Rasch analysis of fatigue severity scale in patients with epilepsy.

OBJECTIVE: To utilize the Rasch model to validate and assess the psychometric properties of the Fatigue Severity Scale (FSS) in patients with epilepsy. METHODS: A total of 307 patients (age > 18 years) with a confirmed diagnosis of epilepsy were consented to participate. Exclusion criteria included patients with psychogenic nonepileptic events, cognitive disabilities, and patients who did not speak/understand English. The nine-step FSS was programmed into software administered to patients on electronic tablets, and patient responses were auto-scored. The Rasch rating scale model (RSM) was used to evaluate the unidimensionality, reliability, and targeting of the FSS. To assess unidimensionality, we examined infit and outfit mean squares. We also assessed unidimensionality of the FSS using a principal component analysis of Rasch residuals, where residuals are understood as the difference between observed and expected data values. We evaluated the internal consistency of person and item performance by examining separation reliability estimates and separation ratio. Differential Item Functioning (DIF) was calculated for gender. RESULTS: There was mixed evidence regarding the extent to which the FSS fit the Rasch model. Outfit values ranged from 0.52 to 2.72 and infit values were 0.60 to 2.18, strongly suggesting the presence of misfitting items: Item 1 ("My motivation is lower when I am fatigued") and Item 2 ("Exercise brings on my fatigue"). SIGNIFICANCE: The nine-item FSS showed fair psychometric properties in this sample of patients with epilepsy. Our study provides unique, supportive information for the use of a modified version of the FSS, omitting the first two items, in patients with epilepsy. Given the prevalence of fatigue and other neuropsychiatric comorbidities of epilepsy, having a validated fatigue scale can aid healthcare providers to identify moderate-to-severe fatigue levels in patients with epilepsy and address the plausible risk factors.

Lacosamide serum concentrations during pregnancy.

Still considered a new ASD, teratogenicity from lacosamide (LCM) exposure during pregnancy is unknown. LCM metabolism through several cytochrome P450 enzymes and minor glucuronidation metabolism in the liver may increase during pregnancy and theoretically lead to lower LCM levels during pregnancy and the risk of increased seizures. Our objective was to determine the impact of pregnancy on serum LCM levels in a series of women with epilepsy (WWE). We identified seven pregnancies with exposure to LCM with at least one level drawn during pregnancy. Patient ages ranged from 18 to 38 years (mean 26.4 years) and total daily doses of LCM ranged from 200 to 600 mg/day. Two patients had increased dose adjustments in response to breakthrough seizures. Dose normalized concentrations (DNC) showed an overall decrease over time through each trimester (p = 0.002) and significantly lower during trimester 2 and 3 (p = 0.001 and p = 0.004, respectively) compared to pre-pregnancy levels. There were no significant changes in seizure frequency and none of the neonates had teratogenic findings at time of birth. We are the first to report a case series on the changes in LCM levels during pregnancy with significant decreased LCM DNC levels during the second and third trimesters in comparison to pre-pregnancy values.

Social Competence Treatment After Traumatic Brain Injury: A Multicenter, Randomized Controlled Trial of Interactive Group Treatment Versus Noninteractive Treatment.

OBJECTIVE: To evaluate the effectiveness of a replicable group treatment program for improving social competence after traumatic brain injury (TBI). DESIGN: Multicenter randomized controlled trial comparing 2 methods of conducting a social competency skills program, an interactive group format versus a classroom lecture. SETTING: Community and veteran rehabilitation centers. PARTICIPANTS: Civilian, military, and veteran adults with TBI and social competence difficulties (N=179), at least 6 months postinjury. INTERVENTIONS: The experimental intervention consisted of 13 weekly group interactive sessions (1.5h) with structured and facilitated group interactions to improve social competence, and the control consisted of 13 traditional classroom sessions using the same curriculum with brief supplemental individual sessions but without structured group interaction. MAIN OUTCOME MEASURES: Profile of Pragmatic Impairment in Communication (PPIC), an objective behavioral rating of social communication impairments after TBI. LaTrobe Communication Questionnaire (LCQ), Goal Attainment Scale (GAS), Satisfaction with Life Scale, Posttraumatic Stress Disorder Checklist-C (PCL) civilian version, Brief Symptom Inventory 18 (BSI-18), Scale of Perceived Social Self-Efficacy (PSSE). RESULTS: Social competence goals (GAS) were achieved and maintained for most participants regardless of treatment method. Significant improvements in the primary outcome (PPIC) and 2 of the secondary outcomes (LCQ and BSI) were seen immediately posttreatment and at 3 months posttreatment in the alternative treatment arm only; however, these improvements were not significantly different between the group interactive structured treatment and alternative treatment arms. Similar trends were observed for PSSE and PCL-C. CONCLUSIONS: Social competence skills improved for persons with TBI in both treatment conditions. The group interactive format was not found to be a superior method of treatment delivery in this study.

