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Background and Objectives: Three malignant pleural mesotheliomas occurred among workers of a small factory that manufactured drying machines for the textile and paper mill industries using asbestos cement (crocidolite, amosite and chrysotile) as insulating panels. The Occupational Medicine Unit of the Local Health Unit of Pistoia, Italy, carried out an intervention programme in the plant in order to 1) assess past asbestos exposure via analysis of the fibre content of samples from drying machines, and of dust samples collected in the factory. Information on the characteristics of occupational exposure was also collected; 2) investigate cancer mortality by means of a mortality study of the employees and, 3) carry out a health intervention programme in workers formally exposed to asbestos in the past., Methods: Samples from the drying machines and dust samples collected in the factory were analysed using X-ray diffractometric methods. Information on the characteristics of occupational exposure were collected by interviewing plant workers. Two-hundred and fifty employees who had worked in the factory between 1962 and 2000 were included in the mortality study. Follow-up was performed from 1962 to 2002. Health intervention in workers exposed to asbestos in the past involved general practitioners and occupational physicians (first level medical examinations); pneumologists and radiologists (second level medical examinations) of the local health unit., Results: Asbestos fibres were found both in samples from drying machines and in dust samples collected in the factory. Interviews with workers showed that asbestos exposure varied considerably. The SMR for mesothelioma and lung cancer in 234 male workers were 37.0 (95%CI: 4.47-130.0), and 1.29 (95%CI: 0.26-3.78), respectively, based on mortality rates for Tuscany region. Sixty-two workers underwent first level medical examinations; 57 second level examinations. Chronic obstructive lung disease was found in 3 workers; restrictive lung disease was found in 3 employees, one of whom had pleural plaques., Conclusions: Further investigation is needed in order to identify unknown asbestos exposures in small metal engineering factories.

The paper reports 9 cases of mesothelioma diagnosed by means of histology or cytology that were observed among women resident in the Veneto Region, Northern Italy, whose only activity that could involve exposure to asbestos was as rag sorter. These cases are part of a group of about 260 subjects with mesothelioma whose entire working and residential history has been collected. The women worked as rag sorters between the 1940's and 1960's in textile recycling (8 cases) or (one case) at a paper mill where cotton was used for paper production. The work as rag sorter helps to explain the high proportion of mesotheliomas among women with an occupational exposure to asbestos.

The statistical methods used in occupational health studies were evaluated by analyzing the papers published from 1986 to 1990 in the proceedings of the annual meetings of the Italian Society of Occupational Medicine and Industrial Hygiene, in order to calculate the degree of understanding of the readers provided with only one-sided knowledge of statistical subjects and to improve the educational objectives in postgraduate schools of occupational health. Almost 70% of the 1151 articles reviewed contained some kind of statistical analysis: methods more complicated than descriptive statistics were used in about 35%. Student's t test (15%) and chi square (12%) were the most common methods. Other methods were less frequently used, so that it was possible to estimate that the learning of any new method would improve the understanding of about 1-2% of the articles. A wider use of statistical methods in data analysis is recommended; the attainment of a higher level of statistical knowledge should be a priority target in occupational health training.

The paper illustrates the life and the achievements of Enrico Ronzani, born in Padua and graduated in Medicine at the Bologna University. He directed the hospitals of Florence and the Ospedale Maggiore of Milan, promoting its growth until it became the seat of the Medical School promoted by Prof Mangiagalli, and he himself became Full Professor of Hygiene. In such a position he taught Hygiene also to Architets and Engineers, built the new Institute of Hygiene and helped to design and build the new great Hospital of Niguarda. But, most of all, he was successful in designing, promoting and officializing the job of the Hospital Directors, which was subsequently recognized by the law; and, publishing a series of books on the role of the modern hospitals, he prefigured their position in a web of medical institutions to include also those devoted to pre- and post-hospital assistance to the population. Practically he foresaw what was realized many years later through the creation of the Italian National Health Service (Law 833 of 1978).

The paper traces the evolution of vaccination policies in Italy in the first 40 years of the National Health Service. Four phases have been identified: the first (1978-98) characterized by the eradication of smallpox, the hopes of further eradications and the introduction of hepatitis B and acellular antipertussis vaccines; the second (1999-2008) coincided with the first national vaccination plans and with the hypothesis of a progressive transition from mandatory vaccinations to nudging initiatives with the relevant experimentation in the Veneto Region; the third phase (2009-14) was characterized by the spread of health information on the web and social networks, by anti-scientific judgments and by an increasingly vaccines hesitancy that led to incorrect perceptions, falls in coverage rates and re-ignition of some epidemics; in the last phase (2015-18) there was a strong political committment that led to the approval of the National Plan (PNPV) 2017-19, to the extension of the mandatory vaccinations and to the sanctions against the anti-vaxxers doctors. This has led to a rapid rise in coverage, but also to a heated political and media debate on the ethical and social aspects linked to the admission bans and sancions of unvaccinated children in schools.

Introduction: In a previous paper on acceleration of failure time we highlighted the difficulties of the application to the case of mesothelioma of the methodology proposed by Berry. In this contribution we elaborate further on the concept of anticipation/acceleration, taking into account the content of the III Italian Consensus Document., Methods: We analyzed the ways in which the concept of anticipation/acceleration has been proposed and interpreted in the III Consensus Document., Results: We show that the concept of anticipation of the III Consensus Document has to do with incidence (frequency) in a population (and not with acceleration of the pathological process in an individual case), and is a measure which is alternative to other measures of frequency effects. In addition, we show that the same epidemiological result is compatible with causal models where no cases, all the cases, or some of the cases are anticipated., Discussion: This paper suggests that the concept of anticipation measurable through epidemiologic data has to do exclusively with the anticipation of a frequency indicator (more occurrencies and anticipated occurrencies are indistinguishable and alternative concepts) but not with the acceleration of the biological process in individual cases. In causal terms, without a biological support it is not possible to infer from the epidemiologic results if a causal model is in action with no, all, or some of cases anticipated.

