Perceived work stressors and the transition to burnout among nurses in response to the pandemic: implications for healthcare organizations

OBJECTIVES

This study aimed to assess the associations of pre-pandemic perceived work stressors and work satisfaction among nurses, including nurse assistants, with burnout profiles and their transitions in response to the pandemic.

METHODS

Three hundred and thirty-seven nurses working in an Italian University hospital participated in a longitudinal study including a survey in August 2019 investigating perceived work stressors (assessed using the HSE Indicator Tool), work satisfaction (Work Satisfaction Scale), and burnout (Maslach Burnout Inventory), and a second survey in December 2020 assessing burnout. Using latent transition analysis, we identified burnout profiles and then estimated the associations between work stressors and satisfaction on profiles and transitions.

RESULTS

We identified three pre-pandemic profiles, namely engaged (67%), ineffective (15%), and burnout (18%); and three pandemic profiles, namely engaged (37%), exhausted (51%), and severe burnout (12%). The severe burnout profile consisted of 70% nurses classified in the burnout profile before the pandemic. Overall, work stressors and satisfaction were associated with both pre-pandemic and pandemic burnout profiles. Among nurses not in the burnout profile prior to COVID-19, pre-pandemic hostile relationships increased [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.05-1.34] and work satisfaction decreased (OR 0.82, 95% CI 0.68-0.98) the probability to transition to exhausted. Moreover, work satisfaction (OR 0.54, 95% CI 0.32-0.91) and participation in work organization (OR 0.69, 95% CI 0.51-0.93) protected from transitioning to severe burnout. The association between peer support and the transition to exhausted needs further investigation.

CONCLUSIONS

Pre-pandemic work stressors and satisfaction were associated with pandemic burnout and burnout transitions. To enhance preparedness for future crises, healthcare managers should carefully assess and tackle work-related constraints affecting nurses.

Systematic Violence Monitoring to Reduce Underreporting and to Better Inform Workplace Violence Prevention Among Health Care Workers: Before-and-After Prospective Study

BACKGROUND

Monitoring workplace violence (WPV) against health care workers (HCWs) through incident reporting is crucial to drive prevention, but the actual implementation is spotty and experiences underreporting.

OBJECTIVE

This study aims to introduce a systematic WPV surveillance in 2 public referral hospitals in Italy and assess underreporting, WPV annual rates, and attributes "before" (2016-2020) and "after" its implementation (November 2021 to 2022).

METHODS

During 2016-2020, incident reporting was based on procedures and data collection forms that were neither standardized between hospitals nor specific for aggressions. We planned and implemented a standardized WPV surveillance based on (1) an incident report form for immediate and systematic event notification, adopting international standards for violence definitions; (2) second-level root cause analysis with a dedicated psychologist, assessing violence determinants and impacts and offering psychological counseling; (3) a web-based platform for centralized data collection; and (4) periodic training for workforce coordinators and newly hired workers. We used data from incident reports to estimate underreporting, defined as an observed-to-expected (from literature and the "before" period) WPV ratio less than 1, and the 12-month WPV rates (per 100 HCWs) in the "before" and "after" periods. During the latter period, we separately estimated WPV rates for first and recurrent events.

RESULTS

In the "before" period, the yearly observed-to-expected ratios were consistently below 1 and as low as 0.27, suggesting substantial violence underreporting of up to 73%. WPV annual rates declined in 1 hospital (from 1.92 in 2016 to 0.57 in 2020) and rose in the other (from 0.52 to 1.0), with the divergence being attributable to trends in underreporting. Available data were poorly informative to identify at-risk HCW subgroups. In the "after" period, the observed-to-expected ratio rose to 1.14 compared to literature and 1.91 compared to the "before" period, consistently in both hospitals. The 12-month WPV rate was 2.08 (95% CI 1.79-2.42; 1.52 and 2.35 in the 2 hospitals); one-fifth (0.41/2.08, 19.7%) was due to recurrences. Among HCWs, the youngest group (3.79; P<.001), nurses (3.19; P<.001), and male HCWs (2.62; P=.008) reported the highest rates. Emergency departments and psychiatric wards were the 2 areas at increased risk. Physical assaults were more likely in male than female HWCs (45/67, 67.2% vs 62/130, 47.7%; P=.01), but the latter experienced more mental health consequences (46/130, 35.4% vs 13/67, 19.4%; P=.02). Overall, 40.8% (53/130) of female HWCs recognized sociocultural (eg, linguistic or cultural) barriers as contributing factors for the aggression, and 30.8% (40/130) of WPV against female HCWs involved visitors as perpetrators.

CONCLUSIONS

A systematic WPV surveillance reduced underreporting. The identification of high-risk workers and characterization of violence patterns and attributes can better inform priorities and contents of preventive policies. Our evaluation provides useful information for the large-scale implementation of standardized WPV-monitoring programs.

Pre-pandemic burnout and its changes during the COVID-19 outbreak as predictors of mental health of healthcare workers: A lesson to be learned

The aim of this study was to identify how previously existing burnout and its changes during the pandemic contributed to PTSD symptoms and psychological distress in a cohort of 388 healthcare workers (HCWs). Each HCW was surveyed in Sep 2019 (before COVID-19) and again in Dec 2020-Jan 2021 (during the pandemic) to assess burnout (MBI); and in the second wave only to assess PTSD (PCL-5-SF), psychological distress (GHQ-12) and resilience (CD-RISC-10). Changes in emotional exhaustion (EE) and depersonalisation (DEP) were stronger in HCWs with lower EE and DEP baseline values. HCWs with higher baseline poor personal accomplishment (PPA) improved more than those with lower baseline values. In multivariable-adjusted models, pre-pandemic EE and its changes were equally associated to both outcomes: standardised-βs of 0.52 and 0.54 for PTSD, respectively; and 0.55 and 0.53 for psychological distress. Changes in DEP were associated with PTSD only (0.10). Changes in PPA had a higher association with psychological distress (0.29) than pre-pandemic PPA (0.13). Resilience was associated with lower psychological distress (-0.25). Preventive actions aimed at reducing EE, e.g., addressing organisational dysfunctions, are needed to mitigate the impact of future crises, whereas improving personal accomplishment levels is a key target to protect HCWs from mental health disorders during a pandemic.

Air pollution is associated with the risk of neurodegenerative disorders: a prominent role of PM10

Background

Studies revealed an implication of air pollution in neurodegenerative disorders, although this link remains unclear. Here, we investigated this testing multiple pollutants simultaneously.

Methods

In the Moli-sani cohort (N = 24,325; ≥35 years; 51.9% women, baseline 2005-2010), we estimated yearly levels of exposure to nitrogen oxides (NOX, NO, NO2), ozone (O3), particulate matter (PM10) and BTX hydrocarbons (benzene, toluene and xylene) in 2006-2018, applying residence geo-localization of participants and Kriging interpolation algorithm to land measurements of air pollutants. We performed a principal component analysis and tested association of the resulting principal components (PCs) with the incident risk of Parkinson (PD) and Alzheimer disease (AD), through multivariable Cox PH regressions adjusted for age, sex and education level completed.

Results

Over 24,308 subjects with pollution data available (51.9% women, 55.8(12.0) years), we extracted three PCs explaining ≥5% of pollution exposure variance: PC1 (38.2%, tagging PM10 exposure), PC2 (19.5%, O3/CO/SO2), PC3 (8.5%, NOx/BTX hydrocarbons). Over a mean follow-up of 10.9(2.1) years, we observed statistically significant associations of PC1 with an increased risk of PD (HR[CI] = 1.04[1.02-1.05]; 405 incident cases) and AD (1.06[1.04-1.08]; 218 cases). These associations were confirmed when we analyzed PM10 levels averaged over follow-up time, in models further adjusted for professional exposures like working class, compartment and toxic compounds and lifestyles like smoking and drinking habits, physical activity and adherence to Mediterranean diet (PD: 1.27 [1.19-1.37]; AD: 1.22[1.16-1.28] per 1 μg/m3 increase of PM10).

Conclusions

This evidence supports an influence of air pollution - especially PM10 - on increased neurodegenerative risk in the Italian population, independent on concurring risk factors. This suggests reducing PM10 pollution as a potential strategy to reduce neurodegenerative risk.

