Post-trial access in implanted neural device research: Device maintenance, abandonment, and cost

BACKGROUND

Clinical trial participants who benefit from experimental neural devices for the treatment of debilitating and otherwise treatment-resistant conditions are generally not ensured continued access to effective therapy or maintenance of devices at the conclusion of trials.

OBJECTIVE/HYPOTHESIS

Post-trial obligations have been extensively examined in the context of drug trials, but there has been little empirical examination of stakeholder perspectives regarding these obligations in the rapidly growing field of neural device research.

METHODS

This study examined the perspectives of 44 stakeholders (i.e., 23 researchers and 21 patient-participants) involved in implantable neural device trials.

RESULTS

Researchers were concerned about current post-trial management, identified barriers like cost, and suggested ways to improve the system. Many patient-participants were unaware of whether they would have post-trial access, but most thought they should keep devices if beneficial, and agreed with researchers that more should be done to help them keep and maintain these neural devices.

CONCLUSION

To our knowledge, this is the first in-depth examination of researcher perspectives regarding continued access to experimental neural devices and only the second such examination of patient-participant perspectives. These data can help inform future ethical and policy decisions about post-trial access to implantable neurotechnology.

Social impact and governance of AI and neurotechnologies

Advances in artificial intelligence (AI) and brain science are going to have a huge impact on society. While technologies based on those advances can provide enormous social benefits, adoption of new technologies poses various risks. This article first reviews the co-evolution of AI and brain science and the benefits of brain-inspired AI in sustainability, healthcare, and scientific discoveries. We then consider possible risks from those technologies, including intentional abuse, autonomous weapons, cognitive enhancement by brain-computer interfaces, insidious effects of social media, inequity, and enfeeblement. We also discuss practical ways to bring ethical principles into practice. One proposal is to stop giving explicit goals to AI agents and to enable them to keep learning human preferences. Another is to learn from democratic mechanisms that evolved in human society to avoid over-consolidation of power. Finally, we emphasize the importance of open discussions not only by experts, but also including a diverse array of lay opinions.

[Cybersecurity of brain-computer interfaces]

Brain-computer interfaces inspire visions of superhuman powers, enabling users to control protheses and other devices solely with their thoughts. But the rapid development and commercialization of this technology also brings security risks. Attacks on brain-computer interfaces may cause harrowing consequences for users, from eavesdropping on neurological data to manipulating brain activity. At present, data protection law, the regulation of medical devices, and the new rules on the sale of goods with digital elements all govern aspects of cybersecurity. There are, nevertheless, significant gaps. The article analyzes how the legal system currently addresses the risks of cyberattacks on brain-computer interfaces-and how policymakers could address such risks in the future.

From vision to action: Canadian leadership in ethics and neurotechnology

This chapter explores the complex neuroethical aspects of neurosurgery and neuromodulation in the context of Canadian healthcare and innovation, as seen through the lens of the Pan Canadian Neurotechnology Ethics Consortium (PCNEC). Highlighted are key areas of ethical focus, each with its own unique challenges: technical advances, readiness and risk, vulnerable populations, medico-legal issues, training, and research. Through an exploration of Canadian neurotechnological practice from these various clusters, we provide a critical review of progress, describe opportunities to address areas of debate, and seek to foster ethical innovation. Underpinning this comprehensive review are the fundamental principles of solution-oriented, practical neuroethics, with beneficence and justice at the core. In our view, it is a moral imperative that neurotechnological advancements include a delineation of ethical priorities for future guidelines, oversight, and interactions.

Gray Matters: Exploring Technologists' Perceptions of Dual-Use Potentiality in Emerging Neurotechnology Applications

In this article, we report on a pilot study examining perceptions of dual use among neurotechnologists and neuroethicists. We carried out 10 semistructured interviews with participants from established universities in the United States, the United Kingdom, and Australia about the risks they saw with the new technology and who has responsibility for safely developing it. We used a grounded theory approach to code and develop themes from the data and establish a foundation for analysis. Our findings showed that dual use was not considered binary, but rather multifaceted and fluid, with the commercialization and globalization of the emerging science shifting participants' understandings of what neurotechnologies are considered beneficial and harmful, rendering future uses unknowable.

