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The Position Paper (PP) on asbestos of the Italian Society of Occupational Medicine (SIML) aims at providing a tool to the occupational physician to address current diagnostic criteria and results of epidemiological studies, and their consequences in terms of preventive and evaluation actions for insurance, compensation and litigation. The PP was based on an extensive review of the scientific literature and was compiled by a Working Group comprising researchers who have contributed to the international literature on asbestos-related diseases, as well as occupational physicians with extensive experience in the evaluation of risks and the medical surveillance of workers currently and formerly exposed to asbestos. The PP was drafted and reviewed between 2017 and 2018; its final version was prepared according to the guidelines of AGREE Reporting Checklist. All the members of the Working Group subscribed to the document, which was eventually approved by SIML's Executive Committee. The first section addresses industrial hygiene issues, such as methods for environmental monitoring, advantages and limitations of different microscopy techniques, the potential role of microfibers and approaches for retrospective assessment of exposure, in particular in epidemiological studies. The second section reviews the biological effects of asbestos with particular attention to the diagnostic aspects of asbestosis, pleural changes, mesothelioma and lung cancer. In the following section the criteria of causal attribution are discussed, together with different hypotheses on the form of the risk functions, with a comparison of the opinions prevalent in the literature. In particular, the models of the risk function for mesothelioma were examined, in the light of the hypothesis of an acceleration or anticipation of the events in relation to the dose. The last section discusses topics of immediate relevance for the occupational physician, such as health surveillance of former exposed and of workers currently exposed in remediation activities.

Objectives: To assess, by means of biological monitoring, exposure to polycyclic aromatic hydrocarbons (PAHs) and to metallic elements in Italian Navy workers operating near the industrial area in Taranto, and thereby estimate the health risk., Methods: A total of 450 workers in the Italian Navy were examined; they had office type jobs, and 150 of them worked near the industrial area in Taranto (exposed group), 150 in Taranto but far from this area (internal control group) and 150 in Brindisi (external control group). The recruited workers were administered a questionnaire inquiring about current and previous working activities, personal medical history, lifestyle and dietary habits, and their residence location. Then they collected a urine sample for the determination of 1-hydroxypyrene, 2-naphthol, cotinine and the metallic elements As, Cd, Co, Cr, Mn, Ni, Pb, Cu, Zn and Hg. The latter were measured in 110 workers in each group. In addition, in some of the work sites of the three groups, environmental samplings were carried out to determine PAHs and the 10 metallic elements, also taking into account the wind direction., Results: Airborne benzo(a)pyrene concentrations at the different sampling sites ranged from 0.02 to 0.06 ng/m3 and naphthalene between <25 and 65.3 ng/m3, regardless of the wind direction. Among the metallic elements, As, Cd, Co, Cr, Hg, Pb, Cu and Zn were present at concentrations below or just above the limit of detection (LOD). Mn and Ni were slightly higher in the work sites of the exposed group. The urinary concentrations of 1-hydroxypyrene, 2-naphthol and the single metallic elements were not higher in the exposed workers group than in the other 2 groups. Smokers had significantly higher urinary 1-hydroxypyrene and 2-naphthol concentrations, whereas cigarette smoking did not condition a higher urinary elimination of metallic elements in the three groups with the exception of Cd and Pb. Moreover, residence location conditioned Mn, Hg and As urinary excretion, consumption of shellfish and/or crustaceans in the 72 hours before urine collection conditioned As elimination, and consumption of legumes in the 72 hours before urine collection conditioned Ni elimination., Conclusions: This research did not find a higher urinary excretion of 1-hydroxypyrene, 2-naphthol and As, Cd, Co, Cr, Mn, Ni, Pb, Cu, Zn and Hg in the exposed workers group as compared to the internal control group working far from the industrial area of Taranto, nor in the group working in another city far away from Taranto, Brindisi. Therefore, it indicated that workers in the Italian Navy operating near the industrial area in Taranto were not exposed to a greater risk attributable to exposure to PAHs and metallic elements than the two control groups.

Objective: To evaluate the occupational exposure to polychlorinated biphenyls (PCBs) in 56 workers employed in 6 electric arc furnace steelmaking plants and 2 secondary aluminum smelting plants located in the highly industrialized area of Brescia, Northern Italy., Methods: Thirty-four PCB congeners were found in both environmental and biological samples from workers engaged in scrap yards, electric arc furnaces, casting and maintenance departments., Results: The highest airborne PCB levels were found in the aluminum plant, even 100 times those detected in the steelwork plants. Dioxin-like PCB congeners (DL-PCBs) were poorly represented in all biological samples, whereas non Dioxin-Like PCB congeners (noDL-PCBs), in particular environmentally widespread congeners (PCB 153, 138, 180), could be detected in almost all samples. The mean total PCB serum level was 3.9 ng/ml, with a range of 1.3-10.3 ng/ml, while the geometric mean for airborne PCBs levels was 9305 pg/m3, with a range of 1138-217806 pg/m3., Conclusions: Despite the higher PCB values recorded in some metallurgical plant workplaces, we failed to find any significant difference between serum concentrations in workers from steel or aluminum production, even in consideration of different tasks or different job seniority, while positive association was found only according to the age of the workers. A possible explanation may be identified in the effectiveness of the individual and collective preventive measures adopted in the workplace. Assessment of the occupational exposure to such compounds, in consideration of the recent classifications as carcinogenic to humans, should be encouraged.