Key messages

• PM10 levels are associated with increased Parkinson and Alzheimer disease risk.

• This suggests to act on air pollution to reduce neurodegenerative risk in the general population.

Incremental utility of circulating biomarkers for cardiovascular risk prediction beyond the updated SCORE2 model

Background

Accurate risk prediction for future cardiovascular disease (CVD) is crucial for timely initiation of preventive measures in high-risk individuals. Most risk scores, such as the recently updated SCORE2 risk-prediction model supported by the European Society of Cardiology, consider only traditional cardiovascular risk factors. Whether the addition of circulating biomarkers to the existing SCORE2 model may improve risk prediction is unclear.

Purpose

We aimed to evaluate the incremental utility of four widely available circulating biomarkers to improve the prediction of 10-year CVD-risk beyond SCORE2.

Methods

Data from ten prospective population-based cohorts from seven countries across Europe were collected if information on SCORE2-variables and at least one of the following four investigational biomarkers was available: high-sensitivity cardiac troponin I (hs-cTnI), NT-pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP) and creatinine-based estimated glomerular filtration rate (eGFR). Primary outcome was incidence of CVD at 10 years, defined as the composite of cardiovascular mortality, non-fatal myocardial infarction and non-fatal stroke. We used Fine and Gray models adjusted for competing-risk and SCORE2-variables as well as penalized cubic splines to assess and visualize the association of individual biomarkers with incident CVD. In a multimarker approach, we performed backward selection to identify biomarkers providing independent predictive value beyond SCORE2-components. C-indices and category-free net reclassification index (cfNRI) were used to compare the performance of the original SCORE2 model to the biomarker-extended model.

Results

In 78'507 individuals, median age was 50 years and 50.3% were females. NT-proBNP, hs-CRP and hs-cTnI but not eGFR showed strong associations with 10-year CVD-risk when adjusted for SCORE2 and provided incremental predictive value when individually added to SCORE2 (Figure 1). In a multimarker approach, all three biomarkers remained independently associated with CVD beyond SCORE2 with strongest association of NT-proBNP, followed by hs-CRP and hs-cTnI (Table 1). The simultaneous addition of these three biomarkers to the SCORE2 model significantly increased discrimination (C-index; 0.782 [95% CI, 0.757, 0.806] versus 0.793 [95% CI, 0.768, 0.817], Delta 0.011 [95% CI, 0.005, 0.016]) and risk reclassification, driven by an improvement in non-events (cfNRIoverall 0.17 [95% CI, 0.12, 0.22], cfNRIevents 0.06 [95% CI, 0.02, 0.11], cfNRInon-events 0.11 [95% CI, 0.10, 0.11]).

Conclusion

NT-proBNP, hs-CRP and hs-cTnI but not eGFR provide incremental predictive value when added to the SCORE2 risk-prediction model and may help to further improve personalized CVD-risk prediction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Community's Seventh Framework Programme (FP7/2007-2013)

The North Italian Longitudinal Study Assessing the Mental Health Effects of SARS-CoV-2 Pandemic Health Care Workers—Part II: Structural Validity of Scales Assessing Mental Health

It is unclear if the factor structure of the questionnaires that were employed by studies addressing the impact of COVID-19 on the mental health of Healthcare Workers (HCW) did not change due to the pandemic. The aim of this study is to assess the factor structure and longitudinal measurement invariance of the Maslach Burnout Inventory (MBI) and the factor structure of the General Health Questionnare-12 (GHQ-12), PTSD Checklist for DSM-5-Short Form (PCL-5-SF), Connor-Davidson Resilience Scale-10 (CD-RISC-10) and Post-Traumatic Growth Inventory-Short Form (PTGI-SF). Out of n = 805 HCWs from a University hospital who responded to a pre-COVID-19 survey, n = 431 were re-assessed after the COVID-19 outbreak. A Confirmatory Factor Analysis (CFA) on the MBI showed adequate fit and good internal consistency only after removal of items 2, 6, 12 and 16. The assumptions of configural and metric longitudinal invariance were met, whereas scalar longitudinal invariance did not hold. CFAs and exploratory bifactor analyses performed using data from the second wave confirmed that the GHQ-12, the PCL-5-SF, the PTGI-SF and the CD-RISC-10 were unidimensional. In conclusion, we found support for a refined version of the MBI. The comparison of mean MBI values in HCWs before and after the pandemic should be interpreted with caution.

Evaluation of menstrual irregularities after COVID-19 vaccination: Results of the MECOVAC survey

We investigated menstrual irregularities after the first and second doses of the COVID-19 vaccine. Women answered a customised online questionnaire (ClinicalTrial.gov ID: NCT05083065) aimed to assess the vaccine type, the phase of the menstrual cycle during which the vaccine was administered, the occurrence of menstrual irregularities after the first and second doses, and how long this effect lasted. We excluded women with gynaecological and non-gynaecological diseases, undergoing hormonal and non-hormonal treatments, in perimenopause or menopause, as well as those who had irregular menstrual cycles in the last 12 months before vaccine administration. According to our data analysis, approximately 50–60% of reproductive-age women who received the first dose of the COVID-19 vaccine reported menstrual cycle irregularities, regardless of the type of administered vaccine. The occurrence of menstrual irregularities seems to be slightly higher (60–70%) after the second dose. Menstrual irregularities after both the first and second doses of the vaccine were found to self-resolve in approximately half the cases within two months. Based on these results, we suggest to consider these elements during the counselling of women who receive the COVID-19 vaccine, letting them know about the potential occurrence of temporary and self-limiting menstrual cycle irregularities in the subsequent month(s).

Mucosal immune response in BNT162b2 COVID-19 vaccine recipients

BACKGROUND

Although the BNT162b2 COVID-19 vaccine is known to induce IgG neutralizing antibodies in serum protecting against COVID-19, it has not been studied in detail whether it could generate specific immunity at mucosal sites, which represent the primary route of entry of SARS-CoV-2.

METHODS

Samples of serum and saliva of 60 BNT162b2-vaccinated healthcare workers were collected at baseline, two weeks after the first dose and two weeks after the second dose. Anti-S1-protein IgG and IgA total antibodies titres and the presence of neutralizing antibodies against the Receptor Binding Domain in both serum and saliva were measured by quantitative and by competitive ELISA, respectively.

FINDINGS

Complete vaccination cycle generates a high serum IgG antibody titre as a single dose in previously infected seropositive individuals. Serum IgA concentration reaches a plateau after a single dose in seropositive individuals and two vaccine doses in seronegative subjects. After the second dose IgA level was higher in seronegative than in seropositive subjects. In saliva, IgG level is almost two orders of magnitude lower than in serum, reaching the highest values after the second dose. IgA concentration remains low and increases significantly only in seropositive individuals after the second dose. Neutralizing antibody titres were much higher in serum than in saliva.

INTERPRETATION

The mRNA BNT162b2 vaccination elicits a strong systemic immune response by drastically boosting neutralizing antibodies development in serum, but not in saliva, indicating that at least oral mucosal immunity is poorly activated by this vaccination protocol, thus failing in limiting virus acquisition upon its entry through this route.

FUNDING

This work was funded by the Department of Medicine and Surgery, University of Insubria, and partially supported by Fondazione Umberto Veronesi (COVID-19 Insieme per la ricerca di tutti, 2020).

Association of glycated haemoglobin A1c levels with cardiovascular outcomes in the general population: results from the BiomarCaRE consortium

Background

Glycated haemoglobin A1c (HbA1c) is used to monitor the quality of diabetes treatment; however, its role in predicting cardiovascular outcomes in the general population remains uncertain.

Purpose

The additional use of glycated haemoglobin A1c (HbA1c) as a biomarker might highlight subjects of the general population with an increased risk for cardiovascular outcomes with cardiovascular disease, cardiovascular mortality or overall-mortality.

Methods

Data from six prospective population-based cohort studies across Europe comprising 36,180 participants were analysed. HbA1c was evaluated in conjunction with classical cardiovascular risk factors (CVRFs) for association with cardiovascular mortality, cardiovascular diseases (CVD), and overall mortality in the study population, in non-diabetic (N=32,477), and diabetic participants (N=3,703).

