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Zusammenfassung Ziel der Studie Ziel der Studie war die Bereitstellung von Ergebnissen zur Nutzung von Teletherapie während der Corona-Pandemie durch Vertreter*innen von drei Gesundheitsfachberufen. Methoden Im Rahmen einer fragebogengestützten Online-Erhebung wurden 282 Beschäftigte der Ergotherapie, Physiotherapie und Sprachtherapie/Logopädie zu Nutzungsverhalten, Herausforderungen, Potentialen und Rahmenbedingungen von Teletherapie befragt. Ergebnisse Insbesondere Ergotherapeut*innen und Logopäd*innen nutzen die Therapieform. Teletherapie bietet aus Sicht der Befragten auch unabhängig von der Corona-Pandemie Potenzial als alternative Therapieform. Allerdings ist der Bedarf an Unterstützungsangeboten und Schulungen im Bereich der Teletherapie groß. Schlussfolgerung Für eine langfristige Etablierung der Therapieform sind neben technischen Anforderungen und Schulungsangeboten insbesondere Klärungen zu zukünftigen Abrechnungsformalitäten nötig.

Background: Strengthening individual health literacy and knowledge about health challenges are important preventive approaches in public health to improve health equality. Health care organizations have come into focus in this regard. They need to raise their organizational health literacy (OHL) to help users to access and navigate information and services. Objective: In Germany, public health departments (PHDs) are responsible for public and environmental health at the population level. This study breaks new ground as it is the first to investigate the OHL of these health care organizations. The study attempts to answer what barriers keep them from raising their OHL and how can these be overcome? Methods: In this explorative study, 10 guideline-oriented interviews with experts from PHDs were conducted in two states in Germany. Qualitative content analysis was used to extract the results from the experts´ statements. Key Results: Eleven barriers to raising OHL were identified. Obstacles were found in leadership and organizational culture, design and implementation of information, and in human resources. False expectations due to negative preconceptions about public service were identified as a new barrier that had not been elucidated in prior literature. The same applies to lack of cooperation on cross-sectoral topics as well as lack of accessibility. Clear communication of tasks and clear jurisdictional authority are some of the recommendations for lowering these barriers. Other examples include identifying and using synergies and involvement of target groups. Conclusions: Overcoming these obstacles could improve the OHL of German PHDs. This, in turn, could improve the health of the general population and thus contribute significantly to overall public health. Extrapolating to the whole of Germany and other countries could further strengthen research on OHL. [ HLRP: Health Literacy Research and Practice. 2021;5(3):e264–e271.] Plain Language Summary: Public health departments (PHDs) must be able to help their users access, understand, and use health information and services. This competence is called organizational health literacy (OHL). Ten experts from German PHDs were interviewed about barriers to raising OHL. This article reports the barriers identified and recommendations for lowering them, as well as three previously unknown obstacles.

Background: Refugees and asylum seekers have a high prevalence of psychiatric disorders such as posttraumatic stress disorder (PTSD), anxiety and depression. Associations between the number of traumatic events and psychiatric disorders have been reported in literature, but knowledge on the influence of post-migration stressors on mental health outcomes in host countries remains scarce. Method: Four databases in the field of public and mental health were systematically searched. From a total of 2,456 studies found, 1,777 were included for title and abstract screening and 61 full texts were separately screened for eligibility by 2 authors. Out of these studies, 23 studies were included in this systematic review. A narrative synthesis was undertaken.Results: The overall findings showed that post-migration stressors have a significant impact on mental health outcomes. Especially uncertain legal status, missing social support and unemployment were shown to negatively influence mental health, but results vary among the different psychiatric disorders, i.e. post-traumatic stress disorder, depression and anxiety. Discussion: Post-migration stressors can contribute to the high prevalence rates of psychiatric disorders in refugees in European high-income countries. However, results must be interpreted with caution because of the heterogeneous study populations included and the variety of post-migration stressors. None of the studies considered the effect of mental disorders on the perceived severity of post-migration stressors.

Die umfassende Berucksichtigung von Geschlecht (biologische und soziale Dimensionen) in der Gesundheitsforschung ist essenziell, um Relevanz und Validitat der Forschungsergebnisse zu erhohen. Im Unterschied zu anderen Bereichen der Gesundheitsforschung fehlt bislang eine systematische Aufarbeitung des Forschungsstandes zur Bedeutung von Geschlecht bei umweltbezogener Gesundheit. In dem interdisziplinaren Forschungsnetzwerk Geschlecht – Umwelt – Gesundheit (GeUmGe-NET) wurde in ausgewahlten Themenfeldern der Forschungsbereiche Umwelttoxikologie, Umweltmedizin, Umweltepidemiologie und Public-Health-Forschung zu Umwelt und Gesundheit der aktuelle Stand zur Integration von Geschlechteraspekten bzw. Genderkonzepten systematisch erhoben. In allen Bereichen wurden Wissenslucken und Forschungsbedarfe identifiziert sowie Potenziale fur methodische Weiterentwicklungen durch Nutzung von Genderkonzepten aufgezeigt. Mit dem Forschungsnetzwerk GeUmGe-NET wurde ein Dialog zwischen biomedizinisch bzw. Public-Health-orientierter Gesundheitsforschung und sozialwissenschaftlicher Genderforschung begonnen. Dieser Dialog ist weiterzufuhren, insbesondere hinsichtlich der gemeinsamen Erprobung methodischer Innovationen bei Datenerhebung und Datenanalyse. Erkenntnisse aus dieser interdisziplinaren Forschung sind relevant fur die Praxisfelder umweltbezogener Gesundheitsschutz, Gesundheitsforderung, Umweltgerechtigkeit und umweltbezogene Gesundheitsberichterstattung.

Current international studies show that environment-related diseases disproportionately affect vulnerable people. This is a case of environmental injustice. Environmental justice goes beyond the mere description of environment- and health-related social inequalities by comprising two dimensions of justice as a normative approach: distributional and procedural justice. Attempts to explain the link between social circumstances, the environment and health deal with both the socially unequal distribution of environmental hazards and environmental resources (exposure variation) and social differences in vulnerability to the health effects of environmental exposures (effect modification). Integrated monitoring approaches provide the basis for deriving interventions under various aspects of environmental justice. Parting from public health research and embedded in the Health in All Policies (HiAP) concept, environmental justice has now been taken up in a number of fields, including politics, administration and practice. There are strategic considerations and attempts to anchor it in politics at the federal, state and the communal level, both by government and non-government groups. Health-promoting urban development is a core field for intervention. The Soziale Stadt (Social City) programme for promoting urban planning and construction as well as place oriented sectoral planning make an important contribution by helping to focus on urban spaces with multiple health hazards and to implement target group-oriented participation processes. There continues to be a need to develop methods and systematically implemented evaluations of political strategies and corresponding interventions regarding their effects on inequalities in health and environmental justice.

