[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.

Does working in an extremely cold environment affects lung function?: 10 years follow-up

OBJECTIVE

The aim of this study is to investigate whether there is an association between brief but repeated exposures to extremely cold temperatures over many years and pulmonary function.

METHODS

We performed a retrospective analysis of the data collected over 10 years in the context of the extended medical examinations of storeworkers exposed to extremely cold temperatures. We considered forced vital capacity (FVC), forced expiratory volume in one second (FEV1), Tiffeneau-Pinelli index (FEV1/FVC), CO diffusion capacity (DL,CO) and Krogh-factor (CO diffusion capacity relative to recorded alveolar volume, DL,CO/VA) reported as %-predicted. We analysed trends in outcome parameters with linear mixed models.

RESULTS

46 male workers participated in at least two extended medical examinations between 2007 and 2017. Overall 398 measure points were available. All lung function parameters had values above the lower limit of normality at the first examination. In the multivariate model including smoking status and monthly intensity of cold exposure (≤ 16 h/month vs. > 16 h/month) FEV1%-predicted and FVC %-predicted had a statistically significant positive slope (FEV1, 0.32% 95% CI 0.16% to 0.49% p < 0.001; FVC 0.43% 95% CI 0.28% to 0.57% p < 0.001). The other lung function parameters (FEV1/FVC %-predicted, DL,CO %-predicted, DL,CO/VA %-predicted) showed no statistically significant change over time.

CONCLUSIONS

Long term intermittent occupational exposure to extreme cold temperatures (-55 °C) does not appear to cause irreversible deleterious changes in lung function in healthy workers, thus the development of obstructive or restrictive lung diseases is not expected.

[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

Evolution of work ability, quality of life and self-rated health in a police department after remodelling shift schedule

Background

There exists a great diversity of schedules concerning the way shift work is organized and implemented with ample agreement regarding recommendable features of a shift system. In order to adapt the shift schedule of a metropolitan police department to current recommendations, a remodelled shift schedule was introduced in 2015. The aim of this study was to evaluate the potential associations between the remodelled shift schedule and work ability, quality of life and self-rated health after one and five years.

Methods

A controlled before-and- after study was conducted during the piloting phase (2015–2016) as well as a 5-year follow-up using paper questionnaires. Outcome parameters included work ability, quality of life and self-rated health.

Results

Work ability, quality of life and self-rated health improved after the first year of the newly implemented shift schedule among police officers working in the piloting police stations compared to those working according to the former schedule. In 5-year follow-up differences between indicators diminished.

Conclusions

The implementation of a remodelled shift schedule including more 12-h shifts accompanied by more days off and a coherent weekend off duty was not associated with detrimental effects to work ability, quality of life or self-reported health among police officers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14098-5.

Workplace-related inhalation test - Specific inhalation challenge: S2k Guideline of the German Society for Occupational and Environmental Medicine e.V. (DGAUM), the German Society for Pneumology and Respiratory Medicine e.V. (DGP) and the German Society for Allergology and Clinical Immunology e.V. (DGAKI)

Not available.

[Adaptation of infection protection measures in public services due to the COVID-19 pandemic]

The COVID-19 pandemic is changing the requirements for occupational health and safety in the workplace. The aim of the measures implemented nationwide is to reduce the spread of the virus. This applies to all areas of life, including the workplace. The "public service" includes many system-relevant occupational groups: police, fire brigade, judiciary, municipal cleaning, waterworks and administrative bodies at local and state levels. There is a broad diversity of activities in communal and federal state enterprises, especially with regard to internal organisation as well as personnel and spatial conditions. Direct interactions with people are often necessary. Maintaining the functionality of these structures is essential for public life. Education institutions and care facilities for children, people with handicaps and vulnerable groups, institutions for nursing and geriatric care as well as public transport are not covered in this statement due to their special work structures. These recommendations address the professionally accountable in the respective public service institutions. It deals with infection control measures at work in the public service, derived from the risk assessments of various settings. The measures presented can be implemented as part of an operational concept for temporary infection control measures. The aim is to provide general guidance on infection protection with respect to work situations in order to slow down the dissemination of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), to protect at-risk groups, and ensure the functioning of the aforementioned structures.

