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Abstract Background Cancer is a significant and growing problem worldwide. While this increase may, in part, be attributed to increasing longevity, improved case notifications and risk-enhancing lifestyle (such as smoking, diet and obesity), hygiene-related factors resulting in immuno-regulatory failure may also play a major role and call for a revision of vaccination strategies to protect against a range of cancers in addition to infections. Discussion Human endogenous retroviruses (HERVs) are a significant component of a wider family of retroelements that constitutes part of the human genome. They were originated by the integration of exogenous retroviruses into the human genome millions of years ago. HERVs are estimated to comprise about 8% of human DNA and are ubiquitous in somatic and germinal tissues. Physiologic and pathologic processes are influenced by some biologically active HERV families. HERV antigens are only expressed at low levels by the host, but in circumstances of inappropriate control their genes may initiate or maintain pathological processes. Although the precise mechanism leading to abnormal HERVs gene expression has yet to be clearly elucidated, environmental factors seem to be involved by influencing the human immune system. HERV-K expression has been detected in different types of tumors. Among the various human endogenous retroviral families, the K series was the latest acquired by the human species. Probably because of its relatively recent origin, the HERV-K is the most complete and biologically active family. The abnormal expression of HERV-K seemingly triggers pathological processes leading to melanoma onset, but also contributes to the morphological and functional cellular modifications implicated in melanoma maintenance and progression. The HERV-K-MEL antigen is encoded by a pseudo-gene incorporated in the HERV-K env-gene. HERV-K-MEL is significantly expressed in the majority of dysplastic and normal naevi, as well as other tumors like sarcoma, lymphoma, bladder and breast cancer. An amino acid sequence similar to HERV-K-MEL, recognized to cause a significant protective effect against melanoma, is shared by the antigenic determinants expressed by some vaccines such as BCG, vaccinia virus and the yellow fever virus. HERV-K are also reactivated in the majority of human breast cancers. Monoclonal and single-chain antibodies against the HERV-K Env protein recently proved capable of blocking the proliferation of human breast cancer cells in vitro, inhibiting tumor growth in mice bearing xenograft tumors. Summary A recent epidemiological study provided provisional evidence of how melanoma risk could possibly be reduced if the yellow fever virus vaccine (YFV) were received at least 10 years before, possibly preventing tumor initiation rather than culling melanoma cells already compromised. Further research is recommended to confirm the temporal pattern of this protection and eliminate/attenuate the potential role of relevant confounders as socio-economic status and other vaccinations. It appears also appropriate to examine the potential protective effect of YFV against other malignancies expressing high levels of HERV-K antigens, namely breast cancer, sarcoma, lymphoma and bladder cancer. Tumor immune-therapy, as described for the monoclonal antibodies against breast cancer, is indeed considered more complex and less advantageous than immune-prevention. Cellular immunity possibly triggered by vaccines as for YFV might also be involved in anti-cancer response, in addition to humoral immunity.

Abstract Background The current literature reports increased infectious disease occurrence in various construction occupations, as an important contributor to morbidity and mortality arising from employment. These observations should be expanded to asbestos abatement workers, as the abatement can create an environment favorable for bacterial, viral and fungal infections. Discussion Asbestos abatement work employs activities resulting in cuts, blisters and abrasions to the skin, work in a dirty environment and exposure to dust, mists and fumes. Furthermore, this population exhibits a high smoking rate which increases the risk of chronic obstructive pulmonary disease and respiratory infections. In addition, these workers also commonly employ respirators, which can accumulate dirt and debris magnifying exposure to microbes. Use of respirators and related types of personal protective equipment, especially if shared and in the close environment experienced by workers, may enhance communicability of these agents, including viruses. Summary Abatement workers need to be provided with information on hazards and targeted by appropriate health education to reduce the infection risk. Epidemiological studies to investigate this risk in asbestos removers are recommended.