A cross-sectional analysis among 1041 urban residents was done to examine associations between self-reported walking distance to and use of freshwater urban blue space and health-related quality of life in two German cities: a city with “poor” urban blue space supply (Bielefeld; 0.8% blue space) and one with “better” urban blue space supply (Gelsenkirchen; 3.0% blue space). Health-related quality of life was assessed with the SF-12v2, which measures residents’ self-reported mental and physical health. Results showed a significant association between use frequency and perceived walking distance to blue space. Blue space use was a better indicator of health outcomes than perceived walking distance. After controlling for green space, socio-economic and demographic variables, use frequency was associated with higher mental health in Gelsenkirchen. These cross-sectional findings suggest that blue space use increases the probability of being healthier in highly urbanised areas in cities with an appropriate amount of blue space.

ZIEL DER STUDIE: Umweltrisikofaktoren haben häufig eine hohe gesundheitliche Relevanz mit einem großen und z. T. nicht ausreichend genutzten Präventionspotenzial. Das Wissen über die komplexen Wirkungszusammenhänge zwischen Umwelt und Gesundheit ist für einige Umweltrisikofaktoren begrenzt. Ein Instrument, das bestehende Evidenz nutzt, um die gesundheitlichen Auswirkungen für eine Bevölkerung oder Bevölkerungsgruppe zu quantifizieren, ist das Konzept der umweltbedingten Krankheitslast (Environmental Burden of Disease, EBD). Ziel des Beitrages ist es, das Konzept der umweltbedingten Krankheitslast vorzustellen sowie den Nutzen aber auch die Kritikpunkte zu benennen. METHODIK: EBD fasst Morbiditäts- und Mortalitätsdaten in einem Summenmaß, dem Disability-Adjusted Life Year (DALY), zusammen und ermöglicht eine vergleichende Darstellung von Krankheitslasten. Hierfür werden Lebensjahre als Einheit genutzt. Mithilfe des attributablen Anteils kann ermittelt werden, welcher Anteil der Gesamtkrankheitslast auf umweltbedingte Risikofaktoren zurückzuführen ist. ERGEBNISSE: Das EBD-Konzept wird, trotz seiner zunehmenden Anwendung im internationalen Raum, häufig kritisch diskutiert, da die Einschränkung des mehrdimensionalen Konstrukts Gesundheit in einer Maßzahl zusammengefasst wird. Weitere Kritik bezieht sich auf die sozialen und normativen Konventionen, die das Konzept beinhaltet. Fehlende oder unzureichende Eingangsdaten können zudem die Qualität und Aussagekraft von EBD-Schätzungen limitieren. SCHLUSSFOLGERUNG: Es bedarf eines wissenschaftlichen Diskurses, in welchem Rahmen das Konzept in Deutschland genutzt werden kann und sollte. GOAL OF THE STUDY: Environmental risk factors are of great importance for public health with a considerable but often unused potential for prevention. However, knowledge about the complex associations between the environment and health effects is limited for some risk factors. A concept, which is using the existing evidence on associations between the impact of environmental factors and health effects, is the environmental burden of disease (EBD) concept. The aim of this article is to present the quantification method of the EBD concept and to discuss the advantages and its points of criticism. METHODS: The EBD concept combines morbidity and mortality data in a single measure (Disability-Adjusted Life Year, DALY) to enable a comparative description of the burden of disease. Life years are used as measurement unit. The environmental share of the total DALYs is quantified by using the attributable fraction. RESULTS: Despite its increasing application especially in the international context, the method is still criticized, because by summarizing the complex construct of health in one single measurement unit, much important information about quality of life is lost. A further criticism refers to partly arbitrarily set social value choices. Additionally, missing or insufficient data can limit the quality and validity of EBD estimations. CONCLUSION: A scientific discourse is needed to decide to what extent the EBD approach can and should be used in Germany.

Background To master challenges to their environmental health, people have to have health literacy (HL). At a national and communal level, focus is shifting from individual HL to health care organizations. They have to raise their organizational health literacy (OHL) to help their users to access information and services. In Germany, public health departments are responsible for environmental health at a population level while the environmental administration is responsible for health-related environmental protection. To date, there is no research on the OHL of public health departments in Germany. Which are the barriers that keep public health organizations from raising their OHL as well as from making better use of possible synergies with the environmental administration? Methods The study consisted of interviews with experts from public health (n = 7) and environmental departments (n = 5) at communal (n = 8) up to federal state level (n = 4). Experts were asked for their insight on barriers for OHL as well as for cross-sector collaboration. They were selected for a wide range in socioeconomic factors and administrative levels. The interviews were recorded between 10/2018-04/2019. After transcription the anonymized interviews underwent qualitative content analysis. Results In twelve interviews 10.4 h of audio were recorded. Content analysis revealed 13 barriers for OHL. Several of those had been described for hospitals before while others, like low responsiveness to the needs of the public, were unknown so far. Preliminary results also indicated several barriers for cross-sectoral cooperation as well as recommendations to overcome said barriers. Conclusions Interviews with public health and environmental administrative organizations turned up 13 barriers that keep them from raising their OHL. Implementing preliminary recommendations could result in better cooperation, in higher OHL, higher environmental health and therefore contribute to public health in the general population. Key messages Interviews with experts from public health and environmental administrative organizations in Germany turned up barriers that keep them from raising both their OHL and cross-sectoral cooperation. Implementing preliminary recommendations could result in higher OHL of public health departments and higher environmental health of the general public and thus contribute greatly to public health.

