[Standards in the use of fiberoptic endoscopic evaluation of swallowing in Germany : A questionnaire survey]. / Standards bei der Anwendung der fiberendoskopischen Schluckuntersuchung in Deutschland : Eine Fragebogenerhebung.

BACKGROUND: The fiberoptic endoscopic evaluation of swallowing (FEES) is considered to be an indispensable instrumental procedure in the management of patients with dysphagia. The aim of the implemented training curriculum is to raise the quality standards and to contribute to an upgrading of the procedure. OBJECTIVE: The study evaluated to what extent a standardized implementation, evaluation and documentation of FEES takes place in Germany after the introduction of the curriculum. MATERIAL AND METHODS: In this study 603 neurological and geriatric hospitals in Germany were interviewed by the use of an online questionnaire regarding structural features and the course of the investigation. RESULTS: A total of 190 institutions completed the survey. Of the institutions 43.31% had only implemented FEES since the publication of the curriculum. The practical application is increasingly carried out by physicians (59%), the clinical reports and cost recommendations are carried out by speech therapists (62% and 83%, respectively). The practical application by speech therapists increases with increasing level of training. Despite orientation towards the standard protocol according to Langmore, there are differences in the implementation of the anatomical physiological examination, the consistencies and foods administered and the scoring of swallowing-relevant parameters. DISCUSSION: The introduction of the curriculum has led to an upgrading of the FEES and to a strengthening of speech therapy as the implementing professional group. At the current state of the art there is a homogeneous course of the examination in essential aspects but it shows a need for further uniformity. The FEES curriculum could be used as a guiding instrument for further standardization.

Neuropsychological effects of occupational exposure to polychlorinated biphenyls.

In the context of a health surveillance program for former PCB-exposed workers of a transformer and capacitor recycling company in Germany, their family members, employees of surrounding companies and area residents a broad range of cognitive functions covering attention, executive processing, reasoning, memory and motor performance was examined. The study aimed at identifying potential adverse effects of PCB load on cognitive functions. Detailed analysis of PCB burden of the participants revealed rather high correlations of lower and higher chlorinated as well as dioxin-like PCBs. Nearly one half of the participants exhibited increased burden in all three PCB classes whereas only 33 out of 237 participants did not show any increased PCB burden. Thus, data analysis followed a two-fold strategy: (1) Based on studies providing data on PCB exposure of the German general population the PCB burden of every participant was classified as normal (percentile rank PR <95) or increased (PR ≥95). Increased burden with respect to lower (LPCBs) and higher chlorinated (HPCBs) as well as dioxin-like (dlPCBs) PCBs was assumed if a participant showed at least one congener surpassing the PR95 criterion for the respective congener class and (2) Overall plasma PCB level per congener class was used as measure of PCB load. In a multivariate approach using structural equation modelling and multiple regression analysis we found a significant impact of PCBs on word fluency and sensorimotor processing irrespective of the measure of PCB burden (PR95 criterion or overall plasma level). However, no effect of PCB burden on memory, attention, and cognitive flexibility could be demonstrated. Particularly, an increase of LPCBs was associated with an overall reduction of verbal fluency of letter and semantic word generation as well as word production based on a single or two alternating criteria. In addition, participants with increased burden of LPCBs exhibited a time-on-task effect in terms of a stronger decline of performance with increasing duration of the verbal fluency task. Moreover, we found adverse effects of HPCBs on Aiming and of dlPCBs on Line Tracking. Results are discussed in terms of (1) a decrease of cerebral dopamine (DA) with non-coplanar PCBs resulting in an impact on fronto-striatal cerebral structures subserving verbal fluency and motor processing, (2) a PCB-induced reduction of norepinephrine leading to the time-on-task effect with verbal fluency, and (3) adverse effects of PCBs on dopaminergic receptors in the cerebellum resulting in impaired fine motor function.

Depth perception in virtual reality: distance estimations in peri- and extrapersonal space.

The present study investigated depth perception in virtual environments. Twenty-three participants verbally estimated ten distances between 40 cm and 500 cm in three different virtual environments in two conditions: (1) only one target was presented or (2) ten targets were presented at the same time. Additionally, the presence of a metric aid was varied. A questionnaire assessed subjective ratings about physical complaints (e.g., headache), the experience in the virtual world (e.g., presence), and the experiment itself (self-evaluation of the estimations). Results show that participants underestimate the virtual distances but are able to perceive the distances in the right metric order even when only very simple virtual environments are presented. Furthermore, interindividual differences and intraindividual stabilities can be found among participants, and neither the three different virtual environments nor the metric aid improved depth estimations. Estimation performance is better in peripersonal than in extrapersonal space. In contrast, subjective ratings provide a preferred space: a closed room with visible floor, ceiling, and walls.

Emergence and early cognitive function in the elderly after xenon or desflurane anaesthesia: a double-blinded randomized controlled trial.