Emergency department visits in patients with low acuity conditions: Factors associated with resource utilization.

OBJECTIVES: To identify health beliefs of emergency department (ED) patients with low acuity conditions and how these affect ambulance (AMB) utilization. METHODS: We performed a prospective, observational study on a convenience sample of patients 18years or older, who presented to the ED of an urban, academic hospital with an Emergency Severity Index (ESI) triage level of 4 or 5. Demographics, treatment, and disposition data were obtained along with self-administered surveys. Characteristics of patients with low acuity conditions who presented to the ED by AMB were compared to the patients who came to the ED by private transportation (PT). Data were analyzed with the chi-square test, t-test, and Mann-Whitney test. RESULTS: A total of 197 patients (97 AMB and 100 PT) were enrolled. Compared to PT, AMB patients were more likely to: be insured (82% vs. 56%; p=0.000), have a primary care provider (62% vs. 44%; p=0.048), and lack a regular means of transportation (53% vs. 33%; p=0.005). Three surveys were used the SF-8, Short Test of Functional Health Literacy in Adults [STOFHLA], and Health Belief Model [HBM]. Answers to HBM showed patients perceive that their illness required care within one hour of arrival (38% vs. 21%; p=0.04), have used an ambulance in the past year (76% vs. 33%; p=0.001) and to utilize an ambulance in the future for similar concerns (53% vs. 15%; p=0.000). AMB patients were more likely to call an ambulance for any health concern (p=0.035) and felt that there were enough ambulances for all patients in the city (p=0.01). There were no differences in age, employment, level of income and education, nor hospital admission rate between groups. CONCLUSIONS: Ambulance use in low-acuity ED patients is associated with misperceptions regarding severity of illness and resource allocation as well as limited access to private transportation. Understanding patient perceptions of illness and other barriers to receiving care is imperative for the development of interventions aimed at enabling change in health behaviors such as the elective use of limited resources.

Blood pressure variability as an indicator of sepsis severity in adult emergency department patients.

STUDY OBJECTIVE: Quantify the correlation between blood pressure variability (BPV) and markers of illness severity: serum lactate (LAC) or Sequential Organ Failure Assessment (SOFA) scores. METHODS: We performed a secondary analysis of data from a prospective, observational study evaluating fluid resuscitation on adult, septic, ED patients. Vital signs and fluid infusion volumes were recorded every 15min during the 3h following ED arrival. BPV was assessed via average real variability (ARV): the average of the absolute differences between consecutive BP measurements. ARV was calculated for the time periods before and after 3 fluid infusion milestones: 10-, 20-, and 30-mL/kg total body weight (TBW). Spearman's rho correlation coefficient analysis was utilized. A p-value<0.05 was considered statistically significant. RESULTS: Forty patients were included. Mean fluid infusion was 33.7mL/kg TBW (SD 22.1). All patients received fluid infusion≥10mL/kg TBW, 25 patients received fluid infusion>20mL/kg TBW, and 16 patients received fluid infusion>30mL/kg TBW. Mean initial LAC was 4.0mmol/L (SD 3.2). Mean repeat LAC was 3.1mmol/L (SD 3.2), obtained an average of 6.6h (SD 5.3) later. Mean SOFA score was 7.0 (SD 4.4). BPV correlated with both follow-up LAC (r=0.564; p=0.023) and SOFA score (r=0.544; p=0.024) among the cohort that received a fluid infusion>20-mL/kg TBW. CONCLUSION: With the finding of a positive correlation between BPV and markers of illness severity (LAC and SOFA scores), this pilot study introduces BPV analysis as a real-time, non-invasive tool for continuous sepsis monitoring in the ED.

Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure.

OBJECTIVES: The purpose of this study was to compare health care resource utilization among patients who were given intravenous nitroglycerin for acute heart failure (AHF) in the emergency department (ED) by intermittent bolus, continuous infusion, or a combination of both. METHODS: We retrospectively identified 395 patients that received nitroglycerin therapy in the ED for the treatment of AHF over a 5-year period. Patients that received intermittent bolus (n=124) were compared with continuous infusion therapy (n=182) and combination therapy of bolus and infusion (n=89). The primary outcomes were the frequency of intensive care unit (ICU) admission and hospital length of stay (LOS). RESULTS: On unadjusted analysis, rates of ICU admission were significantly lower in the bolus vs infusion and combination groups (48.4% vs 68.7% vs 83%, respectively; P<.0001) and median LOS (interquartile range) was shorter (3.7 [2.5-6.2 days]) compared with infusion (4.7 [2.9-7.1 days]) and combination (5.0 [2.9-6.7 days]) groups; P=.02. On adjusted regression models, the strong association between bolus nitroglycerin and reduced ICU admission rate remained, and hospital LOS was 1.9 days shorter compared with infusion therapy alone. Use of intubation (bolus [8.9%] vs infusion [8.8%] vs combination [16.9%]; P=.096) and bilevel positive airway pressure (bolus [26.6%] vs infusion [20.3%] vs combination [29.2%]; P=.21) were similar as was the incidence of hypotension, myocardial injury, and worsening renal function. CONCLUSIONS: In ED patients with AHF, intravenous nitroglycerin by intermittent bolus was associated with a lower ICU admission rate and a shorter hospital LOS compared with continuous infusion.

Rasch analysis of the coping inventory for stressful situations in individuals with moderate to severe traumatic brain injury.

OBJECTIVE: To evaluate psychometric properties of the Coping Inventory for Stressful Situations (CISS) in individuals with traumatic brain injury (TBI). DESIGN: Archival study using Rasch analysis. SETTING: Postacute rehabilitation hospital. PARTICIPANTS: Adults (N=331) 1 to 15 years after moderate to severe TBI, recruited consecutively. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: CISS. RESULTS: Indices of unidimensionality and model fit supported the scale's proposed multidimensional structure consisting of Task, Emotion, and Avoidant coping style; 3 unidimensional scales showed better fit than a single combined scale. The 3 scales met Rasch expectations of reliability and separation for persons and items, as well as adequate response category functioning. The scales were generally well targeted but showed some evidence of ceiling effect for Task, and floor effects for Emotion and Avoidant coping; item difficulties did not fully capture extreme ranges demonstrated by some participants, suggesting that measurement of coping after TBI on the CISS would be improved with additional items at low and high ranges of difficulty. Results were generally equivalent for cross-sectional groups representing short-term (1y), intermediate (2y), and long-term (5-15y). CONCLUSIONS: The CISS showed good psychometric properties as a measure of coping style among persons with moderate to severe TBI in acute and chronic phases of recovery, and showed evidence of multidimensionality as predicted by theory, consistent with 3 unidimensional scales. Added items tapping broader (or more accessible, less cognitively complex) ranges of coping responses would likely benefit the scale overall and improve correspondence with the response needs of people with TBI.

Comorbidity and insurance as predictors of disability after traumatic brain injury.

