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Singh MF, Cole MW, Braver TS, Ching S. Developing control-theoretic objectives for large-scale brain dynamics and cognitive enhancement. ANNUAL REVIEWS IN CONTROL 2022; 54:363-376. [PMID: 38250171 PMCID: PMC10798814 DOI: 10.1016/j.arcontrol.2022.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The development of technologies for brain stimulation provides a means for scientists and clinicians to directly actuate the brain and nervous system. Brain stimulation has shown intriguing potential in terms of modifying particular symptom clusters in patients and behavioral characteristics of subjects. The stage is thus set for optimization of these techniques and the pursuit of more nuanced stimulation objectives, including the modification of complex cognitive functions such as memory and attention. Control theory and engineering will play a key role in the development of these methods, guiding computational and algorithmic strategies for stimulation. In particular, realizing this goal will require new development of frameworks that allow for controlling not only brain activity, but also latent dynamics that underlie neural computation and information processing. In the current opinion, we review recent progress in brain stimulation and outline challenges and potential research pathways associated with exogenous control of cognitive function.
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Affiliation(s)
- Matthew F Singh
- Electrical and Systems Engineering, Washington University in St. Louis, St. Louis, 63130, MO, USA
- Center for Molecular and Behavioral Neuroscience, Rutgers University, Newark, 07102, NJ, USA
- Psychological and Brain Science, Washington University in St. Louis, St. Louis, 63130, MO, USA
| | - Michael W Cole
- Center for Molecular and Behavioral Neuroscience, Rutgers University, Newark, 07102, NJ, USA
| | - Todd S Braver
- Psychological and Brain Science, Washington University in St. Louis, St. Louis, 63130, MO, USA
| | - ShiNung Ching
- Electrical and Systems Engineering, Washington University in St. Louis, St. Louis, 63130, MO, USA
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2
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Rasmussen SA, Goodman WK. The prefrontal cortex and neurosurgical treatment for intractable OCD. Neuropsychopharmacology 2022; 47:349-360. [PMID: 34433915 PMCID: PMC8616947 DOI: 10.1038/s41386-021-01149-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/14/2021] [Accepted: 07/29/2021] [Indexed: 01/03/2023]
Abstract
Over the past two decades, circuit-based neurosurgical procedures have gained increasing acceptance as a safe and efficacious approach to the treatment of the intractable obsessive-compulsive disorder (OCD). Lesions and deep brain stimulation (DBS) of the longitudinal corticofugal white matter tracts connecting the prefrontal cortex with the striatum, thalamus, subthalamic nucleus (STN), and brainstem implicate orbitofrontal, medial prefrontal, frontopolar, and ventrolateral cortical networks in the symptoms underlying OCD. The highly parallel distributed nature of these networks may explain the relative lack of adverse effects observed following surgery. Additional pre-post studies of cognitive tasks in more surgical patients are needed to confirm the role of these networks in OCD and to define therapeutic responses to surgical intervention.
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Affiliation(s)
- Steven A. Rasmussen
- grid.40263.330000 0004 1936 9094Department of Psychiatry and Human Behavior, Alpert School of Medicine, Brown University, Providence, RI USA ,grid.40263.330000 0004 1936 9094Carney Brain Science Institute, Brown University, Providence, RI USA
| | - Wayne K. Goodman
- grid.39382.330000 0001 2160 926XMenninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX USA
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Abstract
Obsessive-compulsive disorder (OCD) is a common, chronic, and oftentimes disabling disorder. The only established first-line treatments for OCD are exposure and response prevention, and serotonin reuptake inhibitor medications (SRIs). However, a subset of patients fails to respond to either modality, and few experience complete remission. Beyond SRI monotherapy, antipsychotic augmentation is the only medication approach for OCD with substantial empirical support. Our incomplete understanding of the neurobiology of OCD has hampered efforts to develop new treatments or enhance extant interventions. This review focuses on several promising areas of research that may help elucidate the pathophysiology of OCD and advance treatment. Multiple studies support a significant genetic contribution to OCD, but pinpointing the specific genetic determinants requires additional investigation. The preferential efficacy of SRIs in OCD has neither led to discovery of serotonergic abnormalities in OCD nor to development of new serotonergic medications for OCD. Several lines of preclinical and clinical evidence suggest dysfunction of the glutamatergic system in OCD, prompting testing of several promising glutamate modulating agents. Functional imaging studies in OCD show consistent evidence for increased activity in brain regions that form a cortico-striato-thalamo-cortical (CSTC) loop. Neuromodulation treatments with either noninvasive devices (e.g., transcranial magnetic stimulation) or invasive procedures (e.g., deep brain stimulation) provide further support for the CSTC model of OCD. A common substrate for various interventions (whether drug, behavioral, or device) may be modulation (at different nodes or connections) of the CSTC circuit that mediates the symptoms of OCD.
