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Krug H, Scharf A, Weber K, Kühn AA, Krause P, Haug S. [Pacemaker, organ or walking stick? Pre-op association with and post-op subjective perception of a deep brain stimulation device]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2023. [PMID: 38113904 DOI: 10.1055/a-2202-9772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
AIM OF THE STUDY This study was conducted in a pre-post design with a survey of patients who had undergone deep brain stimulation (DBS) as treatment for a neurological movement disorder. The aim of the study was to compare patients' expectations and beliefs before a DBS intervention with patients' subjective experience of this intervention. METHODOLOGY The longitudinal study of patients (n=132) with an indication for DBS therapy was based on a written survey at the time points of preoperative screening (pre-op) and one-year follow-up (post-op). RESULTS Preoperatively, a clear majority of respondents believed DSB to be similar to a pacemaker intervention, but one year after the intervention less than one third did so, as they compared DBS to using a walking stick or glasses. CONCLUSION The experience of DBS in the patient's own body seems to be comparable by means of individually different associations, whereby the comparison with non-invasive aids predominates postoperatively. The discussion of these descriptions in the educational interview can contribute to a realistic horizon of patients' expectations before DBS.
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Affiliation(s)
- Henriette Krug
- Fakultät Gesundheitswissenschaften, MSH Medical School Hamburg University of Applied Sciences and Medical University, Hamburg, Germany
| | - Anna Scharf
- Institut für Sozialforschung und Technikfolgenabschätzung, Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Karsten Weber
- Institut für Sozialforschung und Technikfolgenabschätzung, Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Andrea A Kühn
- Klinik für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Patricia Krause
- Klinik für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sonja Haug
- Institut für Sozialforschung und Technikfolgenabschätzung, Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
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Debrah AF, Adebusoye FT, Shah MH, Awuah WA, Tenkorang PO, Bharadwaj HR, Wellington J, Ghosh S, Abiy L, Fernandes C, Abdul-Rahman T, Lychko V, Volodymyrivna BT, Mykolayivna NI. Neurological disorders in pregnant women in low- and middle-income countries-Management gaps, impacts, and future prospects: A review perspective. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231210265. [PMID: 37955275 PMCID: PMC10644749 DOI: 10.1177/17455057231210265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/25/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023]
Abstract
Neurological disorders during pregnancy are a substantial threat to women's health, particularly in low- and middle-income countries. Furthermore, a critical shortage of mental health workers and neurologists exacerbates the already pressing issue, where a lack of coordination of respective healthcare among multidisciplinary teams involved in managing these conditions perpetuates the current state of affairs. Financial restrictions and societal stigmas associated with neurological disorders in pregnancy amplify the situation. Addressing these difficulties would necessitate a multifaceted approach comprising investments in healthcare infrastructure, healthcare professional education and training, increased government support for research, and the implementation of innovative care models. Improving access to specialized treatment and coordinated management of antenatal neurological diseases will precipitate improved health outcomes for women and their families in low- and middle-income countries.
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Affiliation(s)
| | | | | | | | | | | | - Jack Wellington
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Lydia Abiy
- Donetsk National Medical University, Kropyvnytskyi, Ukraine
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Shlobin NA, Rosenow JM. Ethical Considerations in the Implantation of Neuromodulatory Devices. Neuromodulation 2022; 25:222-231. [PMID: 35125141 DOI: 10.1111/ner.13357] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/26/2020] [Accepted: 12/21/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Neuromodulatory devices are increasingly used by neurosurgeons to manage a variety of chronic conditions. Given their potential benefits, it is imperative to create clear ethical guidelines for the use of these devices. We present a tiered ethical framework for neurosurgeon recommendations for the use of neuromodulatory devices. MATERIALS AND METHODS We conducted a literature review to identify factors neurosurgeons should consider when choosing to offer a neuromodulatory device to a patient. RESULTS Neurosurgeons must weigh reductions in debilitating symptoms, improved functionality, and preserved quality of life against risks for intraoperative complications and adverse events due to stimulation or the device itself. Neurosurgeons must also evaluate whether patients and families will maintain responsibility for the management of neuromodulatory devices. Consideration of these factors should occur on an axis of resource allocation, ranging from provision of neuromodulatory devices to those with greatest potential benefit in resource-limited settings to provision of neuromodulatory devices to all patients with indications in contexts without resource limitations. Neurosurgeons must also take action to promote device effectiveness throughout the duration of care. CONCLUSIONS Weighing risks and benefits of providing neuromodulatory devices and assessing ability to remain responsible for the devices on the level of the individual patient indicate which patients are most likely to achieve benefit from these devices. Consideration of these factors on an axis of resource allocation will allow for optimal provision of neuromodulatory devices to patients in settings of varied resources. Neurosurgeons play a primary role in promoting the effectiveness of these devices.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
| | - Joshua M Rosenow
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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Thomson CJ, Segrave RA, Fitzgerald PB, Richardson KE, Racine E, Carter A. "Nothing to Lose, Absolutely Everything to Gain": Patient and Caregiver Expectations and Subjective Outcomes of Deep Brain Stimulation for Treatment-Resistant Depression. Front Hum Neurosci 2021; 15:755276. [PMID: 34658822 PMCID: PMC8511461 DOI: 10.3389/fnhum.2021.755276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/06/2021] [Indexed: 11/25/2022] Open
Abstract
Background: How "success" is defined in clinical trials of deep brain stimulation (DBS) for refractory psychiatric conditions has come into question. Standard quantitative psychopathology measures are unable to capture all changes experienced by patients and may not reflect subjective beliefs about the benefit derived. The decision to undergo DBS for treatment-resistant depression (TRD) is often made in the context of high desperation and hopelessness that can challenge the informed consent process. Partners and family can observe important changes in DBS patients and play a key role in the recovery process. Their perspectives, however, have not been investigated in research to-date. The aim of this study was to qualitatively examine patient and caregivers' understanding of DBS for TRD, their expectations of life with DBS, and how these compare with actual experiences and outcomes. Methods: A prospective qualitative design was adopted. Semi-structured interviews were conducted with participants (six patients, five caregivers) before DBS-implantation and 9-months after stimulation initiation. All patients were enrolled in a clinical trial of DBS of the bed nucleus of the stria terminalis. Interviews were thematically analyzed with data saturation achieved at both timepoints. Results: Two primary themes identified were: (1) anticipated vs. actual outcomes, and (2) trial decision-making and knowledge. The decision to undergo DBS was driven by the intolerability of life with severe depression coupled with the exhaustion of all available treatment options. Participants had greater awareness of surgical risks compared with stimulation-related risks. With DBS, patients described cognitive, emotional, behavioral and physical experiences associated with the stimulation, some of which were unexpected. Participants felt life with DBS was like "a roller coaster ride"-with positive, yet unsustained, mood states experienced. Many were surprised by the lengthy process of establishing optimum stimulation settings and felt the intervention was still a "work in progress." Conclusion: These findings support existing recommendations for iterative informed consent procedures in clinical trials involving long-term implantation of neurotechnology. These rich and descriptive findings hold value for researchers, clinicians, and individuals and families considering DBS. Narrative accounts capture patient and family needs and should routinely be collected to guide patient-centered approaches to DBS interventions.