[Classroom teaching at universities and colleges under the conditions of the SARS-CoV-2 pandemic]

In order to maintain university teaching while observing the distance rules in accordance with the occupational health and safety standard of the German Federal Ministry of Labour and Social Affairs (BMAS), special regulations and measures must be observed under the conditions of the COVID-19 pandemic when students and teaching staff meet in large groups (lecture hall) and small teaching rooms (seminars, internships). The article gives detailed recommendations for the practical implementation of protective and preventive measures according to the STOP principle, which is customary in occupational health and safety: substitution, technical, organisational and personal protective measures. Responsibilities are named and also difficult situations where physical proximity is necessary (e.g. teaching medical examinations, joint laboratory work, sports and dance seminars) are analysed with regard to the necessary measures; recommendations are formulated.

Musculoskeletal pain among offshore wind industry workers: a cross-sectional study

Objective

To assess whether there are differences in musculoskeletal pain among different types of occupations offshore and their relationship to ergonomic demands.

Methods

We conducted a web-based cross-sectional survey among workers from offshore wind energy companies operating within the German exclusive economic zone. We selected workers with regular offshore commitments and at least 28 days spent offshore in the past year (n = 268). Musculoskeletal pain was assessed using the Subjective Health Complaints inventory (SHC), which considers the past month.

Results

Of the 268 male participants eligible for analysis, 54% reported back pain 50.4% neck pain, 40.3% lower back pain, 35.5% shoulder, 23.3% arm and 22.1% leg pain, all of them during the past month. Compared to other offshore occupations, technicians reported more frequently arm (OR 3.13; 95% CI 1.58–6.19), back (OR 1.97; 95% CI 1.15–3.39), shoulder (OR 1.94; 95% CI 1.11–3.40) and neck pain (OR 1.89; 95% CI 1.11–3.22). After adjusting for age and nationality, lifting and carrying heavy loads were associated with all types of pain except leg pain. Overhead work, work in awkward postures, and the use of personal protection equipment and heavy tools was associated with shoulder, back and arm pain.

Conclusions

Our findings suggest that occupational health counselling, health promotion and preventive interventions of offshore wind energy workers needs to consider the specific tasks of the employee and be particularly tailored to the ergonomic needs of technicians.

Spiroergometric measurements under increased inspiratory oxygen concentration (FIO2)-Putting the Haldane transformation to the test

Spiroergometric measurements of persons who require oxygen insufflation due to illness can be performed under conditions of increased inspiratory oxygen concentration (FIO2). This increase in FIO2, however, often leads to errors in the calculation of oxygen consumption ([Formula: see text]). These inconsistencies are due to the application of the Haldane Transformation (HT), an otherwise indispensable correction factor in the calculation of [Formula: see text] that becomes inaccurate at higher FIO2 concentrations. A possible solution to this problem could be the use of the 'Eschenbacher transformation' (ET) as an alternative correction factor. This study examines the concentration of FIO2 at which the HT and the ET are valid, providing plausible data of oxygen consumption corresponding to the wattage achieved during cycle ergometry. Ten healthy volunteers underwent spiroergometric testing under standard conditions (FIO2 = 20.9%), as well as at FIO2 = 40% and 80%. When compared with the predicted values of [Formula: see text], as calculated according to Wasserman et al. (2012), the data obtained show that both the HT and ET are valid under normal conditions and at an increased FIO2 of 40%. At FIO2 concentrations of 80%, however, the [Formula: see text] values provided by the HT begin to lose plausibility, whereas the ET continues to provide credible results. We conclude that the use of the ET in place of the HT in spiroergometric measurements with increased FIO2 allows a reliable evaluation of stress tests in patients requiring high doses of supplemental oxygen.

The physical performance of workers on offshore wind energy platforms: is pre-employment fitness testing necessary and fair?

Purpose

Workers on offshore wind turbine installations face a variety of physical and psychological challenges. To prevent potentially dangerous situations or incidents, guidelines for the physical aptitude testing of offshore employees in Germany and other European countries have been developed. However, these criteria have not been previously empirically tested for validity. Although an important component of occupational health and safety, such aptitude testing should not lead to the unjustified exclusion of potential employees.

