[Neuroimmunology of allergic rhinitis part 2 : Interactions of neurons and immune cells and neuroimmunological units]. / Neuroimmunologie der allergischen Rhinitis Teil 2 : Interaktionen von Neuronen und Immunzellen und neuroimmunologische Einheiten.

Allergic rhinitis is an IgE-mediated, type­2 inflammatory disease. neuropeptides are released by neurons and interact with immune cells. Via colocalization, neuroimmune cell units such as nerve-mast cell units, nerve-type 2 innate lymphoid cell (ILC2) units, nerve-eosinophil units, and nerve-basophil units are formed. Markedly elevated tryptase levels were found in nasal lavage fluid and were strongly associated with neuropeptide levels. A close anatomical connection allows bidirectional communication between immune and neuronal cells. Transient receptor potential vanilloid 1 (TRPV1) and transient receptor potential ankyrin repeat 1 (TRPA1) are critically involved in immunological reactions in the setting of allergic rhinitis. Neuroimmunological communication plays an important role in the inflammatory process, so that allergic rhinitis can no longer be considered a purely immunological disease, but rather a combined neuroimmunological disease.

[Neuroimmunology of allergic rhinitis : Part 1: Cellular and humoral basic principles]. / Neuroimmunologie der allergischen Rhinitis : Teil 1: Zelluläre und humorale Grundlagen.

Allergic rhinitis (AR) is a very common disease with a high prevalence worldwide. It is an IgE-mediated type 2 inflammatory disease following exposure to inhalant allergens. A multitude of different neuropeptides including substance P, vasoactive intestinal peptide (VIP), calcitonin gene-related peptide (CGRP), nerve growth factor (NGF), and neuromedin U (NMU) can be released via peripheral axon or central reflexes, interact with immune cells, and thus contribute to neurogenic inflammation which causes the nasal hyperreactivity (NHR) characteristic of AR. Independent production of neuroendocrine hormones and neuropeptides by immune cells has also been demonstrated. Neuro-immune cell units arise when immune and neuronal cells colocalize, for which typical anatomic regions are, e.g., the mast cell-nerve functional unit. The focus of this review is the elucidation of neuroimmune communication mechanisms in AR.

[From reconstruction to function : Hands-on training in tympanoplasty using real-time feedback]. / Von der Rekonstruktion zur Funktion : Tympanoplastik-Training mit Real-Time-Feedback.

BACKGROUND: Surgery of the middle ear requires a very high level of fine motor skills. Due to the increased potential for complications in middle ear operations, it is appropriate to acquire these skills beforehand by operating on a model. OBJECTIVE: How satisfactory is the training on suitable models? Are the skills acquired from working on a model transferable to intraoperative situations? Will the type of model and its use for training influence ear surgery in the future? MATERIAL AND METHODS: Available publications and own experiences with the Dresden tympanoplasty model (DTM) are analyzed and discussed. RESULTS: Although middle ear surgery makes very high demands on the surgeon and there is a significant risk for severe complications to the ear as a sense organ, there are currently very few options to train surgeons in advance. The DTM is a validated training model, which is capable of closing this gap. Due to the possibility of using a real-time feedback variation of the model, the understanding for reconstruction quality and intraoperative acoustic stress can be improved. The translation of the real-time feedback idea into actual middle ear surgery can improve reconstruction quality in the future. CONCLUSION: Training on suitable models is indispensable, especially when training as a surgeon to carry out middle ear operations. Adding another sense perception to the internal and external quality assessment of tympanoplasty by inclusion of the real-time feedback option, can optimize learning and operating processes.

[Learning curve of the ENT mirror examination : Goal-oriented curriculum planning for psychomotor learning]. / Lernkurve der HNO-Spiegeluntersuchung : Zielgerichtete Lehrveranstaltungsplanung zu einer psychomotorischen Fertigkeit.

