The pantomime of mental rotation: Left-handers are less lateralized.

INTRODUCTION: The conceptualization of skilled hand movements (praxis) may be grounded in hemispherically specialized functions. However, a left-hemispherical advantage of (tool-use) pantomime gestures and a right-hemispherical advantage of spatial gestures may be more prominent in right-handed than left-handed individuals. We therefore investigated the hypothesis that right-handed but not left-handed individuals show a superiority of the left hemisphere (/right-hand preference) for the execution of pantomime (rotation of an object) gestures as well as a right-hemispherical superiority (/left-hand preference) for gestures that depict spatial information (/positioning of an object). METHODS: 20 right- and 20 left-handed participants were asked in two experiments to demonstrate with their two hands how to move tachistoscopically (in the left (LVF) or right visual hemifields (RVF)) presented geometric objects of different rotations into an identical final position. Two independent blind raters evaluated the videotaped hand gestures employing the Neuropsychological Gesture (NEUROGES) Coding System. RESULTS: In contrast to left-handed individuals, right-handed individuals present increased pantomime - rotation gestures with the right hand and pantomime - position gestures with the left hand during stimuli presentation in either visual field. Left-handers showed significantly increased left-hand pantomime - rotation gestures during stimulus presentation within the LVF (only). DISCUSSION: Right-handed individuals increase their pantomime - rotation gestures with the right hand to depict motion but use their left hand for pantomime - position gestures to describe spatial relations of the objects. Left-handers do not show a clear lateralization of the right and left hand with regards to either handedness or hemispherically lateralized motor functions. The hemispherical lateralization of praxis functions is therefore more pronounced in right-handed than left-handed individuals.

Hemispheric specialization for nonverbal gestures depicting motion and space.

INTRODUCTION: The right hemispheric specialisation for mental rotation suggests a left hand preference for nonverbal gestures that depict spatial information. We therefore hypothesized that nonverbal depictions of spatial information are preferentially demonstrated by the left hand, i.e., are grounded in right hemispheric functions. METHODS: Right-handed participants were asked in two experiments to nonverbally demonstrate how to move tachistoscopically presented (in the left or right visual hemifields) geometric objects of different rotations into an identical final position. Two independent blind raters evaluated the videotaped hand gestures employing the Neuropsychological Gesture (NEUROGES) Coding System. RESULTS: Pantomime gestures increase in order to rotate gravitationally unstable objects whereas spatial relation presentation gestures increase when to nonverbally demonstrate a gravitationally stable object. Individuals preferred the right hand for pantomime gestures but the left hand for spatial relation presentation gestures. DISCUSSION: Individuals increase their pantomime gestures to nonverbally depict motion particularly with the right hand, i.e. the left hemisphere. In contrast, increased left hand spatial relation presentations gestures indicate that those gestures are of right hemispheric origin. Thus, the hemispherical lateralization of nonverbal gestures seems to depend on the hands' functional depiction.

Reduced frontopolar brain activation characterizes concussed athletes with balance deficits.

OBJECTIVES: Athletes with sport-related concussions (SRC) often demonstrate deficits in postural stability. Lower cerebral blood flow in frontal cortices has been documented in athletes with symptoms after SRC, however, it is unclear if functional brain oxygenation during postural control tasks is reduced in symptomatic athletes after SRC in the same manner. We therefore compared brain oxygenation patterns in frontal cortices of symptomatic and asymptomatic athletes with SRC during postural control tasks with the hypothesis that symptomatic athletes are characterized by reduced functional brain oxygenation during postural control. METHODS: 62 concussed athletes (n = 31 symptomatic, n = 31 asymptomatic) were investigated during four postural control tasks with eyes closed versus eyes opened conditions and stable vs. unstable surface conditions. Brain oxygenation was assessed using functional NearInfraRed Spectroscopy (fNIRS) on frontopolar cortices of each hemisphere. Postural sway was measured by the analysis of ground reaction forces. RESULTS: Symptomatic athletes showed greater postural sway when compared to asymptomatic athletes during postural control, particularly during closed eyes and/or unstable surface conditions. Changes of oxygenated hemoglobin (∆HbO2) within the left hemispheric frontopolar cortex were significantly reduced in symptomatic athletes when compared to asymptomatic athletes during the eyes closed condition. A stepwise linear regression analysis revealed that self-reported post-concussion symptoms such as headaches and sadness predict decreased brain oxygenation during postural control with closed eyes. CONCLUSION: Symptomatic athletes with increased postural sway are characterized by decreased frontopolar brain oxygenation during postural control tasks, particularly during conditions with closed eyes. Because the frontopolar cortex showed to be involved in redistributing executive functions to novel task situations, we conclude that athletes with post-concussion symptoms suffer from a deficit in coordinating postural adjustments to balance control tasks with reduced sensory input.

