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A 52 year old farmer was referred to us for investigation of suspected farmer's lung. For many years the farmer had been exposed to hay, straw, pigeons, and fuel chip dust. Under exertion he suffered from shortness of breath. In the farmer's own fuel chips we could identify Aspergillus fumigatus, Paecilomyces species and Mucor species. In the farmer's blood we found IgG-antibodies against his own fuel chips, thermophilic actinomycetes, Penicillium species, Mucor species and Aspergillus fumigatus. We did not detect any IgG-antibodies against pigeon serum or pigeon faeces. In order to determine the responsible allergen we performed two challenge tests. In the first test the farmer had to inhale his own hay and straw dust for one hour. This provocation was negative. A second one-hour inhalative challenge was carried out 16 days later using his own fuel chips. This time he experienced significant pulmonary and systemic reactions: body temperature rose by 3.3 degrees C, leucocytes by 12,200/mm3; PO2 fell by 39.4 mmHg, vital capacity by 52%, DLCO by 36%. After the challenge the farmer complained of coughing and dyspnoea. Rales could be heard on auscultation, and an interstitial infiltrate was seen to develop on chest x-rays. After the challenge the patient had to be treated with oxygen and systemic corticosteroids. We diagnosed a fuel chip-induced exogenous allergic alveolitis (EAA). Eight days later the parameters were back to normal and the farmer was discharged from our hospital with further corticosteroid medication. This method of inhalative provocation is very important in diagnosing an EAA. Problems arise when the mode and duration of exposure to substances has to be chosen. Because of the risk of severe reactions, inhalative provocations relating to EAAs should only be performed in special centres with an intensive care unit. In this paper we present a diagnosis of fuel chip lung, which is rarely seen in Germany. However, with the rising use of fuel chips as heating material it is necessary to consider this use as a cause of EAA among farmers.

Since there is evidence that wood dust may cause adenocarcinoma of the nose and sinuses, the question is whether carcinomas of the remaining upper respiratory tract especially of the larynx might be induced or promoted by occupational exposure to wood dust. We reviewed available evidence and found ten case control studies suggesting a causal relationship, whereas in five case control studies regarding this question such a relationship could not be demonstrated. Six cohort studies did not reveal such a relationship either. It should be mentioned that two cohort studies were designed as registry-based studies including cases without fatal outcome. Even these studies failed to reveal a causal relationship. We conclude that the question as to whether laryngeal cancer might be caused by wood dust exposure is still open. Under these circumstances we cannot recommend classifying this disease-exposure-constellation as an approved occupational disease.

Background: Adenocarcinomas of the nasal cavity and the paranasal sinuses after occupational exposure to sawdust from oak and beech have been listed as occupational diseases in Germany since 1988. Given that modes of treatment have changed, we analyzed the guidelines based on the recommendations of Hartung et al. for developing an expert assessment on reduced earning capacity., Materials and Methods: A retrospective analysis of 43 cases which had been evaluated between March 1994 and February 2007 for an occupational disease #4203, in the Ear-Nose-Throat clinic of the Münster University Hospital, Germany., Results: Following the guidelines of Hartung et al., it was impossible to formally classify 21 of 43 cases (48.8 %) in an unambiguous manner. This was primarily due to the assessment of the results of radiotherapy, either adjuvant or therapeutic, as well as the grading of postoperative dysfunction in the area of the sinuses operated on (Rhinitis, Ozaena). Suggestions for a revision of the classification system include a modified assessment of radiotherapy as well as evidence for grading post-therapeutic inflammations of the sinus operated on based on the need for further care. These changes enable all cases in question to be classified unambiguously., Conclusions: The use of the revised guidelines is recommended for expert assessment of adenocarcinomas of the nasal cavity and the paranasal sinuses caused by wood dust.

Densitometric measurements were carried out on various types of glass, plastic and wood in order to determine the scope of computer tomography in detecting nonmetallic foreign bodies. CT was superior to conventional film techniques for localising glass when situated near bone. Densitometry of plastic materials showed wide variation of these substances and the results hae been tabulated. Heavy polymers exceeded +200 H, light synthetic materials were between 0 and -100 H. Computer tomographic absorption measurements of wood showed that the density depended on its water content. Measurements of different types of wood, with different degrees of hydration, showed that changes in density could be brought about by incorporation of fluid into the wood.

Wood preservatives as pentachlorophenol and lindane containing the highly toxic compound dioxin were common to be used to protect woods inside the house. In a case report a couple of symptoms are shown as upper airway irritation with dry mucosa, headaches, sleeplessness, lack of concentration and psychosomatic problems caused by those wood preservatives. The typical sequence of the symptoms is given. The results of blood and urine analysis on pentachlorophenol and lindane lead to investigations on indoor materials, air and dust. Taking out the contaminated materials is the best and only treatment.

A 71-year-old female patient fell in her garden, inducing a skin wound on the temporal left eyebrow. Skin disinfection and wound closure were performed elsewhere, an X-ray image did not reveal a foreign body. She was referred to our service three days later with a progressive left periorbital swelling. Clinical inspection demonstrated a painfully, fluctuant swelling around the wound with an inflammatory pseudoptosis of the left eye. Vision was reduced on the left eye; anterior and posterior segments of both eyes were unharmed. After opening the wound sutures a purulent liquid was drained and a wooden fragment was found, measuring 22 x 0.5 mm. Because of restriction of abduction of the left eye, magnetic resonance imaging (MRI) was performed, detecting another organic intraorbital foreign body and a fracture of the left medial orbital wall. Anterior orbitotomy was performed and a wooden fragment was removed, measuring 47 x 0.6 mm. Under administration of intravenous antibiotics vision and ocular motility recovered uneventfully. This case emphasizes the value of MRI in the diagnostics of retained wooden foreign bodies as well as the importance of a soigneuse inspection of skin wounds with a high risk for remaining foreign bodies.

