Dementia is one of the most common neurological syndromes in the world. Usually, diagnoses are made based on paper-and-pencil tests and scored depending on personal judgments of experts. This technique can introduce errors and has high inter-rater variability. To overcome these issues, we present an automatic assessment of the widely used paper-based clock-drawing test by means of deep neural networks. Our study includes a comparison of three modern architectures: VGG16, ResNet-152, and DenseNet-121. The dataset consisted of 1315 individuals. To deal with the limited amount of data, which also included several dementia types, we used optimization strategies for training the neural network. The outcome of our work is a standardized and digital estimation of the dementia screening result and severity level for an individual. We achieved accuracies of 96.65% for screening and up to 98.54% for scoring, overcoming the reported state-of-the-art as well as human accuracies. Due to the digital format, the paper-based test can be simply scanned by using a mobile device and then be evaluated also in areas where there is a staff shortage or where no clinical experts are available.

Gaussian mixture (GM) models can be applied for statistical classification of various types of dementia. As opposed to linear boundaries, they do not only provide the class membership of a case, but also a measure of its probability. This enables an improved interpretation and classification of neurodegenerative dementia datasets which comprise various stages of the disease, and also mixed forms of dementia. In this work, GM models are applied to a total number of 103 technetium-99methylcysteinatedimer (99mTc-ECD) SPECT datasets of asymptomatic controls (CTR), as well as Alzheimer's disease (AD) and frontotemporal dementia (FTD) patients in early or moderate stages of the disease. Prior to classification, multivariate analysis is applied: Principal component analysis (PCA) is used for dimensionality reduction, followed by a differentiation of the datasets via multiple discriminant analysis (MDA). A GM model on the resulting discrimination plane is constructed by computing the GM distribution associated with the underlying training set. The posterior probabilities of each case indicate its class membership probability. The performance of GM models for classification is assessed by bootstrap resampling and cross validation. Accuracy and robustness of the method are evaluated for different numbers of principal components (PCs), and furthermore the detection rate of dementia in early stages is calculated. The GM model outperfomes classification with linear boundaries in both predicted accuracy and detection rate of early dementia, and is equally robust.

Multiple discriminant analysis (MDA) is a generalization of the Fisher discriminant analysis (FDA) and makes it possible to discriminate more than two classes by projecting the data onto a subspace. In this work, it was applied to technetium- 99methylcysteinatedimer (99mTc-ECD) SPECT datasets of 10 Alzheimer's disease (AD) patients, 11 frontotemporal dementia (FTD) patients and 11 asymptomatic controls (CTR). Principal component analysis (PCA) was used for dimensionality reduction, followed by projection of the data onto a discrimination plane via MDA. In order to separate the different groups, linear boundaries were calculated by applying FDA to two classes at a time (linear machine). By executing the F-test for different numbers of principal components and examining the corresponding classification accuracy, an optimal discrimination plane based on the first three principal components was determined. In order to further assess the method, another dataset comprising patients with early-onset AD and FTD (beginning or suspected disease) was projected by the same method onto this discrimination plane, resulting in a correct classification for most cases. The successful discrimination of another dataset on the same plane indicates that the model is well suited to account for disease-specific characteristics within the classes, even for patients with early-onset AD and FTD.

BACKGROUND:The contribution of potential treatable dementia aetiologies diagnosed using cerebral imaging varied considerably in previous studies and was not evaluated in a recent larger German sample of patients from a memory clinic.MATERIAL AND METHODS:MRI images of 502 patients were retrospectively reassessed. Beside the proportion of potentially treatable dementia aetiology, the extent of whole brain atrophy (semiquantitative) and vascular white matter lesions were assessed.RESULTS:Mean age of the patients was 63.7 ± 13.1 years; 49 % were female, mean MMST was 24.2 ± 5.5. In 74 % there was an agreement between the clinical dementia syndrome and MRI. 9 % (45 patients) had clearly discrepant imaging results, according to MRI criteria (21 × ischaemia, 20 × normal pressure hydrocephalus (NPH), 4 × intracerebral haemorrhage). These patients could not not be differentiated using age and MMST alone as clinical criteria. There was a significant correlation between global brain atrophy and MMST (r = -0.32; p < 0.001) and white matter lesion score (r = 0.28; p < 0.001).CONCLUSION:In 9 % there was a clear discrepancy between MRI results and the clinical syndrome diagnosis in memory-clinic patients. As known from earlier studies and current German 3 rd generation guidelines, it is reasonable to perform MRI imaging in dementia to improve the aetiological and differential diagnoses and to detect a different aetiology that can be missed using the clinical dementia criteria alone.