BACKGROUND: Postoperative cognitive impairment after general anaesthesia, especially in the elderly, is a well-recognized problem. Xenon, known to be an N-methyl-d-aspartate antagonist, may be advantageous. In this study, the early cognitive function in the elderly after general anaesthesia with xenon was compared with that after desflurane. METHODS: After approval by the local ethical committee and after obtaining written informed consent, patients were enrolled in this randomized, double-blinded, controlled study. Thirty-eight patients (65-75 yr old, ASA status I-III) undergoing an elective surgery with a planned duration of 60-180 min were allocated to either the xenon (n = 18) or the desflurane (n = 20) anaesthesia group. The primary outcome was the cognitive Test for Attentional Performance (TAP) with its subtests Alertness, Divided Attention, and Working Memory. After baseline assessment 12-24 h before operation, patients were followed-up 6-12 and 66-72 h after operation. Secondary outcomes were emergence times from anaesthesia and the modified Aldrete score. RESULTS: No difference was found between the groups in the TAP at 6-12 and 66-72 h after operation. In the xenon group, emergence time was significantly faster for the following parameters: time to open eyes (P = 0.001), to react on demand (P = 0.001), to extubation (P = 0.001), and for time and spatial orientation (P = 0.007). The modified Aldrete score was significantly higher after 30, 45 and 60 min in the xenon group. CONCLUSIONS: There was no difference in the postoperative cognitive testing at 6-12 and 66-72 h. Xenon was associated in the elderly with a faster emergence from general anaesthesia than desflurane.

Influence of a 30-min break on divided attention and working memory in resident anaesthetists on daily routine.

BACKGROUND: The aim of this study is to test the hypothesis that a standard 30-min break in a routine 7.5 h period of work makes a difference in cognitive function. METHODS: In a double-blinded, cross-over trial 30 residents in anaesthesia were randomized to receive or not to receive a 30-min break between the assessment times of 07:30 and 14:00. in a normal working day. After at least 28 days the test was repeated with each resident in the opposite group. Primary outcome measure was the Test for Attentional Performance with the subtest of working memory and divided attention. Secondary outcomes are the Stanford Sleepiness Scale and the State-Trait Anxiety Inventory test. RESULTS: The sleep, caffeine and nicotine habits in both groups were comparable. There was no difference between the two groups in the Test for Attentional Performance, Stanford Sleepiness Scale and the State-Trait Anxiety Inventory. The correlation between recovery through sleep and sleep disturbance in the night before investigation to the Stanford Sleepiness Scale (P<0.001 and P=0.003) and State-Trait Anxiety Inventory (P<0.001 and P=0.001) at the 07:30 assessment is significant. For the 14:00 assessment the only significant correlation is between the recovery through sleep with the Stanford Sleepiness Scale (P=0.04) and the State-Trait Anxiety Inventory (P=0.05). CONCLUSION: A 30-min break during a 7.5 h daily routine did not influence cognitive function tests.

The effect of low arousal on visuo-spatial attention.

Clinical and experimental evidence suggests a special role of the right hemisphere for alerting and orienting. However, it is not clear whether these attentional aspects should be taken to be independent or interacting. At least on the functional neuroanatomical level there seems to be an overlap in right parietal and frontal cortical structures. In this sleep deprivation study we examined the effect of different levels of arousal on covert orienting of attention repeatedly over a period of 28 h in 11 healthy subjects. The main finding is a disproportionate and significant slowing of responses to stimuli presented to the left visual hemifield that could only be observed in a state of maximally reduced arousal at 5:00 a.m. Furthermore, a facilitation of attentional shifts to the right could be observed in invalid trials when attention had to be reoriented. These results suggest an interaction of arousal and orienting, at least in situations of maximally reduced activation when attentional asymmetries could be provoked even in healthy subjects. The findings are compatible with a right hemisphere dominance for alerting and orienting, and they are discussed in the light of theoretical accounts of visual orienting.

Spatial attention: more than intrinsic alerting?

It has been proposed that the right hemisphere alerting network co-activates, either directly or via the brainstem, the attention system in the parietal cortex involved in spatial attention. The observation that impaired alertness and sustained attention can predict the outcome of neglect might suggest such a relationship, too. In the present fMRI study, we intended to analyse and compare the functional anatomy of two attentional conditions both involving intrinsic (endogenous) alerting and fixation but differing with respect to the degree of spatially distributed attention by using the same paradigm under two different attentional conditions. In a group of ten participants, both a focused and a distributed visuospatial attention condition evoked similar patterns of activation in dorsolateral prefrontal regions, in the anterior cingulate gyrus, in the superior and inferior parietal cortex as well as in the superior temporal gyrus and in the thalamus. These activation foci were stronger in the right hemisphere under both conditions. After subtraction of the alertness condition with focused spatial attention, distributed spatial attention with stimuli appearing at unpredictable locations within both visual fields induced additional bilateral activations only in the left and right superior parietal cortex and in the right precuneus suggesting that these regions are specific for a more widespread dispersion of spatial attention.

Asymmetries of visual attention after circumscribed subcortical vascular lesions.