In 1997 so far unknown indoor contaminations were detected in a flat of former American Forces living quarters in Frankfurt/Main, Germany. Household dust samples were found to be contaminated with polycyclic aromatic hydrocarbons (PAH), respectively with benzo(a)pyrene (BaP), due to the use of a coal tar pitch parquet glue that had been standard building practice in Germany up to the 'sixties. To assess the amount of exposure, the local Health Services department organised analyses of PAH metabolites in the urine of children below 6 years of age considered to be at risk for oral exposure to BaP in household dust while playing on the floor. In addition the local Health Services informed all ministeries concerned of the problem. During the following months several meetings on this topic were held by experts in the respective spheres and recommendations for redeveloping indoor sites were outlined. In almost 3,000 analyses of samples of household dust and parquet glue and about 1,200 urine analyses for PAH-metabolites in Frankfurt/Main no correlation was seen between the BaP levels in parquet glue and the BaP levels in household dust samples, as well as with interual exposure. Recommendations for further action were made in view of the importance of the composition of parquet flooring for possible indoor contamination.

The evaluation of indoor pollution by wood preservatives and pesticides has been a matter of increasing interest for the past years. The present paper reviews actual knowledge. The so-called "wood preservative syndrome" is referred to. Basics and evaluation criteria concerning the investigation of external exposure (wood, dust, air) and human biomonitoring is summarized. Several substances, in particular pentachlorophenol, lindane and pyrethroids, and principle possibilities to decrease exposure are considered.

We report on a 37-year old patient with a simple viral infection who presented with acute bronchitis with bronchospasm, a productive cough and severe dyspnoea. Because of his specific occupational history--the patient is a forester and was exposed to wood dust and fungi--he was at high risk for extrinsic allergic alveolitis with mucoid impaction, so that the cause of hypoxemia and cyanosis was obvious. Repeated immunological parameters including gel-precipitations were negative: The lung function pattern (reduced vital capacity, a reduced FEV1, reduced flow values at low vital capacity and with the characteristic shape of the flow volume-curve but normal airway-resistance) suggested the diagnosis of intrinsic asthma limited to the small airways - "bronchiolar asthma" - severe small airway disease.

Aim: To judge the possibilities of detection of orbital foreign bodies in multidetector CT (MDCT) with a focus on glass slivers., Materials and Methods: Experimental systematic measuring of Hounsfield Units (HU) of 20 different materials, containing 16 different types of glass with 4 different types of ophthalmic lenses among them. The measurements were performed using a standardized protocol with an orbita phantom being scanned with 16-slice MDCT. Using the resulting density values, the smallest detectable volume was calculated. Using this data we produced slivers of 5 different glass types in the sub-millimeter range and calculated their volume. Those micro-slivers underwent another CT scan using the same protocol as mentioned above to experimentally discern and confirm the detection limit for micro-slivers made of different materials., Results: Glass has comparatively high density values of at least 2000 HU. The density of glasses with strong refraction is significantly higher and reaches up to 12 400 HU. We calculated a minimum detectable volume of 0.07 mm (3) for glass with a density of 2000 HU. Only glass slivers with a density higher than 8300 HU were experimentally detectable in the sub-millimeter range up to a volume as small as 0.01 mm (3). Less dense glass slivers could not be seen, even though their volume was above the theoretically calculated threshold for detection., Conclusion: Due to its high density of at least 2000 HU, glass is usually easily recognizable as an orbital foreign body. The detection threshold depends on the object's density and size and can be as low as 0.01 mm (3) in the case of glass with strong refraction and thus high density. The detection of glass as an orbital foreign body seems to be secure for slivers with a volume of at least 0.2 mm (3) for all types of glass., (© Georg Thieme Verlag KG Stuttgart · New York.)

Anorexia nervosa has been related to alterations in brain activity in terms of hyperactive EEG patterns. This case report illustrates the principles and results of a five-week neurofeedback treatment in a 29-year-old woman suffering from anorexia nervosa. A neurofeedback protocol to enhance alpha activity (8 - 12 Hz) was developed and conducted additionally to the standardized treatment for eating disorders in training sessions twice a week. Pre- and post-test measurements included resting state EEG measurements and a psychological test battery. The results show improvements from pre- to post-test in eating disorder psychopathology including psychological wellbeing, emotional competence, and eating behavior traits. In addition, a decrease in theta power (4 - 7 Hz), a well-known trait marker of anorexia nervosa, was measured. However, our data should be interpreted with caution because this is a single case study. Nevertheless, this report documents the practicability and method of neurofeedback as treatment adjunct in eating disorders from the clinical perspective. Although the use of neurofeedback in the treatment of anorexia nervosa is recommended in literature, empirical studies are still lacking. Randomized controlled trials to evaluate short- and long-term effects of neurofeedback are needed., (© Georg Thieme Verlag KG Stuttgart · New York.)

The aims of the population-based, cross-sectional survey "Study of Health in Pomerania" (SHIP) are to describe prevalences and distributions of a broad range of diseases, as well as environmental and behavioural risk factors in the region of Pomerania (North-eastern Germany). The examinations are performed in two study units by different physicians, technicians and interviewers and laboratory analyses in two separate laboratories. In addition, the study will take at least 3 years and approximately 7000 persons will be examined. Because of the design of the study a special concept of quality assurance is indispensable. In the present paper methods are presented for quality assurance and control in anthropometry, ECG, echocardiography, abdominal sonography, carotid ultrasound, sonography of the thyroid gland, blood pressure measurements as well as clinical laboratory analyses. The technical control protocols, the training programmes of the observers and methods to establish observer and method variabilities are presented by means of typical examples. The logistic, personal and technical measures for quality assurance and control require appropriate attention. The methods and procedures presented here are expected to provide an effective instrument to continually monitor the quality of medical examinations in the SHIP study.

