Use of local anesthesia for inguinal hernia repair has decreased over time in the VA system.

PURPOSE: In 2003, randomized trials demonstrated potentially improved outcomes when local instead of general anesthesia is used for inguinal hernia repair. Our study aimed to evaluate how the use of local anesthesia for this procedure changed over time following the publication of the trials' level 1 evidence. METHODS: We used the 1998-2018 Veterans Affairs Surgical Quality Improvement Program database to identify adults who underwent open, unilateral inguinal hernia repair under local or general anesthesia. Our primary outcome was the percentage of cases performed under local anesthesia. We used a time-series design to examine the trend and rate of change of the use of local anesthesia. RESULTS: We included 97,437 veterans, of which 22,333 (22.9%) had hernia surgery under local anesthesia. The median age of veterans receiving local anesthesia remained stable at 64-67 years over time. The use of local anesthesia decreased steadily, from 38.2% at the beginning year to 15.1% in the final year (P < 0.0001). The publication of results from randomized trials (in 2003) did not appear to increase the overall use or change the rate of decline in the use of local anesthesia. Overall, we found that the use of local anesthesia decreased by about 1.5% per year. CONCLUSION: The utilization of local anesthesia for inguinal hernia repair in the VA has steadily declined over the last 20 + years, despite data showing equivalence or superiority to general anesthesia. Future studies should explore barriers to the use of local anesthesia for hernia repair.

Perceived Recovery and Self-Reported Functioning in Adolescents with Mild Traumatic Brain Injury: The Role of Sleep, Mood, and Physical Symptoms.

Purpose: To determine the contributions of anxiety, depressive, and concussion symptoms and sleep quality to self-perceived recovery in adolescents with concussion.Method: Adolescents aged 12-20 (n = 298) completed anxiety, depression, concussion symptoms, and sleep measures at an initial concussion clinic visit and three-month follow-up. At follow-up, they reported self-perceived recovery as percent back to normal.Results: Injury-related factors alone did not predict self-perceived recovery (R2Adj =.017, p =.074). More concurrent physical, mental health, and sleep symptoms explained 18.8% additional variance in poorer self-perceived recovery (R2Adj Change =.188, p <.05). Physical symptoms (Bstand = -.292) and anxiety (Bstand = -.260) accounted for the most variance in self-perceived recovery.Conclusion: Post-concussive symptoms, in particular anxiety and self-reported physical symptoms, seem to characterize protracted recovery. Self-perceived recovery as an outcome measure may provide a more holistic understanding of adolescents' experiences after concussion.

Detecting differential memory performance among Spanish-speaking patients with temporal lobe epilepsy.

There is relatively little research pertaining to neuropsychological assessment of Spanish-speaking individuals with intractable temporal lobe epilepsy (TLE). The current study examined verbal and visual memory performances in 38 primarily Spanish-speaking patients with TLE (Right = 15, Left = 23) of similar epilepsy duration to determine if lateralizing differences can be found using verbal and nonverbal memory tests. On a test specifically designed to assess auditory learning and memory among Spanish-speaking individuals, the Spanish Verbal Learning Test (SVLT), patients with left TLE performed significantly worse than patients with right TLE. In contrast, no significant differences in story or visual memory were seen using common memory tests translated into Spanish. Similar to what has been found in English speakers, these results show that verbal memory differences can be seen between left and right sided TLE patients who are Spanish-speaking to aid in providing lateralizing information; however, these differences may be best detected using tests developed for and standardized on Spanish-speaking patients.

Annualized functional change in Alzheimer's disease participants and normal controls.

