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Background Objective and volumetric quantification is a necessary step in the assessment and comparison of endolymphatic hydrops (ELH) results. Here, we introduce a novel tool for automatic volumetric segmentation of the endolymphatic space (ELS) for ELH detection in delayed intravenous gadolinium-enhanced magnetic resonance imaging of inner ear (iMRI) data. Methods The core component is a novel algorithm based on Volumetric Local Thresholding (VOLT). The study included three different data sets: a real-world data set (D1) to develop the novel ELH detection algorithm and two validating data sets, one artificial (D2) and one entirely unseen prospective real-world data set (D3). D1 included 210 inner ears of 105 patients (50 male; mean age 50.4 ± 17.1 years), and D3 included 20 inner ears of 10 patients (5 male; mean age 46.8 ± 14.4 years) with episodic vertigo attacks of different etiology. D1 and D3 did not differ significantly concerning age, gender, the grade of ELH, or data quality. As an artificial data set, D2 provided a known ground truth and consisted of an 8-bit cuboid volume using the same voxel-size and grid as real-world data with different sized cylindrical and cuboid-shaped cutouts (signal) whose grayscale values matched the real-world data set D1 (mean 68.7 ± 7.8; range 48.9–92.8). The evaluation included segmentation accuracy using the Sørensen-Dice overlap coefficient and segmentation precision by comparing the volume of the ELS. Results VOLT resulted in a high level of performance and accuracy in comparison with the respective gold standard. In the case of the artificial data set, VOLT outperformed the gold standard in higher noise levels. Data processing steps are fully automated and run without further user input in less than 60 s. ELS volume measured by automatic segmentation correlated significantly with the clinical grading of the ELS (p Conclusion VOLT enables an open-source reproducible, reliable, and automatic volumetric quantification of the inner ears’ fluid space using MR volumetric assessment of endolymphatic hydrops. This tool constitutes an important step towards comparable and systematic big data analyses of the ELS in patients with the frequent syndrome of episodic vertigo attacks. A generic version of our three-dimensional thresholding algorithm has been made available to the scientific community via GitHub as an ImageJ-plugin.

In practice, standard scheduling of parallel computing jobs almost always leaves significant portions of the available hardware unused, even with many jobs still waiting in the queue. The simple reason is that the resource requests of these waiting jobs are fixed and do not match the available, unused resources. However, with alternative but existing and well-established techniques it is possible to achieve a fully automated, adaptive parallelism that does not need pre-set, fixed resources. Here, we demonstrate that such an adaptively parallel program can run productively on a machine that is traditionally considered “full” and thus can indeed fill all such scheduling gaps, even in real-life situations on large supercomputers in which a fixed-size job could not have started.

Schwindel als haufiges Leitsymptom in der klinischen Praxis kann otologische, neurologische, internistische und psychiatrische Ursachen haben und stellt damit eine interdisziplinare Herausforderung dar. Durch eine systematische Anamnese und umfassende klinische Untersuchung gelingt in aller Regel eine eindeutige Zuordnung zu peripher-, zentral- oder nicht-vestibularen Krankheitsbildern. Wichtige Unterscheidungskriterien sind dabei der zeitliche Verlauf, die Art der Symptome, modulierende Faktoren und begleitende Symptome. Fur die klinische Untersuchung sind folgende Tests relevant: Kopfimpulstest, Untersuchung auf Spontannystagmus, Lagenystagmus, zentrale okulomotorische Zeichen und Romberg-Test. Dennoch gibt es neurootologische Grenzfalle, bei denen eine kombinierte peripher- und zentral-vestibulare Storung vorliegt. Ein Verschluss der A. cerebelli anterior inferior fuhrt zu einer Ischamie des Labyrinths und Zerebellums und verursacht dadurch einen akut auftretenden Schwindel mit unilateralem Horverlust. Bei rezidivierend auftretenden Schwindelattacken mit Ohrsymptomen und Kopfschmerzen gibt es ein Uberlappungssyndrom zwischen einem Morbus Meniere und einer vestibularen Migrane, das haufig einer dualen prophylaktischen Therapie bedarf. Patienten mit chronischem Schwankschwindel und Gangunsicherheit konnen unter dem Krankheitsbild CANVAS leiden, bei dem eine bilaterale Vestibulopathie zusammen mit einer Polyneuropathie und einem zerebellaren Syndrom auftritt. Chronische Schwindelbeschwerden mit peripher- und zentral-vestibularen Zeichen findet man auch bei Raumforderungen im Kleinhirnbruckenwinkel mit Kompression zentraler Strukturen. Zusammenfassend sollten in der Diagnostik bei Schwindel daher immer peripher- und zentral-vestibulare sowie okulomotorische Funktionen gepruft werden.

