[Injuries under the influence of alcohol]. / Verletzungen unter Alkoholeinfluss.

BACKGROUND: In Germany, an average of 9.5 L of pure alcohol is consumed per capita per year. Alcohol is known to negatively influence psychomotor abilities. The aim of this study was to evaluate injuries that lead to hospital admission with and without prior intake of alcohol. PATIENTS AND METHODS: Over a 7-month period, all 1317 patients who were admitted to the hospital because of an injury were evaluated with respect to their blood-alcohol level. Patient data of both groups (139 injuries under alcohol influence and 1178 injuries without alcohol influence) were compared with respect to the mechanism and type of injury, patient demographics, and treatment costs. RESULTS: At the time of presentation, 11 % (n = 139) of all admitted patients had detectable blood-alcohol levels of more than 0.1 g/L with an average blood-alcohol level of 2.21 g/L. Female patients had an average of 1.96 g/L and males an average of 2.28 g/L (N.S.). Almost every fifth male patient (109 out of 570, 19 %) had a detectable blood-alcohol level, compared to only 4 % of all admitted female patients. Among the patients admitted between 11:00 p.m. and 5:00 a.m., 35 % had detectable blood-alcohol levels and among the 20- to 30-year-old patients, 24 % had detectable blood-alcohol levels. The leading mechanisms of injury among intoxicated patients were falls (50 %, n = 70) and physical violence (18 %, n = 25). The latter was recorded significantly (p = 0.01) less among sober patients (0.17 %, n = 2). The most frequent diagnosis was a mild concussion in both intoxicated (60%, n = 84) and sober (34 %, n = 402) patients (p = 0.04). The time to discharge averaged 4.3 days for intoxicated and 5.6 days for sober patients. CONCLUSIONS: Injuries that occur while under the influence of alcohol that lead to hospital admission are particularly frequent in male patients aged between 20 and 30 years. They do not necessarily lead to more severe injuries.

Minor groove recognition is important for the transcription factor PhoB: a surface plasmon resonance study.

The two-component regulatory system PhoR/PhoB induces the expression of several genes in response to phosphate starvation in Escherichia coli. In order to quantify these protein-DNA interactions and to study the time-resolved dynamics of the binding mechanism, the specific recognition of different oligonucleotide duplexes by the DNA-binding domain of PhoB (PhoB(DBD)) was analyzed using surface plasmon resonance. In addition the two point mutants PhoB(DBD)D196A and PhoB(DBD)R219A were obtained and the DNA recognition in comparison to the wildtype PhoB(DBD) was investigated. Aspartic acid 196 and arginine 219 mediate specific minor groove interactions. All results reveal that at high PhoB(DBD)-concentrations all recognition sequences of the pho box are occupied. Decreasing the protein amount results in a mixture of free oligonucleotides and DNA molecules occupied by two WT-PhoB(DBD). Moreover, the SPR results indicate that both binding site segments, the TGTCA-motif and the A/T-rich minor groove, are essential for the binding process. A comparison of different regulons additionally proved the dependency of the recognition process on the base composition of the minor groove.

Effectiveness of a novel endoscopy training concept.

BACKGROUND AND STUDY AIMS: Training standards in gastrointestinal endoscopy are poorly defined even though different simulators are increasingly used for skills training. In 2001 a new training concept called "GATE--gastroenterological education-training endoscopy" was established, which provides a combination of background theory, video demonstrations, and simulator training. We aimed to evaluate the acceptance and training effect of this training model. METHODS: In total, 98 physicians participating in four training courses were included. Data were collected on baseline characteristics, acceptance (5-point Likert scale), and pre- and post-course knowledge through a structured questionnaire (A-type and Pick-N multiple choice questions). A total of 13 trainees were randomly selected for additional simulator assessment of training effects on manual skills (5-point Likert scale). RESULTS: A total of 78 trainees (80%) provided complete data sets. The evaluation showed a positive acceptance of the training program (value 1 and 2, Likert scale); for example, 88% of participants suggested the inclusion of the GATE course as an obligatory part of endoscopic education. There was a significant improvement in theoretical knowledge in the post-test set compared with the pre-test set (mean 3.27 ±1.30 vs. 1.69 ±1.01 points; P<0.001). The training effect on practical skill showed a significant reduction in time needed for a procedure (445 ±189 s vs. 274 ±129 s; P<0.01). The mean assessment rating for practical skills improved from 3.05 ±0.65 at baseline to 2.52 ±0.59 on Likert scale ( P=0.085). CONCLUSIONS: The integrated GATE training improved theoretical knowledge and manual skill. The GATE courses have been accredited by the German Society of Gastroenterology, underlining the demand for implementing preclinical training courses in endoscopic training.

