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We present some cases of rhinitis and asthma in wooding workers exposed to hard or soft woods. The specific provocation test confirmed the diagnosis of rhinitis in three patients and of asthma in four. Rhinitis was caused by oak, beech, and pine, while asthma was caused by obeche, chestnut, acacia, and iroko. Occupational exposure to the specific wood, before onset of symptoms (symptom latency) was shorter for patients with asthma. All seven patients with respiratory symptoms were nonsmokers; three were atopics and four, all with asthma, had nonspecific bronchial hyperreactivity. Twenty-four hours after the test, PD20FEV1 had decreased in two cases with rhinitis and two with asthma, although the data did not reach statistical significance (Wilcoxon matched-pairs test: NS). After the SBPT, blood eosinophils increased in two cases with rhinitis and three with asthma, and the data were at the limit of statistical significance (P = 0.046). The study confirms that not only hard essences, but also soft woods can cause respiratory symptoms, although the pathogenetic mechanisms are still unclear. A specific provocation test is still the best and sometimes only means of diagnosing wood asthma; standardized protocols with repeated measurements of nonspecific airway responsiveness and of eosinophils in the blood may be helpful for a better understanding of the pathogenetic mechanism and predisposing factors.

Two cases of paraoccupational asthma caused by toluene diisocyanate (TDI) are reported. The first patient was a metal worker in a machine shop situated near a factory producing polyurethane foam. Symptoms at work were not explainable by any specific exposure to irritants or allergens in the work site. As the patient recalled previous occasional work in the adjacent polyurethane factory with accompanying worsening of respiratory symptoms, a specific inhalation (SIC) test was performed with TDI, which confirmed the diagnosis of TDI asthma. The second case was a woman working part time as a secretary in the offices of her son's factory for varnishing wooden chairs. TDI was present in the products used in the varnishing shed. The SIC test confirmed the diagnosis of TDI asthma, despite the fact that the patient's job did not present risk of exposure to the substance. In both patients, symptoms disappeared when further exposure was avoided. These two cases confirm that paraoccupational exposure to TDI must be considered when evaluating patients with asthma not mediated by immunoglobulin E. They also suggest the need for more prospective studies evaluating the health risk for the general population living near polyurethane factories or other firms that use TDI. Keywords: paraoccupational exposure; toluene diisocyanate; asthma

Background. The severity of occupational asthma (OA) at the time of diagnosis is not known. In this study we aimed to evaluate some features of the disease at the time of diagnosis, particularly looking at severity and treatment before diagnosis. Methods: Medical records of subjects (n = 197) who had received a diagnosis of OA in six specialized centres of Northern and Central Italy in the period 1992–97 were reviewed. The severity of the disease at the time of diagnosis was determined on the basis of symptoms, peak expiratory flow (PEF, percentage predicted), forced expiratory volume in one second (FEV1, percentage predicted), and PEF variability, following the criteria of the National Institutes of Health and World Health Organizaton (NIH/WHO) guidelines on asthma. Medications used in the month before diagnosis were recorded. Results: The most common etiological agents were isocyanates (41.6%), flours (19.8%), woods (9.7%) and natural rubber latex (7.6%). The level of asthma severity (AS) was mild intermittent in 23.9% patients, mild persistent in 28.9%, moderate in 41.6%, and severe in 5.6%. Asthma severity was positively associated with current or previous smoking (P

Haemopoietic effects of ethylene glycol monomethyl ether (EGME) are described in three young women employed in a frame factory where the substance was applied under apparently safe hygienic conditions. In a ventilated room they used a mixture of acetone (70%) and EGME (30%) to glue together cellulose acetate frame components. During a periodic medical examination their white blood cell count was found to be abnormally low, with a relative lymphocytosis, macrocytosis with red blood cells, and haemoglobin at borderline normal values. These findings persisted over the exposure period but the haematological parameters returned to normal on stopping exposure. The subjects remained clinically healthy during the exposure period. This exposure to EGME occurred in an industry where such toxicity had not been previously reported and describes a situation in which the risk did not come from the exposure to vapour but most likely from an insufficient skin protection.

