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1.  General practitioners in German metropolitan areas – distribution patterns and their relationship with area level measures of the socioeconomic status 
Background
Geographical variation of the general practitioner (GP) workforce is known between rural and urban areas. However, data about the variation between and within urban areas are lacking.
Method
We analyzed distribution patterns of GP full time equivalents (FTE) in German cities with a population size of more than 500,000. We correlated their distribution with area measures of social deprivation in order to analyze preferences within neighborhood characteristics. For this purpose, we developed two area measures of deprivation: Geodemographic Index (GDI) and Cultureeconomic Index (CEI).
Results
In total n = 9034.75 FTE were included in n = 14 cities with n = 171 districts. FTE were distributed equally on inter-city level (mean: 6.49; range: 5.12–7.20; SD: 0.51). However, on intra-city level, GP distribution was skewed (mean: 6.54; range: 1.80–43.98; SD: 3.62). Distribution patterns of FTE per 10^4 residents were significantly correlated with GDI (r = −0.49; p < 0.001) and CEI (r = −0.22; p = 0.005). Therefore, location choices of GPs were mainly positively correlated with 1) central location (r = −0.50; p < 0.001), 2) small household size of population (r = −0.50; p < 0.001) and 3) population density (r = 0.35; p < 0.001).
Conclusion
Intra-city distribution of GPs was skewed, which could affect the equality of access for the urban population. Furthermore, health services planners should be aware of GP location preferences. This could be helpful to better understand and plan delivery of health services. Within this process the presented Geodemographic Index (GDI) could be of use.
doi:10.1186/s12913-016-1921-5
PMCID: PMC5123403  PMID: 27884186
Primary care; Access; Distribution; Urban; Socioeconomic status
2.  High particulate matter emission from additive-free Natural American Spirit cigarettes 
SpringerPlus  2016;5(1):1958.
Background
Involuntary exposure to health-threatening environmental tobacco smoke (Combined Mainstream and Side-stream Smoke, CMSS) is a worldwide problem, causing premature death of thousands of people. CMSS consists of particulate matter (PM), one of the main sources of indoor air pollution. PM constitutes a considerable health risk for passive smokers. It is important to inform the public about brand-specific differences in CMSS-associated PM, especially in the case of brands without additives, which are therefore promoted as natural and less health-threatening.
Methods
Mean concentrations and the area under the curve of PM10, PM2.5 and PM1 generated by Natural American Spirit cigarettes without additives and the 3R4F standard research cigarette (University of Kentucky, USA) were measured, analyzed and compared with each other. An automatic environmental tobacco smoke emitter was used to smoke 100 cigarettes, 20 of each brand, according to a standardized smoking protocol.
Results
This study could show that CMSS-associated PM released from tobacco brands without additives, which are therefore promoted as natural and less harmful, are higher than expected
Conclusions
It is highly improbable that Natural American Spirit tobacco products are a less harmful choice—at least not for passive smokers as this study could show. We conclude, the CMSS-associated PM level of every single customized brand should be measured because the origin of the tobacco and not the amount of CO, tar and nicotine (given as product information) seem to be responsible for the brand-specific PM release. This data is urgently needed to adequately inform the public about CMSS-associated PM exposure and the related health risk especially for passive smokers.
doi:10.1186/s40064-016-3635-x
PMCID: PMC5106410  PMID: 27933238
Particulate matter; Indoor air pollution; Cigarettes
3.  Snakebite Envenoming – A Combined Density Equalizing Mapping and Scientometric Analysis of the Publication History 
PLoS Neglected Tropical Diseases  2016;10(11):e0005046.
Estimates suggest that more than 25,000 to 125,000 people die annually from snakebite envenomation worldwide. In contrast to this major disease burden, thorough bibliometric studies do not exist so far that illustrate the overall research activity over a long time span. Therefore, the NewQIS-platform conducted an analysis on snakebite envenoming using the Thomson Reuters database Web of Science. To determine and assess changes regarding the scientific activities and to specifically address the more recent situation we analyzed two time intervals (t). During the first time interval from 1900 to 2007 (t1) 13,015 publications (p) were identified. In the following period (2008–2016 = t2) 4,982 publications were identified by the same search strategy. They originate from 114 (t1) respectively 121 countries (t2), with the USA (p = 3518), Brazil (p = 1100) and Japan (p = 961) being most productive in the first period, and the USA (p = 1087), Brazil (p = 991) and China (p = 378) in the second period, respectively. Setting the publication numbers in relation to GDP/capita, Brazil leads with 92 publications per 10,000 Int$GDP/capita, followed by India with 79 publications per 10000 Int$GDP/capita (t1). Comparing the country’s publication activity with the Human Development Index level indicates that the majority of the publications is published by highly developed countries. When calculating the average citation rates (citations per published item = CR) mainly European countries show the highest ranks: From 1900–2007 Sweden ranks first with a CR = 27, followed by the Netherlands (CR = 24.8), Switzerland (CR = 23), Spain, Austria and the USA (CR = 22). From 2008 to 2016 the highest rate achieves Switzerland with a value of 24.6, followed by Belgium (CR = 18.1), Spain (CR = 16.7), Costa Rica (CR = 14.9) and Netherlands (CR = 14). Compared with this, the USA was placed at rank 13 (CR = 9,5).
In summary, the present study represents the first density-equalizing map projection and in-depth scientometric analysis of the global research output on snakebites and its venoms. So it draws a sketch of the worldwide publication architecture and indicates that countries with a high incidence of snakebites and a low economical level still need to be empowered in carrying out research in this area.