Methods

Heart rate (HR) and oxygen consumption (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot {V}{{\text{O}}_2}$$\end{document}V˙O2) measurements of 23 male offshore employees and trainers were taken during typical field activities, within the framework of mandatory training exercises. These were evaluated in relation to the individual maximum values of the subjects, determined by cycle spiroergometry.

Results

For the training modules, average HR and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot {V}{{\text{O}}_2}$$\end{document}V˙O2 values of approximately 40% and 33–48% of the maximum values, respectively, were found. Furthermore, 65% of the participants achieved average HR values that exceeded 30% of their individual heart rate reserve and 45% had \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot {V}{{\text{O}}_2}$$\end{document}V˙O2 values above 35% of their individual \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot {V}{{\text{O}}_{2,\text{max} }}$$\end{document}V˙O2,max.

Conclusion

Our preliminary results show that offshore work is a form of heavy physical labor, thereby justifying the criteria put forth in the various fitness to work guidelines. We propose that more in-depth investigations should be performed, incorporating task-specific fitness testing as well as higher level aspects of work safety and security, including effective communication skills and teamwork. We also recommend a re-evaluation of the current limits for physical work provided in the literature. The results of such studies could then be applied to other aptitude tests, thereby strengthening the evidence for such measures.

[Exercise Testing in Respiratory Medicine - DGP Recommendations]

This document replaces the DGP recommendations published in 1998 and 2013. Based on recent studies and a consensus conference, the indications, choice and performance of the adequate exercise testing method and its necessary technical and staffing setting are discussed. Detailed recommendations are provided: for blood gas analysis and right heart catheterization during exercise, walk tests, spiroergometry, and stress echocardiography. The correct use of different exercise tests is discussed for specific situations in respiratory medicine: exercise induced asthma, obesity, monitoring of rehabilitation or therapeutical interventions, preoperative risk stratification, and evaluation in occupational medicine.

Linking quantitative demands to offshore wind workers' stress: do personal and job resources matter? A structural equation modelling approach

Background

Employees in the offshore wind industry are exposed to various job demands, increasing the workers’ risk of experiencing strain reactions. However, personal and job resources might play a role in the stressor-strain context. The aim of this study was (1) to examine the link between offshore employees’ quantitative demands and stress, and (2) to study the role of personal and job resources (psychological detachment from work, social support, and influence at work) in this stressor-strain relationship.

Methods

Two hundred fifty offshore wind workers responded to an anonymous web-based survey, assessing the workers’ quantitative demands, social support, influence at work, psychological detachment from work, and stress. Descriptive statistical analyses and structural equation modelling were applied to test the hypotheses.

Results

Correlation analyses revealed substantial associations between employees’ quantitative demands, personal and job resources, and stress. Results of structural equation modelling indicated a good fit of the hypothesized model. Quantitative demands were positively related to stress, and psychological detachment from work partially mediated this relationship. Social support was negatively related to stress, while influence at work was not. Neither social support nor influence at work moderated the stressor-strain or stressor-detachment relationship.

Conclusions

The results contribute to the current knowledge on the topic. They can be used to design health promotion interventions aimed at reducing offshore employees’ quantitative demands, fostering their ability to mentally detach from work, and enhancing social support at the offshore workplace.

A cross-sectional survey of physical strains among offshore wind farm workers in the German exclusive economic zone

OBJECTIVES

To assess the physical strains of employees in the German offshore wind industry, according to job type and phase of the wind farm (under construction or operation).

DESIGN

Web-based cross-sectional survey.

SETTING

Offshore wind farm companies operating within the German exclusive economic zone.

PARTICIPANTS

Male workers with regular offshore commitments and at least 28 days spent offshore in the past year (n=268).

OUTCOME MEASURES

Physical strains (eg, climbing, noise, working overhead, with twisted upper body or in confined spaces, vibration, heavy lifting, humidity, odours).