Background: Biological reference values (RVs) explore the relationships between humans and their environment and habits. RVs are fundamental in the environmental field for assessing illnesses possibly associated with environmental pollution, and also in the occupational field, especially in the absence of established biological or environmental limits., Objectives: The Italian Society for Reference Values (SIVR) determined to test criteria and procedures for the definition of RVs to be used in the environmental and occupational fields., Methods: The paper describes the SIVR methodology for defining RVs of xenobiotics and their metabolites. Aspects regarding the choice of population sample, the quality of analytical data, statistical analysis and control of variability factors are considered. The simultaneous interlaboratory circuits involved can be expected to increasingly improve the quality of the analytical data., Results: Examples of RVs produced by SIVR are presented. In particular, levels of chromium, mercury, ethylenethiourea, 3,5,6-trichloro-2-pyridinol, 2,5-hexanedione, 1-hydroxypyrene and t,t-muconic acid measured in urine and expressed in micrograms/g creatinine (μg/g creat) or micrograms/L (μg/L) are reported., Conclusions: With the proposed procedure, SIVR intends to make its activities known to the scientific community in order to increase the number of laboratories involved in the definition of RVs for the Italian population. More research is needed to obtain further RVs in different biological matrices, such as hair, nails and exhaled breath. It is also necessary to update and improve the present reference values and broaden the portfolio of chemicals for which RVs are available. In the near future, SIVR intends to expand its scientific activity by using a multivariate approach for xenobiotics that may have a common origin, and to define RVs separately for children who may be exposed more than adults and be more vulnerable.

Objective: A method for risk assessment of occupational exposure to strontium chromate (SrCrO4) in painters employed in the aeronautical industry is described., Methods: Assessment was made of 21 male workers of the painting division, potentially exposed to SrCrO4 (exposed), and 20 male workers of the tests and warehouse divisions (controls). All participants completed a questionnaire about work tasks, lifestyle habits, hobbies and diet. Personal active sampling for the determination of Cr and Sr was performed both during paint-spraying and during other operations in the painting division area. On the same day as environmental sampling, urine samples were collected at the beginning and end of the work shift in exposed workers to determine urinary chromium (CrU), and only at the end of the shift in controls. In the second half of the shift, a blood sample was taken in 10 exposed workers and 10 controls, to determine Cr in plasma (CrP) and in red blood cells (CrRBC)., Results: During paint-spraying, Cr concentrations ranged between 1.38 and 17.10 microg/m3, versus 0.02 to 0.07 microg/mi in the painting division area, while the Sr concentration was 22.90 microg/m3 in the paint-spray booth versus 0.07 microg/m3 in the painting division area. CrU at the end of the work shift, CrP and CrRBC, did not show significant differences between exposed workers and controls. Moreover, in exposed workers there were no differences between CrU measured at the beginning and at the end of the work shift., Conclusions: This approach, consisting of simultaneous environmental and biological monitoring, suggested no absorption of chromium in the painters thanks to the efficacy of the technical, organizational and personal protection measures adopted. However, the evident exposure to high levels of SrCrO4 during paint-spraying highlights how absolutely essential it is to ensure strict compliance with all the preventive measures foreseen by the EU and national regulations for occupational exposure to carcinogens.

Background: Ocular trauma is a major cause of monocular blindness and visual impairment in industrialized countries., Objectives: The aim of this paper was to study epidemiology, causes, and clinical features of work-related and non-work-related eye injuries in a highly industrialized area of northern Italy., Methods: All patients hospitalized for eye injuries were enrolled. Two 3-year periods were studied (1994-1996 and 2005-2007). The variables analyzed included sex, age, social class of the patients, nature of the injuring agent (e.g., metal, plastic, etc.), place where the accident occurred (e.g., home, work, etc.), and time of the year (e.g., summer, winter, etc.)., Results: We enrolled 1001 men and 129 women. There were no significant differences between the two 3-year periods as regards distribution of sex, age, and location. Road-related injuries significantly decreased (p < 0.004). Comparison of injuring agents showed a decrease in metallic agents (p < 0.001) and an increase in lime agents (p < 0.001). Analysis of the type of trauma showed a decrease in blunt traumas (p < 0.001) and an increase in chemical injuries (p < 0.001) and actinic keratitis (p = 0.002). In the second 3-year period, we found a significant increase in injuries in non-Italian subjects (p < 0.001)., Conclusions: Work-related injuries were the major cause of eye trauma. Road accident-related eye injuries dropped significantly in the second 3-year period. The adoption of higher safety standards, as well as information and educational campaigns, can significantly reduce work-related and non-work-related eye injuries.

Background and Objectives: Despite its advantages over environmental monitoring, biological monitoring of exposure to 2,4-:2,6-toluene diisocyanate (TDI) mixtures is still underused. The present study was designed in order to evaluate the feasibility and reliability of biological monitoring in a factory producing polyurethane foam blocks., Methods: Airborne TDI isomers were sampled by both static and personal pumps and determined by HPLC with fluorimetric detection. Specific metabolites 2,4- and 2,6-toluenediamine (TDA) were determined by gas chromatography-mass spectrometry on hydrolysed urine samples collected from 16 workers at the beginning of the workweek and both before (BS) and at the end (ES) of the 4th workday. Additional samples were collected at the end of the 1st half-shift and at the beginning of the 2nd half-shift in 5 workers., Results: In the foam production shop, TDI values were on average about 20 microg/m3, with higher levels in the 2nd half-shift and peak levels in workers operating along the polymerization tunnel. Average TDI levels were significantly correlated with ES TDA concentrations (p < 0.0001). TDA showed a fast urinary elimination phase leading to progressively higher TDA levels either during the shift (5 workers) and at the end-of-shift. A slower elimination phase with a weekly accumulation was demonstrated by values at the beginning of the workweek (higher than in unexposed subjects) and by their elevation in subsequent BS samples., Conclusions: The study demonstrates the feasibility and reliability of biological monitoring in workers exposed to 2,4-:2, 6-TDI mixtures. This approach can provide information about both the daily and weekly exposure levels.