Symptoms after sport-related concussions alter gestural functions.

OBJECTIVES: Symptoms after sport-related concussions (SRC) are common. Because post-concussion symptoms are often not clearly visible, speech-accompanying gestures may help clinicians to gain additional information about the patient's history and symptoms during medical consultation. We hypothesized that athletes with SRC and who suffered from persisting symptoms would display more gestures during concussion assessment protocols when compared to non-concussed athletes because of the athletes' previous motor-sensory experiences made during the concussive event. DESIGN: A retrospective cross-sectional study. METHODS: Three matched groups of 40 (active) athletes were investigated in the context of concussion assessment (/and baseline) protocols: 14 symptomatic and 14 asymptomatic athletes with a SRC, and 12 non-concussed athletes. Certified raters using a standard analysis system for nonverbal behaviour analysed videotaped hand movements and gestures during a standardized concussion assessment protocol. RESULTS: Symptomatic athletes spent significantly more time with in space hand movements, i.e., movements that act in the body-external free space without touching anything and specifically, motion quality presentation gestures than non-concussed athletes. CONCLUSIONS: Increased in space movements, which are functionally gestures, and specifically, motion quality presentation gestures in symptomatic athletes indicate that the more vivid sensory motor experience of the head trauma is reflected in more gestural expressions. Thus, hand movements and gestures differentiate athletes who suffer from post-concussion symptoms from non-concussed athletes indicating the athletes' motor-sensory experiences of the event and its aftereffects. The present study highlights the fact that gestures can be employed as behavioural markers of symptoms after sport-related concussions.

Aortic Elongation and Stanford B Dissection: The Tübingen Aortic Pathoanatomy (TAIPAN) Project.

OBJECTIVE/BACKGROUND: Aortic elongation has not yet been considered as a potential risk factor for Stanford type B dissection (TBD). The role of both aortic elongation and dilatation in patients with TBD was evaluated. METHODS: The aortic morphology of a healthy control group (n = 236) and patients with TBD (n = 96) was retrospectively examined using three dimensional computed tomography imaging. Curved multiplanar reformats were used to examine aortic diameters at defined landmarks and aortic segment lengths. RESULTS: Diameters at all landmarks were significantly larger in the TBD group. The greatest diameter difference (56%) was measured in dissected descending aortas (p < .001). The segment with the most considerable difference between the study groups with regard to elongation was the non-dissected aortic arch of patients with TBD (36%; p < .001). Elongation in the aortic arch was accompanied by a diameter increase of 21% (p < .001). In receiver-operating curve analysis, the area under the curve was .85 for the diameter and .86 for the length of the aortic arch. CONCLUSIONS: In addition to dilatation, aortic arch elongation is associated with the development of TBD. The diameter and length of the non-dissected aortic arch may be predictive for TBD and may possibly be used for risk assessment in the future. This study provides the basis for further prospective evaluation of these parameters.

Hand movements with a phase structure and gestures that depict action stem from a left hemispheric system of conceptualization.

