[Irreversible brain death-Part 2. Spinalization phenomena]. / Irreversibler Hirnfunktionsausfall ­ Teil 2. Spinalisationsphänomene.

Spinal automatisms and reflexes, peripheral neurogenic and myogenic reactions are common in patients with irreversible brain death. They are therefore compatible and are even understood by experienced investigators as confirmation of irreversible brain death. This article provides an overview of the phenomenology of irreversible brain death and discusses it from a neuropathological perspective. Furthermore, irreversible brain death is described in order to distinguish it from pathological movements and motor reactions in comatose patients or patients with disturbed consciousness due to severe brain disorders.

[Irreversible loss of brain function-Part 1: pitfalls in clinical diagnosis]. / Irreversibler Hirnfunktionsausfall ­ Teil 1: Fallstricke der klinischen Diagnostik.

A significant change in the fourth update of the German guidelines on determining brain death is that it includes an explicit profile of requirements on physicians involved in ILBF diagnosis. These requisite qualification criteria have also been formulated due to the fact that, in many hospitals, ILBF diagnosis is only rarely carried out and, as a result, uncertainty frequently arises. Typical difficulties emerge at all stages of ILBF diagnosis, and numerous relevant pitfalls arise that need to be taken into consideration and which might also be relevant in the selection of the method(s) to detect irreversibility. The approaches presented here are suited to achieving a valid result in the evaluation of equivocal ILBF.

[Diabetes and the central nervous system]. / Diabetes und Zentralnervensystem.

Diabetes increases the risk of stroke by a factor of 2-4. For primary and secondary stroke prevention, strict glycemic control alone was not superior to standard treatment. However, the risk of stroke in patients with diabetes could be reduced by multimodal risk interventions during the last 20 years by about 50%. Increased glucose levels (poststroke hyperglycemia (PSH)) which indicate a worse prognosis develop in 50% of stroke patients. The potentially beneficial effect of strict glycemic control in PSH by i. v. insulin was neutralized by negative effects of an increased rate of hypoglycemic episodes. Diabetes leads to an increased risk of vascular dementia, but also of the neurodegenerative Alzheimer 's type. Recurrent hypoglycemic episodes affect the timely perception of hypoglycemia by cerebral-mediated mechanisms, which reduces the possibility of counterreactions.

[Telemedicine: Comprehensive coverage and quality - Not a contradiction : Practical experience from the stroke network with telemedicine in northern Bavaria (STENO)]. / Telemedizin: Flächendeckung und Qualität ­ kein Widerspruch : Praktische Erfahrungen aus dem Schlaganfallnetzwerk mit Telemedizin in Nordbayern STENO.

Telemedicine is widely used in the field of stroke treatment. Following the pioneering and implementation phase, the quality of the whole stroke treatment process needs to be ensured in telemedically connected hospitals. This is particular important for telestroke hospitals without neurological expertise and can be achieved by integrating telemedicine into the stroke unit concept and stroke networks. The Stroke Network with Telemedicine in Northern Bavaria (STENO) provides an example of how quality management can be practically implemented. The implementation of STENO has established a network-wide quality management system which has been certified according to DIN EN ISO 9001:2008 since 2011.

[Focal point emergency departments]. / Brennpunkt Notaufnahme.

The number of patients treated in hospital emergency departments in Germany has risen in recent years to approximately 20 million. This escalation also applies to the increasing numbers of patients presenting with neurological symptoms and diseases, which occur in approximately 20 % of emergency patients. In addition to patients with stroke, inflammatory or degenerative central nervous system (CNS) and peripheral nervous system (PNS) disorders who need urgent treatment, more and more patients with nonspecific complaints or conditions attend emergency departments for elective treatment, not least because timely appointments with specialist neurologists in practices could not be obtained. Neurological expertise and presence in emergency departments at the level of specialist standard are therefore indispensable for providing a professional level of treatment, which also corresponds to current legal requirements. The implementation of a generalist emergency physician in Germany, as introduced in some European countries, would mean a retrograde step for neurological expertise in emergency admission management. The discipline of neurology must work together with other emergency disciplines to improve the financing of emergency departments and provide neurologists working there with a substantive curriculum of further and continuing education in emergency-related aspects of neurology. The discipline of neurology has a responsibility to emergency patients within its range of competencies and must, therefore, strengthen and improve its role in healthcare politics and concerning organizational and personnel aspects of neurological emergencies.

[Nutrition and dietary supplements in neurological diseases]. / Ernährung und Nahrungsergänzungsmittel bei neurologischen Erkrankungen.

