Moderators of the effect of preoperative emotional adjustment on postoperative depression after surgery for temporal lobe epilepsy.

PURPOSE: Other outcome measures besides seizure control must be considered when assessing the benefit of epilepsy surgery. We investigated the effect of preoperative psychosocial adjustment on postoperative depression in epilepsy patients followed up prospectively for 2 years after temporal lobectomy. METHODS: The Washington Psychosocial Seizure Inventory (WPSI) evaluated psychosocial functioning; the Centre for Epidemiological Studies Depression Scale (CES-D) measured depression. Both were completed at baseline and follow-up. RESULTS: Follow-up occurred in 39 temporal lobectomy patients at 2 years after surgery. Greatest improvement in depression scores was limited to patients with good seizure outcomes (seizure free, or marked reduction in seizure frequency), and seizure outcome was a significant predictor of postoperative depression. Despite this, preoperative scores on the emotional adjustment scale of the WPSI were most highly correlated with depression 2 years after surgery. To clarify this relation, moderated hierarchic regression suggested that good preoperative emotional adjustment (WPSI) was generally associated with less depression after surgery. Moreover, poorer preoperative adjustment combined with older age, generalized seizures, the finding of preoperative neurologic deficits, a family history of psychiatric illness, and/or a family history of seizures was related to higher depression scores 2 years after surgery. CONCLUSIONS: Depression after temporal lobectomy is dependent on a complex interaction of variables and can have a significant effect on indices of postoperative adjustment. The WPSI emotional adjustment scale may help to predict which patients are likely to be chronically depressed after surgery.

Health-related quality of life and seizure control in temporal lobe epilepsy.

We conducted a prospective study over 24 months to compare health-related quality of life in surgically and medically treated patients with intractable temporal lobe epilepsy. Seizure frequency and health-related quality of life were assessed in 81 patients before and 6, 12, and 24 months after treatment. Using the Epilepsy Surgery Inventory 55 (ESI-55), we compared (1) different seizure outcome groups and (2) temporal lobectomy with continuing medical management. Follow-up was satisfactory in 72 patients (89%), 51 treated with temporal lobectomy and 21 with no surgery. Pretreatment seizures and health-related quality of life were comparable in the two groups. Seizure outcome was significantly better at 6, 12, and 24 months after surgery. At 24 months, seizure-free patients and those with at least a 90% reduction in seizure frequency reported significant improvements in health-related quality of life (on 5 of 10 subscales and overall Epilepsy Surgery Inventory 55 scale). Deterioration in quality of life occurred with less than 90% seizure reduction. Only one Epilepsy Surgery Inventory 55 subscale at 6 months and two subscales at 12 months showed a significant difference. Patients with good seizure outcome experience improved health-related quality of life after treatment. Since temporal lobectomy results in considerably better seizure control than continued medical management, the findings support surgery as the preferred treatment, although changes in health-related quality of life may not be evident until the second postoperative year.

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.

Neuroticism in temporal lobe epilepsy: assessment and implications for pre- and postoperative psychosocial adjustment and health-related quality of life.

We assessed 77 candidates for epilepsy surgery to determine the association among neuroticism (a dimension of personality characterized by chronic negative emotions and behaviors), psychosocial adjustment as measured by the Washington Psychosocial Seizure Inventory (WPSI), and health-related quality of life (HRQOL) as measured by the Epilepsy Surgery Inventory 55 (ESI-55). Minnesota Multiphasic Personality Inventory 2 (MMPI-2) Neuroticism scale scores were significantly correlated with many domains of patient -perceived psychosocial adjustment and HRQOL regardless of frequency or type of seizures. We then followed 45 of the patients who subsequently underwent epilepsy surgery to determine the influence of neuroticism on postoperative functioning. Two-way analysis of variance (ANOVA) indicated that patients with high preoperative neuroticism had significantly poorer postoperative psychosocial adjustment and HRQOL scores than patients who had low or moderate preoperative neuroticism scores. These results support the validity of the MMPI-2 as a useful measure of neuroticism. Preoperative neuroticism has an important influence on postoperative psychosocial adjustment and HRQOL that is independent of postoperative seizure outcome. Understanding the influence of personality variables, such as neuroticism, on psychosocial functioning both before and after epilepsy surgery is essential in managing intractable seizures.

Intensive swimming: can it affect your patients' smiles?

Athletes who swim intensively, such as those who swim laps more than six hours a week, may develop unusual yellowish brown or dark brown stains on their teeth. The authors hypothesize that long-term contact of the teeth with swimming pool water, as well as the mixture of oral fluids with swimming pool water, leads to the formation of these deposits. The authors report two cases of development of such stains.

Patient expectations and postoperative depression, anxiety, and psychosocial adjustment after temporal lobectomy: a prospective study.