The rate of functional change in persons with mild Alzheimer's disease (AD) was compared to that of cognitively normal elderly control subjects. A comparison of annualized rates of change on the Test of Everyday Functional Abilities (TEFA) was carried out, along with a brief measure of instrumental activities of daily living skills, in persons with mild AD (Mini-Mental State Exam score >20) and cognitively normal elderly controls. Persons with AD (N = 30) showed an 8.5 % (3.5 point) annualized decline in TEFA scores over an average of 1.2 years; there was no decline in a group of elderly normal controls (N = 20) over an average of 1.5 years. Persons with mild AD showed functional changes over the course of a year on a direct measure of instrumental activities of daily living; a comparable group of normally aging persons did not.

Neuropsychological functioning in MRI-derived subgroups of schizophrenia.

This study examined neuropsychological functioning in two subgroups of patients with familial schizophrenia. Those who showed evidence of progressive ventricular enlargement observed across serial MRI scans (n=6) were compared with subjects whose ventricular volume remained static (n=10) over an average of 28 months. No differences were found in terms of age, education, ethnicity, level of psychotic symptomatology, DSM-IV subtype, age of onset, or duration of illness. Neurocognitively, the static ventricle group was impaired across more cognitive domains and had a larger percentage of subjects falling into the impaired range on a majority of measures, with the greatest differences on measures of attention (p<0.02) and nonverbal memory (p<0.07). These results suggest that clinically meaningful differences between these two MRI-derived subgroups of patients with schizophrenia may exist, and further underscore the heterogeneity of the illness.

A total score for the CERAD neuropsychological battery.

OBJECTIVE: To develop a total or composite score for the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery. METHOD: CERAD total scores were obtained by summing scores from the individual CERAD subtests (excluding the Mini-Mental State Examination [MMSE]) into a total composite (maximum score = 100). The method of tabulating the total score was constructed using normal controls (NCs; n = 424) and patients with AD (n = 835) from the CERAD registry database. The utility of the total score was further tested in independent samples of mild AD (n = 95), mild cognitive impairment (MCI; n = 60), and NC (n = 95) subjects. RESULTS: The CERAD total score was highly accurate in differentiating NC and AD subjects in the CERAD registry. Age, gender, and education effects were observed, and demographic correction scores were derived through multiple regression analysis. Demographically corrected CERAD total scores showed excellent test-retest reliability across samples (r = 0.95) and were highly correlated with the MMSE (r = 0.89) and Clinical Dementia Rating Scale (r = -0.83) in mixed AD and NC samples and with the Blessed Dementia Rating Scale in an AD sample (r = -0.40). The CERAD total score was highly accurate in differentiating independent samples of NC, MCI, and AD subjects. CONCLUSION: Results provide support for the validity of a Consortium to Establish a Registry for Alzheimer's Disease (CERAD) total score that can be used along with the normative data to provide an index of overall level of cognitive functioning from the CERAD neuropsychological battery.

Qualitative analysis of WMS-III Logical Memory and Visual Reproduction in temporal lobe epilepsy.

Clinical observation of performance on the Logical Memory (LM) and Visual Reproduction (VR) subtests from the WMS-III has revealed some variability in retention rates across stories and figures. This paper examined the degree to which this variability occurs in lateralized temporal lobe epilepsy (TLE) in comparison to a matched group from the WMS-III standardization sample, and explored whether analysis of qualitative aspects of LM and VR performance yield additional lateralizing information in TLE. Analysis of LM and VR scaled scores revealed differences between the TLE groups for LM, but not VR scores. All subjects benefited from repetition of LM Story B, with greater improvement in story retention in the Left versus Right TLE group. Variability in VR recall across figures was seen in all groups, with a bimodal distribution of retention rates for each figure and a sizable percentage of each group completely forgetting two or more figures. These results suggest that more careful analysis of individual LM story performance may be useful in some patients with TLE, whereas variability in VR retention across figures is common and should not be over interpreted.

Category fluency in mild cognitive impairment: reduced effect of practice in test-retest conditions.

