German Neurologist Research Articles

Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome: a survey of German neurologists

Diagnosis and decisions on life-sustaining treatment (LST) in disorders of consciousness, such as the vegetative state (VS) and the minimally conscious state (MCS), are challenging for neurologists. The locked-in syndrome (LiS) is sometimes confounded with these disorders by less experienced physicians. We aimed to investigate (1) the application of diagnostic knowledge, (2) attitudes concerning limitations of LST, and (3) further challenging aspects in the care of patients. A vignette-based online survey with a randomized presentation of a VS, MCS, or LiS case scenario was conducted among members of the German Society for Neurology. A sample of 503 neurologists participated (response rate 16.4%). An accurate diagnosis was given by 86% of the participants. The LiS case was diagnosed more accurately (94%) than the VS case (79%) and the MCS case (87%, p < 0.001). Limiting LST for the patient was considered by 92, 91, and 84% of the participants who accurately diagnosed the VS, LiS, and MCS case (p = 0.09). Overall, most participants agreed with limiting cardiopulmonary resuscitation; a minority considered limiting artificial nutrition and hydration. Neurologists regarded the estimation of the prognosis and determination of the patients’ wishes as most challenging. The majority of German neurologists accurately applied the diagnostic categories VS, MCS, and LiS to case vignettes. Their attitudes were mostly in favor of limiting life-sustaining treatment and slightly differed for MCS as compared to VS and LiS. Attitudes toward LST strongly differed according to circumstances (e.g., patient’s will opposed treatment) and treatment measures.

Translating Science: Contexts and Contests

At the beginning of the 20th century, the well known German neurologist Möbius published an essay entitled Über den physiologischen Schwachsinn des Weibes (On the Physiological Mental Deficiency of Woman). In this scientific compendium, Möbius developed a theory to prove the mental inferiority of women. The essay achieved wide circulation at the time and in 1904 was released in Spain as La inferioridad mental de la mujer (The Mental Inferiority of Woman) by a major publishing house. The translator was the eminent writer Carmen de Burgos, known for her radical politics and feminism. The Spanish edition contains an extensive paratextual apparatus written by the translator herself Informed by recent theoretical and methodological poststructuralist debates in translation studies, history of science, critical discourse analysis and feminist studies, this paper analyzes Carmen de Burgos’s paratext as an important site for elaborating the voice of the translator. It demonstrates that translation as a social practice is interwoven with the social and historical context in which it is framed.

“Resources for each other.” The society of German neurologists and psychiatrists and the Nazi “health leadership”

The history of the German Association for Psychiatry and--after its merger with the Society of German Neurologists in 1935--the Society of German Neurologists and Psychiatrists (Gesellschaft deutscher Neurologen und Psychiater, GDNP) during the period of National Socialism has been subjected to only rudimentary research. The conventionally accepted idea that two independent professional associations were "coordinated" from above and turned into the extended arm of Nazi genetic health policy (Erbgesundheitspolitik) against their will must be reconsidered. This paper asks how the relationship between the GDNP and the Nazi state can be described adequately. Psychiatry and neurology as practice and science, and the biopolicy development dictatorship of National Socialism functioned, so the basic thesis, as "resources for each other" (Mitchell Ash).

Ludwig Edinger (1855–1918)

Ludwig Edinger, a German neurologist is considered as one of the founders of modern neuroanatomy. He was conferred the degree of Doctor of Medicine at the University of Strassburg. His observation of small living organisms under a microscope at an early age led him to study medicine. Edinger had many discoveries to his credit. He was the first to describe the ventral and dorsal spinocerebellar tracts, to distinguish between paleo-encephalon and neo-encephalon, and between paleo-cerebellum and neo-cerebellum. He coined the terms "gnosis" and "praxis," which were later adopted in psychological descriptions of agnosia and apraxia. He identified the Edinger-Westphal nucleus in 1885 and was the first to describe the syndrome of thalamic pain. Edinger worked with renowned clinicians and published a large number of papers. He founded the Neurological Institute at the Goethe University in Frankfurt, which is the oldest neurological Institute in Germany. Edinger was a rare combination of a profound scientist, a brilliant teacher, a fine artist, and a noted hypnotist. While at the height of his career, he underwent a surgery and died a few hours later. It was his last will that his brain should be dissected in his own institute. It showed extraordinarily well-developed occipital lobes as well as other unusual features.