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Affiliation(s)
- Cassandra J. Thomson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Rebecca A. Segrave
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Paul B. Fitzgerald
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare, Camberwell, VIC, Australia
- Department of Psychiatry, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Karyn E. Richardson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de Recherches Cliniques de Montréal, Montreal, QC, Canada
- Department of Medicine and Social and Preventive Medicine, Université de Montréal, Montreal, QC, Canada
- Medicine and Biomedical Ethics Unit, Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Adrian Carter
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
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Torres Díaz CV, Treu S, Strange B, Lara M, Navas M, Ezquiaga E, Zazo ES, Vicente JS, Muñiz I, Fernandez FS. Deep Brain Stimulation of the Nucleus Accumbens, Ventral Striatum, or Internal Capsule Targets for Medication-Resistant Obsessive-Compulsive Disorder: A Multicenter Study. World Neurosurg 2021; 155:e168-e176. [PMID: 34403796 DOI: 10.1016/j.wneu.2021.08.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Deep brain stimulation of the nucleus accumbens, ventral striatum, or internal capsule region has shown a 45%-60% response rate in adults with severe treatment-refractory obsessive-compulsive disorder, regardless of which target is used. We sought to improve the effectiveness of deep brain stimulation by placing the electrode along a trajectory including these 3 targets, enabling a change of stimulation site depending on the patient's response. METHODS This study used the medical records of 14 patients from 4 different Spanish institutions: 7 from the Hospital Universitario La Princesa, 3 from the Hospital Universitario Central de Asturias, 2 from Hospital Universitario Fundación Jiménez Díaz, and 2 from Hospital Universitari Son Espases. All patients were operated on under the same protocol. Qualitative and quantitative data were collected. RESULTS Of 14 patients, 11 showed significant improvement in obsessive-compulsive disorder symptoms, as evident in a reduction ≥35% in Yale-Brown Obsessive Compulsive Scale scores following stimulation relative to preoperative scores. Seven patients responded to stimulation at the nucleus accumbens (the first area we set for stimulation), whereas 4 patients needed to have the active contact switched to the internal capsule to benefit from stimulation. CONCLUSIONS Deep brain stimulation of the nucleus accumbens, internal capsule, and ventral striatum significantly benefited our cohort of patients with medication-resistant obsessive-compulsive disorder. Electrode insertion through the 3 main targets might confer additional therapeutic efficacy.
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Affiliation(s)
- Cristina V Torres Díaz
- Department of Neurourgery, Hospital Universitario La Princesa, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Svenja Treu
- Laboratory for Clinical Neuroscience, Centre of Biomedical Technology, Universidad Politécnica de Madrid, Madrid, Spain
| | - Bryan Strange
- Laboratory for Clinical Neuroscience, Centre of Biomedical Technology, Universidad Politécnica de Madrid, Madrid, Spain
| | - Monica Lara
- Department of Neurosurgery, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Marta Navas
- Department of Neurourgery, Hospital Universitario La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Elena Ezquiaga
- Department of Psychiatry, Hospital Universitario La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Elisa Seijo Zazo
- Department of Psychiatry, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Isabel Muñiz
- Department of Psychology, Universidad Anáhuac Cancún, Cancún, Mexico
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McDonald PJ, Hrincu V, Connolly MB, Harrison MJ, Ibrahim GM, Naftel RP, Chiong W, Udwadia F, Illes J. Novel Neurotechnological Interventions for Pediatric Drug-Resistant Epilepsy: Physician Perspectives. J Child Neurol 2021; 36:222-229. [PMID: 33111593 PMCID: PMC7855396 DOI: 10.1177/0883073820966935] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This qualitative study investigated factors that guide physicians' choices for minimally invasive and neuromodulatory interventions as alternatives to conventional surgery or medical management for pediatric drug-resistant epilepsy. North American physicians were recruited to one of 4 focus groups at national conferences. Discussions were analyzed using qualitative content analysis. A pragmatic neuroethics framework was applied to interpret results. Discussions revealed 2 major thematic branches: (1) clinical decision making and (2) ethical considerations. Under clinical decision making, physicians emphasized scientific evidence and patient candidacy when assessing neurotechnologies for patients. Ongoing seizures without intervention was important for safety and neurodevelopment. Under ethical considerations, resource allocation, among other financial considerations for technology adoption, were considerable sources of pressure on decision making. Access to neurotechnology was a salient theme differentiating Canadian and American contexts. When assessing novel neurotechnological interventions for pediatric drug-resistant epilepsy, physicians balance clinical and ethical factors to guide decision making and best practice.
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Affiliation(s)
- Patrick J. McDonald
- University of British Columbia, Division of Neurology, Department of Medicine, Vancouver, British Columbia, Canada,Faculty of Medicine, Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada,Correspondence: Judy Illes, CM, PhD, Professor of Neurology, Department of Medicine, University of British Columbia, 2211 Wesbrook Mall, Koerner S124, Vancouver, BC V6T 2B5 CANADA, Tel: 604.822.0746
| | - Viorica Hrincu
- University of British Columbia, Division of Neurology, Department of Medicine, Vancouver, British Columbia, Canada
| | - Mary B. Connolly
- Department of Pediatrics, Division of Neurology, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Mark J. Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada,Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - George M. Ibrahim
- Division of Neurosurgery, Hospital for Sick Children and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Robert P. Naftel
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Winston Chiong
- Weill Institute for Neurosciences, Department of Neurology, Memory and Aging Center, University of California San Francisco, San Francisco, California
| | - Farhad Udwadia
- University of British Columbia, Division of Neurology, Department of Medicine, Vancouver, British Columbia, Canada
| | - Judy Illes
- University of British Columbia, Division of Neurology, Department of Medicine, Vancouver, British Columbia, Canada,Correspondence: Judy Illes, CM, PhD, Professor of Neurology, Department of Medicine, University of British Columbia, 2211 Wesbrook Mall, Koerner S124, Vancouver, BC V6T 2B5 CANADA, Tel: 604.822.0746
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Khairuddin S, Ngo FY, Lim WL, Aquili L, Khan NA, Fung ML, Chan YS, Temel Y, Lim LW. A Decade of Progress in Deep Brain Stimulation of the Subcallosal Cingulate for the Treatment of Depression. J Clin Med 2020; 9:jcm9103260. [PMID: 33053848 PMCID: PMC7601903 DOI: 10.3390/jcm9103260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022] Open
Abstract
Major depression contributes significantly to the global disability burden. Since the first clinical study of deep brain stimulation (DBS), over 446 patients with depression have now undergone this neuromodulation therapy, and 29 animal studies have investigated the efficacy of subgenual cingulate DBS for depression. In this review, we aim to provide a comprehensive overview of the progress of DBS of the subcallosal cingulate in humans and the medial prefrontal cortex, its rodent homolog. For preclinical animal studies, we discuss the various antidepressant-like behaviors induced by medial prefrontal cortex DBS and examine the possible mechanisms including neuroplasticity-dependent/independent cellular and molecular changes. Interestingly, the response rate of subcallosal cingulate Deep brain stimulation marks a milestone in the treatment of depression. DBS achieved response and remission rates of 64–76% and 37–63%, respectively, from clinical studies monitoring patients from 6–24 months. Although some studies showed its stimulation efficacy was limited, it still holds great promise as a therapy for patients with treatment-resistant depression. Overall, further research is still needed, including more credible clinical research, preclinical mechanistic studies, precise selection of patients, and customized electrical stimulation paradigms.