Few studies have evaluated exercise interventions for smokers with depression or other psychiatric comorbidities. This pilot study evaluated the potential role of supervised vigorous exercise as a smoking cessation intervention for depressed females. Thirty adult women with moderate-severe depressive symptoms were enrolled and randomly assigned to 12 weeks of thrice weekly, in person sessions of vigorous intensity supervised exercise at a YMCA setting (EX; n = 15) or health education (HE; n = 15). All participants received behavioral smoking cessation counseling and nicotine patch therapy. Assessments were done in person at baseline, at the end of 12 weeks of treatment, and at 6 months post-target quit date. Primary end points were exercise adherence (proportion of 36 sessions attended) and biochemically confirmed 7-day point prevalence abstinence at Week 12. Biomarkers of inflammation were explored for differences between treatment groups and between women who smoked and those abstinent at Week 12. Treatment adherence was high for both groups (72% for EX and 66% for HE; p = .55). The Week 12 smoking abstinence rate was higher for EX than HE (11/15 [73%] vs. 5/15 [33%]; p = .028), but no significant differences emerged at 6-month follow-up. Interleukin-6 levels increased more for those smoking than women abstinent at Week 12 (p = .040). Vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. Innovative and cost-effective strategies to bolster long-term exercise adherence and smoking cessation need evaluation in this population. Inflammatory biomarkers could be examined in future research as mediators of treatment efficacy. This preliminary study found that vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. This research addressed an important gap in the field. Despite decades of research examining exercise interventions for smoking cessation, few studies were done among depressed smokers or those with comorbid psychiatric disorders. A novel finding was increases in levels of a pro-inflammatory biomarker observed among women who smoked at the end of the intervention compared to those who did not.

Mit dem Nachweis der onkologischen Sicherheit der haut- und nippelsparenden Mastektomie haben sich die Moglichkeiten der Brustrekonstruktion nach Mastektomie verbessert. Dies und die stetige Verbesserung der zur Verfugung stehenden Silikonimplantate haben die heterologe Brustrekonstruktion zu der am haufigsten durchgefuhrten Operationstechnik im Bereich der Wiederherstellungschirurgie nach Brustkrebs gemacht. Durch die zusatzliche Einfuhrung von supportiven alloplastischen Materialien wie synthetischen Netzen und azellularen dermalen Matrices besteht nun fur ein weiteres gut selektioniertes Patientenkollektiv eine Moglichkeit, die Indikationsstellung zur Implantatrekonstruktion nach Mastektomie zu erweitern. Dies ist ein erneuter Schritt, die Lebensqualitat fur diese Brustkrebspatientinnen zu verbessern. Es bleibt allerdings anzumerken, dass diese supportiven alloplastischen Produkte keine Losung fur alle Probleme darstellen und dementsprechend nur reflektiert eingesetzt werden durfen. Dieser Beitrag soll einen Uberblick uber die zur Verfugung stehenden Materialien geben und deren Einsatz kritisch diskutieren.

Introduction: Qualified training in senology is essential for maintaining adequate, high quality patient care. In order to meet the needs of doctors in training and those of the medical infrastructure it is necessary to assess the quality of training regularly, to enable its adaption and optimisation. Methods: We developed a comprehensive, 10 item online questionnaire to assess the quality of specialised training in senology. This questionnaire was sent to 4000 speciality trainees and young specialists countrywide via the DGGG newsletter and was accessible for over four weeks. Results: 111 obstetrics and gynaecology speciality trainees participated in this national survey, 79 % of whom were female. 33 % of participants were working at university hospitals, 29 % at hospitals offering maximal level care without an associated medical faculty, 37 % at hospitals offering primary and secondary level care and 2 % at gynaecology practices. 25 % of participants could imagine working in the field of senology in future. On average the current perception of general specialist training was satisfactory. Specialist trainees at university hospitals rated training in senology highest (score: 2.95) compared to those at other hospitals. A fixed rotation through a breast centre offering comprehensive advanced training was seen as a potential improvement to senology training. Conclusions: This is the first survey of specialised training in senology to be conducted in Germany. Results showed that there is significant potential for young doctors to enter the speciality in future. There are also significant differences in the perceived quality of senology training between training facilities. This survey aimed to determine the quality of specialised training at senology centres and hopes to contribute to a sustainable improvement in training. The intention is to continue to make senology attractive to gynaecologists and to ensure well-grounded training.