OBJECTIVES—To investigate the occurrence of work related respiratory symptoms and to assess the effect of atopy in a group of trainee bakers. METHODS—A prospective study of work related respiratory symptoms among 125 trainee bakers who were investigated with a questionnaire plus skin prick test with wheat flour and α-amylase allergens at baseline and then after 6, 18, and 30 months. RESULTS—At the baseline examination, four students (3.2%) complained of respiratory symptoms (cough and rhinitis) when working with flours and four were skin positive to wheat flour or α-amylase. The incidence of work related respiratory symptoms was 3.4% at 6 months, and the cumulative incidence was 4.8% and 9.0% at 18 and 30 months, respectively. The incidence of skin sensitisation to occupational allergens was 4.6% at 6 months and the cumulative incidence was 4.6% at 18 months and 10.1% at 30 months. The generalised estimating equation approach to longitudinal data showed that work related respiratory symptoms in the study population was significantly associated with a personal history of allergic disease (odds ratio (OR) 5.8, 95% confidence interval (95% CI) 1.8 to 18.2) and skin sensitisation to wheat flour or α-amylase (OR 4.3, 95% CI 1.2 to 14.9). Atopy based on prick test was not related to the occurrence of work related respiratory symptoms over time (OR 1.1, 95% CI 0.3 to 3.8). CONCLUSIONS—Personal history of allergic disease is a predisposing factor for the development of symptoms caused by exposure to wheat flour and may be a criterion of unsuitability for starting a career as a baker. Atopy based on the skin prick test is useful for identifying subjects with allergic disease, but should not be used to exclude non-symptomatic atopic people from bakery work. Keywords: follow up study; wheat flour; α-amylase sensitisation; work related respiratory symptoms

Objective: The aim of this study was to eval- uate the outcome of the specific inhalation challenge test (SIC) in 160 subjects with suspected baker's asthma and to assess its relation to total flour dust levels and to personal characteristics such as specific skin sensitisa- tion, non-specific bronchial hyper-responsiveness (NSBH) and atopy. Methods: We investigated the out- come of SIC tests performed with wheat flour in six Italian laboratories. For each subject, data was available regarding skin sensitisation to wheat flour, NSBH, ato- py, forced expiratory volume at 1 s (FEV1) monitoring and airborne flour dust in the challenge chamber mea- sured by the gravimetric method (total dust in mg/m 3 ). Results: The SIC test was positive for early asthma in 42 subjects (26%) and for late/dual asthma in 18 (11%). Positive outcome to SIC was significantly associated with NBSH (odds ratio, OR: 3.5, 95% CI: 1.6-7.7) and skin sensitisation to wheat flour (OR: 3.1, 95% CI: 1.3- 7.0). Exposure level to wheat flour was less than or equal to 10 mg/m 3 in 12% of individuals, ranged between 11 and 30 mg/m 3 in 43% and exceeded 30 mg/m 3 in 45%. The outcome of SIC was always negative among workers not skin sensitised to wheat flour and without NSBH and atopy. An increasing prevalence of positive SIC was observed among workers with one or more of the above-mentioned personal characteristics whose challenge exposure was greater than 10 mg/m 3 (P < 0.001). Conclusion: Procedures currently adopted for wheat flour dust exposure during SIC need to be better standardised in order to avoid excessive airborne dust exposure. Over-exposure seems to be of no use for the diagnosis and risks making the asthmatic reaction worse, particularly in patients who are both sensitised to wheat allergens and have NSBH and/or atopy.

OBJECTIVES--To assess the prevalence of atopy in a vocational school so as to evaluate the feasibility of pre-employment screening. METHODS--The prevalence of atopy by family diathesis, prick tests, immunoglobulin E (IgE) concentrations, and personal history of allergic respiratory diseases was investigated in 144 trainee bakers and 81 students on a graphic artists course (mean age 15.4 years). Skin sensitisation to wheat, rye, and barley flours, to alpha amylase, and to storage mites was also evaluated. RESULTS--Personal allergic symptoms were reported by 13.2% of the bakers and 14.7% of the graphic artists and there was a significant association between symptoms and atopy by prick tests (odds ratio (OR) 17.2; 95% confidence interval (95% CI) 5.27-56.4) and by family history (OR 3.11; 95% CI 1.02-9.53). When bakers were grouped according to the presence of allergic symptoms and results of immunological tests, 6.9% had asthma, 6.3% had rhinoconjunctivitis, and a high percentage (28.5%) were without symptoms but scored positive on prick tests or family symptoms. Skin sensitisation to storage mites had similar prevalences (16%) in the two groups of trainees and occurred nearly always in atopic people. Positive skin tests to wheat flour (3.5%), rye (0.7%), and alpha amylase (0.7%) were specific to bakers. CONCLUSIONS--Pre-employment screening is a useful source of medical information and allows for counseling. The presence of asthma, or of another allergic disease in a severe form, is suggested as a criterion for excluding students of a vocational school from training as bakers. Student bakers without allergic symptoms but atopic by other criteria should be informed about their risks of developing occupational asthma, and periodic check ups must be recommended. Screening studies in vocational school provide a better understanding of specificity of skin sensitisation to occupational allergens.