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Affiliation(s)
- Sharafuddin Khairuddin
- Neuromodulation Laboratory, School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, L4 Laboratory Block, 21 Sassoon Road, Hong Kong, China; (S.K.); (F.Y.N.); (W.L.L.); (M.-L.F.); (Y.-S.C.)
| | - Fung Yin Ngo
- Neuromodulation Laboratory, School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, L4 Laboratory Block, 21 Sassoon Road, Hong Kong, China; (S.K.); (F.Y.N.); (W.L.L.); (M.-L.F.); (Y.-S.C.)
| | - Wei Ling Lim
- Neuromodulation Laboratory, School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, L4 Laboratory Block, 21 Sassoon Road, Hong Kong, China; (S.K.); (F.Y.N.); (W.L.L.); (M.-L.F.); (Y.-S.C.)
- Department of Biological Sciences, School of Science and Technology, Sunway University, Bandar Sunway 47500, Malaysia
| | - Luca Aquili
- School of Psychological and Clinical Sciences, Charles Darwin University, NT0815 Darwin, Australia;
| | - Naveed Ahmed Khan
- Department of Biology, Chemistry and Environmental Sciences, College of Arts and Sciences, American University of Sharjah, Sharjah 26666, UAE;
| | - Man-Lung Fung
- Neuromodulation Laboratory, School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, L4 Laboratory Block, 21 Sassoon Road, Hong Kong, China; (S.K.); (F.Y.N.); (W.L.L.); (M.-L.F.); (Y.-S.C.)
| | - Ying-Shing Chan
- Neuromodulation Laboratory, School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, L4 Laboratory Block, 21 Sassoon Road, Hong Kong, China; (S.K.); (F.Y.N.); (W.L.L.); (M.-L.F.); (Y.-S.C.)
| | - Yasin Temel
- Departments of Neuroscience and Neurosurgery, Maastricht University, 6229ER Maastricht, The Netherlands;
| | - Lee Wei Lim
- Neuromodulation Laboratory, School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, L4 Laboratory Block, 21 Sassoon Road, Hong Kong, China; (S.K.); (F.Y.N.); (W.L.L.); (M.-L.F.); (Y.-S.C.)
- Department of Biological Sciences, School of Science and Technology, Sunway University, Bandar Sunway 47500, Malaysia
- Correspondence:
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Mankin EA, Fried I. Modulation of Human Memory by Deep Brain Stimulation of the Entorhinal-Hippocampal Circuitry. Neuron 2020; 106:218-235. [PMID: 32325058 DOI: 10.1016/j.neuron.2020.02.024] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/13/2020] [Accepted: 01/27/2020] [Indexed: 01/02/2023]
Abstract
Neurological disorders affecting human memory present a major scientific, medical, and societal challenge. Direct or indirect deep brain stimulation (DBS) of the entorhinal-hippocampal system, the brain's major memory hub, has been studied in people with epilepsy or Alzheimer's disease, intending to enhance memory performance or slow memory decline. Variability in the spatiotemporal parameters of stimulation employed to date notwithstanding, it is likely that future DBS for memory will employ closed-loop, nuanced approaches that are synergistic with native physiological processes. The potential for editing human memory-decoding, enhancing, incepting, or deleting specific memories-suggests exciting therapeutic possibilities but also raises considerable ethical concerns.
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Affiliation(s)
- Emily A Mankin
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Itzhak Fried
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA 90095, USA; Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA 90095, USA; Tel Aviv Medical Center and Tel Aviv University, Tel Aviv, Israel.
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Desmoulin-Canselier S. DBS: a compelling example for ethical and legal reflection-a French perspective on ethical and legal concerns about DBS. Monash Bioeth Rev 2020; 38:15-34. [PMID: 32335863 DOI: 10.1007/s40592-020-00111-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Deep brain stimulation (DBS) is an approved treatment for neurological diseases and a promising one for psychiatric conditions, which may produce spectacular results very quickly. It is also a powerful tool for brain research and exploration. Beyond an overview of the ethical and legal literature on this topic, this paper aims at showing that DBS is a compelling example for ethical-legal reflection, as it combines a highly technical surgical procedure, a complex active medical device and neuromodulation of the human brain to restore lost abilities caused by a chronic and evolving disease. Some of the ethical and legal issues raised by DBS are not specific, but shed new light on medical ethics and law. Others are more DBS-specific, as they are linked to the intricacies of research and treatment, to the need to tune the device, to the patients' control over the device and its effects and to the involvement of family caregivers.
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Affiliation(s)
- Sonia Desmoulin-Canselier
- NormaStim Program ANR14-CE30-0016, University of Nantes (UMR 6297 DCS), Nantes, France. .,Laboratoire Droit et Changement Social, UMR CNRS 6297: Faculté de Droit de Nantes, Chemin de la Censive du Tertre, BP 8130744 313, Nantes Cedex 3, France.
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Gardner J, Warren N. Learning from deep brain stimulation: the fallacy of techno-solutionism and the need for 'regimes of care'. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:363-374. [PMID: 30069813 DOI: 10.1007/s11019-018-9858-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Deep brain stimulation (DBS) is an effective treatment for the debilitating motor symptoms of Parkinson's disease and other neurological disorders. However, clinicians and commentators have noted that DBS recipients have not necessarily experienced the improvements in quality of life that would be expected, due in large part to what have been described as the 'psychosocial' impacts of DBS. The premise of this paper is that, in order to realise the full potential of DBS and similar interventions, clinical services need to be arranged in such a way that these psychosocial dimensions are recognised and managed. Our starting point is that the psychosocial effects of DBS 'in the field' present us with analytically-useful disruptions: they disturb and foreground deeply held assumptions relating to the individual, health and its treatment, and which in a crude form manifest as the myth of technological solutionism within health care. Drawing on scholarship in medical sociology and science and technology studies (STS), we argue that DBS brings to the fore the relational dimensions of personhood, and demonstrates the emotional and social turmoil that can result if the relational dimensions of personhood are ignored by clinical services. In light of this, we argue that DBS should be implemented within a regime of care. Drawing on ethnographic research of a paediatric DBS clinical service, we provide an example of a regime of care, and conclude by reflecting on what other DBS services might learn from this paediatric service.
