Stereoelectroencephalography in the setting of a previously implanted responsive neural stimulation device: illustrative case.

BACKGROUND: Responsive neural stimulation (RNS) is a relatively novel procedure for drug-resistant epilepsy, which involves implantation of a device into the skull and brain. As more devices are implanted, there may be an increasing need to perform intracranial electrocorticography in implant patients with persistent seizures. Given the device location, imaging difficulties with implanted devices, and other technical hurdles, stereoelectroencephalography (SEEG) could be especially challenging. The authors describe the first reported SEEG investigation in a patient with an RNS device, highlighting the technical challenges and clinical data ascertained. OBSERVATIONS: A 41-year-old male with drug-resistant epilepsy presented several years after a local surgeon had placed an RNS device with two electrodes in the bilateral parieto-occipital lobes. Because of inadequate seizure control, the patient was offered a repeat SEEG investigation to characterize his epilepsy better. Although more technically challenging than a traditional SEEG implantation, the SEEG investigation was successfully performed, which led to a confirmation of bilateral hippocampal seizure onset. The patient underwent repositioning of his RNS leads with a significant decrease in his seizure frequency. LESSONS: Concurrent implantation of SEEG electrodes in a functioning RNS device can be safely performed and can augment our understanding of a patient's seizures.

Real world prognosis in MS: does early versus late diagnosis matter?

BACKGROUND: Multiple sclerosis (MS) often presents soon after the onset of a recognized clinically isolated syndrome (CIS). In order to interpret data from CIS trials, it is important to know whether patients presenting as classical CIS provide group data representative of RRMS. OBJECTIVE: We aimed to determine whether or not MS patients presenting soon after the onset of symptoms with clinically isolated syndromes have an identifiable clinical profile, including worse outcomes, versus MS patients presenting later. METHODS: Chart review of consecutive patients with newly diagnosed relapsing MS, diagnosed in our clinic between 1989 and 2005. We divided patients into an early presentation group (EP), versus the remaining late presenting group (LP), and analyzed the impact of delay in presentation on 10- and 15-year disability outcomes. We also sought to identify reasons for later presentation. RESULTS: The two groups were similar in terms of many demographics, clinical risk factors, and long-term disability outcomes (median EDSS 2.25 versus EDSS 2.0 at 10 years). Exceptionally, patients in the EP group had more frequent attacks in the first few years after onset and were diagnosed and treated earlier. CONCLUSIONS: Patients in our MS clinic with EP versus LP were more likely to have multiple attacks in the first 2 years after onset and were treated earlier, but did not have a better 10- or 15-year outcome.

Medicine and surgery residents' perspectives on the impact of COVID-19 on graduate medical education.

The COVID-19 crisis has had an unprecedented impact on resident education and well-being: social distancing guidelines have limited patient volumes and forced virtual learning, while personal protective equipment (PPE) shortages, school/daycare closures, and visa restrictions have served as additional stressors. Our study aimed to analyze the effects of COVID-19 crisis-related stressors on residents' professional and personal lives. In April 2020, we administered a survey to residents at a large academic hospital system in order to assess the impact of the pandemic on residency training after >6 weeks of a modified schedule. The primary outcome was to determine which factors or resident characteristics were related to stress during the pandemic. Our secondary goals were to examine which resident characteristics were related to survey responses. Data were analyzed with regression analyses. Ninety-six of 205 residents completed the survey (47% response rate). For our primary outcome, anxiety about PPE (P < 0.001), female gender (P = 0.03), and the interaction between female gender and anxiety about PPE (P = 0.04) were significantly related to increased stress during the COVID-19 pandemic. Secondary analyses suggested that medicine residents were more comfortable than surgical residents using telemedicine (P > 0.001). Additionally, compared to juniors, seniors believed that the pandemic was more disruptive, modified schedules were effective, and virtual meetings were less effective while virtual lectures were more effective (all P ≤ 0.05) Furthermore, the pandemic experience has allowed seniors in particular to feel more confident to lead in future health crises (P ≤ 0.05). Medicine and surgery residency programs should be cognizant of and closely monitor the effects of COVID-19 crisis-related factors on residents' stress and anxiety levels. Transparent communication, telemedicine, online lectures/meetings, procedure simulations, advocacy groups, and wellness resources may help to mitigate some of the challenges posed by the pandemic.