Author Summary
Snakebite injury is a neglected tropical disease and lead to an enormous burden of disease in many parts of the world with about 25,000–125,000 estimated deaths. Therefore, research on this area of medicine is crucial since new diagnostic and therapeutic pathways may help to diminish disease burden. This study provides the first detailed landscape of the global snakebite research, which can be used by funding agencies and politicians to plan new programs. From 1900 to 2007 we found over 13,000 publications related to snakebites originating from over 110 countries, with the USA, Brazil and Japan being most active. The second period from 2008 until 2016 was characterized by 4,982 publications out of 121 countries. Here, the rank order was USA, Brazil and China. When efforts are analyzed from a socioeconomic perspective applying the GDP per Capita, Brazil and India take a lead position. The Human Development Index indicates that the vast majority of research is performed by highly developed countries. Closer investigations demonstrated that a large part of the research deals with scientific studies that used venom ingredients to unravel basic mechanisms of human physiology or to develop new pharmaceutical compounds. In summary, we here draw the first sketch of the overall global research architecture concerning snakebite envenoming. We found that countries with a high incidence of snakebites and a low economical level need to be empowered to carry out research in this area.
doi:10.1371/journal.pntd.0005046
PMCID: PMC5098783  PMID: 27820835
4.  Photoaging smartphone app promoting poster campaign to reduce smoking prevalence in secondary schools: the Smokerface Randomized Trial: design and baseline characteristics 
BMJ Open  2016;6(11):e014288.
Introduction
Smoking is the largest cause of preventable death globally. Most smokers smoke their first cigarette in early adolescence. We took advantage of the widespread availability of mobile phones and adolescents’ interest in appearance to develop a free photoaging app which is promoted via a poster campaign in secondary schools. This study aims to evaluate its effectiveness regarding smoking prevalence and students’ attitudes towards smoking.
Methods and analysis
A randomised controlled trial is conducted with 9851 students of both genders with an average age of 12 years in grades 6 and 7 of 126 secondary schools in Germany. At present, cigarette smoking prevalence in our sample is 4.7%, with 4.6% of the students currently using e-cigarettes (1.6% use both). The prospective experimental study design includes measurements at baseline and at 6, 12 and 24 months postintervention via a questionnaire plus a random cotinine saliva sample at 24 months postintervention. The study groups consist of randomised schools receiving the Smokerface poster campaign and control schools with comparable baseline data (no intervention). The primary end point is the difference of change in smoking prevalence in the intervention group versus the difference in the control group at 24 months follow-up. Longitudinal changes in smoking-related attitudes, the number of new smokers and quitters and the change in the number of never-smokers will be compared between the two groups as secondary outcomes.
Ethics and dissemination
Ethical approval was obtained from the ethics committee of the University of Gießen and the ministries of cultural affairs, both in Germany. Results will be disseminated at conferences, in peer-reviewed journals, on our websites and throughout the multinational Education Against Tobacco network.
Trial registration number
NCT02544360, Pre-results.
doi:10.1136/bmjopen-2016-014288
PMCID: PMC5128772  PMID: 27821601
Smokerface; tobacco prevention; mobile apps; schools; photoaging
5.  Kinematic analysis of work-related musculoskeletal loading of trunk among dentists in Germany 
Background
In Germany, about 86.7 % of the dentists have stated to suffer from pain in the neck and shoulder region. These findings are predominantly based on surveys. Therefore the objective of this study is to conduct a kinematic analysis of occupational posture in dentistry.
Methods
Twenty one dentists (11 f/10 m; age: 40.1 ± 10.4 years) have participated in this examination. The CUELA-System was used to collect kinematic data of the activities on an average dental workday. A detailed, computer-based task analysis took place parallel to the kinematic examination. Through the synchronization of data collected from both measurements, patterns of posture were arranged chronologically and in conjunction with the tasks performed: (I) “treatment” (II) “office” and (III) “other activities”. For the data analysis, characteristic data of joint angular distributions (percentiles P05, P25, P50, P75 and P95) of head, neck and torso at pre-defined tasks were examined and assessed corresponding to ergonomic standards.
Results
Forty one percent of tasks executed on an average dental workday can be categorized as the treatment of patients. These tasked are most frequently performed in “straight back” positions (78.7 %), whereas 20.1 % were carried out in a “twisted or inclined” torso posture, 1.1 % “bowed” and only 0.1 % “bowed and twisted/inclined to the side” upper body position. In particular, it can be observed that in the area of the cervical and thoracic spine the 75th and 95th percentile show worse angular values during treatment than during non-dental tasks. For the period of treatment (at a standardized dental chair construction), a seated position with a strong inclination of the thoracic spine to the right while the lumbar spine is inclined towards the left is adopted.
Conclusion
The kinematic analysis of dentists illustrates typical patterns of postures during tasks that are essential to the dental treatment of patients. The postures in the area of the cervical and thoracic spine have higher angular values during treatment compared to other dental tasks. Consistently, appropriate ergonomic design measures to optimize the dental chair and equipment as well as integrated training in ergonomics as part of the study of dentistry to prevent musculoskeletal are recommended.
Electronic supplementary material
The online version of this article (doi:10.1186/s12891-016-1288-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12891-016-1288-0
PMCID: PMC5069924  PMID: 27756271
CUELA; Kinematic analysis; Dentist; Musculoskeletal disorder
6.  Imbalances in the German public health system - numbers of state-certified occupational physicians and relation to socioeconomic data 
Background
State-certified occupational physicians who work as civil servants in the Federal Republic of Germany are key players in the German Public Health system. They control i.e. the legal compliance in occupational health and participate in the occupational disease procedures. Despite the role model function of the German Public health system for many developing countries, this area of Public health is debated to have been hampered in the past years by a disregard concerning structural developments.