Verbal fluency tests are commonly used in neurocognitive and mental status examinations in patients with suspected dementia. Inflation of test scores as a result of practice effects may yield false-negative results in test-retest and multidisciplinary settings, particularly among patients with mild cognitive deficits. To address this issue, animal naming was administered twice within a 1-week period to a group of individuals referred for suspected dementia who were ultimately diagnosed with mild cognitive impairment (MCI; amnestic form), probable Alzheimer disease (AD), or no dementia. A 2 x 3 repeated-measures analysis of variance revealed a statistically significant interaction between administration time and group. Post hoc analyses indicated that nondemented controls were the only group to demonstrate a significant practice effect, producing an average of approximately three more animal names at time two. Like patients with a diagnosis of AD, subjects with amnestic MCI failed to benefit from repeated exposure to the animal naming test, and only controls showed an average improvement upon retest. This underscores the cognitive similarity between individuals diagnosed with amnestic MCI and AD and suggests that improvement upon retest may be a diagnostically useful finding.

Differential activation on fMRI of monozygotic twins discordant for AD.

This is the first report of fMRI in monozygotic twins discordant for AD. FMRI brain activation patterns were examined during visuospatial and verbal working memory tasks. The affected twin had greater parietal involvement bilaterally during both working memory tasks and reduced left dorsolateral prefrontal cortex activity on the visuospatial memory task. Thus, fMRI may identify additional brain regions recruited in patients with AD to perform a given cognitive task.

Comparison of the hopkins verbal learning test-revised to the California verbal learning test in Alzheimer's disease.

We examined the validity of the revised Hopkins Verbal Learning Test (HVLT-R) by comparing performances on the HVLT-R and the California Verbal Learning Test (CVLT) in participants with Alzheimer's disease (AD). Total learning, delayed recall, intrusion errors, and recognition performance were significantly related across tests, but the number of perseverative responses showed no linear association. Despite similar results across measures, some of the variables were only modestly correlated, which may reflect differences in test procedures and the limited range of scores for some variables. Furthermore, the HVLT-R may not be challenging enough to elicit some of the types of recall errors commonly seen in AD to the same extent as the CVLT Nonetheless, the HVLT-R shows promise for providing a multidimensional assessment of verbal learning and memory and may be ideal in cases where brief assessment ofmemory and/or serial evaluations are needed.

Quantitative and qualitative interpretation of neuropsychological data in the assessment of temporal lobectomy candidates.

Neuropsychologists who serve as members of an epilepsy surgery team are often asked to provide information regarding localized cerebral dysfunction that may relate to the seizure focus in patients with intractable temporal lobe epilepsy (TLE). However, the rate at which neuropsychological (NP) assessment results correspond with the side of seizure focus (i.e., left vs. right) in TLE patients is unknown. The majority of literature in this area has focused on the ability of single NP tests to detect lateralized cognitive dysfunction in groups of TLE patients, with mixed findings and few consistent replications. The primary purpose of this study was to examine the rate at which qualitative clinician interpretations of NP profiles agree with seizure lateralization as determined by a multidisciplinary surgery team in temporal lobectomy candidates. Quantitative analyses of single NP test scores and groups of test scores (i.e., cognitive domain composite scores) were also conducted to examine their effectiveness in discriminating left from right TLE groups. Only four of the 19 NP test variables and three of the nine composite cognitive domain scores significantly differed between the groups. However, clinician interpretation of NP profiles agreed with the surgery conference team's determination of seizure laterality in two-thirds of cases. These findings suggest that qualitative aspects of NP performance play an important role in identifying lateralized cerebral dysfunction in TLE patients, and provide additional support for the use of NP assessment results in the selection of temporal lobectomy candidates.

Contribution of asymmetric synapse loss to lateralizing clinical deficits in frontotemporal dementias.