Abstract Background Although the management of sarcoma is improving, non adherence to clinical practice guidelines (CPGs) remains high, mainly because of the low incidence of the disease and the variety of histological subtypes. Since little is known about the health economics of sarcoma, we undertook a cost-effectiveness analysis (within the CONnective TIssue CAncer NETwork, CONTICANET) comparing costs and outcomes when clinicians adhered to CPGs and when they did not. Methods Patients studied had a histological diagnosis of sarcoma, were older than 15 years, and had been treated in the Rhône-Alpes region of France (in 2005/2006) or in the Veneto region of Italy (in 2007). Data collected retrospectively for the three years after diagnosis were used to determine relapse free survival and health costs (adopting the hospital's perspective and a microcosting approach). All costs were expressed in euros (€) at their 2009 value. A 4% annual discount rate was applied to both costs and effects. The incremental cost-effectiveness ratio (ICER) was expressed as cost per relapse-free year gained when management was compliant with CPGs compared with when it was not. To capture uncertainty surrounding ICER, a probabilistic sensitivity analysis was performed based on a non-parametric bootstrap method. Results A total of 219 patients were included in the study. Compliance with CPGs was observed for 118 patients (54%). Average total costs reached 23,571 euros when treatment was in accordance with CPGs and 27,313 euros when it was not. In relation to relapse-free survival, compliance with CPGs strictly dominates non compliance, i.e. it is both less costly and more effective. Taking uncertainty into account, the probability that compliance with CPGs still strictly dominates was 75%. Conclusions Our findings should encourage physicians to increase their compliance with CPGs and healthcare administrators to invest in the implementation of CPGs in the management of sarcoma.

When we go back in mythological time, far, far, back, maybe as far back as the Garden of Eden we see a primordial symbol, a serpent coiled around a tree. [...]

Abstract Background Although popular tattoos are often regretted later on for different reasons. Nevertheless, tattoo removal is a complicated and costly procedure seldom providing satisfactory results. The aim of this study was to investigate the awareness of the implications of tattoo removal among a substantial sample of Italian secondary school adolescents. Findings Students were recruited by a stratified convenience sample and surveyed by a self administered questionnaire. Logistic regression analysis was performed, reporting adjusted Odds Ratios (OR), with 95% Confidence Interval (CI). 4,277 pupils returned a usable questionnaire. Piercings were more frequently undertaken than tattoos. Only 40% of the respondents were aware of the issues related to tattoo removal. Males and pupils with younger fathers were less likely to be aware, whereas students satisfied with their physical appearance and those with a positive attitude towards body art were more likely to be aware. Conclusions Male adolescents with younger fathers can be regarded as the ideal target of corporate health education programs driven by school counsellors and primary care physicians.

Abstract Background Osteopontin (OPN) is a plasma protein/cytokine produced in excess in several malignancies. In a recent study OPN was reported as being related to the duration of asbestos exposure and presence of benign asbestos-related diseases; however, it was unclear whether this protein was an indicator of exposure or effect. Methods In 193 workers, 50 with pleural plaques (PP), in whom different indicators of past asbestos exposure were estimated, OPN plasma levels were assessed using commercial quantitative sandwich enzyme immunoassays according to the manufacturer's instructions. Results Osteopontin increased with increasing age and several aspects of asbestos exposure, without differences related to the presence of pleural plaques. At multivariable regression analysis, the explanatory variables with a significant independent influence on OPN were length of exposure (positive correlation) and time elapsed since last exposure (positive correlation). Conclusions Since asbestos in lung tissue tends to wane over time, OPN should decrease (rather than increase) with time since last exposure. Therefore, OPN cannot be a reliable biomarker of exposure nor effect (presence of pleural plaques).