Vertigo/dizziness (VD) ranks high in lifetime prevalence and clinical relevance. Nearly half of the complex VD disorders presenting at specialised units for vertigo or otoneurological disorders are not fully explained by an identifiable medical illness, but instead are related to anxiety, depressive, or somatoform disorders. Although there is some evidence that psychotherapy may be effective for these patients, therapeutic options remain unsatisfactory. This report describes the objectives, design and methods of a randomised, controlled clinical trial, evaluating the efficacy of manualised, multimodal group psychotherapy, based on integrative psychotherapy (IPT) and tailored to subgroups of mental disorders in medically unexplained VD. This psychotherapeutic approach will be compared to self-help groups (n = 172; n = 86 per study arm). Improvements with regard to handicap due to VD at 12 months follow-up will serve as primary outcome. Additionally, measures of generic quality of life, severity of vertigo, depression, anxiety, somatisation as well as Head Impulse Test and Computerized Static Posturography will be applied. We will also analyse the cost-effectiveness of this trial. The study aims to improve treatment of this therapeutically underserved population who are often severely impaired in their working and daily lives. Trial Registration: ClinicalTrials.gov Identifier: NCT02320851. Trial Status: This is an on-going study; recruitment for the study is about to start.

Vestibular-evoked myogenic potentials (VEMPs) are frequently used in the clinical diagnosis and research of vertigo syndromes. Altered latencies or amplitudes are typically interpreted as an indication of disturbance in the processing of vestibular stimuli along the otolithic pathways. Correct interpretation, however, can be difficult as VEMP amplitudes can vary greatly across subjects and across laboratories, likely because they are very sensitive to measurement conditions. Here, we attempted to quantify the impact of examiner differences on VEMP data. We collected data from 1,038 people using eight different experimental examiners, and investigated the effect of examiner on VEMP latencies and amplitudes. We found that the examiner collecting the data had a strong effect on outcome measures with significant differences (p < 0.001) in cVEMP and oVEMP latencies and in oVEMP amplitudes. No significant differences between examiners were found for the cVEMP amplitudes. When we compared the healthy and pathological sides of patients with a clinically diagnosed unilateral disease, no significant differences between sides were found. Given our results and the results reported in the literature, we conclude that the signal features of VEMPs are very sensitive to variables that may be influenced by the examiner. The field should therefore work on a better standard for VEMP recordings.

Introduction Orthostatic tremor (OT) is a rare disorder of unclear etiology characterized by a 13–18 Hz tremor of the legs while standing with resolving symptoms during sitting or walking. OT is associated with other movement disorders such as parkinsonism, essential tremor or cerebellar disorders. Although gait disturbances are frequently described in these diseases, there is no systemic analysis of the gait disorder linked to OT. Therefore, the aim of this study is to investigate the gait performance of patients with OT assessed by a standardized sensorimotor and cognitive walking paradigm. Methods Patients with a diagnosis of primary OT were screened and included in this study after informed consent. Gait performance was investigated during 8 different walking conditions using a pressure-sensitive sensor carpet (GAITRite®). Patients walked at preferred, slow and maximum walking speeds (PS, SS, MS), during head reclination and eyes closed conditions (HR, EC) as well as calculatory, semantic and motoric dual task conditions (DTC, DTS, DTM). The gait performance of patients was compared to age-matched healthy subjects. Gait parameters were assessed by a multivariate analysis of variance. Results Eighteen patients with a diagnosis of primary OT with a mean age of 70.4 ± 5.9 years were included in the study. In all walking conditions gait velocity (p Discussion Although OT symptoms diminish during walking, we identified constant impairments of locomotion control. The gait disturbance was characterized by an increased level of a cautious gait (slow, small-stepped, increased double support phases and BOS). Moreover, we identified disturbance of gait stability (increased CV) and interlimb coordination (left-right asymmetry). The specific alterations were found in conditions with increased sensory feedback control as well as attentional cognitive gait control. This implies an impaired integration of sensory feedback, possibly due to a dysfunction of midline cerebellar structures, as cerebellar dysfunction in OT was frequently described.

