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European (Directive 2003/10/CE) and italian rules (DLgs 81/08), both establish that "as far as technically achievable, any effects on workers' health and safety resulting from interactions between noise and work-related ototoxic substances, and between noise and vibrations". The scientific knowledge on this subject is still lacking, but are generally considered as ototoxic, either alone or in concert with noise, toluene, styrene, ethylbenzene, carbon disulphide, lead, mercury and carbon monoxide. With particular reference to health surveillance we propose yearly audiograms for workers whose exposures are at 50% or more of the specific OEL, for noise LEPd less than 85 dB(A); for concomitant noise LEPd greater than 85 dB(A) (by wich workers are normally submitted to an yearly audiogram) the occupational physician will consider if shorten the time between audiograms. [ABSTRACT FROM AUTHOR]

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.

This paper summarises the past, present and future of asbestos exposure. The future scenarios as to the mesothelioma incidence in countries, where asbestos has been banned, are discussed., Competing Interests: Conflicts of Interest: E Pira and G Discalzi reported personal fees for the defence from several law firms in asbestos litigations, outside the submitted work. F Donato and L Maida have no conflicts of interest to declare.

European (Directive 2003/10/CE) and italian rules (DLgs 81/08), both establish that "as far as technically achievable, any effects on workers' health and safety resulting from interactions between noise and work-related ototoxic substances, and between noise and vibrations". The scientific knowledge on this subject is still lacking, but are generally considered as ototoxic, either alone or in concert with noise, toluene, styrene, ethylbenzene, carbon disulphide, lead, mercury and carbon monoxide. With particular reference to health surveillance we propose yearly audiograms for workers whose exposures are at 50% or more of the specific OEL, for noise LEPd less than 85 dB(A); for concomitant noise LEPd greater than 85 dB(A) (by wich workers are normally submitted to an yearly audiogram) the occupational physician will consider if shorten the time between audiograms.

Italian law on safety at work does not clarify specific levels of load for safe manual material handling. For this reason professionals appointed for safety need to define new target range value for the correct application of D.Lgs. 81/2008 law. Authors, discussing about indication of the national laws and international rules, suggest the assumption of a load of 25 and 20 kg as reference values for male and female adult and healthy workers. They also examine the graduation of the acceptable loads in relation to workers' age and the Lifting Index values to be adopted as action limit and exposure limit.

In the period of 1998-2004, seven workers affected by manganese-induced Parkinsonism were diagnosed, studied and treated with CaNa2EDTA at our Occupational Health Ward. Biological markers, as well as magnetic resonance imaging and clinical examinations, were used to assess the disease trend. Those workers still employed were immediately removed from exposure. Our results seem to confirm that very good clinical, biological and neuroradiological results can be obtained by timely removal from exposure and chelating treatment, and that amelioration can persist in time. Manganism is, however, a severe condition that can also progress independent of further exposure. Therefore, chelating treatment can be a great aid in overt manganism, but particular attention must be paid to primary prevention, as this disease should now be totally preventable and definitely merits eradication.

In this paper we have defined the new biomarkers of exposure (NBE) as those biomarkers discovered in the last five years and, among previously validated biomarkers, also those applied in different ranges of doses or those determined in biological matrices which differ from matrices originally considered. We examined the results from the surveys carried out by the main Italian research units involved in biological monitoring, i.e. those from the Universities of Brescia, Milan, Naples, Padua, Parma, Pavia, Turin and Verona. The data were collected using a standardized model and included the following: type of element or organic compound, type of biomarker, analytical technique and method, their relationship with environmental monitoring data, their relationship with effect indicators or effects in general, improvement with respect to old biomarkers, reference values. Twenty two NBEs were identified: 14 elements and chemical compounds as such or as metabolites, 4 examples of mixtures, 3 of new matrices, one of speciation. Among the others, aspects such as interest in requiring NBE, quality assurance, availability, cost-benefit ratio were discussed. We conclude that development of this specific field of research appears to be a crucial point for future improvement in risk assessment and health surveillance procedures.

A 34-years-old floor-layer developed optic neuropathy and motor neuron disease after being accidentally exposed to a solvent mixture containing methanol and other substances. Optic neuropathy is a complication of methanol poisoning, but the onset of a motor neuron disorder resembling amyotrophic lateral sclerosis after the exposure to these substances has not been previously described. The temporal onset of the clinical symptoms, biological plausibility, young age of the patient and absence of neurological disorders in the family history raises suspicion of a possible causative relationship.