Methods
Different databases were screened for occupational health benchmarks. Obtained data were compared to socioeconomic data and indices were calculated.
Results
The overall numbers of State-certified occupational physicians decreased in Germany between 1992 and 2012 from 136 to 86 (63 %). On the single state level, the ratios of State-certified occupational physicians per 1 Mio. working population ranged from 8 for the state of Saarland to 0.8 for the state of North Rhine Westphalia. A general difference was found for old versus new German states. Also, large differences were present for the ratios of State-certified occupational physicians per 106 employees towards public debt per capita (€) and the ratios of State-certified occupational physicians per Gross Domestic Product (GDP) in the 16 German states in 2012.
Conclusions
In striking contrast to the WHO document on the Occupational safety and health (OSH) system that states in its executive summary that the human and institutional capacities of the German occupational health system are very strong in both quantity and quality, we here show extreme imbalances present at the single state levels that developed over the past 20 years. With a regard to the increasing complexity of the economic system a reversal of this trend should be demanded.
doi:10.1186/s12995-016-0136-3
PMCID: PMC5062824  PMID: 27752276
Public health administration; Occupational health
7.  Endometriosis and its global research architecture: an in-depth density-equalizing mapping analysis 
BMC Women's Health  2016;16:64.
Background
Endometriosis is one of the most common gynecological diseases. It is still a chameleon in many aspects and urges intense research activities in the fields of diagnosis, therapy and prevention. Despite the need to foster research in this area, no in-depth analysis of the global architecture of endometriosis research exists yet.
Methods
We here used the NewQIS platform to conduct a density equalizing mapping study, using the Web of Science as database with endometriosis related entries between 1900 and 2009. Density equalizing maps of global endometriosis research encompassing country-specific publication activities, and semi-qualitative indices such as country specific citations, citation rates, h-Indices were created.
Results
In total, 11,056 entries related to endometriosis were found. The USA was leading the field with 3705 publications followed by the United Kingdom (952) and Japan (846). Concerning overall citations and country-specific h-Indices, the USA again was the leading nation with 74,592 citations and a modified h-Index of 103, followed by the UK with 15,175 citations (h-Index 57). Regarding the citation rate, Sweden and Belgium were at top positions with rates of 22.46 and 22.26, respectively. Concerning collaborative studies, there was a steep increase in numbers present; analysis of the chronological evolution indicated a strong increase in international collaborations in the past 10 years.
Conclusions
This study is the first analysis that illustrates the global endometriosis research architecture. It shows that endometriosis research is constantly gaining importance but also underlines the need for further efforts and investments to foster research and ultimately improve endometriosis management on a global scale.
Electronic supplementary material
The online version of this article (doi:10.1186/s12905-016-0336-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12905-016-0336-0
PMCID: PMC5031306  PMID: 27653503
Endometriosis; Density equalizing; Mapping; Research architecture
8.  Gendermetrics.NET: a novel software for analyzing the gender representation in scientific authoring 
Background
Imbalances in female career promotion are believed to be strong in the field of academic science. A primary parameter to analyze gender inequalities is the gender authoring in scientific publications. Since the presently available data on gender distribution is largely limited to underpowered studies, we here develop a new approach to analyze authors’ genders in large bibliometric databases.
Results
A SQL-Server based multiuser software suite was developed that serves as an integrative tool for analyzing bibliometric data with a special emphasis on gender and topographical analysis. The presented system allows seamless integration, inspection, modification, evaluation and visualization of bibliometric data. By providing an adaptive and almost fully automatic integration and analysis process, the inter-individual variability of analysis is kept at a low level. Depending on the scientific question, the system enables the user to perform a scientometric analysis including its visualization within a short period of time.
Conclusion
In summary, a new software suite for analyzing gender representations in scientific articles was established. The system is suitable for the comparative analysis of scientific structures on the level of continents, countries, cities, city regions, institutions, research fields and journals.
doi:10.1186/s12995-016-0133-6
PMCID: PMC5024497  PMID: 27651823
Gender; Gender analysis; Scientometric analysis; Bibliometric analysis; Software tool; Science structure
9.  Particulate Matter in Second-Hand Smoke Emitted from Different Cigarette Sizes and Types of the Brand Vogue Mainly Smoked by Women 
Indoor air pollution with harmful particulate matter (PM) is mainly caused by cigarette smoke. Super-Slim-Size-Cigarettes (SSL) are considered a less harmful alternative to King-Size-Cigarettes (KSC) due to longer filters and relatively low contents. We ask if “Combined Mainstream and Sidestream Smoke” (CMSS)-associated PM levels of SSL are lower than of KSC and thus are potentially less harmful. PM concentrations in CMSS (PM10, PM2.5, and PM1) are measured from four cigarette types of the brand Vogue, using an “automatic-environmental-tobacco-smoke-emitter” (AETSE) and laser aerosol spectrometry: SSL-BLEUE, -MENTHE, -LILAS and KSC-La Cigarette and -3R4F reference. This analysis shows that SSL MENTHE emitted the highest amount of PM, and KSC-La Cigarette the lowest. 3R4F reference emitted PM in the middle range, exceeding SSL BLEUE and falling slightly below SSL LILAS. It emerged that PM1 constituted the biggest proportion of PM emission. The outcome shows significant type-specific differences for emitted PM concentrations. Our results indicate that SSL are potentially more harmful for passive smokers than the respective KSC. However, this study cannot give precise statements about the general influence of the size of a cigarette on PM. Alarming is that PM1 is responsible for the biggest proportion of PM pollution, since smaller particles cause more harmful effects.
doi:10.3390/ijerph13080799
PMCID: PMC4997485  PMID: 27509517
particulate matter; size of cigarettes; environmental tobacco smoke; menthol; automatic environmental tobacco smoke emitter
10.  Standard values of the upper body posture and postural control: a study protocol 
Background
Decisions on orthopedic interventions on upper body posture and its control have usually resulted from comparisons with the healthy state. Therefore, practitioners as well as scientists in human movement science or orthopedics need access to such kind of data which are patient-centered and well measured. Until now, these data have been missing concerning upper body posture as well as postural control and their control. That is why the aim of the current project is to measure these data with healthy participants across the lifespan.
