[Determinants of asthma among children and adolescents in Germany. Results of the German Health and Examination Survey for Children and Adolescents (KiGGS)]. / Einflussfaktoren für Asthma bronchiale bei Kindern und Jugendlichen in Deutschland. Ergebnisse der KiGGS-Studie.

In this study, associations between current asthma and possible determinants were studied using data of the German Health Interview and Examination Survey for Children and Adolescents ("Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland," KiGGS). In this nationwide cross-sectional survey, 17,461 subjects aged 0-17 years were examined between 2003 and 2006. Data collection included a medical examination of the child, an interview of the parents, and written questionnaires. Apart from prevalence estimates, multivariate logistic regression analyses were performed. Increasing age and male sex, previous atopic diseases of the child, a positive family history of allergic diseases and low birth weight were significant risk factors of asthma, as were overweight and moldy walls in the residence. Breast feeding was not associated with a reduced risk of asthma. Low age at delivery of the mother and living in rural or provincial regions were shown to be protected. Overall, this study suggests that allergies of the parents and previous atopic disease of the child are the strongest determinants of asthma. However, environmental factors (mold on walls, living in rural and provincial towns) and lifestyle factors could also modify asthma risk.

Microbial volatile organic compounds in the air of moldy and mold-free indoor environments.

UNLABELLED: A single-blinded study was performed to analyze whether indoor environments with and without mold infestation differ significantly in microbial volatile organic compounds (MVOC) concentrations. Air sampling for MVOC was performed in 40 dwellings with evident mold damage and in 44 dwellings, where mold damage was excluded after a thorough investigation. The characteristics of the dwellings, climatic parameters, airborne particles and air exchange rates (AER) were recorded. The parameters mold status, characteristics of the interiors and measured climatic parameters were included in the multiple regression model. The results show no significant association between most of the analyzed MVOC and the mold status. Only the compounds 2-methyl-1-butanol and 1-octen-3-ol indicated a statistically significant, but weak association with the mold status. However, the concentrations of the so-called MVOC were mainly influenced by other indoor factors. 2-Methylfuran and 3-methylfuran, often used as main indicators for mold damage, had a highly significant correlation with the smoking status. These compounds were also significantly correlated with the humidity and the AER. The compounds 3-methyl-1-butanol, 2-hexanone, 3-heptanone and dimethyl disulfide were weakly correlated with the recorded parameters, the humidity being the strongest influencing factor. Only 2-methyl-1-butanol and 1-octen-3-ol showed a statistically significant association with the mold status; however, only a small portion (10% in this case) of the total variability could be explained by the predictor mold status; they do not qualify as indicator compounds, because such minor correlations lead to a too excessive part of incorrect classifications, meaning that the diagnostic sensitivity and specificity of these compounds are too low. PRACTICAL IMPLICATIONS: The assumption that mold infestations might be detected by microbial VOC emissions must be considered with great reservation. The major part of the total variability of the measured MVOC concentrations originates from not known influencing factors and/or from factors not directly associated with the mold status of the dwellings (confounders). More specific and sensitive markers for the assessment of the mold status should be found, if the screening for mold infestations should be performed by volatile organic compounds.

Emission patterns and emission rates of MVOC and the possibility for predicting hidden mold damage?

UNLABELLED: Laboratory trials were performed in order to search for the variety of the production of microbial volatile organic compounds (MVOC), which could be used as indicators for hidden mold damage. Concerning MVOC production the experiments showed a dependency on the mold genus/species, the different strains used and the building materials used as substrate. It could be proved that the production of certain MVOC is not consistent at all times. On the whole low emission rates in terms of microg/h/m2 of the MVOC were found. Extrapolating the emissions rates from the laboratory trails to an indoor air situation results in concentrations below the analytical detection limit in most cases. According to these results only heavy or very large fungal contaminations might be detected by this method in indoor air. The studies were performed at the Institute of Hygiene and Environmental Medicine, Charite, Germany. PRACTICAL IMPLICATIONS: Microorganisms like bacteria and molds produce a huge variety of substances, and a part of them are released into the environment. Some compounds like, e.g. alcohols or ketones are volatile, therefore found in the air and called MVOC. Those compounds were considered helpful to track especially hidden mold damage. The study presented here showed, that the emission pattern varies from genus to genus and sometimes even from fungal strain to fungal strain. The results concerning the emission rates from different infested building materials proved, that the concentrations produced are much too low to be detected in indoor air, especially considering the dilution because of ventilation. Therefore, we conclude that MVOC should not be used as predictors for mold damage in indoor environments.

