[Laparoscopic cholecystectomy--a never-ending success story?]. / Serie Schlüssellochchirurgie, Teil 3: Cholezystektomie. So lassen sich Komplikationen vermeiden.

Today, laparoscopic cholecystectomy is the most commonly used surgical laparoscopic intervention. The surgeon must familiarize himself with the patient's biliary anatomy using appropriate imaging techniques. Prior to the intervention, an esophago-gastro-duodenoscopy is performed to exclude a florid ulcer. The most serious complication is an unrecognized injury to the common bile or hepatic duct. Intra-operative bleeds can usually be managed endoscopically. If the pathologist diagnoses a gallbladder carcinoma the patient must undergo appropriate staging and a conventional revision procedure (removal of any metastases that might be present and resection of the gallbladder bed).

Glutathione S-transferase polymorphism in Parkinson's disease.

Glutathione S-transferases (GSTs) are involved in the detoxification of endogenous or exogenous toxins, which may play a role in the pathogenesis of Parkinson's disease. We genotyped the Glutathione-S-Transferase isoenzymes GSTM1 and GSTT1 by polymerase chain reaction in order to evaluate different gene polymorphisms of these isoenzymes in 149 parkinsonian and 99 control subjects. No differences appeared between both groups regarding the frequencies of the homozygous deletion of GSTM1 (odds ratio 1.021; 95% CI [0.613; 1.699], p < 0.521 Fisher's exact test) and GSTT1 (odds ratio 1.514; 95% CI [0.811; 2.824], p < 0.127). Age of onset of PD did not correlate to GSTM1 and GSTT1 polymorphisms. These results do not support the hypothesis of a possible impact of GSTM1 and GSTT1 detoxification activities in the pathogenesis of Parkinson's disease.

[Catamnestic results and questions in neurologic rehabilitation--in relation to encephalomyelitis disseminata (multiple sclerosis)]. / Katamnestische Ergebnisse und Fragen zur neurologischen Rehabilitation--anhand der Encephalomyelitis disseminata (Multiple Sklerose).

Owing to the changes in the laws governing the health care system, medical rehabilitation for patients treated as in-patients is becoming increasingly a subject of discussion, especially for chronic illnesses. Using multiple sclerosis (encephalomyelitis disseminata) as an example, a special database is used to examine the courses, contents, improvements or deteriorations seen in in-patient rehabilitation as experienced by 901 patients who were in rehabilitation clinic in the years 1995-1998. This period was selected to allow the ascertainment of possible effects of far-reaching changes in the law taking effect from autumn 1996 onward. The EDSS (Expanded Disability Status Scale) was applied, and patients financed by statutory health insurances were compared with those financed by pension insurance funds for length of stay, outcome and therapeutic content. In the case of 256 patients being financed by pension funds it was possible to use the classification of therapeutic services as a basic tool and the connection with degree of disability was recognizable: different degrees of severity of the illness led to different treatment programmes. Health insurance patients were always more severely ill than those financed by pension insurance. Interestingly, the legal changes had no effect on the treatment outcomes of the patients. The data retrieved confirm the efficacy of the rehabilitation programmes.

Prolongation of the frequency-corrected QT dispersion following cerebral strokes with involvement of the insula of Reil.

Prolonged QT dispersion is a risk factor for cardiac arrhythmias and sudden death in patients with cardiac and peripheral artery diseases, but there is no study about prolonged QT dispersion in patients with ischaemic strokes. The insular cortex may play an important role in the genesis of cardiac arrhythmias and sudden death. In our study with 40 patients suffering from unilateral hemispheric ischaemic stroke, the QT dispersion was analysed and correlated to the location of the cerebral lesion. We found that in patients with involvement of the insular cortex, the QT dispersin is significantly longer than in those without insular involvement.

Impaired visual function in focal idiopathic dystonia.

Visual dysfunctions have previously been reported in Parkinson's disease and Huntington's chorea. To further characterize the pathophysiology of vision in basal ganglion diseases, we studied visual functions in focal dystonic syndromes. Colour discrimination and visual contrast perception were investigated in 37 patients with focal idiopathic dystonia (ID; 20 spasmodic torticollis, 17 blepharospasm) and in age- and sex-matched healthy volunteers using the Farnsworth-Munsell 100-hue test and stationary contrast targets (Vistech plates). The mean total error score as well as the partial scores for the 'red-green' and the 'blue-yellow' axes in the Farnsworth-Munsell 100-hue test of the patients with ID were significantly elevated as compared to controls (spasmodic torticollis mean total error score 90.9 +/- 67.6, controls: 16.6 +/- 10.2; blepharospasm mean total error score 119.4 +/- 78.6, controls: 22.7 +/- 7.9). Additionally, the spatial contrast sensitivity was impaired in patients as compared to controls. The results indicate that the visual system is affected in ID. The visual disorder may be related to an imbalance of certain neurotransmitters in the visual system of patients, e.g. in the catecholaminergic pathways.