Zusammenfassung Der dritte Teil des DGP-Positionspapiers stellt den aktuellen Wissensstand zu bislang weniger untersuchten Gesundheitsgefährdungen durch Luftschadstoffe vor: gestörte Glukosetoleranz und Diabetes sowie neurodegenerative Erkrankungen und neurokognitive Entwicklung bei Kindern. Weiterhin wird die Bedeutung einer Exposition während der Schwangerschaft für Mutter und Kind beschrieben und abschließend in die derzeit diskutierten Mechanismen zur Erklärung der unterschiedlichen adversen Effekte von Luftschadstoffen eingeführt. Verschiedene, sich oft ergänzende Pathomechanismen bilden die Grundlage für die unterschiedlichen, durch Luftschadstoffe bedingten Gesundheitseffekte. Oxidativer Stress und eine subklinische entzündliche Reaktion in der Lunge, aber auch auf systemischer Ebene („low-grade systemic inflammation“), stehen dabei im Mittelpunkt. Diese begünstigen sekundäre Veränderungen im Organismus wie vaskuläre oder metabolische Prozesse und können darüber hinaus zu epigenetischen Effekten oder zur „Neuroinflammation“ führen. Die Bedeutung von löslichen, systemisch verfügbaren Partikelbestandteilen aber auch die Translokation von ultrafeinen Partikeln aus der Lunge über die Blutbahn in sekundäre Zielorgane wie Leber, Gehirn oder den Fötus wird dabei intensiv diskutiert. Diabetes mellitus ist eine der häufigsten chronischen Erkrankungen weltweit, mit einer Prävalenz von knapp 14 % in Deutschland. Bei dem mit großem Abstand häufigeren Typ 2-Diabetes mellitus spielen Lebensstilfaktoren bei der Genese eine wesentliche Rolle. Toxikologische und epidemiologische Studien legen darüber hinaus nahe, dass auch eine langfristige Luftschadstoffbelastung zu einem erhöhten Risiko v. a. für den Typ 2-Diabetes beitragen kann. Zusätzliche Hinweise für eine ursächliche Rolle liefern Studien zur Glukoseregulation, der Insulinsensitivität und dem Schwangerschaftsdiabetes. Ergebnisse experimenteller Studien unterstützen diese Zusammenhänge und zeigen plausible biologische Mechanismen auf. Jedoch sind zur Stärkung der gegenwärtigen Evidenz prospektive Studien mit Berücksichtigung multipler Lebensstil- und Umweltfaktoren wie Grünflächen oder Lärm und einer präziseren individuellen Abschätzung der Schadstoffbelastung notwendig. Mit der Altersentwicklung in der Bevölkerung nimmt die Krankheitslast durch neurodegenerative Erkrankungen zu. Erste Studien weisen auf einen möglichen Beitrag durch Luftschadstoffe, v. a. durch Feinstaub, hin. So wird in einigen Studien bei einer erhöhten Schadstoffbelastung eine Abnahme der neurokognitiven Leistungsfähigkeit im Erwachsenenalter und ein erhöhtes Risiko für eine Demenz oder eine Alzheimer-Erkrankung beobachtet, jedoch sind die Studien in Bezug auf Design, Expositionsabschätzung und Gesundheitseffekt noch inhomogen und die Studienergebnisse insgesamt gesehen noch inkonsistent. In Bezug auf die neurokognitive Entwicklung im Kindesalter beschreiben erste Studien einen Zusammenhang zwischen dem Grad der Luftverschmutzung, z. B. an der Schule, und einer verzögerten kognitiven Entwicklung. Auch wenn die Evidenz für die verschiedenen biologischen Endpunkte während der Schwangerschaft noch sehr heterogen ist, weisen die Studien insgesamt auf einen negativen Einfluss der Luftschadstoffe auf den mütterlichen und fetalen Organismus hin. Die stärkste Evidenz liegt für ein verringertes Geburtsgewicht im Zusammenhang mit erhöhten Luftschadstoffen vor, allerdings mit relativ niedriger Effektgröße von im Mittel nur wenigen Gramm. Darüber hinaus kommt es zu einer erhöhten Häufigkeit von zu geringem Geburtsgewicht (, The third part of the DGP statement introduces the current body of knowledge on less studied health outcomes associated with exposure to ambient air pollution: the negative impact on metabolism leading to impaired glucose tolerance and diabetes as well as contribution to the development of neurodegenerative disorders and delayed cognitive function in children. Furthermore, prenatal exposure and adverse effects on mother and child are addressed. Finally, the currently discussed biological mechanisms underlying various health effects associated with exposure to air pollution are described.Differing, but often complementary biological mechanisms create the basis for the diverse health outcomes caused by air pollution. Oxidative stress and a subclinical inflammatory response in the lungs and on a systemic level ("low-grade systemic inflammation") are considered to be key mechanisms. They promote secondary alterations in the body, such as vascular or metabolic processes, and may also result in the currently studied epigenetic phenomena or neuroinflammation. In this context, the health significance of soluble particulate matter and the role of ultrafine particles translocated across biological membranes into blood vessel and transported via the circulation to secondary target organs, such as liver, brain or the fetus, are intensively discussed.Diabetes is one of the leading chronic diseases worldwide, with a prevalence of almost 14 % in Germany. Although lifestyle factors are the main causes, current evidence suggests that long-term exposure to air pollution may additionally increase the risk for type 2 diabetes. Supporting evidence for a causal role of air pollution is provided by studies addressing the regulation of the blood glucose levels in metabolically healthy participants, insulin sensitivity, or pregnancy-related diabetes. Experimental studies provide further support for plausible biological mechanisms. However, prospective studies are needed to gain more evidence, taking multiple lifestyle and environmental factors, such as green space and noise, and an improved individual exposure assessment into account.The aging population has an increased risk of neurodegenerative diseases. First studies point towards a contribution of chronic exposure to air pollution, specifically by particulate matter. Several studies report its association with decreased neurocognitive capacity or an increased prevalence of dementia or Alzheimer's disease in adults. However, the studies are inhomogeneous regarding design, exposure and outcome, leading to inconsistent results. With respect to the influence on neurocognitive development of children, first studies suggest an association between the level of air pollution, e. g. at school, and delayed cognitive development.Even though the evidence for the different biological endpoints during pregnancy is still heterogeneous, the studies generally point towards an adverse impact of air pollution on the maternal and fetal organisms. The strongest evidence exists for low birth weight, with small effect sizes of only some grams, and for a higher incidence of reduced birth weight (

Zusammenfassung Der Beitrag befasst sich mit der Berichterstattung zur Teilhabe von Menschen mit Behinderungen in Deutschland. Hierbei wird auf die vorhandenen Daten zur gesundheitlichen Lage und Versorgung von Menschen mit Behinderungen und Beeinträchtigungen fokussiert. Weitergehend werden Erfordernisse der zukünftigen Berichterstattung aufgezeigt.

Umweltbedingte Risikofaktoren konnen die menschliche Gesundheit masgeblich beeinflussen. Mithilfe der „Environmental Burden of Disease“(EBD‑)Methode konnen umweltbedingte Gesundheitseinbusen quantitativ in Form verlorener gesunder Lebensjahre (Disability-Adjusted Life Years, DALYs) ermittelt werden. Ziel dieses Beitrags ist es, die Krankheitslast von umweltbedingten Risikofaktoren darzustellen und zu bewerten. Der Fokus liegt auf bereits veroffentlichten Berechnungen fur Deutschland. Anhand der aktuellen EBD-Studienlage prasentiert dieser Artikel die umweltbedingte Krankheitslast in Form des attributablen Anteils fur die gesamte Welt und in Form von DALYs fur Deutschland. Mittels der prasentierten Ergebnisse fur Feinstaub, wasserassoziierte Risiken und Umgebungslarm wird die Bedeutung der Verfugbarkeit und Qualitat der in Krankheitslastberechnungen eingehenden Daten aufgezeigt. Der Anteil der Krankheitslast weltweit, der auf umweltbedingte Risikofaktoren zuruckzufuhren ist, variiert je nach betrachteter Studie zwischen 13 und 22 %. Fur Deutschland gibt es fur insgesamt zwolf Umweltrisikofaktoren EBD-Schatzer. Die meisten Schatzer gibt es fur Feinstaub; auch hier sind grose Unterschiede in der Krankheitlast je nach Studie festzustellen. Unabhangig davon ist Feinstaub nach jetzigem Stand der Forschung der umweltbedingte Risikofaktor mit der hochsten Krankheitslast in Deutschland. Unterschiede in der Hohe der berechneten Krankheitslast fur einzelne umweltbedingte Risikofaktoren sind auf unterschiedliche Annahmen (z. B. Lebenserwartung, gesundheitliche Wirkungsschwelle) und die jeweilig verwendeten Eingangsdaten zuruckzufuhren.