BACKGROUND: Synapse loss has been found to be the major correlate of cognitive decline in Alzheimer disease (AD), and prefrontal synapse loss has been found in patients with frontotemporal dementia (FTD). OBJECTIVE: To see if our hypothesis that within each FTD case, regional synapse loss would correlate with lateralizing neuropsychologic and neurobehavioral deficits would be correct. DESIGN: We analyzed synaptophysin as a marker for synapse loss in snap-frozen brain samples, using an enzyme-linked immunosorbent assay technique. Quantitative results were obtained by comparing patient data with a standard curve made by analyzing serial dilutions of a recombinant synaptophysin protein fragment. A board-certified neuropsychologist and a board-certified neurologist, both unaware of the synaptophysin results, determined areas of primary neuropsychologic and neurobehavioral dysfunction. Relationships between areas of primary dysfunction and synapse loss were analyzed using the binomial test. PATIENTS: Six cases of FTD, 28 cases of AD, and 16 nondemented control subjects. RESULTS: Five of 6 FTD cases had regional synaptophysins correlating with lateralizing frontal or temporal deficits. Three of 6 correlated in 2 or more regions. Although our results were higher than that expected based on a pure-chance mechanism (50% vs 34%), statistical significance was not attained. CONCLUSIONS: We found a trend for an association between synapse loss and lateralizing neuropsychologic and neurobehavioral deficits in FTD. Studies in larger numbers of FTD cases are planned with the goal of attaining statistically significant conclusions.

Performance-Based instrument to assess functional capacity in dementia: The Texas Functional Living Scale.

OBJECTIVE: The Texas Functional Living Scale (TFLS) is a new performance-based measure of functional abilities with an emphasis on instrumental activities of daily living skills that is brief and weighted toward cognitive tasks. The purpose of this study was to examine its psychometric properties and clinical utility in patients with Alzheimer disease (AD) and normal elderly individuals. BACKGROUND: Measures of daily functional capacities used in patients with dementia often rely upon informant-based behavioral ratings or lengthy assessments of instrumental activities of daily living. Few existing quantitative tools emphasize performance-based cognitively-oriented tasks designed for patients with AD, although there is a need for such measures. METHOD: Twenty-two AD patients and 21 healthy controls were administered the TFLS and a measure of global cognitive status (Mini-Mental State Examination). Additionally, informant-based ratings of daily living skills (Blessed Dementia Rating Scale) and emotional and behavioral status (Consortium to Establish a Registry for Alzheimer's Disease Behavior Rating Scale for Dementia) were obtained from caregivers of the AD patients. All subjects were re-evaluated approximately 1 month later using the same instruments. RESULTS: The TFLS showed a strong correlation with the Mini-Mental State Examination (r = 0.92). At 1 month, test-retest reliability was high, and TFLS subscale scores were highly correlated (r > 0.90 for most) with the total score. The TFLS was moderately correlated with informant ratings of functional skills as assessed with the Blessed Dementia Rating Scale but was unrelated to emotional and behavioral symptoms as assessed with the Consortium to Establish a Registry for Alzheimer's Disease Behavior Rating Scale for Dementia. CONCLUSIONS: The TFLS showed evidence of good reliability, internal consistency, and convergent and discriminant validity with several popular measures of global cognitive status and behavioral functioning. It is a brief and easily administered performance-based measure of daily functional capabilities that is sensitive to level of cognitive impairment and seems applicable in patients with varying degrees of dementia.

Nicardipine improves the antidepressant action of ECT but does not improve cognition.

