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Background: The terrorist attacks on the World Trade Center (WTC) of September 11, 2001 resulted in the deaths of 2,823 persons. They also generated a long-lasting burden of multiple physical and mental health illnesses among the cohort of 50,000 rescue workers who responded to the attacks and in the 400,000 residents and workers in nearby areas of New York City. A comprehensive health surveillance program was developed from the first months after the accidents and was further developed in the subsequent ears. Individual exposure and health data were stored in ad hoc databases and produced epidemiological outcomes on the various exposure-related illnesses., Methods: About 10 years of longitudinal assessment of this large cohort of WTC rescue and recovery workers, yielded data from participants in the WTC Screening, Monitoring, and Treatment Program. Police officers, firefighters, construction workers, and municipal workers were included in the cohort. Cumulative and annual incidence were estimated for various physical disorders including asthma, sinusitis, and gastroesophageal reflux disease, mental health disorders including depression, post-traumatic stress disorder [PTSD], and panic disorder. Respiratory functionality was also assessed. Exposure was characterized with qualitative parameter including working on the pile and being engulfed in the dust cloud, and quantitative parameters including the time of arrival on site and the exposure duration., Results: Upper and lower respiratory conditions such as rhinosinusitis and asthma have been found in a significant number of people in WTC-exposed populations. A lack of appropriate respiratory protection may have contributed to these effects. Other commonly observed physical health conditions include gastro-esophageal reflux disease, obstructive sleep apnea and musculo-skeletal injuries. Many WTC-exposed individuals also suffer from mental health conditions, primarily post-traumatic stress disorder, depression, panic disorder, and substantial stress reaction. Recent studies suggest that WTC exposure may increase the risk of cancer and of mortality from cardiac disease., Conclusion: Ten years of systematic health surveillance after the 9/11 WTC attacks, show long lasting burden of physical and mental health problems. Continued monitoring and treatment of this population is needed for early diagnoses of initial clinical conditions that can be treated more effectively. The experience of September 11 offers also indications on how to approach the acute and delayed health effects of civilian catastrophes. Critical lessons are derived about the importance of having trained responders--medical and non-medical--in place in advance of disasters, and about the need to proceed with adequate exposure assessment in a timely manner.

This paper describes the experience of the School of Occupational Medicine of the University of Brescia at the current edition of the New York and New Jersey Education and Research Center--Historical Perspectives Tour on Occupational Safety and Health, that involved 5 different industrial and environmental sites, appropriate for understanding the complex occupational health and safety problems. In every site, the participants have interacted with workers and professionals and discussed about the specific work processes, to better understand the risk faced by the workers, occupational pathologies that can occur, personal protective equipment used and preventive measures adopted. This experience has been successful in provide interdisciplinary educations to occupational safety and health professionals in training in order to prepare them for the collaboration and cooperation required to solve the complex occupational health and safety problems they will face in their future careers.

Epidemiological data show excess of respiratory, dermatological, infectious, carcinogenic and musculoskeletal disorders among agricultural workers. Nevertheless, the national rates of reported cases do not correspond to the expected epidemiological data. In 2009, 3.914 cases of occupational diseases were reported to the national work compensation Institute (INAIL), as related to 1,200.000 agricultural workers employed in Italy. About 71% of these cases were related to musculoskeletal disorders. This shows a relevant difference between observed and expected cases, even more evident than in other sectors like constructions. More efficient preventive intervention is needed to improve this situation of under-reporting, through the implementation of epidemiological surveillance based on multiple sources of information. These sources should include the periodical health surveillance of active workers, the databank of General Practitioners, the hospital admission charts, and the case-lists of patients admitted to the Institutes of Occupational Health, according to a systematic active search of occupational cases.