RESULTS

The most frequently mentioned physical strain was 'climbing' with 63.8% of the respondents reporting to be always or frequently confronted with climbing and ascending stairs during offshore work. Work as a technician was associated with a greater exposition to noise, vibrations, humidity, cold, heat, chemical substances, lifting/carrying heavy loads, transport of equipment, working in non-ergonomic positions and in cramped spaces, as well as climbing.Indeed, statistical analyses showed that, after adjusting for phase of the wind farm, age, nationality, offshore experience, work schedule and type of shift, compared with non-technicians, working as a technician was associated with more frequently lifting/carrying of heavy loads (OR 2.58, 95% CI 1.58 to 4.23), transport of equipment (OR 2.06 95% CI 1.27 to 3.33), working with a twisted upper body (OR 2.85 95% CI 1.74 to 4.69), working overhead (OR 2.77 95% CI 1.67 to 4.58) and climbing (OR 2.30 95% CI 1.40 to 3.77). Working in wind farms under construction was strongly associated with increased and decreased exposure to humidity (OR 2.32 95% CI 1.38 to 3.92) and poor air quality (OR 0.58 95% CI 0.35 to 0.95), respectively.

CONCLUSIONS

Workers on offshore wind farms constitute a heterogeneous group, including a wide variety of occupations. The degree of exposure to detrimental physical strains varies depending on the type of job. Technicians are more exposed to ergonomic challenges than other offshore workers.

Healthy offshore workforce? A qualitative study on offshore wind employees' occupational strain, health, and coping

BACKGROUND

Offshore work has been described as demanding and stressful. Despite this, evidence regarding the occupational strain, health, and coping behaviors of workers in the growing offshore wind industry in Germany is still limited. The purpose of our study was to explore offshore wind employees' perceptions of occupational strain and health, and to investigate their strategies for dealing with the demands of offshore work.

METHODS

We conducted 21 semi-structured telephone interviews with employees in the German offshore wind industry. The interviews were transcribed and analyzed in a deductive-inductive approach following Mayring's qualitative content analysis.

RESULTS

Workers generally reported good mental and physical health. However, they also stated perceptions of stress at work, fatigue, difficulties detaching from work, and sleeping problems, all to varying extents. In addition, physical health impairment in relation to offshore work, e.g. musculoskeletal and gastrointestinal complaints, was documented. Employees described different strategies for coping with their job demands. The strategies comprised of both problem and emotion-focused approaches, and were classified as either work-related, health-related, or related to seeking social support.

CONCLUSIONS

Our study is the first to investigate the occupational strain, health, and coping of workers in the expanding German offshore wind industry. The results offer new insights that can be utilized for future research in this field. In terms of practical implications, the findings suggest that measures should be carried out aimed at reducing occupational strain and health impairment among offshore wind workers. In addition, interventions should be initiated that foster offshore wind workers' health and empower them to further expand on effective coping strategies at their workplace.

"It's still a great adventure" - exploring offshore employees' working conditions in a qualitative study

Background

Despite the particular demands inherent to offshore work, little is known about the working conditions of employees in the German offshore wind industry. To date, neither offshore employees’ job demands and resources, nor their needs for improving the working conditions have been explored. Therefore, the aim of this study was to conduct a qualitative analysis to gain further insight into these topics.

Methods

Forty-two semi-structured telephone interviews with German offshore employees (n = 21) and offshore experts (n = 21) were conducted. Employees and experts were interviewed with regard to their perceptions of their working conditions offshore. In addition, employees were asked to identify areas with potential need for improvement. The interviews were analysed in a deductive-inductive process according to Mayring’s qualitative content analysis.

Results

Employees and experts reported various demands of offshore work, including challenging physical labour, long shifts, inactive waiting times, and recurrent absences from home. In contrast, the high personal meaning of the work, regular work schedule (14 days offshore, 14 days onshore), and strong comradeship were highlighted as job resources. Interviewees’ working conditions varied considerably, e.g. regarding their work tasks and accommodations. Most of the job demands were perceived in terms of the work organization and living conditions offshore. Likewise, employees expressed the majority of needs for improvement in these areas.

