Economic evaluation of applying the Canadian Syncope Risk Score in an Australian emergency department.

OBJECTIVE: To evaluate the Canadian Syncope Risk Score (CSRS) in syncope patients presenting to the ED from an economic perspective, using very-low and low-risk patients (CSRS -3 to 0) as a threshold for avoiding hospital admissions. METHODS: A decision-analytic model, specifically a decision-tree, was developed to evaluate application of the CSRS. A hypothetical cohort of 1000 patients was modelled based on characteristics and outcome of patients enrolled in a clinical validation study performed alongside this evaluation. Several analytic based approaches were used to handle model outputs and uncertainties. RESULTS: For a cohort of 1000 patients, applying the CSRS was associated with 169 less inpatient admissions from the ED, when compared to usual care. There was also a cost-saving of $8255 per admitted patient, when the CSRS was applied, compared to usual care. Adopting the CSRS was the optimal approach in all scenario analyses and was robust to changes in model parameters. More than three-quarters (78.6%) of all model simulations showed that applying the CSRS is a cost-saving approach to managing syncope. There was high confidence in all results, with the approach using the CSRS reducing the costs and number of syncope-related hospital admissions. CONCLUSIONS: Compared to usual care, applying the CSRS appeared as a cost-effective strategy. This new evidence will help decision-makers choose cost-effective approaches for the management of patients presenting to the ED with syncope, as they search for efficient ways to maximise health gain from a finite budget.

The enigma: Decision-making to transfer residents to the emergency department; communication and care delivery between emergency department staff and residential aged care facilities' nurses.

OBJECTIVE: To investigate the experience of nurses involved in decision-making to transfer residents from a residential aged care facility (RACF) to their local hospital emergency department. This paper reports on the findings of the second phase of a two-phase study. METHODS: Qualitative semi-structured interviews with 19 aged care nurses were conducted. Interviews were audio-taped and transcribed verbatim, and a thematic analysis was carried out. RESULTS: The analysis revealed five major themes that influenced decision-making in relation to the transfer of a resident from the residential aged care facility to the emergency department: conflict with key stakeholders; knowledge and experience; policy and process; stakeholder perception; and recognition and support. CONCLUSIONS: Robust outreach programs, support from other health-care professionals, and improving interdisciplinary understanding and communication between aged care nurses, paramedics and the emergency department would be advantageous to ensure effective care delivery and decision-making.

The economic impact of rostering junior doctors to triage to assist nursing staff in the early part of the patient journey through the emergency department.

OBJECTIVE: This study aims to determine whether redeploying junior doctors to assist at triage represents good value for money and a good use of finite staffing resources. METHODS: We undertook a cost-minimisation analysis to produce new evidence, from an economic perspective, about the costs associated with reallocating junior doctors in the emergency department. We built a decision-analytic model, using a mix of prospectively collected data, routinely collected administrative databases and hospital costings to furnish the model. To measure the impact of uncertainty on the model's inputs and outputs, probabilistic sensitivity analysis was undertaken, using Monte Carlo simulation. RESULTS: The mean costs for usual care were $27,035 (95% CI $27,016 to $27,054), while the mean costs for the new model of care were $25,474, (95% CI $25,453 to $25,494). As a result, the mean difference was -$1,561 (95% CI -$1,533 to -$1,588), with the new model of care being a less costly approach to managing staffing allocations, in comparison to the usual approach. CONCLUSION: Our study shows that redeploying a junior doctor from the fast-track area of the department to assist at triage provides a modest reduction in cost. Our findings give decision-makers who seek to maximise benefit from their finite budget, support to reallocate personnel within the ED.

External validation of the Canadian Syncope Risk Score for patients presenting with undifferentiated syncope to the emergency department.

OBJECTIVE: To validate the accuracy and safety of the Canadian Syncope Risk Score (CSRS) for patients presenting with syncope. METHODS: Single centre prospective observational study in Brisbane, Australia. Adults presenting to the ED with syncope within the last 24 h were recruited after applying exclusion criteria. Study was conducted over 1 year, from March 2018 to March 2019. Thirty-day serious adverse events (SAE) were reported based on the original derivation study and standardised outcome reporting for syncope. Individual patient CSRS was calculated and correlated with 30-day SAE and disposition status from ED. RESULTS: Two hundred and eighty-three patients were recruited to the study. Average age was 55.6 years (SD 22.7 years), 37.1% being male with a 39.9% admission rate. Thirty-day SAE occurred in seven patients (2.5%) and no recorded deaths. The CSRS performed with a sensitivity of 71.4% (95% confidence interval [CI] 30.3-94.9%), specificity 72.8% (95% CI 67.1-77.9%) for a threshold score of 1 or higher. CONCLUSION: Syncope patients in our study were predominantly very low to low risk (72%). The prevalence of 30-day SAE was low, majority occurring following hospital discharge. Sensitivity estimates for CSRS was lower than the derivation study but lacked robustness with wide CIs because of a small sample size and number of events observed. However, the CSRS did not miss any clinically relevant outcomes in low risk patients making it potentially useful in aiding their disposition. Larger validation studies in Australia are encouraged to further test the diagnostic accuracy of the CSRS.

