Assessing evidence quality in research reporting neurocognitive outcomes following paediatric temporal lobe surgery for epilepsy.

PURPOSE: RCTs are the gold standard in determining intervention efficacy with journal impact factor assumed to index research quality. Flint et al's (2017) systematic review examined neurocognitive outcomes following paediatric temporal lobe epilepsy surgery. Retrieved evidence was restricted to non-RCTs, which pose greater risk of bias and thus diminish research quality. The current study evaluated risk of bias in sources retrieved by Flint et al. and explored whether impact factor related to research quality within this selected field. METHODS: Methodological and reporting bias was evaluated using categories of bias specified by Cochrane. The relationship between the identified number of biases and journal impact factors of retrieved sources was examined. RESULTS: All studies carried substantial risk for bias. Methodology bias included low sample size (76.71%; 56/73), risk of confounding cognitive outcomes due to failure to report pre-surgery neurocognitive data (21.92%; 16/73) and to determine whether patients were prescribed antiepileptic drugs at follow-up (53.42%; 39/73). Reporting bias included overstating claims based on findings (53.42%; 39/73), failure to report individual patient characteristics (66%; 33/50) and omitting the nature of surgical interventions (15.07%; 11/73). The number of sources of common bias within studies was not associated significantly with journal impact factor (p = .878). CONCLUSION: This evaluation highlights risk of bias when sources are predominantly uncontrolled non-RCTs and provides evidence that journal impact factor is not a reliable indicator of quality within this field. Authors should limit bias in their methods and reporting of results, to ensure the highest quality evidence possible is used to inform treatment decisions and prognosis.

Evita's lobotomy.

For 60 years, the details about Eva Perón's illness and lobotomy at the end of her life have been obscured from the public. Here, we examine the sociopolitical factors that may have contributed to this secrecy. The first involves Eva Perón's political status and the personality cult surrounding her image, including partisan efforts to present her as a patron saint of Peronism. The second involves the social perceptions, which are often stigmatizing, regarding disease in political or public figures. Notably, neuropsychiatric illness and associated indications for treatment were viewed as oligarchic by the Perón regime, and admission to a lobotomy may have been perceived as anti-Peronist. A third factor involves the growing ignominy of prefrontal lobotomy as a surgical modality, which may have precluded operative exposés. A final factor may be that Eva Perón's lobotomy was in fact performed for behavior and personality modification, and not just for pain control. A brief history of lobotomy is presented, highlighting its adoption as a procedural panacea for psychiatric illnesses, relief of intractable pain from cancer, and management of belligerent behavior, and its subsequent fall from clinical favor. Although a shroud of secrecy still surrounds Eva Perón's prefrontal lobotomy, these factors provide a potential rationale for the circumstances, as well as foster a discussion of cultural elements that may still play a role in the public perception of psychosurgery today.

The contemporary practice of psychiatric surgery: results from a global survey of functional neurosurgeons.

BACKGROUND: Interest in neurosurgery for psychiatric diseases (NPD) has grown globally. We previously reported the results of a survey of North American functional neurosurgeons that evaluated general attitudes towards NPD and the future directions of the field. OBJECTIVES: The purpose of this study was to expand on our previous work and obtain a snapshot in time of global attitudes towards NPD among practicing functional neurosurgeons. We measure general and regional trends in functional neurosurgery and focus specifically on surgery for mind and mood, while exploring the future prospects of the field. METHODS: We designed an online survey and distributed it electronically to 881 members of the following international organizations: World Society for Stereotactic and Functional Neurosurgery, European Society for Stereotactic and Functional Neurosurgery, Asian-Australasian Society for Stereotactic Functional Neurosurgery and the South and Latin American Society for Stereotactic and Functional Neurosurgery. Subsequent statistical and thematic analysis was performed on the data obtained. RESULTS: Of 881 surveys distributed, 106 were returned (12.8%). Eighty-two percent of functional neurosurgeon respondents were fellowship trained, with movement disorders and pain making up the majority of their practice. Psychiatric indications are the most frequently treated conditions for 34% of survey respondents, and over half of participants (51%) perform epilepsy surgery. Of the psychiatric conditions, obsessive-compulsive disorder and depression are the most common disorders treated. The majority of respondents (90%) felt optimistic about the future of NPD. Two thirds cited the reluctance of psychiatrists to refer patients as the greatest obstacle facing the field, and a majority reported that a cultural stigma surrounding psychiatric diseases exists in their community. In response to hypothetical situations involving cognitive and personality enhancement, opinions varied, but the majority opposed enhancement interventions. Regional variations were examined as well and uncovered distinct attitudinal differences depending on geographic location. CONCLUSIONS: Surgery for psychiatric conditions is an expanding field within functional neurosurgery. The opinions of international functional neurosurgeons were largely in line with those of their North American colleagues. Optimism regarding the future of NPD predominates, and future editions of this survey can be used to track the evolution of neurosurgeons' attitudes towards NPD and neuroenhancement.

