[Clinical examination of spatial neglect and other disorders of spatial cognition]. / Klinische Untersuchung des unilateralen Neglects und weiterer Störungen der Raumkognition.

Neglect occurring after stroke, neoplasms or degenerative processes can lead to considerable disability in everyday life as can other disorders of spatial orientation. Therefore, a dedicated examination and early diagnostic classification are obligatory. Behavioral tests are helpful in this respect, enabling the clinician to obtain an initial overview of the existing deficits even at the patient's bedside. The clinical (bedside) examination of spatial neglect as well as the corresponding differential diagnostic procedure for the clarification of (possibly additionally or exclusively existing) hemianopia and extinction, as well as the examination of disorders of visuospatial perception, visuoconstructive disorders, topographic disorders, Bálint's syndrome, simultanagnosia, and optic ataxia are presented. The presentation is based on the newly revised (year 2023) guidelines of the Association of the Scientific Medical Societies in Germany (AWMF) on this subject area.

The need for hemispheric separation in pairwise structural disconnection studies.

The development of new approaches indirectly measuring the structural disconnectome has recently led to an increase in studies investigating pairwise structural disconnections following brain damage. Previous studies jointly analyzed patients with left hemispheric and patients with right hemispheric lesions when investigating a behavior of interest. An alternative approach would be to perform analyses separated by hemisphere, which has been applied in only a minority of studies to date. The present simulation study investigated whether joint or separate analyses (or both equally) are appropriate to reveal the ground truth disconnections. In fact, both approaches resulted in very different patterns of disconnection. In contrast to analyses separated by hemisphere, joint analyses introduced a bias to the disadvantage of intra-hemispheric disconnections. Intra-hemispheric disconnections were statistically underpowered in the joint analysis and thus surpassed the significance threshold with more difficulty compared to inter-hemispheric disconnections. This statistical imbalance was also shown by a greater number of significant inter-hemispheric than significant intra-hemispheric disconnections. This bias from joint analyses is based on mechanisms similar to those underlying the "partial injury problem." We therefore conclude that pairwise structural disconnections in patients with unilateral left hemispheric and with unilateral right hemispheric lesions exhibiting a specific behavior (or disorder) of interest should be studied separately by hemisphere rather than in a joint analysis.

Thalamocortical disconnection involved in pusher syndrome.

The presence of both isolated thalamic and isolated cortical lesions have been reported in the context of pusher syndrome-a disorder characterized by a disturbed perception of one's own upright body posture, following unilateral left- or right-sided stroke. In recent times, indirect quantification of functional and structural disconnection increases the knowledge derived from focal brain lesions by inferring subsequent brain network damage from the respective lesion. We applied both measures to a sample of 124 stroke patients to investigate brain disconnection in pusher syndrome. Our results suggest a hub-like function of the posterior and lateral portions of the thalamus in the perception of one's own postural upright. Lesion network symptom mapping investigating functional disconnection indicated cortical diaschisis in cerebellar, frontal, parietal and temporal areas in patients with thalamic lesions suffering from pusher syndrome, but there was no evidence for functional diaschisis in pusher patients with cortical stroke and no evidence for the convergence of thalamic and cortical lesions onto a common functional network. Structural disconnection mapping identified posterior thalamic disconnection to temporal, pre-, post- and paracentral regions. Fibre tracking between the thalamic and cortical pusher lesion hotspots indicated that in cortical lesions of patients with pusher syndrome, it is disconnectivity to the posterior thalamus caused by accompanying white matter damage, rather than the direct cortical lesions themselves, that lead to the emergence of pusher syndrome. Our analyses thus offer the first evidence for a direct thalamo-cortical (or cortico-thalamic) interconnection and, more importantly, shed light on the location of the respective thalamo-cortical disconnections. Pusher syndrome seems to be a consequence of direct damage or of disconnection of the posterior thalamus.

Right hemispheric white matter hyperintensities improve the prediction of spatial neglect severity in acute stroke.

White matter hyperintensities (WMH) are frequently observed in brain scans of elderly people. They are associated with an increased risk of stroke, cognitive decline, and dementia. However, it is unknown yet if measures of WMH provide information that improve the understanding of poststroke outcome compared to only state-of-the-art stereotaxic structural lesion data. We implemented high-dimensional machine learning models, based on support vector regression, to predict the severity of spatial neglect in 103 acute right hemispheric stroke patients. We found that (1) the additional information of right hemispheric or bilateral voxel-based topographic WMH extent indeed yielded a significant improvement in predicting acute neglect severity (compared to the voxel-based stroke lesion map alone). (2) Periventricular WMH appeared more relevant for prediction than deep subcortical WMH. (3) Among different measures of WMH, voxel-based maps as measures of topographic extent allowed more accurate predictions compared to the use of traditional ordinally assessed visual rating scales (Fazekas-scale, Cardiovascular Health Study-scale). In summary, topographic WMH appear to be a valuable clinical imaging biomarker for predicting the severity of cognitive deficits and bears great potential for rehabilitation guidance of acute stroke patients.

Interprofessional Simulation in a Digital World: Teaching Collaborative Practice in Web-Based Environments.