Are expiratory radiographs more sensitive than inspiratory radiographs for the diagnosis of pneumothorax in the emergency department? A retrospective observational study.

OBJECTIVES: Expiratory radiographs are sometimes performed in addition to inspiratory radiographs when a diagnosis of pneumothorax is suspected. There is little published evidence to support this practice and most studies suggest the additional radiograph does not confer any benefit in terms of increased sensitivity. The present study is the first to assess if specialist emergency physicians are more likely to detect a pneumothorax on an inspiratory radiograph compared to an expiratory radiograph. METHODS: Across two urban district EDs 103 paired radiographs positive for pneumothorax and 112 negative controls were identified for inclusion in the study. These were reviewed by three specialist emergency physicians who rated them as either positive or negative for pneumothorax. RESULTS: The mean sensitivity for the three reviewers was 84.8% (95% CI 82.0-87.5) for the inspiratory radiographs and 91.9% (95% CI 88.2-95.6) for the expiratory radiographs, a mean absolute difference of 7.1% (95% CI 2.2-12.1, P = 0.025) in favour of expiratory radiographs. CONCLUSIONS: When reviewed by emergency physicians the present study found expiratory radiographs confer an increase in sensitivity for the diagnosis of pneumothorax compared with inspiratory radiographs. In certain patients where the clinical suspicion for pneumothorax is high performing an expiratory radiograph may increase the likelihood of the diagnosis being made in the ED.

Understanding registered nurse decision-making, communication and care delivery between emergency departments and residential aged care facilities: A research protocol.

OBJECTIVES: Nursing staff in residential aged care facilities (RACF)s often make decisions about the transfer of residents to the emergency department (ED). This paper describes the protocol of a study that aims to understand decision-making process utilised by RACF registered nurses (RNs) and to explore the perceptions of RNs about the decision and communication process between RACF and ED. METHODS: The proposed mixed-method study will survey and interview RACF RNs to understand their decision to transfer a resident and collect information about older people referred to the ED. Data collection will involve telephone survey, ED information system (EDIS) data and semistructured interviews. RESULTS: The project outcomes will provide an understanding of existing ED service provision, communication between facilities and the reasons for transfer of older person to ED. This may inform redesign in communication processes between the ED and local RACFs and outreach care from the ED to RACFs.

Evaluating patients presenting to the emergency department after syncope: validation of the Canadian Syncope Risk Score.

BACKGROUND: Syncope is a common problem but can have any of a broad range of underlying causes. Initial evaluation of the patient in the emergency department often does not identify a specific cause, and the cornerstone of management is reliable risk stratification with clinical decision rules. OBJECTIVES: The primary objective is to validate the utility and safety of the Canadian Syncope Risk Score (CSRS) as a clinical decision rule when assessing patients who present with syncope to Australian emergency departments. Our secondary objective is to evaluate the economic benefits of diverting patients with syncope at low risk of serious adverse events from admission to hospital. METHODS AND ANALYSIS: Prospective, observational study. Patients aged 18 years or more who present to the emergency department (ED) after syncope in the preceding 24 hours and have returned to their baseline state will be enrolled. Patients will be contacted by telephone to determine whether they have experienced any adverse events within 30 days of their initial presentation to the ED. The CSRS will be applied retrospectively to determine the relationship between whether patients were admitted to hospital or discharged home and the reporting of serious adverse events for each CSRS risk level. We will also undertake a cost-effectiveness analysis from the health care perspective. ETHICS APPROVAL: Prince Charles Hospital Human Research Ethics Committee (reference, HREC/17/QPCH/48). DISSEMINATION OF RESULTS: Outcomes will be disseminated by Queensland Health and the funding body via social media, presented at local and national emergency medicine conferences, and published in international emergency medicine and health economics journals. CLINICAL TRIALS REGISTRATION: Not applicable.