Background Heart failure is one of the most common and cost-intensive chronic diseases worldwide. Telemonitoring offers the potential to improve care of heart failure treatment and reduce cost. Empirical findings of its efficacy are inconsistent up to now. This systematic review examines the current state of research regarding health-related and economic endpoints. Methods A systematic review was conducted in July 2016 using the PubMed database and randomised controlled trials for the years 2011-2016. Only clinical research trials with heart failure patients were considered where the intervention was performed using external monitoring devices which transmitted data via information and communication technology. In all, 10 clinical trials were included. Results There is no definite evidence regarding improvement in care based solely on the most recent literature. Hospitalisation for heart failure and health-related quality of life were most positively influenced. There was no correlation between mortality and hospitalisations for all causes regarding telemonitoring. The overall costs tended to be higher for telemonitoring. Conclusion Further research is needed to examine the health-related and economic benefits of telemonitoring for heart failure. A particular challenge is the evidence of cause-effect relationships within complex technology-supported health-care settings. The latest studies support the previous state of research.

Hintergrund: Der Schlaganfall ist eine der haufigsten Todesursachen weltweit, eine der zentralen indikationsbezogenen Ursachen fur Behinderung und damit eine wesentliche Herausforderung fur die Gesundheitsversorgung. Teleneurologische Ansatze zeigen in der praklinischen, klinischen und rehabilitativen Versorgung ihre Wirksamkeit mit Blick auf die Verbesserung gesundheitsbezogener Endpunkte sowie die Reduktion der Versorgungskosten. Entscheidend fur die nachhaltige Implementierung telemedizinischer Versorgung ist die Akzeptanz der Nutzerinnen und Nutzer. Fragestellung: Der gewahlte qualitative Forschungsansatz untersucht, welche Haltungen, Motive und Einstellungen die Verhaltensintention zur Nutzung telemedizinischer Versorgungskonzepte in der Sekundarpravention nach Schlaganfall bei Patientinnen und Patienten beeinflussen. Material und Methode: Im Rahmen der stationaren Rehabilitation wurden 8 Fokusgruppen mit insgesamt 40 Patientinnen und Patienten durchgefuhrt und inhaltsanalytisch ausgewertet. Zur Abbildung der Einstellungsprozesse gegenuber dem Technikeinsatz wurde den Teilnehmerinnen und Teilnehmern ein telemedizinisches Versorgungssetting vorgestellt. Als strukturgebende Theorie in der Erhebung des Materials rekurriert die vorliegende Studie auf die Unified Theory of Acceptance and Use of Technology (UTAUT). Ergebnisse: Haltungen und Einstellung zur Nutzung telemedizinischer Verfahren in der poststationaren Versorgung sind bei Patientinnen und Patienten eindeutig nutzwertorientiert – auch wenn latente Angste (z. B. hinsichtlich des Datenschutzes oder eines zu unpersonlichen Kontaktes zu den Arztinnen und Arzten) vorliegen. Der Prozess der Entscheidungsbildung lasst sich durch die Adoptoren „Leistungserwartung“, „Aufwandserwartung“, „soziale Einflusse“ und „handlungserleichternde Rahmenbedingungen“ charakterisieren. Schlussfolgerungen: Die Einstellungen und Haltungen von Patientinnen und Patienten mussen in der Weiterentwicklung telemedizinischer Versorgungssettings zielgruppenspezifische Berucksichtigung finden. Aufgrund der klaren Nutzwertorientierung kommt der evidenzbasierten Entwicklung und Implementierung der Telemedizin ein besonderer Stellenwert zu.

Zusammenfassung Hintergrund In den vergangenen Jahren lässt sich eine deutliche Zunahme an onlinebasierten Therapieangeboten für Menschen mit depressiven Erkrankungen beobachten. In einer Vielzahl von wissenschaftlichen Arbeiten konnten bereits die Wirksamkeit und Effizienz dieser Programme bestätigt werden. Einen wesentlichen Erfolgsfaktor für eine erfolgreiche Etablierung dieser neuen Versorgungsangebote stellt die Nutzerinnen- und Nutzerakzeptanz dar. Theoriebasierte Akzeptanzanalysen können für eine langfristige Einführung wertvolle Erkenntnisse liefern. Methoden Im Rahmen einer bundesweiten Onlineerhebung wurden Einstellung und Haltung gegenüber internetgestützten Psychotherapieangeboten bei depressiven Erkrankungen, der aktuelle Wissenstand sowie die Nutzungsintention von 186 Studienteilnehmerinnen und -teilnehmern erfasst. Die Rekrutierung erfolgte über Selbsthilfegruppen für depressive Erkrankungen. Die in die binär logistische Regression einfließenden Determinanten der Nutzungsintention von Onlinetherapie beruhen auf der Unified Theory of Acceptance and Use of Technology (UTAUT). Ergebnisse Fast zwei Drittel der Befragten können sich vorstellen, Onlinetherapieangebote zukünftig zu nutzen. Als signifikant einflussnehmende Prädiktoren auf die Nutzungsintention erwiesen sich die wahrgenommenen Leistungs- und Aufwandserwartungen. Hierzu zählen insbesondere die Bewertung des Einsatzes von E-Mental-Health als Hilfsmittel zur Krankheitsbewältigung, zur Aktivierung und besseren Einschätzung des eigenen Krankheitsverlaufes. Schlussfolgerungen Ob E-Mental-Health-Angebote langfristig einen Beitrag zur Verbesserung der psychosozialen und psychotherapeutischen Versorgung leisten können, wird, neben technik- und rechtwissenschaftlichen Begutachtungen, ganz maßgeblich von Fragen der Evidenzbasierung und der Nutzerinnen- und Nutzerorientierung innerhalb von Forschung, Entwicklung und Implementation abhängen. Die vorliegenden Ergebnisse bieten einen ersten theoriegeleiteten Ansatz im Bemühen um eine stärker nutzerinnen- und nutzerorientierte Technikforschung im Gesundheitswesen, innerhalb der zukünftig weitere Diversitätskriterien berücksichtigt werden müssen.