Who was the man who discovered the “Lewy bodies”?

In 1912, Fritz Heinrich Lewy described neuronal inclusions in the brain of patients who had suffered from Paralysis agitans (i.e., Parkinson's disease). Later, these findings became the so-called "Lewy bodies." However, little is known about the man who made this discovery. Our aim was to investigate Lewy's private and professional life and to gather information for a detailed biography. We contacted over 100 archives, libraries, and museums in Germany, Poland, Switzerland, United Kingdom, and United States. Over 300 documents, publications, and photos were collected. Lewy was born in Berlin, Germany in 1885 and lived there until 1933. After his dismissal on racial grounds by the Nazis, Lewy emigrated to England in 1933 and to the United States of America in 1934, where he lived and worked until his death in 1950. This article gives a summary of Lewy's life and briefly presents his contribution to German and American neurology.

Current Management and Risk of Recurrent Stroke in Cerebrovascular Patients with Right-to-Left Cardiac Shunt

Background: Right-to-left cardiac shunt (RLS) is considered a risk factor for stroke, especially in patients aged <55 years. We aimed to investigate the current management and prognosis in consecutive patients with RLS and otherwise cryptogenic cerebrovascular events. Methods: In total, 1,126 patients with cryptogenic stroke or TIA were included from 17 German neurology departments. During a mean follow-up of 28.4 months, we assessed current antithrombotic medication, percutaneous device closure (PDC) and recurrent cerebrovascular events in 899 patients (79.8%). Stroke recurrence was compared between 548 patients without RLS and 351 patients with RLS under various prevention regimens. Results: RLS was detected in 35.9% of cryptogenic cerebrovascular patients, but could not be evaluated as an independent predictor for recurrent stroke (adjusted HR 1.6, 95% CI: 0.9–2.7). In RLS-positive patients, the Kaplan-Meier estimate for stroke during the first year was 4.1% (95% CI: 1.9–6.3%) and 1.7% (95% CI: 0.9–2.4%) per year thereafter. At the last follow-up before recurrent stroke or end of study, 117 RLS-positive patients (33.3%) had received a PDC, 154 (43.9%) were receiving antiplatelets, 63 (17.9%) received anticoagulation, and 17 (4.8%) received none of the above. No association with recurrent stroke was found for the secondary preventive regime. Conclusion: Our multicenter hospital-based cohort study confirmed low recurrent event rates in RLS patients with otherwise cryptogenic stroke or TIA, as well as a great heterogeneity of current management. Despite the lack of scientific evidence, a substantial number of RLS-positive patients underwent PDC for secondary stroke prevention.

Attitudes and barriers to clinical practice guidelines in general and to the guideline on Parkinson’s disease. A National Survey of German neurologists in private practice

Although much progress has been made in the development of clinical practice guidelines (CPGs), there are few strategies for dissemination and implementation of these guidelines. This study examines the attitudes of neurologists to CPGs and barriers to CPG implementation, with a particular focus on the Parkinson's disease CPG (PD-CPG). A cross-sectional survey was performed in 2007 with a representative sample of 213 neurologists in private practice in Germany. The main outcome measures were the Tunis Attitudinal Scale and barrier assessment of CPGs. In addition, the awareness, applicability, and usefulness of the PD-CPG were assessed. Most of the neurologists agreed that CPGs are intended to improve the quality of care (82.2%; n = 171), are good educational tools (59.4%; n = 120), and are an unbiased synthesis of expert opinion (58.9%; n = 119). The main barriers to guideline implementation were lack of time (39.3%; n = 81), inability to reconcile patient preferences with guideline recommendations (34.3%; n = 71), and lack of awareness (32.5%; n = 67). A total of 187 (88.2%) of the neurologists were aware of the PD-CPG, of whom 163 (92.6%) found it "beneficial" and 173 (94.6%) applied it in daily practice. Nevertheless, only 51 (28.8%) of neurologists considered that the guidelines led to an improvement in the quality of care. However, 63 (32%) favored a special guideline for patients. Qualitative data analysis revealed more positive than negative aspects of the PD-CPG; positive comments included "treatment facilitation", "a stepped therapy schema" and "increasing self-efficacy". Criticism mostly concerned the lack of relevance to everyday practice and the rigidity of the guidelines. Neurologists in private practice have a generally positive attitude to guidelines. The PD-CPG is well-known and often used, but its impact on quality of care is considered to be only modest. Thus, further research is needed to address issues of daily practice in future versions of the PD-CPG and to investigate the effects of implementation at the physician and patient levels.