The present study addresses the previously discussed controversy on the contribution of the right and left cerebral hemispheres to the production and conceptualization of spontaneous hand movements and gestures. Although it has been shown that each hemisphere contains the ability to produce hand movements, results of left hemispherically lateralized motor functions challenge the view of a contralateral hand movement production system. To examine hemispheric specialization in hand movement and gesture production, ten right-handed participants were tachistoscopically presented pictures of everyday life actions. The participants were asked to demonstrate with their hands, but without speaking what they had seen on the drawing. Two independent blind raters evaluated the videotaped hand movements and gestures employing the Neuropsychological Gesture Coding System. The results showed that the overall frequency of right- and left-hand movements is equal independent of stimulus lateralization. When hand movements were analyzed considering their Structure, the presentation of the action stimuli to the left hemisphere resulted in more hand movements with a phase structure than the presentation to the right hemisphere. Furthermore, the presentation to the left hemisphere resulted in more right and left-hand movements with a phase structure, whereas the presentation to the right hemisphere only increased contralateral left-hand movements with a phase structure as compared to hand movements without a phase structure. Gestures that depict action were primarily displayed in response to stimuli presented in the right visual field than in the left one. The present study shows that both hemispheres possess the faculty to produce hand movements in response to action stimuli. However, the left hemisphere dominates the production of hand movements with a phase structure and gestures that depict action. We therefore conclude that hand movements with a phase structure and gestures that represent action stem from a left hemispheric system of conceptualization.

Effects of haemofiltration and mannitol treatment on cardiopulmonary-bypass induced immunosuppression.

Cardiac surgery using cardiopulmonary bypass (CPB) causes a systemic inflammatory response. Additionally, an impairment of the responsiveness of peripheral blood mononuclear cells (PBMC) to further immunological stimuli has been observed. The aim of our present study was to evaluate the ability of antioxidant therapy with mannitol or haemofiltration during CPB to modulate this immunosuppression after CPB. Forty-five patients undergoing elective heart-surgery were prospectively enrolled and randomized into three groups (control, mannitol, haemofiltration). Blood samples were taken after induction of anaesthesia (T1), 20 min after CPB (T2) and 24 h post-operatively (T3). Expression density of the monocytic surface receptor CD14, HLA-DR expression and cytokine release (TNF-alpha and IL10) after lipopolysaccharide-stimulation were evaluated. At T2, the CD14(dim) cell population was maintained in both intervention groups while in the control group there was a decrease of this proinflammatory monocytic phenotype. No significant differences regarding HLA-DR expression or cytokine release could be demonstrated. This study shows that the suppression of the stimulated immune response after CPB can potentially be alleviated by mannitol or haemofiltration in an experimental in-vitro setting. In the light of data showing that this depression of the immune response might affect the post-operative course of patients, these results could have a potential clinical relevance.

Valve repair in aortic regurgitation without root dilatation--aortic valve repair.

BACKGROUND: Aortic valve repair was established in the context of aortic root remodeling. Variable results have been reported for isolated valve repair. We analyzed our experience with isolated valve repair and compared the results with those of aortic root remodeling. METHODS: Between October 1995 and August 2003, isolated repair of the aortic valve was performed in 83 patients (REP), remodeling of the aortic valve in 175 patients (REMO). The demographics of the two groups were comparable (REP: mean age 54.4 +/- 20.7 yrs, male-female ratio 2.1 : 1; REMO: mean age 60.8 +/- 13.6 yrs, male-female ratio 2.4 : 1; p = ns). In both groups the number of bicuspid valves was comparable (REP: 41 %, REMO: 32 %; p = ns). All patients were followed by echocardiography for a cumulative follow-up of 8204 patient months (mean 32 +/- 23 months). RESULTS: Overall in-hospital mortality was 2.4 % in REP and 4.6 % in REMO ( p = 0.62). Systolic gradients were comparable in both groups (REP: 5.8 +/- 2.2, REMO: 6.5 +/- 3.1 mm Hg, p = 0.09). The mean degree of aortic regurgitation 12 months postoperatively was 0.8 +/- 0.7 after REP and 0.7 +/- 0.7 after REMO ( p = 0.29). Freedom from significant regurgitation (> or = II degrees ) after 5 years was 86 % in REP and 89 % in REMO ( p = 0.17). Freedom from re-operation after 5 years was 94.4 % in REP and 98.2 % in REMO ( p = 0.33). CONCLUSIONS: Aortic regurgitation without concomitant root dilatation can be treated effectively by aortic valve repair. The functional results are equivalent to those obtained with valve-preserving root replacement. Aortic valve repair appears to be an alternative to valve replacement in aortic regurgitation.