Zu den umweltmedizinischen Syndromen zahlen das Sick Building Syndrom (SBS), die Multiple Chemikaliensensibilitat (MCS)/Idiopathic Environmental Intolerances (IEI), die Elektrosensibilitat, das Chronische Erschopfungssyndrom (CFS), Burnout, die Fibromyalgie und das Candida-Syndrom, zwischen denen verschiedenste Ubergange in der Literatur beschrieben sind. Nach wie vor liegen fundierte Kenntnisse zu Atiologie, Pathologie, Pathophysiologie, Diagnostik, Therapie, Pravention und Prognose nicht vor. Es wird angenommen, dass es sich bei diesen Syndromen um ein bisher unzureichend verstandenes komplexes Zusammenspiel von physikalischen, chemischen und/oder (mikro)biologischen Umweltbelastungen, individuellen Dispositionen, psychischen Einflussfaktoren sowie von Wahrnehmungs- und Verarbeitungsprozessen handelt. Auch wird diskutiert, dass Varianten von Somatisierungsstorungen, durch kulturelle und soziale Strukturen bedingter oder begunstigter Dysstress oder iatrogene Determinierungen vorliegen. Differenzierte Untersuchungs- und Behandlungsmethoden mussen entwickelt oder bereits vorhandene wissenschaftlich validiert werden. Alle Unsicherheiten in der Beurteilung dieser Syndrome entbinden nicht von der arztlichen Pflicht, die Betroffenen ernst zu nehmen und ihnen nach bestem Wissen und Gewissen zu helfen.

Zusammenfassung Hintergrund: Informations- und Kommunikationstechnologien gewinnen im Gesundheitswesen zunehmend an Bedeutung. Insbesondere Leistungen des Telemonitorings zeigen im Rahmen randomisierter klinischer Studien erste medizinische Evidenz mit Blick auf die Steigerung der Versorgungsqualität, die Verringerung stationärer Aufenthalte und die Reduzierung von Behandlungskosten. Für die Erschließung der angedeuteten Potenziale und die langfristige Implementation in die Versorgungspraxis ist eine nutzerinnen- und nutzerorientierte Technikentwicklung unter Berücksichtigung häufig komplexer Strukturen der Technikakzeptanz erforderlich. Methden: Einstellungen und Haltungen sowie die vorliegenden Wissensbestände zum Telemonitoring vonseiten klinisch tätiger Ärztinnen und Ärzte (Zufallsstichprobe, N=614) wurden im Rahmen einer online-basierten Erhebung mit einer Rücklaufquote von 21% (n=133) ermittelt. Zur Analyse der Herausbildung positiver Haltungsmuster gegenüber Telemonitoringanwendungen wurden Wirkungszusammenhänge zwischen psychologischen und technikbezogenen Persönlichkeitsmerkmalen sowie den wahrgenommenen Wissensbeständen ermittelt. Ergebnisse: Positive Einstellungsmuster gegenüber dem Telemonitoring werden maßgeblich durch das individuelle Wissen und die Verträglichkeit (als Persönlichkeitsmerkmal, welches stark durch altruistische Züge und zwischenmenschliches Vertrauen geprägt ist) eines Individuums beeinflusst. Die Einstellungen zum Telemonitoring sind mit dem Ziel einer qualitativen Verbesserung der Versorgungssituation klar nutzwertorientiert und unterscheiden sich nach Versorgungssektor und Geschlecht. Insgesamt fühlen sich nur 57% der befragten Ärztinnen und Ärzte ausreichend über den Einsatz des Telemonitorings informiert. Schlussfolgerung: Vor dem Hintergrund der Nutzwertorientierung im Rahmen der Einstellungsbildung kommt der evidenzbasierten Entwicklung der Telemedizin eine besondere Bedeutung für eine gelingende Adoption zu. Hierfür bedarf es zukünftig deutlicherer Bemühungen im Wissenstransfer, im Austausch von Best-Practice-Lösungen und der Verankerung der Telemedizin in Aus- und Fortbildung.

Erganzend zur Haus- und Facharztversorgung wurde im GKV-Versorgungsstarkungsgesetz 2015 eine spezialisierte Versorgungsform geschaffen – medizinische Zentren fur Erwachsene mit geistiger und mehrfacher Behinderung (MZEB) – und damit eine langjahrige Versorgungslucke geschlossen. Fur die erfolgreiche Umsetzung der MZEB ist relevant, welche Erfahrungen in Modellprojekten gesammelt wurden und was fur MZEB-Neugrundungen abzuleiten ist. Daher wird die Frage nach hemmenden (h) und fordernden (f) Faktoren bei der Etablierung von MZEB aus Sicht der Leistungserbringenden gestellt. Anhand offener leitfadenbasierter Experteninterviews wurden arztliche Leiterinnen und Initiatoren von bestehenden und geplanten MZEB befragt. Die Auswertung erfolgte mittels qualitativer Inhaltsanalyse. Laut Leistungserbringenden ist der Abbau von „Barrieren in den Kopfen“ notwendig. Im Zuge der Zulassungsverfahren sind Vorbehalte unterschiedlicher Akteure und Institutionen gegenuber MZEB ersichtlich (h). Folglich wird bei der Bedarfsermittlung der Ermessensspielraum zuungunsten der Zulassung ausgeschopft (h). Bei den Finanzierungsverhandlungen wurde eine Charakterisierung der Zielgruppe nach ICD-Diagnoselisten gefordert, welche nicht die Versorgungsbedarfe abbildet (h). Durch groses Engagement und Realisierungswillen der Initiatoren, verbunden mit der Bereitschaft kooperierender Akteure, kann eine Etablierung dennoch gelingen (f). Der Prozess der Etablierung von MZEB wurde expliziert, wodurch sich potenzielle MZEB-Trager fur eine Etablierung inspirieren lassen konnen. Weitere Forschungsvorhaben zu dem Etablierungsprozess der MZEB stehen aus, insbesondere unter Einbeziehung aller beteiligten Akteure.

Background: Pneumococcal conjugate vaccines (PCV) have decreased nasopharyngeal carriage of vaccine types but little data exist from rural areas. We investigated bacterial density, serotype distribution and antibiotic resistance of pneumococcal strains within the nasopharynx of young children in the Peruvian Andes, 2 years after PCV7 was introduced. Methods: Pneumococcal strains were isolated from a subset of 125 children from our Peruvian cohort, who entered the study in 2009 and had pneumococcus detected in the nasopharynx in both 2009 and during follow-up in 2011. Strains were Quellung serotyped and tested for susceptibility to antibiotics. Bacterial density was determined by quantitative polymerase chain reaction. Results: The prevalence of PCV7 strains decreased from 48% in 2009 to 28.8% in 2011, whereas non-PCV7 types increased from 52% to 71.2% (P = 0.002). There was a 3.5-fold increase in carriage of serotype 6C in 2011 (P = 0.026). Vaccination with PCV7 did not affect pneumococcal density in children colonized by a PCV7 type but did increase density in those colonized with a non-PCV7 type. Antibiotic resistance did not change after vaccine introduction; strains were nonsusceptible to tetracycline (97.2%), trimethoprim-sulfamethoxazole (56.4%), penicillin (34%), erythromycin (22.4%), chloramphenicol (18.8%) and clindamycin (12.4%). Conclusions: Serotype replacement was observed post-PCV7 vaccination with a concomitant, not previously recognized, increased nasopharyngeal density.