BACKGROUND: Learning complex psychomotor sequences requires a high number of training sessions to achieve precise execution. In the current student curriculum there are only few study sessions available to achieve this level of competence. OBJECTIVE: The objective of the current study was to record the learning curve of psychomotor proficiency using the example of the ENT mirror examination. Particular focus was on the number of practice sessions needed to achieve safe execution of the examination and the learning success as assessed in partial investigations. MATERIALS AND METHODS: During a 5­day period of their ENT block internship, students were taught and practiced the correct ENT mirror examination. At the end of each internship day, the learning progress of a total of 48 students was statistically evaluated by a checklist-based assessment. RESULTS: In the full study and in the partial studies, a significant increase in points was shown over the days, which proved a growing learning curve of the students. The students required at least five training sessions (each 45 min) for safe execution (Bloom taxonomy level 3) and six training sessions for routine execution (Bloom taxonomy level 4; Nationaler kompetenzorientierter Lernzielkatalog Medizin, NKLM, level 3a). CONCLUSION: Looking at the ENT mirror examination, an improvement in psychomotor skills was shown with an increasing number of practice sessions. This study is therefore representative as an example of resource-optimized curriculum planning based on the previously defined level of competence that students should have attained by the end of a course.

Severe dysosmia is specifically associated with Alzheimer-like memory deficits in nondemented elderly retirees.

OBJECTIVES: To determine whether or not (1) impaired olfactory function is associated with impaired memory on neuropsychological testing in healthy retirees, and if so then (2) whether memory impairment is most consistent with a mesiotemporal rather than frontal system disorder. METHODS: 173 independent residents of a continuing care retirement community were studied. Subjects completed the University of Pennsylvania Smell Identification Test (UPSIT) and a battery of both general and specific cognitive measures that included the Mini-Mental State Examination (MMSE) and the Executive Interview (EXIT25). Subjects were examined twice over 3 years. RESULTS: UPSIT performance was normal in 21% and in the 'anosmic' range in 25% of subjects. Anosmic UPSIT performance was associated with significantly worse performance on all cognitive tests. However, only short-term verbal memory was independently associated with UPSIT-defined anosmia. This association remained significant after adjusting for the other cognitive and sociodemographic variables. The memory deficits of anosmic subjects were qualitatively consistent with a cortical type (type 1) dementing illness such as Alzheimer's disease (AD). Over time, UPSIT-defined 'anosmic' cases suffered significantly greater declines on both the MMSE and the EXIT25, independently of baseline age, gender and MMSE score. CONCLUSIONS: Impaired odor identification in individuals without overt dementia is associated with an AD-like memory impairment and an increased rate of cognitive decline. The comorbid association of these deficits is consistent with the known hierarchical spread of preclinical AD pathology and may be a specific indicator of future clinical AD dementia.

Frontal MRI findings associated with impairment on the Executive Interview (EXIT25).

We examined the association between the Executive Interview (EXIT25), a bedside measure of executive control, and regional magnetic resonance imaging (MRI) pathology among 52 consecutive geriatric patients presenting to a university dementia assessment clinic. Left frontal (p < .002), left medial (p < .03), right frontal (p < .02), and right medial (p < .02) cortical lesions significantly worsened EXIT25 scores, even after adjusting for age, global cognitive impairment (on the Mini-Mental State Examination), and the severity of cortical dementia on the Qualitative Evaluation of Dementia [QED]. The EXIT25's associations with right hemisphere lesions did not persist after adjusting for left frontal lesions. Left posterior lesions did not significantly affect the EXIT25. Similarly, left frontal circuit pathology worsened EXIT25 scores (p < .05). Pathology in left anterior subcortical structures showed a trend (p = .052). EXIT25 scores were not affected by right subcortical pathology, nor by pathology in either hippocampus. We conclude that the EXIT25 is specifically affected by frontal system MRI lesions, particularly on the left. This conclusion is consistent with earlier functional neuroimaging studies associating EXIT25 performance with left mesiofrontal perfusion.

Correlates of disability among elderly retirees with "subclinical" cognitive impairment.

