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During the current corona pandemic, the question to which extent people could reach the middle of the elbow joint with the tip of their nose, which the Federal Ministry of Health recommended as a preventive measure when sneezing, was investigated with the help of an online questionnaire. The analysis included 316 fully completed online questionnaires and 16 additional telephone interviews, a total of 332 test persons (average age 29.5 (± 14.3) years, average BMI 22.9 (± 3.4) kg/m²; 226 women, 106 men). The results of this study show that 84.6% of respondents followed the recommended coughing etiquette and sneezed into the crook of their arm, 15.4% did not. The most common reason given for not using it was habit. Nevertheless, 92.8% of the participants found sneezing or coughing in the crook of their arm to be useful. When measuring the distance, 76.2% of the participants were able to touch the crook of the arm at the specific angle on both sides. The average measured distance was 1.13 cm on the right and 1.23 cm on the left. It was found that the BMI and age had a significant relationship with the measured distance. In a gender-specific comparison, more women than men sneezed into the crook of their arm, while no significant differences were found when measuring the distance. If the results of this study are put into practice, it makes perfect sense to continue to recommend sneezing or coughing in the crook of the arm. However, a note should be attached to this recommendation, which prompts one to take the sneeze position once and to check whether the crook of the arm can really be reached effectively. If this is not possible, alternative options should be recommended.

During residence in high mountain regions, the human water hydration status changes and, from the height of approximately 3000 m above sea level, is associated with the risk of mountain sickness. The present investigation should assess this phenomenon in moderate height (1300–2300 m above sea level) after a residence time of approximately one week by means of bioelectric impedance analysis (BIA). 50 volunteers, attendees of a sports medicine congress (33 men, 17 women), agreed to enter the study. All participants underwent BIA measurements initially and after one week. Apart from the basic characteristics – resistance (resistor, R) and capacitor resistor (reactance, Xc) – derived characteristics, such as total body water (TBW), body cell mass (BCM) and extra-cellular mass (ECM) were of interest. Significant changes after the stay in moderate altitude were not verified. As resistance decreased in both men and women, extracellular hydration was probably stimulated. Altogether, the study shows that an approximately one-week stay had no substantial influence on the BIA parameters in moderate altitude. In this regard, additional investigations in high altitudes or studies with longer duration of stay should be encouraged.

Arzt- und Krankenhausserien im TV sind beliebt und weisen hohe Einschaltquoten auf. Die Medienwirkungsforschung zeigt, dass TV-Konsum einen Einfluss auf die Erwartungen und die Einschatzung der Krankenhausrealitat der Konsumenten hat. Wir haben an einem Patientenkollektiv untersucht, ob die Differenzierung zwischen den TV-Serien und der Krankenhauswirklichkeit gelingt. Uber 15 Monate wurden 162 chirurgische Patienten vor und nach einer Hernienoperation oder Cholezystektomie standardisiert zu ihrem Fernsehkonsum, der Realitatseinschatzung von Arzt- und Krankenhausserien sowie zu ihren Erwartungen an den Klinikaufenthalt befragt. Die Zahl der bekannten Arzt- und Krankenhausserien hangt signifikant mit dem vermuteten medizinischen Wahrheitsgehalt dieser Serien und der Fehleinschatzung der Klinikwirklichkeit zusammen (p

Publisher’s Note: This conference presentation, originally published on 3/21/18, was withdrawn per author request on 3/21/18.

Background: Childhood amnesia starts with about 5 to 7 years of age and is attributed to neuronal remodeling in early childhood, particularly in the hippocampus. Traditional, psychosocial and cultural factors influence the first memory as an indicator of childhood amnesia.

The following report describes the possible techniques of CT-guided puncture for direct magnetic resonance (MR) arthrography of the shoulder. CT-guided puncture can be regarded as an alternative technique to fluoroscopic- or ultrasound-guided puncture for MR-arthrography of the shoulder with high efficiency, low dose and extremely low complication rate.

Risperdal ConstaTM (risperidone) was the first long-acting depot formulation of an atypical antipsychotic belonging nowadays to standard treatments for schiz-ophrenic patients. The microsphere technology of this depot formulation re-sults in a complex pharmacokinetics with a delay (lag time) of relevant drug levels for 3 to 4 weeks, which therefore initially requires additional oral doses. The piecewise polynomial regression approach based on sign functions was used to define the complex concentration versus time curve after a single in-tramuscular injection. A 3-phase linear model with logarithmic transformation of concentration data was suited to fit the concentration time data and gave valuable data on both half-lives and phase borders (deflection points).