Introduction Intravenous contrast agent enhanced magnet resonance imaging (ivMRI) of the endolymphatic space (ELS) of the inner ear permits the in vivo non-invasive verification of the endolymphatic hydrops (ELH). This might prove especially helpful in the at times complex clinical differentiation between Vestibular Migraine (VM) and Menieres Disease (MD) ( Nakada et al., 2014 ). However, current quantification methods of the ELS are cumbersome and experience-dependent ( Gurkov et al., 2015 ). The aim of this study was (i) the development of a multimodal probabilistic atlas of the bony structures of the human inner ear, (ii) the establishment of an atlas-based segmentation of the ELS to then (iii) enable an automated and reproducible volume-based quantification of the ELS. Methods Twenty-four patients with vestibular migraine, but without ELH (12 females, aged 20 −76 years, mean age: 51.5 ± 3.9 years) underwent a delayed MRI of the ELS 4 h after the intravenous injection of gadobutrol was performed in a 3 T scanner ( Nakada et al., 2014 ). Diagnostic work-up included neurologic & neuro-orthoptic assessment, VOG during caloric stimulation and head-impulse [HIT], audiometry. The preprocessing is performed by an affine and deformable fusion pipeline and the probabilistic multimodal atlas was created using a label-based approach ( Brandt and Dieterich, 2017 ). Results The performance of the atlas was evaluated using three factors: population, number of control points and second Gaussian kernel. The optimum value of the factors for the used algorithm was recognized and atlas based segmentation was conducted. The accuracy of the segmentation was assessed using a dice score (right and left side mean dice score 89% and 86%). Right and left inner ear probabilistic atlas resulted in a 4.7% discrepancy. Discussion This novel multimodal probabilistic atlas of the human inner ear enables an automated and reliable segmentation of the endolymphatic space using a deformable registration pipeline, in which each newly generated template includes more comprehensive and plenary information. Applications include automated 3D segmentation and quantification of the inner ear and its different fluid-filled spaces, as well as of the vestibulocochlear nerve.

Introduction An endolymphatic sac tumour (ELST) is a rare form of a locally invasive very slowly growing papillary epithelial neoplasm originating from the endolymphatic sac and/or duct ( Wick et al., 2015 ). This single case study exemplifies the usefulness of delayed intravenous gadolinium-enhanced magnetic resonance imaging (iMRI) of the inner ear for differentiation of divers vestibular pathologies in complex cases of dizziness ( Nakada et al., 2014 ). Case report & methods A 48-year old, highly burdened right-handed female patient who had been operated on an ELST in the right petrosal bone presented with three different vestibular symptoms: (i) a persistent to-and-fro vertigo since 20 years, (ii) reproducible position-dependent short vertigo attacks accompanied by an inconsistent nystagmus when laying down on her side (R > L), and (iii) spontaneous rotational vertigo attacks for several hours associated by ear pressure, nausea, vomiting, and diarrhea. The diagnostic work-up included a careful neurootological and neuro-orthoptic assessment, videooculography during oculomotor examination (VOG), caloric stimulation (caloric) and head-impulse (HIT), audiometry, as well as an iMRI 4 h after injection of i.v. contrast agent ( Nakada et al., 2014 ). Endolymphatic hydrops (ELH) was characterized by criteria previously described ( Barath et al., 2014 ). Volumetric assessment used manual segmentation in combination with machine learning and automated local thresholding algorithms ( Gurkov et al., 2015 ). Results The structural MRI showed a focal defect zone in the right cerebellar hemisphere. In line, the neuro-orthoptic examination revealed a cerebellar syndrome with downbeat-nystagmus (DBN) that increased when lying down on her R > L side. Furthermore, a right-sided audio-vestibular peripheral deficit was disclosed (HITmean gain: R = 0.66, L = 0.98; caloricsmean[°/s]: R = 4, L = 11; audiometrymean [dB]: R = 50, L = 15). The iMRI revealed a high-grade unilateral right-sided ELH (R = 87 mm3, Rcochlea(=c) = grade II-III, Rvestibule(=v) = grade III), whereas the left ear showed normal values (L = 32 mm3, Lc/v = grade 0). Discussion On the basis of these results the (i) ongoing vertigo with (ii) exacerbation when lying down on the side could be assigned to a DBN syndrome with central positional vertigo due to the cerebellar lesion. The spontaneous attacks (iii) were caused by a secondary right-sided ELH. The differentiation of aetiologies allowed a stepwise treatment with a combination of 4-aminopyridine (5 × 5 mg/d) to improve the DBN and betahistin (3 × 48 mg/d) to improve the ELH. Both medications lead to a considerable clinical benefit. Here, iMRI was crucial in assigning a complex symptomatology to different central and peripheral vestibular pathologies resulting in a successful treatment ( Brandt and Dieterich ).

We present the implementation of a new molecular mechanics program designed for use in mobile platforms, the first specifically built for these devices. The software is designed to run on Android operating systems and is compatible with several modern tablet-PCs and smartphones available in the market. It includes molecular viewer/builder capabilities with integrated routines for geometry optimizations and Monte Carlo simulations. These functionalities allow it to work as a stand-alone tool. We discuss some particular development aspects, as well as the overall feasibility of using computational chemistry software packages in mobile platforms. Benchmark calculations show that through efficient implementation techniques even hand-held devices can be used to simulate midsized systems using force fields.