[Environmental Survey for Children-- the environmental module of KiGGS. I. Design and research program]. / Kinder-Umwelt-Survey--das Umweltmodul im KiGGS. Teil 1: Konzeption und Untersuchungsprogramm.

The German Environmental Survey for Children (GerES IV) is the environment-oriented module of the National Health Interview and Examination Survey for Children and Adolescents (KiGGS) which is being performed nationwide in Germany. From 2003 to 2006, a random subsample of 1800 children aged 3-14 years is being studied with regard to their body burden and health impairments linked to housing conditions and the personal environment- and health-relevant behaviour. The basic study programme includes the analysis of blood, urine, tap water and house dust as well as the application of an extensive questionnaire. The data gained from this population sample, which is representative for Germany's children, are the basis for deriving reference values to characterise the background exposure of children aged 3-14 years. Trends over time can be detected and the success of environmental policies verified by comparing the data with those of the German Environmental Survey 1990/92 (GerES II), also conducted in close cooperation with the National Health Survey, which included children aged 6-14 years. By linking the data from the Environmental and the Health Surveys, health-relevant environmental exposures can be detected and different scientific hypotheses can be tested. The main subjects that are being dealt with using subcollectives of GerES IV are 'VOC and eye and nasopharynx irritation', 'indoor allergens and allergic diseases of the respiratory system', 'chromium, nickel, fragrances and contact allergens', and 'noise, hearing capacity and stress hormones'.

[Comparison of mycological and chemical analytical laboratory methods for detecting mold damage in indoor environments]. / Vergleich mykologischer und chemisch-analytischer Labormethoden zum Nachweis von Schimmelpilzbefällen in Innenräumen.

To evaluate frequently used methods that discriminate between moldy and nonmoldy indoor environments, 45 homes with visible mold growth and 47 definitively non-infested homes, both confirmed by inspection, were investigated by microbiological and chemical analytical methods. The study was laboratory blinded in relation to the confirmed mold status of the rooms. Statistical evaluation of the results of the applied mycological methods with the Receiver Operating Characteristic (ROC) curve analysis showed that these methods (impaction, open Petri dish method, and determination of mold spores in house dust samples) performed very well in discriminating between rooms with visible mold growth and nonmoldy rooms when the sum score of the mold genera Aspergillus and Penicillium was used as an indicator. The calculated areas under the ROC curves (AUC) of the three mycological methods were: 0.992 (95% CI 0.942-0.997) for mold spores in house dust samples, 0.996 (95% CI 0.940-0.998) for the open Petri dish method, and 0.999 (95% CI 0.957-1.000) for the determination of airborne spores with the Andersen impactor, respectively. A perfect discrimination would lead to an AUC of 1. These results were obtained with DG 18-agar as well as with malt extract agar. In contrast to the results of the mycological methods, the chemical analytical method under the same study conditions showed a distinctly lower performance in discriminating rooms according to their mold status when a sum score (concentration of eight typical MVOC) was used as an indicator. The area under the ROC curve (AUC) had a value of 0.620 (95% CI 0.509-0.723). A completely useless test would have an AUC of 0.5. As the lower limit of the 95% confidence interval of the area under the ROC curve is close to 0.5, the results obtained with the MVOC method do not differ from the classification results which can be obtained simply by chance. Possible methodological biases which could have lead to this interpretation are discussed.

"Amalgam disease"--poisoning, allergy, or psychic disorder?

Frequently, patients in environmental health out-patient units relate various complaints to their amalgam fillings. However, an association between the toxic exposure and the reported complaints appears plausible only in few cases. We investigated toxicological, allergological and psychological parameters in patients with amalgam-associated complaints and compared them to controls with similar numbers of amalgam fillings. Forty patients with health disturbances related to amalgam were compared to a control group without amalgam-associated complaints (n = 40), carefully matched for age, sex, and dental status. Mercury concentrations were analyzed in blood, saliva, and 24-h-urine. Atopic predisposition, determination of IgE, patch testing with amalgam and amalgam-associated metals and a psychometric assessment were performed in all participants. Mercury concentrations in blood or urine were similar in patients and controls. Atopic predisposition was markedly enhanced in patients (11/40) as compared to controls (5/40). Only one patient with a lichen ruber of the oral mucosa showed a contact sensitization to amalgam. Patients reported more psychic strain and higher depression scores than controls. Somatization disorders were found in 10 patients (25%) and in one control. Eighteen patients (45%) neither showed an atopic predisposition nor an influence of psychosocial factors. Toxic exposure to mercury does not appear to play a role in "amalgam disease". Since many of these patients are atopic without an "amalgam allergy", but with more psychic strain and notably more depression, the treatment should be focused on allergologic and psychological factors.