OBJECTIVE: To examine the unique contribution of self-reported medical comorbidity and insurance type on disability after traumatic brain injury (TBI). DESIGN: Inception cohort design at 1-year follow up. SETTING: A university affiliated rehabilitation hospital. PARTICIPANTS: Adults with mild-complicated to severe TBI (N=70). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Self-reported medical comorbidities were measured using the Modified Cumulative Illness Rating Scale, while insurance type was classified as commercial or government-funded; disability was measured using the Disability Rating Scale. RESULTS: Two models were run using multiple linear regression, and the best-fitting model was selected on the basis of Bayesian information criterion. The full model, which included self-reported medical comorbidity and insurance type, was significantly better fitting than the reduced model. Participants with a longer duration of posttraumatic amnesia, more self-reported medical comorbidities, and government insurance were more likely to have higher levels of disability. Meanwhile, individual organ systems were not predictive of disability. CONCLUSIONS: The cumulative effect of self-reported medical comorbidities and type of insurance coverage predict disability above and beyond well-known prognostic variables. Early assessment of medical complications and improving services provided by government-funded insurance may enhance quality of life and reduce long-term health care costs.

Role of character strengths in outcome after mild complicated to severe traumatic brain injury: a positive psychology study.

OBJECTIVE: To examine the effects of character strengths on psychosocial outcomes after mild complicated to severe traumatic brain injury (TBI). DESIGN: Prospective study with consecutive enrollment. SETTING: A Midwestern rehabilitation hospital. PARTICIPANTS: Persons with mild complicated to severe TBI (N=65). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community Integration Measure, Disability Rating Scale, Modified Cumulative Illness Rating Scale, Positive and Negative Affect Schedule, Satisfaction with Life Scale, Values in Action Inventory of Strengths, and Wechsler Test of Adult Reading. RESULTS: Character virtues and strengths were moderately associated with subjective outcomes, such that there were fewer and less strong associations between character virtues/strengths and objective outcomes than subjective outcomes. Specifically, positive attributes were associated with greater life satisfaction and perceived community integration. Fewer and less strong associations were observed for objective well-being; however, character strengths and virtues showed unique value in predicting physical health and disability. Positive affectivity was not meaningfully related to objective outcomes, but it was significantly related to subjective outcomes. In contrast, negative affectivity was related to objective but not subjective outcomes. CONCLUSIONS: Given the strength of the associations between positive aspects of character or ways of perceiving the world and positive feelings about one's current life situation, treatments focused on facilitating these virtues and strengths in persons who have experienced TBI may result in better perceived outcomes and potentially subsequently lower comorbidities.

Rasch analysis of the community integration measure in persons with traumatic brain injury.

OBJECTIVE: To examine the measurement properties of the Community Integration Measure (CIM) in persons with traumatic brain injury (TBI). DESIGN: Rasch analysis was used to retrospectively evaluate the CIM. SETTING: Rehabilitation hospital. PARTICIPANTS: Persons (N=279) 1 to 15 years after a TBI. INTERVENTIONS: None. MAIN OUTCOME MEASURE: CIM RESULTS: The CIM met Rasch expectations of unidimensionality and reliability (person separation ratio=2.01, item separation ratio=4.52). However, item endorsibility was poorly targeted to the participants' level of community integration. A ceiling effect was found with this sample. CONCLUSIONS: The CIM is a relatively reliable and unidimensional scale. Future iterations might benefit from the addition of items that are more difficult to endorse (ie, improved targeting).

Changes in sexual functioning from 6 to 12 months following traumatic brain injury: a prospective TBI model system multicenter study.

OBJECTIVE: To investigate longitudinal changes in sexual functioning during the first year following moderate to severe traumatic brain injury (TBI). DESIGN: Prospective cohort study. SETTING: Community. PARTICIPANTS: 182 persons (53 women and 129 men) with moderate to severe TBI who were admitted to 1 of 6 participating TBI Model System centers and followed in the community at 6 and 12 months after injury. MAIN MEASURES: Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Sexual Satisfaction Index (GSSI). RESULTS: Mean T-scores on the DISF-SR Arousal subscale demonstrated marginal improvement over time, with a 2.59-point increase (P = .05) from 6 to 12 months after injury. There were no significant differences over this 6-month period on the remaining DISF-SR subscales, including sexual cognition/fantasy, sexual behavior/experience, and orgasm. There was no significant change in satisfaction with sexual functioning on the GSSI from 6 months (72% satisfied) to 12 months (71% satisfied). CONCLUSIONS AND IMPLICATIONS: Sexual function and satisfaction appears to be stable in those with moderate to severe TBI from 6 to 12 months after injury, with the exception of minimal improvement in arousal. These findings, to our knowledge, reflect the first evidence regarding prospective changes in sexual functioning in this population. Future research can go far to assist clinicians in treatment planning and managing patient expectations of recovery of sexual functioning after TBI.