Results

Kaplan-Meier curves showed higher event rates with increasing continuous log-transformed HbA1c levels. Cox regression analysis revealed significant associations between HbA1c (in mmol/mol) log-transformed divided by interquartile range and the examined outcomes, with a hazard ratio (HR) of 1.12 (95% confidence interval (CI): 1.04–1.20, p=0.0019) for cardiovascular mortality, 1.10 (95% CI: 1.04–1.16, p&lt;0.001) for CVD, and 1.09 (95% CI: 1.05–1.14, p&lt;0.001) for overall mortality per one unit increase.

An increased risk of CVD was observed in subjects without diabetes with increased HbA1c levels (HR 1.09; 95% CI: 1.01–1.16, p=0.021). An HbA1c cut-off value of 39.89 mmol/mol (5.8%), 36.62 mmol/mol (5.5%), and 38.80 mmol/mol (5.7%) for cardiovascular mortality, CVD, and overall mortality, respectively, was determined for selecting individuals at an increased risk.

Conclusion

HbA1c was demonstrated to be an independent prognostic biomarker for all investigated outcomes in the general European population. An approximately linear relationship was observed between an increase of HbA1c levels and the outcomes. Elevated HbA1c levels were also associated with the outcomes in participants without diabetes (i.e. HbA1c levels &lt;6.5% (&lt;48mmol/mol) which underlines the importance of HbA1c levels in the overall population.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union Seventh Framework ProgrammeEuropean Union FP 7 project CHANCES Kaplan-Meier curves for the outcomesPenalised cubic splines HbA1c/time event

Occupational class differences in ankle-brachial index and pulse wave velocity measurements to detect subclinical vascular disease

Background:

High pulse wave velocity (PWV) and low ankle brachial index (ABI) have been proposed as surrogate end-points for cardiovascular disease (CVD).

Objectives:

In a cross-sectional setting, we aimed at assessing the distributions of PWV and ABI among occupational classes (OC) in a population-based ever-employed salaried sample.

Methods:

We enrolled 1388 salaried CVD-free workers attending a CVD population-based survey, the RoCAV study, and classified them into four OC, based on current or last job title: manager/director (MD), non-manual (NMW), skilled-manual (SMW) and (UMW) unskilled-manual workers. We derived brachial-ankle PWV and ABI from four-limb blood pressures measurements, then carotid-femoral PWV (cfPWV) was estimated. We estimated the OC gradients in cfPWV and ABI using linear and logistic regression models.

Results:

Compared to MD (reference category), UMW had higher age- and BMI-adjusted cfPWV mean values both in men (0.63 m/s; 95%CI:0.11-1.16) and women (1.60 m/s; 0.43-2.77), only marginally reduced when adjusting for CVD risk factors. Decreased ABI mean values were also detected in lower OC. The overall detection rate of abnormal cfPWV (≥12 m/s) or ABI (≤0.9) values was 28%. Compared to MD, the prevalence of abnormal cfPWV or ABI was higher in NMW (OR=1.77; 95%CI:1.12-2.79), SMW (1.71; 1.05-2.78) and UMW (2.72; 1.65-4.50). Adjustment for CVD risk factors used in risk score equations did not change the results.

Discussion:

We found a higher prevalence of abnormal values of arterial stiffness measures in lower OC, and these differences were not explained by traditional CVD risk factors. These may be presumably determined by additional work- and environmental-related risk factors.

Association of Circulating Metabolites With Risk of Coronary Heart Disease in a European Population: Results From the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) Consortium

Importance

Risk stratification for coronary heart disease (CHD) remains challenging because of the complex causative mechanism of the disease. Metabolomic profiling offers the potential to detect new biomarkers and improve CHD risk assessment.

Objective

To evaluate the association between circulating metabolites and incident CHD in a large European cohort.

Design, Setting, and Participants

This population-based study used the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) case-cohort to measure circulating metabolites using a targeted approach in serum samples from 10 741 individuals without prevalent CHD. The cohort consisted of a weighted, random subcohort of the original cohort of more than 70 000 individuals. The case-cohort design was applied to 6 European cohorts: FINRISK97 (Finland), Monitoring of Trends and Determinants in Cardiovascular Diseases/Cooperative Health Research in the Region of Augsburg (MONICA/KORA; Germany), MONICA-Brianza and Moli-sani (Italy), DanMONICA (Denmark), and the Scottish Heart Health Extended Cohort (United Kingdom).

Main Outcomes and Measures

Associations with time to CHD onset were assessed individually by applying weighted and adjusted Cox proportional hazard models. The association of metabolites with CHD onset was examined by C indices.

Results

In 10 741 individuals (4157 women [38.7%]; median [interquartile range] age, 56.5 [49.2-62.2] years), 2166 incident CHD events (20.2%) occurred over a median (interquartile range) follow-up time of 9.2 (4.5-15.0) years. Among the 141 metabolites analyzed, 24 were significantly associated with incident CHD at a nominal P value of .05, including phosphatidylcholines (PCs), lysoPCs, amino acids, and sphingolipids. Five PCs remained significant after correction for multiple testing: acyl-alkyl-PC C40:6 (hazard ratio [HR], 1.13 [95% CI, 1.07-1.18]), diacyl-PC C40:6 (HR, 1.10 [95% CI, 1.04-1.15]), acyl-alkyl-PC C38:6 (HR, 1.11 [95% CI, 1.05-1.16]), diacyl-PC C38:6 (HR, 1.09 [95% CI, 1.04-1.14]) and diacyl-PC C38:5 (HR, 1.10 [95% CI, 1.05-1.16]). Lower levels of these metabolites were associated with increased risk of incident CHD. The strength of the associations competes with those of classic risk factors (C statistics: acyl-alkyl-PC C40:6, 0.756 [95% CI, 0.738-0.774], diacyl-PC C40:6, 0.754 [95% CI, 0.736-0.772], acyl-alkyl-PC C38:6, 0.755 [95% CI, 0.736-0.773], diacyl-PC C38:6, 0.754 [95% CI, 0.736-0.772]), diacyl-PC C38:5, 0.754 [95% CI, 0.736-0.772]). Adding metabolites to a base risk model including classic risk factors high-sensitivity C-reactive protein and high-sensitivity troponin I did not improve discrimination by C statistics.

Conclusions and Relevance

Five PCs were significantly associated with increased risk of incident CHD and showed comparable discrimination with individual classic risk factors. Although these metabolites do not improve CHD risk assessment beyond that of classic risk factors, these findings hold promise for an improved understanding of the pathophysiology of CHD.

Cardiovascular disease prevention at the workplace: assessing the prognostic value of lifestyle risk factors and job-related conditions

Objectives

The prognostic utility of lifestyle risk factors and job-related conditions (LS&JRC) for cardiovascular disease (CVD) risk stratification remains to be clarified.

Methods

We investigated discrimination and clinical utility of LS&JRC among 2532 workers, 35–64 years old, CVD-free at the time of recruitment (1989–1996) in four prospective cohorts in Northern Italy, and followed up (median 14 years) until first major coronary event or ischemic stroke, fatal or non-fatal. From a Cox model including cigarette smoking, alcohol intake, occupational and sport physical activity and job strain, we estimated 10-year discrimination as the area under the ROC curve (AUC), and clinical utility as the Net Benefit.

Results

N = 162 events occurred during follow-up (10-year risk: 4.3%). The LS&JRC model showed the same discrimination (AUC = 0.753, 95% CI 0.700–0.780) as blood lipids, blood pressure, smoking and diabetes (AUC = 0.753), consistently across occupational classes. Among workers at low CVD risk (n = 1832, 91 CVD events), 687 were at increased LS&JRC risk; of these, 1 every 15 was a case, resulting in a positive Net Benefit (1.27; 95% CI 0.68–2.16).

Conclusions

LS&JRC are as accurate as clinical risk factors in identifying future cardiovascular events among working males. Our results support initiatives to improve total health at work as strategies to prevent cardiovascular disease.