This new paper on chemical risk from anaesthetic agents in operating theatres is the natural progression of that published in this journal in supplement 1-2013, as it constitutes a development and complement of the previous work and an applicative confirmation from the highest organ of administrative justice, the Consiglio di Stato, regarding, in particular, the obligation of adopting the technically most advanced "measures" to eliminate or, at least, minimise risk in the use of new generation and the most commonly-used anaesthetic agents (sevoflurane and desflurane). Therefore, in this paper, the authors commence by referring to the starting point, consisting in the conclusions of the previous study, which highlighted the extraordinary convergence of technical and scientific, legislative and case law data on the same result, constituted by the possibility, and consequent obligation, of implementing, also in operating theatres, the greatest technologically possible safety, starting with the choice of the most suitable equipment, methods and quality systems for avoiding the diffusion, dispersion and /or leakage of volatile hazardous agents that may contribute - together with those chemical reactions that are foreseeable and avoidable, given the characteristics of the materials, substances and relative "packaging" - to workplace pollution, which can, in any case, reach levels that are hazardous due to the concentration of anaesthetic gases. Subsequently, once the "scientific" fruit of the previous contributions has been discussed, the authors evaluate the impact of the result already achieved in practice with concrete cases and the judgement expressed with a series of judgements issued in rapid succession by the Consiglio di Stato, showing the application, not merely of the legislative "data" but also of the references and citations that these "data" contain regarding the "knowledge acquired regarding the relationship with technical progress". Lastly, the Authors provide, as a further, definitive conclusion, the singular unit of the guidelines provided by case law, the result of a univocal and continuous multitude of judgements issued at the highest degree of administrative justice, albeit for very diverse situations and circumstances, which provide, therefore, a direction and an operative guide for which they are called on to adopt roles and responsibilities for the choices of "products", "systems" and "methods" destined to affect - for the use of anaesthetic agents - the health and safety of healthcare staff and of patients themselves.

Background: In the last few years, the incidence of upper limbs tendon injuries has seen a dramatic increase among workers. Conservative treatment is the first choice to relieve symptoms, allowing a safe return to work. However, the scientific evidence of its  efficacy is widely debated., Objective and Methods: Research and literature review on the efficacy of conservative treatment of upper limbs tendon injuries in occupational settings., Results: A total of 271 references were found on Medline and Embase up to May 2015. 116 papers were excluded, 155 articles were included and the full text read., Conclusions: After a timely diagnosis, a prompt start of the rehabilitation programme and a limitation of complete rest are useful to relieve pain, increase functionality and reduce work absenteeism in the long term. Conservative treatment combinations, such as manual therapy, specific exercises focused on increasing flexibility and muscle strength and specific-gesture training, achieves more significant results than a single isolated treatments. Currently, there is no strong scientific evidence to support prolotherapy and Platelet-Rich Plasma (PRP). However, current promising results will encourage further studies. Awareness among both employers and employees about prevention and risk factors should be enhanced.

Introduction: Taking a publication by Berry in 2007 (3) as a cue, this paper presents in didactic form the topic of acceleration of events as a consequence of a harmful exposure and extends the proposed approach to the case of the asbestos-mesothelioma relationship., Methods: Berry's approach was applied to lung cancer and mesothelioma data., Results: The effects of the acceleration of events are presented as a function of age at onset in exposed subjects, relative risk, scale factor, in addition to age and geographical variability of the relationship between age and mesothelioma rates., Discussion: The discussion regards the general characteristics of the method of acceleration, its meaning and interpretation, and the difficulties associated with its application in the context of diseases with low occurrence; the conditions, applicability constraints, and specific results in the case of mesothelioma; the epidemiologic meaning of acceleration and the difficulties of its extension to individual subjects.

Through the study of 65 cases of probable pleural mesothelioma currently under discussion in 4 criminal trials in the Lombardy Region, who died between 2002 and 2015, this study aimed to provide economical information regarding the health expenditures sustained by the Regional Health Service (RHS) for providing hospitalization, outpatient services and drugs to such patients. Health information regarding the services provided for the cases under study were electronically retrieved from the RHS information system. For each pleural mesothelioma case the costs (on average) were about 67,000 euros, 37,000 of which were spent after the date of diagnosis. Drugs formed the largest part of health expenditure (about 37,000 euros per person). Per capita expenditures showed a peak near (before and after) the date of diagnosis, rising when approaching the date of death and with increasing age of the patient, and did not vary with survival time. This information, reported for the first time in detail in this paper, will be useful for out-of-court agreements and for setting up reimbursement schemes, and describe per capita expenditures which are higher than estimations proposed in recent criminal trials in Italy and to those reported in the international literature.

Background: Seaports are complex systems where workers can be exposed to a large variety of safety and health risks. Nevertheless, the literature available on this topic is scarce, if we exclude the specific area of the shipbuilding industry., Objectives and Methods: The aim of this paper is to provide a review of the scientific evidence concerning the occupational risks in seaports. Literature on this theme, obtained consulting the main databases (PubMed, Scholar and CCOHS) up to 2012, was reviewed., Results: Loading/unloading procedures, transport and storage of goods in docks are identified as the major causes of injuries (such as falls, crushing and entrapments) and accidents (release of chemicals, fires or explosions). Moreover, attention is drawn to the risks related to goods handled: in particular, authors described risks of asphyxia or intoxication in restricted and poorly ventilated areas such as containers or ship holds., Conclusions: The following main prevention measures were identified by all authors as those most effective: implementation of workers' training and information and intensification of controls on ships, particularly concerning loading/unloading procedures and documents accompanying the goods.

Introduction: In the period 1957/1995 more than 200,000 tons of asbestos arrived at the Port of Livorno. This paper attempts to reconstruct the levels of exposure of the dockers during this period, given the absence of any environmental investigations., Methods: The estimates were calculated using the quantities unloaded annually, the number of dockers, the duration and frequency of the unloading operations, the type of packaging and the background pollution. The Time Weighted Average annual exposure allows calculation of a range of cumulative exposure for each worker with a known period of employment. The working methods were reconstructed interviewing employees and the levels of pollution used in the calculations were partly obtained from published data., Results: Significant doses were accumulated by dockers who worked at the port in the 60's and 70's. Non-coincidence of the period with the highest imports with that of highest exposure is worth highlighting. Since 1980 the annual average exposure levels were well below the level required for granting insurance compensation benefits. This suggests caution in the use of lists of beneficiaries for epidemiological purposes since the statistical power would be very low., Conclusions: The strongest point of the research is the estimated annual TWA exposure that, regardless of the accuracy of the data, does however allow an epidemiological analysis of the cohort for subgroups with different exposure. The twenty-three cases of mesothelioma already recorded in this cohort were first employed before 1966. This method can be used to estimate exposure in other ports, where basic information is available.

Introduction: Periodic spirometric assessment is critical in the health surveillance of workers who are exposed to respiratory pollutants and plays a key role in the prevention of occupational lung diseases., Objectives: The aim of this review is to provide updates on the proper spirometry examination procedure and the criteria for data interpretation, in order to correctly diagnose obstructive impairment and longitudinal decline of pulmonary function., Methods: A review of the most recent scientific literature was carried out focusing on those papers dealing with spirometric techniques, choice of reference values, and criteria for data interpretation., Results: Over the years, the use of different diagnostic algorithms and reference values have led to poor clarity among users as well as diagnostic misclassifications., Conclusions: For spirometric data reliability it is mandatory to perform appropriate pulmonary function tests, make a correct selection of reference values and use updated interpretive criteria.

