[Retrospective analysis of routine-MRI and correlation with aetiology of dementia, severity and neuropsychology in a memory-clinic population]. / Retrospektive Analyse der MRT-Routinebefunde und Korrelation mit Demenzätiologie, Schweregrad und neuropsychologischen Befunden von Patienten aus einer universitären Gedächtnisambulanz.

BACKGROUND: The contribution of potential treatable dementia aetiologies diagnosed using cerebral imaging varied considerably in previous studies and was not evaluated in a recent larger German sample of patients from a memory clinic. MATERIAL AND METHODS: MRI images of 502 patients were retrospectively reassessed. Beside the proportion of potentially treatable dementia aetiology, the extent of whole brain atrophy (semiquantitative) and vascular white matter lesions were assessed. RESULTS: Mean age of the patients was 63.7 ± 13.1 years; 49 % were female, mean MMST was 24.2 ± 5.5. In 74 % there was an agreement between the clinical dementia syndrome and MRI. 9 % (45 patients) had clearly discrepant imaging results, according to MRI criteria (21 × ischaemia, 20 × normal pressure hydrocephalus (NPH), 4 × intracerebral haemorrhage). These patients could not not be differentiated using age and MMST alone as clinical criteria. There was a significant correlation between global brain atrophy and MMST (r = -0.32; p < 0.001) and white matter lesion score (r = 0.28; p < 0.001). CONCLUSION: In 9 % there was a clear discrepancy between MRI results and the clinical syndrome diagnosis in memory-clinic patients. As known from earlier studies and current German 3 rd generation guidelines, it is reasonable to perform MRI imaging in dementia to improve the aetiological and differential diagnoses and to detect a different aetiology that can be missed using the clinical dementia criteria alone.

[Assessment of possible drug-drug interactions in psychopharmacotherapy after hospital discharge using an interactive database]. / Datenbankgestützte Prüfung von möglichen Psychopharmakainteraktionen nach Entlassung aus stationärem Aufenthalt.

INTRODUCTION: Psychiatry is confronted with increasing requirements in quality management, guidelines and an increasing proportion of elderly, chronic multimorbid patients with psychiatric disorders. The latter give rise to polypharmacy which may lead to drug-drug interactions. Assessment of drug interactions is more and more difficult as the total number of drugs taken increases. In the present study hospital discharge medication was analysed semiautomatically for possible drug-drug interactions. METHODS: In-hospital cases were randomly selected. Discharge medication was analysed using PsiacOnline, a large web-based database for drug interactions. RESULTS: The selection yielded 342 cases from 213 patients (mean age 46.3 years, 53 % females). 86 patients had one psychiatric diagnosis; the other patients had at least two or more diagnoses. The discharge prescription was analysed for 55 different psychotropic drugs from 4 large drug groups (18 antidepressants; 17 antipsychotic drugs; 5 mood stabilisers/epileptic drugs and 13 different hypnotic/anxiolytic drugs). Antipsychotic drugs were the most frequent drugs (n = 334); followed by antidepressants (n = 312) and mood stabilizers (n = 112). 47 patients (13.7 %) were discharged with monotherapy. Mean drug number was 2.7. PsiacOnline revealed 535 hits: 126 (23.6 %) combinations were non-critical, 86 (16.1 %) combinations were critical based on pharmacological properties of the drugs; 232 (43.4 %) combinations were critical according to in vitro studies or animal experiments; critical drug combinations in high-risk patients: 67 × (12.5 %); combinations with reported risks for side effects due to interaction: 17 × (3.2 %) and combinations with documented risks for severe drug interactions: 7 × (1.3 %). CONCLUSION: Although the majority of drug combinations was considered not critical, approximately 3 % of cases had an increased risk for adverse drug actions and a further 1.3 % cases with a severe risk gave evidence that integration of an IT-based pharmacological expert system in a computerised physician order entry (CPOE) should be considered. Suggested beneficial effects need to be shown by an appropriately-designed clinical study.