Neutrophilic granulocytes in the lower respiratory tract are of decisive importance for the elimination of pathogenic germs in bacterial pneumonia. On the other hand, the liberation of phagocyte products (e.g. elastase) can result in tissue damage in the parenchyma of the lungs. For this reason, we determined in patients suffering from acute pneumonia (n = 21), in patients with acute pneumonia associated with immunosuppression (n = 12), in patients who had overcome their pneumonia (n = 9) and in controls (n = 17) in bronchoalveolar lavage (BALF) and in plasma, the concentration of the locally produced granulocyte products myeloperoxidase (MPO), lactoferrin (LF) and elastase-alpha 1 proteinase complex (ELA) as well as of the alpha 1 proteinase inhibitor (alpha 1 Pi) and alpha 2 proteinase inhibitor (alpha 2 Pi) via chemoluminescence immunoassay, and compared the same with the differential cell count in the BALF. The protein concentrations were referred to the albumin concentration (Alb) for standardisation. This concentration did not differ significantly between the various patients and control groups. The BALF concentration of ELA in the group with pneumonia (median: 86.3 micrograms/l or 8.5 micrograms/mg Alb) was about eight times higher than in the group of patients suffering from pneumonia with immunosuppression (median: 16 micrograms/l or 1.0 micrograms/l Alb, p less than 0.001) or in whom the pneumonia was no longer present (17.6 micrograms/l or 0.5 micrograms/mg), and approximately 40 times higher than in the control group (3 micrograms/l or 0.2 micrograms/mg, respectively). Similar results were obtained for LF (61 micrograms/mg Alb vs. 11.3; 16.8 and 5.9 micrograms/mg; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary hypertension associated with left heart disease (PH-LHD) corresponds to group two of pulmonary hypertension according to clinical classification. Haemodynamically, this group includes isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH). PH-LHD is defined by an mPAP > 20 mmHg and a PAWP > 15 mmHg, pulmonary vascular resistance (PVR) with a cut-off value of 2 Wood Units (WU) is used to differentiate between IpcPH and CpcPH. A PVR greater than 5 WU indicates a dominant precapillary component. PH-LHD is the most common form of pulmonary hypertension, the leading cause being left heart failure with preserved (HFpEF) or reduced ejection fraction (HFmrEF, HFrEF), valvular heart disease and, less commonly, congenital heart disease. The presence of pulmonary hypertension is associated with increased symptom burden and poorer outcome across the spectrum of left heart disease. Differentiating between group 1 pulmonary hypertension with cardiac comorbidities and PH-LHD, especially due to HFpEF, is a particular challenge. Therapeutically, no general recommendation for the use of PDE5 inhibitors in HFpEF-associated CpcPH can be made at this time. There is currently no reliable rationale for the use of PAH drugs in IpcPH, nor is therapy with endothelin receptor antagonists or prostacyclin analogues recommended for all forms of PH-LHD., Competing Interests: A.S.: Vortragshonorare im Zusammenhang hiermit: Actelion, Abbott, Edwards, MSD, Forschungsgrands: Abbott.S.S.: Vortragshonorare und Reiseunterstützung von MSD und Johnson & Johnson.A.Y.: Reports personal fees from MSD outside the submitted work.A.J.R.: Vortragshonorare von AstraZeneca und Bayer sowie Reisekostenunterstützung von Johnson & Johnson und Servier, alles ohne Zusammengang mit dem vorliegenden Manuskript.E.P.-J.: Reisekostenunterstützung OMT, Actelion, Boehringer-Ingelheim sowie Honorar von Actelion.K.H.S.: Vortragshonorare von Janssen, MSD und Abbott.Die weiteren Autoren haben keine Interessenkonflikte angegeben., (Thieme. All rights reserved.)