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Affiliation(s)
- John Gardner
- Health & Biofutures Program, School of Social Sciences, Monash University, W414 Menzies Building, Melbourne, 3800, Australia.
| | - Narelle Warren
- School of Social Sciences, Monash University, Menzies Building, Melbourne, 3800, Australia
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11
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Desmoulin-Canselier S. Patient's lived experience with DBS between medical research and care: some legal implications. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:375-386. [PMID: 30074133 DOI: 10.1007/s11019-018-9859-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In the past 50 years, an ethical-legal boundary has been drawn between treatment and research. It is based on the reasoning that the two activities pursue different purposes. Treatment is aimed at achieving optimal therapeutic benefits for the individual patient, whereas the goal of scientific research is to increase knowledge, in the public interest. From this viewpoint, the patient's experience should be clearly distinguished from that of a participant in a clinical trial. On this premise, two parallel and mutually exclusive regimes have been established. Yet in the case of deep brain stimulation (DBS), this presentation is a poor fit, for both the patient's lived experience and medical practice and research. The frictions may be explained by the specificities of the treatment (including surgery and medical devices) and of the pathologies concerned (chronic and evolutive), and by the characteristics of the medical team implementing the treatment. These particularities challenge the dominant frame of reference in medical bioethics and cause difficulties for the current legal framework in fulfilling its dual role: to protect patients while supporting the development of innovative treatments. The dominant model is still the clinical trial for medication safety and legal requirements of drug market regulation. However, DBS forces us to reflect on a medical device that is permanently implanted in the brain by highly specialized multi-disciplinary neurosurgical teams, for the treatment of chronic evolutive diseases. These devices demand fine-tuning on a case-by-case basis and there is still a lot to discover about why DBS is effective (or not). As a result, the wall between treatment and research is osmotic: many discoveries are made incidentally, in the course of treatment. The following study begins with these observations, and suggests that we review legal provisions (especially in French and United States law) so that they are better adapted to the first-person needs and experience of the patient undergoing brain stimulation.
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Affiliation(s)
- Sonia Desmoulin-Canselier
- CNRS/Université de Nantes UMR 6297 Droit et Changement Social, Faculté de Droit et de sciences politiques, Université de Nantes, Chemin de la Censive du Tertre, Nantes, France.
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Liu XD, Bao Y, Liu GJ. Comparison Between Levodopa-Carbidopa Intestinal Gel Infusion and Subthalamic Nucleus Deep-Brain Stimulation for Advanced Parkinson's Disease: A Systematic Review and Meta-Analysis. Front Neurol 2019; 10:934. [PMID: 31507529 PMCID: PMC6718716 DOI: 10.3389/fneur.2019.00934] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/12/2019] [Indexed: 11/29/2022] Open
Abstract
Background: Currently, some advanced treatments such as Levodopa-Carbidopa intestinal gel infusion (LCIG), deep-brain stimulation (DBS), and subcutaneous apomorphine infusion have become alternative strategies for advanced Parkinson's disease (PD). However, which treatment is better for individual patients remains unclear. This review aims to compare therapeutic effects of motor and/or non-motor symptoms of advanced PD patients between LCIG and DBS. Methods: We manually searched electronic databases (PubMed, Embase, Cochrane Library) and reference lists of included articles published until April 04, 2019 using related terms, without language restriction. We included case-controlled cohort studies and randomized-controlled trials, which directly compared differences between LCIG and DBS. The Newcastle-Ottawa scale (NOS), proposed by the Cochrane Collaboration, was utilized to assess the quality of the included studies. Two investigators independently extracted data from each trial. Pooled standard-mean differences (SMDs) and relative risks (RRs) with 95% confidence intervals (CIs) were calculated by meta-analysis. Outcomes were grouped according to the part III and part IV of the Unified Parkinson Disease Rating Scale (UPDRS) and adverse events. We also descriptively reviewed some data, which were unavailable for statistical analysis. Results: This review included five cohort trials of 257 patients for meta-analysis. There were no significant differences between LCIG and subthalamic nucleus deep-brain stimulation (STN-DBS) on UPDRS-III and adverse events comparisons: UPDRS-III (pooled SMDs = 0.200, 95% CI: −0.126–0.527, P = 0.230), total adverse events (pooled RRs = 1.279, 95% CI: 0.983–1.664, P = 0.067), serious adverse events (pooled RRs = 1.539, 95% CI: 0.664–3.566, P = 0.315). Notably, the improvement of UPDRS-IV was more significant in STN-DBS groups: pooled SMDs = 0.857, 95% CI: 0.130–1.584, P = 0.021. However, the heterogeneity was moderate for UPDRS-IV (I2 = 73.8%). Conclusion: LCIG has comparable effects to STN-DBS on motor function for advanced PD, with acceptable tolerability. More large, well-designed trials are needed to assess the comparability of LCIG and STN-DBS in the future.
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Affiliation(s)
- Xiao Dong Liu
- Department of Neurology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yi Bao
- Department of Neurology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Guang Jian Liu
- Department of Neurology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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Carlson JD, Palmer M, Hoefer A, Cox E, McLeod P, Mark J, Aldred J. Deep Brain Stimulation Generator Replacement in End-Stage Parkinson Disease. World Neurosurg 2019; 128:e683-e687. [DOI: 10.1016/j.wneu.2019.04.233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/26/2019] [Accepted: 04/27/2019] [Indexed: 11/29/2022]
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Haines S, Savic M, Carter A. Advancing Medicine Ethically: Important Considerations for Innovative Practice. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:38-40. [PMID: 31135311 DOI: 10.1080/15265161.2019.1602186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Desmoulin-Canselier S, Moutaud B. Animal Models and Animal Experimentation in the Development of Deep Brain Stimulation: From a Specific Controversy to a Multidimensional Debate. Front Neuroanat 2019; 13:51. [PMID: 31191261 PMCID: PMC6548025 DOI: 10.3389/fnana.2019.00051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/08/2019] [Indexed: 11/13/2022] Open
Abstract
In this article, we explore a specific controversy about animal experimentation and animal models in the recent history of deep brain stimulation (DBS), and we question its ramifications. DBS development intertwines clinical practice with fundamental research and stands at the crossroads of multiple legacies. We take up the various issues and controversies embedded in this rarely addressed dispute, from a standpoint that combines socio-anthropological and legal aspects. Our starting point is a debate on the role of animal experimentation in the development of DBS between Jarrod Bailey, a researcher promoting the abolition of animal experimentation, and Alim Louis Benabid, Marwan Hariz, and Mahlon DeLong, three key figures in the area of DBS and neuroscience. By clarifying the positions of the different protagonists and retracing the issues raised in these discussions, our objective is to show how this specific debate has extended from its initial space and how it provides an object of study with heuristic scope. We first present this partially polemic discussion about the history of DBS, and its link with a more general debate on the validity and use of animal models and the need for animal experiments. Then, we raise the issue of the relations and interactions between experiments on animals and on humans in the logics of biomedical innovation. The third step is to situate the discussion within the wider framework of opposition towards animal experimentation and the promotion of animal' rights. Finally, combining these interweaved issues, possible implications emerge regarding the future of DBS. We show that behind these several controversies lie the question of translational research and the model of medicine upheld by DBS. We describe how the technology contributes to blurring the lines between research (fundamental, preclinical and clinical research) and care, as well as between humans and animals as substrates and objects of knowledge. The dynamics of DBS future development might then become a point of convergence for neuroscientists and animal rights defenders' interests.