A Queensland research support network in emergency healthcare.

PURPOSE: The purpose of this paper is to describe the structure and impact of a Queensland Research Support Network (RSN) in emergency medicine (EM). DESIGN/METHODOLOGY/APPROACH: This paper presents a descriptive summary of EM networks, network evaluations and the structure and development of the Emergency Medicine Foundation's (EMF) RSN in Queensland, including an observational pre- and post-study of research metrics. FINDINGS: In two years, the RSN supported 33 Queensland emergency departments (EDs), of which 14 developed research strategies. There was an increase in research active clinicians, from 23 in 2015 to 181 in 2017. Collaborator engagement increased from 9 in 2015 to 276 in 2017 as did the number of research presentations, from 6 in 2015 to 61 in 2017. EMF experienced a growth in new researchers, with new investigators submitting approximately 60 per cent of grant applications in 2016 and 2017. EMF also received new applications from a further three HHS (taking EMF-funded research activity from 8 to 11 HHS). RESEARCH LIMITATIONS/IMPLICATIONS: This paper describes changes in KPIs and research metrics, which the authors attribute to the establishment of the RSN. However, it is possible that attribution bias plays a role in the KPI improvements. SOCIAL IMPLICATIONS: This network has actively boosted and expanded EM research capacity and capability in Queensland. It provides services, in the form of on-the-ground managers, to develop novice clinician-researchers, new projects and engage entire EDs. This model may be replicated nationwide but requires funding commitment. ORIGINALITY/VALUE: The RSN improves front-line clinician research capacity and capability and increases research activity and collaborations with clear community outcomes. Collaborations were extended to community, primary health networks, non-government organisations, national and international researchers and academic institutions. Evaluating and measuring a network's benefits are difficult, but it is likely that evaluations will help networks obtain funding.

Impact of an emergency department-run clinical decision unit on access block, ambulance ramping and National Emergency Access Target.

OBJECTIVE: ED access block is an ongoing significant problem and has been associated with excess mortality. Multiple models of care have been studied in an effort to improve access block and other key performance indicators (KPIs) of ED. METHODS: This present study describes the impact of a new model of care using an ED led, consultant run clinical decision unit (CDU) on performance, using a retrospective analysis of data for 9 month periods before and after the introduction of the CDU model of care. Primary outcomes were access block (percentage of patients admitted >8 h), discharge National Emergency Access Target (NEAT) adherence and Queensland Ambulance Service level three escalations. RESULTS: After the implementation of the CDU, access block significantly improved. There was a significant improvement in NEAT adherence. Total ambulance ramping time fell by 58% and ambulance service level three escalations fell from 21 to 5 post-CDU implementation. Overall there was no change to hospital mortality numbers. The percentage of patients that did not wait and 30 day representations showed a small but statistically significant decrease. CONCLUSION: In summary, this ED led, consultant run CDU model of care resulted in significantly improved performance on a range of KPIs, including improvement in access block and NEAT figures. The substantial improvements in ambulance ramping and escalations also indicated that the department was able to cope better with periods of high activity.

Altered functional connectivity in mesial temporal lobe epilepsy.

Growing evidence of altered functional connectivity suggests that mesial temporal lobe epilepsy (mTLE) alters not only hippocampal networks, but also a number of resting state networks. These highly coherent, yet functionally distinct brain circuits interact dynamically with each other in order to mediate consciousness, memory, and attention. However, little is currently known about the modulation of these networks by epileptiform activity, such as interictal spikes and seizures. The objective of the study was to use simultaneous EEG-fMRI to investigate functional connectivity in three resting state networks: default mode network (DMN), salience network (SN), and dorsal attentional network (DAN) in patients with mTLE compared to a healthy cohort, and in relation to the onset of interictal spikes and the period immediately prior to the spikes. Compared to the healthy participants, mTLE patients showed significant alterations in functional connectivity of all three resting state networks, generally characterized by a lack of functional connectivity to prefrontal areas and increased connectivity to subcortical and posterior areas. Critically, prior to the onset of interictal spikes, compared to resting state, mTLE patients showed a lack of functional connectivity to the DMN and decreased synchronization within the SN and DAN, demonstrating alterations in functional coherence that may be responsible for the generation of epileptiform activity. Our findings demonstrate mTLE-related alterations of connectivity during the resting state as well as in relation to the onset of interictal spikes. These functional changes may underlie epilepsy-related cognitive abnormalities, because higher cognitive functions, such as memory or attention, rely heavily on the coordinated activity of all three resting state networks.