Lung diseases and hypoventilation syndromes are often associated with pulmonary hypertension (PH). In most cases, PH is not severe. This is defined hemodynamically by a mean pulmonary arterial pressure (PAPm) > 20 mmHg, a pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg and a pulmonary vascular resistance of ≤ 5 Wood units (WU). Both the non-severe (PVR ≤ 5 WU) and much more the severe PH (PVR > 5 WU) have an unfavorable prognosis.If PH is suspected, it is recommended to primarily check whether risk factors for pulmonary arterial hypertension (PAH, group 1 PH) or chronic thromboembolic pulmonary hypertension (CTEPH, group 4 PH) are present. If risk factors are present or there is a suspicion of severe PH in lung patients, it is recommended that the patient should be presented to a PH outpatient clinic promptly.For patients with severe PH associated with lung diseases, personalized, individual therapy is recommended - if possible within the framework of therapy studies. Currently, a therapy attempt with PH specific drugs should only be considered in COPD patients if the associated PH is severe and a "pulmonary vascular" phenotype (severe precapillary PH, but typically only mild to moderate airway obstruction, no or mild hypercapnia and DLCO < 45 % of predicted value) is present. In patients with severe PH associated with interstitial lung disease phosphodiesterase-5-inhibitors may be considered in individual cases. Inhaled treprostinil may be considered also in non-severe PH in this patient population., Competing Interests: M.H.: Honorare für Vortrags- und Beratertätigkeiten von AstraZeneca, Janssen und MSD. Reisekosten von Janssen. Alle nicht im Zusammenhang mit der aktuellen Übersichtsarbeit.K.E.Z.: Reisekosten und Vortragstätigkeiten von Fa. MSD, Janssen und Ferrer. Alle nicht im Zusammenhang mit der aktuellen Übersichtsarbeit.N.S.: Honorare für Berater- und Vortragstätigkeiten von MSD und Janssen. Alle nicht im Zusammenhang mit der aktuellen Übersichtsarbeit.S.U.: Forschungsgelder vom Schweizerischen Nationalfond, der Lungenliga Schweiz, der Lunge Zürich, der Emdo Foundation, von Janssen SA, Orpha Swiss. Reisekosten und Vortragstätigkeiten von Janssen SA, Orpha Swiss, MSD und Novartis, alle nicht im Zusammenhang mit der aktuellen Übersichtsarbeit.M.H.: Beratungshonorare: Actelion, Bayer Healthcare, Bristol Myers Squibb, Boehringer Ingelheim, Janssen, MSD, Pfizer. Honorare für Vorträge von: Actelion, AstraZeneca, Bayer HealthCare, Berlin Chemie, Boehringer Ingelheim, Bristol Myers Squibb, Daichi Sankyo, Janssen, MSD, Pfizer, Santis.T.K.: Honorare für Vortragstätigkeiten und Reisekostenübernahme von AstraZeneca, Berlin Chemie, Janssen und MSD. Alle nicht im Zusammenhang mit der aktuellen Übersichtsarbeit.V.F.: Honorare für Vortragstätigkeiten und Reisekostenübernahme von Boehringer Ingelheim, BMS, Chiesi, Janssen, MSD, alle nicht im Zusammenhang mit der aktuellen Übersichtsarbeit.M.H.: keineC.N.: Honorare für Vortrags- und Beratertätigkeiten von AstraZeneca, Janssen und MSD. Alle nicht im Zusammenhang mit der aktuellen Übersichtsarbeit.J.R.: keineS.H.: Zuwendungen von Janssen, Bayer und MSD, die in keinem Zusammenhang mit dieser Arbeit stehen.D.S.: Vortrags- und Beratungshonorare und/oder Forschungsunterstützung von AstraZeneca, Bayer, Boehringer Ingelheim, Chiesi, GSK, Janssen, MSD, Sanofi, DFG, BMBF. Alle nicht im Zusammenhang mit der aktuellen Übersichtsarbeit.N.K.: erhielt finanzielle Zuwendungen von Janssen, Ferrer, Bayer und MSD, die in keinem Zusammenhang mit dieser Arbeit stehen.J.B.: Honorare für Vorträge und Beratertätigkeit von AstraZeneca, Biogen, Boehringer-Ingelheim, BMS, Ferrer, Novartis, Roche, and Sanofi-Genzyme. Für Tätigkeiten im Rahmen von Data Monitoring and Safety Boards erhielt er Honorare von Actelion und Galapagos. Es besteht kein Zusammenhang mit der vorliegenden Publikation., (Thieme. All rights reserved.)

Background: Globe ruptures are ophthalmological emergencies where the primary diagnosis using a slit lamp is often a challenge., Objectives: The retrospective case study aimed to characterise the predilection sites, the demographic profile and the causes of bursts due to blunt globe trauma., Materials and Methods: The surgical plan of the Eye Centre of the Medical Centre (University of Freiburg) was electronically searched using the keyword "globe rupture" over a period of 18 years (2000 - 2018). This led to 350 hits, which were scrutinised by hand. 134 globe ruptures due to blunt globe trauma were then identified., Results: The most common predilection sites were the upper nasal and the upper temporal paralimbal zones with 37 and 32% of the examined globe ruptures, respectively. The average age at the time of rupture was 60 (from 2 to 97) years. The median age was 62.5 years. 37% (49/134) of patients were female. The most frequent causes of accidents were falls (43%), "flying" wooden and metal objects (18%) and acts of violence (10%)., Conclusions: Special attention should be paid to the upper paralimbal zone in the exploratory primary care of globe ruptures. If the rupture occurred due to "flying" wooden and metal objects, the posterior sclera burst most frequently. The epidemiological data suggest that targeted prevention against falls for individuals over 60 years and consistent wearing of protective eyewear when working with wood or metal could reduce the incidence of bulbar bursting. It was also noticeable that acts of violence were the third most frequent cause of rupture, although woman did not report that they were affected by this. Given the high occurrence of violence against women, shame and stigma may lead to an incorrect inquiry about the cause of the accident. This could be mitigated by training employees specifically to take a sensitive history., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

In a multicenter study (7 participating centres) 132 patients with bronchial asthma (grade II or III) and sensitization to storage mites (SM) and/or house dust mites (HSM) were screened and asked to undergo further allergological evaluation. 90 patients agreed. In addition to routine skin prick tests and RAST, quantitative skin prick tests (QSPT) and bronchial provocation tests (BPT) were also performed with the suspected mite allergens. The results were correlated with aspects of the domestic and working environments. Furthermore we questioned whether the outcome of BPT could be predicted from the results of the routine skin tests/RAST and QSPT respectively. Out of a total of 145 BPTs there were 79 positive results with SM and/or HSM. Three patients were mono-allergic to SM. The correlation with the domestic environment was unremarkable. Correlation with occupational factors revealed a strong predominance of farmers (42 of 90) and suggested the same for professions involved in work in dust-laden environments like bakers (5 of 90) and workers in wood- and paper industry (7 of 90). This also means, that SM-allergy occurs in persons not occupationally exposed to dust. A prediction as to the allergological relevance of SM-allergen was not possible from viewing the routine skin prick test however positive RAST data showed a significant correlation with positive BPT to SM Lepidoglyphus. Similarly it was possible to draw an inference from QSPT as to the relevant allergy. With a positive QSPT to the SM Lepidoglyphus destructor a positive result with a BPT was highly probable. Due to small numbers it is not possible to make a similar statement for the other SM species (Acarus and Tyrophagus).