Conclusions

Our study offers important insight into the working conditions of employees in the German offshore wind industry. The results can provide a basis for further quantitative research in order to generalize the findings. Moreover, they can be utilized to develop needs-based interventions to improve the working conditions offshore.

Electronic supplementary material

The online version of this article (10.1186/s12995-017-0179-0) contains supplementary material, which is available to authorized users.

IgE Reactivity, Work Related Allergic Symptoms, Asthma Severity, and Quality of Life in Bakers with Occupational Asthma

In Germany, bakers with occupational asthma willing to stay in their job are included in an interdisciplinary program of the Social Accident Insurance for Foodstuff and Catering Industry (BGN). The primary aim is to reduce flour dust exposure, and to provide adequate medical treatment. Our aim was to evaluate the program's effect on the disease's course using routinely collected data. Forty three bakers with allergic occupational asthma and with the available baseline level of IgE (f4, f5) were investigated. Changes in IgE related to wheat and rye flour exposure were measured by ImmunoCAP test during follow-up visits. A questionnaire on work-related allergic complaints (WRAC), the Asthma Control Test (ACT), a 10-point scale of asthma severity grade, and quality of life instruments (EQ-5D-5L, Mini-AQLQ) were administered. We found an improvement of asthma severity in 88.4 % of the bakers. WRAC were reported by 65 %; 77 % had good asthma control (ACT ≥ 20); and 81 % had regular asthma medication. A relevant reduction of ≥2 CAP-classes for both allergens was seen in 12 % of the subjects. Health-related and asthma-specific quality of life was high. We conclude that satisfactory asthma control is probably the result of adequate medical management. In a subgroup of bakers with decreased specific IgE, it may also be attributed to reduced allergen exposure.

Measured by the oxygen uptake in the field, the work of refuse collectors is particularly hard work: Are the limit values for physical endurance workload too low?

Purpose

Collecting waste is regarded as a benchmark for “particularly heavy” work. This study aims to determine and compare the workload of refuse workers in the field. We examined heart rate (HR) and oxygen uptake as parameters of workload during their daily work.

Methods

Sixty-five refuse collectors from three task-specific groups (residual and organic waste collection, and street sweeping) of the municipal sanitation department in Hamburg, Germany, were included. Performance was determined by cardiopulmonary exercise testing (CPX) under laboratory conditions. Additionally, the oxygen uptake (VO₂) and HR under field conditions (1-h morning shift) were recorded with a portable spiroergometry system and a pulse belt.

Results

There was a substantial correlation of both absolute HR and VO₂ during CPX [HR/VO₂R 0.89 (SD 0.07)] as well as during field measurement [R 0.78 (0.19)]. Compared to reference limits for heavy work, 44 % of the total sample had shift values above 30 % heart rate reserve (HR_R); 34 % of the individuals had mean HR during work (HR_sh) values that were above the HR corresponding to 30 % of individual maximum oxygen uptake (VO_2,max). All individuals had a mean oxygen uptake (VO_2,1h) above 30 % of VO_2,max.

Conclusion

HR as well as the measurement of VO₂ can be valuable tools for investigating physiological workload, not only under laboratory conditions but also under normal working conditions in the field. Both in terms of absolute and relative HR and oxygen consumption, employment as a refuse collector should be classified in the upper range of defined heavy work. The limit of heavy work at about 33 % of the individual maximum load at continuous work should be reviewed.

Tuberculosis in healthcare workers - a narrative review from a German perspective

Introduction

Despite the decline of tuberculosis in the population at large, healthcare workers (HCW) are still at risk of infection.

Methods

In a narrative review the TB risk in HCW and preventive measures are described, with the focus on epidemiology and Occupational Safety and Health (OSH) regulations in Germany.

