Gradient-Robust Hybrid DG Discretizations for the Compressible Stokes Equations.

This paper studies two hybrid discontinuous Galerkin (HDG) discretizations for the velocity-density formulation of the compressible Stokes equations with respect to several desired structural properties, namely provable convergence, the preservation of non-negativity and mass constraints for the density, and gradient-robustness. The later property dramatically enhances the accuracy in well-balanced situations, such as the hydrostatic balance where the pressure gradient balances the gravity force. One of the studied schemes employs an H ( div ) -conforming velocity ansatz space which ensures all mentioned properties, while a fully discontinuous method is shown to satisfy all properties but the gradient-robustness. Also higher-order schemes for both variants are presented and compared in three numerical benchmark problems. The final example shows the importance also for non-hydrostatic well-balanced states for the compressible Navier-Stokes equations.

Divergence-Conforming Velocity and Vorticity Approximations for Incompressible Fluids Obtained with Minimal Facet Coupling.

We introduce two new lowest order methods, a mixed method, and a hybrid discontinuous Galerkin method, for the approximation of incompressible flows. Both methods use divergence-conforming linear Brezzi-Douglas-Marini space for approximating the velocity and the lowest order Raviart-Thomas space for approximating the vorticity. Our methods are based on the physically correct viscous stress tensor of the fluid, involving the symmetric gradient of velocity (rather than the gradient), provide exactly divergence-free discrete velocity solutions, and optimal error estimates that are also pressure robust. We explain how the methods are constructed using the minimal number of coupling degrees of freedom per facet. The stability analysis of both methods are based on a Korn-like inequality for vector finite elements with continuous normal component. Numerical examples illustrate the theoretical findings and offer comparisons of condition numbers between the two new methods.

Treatment as prevention and other interventions to reduce transmission of multidrug-resistant tuberculosis.

Drug-resistant tuberculosis (DR-TB) represents a major programmatic challenge at the national and global levels. Only ∼30% of patients with multidrug-resistant TB (MDR-TB) were diagnosed, and ∼25% were initiated on treatment for MDR-TB in 2016. Increasing evidence now points towards primary transmission of DR-TB, rather than inadequate treatment, as the main driver of the DR-TB epidemic. The cornerstone of DR-TB transmission prevention should be earlier diagnosis and prompt initiation of effective treatment for all patients with DR-TB. Despite the extensive scale-up of Xpert® MTB/RIF testing, major implementation barriers continue to limit its impact. Although there is longstanding evidence in support of the rapid impact of treatment on patient infectiousness, delays in the initiation of effective DR-TB treatment persist, resulting in ongoing transmission. However, it is also imperative to address the burden of latent drug-resistant tuberculous infection because it is estimated that many DR-TB patients will become infectious before seeking care and encounter various diagnostic delays before treatment. Addressing latent DR-TB primarily consists of identifying, treating and following the contacts of patients with MDR-TB, typically through household contact evaluation. Adjunctive measures, such as improved ventilation and use of germicidal ultraviolet technology can further reduce TB transmission in high-risk congregate settings. Although many gaps remain in our biological understanding of TB transmission, implementation barriers to early diagnosis and rapid initiation of effective DR-TB treatment can and must be overcome if we are to impact DR-TB incidence in the short and long term.

FAST implementation in Bangladesh: high frequency of unsuspected tuberculosis justifies challenges of scale-up.

SETTING: National Institute of Diseases of the Chest and Hospital, Dhaka; Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka; and Chittagong Chest Disease Hospital, Chittagong, Bangladesh. OBJECTIVE: To present operational data and discuss the challenges of implementing FAST (Find cases Actively, Separate safely and Treat effectively) as a tuberculosis (TB) transmission control strategy. DESIGN: FAST was implemented sequentially at three hospitals. RESULTS: Using Xpert® MTB/RIF, 733/6028 (12.2%, 95%CI 11.4-13.0) patients were diagnosed with unsuspected TB. Patients with a history of TB who were admitted with other lung diseases had more than twice the odds of being diagnosed with unsuspected TB as those with no history of TB (OR 2.6, 95%CI 2.2-3.0, P < 0.001). Unsuspected multidrug-resistant TB (MDR-TB) was diagnosed in 89/1415 patients (6.3%, 95%CI 5.1-7.7). Patients with unsuspected TB had nearly five times the odds of being diagnosed with MDR-TB than those admitted with a known TB diagnosis (OR 4.9, 95%CI 3.1-7.6, P < 0.001). Implementation challenges include staff shortages, diagnostic failure, supply-chain issues and reliance on external funding. CONCLUSION: FAST implementation revealed a high frequency of unsuspected TB in hospitalized patients in Bangladesh. Patients with a previous history of TB have an increased risk of being diagnosed with unsuspected TB. Ensuring financial resources, stakeholder engagement and laboratory capacity are important for sustainability and scalability.