Background: The success of penetrating keratoplasty (PKP) after penetrating eye injuries is often worse than in keratoplasty with Fuchs' endothelial dystrophy. However, comparable investigations are rare. Therefore, we have retrospectively analyzed the results and complication rates of PKPs in patients who experienced penetrating eye injuries., Patients and Methods: Between 1990 and 1997 forty-four patients who received a corneal transplant at Kiel University Eye Hospital after penetrating eye injury (study group S) were analyzed. 29 patients were re-examined (visual acuity testing, slit lamp microscopy, applanation tonometry, stereo testing, corneal TMS topography, keratometry, endothelial microscopy, perimetry, indirect retinoscopy, testing of the retinal visual acuity and probatory contact lens fitting). Postoperative follow-up ranged between 1 and 6 years (median 3 years). The results were compared to a group of corneal grafts performed in patients with Fuchs' endothelial dystrophy (K, n = 18 patients, 25 eyes, median follow-up 2.8 years)., Results: 38males and 6 women had had a bilateral visual acuity of 0.8 or better before the accident, except for three cases. At the time of eye injury the patients' age ranged from 4 to 76 years. The eye trauma was caused by splinters of metal (45 %), glass (20 %), wood (16 %) or stone (11 %). In 73 % of the cases the injury was confined to the anterior segment of the eye (S1). The posterior part of the eye was involved in 27 % (S2). BCVA of S before keratoplasty (KP) was 1/15 on average (K 0.2), at least one year after KP 0.25 (K 0.4); post KP S1 was better than S2 (p = 0.0234), and K better than S (p = 0.0009). In group S 29 patients received a graft at random because of a central corneal scar, 14 patients received an HLA-typed graft with 2.3 mismatches on average. 93 % of the grafts (41 patients) were clear at the last examination, 8 patients showed rejection episodes, half of them were reversible. 5 patients received a second graft because of an irreversible rejection or endothelial decompensation. BCVA improved by at least one line in 84 % in S (K 92 %). BCVA was unchanged after KP in 6.8 % (K 8 %). In 9.1 % of S BCVA after KP was worse (K 0 %). 32 out of 44 patients had a BCVA of 0.1 or better after the last check-up, 13 out of 44 patients presented with a BCVA of 0.5 or better (K40 %). 15 out of 29 patients separately tested showed stereopsis compared to 8 preoperatively in S. In 48 % of the patients studied stereovision could not be restored. 82 % of the patients suffered from topographical irregular astigmatism in S, the superficial geometry of recipient's cornea seems relevant for astigmatism of the graft. Frequent postsurgical complications consisted of secondary glaucoma (S 27 %, K 4 %), immunological rejections (S 18 %, K 0 %), and amblyopia (S 14 %, K 0 %)., Conclusion: Compared to patients with Fuchs' dystrophy the results of grafting after eye injuries are significantly worse. This relates to BCVA, astigmatism, frequency of secondary glaucoma and graft rejection.

Objectives: O. Sacks describes in his book "A leg to stand on" the inability to move his leg for along period after rupture of the tendon of m. quadriceps. He refers the history of similar cases, especially of a woman with a hip fracture. He discusses this as a result of disruption of proprioception (peripheral induced neglect). The aim of this investigation is to answer the question how frequently this symptom may be found in patients with hip fracture and/or arthrosis perioperativly after implantation of a total prosthesis., Methods: we examined 106 patients aged 70.35 +/- 10.01 years (36-male 67.54 +/- 9.74 years and 69 female 71.9 +/- 9.9 years) who underwent an implantation of a hip prosthesis - antero-lateral access Watson-Jones - (right side n = 61, left n = 44) because of arthrosis (n = 81) or a hip fracture (n = 18) on postoperative day 1./2. and 10. - 14. Besides exact neurologic examination, we particularly asked for changed perception of the operated leg., Results: by neurological examination we found only rarely signs of peripheral nerve lesion as a complication of implantation of hip prosthesis (1 femoral nerve lesion, 1 ischiadicus nerve lesion). 14 patients reported a changed perception at the first examination: 5 patients felt their operated leg shorter or longer, 4 patients described their leg changed in a strange manner (like a block of wood or lead), 2 patients felt their leg changed, but could not tell how. At follow-up examination there was no patient with a changed perception of the operated leg., Conclusions: at first examination only a small number of patients report a changed perception of the operated leg. Early mobilization of the operated leg may be the cause of quick normalization of perception. The peripherally induced neglect, described by O. Sacks, was possibly caused by decrease of cortical representation because of immobilization, but not by disrupted proprioception.

Background: Whereas a tubular adenoma is a unique finding within the paranasal sinuses, intestinal adenocarcinomas are especially in patients with long-term exposure to wood dust, common tumours in this location., Case: In a 65 year old joiner endonasal sinus surgery performed to treat suspected chronic pansinusitis brought up by chance the histological finding of a tubular adenoma. As the patient at first refused surgical revision, but magnetic resonance imaging during follow-up revealed evidence for a space occupying lesion affecting the ethmoid and sphenoid sinuses revision surgery took place one year later. Histopathological evaluation now found a papillary adenocarcinoma. Clinical follow-up and magnetic resonance imaging one year after second surgery found no evidence for tumour recurrence., Conclusions: Progression of a tubular adenoma to an adenocarcinoma like in the adenoma-carcinoma model well known for colorectal carcinomas has so far not been observed within the paranasal sinuses. But, an adenocarcinoma already present at the time of first surgery can not be ruled out completely in the presented case as histopathological evaluation may have failed to detect an adenocarcinoma in the available specimens after first surgery. Either malignant transformation of a tubular adenoma had occurred or proof of an adenocarcinoma has failed with misdiagnosis of a tubular adenoma. A tubular adenoma as well as an adenocarcinoma require complete resection and careful clinical and radiological follow-up to avoid adenocarcinoma development from a tubular adenoma or to detect an adenocarcinoma by histological evaluation of the whole specimen.