Differing associations for sport versus occupational physical activity and cardiovascular risk

OBJECTIVES

We investigate the independent and interacting long-term associations of occupational physical activity (OPA) and sport physical activity (SpPA) with the incidence of coronary heart disease (CHD) and cardiovascular diseases (CVD; CHD plus ischaemic stroke) in North Italian male workers.

METHODS

3574 employed men aged 25-64 years, free of CVD at baseline, recruited in three population-based and one factory-based cohorts, were included in the analysis. The Baecke Questionnaire was used to assess OPA and SpPA in 'minutes per week' of moderate or vigorous PA. We estimated the associations between different domains of PA and the endpoints, adjusting for major CVD risk factors, using Cox models.

RESULTS

During a median follow-up of 14 years, 135 and 174 first CHD and CVD events, fatal and non-fatal, occurred. Compared with the intermediate OPA tertile, the HRs for CHD among low and high OPA workers were 1.66 (95% CI 1.06 to 2.59) and 1.18 (0.72 to 1.94), respectively (P value=0.07). Decreasing trends in CHD and CVD rates across increasing levels of SpPA were also found, with an HR for CVD of 0.68 (0.46 to 0.98) for intermediate/recommended SpPA compared with poor SpPA. We also found a statistically significant SpPA-OPA interaction, and the protective effect of SpPA was only found among sedentary workers, for both endpoints. Conversely, high OPA workers with intermediate/recommended SpPA levels had increased CHD and CVD rates compared with the poor SpPA category.

CONCLUSIONS

Our results provide further evidence on the health paradox of OPA, with higher CVD rates among workers with intense PA at work. Moreover, the protective effect on CVDs of SpPA is prominent in sedentary workers, but it attenuates and even reverses in moderate and strenuous OPA workers.

Prevalence of abdominal aortic aneurysms and its relation with cardiovascular risk stratification: protocol of the Risk of Cardiovascular diseases and abdominal aortic Aneurysm in Varese (RoCAV) population based study

BACKGROUND

Recent meta-analyses suggested that screening program for abdominal aortic aneurysms (AAA) in 65-year old males is cost-effective at prevalence of about 1%. Since some events occur also in females and among the youngers, screening could be feasible among those at higher risk, such as smokers or individuals with a family history of AAA. The RoCAV (Risk of Cardiovascular diseases and abdominal aortic Aneurysms in Varese) Project is a population-based study aimed to evaluate AAA prevalence in Northern Italy in males over-65 years as well as among females and younger males, and to identify new markers for risk stratification by collecting a large set of CVD risk factors. The aims of the project are: (i) cross-sectional evaluation of AAA prevalence (ii); evaluation of standard CVD risk score as criteria for selecting subgroup at higher risk to be included in a screening program; (iii) identification of new risk markers and risk score algorithm for AAA and CVD risk stratification; (iv) cost-effective evaluation during the follow-up.

METHODS

Males aged 50-75 years and females aged 60-75 years, resident in the city of Varese (Lombardy Region), were randomly selected from the civil registry. Among 5198 successfully invited, 3777 subjects accepted to participate and were finally recruited (participation rate 63.8%) from June 2013 to May 2016. Trained operators administered a computerized anamnestic questionnaire, measured anthropometric parameters (BMI, body circumferences, skinfolds), blood pressure, ankle-brachial index, pulse wave velocity and performed abdominal aortic ultrasound scan, ECG and spirometry. All methods were internationally validated. A blood sample was collected and stored in biobank. A follow-up will be carried out through linkage with electronic records.

DISCUSSION

Participation rate and data quality assessment were as expected and will reasonably allow to reach the project aims. The expected impact in public health of the RoCAV project will be the potential implementation of a AAA screening program to the whole region as well as the formulation of new criteria for risk assessment of AAA and CVD.

[Non-intestinal type sinonasal cancers and exposure to occupational carcinogens: a case-control study]

BACKGROUND

Sinonasal cancers are rare, often fatal, tumors with a very high proportion of cases attributable to occupational exposures. The relevance of different carcinogens deeply varies among histological subtypes, with intestinal type adenocarcinomas (ITAC) characterized by a very large proportion of workers exposed to wood dust. The role of occupation in the etiology of other histotypes is less clear and more disputed, with authors questioning the possible occupational origin of non-ITAC cancers.

METHODS

We conducted a hospital-based case-control study on 50 consecutives non-ITAC cancers and 50 controls, in Varese, Italy. Relative risks for previous exposure to carcinogens (any or single agent, i.e. wood/leather dust, solvents, metals) were calculated by multivariate logistic regression models adjusted for age, gender, smoking habits and residence (within or outside the Lombardy region).

RESULTS

Having been exposed to any occupational carcinogen carried an OR of 3.04 (95%CI: 0.91-10.21). Considering single carcinogens, we observed no increased risk for wood dust exposure (OR=1.02, 95%CI: 0.21-4.94), while a large effect associated with previous exposure to other recognized carcinogens (leather dust, solvents or metals) appeared: OR=7.01 (95%CI: 1.51-32.8).

DISCUSSION

Our results highlighted the importance of properly considering sinonasal cancers histological subtypes when investigating the role of occupational carcinogens. Grouping together all sinonasal cancers may end up in underestimating the role of wood in ITAC etiology as well as the relevance of other occupational exposures for non-ITAC tumors. All sinonasal cancers deserve a thorough investigation of the occupational history.

Workplace drug testing on urine samples: evidence for improving efficacy of a first-level screening programme

BACKGROUND

Previous reports revealed poor performance in identifying drugs of abuse users through first-level workplace drug testing (WDT), based on urine samples. In a cross-sectional study, we evaluated: (i) the effect of creatinine normalization of drug values from diluted urine samples (creatinine levels ≤ 20 mg/dL) on the prevalence of drug users; (ii) the independent procedure-related predictors of positivity and dilution.

METHODS

Workers' urine samples were collected at the workplace or at our certified laboratory between 2008 and 2012. All samples were analysed for drugs of abuse by immuno-enzymatic method in our laboratory, according to the Italian WDT law. Detectable drugs of abuse concentrations lower than the positive cutoff values were normalized based on mean levels of urinary creatinine. Detectable concentrations of drugs were confirmed by GC/MS. Multivariate logistic regression was used to detect independent procedure-related predictors of positive and diluted urine samples.

RESULTS

Of the 3080 urine samples screened, 51 (1.7%) were found positive for some drugs of abuse (26 cannabinoids and 16 cocaine) and 116 (3.8%) were diluted. Seventeen out of 23 diluted urine samples with detectable concentrations of cannabinoids or cocaine were found positive after urine creatinine normalization and GC/MS confirmed both negative and positive results. This increased the percentage of positivity for cannabinoids and cocaine from 1.35% to 2.09% (+55%, p=0.0005), which is closer to the expected prevalence of drug users based on Italian self-reported surveys. Collection of samples in the laboratory was an independent predictor of positivity (OR=2.33, 95%CI 1.27-4.28) and diluted urine sample (OR=1.65, 95%CI 1.04-2.61).

CONCLUSIONS

Efficacy of first-level WDT could be improved by well-controlled pre-analytical procedures and urine creatinine normalization of detected concentrations of drugs of abuse.

Improving long-term prediction of first cardiovascular event: the contribution of family history of coronary heart disease and social status

OBJECTIVE

The aim of this study is to assess whether family history of coronary heart disease (CHD) and education as proxy of social status improve long-term cardiovascular disease risk prediction in a low-incidence European population.

METHODS

The 20-year risk of first coronary or ischemic stroke events was estimated using sex-specific Cox models in 3956 participants of three population-based surveys in northern Italy, aged 35-69 years and free of cardiovascular disease at enrollment. The additional contribution of education and positive family history of CHD was defined as change in discrimination and Net Reclassification Improvement (NRI) over the model including 7 traditional risk factors.

RESULTS

Kaplan-Meier 20-year risk was 16.8% in men (254 events) and 6.4% in women (102 events). Low education (hazard ratio=1.35, 95%CI 0.98-1.85) and family history of CHD (1.55; 1.19-2.03) were associated with the endpoint in men, but not in women. In men, the addition of education and family history significantly improved discrimination by 1%; NRI was 6% (95%CI: 0.2%-15.2%), raising to 20% (0.5%-44%) in those at intermediate risk. NRI in women at intermediate risk was 7%.