[Dysphagia in children with cerebral palsy--fiberoptic-endoscopic findings]. / Dysphagie bei Kindern mit Infantiler Zerebralparese--Fiberoptisch-endoskopische Befunde.

OBJECTIVE: Cerebral Palsy (CP) is associated frequently with swallowing disorders. By means of fiberoptic endoscopy, pathological findings in dysphagic patients with CP have been intended to be described, to be quantified, and to be related to selected anamnestic aspects. PATIENTS AND METHODS: Swallowing competency has been analysed endoscopically in 54 patients with spastic tetraparesis (range of age: 3 months to 15 years and 11 months). RESULTS: Over 60% of all patients examined endoscopically showed deficits in terms of penetration (24%) or aspiration (39%) of saliva. Two-thirds of the patients who have been tested with food had a penetration or aspiration of food, more than half of them without airway protection by cough reflex. Patients who have been fed orally before examination reported aspirations of food for 40%. Interestingly, about 40% of the children without history of pneumonia had aspirations of saliva and food. Drooling phenomena where associated with aspirations of saliva in 54% and with aspiration of food in 53% of our patients. CONCLUSIONS: Fiberoptic endoscopy is useful to detect a potentially dangerous penetration or aspiration of saliva, secretions and food. Thereby it enables the physician to change airway and feeding management. This is of special importance as children who formerly have been fed orally without suspicion of risks and pneumonia anamnesis turned out to have severe swallowing deficits. A close connection between appearance of drooling phenomena and aspiration of saliva and food has also to be considered in children with CP.

[Fattening bull raising--alternative housing on slatted floors]. / Mastbullenhaltung--Alternativen in der Spaltenbodenhaltung.

Rubber topped slatted floor gives more lying comfort to intensive fed fattening bulls, reduces risks of integument lesions as well as increases their locomotion comfort. On the other side there are more fissured alterations and defects in the sole and heel horn due to lack of sufficient wear away which often made the bearing surface to be overgrown. Overgrown claws are also seen on solid slatted floors, but these horn parts were normally grated down in short time that frequently goes along with abrasions of the claw peak and the wall horn as well. The current experiences of our study show favour to the use of a floor that combines hard and soft qualities. Weak claw performance and health has a link to a bad state of cleanness of the pens and the animals as well and must be assessed with regard to permanent wetness on the grounds. Animals out of greater pens are less dirty because the solid floor becomes sooner dry than in cases with higher crowding degrees of animals. More space per animal and higher comfort gives chance for higher daily weight gain. The recordings and evaluations of this project are still in progress.

[Dysphagia in children and young persons. The value of fiberoptic endoscopic evaluation of swallowing]. / Dysphagien im Kindes- und Jugendlichenalter. Zum Stellenwert der fiberoptisch-endoskopischen Schluckdiagnostik.