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Affiliation(s)
- Wayne K. Goodman
- Menninger Department of Psychiatry and Behavioral Sciences (all authors) and Department of Neurosurgery (Sheth), Baylor College of Medicine, Houston
| | - Eric A. Storch
- Menninger Department of Psychiatry and Behavioral Sciences (all authors) and Department of Neurosurgery (Sheth), Baylor College of Medicine, Houston
| | - Sameer A. Sheth
- Menninger Department of Psychiatry and Behavioral Sciences (all authors) and Department of Neurosurgery (Sheth), Baylor College of Medicine, Houston
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Ereifej ES, Shell CE, Schofield JS, Charkhkar H, Cuberovic I, Dorval AD, Graczyk EL, Kozai TDY, Otto KJ, Tyler DJ, Welle CG, Widge AS, Zariffa J, Moritz CT, Bourbeau DJ, Marasco PD. Neural engineering: the process, applications, and its role in the future of medicine. J Neural Eng 2019; 16:063002. [PMID: 31557730 DOI: 10.1088/1741-2552/ab4869] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Recent advances in neural engineering have restored mobility to people with paralysis, relieved symptoms of movement disorders, reduced chronic pain, restored the sense of hearing, and provided sensory perception to individuals with sensory deficits. APPROACH This progress was enabled by the team-based, interdisciplinary approaches used by neural engineers. Neural engineers have advanced clinical frontiers by leveraging tools and discoveries in quantitative and biological sciences and through collaborations between engineering, science, and medicine. The movement toward bioelectronic medicines, where neuromodulation aims to supplement or replace pharmaceuticals to treat chronic medical conditions such as high blood pressure, diabetes and psychiatric disorders is a prime example of a new frontier made possible by neural engineering. Although one of the major goals in neural engineering is to develop technology for clinical applications, this technology may also offer unique opportunities to gain insight into how biological systems operate. MAIN RESULTS Despite significant technological progress, a number of ethical and strategic questions remain unexplored. Addressing these questions will accelerate technology development to address unmet needs. The future of these devices extends far beyond treatment of neurological impairments, including potential human augmentation applications. Our task, as neural engineers, is to push technology forward at the intersection of disciplines, while responsibly considering the readiness to transition this technology outside of the laboratory to consumer products. SIGNIFICANCE This article aims to highlight the current state of the neural engineering field, its links with other engineering and science disciplines, and the challenges and opportunities ahead. The goal of this article is to foster new ideas for innovative applications in neurotechnology.
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Affiliation(s)
- Evon S Ereifej
- Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, MI, United States of America. Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America. Department of Neurology, University of Michigan, Ann Arbor, MI, United States of America. Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States of America
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Serruya MD, Harris JP, Adewole DO, Struzyna LA, Burrell JC, Nemes A, Petrov D, Kraft RH, Chen HI, Wolf JA, Cullen DK. Engineered Axonal Tracts as "Living Electrodes" for Synaptic-Based Modulation of Neural Circuitry. ADVANCED FUNCTIONAL MATERIALS 2018; 28:1701183. [PMID: 34045935 PMCID: PMC8152180 DOI: 10.1002/adfm.201701183] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Brain-computer interface and neuromodulation strategies relying on penetrating non-organic electrodes/optrodes are limited by an inflammatory foreign body response that ultimately diminishes performance. A novel "biohybrid" strategy is advanced, whereby living neurons, biomaterials, and microelectrode/optical technology are used together to provide a biologically-based vehicle to probe and modulate nervous-system activity. Microtissue engineering techniques are employed to create axon-based "living electrodes", which are columnar microstructures comprised of neuronal population(s) projecting long axonal tracts within the lumen of a hydrogel designed to chaperone delivery into the brain. Upon microinjection, the axonal segment penetrates to prescribed depth for synaptic integration with local host neurons, with the perikaryal segment remaining externalized below conforming electrical-optical arrays. In this paradigm, only the biological component ultimately remains in the brain, potentially attenuating a chronic foreign-body response. Axon-based living electrodes are constructed using multiple neuronal subtypes, each with differential capacity to stimulate, inhibit, and/or modulate neural circuitry based on specificity uniquely afforded by synaptic integration, yet ultimately computer controlled by optical/electrical components on the brain surface. Current efforts are assessing the efficacy of this biohybrid interface for targeted, synaptic-based neuromodulation, and the specificity, spatial density and long-term fidelity versus conventional microelectronic or optical substrates alone.