A prospective study of anxiety with respect to seizure outcome after epilepsy surgery.

PURPOSE: To evaluate if degree of anxiety proneness is affected by seizure outcome after epilepsy surgery. METHODS: Five scales related to anxiety, which are part of the Karolinska Scales of Personality (KSP), were administered pre-operatively and 2-8 years post-operatively to 31 female and 26 male patients. High scores indicate a high degree of anxiety. Seizure outcome was either Engel I or Engel II-IV. RESULTS: Mean age of the patients was 39 years (S.D. 10). Forty-seven patients had temporal surgery and 10 patients had extra-temporal surgery. The outcome in 34 patients was classified as Engel I and in 23 patients as Engel II-IV. There were statistically significant decreases (paired t test) in t scores for the Somatic Anxiety scale (expected mean 50, from 55.4 to 50.2, P = 0.001) and the Psychic Anxiety scale (expected mean 50, from 56.2 to 51.6, P = 0.006) in patients in Engel I. No other significant differences were observed. After taking baseline imbalances into account (ANCOVA), there were no statistically significant differences in the change in degree of anxiety proneness between patients in the two outcome groups. CONCLUSION: Patients undergoing successful epilepsy surgery experienced small decreases in somatic anxiety and psychic anxiety. Since there were important pre-operative imbalances between the two outcome groups, these differences could not be attributed to the effect of seizure freedom after epilepsy surgery.

Empirical methods for assessing meaningful neuropsychological change following epilepsy surgery.

Traditional methods for assessing the neurocognitive effects of epilepsy surgery are confounded by practice effects, test-retest reliability issues, and regression to the mean. This study employs 2 methods for assessing individual change that allow direct comparison of changes across both individuals and test measures. Fifty-one medically intractable epilepsy patients completed a comprehensive neuropsychological battery twice, approximately 8 months apart, prior to any invasive monitoring or surgical intervention. First, a Reliable Change (RC) index score was computed for each test score to take into account the reliability of that measure, and a cutoff score was empirically derived to establish the limits of statistically reliable change. These indices were subsequently adjusted for expected practice effects. The second approach used a regression technique to establish "change norms" along a common metric that models both expected practice effects and regression to the mean. The RC index scores provide the clinician with a statistical means of determining whether a patient's retest performance is "significantly" changed from baseline. The regression norms for change allow the clinician to evaluate the magnitude of a given patient's change on 1 or more variables along a common metric that takes into account the reliability and stability of each test measure. Case data illustrate how these methods provide an empirically grounded means for evaluating neurocognitive outcomes following medical interventions such as epilepsy surgery.

Determinants of health-related quality of life after temporal lobe epilepsy surgery.

Temporal lobectomy appears to be an effective treatment for medically intractable epilepsy. However, the influences of pre-operative health status and post-operative reductions in seizure activity on post-surgical health-related quality of life (HRQOL) are not well understood. We used the Epilepsy Surgery Inventory 55 (ESI-55) to evaluate changes between pre- and post-operative HRQOL in 47 temporal lobectomy patients. Patients exhibited significantly improved scores in five HRQOL domains: health perceptions; energy fatigue; social function; cognitive function and role limitations due to physical problems. Although significant improvements in HRQOL were observed, this was not the case for all patients. Specifically, patients with low or medium pre-operative HRQOL scores were found to have the greatest degree of improvement post-operatively. Patients with high pre-operative scores did not exhibit these same improvements, although they continued to report high scores. The results indicate that the ESI-55 is a satisfactory instrument to measure change in HRQOL but also emphasizes that the magnitude of change in post-operative HRQOL scores tends to vary according to baseline scores. The outcome of temporal lobectomy is not entirely based upon the procedure's ability to reduce the frequency of seizures, but is also influenced by level of HRQOL prior to surgery.

Psychosocial function following temporal lobectomy: influence of seizure control and learned helplessness.

Learned helplessness is the perception that one's behaviour cannot produce a desired outcome. Individuals with intractable epilepsy who have learned that the occurrence of a seizure is beyond their control can develop such a helpless attitude with cognitive, affective and behavioral components which may generalize to many aspects of life. Post-operative testing was done on 42 patients, aged 17-60 years with I.Q. > 80 who had temporal lobectomies (25 R, 17 L) with follow-up 1-14 years (mean 5 years). In addition to seizure outcome, psychosocial adjustment was measured using the Washington Psychosocial Inventory (WPSI) and a structured interview. Three variables of learned helplessness were also assessed: internal or external locus of control, resourcefulness, and depression. Seizure outcome was: completely seizure free, 36%; > 90% improvement, 38% < 90% improvement, 26%. Overall post-operative psychosocial adjustment was good, marked improvement in lifestyle was noted by 85%, personality change for the better by 65% and improved mood by 47%. A transient mood disorder was noted by 38% in the first six months following surgery. Psychosocial adjustment was better in patients who were seizure free or had > 90% reduction in seizures compared to those with < 90% improvement. Two measures of learned helplessness, depression and lack of resourcefulness correlated with poor postoperative psychosocial adjustment. Other variables beside seizure control must be considered in determining the ultimate outcome of epilepsy surgery.

