Liability Insurance Association Research Articles

Occupational cancer of the urinary tract-incidence, reporting behavior, and administrative procedures

Tumors of the urinary tract are among the most common types of occupational cancer. Asignificant proportion of about 5-15% may be of occupational etiology. Suspicion of an occupational genesis is subject to mandatory reporting. However, epidemiological analyses show that the number of reports received by accident insurance companies and employers' liability insurance associations is significantly lower than expected. Finally, the economic and administrative effort in surveying apatient's occupational history hinders adequate reporting. By routinely and systematically using astructured questionnaire as part of clinical routine in our hospital, asignificantly improved detection of justified suspected cases (from about 4.8% to about 67% of the theoretically expected value) has been achieved since about 2006. In addition to improved medical care and adequate compensation for recognition as an occupational disease, disease-related care is subject to extra-budgetary remuneration in Germany (UV-GOÄ).

Gewalt gegen Pflegende in Notaufnahmen. Eine explorative Analyse zu Stressbelastung, Coping und Persönlichkeit

Violence against nurses in emergency departments. An explorative analysis of stress, coping strategies and personality Objectives: The aim of this work is to determine the prevalence and type of violence, feelings of stress, stress symptomatology, coping strategies and personality traits and to examine correlations between these variables. Methods: The nationwide survey targeted nurses in accordance with the German Nursing Professions Act who worked in the emergency department. Hospitals with emergency departments were contacted via an electronic cover letter (N = 1479). The online questionnaire included items on the prevalence of verbal, physical and sexual violence, reporting behaviour, perception of stress, stress symptomatology, coping strategies, personality traits and socio-demographic information. Hypotheses were tested with regression analyses. In addition, guided expert interviews were conducted (mixed methods). Results: 250 nurses participated in the survey. Violence against nurses in the emergency department workplace is common, places great stress on most victims and correlates significantly with stress. The central coping strategies of positive thinking, active stress management and social support are above average, but have no influence on the stress symptoms, because affected persons do not talk about experienced violence due to fear, shame and feelings of guilt. Risk factors for experiencing violence are little work experience, victim behaviour and female gender. No correlation was found between personality and experienced violence. Conclusion: Organisations and managers should take more responsibility for this issue, comply with regulations of the Occupational Safety and Health Act and introduce measures for prevention and aftercare in a targeted manner based on a risk assessment involving employees. Patient assaults should be reported to the employers' liability insurance association as an occupational accident. Even if there are no injuries, patient assaults should always be documented confidentially within the company. Employees should be made more aware that violence is not part of their job, reject the role of victim, not be afraid to report assaults and seek help. Keywords: workplace violence – emergency department – coping strategies – personality – health consequences

Assessment of patellar dislocations in childhood and adolescence : Accident-related or predisposition-related?

Numerous predisposing factors are known for patellar dislocations but the extent to which these or the trauma cause the dislocation is often unclear. This study investigated whether the analysis of the accident mechanism and anatomical predisposition in juvenile patellar dislocations enables a conclusion as to the causality. Retrospective cohort study, evidence levelIII. In-house employers' liability insurance association (BG) cases with the diagnosis of patella dislocation in patients under 18years were descriptively evaluated with respect to demographic and predisposing aspects as well as regarding accident information. The accident mechanisms were sorted into subgroups: direct impact, trivial trauma, fall, torsional trauma. A total of 54 patellar dislocations were identified with apatient age of 14 years (range 9-18 years). Amild valgus configuration was found in 39% of the cases, on average normal torsion, a tibial tuberosity-trochlea groove (TTTG) distance of 17 mm (range 8-24mm), with 41% ahigh proportion of patella alta and atrochlear deformity in 57%. Only 20% of the children had no relevant predispositions. The trivial traumas showed the highest proportion of recurrent dislocations with 50% and in the other accident categories the proportion of first dislocations was >75%. In the fall cohort the rate of children without relevant predisposition was highest. The predisposition rate in infantile patellar dislocations is high; however, falls are always significant accident events as well as medial direct impact. Torsional trauma is also a significant causative factor, unless high-grade trochlear dysplasia is present, whereas trivial traumas are not.