[The patient in the psychiatric emergency ambulance: diagnoses, reasons and comparison of layperson vs. physician viewpoints]. / Der Patient in der psychiatrischen Notambulanz: Erstdiagnosen, Vorstellungsgründe und Vergleich der Laien- vs. Arztsicht.

A survey in specialties other than psychiatry showed that "emergency room"-patients have factors other than the presenting disease that determine the usage of urgent medical evaluation. In the following prospective study 104 outpatients presenting at daytime in a university psychiatric emergency care unit were included over 6 months. Apart from social and epidemiological data, illnesses according to ICD-10, reason for presentation from the patient's point of view and in this regard the physician's evaluation were included. The most prevalent diagnoses were depression, adjustment disorders and anxiety disorders, comprising together 75 %. Organic disorders or addictive disorders were less frequent; psychoses were found in 8 %. Concerning the presentation as an emergency, 70 % of patients reported a subjective clinical deterioration but only 44 % were regarded as an urgent need in the responsible physician's point of view (Cohen's kappa 0.39). Our findings show that patients presenting as "psychiatric emergency cases" without appointment mainly suffer from depression, adjustment disorders and panic disorders. Furthermore, the layperson's point of view of clinical deterioration justifying an emergency presentation differs from physician's evaluation. The most likely cause for this disagreement between physicians and patients in the assessment to utilise a medical emergency care service in psychiatry might be dysfunctional or, respectively, negative-biased cognitions accompanying depressive syndromes.

Validation of the German revised Addenbrooke's cognitive examination for detecting mild cognitive impairment, mild dementia in alzheimer's disease and frontotemporal lobar degeneration.

BACKGROUND/AIMS: The diagnostic accuracy of the German version of the revised Addenbrooke's Cognitive Examination (ACE-R) in identifying mild cognitive impairment (MCI), mild dementia in Alzheimer's disease (AD) and mild dementia in frontotemporal lobar degeneration (FTLD) in comparison with the conventional Mini Mental State Examination (MMSE) was assessed. METHODS: The study encompasses 76 cognitively healthy elderly individuals, 75 patients with MCI, 56 with AD and 22 with FTLD. ACE-R and MMSE were validated against an expert diagnosis based on a comprehensive diagnostic procedure. Statistical analysis was performed using the receiver operating characteristic method and regression analyses. RESULTS: The optimal cut-off score for the ACE-R for detecting MCI, AD, and FTLD was 86/87, 82/83 and 83/84, respectively. ACE-R was superior to MMSE only in the detection of patients with FTLD [area under the curve (AUC): 0.97 vs. 0.92], whilst the accuracy of the two instruments did not differ in identifying MCI and AD. The ratio of the scores of the memory ACE-R subtest to verbal fluency subtest contributed significantly to the discrimination between AD and FTLD (optimal cut-off score: 2.30/2.31, AUC: 0.77), whereas the MMSE and ACE-R total scores did not. CONCLUSION: The German ACE-R is superior to the most commonly employed MMSE in detecting mild dementia in FTLD and in the differential diagnosis between AD and FTLD. Thus it might serve as a valuable instrument as part of a comprehensive diagnostic workup in specialist centres/clinics contributing to the diagnosis and differential diagnosis of the cause of dementia.

[The quality of university teaching in psychiatry and psychotherapy: results of a survey on the current status following the introduction of the new medical accreditation system]. / Qualität der universitären Lehre im Fach Psychiatrie und Psychotherapie: Ergebnis einer Umfrage zum aktuellen Stand nach Einführung der neuen Approbationsordnung für Arzte.