OBJECTIVE: To investigate the role of the basal ganglia and the thalamus for basic processes of visuospatial attention METHODS: Fifteen patients with acute circumscribed vascular lesions (10 with haemorrhage and five with infarction) were included in the study. The lesions were confined exclusively to subcortical structures, such as the basal ganglia, internal capsule, and thalamus, which was confirmed by initial CT on the day of referral and MRI taken 14-28 days after clinical onset. These patients were examined with two computerised attentional tasks (one detection and one search task) measuring spatial visual attention. RESULTS: There was a clear attentional asymmetry in patients with right hemispheric lesions (RHLs) in the visual search task. Seven out of eight patients with RHLs tended to be slower and/or missed significantly more target stimuli in the left sided part of a stimulus array consisting of 25 small squares than in right sided parts, although none of these patients showed signs of visual hemineglect in the visual detection task presenting visual information simultaneously to the right and left visual hemispace. All but one of these patients showed lesions in the posterior limb of the internal capsule and the putamen. On the other hand, patients with left hemispheric lesions were not impaired in the search task with only one patient showing more contralesional omissions of target stimuli than could be expected from the behaviour of normal controls. CONCLUSIONS: The results are in line with previous results showing a dominant role of right hemispheric neuronal structures for spatial attention. Furthermore, the data suggest that even with right hemispheric subcortical lesions without cortical involvement deficits in spatial orienting of attention to the left hemispace can be seen. These asymmetries of visual attention in the absence of neglect symptoms are supposed to be caused (1) by a disruption of the motor corticostriato-pallidothalamo-cortical neuronal circuit or (2) by a (partial) disconnection of relevant parts within the posterior attention network-namely, parietal and thalamic structures.

Impaired cognitive performance in drug free users of recreational ecstasy (MDMA)

OBJECTIVES: Ecstasy (3,4-methylenedioxymethamphetamine (MDMA) and related congerers: MDA, MDEA) is the name given to a group of popular recreational drugs. Animal data raise concern about neurotoxic effects of high doses of ecstasy on central serotonergic systems. The threshold dose for neurotoxicity in humans is not clear and serotonin is involved in several functions including cognition. The purpose of this study was to investigate cognitive performance in a group of typical recreational ecstasy users. METHODS: A comprehensive cognitive test battery was administered to 28 abstinent ecstasy users with concomitant use of cannabis only and to two equally sized matched groups of cannabis users and non-users. The sample consisted of ecstasy users with a typical recreational use pattern and did not include very heavy users. RESULTS: Ecstasy users were unimpaired in simple tests of attention (alertness). However, they performed worse than one or both control groups in the more complex tests of attention, in memory and learning tasks, and in tasks reflecting aspects of general intelligence. Heavier ecstasy and heavier cannabis use were associated with poorer performance in the group of ecstasy users. By contrast, the cannabis users did not differ significantly in their performance from the non-users. CONCLUSIONS: The present data raise concern that use of ecstasy possibly in conjunction with cannabis may lead to cognitive decline in otherwise healthy young people. Although the nature of the emerging cognitive disturbance is not yet clear, an impairment of working memory might be the common denominator underlying or contributing to declines of performance in various tasks. The cognitive disturbance is likely to be related to the well recognised neurotoxic potential of ecstasy. The data suggest that even typical recreational doses of ecstasy are sufficient to cause neurotoxicity in humans.

Different mechanisms underly shifting set on external and internal cues in Parkinson's disease.

A set shifting task consisting of the comparison of two digits according to their numerical value or their form guided by an explicit (external cue) or implicit (internal cue) rule was performed by 8 untreated and 19 treated patients suffering from Parkinson's disease (PD) and 15 control subjects. The subjects could not predict the number of trials for a given target. The treated PD patient group exhibited increased post-shift error rates under the internal cue condition. In the external cue condition, only the untreated patients produced more errors when shifting to a new response criterion. Reaction times were prolonged in treated PD patients, irrespective of type of cue. Large interindividual variability within the patient groups is considered as meaningful and indicates individual differences in the neuropsychological impairment and/or the neurotransmission deficit. Pathophysiological and neuropsychological impairments underlying these findings are discussed on the basis of the models of Penney and Young (1983/1986) and Norman and Shallice (1980/1986).

Cognitive slowing in decision tasks in early and advanced Parkinson's disease.

Ten untreated patients with recently diagnosed Parkinson's disease (PD), 9 treated patients with more advanced pathology, and 17 matched normal controls were investigated with three reaction tasks with increasing cognitive load but identical motor requirements: simple reaction, choice reaction with indicative stimuli, and choice reaction with ambiguous stimuli. Times required until a home key was released (= reaction time) and from then until a response key was pressed (= movement time) were recorded. Estimates of pure decision time (overall response time minus movement time in a simple reaction time task) revealed a difference between advanced and early PD patients. Advanced PD patients showed an overall slowing of decision time in the reaction time tasks, but the effect of the cognitive load of the tasks on the decision time was comparable to a control group. The untreated early PD patients performed quite normally in the more simple decision tasks but showed a disproportionate slowing of decision time in tasks with higher cognitive load.