Die ärztliche Tätigkeit in der Neurologie – eine objektive Tätigkeitsanalyse in deutschen Krankenhäusern

Background During the past few years, neurologists have often complained about their working situation. It is necessary to analyse these statements using not only questionnaires but also by carrying out objective task analyses. However, such data are not available at present. Therefore, the aim of the present investigation was to observe neurologists during their work at German hospital departments and evaluate their working routines. Method Twenty neurologists were shadowed individually during 553 working hours. By using an ultra mobile computer all tasks performed by these physicians were collected within this time. Results On average eighty different job tasks were undertaken within an average working day of 9 hours 13 minutes (SD = 1:04:48 h). These tasks included time shares spent on, i.e., meetings, indirect and direct patient care as well as ward rounds and admission to hospital. Conclusion This is the first job task analysis on how neurologists spend their working hours at German hospitals. Some self-reported problems about work obstacles, administration duties and multitasking could be confirmed. These findings make a contribution towards prospective optimisation processes on the working situation of German neurologists.

Causes, characteristics and management of dystonia

Dystonia is the third most common neurological movement syndrome, affecting an estimated 40 000 people in the UK and more than 3 million people worldwide (Jinnah and Hess, 2008). The disorder is characterized by excessive involuntary muscle contractions that lead to twisting movements and unnatural postures, with or without tremor (Fahn et al, 1998). Although dystonia is a neurological disorder, it does not usually lead to problems with other functions of the brain such as cognition. The German neurologist Hermann Oppenheim first used the term ‘dystonia musculorum deformans’ in 1911; however, only one third of people affected by dystonia are known to be receiving medical treatment due to difficulties in recognizing and diagnosing the condition (Grant and Meager, 2005).

Long-term mortality and risk of stroke after transient ischemic attack

Stroke and mortality rates in patients with transient ischemic attack (TIA) differ widely between community-based studies and research cohorts. Our aim therefore was to provide a reliable estimate for TIA patients treated in German neurology departments with an acute stroke unit. A total of 1951 consecutively admitted TIA patients were prospectively documented in 13 centers and 1480 (75.9%) gave consent for long-term follow-up. During a mean follow-up of 23.4 months, we assessed recurrent cerebrovascular events and cause of death in 1448 patients via standardized telephone interview including confirmation of endpoint events by the treating physician. Overall 94 patients (6.5%) suffered a stroke and 118 patients (8.1%) died, 21 due to stroke. The Kaplan-Meier estimate for stroke during the first year was 4.4% (95% CI 3.2-5.6%) which corresponds to a relative risk of 9.5 (95% CI 7.4-12.3) compared to the population-based stroke incidence in Germany. The annual rates after the first year were 2.2% (95% CI 1.7-2.7%) for stroke and 3.2% (95% CI 2.7-3.8%) for death. Independent predictors for stroke during follow-up were age and previous cerebrovascular events. The ABCD(2) score did not provide any meaningful prediction of stroke risk at 90 days. While the in-hospital risk of stroke was low, long-term stroke rates in our well-defined multicenter hospital-based cohort were comparable to a large randomized trial. In patients with a well-established diagnosis of TIA, only age and previous cerebrovascular events seem to constitute independent predictors for stroke during long-term follow-up.

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2.202 Use of dopamine agonists and levodopa in Germany: Do German neurologists adhere to national Parkinson guidelines?

