Home video prediction of epileptic vs. nonepileptic seizures in US veterans.

OBJECTIVE: Using video-EEG (v-EEG) diagnosis as a gold standard, we assessed the predictive diagnostic value of home videos of spells with or without additional limited demographic data in US veterans referred for evaluation of epilepsy. Veterans, in particular, stand to benefit from improved diagnostic tools given higher rates of PNES and limited accessibility to care. METHODS: This was a prospective, blinded diagnostic accuracy study in adults conducted at the Houston VA Medical Center from 12/2015-06/2019. Patients with a definitive diagnosis of epileptic seizures (ES), psychogenic nonepileptic seizures (PNES), or physiologic nonepileptic events (PhysNEE) from v-EEG monitoring were asked to submit home videos. Four board-certified epileptologists blinded to the original diagnosis formulated a diagnostic impression based upon the home video review alone and video plus limited demographic data. RESULTS: Fifty patients (30 males; mean age 47.7 years) submitted home videos. Of these, 14 had ES, 33 had PNES, and three had PhysNEE diagnosed by v-EEG. The diagnostic accuracy by video alone was 88.0%, with a sensitivity of 83.9% and specificity of 89.6%. Providing raters with basic patient demographic information in addition to the home videos did not significantly improve diagnostic accuracy when comparing to reviewing the videos alone. Inter-rater agreement between four raters based on video was moderate with both videos alone (kappa = 0.59) and video plus limited demographic data (kappa = 0.60). SIGNIFICANCE: This study demonstrated that home videos of paroxysmal events could be an important tool in reliably diagnosing ES vs. PNES in veterans referred for evaluation of epilepsy when interpreted by experts. A moderate inter-rater reliability was observed in this study.

Validation and diagnostic utility of the dementia rating scale in a mixed dementia population.

The Dementia Severity Rating Scale (DSRS), a previously validated caregiver-based measure assessing dementia severity, was recently revised to improve clarity. Our study aims included: (1) identifying the DSRS factor structure, (2) examining the relation between neuropsychological measures, the Mini-Mental State Examination, and clinical diagnoses with the DSRS, and (3) determining the clinical utility of the DSRS in a mixed clinical sample. A total of 270 veterans were referred to a cognitive disorders clinic at a VA medical center and completed neuropsychological, affective, and cognitive screening measures. Caregivers completed the DSRS. Principal components analysis identified a 2-factor solution. After controlling for age and education, memory and language were related to the Cognitive factor, whereas attention, processing speed, visuospatial processing, and executive functioning were related to both Cognitive and Self-Care factors. Neither factors correlated with depression. The total DSRS score was able to differentiate patients by the Mini-Mental State Examination scores and diagnoses of mild cognitive impairment and dementia (mixed vascular Alzheimer, vascular dementia, and Alzheimer disease). A cut-score >15 was optimal for detecting dementia in a mixed clinical sample (sensitivity=0.41, specificity=0.79), with a posttest probability of 74%. This study suggests that the DSRS improves detection of dementia and requires minimal effort to implement.

Gradenigo's and Vernet's syndrome in an adult man with Candida mastoiditis.

The authors report a case of fungal otitis media complicated by extension of the infection into adjacent structures causing apical petrositis and subsequently involvement of the jugular foramen in a 71-year-old diabetic man. First described in 1907, Gradenigo's syndrome is a serious but rare clinical triad of acute otitis media, unilateral pain in the distribution of cranial nerve V (trigeminal) and ipsilateral cranial nerve VI (abducens) palsy that commonly presents without all three features and is therefore often missed. In this report, our patient was initially misdiagnosed as having a diabetic cranial neuropathy, and later he developed Vernet's syndrome. Despite aggressive surgical and medical management, he did poorly and died a few weeks later. Clinicians need to be aware of this serious and life-threatening complication of otitis media in high-risk individuals with diabetes or immunocompromised states, to allow early diagnosis and improved clinical outcomes.