Objective: To assess the critical issues concerning the use of urinary inorganic arsenic (iAs), including As3, As5, monomethylarsonic acid (MMA) and dimethylarsinic acid (DMA), as biomarker of internal dose in order to monitor environmental and occupational exposure to inorganic As, considering the influence of diet and drinking water on excretion of iAs., Methods: The design protocol stipulated collection of weekly urine samples from 6 male subjects for 5 consecutive months. In all the urine samples, iAs was determined by Hydride Generation-Atomic Absorption Spectrophotometry (HG-AAS). In the subjects with iAs higher than 35 microg/L, Biological Exposure Index (BEI) proposed by the American Conference of Governmental Industrial Hygienists (ACGIH), urinary arsenic speciation was performed by HPLC-ICP-MS. Exposure to airborne As was evaluated monthly using personal environmental samplers worn for 8 hours. Throughout the study, the participants filled out a daily food diary, also detailing types of water drunk., Result: Exposure to airborne As was invariably below the limit of detection, equal to 1 ng/m3. A total of 77 urine samples were collected. iAs was always detectable and was higher in 7 urine samples, obtained from 5 of the 6 subjects examined, than the BEI. Among foods with a high As content, the intake of seafood and fish within 72 hours before providing the sample seems to be the principal source of the iAs concentrations, while the intake of rice or drinking water showed no influence on this biological marker. Instead, drinking wine within 24 hours before urine sample collection can cause a significant increase in the excretion of iAs., Conclusions: In populations that eat large amounts of fish and seafood, the use of iAs to monitor occupational and environmental exposure to inorganic As seems to present some problems, and urinary As speciation may be essential at least in cases with As measurements above the biological limit values. In any case, a diet sheet reporting all foods eaten within 3 days of urine collection seems to be an indispensable tool to ensure a correct interpretation of the results.

Background: Few data exist on the risk of musculoskeletal disorders in road paving workers, in addition methods for risk assessment of biomechanical overload of the lower limbs and the spine are also lacking., Objectives: The aim of this study was to assess the risk from biomechanical overload for the whole musculoskeletal system and manual handling involved in the activity of stone paving of roads., Methods: In accordance with the guidelines of the Italian Society of Occupational Medicine and Industrial Hygiene various risk assessment methods were used., Results: The Washington State checklist revealed the presence of biomechanical overload of the spine in flexion. The Turin checklist showed a risk score higher than the acceptable limit for the cervical and lumbar spine and limbs (risk level similar to that obtained from the OCRA checklist for the upper limbs). The assessment of risk from manual handling of loads carried out using the NIOSH method provided a synthetic risk index whereas evaluation conducted using the Washington State method was acceptable., Conclusions: Biomechanical risk assessment showed the presence of risk for use of force and awkward postures of the wrist and elbow, which agrees with literature data. The division of tasks among workers and the distribution of breaks helped to reduce the risk to an acceptable level for limbs. All methods however showed a risk for the spine. Health surveillance showed disorders of the spine in 28% of the workers and no disorders of the upper limbs, which agrees with the risk assessment.

Background: Permanent education of health workers is obligatory under Italian legislation and is managed by the Ministry of Health through its Permanent Education Programme., Methods: In 2000 the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII), set up and implemented a programme of Permanent Education and Accreditation for specialists in occupational medicine, based on participation in "non-mandatory" and "mandatory" educational activities. "Non-mandatory" activities were chosen by the individual physician for education in topics related to occupational medicine. "Mandatory" educational activities, which were organised by the Society, included in-depth analysis of the Society's guidelines related to specific topics in occupational medicine., Results and Discussion: The Guidelines study course played a pre-eminent role in the Society's permanent education programme and was greatly appreciated by all participants. The Board of the Society has recently approved a new Plan of Permanent Education, identifying the means (Guidelines, Consensus Documents) whereby occupational physicians can improve their professional standards. The Plan's aims are to facilitate accreditation and also to identify and promote high-quality updating programmes which will lead to recognition of 'professional excellence". Crucial to its success will be a 3-year on-line learning programme (MeLA) that SIMLII has just implemented, which will enable occupational physicians to acquire credits in "Occupational Medicine and Workplace Safety", as required by current Italian legislation. This article summarizes SIMLII activities over the past ten years in the field of permanent medical education for occupational physicians.

Background: in some sequences of the film "Modern Times" Chaplin is clearly involved in activities at high risk for work-related musculo-skeletal disorders of the upper extremities (UEWMSDs), but evidence and perception of any complaint are not evident., Objectives: To evaluate the extent of the biomechanical risk using current risk assessment methods and discuss the possible reasons for lack of complaints., Methods: we made an analysis using six of the current methods for ergonomic risk assessment (State of Washington, check list OCRA, HAL by ACGIH, RULA Strain Index, OREGE)., Results: All the methods applied demonstrated high-to-very high levels of biomechanical risk for the upper extremities, with evident psychic effects but without apparent musculo-skeletal disorders., Conclusions: The discrepancy between evident psychological disorders ad apparent absence of UEWMSDs are discussed as being due to either: an artistic choice by Charlie Chaplin who focused on the aspects thought to be more immediately and easily comic; the short duration of the physical load exertion; or because of a different perception of muscular work and fatigue that was also typical until the 1970's and 1980's, which also confirmed the principles and practices of our preventive and medical disciplines at that time.

Background: We reviewed the Italian tools for updating and validating the activities of occupational health physicians (guidelines, consensus documents, technology assessment, good practices, etc.) from the point of view of efficacy and appropriateness., Results and Conclusions: We examined more than 20 guidelines produced since 2003 by the Italian Society of Occupational Health and Industrial Hygiene (SIMLII), the procedures issued by the National System of Guidelines in Medicine/SNLG) by the Italian National Health Institute (ISS) and the new law on occupational safety and health "Decreto Legislativo 81/08", which for the first time includes and defines in specific legislation the different possible instruments for guiding the activities of the occupational health physician, not only to improve the effectiveness of interventions but also aimed at constantly adopting rigorous methodologies based on evidence.

Background: The SIMLII set up a program of continuous training and accreditation of postgraduate specialists in Occupational Health in 2000, before continuous medical training (ECM) was formally introduced. Therefore, especially over the past few years, SIMLII has involved its membership to an ever increasing extent, in an attempt to understand their expectations as regards the scientific community and as regards a continuously evolving discipline that is subject to continuous changes in educational requirements., Objectives and Conclusions: The self-administered questionnaire in a survey carried out in 2005 by the National Institute of Occupational Safety and Prevention (ISPESL), in collaboration with SLMLII, provided data that, besides identifying the type of activity of the membership, attempted to assess members' compliance with the society's initiatives, with special reference to the Programme for continuous training and accreditation of postgraduates in Occupational Health and the issue of Guidelines.