A survey was carried out on respiratory symptoms and skin prick test response to common allergens (atopy), storage mites, and occupational allergens among 226 bakers and pastry makers from 105 small businesses in northern Italy. Atopy was present in 54 workers (23.4%); 40 workers (17.7%) were skin positive to at least one storage mite, 27 (11.9%) to wheat flour and 17 (7.5%) to alpha-amylase. Work related asthma was reported by 11 (4.9%) workers and rhinoconjunctivitis by 31 (17.7%); 22 workers (10.2%) complained of chronic bronchitis. The distribution of skin prick test results among bakers and among 119 white collar workers did not indicate (by logistic analysis) an increased risk for bakers to skin sensitisation to common allergens, storage mite, or to a group of five flours. Sensitisation to wheat flour, on the other hand, was present only among exposed workers. Skin sensitisation to occupational allergens was significantly associated with atopy (p < 0.001), smoking habit (p = 0.015), and work seniority (p = 0.027). The risk of work related symptoms was associated with sensitisation to wheat or alpha-amylase, and with atopy, but not with sensitisation to storage mites, work seniority, or smoking habit. The results of the study indicate that there is still a significant risk of allergic respiratory disease among Italian bakers. Not only wheat allergens, but also alpha-amylase must be considered as causative agents, although sensitisation to storage mites is not important in the occupational allergic response. Atopy must be regarded as an important predisposing factor for skin sensitisation to occupational allergens and for the onset of symptoms at work. The data confirm that for effective prevention, greater care should be taken not only in limiting environmental exposure, but also in identifying susceptible people.

Hypersensitivity to rubber is usually reported as contact dermatitis due to substances used in its processing; however, recent reports in patients attribute IgE mediated reactions specifically to latex and not to chemical additives. These patients were first seen with contact urticaria, but tissue contact with both medical and non-medical latex rubber may also precipitate anaphylactic reactions mediated by IgE.1"3 We describe a case of immediate hypersensitivity to natural latex in a nurse working in a dialysis unit.

The authors report on pollution measures in some operating theatres and consider biological data for the hepatic and hemopoietic functions in operating room personnel and in control groups. Waste gas concentrations range from 17.3 to 22.6 ppm for enfluorane and from 500 to 1275 for N2O in theatres not equipped with antipollution systems. Pollution is 3-8 times lower when a scavenging system is present, while with horizontal laminar air flow exhaust in function, the gas concentration in the air is insignificant. Tests for the hepatic and hematological functions, done on 61 operating room personnel, 87 ward nurses, and 69 technicians and physicians of radiology services, do not show any significant difference between those exposed to anesthetic gases and controls.

Dock workers (n = 218) occupationally exposed to green coffee beans (GCB) were studied, using a specific questionnaire for allergic symptoms and skin tests for common and occupational allergens. Thirty-one workers (14.3%) complained of allergic symptoms of the eye, nose and bronchial system at the workplace. The prick tests, using both commercial allergens and specific extracts prepared from the most common types of coffee and their corresponding sacks, confirmed a sensitization in 21 workers (9.6%). A positive skin reaction to castor beans (CB) was found in nearly all these cases; in ten workers there was also a positive reaction to GCB allergens and in 14 cases prick tests were positive to extracts of sacks. There was a good concordance between prick tests and specific IgE for CB (95.0%) and also, but to a lesser extent, for GCB. The authors concluded that there is a significant risk of sensitization to CB and GCB allergens in dock workers occupied in handling green coffee bean, despite the fact that the exposure is not continuous. CB emerged as a common contaminant of GCB from various countries. For effective prevention, a modification of the methods of transport is required to avoid CB contamination to other products. Eliminating environmental dust during shipping operations is the most important preventive measure and it can be achieved by the use of containers, as some exporting countries are already doing.