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Affiliation(s)
- Mijail D Serruya
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - James P Harris
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
| | - Dayo O Adewole
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA; Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Laura A Struzyna
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA; Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Justin C Burrell
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
| | - Ashley Nemes
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
| | - Dmitriy Petrov
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
| | - Reuben H Kraft
- Computational Biomechanics Group, Department of Mechanical & Nuclear Engineering, Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA 16801, USA
| | - H Isaac Chen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
| | - John A Wolf
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
| | - D Kacy Cullen
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
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Wang D, Liu X, Zhou B, Kuang W, Guo T. Advanced research on deep brain stimulation in treating mental disorders. Exp Ther Med 2017; 15:3-12. [PMID: 29250146 DOI: 10.3892/etm.2017.5366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 07/10/2017] [Indexed: 11/05/2022] Open
Abstract
Deep brain stimulation is a method that involves using an electric stimulus on a specific target in the brain with stereotaxis. It is a minimally invasive, safe, adjustable and reversible nerve involvement technology. At present, this technique is widely applied to treat movement disorders and has produced promising effects on mental symptoms, including combined anxiety and depression. Deep brain stimulation has therefore been employed as a novel treatment for depression, obsessive-compulsive disorder, habituation, Tourette's syndrome, presenile dementia, anorexia nervosa and other refractory mental illnesses. Many encouraging results have been reported. The aim of the present review was to briefly describe the mechanisms, target selection, side effects, ethical arguments and risks associated with deep brain stimulation. Although deep brain stimulation is a developing and promising treatment, a large amount of research is still required to determine its curative effect, and the selection of patients and targets must be subjected to strict ethical standards.
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Affiliation(s)
- Dongxin Wang
- Mental Health Institute of Hunan Province, The Brain Hospital of Hunan Province, Changsha, Hunan 410007, P.R. China
| | - Xuejun Liu
- Mental Health Institute of Hunan Province, The Brain Hospital of Hunan Province, Changsha, Hunan 410007, P.R. China
| | - Bin Zhou
- Surgery Department of Mental Disease, The Brain Hospital of Hunan Province, Changsha, Hunan 410007, P.R. China
| | - Weiping Kuang
- Surgery Department of Mental Disease, The Brain Hospital of Hunan Province, Changsha, Hunan 410007, P.R. China
| | - Tiansheng Guo
- Mental Health Institute of Hunan Province, The Brain Hospital of Hunan Province, Changsha, Hunan 410007, P.R. China
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Edwards CA, Kouzani A, Lee KH, Ross EK. Neurostimulation Devices for the Treatment of Neurologic Disorders. Mayo Clin Proc 2017; 92:1427-1444. [PMID: 28870357 DOI: 10.1016/j.mayocp.2017.05.005] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/16/2017] [Accepted: 05/01/2017] [Indexed: 12/01/2022]
Abstract
Rapid advancements in neurostimulation technologies are providing relief to an unprecedented number of patients affected by debilitating neurologic and psychiatric disorders. Neurostimulation therapies include invasive and noninvasive approaches that involve the application of electrical stimulation to drive neural function within a circuit. This review focuses on established invasive electrical stimulation systems used clinically to induce therapeutic neuromodulation of dysfunctional neural circuitry. These implantable neurostimulation systems target specific deep subcortical, cortical, spinal, cranial, and peripheral nerve structures to modulate neuronal activity, providing therapeutic effects for a myriad of neuropsychiatric disorders. Recent advances in neurotechnologies and neuroimaging, along with an increased understanding of neurocircuitry, are factors contributing to the rapid rise in the use of neurostimulation therapies to treat an increasingly wide range of neurologic and psychiatric disorders. Electrical stimulation technologies are evolving after remaining fairly stagnant for the past 30 years, moving toward potential closed-loop therapeutic control systems with the ability to deliver stimulation with higher spatial resolution to provide continuous customized neuromodulation for optimal clinical outcomes. Even so, there is still much to be learned about disease pathogenesis of these neurodegenerative and psychiatric disorders and the latent mechanisms of neurostimulation that provide therapeutic relief. This review provides an overview of the increasingly common stimulation systems, their clinical indications, and enabling technologies.