Societal return on investment may greatly exceed financial return on investment in neurotechnology-based therapies: A case study in epilepsy therapy development

Background:

This research study is an economic analysis of a neurotechnology-based translational research and development venture focused on the development of a therapy for patients with epilepsy. In the conceptualization, planning, financing, and execution of neurotechnology ventures, many factors come into play in determining value and ability to secure financing at each stage of the venture. Conventionally, these have included factors that determine the return on investment for the stakeholders of the venture, most notably the investors and the team members, the former investing hard earned capital, and the latter investing significant portions of their professional careers. For a variety of reasons, the positive impact on society is often not quantified and taken into consideration.

Methods:

To address this, a new term is defined and assessed at a first approximation level using an index technology. The metric is termed the societal return on investment (sROI).

Results:

Among chronic conditions, neurological disease is virtually unique in the magnitude of economic devastation that it can inflict on a person and a family. Because the device costs do not reflect this value that is lost and subject to restoration, these are missing from this important calculation. The index project is the development of a seizure advisory system, which cost $71.2 million to develop and conduct a First-In-Man (FIM) study (NCT01043406) and which was estimated to require $50 million to complete a pivotal study.

Conclusion:

Despite the immense costs required to develop, test, and commercialize such a system, the direct and indirect economic costs imposed by uncontrolled seizures are sufficiently staggering that a sROI becomes positive after only 400 patients have been successfully treated and returned to work.

In vivo spatiotemporal patterns of oligodendrocyte and myelin damage at the neural electrode interface

Intracortical microelectrodes with the ability to detect intrinsic electrical signals and/or deliver electrical stimulation into local brain regions have been a powerful tool to understand brain circuitry and for therapeutic applications to neurological disorders. However, the chronic stability and sensitivity of these intracortical microelectrodes are challenged by overwhelming biological responses, including severe neuronal loss and thick glial encapsulation. Unlike microglia and astrocytes whose activity have been extensively examined, oligodendrocytes and their myelin processes remain poorly studied within the neural interface field. Oligodendrocytes have been widely recognized to modulate electrical signal conductance along axons through insulating myelin segments. Emerging evidence offers an alternative perspective on neuron-oligodendrocyte coupling where oligodendrocytes provide metabolic and neurotrophic support to neurons through cytoplasmic myelin channels and monocarboxylate transporters. This study uses in vivo multi-photon microscopy to gain insights into the dynamics of oligodendrocyte soma and myelin processes in response to chronic device implantation injury over 4 weeks. We observe that implantation induces acute oligodendrocyte injury including initial deformation and substantial myelinosome formation, an early sign of myelin injury. Over chronic implantation periods, myelin and oligodendrocyte soma suffer severe degeneration proximal to the interface. Interestingly, wound healing attempts such as oligodendrogenesis are initiated over time, however they are hampered by continued degeneration near the implant. Nevertheless, this detailed characterization of oligodendrocyte spatiotemporal dynamics during microelectrode-induced inflammation may provide insights for novel intervention targets to facilitate oligodendrogenesis, enhance the integration of neural-electrode interfaces, and improve long-term functional performance.

Brain-Machine Interfaces: The Role of the Neurosurgeon

Neurotechnology is set to expand rapidly in the coming years as technological innovations in hardware and software are translated to the clinical setting. Given our unique access to patients with neurologic disorders, expertise with which to guide appropriate treatments, and technical skills to implant brain-machine interfaces (BMIs), neurosurgeons have a key role to play in the progress of this field. We outline the current state and key challenges in this rapidly advancing field, including implant technology, implant recipients, implantation methodology, implant function, and ethical, regulatory, and economic considerations. Our key message is to encourage the neurosurgical community to proactively engage in collaborating with other health care professionals, engineers, scientists, ethicists, and regulators in tackling these issues. By doing so, we will equip ourselves with the skills and expertise to drive the field forward and avoid being mere technicians in an industry driven by those around us.

Epilepsy through the eyes of the media: A paradox of positive reporting and challenges of access to advanced neurotechnology

OBJECTIVE

Media coverage of disorders and medical advancements can impact public perception regarding the riskiness, effectiveness, and accessibility of treatment options. We studied that coverage for epilepsy with a focus on surgical interventions and emerging neurotechnologies.