Genetic Polymorphisms in the Toll-like Receptor 10, Interleukin (IL)17A and IL17F Genes Differently Affect the Risk for Tuberculosis in Croatian Population.

Proinflammatory conditions leading to activation of macrophages via interferon-γ bear an important role in host defence against intracellular bacteria such as Mycobacterium tuberculosis (Mt). Interleukin-17 plays a similar role, as it appears to be also an activator of macrophages. Recently, the TLR-10 was identified as an anti-inflammatory factor that exerts its action via association with the TLR-2 chain at the cell surface of macrophages, the latter being an Mt-binding protein. We have previously found that gene polymorphisms that either inactivate the TLR2 gene product or have a dominant-negative role are associated with tuberculosis (TB) in Croatian population. We have now extended our survey and found that single nucleotide polymorphism (SNP) in TLR10 (rs11096957) is associated with risk for TB. Homozygotes carrying the A allele are associated with predisposition to disease as analysed by the dominant model of inheritance. In contrast, SNPs in the proinflammatory IL17A and IL17F genes (rs2275913 and rs763780, respectively), found previously to correlate with the disease occurrence in Chinese population, were not significantly associated with tuberculosis in the Croatian population.

[Workplace health promotion in network structures - the Erlangen Model of "enterprises in motion"]. / Betriebliche Gesundheitsförderung in Netzwerkstrukturen am Beispiel des Erlanger Modells - "Bewegte Unternehmen."

INTRODUCTION: Evidence-based health promotion and prevention are the only means to meet the future economic challenges in health care. Since preventive measures do not penetrate all strata of society alike, the workplace is a probable platform for health education and promotion. Against this background, the network of the 'Erlangen Model' attempts to include health promotion as an integral part of enterprise policy; the present paper evaluates preliminary results of this programme. METHOD: Questionnaires and interviews were conducted among employees of 6 companies and authorities forming the network "Agitating Enterprises". A total of 1,748 subjects were included and answered questions about their professional and health-related situation, physical activities, and expectations in connection with the programme. RESULTS: Almost half of the subjects (48%) had no intention to participate in one of the programme's courses. Most frequent mentioned reasons in favour of participation were the expectation of positive effects on general health (75%), well-being (78%), team work (32%) and enjoyment of sports (70%). Factor analysis extracted 5 dimensions of occupational burden out of over 50 items: "Co-operation with colleagues and superiors", "safety at work", "workflow organisation", "individual complaints" and "workplace design". Between participating companies the expression of these dimensions varied substantially; employees of the university hospital in general reported a higher-than-average burden. In contrast, differences regarding the health status, satisfaction with employment conditions and individual activity scores were minor. CONCLUSION: Health promotion at the workplace is meaningful, especially for health-care employees. Differential analyses of reasons for non-participation may reveal starting points for an improvement of attendance in health-promotion programmes.

[Morbidity and early retirement among teachers at vocational schools]. / Morbidität und vorzeitige Dienstunfähigkeit von Lehrkräften an beruflichen Schulen.