Nuclear medicine techniques were the first functional imaging techniques used to support the clinical diagnosis of Alzheimer's Disease (AD). Perfusion-SPECT allows registration of regional cerebral blood flow (rCBF) which is altered in a characteristic temporal-parietal pattern in AD. Numerous studies have shown the diagnostic value of reduced CBF and metabolic changes using perfusion-SPECT and FDG-PET in AD diagnosis as well as in differential diagnosis against frontotemporal dementia (FTD), dementia with Lewy-Bodies (DLB), and vascular cognitive disorders. This renders perfusion-SPECT an important piece of the puzzle (together with other diagnostic tests) by the clinician is often faced when making a final etiologic dementia diagnosis especially between AD and FTD. A similar diagnostic value can be expected when arterial spin labeling (ASL) MRI sequence is used, but the diagnostic value has yet to be confirmed in lager studies. Recently, more pathophysiology-based biomarkers in CSF and Amyloid-PET tracers have been developed that probably have a higher diagnostic accuracy than the more indirect rCBF changes seen in perfusion-SPECT. In the current review, we describe recent advances in AD biomarkers as well as improvements in the SPECT technique.

A survey in specialties other than psychiatry showed that "emergency room"-patients have factors other than the presenting disease that determine the usage of urgent medical evaluation. In the following prospective study 104 outpatients presenting at daytime in a university psychiatric emergency care unit were included over 6 months. Apart from social and epidemiological data, illnesses according to ICD-10, reason for presentation from the patient's point of view and in this regard the physician's evaluation were included. The most prevalent diagnoses were depression, adjustment disorders and anxiety disorders, comprising together 75 %. Organic disorders or addictive disorders were less frequent; psychoses were found in 8 %. Concerning the presentation as an emergency, 70 % of patients reported a subjective clinical deterioration but only 44 % were regarded as an urgent need in the responsible physician's point of view (Cohen's kappa 0.39). Our findings show that patients presenting as "psychiatric emergency cases" without appointment mainly suffer from depression, adjustment disorders and panic disorders. Furthermore, the layperson's point of view of clinical deterioration justifying an emergency presentation differs from physician's evaluation. The most likely cause for this disagreement between physicians and patients in the assessment to utilise a medical emergency care service in psychiatry might be dysfunctional or, respectively, negative-biased cognitions accompanying depressive syndromes.

Objective Analysis of liaison psychiatry cases of a university hospital.Methods Descriptive analysis on the basis of all psychiatric consultations realized in the year 2008 at the university hospital of Erlangen.Results About 1% of all patients with somatic diseases receive a psychiatric treatment by the liaison psychiatry at the same time. Suspected and final diagnosis of correspond in only one third of cases. The diagnoses are focused on only a few diseases. Suicidality is confirmed in a small number of cases. Most commonly a medicamentous treatment is recommended, above all antidepressant and typical neuroleptics.Conclusions The interdisciplinary treatment of patients with somatic diseases by the liaison psychiatry is an increasingly used instrument of other disciplines and serves to optimize the diagnostic and therapeutic efficiency of public health.

Die klassische Kritik am Medizinstudium wurde 2002 in eine entsprechend reformierte ärztliche Approbationsordnung (ÄAppO) umgesetzt. Für das Fach Psychiatrie und Psychotherapie fand am 23.01.2004 in Heidelberg ein bundesweiter Workshop der DGPPN (Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde) zur Implementierung dieser neuen gesetzlichen Vorgaben in der Lehre statt. Im Jahr 2008 führte die DGPPN eine postalische Umfrage zum aktuellen Stand der Umsetzung der Vorschläge an den 36 deutschen medizinischen Fakultäten mit den Hauptthemen allgemeine Struktur der Pflichtlehre, studentenzentrierte Lehrangebote und allgemeiner Stellenwert der Lehre durch. Bei einer Rücklaufquote von 75% sind die Ergebnisse dieser Befragung als repräsentativ anzusehen. Insgesamt kann ein positives Fazit zur Umsetzung der Approbationsordnung gezogen werden, diese ist jedoch keinesfalls abgeschlossen und bedarf noch der Optimierung, so z. B. hinsichtlich einer nicht nur theoretisch, sondern auch mehr praktisch ausgerichteten Prüfung.