Injuries after Forklift Trucks Accidents - Injury Patterns, Therapy and Outcome in the Context of the Statutory Accident Insurance.

The use of forklift trucks during work has a high accident potential. The aim of this study is to describe injury patterns, treatment and outcome after forklift truck accidents in the context of the employers' liability insurance association. Retrospective data collection of all cases between 2004 and 2019. Excluded were patients < 18 years, without follow-up or with definitive external treatment. Trauma mechanism, injury patterns and distribution, treatment, complications, time of incapacity for work, return to work and impairment of earning capacity were recorded. Of 109 patients with 110 injuries, 52.7% showed isolated injuries and 47.3% combined injuries, which affected the lower extremity in 95 cases. There were fractures in 85.5%, including 32.7% in open form. The mean length of stay was 29.1 days (range 1 - 129); an indication for surgery was seen in 80.9%. Surgical treatment required an average of 3 interventions, with significantly more operations for soft tissue closure than for the fractures (p ≤ 0.023). Amputations were necessary in 8 cases; complications occurred in 29.1%. Return to work was possible in 90%, after a mean period of incapacity for work of 33.6 weeks. A total of 40% showed a pensionable impairment of earning capacity. Accidents with forklift trucks result in complex lower extremities injuries with the need of multi-stage treatment and show relatively high complication rates. A return to work is often possible after a long period of convalescence, and a pensionable impairment of earning capacity often persists.

Video Consultation Hours in the Statutory Accident Insurance - Application Possibilities and Economic Evaluation

Video consultations are becoming more and more important for health care providers as they enable new treatment options. Since 2017 video consultations have been used by the public health insurance companies in Germany. However, similar options are lacking in the employer's liability insurance association (BG in Germany) health insurance system. The aim of this article is to present and discuss possible applications of video consultations in the latter system and to evaluate economic advantages. Possible applications of video consultations are discussed in the context of feasibility, potential benefits and the existing scale of fees for physicians (in Germany UV-GOÄ). Video consultations can be used for follow-up evaluations as well as preparation for initial medical examinations especially in complex cases and for case conferences. Even though video consultations are not included in the reimbursement system, similar CPT codes (current procedural terminology) already do exist. Video consultations might help improve the quality and reduce the costs of the public health insurance system. Furthermore, since video consultations can be expected to become more important in the future, they should be included as a standard tool in the employer's liability insurance association insurance system and an adequate reimbursement system be established.

Diagnosis of epilepsy – consequences for work and professional activities

Summary Introduction. The correct diagnosis of epileptic seizures and non-epileptic attacks has a decisive influence on treatment, counseling and duration of possible work limitations. Diagnostic efforts should aim towards classifying the seizure as precisely as possible. For risk assessments, e.g. at the workplace, a close cooperation and networking of all professionals involved in the epilepsy treatment, care and consultation processes is required. Aim. To present guidelines for assessment of occupational capacity of persons with epilepsy and to discuss their value in clinical practice. Method and Material. The German employer’s liability insurance association has recently published the new revised BGI 585 Risk Assessment Guidelines (DGUV information 250-001) framework and assistance in epilepsy in view of protection against unfair dismissal. These guidelines provide information on safety and health in the workplace. Throughout all the German federal states, 24 Network teams were established. During the period January 2010 and December 2013, 374 employees with epilepsy were consulted by an expert member of Network Epilepsy and Work (NEA) Team, of which 80 were prospectively included in a study and scientifically evaluated. Guidelines and discussion. While conducting the risk assessment, a special medical fact check in accordance with the guidelines was used. In addition to medical aspects, the individual vocational and occupational situation was considered. Based on this assessment an individual recommendation was made relating to continuation of employment. The project NEA established regional teams of physicians, therapists, consultants from social services, employment offices and rehabilitation authorities across Germany in order to link by networks the complex medical and social aspects of reducing the risk of people with epilepsy losing their job. Results. It was shown that support and consultation through the NEA team led to an endangered position of employment being maintained in 70% of cases. Conclusion. In many cases, loss of employment can be prevented by consequent application of DGUV information 250-001 (recently revised from BGI 585) for risk assessment of epilepsy in employment, together with improved networking between medical professionals, occupational health professionals and social services.