To determine the diagnostic value of semi-quantitative and quantitative parameters of three functional techniques in multiparametric (mp)-MRI of the prostate.Mp-MRI was performed in 110 patients with suspicion of prostate cancer (PCA) before transrectal ultrasound (TRUS)-guided core biopsy. Peak-enhancement, initial and post-initial enhancement, initial area under gadolinium curve, Ktrans (forward rate constant), Kep (efflux rate constant), Ve (extracellular volume), ADC (apparent diffusion coefficient) and MR spectroscopy ratio were obtained for malignant and benign lesions. For iAUGC, Ktrans, Kep and Ve we evaluated median, mean and the difference (Diff) between mean and median. For ADC we evaluated mean, median, Diff between mean and median, and min. In addition, we evaluated these parameters in dependence of Gleason score in PCA. Receiver operating characteristic analysis and area under curve (AUC) were determined.ADC min and Kep Diff were the best predictors of malignancy in all lesions (AUC: 0.765). ADC min was the best predictor of malignancy for lesions in peripheral zone (PZ) (AUC: 0.7506) and Kep Diff was the best predictor of malignancy for lesions in transitional zone (AUC: 0.7514). Peak enhancement was the best parameter in differentiation of low-grade PCA with Gleason score 6 from high-grade PCA with Gleason score ≥ 7 (AUC: 0.7692).ADC min can differentiate PCA from benign prostate lesions in PZ. Kep Diff could possibly improve prostate cancer detection in. Peak enhancement might be able to differentiate low grade from high-grade PCA. Semi-quantitative and quantitative parameters may be useful for the functional techniques in mp-MRI. Advances in knowledge: ADC min can differentiate PCA from benign prostate lesions in PZ. Peak enhancement might be able to differentiate low grade from high-grade PCA.

Background The recreational use of trampolines is an increasingly popular activity among children and adolescents. Several studies reported about radiological findings in trampoline related injuries in children. The following publication presents our experience with MRI for detection of trampoline injuries in children. Methods 20 children (mean 9.2 years, range: 4–15 years) who had undergone an MRI study for detection of suspected trampoline injuries within one year were included. 9/20 (45%) children had a radiograph as the first imaging modality in conjunction with primary care. In 11/20 (55%) children MR imaging was performed as the first modality. MR imaging was performed on two 1.5 T scanners with 60 and 70 cm bore design respectively without sedation. In 9/20 (45%) children the injury mechanism was a collision with another child. 7/20 (35%) children experienced leg pain several hours to one day after using the trampoline without acute accident and 4/20 (20%) children described a fall from the trampoline to the ground. Results All plain radiographs were performed in facilities outside the study centre and all were classified as having no pathological findings. In contrast, MR imaging detected injuries in 15/20 (75%) children. Lower extremity injuries were the most common findings, observed in 12/15 (80%) children. Amongst these, injuries of the ankle and foot were diagnosed in 7/15 (47%) patients. Fractures of the proximal tibial metaphysis were observed in 3/15 children. One child had developed a thoracic vertebral fracture. The two remaining children experienced injuries to the sacrum and a soft tissue injury of the thumb respectively. Seven children described clinical symptoms without an overt accident. Here, fractures of the proximal tibia were observed in 2 children, a hip joint effusion in another 2, and an injury of the ankle and foot in 1 child. There were no associated spinal cord injuries, no fracture dislocations, no vascular injuries and no head and neck injuries. Conclusions In the majority of children referred for MR imaging with pain after trampoline MR imaging detects injuries. These injuries are often not visible on plain radiographs. Therefore we recommend a generous use of MR imaging in these children after initial negative plain radiography.

Polycyclic aromatic hydrocarbons (PAH) in tobacco are potent inducers of Cytochrome P450 (CYP) 1A2, which metabolizes a plenty of drugs including antipsychotics such as olanzapine or clozapine. With regard to haloperidol and risperidone, CYP3A4 is supposed to be the major isoenzyme. We present the case of a 60-year old woman who suffered from chronic schizophrenia and smoked more than 40 cigarettes per day, which indicates that PAH also induces CYP3A4, causing ultrarapid metabolisation of risperidone and haloperidol with subtherapeutic drug levels both after oral or intramuscular depot administration. Acta Medica Medianae 2014;53(3):42-45.

The prevalence of Late-life Depression (LLD) is estimated between 10 and 15 % and therefore LLD is a considerable world-wide problem. The psychopathology is not substantially different from that of depressive episodes in young adults, but somatic complaints in combination of end-of-life perspective leave an imprint on emotional experience. Frequent suicide ideation, especially in old unmated men, remains a particular challenge. It is important to combine psychiatric and somatic diagnostics including modern methods such as cMRT (magnetic resonance tomography) or extensive clinical laboratory to exclude organic underlying diseases. The treatment is a multidisziplinary approach including biological, psychotherapeutic and physiotherapeutic or sociotherapeutic methods. Modern antidepressants and augmentation strategies allow to treat the old-aged population with sufficient safety, tolerability and therapeutic efficiency.

The association between sleepwalking, a non-rapid-eye-movement parasomnia, and biological rhythms has not been subject of research in the past, although shift work is a known risk factor of the disorder. We present the case of a 36-year-old policeman who suffered for years from sleepwalking and was referred to the hospital for polysomnography. All standard investigations including multiple sleep latency or maintenance wakeful test were normal. On the contrary, chronobiological assessment revealed phase delay of vital functions and body temperature, whereas acrophases of melatonin and cortisol remained stable. We postulate an increase in sleep fragmentation due to shift work, but further research is needed to substantiate the hypothesis.

Psychiatric disease, particularly depression and stress disorders, worsen the outcome of cardi-ovascular disease substantially. Although this mind-heart interaction is known since the 1930s, many questions with regard to the underlying pathophysiology remain to be answered. Apart from psychological stress and psychiatric disease, inflammatory or psychoimmunology processes, metabolic or endocrinological mechanisms may be involved as are lifestyle and effects of drug treatment. The takotsubo or broken heart cardiomyopathy, which can be regu-larly referred to stressful event, may serve as paradigm to understand pathological base of the mind-heart relation. Further research is essential with regard to pathophysiology and pathopsychology, but it is our duty to struggle for care in everyday practice.