BACKGROUND: The aim of this retrospective study was to evaluate fiberoptic endoscopic examination of swallowing in the pediatric patient by focusing on its feasibility and typical complications. PATIENTS AND METHODS: From 1997 to 2005, 164 children and young persons with swallowing disorders, who had not previously undergone endoscopic examination, presented for fiberoptic endoscopic examination of swallowing. Of these patients, 47% were age 6 years or younger. The most frequent reasons for the swallowing disorders were neurogenous (87%). RESULTS: In 129 of the 164 patients (78.6%), relevant informations about swallowing pathology was obtained. Because of anatomical restrictions or lack of cooperation, endoscopic examination was impossible in eight cases (4.9%). In 27 patients (16.5%) the procedure had to be terminated early because of inadequate cooperation. Severe complications concerning the endoscopic procedure did not occur. CONCLUSIONS: Fiberoptic endoscopic examination of swallowing turned out to be a feasible tool for the diagnostics of pediatric swallowing disorders. Its complications are rare if basic precautions are respected.

MRI and proton MR spectroscopy in acute disseminated encephalomyelitis.

INTRODUCTION: Acute disseminated encephalomyelitis (ADEM) is one of a group of demyelinating disorders of the central nervous system (CNS). It is said to be attributed to an overshooting immunologic response following an infection or vaccination. The clinical course and type of manifestation is heterogeneous. The early application of corticosteroids has been shown to be beneficial to outcome; thus, an early diagnosis is highly desirable. METHODS: The potential diagnostic value of advanced MR techniques such as proton MR spectroscopy and diffusion-weighted imaging (DWI) was investigated in two paediatric patients with ADEM, one of whom had a remitting and relapsing clinical course and presented with additional cranial nerve involvement. Proton MR spectroscopy revealed typical signs of acute demyelination, such as increased macromolecules, not found in other forms of non-necrotising pathology. CONCLUSION: The addition of proton MR spectroscopy and DWI adds to the diagnostic power of MRI in the setting of post-infectious demyelinating disorders of the CNS or ADEM and may obviate the need for biopsy.

Acute haemorrhagic encephalomyelitis (AHEM): MRI findings.

Acute disseminated encephalomyelitis (ADEM) comprises a group of demyelinating disorders of the CNS, of which a haemorrhagic variant indicates the most severe clinical course (AHEM). It is supposed to be caused by an overshooting immunological response following an infection or a vaccination. Restricted diffusion of protons could be demonstrated using DW-MRI in a case of rapidly progressive disease with additional haemorrhage. Hence, the addition of DWI adds to the diagnostic power of MRI in the setting of post-infectious demyelinating disorders of the CNS.

Clinically significant persistence and enlargement of an antenatally diagnosed isolated choroid plexus cyst.

Isolated choroid plexus cysts are usually diagnosed at the time of screening ultrasonography during the second trimester. While they raise the question of underlying chromosomal abnormalities, their clinical course is almost invariably benign with complete resolution often by the third trimester. We report the highly unusual case of a choroid plexus cyst diagnosed at 14 weeks of gestational age with subsequent further enlargement of the cyst, necessitating postpartum neurosurgical intervention.

Early left periventricular brain lesions induce right hemispheric organization of speech.

Right-hemispheric organization of speech has been observed following early left-sided brain lesions involving the language cortex. The authors studied speech organization in hemiparetic patients with pre- and perinatally acquired lesions in the left periventricular white matter using fMRI, and found that right-hemisphere activation correlated with left facial motor tract involvement. This suggests that the impairment of speech motor output from the left hemisphere plays an important role in this alteration of language representation.

Late detection of neuroblastoma in a patient with prolonged cerebellar ataxia without opsoclonus.

A 19-month-old boy presented with acute-onset cerebellar ataxia following immunisation. Ataxia was prolonged with a fluctuating course over a period of two years. Opsoclonus was never observed. Extensive diagnostic studies were negative during this time. Finally, a neuroblastoma was discovered. Ataxia disappeared completely during polychemotherapy. This report suggests that occult neuroblastoma must be considered in any child with unexplained prolonged cerebellar ataxia. Specific investigations are recommended for such cases.

Retraining movement in patients with acquired brain injury using a virtual environment.