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Affiliation(s)
- Sonia Desmoulin-Canselier
- Centre National de la Recherche Scientifique (CNRS), Nantes, France
- Droit et Changement Social, UMR 6297, Université de Nantes, Nantes, France
| | - Baptiste Moutaud
- Centre National de la Recherche Scientifique (CNRS), Nantes, France
- Laboratoire d’ethnologie et de sociologie comparative, UMR 7186, Université Paris Nanterre, Nanterre, France
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Gardner J, Warren N, Addison C, Samuel G. Persuasive bodies: Testimonies of deep brain stimulation and Parkinson's on YouTube. Soc Sci Med 2018; 222:44-51. [PMID: 30599435 DOI: 10.1016/j.socscimed.2018.12.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 11/22/2018] [Accepted: 12/23/2018] [Indexed: 02/06/2023]
Abstract
Contemporary publics actively engage with diverse forms of media when seeking health-related information. The hugely popular digital media platform YouTube has become one means by which people share their experiences of healthcare. In this paper, we examine amateur YouTube videos featuring people receiving Deep Brain Stimulation (DBS) for the treatment of Parkinson's disease. DBS has become a widely implemented treatment, and it is surrounded by high expectations that can create difficulty for clinicians, patients and their families. We examine how DBS, Parkinson's disease, and DBS recipients themselves, are delineated within these YouTube videos. The videos, we demonstrate, contain common compositional and stylistic elements that collectively represent DBS as a technological fix, and which accentuate the autonomy of the DBS recipient. The relational, interpersonal dimensions of chronic illness, and the complex impact of DBS on family dynamics, are elided. We therefore shed light on the means by which high expectations regarding DBS are sustained and circulated, and more generally, we illustrate how potentially powerful representations of medical technologies can emerge from the intersection of social media platforms, afflicted bodies and patient narratives.
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Affiliation(s)
- John Gardner
- School of Social Sciences, Monash University, Melbourne, Australia.
| | - Narelle Warren
- School of Social Sciences, Monash University, Melbourne, Australia.
| | - Courtney Addison
- Science in Society, Victoria University of Wellington, New Zealand.
| | - Gabby Samuel
- Department of Global Health and Social Medicine, Kings College London, UK.
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Quintal A, Messier V, Rabasa-Lhoret R, Racine E. A critical review and analysis of ethical issues associated with the artificial pancreas. DIABETES & METABOLISM 2018; 45:1-10. [PMID: 29753624 DOI: 10.1016/j.diabet.2018.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 04/13/2018] [Accepted: 04/18/2018] [Indexed: 12/13/2022]
Abstract
The artificial pancreas combines a hormone infusion pump with a continuous glucose monitoring device, supported by a dosing algorithm currently installed on the pump. It allows for dynamic infusions of insulin (and possibly other hormones such as glucagon) tailored to patient needs. For patients with type 1 diabetes the artificial pancreas has been shown to prevent more effectively hypoglycaemic events and hyperglycaemia than insulin pump therapy and has the potential to simplify care. However, the potential ethical issues associated with the upcoming integration of the artificial pancreas into clinical practice have not yet been discussed. Our objective was to identify and articulate ethical issues associated with artificial pancreas use for patients, healthcare professionals, industry and policymakers. We performed a literature review to identify clinical, psychosocial and technical issues raised by the artificial pancreas and subsequently analysed them through a common bioethics framework. We identified five sensitive domains of ethical issues. Patient confidentiality and safety can be jeopardized by the artificial pancreas' vulnerability to security breaches or unauthorized data sharing. Public and private coverage of the artificial pancreas could be cost-effective and warranted. Patient selection criteria need to ensure equitable access and sensitivity to patient-reported outcomes. Patient coaching and support by healthcare professionals or industry representatives could help foster realistic expectations in patients. Finally, the artificial pancreas increases the visibility of diabetes and could generate issues related to personal identity and patient agency. The timely consideration of these issues will optimize the technological development and clinical uptake of the artificial pancreas.
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Affiliation(s)
- A Quintal
- Unité de recherche en neuroéthique, Institut de recherches cliniques de Montréal (IRCM), 110, avenue des Pins Ouest, QC H2W 1R7 Montréal, Canada; Département de médecine sociale et préventive, École de santé publique, Université de Montréal, C.P. 6128, succursale Centre-ville, QC H3C 3J7 Montréal, Canada
| | - V Messier
- Unité de recherche sur les maladies métaboliques, Institut de recherches cliniques de Montréal (IRCM), 110, avenue des Pins Ouest, QC H2W 1R7 Montréal, Canada
| | - R Rabasa-Lhoret
- Unité de recherche sur les maladies métaboliques, Institut de recherches cliniques de Montréal (IRCM), 110, avenue des Pins Ouest, QC H2W 1R7 Montréal, Canada; Département de nutrition, Faculté de médecine, Université de Montréal, 2405, chemin de la Côte-Sainte-Catherine, QC H3T 1A8 Montréal, Canada; Montreal Diabetes Research Centre and Endocrinology Division, centre hospitalier de l'Université de Montréal, QC H2X 3J4 Montréal, Canada
| | - E Racine
- Unité de recherche en neuroéthique, Institut de recherches cliniques de Montréal (IRCM), 110, avenue des Pins Ouest, QC H2W 1R7 Montréal, Canada; Département de médecine sociale et préventive, École de santé publique, Université de Montréal, C.P. 6128, succursale Centre-ville, QC H3C 3J7 Montréal, Canada; Department of Neurology and Neurosurgery, McGill University, 3801 University Street, QC H3A 2B4 Montréal, Canada; Experimental Medicine and Biomedical Ethics Unit, McGill University, 1110, avenue des Pins Ouest, QC H3A 1A3 Montréal, Canada; Département de médecine, Université de Montréal, C.P. 6128, succursale Centre-ville, QC H3C 3J7 Montréal, Canada.