METHODS

Epilepsy-related English language articles published through 2019 were retrieved from online International news media with a circulation of 80,000 or above. We used directed content analysis of news articles to code content into a priori categories both to identify salient themes and to characterize their valence.

RESULTS

One hundred forty-six unique articles matched our search terms. Overall, there was a steady increase in epilepsy reporting over time, with a majority of articles published with a positive tone. Neuromodulation was the focus of over 50% of all the articles in the time points analyzed. Vagus nerve stimulation (VNS) and deep-brain stimulation (DBS) were discussed more prominently than other types of neurotechnological interventions; VNS was the neurotechnological focus in 39% of the pediatric articles; resective surgery was the focus in 34% of adult articles. Access, support, and epilepsy literacy were the central themes in the context of ethical, legal, and social issues.

SIGNIFICANCE

News media can influence the trust that the public places in science and medicine, and by extension, influences health policy. As innovations in neurotechnology for epilepsy emerge, understanding of individual and societal values is essential to their beneficial evolution and translation to care.

Correcting the Brain? The Convergence of Neuroscience, Neurotechnology, Psychiatry, and Artificial Intelligence

The incorporation of neural-based technologies into psychiatry offers novel means to use neural data in patient assessment and clinical diagnosis. However, an over-optimistic technologisation of neuroscientifically-informed psychiatry risks the conflation of technological and psychological norms. Neurotechnologies promise fast, efficient, broad psychiatric insights not readily available through conventional observation of patients. Recording and processing brain signals provides information from 'beneath the skull' that can be interpreted as an account of neural processing and that can provide a basis to evaluate general behaviour and functioning. But it ought not to be forgotten that the use of such technologies is part of a human practice of neuroscience informed psychiatry. This paper notes some challenges in the integration of neural technologies into psychiatry and suggests vigilance particularly in respect to normative challenges. In this way, psychiatry can avoid a drift toward reductive technological approaches, while nonetheless benefitting from promising advances in neuroscience and technology.

Narrative Devices: Neurotechnologies, Information, and Self-Constitution

This article provides a conceptual and normative framework through which we may understand the potentially ethically significant roles that information generated by neurotechnologies about our brains and minds may play in our construction of our identities. Neuroethics debates currently focus disproportionately on the ways that third parties may (ab)use these kinds of information. These debates occlude interests we may have in whether and how we ourselves encounter information about our own brains and minds. This gap is not yet adequately addressed by most allusions in the literature to potential identity impacts. These lack the requisite conceptual or normative foundations to explain why we should be concerned about such effects or how they might be addressed. This article seeks to fill this gap by presenting a normative account of identity as constituted by embodied self-narratives. It proposes that information generated by neurotechnologies can play significant content-supplying and interpretive roles in our construction of our self-narratives. It argues, to the extent that these roles support and detract from the coherence and inhabitability of these narratives, access to information about our brains and minds engages non-trivial identity-related interests. These claims are illustrated using examples drawn from empirical literature reporting reactions to information generated by implantable predictive BCIs and psychiatric neuroimaging. The article concludes by highlighting ways in which information generated by neurotechnologies might be governed so as to protect information subjects' interests in developing and inhabiting their own identities.

First-In-Human Experience With Integration of Wireless Intracranial Pressure Monitoring Device Within a Customized Cranial Implant

BACKGROUND

Decompressive craniectomy is a lifesaving treatment for intractable intracranial hypertension. For patients who survive, a second surgery for cranial reconstruction (cranioplasty) is required. The effect of cranioplasty on intracranial pressure (ICP) is unknown.

OBJECTIVE

To integrate the recently Food and Drug Administration-approved, fully implantable, noninvasive ICP sensor within a customized cranial implant (CCI) for postoperative monitoring in patients at high risk for intracranial hypertension.

METHODS

A 16-yr-old female presented for cranioplasty 4-mo after decompressive hemicraniectomy for craniocerebral gunshot wound. Given the persistent transcranial herniation with concomitant subdural hygroma, there was concern for intracranial hypertension following cranioplasty. Thus, cranial reconstruction was performed utilizing a CCI with an integrated wireless ICP sensor, and noninvasive postoperative monitoring was performed.