Objective To determine the rate of malignancy after follow-up MR imaging of the prostate in PI-RADS 3 lesions without core biopsy and PI-RADS 4 lesions after negative initial core biopsy. Materials and methods We performed follow-up MRI in 46/72 (64%) patients with PI-RADS 3 lesions and 26/72 (36%) patients with PI-RADS 4 lesions in baseline MRI. Results The rate of malignancy in PI-RADS 3 lesions was 4% (2/46) and in PI-RADS 4 lesions 69% (18/26). Conclusions Follow-up MRI for PI-RADS 3 lesions should be performed. For PI-RADS 4 lesions with initial negative biopsy we recommend an instant repeat core biopsy.

Stroke is the most frequent cause of neurogenic oropharyngeal dysphagia (NOD). In the acute phase of stroke, the frequency of NOD is greater than 50% and, half of this patient population return to good swallowing within 14 days while the other half develop chronic dysphagia. Because dysphagia leads to aspiration pneumonia, malnutrition, and in-hospital mortality, it is important to pay attention to swallowing problems. The question arises if a prediction of severe chronic dysphagia is possible within the first 72 hours of acute stroke.On admission to the stroke unit, all stroke patients were screened for swallowing problems by the nursing staff within 2 hours. Patients showing signs of aspiration were included in the study (n = 114) and were given a clinical swallowing examination (CSE) by the swallowing/speech therapist within 24 hours and a swallowing endoscopy within 72 hours by the physician. The primary outcome of the study was the functional communication measure (FCM) of swallowing (score 1-3, tube feeding dependency) on day 90.The grading system with the FCM swallowing and the penetration-aspiration scale (PAS) in the first 72 hours was tested in a multivariate analysis for its predictive value for tube feeding-dependency on day 90. For the FCM level 1 to 3 (P.0022) and PAS level 5 to 8 (P.00001), the area under the curve (AUC) was 72.8% and showed an odds ratio of 11.8 (P.00001; 95% confidence interval 0.036-0.096), achieving for the patient a 12 times less chance of being orally fed on day 90 and therefore still being tube feeding-dependent.We conclude that signs of aspiration in the first 72 hours of acute stroke can predict severe swallowing problems on day 90. Consequently, patients should be tested on admission to a stroke unit and evaluated with established dysphagia scales to prevent aspiration pneumonia and malnutrition. A dysphagia program can lead to better communication within the stroke unit team to initiate the appropriate diagnostics and swallowing therapy as soon as possible.

Background and Hypotheses: The growing number of medical television series and the increasing amount of time people spend watching TV will have an influence on what they expect from their treatment in a hospital. We suspect that reality as presented in the media and the actual reality of hospitals are not always conceived of as two different worlds. Many medical TV shows present dramatic, life-threatening operations much more often than they occur in reality. Patients who frequently watch such shows might be induced to believe that even routine operations are often dangerous, which could result in higher levels of fear before such an operation. We suspect then that there is a significant relation between preoperative levels of fear and TV viewing habits. Methods: A standardized questionnaire was used to interview 162 in-house patients who had come to the hospital for an elective standard operation in a German hospital. They were interviewed 1-2 days prior to operation and shortly before discharge from hospital. The questions aimed at their social situation, their TV viewing habits with special consideration of medical TV shows, and the patients' preprocedural fear. Results: The links between levels of education, age, and gender on the one hand, and viewing habits on the other, which have been shown in cultivation research, are supported by our findings. Approximately 50% reported a relevant anxiety level above 4 (on a scale of 0-10). There is a significant association between levels of fear and TV viewing habits. Thirteen subjects (8%) indicated that they suffered the highest imaginable degree of fear, all of them frequent watchers of medical TV shows. Frequent viewers of medical TV shows were definitely more scared than all other patients (p = 0.039). The preoperative level of fear was highest in the age group of under 40 years and significantly lower (p = 0.0042) in the age group of over 70 years. Conclusion: The assumed effects of cultivation with in-house patients caused by watching TV series could be shown to be statistically significant. Watching medical TV shows increases the patients' preoperative fear.

A 42-year-old patient with cognitive deficits due to childhood meningitis suffered from recurrent episodes of familial hemiplegic migraine. Additionally, he developed concomitant psychotic episodes requiring subsequent in-patient psychiatric treatment. Following combined neurological and psychiatric treatment he always recovered from the episodes within a few weeks time. Prophylactic treatment of migraine using topiramate and acetazolamide (off-label) prevented attacks for several months. When off-label compensation was refused and, as a consequence, the drug discontinued, hemiplegia relapsed within a few days. Hence, acetazolamide was prescribed again and the family paid for the medication. Since that time, the patient did not show severe attacks for at least 8 months apart from a transient attack induced by acute flu-like illness.

Hypoxic brain injuries are severe consequences of cardiac and pulmonary events requiring resuscitation due to trauma, serious blood loss or suicide attempts. The circadian course of body temperature, heart rate and blood pressure of 24 patients aged 56.2 years (SD 15.1) who were admitted into a neurological rehabilitation intensive care unit after hypoxic brain injury was analysed retrospectively. Chronograms revealed a loss of diurnal variation of the investigated parameters. Particularly, the increase of heart rate and blood pressure during morning hours could not be verified. The results can be explained by damage of oscillatory centres as a consequence of cerebral hypoxia.