[Neurologic consultation practice in a general hospital of a rural area]. / Neurologische Konsiliartätigkeit an einem Allgemeinkrankenhaus im ländlichen Raum.

The long-standing consultant service for neurological patients in a general hospital requires questions to about the dimensions and efficiency of being answered cooperation between a general hospital and a neighbouring neurological clinic with a casualty ward and neuroradiology. From 1987 to 1995, 1471 patients with neurological diagnoses were observed retrospectively. The small number of requested consultancies (4-5%) was conspicious related to the total member of patients treated in the general hospital. About 25% of the recommendations of the consultants were realized. The percentage of pensioners and housewives was distinctly higher (45%). With the help of the diagnosis "concussion of the brain" good cooperation was observed between the general physicians to whom the consultant's recommendations had been passed on and the neurological casualty ward. The results, tendencies and possibilities for improvement of interdisciplinary cooperation are discussed.

[Facial-oral therapy in craniocerebral diseases]. / Fazioorale Therapie (FOTT) bei Schädel-Hirn-Erkrankungen.

Presented are 16 patients (4 women and 12 men) of a neurological early rehabilitation ward with various neurological initial situations. Diagnoses range from traumatic brain damages to hypoxic brain lesions caused by complications during anaesthesia, from subarachnoid haemorrhages with consecutive complications, to intracerebral haemorrhages. All patients have been examined at the beginning by an ENT specialist and/or phoniatrically. Regarding the structure of the patients' complex neurological symptoms, they were all suffering from more or less severe impairments in the faciooral tract. At the beginning of the multifocal neurological rehabilitation treatment all patients had been submitted to dysarthrophony and/or dysphagia examination according to K. Coombes. We will compare results, objectives and therapeutic developments during the faciooral therapy including physiotherapy and ergotherapy based on the Bobath concept. We will further discuss the periods between occurrence of the damaging event and the onset of multimodular neurological rehabilitation. Further discussed is the influence of secondary complications on the therapeutic development and, finally, the clinical-social outcome of the patients.

[Whiplash injuries of the cervical spine. Neurologic contribution to diagnosis. Therapy and expert evaluation]. / Beschleunigungsverletzungen der Halswirbelsäule. Beitrag der Neurologie zu Diagnostik, Therapie und Begutachtung.

The cervical spine is an extremely complex functional unit and has always been the subject of impassioned discussions among surgeons, orthopedic specialists and neurologists. In the presence of injuries affecting this section of the spine, which sometimes have grave consequences--including implications for legal insurance aspects, neurologists are usually at the end of the line when it comes to diagnosis and treatment. In fact, in view of the clinical and technical neurophysiological options available to neurologists, it would be desirable for them to be involved as early as possible. In this paper the relative value of neurology, compared with orthopedics and surgery, in the diagnosis and treatment of whiplash injury to the cervical spine is discussed. The newer options available--particularly in neurophysiology--are highlighted, as are the differential diagnosis and problems concerned with official expert assessments, which also involve other specialties.

[Cranial magnetic resonance tomography--value in diagnosis of dementia. Important additional information for differential diagnosis]. / Kraniale Magnetresonanztomographie-Stellenwert in der Demenzdiagnostik. Wichtige Zusatzinformationen für die Differentialdiagnose.

The clinical data and the magnetic resonance imaging (MRI) findings of 41 patients with clinically diagnosed dementia of the Alzheimer type (DAT) and 20 age-matched healthy controls were evaluated with the aim of determining the value of MRI in the diagnosis and differential diagnosis of dementia. Patients and controls with cerebrovascular risk factors, including a history of stroke, were excluded from the analysis. The MRI findings of patients with dementia revealed pathological changes, in particular cerebral atrophy (p < 0.0005), significantly more frequently than did those of controls (p < 0.005). Periventricular demyelinisation and lesions of the white matter were found in 23 (56%) patients, and in 6 (30%) of the controls. MRI revealed one case each of subdural hematoma, hydrocephalus and cerebral amyloid angiopathy. In 14 patients, the detection MRI scans of cerebral infarctions or hematomas suggested a major vascular component of the dementia. In contrast, lesions of the white matter can not reliably by ascribed to a vascular etiology. On the basis of our findings, it is concluded that cranial MRI is of great value for the differential diagnosis of dementia, even when the clinical diagnosis of Alzheimer's dementia is probable and cerebrovascular risk factors are absent.