RESULTS

Intermittent ICP measurements were obtained twice daily using a wireless, handheld monitor. The ICP ranged from 2 to 10 mmHg in the supine position and from -5 to 4 mmHg in the sitting position. Interestingly, an average of 7 mmHg difference was consistently noted between the sitting and supine measurements.

CONCLUSION

This first-in-human experience demonstrates several notable findings, including (1) newfound safety and efficacy of integrating a wireless ICP sensor within a CCI for perioperative neuromonitoring; (2) proven restoration of normal ICP postcranioplasty despite severe preoperative transcranial herniation; and (3) proven restoration of postural ICP adaptations following cranioplasty. To the best of our knowledge, this is the first case demonstrating these intriguing findings with the potential to fundamentally alter the paradigm of cranial reconstruction.

Brain Recording, Mind-Reading, and Neurotechnology: Ethical Issues from Consumer Devices to Brain-Based Speech Decoding

Brain reading technologies are rapidly being developed in a number of neuroscience fields. These technologies can record, process, and decode neural signals. This has been described as 'mind reading technology' in some instances, especially in popular media. Should the public at large, be concerned about this kind of technology? Can it really read minds? Concerns about mind-reading might include the thought that, in having one's mind open to view, the possibility for free deliberation, and for self-conception, are eroded where one isn't at liberty to privately mull things over. Themes including privacy, cognitive liberty, and self-conception and expression appear to be areas of vital ethical concern. Overall, this article explores whether brain reading technologies are really mind reading technologies. If they are, ethical ways to deal with them must be developed. If they are not, researchers and technology developers need to find ways to describe them more accurately, in order to dispel unwarranted concerns and address appropriately those that are warranted.

Introduction to the special issue on physics of mind

In recent years, both fields of physics and psychology have made important scientific advances. The emergence of new instruments gave rise to a data-driven neuroscience allowing us to learn about the state of the brain supporting known mental functions and conversely. In parallel, the appearance of new mathematics allowed the development of computational models describing fundamental brain functions and implementing them in technological applications. While emphasizing the methodology of physics, the special issue aims to bring together these trends in both the experimental and theoretical sciences in order to explain some of the most basic mental processes such as perception, cognition, emotion, consciousness, and learning. In this editorial, we define unsolved problems for brain and psychological sciences, discuss possible means toward their respective solutions, and outline some collaborative initiatives aiming toward these goals. The following problems are defined in gradual order of difficulty: what are the universal properties of human behavior across conditions and cultures? What have each culture learned over historical times and why should specific elements of knowledge be accumulated over cultural evolution? Can computational psychiatry help predict, understand, and cure mental disorders? What is the function of art and cultural artifacts such as music, fiction, or poetry for the cognitive system? How to explain the relation between first-person subjective experience and third-person objective physiological data? What neural mechanisms operate on which mental content at the highest levels of organization of the hierarchical brain? How do abstract ideas emerge from sensory-motor contingencies and what are the conditions for the birth of a new concept? Could symmetry play a role in psychogenesis and support the emergence of new hierarchical layers in cognition? How can we start addressing the question of meaning scientifically, and what does it entail for the physical sciences?

A translational framework for peripheral nerve stimulating electrodes: Reviewing the journey from concept to clinic