The birth data of 816 patients with the diagnosis of multiple sclerosis (MS) according to the McDonald criteria referred to the University Clinic of Neurology Regensburg were assessed for annual periodicity of birth dates. All data were expressed as rates, i.e., number MS births per total number of births per month, prior to descriptive and time series analysis. A significant annual variation of birth rates was found in both genders, with the peak in birth rates per month occurring in late winter and spring months. A cosinor model indicated an acrophase (cosine-model approximation derived peak time) of birth rate in April. These results are consistent with the findings of most of the earlier studies conducted in other countries located in the Northern hemisphere that revealed an excess of MS births in the spring.

Purpose 2- and 3-dimensional evaluation of quantitative pharmacokinetic parameters derived from the Tofts model modeling dynamic contrast enhancement of lesions in MR mammography. Materials and methods In 95 patients, MR mammography revealed 127 suspicious lesions. The initial rate of enhancement was coded by color intensity, the post-initial enhancement change is coded by color hue. 2D and 3D analysis of distribution of color hue and intensity, vascular permeability and extracellular volume were performed. Results In 2D, malignant lesions showed significant higher number of bright red, medium red, dark red, bright green, medium green, dark green and bright blue pixels than benign lesions. In 3D, statistical significant differences between malignant and benign lesions was found for all this parameters. Vascular permeability was significant higher in malignant lesions than in benign lesions. Regression model using the 3D data found that the best discriminator between malignant and benign lesions was combined number of voxels and medium green pixels, with a sensitivity of 79.4% and a specificity of 83.1%. Conclusions Quantitative analysis of pharmacokinetic variables of contrast kinetics showed significant differences between malignant and benign lesions. 3D analysis showed superior diagnostic differentiation between malignant and benign lesions than 2D analysis. The parametric analysis using a pharmacokinetic model allows objective analysis of contrast enhancement in breast lesions.

Objectives: (1) To investigate the risk of extrapyramidal motor side effects (EPS) associated with the prescription of different antipsychotics under naturalistic treatment conditions; (2) to test the rationale of the terms ‘typical’ and ‘atypical’ based on EPS rates. Design: Cross-sectional study in the federal state of Bavaria. Setting: 20 psychiatric hospitals in Bavaria. Participants: 6,061 inpatients, aged 18–65 years, with psychotic disorders. Main Outcome Measures: Co-medication with the anticholinergic biperiden was used as an index of EPS. Odds ratios for EPS and numbers needed to harm [number of patients who would need to be treated to obtain one more case with an adverse outcome (i.e. EPS) as compared with the control treatment (clozapine)] were calculated to obtain risk estimates for 15 different antipsychotics. Results: Groups of ‘typical’ and ‘atypical’ antipsychotics were not homogeneous in their EPS rates, and showed wide variation within each group. Nor did the frequency of EPS allow a clear distinction between the groups. There were 2 reasons for this: first, EPS rates rose continuously over the whole spectrum of drugs under study, and therefore precluded the definition of a cut-off score; second, there was considerable overlap between the 2 groups as EPS rates of various ‘atypicals’ (e.g. amisulpride, risperidone and zotepine) did not differ from some ‘typical’ substances (e.g. fluphenazine), while one ‘typical’ antipsychotic (perazine) even had a lower EPS risk than most ‘atypicals’. Conclusions: The odds of inducing EPS are not distinguishable between ‘typical’ and ‘atypical’ antipsychotics as EPS rates rise on a continuous scale throughout both classes. We propose dropping the categorization of antipsychotics as ‘typical’ and ‘atypical’ and instead using risk estimates like number needed to harm for EPS to help in benefit/risk considerations for antipsychotic treatment.

This prospective study evaluates the feasibility of the magnetic resonance (MR)-guided vacuum-assisted breast biopsy with a handheld vacuum-biopsy system and documents the biopsy results with MR mammography 24 h after the procedure. MR-guided biopsy was undertaken in 33 patients with 34 lesions on dynamic MR mammography. The interventions were performed with the handheld 10-gauge Vacora vacuum-biopsy system. In all cases, dynamic MR mammography was performed 24 h after the procedure to determine the extent of the lesion removal and to identify the lesions that were missed. In 5/34 (14.7%) lesions, biopsy was not performed because no suspicious lesion was identified on the day of biopsy. In 25/29 (86.2%) lesions, the biopsy was successfully performed with a complete removal in 4/29 (13.8%) and a partial removal of 21/29 (72.4%) lesions. In 4/29 (13.8%) interventions the lesion was missed with the biopsy. In one case, histopathology after surgical excision revealed ductal carcinoma in situ. Histopathology revealed 9/29 (31%) malignant and 20/29 (68.9%) benign lesions. MR-guided vacuum-assisted breast biopsy with the handheld Vacora vacuum-biopsy system is technically feasible in most cases. MR mammography 24 h after the biopsy should be performed in those cases in which the biopsy success is unclear immediately after the procedure.

A 51-year old women suffering from depression with psychotic symptoms and a history of meningitis and epilepsia since childhood was treated paroxetine, olanzapine and lamotrigine for years.