Neurologic complications of hepatitis C.

BACKGROUND: Hepatitis C virus (HCV) infection is a common and chronic disorder with numerous extrahepatic manifestations. We review the neurologic complications in this article. REVIEW SUMMARY: Neurologic complications can involve the peripheral or the central nervous system. The most frequently reported complication is a subacute, distal, symmetric, sensorimotor polyneuropathy in the presence of mixed cryoglobulinemia (MC). HCV infection is the most common cause of MC. In HCV-infected patients without MC, mononeuropathy or mononeuropathy multiplex is more common. Both ischemic and hemorrhagic strokes, probably related to MC and vasculitis, have been described. More recently, transverse myelopathy and cognitive impairment have been linked to HCV infection, but the association is less certain and needs to be confirmed in larger studies. HCV has also been reported as a possible cause of encephalomyelitis in some cases. Although there are no definite treatment guidelines, immunomodulating agents and antiviral therapy are most often used with favorable outcomes. CONCLUSIONS: HCV infection should be considered in the differential diagnosis of a variety of neurologic disorders. Further studies are necessary to establish the full spectrum of the neurologic complications, identify specific pathophysiologic mechanisms, and provide clear guidelines for management.

The Severe Impairment Profile: A Conceptual Shift.

OBJECTIVE: The current study sought to evaluate and replicate the severe impairment profile (SIP) of the Word Memory Test (WMT) in patients referred for dementia evaluations. METHOD: The sample consisted of 125 patients referred for a neuropsychological evaluation at a large Veterans Affairs Medical Center. Patients were assigned a Clinical Dementia Rating (CDR) by blind raters, and were classified according to their performance on performance validity testing. Subsequent chart reviews were conducted to help in more accurately determining the presence of severe memory impairment likely due to an underlying dementing process versus poor effort/task engagement. RESULTS: In our sample, 51% of patients failed easy WMT subtests and 93% of these patients obtained the SIP. The rates of failure on these easy subtests generally coincided with both more severely impaired CDR ratings, as well as more impaired delayed memory composite scores. Upon chart review, it was determined that there were likely a significant portion of classification errors using the SIP, with a positive posttest probability of impairment based on having the SIP being 65% as opposed to 28% for a negative result. CONCLUSIONS: Our findings suggest that the SIP does not appear to function effectively in a mixed dementia sample where there is increased potential for secondary gain. Additional concern is expressed regarding the overall likelihood of obtaining the SIP and subsequent inferential decisions related to obtaining an SIP. Future research should examine more optimal cut scores or alternative methods for more accurately classifying patients in different clinical contexts and patterns of impairment.

Dependency aspect of caregiver burden is uniquely related to cognitive impairment in Veterans.

The psychosocial toll of caring for an individual with dementia is an important, if understudied, concept. For practitioners and researchers alike, understanding the relation between patient characteristics and different facets of caregiver burden is important for guiding treatment and prevention efforts. The current study analyzed the dimensions of caregiver burden and the relation between caregiver burden and results of neuropsychological testing. Participants included 243 dyads of caregivers and Veterans referred for neuropsychological evaluation. Caregivers completed the Zarit Burden Interview (ZBI) to assess caregiver burden. Patients completed a battery of neuropsychological tests measuring the domains of attention/processing speed, memory, language, and executive functioning. A principal components analysis of the ZBI revealed a three-factor structure: psychosocial burden, dependency burden, and guilt. Correlations with neuropsychological test performance by Veteran patients suggested that test performance in the memory, attention, processing speed, executive functioning, and emotional functioning domains were solely related to the caregiver dependency burden factor of the ZBI. Additional analyses suggested severity of dementia and number of tests in the impaired range further influenced reported caregiver burden. The current study is one of the few studies examining caregiver burden in relation to neuropsychological functioning in a mixed clinical sample and has important implications for clinical practice.