Results

There is an increased risk of infection not only in pneumology and laboratories with regular contact with tuberculosis patients or infectious materials. Epidemiological studies have also verified an increased risk of infection from activities that involve close contact with patients’ breath (e.g. bronchoscopy, intubation) or close contact with patients in need of care in geriatric medicine or geriatric nursing. In occupational disease claim proceedings on account of tuberculosis, the burden of proof can be eased for insured persons who work in these or other comparable fields. Forgoing evidence of an index person as a source of infection has led to a doubling of the rate of cases of tuberculosis recognised as an occupational disease and has halved the duration of occupational disease claim proceedings in Germany. For several years now, it has been possible to use the new interferon-y release assays (IGRAs) to diagnose a latent tuberculosis infection (LTBI) with significantly greater validity than with the traditional tuberculin skin test (TST). However, variability of the IGRAs around the cut-off poses problems especially in serial testing of HCWs. At around 10%, LTBI prevalence in German healthcare workers is lower than had been assumed. It can make sense to treat a recent LTBI in a young healthcare worker so as to prevent progression into active tuberculosis. If the LTBI is occupational in origin, the provider of statutory accident insurance can cover the costs of preventive treatment. However, little is known about disease progression in HCWs with positive IGRA sofar.

Conclusion

TB screening in HCWs will remain an important issue in the near future even in low incidence, high income countries, as active TB in HCWs is often due to workplace exposure. The IGRAs facilitate these screenings. However, variability of IGRA results in serial testing of HCWs need further investigations.

Circulating mitochondrial DNA as biomarker linking environmental chemical exposure to early preclinical lesions elevation of mtDNA in human serum after exposure to carcinogenic halo-alkane-based pesticides

There is a need for a panel of suitable biomarkers for detection of environmental chemical exposure leading to the initiation or progression of degenerative diseases or potentially, to cancer. As the peripheral blood may contain increased levels of circulating cell-free DNA in diseased individuals, we aimed to evaluate this DNA as effect biomarker recognizing vulnerability after exposure to environmental chemicals. We recruited 164 individuals presumably exposed to halo-alkane-based pesticides. Exposure evaluation was based on human biomonitoring analysis; as biomarker of exposure parent halo-methanes, -ethanes and their metabolites, as well as the hemoglobin-adducts methyl valine and hydroxyl ethyl valine in blood were used, complemented by expert evaluation of exposure and clinical intoxication symptoms as well as a questionnaire. Assessment showed exposures to halo alkanes in the concentration range being higher than non-cancer reference doses (RfD) but (mostly) lower than the occupational exposure limits. We quantified circulating DNA in serum from 86 individuals with confirmed exposure to off-gassing halo-alkane pesticides (in storage facilities or in home environment) and 30 non-exposed controls, and found that exposure was significantly associated with elevated serum levels of circulating mitochondrial DNA (in size of 79 bp, mtDNA-79, p = 0.0001). The decreased integrity of mtDNA (mtDNA-230/mtDNA-79) in exposed individuals implicates apoptotic processes (p = 0.015). The relative amounts of mtDNA-79 in serum were positively associated with the lag-time after intoxication to these chemicals (r = 0.99, p<0.0001). Several months of post-exposure the specificity of this biomarker increased from 30% to 97% in patients with intoxication symptoms. Our findings indicate that mitochondrial DNA has a potential to serve as a biomarker recognizing vulnerable risk groups after exposure to toxic/carcinogenic chemicals.

[Epidemiological and occupational medicine aspects of pleural mesothelioma]

Malignant mesothelioma of the pleura represents a signal tumour for (occupational) exposure to asbestos. Almost 20 years after the ban of asbestos in Germany, incident cases are still occurring due to the long latency period between the initial exposure to asbestos and the onset of the tumour. Of particular interest is the development of mesothelioma epidemiology. In Germany, it is extensively discussed whether the incidence of malignant pleura mesothelioma continues to rise, has already reached a plateau or is expected to decline in the next few years. The development is predominantly caused by the total asbestos use, its application and the gradual substitution of asbestos. The prevention of asbestos-related diseases due to former exposures, but also due to existing asbestos contaminations and their restoration is still a hot topic in occupational medicine. It is thus of major importance to ensure an adequate occupational safety and to care for asbestos-exposed workers - even after cessation of their exposure - with effective and efficient measures of early detection. New technologies, such as nanotechnology with carbon nanotubes, represent new potential health hazards.