Background: There are few studies in the literature on work-related musculoskeletal disorders among housewives, also due to the difficulties encountered during risk assessment., Objectives: The aim of this study was evaluation of the biomechanical load for the upper limbs in housewives' tasks, using the different methods described in the literature., Methods: A questionnaire was submitted to 104 women (aged 25-60 years), 62 of whom were housewives only. Twelve subjects accepted to be filmed on video-cameras while working, which was necessary for risk evaluation. A number of tasks were chosen to be evaluated (loading the dishwasher, cleaning kitchen work surfaces, sweeping, cleaning floors, using the vacuum cleaner, dusting, cleaning the bathroom, ironing, making beds) because they were more frequently performed over a day or a week and because they involved specific physical risk factors. The preliminary analysis was based on the search for such risks, identification of "caution zone" housework, and subsequent evaluation by advanced level tools., Results: Biomechanical risk analysis showed that higher overloads were detected in ironing, cleaning floors and cleaning kitchen worktops but all housework analyzed in this study involved exposure to biomechanical risk when performed for four hours in a day., Conclusion: Housework involves exposure to several risk factors for the musculoskeletal system. Nevertheless, housewives are able to self-organise work and recovery times (even with the limits imposed by family demands) but their activities are characterised by repetitiveness and often by high hand/arm force associated with awkward postures.

Italian legislation on prevention in occupational hygiene and safety, which is based largely on European Union Directives, requires health surveillance when risk assessment has identified a risk for workers' health. Health surveillance must be carried out by the occupational physician and concludes with the issue of a fitness for work certificate for the specific job. The guidelines produced by the "Italian Society of Occupational Medicine and Industrial Hygiene" (SIMLII), through the "Consortium for Accreditation and Updating in Occupational Medicine" founded by the "S. Maugeri Foundation of Pavia", Italy, focus firstly on the definition of judgment of fitness for a specific job. They outline the theoretical basis of the medico-legal terminology for fitness for work, which is founded on the concepts of suitability, fitness, capacity, ability, representing successive degrees of qualification and specific potential that the worker may attain during accomplishment of the tasks involved in the job. To assess fitness for a specific job, the occupational physician must consider whether the worker possesses the psycho-physical requisites normally needed to do the job, not the top levels of such requisites. The intrinsic characteristics of any judgment of fitness for work, namely its individual, probabilistic and time-dependent nature, are illustrated. The operative methodological model for making a judgment must include: assessment of the job and work environment, assessment of the worker through health surveillance, comparison and correlation of the two terms of the equation: human subject-work environment, the judgment thus made and the choice of any necessary measures and/or intervention. The methods for conducting the assessment process culminating in a judgement are presented, as stipulated in the pertinent legislation, and include the following conclusions: fitness, partial or total unfitness, temporary unfitness, fitness provided suitable prescriptions are observed,fitness provided some conditions are met. These definitions are analyzed in greater depth, especially the possible confusion between partial unfitness and fitness provided suitable prescriptions are observed. The employer or worker may lodge an appeal with the local health service inspection service against certain judgments of unfitness for work. Finally, as health surveillance is governed by different legal norms, the contents of which appear to be to some extent contradictory, even though aimed at safeguarding the dignity and freedom of the worker, the reasons why the occupational physician should take into account diseases apart from those of the organs exposed to specific risk are discussed. These should be borne in mind when issuing the specific fitness for work certificate at the end of preventive and periodical medical examinations.

Aims: To assess and classify exposure to Polycyclic Aromatic Hydrocarbons (PAHs) in some specific working areas of a steel foundry operating with a continuous casting process and evaluate biomonitoring data in different job tasks., Methods: Exposure to dusts and six PAHs classified as carcinogenic by EU directives was studied in a cohort of 35 male foundry workers (aged 41.1 +/- 6.9 years), who were examined both prior to and at the end of the work-shift (06:00 a.m.-02:00 p.m.) in two different periods. The urinary excretion of 1-hydroxypyrene (1-OH-P) was measured as a biomarker of exposure to pyrene., Results: PAHs concentrations ranged from 461.8 to 935.6 ng/m3 near the continuous casting area, whereas lower values were measured near the ladle furnace. End of shift 1-OH-P values were higher in 11 non-smoking workers involved in continuous casting process as compared to those employed in mantenance and furnace areas (median of the second determination: 5.70 microg/g creatinine--range: 1.24-21.24 vs 1.17 microg/g creatinine--range: 0.23-4.49; p< 0.001). 1-OH-P excretion was significantly correlated with both the sum of six carcinogenic PAHs and pyrene airborne concentrations. In two biomonitoring sessions, 9.1% and 34.3% of the workers respectively showed end-of-shift 1-OH-P values exceeding the occupational exposure limit (OEL) (4.4 microg/g creatinine or 2.3 micromol/mol(-1) creatinine) recommended for coke-oven workers., Conclusions: 1-OH-P is a useful biomarker in assessing PAH exposure and is associated with job category at a Steelplant. Due to exposure variability, to assess risk associated with PAHs exposure, biological monitoring should be carried out periodically.

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

Background: Urinary N-acetyl-beta-D-glucosaminidase (U-NAG) and its isoenzyme B (U-NAG-B) have been demonstrated useful and early markers of renal damage, although they are present in many other tissues and organs., Objectives: To evaluate semen contamination of the urine and its role in variability of U-NAG., Methods: To assess control group values beta2-microglobulin, retinol-binding protein and U-NAG were measured in the urine of 30 healthy, non-smoking and non metal-exposed adults (19 females and 11 males)., Results: In four urine samples U-NAG was higher than the method reference value (5 U/g creatinine), without increases in other functional markers. Microscope examination revealed the presence of sperm in these samples. U-NAG variability decreased after the exclusion of these four values. The role of contamination was confirmed by adding semen to urine: when semen to urine ratio was 1:1000, enzyme activity was more than twice the basal level., Conclusions: U-NAG variability is strongly increased by contamination with semen, where enzyme concentration (especially NAG-B) is very high. Increased excretion of U-NAG and of its iso-form (U-NAG-B) in males, not correlated with other renal alterations or with exposure to heavy metals or other renal toxic substances, should be carefully evaluated and microscopic observation is advisable to detect the presence of sperm in urine.

