[Does the Prevention Act Improve Prevention in Pediatric Outpatient Settings!?]

Aim of the study: The Prevention Act was adopted by the German Federal Parliament on 18.06.2015. The paediatric practice is an important place from which to reach out to children and teenagers and to positively influence them through targeted prevention services in their health-related behaviour. It is therefore an important setting for the implementation of the Prevention Act. Could the delegation of prevention services to qualified medical assistants promote the successful implementation of the Prevention Act? Since 2003, medical assistants have qualified as "Prevention Assistants" after completing training courses and offered support in preventive services to children and teenagers in the paediatrician's office. The aim of this study was to improve the effectiveness of the training to increase the competence of the participants, expansion of preventive services for children and teenagers in the paediatrician's office and reduction of physician workload. Methodology: Training was accompanied by ongoing evaluation; there were two extensive studies in 2009 and 2011, respectively. Between 2003 and 2006 (n=126, after 75% response rate) and in 2011 (n=119 after 24% response rate), participants were assessed with standardized questionnaires, and in the survey of 2011, their employers also were interviewed, (n=76, after 22% response rate). Results: The prevention assistants assess their learning successes as good and are able to take over delegated tasks in the paediatrician's office. The involvement of a trained prevention assistant contributed to the transformation and re-establishment of prevention offers in paediatrician's offices and reduced physician workload. 44% of physicians felt that the time saved by prevention assistant was very good or good, 80% of physicians surveyed also indicated that prevention assistants carried out preventive consultations in the doctor's office. Conclusion: In light of the paediatricians' workload and their own wishes and demands, and for a targeted implementation of the Prevention Act, it is necessary to delegate preventive services to trained personnel. It is also possible to accomplish this task. It is necessary to introduce billing numbers in the fee schedule for doctors similar to the billing numbers for dental health prophylaxis.

[Perinatal mortality by mother's country of origin in Tyrol 2000-2008]

INTRODUCTION

This study analyses for the first time the Tyrolean perinatal mortality stratified by the country of origin of the mother. Data of the Tyrolean birth registry were evaluated from 2000-2008. The aim of our study was to analyse differences in perinatal mortality according to the country of origin of the mother.

METHODS

58 787 single births were assessed between the years 2000-2008. Mothers with similar experiences of how to access the health-care system were aggregated into 5 groups: (1) "Tyrol/Austria", (2) "western Europe/West", (3) "former Yugoslavia/eastern Europe", (4) "Turkey" and (5) "other countries". The odds ratio for perinatal mortality according to the country of origin of the mother was calculated in a multivariate model. The following independent variables were included: age of mother at birth, parity, housewife during pregnancy, week of gestation at the first check-up visit, smoking, preterm delivery and weight of the newborn.

RESULTS

The number of mothers of Tyrolean/Austrian origin decreased over the years by 2% whereas the number of mothers from Western Europe/West increased by 3%. The other migration groups remained constant or were slightly decreased. In the multivariate model; the perinatal mortality [odds ratio (CI)] was for the subgroups "Turkey" 1.06 (0.61-1.83) and for "western Europe/West" 1.09 (0.64-1.86), and therefore almost identical with the reference subgroup "Tyrol/Austria" (OR=1); the perinatal mortality was significantly increased with 2.14 (1.37-3.34) for the subgroup "former Yugoslavia/eastern Europe and for the subgroup "other countries" 2.54 (1.21-5.36). The variables "age under 18 years" OR 1.99 (0.80-4.93) and "mulitpara" OR 1.30 (0.96-1.74) were not significantly increased. Significantly increased was "preterm delivery" OR 4.53 (2.80-7.33) and "low birthweight" (<1 500 g) OR 53.60 (32.02-89.73) and 1 500 to 2 499 g OR 4.85 (2.96-7.96). There are considerable differences comparing the odds ratios between the 5 subgroups for perinatal mortality. The subgroups "Turkey" and "western Europe/West" have a similar odds ratio compared to the reference group "Tyrol/Austria". The subgroups "former Yugoslavia" and "other countries" have a significantly increased perinatal mortality (OR 2-2.5).