Results
For standard value determination tolerance range and confidence intervals will be calculated. In addition, Pearson- or Spearman-Rank correlations will be used as well as two-sample-t-tests or Mann-Whitney-U-tests for specific group differences. All tests will be two-sided with the level of significance of 5 %.
Discussion
This project aims at improving classifications in adaptations of upper body posture and postural control. Measured standard values have not been determined before to this extent. Therefore, interventional effects may become better quantifiable and justiciable.
doi:10.1186/s12995-016-0122-9
PMCID: PMC4947251  PMID: 27429641
Study protocol; Upper body posture; Postural control; Standard value; Confidence interval
11.  Acetylsalicylic acid as a potential pediatric health hazard: legislative aspects concerning accidental intoxications in the European Union 
Acetylsalicylic acid is a frequently used medication worldwide. It is not used in pediatrics due its association with Reye syndrome. However, in case of pediatric intoxication, children are more fragile to salicylate poisoning because of their reduced ability of buffer the acid stress. Intoxication leads to a decoupling of oxidative phosphorylation and subsequently to a loss in mitochondrial function. Symptoms of poisoning are diverse; eventually they can lead to the death of the patient. Governmental websites of various EU countries were searched for legal information on acetylsalicylic acid availability in pharmacies and non-pharmacy stores. Various EU countries permit prescription-free sales of acetylsalicylic acid in pharmacies and non-pharmacy stores. In Sweden acetylsalicylic acid 500 mg may be sold in a maximum package size of 20 tablets or effervescent tablets in a non-pharmacy. In the UK a maximum of 16 tablets of acetylsalicylic acid 325 mg is allowed to sell in non-pharmacies. In Ireland acetylsalicylic acid is classified as S2 medication. Subsequently, acetylsalicylic acid is allowed to be sold prescription-free in pharmacies and non-pharmacy stores. In the Netherlands acetylsalicylic acid may only be sold in drug stores or pharmacies. A maximum of 24 tablets of 500 mg is allowed to purchase in a drug store. Several countries in the European Union are permitted to offer acetylsalicylic acid prescription-free in pharmacies and non-pharmacy stores without legal guidance on the storage position within the store. Further research is needed to investigate whether acetylsalicylic acid is located directly accessible to young children within the stores in EU countries which permit prescription-free sales of acetylsalicylic acid.
doi:10.1186/s12995-016-0118-5
PMCID: PMC4944482  PMID: 27418941
Acetylsalicylic acid; Analgesics; Poisoning; Intoxication; Child; Pediatrics; Legislation; European Union; Non-pharmacy
12.  Community Willingness to Participate in a Dengue Study in Aceh Province, Indonesia 
PLoS ONE  2016;11(7):e0159139.
Background
Dengue virus infection is the most rapidly spreading vector-borne disease in the world. Essential research on dengue virus transmission and its prevention requires community participation. Therefore, it is crucial to understand the factors that are associated with the willingness of communities in high prevalence areas to participate in dengue research. The aim of this study was to explore factors associated with the willingness of healthy community members in Aceh province, Indonesia, to participate in dengue research that would require phlebotomy.
Methodology/Principal Findings
A community-based cross-sectional study was carried out in nine regencies and municipalities of Aceh from November 2014 to March 2015. Interviews using a set of validated questionnaires were conducted to collect data on demography, history of dengue infection, socioeconomic status, and knowledge, attitude and practice regarding dengue fever. Two-step logistic regression and Spearman’s rank correlation (rs) analysis were used to assess the influence of independent variables on dependent variables. Among 535 participants, less than 20% had a good willingness to participate in the dengue study. The factors associated with good willingness to participate were being female, working as a civil servant, private employee or entrepreneur, having a high socioeconomic status and good knowledge, attitude and practice regarding dengue. Good knowledge and attitude regarding dengue were positive independent predictors of willingness to participate (OR: 2.30 [95% CI: 1.36–3.90] and 3.73 [95% CI: 2.24–6.21], respectively).
Conclusion/Significance
The willingness to participate in dengue research is very low among community members in Aceh, and the two most important associated factors are knowledge and attitude regarding dengue. To increase participation rate, efforts to improve the knowledge and attitude of community members regarding dengue fever and dengue-related research is required before such studies are launched.
doi:10.1371/journal.pone.0159139
PMCID: PMC4942142  PMID: 27404663
13.  Measuring Spatial Accessibility of Health Care Providers – Introduction of a Variable Distance Decay Function within the Floating Catchment Area (FCA) Method 
PLoS ONE  2016;11(7):e0159148.