Background: The studies dealing with the relationship between cardiovascular disease and exposure to environmental and occupational chemical risks are out-dated and insufficient. However, this is not true of studies on lead., Objectives: This paper aims to investigate in particular the etiopathogenesis of the relationship between lead exposure and hypertension., Methods: The studies published in the last decade concerning both the general population and occupationally exposed subjects were reviewed., Results and Conclusion: The effects due to high levels of exposure to lead are well known and have been studied for over a century. Knowledge on the chronic effects deriving from low and long-term exposure is still very controversial but is currently the most interesting topic; in particular lead hypertension is the topic of an increasing number of studies. Chronic exposure to low levels of lead can cause hypertension via several mechanisms. The most important are: oxidative stress associated with functional NO deficiency, elevation of sympathetic activity coupled with depressed vascular and increased renal beta receptor densities, activation of the renin-angiotensin-aldosterone system, rise in endothelin production, reduction in vasodilatatory prostaglandins and elevation of vasoconstrictive prostaglandins.

Background: Since the use of video display units (VDU) has become widespread in the workplace, more and more research has been conducted to evaluate the possible onset of adverse effects., Objectives: We carried out a multidisciplinary investigation on a group of 660 VDU operators working for a service agency, aimed at analysing the relationship between ophthalmological, musculoskeletal and neuropsychological parameters and asthenopia., Methods: In this study we propose a method for a qualitative and quantitative evaluation of the asthenopic syndrome based on data collected with an easy semi-structured questionnaire., Results and Conclusions: No relationship between asthenopia and refractive alteration was noted, whereas a significant association was observed between a lengthened convergence near point and the average time of daily VDU exposure. A significant relationship was also shown between asthenopia, cervical and lumbar disorders, and neuropsychological symptoms. The method for evaluation of asthenopia and the results of this study suggest useful implications in health surveillance programs. After an appropriate validation procedure, this method could represent a useful screening tool and a valid support for preventive interventions. The use of this instrument in longitudinal studies will also provide the opportunity of verifying the existence of long-term effects due to VDU exposure.

Background: The Italian Society for Occupational Health and Industrial Hygiene (Società Italiana di Medicina del Lavoro e Igiene Industriale)--SIMLII--has taken a systematic approach to the topic of permanent education of occupational health physicians over the last 4 years, developing its own project entitled "SIMLII Permanent Education and Excellency Accreditation"., Objectives: The SIMLII Project, which is addressed to occupational health specialists and physicians authorized under Law 277/91, art. 55, is based on the participation of "obligatory" and "non-obligatory" educational activities and on assessment of professional activity. "Obligatory" educational activities are events organized directly by SIMLII and consist of a detailed study of the guidelines concerning specific occupational health topics. The "non-obligatory" events are those regarding occupational health that the physician chooses voluntarily, with accreditation by the Ministry of Health and/or by SIMLII. The occupational health physician who enrolls for the 3-year course must obtain a total of 180 SIMLII training credits in the 3 years (60 per year). Assessment of activity performed is made at the end of the 3 years of training according to criteria set out by SIMLII and approved by the membership, via a self-administered questionnaire., Methods and Results: The SIMLII Project has laid great emphasis on drawing up guidelines on topics specific for occupational health. These guidelines are developed by groups of experts selected by SIMLII and deal with topics that the occupational health physician most frequently encounters in the course of his/her professional activity. There are 405 participants in the first 3-year training course covering the whole of Italy. The aim of the Italian Society for Occupational Health and Industrial Hygiene, via excellency accreditation and drawing up of guidelines for particularly important topics, is to provide useful tools to satisfy the training requirements of its membership, to improve the quality of professional services and to emphasize the uniqueness and specific nature of occupational health within the medical specialties.

Background: It was considered appropriate to update of the significance and use of the different mercury exposure indicators., Objective: The aim of the this paper was to correctly select biological media and sampling time and to understand the toxic kinetics of mercury for assessment of accurate biological monitoring., Results: It was confirmed that mercury in blood (B-Hg) is a good indicator of recent exposure, while urinary mercury (U-Hg) indicates current exposure when mercury reaches the renal steady state. B-Hg values are greatly influenced by fish consumption, while the variables influencing U-Hg values are amalgam fillings, commercial gamma-globulin preparations, vaccines, topical remedies, environmental pollution and hobbies, occupational exposure and, partly, fish consumption. The speciation of mercury (Hg0, Hg++, methylmercury and ethylmercury) in biological media, should provide additional and important information in evaluating mercury toxicity., Conclusion: It was stressed that the appropriate choice of exposure indicators has to take account of the different variability factors and the characteristics of the toxic kinetics of mercury. The results of biological monitoring must be compared with references values, which are generally in the order of several micrograms/g creatinine, and limit values such as ACGIH BEI (U-Hg 35 micrograms/g creatinine and B-Hg 15 micrograms/l) or the DFG BAT (U-Hg 100 micrograms/l and B-Hg 25 micrograms/l).