Relation between mercury concentrations in saliva, blood, and urine in subjects with amalgam restorations.

The aim was to determine the relationship between mercury content of resting and stimulated saliva, and blood and urine. Eighty subjects participated; 40 of them attributed their self-reported complaints to dental amalgam (patients), the others were matched with respect to age, sex and amalgam restorations (controls). Serum, 24-h urine, resting and chewing stimulated saliva were analyzed for mercury using the ASS-technique. Quality, number, surfaces and total area of amalgam fillings were recorded clinically and using study models. Median (range) mercury levels in serum were 0.67 (0.1-1.52) microgram/l for patients and 0.60 (0.1-1.3) for controls. In urine levels were found to be 0.77 (0.11-5.16) and 0.94 (0.17-3.01) microgram/g creatinine respectively. No significant differences were found between the groups. Resting saliva contained 2.97 (0.10-45.46) micrograms/l in patients and 3.69 (0.34-55.41) in controls (not significant). Chewing mobilized an additional amount of 16.78 (-6.97 to 149.78) micrograms/l in patients and 49.49 (-1.36 to 504.63) in controls (P < or = 0.01). Only a weak correlation was found between mobilized mercury in saliva and serum (r = 0.27; P < or = 0.05) or urine (r = 0.47; P < or = 0.001). For resting saliva the respective values were r = 0.45 (P < or = 0.001) and r = 0.60 (P < or = 0.001). Saliva testing is not an appropriate measure for estimating the mercury burden derived from dental amalgam.

Clinical ecology--an unproved approach in the context of environmental medicine.

This contribution outlines the historic development of Clinical Ecology (CE) and the differences it poses to scientific environmental medicine. The pathogenic, diagnostic and therapeutic concepts of clinical ecology are presented and critically acknowledged. Particular attention is given to behavioral and mental illnesses which, according to the beliefs of clinical ecologists, are related to food and chemicals, whereby this occurrence is considered a "cerebral allergy". The term "allergy" is, however, understood in the broader sense, as opposed to the usual medical term, to include non-immunological, pseudo-allergic and other intolerance reactions. Below are details of the validity and effectiveness of clinical ecology methods. Clinical ecology is concerned, not least, with unspecified, little understood health disorders and chronically fluctuating illnesses which are mainly attributed by clinical medicine to psychosomatic complaints. Many patients are critical of the lack of an adequate, literally "integral" treatment, i.e. one which also includes psychosocial aspects. They tend to search for simple answers and "alternative" treatment possibilities associated with it. Clinical ecologists and other "alternative practitioners" respond to this demand. They initially confirm or suggest to the patient the possibility of poisoning and offer a therapy that is allegedly causal and effective. The iatrogene fixation of patients with environment related illnesses has become a problem for the person in question, clinical medicine and the insured. Of course, those affected interpret their situation in another way. They consider themselves to be the victims of medical ignorance. The challenge posed by unconventional schools of medical thought should be met by increased efforts to create "sound medical practice" and by the attempt to achieve generally binding criteria for quality in the sense of effective "consumer protection".

[Environmental noise and satisfaction with area of residence]. / Umweltbedingter Lärm und Wohnzufriedenheit.

In the German National Health Interview and Examination Survey, more than one third, i.e. 36.2% of persons interviewed on the matter of noise nuisance in their homes attributed to outdoor noise confirmed the occurrence of noise. Regarding this result only small and statistically insignificant differences have been assessed in East and West Germany. The frequency of affirmative answers given by German women, ages 20-39, was significantly higher as compared to men in the same ages bracket. Regarding the dominant noise effects in their home, 87% of persons affected mentioned traffic noise as a source. In the second place neighbour noise has been reported by 32%. Aircraft and railway noises percepted by 20%, are in the third and fourth place. Particularly severe indoor noise effects, i.e. persisting noise during the night, are accompanied with clearly increased discontent regarding the home and living area.

[Diagnosis in environmental medicine: basic principles and problems]. / Umweltmedizinische Diagnostik: Grundzüge und Probleme.