AIM OF THE STUDY: Teachers at vocational schools often feel overburdened and emotionally exhausted. The aim of our study was to gather new evidence-based information on the type and extent of the morbidity spectrum and health-related early retirement of teachers at vocational schools, using objective parameters and larger numbers of cases. METHODS: In a prospective total assessment (the entire state of Bavaria) over the period of 1996-1999 all official medical examinations among teachers of vocational schools in the public health centres were evaluated with regard to premature unfitness for work. The analysis included for example socio-demographic/occupational factors, the morbidity spectrum, assessment of performance, rehabilitation and a comparison of the prevalence rates of psychiatric disorders and rehabilitation among disabled teachers of various types of schools in Bavaria ("Erlanger Lehrerstudie"). The answers given in a standardised, anonymous questionnaire provided the database. Evaluation was carried out by means of descriptive statistics. RESULTS: Of the 451 teachers studied, 31% (n=138) were women and 69%(n=313) were men. The median age was 56 years (range: 29-62 years). 70% (n=314) of the teachers were assessed to be unfit for work. The main reasons for early retirement were psychic and psychosomatic illnesses (F-ICD10) which made up 53% of the cases. Among the psychiatric diagnoses, depressive disorders (43%) and burnout syndrome (16%) dominated. The most frequent somatic diseases were muscular/skeletal disorders (M-ICD10) in 13% of cases, then cardiovascular disorders (I-ICD10) in 7% and malignant tumours (C-ICD10) in 7% of cases. In the gender-based analysis the relative frequency of psychiatric disorders (58% vs. 50%) and malignant tumours (15% vs. 3%--difference of statistical significance) was higher in women than in men, while the prevalence of cardiovascular (3% vs. 9%) and muscular/ skeletal disorders (6% vs. 16%--difference of statistical significance) was lower in women than in men. 63% (n=198) of the teachers assessed unfit for work had participated in at least one medical rehabilitation measure before early retirement. CONCLUSIONS: The main reason for early retirement of teachers at vocational schools is mental ill health. Beyond this fact there is a striking gender difference in the psychic and somatic morbidity. Measures of prevention and intervention would have to focus on mental health at the workplace and also take gender aspects into consideration.

Ill health and early retirement among school principals in Bavaria.

OBJECTIVES: School principals play an important role in maintaining the performance and health of teachers but often feel over-burdened themselves and suffer illnesses, which not only impairs their health-promoting function but also leads to limitations in their fitness for the occupation. The aim of our study was, therefore, using objective parameters and larger numbers of cases, to obtain a differentiated insight into the morbidity and the health-related early retirement of school principals. METHODS: In a prospective total assessment (the whole of Bavaria, a state in southern Germany) in the period from 1997 to 1999 all medical examinations of school principals performed to decide the question of early retirement were evaluated. The analysis included, e.g., socio-demographic/occupational factors, diagnoses, assessment of performance and rehabilitation. The data were sampled in a standardised, anonymous questionnaire, which provided the database. Evaluation was carried out by means of descriptive statistics. RESULTS: The median age of the 408 school principals included in the evaluation (heads and vice-heads, 30% of whom were women) was 58 years (minimum 41 years, maximum 64 years). The most frequent workplaces were primary schools (63%). A total of 84% (n=342) of the headmasters was assessed to be unfit for work. The main reasons for early retirement were psychiatric/psychosomatic disorders (F-ICD 10) which made up 45% of the cases. The relative frequency was higher in women than in men. Depressive disorders and exhaustion syndromes (burnout) dominated among the psychiatric diagnoses (proportion 57%). The most frequent somatic illnesses were cardiovascular diseases (I-ICD10) in 19% of cases, then muscular/skeletal diseases (M-ICD10) in 10% and malignant tumours (C-ICD 10) in 9% of cases. Cardiovascular diseases, in particular arterial hypertension and ischaemic heart disease, were found in headmasters significantly more frequently than in teachers without a headship function (P

[Early factors influencing body weight and prevalence of overweight in 4610 children prior to school entry in the Erlangen District (Northern Bavaria)]. / Frühe Einflussfaktoren auf das Körpergewicht und die Prävalenz von Ubergewicht zum Zeitpunkt der Schuleingangsuntersuchung bei 4610 Kindern im Raum Erlangen/Nordbayern.