Abstract Background Some industrial hygiene studies have assessed occupational exposure to antineoplastic drugs; other epidemiological investigations have detected various toxicological effects in exposure groups labeled with the job title. In no research has the same population been studied both environmentally and epidemiologically. The protocol of the epidemiological study presented here uses an integrated environmental and biological monitoring approach. The aim is to assess in hospital nurses preparing and/or administering therapy to cancer patients the current level of occupational exposure to antineoplastic drugs, DNA and chromosome damage as cancer predictive effects, and the association between the two. Methods/Design About 80 healthy non-smoking female nurses, who job it is to prepare or handle antineoplastic drugs, and a reference group of about 80 healthy non-smoking female nurses not occupationally exposed to chemicals will be examined simultaneously in a cross-sectional study. All the workers will be recruited from five hospitals in northern and central Italy after their informed consent has been obtained. Evaluation of surface contamination and dermal exposure to antineoplastic drugs will be assessed by determining cyclophosphamide on selected surfaces (wipes) and on the exposed nurses' clothes (pads). The concentration of unmetabolized cyclophosphamide as a biomarker of internal dose will be measured in end-shift urine samples from exposed nurses. Biomarkers of effect and susceptibility will be assessed in exposed and unexposed nurses: urinary concentration of 8-hydroxy-2-deoxyguanosine; DNA damage detected using the single-cell microgel electrophoresis (comet) assay in peripheral white blood cells; micronuclei and chromosome aberrations in peripheral blood lymphocytes. Genetic polymorphisms for enzymes involved in metabolic detoxification (i.e. glutathione S-transferases) will also be analysed. Using standardized questionnaires, occupational exposure will be determined in exposed nurses only, whereas potential confounders (medicine consumption, lifestyle habits, diet and other non-occupational exposures) will be assessed in both groups of hospital workers. Statistical analysis will be performed to ascertain the association between occupational exposure to antineoplastic drugs and biomarkers of DNA and chromosome damage, after taking into account the effects of individual genetic susceptibility, and the presence of confounding exposures. Discussion The findings of the study will be useful in updating prevention procedures for handling antineoplastic drugs.

A major natural disaster, like the recent Asian tsunami in the Indian Ocean has triggered much debate and discussion, including editorials and commentaries in a variety of journals [1-4] and [...]

Abstract Background Statistics on occupational accidents are based on data from registered employees. With the increasing number of immigrants employed illegally and/or without regular working visas in many developed countries, it is of interest to estimate the injury rate among such unregistered workers. Findings The current study was conducted in an area of North-Eastern Italy. The sources of information employed in the present study were the Accidents and Emergencies records of a hospital; the population data on foreign-born residents in the hospital catchment area (Health Care District 4, Primary Care Trust 20, Province of Verona, Veneto Region, North-Eastern Italy); and the estimated proportion of illegally employed workers in representative samples from the Province of Verona and the Veneto Region. Of the 419 A&E records collected between January and December 2004 among non European Union (non-EU) immigrants, 146 aroused suspicion by reporting the home, rather than the workplace, as the site of the accident. These cases were the numerator of the rate. The number of illegally employed non-EU workers, denominator of the rate, was estimated according to different assumptions and ranged from between 537 to 1,338 individuals. The corresponding rates varied from 109.1 to 271.8 per 1,000 non-EU illegal employees, against 65 per 1,000 reported in Italy in 2004. Conclusions The results of this study suggest that there is an unrecorded burden of illegally employed immigrants suffering from work related injuries. Additional efforts for prevention of injuries in the workplace are required to decrease this number. It can be concluded that the Italian National Institute for the Insurance of Work Related Injuries (INAIL) probably underestimates the incidence of these accidents in Italy.

Abstract Background The Italian Protective Maternity Legislation allows a woman to apply for early maternity leave from work during pregnancy if she is affected by health problems (option A) or if her working conditions are incompatible with pregnancy (option B). A community based health education program, implemented between 1995 to 1998 in North Eastern Italy, provided counseling (by a team of gynecologists, pediatricians, geneticists, psychologists and occupational physicians), and an information leaflet detailing the risks during pregnancy and the governmental benefits available to expectant mothers. This leaflet was distributed to women who were under occupational medical surveillance and to women attending any healthcare office and outpatient department and was also mailed to women working at home as shoemakers. The effectiveness of this intervention has been evaluated in this investigation using an evidence based approach. Methods A quasi-experimental design was adopted, applying several outcome measurements before (1989 to 1994) and after (1999 to 2005) the intervention. The outcome (ratio B/A) is the number of women receiving approval for B (circumstance where the pregnant woman is employed to undertake activities forbidden under the Article 7 of Law 151/2001, and it is impossible to change her duties) to those receiving approval for A (risky pregnancy due to personal medical conditions, Article 17 of the same Law). A linear regression coefficient (for B/A against years) was obtained separately for time periods "before" (1989-94) and "after" (1999-2005) the intervention program. The two regression coefficients were compared using a t-test. Results The trend over-time for the ratio B/A was steady before the initial intervention (y = 0.008x - 16.087; t = 2.09; p > 0.05) then increased considerably (y = 0.0426x - 84.89; t = 19.55; p < 0.001) in coincidence with the start of the education campaign. There was a significant difference between the two regression coefficients (t = 7.58; p < 0.001). Conclusion From a bureaucratic perspective Option B is far more complicated than A. In fact it implies an active approach involving an arrangement between the claimant and the employer, who has to certify to the relevant Authority that the woman's working conditions are incompatible with pregnancy. The increasing number of women availing of option B, as recommended, therefore suggests the suitability of such educational campaign(s).

