Sam Al-Saadi

Ictal EEG remains the prominent predictor of seizure-free outcome after temporal lobectomy in epileptic patients with normal brain MRI.

PURPOSE While an abnormal pre-operative high-resolution brain MRI portends a favorable outcome in patients undergoing resective epilepsy surgery for medically intractable localization-related epilepsy (LRE), a normal MRI is less favorable. Ascertaining desirable pre-operative predictors for successful anterior temporal lobectomy (ATL) in LRE patients with a normal brain MRI is essential to better anticipate surgical outcome. METHODS Patients with LRE and normal temporal structures on MRI underwent ATL at two epilepsy centers in the southeastern US (FL and NC). Outcome was separated into those patients that were seizure free (SF), and those that were not seizure free (NSF), and those NSF were stratified in accordance with the Engel classification system. Those with a pre-operative history of clinical risk factors, unilateral anterior temporal interictal epileptiform discharges (IEDs), well localized scalp ictal EEG with rhythmic temporal theta at onset, localized PET/ictal SPECT, and Wada asymmetry with >2.5/8, were evaluated for the purpose of predicting outcome. Where appropriate, data is presented as a median (mean +/- S.D.). RESULTS Thirty-nine patients, median age 33 years, were followed up 2 years (3+/-1.2) after ATL. Overall, 22/39 (56.4%) patients were identified as SF, and 17/39 (43.6%) patients were NSF. Ictal EEG with rhythmic temporal theta at onset was the only predictive measure of seizure-free outcome (p=0.001, Fishers exact test), and also favorably correlated with seizure reduction (p=0.0001, r(2)=0.34, multiple regression analysis). None of the other predictors examined added greater predictive value. CONCLUSIONS ATL is a favorable option for patients with LRE even when high-resolution brain MRI reveals normal temporal structures. Normal brain MRI patients with localizing pre-operative scalp ictal EEG, have better outcomes following ATL.

Surgeons Can Favorably Influence Career Choices and Goals for Students Interested in Careers in Medicine

BACKGROUND This study was undertaken to determine the impact of an academic summer research, shadowing, and mentorship program on students interested in medicine and surgery. STUDY DESIGN Forty-four (92%) of 48 participants of a summer research, shadowing, and mentorship program returned blinded questionnaires that focused on the programs impact on their scholarly skills, career choices, and goals. The program interfaced academic surgeons with students interested in careers in medicine and enabled students to participate in research projects, attend daily lectures, and shadow physicians in the operating room, clinic, and hospital. Proficiency in scholarly skills, before and after the program, was scored by the participants using a Likert scale (0 = none to 10 = proficient). RESULTS Ninety-three percent of participants were in or had completed college; only 7% had advanced degrees. With the program, proficiency in all categories assessed improved considerably, including medical terminology, abstract writing, statistical analysis, graph and table construction, article writing, and video production. During the last 5 years, participants coauthored 112 national presentations (29 video presentations), 46 published abstracts, and 57 peer-reviewed published articles. Ninety-two percent developed more favorable opinions of a career in medicine; 8% believed the experience deterred them from a career in medicine because of lifestyle and studious demands. Seventy-seven percent believed the program promoted a career in surgery; 82% believed it elevated their goals to become leaders in American medicine. CONCLUSIONS Shadowing opportunities, mentoring, and didactic teaching of scholarly skills for college and graduate students foster academic productivity and elevation of career goals. Academic surgeons can favorably influence career choices and goals for students interested in careers in medicine and surgery.

Outpatient case management in low-income epilepsy patients ☆

BACKGROUND Case management (CM) has been shown to improve the medical care of patients in several paradigms of general medicine. This study was undertaken to assess the impact of CM on low-income patients with epilepsy. METHODS From 2002 to 2003, 737 epilepsy patients had CM provided by a non-profit, state-supported, epilepsy service subserving a four county region in southeastern Florida. Standardized survey forms distributed by the Florida Department of Health were completed by 159 consecutive patients at program admission. Follow-up information regarding seizure frequency, antiepileptic drugs, and quality of life self-rating was performed after 1 year of CM. RESULTS The patients evaluated were composed of 58.5% men, with a mean age of 41.0 years. After CM, an increase in self-reported seizure control was seen in 40.2% of patients (p<0.0001, Fishers exact test), in addition to a shift in the principal utilization of the older to the newer antiepileptic drugs. Furthermore, the total number of emergency department (ED) visits was reduced by 90% with a mean reduction of ED visits per patient from 1.83 per patient per year before CM to 0.14 per patient per year after CM (p<0.0001, Wilcoxon matched-pairs test). Following CM, fewer patients reported difficulty with friends, employers, problems socializing, and feelings of anger (p<0.05, Fishers exact test). CONCLUSIONS CM of low-income patients with epilepsy resulted in self-reported improvement in seizure control, QoL, and significantly reduced ED visitation. CM in epilepsy is feasible and represents a cost-effective improvement in outpatient epilepsy management.

Upright, supine, or bipositional reflux : Patterns of reflux do not affect outcome after laparoscopic Nissen fundoplication

IntroductionThis study was undertaken to determine if the body position in which gastroesophageal reflux occurs before fundoplication—i.e., pattern of reflux—affects symptoms before or after laparoscopic Nissen fundoplication.MethodsA total of 417 patients with gastroesophageal reflux disease (GERD) underwent pH studies, and the severity of reflux in the upright and supine positions was determined. The percent time with pH less than 4 was used to assign patients to one of four groups: upright reflux (pH < 4 more than 8.3% of time in upright position, n = 80), supine reflux (pH < 4 more than 3.5% of time in supine position, n = 73), bipositional reflux (both supine and upright reflux, n = 163), or neither (n = 101). Before and after laparoscopic Nissen fundoplication, the frequency and severity of symptoms of reflux (e.g., dysphagia, regurgitation, choking, heartburn, chest pain) were scored on a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). For each patient, symptom scores before versus after fundoplication were compared using the Wilcoxon matched pairs test; comparisons of symptom scores among patients grouped by reflux patterns were made using Kruskal-Wallis test.ResultsBefore fundoplication, the patterns of reflux did not affect the frequency or severity of reflux symptoms. After laparoscopic fundoplication, all symptoms of bipositional reflux improved, and essentially all symptoms of isolated supine or upright reflux or neither improved.ConclusionsPreoperatively, regardless of the patterns of reflux, symptoms among patients were similar. After fundoplication, symptoms of GERD improved for all patterns of reflux. Laparoscopic fundoplication imparts dramatic and broad relief of symptoms of GERD, regardless of the patterns of reflux. Application of laparoscopic Nissen fundoplication is encouraged.