Since November, 1999 environmental medical advice is offered to interested citizens in the Aachen district at the District Aachen Public Health Office in cooperation with the outpatient unit of environmental medicine (UEM) of the Institute of Hygiene and Environmental Medicine of the University Hospital at Aachen, Germany. Advisory cases are documented in a data bank of Microsoft(R) Access 97. Until now, all advisory cases between November, 1999 and March, 2001 have been descriptively analysed. In this period, 34 personal and two telephonic advices were performed. The frequency of advisory activities is in the lower rang of published experiences in environmental medicine. Age distribution, more frequent advice utilization by women than by men and predominance of unspecific health disorders are comparable with published environmental medical experiences. However, in respect of suspected exposures, unspecific indoor-related environmental factors are predominant. In the past this was true for wood preservatives. Judgement about possible relationships between suspected environmental factors and health disorders or diseases was positive among 11.8 % of the persons seeking advice. This percentage is higher than published experiences which mostly show values below 10 %. It must be considered that this judgement depends primarily on the physician. Other reasons may be the too small number of advice seeking persons and selective influences. Furthermore, a definite judgement can be made only after environmental medical diagnostics (biological monitoring, local inspection, ambient monitoring) and differential diagnostics. Conspicuously, 76.5 % of the advisory cases had no contact to environmental medicine prior to the environmental medical advice at the Aachen District Public Health Office. This points to an information deficit about possibilities to clarify questions concerning environmental medicine in the population. In this context a regional guide on environmental medicine may be helpful. The environmental medical advice for citizens is an excellent example of a successful cooperation between a public health office and an university, which have different special experience in environmental hygiene and environmental medicine. This cooperation brings selectively citizens seeking for advice in environment-related health risks and disorders to practitioners specialised in environmental medicine.

As part of an environmental epidemiological study on potential exposure to a toxic waste incineration we investigated whether children in an area with a toxic waste incinerator (TWI) have different levels of thyroid hormones than children in two comparative regions. The TWI region is situated in the Rhine valley (about 30 km across) with low mountains on both sides. Other industries such as a chemical plant are nearby, and several municipalities are located in the environment of these. One comparative area 20 km north is also industrially and agriculturally used, but has no incinerator (Rhine Valley comparison group, RVC group). South-East of the incinerator region in an area of low mountains (about 400 m high) we investigated the second comparison group (Odenwald comparison group, OWC group). Altogether 671 children from 18 municipalities participated in 1994/95 (participation 61.5%). Blood samples were taken from 341 children, aged 7 to 10 years, living in non-smoking households or in households with only light smokers. Serum levels of thyrotropin stimulating hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) were analysed. In a self-administered questionnaire for the parents, which was checked during the medical examination, we gathered information on age, gender, passive smoking, consumption of fish, as well as use of wood preservatives and pesticides at home. By means of adjusted regression analysis the first step was to check whether the TWI group had means of TSH, FT4 and FT3 that differed from the OWC group and the RVC group. If differences were at least marginally significant, the second step was to analyse whether children from different municipalities had statistically different mean values and if the pattern of these municipalities fitted into the three regions. For the latter, children from a town in the Odenwald served as comparison group. The TWI group had statistically significantly (p < or = 0.05) reduced FT3 and FT4 values with a higher prevalence of FT3 values below clinical references (TWI group: 7.7%, RVC group: 3.2%, OWC group: 1.2%). Children from four out of nine TWI municipalities showed statistically significantly lower FT3 means than children from the reference town, and one of the seven municipalities from the comparative areas. The mean FT4 was significantly lower in four municipalities of the TWI area and in one of the two other areas. The mean TSH was only marginally different, mainly influenced by gender differences with boys having higher TSH levels. Comparison of the municipalities did not reveal a consistent pattern. Industrial pollution might influence the regulatory system of the pituitary thyroid axis. Reduced peripheral thyroid hormones associated with exposure to polychlorinated biphenyls (PCB) and dioxins/furans (PCDD/F) were found in previous studies. Our results suggest that children exposed to toxic waste incineration in their environment have lower thyroxine and triiodothyronine levels.

A new technique for pulmonary lobectomy has been utilized for malignant lesions. Eighty-five consecutive patients with pulmonary neoplasms underwent a VATS non-rib spread Simultaneously Stapled Lobectomy. There were 34 males and 51 females with 61 adeno, 21 squamous, 2 large cell and 1 carcinoid tumor who underwent 18 left upper, 13 left lower, 20 right upper, 7 right middle and 27 right lower lobectomies. Forty-one mediastinoscopies were negative. Patients with positive mediastinoscopies were not selected for curative resection. At VATS exploration, 10 patients had positive nodes. All resected nodes were negative in the other patients. Every bronchoscopy was negative. Operating times averaged 84.5 minutes. No patient received a transfusion. Lesions ranged from 1 cm to 8 cms with an average size of 3.62 cms. Post-operative length of stay averaged 3.38 days. There was no surgical mortality, no hemorrhage, no transfusion and no conversion to an open case in the entire series. No bronchial, vascular or broncho vascular fistula occurred. Complications were minor from which all patients recovered completely. Survival seems similar to patients resected by traditional open techniques.