"Healthy" diets and supplements are widely used for prevention and disease modification in vascular, inflammatory and degenerative neurological diseases. Apart from a large number of cross-sectional and prospective cohort studies, there are only few interventional studies on individual dietary measures. A recent study confirmed the stroke preventive effect of a Mediterranean diet rich in olive oil and nuts; a ketogenic diet reduces seizure frequency in epilepsy. Supplementation of riboflavin, magnesium and coenzyme Q10 are probably effective in migraine prophylaxis. Creatine can improve muscle strength in muscular dystrophy and myositis. There is insufficient evidence to recommend any of the many dietary supplements, such as vitamins, omega-3 fatty acids and other substances for the prevention or improvement of all other neurological diseases. This review critically evaluates the present data on the role of nutrition and dietary supplements in neurological diseases.

[Nutrition and dietary supplements in psychiatric diseases]. / Ernährung und Nahrungsergänzungsmittel bei psychiatrischen Erkrankungen.

Nutrition and specific nutritional supplements can have prophylactic or therapeutic properties with respect to certain psychiatric disorders. A traditional Mediterranean diet, for example, seems to have prophylactic benefits against depression and dementia, whereas overeating and obesity increase the risk for both.Although evidence for nutritional supplements in the treatment of psychiatric disorders is not sufficient for general recommendations, data from observational studies and randomized controlled trials (RCT) seem to point to their use for specific indications. Folate, S-adenosylmethionine (SAM) and eicosapentaenoic acid (EPA), for instance, seem to have antidepressant properties, zinc may be beneficial in attention deficit hyperactivity disorder (ADHD), vitamin B6 (pyridoxine) could reduce extrapyramidal side effects of antipsychotics and N-acetylcysteine (NAC) seems to be effective against negative symptoms, abnormal movements and akathisia in schizophrenia.Psychiatric disorders, in turn, may lead to deficiency of mineral nutrients and vitamins. For instance, vitamin B1 (thiamine) deficiency is common in alcohol-dependent patients and should therefore be considered during withdrawal treatment. Although vitamin malnutrition is uncommon in developed countries, vitamin deficiency syndromes, such as pernicious anemia or Wernicke's encephalopathy are still relevant differential diagnoses.Some psychopharmacological drugs may additionally change the nutritional habits of the patients in an unfavorable way leading to weight gain and obesity and the risk for further psychiatric problems.

[Increased intracranial pressure and brain edema]. / Hirndruck und Hirnödem.

In primary and secondary brain diseases, increasing volumes of the three compartments of brain tissue, cerebrospinal fluid, or blood lead to a critical increase in intracranial pressure (ICP). A rising ICP is associated with typical clinical symptoms; however, during analgosedation it can only be detected by invasive ICP monitoring. Other neuromonitoring procedures are not as effective as ICP monitoring; they reflect the ICP changes and their complications by other metabolic and oxygenation parameters. The most relevant parameter for brain perfusion is cerebral perfusion pressure (CPP), which is calculated as the difference between the middle arterial pressure (MAP) and the ICP. A mixed body of evidence exists for the different ICP-reducing treatment measures, such as hyperventilation, hyperosmolar substances, hypothermia, glucocorticosteroids, CSF drainage, and decompressive surgery.

[Between patient autonomy and the ethics of care : difficult end-of-life decision-making in intensive care]. / Zwischen Selbstbestimmung und Fürsorge : Schwierige intensivmedizinische Entscheidungen am Lebensende.

The article illustrates the ethical principles and the legal context of end-of-life decision-making in the intensive care unit (ICU). After a long period of preference for medical paternalism, patient autonomy has now developed into the standard for medical decision-making. Medical interventions are justified by medical indications and patient consent. A competent patient may make a decision which is unreasonable from the physician's view. A mentally incompetent patient will can be explored by studying the written anticipated advance directive in which the patient has formulated value priorities. The binding character of patient advance directives was regulated in German law in 2009; the decision has to be made in a dialogue between the physician and the proxy. A judgment of the German High Court in 2010 confirmed that even an active withdrawal of therapeutic measures, such as mechanical ventilation is legal.

[Core curriculum Medical intensive care medicine of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]. / Curriculum Internistische Intensivmedizin.

Medical intensive care medicine treats patients with severe, potentially life-threatening diseases covering the complete spectrum of internal medicine. The qualification in medical intensive care medicine requires a broad spectrum of knowledge and skills in medical intensive care medicine, but also in the general field of internal medicine. Both sides of the coin must be taken into account, the treatment with life-sustaining strategies of the acute illness of the patient and also the treatment of patient's underlying chronic diseases. The indispensable foundation of medical intensive care medicine as described in this curriculum includes basic knowledge and skills (level of competence I-III) as well as of behavior and attitudes. This curriculum is primarily dedicated to the internist in advanced training in medical intensive care medicine. However, this curriculum also intends to reach trainers in intensive care medicine and also the German physician chambers with their examiners, showing them which knowledge, skills as well as behavior and attitudes should be taught to trainees according to the education criteria of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN).