Tertiary individual prevention improves mental health in patients with severe occupational hand eczema.

Occupational hand eczema (OHE) is associated with impaired health-related quality of life (QoL) and mental distress. Interdisciplinary inpatient rehabilitation measures in the framework of tertiary individual prevention (TIP) offered by the German employers' liability insurance associations include dermatological treatment, education and psychological interventions. To investigate the effects of interdisciplinary inpatient rehabilitation in the framework of TIP on mental health in patients with severe OHE and the relationships between recovery of OHE and improvement of mental health and QoL. A total of 122 patients participated in the study. A test battery consisting of the German versions of the Hospital Anxiety and Depression Scale (HADS-D), the Dermatology Life Quality Index (DLQI), the Short Form Health Survey-36 (SF-36) and the Trier Inventory for the Assessment of Chronic Stress (TICS) was applied at the time of admission (T1) and 3 weeks after dismissal (T2). Severity of hand eczema was assessed with the Osnabrueck Hand Eczema Severity Index (OHSI). All parameters improved significantly from T1 to T2. A relationship was established between the improvement of QoL and recovery of OHE, while there was no such relationship between the improvement of mental distress and improvement of OHE. Nonresponders had significantly more cumulative days of sickness at T1. Our data underscore the importance of psychological interventions in addition to dermatological treatment in the framework of prevention measures for OHE. These measures should be applied at an early stage of OHE prior to the occurrence of sick leave.

Zytopathologische Ergussdiagnostik in der berufsgenossenschaftlichen Begutachtung von Asbest-assoziierten malignen Mesotheliomen und Lungenkarzinomen

Pleural effusion often represents the first clinical symptom of lung carcinoma and malignant mesothelioma. As pleural punctation is performed quite early in the diagnostic procedure, effusion cytology frequently gives the first evidence about the presence of tumour cells and tumor histogenesis. In this study, we report on seven cases which were evaluated in our institution for the Employers' Liability Insurance Association, based solely on cytology findings.The mean age of the seven patients with a given long-term asbestos exposure during their working life was 81.7 years. On average eight smears per patient were investigated. In addition to routine cytology, immunocytochemistry, DNA image cytometry, AgNOR-analysis and fluorescence in situ hybridization were applied in a case-specific way. The results were interpreted against the clinical and occupational history of the respective patient.Definitive diagnosis could be made in six cases. In three of them, the diagnosis of malignant mesothelioma was made. Two cases were diagnosed as malignant effusion due to metastatic lung cancer. In one case, cells of high-grade Non-Hodgkin's lymphoma (NHL) were diagnosed and a malignant mesothelioma was excluded. In the last case, malignant mesothelioma could not be diagnosed unequivocally by cytology. In all seven cases, our interpretation was accepted by Employers' Liability Insurance Association. The five mesothelioma or lung cancer cases were accepted as asbestos-associated occupational disease, while the NHL case was rejected. In the last case, malignant mesothelioma was diagnosed later by autopsy, and the case was retroactively accepted as occupational disease.Cytology-based tumor diagnosis including adjuvant methods is a useful and reliable approach in cases of asbestos-associated tumours. Acceptance of occupational disease on the basis of cytological diagnoses even by the Employers' Liability Insurance Association helps avoid invasive pleural or lung biopsies in cases with an unequivocally positive effusion cytology of lung cancer or malignant mesothelioma.

Traumatische Ruptur eines Hydrogel-Brustimplantates: Ein Fall für die Berufsgenossenschaft?

Today textured breast implants for augmentation and reconstruction are commonly used to reduce the incidence of capsular contractures. Despite modified surfaces, capsular contracture may occur as result of traumatic or iatrogenic ruptures of the implant along with discharge of filling material.We report the interesting case of a female patient with traumatic rupture of one prosthesis in an industrial accident 14 years after implantation of hydrogel-filled breast prostheses. As it was a work related accident, the Employer's Liability Insurance Association is responsible for covering the treatment. The patient history and the histological exam have proven that the accident was work related.