Sleep disorders and related diseases are becoming increasingly relevant for the health and wellbeing of the general and working populations. Sleep disorders affect all aspects of health, showing a bi-directionality with health conditions and comorbidity with several diseases. Consequently, sleep disorders may have severe negative consequences both for the individual and the enterprise, as well as for society on the whole, in terms of health, productivity and social costs. When considering the disturbances of the sleep/wake cycle, it is important to distinguish between those connected with endogenous biological factors from those related to socio-environmental conditions, including work, and those associated with mental and physical diseases, that are often associated and interact with each other. Many sleep disorders are still underestimated and under-valued in clinical practice and, to a much greater extent, in workers' health surveillance. The present paper is aimed at drawing the attention of the occupational health physician to some key issues, particularly regarding excessive daytime sleepiness, obstructive sleep apnea syndrome and shift and night work, as well as their implications in terms of health and occupational consequences. Information on the main aspects of clinical diagnosis and health surveillance, as well as risk management and prevention at the workplace, are provided.

Protection of working mothers: operational guide document. The aim of this operational guide document is to protect the health of working mothers and their babies during pregnancy, puerperium and breastfeeding. The project was developed by a technical working group which included professionals in the pertinent fields from the Workplace Prevention and Safety Services of the local Vasta-2 Area of the Marche Regional Health Service:physicians, health assistants, and nurses. It is considered to be a useful tool for risk assessment at the workplace aimed at professionals who are involved, with various duties and responsibilities, in the health care of the working mother. This paper consists of two functionally related sections, "Table of risks" and "Technical specifications". In the "Table of Risks" section, the occupational hazards for women during pregnancy or postpartum were analyzed with the highest possible degree of care. To this end the technical group provided, for each occupational hazard, its own operational suggestions, in relation to legislation, current scientific knowledge and Guidelines of other Italian Regions. The Marche Regional Section of the Italian Society of Occupational Health and Industrial Hygiene (SIMLII) participated in the final draft of the entire document. The second section, "Technical Specifications", illustrates the main tasks and any risks involved in the 34 manufacturing sectors most prevalent in this area. This operational guide document is intended to be the beginning of a common strategy in public health to achieve a wider field of action in promotion and information aimed at protecting the reproductive health of working mothers.

The paper aims at analyzing the development of Ramazzini's train of thought in Diatriba within the cultural, economic and social context of the Duchy of Modena in the second half of the seventeenth century. The period was characterized by a deep recession affecting every aspect of life in the territory: culture was mostly at the service of the court's image, the economy, mainly based on agriculture, was in crisis and many crafts depended on the demands of the nobility. The culture of the Este court had, however, little influence on Ramazzini's ideas, whereas social and economic aspects were the stimulus to his experimentalism via observation. In this context, Ramazzini was an illuminated nonconformist, who analysed the vulnerability of the population with an anthropological approach that embraced individuals, environment, social and economic status.

Introduction: This paper presents an innovative device for measuring artificial optic radiations (AOR). AOR are required to be measured in accordance with both Italian and European regulations. The traditional measurement methods do not provide a quantitative measurement of the energy affecting the retina and in particular the fovea. Hence, they are not suitable to assess the real risk to the eye. Furthermore traditional methods are not even able to measure the exposure time (in relation to the position of the head with respect to the source)., Materials and Methods: The device permits the acquisition of essential information about AOR source direction and position so as to obtain an evaluation of the relative impact on worker's everyday activity. The device acts as both a wearable personal dosimeter and an instantaneous radiance detector. The main components are: a colour light sensor mounted at the centre of a pair of safety goggles (placed on the same line of the worker's sight) used to determine AOR intensity; an inertial/position sensor used for measuring head position/movement, and lastly a video camera to localize emission sources and generate the background in augmented reality visualization. The device is connected by means of a thin, flexible cable to a datalogger and/or netbook? for recording data., Results: the experiments were carried out in order to evaluate AOR sources during work activity; the results obtained and duly processed are presented in the paper., Conclusion: the aims are to achieve work place safety zoning so as to distinguish unsafe from safe areas, and not only specific dangerous areas, via analysis and integration of the overlapping pieces of information obtained with the proposed device.

Background: The paper involves exposure to noise of the State Police officers connected with the use of firearms. The noise generated by these weapons is of short duration and high intensity., Methods: The research was carried out during the sessions of firearm training of State Police officers to assess exposure to noise., Results: The values of the various investigations, both audiometric and phonometric, carried out made it possible to demonstrate a significant exposure and a temporary increase in the threshold, above the frequency of 6000 Hz., Conclusion: Even taking account of the abatement from use of headphones, an exposure was demonstrated that was above the statutory limits, as was confirmed by the temporary hearing threshold shift.

Background: The wide-spread presence of silica in nature and the variety of materials containing it cause crystalline silica exposure of workers in various industrial activities. Moreover crystalline silica is classified as carcinogenic to humans (Group 1) by IARC, in relation to its possible lung carcinogenicity., Objectives and Methods: The purpose of this paper was to assess respirable particles and crystalline silica exposure of workers in a number of some building sites located in the area of a Local Health Unit in the Umbria region. The study examined differences in four types of building sites: "construction of new buildings", "renovation of old buildings", "road construction" and "transport of aggregates by loaders in crushing plants". According to the strategy suggested by European Standard EN 689/1997, personal air samples were collected during work in jobs characterized by elevated amounts of widespread dust., Results and Conclusions: Analysis of data showed that levels of exposure to crystalline silica were lower than the limits recommended by ACGIH/2010 in almost all samples except one. The percentages of crystalline silica in respirable particles were in the range 0.4%-21%. Crystalline silica exposure levels were different in the various jobs and comparison between the mean values of exposure levels in each one showed statistically significant differences (p < 0.01, variance analysis). Work with the highest exposure to crystalline silica were: brick cutting, plaster brushing, "Serena stone" cutting, as they use tools operating at high speed and often in dry conditions (grinder, power drill, pneumatic hammer), producing low-size airborne particles (respirable fraction). During work in these jobs levels of worker exposure to crystalline silica showed high variability, so that it was impossible to establish if in the medium-long term, they were lower than the Threshold Limit Values with a set probabilistic certainty (OTL test, confidence level 95%). In the remaining jobs the assessment of occupational exposures to crystalline silica showed a low probability of exceeding the Threshold Limit Values.