Interprofessional education (IPE) is difficult to implement for many reasons. The Excellence in Interprofessional Simulation Education is an effective in-person IPE program that pivoted to a teleconferencing format. We conducted 40 simulations with 800 students representing nursing, advanced practice nursing, medicine, respiratory therapy, occupational therapy, physical therapy, pharmacy, medical dietetics, speech and language pathology, and social work in an academic year. Months of careful planning to recreate all aspects of the in-person activity in a web-based environment, create roles and duties, and conduct simulation dress rehearsals were necessary for success. Students who participated rated the simulations as highly effective.

Tilted 3D visual scenes influence lateropulsion: A single case study of pusher syndrome.

INTRODUCTION: Hemiparetic stroke patients with so-called "pusher syndrome" (synonyms: contraversive lateropulsion, contraversive pushing) use their non-paretic extremities to push toward their paralyzed side and actively resist external posture correction. The disorder is associated with a distorted perception of postural vertical combined with a maintained, or little deviating perception of visual upright. With the aim of reducing this mismatch, and thus reducing contraversive lateropulsion, we manipulated the orientation of visual input in a virtual reality setup. METHOD: We presented healthy subjects and an acute stroke patient with severe pusher syndrome a 3D visual scene that was either upright or tilted in roll plane by 20°. By moving the sitting participants in roll plane to the left and right, we assessed the occurrence of contraversive lateropulsion, namely the active resistance to external posture manipulation. RESULTS: With the 3D visual scene oriented upright, the patient with pusher syndrome showed the typical active resistance against tilts toward the ipsilesional side. He used his non-paretic arm to block the examiner's attempt to move the body axis toward that side. With the visual scene tilted to the ipsiversive left, his pathological resistance was significantly reduced. Statistically, the tolerated body tilt angles no longer differed from those of healthy subjects. CONCLUSIONS: We conclude that even short presentations of tilted 3D visual input can reduce symptoms of severe contraversive lateropulsion. The technique provides potential for a new treatment method of pusher syndrome and offers a simple, straightforward approach that can be effortlessly integrated in clinical practice. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00026700).

Use of an Academic Electronic Health Record With an Interprofessional Simulation for Advanced Practice Nursing Students.

ABSTRACT: Simulation with interprofessional teams provides case management opportunities for advanced practice RN students they may not encounter in preceptorships. We designed standardized patient simulations to improve health care safety and outcomes; an academic electronic health record was used in some simulations. We report quality improvement findings from 74 APRN students who completed a survey with open-ended questions. We found that simulation in interprofessional teams positively impacted role immersion, confidence, problem-solving skills, and teamwork. Use of the academic electronic health record added realism. The findings are being incorporated as part of continuous quality improvement in the teaching-learning process.

The occipital face area is causally involved in identity-related visual-semantic associations.

Faces are processed in a network of areas within regions of the ventral visual stream. However, familiar faces typically are characterized by additional associated information, such as episodic memories or semantic biographical information as well. The acquisition of such non-sensory, identity-specific knowledge plays a crucial role in our ability to recognize and identify someone we know. The occipital face area (OFA), an early part of the core face-processing network, is recently found to be involved in the formation of identity-specific memory traces but it is currently unclear if this role is limited to unimodal visual information. The current experiments used transcranial magnetic stimulation (TMS) to test whether the OFA is involved in the association of a face with identity-specific semantic information, such as the name or job title of a person. We applied an identity-learning task where unfamiliar faces were presented together with a name and a job title in the first encoding phase. Simultaneously, TMS pulses were applied either to the left or right OFA or to Cz, as a control. In the subsequent retrieval phase, the previously seen faces were presented either with two names or with two job titles and the task of the participants was to select the semantic information previously learned. We found that the stimulation of the right or left OFA reduced subsequent retrieval performance for the face-associated job titles. This suggests a causal role of the OFA in the association of faces and related semantic information. Furthermore, in contrast to prior findings, we did not observe hemispherical differences of the TMS intervention, suggesting a similar role of the left and right OFAs in the formation of the visual-semantic associations. Our results suggest the necessity to reconsider the hierarchical face-perception models and support the distributed and recurrent models.

Designing a disaster.

A mass casualty simulation was developed and implemented for senior-level nursing students in a large baccalaureate program. This simulation was developed to introduce students to rapid triage in an interactive and immersive experience. The purpose of the simulation was to provide students with a realistic, hands-on experience in a safe environment. Unlike other similar exercises, all students participated in the health care provider role rather than as observers or victims. Didactic content regarding triage and a short video preceded the surprise simulated "bus crash." The element of surprise was used to create the chaos and confusion that often accompanies these incidents. Fifteen victims were comprised of static manikins, high-fidelity human patient simulators, and live actors with various injuries. The students worked in small groups and assigned each victim an appropriate Simple Triage and Rapid Treatment triage category on the basis of what they learned in lecture. Participating students performed well on their final examinations on questions covering the triage content they learned in this unit and feedback regarding the simulated experience was overwhelmingly positive. This simulation could be adapted for the education of other health care providers who may be involved in a future mass casualty incident.