The problem of communication in treating multiple chemical sensitivity (MCS) was analysed and evaluated using the documentation of an MCS chatroom which was set up in April 2001 following the TV programme Gesundheitsmagazin Praxis (Health Magazine: Practice). Approaches were developed for solving communication problems in the chatroom. A total of 490 cases were evaluated, most of which (355) were directly or indirectly affected, 76 came from self-help groups and 10 were from 4 guest experts invited by ZDF (Zweites Deutsches Fernsehen, Second German TV channel). Of these 4 experts, 2 were environmental medicine specialists, 1 psychosomatics expert and 1 psychiatrist. Fourty-nine of the cases included a petition for chatroom participants to join a class-action law. Aside from exchanging basic information on MCS, frequent topics of discussion on the air were the assessment of physicians, clinics, self-help groups and experts. The participants also expressed their views on problems with society, politics, the economy, science and social security. Another common topic was communication in the chatroom itself, which for the most part consisted of sarcasm and insults, which were cause for conflicts in the chatroom. These communication problems led to the conclusion that a chatroom is not the best medium for discussing MCS. If a chatroom is to be used profitably to this end, it is imperative to have a well-defined organisational framework which allows the exchange of current, scientifically accurate information while keeping discussions from escalating and degenerating into arguments.

To date, relatively little is known about the etiology, pathophysiology, diagnosis, therapy, prevention and prognosis of environment-related syndromes like multiple chemical sensitivity (MCS), idiopathic environmental intolerance (0), sick building syndrome (SBS), chronic fatigue syndrome (CFS), candida syndrome (CS) and burnout syndrome (BS). Part of the reason is that these syndromes have not been clearly defined and classified in scientific categories distinct from each other, and that they show clinical similarities to classified somatoform disorders. Furthermore, there are at least three possible explanations for the existence of these syndromes: (1) The syndromes may result from the interaction of environmental factors, individual susceptibility and psychological factors (i.e., how they are perceived and seen by the patient); (2) they may reflect socially and culturally accepted methods of expressing distress; and/or (3) they may be iatrogenic. Despite all the uncertainties in evaluation of environmental syndromes, physicians have the duty to take the affected person's problems seriously. A comprehensive systematic classification which better accounts for these complex clinical manifestations is long overdue. Until these syndromes are well defined, the terms used for them should definitely not be applied to connote a specific disease process. (C) 2003 Elsevier Science Ltd. All rights reserved.

One of the multiresistant pathogens is methicillin-resistant Staphylococcus aureus (MRSA),which was increasingly found in the 1980's. In the USA, the ratio of MRSA rose from 2% in 1975 to 29% in 1991. A similarly steep rise was seen in Germany, with the Paul Ehrlich Society for Chemotherapy reporting a rise from 1.7% in 1990 to 15.7% in 1998. In order to control MRSA, the Clinic and Polyclinic of Technical Orthopaedics and Rehabilitation at the University Clinic Munster, Germany,has set up a comprehensive hygiene management programme for early detection and treatment of nosocomial infections. In addition to addressing the usual problems of MRSA carriers (e.g., higher mortality, longer hospital stays, stigmatisation), these preventive measures are also aimed at combating MRSA-caused cost increases.

BACKGROUND: Artisanal small-scale gold mining (ASGM) is the world's largest anthropogenic source of mercury emission. Gold miners are highly exposed to metallic mercury and suffer occupational mercury intoxication. The global disease burden as a result of this exposure is largely unknown because the informal character of ASGM restricts the availability of reliable data. OBJECTIVE: To estimate the prevalence of occupational mercury intoxication and the disability-adjusted life years (DALYs) attributable to chronic metallic mercury vapor intoxication (CMMVI) among ASGM gold miners globally and in selected countries. METHODS: Estimates of the number of artisanal small-scale gold (ASG) miners were extracted from reviews supplemented by a literature search. Prevalence of moderate CMMVI among miners was determined by compiling a dataset of available studies that assessed frequency of intoxication in gold miners using a standardized diagnostic tool and biomonitoring data on mercury in urine. Severe cases of CMMVI were not included because it was assumed that these persons can no longer be employed as miners. Cases in workers' families and communities were not considered. Years lived with disability as a result of CMMVI among ASG miners were quantified by multiplying the number of prevalent cases of CMMVI by the appropriate disability weight. No deaths are expected to result from CMMVI and therefore years of life lost were not calculated. Disease burden was calculated by multiplying the prevalence rate with the number of miners for each country and the disability weight. Sensitivity analyses were performed using different assumptions on the number of miners and the intoxication prevalence rate. FINDINGS: Globally, 14-19 million workers are employed as ASG miners. Based on human biomonitoring data, between 25% and 33% of these miners-3.3-6.5 million miners globally-suffer from moderate CMMVI. The resulting global burden of disease is estimated to range from 1.22 (uncertainty interval [UI] 0.87-1.61) to 2.39 (UI 1.69-3.14) million DALYs. CONCLUSIONS: This study presents the first global and country-based estimates of disease burden caused by mercury intoxication in ASGM. Data availability and quality limit the results, and the total disease burden is likely undercounted. Despite these limitations, the data clearly indicate that mercury intoxication in ASG miners is a major, largely neglected global health problem.

In artisanal small-scale gold mining, mercury is used for gold-extraction, putting miners and nearby residents at risk of chronic metallic mercury vapor intoxication (CMMVI). Burden of disease (BoD) analyses allow the estimation of the public health relevance of CMMVI, but until now there have been no specific CMMVI disability weights (DWs). The objective is to derive DWs for moderate and severe CMMVI. Disease-specific and generic health state descriptions of 18 diseases were used in a pairwise comparison survey. Mercury and BoD experts were invited to participate in an online survey. Data were analyzed using probit regression. Local regression was used to make the DWs comparable to the Global Burden of Disease (GBD) study. Alternative survey (visual analogue scale) and data analyses approaches (linear interpolation) were evaluated in scenario analyses. A total of 105 participants completed the questionnaire. DWs for moderate and severe CMMVI were 0.368 (0.261-0.484) and 0.588 (0.193-0.907), respectively. Scenario analyses resulted in higher mean values. The results are limited by the sample size, group of interviewees, questionnaire extent, and lack of generally accepted health state descriptions. DWs were derived to improve the data basis of mercury-related BoD estimates, providing useful information for policy-making. Integration of the results into the GBD DWs enhances comparability.