Epilepsy brain surgery: a Pittsburgh perspective.

The views of the authors are presented about the past history and recent situation of epilepsy brain surgery in the United States. Issues of efficacy and quality of life are reviewed, and little empirical evidence is found supporting epilepsy brain surgery as a cost-effective treatment modality. Prospective randomized clinical trials have not been run to address these issues and various problems with patient recruitment and funding seem destined to preclude them.

Improvement of quality-of-life following resective surgery for temporal lobe epilepsy: results of patient and family assessments.

In order to evaluate the quality-of-life (QOL) of epilepsy surgery patients, we surveyed patients' degree of life satisfaction and their families' degree of satisfaction with patient's status in a range of domains both pre- and post-operatively. Of 100 patient-family sets of surveys that were mailed out, 93 were completed and returned from patients and 91 from their families. All patients surveyed had temporal lobe epilepsy and had been followed for longer than 2 years after resective surgery. Patients and their families rated overall QOL as having markedly improved following surgery. However, they rated social domains of QOL, including role activities, financial status, and social and family relationships as having improved relatively little. Despite freedom from seizures, a few patients' families were dissatisfied with the patients' post-operative status, primarily for psychosocial reasons. Patients operated on at a later age reported little gains in life satisfaction following surgery. This study supports the conclusion that surgical intervention should occur before patients are subjected to the psychological conflicts and social handicaps associated with chronic intractable epilepsy.

Using a multidisciplinary follow-up program to assist patient adjustment following temporal lobectomy.

A follow-up program for patients following temporal lobectomy for seizure control was established in 1983 at the UCLA Neuropsychiatric Hospital in response to patients' requests for information and assistance. The purpose of this program was to identify changes requiring adaptation and to offer assistance. Forty patients were contacted monthly by telephone for one year after surgery. They were interviewed by either a nurse or occupational therapist about medical and psychosocial issues. The information, support or referral needed were provided by the nurse, occupational therapist or social worker in consultation with appropriate member(s) of the multidisciplinary team. Problems encountered when beginning a less disabled lifestyle might not have been detected or resolved without active intervention through a multidisciplinary follow-up program.

Cognitive rehabilitation two and one-half years post right temporal lobectomy.

A 45-year old radiologist, who underwent a right temporal lobectomy to remove a tumor, sought treatment for difficulties with attention/scanning, sustained concentration, leisure reading, driving, and self-monitoring in social situations. A neuropsychological evaluation conducted 2.5 years postsurgery revealed impaired visual-spatial memory, inefficiency in general visual scanning, a mild left-sided neglect, and diminished social perception. The patient subsequently underwent a 4-month cognitive retraining program, which was tailored to his specific neuropsychological deficits. At the termination of treatment, improvements were observed on follow-up neuropsychological data, behavioral observations made by the patient's wife, and efficiency on work-related tasks. This case illustrates the ecological validity of cognitive rehabilitation procedures and emphasizes the need to tailor the procedures to specific cognitive deficits revealed on neuropsychological testing.

Evidence for the involvement of orbitofrontal cortex in memory functions: an interference effect.

Although it is frequently stated that the frontal lobes play a significant role in memory function, research proof has been ambiguous at best. This problem was addressed by administering a variety of memory tests to 16 schizophrenic patients who had undergone prefrontal leucotomy approximately 25 years earlier. The 16 were divided into three groups on the basis of recovery after surgery. Two comparison groups were established to control for psychiatric symptomatology, years of institutionalization, age, and years of education. The results demonstrate that large bilateral orbitofrontal lesions may not result in amnesia; in fact, the nonoperated schizophrenic control group performed the most poorly. Proactive interference was demonstrated, however, resulting in significant impairment for all patients with prefrontal lobe damage despite normal scores on commonly used memory tests. Ability to maintain consistent and directed attention and to overcome interference is proposed as a role of the frontal lobes in memory function.

Leucotomized and nonleucotomized schizophrenics: comparison on tests of attention.

Deficits in attention have been strongly linked with both schizophrenia and pathology in the prefrontal cortex. This observation was tested by administering a battery of commonly used tests of attention, sustained mental activity, and tracking to 16 patients who had undergone prefrontal leucotomy approximately 25 years earlier. Presurgical diagnosis in each patient was schizophrenia. The 16 were divided into three groups based on their recovery after surgery. A control group of nonleucotomized schizophrenics was established to control for psychiatric symptomatology. A second control group consisted of subjects without history of psychiatric or CNS disorder. In general, there was no statistically significant impairment of performance in attention tests between the patients with prefrontal psychosurgery and the normal control subjects. The nonoperated schizophrenic control group performed most poorly. Lesion chronicity, interaction of leucotomy and presurgical psychiatric state, and conditions of test administration are suggested as possible explanations for the unexpected results.