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Affiliation(s)
- Christine A Edwards
- School of Engineering, Deakin University, Geelong, Victoria, Australia; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Abbas Kouzani
- School of Engineering, Deakin University, Geelong, Victoria, Australia
| | - Kendall H Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| | - Erika K Ross
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN; Department of Surgery, Mayo Clinic, Rochester, MN.
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A Neurophysiological Perspective on a Preventive Treatment against Schizophrenia Using Transcranial Electric Stimulation of the Corticothalamic Pathway. Brain Sci 2017; 7:brainsci7040034. [PMID: 28350371 PMCID: PMC5406691 DOI: 10.3390/brainsci7040034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/11/2017] [Accepted: 03/24/2017] [Indexed: 12/16/2022] Open
Abstract
Schizophrenia patients are waiting for a treatment free of detrimental effects. Psychotic disorders are devastating mental illnesses associated with dysfunctional brain networks. Ongoing brain network gamma frequency (30–80 Hz) oscillations, naturally implicated in integrative function, are excessively amplified during hallucinations, in at-risk mental states for psychosis and first-episode psychosis. So, gamma oscillations represent a bioelectrical marker for cerebral network disorders with prognostic and therapeutic potential. They accompany sensorimotor and cognitive deficits already present in prodromal schizophrenia. Abnormally amplified gamma oscillations are reproduced in the corticothalamic systems of healthy humans and rodents after a single systemic administration, at a psychotomimetic dose, of the glutamate N-methyl-d-aspartate receptor antagonist ketamine. These translational ketamine models of prodromal schizophrenia are thus promising to work out a preventive noninvasive treatment against first-episode psychosis and chronic schizophrenia. In the present essay, transcranial electric stimulation (TES) is considered an appropriate preventive therapeutic modality because it can influence cognitive performance and neural oscillations. Here, I highlight clinical and experimental findings showing that, together, the corticothalamic pathway, the thalamus, and the glutamatergic synaptic transmission form an etiopathophysiological backbone for schizophrenia and represent a potential therapeutic target for preventive TES of dysfunctional brain networks in at-risk mental state patients against psychotic disorders.
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Morishita T, Fayad SM, Higuchi MA, Nestor KA, Foote KD. Deep brain stimulation for treatment-resistant depression: systematic review of clinical outcomes. Neurotherapeutics 2014; 11:475-84. [PMID: 24867326 PMCID: PMC4121451 DOI: 10.1007/s13311-014-0282-1] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Major depressive disorder (MDD) is a widespread, severe, debilitating disorder that markedly diminishes quality of life. Medication is commonly effective, but 20-30 % of patients are refractory to medical therapy. The surgical treatment of psychiatric disorders has a negative stigma associated with it owing to historical abuses. Various ablative surgeries for MDD have been attempted with marginal success, but these studies lacked standardized outcome measures. The recent development of neuromodulation therapy, especially deep brain stimulation (DBS), has enabled controlled studies with sham stimulation and presents a potential therapeutic option that is both reversible and adjustable. We performed a systematic review of the literature pertaining to DBS for treatment-resistant depression to evaluate the safety and efficacy of this procedure. We included only studies using validated outcome measures. Our review identified 22 clinical research papers with 5 unique DBS approaches using different targets, including nucleus accumbens, ventral striatum/ventral capsule, subgenual cingulate cortex, lateral habenula, inferior thalamic nucleus, and medial forebrain bundle. Among the 22 published studies, only 3 were controlled trials, and 2, as yet unpublished, multicenter, randomized, controlled trials evaluating the efficacy of subgenual cingulate cortex and ventral striatum/ventral capsule DBS were recently discontinued owing to inefficacy based on futility analyses. Overall, the published response rate to DBS therapy, defined as the percentage of patients with > 50 % improvement on the Hamilton Depression Rating Scale, is reported to be 40-70 %, and outcomes were comparable across studies. We conclude that DBS for MDD shows promise, but remains experimental and further accumulation of data is warranted.