OBJECTIVE: Childhood obesity is a growing health problem among German children. Birth weight is considered to have a major influence on the course of postnatal weight. The present study investigates the relation between birth weight and body weight at health examination prior to school entry. We tested other parameters influencing childhood obesity, and hypothesized that within a 5-year interval the prevalence of obesity in children has increased significantly. METHODS: Our study is based on the retrospective analysis of the school enrolment health examinations of 4610 children in North Bavaria, e. g. the town Erlangen and administrative district Erlangen-Hoechstadt in 1995/96 and 2000/01. RESULTS: A higher birth weight was associated with a higher weight and BMI at school entry examination (p < 0.0001). An increased birth weight is therefore a considerable risk factor for later overweight in childhood. Hypotrophic newborn, however, gain less weight and exhibit a lower BMI in our study group. In general, boys were significantly heavier than girls (p < 0.001). Children of foreign origin were heavier and had a higher BMI corrected for age than German pupils but they were also 0.07 years older. Our regional survey revealed local differences in the prevalence of obesity. Comparing the cohorts 1995/96 and 2000/01 at school entry, a significant increase of BMI in the latter was found (p < 0.0001). CONCLUSIONS: A highly significant increase in the prevalence of infantile overweight has to be faced. Early prevention of childhood obesity is therefore mandatory to avoid the complications and higher morbidity.

Possible reentrance of the fractional quantum Hall effect in the lowest Landau level.

In the framework of a recently developed model of interacting composite fermions, we calculate the energy of different solid and Laughlin-type liquid phases of spin-polarized composite fermions. The liquid phases have a lower energy than the competing solids around the electronic filling factors nu = 4/11,6/17, and 4/19 and may thus be responsible for the fractional quantum Hall effect at nu = 4/11. The alternation between solid and liquid phases when varying the magnetic field may lead to reentrance phenomena in analogy with the observed reentrant integral quantum Hall effect.

["They'll never come back...""--Expectations and reality of occupational reintegration of teachers unfit for service]. / "They'll never come back ..." -- Anspruch und Wirklichkeit der beruflichen Reintegration dienstunfähiger Lehrkräfte.

AIM OF THE STUDY: The reactivation of teachers with experience of both life and the profession who have become unfit for work is regarded by politicians not only as a suitable measure against the imminent lack of teaching staff, but also as a promising strategy for reducing the cost of health care. The aim of our study was to gather new evidence- based information on the occupational reintegration of teachers who took early retirement and to investigate to what extent official medical reactivation examinations are an effective instrument of tertiary prevention. DATABASE AND METHODS: In a prospective total assessment (the entire state of Bavaria) over the period of 1997 - 1999 all official medical examinations in the public health centres (Gesundheitsamter und Medizinische Untersuchungsstellen der Bezirksregierungen) were evaluated with regard to the reactivation of teachers unfit for work. The analysis included e. g. socio-demographic/occupational factors, the morbidity spectrum, rehabilitation and the assessment of performance. The answers given in a standardised, anonymous questionnaire provided the database. Evaluation was carried out by means of descriptive statistics. RESULTS: Of the 1465 teachers studied, 64 % (n = 939) were women and 36 % (n = 526) were men. The median age was 53 years (range: 31 - 63 years), and the proportion of over 60-year-olds was 5.5 %. 22 % of those who took early retirement were recognised as being severely disabled. In 77 % of cases, examination of unfitness for work was carried out at the order of the authorities. 57 % (n = 835) of the teachers had taken part in at least one medical rehabilitation measure, 13 % (n = 190) in at least one occupational rehabilitation measure. Within the morbidity spectrum, psychic and psychosomatic illnesses (F-ICD10) took first place with a share of 59 % the prevalence in female teachers of such illnesses was significantly higher than that in male teachers (p < 0.05). Among the psychiatric diagnoses, depressive illnesses dominated (share: 35 %). The most frequent somatic diseases were muscular/skeletal disorders (M-ICD10) in 12 % of cases, then cardiovascular disorders (I-ICD10) in 7 % and malignant tumours (C-ICD 10) in 5 % of cases. In 33 % of cases multi-morbidity was found. 93 % (n = 1,360) of the teachers investigated in follow-up examinations were again classified as unfit for work. In only 7 % (n = 105) reactivation was recommended by the physician; the lowest reactivation quotas were found among teachers with psychic illnesses and grammar school teachers. In who teachers that returned to work, compared to those still unfit for work, a lower age and lower prevalence of severe disability, multi-morbidity and psychic disturbances were objectified. CONCLUSIONS: Teachers who take early retirement return to the profession only in exceptional cases. The time and expense needed for reactivation examinations should be critically compared with the benefits. The same applies to the quality of the results of intervention and rehabilitation measures for restoring psychological and physical health. In this context problem-oriented disability management appears superfluous.