360 Dose-response relationship between a particular form of cryptocrystalline silica and the incidence of silicosis

ObjectivesIt has been known for centuries that crystalline silica induces silicosis. However, there are different entities of crystalline silica. Siliceous earth is a worldwide unique blend of amorphous and cryptocrystalline...

Notwendige Veränderungen des berufsgenossenschaftlichen Heilverfahrens

The present article discusses the planned adjustments to medical treatment offered by the statutory accident insurance from the perspective of authorised medical examiners as well as the German association of physicians active for the employer’s liability insurance association.

Änderungen der stationären Versorgung

Against the background of the altered health care framework and its new challenges, the German Statutory Accident Insurance (DGUV) has initiated a review of its approach to in- and outpatient treatment. The ultimate goal of this review is a strengthening of quality- and demand-oriented structures, while maintaining the principles proven in the past. To achieve this aim, a draft paper outlining the main points is to be approved and stepwise implemented. The most relevant points, such as establishing treatment structures tailored to meet health care needs, adapting the process by which patients are treated according to type of injury, the possibilities for trauma networks as well as hospitals which fall under the auspices of the German Employers’ Liability Insurance Association, establishing quality assurance systems and developing rehabilitation management are all discussed in the present article.

N-Acetyltransferase-2 and Medical History in Bladder Cancer Cases with a Suspected Occupational Disease (BK 1301) in Germany

In 187 bladder cancer cases reported to the employers' liability insurance association in Germany as suspected cases of an occupational disease produced by aromatic amines, N‐ acetyltransferase-2 (NAT2) activity status, occupational exposure data, period of latency, and clinical parameters were determined. In 83 out of 187 cases surveyed within the period 1991–1999, the NAT2 acetylator status was investigated by determining the molar ratio of an acetylated and a nonacetylated caffeine metabolite in urine (phenotyping) and/or by NAT2 genotyping according to standard polymerase chain reaction (PCR) protocol. The proportion of slow NAT2 acetylators in the surveyed 83 bladder cancer cases was 67%. In the entire group of surveyed 187 cases, mean duration of exposure was 17.6 yr and mean period of latency was 34.7 yr. Occupational exposures to potential bladder carcinogens were observed in 73 occupations, including chemical industry (25%), and occupations as a painter and/or varnisher (23%) were most often encountered. In 12% of the surveyed bladder cancer cases, a second primary malignancy was observed. The NAT2 distribution observed in the 83 cases is comparable to the proportion in 40 occupationally exposed bladder cancer cases in a Department of Urology located close to a former German production site of benzidine-based azo dyes, but higher than in most studies involving NAT2 genetic status in bladder cancer cases.

BG-Aktuell

Plans have been made for basic legal innovations concerning the organization of statutory accident insurance and the right to social benefits. The general framework was established in the 2006 benchmark paper but it has not yet been implemented by the government. The employer’s liability insurance associations have, however, already effected broad changes. Fusions were initiated and completed. The ultimate target is to form nine associations instead of the six prescribed in the benchmark paper. Policy-making authorities have agreed to this goal and incorporated the number nine into the current draft for the law reforming accident insurance. The political demand that a joint umbrella organization be formed was also quickly met by the accident insurance providers. It is not yet clear whether policy-makers will adhere to the stipulation that the head organization be nationalized, which had not been planned by accident insurance providers. With respect to financing, the associations have suggested a fundamental reorganization, which diverges from the benchmark paper. This was accepted and is part of the current law draft. In contrast, the task of reforming the right to benefits and achieving social consensus appears to be considerably more difficult. Plans formulated up to now in this regard are presented.

Latexerkrankungen

This article presents the development of glove purchasing in all acute hospitals insured by the employers’ liability insurance association for the health service and promotion of wellbeing (BGW) since the duty of substitution was introduced and since suspicion of occupational illnesses caused by allergies to natural latex became notifiable. A significant positive correlation was statistically documented between the use of powdered natural latex gloves and the number of cases in which an occupational illness attributable to natural latex allergy was notified. The results show that prevention by means of substitution of unpowdered gloves low in natural latex for powdered gloves with a high allergen content is of decisive importance. This simple countermeasure is easy to implement, and when it is consistently applied it significantly reduces the development of occupational allergies to natural latex and makes it possible for even sensitised members of staff to stay in their workplace.