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Affiliation(s)
- Takashi Morishita
- />Department of Neurosurgery, McKnight Brain Institute, University of Florida College of Medicine/Shands Hospital, Center for Movement Disorders and Neurorestoration, 1149 South Newell Drive, Gainesville, FL 32611 USA
| | - Sarah M. Fayad
- />Department of Psychiatry, McKnight Brain Institute, University of Florida College of Medicine/Shands Hospital, Center for Movement Disorders and Neurorestoration, Gainesville, FL USA
| | - Masa-aki Higuchi
- />Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine/Shands Hospital, Center for Movement Disorders and Neurorestoration, Gainesville, FL USA
| | - Kelsey A. Nestor
- />Department of Neurosurgery, McKnight Brain Institute, University of Florida College of Medicine/Shands Hospital, Center for Movement Disorders and Neurorestoration, 1149 South Newell Drive, Gainesville, FL 32611 USA
| | - Kelly D. Foote
- />Department of Neurosurgery, McKnight Brain Institute, University of Florida College of Medicine/Shands Hospital, Center for Movement Disorders and Neurorestoration, 1149 South Newell Drive, Gainesville, FL 32611 USA
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Pisapia JM, Halpern CH, Muller UJ, Vinai P, Wolf JA, Whiting DM, Wadden TA, Baltuch GH, Caplan AL. Ethical Considerations in Deep Brain Stimulation for the Treatment of Addiction and Overeating Associated With Obesity. AJOB Neurosci 2013; 4:35-46. [PMID: 29152408 PMCID: PMC5687095 DOI: 10.1080/21507740.2013.770420] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The success of deep brain stimulation (DBS) for movement disorders and the improved understanding of the neurobiologic and neuroanatomic bases of psychiatric diseases have led to proposals to expand current DBS applications. Recent preclinical and clinical work with Alzheimer's disease and obsessive-compulsive disorder, for example, supports the safety of stimulating regions in the hypothalamus and nucleus accumbens in humans. These regions are known to be involved in addiction and overeating associated with obesity. However, the use of DBS targeting these areas as a treatment modality raises common ethical considerations, which include informed consent, coercion, enhancement, threat to personhood, and manipulation of the reward center. Pilot studies for both of these conditions are currently investigational. If these studies show promise, then there is a need to address the ethical concerns related to the initiation of clinical trials including the reliability of preclinical evidence, patient selection, study design, compensation for participation and injury, cost-effectiveness, and the need for long-term follow-up. Multidisciplinary teams are necessary for the ethical execution of such studies. In addition to establishing safety and efficacy, the consideration of these ethical issues is vital to the adoption of DBS as a treatment for these conditions. We offer suggestions about the pursuit of future clinical trials of DBS for the treatment of addiction and overeating associated with obesity and provide a framework for addressing ethical concerns related to treatment.
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Parker D, Srivastava V. Dynamic systems approaches and levels of analysis in the nervous system. Front Physiol 2013; 4:15. [PMID: 23386835 PMCID: PMC3564044 DOI: 10.3389/fphys.2013.00015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 01/19/2013] [Indexed: 01/21/2023] Open
Abstract
Various analyses are applied to physiological signals. While epistemological diversity is necessary to address effects at different levels, there is often a sense of competition between analyses rather than integration. This is evidenced by the differences in the criteria needed to claim understanding in different approaches. In the nervous system, neuronal analyses that attempt to explain network outputs in cellular and synaptic terms are rightly criticized as being insufficient to explain global effects, emergent or otherwise, while higher-level statistical and mathematical analyses can provide quantitative descriptions of outputs but can only hypothesize on their underlying mechanisms. The major gap in neuroscience is arguably our inability to translate what should be seen as complementary effects between levels. We thus ultimately need approaches that allow us to bridge between different spatial and temporal levels. Analytical approaches derived from critical phenomena in the physical sciences are increasingly being applied to physiological systems, including the nervous system, and claim to provide novel insight into physiological mechanisms and opportunities for their control. Analyses of criticality have suggested several important insights that should be considered in cellular analyses. However, there is a mismatch between lower-level neurophysiological approaches and statistical phenomenological analyses that assume that lower-level effects can be abstracted away, which means that these effects are unknown or inaccessible to experimentalists. As a result experimental designs often generate data that is insufficient for analyses of criticality. This review considers the relevance of insights from analyses of criticality to neuronal network analyses, and highlights that to move the analyses forward and close the gap between the theoretical and neurobiological levels, it is necessary to consider that effects at each level are complementary rather than in competition.