One of the most relevant aspects in the evaluation of occupational stress is concerned with the survey methodology. Several studies adopted subjective and objective methods of evaluation and the debate about the benefits and limitations of both approaches has continued for several years (Frese et al. 1988, Hurrell et al. 1998). To choose an appropriate, specific and focused-on-context evaluation, it is necessary to identify the sources of risk in the investigated area. Then, it is necessary to choose the methods, subjective and objective, more suitable for stress evaluation. In this study we reviewed the psychosocial risk factors that are specific to the health sector and the instruments, objective and subjective, most used in this context. We considered also the methods for the detection of episodes of violence. Finally, we presented the results of a study conducted in the health care sector, which has adopted and compared objective parameters, as potential stressors, and subjective symptoms. The study revealed statistically significant correlations between objective and subjective indicators, suggesting the importance of integrated methods of evaluation.

To assess the risk from exposure to occupational stress and burnout in health care workers (HCW), a cross-sectional study was planned to compare objective data that can represent potential job stressors in hospital wards and subjective symptoms reported by the workers. Medical doctors, nurses and ancillary workers of the Internal Medicine Wards of a large public hospital in Northern Italy were enrolled in the study. Three subjective questionnaires were administered: the Job Content Questionnaire, the State-Trait Anxiety Inventory, the Maslach Burnout Inventory. In addition, seven objective parameters were collected as average on the 3 months period prior to the study: a) working understaffed; b) number of patients/HCW on service; c) number of HCW on sick leave/on service; d) number of skipped days off after night shifts; e) number of sick leaves; f) number of deceased patients; g) number of accidents at work. A total group of 230 HCW were examined, employed in six different sub-units of the Medical wards. The female workers were 67.8% and the male workers 32.2%, the mean age was 37.4 years (SD 9.3) in the total group, 35.1 years (SD 7.9) in females and 42.3 years (SD 10.3) in males. The average scores of subjective and objective parameters resulted significantly higher in the same sub-units. The correlation analysis showed that the subjective questionnaires were highly inter-related. The multivariate analysis showed that the number of sick leave days was significantly related to the subjective questionnaires, and the subjective subscales of emotional exhaustion, job demand, decision latitude and STAIt were significantly related to some of the objective parameters. Therefore, the best approach to measure occupational stress is an integrated one, which involves the use of multiple subjective and objective assessment modalities.

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

Background: Environmental exposure to heavy metals and especially manganese (Mn) took place in Valcamonica, Italy, where a high prevalence of Parkinsonism was observed (age and sex standardized 407/100,000; 95% CI: 393.87-420.12), and the Standardized Morbidity Ratios was associated with environmental Mn levels., Methods: A cross sectional study compared Parkinsonian patients residents in Valcamonica with patients from Brescia, Italy. Age- and sex-matched healthy individuals were recruited as controls. The protocol included information on clinical, occupational, residential history and life habits, neuro-psychological testing, and assessment of genetic polymorphism., Results: The target group included 65 patients and 52 controls from Valcamonica, 28 patients and 14 controls from Brescia. Age at onset of the disease was lower in women from both areas. After adjusting for age and age at onset, patients from Valcamonica showed more severe motor impairment at the UPDRS scale, higher damage of cognitive and motor functions at MMSE, Token and Trial Making tests. Genetic variables showed a different allelic distribution of DRD4 gene between cases and controls, outside Valcamonica, where a less frequent familiarity for parkinsonism was reported., Conclusions: Parkinsonian patients with previous exposure to metals showed a more severe neuropsychological phenotype, without detectable contribution from genetic factors.

To compare data obtained in a pilot study (2002) which evaluated the risk from exposure to stress and burnout in health care workers, the same three subjective questionnaires were administered: the Job Content Questionnaire (JCQ), the State-Trait Anxiety Inventory (STAI), the Maslach Burnout Inventory (MBI). The evaluation considered 294 workers employed in eight units: two of the six previous units were reorganized in four subunits. Preliminary data showed that questionnaires' scores have a concordant trend in the different units, as observed in 2002, confirming the validity of the instruments adopted. Results indicated a decreased level of the perceived stress in all the units, especially in the Third Division. We can hypothesize that the new organization, workers' turnover during the 5 years and the effect due to individual variables could have contribute to the observed variation. No significant associations, compared to 2002, between questionnaires' scores and task were found. Further evaluations, including measurement of objective parameters, will be carried out to complete the follow-up study and to determine which variables could have a role in the variation of the levels of stress and burnout's subjective perception.