BACKGROUND: We assessed the effects of impaired Executive Control Function (ECF) on Instrumental Activities of Daily Living (IADL) and level of care among noninstitutionalized elderly retirees with "subclinical" cognitive impairment. METHODS: Subjects (N = 561; age 78.2 +/- 5.0 years) were residents of a single, 1,500 bed, continuing care retirement community. Subjects were examined for cognitive impairment using the Executive Interview (EXIT25), Mini-Mental State Examination (MMSE), and an executive clock-drawing task (CLOX). The CLOX is divided into executively sensitive (CLOX 1) and simple constructional (CLOX2) subtests. RESULTS: Residents in congregate high-rises (n = 301) differed significantly from those in independent-living apartments (n = 260) with respect to age, gender, percent living alone, EXIT25, CLOX1, MMSE, and CLOX2 scores (all p < .03). Only differences in ECF measures persisted after adjusting for age and living alone (p < .004). The EXIT25 (p < .006) and CLOX2 (p = .02) were associated with the use of prostheses. The differences in EXIT25 scores persisted after adjusting for level and living alone (p = .01). All instruments distinguished residents with impairment in IADLs. However, only CLOX2 (p < .001), EXIT25 (p < .001), and age (p < .001) made significant independent contributions. CONCLUSIONS: ECF has statistically significant effects on level of care and IADL impairment, even among noninstitutionalized retirees. This emergent disability is not well detected by traditional global cognitive measures. Evaluation and treatment may be delayed unless ECF measures are employed.

Clock drawing is sensitive to executive control: a comparison of six methods.

We examined six clock-drawing task (CDT) scoring systems relative to the Executive Interview (EXIT25, a measure of Executive Control Function [ECF]) and the Mini-Mental State Exam (MMSE). Subjects included n = 33 National Institute of Neurological, Communicative Disorders, and Stroke "probable" Alzheimer's disease (AD) cases and n = 52 independent living controls. AD cases and controls differed on the EXIT25, MMSE, and all CDTs. All CDTs were significantly correlated with the EXIT25 (ranging from r = .56 to r = .78). These associations generally persisted after adjusting for Age, Education, and MMSE scores. In backwards stepwise linear multivariate regression models, only CLOX: An Executive Clock-Drawing Task scores contribute significantly to EXIT25 scores (R2 = .68) and MMSE scores (R2 = .72). Clock drawing draws upon both executive and general cognitive resources. CLOX explains incrementally more variance in ECF than other CDTs.

Anterior crossbite correction with fixed appliances in the adult dentition.

Anterior crossbite in the adult dentition, if not corrected, can cause other functional problems for the patient. These adult patients can be treated quickly and with confidence by most general dentists with the use of pre-adjusted appliances and straight wire. This article presents a clinical picture of three cases involving anterior crossbite correction in the adult patient with the use of fixed appliances and an acrylic splint.

Executive dyscontrol: an important factor affecting the level of care received by older retirees.

OBJECTIVES: To examine the relative contributions of Executive Control Function (ECF), general cognition, mood, problem behavior, physical disability, demographic variables, and the number of prescribed medications to the level of care received by older retirees. DESIGN: Multivariate regression and discriminant modeling. SETTING: A single Continuing Care Retirement Community (CCRC) in San Antonio, Texas. PARTICIPANTS: A total of 107 older retirees (mean age = 83.7+/-7.2 years), including 17 community-dwelling, well, older controls and 90 CCRC residents. CCRC subjects represented a convenience sample of consecutive referrals for geropsychiatric assessment. Sixty-one subjects resided at a noninstitutionalized level of care, and 46 were institutionalized. MEASUREMENTS: Tests of ECF (the Executive Interview (EXIT25)), general cognition (the Mini-Mental State Examination (MMSE)), mood (the Geriatric Depression Scale short-form (sGDS)), problem behavior (the Nursing Home Behavior Problem Scale (NHBPS)), physical disability (the Cumulative Illness Rating Scale (CIRS)), age, gender, years of education, and the number of prescribed medications were studied. RESULTS: All variables except gender and education varied significantly across level of care. Four variables made significant independent contributions; EXIT25 score (r2 = .48, P< .001), medication usage (partial r2 = .11, P<.001), sGDS score (partial r2 = .06, P = .001), and problem behavior (partial NHBPS r2 = .04, P<.04). These variables accounted for 69% of the total variance in level of care (R2 = .69; F (df 7,99) = 32.1, P<.001). A discriminant model based on the number of prescribed medications, EXIT25, sGDS, and NHBPS scores classified 83.2% of cases correctly (Wilke's lambda = .50, F(5,101) = 20.1; P<.001). The MMSE enters but fails to contribute significantly, independent of the other variables. Age and CIRS scores fail to enter. CONCLUSIONS: Cognitive (particularly ECF) impairment contributes most to the observed variance in level of care received by older retirees in this CCRC. In contrast, markers of general cognition, depression, and physical illness contributed relatively little additional variance. ECF is not detected well by traditional cognitive measures and must be sought by specific tests. Further study is needed to replicate these findings in other populations.