Aim To investigate the natural course of progression of ocular motor signs in patients with progressive supranuclear palsy (PSP). Methods 114 patients with a possible or probable PSP following NINDS-SPSP criteria seen at the Department of Neurology and the German Center for Vertigo and Balance Disorders (LMU, Munich) were included in this retrospective study. All patients underwent a structured neuro-ophthalmological testing by a orthoptist at initial diagnostic evaluation, 35 patients several times during their course of disease. The following ocular motor signs were extracted from the charts: Saccadic slowing (with normal range of movement) and saccadic paresis (loss of saccade initiation or severe saccadic hypometria) in vertical and horizontal direction, range of up- and downward as well as horizontal ocular motility during smooth pursuit in mm, presence of square wave jerks, function of the vestibulo-ocular reflex on head impulse testing. Clinical ocular motor signs were analysed in all patients in relation to the duration of disease at the time of examination (based on the medical history of the first sign indicative for PSP) or longitudinally during the course of disease in a subgroup of 35 patients. Results In the whole group of PSP patients saccadic abnormalities showed the following distribution over time: at 1 year of disease duration 10% showed only saccadic slowing on upgaze, 40% on up- and downgaze, 21% saccadic paresis on upgaze and 29% complete vertical saccade paresis; at 2 years the proportion of vertical saccade paresis was 32%, at 3 years 65% and at 4 years 82%. Progression of horizontal saccade paresis was slower (year 1: 6%, year 2: 9%, year 3: 21%, year 4: 41%). The subgroup of patients with longitudinal follow up showed a similar tendency. Ocular motility in this group decrease by a mean of 1.5 mm/a on upgaze, 1.6 mm/a on downgaze and 1.4 mm/a on horizontal gaze. The degree of motility loss on up- and downgaze over time showed a good correlation (R2 = 0.71). Conclusion Ocular motor examination can be used as a robust marker of disease progression. Variability between patients however is considerable. Prospective clinical and apparative quantification of ocular motor markers in well-characterized cohorts of PSP patients is needed.

Introduction Bilateral vestibular loss leads to anatomical and functional changes in the hippocampal formation, which are reflected in subjective and objective behavioural deficits in spatial navigation, learning and memory ( Thomas et al., 2005 , Kremmyda et al., 2016 ). The aim of our study was to specify the seen hippocampal volume changes within grey and white matter in BVP using a novel hippocampus subfield segmentation approach ( Pipitone et al., 2014 ). Methods 50 right handed subjects (25 healthy controls (HC): aged 58 years, range 31–86 years with physiological vestibular function [head impuls test (HT) gain at 60 ms right 0.9, left 1.0] and 25 patients with bilateral vestibulopathy (BVP) with residual vestibular function (calorics warm left: −2.6°/s; right 2.8°/s) aged 61 years, range 24–87 years] were measured in a 3 T MRI (Erlangen, Siemens, Verio.After hippocampal subfield segmentation ( Pipitone et al., 2014 ) and intracranial volume correction, ANOVA was performed for both left and right hemispheres to evaluate the Bonferoni-corrected differences in the hippocampal subfield volumes between HC and BVP using FSL and R. Results Whole brain analysis did not reveal any areas of grey matter change for both contrasts (BVP > HC and HC > BVP).Within the hippocampus-subfield specific grey matter analysis volume decrease was most significant in the posterior part, more specifically in the right CA1 and subiculum ( p p p Discussion Our findings are in line with previous human and animal studies that were able to link chronic bilateral vestibulopathy to hippocampal atrophies ( Thomas et al., 2005 , Kremmyda et al., 2016 , Horii et al., 2004 ). More specifically white matter changes were laterality-unspecific and a little more localized to the anterior/middle part of the hippocampus, which is thought to represent inputs from the vestibular system (required for estimating direction during path integration). Whereas grey matter changes were right-sided and more localized to the middle/posterior part of the hippocampus, which is thought be involved in spatial navigation ( Horii et al., 2004 , Hufner et al., 2011 ).