[School principals--too ill for healthy schools?]. / Führungskräfte im Schuldienst--zu krank für gesunde Schulen?

AIM OF THE STUDY: School principals on the one hand play an important role in maintaining the performance and health of teachers, but on the other hand often feel over-burdened themselves and suffer from illnesses which not only impair their health-promoting function, but also lead to limitations in their fitness for the occupation. The aim of our study was therefore, using objective parameters and larger numbers of cases, to obtain a differentiated insight into the type and extent of morbidity spectrum and the health-related early retirement of school principals. METHODS: In a prospective total assessment (the whole of Bavaria in the period 1997-1999), all the reports about the premature unfitness for work of school directors were evaluated. The analysis included for example socio-demographic/occupational factors, diagnoses, assessment of performance and rehabilitation. The answers given in a standardised, anonymous questionnaire provided the database. Evaluation was carried out by means of descriptive statistics. RESULTS: The median age of the 408 school principals included in the evaluation (heads and vice-heads, 30% of whom were women) was 58 (min: 41 years old, max: 64 years old). The most frequent workplaces were primary schools (38%) and secondary schools (25%). 84% (n=342) of the headmasters were assessed to be unfit for work. The main reasons for early retirement were psychic/psychosomatic illnesses (F-ICD 10) which made up 45% of the cases. The relative frequency was higher in women than in men. Depressive disorders and exhaustion syndromes (burnout) dominated among the psychiatric diagnoses (proportion: 57%). The most frequent somatic diseases were cardio-vascular diseases (I-ICD10) in 19% of cases, then muscular/skeletal diseases (M-ICD10) in 10% and malignant tumours (C-ICD 10) in 9% of cases. Cardio-vascular diseases, in particular arterial hypertonia and ischaemic heart disease, were, in addition, found in headmasters significantly more frequently than in teachers without a leadership function (p < or = 0.05). 63% (n=257) of the school principals had participated in at least one medical rehabilitation measure before the proceedings for determining unfitness for work were instigated. The performance of 66% (n=226) of those judged unfit for work was assessed to be so severely impaired that no other employment could be expected of them. CONCLUSIONS: The morbidity spectrum of school principals prematurely unfit for work is characterised by stress-associated illnesses. The health disorders objectified are of considerable relevance for public health. Specific measures of prevention and intervention must, therefore, also include this occupational group. Activity should not be limited to the prevention of behavioural problems, but should also take into account important aspects for preventing adverse circumstances arising at the school workplace.

[Evaluation of the premature unfitness for work among civil servants career--groups and morbidity]. / Evaluation der Dienstunfähigkeit bei Beamtinnen und Beamten--Laufbahn und Morbidität.

Out of the data obtained in a prospective study over 11,528 assessments concerning premature unfitness for work among civil servant over a period of four years the collective groups of those assessed unfit for work (n = 6,861, 2,723 women i. e. 39.7 % and 4,128 men i. e. 60.2 %) were included in this study. The median age was 54 years (women 52, men 55), 4,112 were teachers, in the administration 1,644, in the technical service 386 and in activities with special request (e. g. fire-brigade or law execution service) 483. Career groups: official-legal groups of careers in lower service categories were 266, in medium categories about 29, in elevated service 2,766 and higher service 2,146 woman officials and male officials. In all fields of activity and groups of careers psychic disorders (ICD 10: F) had a prevalence between 30.8 % in lower service and 48.0 % in the elevated service as "Premature Retirement Suffering No. 1". Women in all fields of activity were clearly more frequently concerned than men (differences from 3.1 per cent points to 18.1 per cent points middle service or technical service, p < 0.01). Second place was taken by muscular/skeletal diseases (ICD 10 group M) in 17.4 % of cases (n = 1,630), and third place by cardiovascular diseases (ICD 10 group I) in 10.4 % of cases (n = 972). The altogether lower prevalence of musculoskeletale illnesses (ICD 10: I) showed a dependency on the activity request and was highest in the technical services and in lower service categories. The median of entrance into premature unfitness for health reasons was between 15 and 9 years earlier than the age limit by law and presented itself differently in the groups of careers. Although this analysis only shows the prevalence of illnesses causal for premature retirement and not the health situation of all civil servants, it can give however pointers to emphasis for a necessary prevention.