Aiming to register workplace violence in health care workers, we adopted two evaluation methods: direct and indirect. The direct method is represented by the Violent Incident Form (VIF), a 16 items checklist, which resumes the key aspects of violence events, identifying spatial and temporal circumstances, aggressor, type of violence and consequences. Indirect method is constituted by the observation of injury reports, through three sources: the Prevention and Protection Service (SPP), the Public Relation Office and the Police Position of the First Aid Unit. Although the instruments adopted, thus not comparable each other, pointed out a rather high number of violence events suffered by health care workers (direct method: 34 reports in the period 2002-2006; indirect method: 25 subjects, 8.5% of total); in most cases, the events were perpetrated by a patient, and directed against female of nurses. The most reported types of violence were: kicking, beating, hitting (indirect method) and verbal assault/threats (direct method). The study pointed out that workplace violence is an important risk factor, and therefore it is necessary to consider it for preventive intervention.

Our Institute has been following for 20 years a group of workers of a ferroalloy industry in order to evaluate neurobehavioral effects due to manganese exposure. Five years after the last study we have planned another one, to evaluate differences in neuromotor e cognitive functions between exposed and controls and to perform a longitudinal evaluation of the results. Environmental and biological sampling were collected, liver and kidney functionality, haemochrome, iron metabolism and sieric prolactine were evaluated. Several tests were administered: postural evaluation, tremor, four tests of the SPES battery, Pursuing Aiming, five tests of the Luria Nebraska Motor Battery, Raven Progressive Matrices, Trail Making Test, Mood Scale, Brief Symptoms Inventory, neuropsychological symptoms questionnaire. Personal habits and working, living and clinical histories were collected. We evaluated 43 exposed workers and 40 controls. Exposure indicators resulted all significantly higher in exposed workers. Neuropsychological examination showed differences in Raven Progressive Matrices and Pursuit Aiming, higher tremor values and differences in postural evaluation between exposed and controls.

Background: Parkinson's disease (PD) is characterized by a progressive degeneration of the nigrostriatal dopaminergic pathway resulting in movement disorders. PD is a complex disease, in which and environmental factors, as exposure to toxins or metals coul be involved., Objective: To assess if serum metals (Cu, Fe, Zn), biological variables of their metabolism, total peroxides and antioxidants were abnormal in PD, in relation to environmental exposure., Methods: We compared levels of serum copper, iron, zinc, ceruloplasmin and transferrin, peroxides, antioxidants (TRAP) in 65 PD patients coming from an Industrial zone highly exposed to metal pollution (Valcamonica) with measures from 28 PD patients from no metal pollution areas of the province of Brescia and 52 healthy controls coming from Valcamonica and 24 from the province of Brescia., Results: PD patients had higher serum concentration of zinc than controls. Only in PD patients coming from Valcamonica levels of Cu were higher than in subjects coming from the province of Brescia. Moreover, In patients with PD levels of sieric Cu significantly correlated with score of the Unified Parkinson's Disease Rating Scale (UDPRS)., Conclusions: Zinc seems to be higher in PD independently from the exposition to metal pollution. Perturbation of copper metabolism in PD seems to be related to exposition to environmental toxins or metal pollution and coul be involved in the progression of the disease itself.