In Alzheimer disease, CSF biomarkers and nuclear imaging are of particular interest. Many studies investigated only one technique, limiting comparison. Here, in 76 patients blinded 99mTc-SPECT was compared to CSF. Sensitivity of CSF was 92%; and 51% for SPECT. Specificity favored SPECT (90 vs. 80%). Both techniques showed no coherence (p = 0.17-0.47). Our results confirm that CSF biomarkers show higher sensitivity. SPECT has higher specificity and can also be used for other dementias without established CSF biomarkers.

Der vorliegende Artikel leitet den Beginn der Verhaltenstherapie aus der empirischen Psychologie her. Grundlegende theoretische Konzepte und Techniken werden ihrer Zeit und den Protagonisten zugeordnet.

SPECT allows registration of regional cerebral blood flow (rCBF) which is altered in a characteristic temporoparietal pattern in Alzheimer's Dementia. Numerous studies have shown the diagnostic value of reduced cerebral blood flow and metabolic changes using perfusion SPECT and FDG-PEPT in AD diagnosis as well as in differential diagnosis against frontotemporal dementia, dementia with Lewy bodies and vascular disease. Recently more pathophysiology-based biomarkers in CSF and Amyloid-PET tracers have been developed that probably have a higher diagnostic accuracy than the more indirect rCBF changes seen in perfusion SPECT. In the paper review, we describe recent advances in AD biomarkers as well as improvements in the SPECT technique.

The classic criticism levelled at German medical studies was addressed in 2002 with the reform of the German medical accreditation system. For the specialties Psychiatry and Psychotherapy, a national workshop of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) was held in Heidelberg on 23.01.2004 to implement the new legal requirements for teaching. In 2008, a postal survey was conducted among the 36 German medical faculties by the DGPPN to establish the current status of the proposed implementation, with the general structure of undergraduate medical training, student-centered syllabuses and the general significance of teaching forming the main points. With a response rate of 75%, the results can be considered representative. In general, a cautiously positive conclusion can be drawn on the implementation of the medical accreditation system. Having said that, it should be borne in mind that implementation is not yet complete and still requires optimization, for example in terms of making examinations not only theoretical but also more practical in approach.

Multiple-Choice-Fragen spielen in der Aus- und Weiterbildung eine wichtige Rolle. Seit 2002 gibt es in Der Nervenarzt CME („continuing medical education”) -Artikel mit meist 10 Multiple-Choice-Fragen. Untersuchungen aus anderen Fachgebieten zeigten, dass CME-Fragen häufig formal-didaktisch ungünstige Formate enthalten. In der vorliegenden Studie haben wir die CME-Fragen aus Der Nervenarzt auf ihre formal-didaktische Qualität untersucht.

Die moderne Psychiatrie wurde im 19. Jahrhundert von Ärzten als eigenständiges Fach in der Medizin etabliert. Ärzte waren es auch, die die Psychiatrie in der Folgezeit weiterentwickelten und in der 2. Hälfte des 20. Jahrhunderts grundlegend reformierten. Sie waren bei diesen Initiativen nicht allein, aber haben sie doch dominiert. Auch heute sind die meisten Professoren in der Psychiatrie Ärzte, und Ärzte haben mehr rechtliche Kompetenzen und Verantwortung in der psychiatrischen Versorgung als jede andere Berufsgruppe. Auf Psychiaterkongressen kann man weiterhin den Eindruck gewinnen, die ärztliche Dominanz in der Psychiatrie sei ungebrochen. Aber ist das wirklich so?