CLOX: an executive clock drawing task.

OBJECTIVE: To describe a clock drawing task (CLOX) designed to elicit executive impairment and discriminate it from non-executive constructional failure. SUBJECTS: 90 elderly subjects were studied (45 elderly and well persons from the independent living apartments of a continuing care retirement community and 45 patients with probable Alzheimer's disease). The clock drawing performance of elderly patients was compared with that of 62 young adult controls. METHODS: Subjects received the CLOX, an executive test (EXIT25), and the mini mental state examination (MMSE). The CLOX is divided into an unprompted task that is sensitive to executive control (CLOX1) and a copied version that is not (CLOX2). Between rater reliability (27 subjects) was high for both subtests. RESULTS: In elderly subjects, CLOX subscores correlated strongly with cognitive severity (CLOX1: r=-0.83 v the EXIT25; CLOX2: r=0.85 v the MMSE). EXIT25 and MMSE scores predicted CLOX1 scores independently of age or education (F(4,82)=50.7, p<0.001; R2=0.71). The EXIT25 accounted for 68% of CLOX1 variance. Only the MMSE significantly contributed to CLOX2 scores (F(4,72)= 57.2, p<0.001; R2=0.74). CLOX subscales discriminated between patients with Alzheimer's disease and elderly controls (83.1% of cases correctly classified; Wilkes' lambda=0.48, p<0.001), and between Alzheimer's disease subgroups with and without constructional impairment (91.9% of cases correctly classified; Wilkes' lambda=0.31, p<0.001). CONCLUSIONS: The CLOX is an internally consistent measure that is easy to administer and displays good inter-rater reliability. It is strongly associated with cognitive test scores. The pattern of CLOX failures may discriminate clinical dementia subgroups.

Dementias that present with and without posterior cortical features: an important clinical distinction.

There are distinct qualitative differences between the dementias that present with and without posterior cortical features. These can be utilized in dementia assessment. This paper reviews the validity and potential utility of a dichotomy based on generalized cortical (Type 1) versus isolated frontal system pathology (Type 2). These syndromes are associated with distinct differentials and problem behaviors. They may also result in different caregiving burdens or treatment responses. Alzheimer's disease (AD) is by far the most common cause of the Type 1 syndrome. Type 2 presentations select for potentially reversible non-AD conditions. Common cognitive screening instruments are insensitive to Type 2 cases. However, the Type 1/Type 2 distinction can be made reliably using qualitative clinical rating scales. We will review these instruments and discuss their application in clinical settings.

Esthetic orthodontic considerations for the adult patient: a general dentist's perspective.

Esthetic orthodontics is a viable treatment option for patients seeking cosmetic enhancement. Today, the use of preadjusted orthodontic brackets and straight wire allow general dentists to create optimum esthetic results in a short period of time. Two cases are presented to demonstrate a clinical technique to enhance a patient's smile through adjunctive orthodontic therapy.

Executive control and the comprehension of medical information by elderly retirees.

This study examined the independent contributions of executive control function, general cognition, age, education, and medication usage to the comprehension of medical information. Randomly selected elderly retirees (N = 105) more than 70 years of age completed the Executive Interview (EXIT25), the Mini-Mental State Exam (MMSE), and the Hopkins Competency Assessment Test (HCAT). Cognitive measures were stronger predictors of HCAT scores than age, education, or number of prescribed medications. A discriminant model based on EXIT25 and MMSE scores correctly classified 91% of subjects relative to their HCAT scores. It was concluded that executive impairment is strongly associated with impaired comprehension of medical information. As many as 88% of probable Alzheimer's disease patients, 69% of institutionalized elderly retirees, and 49% of noninstitutionalized retirees may be impaired in their ability to comprehend medical information, even when it has been presented well below their educational level.