We report preliminary results of an ongoing study in which a virtual environment (VE) system is used to facilitate motor relearning of a pouring task in patients with Acquired Brain Injury (ABI). Four subjects were evaluated pre- and post-VE training using virtual-world and real-world tests in which subjects performed a pouring motion while holding a cup. Standard clinical tests of motor and functional ability were also used. Three of four subjects demonstrated improvement in end-point trajectories (cup path) performed during the virtual and real world tests. Clinical test scores also improved. Results indicate that subjects with ABI were able to learn a movement in VE, and generalize this ability to real-world performance of similar and unrelated tasks. VE training appears to be a feasible and promising approach to the rehabilitation of subjects with ABI.

Acute encephalopathy associated with vigabatrin in a six-month-old girl.

PURPOSE: Vigabatrin (VGB) is a new-generation anticonvulsant used in the treatment of partial seizures and West syndrome. Side effects of VGB treatment in adults and children are well described. Acute encephalopathy with VGB has recently been reported in eight adults. They developed stupor, confusion, and electroencephalographic abnormalities after starting VGB. Does the acute encephalopathy with VGB also occur in childhood? METHODS: We describe a 6-month-old girl with infantile Alexander disease with hydrocephalus who developed similar clinical symptoms with apathia, somnolence, and sopor, as well as slowing of the background activity in EEG, 3 days after starting VGB. After exclusion of shunt dysfunction, encephalitis, metabolic dysfunction, and renal failure, VGB was discontinued. RESULTS: During the next 2 days, symptoms subsided, and after 10 days, EEG background activity returned to the one before starting VGB. CONCLUSIONS: Acute encephalopathy associated with VGB in children seems to be very rare, but should not be ignored.

The pyramidal tract in congenital hemiparesis: relationship between morphology and function in periventricular lesions.

Three-dimensional MRI data sets were obtained from 12 young adult patients with congenital spastic hemiparesis caused by unilateral periventricular white matter lesions. The impact of these lesions on corticospinal projections to the upper and lower extremities was assessed on reconstructed semi-coronal planes following anatomical landmarks of somatotopic organization in the precentral gyrus and in the internal capsule: a more anterior plane running through the hand-knob of the precentral gyrus and the anterior portion of the posterior limb of the internal capsule representing projections to the upper extremity, and a more posterior plane running through the top of the precentral gyrus and the middle portion of the posterior limb of the internal capsule representing projections to the lower extremity. In addition, the total lesion extent was determined volumetrically, and Wallerian degeneration was assessed qualitatively in the internal capsule and quantitatively by measuring brainstem asymmetry. We found a strong correlation between motor dysfunction of the upper and lower limb and the lateral extent of the periventricular lesion measured on the respective semi-coronal planes. The total lesion volume and the degree of Wallerian degeneration correlated less strongly, both reaching statistical significance only with motor impairment of the hand.

[Why do newborn infants already suffer from "stroke". Studies of focal, arterial, ischemic infarct]. / Warum erleiden schon Neugeborene einen "Schlaganfall". Untersuchungen zum fokalen, arteriellen, ischämischen Infarkt.

In most cases the etiology of the focal ischemic stroke in newborns is still obscure. We considered patients with congenital hemiparesis due to a lesion in the territory of the middle cerebral artery (shown by CT or MRI) as a model of this infarction. A detailed history including maternal and familiar data was obtained from 9 affected patients. Duplex-sonography was performed and biochemical parameters were analysed in all patients and their mothers. There were no convincing hints for a prenatal (for instance infectious, traumatic or toxic) origin. Also the reconstruction of the perinatal period could not explain the infarction. Duplex-sonography revealed no anatomic variants of the intra- or extracerebral arteries. Haemostasiological results were within normal limits--except the antiphospholipid antibodies, which were detected in 7 of the 9 families (patient or mother). The significance of these results is still unknown. We propose, antiphospholipid antibodies and further haemostasiological parameters should be investigated as near as possible to the neonatal period.