We prospectively evaluated the diagnostic accuracy of cerebrospinal fluid (CSF)-beta-amyloid1-42 (Abeta42), -total-tau (tau) and -phosphorylated-tau181 (p-tau181) as measured by sandwich ELISAs in the clinical routine of a community state hospital to discriminate between patients with Alzheimer's disease (AD), healthy controls (HC), non-AD-dementias, a group composed of various psychiatric disorders (non-AD-dementias, mental diseases) and an age-matched random sample (RS) (total N=219). By comparing patients with AD to HC as reference, tau revealed sensitivity (sens)/specificity (spec) of 88%/80%, p-tau(181) 88%/80%, tau/Abeta42-ratio 81%/85% and phospho-tau(181)/Abeta42-ratio 81%/78%. Discriminative power between HC and all dementias under investigation was estimated lower for tau (78%/77%) and p-tau(181) (73%/79%). Relative to patients with AD, ROC analysis for the RS revealed highest sens/spec for p-tau181 (79%/77%) and p-tau181/Abeta42 ratio (78%/75%). Differentiation between AD versus a group made of patients with various psychiatric disorders was optimised by using CSF-p-tau181 (80%/77%). Under clinical routine conditions current CSF-biomarkers show a substantial capacity to discriminate between AD and HC as reference and to mark off AD patients from RS and heterogeneous diagnostic groups composed of non-AD dementias and other psychiatric conditions. Despite a residual substantial overlap between the groups, we conclude that current CSF markers are well suited to support AD-related diagnostic procedures in every-day clinics.

PURPOSE The purpose of this prospective study was to determine the restenosis grade, the intima hyperplasia and the stent expansion via angiographic follow-up six months after carotid artery stenting. MATERIALS AND METHODS In 100 patients, angiographic follow-up was performed 5.9 months (range: 2.9-11.4 months) after carotid artery stenting. The restenosis grade, the intima hyperplasia and the stent expansion were measured by selective angiography of the treated carotid artery. RESULTS The mean restenosis grade was 16 % (range: 0-78 %). In 6 of 100 patients (6 %), a restenosis grade of > 50 % was measured. In 4 patients the restenosis grade was 50-70 %. In 2 patients the restenosis grade was > 70 %. In 91 of 100 patients (91 %), the restenosis was localized in the former area of stenosis of the carotid artery, and in 9 of 100 patients (9 %), the restenosis was localized in the cranial stent end. The mean grade of intima hyperplasia was 31 % (range: 2-70 %). The mean increase in stent expansion at the time of follow-up was 10 % (range: 0-59 %). No correlation was able to be determined between the grade of stenosis and the grade of restenosis (rho = 0.017, range: - 0.180-0.213), between the grade of residual stenosis and the grade of restenosis (rho = 0.257, range: 0.064-0.431) and between intima hyperplasia and the grade of restenosis (rho = 0.476, range: 0.309-0.615). CONCLUSIONS Carotid artery stenting is associated with a low incidence of high-grade restenosis 6 months after an intervention. The intima hyperplasia, which can be observed in each Wallstent, is partly compensated by the expansion of the self-expandable stent. Without a correlation between the grade of residual stenosis and the grade of restenosis, low-grade residual stenosis can be accepted. Therefore, we recommend undersized postdilation of the Wallstent.

Our aim was to evaluate quantitative parametric analysis for characterization of breast lesions in contrast-enhanced magnetic resonance (MR) mammography. In 62 patients, contrast-enhanced MR mammography revealed 75 suspicious lesions, of which 18 were benign and 57 were malignant. The quantitative parametric analysis delineates signal intensity changes of contrast-enhanced lesions on a pixel-by-pixel basis. The initial rate of enhancement is coded by color intensity: a slow rate is coded to dark; a fast rate, bright. The postinitial enhancement change is coded by color hue: blue for increasing signal intensity, green for plateau, and red for decrease in signal intensity. Malignant lesions showed a significantly higher number of bright-red (P = 0.004) and medium-red (P0.001) pixels than benign lesions. Benign lesions showed significantly more blue pixels than did malignant lesions (P = 0.010). Of the 75 lesions, 72 (96%) showed heterogeneous distribution of pixel color hue. Quantitative parametric analysis of contrast kinetics in lesions can replace the subjective manual region of interest (ROI) method and makes a step toward standardization of MR mammography. It allows quantitative evaluation of different contrast kinetics parameters in contrast-enhanced breast lesions.

The purpose of this study was to establish normal values for the volume of the uterus and cervix in MRI based on age and the menstrual cycle phase. We performed MRI of the pelvis in 100 healthy women. For the uterus, they were further divided into two groups: one with myomas and/or adenomyosis and one without either. The volume of the uterus and cervix and thickness of the uterine wall layers were analysed by age and the menstrual cycle phase. The mean volume of the uterus in both groups and the cervix significantly increased with age to reach its peak at 41-50 years, and then dropped. Likewise, the thickness of the endometrium and the junctional zone, but not the myometrium, significantly increased until 41-50 years, and then decreased. When we compared the volume of the uterus and cervix and the thickness of the uterine wall layers between the two phases of the menstrual cycle, we found no significant differences. The volume of the uterus and cervix and the thickness of the endometrium and junctional zone differ significantly with age, but not between the two phases of the menstrual cycle. Knowledge of MRI-related normal values can be expected to aid the early identification of uterine pathologies.