[english] Aims: There is a growing need to implement teamworking in medical education. In reality, interdisciplinary and interprofessional education is often absent. Here we describe a pilot trial developed jointly by the nursing college and the medical faculty in Erlangen (Germany) in which nursing students and undergraduate medical students formed interprofessional teams and were confronted with interprofessional cases using simulated patients (SPs) and phantoms. The elective was planned using standard curriculum planning instruments and finally evaluated with a novel formative team OSCE (Objective Structured Clinical Evaluation) instrument.Methods: During one year, 20 nursing students participated voluntarily in the project and 10 medical students took the course as an elective. Results: The pilot project was first performed with two tutors, one from the medical school and one from the nursing school, as well as one to two SPs. During the second course, there was only one tutor. Overall evaluation of the voluntary students was good, with some elements (acute stroke, factual knowledge, and general organizational problems) that needed to be improved. Performance of a four-station team OSCE was feasible, but raters reported problems in assessing individuals and the team at the same time. Interobserver agreement was satisfactory (kappa 0.35).Conclusions: Interdisciplinary and interprofessional education between a nursing school and a medical school is feasible within an elective, but requires substantial personnel resources. Design and performance of a team OSCE is possible. The validity of the test has to be shown on follow-up.[german] Zielsetzung: Das Lernziel „Fähigkeit zur interprofessionellen und interdisziplinären Teamarbeit“ wird sowohl in der aktuellen Approbationsordnung für Ärzte als auch im Krankenpflegegesetz gefordert. In der Realität gibt es in beiden Ausbildungen kaum gemeinsame Lehreinheiten. Wir beschreiben ein Pilotprojekt der Medizinischen Fakultät und der Berufsfachschule für Gesundheits- und Krankenpflege in Erlangen, in dem Pflegeschüler und Medizinstudenten interdisziplinär vor Aufgaben gestellt werden, die sie im interprofessionellen Team lösen sollen. Sie werden unter Einsatz von Simulationspatienten (SP) oder Phantomen mit Szenen aus dem Stationsalltag, interdisziplinären Notfällen und schwierigen Situationen konfrontiert, die interprofessionelles Handeln erfordern. Die Planung des Konzeptes wurde angelehnt an die von Kern beschriebenen Schritte zur Curriculumsentwicklung. Der Kurs wurde mit einem formativen Team-OSCE evaluiert.Methodik: An dem Projekt nahmen im Wintersemester 2008/09 und im Sommersemester 2009 insgesamt 20 Schüler der Berufsfachschule und 10 Medizinstudenten (Curriculäres Wahlpflichtfach nach Approbationsordnung im 5.-9. Semester) teil.Ergebnisse: Der Kurs wurde als Wahlpflichtfach für Studierende der Medizin und freiwillig für Pflegeschüler durchgeführt. Initial waren ein Dozent aus der medizinischen Fakultät und ein Dozent aus der Berufsfachschule anwesend, sowie meistens 1-2 SPs. Im zweiten Durchgang wurde der Kurs von einem Dozenten durchgeführt und einem Experten, der bei Bedarf hinzugezogen werden konnte. Anhand der Evaluationsergebnisse des ersten Kurses konnten konkrete Verbesserungsvorschläge (generell zur Organisation und speziell zum vorausgesetzten Fachwissen) in den Kurs des Folgesemesters implementiert werden. Die Durchführung eines 4-Stationen-Team-OSCE gelang organisatorisch. Im ersten Durchlauf zeigte sich, dass eine gleichzeitige Prüfung der Einzelleistung und der Teamleistung nicht möglich ist. Im Verlauf erfolgte nur eine Beurteilung der Teamleistung mit einem Inter-Observer Kappa-Quotienten von 0,35.Schlussfolgerung: Ein interdisziplinäres und interprofessionelles Ausbildungskonzept für Pflegeschüler und Medizinstudenten ist planbar und umsetzbar, braucht aber große personelle Ressourcen. Die Entwicklung und Umsetzung eines Team-OSCE ist möglich, seine Validität muss in Folgeuntersuchungen geprüft werden. Vermutlich ist eine simultane Beurteilung von Einzel- und Teamleistung im Team-OSCE nicht möglich.

