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Taira T, Goto S. Validation and perspectives of neuromodulation in Japan. Neurol Med Chir (Tokyo) 2012; 52:457-62. [PMID: 22850492 DOI: 10.2176/nmc.52.457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neuromodulation in functional neurosurgery is closely related to the development and availability of devices such as implantable electric stimulators and pumps. All such devices used in Japan are developed and made in foreign countries, and no made-in-Japan device exists. Introduction and approval by the government took many years for most devices, during which time many patients had to continue to live in our medically conservative country. The history of neuromodulation is summarized in Japan and the problems surrounding neuromodulation pointed out. Everyone has to aware of such circumstances and make every effort to improve the internationally unusual situation of neuromodulation in Japan. Otherwise, Japan will become a medically isolated country in the near future.
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Affiliation(s)
- Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.
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52
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Schiff ND. Moving toward a generalizable application of central thalamic deep brain stimulation for support of forebrain arousal regulation in the severely injured brain. Ann N Y Acad Sci 2012; 1265:56-68. [PMID: 22834729 DOI: 10.1111/j.1749-6632.2012.06712.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This review considers the challenges ahead for developing a generalizable strategy for the use of central thalamic deep brain stimulation (CT/DBS) to support arousal regulation mechanisms in the severely injured brain. Historical efforts to apply CT/DBS to patients with severe brain injuries and a proof-of-concept result from a single-subject study are discussed. Circuit and cellular mechanisms underlying the recovery of consciousness are considered for their relevance to the application of CT/DBS, to improve consciousness and cognition in nonprogressive brain injuries. Finally, directions for development, and testing of generalizable criteria for CT/DBS are suggested, which aim to identify neuronal substrates and behavioral profiles that may optimally benefit from support of arousal regulation mechanisms.
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Affiliation(s)
- Nicholas D Schiff
- Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, USA.
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Fins JJ, Dorfman GS, Pancrazio JJ. Challenges to deep brain stimulation: a pragmatic response to ethical, fiscal, and regulatory concerns. Ann N Y Acad Sci 2012; 1265:80-90. [PMID: 22823486 PMCID: PMC4030320 DOI: 10.1111/j.1749-6632.2012.06598.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In response to the early success of deep brain stimulation, we offer some common-sense strategies to sustain the work, addressing the need to do so in a fiscally workable, ethically transparent, and scientifically informed manner. After delineating major threats, we will suggest reforms in both the legislative and regulatory spheres that might remediate these challenges. We will recommend (1) revisions to the Bayh-Dole Act of 1980, which governs intellectual property exchange resulting from federally funded research; (2) revisions to the Association of American Medical Colleges recommendations concerning the management of conflicts of interest when scientists with an intellectual property interest participate in clinical research in tandem; (3) revisions to the Food and Drug Administration's pre-market approval process for new devices, including a proposal for a mini-investigational device exemption; and (4) the establishment of a public-private partnership to build ethical and sustainable synergies between the scientific community, industry, and government that would foster discovery and innovation.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, New York, USA.
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54
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Fargen KM, Frei D, Fiorella D, McDougall CG, Myers PM, Hirsch JA, Mocco J. The FDA approval process for medical devices: an inherently flawed system or a valuable pathway for innovation? J Neurointerv Surg 2012; 5:269-75. [PMID: 22764203 DOI: 10.1136/neurintsurg-2012-010400] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Kyle M Fargen
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
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55
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Pizzolato G, Mandat T. Deep brain stimulation for movement disorders. Front Integr Neurosci 2012; 6:2. [PMID: 22291623 PMCID: PMC3265746 DOI: 10.3389/fnint.2012.00002] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 01/09/2012] [Indexed: 11/13/2022] Open
Abstract
Stereotactic technique and the introduction of deep brain stimulation (DBS) can be considered two milestones in the field of surgical neuromodulation. At present the role of DBS in the treatment of clinically and epidemiologically relevant movement disorders is widely accepted and DBS procedures are performed in many clinical centers worldwide. Here we review the current state of the art of DBS treatment for the most common movement disorders: Parkinson’s disease, essential tremor, and dystonia. In this review, we give a brief description of the candidate patient selection criteria, the different anatomical targets for each of these condition, and the expected outcomes as well as possible side effects.
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Affiliation(s)
- Gilberto Pizzolato
- Neurology Clinic, Department of Medical Sciences, University of Trieste Trieste, Italy
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56
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Kubu CS, Ford PJ. Beyond Mere Symptom Relief in Deep Brain Stimulation: An Ethical Obligation for Multi-faceted Assessment of Outcome. AJOB Neurosci 2012; 3:44-49. [PMID: 22737593 DOI: 10.1080/21507740.2011.633960] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Assessment of outcome following Deep Brain Stimulation (DBS) has traditionally focused on symptom specific and quality of life measures. Greater attention needs to be paid to the diversity of patient goals and values, as well as recognition of the shifting nature of those goals over the course of DBS therapy. We report preliminary data from an empirical study examining patients' goals with respect to DBS in the treatment of Parkinson disease. We argue that a multifaceted assessment of outcome over time, including well validated symptom measures, quality of life, functional and patient specific metrics, is ethically necessary in order to fulfill fiduciary and professional responsibilities. These assessments should be augmented with a deliberative multi-disciplinary process of review and evaluation. Such an approach will lead to improved inform consent, promote better clinical research, and facilitate good patient care by providing a systematic mechanism for capturing and acting on important patient insights. These processes become increasingly critical as DBS begins to be applied to neuropsychiatric disorders.