Background: The Global Burden of Disease (GBD) study is designed to give a comprehensive and standardized assessment of the health of populations around the world. It measures the burden of disease by considering years of life lost due to premature death as well as years lived with disability. The findings enable the identification of secular trends and disparities between countries and can serve as a basis for decision-making in health policy. Methods: In cooperation with the authors of the GBD study, we summarize the key methods used to assess the burden of disease in terms of disability-adjusted life years (DALYs). We present findings that specifically pertain to Germany, drawn from freely available data of the most recent round of analysis for the years 1990 and 2010. Results: According to the GBD study, life expectancy in Germany rose from 75.4 years in 1990 to 80.2 years in 2010. Ischemic heart disease and back pain caused the largest number of DALYs lost (2.5 million and 2.1 million, respectively). Over the period of the study, the absolute number of DALYs due to ischemic heart disease dropped by 33%, while the number of DALYs due to low back pain rose by 11%. Nutrition-related risks ranked first among all risk factors considered, accounting for 13.8% of total DALYs, followed by high blood pressure and high body-mass index, accounting for 10.9% each. Conclusion: In Germany, important changes have been seen over time in the burden of disease attributable to different chronic diseases. Some of these changes reflect the successful interventions of the past, while others indicate a need for new action. The data from Germany that went into the GBD study must be systematically assessed and supplemented by further data relating to questions of specific relevance in this country.

Einleitung Umweltbezogener Gesundheitsschutz bedeutet, sowohl potenziell gesundheitsgefährdende schädliche Umwelteinflüsse zu erkennen, zu bewerten und entsprechend zu verhindern als auch begünstigende Umwelteinflüsse als Gesundheitsressource zu erkennen und zu fördern. Diese Aufgabe obliegt im Regelfall den unteren Gesundheitsbehörden der Landkreise und kreisfreien Städte. Um diese Aufgaben mit hoher Qualität (weiterhin) erfüllen zu können, bedarf es im öffentlichen Gesundheitsdienst der Kontinuität an qualifizierten Mitarbeiter/Mitarbeiterinnen sowie deren regelmäßigen Fortbildung. Die Vielfalt der Aufgabenfelder des umweltbezogenen Gesundheitsschutzes unterstreicht dessen Stellenwert an der Schnittstelle zwischen Humanmedizin, Public Health und Umweltwissenschaften als eine zentrale Einrichtung zum Wohle und zum Schutz der Bevölkerungsgesundheit in Deutschland.

Concerning the syndromes in environmental medicine, like Multiple Chemical Sensitivities (MCS), Idiopathic Environmental Intolerances (IEI), Sick Building Syndrome (SBS), Chronic Fatigue Syndrome (CFS), Candida Syndrome (CS), and Burnout Syndrome (BS), scientific knowledge in etiology, pathology, pathophysiology, diagnosis, therapy, prevention and prognosis is still lacking until now. A critical comparison shows that it is still impossible to find a scientifically satisfying delimitation. Syndromes in environmental medicine show clinical similarities to somatoform disorders. Furthermore, there are the following possible explanations for the existence of these syndromes: Firstly, they may be a complex interaction of environmental impacts, individual predispositions, psychological influences, as well as processes of mental perception and interpretation. Secondly, they may be an effect of distress influenced by culture and social structures and/or thirdly, they may be an latrogenic determination. A more comprehensive characterisation which better considers the complex clinical manifestations is overdue. Although there are neither scientifically validated procedures for diagnosis or therapy nor prophylactic measures, a hardly comprehensible number of partly unvalidated methods is in practical use. Until the syndromes are not finally defined the terms for the syndromes should not be applied to a certain disease. Despite all uncertainities in the evaluation of syndromes in environmental medicine, physicians have the duty to take the affected persons' problems seriously.

Einleitung Risikokommunikation dient der Vermittlung von komplexen Inhalten zur Eintretenswahrscheinlichkeit eines Ereignisses und möglichen Folgen. Der Prozess fokussiert in erster Linie auf den Informationstransfer zwischen ‚Experten‘ und ‚Laien‘. Im Kontext der Risikokommunikation im Gesundheitswesen ist es wichtig die Informationen so zu präsentieren, dass alle relevanten Inhalte den jeweiligen Zielgruppen entsprechend vermittelt werden.

Demographic changes in Germany are expected to cause a rising need for medical care and therapy while capacities are declining. Telemedicine offers the option of minimizing some aspects of these problems, but so far, many telemedicine projects in Germany (including telemonitoring projects) are not applied to the clinical routine. This study was done to assess the influence of health factors on potential willingness to use telemonitoring devices at home.Health status and other health-relevant factors were determined using individual and medical factors (e.g., reported diseases). Principal-component analysis was used to identify groups with a specific response behavior. This study was based on a representative telephone survey conducted in the German state of North Rhine-Westphalia in 2009.Willingness to use telemonitoring was high in North Rhine-Westphalia but decreased with age. Men showed a significantly greater willingness to use telemonitoring than did women. Also, there was an effect associated with the subjects' health status (e.g., cardiovascular diseases caused a decrease of 9.7% in the level of acceptance, whereas musculoskeletal disorders caused a decrease of 5.1%).The target groups for telemonitoring consisted mainly of elderly persons and those with certain diseases. This study showed that being diseased lowered the willingness to use telemonitoring. People need to understand better how telemonitoring can help to improve controlling their health status and coping with the disease. It is necessary to reflect on these specific needs if telemonitoring is to become routine in the German healthcare system.

Tracheal epithelial cells of the golden Syrian hamster can be successfully cultivated in vitro and applied as a model system of respiratory tract epithelium. By morphology and growth characteristics of tracheal epithelial cells, "normal cells", "enhanced growth variants" and "transformed cells" were distinguished in vitro. Hamster tracheal epithelial cells, transformed by Simian virus (SV)-40 expressed in cell nuclei the specific tumor (T-) antigen and showed an accumulation of tumor suppressor protein p53 by immunofluorescence. Cocultivation of "enhanced growth variants" and of "transformed cells" on a "feeder layer" of normal hamster tracheal epithelial cells revealed remarkable differences in loss of "contact inhibition of growth". A "cytokine" released by NIH-3T3 cells stimulated cell proliferation and seems to be important for cell growth of hamster tracheal epithelial cells. Preliminary characterization of the "cytokine" disclosed a molecular weight of more than 30 kDa, a relative thermostability and a loss of activity by treatment with mercaptoethanol indicating disulfide bridges in a molecule.