The classic criticism levelled at German medical studies was addressed in 2002 with the reform of the German medical accreditation system. For the specialties Psychiatry and Psychotherapy, a national workshop of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) was held in Heidelberg on 23.01.2004 to implement the new legal requirements for teaching. In 2008, a postal survey was conducted among the 36 German medical faculties by the DGPPN to establish the current status of the proposed implementation, with the general structure of undergraduate medical training, student-centered syllabuses and the general significance of teaching forming the main points. With a response rate of 75%, the results can be considered representative. In general, a cautiously positive conclusion can be drawn on the implementation of the medical accreditation system. Having said that, it should be borne in mind that implementation is not yet complete and still requires optimization, for example in terms of making examinations not only theoretical but also more practical in approach.

[Improvement of CME questions from Der Nervenarzt]. / Verbesserung der formal-didaktischen Qualität der CME-Fragen aus Der Nervenarzt.

BACKGROUND: Multiple choice questions play an important role in training and continuing education. Der Nervenarzt has been publishing articles for continuing medical education (CME) since 2002 which usually have ten multiple choice questions. Studies from other fields have shown that CME questions are often formulated awkwardly from a didactic standpoint. In this study we analyzed the CME questions contained in Der Nervenarzt to assess their instructional quality. MATERIALS AND METHODS: The standardized evaluation was performed by semiskilled nonprofessionals. The setup permitted differentiation of 15 known quality criteria for multiple choice questions from the educational medical literature. RESULTS: Of the 796 questions studied that had been posed in 2002-2008 (370 neurology, 346 psychiatry, and 80 interdisciplinary), 518 questions had an awkward construction for didactic purposes. A negative wording of the stem, followed by unintentional cues and obsolete combination formats were most frequently observed. The proportion of precisely phrased questions has increased significantly since 2006. CONCLUSION: The CME questions in the German medical journal Der Nervenarzt have improved regarding their instructional quality since the beginning of the program.

[Quality improvement of multiple choice examinations: in psychiatry, psychosomatic medicine, psychotherapy, and neurology]. / Qualitätsverbesserung von Multiple-Choice-Prüfungen: In Psychiatrie, Psychosomatik, Psychotherapie und Neurologie.

We describe a continuous improvement process in planning, performance, and evaluation of multiple choice examination questions in psychiatry, neurology, psychosomatic medicine, and psychotherapy. We analyzed 640 multiple choice questions of 1,419 students during a period of 4 years. Crucial changes concerned the abolishment of problematic question types, implementation of validated new question formats, extension of case-based questions, elongation of question stems, quantitative evaluation of item difficulty, discriminatory value, and the introduction of a peer review system. Consequences of these improvements were greater item difficulty (average 18%) and discriminatory value (average 67%) and reduced post hoc analysis times. Introduction of peer reviews resulted in longer preparation time, which was however appreciated by the peers due to a clear improvement in item quality.

[Differential diagnosis of neurodegenerative disorders in young adults]. / Differenzialdiagnosen zu neurodegenerativen Erkrankungen im jungen Erwachsenenalter.

Neurodegenerative diseases are relatively common and usually occur in older patients. In young adulthood, neurodegeneration is less common and more frequent due to underlying inborn errors of metabolism (IEMs) that typically have a wide range of clinical presentations. In the following overview, we present a case of SSPE and NBIA. The main differential diagnoses, cardinal symptoms, diagnosis and treatment options of neurodegenerative-like disesase in young adults are presented.

[Comparison of patient therapy adherence of two structural different memory clinics]. / Vergleich der Therapietreue von zwei regional benachbarten Gedächtnissprechstunden mit unterschiedlicher Struktur.