Neuer Facharzt für das Durchgangsarzt- und Verletzungsartenverfahren

The requirements that currently have to be met to allow involvement in emergency and injury typing procedures are introduced, and the reasons that have led to them are explained. As always, a special qualification is still needed before a doctor can take part in emergency procedures, as the emergency call-out doctors bear a decisive share of the responsibility for implementation of the statutory tasks of prompt and appropriate specific traumatological rehabilitation that devolve on the statutory accident insurance scheme. In contrast to the doctors accepted as qualified to apply treatments approved by the employers’ liability insurance associations, the emergency doctors decide on the kind of treatment to be initiated. The hospitals in which the injury typing procedure is applied are also required to fulfil specific requirements concerning patient accommodation and staff. The insurance associations pay particular attention to the currently variable management of how the medical councils of the länder redefine the emphasis of trauma surgery used hitherto fit the supplementary designation of special trauma surgery, so as to be able to step in promptly in the event of any problems.

Strategien zur Eingrenzung multiresistenter Erreger im Krankenhaus

The increasingly wide use of antibiotics is responsible for the increasingly frequent development of resistant microorganisms. In trauma and orthopaedic departments the vast majority of postoperative wound infections are caused by Staphylococcus aureus, which means the development and dissemination of methicillin-resistant Staphylococcus aureus (MRSA) is extremely significant. In the treatment of MRSA infections its insensitivity to a large number of conventional antibiotics and the restricted treatment options are importan factors. Extreme significance therefore attaches to prevention of its transmission, and thus to basic hygiene measures. Setting up isolation wards could be one option for this purpose. The isolation ward in the employers’ liability insurance association’s trauma clinic in Murnau is used as an example to show how a ward of this kind should be designed, what treatment and hygiene methods are required and how the quality of care can be guaranteed. The isolation of potentially infectious patients has led to a reduction in the number of MRSA infections, while at the same time understanding of the problems surrounding MRSA and awareness about the basic hygiene measures have improved.

Berufliche Krebserkrankungen im HNO-Fachgebiet

Substances such as cement dust, polycyclic aromatic carbonhydrates (PAC), diesel exhaust and lubricatant cooling may contribute to the formation of cancer, but are not yet recognized as to be causing occupational cancer. By decree, these diseases can be recognized for compensation when there is enough new evidence for causality. The knowledge about these conditions is crucial for judgement. The technical supervisory board of the Employer's Liability Insurance Association should be asked to report information about the working place concentration of the accused substances before a decision can be made, because life-style factors (alcohol, smoking, nutrition) may contribute also.