Purpose: To evaluate the three-time-point (3TP) method for diagnosis of breast lesions detected on contrast-enhanced MR mammography. Materials and Methods: MR imaging was performed in 40 women with 120 suspected breast lesions in mammography and/or sonography. The contrast kinetics was converted by 3TP software on a pixel-by-pixel basis into color-coded images. Lesion diagnosis was made by analysis of color intensity and color hue. The 3TP results were compared with the results of the region-of-interest (ROI) method. In 16 patients, we were able to correlate the results with histopathological findings. Results: The 3TP method could successfully be performed in all MR mammographies. Forty (33%) lesions had a diameter of less than 5 mm, 56 (47%) lesions between 5 and 10 mm, and 24 (20%) lesions were greater than 1 cm. Of all 120 lesions, 65 (54%) showed heterogeneous contrast enhancement. In 117 (97%) of all 120 lesions the results of ROI and the automated 3TP method were considered equivalent. However, in three lesions the manual ROI differed from the 3TP method. After a second, repeated manual ROI placement, we were able to confirm equivalent results with the 3TP images as well. Conclusions: The 3TP method automatically and reliably converts contrast kinetic information of the entire breast into a color-coded image. The 3TP method presents kinetic information of the entire dynamic series in an easy-to-interpret format and this automated method may allow to forego time-consuming and sometimes subjective manual ROI placements. This method displays the heterogeneity of the contrast enhancement pattern often observed in malignant lesions and makes it usable as diagnostic criterion.

This prospective study was undertaken to determine the success rate, complications, and outcome of carotid artery stenting (CAS) without the use of cerebral protection devices. During 12 months, 94 high-grade stenoses of the carotid artery in 91 consecutive patients were treated. Sixty-six (70%) of the stenoses were symptomatic and 28 (30%) were asymptomatic. In all 94 carotid stenoses CAS was successfully performed. During the procedure and within the 30 days afterwards, there were 2 deaths and 3 major strokes in the 66 symptomatic patients, resulting in a combined death and stroke rate of 5 of 66 (7%). Only one of these complications, a major stroke, occurred during the procedure. In the 6-month follow-up, one additional major stroke occurred in a originally symptomatic patient resulting in a combined death and stroke rate of 6 of 66 (10%) for symptomatic patients at 6 months. No major complications occurred in asymptomatic patients during the procedure or in the 6-month follow-up period. At 6 months angiographic follow-up the restenosis rate with a degree of >50% was 3 of 49 (6%) and the rate with a degree of ≥70% was 1 of 49 (2%). Cerebral embolization during CAS is not the only cause of the stroke and death rate associated with the procedure. The use of cerebral protection devices during the procedure may therefore not prevent all major complications following CAS.

Objective: During the last 2 decades, right/left hemisphere dominance was supposed to affect the immune system differently. Experimental and clinical observations indicate that the left hemisphere plays a crucial role in the development of the immune system. The true relationship between immune response and acute ischemic stroke laterality remains to be elucidated. Methods: We studied acute right-handed stroke patients admitted to a single acute neurology department with a specialized stroke unit. Being part of our clinical protocol, blood samples were taken within the first 24 h after the onset of stroke symptoms. The medical record of each patient was reviewed, and demographic, clinical laboratory (key criteria: C-reactive protein, CRP, and white blood cell count, WBC) and neuroimaging information was retrieved. All data were presented descriptively, and bivariate test statistics, ANOVA (log-transformed data) or linear correlations were calculated. Results: Fifty-six of the 187 patients admitted to our Stroke Unit between October 2003 and March 2004 with different stroke subtypes according to the TOAST criteria were retrospectively evaluated in order to characterize the impact of stroke laterality on immunoregulatory response measured by CRP levels and WBC. Correlation analysis revealed that left-sided ischemic stroke yielded a significantly higher correlation between CRP levels and WBC. Following left-sided stroke, a more marked variability in CRP and WBC was found compared to patients with right-sided ischemic stroke, although ANOVA did not show significant differences between immune response values as a function of stroke subtypes. Conclusions: We identified an association between stroke laterality and immunoregulatory response in patients with acute ischemic stroke. Left-sided stroke may be considered as a direct risk factor for infectious disease or immune deficits and should attract special attention. However, these preliminary results need be confirmed by controlled studies.

Background and purpose: Although head&neck and oesophageal carcinomas occur synchronously in up to 12%, almost no data on feasibility and outcome after radiotherapy are available. Materials and methods: From 1989 to 2002, 24 patients were treated at Tuebingen University and Fulda hospital with a radiation based, curative approach. These were analyzed retrospectively. Results: The median overall survival was 37 (1-69) months with a few long-term survivors with a median follow-up of 26 months for patients at risk. 7 local recurrences occured. No major toxicity was seen. Discussion: Even though the prognosis of synchronous head&neck and oesophageal carcinomas is grim, long-term survival is possible. A radiation-based approach is feasible and can be chosen for a curative treatment approach which we recommend.

Background: circannual variations of incidence may influence human tumors. For example, seasonal distribution of breast cancers suggests an influence of circannual hormonal rhythms. Periodicity of brain tumors has not yet been investigated. The aim of this study was to assess the seasonal variation in glioblastomas and anaplastic astrocytomas. Methods: a large dataset of high-grade gliomas (n = 697) was evaluated with the month of diagnosis as key criterion for time series and seasonal analysis. Circannual and ultra-annual cosinor models were calculated. Results: women suffering from glioblastoma show a peak incidence in fall. No suitable circannual or ultra-annual cosinor model months could be fitted to the data. In women with anaplastic astrocytoma, a peak incidence was detected in summer and fall with a nadir in spring. Here, a significant cosinor model with a period of 8.5 months could be calculated. Conclusion: our data strongly suggest seasonality of diagnosis of high-grade gliomas in women...