INTRODUCTION: Cognitive impairment, the most important adverse effect of electroconvulsive therapy (ECT), may involve elevated intracellular calcium ion signaling. Animal research suggests that calcium channel-blocking agents, which attenuate excessive intracellular calcium activity, may reduce cognitive dysfunction caused by ECT. METHOD: The lipid-soluble calcium channel-blocking drug nicardipine or matching placebo were randomly assigned to 26 patients with major depressive disorder receiving ECT. A rater blind to the experimental condition administered the Hamilton Depression Rating Scale, the Montgomery-Asberg Depression Rating Scale, the Beck Depression Inventory, the Mini-Mental State Examination and a comprehensive battery of neuropsychological tests prior to ECT, at the completion of ECT, and 6 months after ECT completion. RESULTS: Compared with patients receiving placebo, patients taking nicardipine had significantly lower scores on the Hamilton and Montgomery-Asberg but not the Beck Depression rating scale scores at the completion of ECT. There were no differences between placebo and nicardipine groups in depression scores 6 months after ECT. Cognitive function declined over the course of ECT and improved over the next 6 months in both groups, but changes were statistically significant for only two subtests on the neuropsychological battery. Changes in Mini-Mental State Examination scores were small and were not significant at any point. There were no significant differences between nicardipine and placebo treated groups in any assessment of cognition. DISCUSSION: Standard approaches to ECT in younger patients without preexisting neurological impairment do not produce cognitive side effects of sufficient severity for calcium channel-blocking agents to reduce these side effects demonstrably. Studies of treatments for cognitive impairment should be conducted in patients with risk factors for more severe cognitive impairment such as geriatric patients or patients with a history of interictal delirium during previous treatment with ECT. A possible effect of nicardipine in enhancing the antidepressant action of ECT requires further investigation in a study designed to test this action.

The effects of vagus nerve stimulation on cognitive performance in patients with treatment-resistant depression.

BACKGROUND: Chronic vagus nerve stimulation (VNS) is effective in the management of treatment-resistant epilepsy. Open-trial evidence suggests that VNS has clinically significant antidepressant effects in some individuals who experience treatment-resistant major depressive episodes. However, limited information regarding the effects of VNS on neurocognitive performance exists. OBJECTIVE: The primary aim of this study was to determine whether VNS leads to neurocognitive deterioration. METHOD: A neuropsychological battery was administered to 27 patients with treatment-resistant depression before and after 10 weeks of VNS. Thirteen neurocognitive tests sampled the domains of motor speed, psychomotor function, language, attention, memory, and executive function. RESULTS: No evidence of deterioration in any neurocognitive measure was detected. Relative to baseline, improvement in motor speed (finger tapping), psychomotor function (digit-symbol test), language (verbal fluency), and executive functions (logical reasoning, working memory, response inhibition, or impulsiveness) was found. For some measures, improved neurocognitive performance correlated with the extent of reduction in depressive symptoms, but VNS output current was not related to changes in cognitive performance. CONCLUSIONS: Vagus nerve stimulation in treatment-resistant depression may result in enhanced neurocognitive function, primarily among patients who show clinical improvement. Controlled investigation is needed to rule out the contribution of practice effects.

Effects of practice on category fluency in Alzheimer's disease.

Evaluation of patients with suspected Alzheimer's disease (AD) often involves clinicians of multiple disciplines working in collaboration to maximize diagnostic accuracy. Accordingly, repeated administrations of some common tests of mental status may occur within a relatively brief time period. The effect of such retesting on subsequent results is largely unknown for many cognitive tasks, despite the possibility that repeated administrations may artificially inflate scores. To assess the potential impact of practice effects on a commonly administered verbal fluency task, animal naming was administered twice within a 1-week period to 111 patients with probable AD and 12 persons without dementia. Non-demended subjects were the only group to demonstrate a small (3 point), but statistically significant practice effect. Regardless of level of cognitive impairment, patients with AD did not show significant practice effects over repeated administrations of animal naming after a relatively brief test-retest interval, suggesting the robust nature of this task in AD.

Platelet APP isoform ratios correlate with declining cognition in AD.