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Abstract
OBJECTIVE The aim of this study was to review the current state of development and application of a wide range of brain stimulation approaches in the treatment of psychiatric disorders. METHOD The approaches reviewed include forms of minimally invasive magnetic and electrical stimulation, seizure induction, implanted devices and several highly novel approaches in early development. RESULTS An extensive range of brain stimulation approaches are now being widely used in the treatment of patients with psychiatric disorders, or actively investigated for this use. Both vagal nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (rTMS) have been introduced into clinical practice in some countries. A small body of research suggests that VNS has some potentially long-lasting antidepressant effects in a minority of patients treated. rTMS has now been extensively investigated for over 15 years, with a large body of research now supporting its antidepressant effects. Further rTMS research needs to focus on defining the most appropriate stimulation methods and exploring its longer term use in maintenance protocols. Very early data suggest that magnetic seizure therapy (MST) has promise in the treatment of patients referred for electroconvulsive therapy: MST appears to have fewer side effects and may have similar efficacy. A number of other approaches including surgical and alternative forms of electrical stimulation appear to alter brain activity in a promising manner, but are in need of evaluation in more substantive patient samples. CONCLUSIONS It appears likely that the range of psychiatric treatments available for patients will grow over the coming years to progressively include a number of novel brain stimulation techniques.
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Affiliation(s)
- Paul B Fitzgerald
- Monash Alfred Psychiatry Research Centre, The Alfred and Monash University School of Psychology and Psychiatry, Melbourne, Victoria, Australia. paul.fi
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58
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Kaplan PW. Obsessive-compulsive disorder in chronic epilepsy. Epilepsy Behav 2011; 22:428-32. [PMID: 21889913 DOI: 10.1016/j.yebeh.2011.07.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 07/22/2011] [Accepted: 07/23/2011] [Indexed: 10/17/2022]
Abstract
There is a long-recognized association between obsessive-compulsive disorder (OCD) and chronic epilepsy, most notably refractory temporal lobe epilepsy (TLE). The literature documents this association with case reports, patient series, and some larger controlled studies that reveal that almost a quarter of patients with TLE exhibit OCD features, which may go unrecognized. Obsession features with ordering, symmetry, exactness, handwashing, and religiosity occur more often in persons with right- or left-sided epileptic foci than in those with idiopathic generalized epilepsies or controls. Neurobiological and social factors suggest abnormalities of the frontal-thalamic-pallidal-striatal-anterior cingulate-frontal circuits stemming from the observation that certain diseases, damage, or surgery along these circuits may produce or, conversely, reduce OCD in TLE. This review explores the literature on case reports, case series, and larger retrospective controlled studies and looks at the associations of epilepsy with OCD. Contemporary speculation on the theoretical neurobiological underpinnings provides some basis on how and where to direct treatment. Invasive deep brain stimulation has triggered recent controversy on newer treatment modalities.
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Affiliation(s)
- Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Abstract
Deep brain stimulation (DBS) has virtually replaced ablative neurosurgery for use in medication-refractory movement disorders. DBS is now being studied in severe psychiatric conditions, such as treatment-resistant depression (TRD) and intractable obsessive-compulsive disorder (OCD). Effects of DBS have been reported in ∼100 cases of OCD and ∼50 cases of TRD for seven (five common) anatomic targets. Although these published reports differ with respect to study design and methodology, the overall response rate appears to exceed 50% in OCD for some DBS targets. In TRD, >50% of patients responded during acute and long-term bilateral electrical stimulation in a different target. DBS was generally well tolerated in both OCD and TRD, but some unique, target- and stimulation-specific adverse effects were observed (e.g., hypomania). Further research is needed to test the efficacy and safety of DBS in psychiatric disorders, compare targets, and identify predictors of response.
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Affiliation(s)
- Wayne K Goodman
- Department of Psychiatry, Friedman Brain Institute of the Mount Sinai School of Medicine, New York, New York 10029, USA.