[Acute diseases of the brain and heart : A reciprocal culprit-victim relationship]. / Akute Erkrankungen von Gehirn und Herz : Wechselseitige Täter-Opfer-Beziehung.

The reciprocal culprit-victim relationship between the brain and the heart leads to dysfunction and damage to the other organ, especially in acute and severe diseases of one of both organs. In addition, both organ systems can be affected by identical systemic processes, e. g., arteriosclerotic changes. Cardiac embolic formation and pumping failure lead to focal cerebral ischemia or global hypoxia. Cerebral diseases leading to cardiac changes are acute cerebrovascular attacks such as cerebral infarction, intracerebral hemorrhage and subarachnoid hemorrhage, as well as epileptic seizures. The pathophysiological mechanisms of changes of the brain-heart axis include cerebrally induced autonomic dysregulation, neuroendocrine regulatory disorders, and systemic inflammatory processes. The effects on the heart are evident in up to 75% of patients with acute brain diseases leading to ECG changes, arrhythmias, increase in cardiac enzymes and myocardial damage even to sudden cardiac death. For this reason, cardiac monitoring should be provided in severe acute brain diseases.

[Critical illness myopathy and polyneuropathy]. / Critical-illness-Myopathie und -Polyneuropathie.

An average of 50-80% of patients treated in the intensive care unit is affected by disturbances of neuromuscular functions due to damage to the nerves and muscles, which has led to the terms critical illness polyneuropathy and myopathy. Both components occur in 30-50% of patients, while the others predominantly show a pure myopathy, while pure neuropathy is rare. Meanwhile, the descriptive term of the concept as intensive care unit-acquired weakness (ICUAW) is preferred. The most significant risk factors for the development of ICUAW are sepsis, multiorgan dysfunction and acute respiratory distress syndrome (ARDS). In at least one third of patients, persistent impairment by paralysis, sensory disturbances and balance problems persist when they leave the ICU. At approximately 10%, these leg-accentuated and highly everyday relevant disorders persist over the first year after ICU therapy. Pure myopathy rarely leads to residual disturbances, while the neuropathic component is responsible for long-term impairments.

[Party and designer drugs : From ecstasy and crystal meth to angel's trumpet]. / Mode- und Designerdrogen : Von Ecstasy und Crystal Meth bis Engelstrompete.

BACKGROUND: The growing abuse of party and designer drugs increases the number of emergency cases related to drug consumption. OBJECTIVES: Presentation of the scenario as well as the diagnostic and therapeutic principles of emergency management and characterization of the most frequently abused drugs and its effects. MATERIALS AND METHODS: Evaluation of drug statistics, and work-up and discussion of expert publications and recommendations. RESULTS: In 2014, there were 1032 drug-related deaths, which is 3 % more incidents than in 2013. However, there is a drastically and steadily increasing consumption of newer enhancing drugs such as crystal meth. Throughout Europe, there are about 1500 designer drugs that are disguised as so-called spice mixtures or bath salts. In addition to stimulating substances, hallucinogenic and sedative drugs are also consumed. Common nonspecific symptoms of emergency drug overdose are psychosis, impaired consciousness, seizures, and disorders of various internal organs. Based on the clinical presentation, different neurotransmitter syndromes can be distinguished and the drug etiology can be diagnosed and proven by laboratory assays. Therapy includes symptom-oriented measures. CONCLUSIONS: Knowledge of different party and designer drugs and their complications enables prompt emergency management.

[End-of-life Decisions]. / Therapieentscheidungen am Ende des Lebens.

End-of-life decisions in neurology have repeatedly given occasion for controversies. Often these are based on lack of knowledge of the juridical and ethical framework conditions. This review describes the juridical-ethical basis for the implementation and continuation, and for withholding and withdrawal of life-sustaining measures, in particular, the significance of medical indication and patient's will. The different forms of assisted dying ("Sterbehilfe"), namely homicide by request, assisted suicide, palliative symptom relief and treatment withdrawal are characterized. The "Principles of the German Medical Association" in end-of-life situations are illustrated. Specific features of neurological treatment scenarios are discussed such as the preclinical and clinical emergency and acute situation, the decompensation of stable chronic severe brain injury situations, and chronically progressive neurodegenerative diseases. In the latter situations, an early "Advance Care Planning" could contribute to improved end-of-life decision-making.