Some Economic Benefits of REACH

Forty years ago, Rachel Carson (1962) wrote in Silent Spring: ‘If we are going to live so intimately with these chemicals—eating and drinking them, taking them into the very marrow of our bones—we had better know something about their nature and their power.’ She could surely not have imagined that her observation: ‘The full scope of the dangerous interaction of chemicals is as yet little known . . .’ would still be so accurate in the third millennium. In 2003 the European Commission published a draft regulation known as REACH (Registration, Evaluation, Administration of Chemicals). This will amend or replace most of the existing European Union (EU) legislation on supply of chemicals, introducing a common approach for existing substances and for substances new to the market, and shifting much of the responsibility for evaluation of hazard from the member states to industry (Musu, 2005). The traditional core area of interest of the occupational hygienist concerned with chemicals is their use in the workplace, andmost legislation on this is not affected. Nevertheless, REACH is likely to have a big effect on the hygienist’s work, and a recent workshop organized jointly by BOHS and the Belgian Society for Occupational Hygiene considered this. The EU Council and Parliament may agree to the new legislation in 2006, and it may then come into force in 2007. Various studies have tried to estimate the negative and positive effects of the draft regulation. The European Commission Extended Impact Assessment estimated the costs to be between d2.8 and d5.2 billion (European Commission, 2003). The health benefits were estimated to be worth between d27 and d54 billion over a 30 year period (RPA, 2003). By these estimates, therefore, the benefits dwarf the costs. However, more than 99% of the calculated benefits were owing to avoided cancer deaths. The modest health benefits estimated for non-cancer diseases seem to be flawed, as the estimated costs are a small fraction of actual costs borne by insurers for these occupational diseases. Figures available for Germany on occupational skin diseases and on occupational asthma show a total expenditure of approximately d240 million in 2001. In contrast, the figures employed in the RPA study for Germany, for the same year and for the same two disease categories, estimated costs to be only about one-hundredth of this figure, about d2.5 million. We can estimate the true costs from the occupational diseases documentation compiled by the industrial employers’ liability insurance associations in Germany, the Gewerbliche Berufsgenossenschaften (BGs). This documentation forms an acceptable basis for an appropriate assessment of the costs of chemical-related occupational diseases, which occur, above all, when lack of knowledge of substance properties prevents adequate protection or when the knowledge exists but the information passed on by manufacturers or users is inadequate. In the following, the basis of the occupational diseases documentation will be explained. Using this, the potential effects of REACH are estimated for occupational skin diseases and occupational asthma, utilizing the same approach as employed in the RPA study (RPA, 2003). Details of the cost estimates are given in supplementary information in the on-line edition of this issue (Ruhl and Wriedt, 2006).

Some Economic Benefits of REACH

Forty years ago, Rachel Carson (1962) wrote in Silent Spring: ‘If we are going to live so intimately with these chemicals—eating and drinking them, taking them into the very marrow of our bones—we had better know something about their nature and their power.’ She could surely not have imagined that her observation: ‘The full scope of the dangerous interaction of chemicals is as yet little known . . .’ would still be so accurate in the third millennium. In 2003 the European Commission published a draft regulation known as REACH (Registration, Evaluation, Administration of Chemicals). This will amend or replace most of the existing European Union (EU) legislation on supply of chemicals, introducing a common approach for existing substances and for substances new to the market, and shifting much of the responsibility for evaluation of hazard from the member states to industry (Musu, 2005). The traditional core area of interest of the occupational hygienist concerned with chemicals is their use in the workplace, andmost legislation on this is not affected. Nevertheless, REACH is likely to have a big effect on the hygienist’s work, and a recent workshop organized jointly by BOHS and the Belgian Society for Occupational Hygiene considered this. The EU Council and Parliament may agree to the new legislation in 2006, and it may then come into force in 2007. Various studies have tried to estimate the negative and positive effects of the draft regulation. The European Commission Extended Impact Assessment estimated the costs to be between d2.8 and d5.2 billion (European Commission, 2003). The health benefits were estimated to be worth between d27 and d54 billion over a 30 year period (RPA, 2003). By these estimates, therefore, the benefits dwarf the costs. However, more than 99% of the calculated benefits were owing to avoided cancer deaths. The modest health benefits estimated for non-cancer diseases seem to be flawed, as the estimated costs are a small fraction of actual costs borne by insurers for these occupational diseases. Figures available for Germany on occupational skin diseases and on occupational asthma show a total expenditure of approximately d240 million in 2001. In contrast, the figures employed in the RPA study for Germany, for the same year and for the same two disease categories, estimated costs to be only about one-hundredth of this figure, about d2.5 million. We can estimate the true costs from the occupational diseases documentation compiled by the industrial employers’ liability insurance associations in Germany, the Gewerbliche Berufsgenossenschaften (BGs). This documentation forms an acceptable basis for an appropriate assessment of the costs of chemical-related occupational diseases, which occur, above all, when lack of knowledge of substance properties prevents adequate protection or when the knowledge exists but the information passed on by manufacturers or users is inadequate. In the following, the basis of the occupational diseases documentation will be explained. Using this, the potential effects of REACH are estimated for occupational skin diseases and occupational asthma, utilizing the same approach as employed in the RPA study (RPA, 2003). Details of the cost estimates are given in supplementary information in the on-line edition of this issue (Ruhl and Wriedt, 2006).