The purpose of this review article is to describe the underlying methodology for successfully translating novel interfaces for electrical modulation of the peripheral nervous system (PNS) from basic design concepts to clinical applications and chronic human use. Despite advances in technologies to communicate directly with the nervous system, the pathway to clinical translation for most neural interfaces is not clear. FDA guidelines provide information on necessary evidence which should be generated and submitted to allow the agency evaluate safety and efficacy of a new medical device. However, a knowledge gap exists on translating neural interfaces from pre-clinical studies into the clinical domain. Our article is intended to inform the field on some of the key considerations for such a transition process specific to neural interfaces that may not be already covered by FDA guidances. This framework focuses on non-penetrating peripheral nerve stimulating electrodes that have been proven effective for motor and sensory neural prostheses and successfully transitioned from pre-clinical through first-in-human and chronic clinical deployment. We discuss the challenges of moving these neural interfaces along the translational continuum and ultimately through FDA approval for human feasibility studies. Specifically, we describe a translational process involving: quantitative human anatomy, neural modeling and simulation, acute intraoperative testing and verification, clinical demonstration with temporary percutaneous access, and finally chronic clinical deployment and functional performance. To clarify and demonstrate the importance of each step of this translational framework, we present case studies from electrodes developed at Case Western Reserve University (CWRU), specifically the spiral cuff, the Flat Interface Nerve Electrode (FINE), and the Composite FINE (C-FINE). In addition, we demonstrate that success along this translational pathway can be further expedited by: appropriate selection of well-characterized materials, validation of fabrication and sterilization protocols, well-implemented quality control measures, and quantification of impact on neural structure, health, and function. The issues and approaches identified in this review for the peripheral nervous system may also serve to accelerate the dissemination of any new neural interface into clinical practice, and consequently advance the performance, utility, and clinical value of new neural prostheses or neuromodulation systems.

Emerging neurotechnology for antinoceptive mechanisms and therapeutics discovery

The tolerance, abuse, and potential exacerbation associated with classical chronic pain medications such as opioids creates a need for alternative therapeutics. Phenotypic screening provides a complementary approach to traditional target-based drug discovery. Profiling cellular phenotypes enables quantification of physiologically relevant traits central to a disease pathology without prior identification of a specific drug target. For complex disorders such as chronic pain, which likely involves many molecular targets, this approach may identify novel treatments. Sensory neurons, termed nociceptors, are derived from dorsal root ganglia (DRG) and can undergo changes in membrane excitability during chronic pain. In this review, we describe phenotypic screening paradigms that make use of nociceptor electrophysiology. The purpose of this paper is to review the bioelectrical behavior of DRG neurons, signaling complexity in sensory neurons, various sensory neuron models, assays for bioelectrical behavior, and emerging efforts to leverage microfabrication and microfluidics for assay development. We discuss limitations and advantages of these various approaches and offer perspectives on opportunities for future development.

Neuroethics of Neuromodulation: An Update

This article reviews neuroethics issues that arise with the development, translation, and use of technologies for neuromodulation. Three electronic databases (PubMed, Embase, and PhilPapers) were searched for relevant articles published between 1/1/16 - 6/26/18. We focus on pressing ethical issues related to the use of deep brain stimulation (DBS), adaptive DBS (aDBS), transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and associated technologies. The neuroethics issues we address include privacy, continued access to devices, device removal, do-it-yourself neurostimulation, neuroenhancement, media coverage, changes in personal identity and agency, informed consent, and neuromodulation in minors. This review should be of assistance to a variety of stakeholders, including neurotechnology developers, as they make important decisions that will drive these neurotechnologies.

Cognitive Deficits in Multiple Sclerosis: Recent Advances in Treatment and Neurorehabilitation

PURPOSE OF REVIEW

This article highlights recent progress in research on treatment and neurorehabilitation of cognitive impairment in multiple sclerosis (MS) including pharmacological interventions, physical exercise, and neuropsychological rehabilitation, both in conventional and technology-assisted settings.

RECENT FINDINGS

The most consistent evidence in terms of improvement or preservation of circumscribed cognitive scores in MS patients comes from moderately sampled randomized clinical trials on multimodal approaches that combine conventional or computerized neuropsychological training with psychoeducation or cognitive behavioral therapy. Disease-modifying treatments also appear to have beneficial effects in preventing or attenuating cognitive decline, whereas there is little evidence for agents such as donepezil or stimulants. Finally, physical exercise may yield some cognitive improvement in MS patients. Despite substantial and often promising research efforts, there is a lack of validated and widely accepted clinical procedures for cognitive neurorehabilitation in MS. Development of such approaches will require collaborative efforts towards the design of interventions that are fundamentally inspired by cognitive neuroscience, potentially guided by neuroimaging, and composed of conventional neuropsychological training and cognitive behavioral therapy as well as physical exercise and therapeutic video games. Subsequently, large-scale validation will be needed with meaningful outcome measures reflecting transfer to everyday cognitive function and maintenance of training effects.