Evaluating an australian emergency nurse practitioner candidate training program.

Nurse Practitioners (NPs) receive core clinical training at master's level, with their employer providing the opportunity to upskill in clinical and procedural competencies. It is increasingly recognised that this generic education requires supplementary training for operating effectively within a specific clinical environment. In this paper we describe a pilot program designed to train Australian NP Candidates to work effectively within the Emergency Department Fast Track model of care. The training program consisted of a 12-month period: four hours in-house training per week over two semesters, running concurrently with the NP candidate's University semesters, and 3 months' clinical practice to consolidate. The training team defined milestones for Semesters one and two, and developed a case review form to assess application of the candidate's knowledge in new clinical situations, as well as check for gaps in understanding. A clinical skills guide was developed for the candidate to work toward, and a comprehensive assessment was carried out at two time points in the training program. Feedback was obtained from the mentors and the candidate at the end point of the training program, and has been used to refine the program for 2017. This in-house training program provided specialised, evidence-based training for the emergency department environment, resulting in development of the nurse practitioner candidate as a high functioning team member.

Influence of BOLD Contributions to Diffusion fMRI Activation of the Visual Cortex.

Reliance on the hemodynamic response as a surrogate marker of neural activity imposes an intrinsic limit on the spatial specificity of functional MRI. An alternative approach based on diffusion-weighted functional MRI (DfMRI) has been reported as a contrast less reliant on hemodynamic effects, however current evidence suggests that both hemodynamic and unique neural sources contribute to the diffusion signal. Here we compare activation patterns obtained with the standard blood oxygenation level-dependent (BOLD) contrast to DfMRI in order to gain a deeper understanding of how the BOLD proportion contributes to the observable diffusion signal. Both individual and group-level activation patterns obtained with DfMRI and BOLD to a visual field stimulation paradigm were analyzed. At the individual level, the DfMRI contrast showed a strong, positive relationship between the volumes of cortex activated in response to quadrant- and hemi-field visual stimulation. This was not observed in the corresponding BOLD experiment. Overall, the DfMRI response indicated less between-subject variability, with random effects analyses demonstrating higher statistical values at the peak voxel for DfMRI. Furthermore, the spatial extent of the activation was more restricted to the primary visual region for DfMRI than BOLD. However, the diffusion signal was sensitive to the hemodynamic response in a manner dependent on experimental manipulation. It was also limited by its low signal-to-noise ratio (SNR), demonstrating lower sensitivity than BOLD. Together these findings both support DfMRI as a contrast that bears a closer spatial relationship to the underlying neural activity than BOLD, and raise important caveats regarding its utilization. Models explaining the DfMRI signal change need to consider the dynamic vascular contributions that may vary with neural activity.

Comprehending Adverbs of Doubt and Certainty in Health Communication: A Multidimensional Scaling Approach.

This research explored the feasibility of using multidimensional scaling (MDS) analysis in novel combination with other techniques to study comprehension of epistemic adverbs expressing doubt and certainty (e.g., evidently, obviously, probably) as they relate to health communication in clinical settings. In Study 1, Australian English speakers performed a dissimilarity-rating task with sentence pairs containing the target stimuli, presented as "doctors' opinions." Ratings were analyzed using a combination of cultural consensus analysis (factor analysis across participants), weighted-data classical-MDS, and cluster analysis. Analyses revealed strong within-community consistency for a 3-dimensional semantic space solution that took into account individual differences, strong statistical acceptability of the MDS results in terms of stress and explained variance, and semantic configurations that were interpretable in terms of linguistic analyses of the target adverbs. The results confirmed the feasibility of using MDS in this context. Study 2 replicated the results with Canadian English speakers on the same task. Semantic analyses and stress decomposition analysis were performed on the Australian and Canadian data sets, revealing similarities and differences between the two groups. Overall, the results support using MDS to study comprehension of words critical for health communication, including in future studies, for example, second language speaking patients and/or practitioners. More broadly, the results indicate that the techniques described should be promising for comprehension studies in many communicative domains, in both clinical settings and beyond, and including those targeting other aspects of language and focusing on comparisons across different speech communities.

Dynamic emotion perception and prior expectancy.