Acute stroke management in the local general hospital.

BACKGROUND AND PURPOSE: The majority of stroke patients are treated in local general hospitals. Despite this fact, little is known about stroke care in these institutions. We sought to investigate the status quo of acute stroke management in nonspecialized facilities with limited equipment and resources. METHODS: Four general hospitals located in smaller cities of a rural area in Germany participated in this study. The 4 hospitals were similar in structure and technical equipment; none had a CT scanner in-house. We reviewed the medical records of every stroke patient hospitalized in 1 of the 4 hospitals within a period of 8 weeks within 1 year. RESULTS: We collected data of a total of 95 patients at all 4 hospitals. The frequency of diagnostic tests was low: at least 1 CT scan was obtained in only 36.8% of all cases, whereas diagnostic methods available in-house were used more frequently, such as Doppler ultrasound (49.0%), echocardiography (42.3%), and 24-hour ECG registration (48.4%). Each hospital had a different therapeutic approach. Main therapeutic options were the use of pentoxyfilline (0% to 90.5%), osmodiuretics (0% to 90%), piracetam (0% to 93.3%), and hydroxyethylstarch (4.8% to 30%). Medication for long-term secondary prevention was given to 69.8% of all patients. CONCLUSIONS: This study provides one of the few data samples reflecting stroke care in smaller general hospitals. The findings demonstrate a partially suboptimal level of care in these institutions. To achieve future improvements, extended human and technical resources as well as research for stroke care should not be restricted to academic stroke centers.

Serum procalcitonin monitoring for differential diagnosis of ventriculitis in adult intensive care patients.

The objective of our study was to assess the value of serum procalcitonin (PCT) monitoring in the differential diagnosis of ventriculitis in adult intensive care (ICU) patients. We analyzed 15 consecutive patients with ventriculitis in which a ventricular catheter had been inserted and contrasted these data with the observations in 10 patients with community-acquired bacterial meningitis. Cerebrospinal fluid (CSF) and blood samples were collected daily to assess serum PCT, C-reactive protein (CRP) and CSF leukocyte count. PCT levels were normal or slightly elevated in patients with ventriculitis with either positive or negative CSF bacterial culture but elevated in patients with bacterial meningitis. A PCT cut-off value of 1.0 ng/ml or more showed a specificity of 77% and a sensitivity of 68% for ventriculitis with positive CSF bacterial culture. Serum PCT levels reflected more accurately the time phases of disease during therapy. We conclude that the monitoring of serum PCT alone is not helpful for the differential diagnosis of ventriculitis, in contrast to that of bacterial meningitis. The value of PCT as an additional marker with which to assess the efficacy of therapy in ventriculitis is suggested, but requires further assessment.

Critical illness polyneuropathy: clinical findings and cell culture assay of neurotoxicity assessed by a prospective study.

OBJECTIVE: First, to evaluate the role of typical intensive care-related conditions like sepsis, prolonged ventilation, drug effects and metabolic disorders in the pathogenesis of critical illness polyneuropathy (CIP); second, to investigate the possible significance of patient serum neurotoxicity assessed by an in vitro cytotoxicity assay with respect to CIP development. DESIGN: Prospective study. SETTING: Neurological intensive care unit. PATIENTS AND PARTICIPANTS: Twenty-eight patients who were on mechanical respiratory support for at least 4 days during a 21-month study period. RESULTS: Diagnosis of CIP was established by clinical and electrophysiological examination in 16 (57%) of 28 patients. Patients were investigated on days 4, 8 and 14 of mechanical ventilation. Two of 16 CIP patients had clinical signs of polyneuropathy at initial examination. Factors that correlated significantly with the development of CIP were: the multiple organ failure score on day 8 of ventilation, the total duration of respiratory support, the presence of weaning problems and the manifestation of complicating sepsis and/or lung failure. The in vitro toxicity assay showed serum neurotoxicity in 12 of 16 CIP patients. Electrophysiological investigations yielded false positive results of the toxicity assay in six patients (not developing CIP) and false negative results in four patients (developing clinical and electrophysiological signs of CIP). Statistical analysis did not reveal a significant correlation between the diagnosis of CIP and the finding serum neurotoxicity. CONCLUSION: The results support the hypothesis of a multi-factorial aetiopathogenesis of CIP. We observed serum neurotoxicity in the majority of CIP patients, indicating the possible involvement of a so far unknown, low-molecular-weight neurotoxic agent in CIP pathogenesis.