Introduction: Obesity is often particularly burdensome for subjects at work and leads to hypertension and diabetes preceded by a low grade of inflammation. Measures to promote health at the workplace can be achieved through periodic health surveillance. Simple parameters such as height, weight, body mass index (BMI), waist circumference (CV), blood pressure (BP), as well as taking into account the type of work and tasks, shift work and smoking, are in fact sufficient to identify the most significant features of the working population so as to adequately design the type of intervention required. The paper describes how a health promotion programme aimed at preventing overweight and obesity was implemented based on analysis of the health surveillance data routinely collected by the occupational physician in an engineering plant in northern Italy., Subjects and Methods: Data on weight, height and BMI were collected for 301 workers with different jobs and shifts in an engineering plant; 32 of these workers, (mean age 44+/-8.4) agreed to undergo a diagnosis and treatment programme at the Obesity and Work Centre of the Clinica del Lavoro in Milan., Interventions and Results: A higher incidence of overweight and obesity was found compared to the national average for similar age classes, therefore meetings were organized at the plant on awareness and information on correct lifestyle and diet targeted for shift workers. The workers who had followed the diagnosis and treatment programme had a mean BMI of 32.6 (SD 2.7) and, considering the parameters investigated, the presence of metabolic syndrome was found in a greater proportion of subjects (62.5%) than the average in our practice (46%) and particularly in workers with three day shifts. CONCLUSIONSThe intervention programme began with assessment of the information obtained in the course of routine periodic health surveillance according to the occupational hazards under study. On the basis of this information it was possible to implement the first awareness campaigns. On completion of the multidisciplinary intervention, which was conducted in collaboration with the occupational physician, two major initiatives were taken: one in the canteen with the aim of improving the nutritional content and type of meals offered to suit the dietary needs of overweight or obese workers, and the other consisted of an agreement with local gyms so as to motivate workers to exercise more. A prerequisitefor this type of initiative is the willingness and understanding of the management to recognize the health of the worker as a priority value.

Introduction: Recently, the National University Council (CUN) recognized the importance of bibliometric indicators in assessing scientific output and the Ministry of Education, University and Research established that the selection committees' decision must be guided by internationally recognized metrics including the impact factor (IF)., Aim: To analyse methods and tools of metrics to assess scientific performance in Occupational Medicine by examining some critical aspects for entry-level positions and academic promotion in the Universities., Methods: By means of different databases (Web of Knowledge, Scopus, SCImago), the h-index was studied to assess the scientific output in the field of Occupational Medicine. The h-index was used as an index of both output and quality of overall output of researchers, disciplines, journals, and countries., Results: Italian scientific output in the Public, Environmental & Occupational Health subject category (h-index = 62) was lower than almost the total of other medical disciplines and, at an international level, is ranked at 12th place (other disciplines ranked 3rd to 9th). Output was 32% compared to that of the USA (other disciplines ranged from 42% and 61%). However, it should be noted that most scientific papers of Occupational Medicine researchers are published mainly in journals of different disciplines (with a higher IF) rather than in journals of Public, Environmental & Occupational Health (with a lower IF)., Conclusion: Assuming that selection committees' decisions will be guided by metrics and will respect the minimum standard proposed by CUN, Occupational Medicine researchers aiming at academic promotion will have good reason to ask themselves not only which journals are most useful but also which journals have the greatest impact. This fact could have profound implications for the future of the discipline.

Background: Hairdressers are exposed to irritants and allergenic compounds that may cause contact dermatitis, rhinitis and asthma., Objectives: In this paper we describe the case of a female, age 33 years, who developed contact dermatitis after 10 years of exposure to ammonium persulfate., Methods: After 7 months of progressively extensive and persistent skin lesions, respiratory symptoms appeared that were related to the occupational exposure (on-off test). SIDAPA and specific occupational patch test for hairdressers and occupational challenge with ammonium persulfate were performed. Clinical parameters of inflammation, ECP (eosinophil cationic protein) and exhaled nitric oxide (FeNO) were detected before and after the specific bronchial challenge., Results: The patch test was positive to ammonium persulfate (++), and bronchial challenge for ammonium persulfate showed a significant late response (FEV1 decrease--33%). Both FeNO and ECP showed a significant increase after 24 hours. Dermatitis, urticaria and angioedema occurred on the uncovered skin due to airborne contact. Topic steroids and anti-histaminic drugs resolved the clinical symptoms., Conclusions: Bronchial challenge is, in fact, considered to be the gold standard for the diagnosis of occupational asthma, although new inflammatory parameters can contribute to the diagnosis and can be useful for monitoring after a specific inhalation test with occupational agents. The described case summarizes the evolution from contact dermatitis to inhalation allergy, suggesting the occurrence of an allergic "march" for occupational allergy.

Introduction: The recently introduced Italian law on the protection of workers' health states that the occupational health physician (competent physician) is required to act according to the Code of Ethics of the International Commission on Occupational Health (ICOH)., Aim: This paper aims at examining the articles of legislative decree 81/2008 dealing with informed consent and confidentiality compared with the corresponding points of the ICOH Ethics Code., Results: Analysis of the relationship between articles 25 and 39 (informed consent) and 18, 20 and 39 (confidentiality) of the decree shows that there are some points of disagreement between the legal requirements and the Code of Ethics, in particular concerning prescribed health surveillance, consent based on appropriate information (points 8, 10 and 12 of the Code) and some aspects of confidentiality (points 10, 20, 21, 22 and 23 of the Code)., Conclusion: Although the competent physician is required to act according to the law, the decisional process could lead to a violation of workers' autonomy.

Background and Objectives: The aim of this paper was to analyze the results of the first year of a study on truck drivers'safety and health. The project, which started in 2008, is promoted by EBITRAL (trade unions and business joint association) and carried out by Occupational Medicine Department of Ospedali Riuniti di Bergamo. The final objective is to improve health conditions of truck drivers, by defining appropriate health surveillance protocols in order to asses fitness for work and by promoting the application of healthy life-styles among the workers. The first step required the collection of bio-statistical data, in order to analyze prevalence and incidence of work-related diseases in the future., Methods: In the first year, 226 truck drivers (mean age 42. 7years, SD 9.5; mean working seniority 26.8 years, SD 10.6) were evaluated via application of an experimental survey protocol: medical examination, questionnaires for the main risks (low back pain, alcohol and drug consumption, sleepiness, etc), instrumental and laboratory tests (ECG, eye test, audiometric test, blood test, urinary drugs test)., Results: We observed 11 work-related diseases: 8 cases of hearing loss caused by chronic exposure to noise and 3 cases of low back disk disease. In 22 cases (9.7%) it was necessary to apply some restrictions to the truck drivers' fitness for work, first of all because of cardiovascular diseases and musculoskeletal disorders. We also found 3 subjects with positive urinary drug test: 1 for cocaine, 1 for methadone, 1 for cannabis. With the application of the experimental survey protocol many unknown diseases were also diagnosed (cardiovascular diseases, arterial hypertension, diabetes mellitus, etc), which could have played a role in increasing accident risk or, without an appropriate therapy, in reducing workers' future fitness for work., Discussion: This first year of experience made it possible to collect bio-statistical data on truck drivers' work-related diseases. As regards fitness for work, we observed that drug consumption is not the most relevant health problem to consider in order to improve truck drivers' safety and citizens' safety on the road.

