ABSTRACT
BACKGROUND: We studied suggestion of benefit combined with motor cortex and premotor cortex repetitive transcranial magnetic stimulation (rTMS) in chronic (>2 years) FMDs. METHODS: Patients were identified from our patient records who had clinically definite FMDs and had undergone neuropsychiatric evaluation. Those with chronic FMDs were offered open-label rTMS over the dominant motor cortex. If they failed to improve they received dominant premotor cortex rTMS. The primary outcome was change from baseline to post-rTMS in quality of life measured by the World Health Organization Quality of Life Brief (WHOQOL-BREF) scale. Secondary outcomes were subject and investigator global impression of change (GIC), blinded Rush psychogenic movements rating scale, Barbers suggestibility scale, baseline expectation of benefit scale, and adverse effects. RESULTS: Six subjects were enrolled. For the primary outcome, there was significant improvement in the physical domain scores but significant reduction in psychological domain scores after premotor cortex rTMS compared to baseline and after motor cortex rTMS. There was no significant change between baseline and motor cortex rTMS or in any other domain after premotor cortex rTMS. Secondary outcome measures showed no meaningful change. Transient headache and worsening of FMD symptoms were the most common adverse effects observed. CONCLUSION: rTMS combined with strong suggestion of benefit provided dissonant results after premotor cortex rTMS with improvement in physical quality of life but reduction in psychological quality of life. These results serve to underscore the complex nature of FMDs where the overt physical manifestation is but one part of a comprehensive neuropsychological syndrome.
Subject(s)
Motor Cortex/physiopathology , Movement Disorders/therapy , Outcome Assessment, Health Care , Somatoform Disorders/therapy , Suggestion , Transcranial Magnetic Stimulation/methods , Adult , Female , Humans , Male , Middle Aged , Movement Disorders/psychology , Pilot Projects , Quality of Life , Somatoform Disorders/psychologyABSTRACT
The Cavitron ultrasonic surgical aspirator (CUSA) was used to fragment and aspirate normal and pathologic renal tissue. The operative blood loss utilizing the CUSA was markedly reduced compared to electrocautery or the cold scalpel. This is due to the ability of the instrument selectively to fragment and aspirate tissue with high-water content, such as renal parenchyma, while sparing tissue with higher elastin and collagen content, such as collecting system or blood vessel. The surgeon can therefore skeletonize and secure the blood vessels before they are divided.