Abstract Background This study examines the underlying characteristics of adolescents attending Italian secondary school who expressed indifference towards or no interest at all in body art. Methods A convenience sample of 4,277 secondary school students from the North Eastern Italy were surveyed with a self-reported questionnaire collecting extensive socio-demographic information. Multivariable logistic regression analysis was employed to investigate the characteristics of those who were not interested or indifferent towards piercing and tattoo, reporting adjusted Odds Ratios (aOR) with a 95% confidence interval (CI). Results Prevalence of tattoo was 6%, whereas body piercing was 20%; 66% (= 558/840) of those with a piercing were underage ( Discussion Proactive health education campaigns by school educators and family physicians should focus on adolescents of less educated fathers and pupils less aware of the health risks associated with body art. In this respect junior secondary school students can be regarded as the ideal target of such campaigns.

Abstract Background Rather than a clinical diagnosis, in occupational medicine the critical point is the etiological diagnosis. The first is useful for the therapy, the latter for preventive, epidemiological, regulatory, and insurance measures. Discussion As with causality criteria which are employed in population studies, the answering of four easy questions allows a Primary Care Practitioner to establish a causal link between the work activities and a potential disease that a specific patient may present. After determining the clinical diagnosis and the actual pathology of an occupational disease, the identity, duration, and intensity of the exposure have to be detected for establishing a close-causal effect. The judgment on the occupational origin of the disease requires an integrated approach using multiple sources of information, and goes beyond the clinical diagnosis. This may require consultation with a specialist in occupational medicine. Summary It is important that the Primary Care Practitioner takes an accurate medical history since this may be the only chance a patient has to have their occupational disease recognised and properly detected/identified. Proper identification of the causative nature of such diseases is important for establishing preventive measures in eliminating and controlling future cases against exposure, epidemiological reporting and studies (particularly in identifying the rates of disease), regulatory reporting requirements and insurance compensation.

Abstract Background Within the context of a European network dedicated to the study of sarcoma the relevant literature on sarcoma risk factors was collected by searching PubMed and Google Scholar, the two information storage and retrieval databases which can be accessed without charge. The present study aims to appraise the relative proficiency of PubMed and Google Scholar. Findings Unlike PubMed, Google Scholar does not allow a choice between "Human" and "Animal" studies, nor between "Classical" and other types of studies. As a result, searches with Google Scholar produced high numbers of citations that have to be filtered. Google Scholar resulted in a higher sensitivity (proportion of relevant articles, meeting the search criteria), while PubMed in a higher specificity (proportion of lower quality articles not meeting the criteria, that are not retrieved). Concordance between Google Scholar and PubMed was as low as 8%. Conclusions This study focused just on one topic. Although further studies are warranted, PM and GS appear to be complementary and their integration could greatly improve the search of references in medical research.

Abstract Background Sarcomas are rare tumors (1-2% of all cancers) of mesenchymal origin that may develop in soft tissues and viscera. Since the International Classification of Disease (ICD) attributes visceral sarcomas (VS) to the organ of origin, the incidence of sarcoma is grossly underestimated. The rarity of the disease and the variety of histological types (more than 70) or locations account for the difficulty in acquiring sufficient personal experience. In view of the above the European Commission funded the project called Connective Tissues Cancers Network (CONTICANET), to improve the prognosis of sarcoma patients by increasing the level of standardization of diagnostic and therapeutic procedures through a multicentre collaboration. Methods/Design Two protocols of epidemiological researches are here presented. The first investigation aims to build the population-based incidence of sarcoma in a two-year period, using the new 2002 WHO classification and the "second opinion" given by an expert regional pathologist on the initial diagnosis by a local pathologist. A three to five year survival rate will also be determined. Pathology reports and clinical records will be the sources of information. The second study aims to compare the effects on survival or relapse-free period - allowing for histological subtypes, clinical stage, primary site, age and gender - when the disease was treated or not according to the clinical practice guidelines (CPGs). Discussion Within CONTICANET, each group was asked to design a particular study on a specific objective, the partners of the network being free to accept or not the proposed protocol. The first protocol was accepted by the other researchers, therefore the incidence of sarcoma will be assessed in three European regions, Rhone-Alpes and Aquitaine (France) and Veneto (Italy), where the geographic distribution of sarcoma will be compared after taking into account age and gender. The conformity of the clinical practice with the recommended guidelines will be investigated in a French (Rhone Alps) and Italian (Veneto) region since the CPGs were similar in both areas.