Ethical Design of Intelligent Assistive Technologies for Dementia: A Descriptive Review

The use of Intelligent Assistive Technology (IAT) in dementia care opens the prospects of reducing the global burden of dementia and enabling novel opportunities to improve the lives of dementia patients. However, with current adoption rates being reportedly low, the potential of IATs might remain under-expressed as long as the reasons for suboptimal adoption remain unaddressed. Among these, ethical and social considerations are critical. This article reviews the spectrum of IATs for dementia and investigates the prevalence of ethical considerations in the design of current IATs. Our screening shows that a significant portion of current IATs is designed in the absence of explicit ethical considerations. These results suggest that the lack of ethical consideration might be a codeterminant of current structural limitations in the translation of IATs from designing labs to bedside. Based on these data, we call for a coordinated effort to proactively incorporate ethical considerations early in the design and development of new products.

Successful use of closed-loop allostatic neurotechnology for post-traumatic stress symptoms in military personnel: self-reported and autonomic improvements

BACKGROUND

Military-related post-traumatic stress (PTS) is associated with numerous symptom clusters and diminished autonomic cardiovascular regulation. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology that produces real-time translation of dominant brain frequencies into audible tones of variable pitch and timing to support the auto-calibration of neural oscillations. We report clinical, autonomic, and functional effects after the use of HIRREM® for symptoms of military-related PTS.

METHODS

Eighteen service members or recent veterans (15 active-duty, 3 veterans, most from special operations, 1 female), with a mean age of 40.9 (SD = 6.9) years and symptoms of PTS lasting from 1 to 25 years, undertook 19.5 (SD = 1.1) sessions over 12 days. Inventories for symptoms of PTS (Posttraumatic Stress Disorder Checklist - Military version, PCL-M), insomnia (Insomnia Severity Index, ISI), depression (Center for Epidemiologic Studies Depression Scale, CES-D), and anxiety (Generalized Anxiety Disorder 7-item scale, GAD-7) were collected before (Visit 1, V1), immediately after (Visit 2, V2), and at 1 month (Visit 3, V3), 3 (Visit 4, V4), and 6 (Visit 5, V5) months after intervention completion. Other measures only taken at V1 and V2 included blood pressure and heart rate recordings to analyze heart rate variability (HRV) and baroreflex sensitivity (BRS), functional performance (reaction and grip strength) testing, blood and saliva for biomarkers of stress and inflammation, and blood for epigenetic testing. Paired t-tests, Wilcoxon signed-rank tests, and a repeated-measures ANOVA were performed.

RESULTS

Clinically relevant, significant reductions in all symptom scores were observed at V2, with durability through V5. There were significant improvements in multiple measures of HRV and BRS [Standard deviation of the normal beat to normal beat interval (SDNN), root mean square of the successive differences (rMSSD), high frequency (HF), low frequency (LF), and total power, HF alpha, sequence all, and systolic, diastolic and mean arterial pressure] as well as reaction testing. Trends were seen for improved grip strength and a reduction in C-Reactive Protein (CRP), Angiotensin II to Angiotensin 1-7 ratio and Interleukin-10, with no change in DNA n-methylation. There were no dropouts or adverse events reported.

CONCLUSIONS

Service members or veterans showed reductions in symptomatology of PTS, insomnia, depressive mood, and anxiety that were durable through 6 months after the use of a closed-loop allostatic neurotechnology for the auto-calibration of neural oscillations. This study is the first to report increased HRV or BRS after the use of an intervention for service members or veterans with PTS. Ongoing investigations are strongly warranted.

TRIAL REGISTRATION

NCT03230890 , retrospectively registered July 25, 2017.

Clinical, hemispheric, and autonomic changes associated with use of closed-loop, allostatic neurotechnology by a case series of individuals with self-reported symptoms of post-traumatic stress

BACKGROUND

The objective of this pilot study was to explore the use of a closed-loop, allostatic, acoustic stimulation neurotechnology for individuals with self-reported symptoms of post-traumatic stress, as a potential means to impact symptomatology, temporal lobe high frequency asymmetry, heart rate variability (HRV), and baroreflex sensitivity (BRS).

