISA. Sociodemographic, clinical, occupational data and sera were obtained during health surveillance.

RESULTS

2934 tests on 1106 HCW were performed. Seropositivity was 91% for V, 89% for R, 80% for Mu, 92% for Me. No significant differencies were found for the variables tested, except for age (< 36 years) and certain job tasks (e.g. residents). 22% of HCW tested were seronegative for at least 1 virus. More seronegatives were detected as compared with the majority of literature data.

DISCUSSION

This study showed a relevant number of susceptible to V, R, Mu and Me. Seroprevalence data are useful for risk assessment, HCW health surveillance, to evaluate fitness for work and to promote vaccination programmes, according to scientific guidelines. OP should include serological screening for Me, Mu, V and R to protect HCW and third parties.

Interaction of rotavirus polymerase VP1 with nonstructural protein NSP5 is stronger than that with NSP2

Rotavirus morphogenesis starts in intracellular inclusion bodies called viroplasms. RNA replication and packaging are mediated by several viral proteins, of which VP1, the RNA-dependent RNA polymerase, and VP2, the core scaffolding protein, were shown to be sufficient to provide replicase activity in vitro. In vivo, however, viral replication complexes also contain the nonstructural proteins NSP2 and NSP5, which were shown to be essential for replication, to interact with each other, and to form viroplasm-like structures (VLS) when coexpressed in uninfected cells. In order to gain a better understanding of the intermediates formed during viral replication, this work focused on the interactions of NSP5 with VP1, VP2, and NSP2. We demonstrated a strong interaction of VP1 with NSP5 but only a weak one with NSP2 in cotransfected cells in the absence of other viral proteins or viral RNA. By contrast, we failed to coimmunoprecipitate VP2 with anti-NSP5 antibodies or NSP5 with anti-VP2 antibodies. We constructed a tagged form of VP1, which was found to colocalize in viroplasms and in VLS formed by NSP5 and NSP2. The tagged VP1 was able to replace VP1 structurally by being incorporated into progeny viral particles. When applying anti-tag-VP1 or anti-NSP5 antibodies, coimmunoprecipitation of tagged VP1 with NSP5 was found. Using deletion mutants of NSP5 or different fragments of NSP5 fused to enhanced green fluorescent protein, we identified the 48 C-terminal amino acids as the region essential for interaction with VP1.

[Exposure to arsenic in the manufacture of glass rods. Results of the biological monitoring and preventive indications]

Nowadays arsenic trioxid is still used in the hand made glass production in Murano. In the last years, many industries have reduced its use but, in some specific lines of production, such as the "bacchetta di vetro" for the secondary "a lume" production, there is still a considerable use. Biological monitoring, carried out through urinary arsenic measurement, shows as workers employed in the mixture preparation and in the furnace work, are still significantly exposed to arsenic, despite the technical preventive measures adopted. We propose further measures to reduce this risk.

Malignant mesothelioma and the working environment: the viewpoint of the occupational physician

BACKGROUND

Firm scientific evidence supports the causal association between malignant mesothelioma (MM) and occupational exposure to asbestos. Risk attributable to occupation varies from 30 to 80% across different populations. The existence of a threshold level below which there is no risk of MM is still debated. A prompt and thorough assessment of exposure is essential to evaluate and manage MM cases, from diagnostic and epidemiological points of view.

OBJECTIVES AND METHODS

To highlight the multiple areas of intervention by Occupational Physicians (OP) in MM evaluation and management, to describe an experience of OP in the province of Brescia.

RESULTS

The main areas of interest of the OP are exposure assessment, diagnosis (clinical, etiological), medico-legal issues, social consequences, preventive strategies, risk communication, scientific dispute/uncertainties. By means of an active search, the Brescia MM registry, managed by OP belonging to the local health authority observed 309 MM from 1977 to 2003; the local Institute of Occupational Health, hosted in a hospital of national relevance, evaluated about 200 MM in the last decade. The main outcomes of OP activity are the high percentage of direct interviews, individual case management, expert exposure assessment, etiological diagnosis, counselling, medico-legal assistance, better knowledge of occupational risks, enhanced cooperation among health professionals (oncologists, pathologists, surgeons, pneumologists, general practitioners and OP), important contribution to Registries and to epidemiology (estimates of attributable risks, incidence, survival rates), with positive social and scientific consequences (insurance agencies, trade union organizations, public events, teaching opportunities).

CONCLUSIONS

This experience highlights the multifaceted role of OP in active research and evaluation of MM cases, in the context of a multidisciplinary approach.