There are more than 100 memory clinics established in Germany, Austria and German-speaking Switzerland. We compared the impact of the structure of two German memory clinics (Erlangen and Nuremberg) on therapeutic outcome. 483 patients suffering from dementia with indication for antidementive therapy were included in this study. The data ascertainment included patient-related data, the mini mental score, comorbidity as well as psychiatric drug therapy. After a mean follow-up of 3.7 years, we performed a single cross-sectional survey covering over 90 % of patients to assess clinical course and adherence to therapy. The patients of the Erlangen University Memory Clinic were significantly younger (69.8 +/- 9.49 vs. 74.6 +/- 10.7 years; p = 0.01) and had a better mini mental score at their first presentation (20.9 +/- 9.4 vs. 19.5 +/- 5.9; p = 0.02). They showed a non-significantly faster disease progression (as measured by mini mental decline per year), than the patients from Nuremberg. Concerning the allocation of diagnosis, more late onset-dementias and dementias of a mixed type were treated at the Nuremberg clinic. At the university clinic, more dementias were of unclassified origin. Concomitant drug therapies, death rates and therapy adherence (53 %) were not different between the two clinics. The two memory clinics under investigation differed in patient age, disease severity and diagnostic assessment. Still, parameters of therapeutic outcome showed converging results.

[Usage of drugs with potential adverse effects on cognition in a memory-clinic]. / Verwendung von Medikamenten mit ungünstigen Wirkungen auf die Kognition in einer Gedächtnissprechstunde.

Cognitive decline is a frequent clinical symptom in elderly patients. In particular, memory disturbances are an early sign and a risk factor for subsequent development of neurodegenerative dementia. At the same time, elderly patients often receive multiple medications due to an increasing number of acquired diseases. Certain drugs have adverse side effects on cognition due to interference with the cholinergic or GABA-ergic system. This could lead to underestimation of the actual cognitive status at initial clinical presentation. In the present study we included 221 patients (mean age 68,5 years) who presented for the first time in a specialized memory-clinic and who had or developed dementia during follow up. Most patients had mixed vascular-degenerative dementia (57 %). On average, patients took 2.1 drugs. 19.9 % of the patients had medications with potential adverse effects on cognition. Patients with medication affecting cognition had a worse cognitive performance than patients with a medication not influencing cognitive functioning (Mini-Mental vs. 18.8. 22.01, p = 0.01) in univariate analysis. Psychotropic drugs were used less frequently (38 %) than primary non-CNS medication. The results remained unchanged even after performing a case-control study with the mixed dementia population with age and gender matched patients. However, in multivariate analysis, only the absolute number of medication taken remained as an independent factor. Our data highlight the clinical importance of medication history in the diagnostic work-up of cognitive impairment. The absolute number of medication taken seems to be more important than medication with possible adverse side effects on cognition.

[Neuropsychological complications after coronary bypass grafting]. / Neuropsychiatrische Komplikationen nach aortokoronarer Bypassoperation.

BACKGROUND: Coronary bypass grafting is more and more performed in elderly, atherosclerotic patients with increased risk of developing postoperative neuropsychological complications. In the present study, we investigated the relative importance of clinical, genetic or metabolic factors with possible impact on any of the primary endpoint encephalopathy, stroke and death after coronary bypass grafting. METHODS: 98 prospective patients (mean age 67.9 years, 23 females, 75 males) underwent conventional elective bypass surgery. All had standardized cardiovascular risk factor assessment, prior stroke, EuroSCORE, a neuropsychologic battery and testing for Apolipoprotein E (APOE) Genotype and Homocysteine. Follow up was possible on 90 patients postoperatively and after 3, 6 and 12 months, monitoring cognitive decline, death or dependency and general health assessment. RESULTS: Early mortality was 3.1 % (3 patients); 3 patients (3.0 %) developed postoperative ischemic stroke and 2 further strokes occurred within the next 3 months. Postoperative encephalopathy occurred in 14 patients (14.3 %). Homocysteine elevation or Apolipoprotein E 4 (APO E 4) did not correlate with immediate postoperative cognitive function. Patients with high EuroSCOREs had significantly lower postoperative Mini-Mental scores. Neither Homocysteine nor presence of an APO E 4 allele was associated with any postoperative endpoint at 3, 6 or 12 months after surgery. The EuroSCORE was modestly associated with postoperative encephalopathy (relative risk 1.3 - 1.5), but not with outcome after one year. Preoperative stroke was highly associated with postoperative ischemic stroke and cognitive decline on follow-up (relative risk 11), but not with postoperative encephalopathy. CONCLUSIONS: Amongst clinical factors, the EuroSCORE may indicate moderate risk increase for acute postoperative encephalopathy. Most strokes occur early after surgery. Patients having suffered stroke prior to cardiac surgery may represent a high-risk group in the acute as well as chronic outcome after cardiac surgery.