Neurochemical Dementia Diagnostics (NDD), i.e., analysis of the cerebrospinal fluid (CSF) concentrations of amyloid-beta peptides and tau/phospho-tau proteins plays important role in the diagnosis of neurodegeneration and dementias. Several studies show alterations of these biomarkers in Alzheimer's disease (AD), however, only a few reports address alterations of other CSF biomarkers (albumin and immunoglobulins' quotients, cell count, lactate concentration, etc.) in the pathophysiology and diagnostic procedures of dementias. Therefore, we analyzed these biomarkers in patients diagnosed for dementia syndromes and carefully characterized with the state-of-the-art NDD analysis: Abeta1-42, Abetax-42, Abetax-42/x-40 ratio, tau, and ptau181. We found intrathecal IgG synthesis in 5 out of 112 patients showing alterations of the NDD biomarkers, and in four out of these five subjects, we could not find any satisfying reason for the intrathecal humoral response. In 25.9% of the patients with altered NDD biomarkers, we found an increased albumin quotient indicating a dysfunction of the blood-CSF barrier; however a similar figure of 25.2% was found in the group of patients without alterations in the NDD. Our findings suggest that at least some patients with increased CSF concentrations of tau/ptau proteins and decreased concentrations of Abeta{42} peptides show simultaneously CSF alterations found otherwise in neuroinflammatory processes. This, in turn, suggests that extended diagnosis should be performed in patients with "isolated" alterations of NDD biomarkers or intrathecal immunoglobulin synthesis.

Multiple-choice questions (MCQs) evaluate factual knowledge in medical education and have a high reliability, if performed appropriately. However, many MCQs contain formal errors leading to reduced validity. The authors developed a Web application capable of recognizing and eliminating five frequent contraindicated practices in MCQs: negative stem, unfocused stem, cueing words, longest item = right item flaw, and stem/item similarities. The authors used simple string algorithms and dynamic comparisons with keywords. The system was successfully validated with a sample of approximately 800 continuous medical education (CME) questions, showing that our system automatically detects 60% of all formal didactic errors. Flaws not detected by the software can easily be avoided using quick manuals on item wording or clear instruction to the authors. The authors conclude that it is feasible to improve the quality of MCQs by designing a Web application that is capable of detecting common flaws by simple string operations.

Multivariate image analysis has shown potential for classification between Alzheimer's disease (AD) patients and healthy controls with a high-diagnostic performance. As image analysis of positron emission tomography (PET) and single photon emission computed tomography (SPECT) data critically depends on appropriate data preprocessing, the focus of this work is to investigate the impact of data preprocessing on the outcome of the analysis, and to identify an optimal data preprocessing method. In this work, technetium-99methylcysteinatedimer (99mTc-ECD) SPECT data sets of 28 AD patients and 28 asymptomatic controls were used for the analysis. For a series of different data preprocessing methods, which includes methods for spatial normalization, smoothing, and intensity normalization, multivariate image analysis based on principal component analysis (PCA) and Fisher discriminant analysis (FDA) was applied. Bootstrap resampling was used to investigate the robustness of the analysis and the classification accuracy, depending on the data preprocessing method. Depending on the combination of preprocessing methods, significant differences regarding the classification accuracy were observed. For 99mTc-ECD SPECT data, the optimal data preprocessing method in terms of robustness and classification accuracy is based on affine registration, smoothing with a Gaussian of 12 mm full width half maximum, and intensity normalization based on the 25% brightest voxels within the whole-brain region.

Background. Multiple choice questions play an important role in training and continuing education. Der Nervenarzt has been publishing articles for continuing medical education (CME) since 2002 which usually have ten multiple choice questions. Studies from other fields have shown that CME questions are often formulated awkwardly from a didactic standpoint. In this study we analyzed the CME questions contained in Der Nervenarzt to assess their instructional quality.Materials and methods. The standardized evaluation was performed by semiskilled nonprofessionals. The setup permitted differentiation of 15 known quality criteria for multiple choice questions from the educational medical literature.Results. Of the 796 questions studied that had been posed in 2002-2008(370 neurology, 346 psychiatry, and 80 interdisciplinary), 518 questions had an awkward construction for didactic purposes. A negative wording of the stem, followed by unintentional cues and obsolete combination formats were most frequently observed. The proportion of precisely phrased questions has increased significantly since 2006.Conclusion. The CME questions in the German medical journal Der Nervenarzt have improved regarding their instructional quality since the beginning of the program.