[From lead colic to moderate risk]

During the 20th century, occupational and environmental exposure to lead was among the main relevant issues studied by occupational physicians, hygienists, and public health administrators. During the different decades there was a progressive reduction in exposure levels and in the mean time a progressive reduction in the severity of clinical symptoms due to very high exposure to this metal. During thefirst forty years of the 20th century, a clear decrease in the frequency of encephalopathy and paralysis of the radial nerve was observed while abdominal colics and anaemia where frequently observed until the sixties. In the first part of the seventies, there was a clear change in the preventive approach to lead poisoning both in the field of research and in the clinical-preventive and legal field. These successful results where obtained despite the disagreement of outstanding physicians and international renowed researchers and industrial associations. Every successful battle allowed a great improvement in the field of occupational and environmental prevention, but the above-mentioned disagreements caused a great delay in the solution of the problem and did not improve workers', children's and teenagers' health. In Italy, there was a very deep interest in the prevention of lead poisoning which led to very good results in a relatively short period even though the current laws did not help and also nowadays do not help the occupational professionals studying and dealing with occupational health. Lead undoubtly represents one of the most largely studied environmental industrial toxics and shows a model, also suitable for other matters involving exposure to different industrial toxics. Nevertheless, there are still problems in the understanding of some pathogenetic aspects of lead and in the significance of some of its early effects which deserve further studies. These matters, strictly linked to low-dose exposure, still present numerous questions. For example, there should be a deep interest in the standardization of its internal dose indicators, in the study the role of the metal in the pathogenesis of cardiological and nephrological diseases, in the characterization of its genetic polymorphisms and in the assessment of its carcinogenicity. A lot of these issues, already examined in old studies concerning casistics of workers affected by lead poisoning, have been analyzed in the multidisciplinary study "Progetto MIUR Piombo" (Project on lead by the Italian Ministry of University and Research) conducted by six different Institutes of Occupational Health (Cagliari, Parma, Perugia, Bari, Ancona and Brescia) which will report their results during this Congress.

Diethylsulphate and methylnitrosourea affect different targets in Chinese hamster fibroblasts: possible mechanisms of aneuploidy induction by these agents

It has been shown that the ethylating agent diethylsulphate (DES) induces centromere-containing micronuclei with kinetics suggesting that molecules other than DNA could be targets. In quiescent Chinese hamster fibroblasts CHEF/18, O6-alkylated bases inhibit ribosomal protein S6 kinase (S6K1), the terminal member of a kinase cascade responsible for an increased rate of protein synthesis, but not extracellular signal-activated kinases (ERK1/2) or terminal kinases of a second cascade which activates transcription. The inhibition correlates with the appearance of abnormal metaphases at the following mitosis, suggesting that alkylation of the nucleotide pool and inhibition of S6K1 could be one of the mechanisms leading to chromosome loss by alkylating agents. To clarify the role of protein kinases in chromosome loss induced by alkylating agents, we have studied the effects of DES and methylnitrosourea (MNU) on S6K1 and ERK1/2 activation by growth factors. The alkylating agents were studied in a battery of Chinese hamster fibroblasts (CHEF/18, CHO and ClB) with normal and mutated p53 to control for DNA damage-induced activation of p53, which could indirectly inhibit protein kinases. The role of repair in induction of micronuclei was studied in mismatch repair-proficient CHO and repair-deficient ClB cells. Our results indicate that DES induced micronuclei in a mismatch repair-independent manner, within 8 h of treatment, in agreement with a role for S6K1 inhibition in micronucleus formation. MNU induced centromere-containing micronuclei only in CHO cells, one cell cycle after treatment, without any detectable influences on either kinase cascade, suggesting a role for mismatch repair in chromosome loss.

Dual-colour FISH analysis to characterize a marker chromosome in cytochrome P450 2B1 recombinant V79 Chinese hamster cells

Recombinant V79 Chinese hamster cell lines have been constructed for the expression of useful functions, e.g. cytochromes P450, in order to study metabolism-dependent toxicity. Recombinant cell lines are derived as single clones upon gene transfer and selection from the parental V79 cell line. It is of fundamental importance for a reliable application of the recombinant cell lines to show that the original biological characteristics of the parental line are maintained. As part of these efforts, fluorescence in situ hybridization with Chinese hamster chromosome-specific DNA libraries was performed in order to identify the origin of the chromosomes from which a marker chromosome present in the recombinant cell line V79MZr2B1 was derived, which could not be identified by standard cytogenetic techniques.

Fragile sites at the centromere of Chinese hamster chromosomes: a possible mechanism of chromosome loss

On the basis of our previous observations showing that fragile sites (FS) mapped essentially in the centromeric regions of Chinese hamster chromosomes, we consider the possibility that the presence of FS at the centromere might be a source of chromosome loss. In this model a centromeric FS causes a centromeric break giving rise to two chromosome arms which could be lost or maintained with different consequences on the ploidy of daughter cells. To test this hypothesis, Chinese hamster cells have been treated both with N-methyl-N-nitrosourea (MNU), a mutagenic agent which also induces aneuploidy, and vinblastin (VBL), a pure aneugen, used as a control compound, which is supposed not to interact with DNA. The results show that MNU induces the formation of translocated and/or truncated chromosomes, on the contrary VBL is not able to induce chromosome rearrangements. The sites most involved in MNU-induced breaks are the centromeric regions of chromosomes where FS are also present. These breaks cause essentially the loss of one chromosome arm, so that the resulting cells are numerically diploid but presenting partial monosomies. The implications of these results are discussed.