[Illness related early pensioning of high school teachers]. / Zur Problematik krankheitsbedingter Frühpensionierungen von Gymnasiallehrkräften.

The problem of premature unfitness for work of (grammar school) teachers is of great social and social-medical interest. The possible causes and suitable measures of intervention remain a subject of controversy. The aim of this study was, on the basis of a random sample of a large number of cases, to gain a differentiated overview of the extent and type of early retirement due to illness of grammar school teachers, in order to be able to develop evidence-based strategies for prevention and intervention. In a prospective evaluation, all the assessments of illness-related unfitness for work drawn up for civil servants and teachers between 1.1.1996 and 31.12.1999 in Bavaria were first of all systematically evaluated. In addition, from the total collective a subgroup was formed of grammar school teachers and this was analysed separately. The answers given in a standardized, anonymous questionnaire provided the database. The evaluation included e.g. socio-demographic and occupational factors, the morbidity spectrum, medical judgement, medical rehabilitation and evaluation of performance. The medical diagnoses of the main and accompanying illnesses were classified according to ICD 10 in organ-related groups. Evaluation was carried out by means of descriptive statistics. Of the 655 grammar school teachers assessed, 65% (n = 429) were men, 35% (n = 226) women. The median age for male teachers was 58 years old (range: 30-64 years old), for female teachers 55 years old (range: 32-63 years old). Previous conflicts at the school workplace were reported in 12% of the cases. Among the main medical diagnoses, psychic/psychosomatic complaints (41%) predominated over muscular/skeletal illnesses (14%) and cardio-vascular diseases (12%). 80% of those examined were judged unfit for work. 56% of the grammar school teachers had participated in at least one medical rehabilitation measure before the proceedings for determining unfitness for work were instigated. Psychic and psychosomatic illnesses took first place among the decisive complaints leading to early retirement, and made up 45% of these. Further differentiation revealed the predominance of depressive illnesses and exhaustion (burnout). The main somatic complaints were far less common: muscular/skeletal illnesses (13%), cardio-vascular diseases (12%) and malignant growths (8%). The performance of 70% of the grammar school teachers judged unfit for work was regarded as so severely reduced that even activity outside of the teaching profession was no longer feasible. In this first representative evaluation of illness-related early retirement in grammar school teachers, the high prevalence and great social-medical importance of psychic and psychosomatic illnesses is noteworthy. In Bavaria, almost every second grammar school teacher therefore becomes unfit for work as a result of such complaints long before they reach the normal retiring age. From a social-medical and occupational-medical point of view, there is urgent need for further research into potential illness-inducing occupational and non-occupational stress factors and the development and implementation of effective and efficient strategies for prevention and intervention.

[Illness-related premature unfitness for work among civil servants in Bavaria - an evaluation in the social medical field]. / Krankheitsbedingte vorzeitige Dienstunfähigkeit von Beamtinnen und Beamten im Freistaat Bayern - eine sozialmedizinische Evaluation.

In a prospective study, over a period of four years 11,528 anonymous questionnaires concerning premature unfitness for work among civil servants were evaluated. The questionnaire was devised by the investigators. The main items of interest were: age, sex, career and occupation, main diagnosis and accompanying symptoms, duration of illness, rehabilitation measures, and working capacity including medical assessment of unfitness for work. Included in this study were 9,348 investigations (excluded were reactivations); 40.9 % were from women and 58.9 % from men. The median age was 54 years (women 52, men 55). The range of illnesses among all those investigated included a large number of psychological disorders (43.3 %, n = 4,052) (diagnosis group F of ICD-10). Second place was taken by muscular/skeletal diseases (ICD-10 group M) in 17.4 % of cases (n = 1,630), and third place by cardiovascular diseases (ICD-10 group I) in 10.4 % of cases (n = 972). The median duration of the main disease was 24 months. Classified as no longer fit for work were n = 7,033 persons, corresponding to 75.2 % of those investigated. Among those unfit for work, psychological disorders were the reason in 46.2 % of cases (men 42.6 %, women 53.4 %). In this first prospective study of illness-related premature unfitness for work in civil servants, psychological and psychosomatic illnesses were found to be the 'number one' illness among persons taking early retirement. The median age at which these persons became unfit for work was 52 in women and 55 in men. In view of the high prevalence of psychological disorders, and the increasing tendency towards early retirement and the considerable jump forward in the age this happens compared to in previous studies with small collectives, a preventive strategy must be developed which takes into account the evidence gained in social-medical and occupational-medical practice.