The aims of this study are to verify the potential lead damage on olfactory function and to identify early effects due to lead exposure. Our diagnostic evaluation included: (i) questionnaire to collect data about work and clinical history, (ii) olfactory evaluation: threshold test (Single-Starcaise) and identification/discrimination test (Wright). Lead exposure was evaluated by air sampling and biological monitoring (PbB, lead in blood). A sample of 18 exposed workers (mean age: 41.3 +/- 7.8; years exposure: 8.38 +/- 6) and of 39 controls (mean age: 41.9 +/- 9.7) were evaluated. The comparison between the threshold test of two groups confirmed a worse olfactory function in exposed (-4.97 log(10)vol/vol) compared to controls (-6.37 log(10)vol/vol), while the Wright test didn't show any significant correlation. The study didn't find a significant association between individual PbB levels and the threshold test. Knowledge of the effect of chronic occupational exposure to industrial chemicals on olfactory function is largely incomplete, but supports the hypothesis that olfactory neuroepithelium is susceptible to environmental exposures to chemicals. Occupational-related olfactory impairment is usually sub-clinical, and can be only detected using adeguate quantitative olfactory function testing procedures for quality research in this field.

Using the Hospital computerized database, individual variables including referral source, gender; age, life style, work sector, clinical and work history, final clinical diagnosis and work-relatedness evaluation were retrieved and analysed. The results of this survey showed a significant increase of number of cases, especially from 1999 to 2006. Shoulder disorders showed a significant increase in the latest years of the observation period, while the other upper limb districts remained constant. The work sectors mostly affected were textile, construction, metalmechanical and food industry. The findings of this study indicates an increasing demand for clinical assessment of work-related musculoskeletal disorders of the upper limb. Therefore, it is important that a standardized diagnostic procedure is applied together with an accurate evaluation of biomechanical overload.

Introduction: Stress is usually defined as the experience of negative events or the perceptions of distress and negative affect that are associated with the inability to cope with them. The parameter most suitable for large-scale field studies is the determination of endocrine activity by measurement of salivary cortisol. The aim of the present study is to identify the presence of sources of stress in an emergency team of urban police and to objective such stress using the PSS (Professional Stress Scale) test and bioumoral markers as salivary cortisol and interleukin 1 /f (IL-IB)., Materials and Methods: We studied 30 policemen who belonged to an emergency team. Salivary samples were collected at the start and at the end of the work-shift. As control we used the same subjects during the holiday. T test was performed to evaluate the differences between the means, the Chi Square's Test was performed to determine the statistically significant association between PSS subscales and salivary cortisol and ILl-B concentrations., Results: Thirty policeman were evaluated, their mean age was 44,5 years, their mean work experience was 17,1 years. The PSS test indicated high scores in three subscales, they were work load, organizational structure and processes and lack of resources. SALIVARY CORTISOL: The mean concentration at the start of work-shift was higher than at the end of shift-work (p<0,05). T test indicated a statistically significant difference between mean cortisol concentrations at the same hour during the work (start and end) and during the holiday (P<0,05). A statistically significant negative association was noted between the PERC1 and PSS subscale called "work load" (p<0,05). SALIVARY IL-1B: the mean concentration of ILl-B at the start of the work-shift resulted higher than at the end, such reduction was statistically significant (P<0.05). We verified a positive association between the subclass of PSS Test called "conflict with other professionals" and salivary IL-1B concentration at the start of shift-work (p<0,05). DISCUSSION. Several precedent studies agree with our results. Our study has suggested a work related stress in urban police employed in an emergency team. We might conclude that salivary IL-1B and cortisol are useful markers of stress. We think that our findings, surely preliminary, have be corroborated by the study of vegetative parameters (heart rate, heart rate variability) that is still current. It might be useful to evaluate again the cortisol and IL-1B variations after some structure organizational modifications and after training that will teach the workers coping strategies. We might conclude that the stress discovered in this study is not hazardous for the health, if the workers have adequate holidays.