Abstract Background The awareness of health risks associated with body art among secondary school pupils has never previously been studied in depth. A large sample of secondary school adolescents from the Veneto Region (North East Italy) were investigated in order to inform health education programs. Methods 6 public secondary schools from each of the 7 Provinces of the Veneto Region were selected. All students attending the 1st, 3rd, and 5th school years were surveyed by an anonymous self administered questionnaire on their perception of health risks related to body art and other explanatory variables. Logistic regression analysis was employed, reporting adjusted Odds Ratios (OR) with 95% Confidence Interval (CI). Results Among 4,277 available students (aged 14-22 years), boys were consistently: less knowledgeable of infectious diseases related to body art (OR = 0.78; CI: 0.66, 0.94), less likely to be aware of the hygienic norms to be observed in a body art parlour (OR = 0.54; 0.44, 0.65), less likely to refer to a certified body art parlour (OR = 0.56; 0.48, 0.66), less likely to refer to a professional health care provider for complications related to body art (OR = 0.71; 0.59, 0.86). Students attending the first school year (baseline) had a lesser knowledge of body art related infectious diseases, were less likely to refer to a certified body art parlour, and to know the mandatory hygienic rules to be observed when performing body modifications. Interviewees from the provinces of Rovigo and Vicenza were less likely to be conscious of the health risks associated with body modifications, and those with tattoos were less knowledgeable about the infection risk (OR = 0.60; 0.42, 0.86) and less likely to refer to a professional health care provider in case of medical complication (OR = 0.68;0.48, 0.95). Students with piercings were less likely to refer to a certified practitioner for receiving body art (OR = 0.62; 0.50, 0.77) or therapy for medical complications (OR = 0.37; 0.29, 0.46). Conclusions Health education programs should focus on males, pupils attending lower school years, living in specific Provinces of the Region, and with a positive attitude towards piercing or tattoo.

Abstract Background Numerous studies have investigated mortality during a heatwave, while few have quantified heat associated morbidity. Our aim was to investigate the relationship between hospital admissions and intensity, duration and timing of heatwave across the summer months. Methods The study area (Veneto Region, Italy) holds 4577408 inhabitants (on January 1st, 2003), and is subdivided in seven provinces with 60 hospitals and about 20000 beds for acute care. Five consecutive heatwaves (three or more consecutive days with Humidex above 40°C) occurred during summer 2002 and 2003 in the region. From the regional computerized archive of hospital discharge records, we extracted the daily count of hospital admissions for people aged ≥75, from June 1 through August 31 in 2002 and 2003. Among people aged over 74 years, daily hospital admissions for disorders of fluid and electrolyte balance, acute renal failure, and heat stroke (grouped in a single nosologic entity, heat diseases, HD), respiratory diseases (RD), circulatory diseases (CD), and a reference category chosen a priori (fractures of the femur, FF) were independently analyzed by Generalized Estimating Equations. Results Heatwave duration, not intensity, increased the risk of hospital admissions for HD and RD by, respectively, 16% (p < .0001) and 5% (p < .0001) with each additional day of heatwave duration. At least four consecutive hot humid days were required to observe a major increase in hospital admissions, the excesses being more than twofold for HD (p < .0001) and about 50% for RD (p < .0001). Hospital admissions for HD peaked equally at the first heatwave (early June) and last heatwave (August) in 2004 as did RD. No correlation was found for FF or CD admissions. Conclusion The first four days of an heatwave had only minor effects, thus supporting heat health systems where alerts are based on duration of hot humid days. Although the finding is based on a single late summer heatwave, adaptations to extreme temperature in late summer seem to be unlikely.