Objectives: The aim of this paper was to analyse the concentrations of HgU and HgB in three different groups: 122 workers exposed, 18 workers formerly exposed and 196 subjects not occupationally or environmentally exposed to mercury., Methods: All the subjects filled out a questionnaire concerning personal data, lifestyle, occupational or non-occupational exposure to Hg and medical history. The amalgam fillings area was measured by a standardised method., Results: Urinary mercury excretion was significantly greater in the group of the exposed workers respect to the group of subjects not occupationally exposed (Median value of 8.3 micrograms/g creatinine and the 5 degrees and 95 degrees percentile respectively of 2.66 e 23.50 micrograms/g creatinine against Median value of 1.2 micrograms/g creatinine and the 5 degrees and 95 degrees percentile respectively of 0.18 and 5.42 micrograms/g creatinine). U-Hg in formerly exposed workers were comparable to U-Hg in non-occupationally exposed subjects, with a median value of 1.6 micrograms/g creatinine. B-Hg values were similar in the three groups: the median value was 3.1 micrograms/l in the non-occupationally exposed, 4.0 micrograms/l in the exposed workers and 3.9 micrograms/l in the past exposed. These value were not significantly different. Among the considered variables (amalgam fillings, fish consumption, age, sex, alcohol intake, chewing-gum and smoking) dental amalgam and fish consumption were significantly related with the Hg urinary excretion and the B-Hg levels. This is particularly true considering the subjects altogether: for the exposed workers, indeed, the occupational exposure was the most relevant variable., Conclusions: The results of the present research confirmed that the U-Hg excretion in non-occupationally exposed subjects is influenced by amalgam dental fillings. Furthermore, in our study Hg urinary excretion was significantly related with fish consumption. This fact can be explained, according to several recent experimental human and animal trials, considering that methylmercury contained in fish is partially converted, through breakage of the carbon-Hg bond, into Hg inorganic forms, which accumulate in the kidney and have a urinary excretion pathway.

The principal aims of the project financed by the Italian Ministry of University and Scientific and Technological Research were: to verify if at the current limit values early biological effects can be demonstrated; to identify the levels of internal dose that can cause early effects; to evaluate the non-occupational factors that can contribute to the levels of internal dose. In particular, the mercury intake derived from dental amalgams and fish consumption was considered. The internal dose was measured with the traditional biological indicators (urinary and blood mercury) and with the speciation of a large percentage of biological samples by ICP-MS. The central nervous system, neuroendocrine function, kidney and the immune system were considered as target organs and were examined using previously standardized indicators of effects. Two groups of subjects were included in the study: workers with occupational exposure to inorganic mercury in different industrial settings and control subjects identified from the general population. The first group was characterized by an exposure level to inorganic mercury clearly below the current limit values; whereas the HgU levels of a relevant number of control subjects were similar to those measured in the exposed subjects. The in vitro studies covered several issues: the percutaneous absorption of mercury using skin derived from human post-mortem samples in a standardized model; the release of the metal from dental amalgams in different physiological conditions of the oral cavity; the effects of increasing doses of mercury chloride on tubular renal cells. The project was realized with the cooperation of seven Research Units from six Italian Universities. Researchers belonging to Departments of Occupational Medicine, Industrial Hygiene, General Pathology, Biochemistry, Odontology, and Biostatistics were involved to achieve a multidisciplinary approach. The results of this research project are described and discussed in the following papers.

Objectives: Mercury (Hg), one of the most diffused and hazardous organ-specific environmental contaminants, exists in a wide variety of physical and chemical states, each of which with unique characteristics of target organ specificity. Exposure to Hg vapour and to organic mercurials specifically affects the CNS, while the kidney is the target organ for inorganic Hg compounds. Despite the increasing number of studies, the molecular bases of the nephrotoxic potential of Hg has not, up to now, been clarified, even if there is evidence suggesting that the ability of the metal to interact with proteins (thiol groups) or to generate oxygen radicals may play a major role. Within this context, the aim of the present study was to investigate, in vitro, the mechanism(s) of the early nephrotoxic potential of mercury chloride (HgCl2), one of the most diffused and biologically active mercury (Hg2+) compounds. For this purpose, two kidney-derived in vitro systems (the MDCK and the LLC-PK1 cell lines) were tested for their sensitivity to the salt, and MDCK was chosen as the most suitable in vitro model for our study. As possible biological markers of the organ-specific toxicity of the metal we analysed: i) critical biochemical parameters related to oxidative stress conditions (effect of Hg2+ on the anti-oxidant status of the cell), and ii) gap-junctional function (GJIC)., Methods: Classical toxicity tests (MTT and NR) were used for assessing the sensitivity (IC50) of LLP-CK1 and MDCK cell lines to the mercuric salt. Complete solubilisation of the salt in the culture media was verified by inductively coupled plasma mass spectrometry (ICP-MS). The influence of the metal on cell growth rate and viability were evaluated by conventional proliferation assays. For the following mechanistic studies, cells were exposed for different time periods (4 to 72 hours) to non-cytotoxic (0.1-50 microM) HgCl2 concentrations. The biochemical analysis of the pro-oxidant properties of the mercuric compound was performed by the measurement of anti-oxidant cellular defences against H2O2 [catalase (Cat), glutathione peroxidase (Gpx), and total glutathione (GSH)]. The influence of the metal on the GJIC capacity of MDCK cells was assessed by the "microinjection/dye-coupling" assay., Results: Among the two kidney-derived in vitro systems, MDCK cell line was the most specifically sensitive to the toxic effect of HgCl2: it was, consequently, chosen as a "tubular cell model" for the following experimental steps. Tested for various time periods at increasing concentrations, the HgCl2 effect on MDCK cell proliferation and viability was found to be time- and dose-related. For concentrations < or = 50 microM, HgCl2 inhibits MDCK cell growth rate, being this effect significant (> 50% in respect to untreated controls) from the 24th from the beginning of the treatment, while, for concentrations > 50 microM, the metal causes cell death. Concerning the influence of HgCl2 on MDCK anti-oxidant defences, the most interesting results were obtained by analysing the influence of the mercury salt on the GSH cell content and Gpx activity. Both were, in fact, significantly affected by the presence of the mercury ion. HgCl2 also induced a rapid, dose- and time-related inhibitory effect on the GJIC capacity of the cells., Conclusions: Even if further investigations are needed to better clarify the possible causal relationship between our findings, they indicate that: a) MDCK cells represent a suitable in vitro model for the study of Hg nephrotoxicity; b) GJIC function is, among those considered in our study, one of the most sensitive biological endpoints for investigating the mechanism(s) of Hg2+ specific toxicity.

The paper proposes a model for health and safety organization in health care units and hospitals which takes account of the risk assessment procedures required by law and the quality assessment of the measures thus taken. A redefinition is given of the role of Medical Director and of the functions, aims and standards on which health and safety service and the services of an authorized occupational health physicians must be based.