[Exercise testing in respiratory medicine]

This document replaces the DGP recommendations published in 1998. Based on recent studies and a consensus conference, the indications, choice and performance of the adequate exercise testing method in its necessary technical and staffing setting are discussed. Detailed recommendations are provided: for arterial blood gas analysis and right heart catherterization during exercise, 6-minute walk test, spiroergometry, and stress echocardiography. The correct use of different exercise tests is discussed for specific situations in respiratory medicine: exercise induced asthma, monitoring of physical training or therapeutical interventions, preoperative risk stratification, and evaluation in occupational medicine.

Health effects due to fumigated freight containers and goods: how to detect, how to act

Headache, concentration and memory disorders, dizziness and nausea, skin irritation, respiratory distress, and muscle cramps - isolated or in various combinations - may be the result of acute or chronic intoxication by fumigants. The occurrence of these symptoms in workers who are engaged in the opening and unloading of containers, unpacking of imported goods, ventilating of containers, or working on bulk carriers are urgent indications of intoxication by fumigants or other toxic chemical residues in the transported goods. The severity of the disorder depends on the concentration and duration of exposure, distribution and release of the fumigant, its kinetics, the individual susceptibility of the person, as well as any simultaneous exposure to other toxic substances. Physical symptoms, acute and chronic health effects due to contact with fumigants, are complex and difficult to discover. In this article we explain how to identify the guiding symptoms and describe the appropriate diagnostic steps and the prevention of such events on cargo vessels as well as in the logistics and the handling of imported goods.

[Cardiopulmonary exercise testing in occupational medical fitness examination and assessment]

Medical expert opinion by occupational physicians and pneumologists has two main objectives: making a diagnosis with probability bordering on certainty and clarifying a causal relationship to a present or former occupational exposure to irritant toxic, allergenic or fibrosing dusts, gases, welding fumes or mineral fibres. Especially for conditions that are associated with exertional dyspnea, the diagnosis at rest using spirometry, body plethysmography, pulmonary function test, blood gas analysis, electrocardiogram and echocardiography is of limited use. This paper identifies the indications for cardiopulmonary exercise testing (CPET) in occupational medicine, explains the related measurements and their differential diagnostic value with special consideration of the flow-volume curve under exercise as well as the alveolar-arterial oxygen gradient. Diagnostic statements on the relevance of oxygen uptake measured at continuous and peak load compared to the wattage ascertained on the bicycle ergometer are presented. Characteristic CPET findings are explained in terms of their differential diagnostic significance. Furthermore, the importance of CPET for the assessment of occupational disease-related functional loss (clinical proportions in the reduction of working capacity) is shown.

Surprises perilous: toxic health hazards for employees unloading fumigated shipping containers

The fumigation of freight containers to protect transported goods from fungal and pest infestation has increased worldwide in the last five years due to international regulations requiring fumigation or heat treatment of wooden packaging material and dunnage. We have found in 2008 that every sixth container and its contents do retain harmful concentrations of various fumigants and chemicals, representing a significant health risk for port and transport workers, customs officials, warehousemen, store employees and consumers. The shipping documents of these containers did not provide any information about the fumigation procedure or the used fumigant. We report here the cases of 26 patients introduced to our outpatient clinic with presumed intoxication to fumigants, or with symptoms due to inhaling the air out of fumigated containers. All patients were examined from 2007 to 2010 according to a standardized comprehensive diagnostic program. We were able to confirm the diagnosis based on typical symptoms and extensive clinical examination; by laboratory analysis we identified ethylene dichloride, methyl bromide, phosphine and methylene chloride. The predominant symptoms were headaches, concentration and memory problems, dizziness and nausea, irritation of the skin and mucous membranes and a reduced ability to do exercise. In addition to the neurological and neuropsychological impairments our analyses verified the development of reactive airways dysfunction syndrome (RADS) in 14 of 26 patients with long lasting symptoms due to their contact with fumigants. Intoxications with fumigants are serious and could be avoided. These systematical explored cases show the sustainable impact for health and socio-economic wellbeing. These findings also emphasize the necessity for international standards on permitted fumigants, appropriate labeling in the shipping documents and handling of fumigated containers.