METHODS

From a cohort of individuals participating in a naturalistic study to evaluate use of allostatic neurotechnology for diverse clinical conditions, a subset was identified who reported high scores on the Posttraumatic Stress Disorder Checklist (PCL). The intervention entailed a series of sessions wherein brain electrical activity was monitored noninvasively at high spectral resolutions, with software algorithms translating selected brain frequencies into acoustic stimuli (audible tones) that were delivered back to the user in real time, to support auto-calibration of neural oscillations. Participants completed symptom inventories before and after the intervention, and a subset underwent short-term blood pressure recordings for HRV and BRS. Changes in temporal lobe high frequency asymmetry were analyzed from baseline assessment through the first four sessions, and for the last four sessions.

RESULTS

Nineteen individuals (mean age 47, 11 women) were enrolled, and the majority also reported symptom scores that exceeded inventory thresholds for depression. They undertook a median of 16 sessions over 16.5 days, and 18 completed the number of sessions recommended. After the intervention, 89% of the completers reported clinically significant decreases in post-traumatic stress symptoms, indicated by a change of at least 10 points on the PCL. At a group level, individuals with either rightward (n = 7) or leftward (n = 7) dominant baseline asymmetry in temporal lobe high frequency (23-36 Hz) activity demonstrated statistically significant reductions in their asymmetry scores over the course of their first four sessions. For 12 individuals who underwent short-term blood pressure recordings, there were statistically significant increases in HRV in the time domain and BRS (Sequence Up). There were no adverse events.

CONCLUSION

Closed-loop, allostatic neurotechnology for auto-calibration of neural oscillations appears promising as an innovative therapeutic strategy for individuals with symptoms of post-traumatic stress.

TRIALS REGISTRATION

ClinicalTrials.gov #NCT02709369 , retrospectively registered on March 4, 2016.

A Preliminary Study of the Effectiveness of an Allostatic, Closed-Loop, Acoustic Stimulation Neurotechnology in the Treatment of Athletes with Persisting Post-concussion Symptoms

BACKGROUND

Effective interventions are needed for individuals with persisting post-concussion symptoms. High-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®) is an allostatic, closed-loop, acoustic stimulation neurotechnology, designed to facilitate relaxation and self-optimization of neural oscillations.

METHODS

Fifteen athletes (seven females, mean age 18.1 years, SD 2.6) with persisting post-concussion symptoms received 18.7 (SD 6.0) HIRREM sessions over a mean of 29.6 (SD 23.2) days, including 11.3 (SD 4.6) in office days. Pre- and post-HIRREM measures included the Rivermead Post-Concussion Symptoms Questionnaire (RPQ, n = 12), the Insomnia Severity Index (ISI, n = 15), the Center for Epidemiologic Studies Depression Scale (CES-D, n = 10), short-term blood pressure and heart rate recordings for measures of autonomic cardiovascular regulation (n = 15), and reaction time by the drop-stick method (n = 7). All participants were asked about their physical activity level and sports participation status at their post-HIRREM data collection visit and 1 to 3 months afterward.

RESULTS

At the post-HIRREM visit, subjects reported improvements in all three inventories (RPQ mean change 19.7, SD 11.4, Wilcoxon p = 0.001; ISI mean change -4.1, SD 4.1, Wilcoxon p = 0.003; CES-D mean change -12.0, SD 10.0, Wilcoxon p = 0.004), including statistically significant reductions in 14 of the 16 individual items of the RPQ. There were also statistically significant improvements in baroreflex sensitivity, heart rate variability in the time domain (SDNN), and drop-stick reaction testing (baseline mean distance of 23.8 cm, SD 5.6, decreased to 19.8 cm, SD 4.6, Wilcoxon p = 0.016). Within 3 months of the post-HIRREM data collection, all 15 had returned to full exercise and workouts, and ten had returned to full participation in their athletic activity.

CONCLUSIONS

The use of HIRREM by a series of athletes with persisting post-concussion symptoms was associated with a range of improvements including, for the majority, return to full participation in their sport. The findings do not appear to be consistent with constituents of the placebo effect. A larger controlled trial is warranted.