[Group work in neuropsychological therapy]. / Gruppenarbeit in der neuropsychologischen Therapie.

The section "Psychology in the Neurological Department" at the Hardtwaldklinik I, of Bad Zwesten, can look back at 18 years of experience with neuropsychological group therapy within the neurological rehabilitation setting. The functions of the psychological section can be subdivided into diagnostic tasks on the one hand, and therapeutical interventions concerning cognitive and emotional aspects on the other, with psychotherapy having a mediating function, depending on the individual indication at hand. Depending on the kind and degree of the neurological impairment present, and based on detailed diagnostics, the patients are treated in the field of cognitive performance either individually or in groups. There are groups with different degrees of difficulty in line with type and extent of the selective disorders present. Experiences have shown that neuropsychological group therapy in particular is aimed at a holistic approach to the pattern of interference and the patient's personality. The possibilities for intervention and therapy are diverse, and range from play material to computer-based individual or group therapy. In the framework of internal quality assurance, experiences have shown that the effects of neuropsychological group therapy are not easily validated. In this respect, the subjective estimates of therapist and patient are the predominant, if not the only, criteria in terms of improved mental functioning.

The motor performance test series in Parkinson's disease is influenced by depression.

The Motor Performance Test Series (MPTS) is widely used for treatment control in Parkinson's disease (PD). To elucidate the possible influence of depression on the fine motor skills in PD, 54 patients with idiopathic PD were investigated with the MPTS. 27 patients with major intensity of depression were compared to 27 age and motor disability matched patients with minor symptoms of depression, evaluated by the Zung depression scale. As determined by the subtest aiming, a significant lower ability for precise, quick complex arm-hand movements in depressed Parkinsonian patients was found. This result may be explained partly by motivation deficits in depressed patients with PD. On the other hand impairment of special motor loops including frontal lobe projections to specific thalamic subnuclei or to the caudate nucleus may cause disturbances of the subtest aiming in depressed Parkinsonian patients. On the basis of these findings impaired aiming may be explained by diminished ability for complex, semivoluntary movements in depressive Parkinsonian patients. The influence of psychiatric comorbidity on MPTS subtest aiming has to be considered in further therapy studies using evaluation of motor deficits by MPTS.

Visual hallucinosis: the major clinical determinant of distorted chromatic contour perception in Parkinson's disease.

Recently distorted chromatic contour perception has been demonstrated in Parkinson's disease (PD). The aim of our study is to determine the clinical factors which influence chromatic contour perception in PD. Chromatic and achromatic contour perception, colour discrimination and clinical data were evaluated in 73 patients with PD. We used a computer-aided method to determine the chromatic fusion time (CFT) which indicates the acuity of monochromatic contour perception. Chromatic CFT was generally shortened in patients as compared to controls (p < 0.01), whereas achromatic CFT was not significantly different. Variance analysis revealed the ability of colour discrimination and the risk of visual hallucinations as statistically significant (p < 0.05) variables influencing contour perception of certain stimuli. In contrast, disease stage, disease duration and disease severity have no relevant effect on chromatic contour perception in Parkinson's disease. On the basis of those properties one may suggest that distorted chromatic contour perception is due to an impairment at a central stage of visual processing in PD and an imbalance of the serotonergic system. Whether CFT is a reliable method to predict the individual risk of hallucinosis in PD has to be evaluated.

[Follow-up of 64 patients with traumatic and atraumatic craniocerebral lesions--a needs analysis of up-to-date rehabilitation possibilities]. / Verlaufsbeobachtung von 64 Patienten mit traumatischen und atraumatischen Schädel-Hirn-Schädigungen--Eine Bedarfsanalyse zeitgemässer Rehabilitations-möglichkeiten.