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60
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Affiliation(s)
- James Cavuoto
- Neurotech Reports, San Francisco, CA 94107, USA. http://www.neurotechreports.com
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61
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Abstract
A range of implantable brain-interfacing devices (IBIDs) is currently in use and development for the treatment of movement disorders and disorders of mood, behaviour and thought. These include cochlear implants, deep brain stimulation (DBS), prosthetic limbs, and optogenetic interventions (the combined use of genetics and optics to control individual cells). While implantable non-brain devices, such as implantable cardioverter defibrillators, began receiving US Food and Drug Administration approval in 1980, the development of IBIDs is recent, with the approval of DBS for Parkinson's disease in 1997. The expansion in use of IBIDs from neurological to psychiatric conditions is even more recent, with current trials underway for a range of disorders including depression, OCD, addiction, Alzheimer's disease and Tourette's syndrome. Emerging applications of existing IBIDs and new devices in development differ from currently approved devices and applications in two potentially crucial ways: 1) They target conditions traditionally seen as psychiatric; and/or 2) They target and modify functions or traits tied closely to agency, personal identity and personhood. As such, understanding patients' and caregivers' conceptions of personal identity in the context of disease and treatment is important not only for the informed consent process, but also for questions of public policy.
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Affiliation(s)
- Debra J H Mathews
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA.
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Leykin Y, Christopher PP, Holtzheimer PE, Appelbaum PS, Mayberg HS, Lisanby SH, Dunn LB. Participants' Perceptions of Deep Brain Stimulation Research for Treatment-Resistant Depression: Risks, Benefits, and Therapeutic Misconception. ACTA ACUST UNITED AC 2011. [PMID: 26225215 DOI: 10.1080/21507716.2011.627579] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) for treatment-resistant depression (TRD) is the focus of great interest and numerous studies. Given the state of this research, the risks of DBS, the uncertainty of direct benefits, and the potential for therapeutic misconception (TM), examination of research participants' perspectives is critical to addressing concerns about the adequacy of consent among people with TRD. METHODS Among 31 participants considering DBS studies at two sites, self-report questionnaires were used to examine three dimensions of TM (eight true/false items). Additional Likert-scale items assessed perceptions of risks, potential benefits, and altruistic motivations. RESULTS Participants correctly identified the surgery itself as the riskiest study procedure, although only four participants rated the surgery as "high risk." Most participants rated the entire DBS study as "moderate" or lower risk. Participants rated the likelihood of others benefiting in the future more strongly than they did the likelihood of personal benefit. Participants held positive attitudes toward research, and were moderately altruistic. Nearly two-thirds of the 31 participants (64.5%) answered at least one of the true/false TM items incorrectly. CONCLUSIONS Individuals considering DBS studies for TRD demonstrated reasonable perceptions of risks and benefits, distinguished among procedural risks, and expressed hopes for personal benefit as well as altruism. Findings related to TM were mixed: Participants understood the experimental stage of DBS for depression and endorsed the possibility of no personal benefit, yet there was some evidence for TM. Although these findings are reassuring, investigators must nevertheless remain vigilant about identifying and addressing potential misconceptions.
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Vorspan F, Mallet L, Corvol JC, Pelissolo A, Lépine JP. Treating addictions with deep brain stimulation is premature but well-controlled clinical trials should be performed. Addiction 2011; 106:1535-6; author reply 1537-8. [PMID: 21749519 DOI: 10.1111/j.1360-0443.2011.03450.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
The realization that medications used to treat movement disorders and psychiatric conditions of basal ganglia origin have significant shortcomings, as well as advances in the understanding of the functional organization of the brain, has led to a renaissance in functional neurosurgery, and particularly the use of deep brain stimulation (DBS). Movement disorders are now routinely being treated with DBS of 'motor' portions of the basal ganglia output nuclei, specifically the subthalamic nucleus and the internal pallidal segment. These procedures are highly effective and generally safe. Use of DBS is also being explored in the treatment of neuropsychiatric disorders, with targeting of the 'limbic' basal ganglia-thalamocortical circuitry. The results of these procedures are also encouraging, but many unanswered questions remain in this emerging field. This review summarizes the scientific rationale and practical aspects of using DBS for neurologic and neuropsychiatric disorders.
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Fins JJ, Schlaepfer TE, Nuttin B, Kubu CS, Galert T, Sturm V, Merkel R, Mayberg HS. Ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation. J Neural Eng 2011; 8:033001. [PMID: 21555849 DOI: 10.1088/1741-2560/8/3/033001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The clinical promise of deep brain stimulation (DBS) for neuropsychiatric conditions is coupled with the potential for ethical conflicts of interest because the work is so heavily reliant upon collaborations between academia, industry and the clinic. To foster transparency and public trust, we offer ethical guidance for the management of conflicts of interest in the conduct of DBS research and practice so that this nascent field can better balance competing goods and engineer new and better strategies for the amelioration of human suffering. We also hope that our ethical analysis will be of relevance to those working with other related neuroprosthetic devices, such brain-computer interfaces and neural arrays, which naturally share many of the same concerns.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, New York Presbyterian-Weill Cornell Medical Center, 435 East 70th Street, Suite 4-J, New York, NY 10021, USA.
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