Objectives: This paper examines the history of an occupational disease which has now disappeared: acroosteolysis of manual tank cleaners in the production of polyvinyl chloride (PVC), which is a rare disease characterized by destructive alterations of the distal phalanges of the hands., Methods: All the available literature on this disease was examined. The history of acroosteolysis was studied within the general framework of the history of the discovery of adverse health effects of exposure to vinyl chloride, and this history was studied up to the end of the 1960's., Results: The disease was observed for the first time in mid-1963 in Belgium (Jemeppe) in a chemical plant operated by Solvay, and affected two workers whose job was the manual cleaning of vessels used for the polymerization of vinyl chloride; similar cases occurred in almost all PVC production plants all over the world, but not in the plants where the main activity was the production of vinyl chloride monomer (VCM). Little more than one hundred cases are described in the scientific literature, and this number increases by a few dozen if we consider known but unpublished cases. These figures confirm the rarity of the disease, which peaked at the end of the 1960's and disappeared during the 1970's, probably due to the complete elimination of manual reactor cleaning. Observation of the disease lasted no more than fifteen years and the disease was not replicated in experimental conditions on animals., Discussion: The disease was clinically characterized, had a short latency (from several months to several years), was rare and unequivocally linked to the manual cleaning of PVC polymerization tanks. However many questions still remain open: the period when the disease first appeared (many years after the start of PVC production in the world), the etiology of the disease (the most accredited hypothesis considers three concomitant factors: a chemical factor--one of the many substances used during polymerization, and particularly vinyl chloride monomer, a physical factor--microtraumas of the fingers during manual cleaning, individual susceptibility), the pathogenetic mechanism (in particular: the role of skin, respiratory, or digestive system, as entrance door), a method (or test) to screen subjects potentially predisposed to the disease. In our view acroosteolysis of manual tank cleaners in PVC production is an occupational disease which is distinct from "vinyl chloride disease" as identified by Viola (1974).

Background: A Local Health Unit in the Umbria Region of Italy carried out environmental investigations to estimate exposure to respirable particles among workers in a number of companies belonging to the ceramics and brick industries manufacturing categories., Objectives: The purpose of this paper was to estimate the degree of agreement of two sampling methods, Dorr-Oliver and GS3 selectors. Both selectors are deemed to comply with the respirable particles sampling reported in European Standard EN 481/1993., Methods: For each worker, respirable particles and the quartz contained therein were collected using Dorr-Oliver and GS3 selectors simultaneously, so that quartz exposure was also measured., Conclusions: The comparison between the two series of airborne concentrations of respirable particles (collected with the two selectors), showed statistically significant differences (p < 0.05 with Student's t test). Moreover, Pearson's coefficient showed a low correlation between the two series of data. A similar conclusion was obtained analysing quartz airborne concentrations. The results seem to confirm that the two sampling methods possess a different capture power ofparticles as a function of their size.

The Italian Constitution (1948) defines 'work' as the founding value of the Italian Republic. This choice was not motivated by mere economic reasons, but rather stemmed from the recognition that work is the most appropriate tool for the expression of the human personality in society, that it is an asset and a right that will increase the dignity of every person, and which corresponds to a fundamental human desire to fulfil oneself in relationship with other persons and the entire world This view of work, including its technical and manual aspects, was unknown to the ancient mentality and became familiar to us through the monastic orders of the early middle ages, which began to conceive and practise human work as a means of participating in the work of creation and transmitted this value over the centuries. As we experience today, if occupation is lacking, a basic condition for the development of the person and for his/her contribution to the growth of society is lost. Given the meaning of work in human experience, it is not surprising that unemployment represents not only a worrisome economic indicator, but also the cause of ill health. At the end of 2009 unemployment in the European Union reached 10%, similar to the rate in the US; in Italy it was estimated at 8.5% in December 2009 and is expected to reach 10% in 2010. In Lombardy, although employment had been constantly increasing between 1995 and 2008, and the current unemployment rate is as low as 4.9%, 100,000 jobs were lost in 2009. Several scientific papers have demonstrated the association between lack of occupation and lack of physical and mental health. In the present period of crisis, increases of 30% in cases of anxiety syndrome and of 15% in cases of depression have been reported. An increase in suicides among unemployed persons has been documented in several countries even if there are still problems of interpretation of the causal chain of events. Mortality among the unemployed increased, not only that due to violent causes, but also mortality for all causes, cardiovascular diseases and cancer. A survey in the Turin area, Northern Italy, showed a twofold increase in mortality among unemployed men. Women were affected both by husbands' unemployment and by their own unemployment because of the previous increasing rate of female occupation. The worse the occupational condition (from "seeking work" to "temporary employment" down to "unemployed and no longer seeking work") the higher the mortality: in the latter category, where the most evident problem is marginalization and social exclusion, the increase in mortality was fourfold. The role of occupational health physicians is to recognize the possible negative effects of working conditions and at the same time promote a positive approach to work, even in difficult conditions. This makes prevention more effective and promotes health. To be aware of the meaning of work makes work itself more liveable and more productive. This is how health promotion contributes to the wellbeing of the individual and, at the same time, to the development of the economy and society at large.

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.

Background: The new law n.81/2008 recognises microclimate as one of physical agents for which risk assessment becomes obligatory. To achieve this it is necessary to evaluate suitable indices, based on heat balance equation, which depend on six parameters: the first four are related to thermal environment and the last two are related to the worker (metabolic rate and thermal insulation). The first four parameters are directly measurable in situ by using a multiple data acquisition unit provided with suitable sensors. Parameters related to the worker are not directly measurable. This aspect represents one of the problems which can lead to an inaccurate risk assessment., Objectives: Aim of the paper was to identify a method which leads to a correct evaluation of the metabolic rate related to the worker under study., Methods: It was decided to follow the procedures described by the standard UNI EN ISO 8996:2005 which presents four different levels to evaluate metabolic rate, each one with an increasing degree of accuracy. Seven workers were selected: three performed light tasks and the other four did heavy work., Results: The study showed that the results appear to be in acceptable agreement in the case of light work while there were detectable differences in value for heavy tasks., Conclusions: The Authors believe it is necessary to stress the importance of a suitable estimation of the metabolic rate in order to carry out a correct risk assessment which quantifies the risk exactly.

Background: Training is a key tool to improve prevention and safety management at the workplace. Few studies have aimed at assessing quality of training and its outcomes., Objectives and Methods: This paper describes the rationale, design, content, and evaluation of an ongoing randomized controlled trial aimed at assessing the effectiveness of a training programme designed to reduce the risk of occupational injuries among employees of the wood processing industry., Discussion and Conclusions: Well designed, targeted training programmes could represent a feasible means of reducing work injuries by improving employers' behaviour and attitudes towards safety; nevertheless, these kinds of interventions have a considerable impact both in terms of human resources and in terms of cost. For these reasons, assessment of effectiveness and knowledge-sharing should be considered as essential phases of injury prevention programmes.