The identification and quantification of elements as such (that make up the historical analytical method used in toxicological studies) are necessary but not sufficient, in all cases, to understand and evaluate the mechanism of interaction between elements and biological targets. In fact, in order to approximate the factors that control the concentrations of elements in environmental or biological media, we need to know the occurrence of species of the elements themselves. This is element speciation, i.e. the capability of separating, identifying and determining the species in which an element is present and/or transformed. There are few, although increasing in latter years, examples of element speciation able to confirm the importance of this research approach in toxicological studies. Some basic information from these studies have found specific application in selecting the most appropriate indicators and the most representative matrices for biological monitoring. Furthermore, element speciation provides additional and often essential information in evaluating metal toxicity. The toxicity of the three oxidation states of Mercury differ considerably. For arsenic, a decreasing order of toxicity arsenite > arsenate > monomethylarsonic (MMA) > dimethylarsenite (DMA) has been proposed. However, the use of speciation in investigating toxicokinetic aspects appears to be difficult to apply to many other metals, mainly due to the lack of information about the existence and significance of species whose determination would be worthwhile and to the lack of analytical methods enabling us to measure species in biological media. Nonetheless, the horizon for speciation is more extensive and less linear than expected since about 15 elements, 20 oxidation states, and 25 organic compounds have been just involved in speciation. Problems might arise for biological monitoring practices, and the following topics should be considered: (i) identification of species and determination of their concentration; (ii) knowledge about the specific (relevant) role in physiologic and pathologic processes in which the element is involved; (iii) availability of analytical methods responding to acceptable quality requisites; (iv) feasibility and ethics of sampling.

Risk assessment for occupational exposure to antiblastic chemotherapeutic drugs (ACD) is carried out by means of environmental and biological monitoring. These practices are not widespread and furthermore their results are frequently difficult to interpret. This paper discusses some of the most important aspects of risk assessment for ACD and in particular for their exposure evaluation. The following guidelines are proposed: a) working rooms, working procedures, type and quantity of drugs, and preventive measures must be checked using a standardized scheme for collecting data: an example of a check list experimented in some Italian hospitals is presented; b) cyclophosphamide, 5-fluorouracil, and Pt coordination compounds have been identified as tracers of drug mixtures usually administered, and their determination is recommended both in environmental and biological samples; c) for a correct evaluation of exposure, ACD should be determined firstly on the contaminated surfaces or on work clothes and secondly in urine of workers; the measurement of ACD in air must be limited to well documented conditions of high exposure and the urinary mutagenicity tests should be avoided; d) the biological monitoring practices should be enhanced, in particular the determination of ACD adducts to proteins and nucleic acids as promising indicators of effective dose.

Present lead (Pb) exposures in working and general environments are undoubtedly lower than several decades ago so that mean blood lead levels (PbB) in the main industrial sectors using lead, such as ceramics and accumulator manufacturing, are now about 30 micrograms/100 ml and in the general population between 10 and 15 micrograms/100 ml and in some situations decidedly below 10 micrograms/100 ml. At the same time increasingly more accurate and sometimes original knowledge has been acquired on the effects of low-level Pb exposure, especially the effects on the nervous system, the cardiovascular system, the endocrine and immune systems, on heme-containing enzymes, and on the reproductive system. The question of a possible mutagenic and carcinogenic action of Pb is, however, still open. It is also clear that many of the above effects were observed for PbB levels considerably below the current limit levels. For certain effects, like those on heme, the central nervous system, and blood pressure, it has not been possible to establish a threshold below which they will not occur. With effects that are so different in nature and degree and with changed exposure conditions, a critical re-examination of the assumptions on which current knowledge and prevention models are based appeared appropriate. In particular, action models are proposed for discussion which, besides the priority aim of restricting use of Pb to those situations where there is no alternative and to those working environments which guarantee compliance with modern regulations and prevention procedures, have two differentiated objectives: the first is to eliminate the dose-dependent effects occurring at exposures higher than those in the general population; the second is to reduce to the lowest possible level the effects with no threshold or with as yet unestablished threshold, by means of actions in favour not only of occupationally exposed groups but also the general population.

The meaning and usefulness of biological indicators in the study of occupational exposure to aluminium (Al) was assessed on the basis of the most recently acquired knowledge on the toxicokinetics of aluminium absorbed by inhalation, results of environmental and biological investigations recently carried out in industrial sectors with low risk of aluminium absorption (refining, casting and pressure moulding covering a total of 8 plants and 119 workers) and the results of investigations on a group of welders exposed to Al concentrations between 5 and 10 mg/m3. It was confirmed that not only the environmental Al concentrations but also certain chemical and physical characteristics (particle size, allotropic state, solubility), simultaneous exposure to other dusts, and mode of exposure (existence of exposure peaks) play a significant role in lung absorption of Al. Urinary Al (AlU) may be considered as an indicator of "recent" exposure with biphase excretion kinetics influenced also by duration of exposure, whereas Al in serum (AlS) can probably furnish indications both on overall exposure and on body burden. In low-level Al exposure (below 0.5 mg/m3), these indicators (especially AlU) permit differentiation of the exposed groups from the general population without, however, any clear relationship with the various environmental Al concentrations. It was also seen that AlU increased with increasing work seniority and was more marked in certain processes, such as casting, and in the first few months or years of work.(ABSTRACT TRUNCATED AT 250 WORDS)

Audiometric tests performed on 41 workers at a metal engineering factory producing tools for the wood manufacturing industry showed hearing loss at 6 kHz in 45.9% of the cases. A study was therefore carried out to check carefully the physical characteristics of the noise via statistical analysis and octave frequencies band analysis in real time. The measurements revealed higher noise levels at the high and medium high frequencies (3.15-6.3 Hz) both for impulsive and continuous noise. The results of the audiometric tests differed from those of a group of 50 workers employed in two different metal engineering factories, where the noise levels were similar but at medium-low frequencies, with no pure tones. In this group of subjects, hearing loss occurred at 6 kHz in 28% of the cases; the differences thus seemed to be related the particular physical characteristics of the noise levels measured in the first factory. The data are discussed against findings already reported in the literature, in relation to their prevention-related aspects and a more correct interpretation of the audiograms.