Soft tissue profile: a survey of African-American preference.

Soft tissue profile is a critical area of interest in the development of an orthodontic treatment plan. This study was designed to elicit the current soft tissue profile preference of African-American respondents. Results indicate that: (1) African-American male and female subjects prefer relatively flat profiles, with varied fullness of the lips. (2) African-American male and female subjects prefer the male subjects to have more protrusive profiles than the female subjects. (3) Respondents do not always correctly select their own profile type. (4) More than a third of the respondents desire a change in their own profile.

Music and language in degenerative disease of the brain.

Music and language functions were studied in two musicians with degenerative disease. Both patients were tested on a standardized language battery and a series of music tasks. In the first case with left cortical atrophy and primary progressive aphasia, expressive music functions were spared with impaired reception of rhythm. The second case with posterior cortical atrophy, greater on the right, was nonaphasic, had spatial agraphia, a visuopractic deficit, and severe expressive music deficits, but intact rhythm repetition. The aphasic patient showed dissociations between music and language in fluency and content; continuous, organized, although reiterative music production was contrasted with nonfluent language. The nonaphasic patient showed the opposite pattern of deficits; unmusical production with impaired melody and rhythm organization that was contrasted with fluent, intelligible language. The double dissociation between language and music functions supports the existence of independent cognitive systems, one consistent with conventional left lateralization models of language, temporal sequence, and analytic music processing and another with a right lateralization model of implicit music cognition.

The structural determinants of recovery in Wernicke's aphasia.

Recovery of comprehension and total language in 22 Wernicke's aphasics was correlated with lesion size and extent of involvement of certain structures on CT. Recovery rates and outcomes were separately examined using 0-3 months and 0-12 months poststroke language data. Quantitative measures of structural damage were regressed on total aphasia and comprehension outcome measures. Supramarginal and angular gyri appeared to be the most significant structures in recovery in addition to initial severity and lesion size. This was confirmed by using ANOVA to compare the extent of involvement in each postcentral structure among the poor, moderate, and good recovery groups. The superior temporal and middle temporal gyri are less involved in the good recovery group. Structures posteriorly adjacent to Wernicke's area are important for compensation in Wernicke's aphasia and in the accompanying comprehension deficit. Persisting Wernicke's aphasia usually involves the supramarginal and angular gyri in addition to the superior temporal area.

Profiles of language impairment in primary progressive aphasia.

OBJECTIVE: The profile of language impairment in patients with primary progressive aphasia in comparison with the language impairment in patients with Alzheimer's disease and after stroke. DESIGN: The Western Aphasia Battery and the Mattis Dementia Rating Scale evaluated the language and cognitive impairment. Follow-up studies were done 1 to 5 years after the initial testing in seven of 10 patients with primary progressive aphasia, and a postmortem examination of the brain was done in two patients. SETTING: All 10 patients with primary progressive aphasia were previously healthy, community-dwelling persons when first tested. PATIENTS AND OTHER PARTICIPANTS: All patients with primary progressive aphasia reported at least a 2-year history of slowly progressive aphasia without other signs of global dementia. The initial Western Aphasia Battery results of the 10 patients with primary progressive aphasia were compared with those of a sample of 10 patients with probable Alzheimer's disease and with those of a sample of 10 patients with aphasia due to a left hemispheric stroke. Both reference samples were matched for age and sex; the sample with stroke-caused aphasia was additionally matched for the aphasia type. RESULTS: Expressive language disability with reduced speech fluency and anomia but preserved language comprehension and nonverbal cognition were typical features in early stages of primary progressive aphasia. Spontaneous speech was significantly more impaired in patients with primary progressive aphasia in comparison with those with aphasia after left hemisphere stroke and with language impairment in patients with Alzheimer's disease. Follow-up examinations revealed continuous, often rapid deterioration of language impairment. The neuropathological examination showed Alzheimer's disease in one patient and Pick's disease in the other. CONCLUSION: The profile of aphasia suggests that primary progressive aphasia tends to affect anterior parts of the language-dominant cortex first.