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Naesström M, Blomstedt P, Hariz M, Bodlund O. Deep brain stimulation for obsessive-compulsive disorder: Knowledge and concerns among psychiatrists, psychotherapists and patients. Surg Neurol Int 2017; 8:298. [PMID: 29285414 PMCID: PMC5735431 DOI: 10.4103/sni.sni_19_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/15/2017] [Indexed: 11/04/2022] Open
Abstract
Background: Deep brain stimulation (DBS) is under investigation for severe obsessive-compulsive disorder (OCD) resistant to other therapies. The number of implants worldwide is slowly increasing. Therefore, it is of importance to explore knowledge and concerns of this novel treatment among patients and their psychiatric healthcare contacts. This information is relevant for scientific professionals working with clinical studies for DBS for this indication. Especially, for future study designs and the creation of information targeting healthcare professionals and patients. The aim of this study was to explore the knowledge and concerns toward DBS among patients with OCD, psychiatrists, and cognitive behavioral therapists. Methods: The study was conducted through web-based surveys for the aimed target groups –psychiatrist, patients, and cognitive behavioral therapists. The surveys contained questions regarding previous knowledge of DBS, source of knowledge, attitudes, and concerns towards the therapy. Results: The main source of information was from scientific sources among psychiatrists and psychotherapists. The patient's main source of information was the media. Common concerns among the groups included complications from surgery, anesthesia, stimulation side effects, and the novelty of the treatment. Specific concerns for the groups included; personality changes mentioned by patients and psychotherapists, and ethical concerns among psychiatrists. Conclusion: There are challenges for DBS in OCD as identified by the participants of this study; source and quality of information, efficacy, potential adverse effects, and eligibility. In all of which the current evidence base still is limited. A broad research agenda is needed for studies going forward.
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Affiliation(s)
| | - Patric Blomstedt
- Unit of Deep Brain Stimulation, Department of Pharmacology and Clinical Neuroscience, Umeå University, Sweden
| | - Marwan Hariz
- Unit of Deep Brain Stimulation, Department of Pharmacology and Clinical Neuroscience, Umeå University, Sweden.,Unit of Functional Neurosurgery, UCL Institute of Neurology, Queen Square, London, United Kingdom
| | - Owe Bodlund
- Department of Clinical Sciences/Psychiatry, Umeå University, Sweden
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Mole JA, Prangnell SJ. Role of clinical neuropsychology in deep brain stimulation: Review of the literature and considerations for clinicians. APPLIED NEUROPSYCHOLOGY-ADULT 2017; 26:283-296. [PMID: 29236528 DOI: 10.1080/23279095.2017.1407765] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Deep Brain Stimulation (DBS) is an effective surgical therapy for several neurological movement disorders. The clinical neuropsychologist has a well-established role in the neuropsychological evaluation and selection of surgical candidates. In this article, we argue that the clinical neuropsychologist's role is much broader, when considered in relation to applied psychologists' core competencies. We consider the role of the clinical neuropsychologist in DBS in relation to: assessment, formulation, evaluation and research, intervention or implementation, and communication. For each competence the relevant evidence-base was reviewed. Clinical neuropsychology has a vital role in presurgical assessment of cognitive functioning and psychological, and emotional and behavioral difficulties. Formulation is central to the selection of surgical candidates and crucial to intervention planning. Clinical neuropsychology has a well-established role in postsurgical assessment of cognitive functioning and psychological, emotional, and behavioral outcomes, which is fundamental to evaluation on an individual and service level. The unique contribution clinical neuropsychology makes to pre- and postsurgical interventions is also highlighted. Finally, we discuss how clinical neuropsychology can promote clear and effective communication with patients and between professionals.
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Affiliation(s)
- Joseph A Mole
- a Russell Cairns Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - Simon J Prangnell
- a Russell Cairns Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust , Oxford , UK
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20
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Kubu CS, Ford PJ. Clinical Ethics in the Context of Deep Brain Stimulation for Movement Disorders. Arch Clin Neuropsychol 2017; 32:829-839. [PMID: 29028865 PMCID: PMC5860076 DOI: 10.1093/arclin/acx088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/30/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Discuss common clinical ethical challenges encountered in working with patients who are candidates for deep brain stimulation (DBS) for the treatment of motor symptoms of Parkinson's disease (PD). METHOD The relevant literature is reviewed and supplemented by descriptive, ethically challenging cases stemming from decades of combined experience working on DBS teams. We outline ethical arguments and provide pragmatic recommendations to assist neuropsychologists working in movement disorder teams. RESULTS The goals of the pre-operative neuropsychological DBS assessment include: (1) identification of potential cognitive risk factors; (2) identification of relevant neuropsychiatric or neurobehavioral factors; (3) assessment of level of family support; and (4) systematic assessment of patient's and family member's goals or expectations for DBS. The information gleaned from the pre-operative neuropsychological assessment is highly relevant to the most commonly studied clinical ethics challenges encountered in DBS: (1) assessment of risk/benefit; (2) determinations regarding inclusion/exclusion; (3) autonomy; and (4) patient's perception of benefit and quality of life. CONCLUSIONS Neuropsychologists are particularly well poised to provide unique and important insights to assist with developing the most ethically sound practices that take into account patient's values as well as fiduciary responsibilities to the patient, the team, the profession, and the broader community.
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Affiliation(s)
- Cynthia S Kubu
- Center for Neurological Restoration, Cleveland Clinic, OH, USA
- Department of Bioethics, Cleveland Clinic, OH, USA
- Department of Psychiatry and Psychology, Cleveland Clinic, OH, USA
| | - Paul J Ford
- Center for Neurological Restoration, Cleveland Clinic, OH, USA
- Department of Bioethics, Cleveland Clinic, OH, USA
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Volpini M, Giacobbe P, Cosgrove GR, Levitt A, Lozano AM, Lipsman N. The History and Future of Ablative Neurosurgery for Major Depressive Disorder. Stereotact Funct Neurosurg 2017; 95:216-228. [PMID: 28723697 DOI: 10.1159/000478025] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 06/05/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND There is an urgent need to develop safe and effective treatments for patients with treatment-resistant depression (TRD). Several neurosurgical procedures have been developed to treat the dysfunctional brain circuits implicated in major depression. OBJECTIVES This review describes the most common ablative procedures used to treat major depressive disorder: anterior cingulotomy, subcaudate tractotomy, limbic leucotomy, and anterior capsulotomy. The efficacy and safety of each are discussed and compared with other current and emerging modalities, including deep brain stimulation (DBS) and MR-guided focused ultrasound (MRgFUS). METHODS The PubMed and MEDLINE electronic databases were used in this study, through July 2016. Keywords, including "treatment resistant depression," and "ablative neurosurgery," etc. were used to generate reference hits. RESULTS Approximately a third to half of patients who underwent ablative procedures achieved a treatment response and/or remission. The efficacy and safety profiles corresponding to both ablative procedures and DBS were very similar. CONCLUSIONS The longitudinal experience with ablative procedures shows that there remains an important role for accurate, discrete lesions in disrupting affective circuitry in the treatment of TRD. New modalities, such as MRgFUS, have the potential to further improve the accuracy of ablative procedures, while enhancing safety by obviating the need for open brain surgery.