A study was carried out in 3 copper alloy industries: a foundry for scrap of various origin producing brass and bronze alloys (foundry A) and 2 foundries that used these same alloys (foundries B and C). An environmental investigation and biological monitoring of the employees for Pb, ZPP, Cu, Zn, Be, Sb, Mn, Ni and Cr were performed in each foundry. The results of biological and environmental monitoring showed that the Pb exposure levels were distinctly higher than those of the other metals in all 3 foundries. The highest levels of PbA and PbB were observed in foundry A, especially during scrap grinding operations, where the limit values were exceeded. The environmental concentrations and the levels of the biological indicators for all other metals, except Pb, were within reasonable limits. Therefore, in the investigated working situations and for the metals under study, except Pb, it would appear that a situation exists of exposure to "microdoses" which, even though not implying a risk of appearance of the classic signs and symptoms of intoxication, raises the problem of the possibility of identifying early effects and interpreting the biological indicators. Biological monitoring of exposed subjects has shown that the levels of the indicators for Cu, Ni and Cr are markedly different from the reference values on a group basis, whereas in individual workers the values are generally below the "upper limits". A comparison with the "limit values'' was only possible for the biological indicators of Pb; for the others, although differences were observed indicating that absorption had taken place, no univocal interpretation criteria exist, considering also the relatively low mean increases observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Although we still have to be careful about situations where there is still a risk of high levels of absorption of the most commonly known metals or where there is exposure to rare metals but with known toxicity, in the current transition phase from macro- to micro-doses of industrial toxics and metals in particular, it seems appropriate to encourage the development of study criteria and methods for this special field of occupational medicine. A number of aspects of the analytical techniques (ICP MS, in vivo measurements) are therefore discussed which should make for a better evaluation of doses; reference values for toxic metals intended as indispensable terms of evaluation of abnormal exposure to be related with any response by the human organism; identification and quantification of certain early effects that are of significant theoretical and practical interest, such as effects on the functional reserve and immunotoxic effects. Occupational medicine should take renewed interest in toxicological problems which, in the authors' view, have wrongly been considered outdated by the evolution of work-related diseases. On the contrary, this evolution calls for fresh and more in-depth interest also in occupational toxicology research.

A number of indicators of renal effect (N-acetyl-glucosaminidase, retinol binding protein, beta-2-microglobulin, albuminuria) were measured in 42 cadmium-exposed workers divided into 3 subgroups on the basis of the results of the last 10 years' biological monitoring (less than 3, 3-10, greater than 10 micrograms/l). An increase in the first three indicators was observed, particularly in the third subgroup, which, however, due to the wide dispersion of the values, was not statistically significant by the Kruskal-Wallis test. Taking the indicators singly, the marked increase in RBP and beta-2-microglobulin in the heavily exposed subjects was confirmed, along with an increasing sensitivity for NAG, while albuminuria levels were unchanged. Assessment of the "degree of association" of the altered tests demonstrated that the number and type of "association" varies between the subgroups in relation to the exposure conditions: in the first group there were no associations between the altered tests, whereas there were 2 duplicates in the second and 2 duplicates, 2 triplicates and 3 quadruplicates in the heavily exposed group. In the study of the renal effects of cadmium, it is therefore advisable to use several indicators and assess their behaviour both singly and combined, and also analyse the altered tests on the basis of the number and type of "association".

Occupational exposure to beryllium (Be) is nowadays much lower than in the past. While the classic Be diseases, such as berylliosis, are clearly on the decline, attention is currently being focussed on the immunological and carcinogenic effects of Be, which suggest that subjects with low-level occupational exposure should also be accurately controlled. Urinary Be (BeU) values were determined in a sample of the general population and in a group of dental technicians exposed to environmental Be concentrations ranging from 0.04 to 1.7 micrograms/m3. The mean BeU values of these workers (0.34 micrograms/l) were higher than those of the general population (0.26 micrograms/l) and the subgroup of dental technicians exposed to higher Be air concentration showed higher BeU levels. Although at present the relationships between external and internal dose and between internal dose and early effects, are not known, we believe that biological monitoring supplies useful information on occupational Be exposure.

The authors present the results of toxicological studies on aluminium from 1983 to 1988. In order to obtain reference values for serum and urine aluminium, 506 healthy adults, not occupationally exposed to the metal, residing in the Brescia area were studied. The following values were obtained: AlS = 5.8 +/- 2.9 micrograms/l; AlU 11.9 +/- 4.3 micrograms/l. The AlU and AlS values did not differ in relation to age, sex, alcohol consumption, smoking habits and residence, contrary to what has been found for some metals determined in the urine and/or blood of the same subjects. In a group of 227 subjects with occupational exposure to aluminium within the range 0.1-1.0 mg/m3, the mean levels of AlU were higher than that of the reference population; however the AlU of the workers were generally lower than 20 micrograms/l which is the upper limit for the reference population; 4 workers who were under treatment with antiacid preparations showed AlU values higher than 150 micrograms/l. Seven workers exposed to atmospheric aluminium concentrations around the TLV-TWA had higher AlU values at the end of their shift on all working days and on Friday morning the values where higher than those encountered on Monday morning. On the other hand no daily and weekly fluctuations were evident for AlS. For 14 workers the relationship between AlU and AlS values were examined in three subsequent periods after the start of working activity. Considering the same values of AlU, it was observed that the AlS increased with the duration of exposure. These results seem to indicate that AlU could be considered as indicator of current exposure and AlS as an indicator of cumulative exposure. Neuroendocrine tests were performed every 6 months in 21 workers after they had been hired. PRL and TSH values were reduced after 1 year of work and were still reduced 6 months later. Further analyses showed a different behaviour: in fact the levels of the two hormones rose above the reference values, while the HGH and other gonadotropins showed no alterations. These results seem to indicate that at the start of exposure to aluminium concentrations below TLV-TWA there is an effect on the hypothalamus-pituitary axis. This phenomenon is probably transient perhaps because of an adaptation mechanism. Further studies are however necessary to verify these results.