[Acute aortic dissection. Differential diagnosis of a thoracic emergency]. / Akute Aortendissektion. Differenzialdiagnose des thorakalen Notfalls.

Acute aortic dissection is an infrequent but important differential diagnosis of acute chest pain. The variability of presenting symptoms makes it difficult to diagnose correctly. Important clinical indicators - besides chest pain - are symptoms related to acute aortic insufficiency and/or pericardial tamponade, variable acute neurologic alterations, or signs of peripheral or visceral malperfusion. The spontaneous prognosis depends on the location and extent of the dissection, and left untreated dissection carries a high mortality. The key goal of preclinical treatment is stabilization with analgesia, mild sedation (opioids, benzodiazepines) and treatment of hypertension (beta-blockers) or hypotension (fluid administration). If the patient presents with a high probability of dissection, early transfer to a specialized center appears advisable. Initial clinical diagnostic studies include transthoracic echocardiogram and computed tomography. If the ascending aorta is involved (Stanford type A) immediate replacement of the proximal aorta is necessary. Isolated dissections of the descending aorta (type B) require aggressive blood pressure control, but can be managed conservatively in most cases. A high level of vigilance is necessary in all patients to detect and treat visceral ischemia.

[Cystic lesion of the dorsal mediastinum]. / Zystische Raumforderung im hinteren Mediastinum.

We present the case of a 52-year-old male who underwent thoracotomy for resection of a suspected bronchogenic cyst in the right posterior mediastinum. The size of the tumor had increased over years, according to repeated X-rays, and the cyst became symptomatic with obstruction of the right subclavian and jugular veins. To our surprise, histopathology revealed a hydatid cyst.

[Pulmonary thromboendarterectomy]. / Pulmonale Thrombendarteriektomie.

Chronic thromboembolic pulmonary hypertension with concomitant right heart failure may develop as a sequela of acute pulmonary embolism with organization instead of thrombolysis of intravascular clots. Medical therapy aims at prevention of recurrent embolism by anticoagulation and vascular remodelling using vasodilator therapy. Lung transplantation or combined heart-lung transplantation is associated with unsatisfactory long-term results and comorbidity and therefore remains justified only in selected patients. Pulmonary thromboendarterectomy allows specific treatment of intravascular obstruction. This closed endarterectomy of the pulmonary arteries requires deep hypothermic circulatory arrest and can be performed with a perioperative mortality of less than 10%. The procedure significantly decreases pulmonary vascular resistance and often normalizes pulmonary hemodynamics and gas exchange. Postoperatively the patients' clinical condition improves and the majority have normal exercise capacity and activity.

[Iloprost and selective pulmonary vasodilation. Clinical results of intraoperative and postoperative inhalation of iloprost]. / Iloprost und selektive pulmonale Vasodilatation. Klinische Ergebnisse bei intra- und postoperativer Iloprostinhalation.

Pulmonary hypertension is a major risk factor in cardiac surgery and has significant impact on morbidity and mortality in the perioperative period. Nitric oxide (NO) is considered to be the gold standard for treatment of pulmonary hypertension in the perioperative setting. The aerosolized administration of the prostacyclin analogue iloprost is a new alternative with similar pulmonary-selective vasodilation and virtually no systemic side-effects. Relevant complications including increased postoperative bleeding have not been observed.

Recent progress in heart valve surgery: innovation or evolution?