Aim Identifying stroke as a cause of acute vertigo, dizziness and imbalance in the emergency room is still a clinical challenge. The aim of the EMVERT trial was to develop a diagnostic index test to identify patients with the high risk to have a stroke as the cause of the balance symptoms. Methods Patients with acute onset of vertigo, dizziness, postural imbalance, gait instability or double vision with symptoms in the last 24 h lasting for at least 10 min were eligible to be included in the study. 840 patients were prospectively screened for inclusion in the study. Patients with benign paroxysmal positional vertigo, recurrent attacks of Meniere’s disease, as well as clear clinical signs of stroke (i.e. hemiparese, hemihypaesthesia) were excluded. 345 patients were included in the study and underwent standardized clinical and apparative neuro-ophthalmological/-physiological testing (including video-oculography, video head impulse testing, mobile posturography, measurement of subjective visual vertical) as well as scores and scales for symptom intensity and vascular risk factors (EMVERT block 1). Within 10 days a standardized magnetic resonance imaging (MRI) protocol was performed as a reference test to identify stroke (EMVERT block 2). Data from block 2 (MRI and clinical follow up) were compared to results from EMVERT block 1 in order to compose a diagnostic index test with a high specificity and sensitivity to predict the risk of stroke in the emergency room. Results In 44 enrolled patients a cerebral ischemia was diagnosed based on diffusion-weighted MRI (12.7%). The most frequent lesion side was the vascular territory of the posterior inferior cerebellar artery. The group of all stroke patients showed significantly higher ABCD2-Scores compared to all other patients (p Conclusion About 5% of all patients with acute vertigo, dizziness and gait instability presenting to the emergency room suffer from stroke. Assessment of the cardio-vascular risk profile by the ABCD2 score and testing of the head impulse test, gaze evoked nystagmus and vertical deviation of the eyes are helpful to detect stroke. Apparative testing by videooculography increases the chance to detect pathological neuro-ophthalmological signs.

Introduction A new reasonable and dependable distinguishing criterion in the difficult clinical differentiation between Vestibular Migraine (VM) and Meniere’s Disease (MD) might be the proof of an endolymphatic hydrops (ELH) via gadolinium-enhanced magnetic resonance imaging of the inner ear (iMRI) Lempert et al. . However, so far published studies are inconclusive and sparse. This single case study clinically documents the volume of the endolymphatic space (ELS) in a VM patient longitudinally over 12 months during an attack-free period (T1), shortly after an VM attack (T2), and three attack-free months later (T3). Case report & methods A 61-year old female patient with a 40-year history of recurrent attacks of spontaneous rotational vertigo lasting from a few hours to several days and occurring 1–4 times in 6 months was classified as definite VM. Additional symptoms during the attacks were unsteadiness, a feeling of bilateral head-fullness, bilateral aural pressure, intolerance of motion, photo- and phonophobia; no affection of hearing. Independent of these attacks, regular episodes of migraneous headache were reported. A bilateral vestibulopathy affecting the lower-frequency range had been detected earlier. Diagnostic work-up included neurootological and neuro-orthoptic assessment, VOG during caloric stimulation and head-impulse test [HIT], and audiometry. A delayed MRI of the ELS 4 h after the intravenous injection of gadobutrol was performed in a 3 T scanner ( Nakada et al., 2014 ). ELH was characterized on published criteria ( Barath et al., 2014 ) whilst including an extra grade. Volumetric assessment of ELS used manual segmentation in combination with machine learning and automated local thresholding algorithms ( Gurkov et al., 2015 ). Results Our study revealed an activity-dependent plasticity of the ELS with phases of ELH grade I-II within the left (L)- and right (R)- sided vestibule (v) or cochlea (c) (T1: R/Lv/c = grade 0; T2 R/Lv = grade II, R/Lc = grade I; T3: Rv = grade II, Rc = grade I; Lv = grade I, Lc = grade I) without relevant change in the other diagnostics (HITmean gain: R/LT1 = 0.8, R/LT2 = 0.9; R/LT3 = 0.8; caloricsmean [°/s]: R/LT1 = 2, R/LT2 = 4; R/LT3 = 5; audiometrymean [dB]: R/LT1 = 15, R/LT2 = 15; R/LT3 = 15). Longitudinal (T1–T3) depiction of detailed results revealed activity-dependent plasticity of the endolymphatic space (ELS) of the right inner ear showing an endolymphatic hydrops (ELH) without relevant changes in the ipsilateral diagnostics (HIT [gain], caloric [°/s], audiometry [dB]). Discussion This is the first time that plasticity of the ELS is described in VM dependent on the disease activity with an ELH during and after an attack. This raises further questions on the pathognomonic significance of the detection of an ELH within the cochlea and/or vestibule in Meniere’s Disease (MD) [2] and even more so in VM patients [4,5].