Calorie and protein intake in acute rehabilitation inpatients with traumatic spinal cord injury versus other diagnoses.

BACKGROUND: Obesity and its consequences affect patients with spinal cord injury (SCI). There is a paucity of data with regard to the dietary intake patterns of patients with SCI in the acute inpatient rehabilitation setting. Our hypothesis is that acute rehabilitation inpatients with SCI consume significantly more calories and protein than other inpatient rehabilitation diagnoses. OBJECTIVE: To compare calorie and protein intake in patients with new SCI versus other diagnoses (new traumatic brain injury [TBI], new stroke, and Parkinson's disease [PD]) in the acute inpatient rehabilitation setting. METHODS: The intake of 78 acute rehabilitation inpatients was recorded by registered dieticians utilizing once-weekly calorie and protein intake calculations. RESULTS: Mean ± SD calorie intake (kcal) for the SCI, TBI, stroke, and PD groups was 1,967.9 ± 611.6, 1,546.8 ± 352.3, 1,459.7 ± 443.2, and 1,459.4 ± 434.6, respectively. ANOVA revealed a significant overall group difference, F(3, 74) = 4.74, P = .004. Mean ± SD protein intake (g) for the SCI, TBI, stroke, and PD groups was 71.5 ± 25.0, 61.1 ± 12.8, 57.6 ± 16.6, and 55.1 ± 19.1, respectively. ANOVA did not reveal an overall group difference, F(3, 74) = 2.50, P = .066. CONCLUSIONS: Given the diet-related comorbidities and energy balance abnormalities associated with SCI, combined with the intake levels demonstrated in this study, education with regard to appropriate calorie intake in patients with SCI should be given in the acute inpatient rehabilitation setting.

CVLT-3 response bias as an indicator of performance validity in a litigating population.

This study examined the efficacy of CVLT-3 response bias (i.e., parametric and nonparametric response bias) indices in differentiating between a clinical sample with traumatic brain injury and a litigating sample with poor performance validity.Participants included 106 individuals, divided into two groups: clinical group with TBI (n = 56) and a litigating group who demonstrated inadequate performance validity (n = 50), as measured by failure on at least two performance validity tests. Archival CVLT-II data was rescored utilizing the CVLT-3 scoring and normative data. Receiver operator characteristic (ROC) curve analysis was used to evaluate the diagnostic discriminability of the two response bias indices.Both parametric and nonparametric bias indices showed acceptable levels of diagnostic discrimination: AUC = .791 for parametric response bias and AUC = .753 for nonparametric response bias.Parametric response bias' discrimination was statistically superior to the nonparametric responses bias' discrimination. The CVLT-3 response bias score demonstrated good sensitivity and specificity when differentiating between individuals in a clinical sample with TBI and individuals in litigation who demonstrated inadequate performance validity.

Comorbid disease in persons with traumatic brain injury: descriptive findings using the modified cumulative illness rating scale.

OBJECTIVE: To provide descriptive findings regarding the overall health status and prevalence of medical comorbidities experienced by traumatic brain injury (TBI) patients. DESIGN: Inception cohort design with cross-sectional follow-up at 1 to 15 years. SETTING: Rehabilitation hospital. PARTICIPANTS: Adults (N=258) with moderate to severe TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Modified Cumulative Illness Rating Scale is a 14-item rating scale used to indicate health status by rating impairment across 14 different domains. RESULTS: The TBI sample had lower rates of comorbidities compared with other rehabilitation populations, including stroke and orthopedic samples. The most commonly encountered medical conditions within our sample were eyes, ears, nose, and throat problems, psychiatric or behavioral disturbances, hypertension, and musculoskeletal injury at mild to moderate severity. Prevalence of conditions did not differ by sex, race, or cause of TBI. CONCLUSIONS: The current TBI sample was relatively healthy with few medical comorbidities. Further, the Modified Cumulative Illness Rating Scale may better be used as a standardized checklist to assess for the presence of co-occurring conditions, given the near absence of conditions in the higher range of severity.