Ionescu-Shiley valve failure. II: Experience with 25 low-profile explants

A group of patients who had low-profile Ionescu-Shiley valves implanted, 237 aortic and 130 mitral, was reviewed for cases of bioprosthetic failure requiring explantation. Fourteen such aortic and 11 mitral valves were recovered at operation. The most common reason for explantation was valvular insufficiency due to cusp tears, accounting for 50.0% of aortic and 82.0% of mitral explants. Morphologic examination of the valves suggested a common mode of failure with tears, and this is illustrated. The clinical and pathologic patterns of this valve's failure are compared with those of the standard-profile Ionescu-Shiley valve, and many similarities exist. A tendency for a larger proportion of mitral valve failures with tears is, however, in contrast to observations of the standard-profile valve, in which aortic failures are more common. Additionally, low-profile valves, in either the aortic or mitral positions, fail after a shorter time in situ than their standard-profile counterparts, at a mean of 45.1 months versus 78.0 in the aortic position (p less than 0.01) and at 52.2 months versus 73.8 in the mitral position (p less than 0.05). These differences in the performance of the Ionescu-Shiley valve models may have implications for the design of future bioprostheses.

Ionescu-Shiley valve failure. I: Experience with 125 standard-profile explants

A group of standard-profile Ionescu-Shiley valve implants, 357 aortic and 190 mitral, was reviewed for cases of failure requiring surgical explantation. To date, 90 (25.2%) of the aortic and 35 (18.4%) of the mitral valves have failed, and are the subject of this analysis. Observations of these explants confirm previous suggestions about the clinical and pathologic patterns of the Ionescu-Shiley valve's failure, but are extended in this study to allow more confident statistical analyses. Cusp tear with insufficiency remains the most important reason for explantation, precipitating removal to date of 19.1% of the aortic and 10.0% of the mitral valves implanted. This difference, aortic versus mitral, is significant (p less than 0.006) and the reverse of observations made in other studies of pericardial valves. In this review there is no significant difference in the proportion of aortic and mitral valves that failed with calcification (2.2% and 3.1%, respectively). Aortic Ionescu-Shiley valves failing with tears had a mean of 3.1 tears per valve, whereas mitral valves had 1.2. Aortic valves also showed considerably more pretear wear than did mitral valves. Although the large number of these Ionescu-Shiley valve failures has been a profound clinical disappointment, it has provided an opportunity to observe and detail the pathology of their failure.

Lambl's excrescences and papillary fibroelastomas: are they different?

OBJECTIVE

To determine if Lambl's excrescences (LEs) and papillary fibroelastomas (PFEs) differ histologically.

SETTING

Materials were obtained from post mortem examinations performed at the Ottawa Civic Hospital, a tertiary care teaching hospital in Ottawa, Ontario.

DESIGN AND PATIENTS

Hearts with grossly 'classic' PFEs (n = 10) or 'typical' LEs (n = 20) were examined. The patients with PFEs had a mean age of 63.5 years (range 24 to 79), similar to that of 68.1 years (range 47 to 83) for those with LEs. The LEs and PFEs were compared regarding their gross characteristics, sizes, locations and microscopic appearances.

MAIN RESULTS

Lesions which were termed LEs had a similar microscopic appearance to grossly categorized PFEs; however, the LEs were smaller and broader-based. Some LEs and PFEs were microscopically indistinguishable.

CONCLUSIONS

As LEs and PFEs may be virtually identical microscopically in some instances, separation of these two lesions may be artificial; however, this separation remains useful because it highlights the gross appearances, unusual locations and potential clinical sequelae of papillary fibroelastomas.

Patterns of failure in Hancock pericardial bioprostheses

A series of Hancock pericardial valve bioprostheses was reviewed for cases of primary valve failure. Thirteen mitral and 10 aortic valve explants were recovered from 21 adult patients. Mitral valves had been in place for a mean of 56.4 months, and aortic valves for 53.8 months. All valves failed with cusp tears from stents (with a mean of 1.7 for mitral valves and 2.6 for aortic valves) in a predictable pattern, suggesting that wear and stress at cusp stitch sites are important in their pathogenesis. The topography of these tears is illustrated as are the less common associates of primary failure, such as calcification, fibrosis, and thrombosis. Similarities and differences of this valve's failure compared with that of the Ionescu-Shiley pericardial valve are discussed.

Severe mitral insufficiency post-balloon valvuloplasty: the late changes found in a disrupted mitral valve

The case of a 45-yr-old woman who had balloon valvuloplasty for rheumatic mitral stenosis is presented. An anterior mitral leaflet tear occurred as a complication of the procedure. Both partial healing of the anterior mitral leaflet and gradual dilatation of the left atrium occurred which allowed the damaged valve to remain in situ for several months. Some of the late changes which occur after such a complicated valvuloplasty are illustrated here, as this patient eventually required surgery and valve excision for definitive repair.