CONCLUSION

In low-incidence populations, family history of CHD and education, easily assessed in clinical practice, should be included in long-term cardiovascular disease risk scores, at least in men.

Physical and psychosocial risk factors for musculoskeletal disorders in Brazilian and Italian nurses

As part of the international CUPID investigation, we compared physical and psychosocial risk factors for musculoskeletal disorders among nurses in Brazil and Italy. Using questionnaires, we collected information on musculoskeletal disorders and potential risk factors from 751 nurses employed in public hospitals. By fitting countryspecific multiple logistic regression models, we investigated the association of stressful physical activities and psychosocial characteristics with site-specific and multisite pain, and associated sickness absence. We found no clear relationship between low back pain and occupational lifting, but neck and shoulder pain were more common among nurses who reported prolonged work with the arms in an elevated position. After adjustment for potential confounding variables, pain in the low back, neck and shoulder, multisite pain, and sickness absence were all associated with somatizing tendency in both countries. Our findings support a role of somatizing tendency in predisposition to musculoskeletal disorders, acting as an important mediator of the individual response to triggering exposures, such as workload.

Prevalence of occupational hazards in patients with different types of epithelial sinonasal cancers

BACKGROUND

Occupational exposure to carcinogens contributes greatly to the etiology of sinonasal cancer (SNC), but the role of different risk factors in determining different histological subtypes is disputed.

METHODOLOGY

All consecutive surgical epithelial SNC cases (case-series study) underwent a systematic occupational medicine examination to determine previous exposure to a wide range of work-related chemical hazards.

RESULTS

We investigated 65 SNC cases including intestinal-type adenocarcinoma [ITAC] squamous-cell carcinoma [SCC], and others. Occupational exposure was recognized for 39 cases. Occupational exposures were sensibly more frequent among ITAC than among SCC or other histotypes. Occupational exposure in ITAC cases was to leather or wood dust only, while among non-ITAC cases, we recognised exposure to formaldehyde, solvents and metal fumes. A high proportion of SNC with occupational exposure originated in the ethmoidal epithelium.

CONCLUSION

In our case-series of SNC, a very high frequency of previous occupational exposure to carcinogens was detected, suggesting that occupational hazards may be associated to the aetiopathogenesis, primarily for ITAC, but also for other histotypes. Besides leather or wood, other chemical agents must be recognized as occupational risk factors.

[Looking for "lost occupational cancers": a systematic evaluation of occupational exposure in a case series of cutaneous squamous cell carcinomas in Italy]

BACKGROUND

Cutaneous carcinomas are tumors with a potential occupational etiology due to exposure to established carcinogens such as polycyclic aromatic hydrocarbons (PAH), ionizing radiation, ultraviolet (UV) radiation and arsenic. The occupational origin of such neoplasms is hugely underestimated in Italy.

OBJECTIVES

To asses the proportion of Squamous Cell Carcinomas (SCC) cases with a previous occupational exposure to carcinogens.

METHODS

We systematically evaluated occupational exposure in a series of consecutive cases, discharged in the period 2010-11 from the Dermatology Unit of Varese Hospital, Italy, with a histological diagnosis of SCC. Through a structured telephone interview we identified patients with a potential exposure to skin carcinogens. As a second-level step, an extensive evaluation by an occupational physician was performed to assess the occupational etiology in those selected cases.

RESULTS

105 patients were identified (65 men). 15 male cases out of a total of 85 patients who did the telephone interview, revealed a potential occupational exposure; 7 cases were confirmed as occupational cancers after second-level evaluation (proportion of male occupational cases = 13.2%). UV radiation and PAH were recognized as major causal agents. Applying those results to the national incidence data, we estimated a number of 700 annual occupational cases, 100-fold more than the cases currently evaluated by the Italian National Workers Compensation Authority.

CONCLUSIONS

Our results revealed that occupational SCC is still at present a substantially "lost disease" in Italy. Greater attention and enhanced collaboration between specialists is thus needed to overcome this tendency.

Temporal trends in ischemic and hemorrhagic strokes in Northern Italy: results from the cardiovascular monitoring unit in Northern Italy population-based register, 1998-2004

BACKGROUND

We compared rates and case fatality from a population-based stroke register in Northern Italy between 1998 and 2004 to assess changes over time and to evaluate changes in case diagnosis and management.

METHODS

The WHO Multinational Monitoring of Trends and Determinants in Cardiovascular Disease criteria were used to identify suspected fatal or nonfatal events occurring among residents 35-74 years of age. Data on in-hospital treatments, symptoms and diagnostic tools were extracted. Out-of-hospital deaths were also investigated. The annual average relative change (ARC) in death rate, attack rate and case fatality were derived from Poisson models.

RESULTS

Death rates due to ischemic stroke (IS) decreased [men: ARC -12.7, 95% confidence interval (CI) -21.3 to -3.2; women: ARC -14.0, 95% CI -23.3 to -3.5]. These reductions are attributable to decreases in case fatality; attack rates of nonfatal IS increased (men: ARC 3.6, 95% CI 0.5-6.7; women: ARC 4.1, 95% CI 0.0-8.2). IS patients showed a higher prevalence of dyslipidemia and hypertension and underwent MRI more frequently in 2004. Both findings may explain the increased proportions of less severe cases. Case fatality and attack rates for hemorrhagic strokes (HS) were stable, with an observed increased prevalence of patients under anticoagulant/antiplatelet treatments.

CONCLUSIONS

In this low-IS-incidence population, death rates decreased substantially during the investigated period. More accurate diagnostic tools increase the probability of detecting less severe cases. HS remains a frequently fatal disease with a stable incidence.

[Job strain and cardiovascular diseases: epidemiologic evidence and prevention]

The present contribution wishes to draw attention to major evidences from more recent studies on the relationship between job strain (JS) and cardiovascular diseases (CVD). In particular the demand-control model and the effort-reward imbalance models will be reviewed. Different outcomes are considered: first hypertension, second coronary heart disease (CHD), third atherosclerosis progression, and finally stroke. All these results are in favor of the association between JS and CVD, but with relevant discrepancies in different socio-cultural contest, in different gender groups, indifferent socio-occupational strata. A recent meta-analysis considering prospective cohort studies attribute to people with high JS a 50% increment in risk of CHD in men. Evidences are scares per women. Many limitations in study design contributes to explain some of the discrepancies in the results obtained so far. Promising first results have been reported for studies exploring the interaction between JS and genetic connotes on blood pressure values. More researchers are needed. Based on the actually available evidences, it is time anyhow to start promotion activities at the workplace to improve Individual coping as well as improve the work climate, contrasting major stressor related to work organization and relationships.

[Job strain and heart rate variability. New evidence and new prospects]

Work stress has been associated with an increased risk for cardiovascular disease. Two major pathways capable to explain the link between job stress and the cardiovascular diseases have been extensively studied: the hypothalamic-pituitary-adrenal axis and the autonomic nervous system (ANS). The analysis of heart rate variability (HRV) has been proposed to assess the regulation of the ANS. Several studies established that HRV reduction is a strong and independent predictor of mortality in patients with various cardiovascular diseases. However the assessment of HRV can also be used as a non-invasive tool to predict cardiovascular events in healthy subjects. The aim of this paper is to review and report the results of main studies assessing the association between JS and HRV. Up to now a limited number of studies assessing the relationship between working conditions and HRV has been published. In the majority of them, higher levels of JS has been found associated with lower values of HRV. The literature suggests that HRV analysis can be a valid indicator of JS effects on the cardiovascular system. For the future studies are necessary longitudinal cohorts studies appropriately selected, to obtain information about the cardiovascular effects of prolonged JS.