A critical examination was carried out on 64 selected case histories of craniocerebral trauma patients, with extraction of as exact data as possible concerning each patient's disease course a difficulty. The majority of the patients severely injured, the study elicited problems during early rehabilitation and discusses the patients' outcomes in view of their vocational and social reintegration. Also dealt with are the problems met with relative to course observation and documentation. Later phases of rehabilitation frequently are complicated by functional loss and deficits, and long waiting lists run counter to the basic idea of early rehabilitation. Treatment shortcomings during the early phase of the acute neurological condition are indicative of the patients' future fate. Discussed is the relevance of rating scales for assessing the course of severe conditions. In view of an ongoing state-of-the-art discussion concerning the concept of neurological early rehabilitation in the narrower sense, a clearly structured treatment approach specifying minimum requirements in terms of staffing, contents, and methods, as well as systematic internal quality control efforts are demanded.

[Multiple sclerosis: atrophy of the corpus callosum and psychosyndrome]. / Multiple Sklerose: Balkenatrophie und Psychosyndrom.

Examination with magnetic resonance imaging of 176 patients with multiple sclerosis showed that corpus callosum (CC) atrophy is common. The thinning of the CC depends on the extension of the coalescent periventricular white matter changes. A highly significant association was found between CC-atrophy and, the severity of organic mental disorder.

[Prognostic significance of lacunar lesions in magnetic resonance tomography in multiple sclerosis]. / Die prognostische Bedeutung von lakunären Herden im Magnetischen Resonanztomogramm bei Multipler Sklerose.

175 patients with definite multiple sclerosis underwent nuclear magnetic resonance imaging. T1-weighted images showed in 59 patients (34%) periventricular lesions with a central area of decreased signal intensity. They appear as lacunar defects in the walls of the lateral ventricle system. In accordance with neuropathological findings we suggest that in these plaques a cystic degeneration has replaced gliosis. Patients with cystic defects are characterized by a high activity of the disease (e.d. increased annual production of plaques) and a poor prognosis. Lacunae are found in the early stages of the disease and provide a prognostic sign in multiple sclerosis.

[The cardiovascular system and cerebrovascular disorders in the elderly with special reference to pacemaker therapy]. / Herz-Kreislauf-System und zerebrovaskuläre Störungen im Alter, unter besonderer Berücksichtigung der Schrittmachertherapie.

Elderly patients are problem patients, especially as far as the selection of the best therapy is concerned. The reduction of cerebral efficiency is caused by a reduced metabolism and blood circulation of the brain. Extracerebral disturbing factors comprise obstructions of the vascular system, disturbances of the pumping action of the heart, changes of blood pressure and a lack of substrates. The symptoms are of a great variety, they may occur in a slowly progressive or an acute form. The pacemaker treatment shows the close connection between diseases of heart and circulation and the cerebral vascular circulation. This treatment improves the contraction of the heart, but it also causes an improvement of the cerebral vascular situation, especially in patients with chronical bradycardiac arrhythmias, demonstrated by a series of EEG investigations and clinical controls. New methods of "physiological" heart stimulations are important in patients having cerebralsclerotic disturbances, whereby the collaboration between cardiologists and neurologists should be intensified.

[Cerebrovascular diseases in advanced and very old age. Significance and correlation of computer tomography studies of the skull and EEG]. / Zerebrovaskuläre Erkrankungen im höheren und hohen Lebensalter. Bedeutung und Korrelation Computer-tomographischer Untersuchungen des Schädels und des EEG.

118 patients between 50 and 90 years of age with an acute cerebrovascular disease were examined. While cranial computerized tomography was helpful in the differential diagnosis of ischemia or hemorrhage it was less helpful in the diagnosis of other cerebrovascular diseases (abnormalities, stenoses). Frequent EEG-analysis permitted in the cases of cerebral ischemia or hemorrhage prognostic conclusions as well as computerized tomography did. Atypical clinical syndromes could be better diagnosed by computerized tomography than by EEG.

[Neurophysiological findings concerning geriatric patients with pacemaker (author's transl)]. / Neurophysiologische Befunde bei Schrittmacherpatienten in der Geriatrie.

Since 1977 neurologic-psychiatric as well as EEG-measurements have been compared in patients before and up to 2 years after implantation of permanent pacemaker system. Standardized EEG-measurements of a conventional method and EEG-spectrograms, so far executed in 138 cases, showed better cerebral blood supply and improvement of metabolic data in patients suffering from chromic bradyrhythmia (67 cases). Measurements in patients with acute disturbances in cardiac rhythm (38 cases) remained approximately the same before and after pacemaker implantation. Special cardiologic measurements combined with EEG-findings confirmed the assumption that the symptoms observed in 8 patients with "passage syndromes" during the postoperative phase were caused by a cerebral oxygen deficiency.