Clinical environmental medicine

[Patient Care in German Outpatient Clinics for Environmental Medicine Illustrated by the Examples of Hamburg and Munich University Hospitals]

People can be affected by various environmental factors (e. g., odor, noise) which can lead to medical complaints or illnesses. Few adequate contact points are available for patients with suspected environmental complaints in Germany. Illustrated by the outpatient clinics for environmental medicine in Hamburg and Munich, this report shows how patients with suspected environmental medical diseases are cared for in Germany. For the exemplary presentation, the data of the environmental medicine outpatient clinics of both the university hospitals from 01.01.2019 to 31.03.2021 are presented and compared. Overall, more female than male patients were treated at both facilities. Suspected exposure to "heavy metals" was most frequently mentioned by patients as the assumed reason for their complaints. Nonetheless, the suspected exposure or "intoxication" could be ruled out in the majority of cases by appropriate examination methods in accordance to current medical guidelines. The data provided by the environmental medicine outpatient clinics show that there is a continuous demand for environmental medical care. A close cooperation between the private practice sector and the outpatient clinics for environmental medicine providing medical care to patients should therefore be sought.

Environment, Environmental Crimes, Environmental Forensic Medicine, Environmental Risk Management and Environmental Criminology

Forensic medicine has always held the human environment, either seen as a source for pathological agents or the background of judicial events, in great consideration. The concept of the environment has evolved through time, expanding itself to include all the physical and virtual sub-spaces in which we exist. We can nowadays talk of technoenvironmental reality; virtual spaces exploded because of the COVID-19 pandemic making us come to terms with the fact that those are the places where we work, where we socialize and, even, where we meet our doctors and can be cured. Artificial Intelligence (AI) has contributed to shaping new virtual realities that have got their own rules yet to be discovered, carved and respected. We already fight a daily battle to save our natural environment: along with the danger of green crimes, comes the need for environmental justice and environmental forensic medicine that will probably develop a forensic branch and an experimental branch, to implement our technical culture leading to definition of the real dimension of the risk itself to improve the role of legal medicine in the Environmental Risk Management. While green criminology addresses widespread green crimes, a virtual environment criminology will also develop, maybe with a contribution of AI in the justice field. For a sustainable life, the environmental revolution must rapidly take place, and there is the need for a new justice, a new forensic medicine and a new criminology too.

Multiple Chemical Sensitivity

Multiple Chemical Sensitivity (MCS), a condition also known as Chemical Sensitivity (CS), Chemical Intolerance (CI), Idiopathic Environmental Illness (IEI) and Toxicant Induced Loss of Tolerance (TILT), is an acquired multifactorial syndrome characterized by a recurrent set of debilitating symptoms. The symptoms of this controversial disorder are reported to be induced by environmental chemicals at doses far below those usually harmful to most persons. They involve a large spectrum of organ systems and typically disappear when the environmental chemicals are removed. However, no clear link has emerged among self-reported MCS symptoms and widely accepted objective measures of physiological dysfunction, and no clear dose-response relationship between exposure and symptom reactions has been observed. In addition, the underlying etiology and pathogenic processes of the disorder remain unknown and disputed, although biologic and psychologic hypotheses abound. It is currently debated whether MCS should be considered a clinical entity at all. Nevertheless, in the last few decades MCS has received considerable scientific and governmental attention in light of the many persons reporting this illness. In this review, we provide a general overview of the history, definition, demographics, prevalence, and etiologic challenges in defining and understanding MCS.

A Systematic Review of Air Quality Sensors, Guidelines, and Measurement Studies for Indoor Air Quality Management

The existence of indoor air pollutants—such as ozone, carbon monoxide, carbon dioxide, sulfur dioxide, nitrogen dioxide, particulate matter, and total volatile organic compounds—is evidently a critical issue for human health. Over the past decade, various international agencies have continually refined and updated the quantitative air quality guidelines and standards in order to meet the requirements for indoor air quality management. This paper first provides a systematic review of the existing air quality guidelines and standards implemented by different agencies, which include the Ambient Air Quality Standards (NAAQS); the World Health Organization (WHO); the Occupational Safety and Health Administration (OSHA); the American Conference of Governmental Industrial Hygienists (ACGIH); the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE); the National Institute for Occupational Safety and Health (NIOSH); and the California ambient air quality standards (CAAQS). It then adds to this by providing a state-of-art review of the existing low-cost air quality sensor (LCAQS) technologies, and analyzes the corresponding specifications, such as the typical detection range, measurement tolerance or repeatability, data resolution, response time, supply current, and market price. Finally, it briefly reviews a sequence (array) of field measurement studies, which focuses on the technical measurement characteristics and their data analysis approaches.

Unnecessary Investigations in Environmental Medicine

BACKGROUND

Patients in environmental medicine often want a thorough diagnostic evaluation of nonspecific symptoms. Unconventional testing, as well as conventional testing for indications other than the established ones, can lead to false diagnoses and, in turn, to substantial emotional, social, and financial harm. The goal of this single-center study was to assess inappropriate diagnostic testing among the patients of a specialized university outpatient clinic for environmental medicine.