CONCLUSION

The good outcome of the mothers from "Turkey" can be seen as similar to the "Latina paradoxon", which means a better outcome of pregnancy and birth of mothers from "Turkey", even though they are more comparable with other migrant groups in some risk factors, such as a lower socioeconomic standard, late check-ups, language difficulties and cultural factors. A single case analysis would be necessary to examine the exact causes.

[Promotion of breast feeding in paediatric outpatient settings]

With some data and examples it can be shown that the competence and the knowledge of paediatric doctor's assistants and paediatric nurses can and should be improved. The training courses to become a "prevention assistant" have been very positively accepted by doctor's assistants and paediatric nurses, and it seems an appropriate method to reach these aims. Prevention and especially promotion of breast feeding is possible in paediatric outpatient settings. The immediate contact between infants, parents, paediatric doctor's assistants, paediatric nurses, and doctors offers a unique opportunity to promote the health of children, mainly due to the high acceptance of regular check-ups. So why not introduce the promotion of breast feeding in paediatric outpatient settings with specially trained doctor's assistants and paediatric nurses?

The Mt. Diwata study on the Philippines 2000-treatment of mercury intoxicated inhabitants of a gold mining area with DMPS (2,3-dimercapto-1-propane-sulfonic acid, Dimaval)

Ninty-five inhabitants of the gold mining area of Mt. Diwata (on Mindanao, Philippines), who were diagnosed to be mercury (Hg) intoxicated, were orally treated with 2 x 200 mg of the chelating agent DMPS (Dimaval, Co. Heyl, Germany) for 14 days in the course of a UNIDO project focusing on mercury pollution abatement. Blood and urine samples before and after treatment, urine after the first application of DMPS and a hair sample were collected and analyzed for Hg. Before and after treatment extensive anamnestic data were collected, medical and neurological investigations and some neuro-psychological tests were performed. In spite of the short time of treatment most of the patients reported a marked improvement of the complaints which were stated by them before the therapy and which are characteristic for a chronic Hg intoxication, for example tremor, loss of memory, sleeplessness, metallic taste, etc. But even in some of the objective neurological parameters like hypo-mimia, Romberg test and tests for tremor/ataxia a statistical significant improvement could be found. Significant improvements could also be found in two neuro-psychological tests (pencil tapping and Frostig). In some cases an extreme high urinary Hg excretion was found under the chelating therapy with DMPS, and by this a distinct reduction of the Hg body burden. Nevertheless, in most cases Hg in blood and urine was not markedly decreased by the treatment. This shows that the duration of the treatment (14 days) was not sufficient for a permanent decrease in Hg. As DMPS excretes Hg mainly through the kidney, it can be concluded that in most cases even after 14 days of treatment there was an ongoing redistribution of Hg from other tissues to the kidney. In conclusion, this study proves that a chelating therapy with DMPS is highly effective even in the case of a mixed chronic and acute intoxication with an unknown combination of Hg vapor, inorganic Hg and organic Hg=methylmercury (MeHg), as characteristic for gold mining areas in the third world. Adverse side effects were rarely reported. Only in one case the medication had to be terminated after the first application due to an allergic skin reaction.

The Mt. Diwata study on the Philippines 1999--assessing mercury intoxication of the population by small scale gold mining