Die verbesserte Therapie von Patientinnen mit Brustkrebs und Malignomen generell hat zu einem verbesserten Gesamtuberleben gefuhrt. Andererseits fuhrt die chemotherapieinduzierte Amenorrho (CIA) zu Infertilitat und vorzeitiger Ovarialinsuffizienz. Gegenwartig gibt es keine evidenzbasierten Empfehlungen fur die Erhaltung der Fertilitat bzw. der Ovarialfunktion bei Krebspatientinnen. Auser der Kryokonservierung von Embryonen sind alle anderen Verfahren experimentell. Die Ergebnisse einiger qualitativ unzureichender Beobachtungsstudien haben nahegelegt, dass GnRH-Agonisten eine CIA bei Patientinnen mit Brustkrebs und anderen Malignomen verhindern konnten. Bis heute wissen wir nicht, wie die GnRH-Agonisten ihre ovarprotektive Wirkung entfalten sollen. Gegenwartig haben wir Ergebnisse aus randomisierten klinischen Studien, wonach GnRH nicht zur Vermeidung der CIA beitragen. Die meisten Patientinnen fangen innerhalb der ersten 6 Monate nach Chemotherapie wieder an zu menstruieren. Darunter sind nahezu alle „sehr jungen“ Patientinnen, bei denen Kinderwunsch besteht. Uber einen langeren Zeitraum steigt die Rate der wieder menstruierenden Frauen weiter an. Zusammenfassend kann derzeit keine Ovarprotektion mit GnRH-Analoga wahrend einer Chemotherapie empfohlen werden.

ZusammenfassungDer Vitamin-B12-Mangel ist charakterisiert durch Störungen an drei verschiedenen Organsystemen mit makrozytärer, hyperchromer, hämolytischer Anämie, Schleimhautatrophie des oberen Intestinaltraktes sowie Veränderungen an ZNS, Rückenmark und peripheren Nerven. Zu den zentral- und peripher-nervösen Störungen, die bei 40% der Patienten auch isoliert auftreten, zählen Enzephalopathie, Myelopathie und sensomotorische Polyneuropathie. Die Enzephalopathie beinhaltet psycho-pathologische Störungen vom leichten hirnorganischen Psychosyndrom mit Hirnleistungsminderung bis zur produktiven organischen Psychose und geht mit einer Leukoenzephalopathie einher, die sich im Kernspintomogramm (MRT) in Form ausgedehnter konfluierendern Läsionen der weißen Substanz äußert. Bei der funikulären Myelose kommt es zu Entmarkungsherden besonders an den Hintersträngen und Pyramidenbahnen des Zervikal- und Thorakalmarkes, die sich in der MRT als langstreckige, hyperintense, intraspinale Läsionen darstellen. Diese sind unter Substitution parallel zur klinischen Besserung teilweise reversibel. An die Möglichkeit einer Vitamin-B12-Hypovitaminose sollte bei klinischen Syndromen mit der Kombination von Hinterstrangsymptomen, Pyramidenbahnzeichen und Paresen mit verminderten/fehlenden Reflexen gedacht werden.

Objective Reactive gliosis may improve recovery after acute unilateral vestibulopathy (AUV). In the present study glial activation was visualized in vivo by [ 18 F]GE180-PET in a rat model of unilateral labyrinthectomy (UL) and compared to behavioural vestibular compensation (VC) over time. Methods 14 Sprague-Dawley rats underwent a left-sided UL by a transtympanic injection of bupivacaine and arsenilate, 14 rats received a left-sided middle-ear sham injection of 0.9% NaCl-solution as a control group (SHAM-UL). For functional imaging of glial activation, PET with [ 18 F]GE180, a novel translocator protein (TSPO) ligand, was performed at baseline and 7, 15, 30 days after UL/SHAM-UL. Ex vivo autoradiography was done at the respective time points for high resolution validation of PET and combined with Nissl-staining of the corresponding slices for detailed anatomic mapping. Established behavioural testing for symptoms of vestibular tone imbalance including registration of postural asymmetry and nystagmus was performed at baseline and at days 1, 2, 3, 7, 15, 30 after UL/SHAM-UL. Results Only after UL rats showed clinical signs of vestibular imbalance which significantly decreased until days 15 and 30. In parallel, [ 18 F]GE180-PET and ex vivo autoradiography depicted glial activation in the ipsilesional vestibular nerve and nucleus at days 7 and 15 after UL. Correlation analysis revealed a strong negative association of [ 18 F]GE180 uptake in the ipsilesional vestibular nucleus at day 7 with the rate of postural recovery (R = −0.90, p 18 F]GE180 binding in the ipsilesional vestibular nerve and nucleus 7 days after symptom onset. Interpretation In the rat glial activation takes place in the ipsilesional vestibular nerve and nucleus within the first 30 days after UL and can be visualized in vivo by [ 18 F]GE180-PET. Comparative analysis of behavioural and [ 18 F]GE180-PET data proves that glial activation is beneficial for VC. In human AUV neuroinflammation seems to analogously appear in the ipsilesional vestibular nerve and nucleus.