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Affiliation(s)
- David Parker
- Department of Physiology, Development and Neuroscience, University of Cambridge Cambridge, UK
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Al-Harbi KS, Qureshi NA. Neuromodulation therapies and treatment-resistant depression. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2012; 5:53-65. [PMID: 23152710 PMCID: PMC3496963 DOI: 10.2147/mder.s33198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Patients with treatment-resistant depression (TRD) who showed partial response to pharmacological and psychotherapeutic interventions need a trial of neuromodulation therapies (NTs). Objective This paper aims to review evidence-based data on the use of NTs in TRD. Method Using keywords and combined-word strategy, multiple computer searches of PubMed, Google Scholar, Quertle(R), and Medline were conducted for retrieving relevant articles published in English-language peer-reviewed journals (2000–2012). Those papers that addressed NTs in TRD were retained for extensive review. Results Despite methodological challenges, a range of 30%–93% of TRD patients showed substantial improvement to one of the NTs. One hundred–percent improvement was reported in two single-case studies on deep brain stimulation. Some studies reported no benefits from transcranial direct current stimulation. NTs were reported to have good clinical efficacy, better safety margin, and benign side-effect profile. Data are limited regarding randomized clinical trials, long-term efficacy, and cost-effectiveness of these approaches. Both modified electroconvulsive therapy and magnetic seizure therapy were associated with reversible but disturbing neurocognitive adverse effects. Besides clinical utility, NTs including approaches on the horizon may unlock the biological basis underlying mood disorders including TRD. Conclusion NTs are promising in patients with TRD, as the majority of them show good clinical response measured by standardized depression scales. NTs need further technological refinements and optimization together with continuing well-designed studies that recruit larger numbers of participants with TRD.
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Synofzik M, Fins JJ, Schlaepfer TE. A neuromodulation experience registry for deep brain stimulation studies in psychiatric research: rationale and recommendations for implementation. Brain Stimul 2011; 5:653-5. [PMID: 22100456 DOI: 10.1016/j.brs.2011.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 10/07/2011] [Indexed: 10/15/2022] Open
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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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Fins JJ, Mayberg HS, Nuttin B, Kubu CS, Galert T, Sturm V, Stoppenbrink K, Merkel R, Schlaepfer TE. Misuse of the FDA's humanitarian device exemption in deep brain stimulation for obsessive-compulsive disorder. Health Aff (Millwood) 2011; 30:302-11. [PMID: 21289352 DOI: 10.1377/hlthaff.2010.0157] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Deep brain stimulation-a novel surgical procedure-is emerging as a treatment of last resort for people diagnosed with neuropsychiatric disorders such as severe obsessive-compulsive disorder. The US Food and Drug Administration granted a so-called humanitarian device exemption to allow patients to access this intervention, thereby removing the requirement for a clinical trial of the appropriate size and statistical power. Bypassing the rigors of such trials puts patients at risk, limits opportunities for scientific discovery, and gives device manufacturers unique marketing opportunities. We argue that Congress and federal regulators should revisit the humanitarian device exemption to ensure that it is not used to sidestep careful research that can offer valuable data with appropriate patient safeguards.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics at the Weill Medical College of Cornell University, in New York City, NY, USA.
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16
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Affiliation(s)
- John F Greden
- Psychiatry and Clinical Neurosciences, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
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Ward MP, Irazoqui PP. Evolving refractory major depressive disorder diagnostic and treatment paradigms: toward closed-loop therapeutics. FRONTIERS IN NEUROENGINEERING 2010; 3:7. [PMID: 20631824 PMCID: PMC2901135 DOI: 10.3389/fneng.2010.00007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Accepted: 05/05/2010] [Indexed: 12/31/2022]
Abstract
Current antidepressant therapies do not effectively control or cure depressive symptoms. Pharmaceutical therapies altogether fail to address an estimated 4 million Americans who suffer from a recurrent and severe treatment-resistant form of depression known as refractory major depressive disorder. Subjective diagnostic schemes, differing manifestations of the disorder, and antidepressant treatments with limited theoretical bases each contribute to the general lack of therapeutic efficacy and differing levels of treatment resistance in the refractory population. Stimulation-based therapies, such as vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation, are promising treatment alternatives for this treatment-resistant subset of patients, but are plagued with inconsistent reports of efficacy and variable side effects. Many of these problems stem from the unknown mechanisms of depressive disorder pathogenesis, which prevents the development of treatments that target the specific underlying causes of the disorder. Other problems likely arise due to the non-specific stimulation of various limbic and paralimbic structures in an open-loop configuration. This review critically assesses current literature on depressive disorder diagnostic methodologies, treatment schemes, and pathogenesis in order to emphasize the need for more stringent depressive disorder classifications, quantifiable biological markers that are suitable for objective diagnoses, and alternative closed-loop treatment options tailored to well-defined forms of the disorder. A closed-loop neurostimulation device design framework is proposed, utilizing symptom-linked biomarker abnormalities as control points for initiating and terminating a corrective electrical stimulus which is autonomously optimized for correcting the magnitude and direction of observed biomarker abnormality.