[Prospectic evaluation of the Italian Workers' Compensation Authority in a large case series of Occupational sino-nasal cancers]

Sino-nasal cancer (SNC) are rare tumours with an elevated occupational etiological fraction, due both to well-established risk factors (wood and leather) and to more rare carcinogens. We evaluated the assessment for workers' compensation performed by the Italian Authority (INAL) in a case-series of occupational SNC (N = 45). We observed an elevated proportion of cases that were recognised as occupational, overall (36 on 39) and for any histotype. INAIL tended to recognize as professional not only patients with exposure to wood and leather but also cases with a documented exposure to formaldehyde, metal, polycyclic hydrocarbons. Significant differences across Italian macro-regions appeared, when the amount of worker compensation was investigated.

[Psychotropic substances and driving]

Consumption of psychotropic substances (alcohol, drugs, medication) has a major impact on complex activity performance such as driving. This issue is of relevant social interest for the high number of potentially involved subjects and the often fatale outcomes, and affects also occupational physicians because of the high number of people whose job is driving. There are still few studies trying to assess the presence of a possible association between increased risk of accident/injury at work and consumption of psychotropic substances and results are not always in agreement. In spite of such uncertainties and some Italian regulations still worth being amended by Legislator, the possible impact of consumption of psychoactive substances on driving is an issue to be still better defined for which occupational physicians may play a basic role in the field of prevention, clinics and rehabilitation.

[Time trends of incidence rates of work accident with blood contamination in a North Italian teaching hospital]

Unbiased estimates of incidence rates of accidents with blood contaminations (ABC) and time trends is the milieu for assessing the effectiveness of preventive interventions. A standardised procedure for registration and follow-up of ABC was et up in a North Italian hospital since 2002. Accurate estimates of rate denominator, as full-time equivalent (FTE) person-years, was calculated, for exposed workers only and excluding periods of prolonged absence. In the observation period (2004-2011), training courses for head nurses on security procedures were repeatedly carried out as well as the progressive introduction of vacuum blood collection systems (since 2009). 1287 ABC have been reported, corresponding to an overall annual crude incidence rate of 4.73 per 100 FTE. Temporal trends, calculated on the biennial incidence, resulted in a reductions over the time period considered, in particular for needlestick injuries. Our results support the notions on the efficacy of the adopted prevention measures.

Fitness for work in health care workers: state of the art and possible operational recommendations for its formulation and management in relationship to alcohol and drug addiction

Both chronic and acute alcohol or drug consumption have severe health consequences, alter the subject's cognitive functions and work performance and increase the risk of work-related accidents, for the worker and for third parties (e.g., co-workers and other people subject to negative impact of worker's actions). Limited scientific evidence has suggested that some working conditions present in the health care sector (e.g., high levels of responsibility, competitiveness, burnout, shiftwork, work-related stress) may favour alcohol and drug abuse. The aim of the present report is to describe the problem of alcohol and drug consumption among health care professionals and to evaluate the problem of related fitness for work. The magnitude of this problem remains unclear; recent estimates have reported alcohol abuse and addiction problems in 1-14% and psychotropic, illicit and non-illicit, substance abuse in 6-15% of health care workers. The prevalence of tranquilizer and sedative/hypnotic drug use is high, particularly among physicians. However, it remains unclear whether the incidence of workplace accidents and injuries is higher among drug abusers, and whether the statutory introduction of prevention programmes has led to actual control of this problem in the workplace. Italian legislation identifies the occupational physician as a key figure to prevent psychotropic substance abuse in some work activities, but some difficulties in its application remain. Legislators should issue simple norms that clearly define the responsibilities and skills of each actor involved in safeguarding workplace health and safety, as well as clearly outlining workplace monitoring procedures.

Shift work and pregnancy outcomes: a systematic review with meta-analysis of currently available epidemiological studies

BACKGROUND

Varying work schedules are suspected of increasing risks to pregnant women and to fetal wellbeing. In particular, maternal hormonal disturbance arising from sleep deprivation or circadian rhythm disruption might impair fetal growth or lead to complications of pregnancy. Two independent meta-analyses (from 2000 to 2007) reported a small adverse effect of shift work on the risk of preterm delivery (PTD). However, these reviews were based on few high-quality studies.

OBJECTIVES

To provide an updated review of the associations of shift work with PTD, low birthweight (LBW), small-for-gestational-age (SGA) infants and pre-eclampsia.

SEARCH STRATEGY AND SELECTION CRITERIA

We conducted a systematic search of MEDLINE using combinations of keywords and MeSH terms.

DATA COLLECTION AND ANALYSIS

For each relevant paper we abstracted standard details, used to summarise design features and rate methodological quality. We calculated pooled estimates of relative risk (RR) in random-effect meta-analyses.

MAIN RESULTS

We retrieved 23 relevant studies. The pooled estimate of RR for PTD was 1.16 (95% CI 1.00-1.33, 16 studies), but when five reports of poorer methodological quality were excluded, the estimated RR decreased to 1.03 (95% CI 0.93-1.14). We also observed increased RRs for LBW (RR 1.27, 95% CI 0.93-1.74) and for SGA (RR 1.12, 95% CI 1.03-1.22), which varied little by study quality. Little evidence was found on pre-eclampsia.

CONCLUSIONS

These findings suggest that overall, any risk of PTD, LBW, or SGA arising from shift work in pregnancy is small.

[Methodological aspects in the evaluation of turn-over and up/down sizing as indicators of work-related stress]

We discuss the methodological aspects related to the evaluation of turn-over and up-down sizing as indicators of work-related stress, in complex organizations like a university hospital. To estimate the active workers population we developed an algorithm which integrated several administrative databases. The indicators were standardized to take into account some potential confounders (age, sex, work seniority) when considering different hospital structures and job mansions. Main advantages of our method include flexibility in the choice of the analysis detail (hospital units, job mansions, a combination of both) and the possibility to describe over-time trends to measure the success of preventive strategies.

[Workplace health promotion: what evidence of effectiveness?]

Workplace health promotion is a strategy that takes in consideration the synergic effects of behavioural and professional health risks. The workplace can help to improve workers' lifestyles, based on specific programmes conducted by trained occupational physicians. In this article we report on the conclusions of two recent reviews, assessing the evidences of effectiveness of workplace health promotion (WHP) programs, recently published. Even if most of the studies are influenced by methodological concerns and limitations, above all the lack of control groups and the use of multiple and heterogenic outcome measures, it is possible to conclude that health assessment programmes with feedbacks are capable to reduce the risks of alcohol abuse, to increase smoking cessation and to improve levels of physical activity in voluntarily recruited employs. Finally, preliminary indications of the SIMLII Workplace Health Promotion Guidelines are briefly commented.

[Drug use among workers: an update]

We present data coming from two years of surveillance of drug use among workers, as provided for by the recent law. Urine samples have been collected either by our lab or by the firm; procedures and investigated substances followed the law. Self-reported information on job duties and history of drug use have also been collected. Between September 2008 and April 2010, n = 2745 workers (age 40.5 +/- 9.5, 98% men, 43% handling workers) were screened, for a total number of 3002 urine samples. Among the samples with creatinine > = 20 mg/dl (n = 2878), 46 were positive (1.6%); no temporal trends were detected. Cannabis e cocaine were the two most spread substances. Positivity was associated with young age and presence of another positive sample in the same firm. Furthermore, we present the results of the analysis (urine and hair samples) on 146 suspected drug abuser selected by the SERT Varese in the same time period.

[Heart disease and work: from rehabilitation to return to work]

Cardiovascular disease is one of the main causes of death and disability in industrialised and post-industrialised countries, including Italy. Improvements in treatment of the acute phase and the efficacy of prevention programmes contribute greatly to extending patient survival, thus increasing the prevalence of the disease even in the population of working age. Thus it is mandatory to provide adequate rehabilitation programmes in order to achieve full social reintegration of such patients, including return to work, which is an important aspect of their quality of life. This report reviews published papers exploring the main factors influencing return to work of patients suffering from a heart complaint. Criteria are also proposed for the assessment of reintegration at work of cardiovascular patients that take account of the residual clinical and functional working capacity of the patient in relation to the specific environmental and organizational work features. With the tools available to monitor the cardiovascular system during work it is possible to pursue to advantage such a comprehensive rehabilitation programme but close cooperation between the occupational physicians and cardiovascular rehabilitation specialists is required In a preliminary phase this can be achieved in hospital outpatient clinics equipped to develop and test specific protocols.