We integrated recent improvements within the floating catchment area (FCA) method family into an integrated ‘iFCA`method. Within this method we focused on the distance decay function and its parameter. So far only distance decay functions with constant parameters have been applied. Therefore, we developed a variable distance decay function to be used within the FCA method. We were able to replace the impedance coefficient β by readily available distribution parameter (i.e. median and standard deviation (SD)) within a logistic based distance decay function. Hence, the function is shaped individually for every single population location by the median and SD of all population-to-provider distances within a global catchment size. Theoretical application of the variable distance decay function showed conceptually sound results. Furthermore, the existence of effective variable catchment sizes defined by the asymptotic approach to zero of the distance decay function was revealed, satisfying the need for variable catchment sizes. The application of the iFCA method within an urban case study in Berlin (Germany) confirmed the theoretical fit of the suggested method. In summary, we introduced for the first time, a variable distance decay function within an integrated FCA method. This function accounts for individual travel behaviors determined by the distribution of providers. Additionally, the function inherits effective variable catchment sizes and therefore obviates the need for determining variable catchment sizes separately.
doi:10.1371/journal.pone.0159148
PMCID: PMC4938577  PMID: 27391649
14.  Noise Exposure of Teachers in Nursery Schools—Evaluation of Measures for Noise Reduction When Dropping DUPLO Toy Bricks into Storage Cases by Sound Analyses 
Background: Although noise is one of the leading work-related health risk factors for teachers, many nursery schools lack sufficient noise reduction measures. Methods: This intervention study evaluated the noise exposure of nursery school teachers when dropping DUPLO toy bricks into storage cases. Sound analyses of the impact included assessment of the maximum sound pressure level (LAFmax) as well as frequency analyses with 1/3 octave band filter. For the purpose of standardization, a customized gadget was developed. Recordings were performed in 11 cases of different materials and designs to assess the impact on sound level reduction. Thereby, the acoustic effects of three damping materials (foam rubber, carpet, and PU-foam) were investigated. Results: The lowest LAFmax was measured in cases consisting of “metal grid” (90.71 dB) or of a woven willow “basket” (91.61 dB), whereas a case of “aluminium” (103.34 dB) generated the highest impact LAFmax. The frequency analyses determined especially low LAFmax in the frequency bands between 80 and 2500 Hz in cases designs “metal grid” and “basket”. The insertion of PU-foam achieved the most significant attenuation of LAFmax (−13.88 dB) and, in the frequency analyses, the best sound damping. Conclusion: The dropping of DUPLO bricks in cases contributes to the high noise level in nursery schools, but measured LAFmax show no evidence for the danger of acute hearing loss. However, continuous exposure may lead to functional impairment of the hair cells and trigger stress reactions. We recommend noise reduction by utilizing cases of woven “basket” with an insert of PU-foam.
doi:10.3390/ijerph13070677
PMCID: PMC4962218  PMID: 27384575
nursery schools; noise intervention measures; sound analyses; occupational health
15.  Physicians' occupational stress, depressive symptoms and work ability in relation to their working environment: a cross-sectional study of differences among medical residents with various specialties working in German hospitals 
BMJ Open  2016;6(6):e011369.
Objectives
This study aimed to analyse and compare differences in occupational stress, depressive symptoms, work ability and working environment among residents working in various medical specialties.
Methods
435 German hospital residents in medical training working in 6 different medical specialties participated in a cross-sectional survey study. Physicians were asked about their working conditions and aspects of mental health and work ability. The Copenhagen Psychosocial Questionnaire, the Work Ability Index, the ICD-10 Symptom Rating and the Perceived Stress Questionnaire were used to measure working conditions, mental health and work ability.
Results
Results show that up to 17% of the physicians reported high levels of occupational distress and 9% reported high levels of depressive symptoms. 11% of the hospital physicians scored low in work ability. Significant differences between medical specialties were demonstrated for occupational distress, depressive symptoms, work ability, job demands and job resources. Surgeons showed consistently the highest levels of perceived distress but also the highest levels of work ability and lowest scores for depression. Depressive symptoms were rated with the highest levels by anaesthesiologists. Significant associations between physicians’ working conditions, occupational distress and mental health-related aspects are illustrated.
Conclusions
Study results demonstrated significant differences in specific job stressors, demands and resources. Relevant relations between work factors and physicians' health and work ability are discussed. These findings should be reinvestigated in further studies, especially with a longitudinal study design. This work suggests that to ensure physicians' health, hospital management should plan and implement suitable mental health promotion strategies. In addition, operational efficiency through resource planning optimisation and work process improvements should be focused by hospital management.
doi:10.1136/bmjopen-2016-011369
PMCID: PMC4916614  PMID: 27311909
depression; work ability; working conditions; MENTAL HEALTH; occupational stress
16.  Global architecture of gestational diabetes research: density-equalizing mapping studies and gender analysis 
Nutrition Journal  2016;15:36.
Objective
Gestational diabetes mellitus (GDM) is associated with substantial morbidity for mothers and their offspring. While clinical and basic research activities on this important disease grow constantly, there is no concise analysis of global architecture of GDM research. Hence, it was the objective of this study to assess the global scientific performance chronologically, geographically and in relation to existing research networks and gender distribution of publishing authors.
Study design
On the basis of the New Quality and Quantity Indices in Science (NewQIS) platform, scientometric methods were combined with modern visualizing techniques such as density equalizing mapping, and the Web of Science database was used to assess GDM-related entries from 1900 to 2012.
Results
Twelve thousand five hundred four GDM-related publications were identified and analyzed. The USA (4295 publications) and the UK (1354 publications) dominated the field concerning research activity, overall citations and country-specific Hirsch-Index, which quantified the impact of a country’s published research on the scientific community. Semi-qualitative indices such as country-specific citation rates ranked New Zealand and the UK at top positions. Annual collaborative publications increased steeply between the years 1990 and 2012 (71 to 1157 respectively). Subject category analysis pointed to a minor interest of public health issues in GDM research. Gender analysis in terms of publication authorship revealed a clear dominance of the male gender until 2005; then a trend towards gender equity started and the activity of female scientists grew visibly in many countries. The country-specific gender analysis revealed large differences, i.e. female scientists dominated the scientific output in the USA, whereas the majority of research was published by male authors in countries such as Japan.