METHODS

The charts of 653 consecutive outpatients seen in the institute and outpatient clinic of occupational, social, and environmental medicine in Erlangen from 2010 to 2015 were evaluated, and inappropriate diagnostic tests were assessed.

RESULTS

9% of the patients had received at least one inappropriate diagnostic test. The most common one was an inappropriate heavy-metal test (26%), followed by an inappropriately ordered hair analysis (15%) and biomonitoring in the blood or urine with an erroneous choice of the testing matrix or an erroneous interpretation of the findings (15%). Biomonitoring performed by us did not confirm the suspected environmental diagnosis in any case. Laboratory values exceeding the normal limits were rarer among these patients than in the patients for whom we considered biomonitoring to be indicated without any pretesting.

CONCLUSION

An appreciable number of patients in environmental medicine were subjected to inappropriate diagnostic testing. When this happens, proper testing often needs to be done thereafter in order to confirm or refute the findings. This phenomenon should be more thoroughly assessed and quantified.

The views of primary care physicians on health risks from electromagnetic fields

BACKGROUND

The aim of this study was to find out what primary care physicians in Germany think about the possible health risks of electromagnetic fields (EMF) and how they deal with this topic in discussions with patients.

METHODS

Questionnaires were mailed to a nationwide, representative sample drawn from the regional associations of statutory health insurance physicians in Germany, consisting of 2795 primary care physicians (7% random sample of the total number in the country). 435 of them returned four-page questionnaires (response rate, 23.3%), and 456 returned a one-page questionnaire (response rate, 49.1%). They were asked about their views on the health risks of electromagnetic fields and about their experience with patients on this topic.

RESULTS

61.4% of the primary care physicians reported having discussed the possible health risks of electromagnetic fields with at least one patient. In 73.4% of these discussions, the patient raised the subject first and presumed that such risks do, in fact, exist. Among all discussions in which the patient expressed this concern, the physician considered the association to be plausible only 24.1% of the time. In half of all consultations in which EMF was discussed as a possible danger, the physician recommended some type of protective measure. The most frequent recommendation was to remove electrical equipment; the second most frequent, to move to another location. The physicians' answers to the questionnaires revealed a poor knowledge of the properties and risks of electromagnetic fields.

CONCLUSION

Primary care physicians often discuss the putative health risks of electromagnetic fields with their patients, yet their recommendations very often are not evidence-based and might have major consequences in their patients' lives.

Radon in indoor spaces: an underestimated risk factor for lung cancer in environmental medicine

BACKGROUND

Occupational medicine has long recognized radon to be a cause of lung cancer, especially among miners working under ground. Until recently, however, little scientific evidence was available about the risk to the general population caused by indoor radon.

METHODS

The authors analyzed literature that they found by a selective search in the light of the recently published S1 guideline of the German Society of Occupational and Environmental Medicine (Deutsche Gesellschaft für Arbeitsmedizin und Umweltmedizin) and a recent publication of the German Commission on Radiological Protection (Strahlenschutzkommission).

RESULTS

Exposure to indoor radon and its decay products is a major contributor to the radiation exposure of the general population. In Germany, the mean radiation exposure due to radon in living rooms and bedrooms is about 49 Bq/m(3). It is well documented in the scientific literature that indoor radon significantly increases the risk of lung cancer, probably in a linear dose-response relationship with no threshold. Every 100 Bq/m(3) increase in the radon concentration is estimated to increase the relative risk for lung cancer by 8% to 16%. After cigarette smoking, radon is the second main cause of lung cancer in the general population without occupational exposure.

CONCLUSIONS

From the point of view of preventive environmental medicine, it is important to identify buildings with high radon concentrations, initiate appropriate measures, and minimize radon exposure, particularly in new buildings.

The assessment of environmental and occupational exposure to hazardous substances by biomonitoring

BACKGROUND

Modern biomonitoring has expanded beyond its origins in occupational medicine to cover a wide variety of diagnostic procedures and assessments of environmental pollution, ranging from exposure to heavy metals and chemicals to the effects of pesticides and environmental tobacco smoke. In biomonitoring, the overall pollutant load and hazardous exposure of an organism is quantitatively determined, by monitoring the pollutants themselves, their metabolic products and/or conjugates with protein or DNA, in either serum, urine or other body fluids, as well as tissue samples in exceptional circumstances.

METHODS

A selective survey of the current literature is exemplified by our recent scientific and clinical experience.

RESULTS

Biomonitoring is an excellent way to monitor potentially hazardous substances, especially for the assessment of systemic uptake from chronic exposure and the evaluation of subsequent health risks. Investigative biomonitoring can highlight incidental/accidental intoxication in individuals and provide new categories of problematic pollutants relevant to the general population.

CONCLUSIONS

In combination with diagnostic procedures, biomonitoring provides an important contribution to the rational assessment of currently recorded pollutants and resulting health risks. It is as an evaluation tool available in daily practice as well as in health and environmental research applications. Legislation is already implemented that incorporates biomonitoring within the remit of specified occupational health screening.