Diagnosis in environmental medicine only differs from the conventional medical diagnosis in a more detailed expositional evaluation on the basis of a respectively expanded anamnesis and a possible local visit, a surrounding examination as well as a so-called biological monitoring. Thus, the essential element of the "diagnosis" in environmental medicine consists in the resolving of a possible internal exposure (and occasionally resulting effects). From this point of view, physicians in environmental medicine could give an advisory contribution to the conventional medicine in selected cases. In contrast to frequently occurring assertions, there are practically no typical environmental diseases due to usual environmental toxicants. At present, a causality between environmental agents and health related disturbances can only be made plausible in less than 10% of out-patients of environmental medicine. These figures are in total contrast to the expansion of the out-patient and clinical environmental medicine. The expansion of the diagnostic offer gives not only to the public but also to the patients and the physicians the impression of a specific competence in diagnostic and therapy of environmental medicine which to this extent does not exist. The consequences are unnecessary and unsuccessful examinations. This is of no help to the patient. Most of the "environmental patients" suffer from civilization caused/psychosomatic and psychosocial disturbances like e.g. phobias, and somatoforme or depressive disturbances. In the genesis probable an increasing readiness for fear, unrealistic threatening convictions (arranged by media, homeopathists, physicians and other authorities), growing fear disturbances as a consequence to this as well as the cognitive connection of "normal" inner disturbances with the suspicious agens play a decisive role. For these patients the clinical environmental medicine lead astray. This is significantly more valid for the numerous "clinical ecologists" who apply scientifically doubtful methods. Considering the clinical approach to environmental medicine urgently needs a critical evaluation by independent research groups.

[Experiences with an ambulance for environmental medicine at the Hygiene Institute of the Heidelberg Universy Hospital]. / Erfahrungen mit der Umweltmedizinischen Ambulanz am Hygiene-Institut des Universitätsklinikums Heidelberg.

Outpatient department and advice centres for environmental medicine were established in the late eighties in Germany. Most of these institutions focus on patient-care, whereas scientific questions have only been dealt with randomely. Thus the evaluation of applied methods and procedures is not satisfactory at present. Patients suffering from "environmental-medical" disorders usually complain about chronic or recurring illnesses. Up to now the complex etiology has not been understood. Generally environment agents in a literal sense do not seem to be of great importance. It is merely impossible to verify the extent to which such exposures influences a multifactorial etiology. Acute health disorders or a disorder that can definitely be related to a specific cause occur very rarely in our field. Thus a serious methodological dilemma results for the clinical aspect of environmental medicine. Nevertheless an increasing number of patients associate their complaints to environmental influences such as harmful substances and physical environmental influences, e.g. electromagnetic fields. Mass media and some physicians support is idea. Scientifically unsound methods of treatment are often applied to "Environmental practices", "Environmental clinics", "Mobile Environmental Outstations", The results of diagnostic examinations are interpreted in a dubious fashion and questionable therapeutic advice is given. An extension of the environmental medical field is not only taking place in the private (commercial) sector; but public institutions, especially public health centres, are participating in the unreflected extension of the outpatient section for environmental medicine. As a consequence we decided to establish a research-oriented "Environmental Outpatient Department" as part of the Hygiene Institute of the Heidelberg University in 1993. The aim was an evaluation of the concept of outpatient stations and if required its further development. The main aspects of the Heidelberg outpatient station-concept will be shown as well as the first case related research results which have reinforced our critical attitude towards clinical environmental medicine. In less than a tenth of the presented cases environmental agents could be proved partly responsible for the mentioned complaints. In a third of all cases a connection between the suspected environmentally harmful substances or others and the apparent health disorders could neither be proved nor totally denied. There was, however, little evidence for a causal connection. In two-thirds of the cases physical-chemical environmental pollution could not be proved responsible for the complaints. More than half of the patients suffered from more or less obvious psychosomatic problems.

[Environmental medicine ambulatory and counseling centers in Germany--conceptional approaches, organizational structures, facility design and responsibilities]. / Umweltmedizinische Ambulanzen und Beratungsstellen in Deutschland--konzeptionelle Ansätze, Organisationsstrukturen, Ausstattung und Arbeitsschwerpunkte.

This paper presents the different concepts of realisation of the currently existing counselling institutions in Germany and ambulances for environmental medicine. It is based on the specific conceptual papers, reports of the ambulances and an inquiry with 20 counselling institutions and ambulances conducted especially for this purpose. From the noted special characteristics a typology of the "ambulance approach" is derived especially with regard to its place in larger institutions, theoretical concepts, specific contents, way of working, diagnostic as well as counselling requests, and usage frequencies. Basic differences exist between research and service projects and between the more general environmental medical services, the special wards in the framework of larger clinical departments (e.g. in dermatology, gynaecology and neurology) and the resources of the departments of occupational medicine. In addition, definite differences exist concerning the number of personnel and equipment, analytical and diagnostical possibilities, data assessment, data documentation, data processing and reporting. Current efforts of standardisation of documentation are presented as well as concepts for a better connection of environmental medical ambulances with physicians' private offices, hospitals, public administrations and laboratories.