A four-part working bibliography of neuroethics: part 3 - "second tradition neuroethics" - ethical issues in neuroscience

BACKGROUND

Neuroethics describes several interdisciplinary topics exploring the application and implications of engaging neuroscience in societal contexts. To explore this topic, we present Part 3 of a four-part bibliography of neuroethics' literature focusing on the "ethics of neuroscience."

METHODS

To complete a systematic survey of the neuroethics literature, 19 databases and 4 individual open-access journals were employed. Searches were conducted using the indexing language of the U.S. National Library of Medicine (NLM). A Python code was used to eliminate duplications in the final bibliography.

RESULTS

This bibliography consists of 1137 papers, 56 books, and 134 book chapters published from 2002 through 2014, covering ethical issues in neuroimaging, neurogenetics, neurobiomarkers, neuro-psychopharmacology, brain stimulation, neural stem cells, neural tissue transplants, pediatric-specific issues, dual-use, and general neuroscience research issues. These works contain explanations of recent research regarding neurotechnology, while exploring ethical issues in future discoveries and use.

Use of an allostatic neurotechnology by adolescents with postural orthostatic tachycardia syndrome (POTS) is associated with improvements in heart rate variability and changes in temporal lobe electrical activity

Autonomic dysregulation and heterogeneous symptoms characterize postural orthostatic tachycardia syndrome (POTS). This study evaluated the effect of high-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM^®), a noninvasive, allostatic neurotechnology for relaxation and auto-calibration of neural oscillations, on heart rate variability, brain asymmetry, and autonomic symptoms, in adolescents with POTS. Seven subjects with POTS (three males, ages 15–18) underwent a median of 14 (10–16) HIRREM sessions over 13 (8–17) days. Autonomic function was assessed from 10-min continuous heart rate and blood pressure recordings, pre- and post-HIRREM. One-minute epochs of temporal high-frequency (23–36 Hz) brain electrical activity data (T3 and T4, eyes closed) were analyzed from baseline HIRREM assessment and subsequent sessions. Subjects rated autonomic symptoms before and after HIRREM. Four of seven were on fludrocortisone, which was stopped before or during their sessions. Heart rate variability in the time domain (standard deviation of the beat-to-beat interval) increased post-HIRREM (mean increase 51 %, range 10–143, p = 0.03), as did baroreflex sensitivity (mean increase in high-frequency alpha 65 %, range −6 to 180, p = 0.05). Baseline temporal electrical asymmetry negatively correlated with change in asymmetry from assessment to the final HIRREM session (p = 0.01). Summed high-frequency amplitudes at left and right temporal lobes decreased a median of 3.8 μV (p = 0.02). There was a trend for improvements in self-reported symptoms related to the autonomic nervous system. Use of HIRREM was associated with reduced sympathetic bias in autonomic cardiovascular regulation, greater symmetry and reduced amplitudes in temporal lobe high-frequency electrical activity, and a trend for reduced autonomic symptoms. Data suggest the potential for allostatic neurotechnology to facilitate increased flexibility in autonomic cardiovascular regulation, possibly through more balanced activity at regions of the neocortex responsible for autonomic management.

Clinical trial registry “Tilt Table with Suspected postural orthostatic tachycardia syndrome (POTS) Subjects,” Protocol Record: WFUBAHA01.

Powerline noise elimination in biomedical signals via blind source separation and wavelet analysis

The distortion of biomedical signals by powerline noise from recording biomedical devices has the potential to reduce the quality and convolute the interpretations of the data. Usually, powerline noise in biomedical recordings are extinguished via band-stop filters. However, due to the instability of biomedical signals, the distribution of signals filtered out may not be centered at 50/60 Hz. As a result, self-correction methods are needed to optimize the performance of these filters. Since powerline noise is additive in nature, it is intuitive to model powerline noise in a raw recording and subtract it from the raw data in order to obtain a relatively clean signal. This paper proposes a method that utilizes this approach by decomposing the recorded signal and extracting powerline noise via blind source separation and wavelet analysis. The performance of this algorithm was compared with that of a 4th order band-stop Butterworth filter, empirical mode decomposition, independent component analysis and, a combination of empirical mode decomposition with independent component analysis. The proposed method was able to expel sinusoidal signals within powerline noise frequency range with higher fidelity in comparison with the mentioned techniques, especially at low signal-to-noise ratio.