Facial palsy and Lyme borreliosis: long-term follow-up of children with antibiotically untreated "idiopathic" facial palsy.

We report on the follow-up of 28 patients, who were admitted to our hospitals between 1968 and 1984, and who, at that time, were diagnosed as having idiopathic facial palsy. These children were neither tested for Lyme borreliosis (LB) nor did they receive antibiotic treatment. In those days LB was an unfamiliar infection. Today we can assume that approximately 30%-50% of the patients we studied represent actual cases of neuroborreliosis. We, therefore, considered them an appropriate model in studying the spontaneous course of LB in children. the analysis of the questionnaire designed for our study as well as the supplementary clinical and serological reexaminations in some cases provided no evidence that neuroborreliosis led to relevant health disorders in any of the children (follow-up 10 to 26 years, mean 17). The results of our retrospective study led us to conclude that tick-borne facial palsy is relatively benign in children and that neuroborreliosis is insignificantly related to late complications.

De novo direct tandem duplication of a small segment of the short arm of chromosome 7 (p21.22-->22.1).

We report a boy with duplication of a small segment of the short arm of chromosome 7 (46,XY, dir dup (7) (p21.2-->22.1). The boy presented with supravalvular pulmonary stenosis, atrial septum defect and mental retardation. The origin of the additional material from chromosome 7 was confirmed by fluorescence in situ hybridization. This technique in combination with the use of single-copy DNA probes may in future help to delineate the phenotype/karyotype correlation.

Transcranial color duplex sonography of basal cerebral arteries: reference data of flow velocities from childhood to adulthood.

A prospective study on transcranial color duplex sonography (TCCD) was performed with 94 healthy children and adolescents between 3 and 18 years of age (age and sex evenly distributed) in order to provide normal data on angle-corrected ("true") flow velocities and wave-form parameters of the main supra- and infratentorial basal cerebral arteries. Using a 2.0 MHz transducer of a computed sonography system, we examined the anterior, middle, and posterior cerebral arteries of either side transcranially, and the vertebrobasilar system suboccipitally. In all arteries, flow velocities decreased continuously from early childhood to adulthood, while wave-form parameters remained constant. There was no difference in flow velocities, and wave-form parameters between girls and boys. On the average, the angle-corrected flow velocities measured by TCCD were about 10%-20% higher than the reference data provided in "blind" transcranial Doppler studies by other groups for the anterior and posterior cerebral arteries as well as the basilar artery, while there were only small differences in the values for the middle cerebral artery. Side-to-side differences in flow velocities were lower in the middle and posterior cerebral arteries than in the anterior cerebral and the vertebral arteries. The reference data presented here provide a basis for the clinical application of the TCCD method in children and adolescents.

[Cerebral palsy (I)--an analysis of the concept]. / Zerebralparese (I)--Analyse eines Begriffs.

A review of the literature reveals that, until now, there is no clear and commonly accepted definition of the term 'cerebral palsy' (CP). The term is used for different kinds of symptomatology and pathogenesis which are actually quite heterogeneous. A detailed analysis of the criteria for defining indicates that a clear definition is impossible. The contradictions inherent in this term arise form the fact that its usage covers a wide range of clinical and pathogenetic essentials which are often incompatible. The term 'CP' is valuable only from the administrative and therapeutic point of view. But as it is often wrongly interpreted as a diagnosis it should no longer be used in medical and scientific communication.

[Cerebral palsy (II)--clinical symptoms and etiopathogenesis]. / Zerebralparese (II)--Klinische Symptomatik und Atiopathogenese.

In our first report we analysed the criteria for defining the term 'cerebral palsy'. In this paper we deal with the problems arising from this terminology and exemplify this by presenting some case reports. It will be shown that the usage of the term 'CP'--misunderstood as a diagnosis--often hinders the correct analysis of the underlying pathogenesis and aetiology. Thus genetic, therapeutic and forensic implications of the underlying disease or lesion are easily over-looked.