Social interactions require the ability to rapidly perceive emotion from various incoming dynamic, multisensory cues. Prior expectations reduce incoming emotional information and direct attention to cues that are aligned with what is expected. Studies to date have investigated the prior expectancy effect using static emotional images, despite the fact that dynamic stimuli would represent greater ecological validity. The objective of the study was to create a novel functional magnetic resonance imaging (fMRI) paradigm to examine the influence of prior expectations on naturalistic emotion perception. For this purpose, we developed a dynamic emotion perception task, which consisted of audio-visual videos that carry emotional information congruent or incongruent with prior expectations. The results show that emotional congruency was associated with activity in prefrontal regions, amygdala, and putamen, whereas emotional incongruency was associated with activity in temporoparietal junction and mid-cingulate gyrus. Supported by the behavioural results, our findings suggest that prior expectations are reinforced after repeated experience and learning, whereas unexpected emotions may rely on fast change detection processes. The results from the current study are compatible with the notion that the ability to automatically detect unexpected changes in complex dynamic environments allows for adaptive behaviours in potentially advantageous or threatening situations.

Functional localization of the human color center by decreased water displacement using diffusion-weighted fMRI.

INTRODUCTION: Decreased water displacement following increased neural activity has been observed using diffusion-weighted functional MRI (DfMRI) at high b-values. The physiological mechanisms underlying the diffusion signal change may be unique from the standard blood oxygenation level-dependent (BOLD) contrast and closer to the source of neural activity. Whether DfMRI reflects neural activity more directly than BOLD outside the primary cerebral regions remains unclear. METHODS: Colored and achromatic Mondrian visual stimuli were statistically contrasted to functionally localize the human color center Area V4 in neurologically intact adults. Spatial and temporal properties of DfMRI and BOLD activation were examined across regions of the visual cortex. RESULTS: At the individual level, DfMRI activation patterns showed greater spatial specificity to V4 than BOLD. The BOLD activation patterns were more prominent in the primary visual cortex than DfMRI, where activation was localized to the ventral temporal lobe. Temporally, the diffusion signal change in V4 and V1 both preceded the corresponding hemodynamic response, however the early diffusion signal change was more evident in V1. CONCLUSIONS: DfMRI may be of use in imaging applications implementing cognitive subtraction paradigms, and where highly precise individual functional localization is required.

Lateralization of Temporal Lobe Epilepsy Based on Resting-State Functional Magnetic Resonance Imaging and Machine Learning.

Lateralization of temporal lobe epilepsy (TLE) is critical for successful outcome of surgery to relieve seizures. TLE affects brain regions beyond the temporal lobes and has been associated with aberrant brain networks, based on evidence from functional magnetic resonance imaging. We present here a machine learning-based method for determining the laterality of TLE, using features extracted from resting-state functional connectivity of the brain. A comprehensive feature space was constructed to include network properties within local brain regions, between brain regions, and across the whole network. Feature selection was performed based on random forest and a support vector machine was employed to train a linear model to predict the laterality of TLE on unseen patients. A leave-one-patient-out cross validation was carried out on 12 patients and a prediction accuracy of 83% was achieved. The importance of selected features was analyzed to demonstrate the contribution of resting-state connectivity attributes at voxel, region, and network levels to TLE lateralization.

Overcoming language barriers in healthcare: A protocol for investigating safe and effective communication when patients or clinicians use a second language.

BACKGROUND: Miscommunication in the healthcare sector can be life-threatening. The rising number of migrant patients and foreign-trained staff means that communication errors between a healthcare practitioner and patient when one or both are speaking a second language are increasingly likely. However, there is limited research that addresses this issue systematically. This protocol outlines a hospital-based study examining interactions between healthcare practitioners and their patients who either share or do not share a first language. Of particular interest are the nature and efficacy of communication in language-discordant conversations, and the degree to which risk is communicated. Our aim is to understand language barriers and miscommunication that may occur in healthcare settings between patients and healthcare practitioners, especially where at least one of the speakers is using a second (weaker) language. METHODS/DESIGN: Eighty individual interactions between patients and practitioners who speak either English or Chinese (Mandarin or Cantonese) as their first language will be video recorded in a range of in- and out-patient departments at three hospitals in the Metro South area of Brisbane, Australia. All participants will complete a language background questionnaire. Patients will also complete a short survey rating the effectiveness of the interaction. Recordings will be transcribed and submitted to both quantitative and qualitative analyses to determine elements of the language used that might be particularly problematic and the extent to which language concordance and discordance impacts on the quality of the patient-practitioner consultation. DISCUSSION: Understanding the role that language plays in creating barriers to healthcare is critical for healthcare systems that are experiencing an increasing range of culturally and linguistically diverse populations both amongst patients and practitioners. The data resulting from this study will inform policy and practical solutions for communication training, provide an agenda for future research, and extend theory in health communication.