Meningeal melanocytoma refers to the uncommon clinical appearance of a generally benign tumour deriving from leptomeningeal melanocytes. Meningeal spread of this tumour is very rarely observed. We present the case of a 38-year-old man with meningeal melanocytoma of the cerebello-pontine angle, who showed a biphasic course of this disease, with a stable period followed by a steady progress within few months. After surgical resection of the melancytoma in the left skull base and of a first local recurrence five years later, a second local recurrence occurred 6 years after diagnosis, with intracerebral and spinal meningeal seeding. This tumor did not respond to a combined radiochemotherapy including oral temozolomide, and the patient died 5 months after starting treatment for this relapse. Secondary malignisation of the melancytoma is suggested.

Elevated concentrations of D-dimers (DDs) in patients with acute ischemic stroke may cause differential diagnostic problems with regard to pulmonary or deep venous thrombosis. The true relationship between plasma DDs and acute ischemic stroke remains uncertain. We studied acute stroke patients admitted to a single acute neurology department with a specialized stroke unit. As part of our clinical protocol, blood samples of each patient had been taken within the first 24 hours after the onset of stroke symptoms and before anticoagulant treatment had been started, to evaluate the coagulation profile. Each patient's medical record was reviewed, and demographic, clinical, laboratory and neuroimaging information was abstracted. Univariate and multivariate statistical analyses were performed. A total of 59 patients admitted to our stroke unit between October 2003 and March 2004 with different stroke subtypes according to the TOAST criteria were evaluated to characterize the impact of stroke category on DD concentration. Family members (n = 23) served as controls in this study. Multivariate regression analysis revealed that patients who sustained cardioembolic stroke had significantly higher DD concentrations than controls and patients who sustained transient ischemic attacks. We identified a correlation between plasma DD levels and different acute ischemic stroke subtypes before any stroke treatment was started. Thus DD concentrations may be considered a direct consequence of marked cerebral infarction and may be useful for physicians when making decisions on treatment for acute ischemic stroke.

The objective of our study was to assess the correlation of routine neuropsychological test results in elderly patients referred to a gerontopsychiatric ward. MMSEs, CTs and SKTs were performed in 94 patients (age: median = 74 years, range = 54-89 years; 64 f, 30 m) with mild to moderate dementia and evaluated retrospectively. Pairwise Spearman rank correlation, multiple regression and response surface analysis were used to assess relations between test results. The scores of all three tests used were reciprocally correlated (P < 0.05) yielding the following pairwise R-values: SKT versus MMSE: -0.77, SKT versus CT: 0.69, MMSE versus Clock test: -0.61. Multiple regression analysis showed a maximum correlation of 0.87 and marked standardised beta values, if SKT was chosen as dependent variable. Test scores could be well fitted to both symmetric linear (SKT = a + b x CT + c x MMSE; R(2) = 0.67, P < 0.01) and non-linear (SKT = a + b x CT + c x MMSE + d x CT(2) + e x MMSE(2) + f x CT x MMSE; R(2) = 0.67, P < 0.01) response surfaces. In conclusion, test scores of SKT, CT or MMSE in patients with dementia showed a marked correlation. In clinical practice the may be considered as almost interchangeable test options.

Approximately 5% of patients with malignant glioma achieve complete response (CR) after first-line combined modality treatment. Although these patients will invariably suffer from tumor recurrence, they usually do not receive any further treatment to maintain remission. According to in vitro and in vivo clinical studies, 13-cis retinoic acid (cRA) may be a promising agent for maintenance therapy in these patients.We initiated a clinical study to evaluate the feasibility and toxicity of high-dose cRA as maintenance therapy in patients with high-grade glioma in complete remission after first-line multimodal treatment.A prospective single-arm phase-II study in patients with CR after combined first-line therapy (neurosurgery, radio- and chemotherapy) was performed. Patients were treated with cRA at 60 mg/m2 BS from day 1 to 21 in four-weekly cycles with a dose escalation of up to 100 mg/m2 BS until tumor recurrence. Clinical controls were performed every 4 weeks, magnetic resonance imaging every 8 weeks.Twenty-three patients (10, grade IV; 13, grade III) were evaluable using an intention-to-treat analysis. Treatment was well tolerated for up to 149 weeks with moderate dermatological symptoms in all patients. No grade 4 toxicities were observed. Median time to progression was 41 weeks, median overall survival 74 weeks after inclusion in the protocol.There is an urgent need for strategies maintaining remission in patients with malignant glioma. Maintenance therapy with high-dose cRA is feasible and well tolerated over long periods of time. A controlled clinical trial to test the efficacy of cRA as a maintenance treatment in malignant glioma is warranted.