[Physical activity and prevention of Alzheimer's dementia: current evidence and feasibility of an interventional trial]. / Körperliche Aktivität und Prävention der Alzheimerdemenz: Ubersicht über die aktuelle Evidenz und Uberlegungen zur Machbarkeit einer Interventionsstudie.

There is accumulating evidence from animal and epidemiologic studies that physical exercise is neuroprotective in healthy animals and humans and can prevent cognitive decline in chronic neurodegenerative processes like Alzheimer's dementia. However, data from well-designed interventional, randomized non-pharmacologic trials is lacking in contrast to other areas of medicine like prevention of hypertension, diabetes or the antipsychotic-associated metabolic syndrome. The demonstration of a potential positive effect of physical exercise on preventing dementia using a controlled study design would represent a significant progress in the prevention of dementia and public health, especially as long as other treatments for dementia prevention are lacking.

[Sensitivity of neurochemical dementia diagnostics in CSF compared to 99mTc-SPECT in Alzheimer's dementia]. / Vergleichende Sensitivität der neurochemischen Demenzdiagnostik im Liquor und rCBF im 99mTc-SPECT bei Patienten mit Alzheimerdemenz.

The diagnosis of Alzheimer's dementia is currently changing from a late and exclusion diagnosis towards a pathophysiology-based early and positive diagnosis. Especially advances in neuro-chemical dementia diagnostics in the cerebrospinal fluid (NDD-CSF) and imaging techniques like PET, SPECT or MRI are of particular interest. Unfortunately, many studies investigated only either one or other technique. In the present study 56 patients (average 67.1 years; average mini-mental status test (MMST) 22.2) were examined with the clinical diagnosis of Alzheimer's dementia. All patients both underwent NDD-CSF as well as 99mTc-SPECT. Only the SPECT, but not the NDD-CSF correlated with disease severity. Sensitivity of NDD-CSF was 89 % and SPECT 48 % for all patients and 93 % resp. 61 % for patients with MMST < 24. Below MMST 20 both methods had equal sensitivity. Both diagnostic techniques showed no statistic coherence (p = 0.27), neither after correction for subgroups like disease severity or the APOE genotype. Our results are compatible with the hypothesis that the NDD-CSF reflects beta-amyloid-aggregation and Tau-Protein pathology as a pathophysiologic biomarker. Our results suggest that SPECT is rather a state parameter for the rCBF changes following cortical neurodegeneration.

Effects of peer-assisted training during the neurology clerkship: a randomized controlled study.

OBJECTIVE: To determine the efficacy of peer-assisted clinical skills training for students during their neurology clerkship. METHODS: Students (n = 122) were randomized to get clinical skills training from either student (peer) instructors (experimental group) or from experienced clinical staff (control group). The remaining schedule during the clerkship did not differ between both groups. Primary endpoint was students' practical skills and knowledge tested at the end of the course by a written test and objective structured clinical examination (OSCE). Secondary endpoints were evaluation of the practical training and self-estimated gain in theoretical and practical competence. RESULTS: In the written test, the peer-trained group (n = 66) scored 69.5 +/- 10.2 (95% CI 67-72) points of 100 and the postgraduates-trained group (n = 56) 66.7 +/- 11.4 (95% CI 63.6-69.8) (P = 0.15). In the OSCE the peer-trained group scored 93.7 +/- 6.3 (95% CI 92.1 to 95.2) points of 100 and the postgraduates-trained group 92 +/- 5.1 (95% CI 90.6 to 93.4) (P = 0.11). In the evaluation and self-assessment items, there was no significant difference between the two groups except for the postgraduates' higher competence (P = 0.004). CONCLUSION: Peer-trained students pass written exam and OSCE as efficient as postgraduates-trained students. Self-assessed learning success is equally rated in both groups.