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Affiliation(s)
- Matthew P. Ward
- School of Biomedical Engineering, Purdue UniversityWest Lafayette, IN, USA
| | - Pedro P. Irazoqui
- School of Biomedical Engineering, Purdue UniversityWest Lafayette, IN, USA
- School of Electrical and Computer Engineering, Purdue UniversityWest Lafayette, IN, USA
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18
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Separating hope from hype: some ethical implications of the development of deep brain stimulation in psychiatric research and treatment. CNS Spectr 2010; 15:285-7. [PMID: 20448518 DOI: 10.1017/s1092852900027504] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Major depression is the most common serious brain disorder with a lifetime prevalence of up to 17%. Despite numerous options currently available for the treatment of depression, ~2 million people in the United States may experience an inadequate response to treatment (treatment-resistant depression [TRD]) at some point in their lives. The definition of TRD is variable, ranging from a failure to respond to two or more trials of antidepressant monotherapy to a failure to respond to four or more trials of different antidepressant therapies, including augmentation, combination therapy, and electroconvulsive therapy. It has been reported that as many as one-third of patients experience only a partial response to initial therapy, while nearly one-fifth are considered nonresponders. In addition to the obvious quality of life issues for the patient with TRD, the economic cost of TRD is significant. Annual healthcare costs increase significantly for patients with TRD with each successive change in antidepressant medication. Early in treatment (two medication changes), the annual costs are <$7,000/Year. By the eighth medication change, annual costs double to nearly $14,000/year.There is a well-documented need for better long-term treatments for TRD, as witnessed by multiple efforts to establish treatment algorithms and best treatment steps when first and subsequent treatment measures prove inadequate. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, which analyzed outcome following several standardized antidepressive treatment steps, reported that 33% of patients did not respond even after four evidence-based treatment steps. A substantial proportion of patients are inadequately treated and some of these will go on to suffer from chronic, debilitating, and life-threatening symptoms.
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Deep brain stimulation in the subgenual cingulate cortex for an intractable eating disorder. Biol Psychiatry 2010; 67:e53-4. [PMID: 20044072 DOI: 10.1016/j.biopsych.2009.11.016] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Accepted: 11/11/2009] [Indexed: 11/20/2022]
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Deep brain stimulation for intractable obsessive compulsive disorder: pilot study using a blinded, staggered-onset design. Biol Psychiatry 2010; 67:535-42. [PMID: 20116047 PMCID: PMC5796545 DOI: 10.1016/j.biopsych.2009.11.028] [Citation(s) in RCA: 221] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Revised: 10/26/2009] [Accepted: 11/01/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Prior promising results have been reported with deep brain stimulation (DBS) of the anterior limb of the internal capsule in cases with severe obsessive compulsive disorder (OCD) who had exhausted conventional therapies. METHODS In this pilot study, six adult patients (2 male; 4 female) meeting stringent criteria for severe (minimum Yale-Brown Obsessive Compulsive Scale [Y-BOCS] of 28) and treatment-refractory OCD had DBS electrode arrays placed bilaterally in an area spanning the ventral anterior limb of the internal capsule and adjacent ventral striatum referred to as the ventral capsule/ventral striatum. Using a randomized, staggered-onset design, patients were stimulated at either 30 or 60 days following surgery under blinded conditions. RESULTS After 12 months of stimulation, four (66.7%) of six patients met a stringent criterion as "responders" (> or =35% improvement in the Y-BOCS and end point Y-BOCS severity < or =16). Patients did not improve during sham stimulation. Depressive symptoms improved significantly in the group as a whole; global functioning improved in the four responders. Adverse events associated with chronic DBS were generally mild and modifiable with setting changes. Stimulation interruption led to rapid but reversible induction of depressive symptoms in two cases. CONCLUSIONS This pilot study suggests that DBS of the ventral capsule/ventral striatum region is a promising therapy of last resort for carefully selected cases of severe and intractable OCD. Future research should attend to subject selection, lead location, DBS programming, and mechanisms underpinning therapeutic benefits.
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Franzini A, Messina G, Gambini O, Muffatti R, Scarone S, Cordella R, Broggi G. Deep-brain stimulation of the nucleus accumbens in obsessive compulsive disorder: clinical, surgical and electrophysiological considerations in two consecutive patients. Neurol Sci 2010; 31:353-9. [PMID: 20127500 DOI: 10.1007/s10072-009-0214-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Accepted: 12/24/2009] [Indexed: 12/12/2022]
Abstract
Obsessive compulsive disorder is a highly disabling pathological condition which in the most severe and drug-resistant form can severely impair social, cognitive and interpersonal functioning. Deep-brain stimulation has been demonstrated to be an effective and safe interventional procedure in such refractory forms in selected cases. We here report the first Italian experience in the treatment of this pathology by means of nucleus accumbens stimulation, pointing out to some technical data which could be of help in localization of the target.