To assess the risk from exposure to stress and burnout in health care workers, a pilot study was planned to compare and integrate the information based on the risk evaluation obtained through different parameters that can be quantified and elaborated to produce a numerical index, called the "Stress Index", and the subjective symptoms from the individual workers. For these purposes, three internationally validated questionnaires were administered: the Job Content Questionnaire, the State-Trait Anxiety Inventory and the Maslach Burnout Inventory. The study considered six different Units from three divisions of Internal Medicine of a large public hospital in Northern Italy, and a total group of 228 health care workers employed in the six units. The results showed an association between the Stress Index scores and the scores from the questionnaires. In particular, in the two units with the highest levels of the index, a significantly higher unbalance between job demand and decision latitude was observed, together with the highest levels of state and trait anxiety and of depersonalization, indicating higher burnout levels.

The prevalence of parkinsonian syndromes was studied in the province of Brescia (Northern Italy), in order to verify its possible increase in the surroundings of ferroalloy plants located in a valley of the pre-Alps. A case-list of subjects affected by these disturbances was identified using four different sources of information: a) registers from local medical clinics; b) admission charts from local hospitals; c) consumption of levodopa; d) NHS list of exemption from prescription payment, due to the illness. Exploratory data show a frequency of parkinsonian disturbances among the residents in the surroundings of the ferroalloy plants and downwind (crude prevalence = 358/100,000 population, standardized for age and sex = 438) significantly higher (s.m.r, = 1.58; C.I. = 1.41-1.76) than the entire Province (crude prevalence 246/100,000). This preliminary result could indicate the interaction of prolonged environmental exposure to heavy metals, such as manganese, and genetic factors, potentially relevant in this mountain population.

In industrialised countries, carpal tunnel syndrome (CTS) is considered an epidemic work-related disease. We have set up the MODS (Malattie Occupazionali Da Sovraccarico biomeccanico, biomechanical overload-related occupational diseases) collaborative group, formed by epidemiologists, ergonomists and occupational physicians to investigate CTS in Italy, applying the methods that epidemiologists commonly use to understand epidemics. Several studies are already ongoing. Two different descriptive studies based on current hospitalisation data are in the reporting phase. A pilot case-control multicentre study (260 cases and 520 controls in 13 centres) is in the final phase of data collection. A longitudinal study on a cohort of 3000 subjects exposed to different risk factors has reached the third year of follow-up. Moreover, a surveillance system has been set up to cover selected districts of the Emilia Romagna region. These studies will generate new information about the prevalence and incidence of CTS in Italy, along with identification of regional, high-risk job titles and work sectors, and the relative influence of non-occupational factors.

Repetitive motions of the upper limb at work can induce muskulo-skeletal alterations, therefore a specific medical surveillance is needed, according to the intensity of risk. In low risk conditions, the medical surveillance is aimed at the identification of hyper-susceptible individuals and the administration of specific information programs. When the risk intensity is higher, medical surveillance should add the recognition of early symptoms and signs of muskulo-skeletal disturbances, in order to remove workers showing early alterations from the exposure and allow medical rehabilitation. The diagnostic protocols with the adequate instrumental evaluation are provided, and the required legal reporting is discussed.

Health education (HE) is very important in the prevention of occupational diseases, particularly when exposure to risk factors can be reduced through working procedures and hygienic behaviours. This pilot study refers to a HE program for prevention of work related muscle-skeletal disorders of upper limbs, carried out in two groups of 15 and 12 workers, respectively employed in trimming and assembling of plastic and metal parts. The first phase of the program consisted of worksite inspections and video recording of working procedures, characteristics of tools and machinery. This was followed by an informative meeting with the workers, which began with the administration of a multiple choice questionnaire, designed to evaluate the baseline knowledge about risk factors, work related muscle-skeletal disorders of upper limbs, working specific procedures and preventive actions. Questionnaires and video recording were repeated after two months in the second phase of the program, as subjective and objective methods of evaluation of HE effectiveness. In both groups, the questionnaire score was significantly increased after the program and a clear improvement was shown in the correct working procedures. This HE program contributed to increase the level of knowledge of the workers and fostered the adoption of working behaviours suitable to reduce the strain for the upper limbs.