Conclusion
This study provides the first global sketch of GDM research architecture. While North-American and Western-European countries were dominating the GDM-related scientific landscape, a disparity exists in terms of research output between developed and low-resource countries. Since GDM is linked to considerable mortality and morbidity of mothers and their offspring and constitutes a tremendous burden for the healthcare systems in underserved countries, our findings emphasize the need to address disparities by fostering research endeavors, public health programs and collaborative efforts in these nations.
doi:10.1186/s12937-016-0154-0
PMCID: PMC4820855  PMID: 27044432
Gestational diabetes; Diabetes mellitus; Scientometrics; Density equalizing mapping; Gender
17.  Are Filter-Tipped Cigarettes Still Less Harmful than Non-Filter Cigarettes?—A Laser Spectrometric Particulate Matter Analysis from the Non-Smokers Point of View 
Background: Environmental tobacco smoke (ETS) is associated with human morbidity and mortality, particularly chronic obstructive pulmonary disease (COPD and lung cancer. Although direct DNA-damage is a leading pathomechanism in active smokers, passive smoking is enough to induce bronchial asthma, especially in children. Particulate matter (PM) demonstrably plays an important role in this ETS-associated human morbidity, constituting a surrogate parameter for ETS exposure. Methods: Using an Automatic Environmental Tobacco Smoke Emitter (AETSE) and an in-house developed, non-standard smoking regime, we tried to imitate the smoking process of human smokers to demonstrate the significance of passive smoking. Mean concentration (Cmean) and area under the curve (AUC) of particulate matter (PM2.5) emitted by 3R4F reference cigarettes and the popular filter-tipped and non-filter brand cigarettes “Roth-Händle” were measured and compared. The cigarettes were not conditioned prior to smoking. The measurements were tested for Gaussian distribution and significant differences. Results: Cmean PM2.5 of the 3R4F reference cigarette: 3911 µg/m3; of the filter-tipped Roth-Händle: 3831 µg/m3; and of the non-filter Roth-Händle: 2053 µg/m3. AUC PM2.5 of the 3R4F reference cigarette: 1,647,006 µg/m3·s; of the filter-tipped Roth-Händle: 1,608,000 µg/m3·s; and of the non-filter Roth-Händle: 858,891 µg/m3·s. Conclusion: The filter-tipped cigarettes (the 3R4F reference cigarette and filter-tipped Roth-Händle) emitted significantly more PM2.5 than the non-filter Roth-Händle. Considering the harmful potential of PM, our findings note that the filter-tipped cigarettes are not a less harmful alternative for passive smokers. Tobacco taxation should be reconsidered and non-smoking legislation enforced.
doi:10.3390/ijerph13040429
PMCID: PMC4847091  PMID: 27092519
particulate matter; cigarette smoke; tobacco taxation; Automatic Environmental Tobacco Smoke Emitter
18.  Design and methodology of the Geo-social Analysis of Physicians’ settlement (GAP-Study) in Germany 
Abstracts
Background
Unequally distributed disease burdens within populations are well-known and occur worldwide. They are depending on residents’ social status and/or ethnic background. Country-specific health care systems - especially the coverage and distribution of health care providers - are both a potential cause as well as an important solution for health inequalities.
Methods
Registers are built of all accredited physicians and psychotherapists within the outpatient care system in German metropolises by utilizing the database of the Associations of Statutory Health Insurance Physicians. The physicians’ practice neighborhood will be analyzed under socioeconomic and demographic perspectives. Therefore, official city districts’ statistics will be assigned to the physicians and psychotherapists according to their practice location. Averages of neighborhood indicators will be calculated for each specialty. Moreover, advanced studies will inspect differences by physicians’ gender or practice type. Geo-spatial analyses of the intra-city practices distribution will complete the settlement characteristics of physicians and psychotherapists within the outpatient care system in German metropolises.
Results
The project “Geo-social Analysis of Physicians’ settlement” (GAP) is designed to elucidate gaps of physician coverage within the outpatient care system, dependent on neighborhood residents’ social status or ethnics in German metropolises.
Conclusion
The methodology of the GAP-Study enables the standardized investigation of physicians’ settlement behavior in German metropolises and their inter-city comparisons. The identification of potential gaps within the physicians’ coverage should facilitate the delineation of approaches for solving health care inequality problems.
doi:10.1186/s12995-016-0104-y
PMCID: PMC4815067  PMID: 27034705
Health care system; Physician; Geospatial analyses; Socioeconomic status
19.  Physicians’ working conditions in hospitals from the students’ perspective (iCEPT-Study)—results of a web-based survey 
Background
Medical students undergo numerous clinical clerkships. On these occasions they are confronted with current working conditions in hospitals. Because of the many implications of the students’ perceptions of these working conditions, it is important to assess those. Hereby the focus was put on the students’ perception of their supervising physician.
Methods
This study is a part of a prospective anonymized web-based survey (iCEPT-Study). The study was conducted in Germany among medical students after their clinical rotations. 1587 medical students took part in this study (63,0 % female and 37,0 % male). 11259 were invited to take part (response rate of 14,1 %). In this study a questionnaire was used which was based on the Effort-Reward-Imbalance (ERI) model and the Job-Demand-Control (JDC) model. A mathematical calculated ratio (ER- and JDC-Ratio; combined as ‘ER/JDC-Ratio’) was used to measure the students’ perceptions of working conditions, namely distress (primary outcome). As a secondary outcome perceived job satisfaction was measured.