Objective: To investigate whether German neurologists put Parkinson’s disease (PD) guidelines to daily practice, exemplified by the actual use of dopamine agonists (DA) and L-Dopa compared to the recommendations of the national guideline (NG). Method: We analysed data on treatments and health status of 451 patients with idiopathic PD. Data was taken from a cross-sectional survey of 60 neurologists in Germany (Adelphi DSP Wave II 2004). The German NG (11/06/2003) was translated into 4 decision rules – 2 for patients aged 70+ and 2 for those under 70 – regarding the use of DA and L-Dopa according to disease stage and presence of long-term motor complications. Adherence to these rules was compared separately within two groups of doctors: one stating to follow the NG and one not stating to follow the NG. Results: As asserted by responding neurologists, 306 patients (68%) were treated according to the NG. As implied by rule 1 (“no DA without L-Dopa in 70+”), neurologists in the “guideline group” used less DA without L-Dopa than the other neurologists (1.5% vs 7% respectively, p = 0.081). As per rule 2 (“L-Dopa = base-therapy if no complications, patients 70+”), L-Dopa was clearly dominating as basal treatment in the “guideline group” as well as the “non-guideline group” (91% vs 71% respectively, p = 0.065). Rule 3 (“in patients <70, start with DA monotherapy”) was observed for 49% of patients in the “guideline group” as opposed to 28% in “nonguideline group” (p = 0.087). Observation of rule 4 (“DA = basal therapy if no complications, patients <70”) was relatively comparable: 80% vs. 70% in the respective groups (p = 0.174). Conclusion: German neurologists generally initiate treatments with DA and L-Dopa which is in high agreement with the NG. Those who claimed to follow the NG tend to adhere to it more strictly. Overall, the NG appears to be relatively well-accepted.

Die Möbius-Stiftung - Eine Quellenstudie zur Geschichte der psychiatrischen und neurologischen Forschungsförderung

The Möbius-Foundation was founded on the initiative of some co-workers and friends of Leipzig neurologist and psychiatrist Paul Julius Möbius, who had died in 1907. Their aim was to venerate the memory of Möbius and to gather support for his and their subjects. After a starting phase of structuring and consolidating, the "Möbius-Foundation" began, according to its statute, to honour achievements in the fields of neurology and psychiatry. The foundation gained reputation throughout Germany in both of these fields. Among the prizewinners of the "Möbius-Award" were Alois Alzheimer, Emil Kraepelin, Max Nonne, Cécile and Oskar Vogt, or Otfrid Foerster. The inflation of 1923 immensely reduced the capital stock of the foundation, sentencing it to inactivity. Until 1938 Johannes Bresler tried to revive the "Möbius-Foundation". Later, the foundation was absorded by the GDNP (Society of German Neurologists and Psychiatrists). However, due to the outbreak of WW II in 1939, the foundation was not able to take up its work again. The history of the foundation mirrors en miniature both the social changes in Germany and German psychiatry in the first half of the twentieth century.

Gordon Holmes lecture: Gordon Holmes and the neurological heritage

Sir Gordon Holmes is one of the great figures in the history of twentienth century neurology. In him, there came together the traditions of German and British neurology which moulded a physiological approach to normal and disordered function of the nervous system with a commitment to interpreting clinical phenomena in the light of meticulous pathological examination. He, more than any other individual, was responsible for the form of the neurological examination as it is now performed; and his insights are fundamental to the way that, nowadays, we think about vision, somato-sensory function, the spinal cord and the cerebellum.

Dementia in low- and middle-income countries

It is 100 years since Dr Alois Alzheimer, a German neurologist, observed changes in the brain that are now known to be the characteristic features of Alzheimer's disease, the commonest form of dementia. Until recently this condition was thought to occur only infrequently in low- and middle-income countries; now it has been realised that the prevalence is as high in these countries as in the rest of the world. Further, because of the rapidly increasing numbers of older people in low- and middle-income countries, they contain far more people with dementia: 16 million compared with 8 million in high-income nations. How can ways be found to provide adequate care for people with dementia in these countries when resources, both skilled manpower and finance, are so limited? The thematic papers that follow address this issue.

Budipine in Parkinson's tremor

It is generally accepted that patients with a tremor-dominant type of idiopathic Parkinson's disease progress more slowly than the ones with the rigid-akinetic type. On the other hand successful treatment of Parkinsonian tremor is a challenge. German neurologists use anticholinergics, budipine, β-blockers, clozapine, dopaminergic substances and for most severe cases deep brain stimulation. Budipine is an enigma because its main mode of action is still unknown, although it is mostly listed under glutamate antagonists. There is however no other anti-Parkinsonian drug available with such a broad spectrum of action as shown for budipine. Budipine has been studied in open and double-blind studies as monotherapy and adjunct therapy. In both instances the drug showed beneficial effects to the patients. It may well be that the non-dopaminergic mode of action of budipine is helpful even for patients who are on stable medication. When 3 years ago reports on budipine-induced prolongation of the QT interval in the ECG emerged larger trials were stopped and nowadays there are strict rules on how to use budipine. Nonetheless, budipine in our hands is a most useful and safe drug to treat tremor and other main symptoms of Parkinson's disease.