[Ornithosis--studies in correlation with an outbreak]. / Ornithose--Untersuchungen im Zusammenhang mit einem Ausbruch.

An outbreak of ornithosis with 8 cases of ornithosis pneumonia and 2 lethal complications was investigated in workers in a poultry farm and processing plant and a comparative seroepidemiological study of antigen responses was performed in 3 collectives: No. I: n = 82/87 workers in the processing plant, where the outbreak occurred; No. II: n = 83 workers in a chicken slaughter-house; No. III: n = 82 as matched-pair group to collective No. I with the same age and sex, but without occupational risk. The test systems were: genus specific complement fixation reaction (CFR), Ipazyme commercial slide kit containing LGV antigen and a type-specific microimmunofluorescence (MIF) technique with antigens binding C. psittaci, pneumonia and trachomatis IgA, IgG and IgM. 57/82 (71.9%) workers in group No. I were chlamydial antibody-positive, whereas only 22/82 of the population Nr. III--control group (odds ratio 6.2/3.2-12.3 p < or = 0.05). 16/83 (19.3%) of the workers in the chicken slaughterhouse had antibodies against chlamydia group antigens. 30/82 of the collective No. I had serological evidence of a recent or current infection with higher antibody titres in CFR and IPAZYME-Test and/or antibody response against IgA and IgM (MIF). 43.3% of the latter could be serologically detected as specific infections with C. psittaci. 10 of 18 (55%) workers employed in the recent 3 months had serological signs of an acute infection. There was no association between the point of contact with the poultry (live hang areas, slaughtery, evisceration, cooling carcasses) and the prevalence of antibody response. The possible routes of infection, inhalation of dried excretions or aerosols and via hand-to-mouth contacts are discussed. In specimens of cloacal swabs and faeces of the ducks chlamydiae could be found although the animals were asymptomatic. The results of this study demonstrate that in poultry plants, where ducks and other poultry living in an aqueous habitat are slaughtered and processed, a high risk of C. psittaci infection (70.2%) and ornithosis morbidity (25%) with a lethality of 8.3% can exist. Since the eradication of C. psittaci in poultry does not seem to be possible at the moment, preventive measures e.g. gloves, masks, information and medical examinations of the workers must be implemented in those slaughterhouses and plants where C. psittaci is suspected or common.

[Quality circles in expert assessment as an instrument in quality management]. / Ringversuche in der Begutachtung als Instrument im Qualitätsmanagement.

An intercomparison programme was carried out as part of the quality management of medical assessments in the public health service in Baden-Württemberg. All physicians who performed medical assessments in January 1997 were invited to participate. They received a case description adopted from medical records of a precedent case (56-year-old head of a department in an administrative authority, severely disabled after left-sided stroke with residual right-sided partial hemiparesis, reduced work performance), and were asked to assess whether the patient was permanently unable to work. Access to medical expert opinions was requested. Participation was voluntary. Assessments were reviewed twice as to whether five prospectively defined evaluation criteria were fully met, or only partially or not at all. Participants and reviewers remained unknown to each other. Among 246 eligible physicians, 103 returned an assessment (43%). Forty-five respondents had requested additional expert opinions. Anticipations for five criteria were met to their full extent with regard to: formal construction, all submissions; case description, 84%; sociomedical diagnosis, 65%; description of ability to work, 53%; and response to the question posed, 75% of submissions. The programme required considerable work time in its preparatory, field, and evaluation phases. The procedure was however found to be practicable, and a suitable element within a quality management programme can contribute towards motivation, quality assurance and the identification of possible deficits, and thus indicate possible topics and issues for continuing education and quality control programmes.

[Social medicine evaluation of pre-employment medical screening of civil service candidates]. / Sozialmedizinische Evaluation von Einstellungsuntersuchungen bei Beamtenanwärtern.