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Affiliation(s)
- Matthew Volpini
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
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Witt K. Identity change and informed consent. JOURNAL OF MEDICAL ETHICS 2017; 43:384-390. [PMID: 28320773 PMCID: PMC5520011 DOI: 10.1136/medethics-2016-103684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 01/10/2017] [Accepted: 01/25/2017] [Indexed: 06/06/2023]
Abstract
In this paper, I focus on a kind of medical intervention that is at the same time fascinating and disturbing: identity-changing interventions. My guiding question is how such interventions can be ethically justified within the bounds of contemporary bioethical mainstream that places great weight on the patient's informed consent. The answer that is standardly given today is that patients should be informed about the identity effects, thus suggesting that changes in identity can be treated like 'normal' side effects. In the paper, I argue that this approach is seriously lacking because it misses important complexities going along with decisions involving identity changes and consequently runs into mistakes. As a remedy I propose a new approach, the 'perspective-sensitive account', which avoids these mistakes and thus provides the conceptual resources to systematically reflect on and give a valid consent to identity-changing interventions.
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Klein E. Informed Consent in Implantable BCI Research: Identifying Risks and Exploring Meaning. SCIENCE AND ENGINEERING ETHICS 2016; 22:1299-1317. [PMID: 26497727 DOI: 10.1007/s11948-015-9712-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 10/19/2015] [Indexed: 06/05/2023]
Abstract
Implantable brain-computer interface (BCI) technology is an expanding area of engineering research now moving into clinical application. Ensuring meaningful informed consent in implantable BCI research is an ethical imperative. The emerging and rapidly evolving nature of implantable BCI research makes identification of risks, a critical component of informed consent, a challenge. In this paper, 6 core risk domains relevant to implantable BCI research are identified-short and long term safety, cognitive and communicative impairment, inappropriate expectations, involuntariness, affective impairment, and privacy and security. Work in deep brain stimulation provides a useful starting point for understanding this core set of risks in implantable BCI. Three further risk domains-risks pertaining to identity, agency, and stigma-are identified. These risks are not typically part of formalized consent processes. It is important as informed consent practices are further developed for implantable BCI research that attention be paid not just to disclosing core research risks but exploring the meaning of BCI research with potential participants.
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Affiliation(s)
- Eran Klein
- Department of Philosophy and Center for Sensorimotor Neural Engineering, University of Washington, Seattle, WA, USA.
- Department of Neurology, Oregon Health and Sciences University, Portland, OR, USA.
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Gardner J, Cribb A. The dispositions of things: the non-human dimension of power and ethics in patient-centred medicine. SOCIOLOGY OF HEALTH & ILLNESS 2016; 38:1043-57. [PMID: 27460832 PMCID: PMC5026057 DOI: 10.1111/1467-9566.12431] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This article explores power relations between clinicians, patients and families as clinicians engage in patient-centred ethical work. Specifically, we draw on actor-network theory to interrogate the role of non-human elements in distributing power relations in clinical settings, as clinicians attempt to manage the expectations of patients and families. Using the activities of a multidisciplinary team providing deep brain stimulation to children with severe movement disorders as an example, we illustrate how a patient-centred tool is implicated in establishing relations that constitute four modes of power: 'power over', 'power to', "power storage" and "power/discretion". We argue that understanding the role of non-human elements in structuring power relations can guide and inform bioethical discussions on the suitability of patient-centred approaches in clinical settings.
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Affiliation(s)
- John Gardner
- Science and Technology Studies UnitDepartment of SociologyUniversity of YorkYorkUK
| | - Alan Cribb
- Department of Education and Professional StudiesKings College LondonLondonUK
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Klein E, Goering S, Gagne J, Shea CV, Franklin R, Zorowitz S, Dougherty DD, Widge AS. Brain-computer interface-based control of closed-loop brain stimulation: attitudes and ethical considerations. BRAIN-COMPUTER INTERFACES 2016. [DOI: 10.1080/2326263x.2016.1207497] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Eran Klein
- Center for Sensorimotor Neural Engineering and Department of Philosophy, University of Washington, Seattle, WA, USA
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Sara Goering
- Center for Sensorimotor Neural Engineering and Department of Philosophy, University of Washington, Seattle, WA, USA
| | - Josh Gagne
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Conor V. Shea
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rachel Franklin
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Samuel Zorowitz
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Darin D. Dougherty
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Alik S. Widge
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Picower Institute for Learning & Memory, Massachusetts Institute of Technology, Boston, MA, USA
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Hariz GM, Limousin P, Hamberg K. "DBS means everything - for some time". Patients' Perspectives on Daily Life with Deep Brain Stimulation for Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2016; 6:335-47. [PMID: 27003786 PMCID: PMC4927913 DOI: 10.3233/jpd-160799] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 02/16/2016] [Indexed: 12/05/2022]
Affiliation(s)
- Gun-Marie Hariz
- Department of Community Medicine and Rehabilitation, Occupational Therapy, Umeå University, Umeå, Sweden
- Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Patricia Limousin
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK
| | - Katarina Hamberg
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
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28
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Ethical safety of deep brain stimulation: A study on moral decision-making in Parkinson's disease. Parkinsonism Relat Disord 2015; 21:709-16. [DOI: 10.1016/j.parkreldis.2015.04.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 03/03/2015] [Accepted: 04/13/2015] [Indexed: 01/10/2023]
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Klein E. Eloquent Brain, Ethical Challenges: Functional Brain Mapping in Neurosurgery. Semin Ultrasound CT MR 2015; 36:291-5. [PMID: 26233862 DOI: 10.1053/j.sult.2015.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Functional brain mapping is an increasingly relied upon tool in presurgical planning and intraoperative decision making. Mapping allows personalization of structure-function relationships when surgical or other treatment of pathology puts eloquent functioning like language or vision at risk. As an innovative technology, functional brain mapping holds great promise but also raises important ethical questions. In this article, recent work in neuroethics on functional imaging and functional neurosurgery is explored and applied to functional brain mapping. Specific topics discussed in this article are incidental findings, responsible innovation, and informed consent.