Memantine, a non-competitive NMDA antagonist, has been clinically used in the treatment of dementia in Germany for over ten years. The rationale for this indication is strongly related to the physiological and to the pathological role of glutamate in neurotransmission. Physiologically, NMDA receptors mediate synaptic plasticity by acting as a coincidence detector. Only those synapses that show temporally and spatially discrete activation of NMDA receptors undergo plastic changes secondary to Ca++ influx after rapid unblocking of Mg++, thus crucially contributing to memory and learning processes. The voltage-dependency of Mg++ is so pronounced that under pathological conditions it leaves the NMDA channel upon moderate depolarisation, thus interrupting memory and learning. Its pharmacological properties allow memantine to rapidly leave the NMDA channel upon transient physiological activation by synaptic glutamate (restoring significant signal transmission), but to block the sustained activation of low glutamate concentration under pathological conditions, i.e. to protect against excitotoxicity as a pathomechanism of neurodegenerative disorders. Memantine acts as a neuroprotective agent in various animal models based on both neurodegenerative and vascular processes as it ameliorates cognitive and memory deficits. Memantine has shown to be effective and safe in the treatment of dementia, particularly Alzheimer's disease, in controlled clinical trials. Provided that the dose is slowly increased it is generally well tolerated and safe up to 20 and 30 mg per day, with intake preferably in the morning. The compound is completely absorbed after oral intake with Cmax values after 6 hours, undergoes little metabolism and has a terminal elimination half life between 60 and 100 hours. Due to its low potential of interaction, memantine can be combined with acetylcholinesterase inhibitors, the mainstay of current symptomatic treatment of Alzheimer's disease and it is suited in elderly patients receiving multiple drug therapy.

The frequency of distal radius fractures between 1997 and 1999 in patients older than 50 and younger than 40 years was evaluated retrospectively by means of a Chi-square test and Kolmogorov Smirnov test. Time series data were fitted to cosine model using nonlinear regression in order to detect a circadian or circannual rhythm. The goodness of fit was assessed by means of the F-statistics and the coefficient of determination r 2 . Accidents at home were recorded most frequently in elderly patients (61.7%) whereas accidents during sports and spare time activities (48.4%) dominated with regard to younger patients. The type of accident was significantly influenced by the factor age. A significant circadian cosine model of frequency of radius fractures could be calculated for both younger and elderly patients with acrophases during the afternoon characterized by a phase advance (approx. 1.5 hours) in the elderly group. The amplitudes of the cosine model were reduced in order of 30% in the elderly. Analysis of seasonal variation showed non-significant maximum values in May and December/January in the elderly. On the contrary, the frequency of distal radius fractures showed an unimodal distribution with peak values during summer in younger patients.

Preamble......1688 Introduction......1688 General Considerations and Perspectives......1688 Nomenclature, Definitions, and Clinical Diagnosis......1689 Obstruction to LV Outflow......1689 Genetics and Molecular Diagnosis......1690 General Considerations for Natural History and Clinical Course

Test results (raw scores) are composed of an unknown true score and an error term. The error term can be estimated by means of test reliability which is defined by the ratio of true variance and obtained variance. Different estimates of reliability either based on single measurements (e. g. Cronbach's coefficient, split half reliability, Kuder Richardson method) or two measurements (test/retest, inter- or intrarater reliability) are available. Parallel test reliability depends on the correlation of two different tests obtained in one session. Canonical correlation methods allow an extension of the parallel test situation and split half technique. Two or more tests are performed in a sample of subjects. Randomized subsets are correlated using canonical correlation technique. The objective of this study is to estimate the homogeneity of test batteries. 94 patients (64 f, 30 m; age: 54 - 89 ys.) supposed to have dementia were tested using the clocktest (CT, scores: 1 - 5), MMSE (mini mental state examination) and SKT (Syndrom Kurztest). Four (i, j: 1 - 4) subsets of 20 patients each were determined by random and the following characteristics were calculated: Empiric correlation coefficient for n = 94 (R), canonical correlation coefficient (Rcan), eigenvalues (EV) and redundancy (Rnd) of corresponding variable sets. The results of canonical analysis showed canonical correlation coefficients in order of 0.8 to 0.9 (p-values < 0,001). This high internal consistency can be interpreted as a measure of reliability of the test batteries. In conclusion, canonical correlation based on parallel tests splitted in subsets gives information on consistency, i. e. reliability, of test batteries in addition to conventional correlation methods.

Background and Purpose — Fear of distal embolization and stroke has aroused concern regarding carotid stenting. Devices to protect the cerebral circulation may make carotid stenting safer. Methods — A multidisciplinary study group tested a balloon occlusion-aspiration emboli entrapment device in conjunction with carotid stenting. The device consists of an elastomeric balloon on a steerable wire with a detachable adapter that inflates and deflates the distal temporary occlusion balloon. An aspiration catheter is used to remove trapped emboli after stenting and before occlusion balloon deflation. Results — Seventy-five patients with severe internal carotid artery stenosis were treated with stents deployed with this cerebrovasculature protection system. All 75 patients (100%) had grossly visible particulate material aspirated, and all were treated successfully without major or minor stroke or death at 30 days. Preintervention stenosis was 81±10%, and residual stenosis was 5±7%. Nine patients (12%) had angiographic evidence of thrombus before intervention, but no patient had thrombus or vessel cutoff after the procedure. Four patients (5%) developed transient neurological symptoms during protection balloon occlusion, but symptoms resolved with balloon deflation. The 22 to 667 particles aspirated per patient ranged from 3.6 to 5262 μm in maximum diameter (mean, 203±256 μm). These particles included fibrous plaque debris, lipid or cholesterol vacuoles, and calcific plaque fragments. Conclusions — Protected carotid stenting was performed successfully and safely in this study early in the experience with cerebrovascular protection devices. Particulate emboli are frequent with stenting, and cerebral protection will likely be necessary to minimize stroke. Randomized trials comparing protected carotid stenting with endarterectomy are warranted.