The findings and resulting number of rejections from 9.043 medical examinations of candidates for posts as civil servants in 1994 in Bavaria and a retrospective evaluation of 500 examinations at two large public health departments in Bavaria were used to discuss the value of such examinations and present possible alternatives. The rate of rejections for medical reasons in the 9.043 examinations of civil servants starting new jobs in Bavaria was 0.57%. The most frequent reason for rejection was obesity. In the retrospective evaluation of 500 medical examinations of candidates starting new jobs there were no cases of final rejection for medical reasons. In 0.4% of cases (n = 2) the candidates were considered suitable for the probationary period before becoming a civil servant, but unsuitable for health reasons for a life-time post in the civil service. In 27% of cases the findings were normal without any diagnosis stated in the examination report. The most frequent diagnoses were refractive ametropia (55.8%) and changes in the locomotor system (22.2%), in particular deviation of the axis are vertebral column (17.6%). The results are comparable with those obtained in studies carried out in Europe, although the procedures and study designs differed. Even with a low number of rejections of around 0.5%, examinations of the candidates economically justified for the employer (the state). In view of the high number of civil servants taking early retirement, the sensitivity and specificity of the medical examinations before starting work are discussed, as well as possible and better alternatives to a single examination. One suggestion is continuous monitoring of all civil servants by a physician specialised in occupational medicine, although in particular for teachers and office workers no standards have been developed for the scope and frequency of occupational-medical health checks and consultation.

Internal exposure to hazardous substances of persons from various continents: investigations on exposure to different organochlorine compounds.

UNLABELLED: The aim of the study was to investigate the concentration of organochlorine compounds of environmental-medical relevance in biological materials from refugees with regard to their countries of origin and to compare these concentrations with the internal exposure of the German general population. METHODS: During medical examination after entry to Germany specimens could be taken from the refugees to determine the following parameters of biological monitoring: 1,1-dichloro-2,2-bis(-chlorophenyl)-ethylene (DDE-P), polychlorinated biphenyls (PCB-P), pentachlorophenol (PCP-P) and the beta- and gamma-hexachlorocyclohexanes (beta-HCH-P, gamma-HCH-P) in plasma and the excretion of chlorophenols (4-MCP-U, 2,4-DCP-U, 2,5-DCP-U, 2,4,5-TCP-U, 2,4,6-TCP-U, 2,3,4,5-TeCP-U, 2,3,5,6-TeCP-U) in urine. One hundred and three men (13 from former Yugoslavia, 29 from the former USSR, 33 Africans and 28 Asians) ranging from 16 to 53 years of age (median 27 years) were investigated. Thirty four male Germans without occupational exposure to these substances and a similar age structure (age 25-36 years; median 26 years) served as a control group. RESULTS: A much higher level of internal exposure was found for the DDT metabolite, DDE, for those persons from Asia, the former USSR and Africa compared with the German controls (medians: 16.9 micrograms/l, 11.9 micrograms/l and 10.9 micrograms/l) and 1.1 micrograms/l). The levels of PCB in plasma were below the detection limit in the majority of refugees. In the control group, however, the PCB levels were higher (sigma PCB; median: 2.1 micrograms/l, maximum: 13.3 micrograms/l). The highest beta-HCH concentrations, up to a maximum of 15.5 micrograms/l, were detected in the persons from the former USSR and Asia. The five groups do not differ with regard to internal exposure to PCP and gamma-HCH. Renal excretion of 4-MCP, 2,4-DCP and TeCP did not differ between the five groups. The concentrations of 2,5-DCP in urine, however, were significantly lower in the Germans than the refugees from the four regions investigated. The median for the Germans was 3.0 micrograms/l and for the refugees between 10.8 and 14.7 micrograms/l. Also the levels of 2,4,5-TCP and 2,4,6-TCP in urine were lower in the German controls than in the men from the former USSR, Africa and Asia. CONCLUSIONS: Organochlorine compounds exist worldwide due to their extensive use. There are, however, regional differences for the various substance groups, which during biological monitoring are seen in the different background exposures of the general population. Particularly characteristic are markedly higher levels of DDE in plasma from the refugees compared with the German population.