Neuropsychological effect of temporal lobe resection in preadolescent children with epilepsy.

PURPOSE: Numerous studies have demonstrated changes in cognitive, memory, and language functioning in adults and adolescents after temporal lobectomy, yet little information is available regarding neuropsychological outcome in preadolescent children. METHODS: We studied pre- and postoperative neuropsychological test results from 14 children who underwent temporal lobe resection for intractable epilepsy at age 7-12 years (mean 9.4 years). RESULTS: Thirteen patients (93%) had no seizures or less than one seizure a year at follow-up 23-48 months (mean 34 months) after operation. Postoperative neuropsychological testing was performed 6-9 months (mean 7 months) after surgery in 13 patients and 36 months after the first operation in 1 patient who underwent two-stage resection of a tumor. Verbal, Performance, and Full Scale IQ were initially in the low-average range, with no significant change across the pre- and postoperative evaluations. Immediate verbal memory performance decreased significantly in children who initially performed above the median preoperatively and tended to decrease in children who had left rather than right temporal lobe resection. Significant postoperative decreases in delayed memory scores were independent of preoperative ability or side of resection. CONCLUSIONS: Our small study suggests vulnerability to postoperative decline in immediate verbal memory scores in preadolescent children who have higher baseline immediate memory function or undergo left rather than right temporal lobe resection, similar to that observed in adolescents in adults. The entire group exhibited a statistically significant decrease in delayed verbal memory. Study of larger series of patients will be important to clarify further the short- and long-term risks and benefits of temporal lobe resection in childhood.

HMO quality and financial performance: is there a connection?

Following the continuing expansion of managed care is a growing public interest in the quality of care provided by managed care organizations. Public and private organizations are actively developing systems for measuring and monitoring quality of care with the intention of holding plans more accountable for quality improvements and encouraging health care consumers to make responsible choices. This article examines correlations between a prevention-based quality measure and other commonly used measures of differentiating health plans, including financial performance and profit status. The findings are instructive in efforts to develop a quality measurement system that incorporates a variety of measures of plan performance.

Parental assessment of functional outcome after corpus callosotomy.

PURPOSE: We wished to evaluate functional outcome and parental satisfaction after corpus callosotomy. METHODS: We studied a cohort of parents of 17 patients who had received an anterior corpus callosotomy > 7 months earlier (mean 26 months) for severe, intractable seizures. Parental satisfaction with the overall surgical results was the primary outcome measure. In addition, the parents assessed behavior changes that had been emphasized preoperatively as important aspects of their children's function, including alertness and responsiveness, falls and injuries, and special care needs. Degree of seizure reduction and extent of corpus callosum were also measured. RESULTS: The parents of 15 (88%) patients reported satisfaction with the surgical outcome. All parents who expressed satisfaction would recommend callosotomy to another family in a similar situation. The behavior change most closely associated with satisfaction was improved alertness and responsiveness (p < 0.03). Although 9 patients experienced > 80% reduction in targeted seizures, satisfaction was not reported at a greater rate as compared with the 6 patients with 50-80% reduction. CONCLUSIONS: Most parents report satisfaction with the outcome of their child's corpus callosotomy, but are influenced by improvement in aspects of function and behavior in addition to seizure reduction.

Language dominance in patients with early childhood tumors near left hemisphere language areas.

RATIONALE: Language function often develops in the right hemisphere following an acute left hemispheric insult in early childhood. Little is known, however, about lateralization of language function in patients with early childhood tumors near potential left hemisphere language areas. Issues of language dominance are important in the strategy for resection of left temporal and frontal tumors. METHODS: We studied 12 patients who had determination of hemispheric language dominance by the intracarotid amobarbital procedure prior to resection of a left inferolateral frontal or left mid or posterior temporal tumor that (1) was near a classic language area and (2) first manifested with partial seizures by age 6 years (mean, 3.7). RESULTS: Hemispheric language dominance was left in 10 patients (83%), right in one patient, and bilateral in one patient. Six patients with left temporal tumors had localization of Wernicke's area with cortical stimulation, and in five the language area was posterior to the tumor. In one patient, the tumor infiltrated Wernicke's area. Eleven of the 12 patients had complete tumor resection (mean age at operation, 11.8 years) and were seizure-free at follow-up (mean, 3.1 years). Neuropsychological testing showed a tendency for improved language function after operation, and no patient had new overt language deficits. CONCLUSIONS: Early low-grade left frontal and temporal tumors usually did not result in transfer of language dominance to the contralateral hemisphere. Tumors may grow slowly along with the developing brain in young children, with continued left hemisphere language development in regions separate from the neoplasm. Successful tumor resection can be accomplished, but it may require cortical stimulation for localization and sparing of nearby language areas.

The relationship between cognitive status and visual information processing.

The present investigation involved an examination of susceptibility to visual masking of older adults displaying evidence of Alzheimer's disease and healthy, cognitively intact older adults. Results indicated that the cognitively impaired group was more susceptible to the perceptual interference of a visual mask than was the cognitively intact group. In addition, the impaired group was found to be particularly susceptible to masking by a visual pattern (which had similar figural characteristics to target stimuli) as compared to masking by random noise (which had figural characteristics unrelated to the target). Finally, susceptibility to masking was found to be negatively correlated with performance on the Information subtest of the Wechsler Adult Intelligence Scale-Revised and with rated level of cognitive functioning. It was concluded that this pattern of results represents an acceleration of changes in perceptual processing typically associated with normal human aging.