[Comparison of the training schemes of the specialization schools of the public health area: a rational basis for a proposal of a core curriculum for the university training programme contained in article 38 of Legislative Decree (D.Lgs) 81/2008]

A document by the B. Ramazzini College of University Teachers of Occupational Medicine of the Italian Society of Occupational Health and Industrial Hygiene (S.I.M.L.I.I). The aim of this document was to compare the professional competence, training profile and core curricula of the three main specialization courses in the Public Health postgraduate medical area, i.e., Occupational Medicine, Hygiene and Preventive Medicine, and Forensic Medicine, such as contained in the Ministerial Decree (D.M) of 1 August 2005. We set out to identify, using clear and objective criteria, the knowledge and skills that specialists in Hygiene or Forensic Medicine must develop, in accordance with Art. 38 of the new Italian law on safety ahd health at work (D.Lgs 81/2008), in order to be authorized to perform occupational health activities as "Competent Physicians" (CP). The comparison revealed significant differences in structure and content among the three courses. In particular, compared to the course in Occupational Medicine, the courses in Hygiene and in Forensic Medicine both lack clinical training, including diagnostic and therapeutic skills, risk-oriented occupational health activities, biological monitoring, assessment of individual susceptibility, and clinical or instrumental procedures to prevent and detect occupational diseases. Furthermore, the specialization course in Hygiene lacks any training regarding the criteria and methods for assessing the individual worker's fitness for work, while the course in Forensic Medicine lacks any training in occupational risk assessment and management. From this comparison, a list was derived of the education and training debits that specialists in Hygiene or Forensic Medicine should cover (credits) in order to be authorized to perform CP activities as indicated by the new law. A core curriculum is proposed here, based on the corresponding credits, for use as a reference.

[Validation of a screening method for occupational bladder cancer]

BACKGROUND

Transitional bladder cancer is the most frequent malignant urinary neoplasm. Occupational exposure to aromatic amines and to polycyclic aromatic hydrocarbons are the main risk factors, in addition to cigarette smoking, recurrent inflammatory diseases of the urinary tract, consumption of certain drugs and a positive family history. Nevertheless cases of work-related bladder cancer are poorly identified in Italy.

OBJECTIVE

The aim of this study is to assess the screening accuracy of a short structured interview to detect suspected cases of occupational bladder cancer, which may be confirmed in a second step assessment by an occupational physician.

METHODS

The study sample consisted of 94 transitional bladder cancer patients, first hospitalised in 2004 and 2005 at the Department of Urology of the Ospedale di Circolo - Fondazione Macchi, in Varese, Italy. Based on data collected through a simple structured interview, it was possible to estimate two occupational exposure indices: one taking into account only the length of employment in industrial settings (DS Index) and the other considering job title in addition (DSM Index). For all cases a second-step assessment by an occupational physician (gold standard) made it possible to establish the occupational origin of cancer and to assess accuracy.

RESULTS

Satisfactory values of the area under the ROC curve were found for both indices (AUC 0,81 for DS and 0,87 for DSM). In particular at the same level of sensitivity (90%), the DSM Index showed a better specificity (72%) in comparison to the DS Index (64%).

CONCLUSIONS

The short structured interview proposed here proved to be a valuable tool for general practitioners and urologists to detect cases of bladder cancer of suspected occupational aetiology, which can be referred to an occupational physician for further investigations.

[Prevention and control of substance abuse in the workplace: a new and significant opportunity for the occupational physician]

OBJECTIVES

Substance abuse is nowadays a recurrent theme in the daily practice of occupational physicians (OP), mainly owing to recent legislation prescribing mandatory assessments for workers performing job tasks involving danger to third parties. While some degree of bureaucracy is inevitable and legislation seems to be inclined towards deterrence, it is recommended to take advantage of the opportunities offered for practical interventions which, in accordance with science and ethics, the OP can carry out in the workplace. Risk assessment, health surveillance, fitness for work, health promotion and cooperation in management issues are the areas of intervention required for the OP to fully accomplish his role in the practice of modern occupational health.

CONCLUSIONS

We propose specific activities for the OP so as to highlight roles and obligations, based on available scientific evidence and established codes of ethics. Lastly, we wish to emphasize the overall role of the OP in taking on responsibilities shared jointly with all the parties and in the approach to the substance abuse problem in all workplaces with the ultimate goal of acting for the benefit of workers, enterprises and society in general.

[Methodological aspects of risk assessment of work related stress. Italian experience of R Karasek JCQ application, a multiphase approach]

Due to a new legislation, the assessment of work stress has become compulsory in Italy for all the enterprise. Work stress is become a leading health problem in work settings all over Europe. The two major approaches, the expert-based direct observations and the measurements of the perceived job strain, are briefly introduced emphasizing on strengthens and weaknesses. Among the methods to assess perceived job stress, the Karasek's Job Content Questionnaire has been extensively used in Italy, and the available results support its use because reliable and able to pick up major constrictiveness at work. In addition, because it is now possible to have reference levels, comparisons are possible for either public or private enterprises. Acknowledging the complexity of carrying out reliable assessment of work stress, a multiphase approach is emphasised: first an analysis or current data can be used to estimate the levels of turnover, down-sizing, outsourcing, extra hours, shift work, sickness absenteeism, changes of job titles, work accidents and work-related diseases. At a second step, on groups of workers selected because recognised at risk at the first phase and on control groups, the JCQ can be used to assess workers stress perception. Finally, when constrain conditions emerge,further investigations are required, including: intervention of experts in work organisation analysis, clinical psychological examinations of selected workers, to separate between work-related and personal psychological problems and health consequences.

[Stress and health in workplace: towards such scenarios. From Occupational medicine to medicine in workplace]

A short review of main results obtained in occupational stress research is presented. Stress activates the sympato-adrenal system with possible dangerous consequences on the cardiovascular apparatus. In field studies the relation between stress and coronary diseases is controversial. However, from a clinical and experimental perspective the relation between breakdown in adaptation and cardiovascular disorder is a fact. More consistent results on the psychosocial determinants of an increased cardiovascular risk are obtained when stress is studied in relation to the socio-economic condition of groups and individuals. To better embrace and describe such factors, a new theoretical contribution has been introduced: social capital. This is a more sophisticated version of social cohesion, social integration and social support. For the future, an interdisciplinary approach is recommended in health surveillance of life and work environment.

[Evaluation and management aspects of drug-abusers in the workplace]

In Italy a recent legislation introduce detailed procedures to detect drug abusers, which had to be carried out in work settings. The purpose of the legislative document is to reduce the risk of work-related accidents which may affect both the working and the general population. In fact for the time being the procedure is foreseen for only a few work categories with a higher level of responsibility for third parties. This action is based on the adoption of the indications of the EU Drugs Action Plan (2005-2008), and it is mainly oriented to prevention through an early detection of occasional drug abusers to hopefully reduce the number of habitual drug consumers. Firm proprietors and manager are responsible of the overall procedure and the occupational physicians are responsible of the application of many parts of it. The paper discuss many aspects related to the application, including: physician responsibility against the law, how to carry out efficient and accurate drug testing, collaboration with other public agencies devoted to rehabilitation of drug-abuse patients, methodological aspects that can allow the procedure to be effective.

[Assessment of job strain and its consequencies in a large public organisation. Findings from the SEMM Study]

The demand-control model originally developed by Robert Karasek is in Italy the preferred tool to investigate perceived work stress due to work-related organizational constrains. We wish to report the comprehensive results of the SEMM Study, carried on a wide sample of civil servants. N. 5271 women and 2601 men, employed at the Municipality of Milan in the years 1991-1996 were enrolled into the study. The overall participation rate was high in both gender group (75% or more), indicating a good compliance of employees for health prevention programmes carried out in work settings. Each participant, who has given consent, in addition to the medical examinations and biological tests related to the investigation of work exposures, underwent to a structured procedure to measure cardiovascular risk factors, according to the methods developed in the WHO MONICA Project, job strain adopting the Job Content Questionnaire (JCQ), and the Baecke Questionnaire to investigate major quotes of physical activity. In this contest the JCQ has shown an acceptable level of internal and external consistency as well as of acceptance, measured by employees compliance. Psychological job demand and decision latitude can be assessed with two different JCQ revisions available in Italian, which were validated with the contribution of the author, at different complexity, but with comparable results of weighted scores. For a comprehensive assessment of the working conditions social support at work is also of relevance. In the work public sector considered, the JCQ major scores resulted to be valid descriptors of key aspects of the work organization. The concurrent assessment of sick leaves, known marker of burnout, allows to identify work- and individual-related determinants and, in a specific work setting, to give indications for coping actions which may improve workers' integration. In addition, the assessment of cardiovascular risk factors, carried out with standardised and then reliable methods, allow to measure overall global CVD risk and to identify unhealthy behaviours that can be addressed with specific preventive programmes.