Alfred Hauptmann, Siegfried Thannhauser, and an endangered muscular disorder.

Alfred Hauptmann (Figure 1), a German neurologist who initially introduced phenobarbital in epilepsy therapy, and Siegfried Thannhauser (Figure 2), an outstanding German metabolism specialist, left Germany during the Nazi regime because of their Jewish origin. Both scientists emigrated to the United States and, in 1941, described a new myopathic entity, 1 later called Hauptmann-Thannhauser muscular dystrophy. Recently, this eponym has largely disappeared from the literature and has been replaced with the term autosomal dominant form of Emery-Dreifuss muscular dystrophy. However, molecular biology as well as more in-depth clinical studies argue that Hauptmann-Thannhauser muscular dystrophy is a distinct entity. On the basis of their discovery and their important contributions in other neurological spheres, we suggest a reinstatement of the term Hauptmann-Thannhauser muscular dystrophy in modern neurological nosology.

Jean-Martin Charcot in German neurology

Jean-Martin Charcot (1825-1893), well known as the founder of modern neurology, was the most celebrated neurologist in the nineteenth century. His international success stemmed not only from mastery descriptions of various neurological disorders but also from his many contacts with scientists all over the world. The aim of this article is to review Charcot's ambivalent relationship to German neuropsychiatry of the time and to examine the German reception of his personality and work. Wilhelm Erb, Ludwig Hirt, Ernst von Leyden, Max Nonne, Adolph Strümpell, and other German physicians cultivated -to varying degrees - professional contacts with Charcot and, based on the fascination of his personality and significance of his work, were long and intensively influenced by the Salpêtrière school. The extent of their admiration became apparent in 1882 by the award of an honorary doctorate to Charcot by the University of Würzburg. Along with increasingly severe criticism of Charcot's research on hysteria and hypnosis, most German neuropsychiatrists became estranged, without neglecting his importance to the development of neurology in Germany.

O conceito freudiano de representação em "Sobre a concepção das afasias"

A noção de representação - uma das mais fundamentais da teoria freudiana - é objeto de uma extensa reflexão na monografia "Sobre a concepção das afasias". Nesta monografia, o autor faz uma revisão crítica das principais hipóteses sobre as afasias que predominavam na época - basicamente as do neurologista alemão Carl Wernicke - a partir das quais ele propõe uma concepção alternativa sobre o funcionamento normal e a patologia da linguagem. Como a teoria de Wernicke fundamentava-se em uma concepção específica de representação, esta acaba sendo também repensada por Freud. O objetivo deste artigo é discutir algumas das hipóteses propostas em "Sobre a concepção das afasias" e apontar as suas implicações para a formulação do conceito de representação e para o sentido que ele adquirirá no âmbito da reflexão metapsicológica.

The Role of Herman Hoppe of Cincinnati in the Initial Clinical Recognition of Myasthenia Gravis

One of the earliest papers describing a case of what came to be known as myasthenia gravis was written in 1892 in the German language by an American, Herman Hoppe, who at the time was an assistant in the Berlin polyclinic of the prominent German neurologist, Hermann Oppenheim. At Oppenheim’s instigation, Hoppe published the pathology of a case that Oppenheim had diagnosed during life; he collected all the reported similar cases and tried to establish a symptom-complex, for which he was given credit in Oppenheim’s great neurology textbook of 1894. Upon his return to Cincinnati, Ohio, Hoppe’s European experience qualified him as a specialist in nervous and mental diseases. His private practice of “neuropsychiatry” was his main occupation, but he also volunteered to teach as Professor of Nervous and Mental Diseases at the University of Cincinnati. In 1901 Oppenheim published the first monograph about what he called “ Die Myasthenische Paralyse (Bulbarparalyse ohne anatomischen Befund) ”, summarizing 60 cases described in the medical literature up to that time. Hoppe, on the other hand, wrote on myasthenia gravis only once again, a review article in 1914 in a Cincinnati weekly, giving Oppenheim credit for the establishment of the disease as a clinical entity.