The region of Diwalwal, dominated by Mt. Diwata, is a gold rush area on Mindanao (Philippines) where approximately 15000 people live. The fertile plain of Monkayo is situated downstream, where people grow crops such as rice and bananas; locally caught fish is eaten frequently. The ore is dug in small-scale mines and ground to a powder by ball-mills while still in Diwalwal. The gold is then extracted by adding liquid mercury (Hg), forming gold-amalgam. To separate the gold from the Hg, in most cases the amalgam is simply heated in the open by blow-torches. A high external Hg burden of the local population must be assumed. To evaluate the internal Hg burden of the population and the extent of possible negative health effects, 323 volunteers from Mt. Diwalwal, Monkayo and a control group from Davao were examined by a questionnaire, neurological examination and neuro-psychological testing. Blood, urine and hair samples were taken from each participant and analyzed for total Hg. A statistical evaluation was possible for 102 workers (occupationally Hg burdened ball-millers and amalgam-smelters), 63 other inhabitants from Mt. Diwata ('only' exposed from the environment), 100 persons, living downstream in Monkayo, and 42 inhabitants of Davao (serving as controls). The large volume of data was reduced to yes/no decisions. Alcohol as a possible bias factor was excluded (level of alcohol consumption and type, see Section 4.4). Each factor with a statistically significant difference of at least one exposed group to the control group was included in a medical score (0-21 points). In each of the exposed groups this score was significantly worse than in the control group (median control, 3; downstream, 9; Mt. Diwata, non-occupational exposed, 6; Hg workers, 10). In comparison to the surprisingly high Hg concentration in blood (median, 9.0 microg/l; max, 31.3) and in hair (2.65 microg/g; max, 34.7) of the control group, only the workers show elevated levels: Hg-blood median 11.4, max 107.6; Hg-hair median 3.62, max 37.8. The Hg urine concentrations of the occupational exposed and non-exposed population on Mt. Diwata was significantly higher than in the control group: control median 1.7 microg/l, max 7.6; non-occupational burdened median 4.1, max 76.4; and workers median 11.0, max 294.2. The participants, living downstream on the plain of Monkayo show no statistically significant difference in Hg-blood, Hg-urine or Hg-hair in comparison with the control group. The German Human-Biological-Monitoring value II (HBM II) was exceeded in 19.5% (control), 26.0% (downstream), 19.4% (Mt. Diwata, non-occupational) and 55.4% (workers) of the cases, the German occupational threshold limit in 19.6% of the workers. Only some of the clinical data, characteristic for Hg intoxication (e.g. tremor, loss of memory, bluish discoloration of the gingiva, etc.), correlate with Hg in blood or urine, but not with Hg in hair. The medical score sum correlates only with Hg in urine. The poor correlation between the Hg concentration in the biomonitors to classic clinical signs of chronic Hg intoxication may be explained by several factors: Hg in blood, urine and hair do not adequately monitor the Hg burden of the target tissues, especially the brain. Inter-individual differences in the sensitiveness to Hg are extremely large. In this area a mixed burden of Hg species must be assumed (Hg vapor, inorganic Hg, methyl-Hg). Chronic Hg burden may have established damage months or even years before the actual determination of the Hg concentrations in the bio-monitors under quite different burden was performed (Drasch G. Mercury. In: Seiler HG, Sigel A, Sigel H, editors. Handbook on metals in clinical and analytical chemistry. New York: Marcel Dekker, 1994:479-494). Therefore, a 'Hg intoxication', that should be treated, was not diagnosed by the Hg concentration in the bio-monitors alone, but by a balanced combination of these Hg values and the medical score sum. In principle, this means the higher the Hg concentration in the bio-monitors, the lower the number of characteristic adverse effects are required for a positive diagnosis. By this method, 0% of the controls, 38% downstream, 27% from Mt. Diwata, non-occupational exposed and 71.6% of the workers were classified as Hg intoxicated. A reduction of the external Hg burden on Mt. Diwata is urgently recommended. An attempt to treat the intoxicated participants with the chelating agent dimercaptopropanesulfonic acid (DMPS) is planned.

[Double-blind comparison of an apple pectin-chamomile extract preparation with placebo in children with diarrhea]

In a prospective, double-blind, randomised, multicentre, parallel group study, children (6 months to 5.5 years of age) with acute, non-complicated diarrhea received either a preparation containing apple pectin and chamomile extract (Diarrhoesan, n = 39) or placebo (n = 40) in addition to the usual rehydration and realimentation diet. At the end of three days of treatment, the diarrhea had ended significantly (p < 0.05) more frequently in the pectin/chamomile (33/39) than in the placebo group (23/40). Pectin/chamomile reduced the duration of diarrhea significantly (p < 0.05) by at least 5.2 h. The parents documented the well-being in a diary twice daily; in contrast to placebo, a trend of continuous improvement was observed in the pectin/chamomile group. The parents expressed their contentment more frequently (82%) with pectin/chamomile than with placebo (60%, not significant). There were no further differences between the treatment groups.