[Occupational medicine faces new health challenges: the example of alcohol dependence]

The regulations for application of the legislation on control of alcohol consumption at the work place, which were published in the Gazzetta Ufficiale No. 75, March 30, 2006, set the occupational physician a more challenging task, in addition to regular activities related to the prevention of the usual work-related risk factors. The aim of the legislation, which was derived from and inspired by the European Alcohol Action Plan 2000-2005, drawn up by the European Office of the WHO, is to prevent alcohol abuse and its consequences, i.e. accidents and injuries to third parties, and to permit subjects with alcohol dependence to go on working. In this context, occupational physicians are asked to contribute to the early identification of subjects prone to alcohol abuse and assess whether alcohol-dependent subjects can return to work in conditions of safety for themselves and for other workers. Various problems arise for the achievement of these aims in practice, and concern confidentiality, ethical aspects, i.e. use of alcohol screening at hiring, integration of such tests with those used for monitoring conventional occupational exposures, interactions with exposures to other chemical products, just to mention the major issues. Due to these difficulties in the application of the new regulations, field trials become all the more important, since they offer the possibility of assessing efficacy and efficiency of the different approaches.

[CDT: a biological marker of alcohol abuse]

BACKGROUND

Laboratory tests may be useful tools in the identification of heavy drinkers, in identifying the etiological role of alcohol in the onset of the disease, and in monitoring changes in alcohol intake.

OBJECTIVES

An ideal diagnostic marker of alcohol abuse should: be characterized by high specificity and sensitivity; show an high specific correlation with alcohol metabolism; be dependent on alcohol intake and have a relatively short half-life (t1/2) so as to be able to monitor abstinence periods.

CONCLUSIONS

CDT (Carbohydrate-Deficient-Transferrin) meets all these requirements and offers the physician a significant tool as a marker of chronic alcohol abuse. CDT can reveal a daily alcohol consumption of 50-80 g of ethanol, corresponding to a bottle of 11 degrees-13 degrees wine, for two consecutive weeks, with normalization after two weeks of abstinence (t1/2 of CDT is 15 days). Compared with other more common alcohol abuse markers, such as GGT or MCK CDT is more specific and provides more detailed information.

[Occupational physicians' new attributions and responsibilities]

BACKGROUND

With the introduction in Italy of the Law regarding alcohol abuse and addiction (Law No.125/01), new tasks and responsibilities were assigned to occupational physicians. This law establishes that in working activities with a high risk of industrial accidents, or which may cause a risk for the safety and health of others, workers are forbidden to consume alcoholic beverages during working hours. In addition, occupational physicians are asked to play a key role in testing workers for alcohol levels. In March 2006 a specific list of job titles was issued which makes the law effective.

DISCUSSION AND CONCLUSIONS

The application of this law gives rise to various consequences and ambiguities, in particular for occupational physicians, mainly concerning the identification of workers with alcohol problems, the subsequent control of such workers, including proposals for valid rehabilitation programmes, and assessment of residual work fitness. All these aspects can, to some extent, produce conflicts between privacy rights and the need to ensure the health and safety of workers and third parties. A specific screening package is proposed for the identification of alcohol abuse as well as methods to overcome some of the constraints. Specific and effective guidelines need to be issued by scientific societies and health authorities.

[Sick leave risk factors in a sample of women employed in the public sector. The SEMM study]

OMS reports describe an increase of levels of sickness leaves (SL) at work in all industrialized countries in last decades. Aims of this study are to assess incidence of SL from work in a sample of women public employees and to identify significant factors, among individual, behavioural, familiar, occupational and work strain related. The survey took place between April 1992 and December 1998. After the baseline examination, a two years follow-up was conducted, to detect any SL longer than one day. N. 8123 female employees of the Municipality of Milan were enrolled, undergoing a baseline health examination. They belong to the following municipality sectors (SM): kindergarten, register office, clerks and police. The overall response rate was 76% (3698 females and 2448 males). The present analysis was restricted to female only, who showed almost double incidence of SL than men. Interpolation of logistic models allowed to identify the following predictive independent factors: physical activity in leisure time, work length and social support at work, for incidence of short SL; physical activity at work, hypertension and smoking habit for intermediate SL; and perceived work strain and number of familiar contacts for long SL.

[Transitional bladder cancer and occupational exposure. Accuracy assessment of a screening method based on structured interview]

The transitional bladder cancer is the most frequent urinary malignant neoplasm. The main risk factors are cigarette smoking, recurrent inflammatory diseases of the urinary tract, assumption of some drugs, familiarity and occupational exposure to aromatic amines and polycyclic aromatic hydrocarbons. The aim of this study is to assess the screening efficacy of a short structured interview to detect the possible occupational bladder cancer, to submit to the specialists evaluation. The sample of the study is represented by 100 subjects, hospitalized for transitional bladder cancer in the years 2004 and 2005 at the Department of Urology of the Ospedale di Circolo - Fondazione Macchi in Varese. Through the structured interview was possible to estimate two occupational exposure indexes: Length-Field Index (DS) and Length-Field-Job Index (DSM). The specialist's evaluation allowed to establish the occupational cancer origin. The analysis of the indexes' accuracy showed good operating characteristics with higher specificity and equal sensitivity for DSM in comparison to DS. Therefore the short structured interview should be considered as a valuable tool to identify urothelial carcinomas worthy of further evaluation of occupational specialist.

[Diagnostic agreement between two different analytic methods for in vitro measurement of specific IgE and comparison with clinical evaluation and in vivo test for ubiquitarian and professional allergens]

This study surveys the diagnostic agreement between two different analytic systems for the measurement of serum specific IgE (sLgE), Immulite 2000 (IML) and ImmunoCap (CAP), with clinic evaluation and in vivo test. Our sample is represented by 33 adults (27 females and 6 males), with suspect of immediate allergic disease and suspect of sensitization to at least one allergen of the study panel (18 allergens: inhalant, alimentary and professional). All patients have been subjected to Skin Prick Test (SPT) for all the studied allergens, therefore sIgE measurement with IML and CAP systems has been executed (twice for each method) only for the allergens which resulted positive to the diagnostic suspect and to SPT, and for an equal number of allergens chosen by bound randomisation. In vitro methods (IML and CAP), evaluated by K Cohen statistics, give good diagnostic agreement. In the same way, the diagnostic agreement of the used analytic systems both with clinical suspect and with in vivo test is satisfying, with higher K values for IML.

[Occupational safety and health in hospitals of Regione Lombardia. Are there differences among public, private nonprofit and private profit hospitals?]

In 2006 an extensive survey took place in all hospitals of Lombardia, to assess, through inspections, the safety conditions and the efficiency of the organisations invested to assure that. During these inspections were evaluated 6 safety sections and hospital organization and efficiency, by means of a questionnaire. The aim was to assess the internal consistency of questionnaire sections, the presence of differences of such scores among public, private non-profit and profit hospitals and the correlations among safety scores and among these latter and efficiency indexes. Significant differences for size factors and efficiency indexes have been pointed out among different types of hospitals. Instead, safety scores showed good internal consistency and have been resulted statistically significant correlated in most cases. For all types of hospital have been observed high values for safety scores, with exception of occupational health service, better organized in public hospitals, and of safety conditions of worker from external agencies, which have been displayed low. This last consideration stick out the need to pay more attention to safety conditions of these workers.