Purpose: To prove the visualisation of orbital foreign bodies by CT., Materials and Methods: In vitro we examined defined small objects of various materials (metal, wood, glass, stone) which are common as orbital foreign bodies, Density and minimum detectable size were studied. The findings of 27 patients with suspected orbital foreign bodies were compared with the results of plain radiographs, Comberg radiographs, sonography, and surgery., Results: For iron, the minimum detectable size was 0.02 mm3. A differentiation of various materials by CT was not always possible, especially in small objects. There were wide differences in density of wood (-600 HU to +130 HU) according to hardness and water content. The CT scans correctly showed number and location of foreign bodies. Other methods were inferior in detection of foreign bodies., Conclusion: In diagnosis of foreign body injuries of the orbit, CT is the imaging method of choice.

In connection with an investigation of state-owned buildings for wood preservatives, human monitoring on pentachlorophenol (PCP) was performed on 484 subjects from Northern Bavaria and 299 persons from Southern Bavaria during the period November 1994 to October 1995. Altogether, a similar pattern of concentrations resulted, the 95th percentile amounting to 15 (Northern Bavaria) and 20 micrograms PCP/l blood plasma (Southern Bavaria), respectively. An inquiry of the exposure conditions of the subjects studied in Southern Bavaria revealed that 28% had been exposed to wood containing 5-100 mg PCP/kg (slightly elevated) and 61 % to wood with > 100 mg PCP/kg (definitely treated). One-third each of the subjects had been exposed to dust containing 5 mg PCP/kg (normal), 5-10 mg/kg (slightly elevated) and > 10 mg/kg (clearly elevated), respectively. The mean exposure period was approx. 10 years with a mean daily stay of 8 hrs. No statistically significant correlations were found between the human monitoring data and PCP concentrations in wood or dust or the stated complaints.

The data of 466 subjects suffering from neurologic disorders which are suggested to be caused by neurotoxic agents in their environment retrospectively was evaluated and documented. Among these cases there were 151 subjects with symptoms of Multiple Chemical Sensitivity Disorder (MCSD). The relationship between the neurological health impairments and neurotoxic agents in the environment of these patients was characterised using five different categories (probable = A, possible = B, uncertain = C, unclarified = D, not probable = E). From the 466 patients 320 subjects (69%) could be assigned to the categories A and B, respectively. Within theses 320 cases with chronic neurotoxic health impairments 136 subjects (79 females and 57 males) showed signs of MCSD. Age and gender of cases as well as duration and character of exposure to neurotoxic substances retrospectively were assessed from the explicit files of the patients, which had been made anonymous for this purpose. Frequency of characteristic symptoms of neurotoxicity were analysed. Results are given for patients with neurotoxic health impairments with MCSD (n = 136) and without MCSD (n = 184). Neurotoxic substances which were used as indoor wood preservatives (mainly Pentachlorophenol and/or Lindane) were found to be the causative agents in 63% of the cases with neurotoxic health impairments and MCSD. Other important neurotoxic substances to which the patients were mainly exposed were organic solvents (25%), formaldehyde (15%), dental materials (15%), pyrethroides (13%), and other biocides (19%) (multiple exposures were possible). The time of exposure was calculated as being > or = 10 years for 55% of the patients with MCSD and for 50% of the group with neurotoxic health impairments but without MCSD. Out of the 184 cases with neurotoxic health impairments but without MCSD there were 22%, and out of the 136 cases with MCSD there were 39% who showed all symptoms of chronic fatigue syndrome. 53% of the cases with MCSD had an allergic disposition compared to only 20% of the cases without MCSD. This work is not a controlled epidemiological study but a retrospective documentation and evaluation of data related to environmental medicine. With the present documentation in this purely descriptive manner the proof of a causal relationship was not possible or intended. But because corresponding epidemiological studies are lacking, this documentation can give important information on characteristic features of Multiple Chemical Sensitivity Disorder and chronic neurotoxic health impairments. Such information is essential for planning and carrying out epidemiological studies urgently needed in this field.

Chlorophenols occur ubiquitously in the environment. They are taken up as such in man or are formed in intermediary metabolism e.g. from chlorobenzenes. In particular pentachlorophenol (PCP) is one of those chemical substances used up to the early 70's as a component of wood preservatives also indoors; for many years it has been at the centre of discussion about the environment. Mono, di, tri and tetrachlorophenols as well as pentachlorophenol occur in the urine in the general population often in surprisingly high concentrations. An increased chlorophenol excretion under certain circumstances also indicates an increased dioxin exposure (pre-dioxins). Possible sources of emission and routes of absorption for corresponding organochlorine compounds can be found in industry, agriculture and also private households. Environmental analysis in the air, in earth or dust do not allow any evaluation of health risks. Only biological monitoring with qualitative and quantitative determination of the actual concentration of the substance taken up by the organism allows a reliable estimation of the individual health risk. The background exposure of the general population not occupationally exposed to organochlorine compounds can be used for the determination of so-called norm values. For the determination of the chlorophenol spectrum 50 ml urine are necessary. The following values can be given as reference values for the most important chlorophenols: 4-monochlorophenol: 7.5 micrograms/l, 2.4-dichlorophenol and 2.5-dichlorophenol: 33.6 micrograms/l, 2.4.6-trichlorophenol: 4.7 micrograms/l, 2.4.5-trichlorophenol: 4.5 micrograms/l, 2.3.4.6-tetrachlorophenol and 2.3.5.6-tetrachlorophenol: 22.0 micrograms/l, pentachlorophenol 9.0 micrograms/l urine.