Non-pharmacologic prevention of Alzheimer's disease: nutritional and life-style risk factors.

We conducted a review of cohort studies and interventional studies on nutritional and life-style risk factors and primary prevention of Alzheimer's Disease. Studies were assessed by the Oxford classification. Interventional studies exist for mental training and vitamin supplementation. For alcohol, fat and fish intake, mediterranean diet, homocysteine, overweight/caloric intake, physical and social activity, hypercholesterolemia, diabetes and smoking, currently there is only evidence from cohort studies. Cognitive stimulation by mental training increases mental functions and can be recommended on the basis of positive interventional studies. Vitamin supplementation cannot prevent AD on the basis of interventional studies. Hyperlipidemia, hyperhomocysteinemia, diabetes and typical life-style factors (alcohol, smoking, obesity etc.) modestly increased AD risk, fish, mediterranean diet and unsaturated fat or n-3 fatty acids and social activity are protective in observational cohorts, but interventional studies are lacking.

Risk and predictors of early epileptic seizures in acute cerebral venous and sinus thrombosis.

We assessed the risk and determined predictors of early epileptic seizures (ES) in patients with acute cerebral venous and sinus thrombosis (CVST). A prospective series of 194 consecutive patients with acute CVST admitted to neurological wards in two German university hospitals was analysed for frequency of ES and in-hospital mortality. Demographic, clinical and radiological characteristics during the acute stage were retrospectively analysed for significant association with ES in univariate and multivariate analyses. During the acute stage, 19 patients (9.8%) died. Early symptomatic seizures were found in 86 patients (44.3%). Status epilepticus occurred in 11 patients (12.8%) of whom four died. Amongst patients with epileptic seizures, mortality was three times higher in those with status than in those without (36.4% and 12%, respectively). In multivariate logistic regression analysis, motor deficit [odds ratio (OR) 5.8; 95% CI 2.98-11.42; P < 0.001], intracranial haemorrhage (OR 2.8; 95% CI 1.46-5.56; P = 0.002) and cortical vein thrombosis (OR 2.9; 95% CI 1.43-5.96; P = 0.003) were independent predictors of early epileptic seizures. Status epilepticus was an important source of morbidity and early mortality in patients with CVST in this study. Patients with focal motor deficits, cortical vein thrombosis and intracranial haemorrhage carried the highest risk for ES. Prophylactic antiepileptic treatment may be an option for these patients.

Nutrient stoichiometry in winter wheat: Element concentration pattern reflects developmental stage and weather.

At least 16 nutrient elements are required by plants for growth and survival, but the factors affecting element concentration and their temporal evolution are poorly understood. The objective was to investigate i) element concentration pattern in winter wheat as affected by crop developmental stage and weather, and ii) whether, in the short term, element stoichiometry reflects the type of preceding crop. We assessed the temporal trajectories of element concentration pattern (N, P, K, Ca, Mg, S, Mn, Fe, Cu, Na, Zn) across the life cycle (from seed to seed) of winter wheat field-grown in cool-temperate Sweden during two years with contrasting weather and when cultivated in monoculture or after different non-wheat preceding crops. We found strong influence of developmental stage on concentration pattern, with the greatest deviation from grain concentrations found in plants at the start of stem elongation in spring. Inter-annual differences in weather affected stoichiometry, but no evidence was found for a short-term preceding-crop effect on element stoichiometry. Winter wheat element stoichiometry is similar in actively growing plant tissues and seeds. Nitrogen exerts a strong influence on the concentration pattern for all elements. Three groups of elements with concentrations changing in concert were identified.