Background: In the dynamic context of occupational medicine an increasing number of occupational health problems requires a high-quality standard practice supported by decisions consistent both with ethics and legislation., Objectives: This paper examines the relationship between legal requirements, ethical values and scientific evidence issues in occupational health practice., Results: i) Legal requirements. Italian law states that practice must be evidence-based and comply with the code of ethics for occupational health professionals of the ICOH. ii) Ethical values. The code itself emphasizes that practice should be relevant, knowledge-based, sound and appropriate to occupational risks. Furthermore, the objectives and methods of health surveillance and biological monitoring must be clearly defined and indicator must be chosen according to their relevance and predictive value. Any dilemma arising from the practice should be dealt with according to the ethical principles of health benefit, independence and justice. iii) Scientific evidence. Both the law and the code of ethics require that practice be based on available evidence., Conclusions: Decisions made on the basis of a comprehensive process founded on scientific evidence should result in effective and high-quality outcomes that respect both the law and the rights of individuals and society.

Introduction: A new Italian law aiming at improving and supporting research productivity establishes that evaluation of academic products is a requisite for accessing research funds,for acting as examiner for recruitments and for individual financial benefits., Aim: To analyse the scientific products of full professors of Occupational Medicine in Italian Universities in order to provide a framework for discussing a standard of productivity with objective metric parameters., Population and Methods: Research products of the 40 full professors of Occupational Medicine indexed in the National Library of Medicine PubMed database were identified. By means of l0 different indicators, including the total number of papers, the papers published in journals included in the Journal Citation Reports (JCR), total Impact Factor (IF), the individual productivity of the last 5 years was measured., Results: In the last 5 years 503 scientific products were published, 231 of which in JCR-indexed journals, with a mean individual IF = 16.741. The total number of papers indexed in PubMed, the number of papers included in JCR-indexed journals and the number of papers included in JCR-indexed journal of Public, Environmental & Occupational Health were associated with the overall number of authors (p < 0.001). This observation accounts for the relevance of the research group as a resource predicting qualitative and quantitative outputs. The total number of papers is inversely associated with age (p < 0.03)., Conclusion: High productivity authors have an elevated number of products both in JCR-indexed journals (targeted to a small number of specialists in the field) and in PubMed-indexed journal (addressed to the broad audience of occupational health professionals). The productivity standard of academics of Occupational Medicine should take into account the overall research products within the Public Health field. In addition, the standard should be shared with that of academics of Hygiene and of Forensic medicine in order to address the recruitment policy in the Public Health field

Introduction: Ethical behaviour consists ofindividual choices inspired by knowledge and professional experience derived from the universally acknowledged ethical principles of beneficience/nonmaleficience, autonomy and justice. However, in spite of the unanimous consent on their universal importance, such principles do not usually have the strength of a law., Aim: The recently introduced Italian law on the protection of workers' health represents a novelty because it gives the Ethics Code of the International Commission on Occupational Health legal strength. This paper aims at examining article 25 of legislative decree 81/2008 by comparing the points of the Ethics Code and the Deontology Code of the Italian medical profession., Results: The relationships between the 12 points of paragraph 1 of article 25, the 26 points ofthe Code ofEthics and the 75 articles of the Deontology Code are described with regard to the occupational health physician's duties (i) of collaboration with other occupational health professionals, (ii) of organization and execution of health surveillance, (iii) of recording, securing, transmitting of medical files on workers' health and (iv) of employee and employer information on the importance and meaning of health surveillance.

Background: Statistics on occupational injuries published by INVAIL (National Insurance Institute for Occupational Accidents and Diseases) are not useful to plan appropriate preventive actions in local manufacturing sectors., Methods: The injury surveillance system, developed by Viareggio Local Health Unit, collects data on all occupational injuries that occurred in the Versilia area, by enterprise, worksite and manufacturing sector. Enterprises operating in particular sectors (e.g. shipyards, construction) are classified differently than in the national injury surveillance system. After trend analysis and interpretation of injury data, the main results are available both in electronic and paper format., Results and Conclusions: Surveillance data are used by the Local Health Unit to promote and formulate specific preventive actions, such as: research and development of safer tools, promotion and control of safer use of specific tools, promotion and enforcement of good practices, control programmes in high risk manufacturing sectors and jobs.

Background: Workplace accident investigations place a heavy, time-consuming load on Italian Occupational Health and Safety Units of the National Health Service. Such investigations entail preventative measures, legal proceedings and likely penalties for enterprises. Staff shortages induce Units to reduce investigations in order to implement other preventive goals., Methods and Results: This paper reports the actions that the Veneto Region performed to achieve a uni form treatment by all Units (inter-unit comparison and a new set of guidelines). We also describe a "short questionnaire-based investigation" aimed at encouraging enterprises to make preventive efforts, thereby enabling our staff to manage more events., Conclusions: We suggest and discuss effectiveness indicators for both practices.

Background: The industrial production of upholstered furniture exposes workers to significant risk of occupational disorders due to ergonomics-related problems, such as repetitive strain and movements of the upper limb, manual load lifting, prolonged static postures., Objective: This paper describes the main measures taken by the biggest company in the "sofa sector" in southern Italy in order to solve such problems in the years 1996-2004., Methods: the classic instruments of ergonomics were used such as risk assessment, medical surveillance, training and information programmes, technological reorganization of the manufacturing process and of single working tasks., Results: The accident rate (number of accidents per million working hours) which showed an increasing trend in the previous years, rose from a value of 31 in 1996 to 51 in the years 1999-2000 (with a percentage of accidents related to load lifting in the range 25-35%). At the same time the incidence rate of work-related upper limb musculoskeletal disorders (UL-WMSDs) in the population of workers (which had increased in the meantime from 2500 to 3500 employees) reached nearly 5% in 2001, with peaks of 8-9% in the work tasks with higher exposure. Accident rates progressively fell in the following three years until a value of 20 was reached in 2004 and 2005, while the mean incidence rate of WMSDs reached a value of nearly 1%. The data need to be compared with the trends in the other companies of the sector in the same period, with an average incidence rate of WMSDs around 2% and a generally increasing trend., Conclusions: Ergonomic interventions not only concur in the management and control of negative events for workers health but also in achieving advantages in terms of lower costs and greater productivity.

Background: Latex is a relevant occupational and environmental allergen, strongly related to the extensive use of natural rubber products., Objectives: Threshold Limit Values have to be identified, as well as biocompatible materials in order to avoid sensitization or appearance of allergic symptoms., Methods: In this paper we consider the main methods, which have been used to detecting latex allergens for environmental monitoring of airborne and latex products., Results: We report our experience in such afield, and our approach to the latex problem, suggesting that quantification of allergens, which is currently applicable according to well standardized methods, should be adopted by manufacturers, agency and consumer organization.