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Affiliation(s)
- Angelo Franzini
- Fondazione Istituto Nazionale Neurologico "Carlo Besta", Via Caloria 11, 20133, Milan, Italy
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22
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Invasive circuitry-based neurotherapeutics: stereotactic ablation and deep brain stimulation for OCD. Neuropsychopharmacology 2010; 35:317-36. [PMID: 19759530 PMCID: PMC3055421 DOI: 10.1038/npp.2009.128] [Citation(s) in RCA: 268] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Psychiatric neurosurgery, specifically stereotactic ablation, has continued since the 1940s, mainly at a few centers in Europe and the US. Since the late 1990s, the resurgence of interest in this field has been remarkable; reports of both lesion procedures and the newer technique of deep brain stimulation (DBS) have increased rapidly. In early 2009, the US FDA granted limited humanitarian approval for DBS for otherwise intractable obsessive-compulsive disorder (OCD), the first such approval for a psychiatric illness. Several factors explain the emergence of DBS and continued small-scale use of refined lesion procedures. DBS and stereotactic ablation have been successful and widely used for movement disorders. There remains an unmet clinical need: current drug and behavioral treatments offer limited benefit to some seriously ill people. Understandings of the neurocircuitry underlying psychopathology and the response to treatment, while still works in progress, are much enhanced. Here, we review modern lesion procedures and DBS for OCD in the context of neurocircuitry. A key issue is that clinical benefit can be obtained after surgeries targeting different brain structures. This fits well with anatomical models, in which circuits connecting orbitofrontal cortex (OFC), medial prefrontal cortex (mPFC), basal ganglia, and thalamus are central to OCD pathophysiology and treatment response. As in movement disorders, dedicated interdisciplinary teams, here led by psychiatrists, are required to implement these procedures and maintain care for patients so treated. Available data, although limited, support the promise of stereotactic ablation or DBS in carefully selected patients. Benefit in such cases appears not to be confined to obsessions and compulsions, but includes changes in affective state. Caution is imperative, and key issues in long-term management of psychiatric neurosurgery patients deserve focused attention. DBS and contemporary ablation also present different patterns of potential benefits and burdens. Translational research to elucidate how targeting specific nodes in putative OCD circuitry might lead to therapeutic gains is accelerating in tandem with clinical use.
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Abstract
Technical advances have facilitated the exploration of factors related to geriatric depression and have helped generate novel biological and psychosocial treatment approaches. This review summarizes the main advancements in epidemiology, clinical presentation and course, genetics, and other areas of biological research. Treatment interventions outlined in this paper include electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, vagus nerve stimulation, deep brain stimulatn, depression prophylaxis, multidisciplinary approaches to depression treatment, and psychotherapy. Forms of psychotherapy for geriatric depression summarized include interpersonal psychotherapy, supportive psychotherapy, cognitive-behavioral therapy, problem-solving therapy, and ecosystem-focused therapy. Neuroimaging techniques based on magnetic resonance imaging are discussed briefly, including volumetric brain studies, diffusion tensor imaging, fractional anisotropy, fiber tractography, magnetization transfer imaging, and blood-oxygenation-level-dependent functional magnetic resonance imaging. Finally, treatment effectiveness is addressed in a discussion of new models to improve access to and quality of care offered in the community.
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Affiliation(s)
- GEORGE S. ALEXOPOULOS
- Weill Medical College of Cornell University, 21 Bloomingdale Road, White Plains, NY 10605, USA
| | - ROBERT E. KELLY JR.
- Weill Medical College of Cornell University, 21 Bloomingdale Road, White Plains, NY 10605, USA
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Deep brain stimulation in obsessive-compulsive disorder. Curr Psychiatry Rep 2009; 11:259-60. [PMID: 19635231 DOI: 10.1007/s11920-009-0049-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Roman M. Brain stimulation in psychiatric disorders part II: working hypotheses and evidence. Issues Ment Health Nurs 2009; 30:348-9. [PMID: 19437257 DOI: 10.1080/01612840902916177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Marian Roman
- College of Nursing, University of Tennessee, Knoxville, 1200 Volunteer Boulevard, Knoxville, TN 37996-4180, USA.
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