Identification of pre-spike network in patients with mesial temporal lobe epilepsy.

BACKGROUND: Seizures and interictal spikes in mesial temporal lobe epilepsy (MTLE) affect a network of brain regions rather than a single epileptic focus. Simultaneous electroencephalography and functional magnetic resonance imaging (EEG-fMRI) studies have demonstrated a functional network in which hemodynamic changes are time-locked to spikes. However, whether this reflects the propagation of neuronal activity from a focus, or conversely the activation of a network linked to spike generation remains unknown. The functional connectivity (FC) changes prior to spikes may provide information about the connectivity changes that lead to the generation of spikes. We used EEG-fMRI to investigate FC changes immediately prior to the appearance of interictal spikes on EEG in patients with MTLE. METHODS/PRINCIPAL FINDINGS: Fifteen patients with MTLE underwent continuous EEG-fMRI during rest. Spikes were identified on EEG and three 10 s epochs were defined relative to spike onset: spike (0-10 s), pre-spike (-10 to 0 s), and rest (-20 to -10 s, with no previous spikes in the preceding 45s). Significant spike-related activation in the hippocampus ipsilateral to the seizure focus was found compared to the pre-spike and rest epochs. The peak voxel within the hippocampus ipsilateral to the seizure focus was used as a seed region for FC analysis in the three conditions. A significant change in FC patterns was observed before the appearance of electrographic spikes. Specifically, there was significant loss of coherence between both hippocampi during the pre-spike period compared to spike and rest states. CONCLUSION/SIGNIFICANCE: In keeping with previous findings of abnormal inter-hemispheric hippocampal connectivity in MTLE, our findings specifically link reduced connectivity to the period immediately before spikes. This brief decoupling is consistent with a deficit in mutual (inter-hemispheric) hippocampal inhibition that may predispose to spike generation.

Comparison of block and event-related experimental designs in diffusion-weighted functional MRI.

PURPOSE: To compare diffusion-weighted functional magnetic resonance imaging (DfMRI), a novel alternative to the blood oxygenation level-dependent (BOLD) contrast, in a functional MRI experiment. MATERIALS AND METHODS: Nine participants viewed contrast reversing (7.5 Hz) black-and-white checkerboard stimuli using block and event-related paradigms. DfMRI (b = 1800 mm/s(2)) and BOLD sequences were acquired. Four parameters describing the observed signal were assessed: percent signal change, spatial extent of the activation, the Euclidean distance between peak voxel locations, and the time-to-peak of the best fitting impulse response for different paradigms and sequences. RESULTS: The BOLD conditions showed a higher percent signal change relative to DfMRI; however, event-related DfMRI showed the strongest group activation (t = 21.23, P < 0.0005). Activation was more diffuse and spatially closer to the BOLD response for DfMRI when the block design was used. DfMRIevent showed the shortest TTP (4.4 ± 0.88 sec). CONCLUSION: The hemodynamic contribution to DfMRI may increase with the use of block designs.

Disentangling the cognitive components supporting Austin Maze performance in left versus right temporal lobe epilepsy.

Neuropsychological tests requiring patients to find a path through a maze can be used to assess visuospatial memory performance in temporal lobe pathology, particularly in the hippocampus. Alternatively, they have been used as a task sensitive to executive function in patients with frontal lobe damage. We measured performance on the Austin Maze in patients with unilateral left and right temporal lobe epilepsy (TLE), with and without hippocampal sclerosis, compared to healthy controls. Performance was correlated with a number of other neuropsychological tests to identify the cognitive components that may be associated with poor Austin Maze performance. Patients with right TLE were significantly impaired on the Austin Maze task relative to patients with left TLE and controls, and error scores correlated with their performance on the Block Design task. The performance of patients with left TLE was also impaired relative to controls; however, errors correlated with performance on tests of executive function and delayed recall. The presence of hippocampal sclerosis did not have an impact on maze performance. A discriminant function analysis indicated that the Austin Maze alone correctly classified 73.5% of patients as having right TLE. In summary, impaired performance on the Austin Maze task is more suggestive of right than left TLE; however, impaired performance on this visuospatial task does not necessarily involve the hippocampus. The relationship of the Austin Maze task with other neuropsychological tests suggests that differential cognitive components may underlie performance decrements in right versus left TLE.