Development of the participation assessment with recombined tools-objective for use after traumatic brain injury.

OBJECTIVE: To develop a new measure, the Participation Assessment With Recombined Tools-Objective (PART-O), based on items from 3 participation instruments. DESIGN: Instrument development based on survey research. SETTING: Community. PARTICIPANTS: Adults (N=400) with traumatic brain injury (TBI) 1 to 15 years postinjury, recruited from 8 TBI Model Systems (TBIMS). INTERVENTIONS: None. MAIN OUTCOME MEASURE: Community Integration Questionnaire version 2; Participation Objective, Participation Subjective; Craig Handicap Assessment and Reporting Technique; PART-O. RESULTS: Using Rasch rating scale analysis to evaluate the psychometric properties of participation items drawn from 3 instruments, a set of 24 items was developed that covered a broad range of participation content and formed a measure with person separation of 2.47, person reliability of .86, item spread of 4.25 logits, item separation of 11.36, and item reliability of .99. Items were well targeted on the sample with only 1 item misfitting. The PART-O showed expected relationships with measures of impairment, activity limitations, and subjective well-being. CONCLUSIONS: The 24-item PART-O is an acceptable measure of objective participation for persons with moderate and severe TBI. It has been adopted as the measure of participation in the TBIMS.

What Determines the Quality of Rehabilitation Clinical Practice Guidelines?: An Overview Study.

OBJECTIVE: The aim of the study was to determine what factors determine the quality of rehabilitation clinical practice guidelines. DESIGN: Six databases were searched for articles that had applied the Appraisal of Guidelines for Research & Evaluation II quality assessment tool to rehabilitation clinical practice guidelines. The 573 deduplicated abstracts were independently screened by two authors, resulting in 81 articles, the full texts of which were independently screened by two authors for Appraisal of Guidelines for Research & Evaluation II application to rehabilitation clinical practice guidelines, resulting in a final selection of 40 reviews appraising 504 clinical practice guidelines. Data were extracted from these by one author and checked by a second. Data on each clinical practice guideline included the six Appraisal of Guidelines for Research & Evaluation II domain scores, as well as the two Appraisal of Guidelines for Research & Evaluation II global evaluations. RESULTS: All six Appraisal of Guidelines for Research & Evaluation II domain scores were statistically significant predictors of overall clinical practice guideline quality rating; D3 (rigor of development) was the strongest and D1 (scope and purpose) the weakest (overall model P < 0.001, R2 = 0.53). Five of the six domain scores were significant predictors of the clinical practice guideline use recommendation, with D3 the strongest predictor and D5 (applicability) the weakest (overall model P < 0.001, pseudo R2 = 0.53). CONCLUSIONS: Quality of rehabilitation clinical practice guidelines may be improved by addressing key domains such as rigor of development.

Withdrawal of antiepileptic drugs after stereotactic laser amygdalohippocampotomy for mesial temporal lobe epilepsy.

OBJECTIVE: This retrospective study investigated the success rate of withdrawal of antiepileptic drugs (AEDs) following stereotactic laser amygdalohippocampotomy (SLAH) for mesial temporal lobe epilepsy (MTLE), and identified predictors of seizure recurrence. MATERIALS AND METHODS: We retrospectively assessed 65 patients who underwent SLAH for MTLE (59 lesional). Patients' demographics, disease characteristics and post-surgical outcomes were evaluated for their potential to predict seizure recurrence associated with withdrawal of AEDs. RESULTS: The mean period of observation post SLAH was 51 months (range 12-96 months) and the mean period to initial reduction of AEDs was 21 months (range 12-60 months). Reduction of AEDs was attempted in 37 patients (57 %) who were seizure free post SLAH and it was successful in approximately 2/3 of them. From the remainder 1/3 who relapsed, nearly all regained seizure control after reinstitution of their AEDs. The likelihood of relapse after reduction of AEDs was predicted only by pre-operative seizure frequency. At the end of the observation period, approximately 14 % of all SLAH patients were seizure free without AEDs and approximately 54 % remained seizure free on AEDs. Compared with preoperative status, the number of AEDs were reduced in 37 % of patients, unchanged in 51 % of them and increased in 12 % of them. CONCLUSIONS: Successful SLAH for MTLE allows for reduction of AEDs in a significant portion of patients and complete withdrawal of AEDs in a subset of them. Patients with higher pre-operative seizure frequency exhibit a greater chance of relapse post reduction of AEDs.