Although heart valve surgery continues to evolve in a dynamic fashion, there is still no optimal solution for all patients. Minimally invasive surgery currently receives considerable attention but its value still needs to be determined. Progress has been made in valve repair, which now allows reconstruction in most patients with mitral valve disease. Reconstruction of the aortic valve is now also possible with results that are now comparable to those of mitral repair. In the future a wider application of repair procedures and further improvements of biologic valves can be anticipated not only to influence long-term results, but also the decision making process for conservative or surgical treatment.

Polyploidization and centrosome hyperamplification in inflammatory bronchi.

OBJECTIVE AND DESIGN: Inflammatory and tumorous bronchi were screened in order to obtain new tumor relevant cytogenetic parameters. MATERIAL OR SUBJECTS: Bronchial cells of 32 patients were cultivated by standard cell culture procedures. METHODS: Tetraploidy and aneuploidy was determined by enumeration of chromosome 7 and 8 versus the number of centrosomes. The resulting data were correlated with histopathological data. RESULTS: Tetra- and aneuploidy of epithelial cells were detectable in 76% of tumor cell cultures, 75% of high grade inflammatory tissues and 40% of non- and low grade-inflammatory tissues. Additionally, we observed centrosome hyper-amplification and multipolar mitoses not only in the tumor but also in the early stages of inflammation. CONCLUSION: Inflammatory bronchi already show tumor-specific features and may consequently represent the preliminary genetic stage of cancer development in bronchi.

Hemispheric specialization in spontaneous gesticulation in a patient with callosal disconnection.

This is an investigation of spontaneous gesticulation in a left-handed patient with a callosal disconnection syndrome due to infarction of the total length of the corpus callosum. After callosal infarction, the patient gesticulated predominantly unilaterally with the left hand despite left apraxia. Bilateral gesticulation occurred later on and was presumably achieved by an increase in ipsilateral proximal control. Movement analysis further indicated that the two hemispheres are specialized for certain gesture types. Gestures with emotional connotation and batons (emphasizing prosody) were generated predominantly in the right hemisphere whereas physiographics which picture the linguistic content concretely and deictics (pointing) were of left-hemispheric origin.

Complete arterial revascularization in multivessel coronary artery disease with 2 conduits (skeletonized grafts and T grafts).

BACKGROUND: Complete arterial CABG is a surgical option to improve long-term results in the treatment of coronary artery disease (CAD). Harvesting of multiple arterial grafts is commonly associated with prolonged operating times and increased trauma. By use of new operative techniques (skeletonized grafts and the T-graft approach), CABG in multivessel CAD is now possible with only 2 grafts. We present our experience in the use of these techniques on a routine basis. METHODS AND RESULTS: Between March 1996 and September 1999, 490 patients (aged 61+/-9 years, 20% female) underwent complete arterial CABG. Left ventricular ejection fraction ranged from 15% to 85% (mean 59+/-15%). Triple-vessel disease was present in 88% of the patients. The incidence of diabetes mellitus was 32% (14% insulin dependent). Either both internal thoracic arteries (ITAs) (23%) or the left ITA and radial artery (77%) were used as conduits. In 85% of the patients, a T graft was created. Mean operating time was 198+/-46 minutes; bypass time, 82+/-25 minutes; and ischemic time, 58+/-22 minutes. Two to 7 (mean 4.1+/-0.9) anastomoses were performed per patient. Perioperative intra-aortic balloon pump was necessary in 12 patients (2.4%). The rate of perioperative myocardial infarction was 1.2%. Sternal complications occurred in 1. 0%, and in-hospital mortality was 2.2%. Postoperative coronary angiography in 172 patients (35%) documented excellent patency rates (left ITA 98.3%, right ITA 96.5%, and radial artery 96.6%). CONCLUSIONS: Complete arterial revascularization in multivessel CAD is possible with the use of only 2 grafts with good perioperative results. This approach allows for complete arterial CABG on a routine basis.

Bronchial and bronchovascular sleeve resection for treatment of central lung tumors.