Recurrent episodes of oscillopsia, rotational vertigo, and postural imbalance were elicited and modulated by changing the horizontal head positions of a patient with an arachnoid cyst in the right cerebellopontine angle that distorted the vestibulocochlear nerve. Oculomotor analysis revealed two different types of attacks depending on the particular head position: 1) episodes of vestibular hypofunction (minutes to several hours) with normal head position and 2) paroxysmal vestibular excitation (seconds) with head rotation to the left. The most likely cause is a transition from conduction block to ectopic discharges, which occurs when various peripheral nerves are compressed. One week after resection of the cyst and decompression of the eighth cranial nerve the patient was symptom free, and the electronystagmogram was normal.

Atypical facial pain is a collective term used for otherwise unclassifiable pain syndromes of the face. It describes mostly unilateral lancinating and burning pain, which is constantly present but fluctuating in intensity and may be accompanied by dys-or paraesthesias over a period of several years. Women are more often affected than men. A strikingly large number of invasive investigative procedures are performed before the final diagnosis is established. Psychopathological abnormalities are frequent and do not consist solely in masked depression. To date there is no cure for atypical facial pain. Most frequently tricyclic antidepressants such as amitriptyline and imipramine, MAO inhibitors or anticonvulsives such as carbamazepine and phenytoin are used, which only alleviate the pain. This also holds true for behaviour therapy, which should be the first-line treatment. Any invasive intervention should be avoided. In the differential diagnosis atypical facial pain should be distinguished from cervicogenic or cluster headache, and also from intracranial tumours of the trigeminal nerve or the cerebellar-pontine angle, erosive tumors of the base of the skull, orbitas and nasopharynx.

Worldwide, breastfeeding saves the lives of infants and reduces their disease burden. Breastfeeding also reduces the disease burden for mothers. This article examines who chooses to breastfeed and for how long in the American context. It also reviews the latest evidence about the consequences of breastfeeding for the health of both the infant and mother. The results of this review provide support for current national and international recommendations that support breastfeeding.

This report describes the objectives, design, and methods of the Munich Diagnostic and Predictor Study of Dizziness, a prospective study investigating diagnostic subgroups, correlates, and predictors of dizziness that is not sufficiently explained medically but clearly related to a psychiatric disorder. All patients presenting at the Integrated Centre for Research and Treatment of Vertigo, Balance and Ocular Motor Disorders at the University Hospital Groshadern in Munich, Germany, are investigated during their first-time visit. The study consists of a baseline and two follow-up assessment points at 6 and 12 months. At the baseline assessment point, all participants complete self-rated questionnaires concerning dizziness, depression, anxiety, dissociative and traumatic experiences, somatization, body sensations and perception, cognitions, attachment, personality, quality of life and experiences with the health care system. Additionally, a structured clinical interview is conducted to assess mental disorders. Then, the neurologists complete questionnaires regarding the subjective doctor-patient relationship and to document the somatic diagnoses and results. The follow-up measurements consist of self-rated questionnaires. This study aims to improve the diagnosis and treatment of patients who suffer from dizziness related to a psychiatric disorder and who are often severely impaired in their working and daily lives.

Maternal obesity is associated with poor breastfeeding outcomes, yet no intervention has been developed to improve them. To ascertain whether increased breastfeeding support or provision of a breast pump is a feasible, effective intervention to improve breastfeeding, we enrolled obese women who intended to breastfeed in two randomized trials.In Bassett Improving Breastfeeding Study (BIBS) 1, 40 women received targeted breastfeeding support in the hospital and via telephone or usual care. Information regarding breastfeeding was collected via telephone for 7 days after delivery and at 30 and 90 days postpartum. In BIBS 2, 34 obese mothers received a manual or electric breast pump to use for 10-14 days or no pump; data collection was similar.In both experiments, randomization failed to distribute women of differing postpartum body mass index adequately among the treatment groups. When analyses were adjusted for this, there was no difference in BIBS 1 between targeted and usual care groups and in BIBS 2 among the treatment groups in the proportion of women still breastfeeding at the times studied.In future studies of obese women, stratified randomization may be necessary. Further development of interventions to help obese women achieve optimal breastfeeding outcomes is required.

Article abstract-We describe the unique case of a woman with embolic infarction within the right middle cerebral artery territory who had nonepileptic rotational vertigo, nausea, and unsteady gait that gradually resolved within a week. A well-demarcated lesion of the posterior insula (homologous to parieto-insular vestibular cortex in monkeys) was probably the cause. This is supported by a contraversive tilt of perceived vertical and by involvement of the adjacent auditory (Heschl's) cortex. Dipole source analysis of late auditory evoked potentials revealed a decreased amplitude of a dipole source in the right insular cortex, whereas two other dipoles situated in the temporal lobe showed symmetric activity.NEUROLOGY 1995;45: 42-44