Predictive Outcome Modeling of Preoperative Clinical Symptoms and Electrodiagnostic Data in Tarsal Tunnel Surgery.

Background The relationship between tarsal tunnel syndrome (TTS), electrodiagnostic (Edx) findings, and surgical outcome is unknown. Analysis of TTS surgical release outcome patient satisfaction and comparison to Edx nerve conduction studies (NCSs) is important to improve outcome prediction when deciding who would benefit from TTS release. Methods Retrospective study of 90 patients over 7 years that had tarsal tunnel (TT) release surgery with outcome rating and preoperative tibial NCS. Overall, 64 patients met study inclusion criteria with enough NCS data to be classified into one of the following three groups: (1) probable TTS, (2) peripheral polyneuropathy, or (3) normal. Most patients had preoperative clinical provocative testing including diagnostic tibial nerve injection, tibial Phalen's sign, and/or Tinel's sign and complaints of plantar tibial neuropathic symptoms. Outcome measure was percentage of patient improvement report at surgical follow-up visit. Results Patient-reported improvement was 92% in the probable TTS group ( n = 41) and 77% of the non-TTS group ( n = 23). Multivariate modeling revealed that three out of eight variables predicted improvement from surgical release, NCS consistent with TTS ( p = 0.04), neuropathic symptoms ( p = 0.045), and absent Phalen's test ( p = 0.001). The R 2 was 0.21 which is a robust result for this outcome measurement process. Conclusion The best predictors of improvement in patients with TTS release were found in patients that had preoperative Edx evidence of tibial neuropathy in the TT and tibial nerve plantar symptoms. Determining what factors predict surgical outcome will require prospective evaluation and evaluation of patients with other nonsurgical modalities.

Superior Verbal Memory Outcome After Stereotactic Laser Amygdalohippocampotomy.

Objective: To evaluate declarative memory outcomes in medically refractory epilepsy patients who underwent either a highly selective laser ablation of the amygdalohippocampal complex or a conventional open temporal lobe resection. Methods: Post-operative change scores were examined for verbal memory outcome in epilepsy patients who underwent stereotactic laser amygdalohippocampotomy (SLAH: n = 40) or open resection procedures (n = 40) using both reliable change index (RCI) scores and a 1-SD change metric. Results: Using RCI scores, patients undergoing open resection (12/40, 30.0%) were more likely to decline on verbal memory than those undergoing SLAH (2/40 [5.0%], p = 0.0064, Fisher's exact test). Patients with language dominant procedures were much more likely to experience a significant verbal memory decline following open resection (9/19 [47.4%]) compared to laser ablation (2/19 [10.5%], p = 0.0293, Fisher's exact test). 1 SD verbal memory decline frequently occurred in the open resection sample of language dominant temporal lobe patients with mesial temporal sclerosis (8/10 [80.0%]), although it rarely occurred in such patients after SLAH (2/14, 14.3%) (p = 0.0027, Fisher's exact test). Memory improvement occurred significantly more frequently following SLAH than after open resection. Interpretation: These findings suggest that while verbal memory function can decline after laser ablation of the amygdalohippocampal complex, it is better preserved when compared to open temporal lobe resection. Our findings also highlight that the dominant hippocampus is not uniquely responsible for verbal memory. While this is at odds with our simple and common heuristic of the hippocampus in memory, it supports the findings of non-human primate studies showing that memory depends on broader medial and lateral TL regions.