Background: Latex allergy is an important medical issue, particularly for some occupationally exposed categories (healthcare personnel). The increase in the number of cases reported, occurred as a consequence of the diffusion of latex use, prompted several scientific and institutional organisms, both on a local and international level, to create guidelines for risk management in healthcare environment., Objectives: To review and compare, more than ten years after the first official guidelines, the directives on latex allergy currently used in different countries and in the Italian regions., Methods: We used the references contained in the relevant literature and in the regulations concerning prevention of latex allergy., Results: Epidemiologic data, together with the recent decrease of the number of papers on latex allergy, suggest a relevant, but still unsatisfactory reduction of the problem., Conclusions: In the light of a recent study performed by National Health Service (NHS) in UK, we point out the need for a critical evaluation of the real application of the existing guidelines, which are often formally present but left unattended in the daily hospital practice.

Background: Road traffic injuries constitute one of the main causes of death and disability in Italy and in the European Union. Occupational medicine should pay special attention to the field of road transport because every year a large number of road accidents occur with fatal outcomes. Via health surveillance the occupational physician can play an important role in the prevention of such events., Objectives: The aim of the article is to summarize the results of the most recent studies on the main risk factors for road transport safety and discuss possible strategies of health surveillance, according to the recent indications of the European Agency for Safety and Health at Work, Bilbao., Methods: A review of the literature was made., Results and Conclusions: The scientific literature provides a large amount of interesting information on the most important risk factors for road accidents, such as drinking and drug abuse, sleepiness and other medical conditions, or excessive speed. The presence of numerous and varied hazards for road transport safety requires, as suggested by the Bilbao Agency, the adoption of occupational health measures, including risk assessment, health education, technical and environmental prevention, health surveillance and clinical interventions (diagnosis and rehabilitation of occupational accidents). Moreover, the paper stresses the need to strengthen collaboration between occupational health physicians and other medical specialists.

Background: Italian law requires that occupational physicians for workers exposed to ionizing radiations consider carefully increased sensitivity to cancer in order to define fitness for work. Cancer risk from radiation is proportional to radiation dose, consistent with the so-called linear no-threshold hypothesis., Objectives: The aim of this paper was to estimate the annual dose limit for ionizing radiation exposure in workers hypersensitive to cancer so that the occupational risk of cancer is the same as that of reference workers., Methods: Relative risks of developing cancer in several situations are multiplied by radiation-induced cancer nominal risk coefficients (ICRP Recommendations) to give cancer sensitivity predictions. It is then possible to estimate the annual dose limit reduction., Results: Examples of annual dose limit (personalized dose limit) were estimated in several situations in which individuals are prone to cancer or are cancer survivors., Conclusions: personalized dose limits makes it possible to define fitness for work and avoid exclusion of these individuals from work.

Background: The biotechnology industry has expanded greatly in the last 20-30 years and has led to a number of applications in different sectors of work, i.e., medical and pharmaceutical, agricultural, chemical, energetic and others. Nowadays hundreds of thousands of workers worldwide are employed in biotechnology plants. Health and safety issues related to such working activities are considered as relevant to workers as well as to the general public. In particular, when compared to traditional biotechnology, modern methods of processing microrganisms have given rise to public concern that they might generate hazards to human beings and to the environment., Objectives and Methods: After summarizing the most important products and fields of application, the paper sets out to detail potential adverse effects for the health of biotechnology workers; in addition, an analysis of the literature highlights the various concepts of primary and secondary prevention., Results and Conclusion: Along with occupational risk factors common to other working activities (i.e. the well-known physical and chemical hazards), the peculiarity of handling microrganisms and/or different biologic systems may induce infections, immunological alterations or non-infective and non-immunologic toxic reactions in the workers involved The need is emphasized for an accurate risk assessment, careful control by means of the current monitoring strategies and implementation of the confinement measures, taking into account the criteria set by Italian legislation for occupational biological risk. Lastly, attention is focussed on examinations for the medical surveillance of workers at risk.

Background: Mount Reventino, a massif located in the Calabria Region of Italy, has several ophiolite outcrops of greenstone. These deposits are an important economical resource in the surrounding area. Some rock layers contain tremolite, a type of asbestos fibre., Objectives: The aim of this paper was to analyze the chemical and physical structure of the outcrops of Mount Reventino, and to assess and reduce the risk to workers associated with exposure to airborne fibres., Methods: Personal and environmental samples were collected and analysed by Scanning Electron Microscopy equipped with energy-dispersive X-ray analysis., Results: The analysis of samples showed a difference in mineralogical features not only between the quarries under study, but also between the two opposite sides of the mountain. Exploitation of the quarries produces a fibre dispersion that is higher than the natural emission. Occupational exposure to asbestos fibres during greenstone transformation was confirmed by by the results of analysis of the collected samples., Conclusions: This study made it possible to identify working activities with highest exposure to asbestos and establish the correct procedures to abate fibre dispersion, in order to reduce the correlated risk. Environmental samples collected in the urban area surrounding the quarries showed that the asbestos fibre concentrations were very low, however, further studies are needed in order to confirm these findings.

Background: Knowledge of the results of studies on effectiveness of preventive interventions is a fundamental requirement in occupational medicine., Objectives: The aim of this review was to identify Italian scientific production regarding this issue in the proceedings of the Italian Society of Occupational Medicine and Industrial Hygiene congresses over the last fifteen years., Methods: An initial selection of the communications on intervention effectiveness studies was performed on the basis of titles, aims, tables and figures of each single presentation. A further selection was made via full reading of the previously selected communications. The selected articles were classified by type of strategy discussed, production sector, study design and several other criteria., Results: 108 studies were selected out of the 3215 papers (3.4%) published in the congress proceedings examined (1989-2003). More than half of these discussed technical control strategies. In the vast majority of cases, the study design was a pre- and post-evaluation of effectiveness, and the 6 (non-randomised) trials concerned vaccination programmes. Almost a quarter of the studies on accident prevention regarded the effectiveness of training programmes. Only 5 studies could be detected in Medline as articles later published in international journals., Conclusions: On the basis of the Italian Society of Occupational Medicine congress proceedings over the last 15 years, the percentage of communications concerning effectiveness of preventive interventions in occupational health was 3.4%. Intervention effectiveness papers published in congress proceedings seem to reveal a quite unexpected production of effectiveness evaluation studies. Nonetheless, recommendations need to be made to improve study design and to promote effective prevention and control strategies.