BACKGROUND: Platelets and neurons both contain large quantities of two carboxyl-truncated 120 to 130 and 110 kDa Alzheimer amyloid precursor proteins (APPs). Platelets taken from patients with AD have been reported to contain a reduced ratio of these APPs. OBJECTIVE: To further study the AD specificity of reduced platelet APP ratios and to determine whether, after 3 years, cognitive losses in AD are accompanied by similarly reduced platelet APP ratios. METHODS: To test the AD specificity of reduced platelet APP ratios, we quantitated these APPs in eight patients with PD and six patients with hemorrhagic stroke (HS). To determine whether further cognitive losses correlate with platelet APP ratio reductions in patients with AD, the authors re-examined platelet APPs and Mini-Mental State Examination (MMSE) scores of 10 patients with AD and 11 controls, who were tested 3 years ago. APP ratios were determined by the average of six assays using Western blotting with m22C11 monoclonal antibody, enhanced chemoluminescence, and digital scanning of autoradiographs. RESULTS: APP ratios were normal in the patients with PD and HS, further supporting the AD specificity of this assay. After 3 years, the MMSE scores and APP ratios of our control subjects changed by <4%. However, the average MMSE scores of our patients with AD declined from 16.4 to 8.3, and their average 120 to 130/110 kDa APP ratios declined from 5.8 to 3.6. The difference between AD and control APP ratios, with no overlap, is significant and the correlation between the 3-year decline in AD MMSE scores and reduced APP ratios (r = 0.69) was significant. CONCLUSIONS: Although the number of subjects analyzed was limited, reduced platelet APP ratios appear to be a specific biological marker of AD and a biological index of the severity of cognitive loss in AD.

Neuropsychological outcome following unilateral stereotactic pallidotomy in intractable Parkinson's disease.

Neuropsychological functioning was examined at baseline and 2- to 3-month follow-up in 40 subjects with advanced Parkinson's disease (PD) who underwent unilateral posteroventral pallidotomy. Most subjects demonstrated improved verbal learning, visual memory, confrontation naming, and figural fluency at follow-up. Right pallidotomy was associated with decreased cognitive flexibility and increased verbal fluency, whereas Left pallidotomy uniquely resulted in a decline in verbal fluency. Significant motor improvement was demonstrated in both groups. Pallidotomy appears to be an effective treatment for advanced PD, providing a significant improvement in motor functioning, while resulting in few deleterious neurocognitive changes in most cases.

Clinical outcome of unilateral stereotactic pallidotomy without microelectrode recording for intractable Parkinson's disease.

OBJECTIVE: To study the effects of unilateral stereotactic pallidotomy performed without microelectrode recording for advanced Parkinson's disease. METHODS: Stereotactic coordinates were calculated by comparing preoperative inversion recovery MRI sequences with intraoperative CT scans. Conventional stereotactic stimulation techniques were employed to confirm correct probe placement. Patients were assessed using a modified CAPIT protocol with the off-state UPDRS motor score as the primary efficacy measure. RESULTS: A statistically significant decline in off-state UPDRS motor scores occurred at 2months (21% improvement in 32 patients) and also at 1year postoperatively (30% improvement in 12 patients). Levodopa-induced dyskinesias on the side contralateral to surgery were reduced 97% in the cohort with 1year of follow-up. No deleterious effects of surgery on global neuropsychological functioning were seen. A major surgical complication (mild but persistent hemiparesis) occurred in one patient. CONCLUSIONS: We believe that stereotactic pallidotomy can be performed safely and effectively without microelectrode recording when coordinates are calculated using CT with comparison to preoperative MRI sequences.

Brief recall tasks and memory assessment in Alzheimer's disease.

Memory measures that permit pattern and error analysis are useful in the differential diagnosis of dementia. However, little is known about the relative utility or relations among verbal memory tests of different lengths. A 6-item verbal learning test (6-VLT) that assesses qualitative performance features was developed and compared to 3-word recall and the California Verbal Learning Test (CVLT) in patients with Alzheimer's disease. Stronger correlations were observed between the 6-VLT and the CVLT. Significant relations were found between 6-VLT and CVLT indexes of learning, recall, and recognition (hits and false positive errors), although free recall errors were unrelated. Brief tasks such as the 6-VLT may provide more useful information regarding gross memory capacity than 3-word recall, although more challenging tasks may be required to elicit characteristic error patterns in Alzheimer's disease.