Excess manganese (Mn) can cause several neurotoxic effects, however only a few studies have reported epileptic syndromes related to manganese intoxication. We describe an epileptic syndrome due to manganese intoxication in a 3 year old male child. His blood manganese was elevated, but no other abnormal values or toxic substances were found in blood or urine. The electroencephalogram (EEG) showed a picture of progressive encephalopathy, while brain magnetic resonance was normal. The patient's conditions rapidly worsened to epileptic status despite the use of antiepileptic drugs. Chelating treatment with CaNa(2)EDTA was initiated to remove excess manganese and promptly succeeded in reverting epileptic symptoms. Concurrently, manganese blood levels and electroencephalogram progressively normalized. Thereafter it has been possible to discontinue antiepileptic treatment, and the patient remains in excellent conditions without any treatment.

Basal ganglia bilateral symmetric hyperintensity in T1-weighted sequences at magnetic resonance imaging (MRI) is recognized to be due to the presence of manganese deposits. This abnormal finding has been reported in occupational exposures, liver cirrhosis and total parenteral nutrition with unbalanced solutions. However, the same imaging is often observed "by chance" in brain MRIs of patients not belonging to these groups. In order to better understand which are the clinical conditions coexisting with such findings, we decided to study systematically patients which showed this kind of imaging, focusing on their manganese and iron status, as it is known that these two metals have similar properties and that iron-deficiency can competitively increase manganese absorption. The 20 patients studied underwent clinical evaluation and the following laboratory tests: whole blood iron and manganese, hemoglobin, plasma iron, transferrin and ferritin. The neuroradiologic evaluation was integrated by pallidal index calculation, in order to provide a semi-quantitative esteem of the hyperintensity. The patients could be classified into four subgroups: Parkinsonism, anemia, cirrhosis, central nervous system tumors. In 18 out of 20 cases, we found abnormalities in iron and/or manganese-related values. Particularly, iron-deficiency seems to be frequent among patients showing brain MRI abnormalities compatible with manganese deposits in basal ganglia. This observation suggests that iron-deficiency could be an important risk factor for manganese-induced neurotoxicity and should, therefore, be accurately considered and treated.

In the first part of this study, the most frequently professional lead exposure observed since 1984 at the Occupational Health Clinic of Turin University are summarized and compared with exposure observed in the past. The second part analyzes the present blood lead levels in the general (non-occupationally exposed) population observed in a screening campaign carried out in Piedmont in 1993-94 within the framework of the national programme by biology surveillance prescribed by Presidential Decree no. 496 of 1982. Results agree with literature data and show a reduction in blood lead levels markedly below the Italian legal limits. Nevertheless, lead pollution in non-exposed subjects still represents a major hygienistic problem, because a relevant number of children have blood lead concentrations above 10 micrograms/ 100 ml, which is considered a safe level for avoiding irreversible injury to nervous system.

We conducted a 5-year longitudinal study on 76 workers of a high and medium aluminium alloy die-casting factory. As in a previous cross-sectional study conducted in 1986 and in accordance with the data in the literature, the 1990 follow-up study showed: a low prevalence of chronic bronchitis (as defined by the ECSC questionnaire on respiratory symptoms); normal mean functional values of FVC, FEV1, FEV1/FVC%. We did not find any significant difference in the levels of lung function over the period of 1986-90. These results show that workers in the secondary aluminium industry are not exposed to a significant risk of chronic pulmonary disease.

Brainstem Evoked Potentials (BAEPs) were recorded in 49 lead exposed workers, and in a control group of 49 age- and sex-matched subjects, never exposed to neurotoxic substances. The mean duration of lead exposure was 7.4 (SD 5.6) yr. Blood lead concentration was analyzed in the morning of the experimental day (PbBc); an averaged PbB level was based on the levels of the 3 previous years (PbBm). Interpeak latency differences (IPLD) I-V, I-III and III-V were considered. The mean PbBc level was 54.6 (SD 16.1) micrograms/dl while the mean PbBm level was 53.5 (SD 15.9) micrograms/dl. Lead exposed workers showed a significant prolongation of IPLDs. IPLD I-V was longer in the subgroup with PbBm greater than 50 micrograms/dl (4.06 vs 3.98, c.l. 95% 0.00-0.16). These results are consistent with literature data and show that BAEPs may be a sensitive detector of subclinical lead effects on brainstem auditory pathways.