[1] Novakovic B, Sibson M, Ng HK, Manuelpillai U, Rakyan V, Down T, et al. Placentaspecific methylation of the vitamin D 24-hydroxylase gene: implications for feedback autoregulation of active vitamin D levels at the fetomaternal interface. J Biol Chem 2009;284(22):14838–48. [2] Scholl TO, Chen X. Vitamin D intake during pregnancy: association with maternal characteristics and infant birth weight. Early Hum Dev 2009;85(4):231–4. [3] Van der Meer IM, Karamali NS, Boeke AJ, Lips P, Middelkoop BJ, Verhoeven I, et al. High prevalence of vitamin D deficiency in pregnant non-Western women in The Hague, Netherlands. Am J Clin Nutr 2006;84(2):350–3. [4] McCullough ML. Vitamin D deficiency in pregnancy: bringing the issues to light. J Nutr 2007;137(2):305–6.

This article covers theoretical background, concepts, methods, and results of environmental justice as a growing field of community-based public health activities and as an academic issue with increasing research activities in several countries. It gives an introduction to the roots of the environmental justice movement within and outside of the USA and addresses core topics and subsequent development of environmental justice as a useful analytic concept for social disparities in environmental exposures and health. Current research and empiric findings from different countries are used to illustrate possible underlying mechanisms of social disparities in environmental health and the importance of the physical, social, and man-made environment. Research approaches that might help environmental justice research are also discussed, as are implications for preventive measures, public health promotion, and policy interventions intended to address social and environmental factors but leading to inequalities in health.

BACKGROUND: Demographic change is a driving force of disease burden. The German population is aging and simultaneously shrinking, due to a rising life expectancy and a declining fertility rate. North Rhine-Westphalia (NRW) is the most populous federal state of Germany including the Ruhr metropolitan area. The NRW population is expected to shrink by 2.5% until 2025, the population of the Ruhr area by 9.5%. At the same time, the population forecast predicts a growth of 30% in the age group > or =55 years for NRW. METHODS: The 'burden of disease' approach of the World Health Organisation (WHO) summarizes the health status of populations. This approach was used to predict the regional disease burden in 2025 by calculating disability adjusted life years (DALY) as the sum of life years lost due to premature death and years lived with disability due to selected diseases. Our projection included selected tumours, myocardial infarction (MI) and dementia. RESULTS: For the Ruhr area, increases in DALYs are expected for all causes studied, i.e. selected tumours (20%), MI (17%) and dementia (36%). The increase in the Ruhr area was estimated to be proportionally lower than in NRW in total, but the disease burden per inhabitant is higher. CONCLUSION: The population shrinking is no cure for 'Ruhr City'. The projection of disease burden shows that health status will decrease due to the demographic change. DALY estimates show the potential health gains, which can be won by implementing measures to reduce premature deaths and to prevent new cases.

Introduction: Clinical environmental medicine deals with environmental effects on human health in individual patients. Patients seek medical advice for problems of many different kinds that may be due to environmental exposures; such exposures must be considered carefully along with other potential causes. An environmental medical assessment should include thorough medical history-taking and physical examination, the formulation of a differential diagnosis, and (whenever indicated) human biomonitoring, site inspections, and ambient monitoring. Methods: This review of clinically relevant environment-related health disturbances is based on a selective evaluation of the pertinent literature and of own experiences. Results: Overall, relevant environmental exposures can be identified in up to 15% of patients who attribute their health complaints to environmental factors. (Clinical disorders are more common and more severe in these patients.) 40% to 75% are found to suffer from other physical and/or emotional conditions without any specific environmental aspect, i.e., without any apparent or verifiable exposure. Discussion: Despite the relative rarity of verifiable environmentally related health disturbances, these must be clearly identified and delimited to avoid further harmful exposures. Environmental medical counseling should include risk assessment and behavior recommendations for all patients who attribute their medical problems to their environment. Physicians performing specific environmental-medical diagnostic procedures must be aware of their limitations in order to avoid performing tests whose results have no therapeutic consequences and are thus of no help to either the physician or the patient.

Background: It is unclear which exposures may cause or modify the adverse effect of rapid weight gain on fat mass development in term children whose birth weight is appropriate-for-gestational age (AGA). Objective: To determine which intrauterine or postnatal exposures increase the risk of or modify the effect of rapid weight gain on body fat percentage (BF%) and body mass index (BMI) trajectories between 2 and 6 y of age. Design: Term AGA singletons (n = 370) from the German Multicenter Allergy Study (MAS-90), a longitudinal birth cohort study, with repeated anthropometric measurements until 6 y, and data on breastfeeding status, exposure to smoking during pregnancy, and maternal anthropometric and socioeconomic characteristics were included in this analysis. Results: A shorter gestation [multivariate-adjusted odds ratio (OR): 5.12; 95% CI: 2.22, 11.82; P = 0.0001], being firstborn (OR: 2.01; 95% CI: 1.10, 3.69; P = 0.02), and having been bottle-fed (OR: 3.02; 95% CI: 1.68, 5.43; P = 0.0002) all significantly increased a child's risk of gaining weight rapidly, whereas a larger BMI at birth was protective (OR: 0.54; 95% CI: 0.38, 0.77; P = 0.0006). Multilevel model analyses showed that rapid growers exposed to tobacco in utero subsequently gained more BF% between 2 and 6 y than did rapid growers who had not been exposed ((3 SE: 0.78 +/- 0.28%/y; P = 0.005). Similarly, change in BF% was greater in rapid growers with an overweight mother than in those with a normal-weight mother (1.01 +/- 0.30%/y; P = 0.0007). Conclusions: The occurrence of rapid weight gain between birth and 2 y and the magnitude of its effect on BF% development in AGA children is influenced by both intrauterine and postnatal exposures.

Background: It is not clear whether the adverse effects of rapid weight gain in infancy are modified by nutrition during the first 2 y of life in term children whose birth weight was appropriate for gestational age (AGA). Objective: We examined the interaction between rapid weight gain and nutrition in infancy and early childhood and their effect on body fat percentage (BF%) trajectories between 2 and 5 y of age. Design: The study population comprised 249 (51.4% female) term AGA participants of the Dortmund Nutritional and Anthropometric Longitudinally Designed Study, for whom repeated anthropometric measurements until 5 y of age and information on breastfeeding status and on diet at 12 and 18-24 mo of age were available. Results: Multilevel model analyses showed that, among rapid growers, those who had been fully breastfed for >= 4 mo had a lower BF% at 2 y of age than did those who had not been fully breastfed for 4 mo (0 SE: -1.53 +/- 0.59%; P = 0.009). This difference persisted until 5 y. Furthermore, those rapid growers who had a consistently high fat intake at both 12 and 18-24 mo did not show the expected physiologic decrease in BF% between 2 and 5 y seen in those rapid growers with an inconsistent or consistently low fat intake at these time points (0.73 +/- 0.26%/y; P = 0.006). Conclusions: Among rapid growers, full breastfeeding for >= 4 mo is protective against a high BF% at 2 y of age, whereas a consistently high fat intake in the second year of life "inhibits" the physiologic decrease in BF% between 2 and 5 y.