BACKGROUND: To improve postoperative pulmonary reserve, we have employed parenchyma-sparing resections for central lung tumors irrespective of pulmonary function. The results of lobectomy, pneumonectomy, and sleeve resection were analyzed retrospectively. METHODS: From October 1995 to June 1999, 422 typical lung resections were performed for lung cancer. Of these, 301 were lobectomies (group I), 81 were sleeve resections (group II), and 40 were pneumonectomies (group III). RESULTS: Operative mortality was 2% in group I, 1.2% in group II, and 7.5% in group III (group I and II vs. group III, p<0.03). Mean time of intubation was 1.0+/-4.1 days in group I, 0.9+/-1.3 days in group II, and 3.6+/-11.2 days in group III (groups I and II vs. group III, p<0.01). The incidence of bronchial complications was 1.3% in group I, none in group II, and 7.5% in group III (group I and II vs group III, p<0.001). After 2 years, survival was 64% in group I, 61.9% in group II, and 56.1% in group III (p = NS). Freedom from local disease recurrence was 92.1% in group I, 95.7% in group II, and 90.9% in group III after 2 years (p = NS). CONCLUSIONS: Sleeve resection is a useful surgical option for the treatment of central lung tumors, thus avoiding pneumonectomy with its associated risks. Morbidity, early mortality, long-term survival, and recurrence of disease after sleeve resection are similar to those seen after lobectomy.

Callosal disconnection syndrome in a left-handed patient due to infarction of the total length of the corpus callosum.

We report on a left-handed patient with an ischemic infarction affecting exclusively the total length of the corpus callosum. This lesion clinically correlated with an almost complete callosal disconnection syndrome as described in callosotomy subjects, including unilateral verbal anosmia, hemialexia, unilateral ideomotor apraxia, unilateral agraphia, unilateral tactile anomia, unilateral constructional apraxia, lack of somesthetic transfer and dissociative phenomena. Despite the patient's left-handedness, his pattern of deficits was similar to the disconnection syndrome found in right-handers. Our report focusses on motor dominance and praxis. We followed-up the improvement in left apraxia and investigated the ability to initiate and learn a new visuo-motor skill. The results permit two tentative assumptions: (1) that the improvement in left apraxia was due to a compensatory increase in ipsilateral proximal muscle control, and (2) that motor dominance, i.e. the competence to initiate and learn a new movement pattern, was hemispherically dissociable from manual dominance in the sense of praxis control.

["Catatonic dilemma". Therapy with lorazepam and clozapine]. / "Katatones Dilemma". Therapie mit Lorazepam und Clozapin.

We are reporting on a patient with a schizoaffective disorder (ICD 10:F25.1), whose catatonic symptoms deteriorated while receiving high-potency neuroleptic drugs in combination with anticholinergic medication. Initially there was a "catatonic dilemma", i.e. it was not possible to differentiate between the morbigenous and pharmacogenic (malignant neuroleptic syndrome) etiology of the catatonic symptoms. Catatonic symptoms were successfully treated with a combination of lorazepam and clozapine. The severe catatonic syndrome was found to be a neuroleptic-induced deterioration of a primary morbogenous catatonic syndrome. Thus, this case also suggests that the malignant neuroleptic syndrome and neuroleptic non-responsive catatonia may not be two different disease entities but that catatonia under neuroleptic medication is caused by the interaction of individual disposition, morbigenous and pharmacogenic factors.

Movement behaviour of patients with eating disorders and inflammatory bowel disease: a controlled study.

BACKGROUND: This study assessed the movement behaviour of patients with eating disorders and inflammatory bowel disease. METHODS: Ninety female patients with anorexia nervosa (n = 30), bulimia nervosa (n = 30), inflammatory bowel disease (n = 30) and a healthy control group (n = 30) were videotaped during a 10-min standardised movement sequence. A movement analysis instrument was developed for the evaluation. RESULTS: The patient groups had a significantly smaller area of movement, less weight shift, more isolated use of their body parts, less integration of the lower body, more peripheral initiation of movement, less strength. No significant differences could be found among the patient groups with eating disorders and inflammatory bowel disease. CONCLUSIONS: The findings are discussed in relation to body scheme disturbances and inhibition of nonverbal expression.