This study examined the effects of patient expectations on short-term postoperative psychological adjustment alter surgery for epilepsy. Twenty-seven subjects (17 operative, 10 nonoperative controls) agreed to participate. A prospective longitudinal design assessed whether changes in psychosocial functioning had occurred at a mean of 7 weeks after surgery relative to the presurgical assessment. The study also examined the relation between postoperative psychosocial adjustment and preoperative patient expectations. It was found that seizure-free outcomes were associated with significant declines in depression and anxiety. Patients who exhibited preoperative optimistic expectations had lower levels of postoperative depression and anxiety, as long as they were rendered seizure-free. Conversely, those who had optimistic preoperative expectations but were not rendered seizure-free postsurgically continued to exhibit moderate to high levels of depression and anxiety. The theoretical significance of optimistic expectations and their effects on individual self-efficacy are discussed to support the notion that postsurgical adjustment is related to personal coping, even in those patients who are seizure-free after surgery.

Postexposure prophylaxis against experimental inhalation anthrax.

Inhalation anthrax is a rare disease that is almost invariably fatal. This study determined whether a prolonged course of postexposure antibiotics with or without vaccination would protect monkeys exposed to a lethal aerosol dose of Bacillus anthracis when the antibiotic was discontinued. Beginning 1 day after exposure, groups of 10 animals were given penicillin, ciprofloxacin, doxycycline, doxycycline plus vaccination, vaccination alone, or saline. Antibiotics were administered for 30 days and then discontinued. Vaccine was given on days 1 and 15. Two animals died of causes other than anthrax and were not included in the statistical analysis. Nine of 10 controls and 8 of 10 animals given only vaccine died. Each antibiotic regimen completely protected animals while on therapy and provided significant long-term protection upon discontinuance of the drug (penicillin, 7 of 10 survived, P < .02; ciprofloxacin, 8 of 9 survived, P < .002; doxycycline, 9 of 10 survived, P < .002; doxycycline plus vaccination, 9 of 9 survived, P < .0002). Protection against rechallenge was provided by combining postexposure antibiotic treatment with vaccination.

Middle ear resonance and acoustic immittance measures in children.

This study established a normal middle ear resonance estimated from sweep frequency tympanometry (250-2000 Hz) and established normal equivalent ear canal volume, static acoustic admittance, and tympanometric peak pressure at 226 Hz in children with normal hearing (N = 90) and in children with severe to profound sensorineural impairments (N = 68). Children's ages ranged from 6 to 15 years. No statistically significant differences between the groups or across ages were found. Means, standard deviations, and 90% ranges (5-95%) for these four tympanometric measures are presented and compared to other studies.

A sensitive period in gestation for nicotine acceleration of neuromuscular maturation.

Nicotine, administered to pregnant Sprague-Dawley rat dams during gestation, altered the maturation of the developing extensor digitorum longus (EDL) muscle-peroneal nerve complex of the 2-week-old offspring. Initial isometric twitch time to peak and rate of rise of tension and tetanus time to peak tension of the group treated with nicotine during gestational (G) days G3-G8 were faster than controls indicating accelerated maturation of EDL muscle. Contractile parameters of the group treated with nicotine during G9-G13, a period immediately prior to muscle innervation, differed little from control. Nicotine administered during G14-G21 significantly increased twitch and tetanus tension and twitch rate of rise. There was little to no effect on motor unit size or number of motor units with nicotine during any of the three prenatal periods. Thus, while late prenatal nicotine administration primarily altered the strength of muscle, early gestational administration of nicotine increased the rate of muscle development suggesting a possible sensitive period for the accelerative action of nicotine on muscle maturation at this time.

Accelerated neuromuscular development in the rat with prenatal exposure to nicotine.

Nicotine, administered to pregnant Sprague-Dawley rats either throughout gestation or during two selective prenatal periods before or after muscular innervation (i.e. before or after gestational day 13), accelerated the maturation of developing nerve and muscle as viewed in 2-week-old offspring. Prenatal treatment of rats with nicotine (tartrate salt; 0.25 mg/kg twice a day; i.p.) induced marked changes in the contractile force and speed of the developing extensor digitorum longus (EDL) muscle when tested in situ on 14 to 15-day-old pups. In all nicotine treatment groups isometric twitch and tetanus half contraction durations were shorter than controls. Use of 2,3,5-triphenyltetrazolium chloride, a biochemical indicator for cellular respiration, showed that totigestational nicotine administration increases cellular metabolic activity of EDL muscle. Hypertrophy of adrenal glands in these animals also was noted. While each of the three courses of nicotine administration accelerated muscle development and maturation, nicotine during the first half of prenatal development, prior to EDL muscle innervation, produced a more dramatic effect than nicotine during the second half of prenatal life.

ACTH/MSH(4-10) peptide increases postnatal metabolic activity of EDL muscle following early prenatal administration.

ACTH/MSH(4-10) (10 micrograms/kg/b.i.d.; IP), administered to pregnant Sprague-Dawley rats during gestational days (GD) 3 to 12, significantly increased the metabolic activity of extensor digitorum longus (EDL) muscle at postnatal day 14. ACTH/MSH peptide, administered from day of birth to postnatal day 13, had no effect on EDL muscle metabolic activity using the 2,3,5-triphenyltetrazolium chloride indicator. By postnatal day 30, no differences were seen between the early prenatally treated group and saline controls. These results confirm our previous electrophysiological studies that showed that early prenatal ACTH/MSH(4-10) administration accelerates EDL muscle maturation.