Results
Distress was perceived by 67.4 % (95 %-CI: 65.1|69.7) of the students. 54.1 % (95 %-CI: 51.7|56.6) of polled students stated that their supervising physician seemed to be very satisfied with his job. Analysis of age distribution revealed that the proportion of students’ who perceived their supervising physician as very satisfied with his job dropped from 72.5 % among under 20-year olds to 63.0 % among 20–24-year olds and was at 44.5 % among the over 30-year olds. Looking at the specialty, the specialty of surgery was rated with the highest distress prevalence (ER/JDC-Ratio > 1): 81.3 % of students stated that their supervising surgeon encountered unfavorable working conditions.
Conclusion
Two out of three medical students rated the physicians working conditions as stressful. This implicates that already in this early phase of their career the majority of medical students get to know the hospital as an unfavorable workplace concerning working conditions. To facilitate the transition from medical schools to hospitals working conditions of physicians must be improved.
doi:10.1186/s12995-016-0094-9
PMCID: PMC4759714  PMID: 26900392
Student; Physician; Hospital; Distress; Satisfaction
20.  Patient safety: the landscape of the global research output and gender distribution 
BMJ Open  2016;6(2):e008322.
Objectives
Patient safety is a crucial issue in medicine. Its main objective is to reduce the number of deaths and health damages that are caused by preventable medical errors. To achieve this, it needs better health systems that make mistakes less likely and their effects less detrimental without blaming health workers for failures. Until now, there is no in-depth scientometric analysis on this issue that encompasses the interval between 1963 and 2014. Therefore, the aim of this study is to sketch a landscape of the past global research output on patient safety including the gender distribution of the medical discipline of patient safety by interpreting scientometric parameters. Additionally, respective future trends are to be outlined.
Setting
The Core Collection of the scientific database Web of Science was searched for publications with the search term ‘Patient Safety’ as title word that was focused on the corresponding medical discipline. The resulting data set was analysed by using the methodology implemented by the platform NewQIS. To visualise the geographical landscape, state-of-the-art techniques including density-equalising map projections were applied.
Results
4079 articles on patient safety were identified in the period from 1900 to 2014. Most articles were published in North America, the UK and Australia. In regard to the overall number of publications, the USA is the leading country, while the output ratio to the population of Switzerland was found to exhibit the best performance. With regard to the ratio of the number of publications to the Gross Domestic Product (GDP) per Capita, the USA remains the leading nation but countries like India and China with a low GDP and high population numbers are also profiting.
Conclusions
Though the topic is a global matter, the scientific output on patient safety is centred mainly in industrialised countries.
doi:10.1136/bmjopen-2015-008322
PMCID: PMC4762108  PMID: 26873042
MEDICAL HISTORY
21.  Congenital toxoplasmosis: an in-depth density-equalizing mapping analysis to explore its global research architecture 
Parasites & Vectors  2015;8:646.
Background
Toxoplasmosis endangers the unborn child if its infectious agent - toxoplasma gondii - is transmitted transplacentally during pregnancy. Although this condition occurs in all parts of the world and represents a major public health burden, no detailed knowledge on the global research architecture of congenital toxoplasmosis is available thus far. Hence, it was the aim of this study to assess the related global research activity over the past 110 years.
Methods
We employed the NewQIS platform, which combines established scientometric and socioeconomic analysis tools with novel visualizing techniques such as density equalizing mapping projections.
Results
In the Web of Science, 13,044 congenital toxoplasmosis-related items published between 1900 and 2012 were identified. These were issued by 26,483 authors originating from 125 countries. The US was the dominating nation (38.7 % of total scientific output), followed by France (10.9 %) and Great Britain (9.2 %). The US also led the ranking in regards to semi-qualitative parameters (total citations, country-specific h-indices and citation rates). When research activity was related to economic figures, the ratio of total toxoplasmosis publications to the total GDP listed Switzerland first with an average of 589.35 toxoplasmosis-related publications per GDP in 1000 Bio US-$, followed by France (545.16), the UK (486.13) and Brazil (431.84) and the US (311.11). The relation of toxoplasmosis-specific publications to the economic power indicator GDP per capita in 1000 US-$ revealed that the US was ranked first with 97.65 toxoplasmosis-related publications/GDP per capita in 1000 US-$, followed by Brazil (85.95). Subject area analysis indicated a relative shortage of studies that addressed pharmacological or public health aspects of congenital toxoplasmosis.
Conclusions
This study is the first in-depth approach to sketch a global picture of the congenital toxoplasmosis research architecture. In contrast to other fields of biomedical research, not only high-income countries play a major role regarding congenital toxoplasmosis research but also countries such as Brazil that have a high incidence of congenital toxoplasmosis.
doi:10.1186/s13071-015-1263-x
PMCID: PMC4687351  PMID: 26691532
22.  Paracetamol as a toxic substance for children: aspects of legislation in selected countries 
Paracetamol is used widely in pediatrics because it has a high drug safety when used in therapeutic dosages. In case of overdose the majority of paracetamol is metabolized to N-acetyl-p-benzoquinone imine (NAPQI), which is responsible for the severe toxic effects. The covalent connection between NAPQI and hepatic proteins leads to hepatocellular damage and possibly to severe liver failure. The antidote for paracetamol is N-acetylcysteine (NAC). It is a precursor of glutathione and aids to fill glutathione stores. The Rumack-Matthew nomogram should be used to decide on antidote treatment. Pediatric drug metabolism differs from adult metabolism. Children have a larger liver size compared to their body weight than adults, resulting in a higher metabolism rate. Young children seem to be less sensitive to acute intoxication than adults. One hypothesis to explain the lower rate refers to the larger liver size. The acute toxic dosage for children is more than 200 mg/kg body weight. There seems to be a global increase in accidental pediatric paracetamol overdose. Governmental websites of various European Union (EU) countries were searched for legal information on paracetamol availability in pharmacies and non-pharmacy stores. Various EU countries permit prescription-free sales of paracetamol in pharmacies and non-pharmacy stores. In Sweden paracetamol 500 mg may be sold in both pharmacies and non-pharmacies in a maximum pack size of 20 units. In the United Kingdom (UK) paracetamol 500 mg is listed in the general sales list with a maximum pack size of 30 effervescent tablets or 16 tablets. In Ireland paracetamol 500 mg may be sold in a maximum pack size of 12 units in a non-pharmacy. In the Netherlands paracetamol 500 mg is legal to be sold in a maximum pack size of 50 units in a drug store and with a maximum of 20 units in any other non-pharmacy. Several countries in the European Union are permitted to offer paracetamol prescription-free in pharmacies and non-pharmacy stores without legal guidance on the storage position within the store. Further research is needed to investigate whether paracetamol is located directly accessible to young children within the stores in EU countries which permit prescription-free sales of paracetamol.