The necessity of measuring the acuity of hearing in a reproducible way arose for the first time when the invention of Volta's pile in 1800 seemed to present the opportunity of curing deafness. For this purpose Chr. H. Wolke in Jever, Northern Germany, in 1802 devised two instruments which he called "acumeter". Details of these instruments were hardly known, and Wolke's publication was believed to be lost. The author has now succeeded in tracing Wolke's publication and another associated paper by J. J. A. Sprenger. Hence, the circumstances of Wolke's and Sprenger's work and details of these first acumeters are now being published together with original figures and the correct dimensions of the instruments. The acumeters had a pendulum-like hammer that would strike against a plate swinging down from varying heights that could be read in degrees of angle from a scale. One of the instruments was made of wood. It was 1.50 m high, with the pendulum raised to the maximal position 2.70 m. The other instrument of similar construction was made of metal and about half the size of the first one, with a height of 0.70 m or 1.30 m respectively. For comparison Itard's acumeter is presented which was published in 1821. It worked on the same principle, and it is likely that Itard had been inspired by Wolke's paper. The development of mechanical acumeters after Wolke's and Itard's instruments is outlined briefly.

A case-control study of squamous cell carcinoma of the upper aerodigestive tract conducted in Heidelberg and Giessen (FRG) provided information on occupational factors in 200 patients and 800 controls (adjusted to sex, age and area of living; 4:1 matched design). The number of subjects exposed to wood dusts, organic chemicals, coal products or to cement was significantly elevated in the tumour group. An increased risk for head and neck cancer was observed after exposition to wood dust (RR = 2,2), organic compounds (RR = 2,4), coal products (RR = 2,7) and especially to cement (RR = 4,4). The cancer risk due to cement exposition showed a positive correlation to the duration of exposition and remained significantly elevated after adjustment for alcohol and tobacco consumption.

New information about occupation-relative inhalative injuries, are reflected in the "Bill on the Modifications of the Regulations Governing Occupational Disease" of 22. 03. 1988; thus, for example, (benign) diseases of the pleura due to asbestos dust (No. 4103 and 4104), malignant neoplasias of the airways and lungs induced by nickel (No. 4109), and cooking plant gas (No. 4110), adenocarcinomas of the nasal sinuses, induced by oak and beech wood dust (No. 4203), exogenous allergic alveolitis, also those induced by other than agricultural dusts (No. 4201) (3) have all undergone modification. Current occupationalmedical problems represented in more detail include the hairdressers' asthma induced by hair bleaching agents, bronchopulmonary diseases induced by cooling and lubricating agents, "metal fume fever", asthma induced by enzyme dusts, flour and baking additives, bronchopulmonary and systemic diseases induced by acid anhydrides and isocynates.

Out of 393 intraocular foreign bodies (1961-1975) 361 were magnetically removed and 32 non-magnetically (copper 7,brass,2,lead 5, glass 10, stone 3, wood 4 and plastic 1).60% of the foreign bodies were caused by hammer and chisel injuries.73 foreign bodies were diagnosed too late, in 71 cases no x-ray was made. The incidence of complications (infection, siderosis, retinal detachment was considerably increased where the foreign bodies were removed late. From the 73 foreign bodies (18.5%) the patient did not consult a doctor in 37 cases because of "insignificance". 4 times the family doctor was consulted, who treated the patient symptomatically. In 4 cases occurring in the weekend no eye-specialist could be ostensibly found. In 26 cases the ophthalmologist performed no x-ray control, and small foreign bodies were twice described as "x-ray plate artefacts" from the roentgen specialist. It must be an absolute rule in the eye-doctor's practice that every injury received while working with metals necessitates an x-ray control!

The usefulness of TGC depends on the scanning technique. The A- and B-scan echograms of the orbit can show much more detailed information of the orbital structures, if TGC and a corresponding scanning technique are applied. The sound beam should be directed preferably through the center of the eyeball to keep the length of vitreous within the sound beam constant. The external eye muscles, orbital fat and optic nerve can much better be identified and localized. Radiolucent orbital foreign bodies (wood splinters) were experimentally examined and could also be shown much better using TGC. The TGC characteristic must be measured for reproducible adjustments. The scale readings of the apparatus are insufficient. Even in apparatus supplied with an indication of the TGC characteristic on the screen checking of the real TGC characteristic proved necessary. A simple measurement technique, easily applicable under hospital conditions is described. It is based on a test reflector made from material for soft corneal contact lenses (testreflector W 38, Poly-HEMA, 38% water content.

From June 1983 to October 1987 199 orthotopic heart transplantations were performed at the Medical School of Hannover. Eighty percent of the organs were explanted in foreign hospitals. Since the cold ischemic time lasts less than 4 hours, a sophisticated transport system is essential. The selection of donors (dissociated brain death, age less than 35 years, systolic blood pressure greater than 70 mm Hg, intensive care for less than 7 days) and recipients (age between 10 and 55 years, final stage of irreversible myocardial insufficiency) is governed by strict criteria. A fixed pulmonary hypertension of more than 8 Wood is an absolute contraindication. The pulmonary wedge pressure and the right atrial pressure are preoperatively raised more than three times from normal. The ejection fraction is reduced to 10%. Seventy percent of the patients suffer from dilated cardiomyopathy. The premedication with flunitrazepam is given orally. Anaesthesia is induced with fentanyl and etomidate followed by pancuronium for intubation. During the time of induction all lines have to be inserted under sterile conditions. For weaning from the heart lung machine always catecholamines (isoproterenol, adrenaline) are applied in combination with vasodilators (nitroglycerin, DHB). Postoperatively patients will be extubated after 17.8 +/- 2.2 hours. Rejection episodes belong to the most threatening sort of complications. For this reason endomyocardial biopsies are done routinely.