ACTH modulation of nerve development and regeneration.

(1) The availability of short amino acid sequences of the naturally occurring ACTH 1-39 molecule has made it possible to separate the corticotropic characteristics of the parent molecule from its neurotrophic effects. Potent neurotrophic fragments are ACTH 4-10, an analog of ACTH 4-9 (Org 2766), and alpha-MSH (ACTH 1-13), peptide fragments that do not evoke corticosteroid secretion, yet clearly affect both the development and regeneration of peripheral nerve. (2) Early postnatal administration of either ACTH 4-10 or Org 2766 accelerates the neuromuscular development of the immature rat, increasing the contractile strength of the EDL muscle and inducing more rapid muscle contractions. Grasping strength and motor activity are increased; these are all changes indicative of more rapid neuromuscular maturation. Prenatal peptide treatment elicits a more complex pattern of response since administration early in gestation (GD 3-12) accelerates neuromuscular development whereas later administration (GD 13-21) decelerates maturation. (3) ACTH peptides have a similar accelerating effect on the morphology of the developing neuromuscular junction. At two weeks of age, nerve arborization is conspicuously increased by postnatal administration of either ACTH 4-10 or Org 2766, as is nerve terminal branching within the endplate itself. However, this is preceded by an initial depression of nerve branching in the 7-day-old rat pup. We conclude that while the developing neuromuscular system is sensitive to ACTH peptides, this susceptibility is age-related. The crucial role of these peptides may be limited to very brief, defined periods during which the peptides may interact with trophic or growth-associated substances, each of which may have its own decisive, circumscribed time frame of influence. (4) Perinatal administration of ACTH peptides affects CNS development. One measurable indication of this is an acceleration of eye opening. Early exposure to ACTH peptides has long-lasting effects on behavior, apparent when these animals are tested as adults. Increased spontaneous motor activity, heightened states of arousal and agitation, and changes in social behavior have been reported. Certain avoidance responses and tests of visual discrimination in male rats are improved by neonatal treatment with alpha-MSH. Overall motor activity is increased and the normal period of hyperactivity is initiated earlier. Male sexual behavior is decreased and sexually dimorphic behaviors in males are eliminated. alpha-MSH may alter the development of its own dopaminergic feedback circuitry while ACTH affects serotonin levels in the preoptic nucleus.(ABSTRACT TRUNCATED AT 400 WORDS)

Maturational changes in neonatal rat motor system with early postnatal administration of nicotine.

Experiments were designed to assess the effects of chronic maximum 'smoking dose' nicotine administration on neonatal motor behavior and neuromuscular structural maturation. Thus, Sprague-Dawley rat neonates received daily subcutaneous injections of nicotine (0.05 mg/kg/day) from postnatal days 1 to 14. Motor behavior (ambulations, stop and go movements) was not affected, but a marked increase in grasping duration resulted, indicating increased neuromuscular maturation. Concomitantly, neuromuscular morphological and dynamic contractile changes were observed in the in situ extensor digitorum longus (EDL) muscle. The EDL muscle showed accelerated morphological dimensions of the endplate at postnatal day 7 and a more rapid twitch at 2 weeks of age. The results suggest that this maximum 'smoking dose' of nicotine induces time-dependent maturational changes in the neuromuscular model.

Neonatal neuromuscular parameters vary in susceptibility to postnatal ACTH/MSH 4-10 administration.

Neonatal Sprague-Dawley rats administered the fragment of adrenocorticotropic hormone ACTH/MSH 4-10 (10 micrograms/kg/daily, SC) postnatally, show marked differences in the plasticity of the functional and morphological parameters of their neuromuscular system. Initial contraction durations of the immature fast muscle, extensor digitorum longus (EDL), are shorter than saline-treated controls indicating accelerated development. Qualitative studies of the developing EDL neuromuscular junctions as viewed by the scanning electron microscope and quantitative analysis permitted by light microscopy confirms that ACTH/MSH 4-10 affects the maturation of the endplate region. Motor behavior of rat pups demonstrates an age-related difference in the susceptibility to this peptide fragment; one week old neonates showing no response to ACTH/MSH 4-10, two week old pups showing an increase in motor activity. The results indicate that while the developing neuromuscular system is sensitive to the input of ACTH/MSH peptide treatment, this susceptibility is age-related.

Mammalian neuromuscular development accelerated with early but slowed with late gestational administration of ACTH peptide.

The neuropeptide ACTH 4-10, a nonsteroidogenic fragment of adrenocorticotropic hormone, has two distinct and opposite effects on developing nerve and muscle. Muscle is positively influenced by ACTH during the first part of gestation (G days 3-12) before innervation occurs. Subsequent effects on innervation are largely depressive and exerted only during G13-21. Treatment during G3-12 increases twitch amplitude, rise time and speed of contraction of directly and indirectly stimulated extensor digitorum longus (EDL) muscle of two wk old rats. Treatment during G13-21 slows contractions of indirectly stimulated EDL, whereas treatment throughout gestation (G3-G21) shows little effect. Thus, ACTH first accelerates muscle development then modulates this development through neuronal depression.