doi:10.1186/s12995-015-0084-3
PMCID: PMC4674926  PMID: 26664414
Paracetamol; Acetaminophen; Analgesics; Poisoning; Intoxication; Child; Pediatrics; Legislation; European Union; Non-pharmacy
23.  Caesarean Section—A Density-Equalizing Mapping Study to Depict Its Global Research Architecture 
Caesarean section (CS) is a common surgical procedure. Although it has been performed in a modern context for about 100 years, there is no concise analysis of the international architecture of caesarean section research output available so far. Therefore, the present study characterizes the global pattern of the related publications by using the NewQIS (New Quality and Quantity Indices in Science) platform, which combines scientometric methods with density equalizing mapping algorithms. The Web of Science was used as a database. 12,608 publications were identified that originated from 131 countries. The leading nations concerning research activity, overall citations and country-specific h-Index were the USA and the United Kingdom. Relation of the research activity to epidemiologic data indicated that Scandinavian countries including Sweden and Finland were leading the field, whereas, in relation to economic data, countries such as Israel and Ireland led. Semi-qualitative indices such as country-specific citation rates ranked Sweden, Norway and Finland in the top positions. International caesarean section research output continues to grow annually in an era where caesarean section rates increased dramatically over the past decades. With regard to increasing employment of scientometric indicators in performance assessment, these findings should provide useful information for those tasked with the improvement of scientific achievements.
doi:10.3390/ijerph121114690
PMCID: PMC4661674  PMID: 26593932
caesarean section; research architecture; scientometrics; density equalizing mapping; gender
24.  Telemedicine – a scientometric and density equalizing analysis 
Background
As a result of the various telemedicine projects in the past years a large number of studies were recently published in this field. However, a precise bibliometric analysis of telemedicine publications does not exist so far.
Methods
The present study was conducted to establish a data base of the existing approaches. Density-equalizing algorithms were used and data was retrieved from the Thomson Reuters database Web of Science.
Results
During the period from 1900 to 2006 a number of 3290 filed items were connected to telemedicine, with the first being published in 1964. The studies originate from 101 countries, with the USA, Great Britain and Canada being the most productive suppliers participating in 56.08 % of all published items. Analyzing the average citation per item for countries with more than 10 publications, Ireland ranked first (10.19/item), New Zealand ranked second (9.5/item) followed by Finland (9.04/item). The citation rate can be assumed as an indicator for research quality. The ten most productive journals include three journals with the main focus telemedicine and another five with the main focus “Information/Informatics”. In all subject categories examined for published items related to telemedicine, “Health Care Sciences & Services” ranked first by far. More than 36 % of all publications are assigned to this category, followed by “Medical Informatics” with 9.72 % and “Medicine, General & Internal” with 8.84 % of all publications.
Conclusion
In summary it can be concluded that the data shows clearly a strong increase in research productivity. Using science citation analysis it can be assumed that there is a large rise in the interest in telemedicine studies.
doi:10.1186/s12995-015-0076-3
PMCID: PMC4619516  PMID: 26500688
Telemedicine; Bibliometry; Scientometry; Density equalizing map; Citation
25.  Ebola and Its Global Research Architecture—Need for an Improvement 
PLoS Neglected Tropical Diseases  2015;9(9):e0004083.
The current Ebola outbreak poses a threat to individual and global public health. Although the disease has been of interest to the scientific community since 1976, an effective vaccination approach is still lacking. This fact questions past global public health strategies, which have not foreseen the possible impact of this infectious disease. To quantify the global research activity in this field, a scientometric investigation was conducted. We analyzed the research output of countries, individual institutions and their collaborative networks. The resulting research architecture indicated that American and European countries played a leading role regarding output activity, citations and multi- and bilateral cooperations. When related to population numbers, African countries, which usually do not dominate the global research in other medical fields, were among the most prolific nations. We conclude that the field of Ebola research is constantly progressing, and the research landscape is influenced by economical and infrastructural factors as well as historical relations between countries and outbreak events.
Author Summary
For the first time in the history of the disease, the Ebola virus left its local setting and affected people not only in isolated rural areas, but reached larger towns and cities leading to worldwide repercussions. This development prompted a joint global response to this health threat. This encompassed not only immediate relief efforts, but also an up search in global research work. In this study, the scientific output in Ebola research available in one of the mayor medical search platforms was characterized. We studied among others the origin of research, the collaboration between countries and the research topics. Partly, the obtained data was weighted against economic parameters. We attained a detailed map of the research activities from the discovery of Ebola in 1976 up to today. Our research provides the first overview of the worldwide Ebola research output. It might help stakeholders in Ebola research to better plan investigations with a global perspective.
doi:10.1371/journal.pntd.0004083
PMCID: PMC4583251  PMID: 26406894

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