Background: Changes in workplaces and work organizations represent a challenge for governments, social partners and occupational health professionals whose aim is to appropriately satisfy emerging requirements and needs. An increasing number of occupational health problems requires a high-quality standard practice supported by ethically consistent decisions. The ethical aspect of the practice is strictly linked to that of appropriateness, involving requirements of effectiveness, efficiency and respect of ethical principles of the individual, community and society., Objectives and Methods: The paper aims at focusing the ethical components of the quality of an occupational health program by taking a systematic approach to the ethical problems. The approach consists of a 2-step process. The first step consists of appraising the basic ethical principles of the dilemma ("to do good": to prevent or to remove evil and to do or to promote good; "not to do evil", implying not to inflict evil; to do no harm; autonomy implying respect of other's freedom and self-determination; justice implying equity, solidarity and non discrimination). The second step consists of detecting the stakeholders involved or interested in the decision. The alternatives are discussed according to the assessment of ethical costs (violating the consistentprinciple) and ethical benefits (fulfilment of the consistent principle) for the stakeholders., Results: Systematic analysis of the ethical components of the dilemma according to ethical principles and their discussion within a framework involving different stakeholders makes it possible to recognise ethical costs and ethical benefits of the alternative decisions. The decisions may have different costs and benefits, which should be considered and weighed to take a proper decision. Although there is no certainty about the suitability of the decision, the assessment of the ethical components may be a valuable tool in decision-making based on the awareness that any ethical aspect has been considered., Conclusion: Occupational health professionals are requested to act with respect for general ethical principles and preferences of the individual, groups and setting. A high-quality practice will take into account the ethical content and the ethical conduct and any intervention will include analysis of ethical principles to compare alternative decisions and their consequences for the different stakeholders. This approach guarantees a practice based on, in addition to scientific evidence, the assessment of ethical costs and ethical benefits to favour decisions preventing conflicts.

Background: In Italy, almost one thousand deaths due to occupational accidents are usually registered by INAIL each year. Case registration by INAIL has merely administrative purposes and therefore it is necessary to use other sources for case ascertainment in order to better estimate the real number of deaths related to occupational accidents, as shown also by previous papers., Objectives: Evaluation of the contribution of another data source, namely the Tuscany Regional Mortality Registry, to obtain the correct figure for occupational accident deaths through the use of a place-of-occurrence notation on the death certificate., Methods: Cases that occurred in residents in Tuscany in 2000-2001 were considered. They were identified from : a) the Tuscany Regional Mortality Registry (RMR) using the E code of the ICD LX code of death, the year and place of occurrence; b) the INAIL archive using the year of event, the type of definition and management., Results: The INAIL source was without doubt the most informative but was only 51% complete, whereas the RMR source, although less informative, was more complete (82.4%) and allowed identification of cases not registered by INAIL, that had occurred for instance in the Armed Forces and in the National Railway Company. However, the vast majority of RMR extra-cases occurred in subjects aged 65+, in agriculture and in the building industry., Conclusion: It is currently possible to plan a systematic linkage of the two sources due to the new possibilities that are available: the place-of-occurrence in the death certificate and the availability of individual data in the INAIL source.

Background: Mesothelioma has until now been considered to be a manifestation, occurring in the pleura and/or peritoneum, of the carcinogenic action of the total burden of inhaled asbestos fibres, in the same way as lung cancer. Because of the pathogenic potential of very low exposure levels, the fact that the onset of the neoplasm always occurs in the parietal pleura, and the absence of any synergism with smoking, which is typical in the case of carcinoma, it was suspected that aetiopathogenetic differences existed but the reasons for such differences still could not be explained. In the past experimental results indicated the oncogenicity of very thin fibres but mesothelioma in practice was not exclusively linked to this specific dimensional size class., Objectives: The paper proposes to take full advantage of the significant knowledge that must emerged from research carried out in recent years and use this knowledge to reconstruct the mosaic of the aetiopathogenesis of mesothelioma. Due consideration will also be given to the consequent new approach required in the field of medical-legal evaluation of cases and in the field of prevention., Results: The most important knowledge that must today be taken as certain is the fact that mesothelioma is not caused, as is the case for asbestosis, by all the fibres that are inhaled but only by the ultrathin fraction of these fibres, having diameter of 0.2 microm and length of only a few microm. Only fibres of this class of size can cross the pulmonary-pleural barrier and are, therefore, the causal agent of mesothelioma and other benign pleural manifestations (plaques). Moreover the ultrathin fibres that translocate from the lung to the pleura are not distributed casually on the parietal and visceral surfaces but move over the surfaces, to concentrate around the lymphatic reabsorption stomata situated on the parietal pleura. Due to their shape, the fibres cannot easily be absorbed into the stoma via the lymphatic flow and so remain clustered for an indefinite period of time among the mesothelial cells that surround the stoma. The concentration of ultrathin fibres in punctiform areas of the parietal pleura and the extremely long biopersistence of the amphiboles now finally explain how very low exposures can cause mesothelioma in susceptible subjects and why the neoplasm always occurs on the parietal pleura., Conclusions: In medical-legal assessments of cases of mesothelioma the etiological importance of the ultrathin fraction of fibres means that any assumption of the disease being avoidable must be discarded, at least up to the second half of the 1980s because until then this class of fibres, which today must be considered as the true causal agent of the neoplasm, was not visible under the optical microscope, nor could such fibres be measured or eliminated from the atmosphere of working environments. The filter materials available both for fixed ventilation systems and for individual protective masks were not able to block the ultrathin fibres and were therefore only efficacious for the prevention of asbestosis and probably pulmonary carcinoma. It was only with the use of highly efficient HEPA filters and "absolute" filters towards the end of the 1980s that efficacious protection against all size classes of respirable fibres became possible in industrial plants. Preventive measures in the public hygiene area must also take account of the aetiological role of ultrathin fibres by making full use of electron microscope investigations and by using "absolute" filters for domestic purposes, in ventilation systems and above all in the filter systems of the mechanical devices used in town street cleaning operations.

Introduction: The Italian Occupation and Safety Act (d.lgs 626/94) provided for the establishment of a nationwide occupational cancer registry, under the National Institute for Occupational Health and Safety (ISPESL), with the aim of detecting cancer cases of occupational origin and estimating the influence of occupation in cancer causation., Methods: Information on cancer cases, drawn from six Italian population-based cancer registries (CRs of Friuli Venezia Giulia Region, Genoa Town and Genoa Province, Macerata Town, Umbria Region, Varese Town, Veneto Region), and on a random sample of population controls selected in each CRs area were linked with data on subjects employed in private enterprises that have been available in electronic form since 1974 at the National Institute for Social Security (INPS). In this way, both for cases and controls, the occupational histories of past employment were collected. A population-based case-control study covering the period 1990-1998 was carried out with the aim of estimating occupational cancer risk in the private sector by site and economic category in each area. Since one of the major drawbacks of this approach is the difficulty in distinguishing true occupational hazards from incidental findings derived from multiple comparisons, an extensive research of occupational literature was carried out, independently of the study results, to compare our results with existing knowledge on occupational risks., Results: Pooled analysis of the most recent incidence data based on 36,379 cases and 29,572 controls was performed; 34 "statistically significant" associations were found for 11 economic categories. Using our literature review, 10 associations were supported by more than 5 publishedpapers, 14 by a number of papers between 1 and 5, and 10 associations had not been previously reported., Conclusions: This system appears suitable for assessing existing occupational cancer risks and can eventually lead to detecting occupational hazards in many areas of Italy. The system can also provide a list of cases suitable for in-depth search for past occupational exposures.