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Affiliation(s)
- Eran Klein
- Neurology Service, Portland VA Medical Center, Portland, OR; Department of Neurology, Oregon Health and Science University, Portland, OR; Department of Philosophy, University of Washington, Seattle, WA.
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Jiménez-Ponce F, García-Muñoz L, Carrillo-Ruiz J. The role of bioethics in the neurosurgical treatment of psychiatric disorders. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2015. [DOI: 10.1016/j.hgmx.2015.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Koivuniemi A, Otto K. When "altering brain function" becomes "mind control". Front Syst Neurosci 2014; 8:202. [PMID: 25352789 PMCID: PMC4196540 DOI: 10.3389/fnsys.2014.00202] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 09/24/2014] [Indexed: 11/25/2022] Open
Abstract
Functional neurosurgery has seen a resurgence of interest in surgical treatments for psychiatric illness. Deep brain stimulation (DBS) technology is the preferred tool in the current wave of clinical experiments because it allows clinicians to directly alter the functions of targeted brain regions, in a reversible manner, with the intent of correcting diseases of the mind, such as depression, addiction, anorexia nervosa, dementia, and obsessive compulsive disorder. These promising treatments raise a critical philosophical and humanitarian question. “Under what conditions does ‘altering brain function’ qualify as ‘mind control’?” In order to answer this question one needs a definition of mind control. To this end, we reviewed the relevant philosophical, ethical, and neurosurgical literature in order to create a set of criteria for what constitutes mind control in the context of DBS. We also outline clinical implications of these criteria. Finally, we demonstrate the relevance of the proposed criteria by focusing especially on serendipitous treatments involving DBS, i.e., cases in which an unintended therapeutic benefit occurred. These cases highlight the importance of gaining the consent of the subject for the new therapy in order to avoid committing an act of mind control.
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Affiliation(s)
| | - Kevin Otto
- Weldon School of Biomedical Engineering, Purdue University West Lafayette, IN, USA ; J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida Gainesville, FL, USA
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Nuttin B, Wu H, Mayberg H, Hariz M, Gabriëls L, Galert T, Merkel R, Kubu C, Vilela-Filho O, Matthews K, Taira T, Lozano AM, Schechtmann G, Doshi P, Broggi G, Régis J, Alkhani A, Sun B, Eljamel S, Schulder M, Kaplitt M, Eskandar E, Rezai A, Krauss JK, Hilven P, Schuurman R, Ruiz P, Chang JW, Cosyns P, Lipsman N, Voges J, Cosgrove R, Li Y, Schlaepfer T. Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders. J Neurol Neurosurg Psychiatry 2014; 85:1003-8. [PMID: 24444853 PMCID: PMC4145431 DOI: 10.1136/jnnp-2013-306580] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 11/30/2013] [Accepted: 12/18/2013] [Indexed: 12/02/2022]
Abstract
BACKGROUND For patients with psychiatric illnesses remaining refractory to 'standard' therapies, neurosurgical procedures may be considered. Guidelines for safe and ethical conduct of such procedures have previously and independently been proposed by various local and regional expert groups. METHODS To expand on these earlier documents, representative members of continental and international psychiatric and neurosurgical societies, joined efforts to further elaborate and adopt a pragmatic worldwide set of guidelines. These are intended to address a broad range of neuropsychiatric disorders, brain targets and neurosurgical techniques, taking into account cultural and social heterogeneities of healthcare environments. FINDINGS The proposed consensus document highlights that, while stereotactic ablative procedures such as cingulotomy and capsulotomy for depression and obsessive-compulsive disorder are considered 'established' in some countries, they still lack level I evidence. Further, it is noted that deep brain stimulation in any brain target hitherto tried, and for any psychiatric or behavioural disorder, still remains at an investigational stage. Researchers are encouraged to design randomised controlled trials, based on scientific and data-driven rationales for disease and brain target selection. Experienced multidisciplinary teams are a mandatory requirement for the safe and ethical conduct of any psychiatric neurosurgery, ensuring documented refractoriness of patients, proper consent procedures that respect patient's capacity and autonomy, multifaceted preoperative as well as postoperative long-term follow-up evaluation, and reporting of effects and side effects for all patients. INTERPRETATION This consensus document on ethical and scientific conduct of psychiatric surgery worldwide is designed to enhance patient safety.
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Affiliation(s)
- Bart Nuttin
- Research Group of Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Leuven, Belgium
- Chair of Committee of Neurosurgery for Psychiatric Disorders of the WSSFN and Department of Neurosurgery, UZ Leuven, Leuven, Belgium
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
| | - Hemmings Wu
- Research Group of Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Helen Mayberg
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA
| | - Marwan Hariz
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Clinical Neuroscience, UCL Institute of Neurology, Queen Square, London, Umea University, Umea, Sweden
| | - Loes Gabriëls
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Chair of the Committee of Neurosurgery for Psychiatric Disorders, Belgium and Belgium and Department of Psychiatry, UZ Leuven, Leuven, Belgium
| | - Thorsten Galert
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Deutsches Referenzzentrum für Ethik in den Biowissenschaften, Bonn, Germany
| | - Reinhard Merkel
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Universität Hamburg/Juristische Fakultät Lehrstuhl für Strafrecht und Rechtsphilosophie, Hamburg, Germany
| | - Cynthia Kubu
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Osvaldo Vilela-Filho
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosciences, Institute of Neurology of Goiânia, Stereotactic and Functional Neurosurgery Service, Medical School, Federal University of Goiás, Medical School, Pontifical Catholic University of Goiás, Goiânia, Brazil
| | - Keith Matthews
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Advanced Interventions Service and Division of Neuroscience, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Takaomi Taira
- Past-president of WSSFN and Chair of Committee of Stereotactic and Functional Neurosurgery, World Federation of Neurosurgical Societies (WFNS), and Department of Neurosurgery, World Federation of Neurosurgical Societies (WFNS), Tokyo Women's Medical University, Tokyo, Japan
| | - Andres M Lozano
- Past-president of WSSFN and Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Gastón Schechtmann
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosurgery and Clinical Neuroscience, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Paresh Doshi
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Stereotactic and Functional Neurosurgery Program, Jaslok Hospital and Research Centre, Mumbai, India
| | - Giovanni Broggi
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosurgery, Instituto Neurologico C. Besta, Milano, Italy
| | - Jean Régis
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Functional Neurosurgery, Hôpital La Timone, Aix-Marseille Université, Marseille, France
| | - Ahmed Alkhani
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosciences, King Faisal Specialist Hospital and Research Centre, AlFaisal University, Riyadh, Saudi Arabia
| | - Bomin Sun
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Center for Functional Neurosurgery, Shanghai Jiao Tong University Rui Jin Hospital, Shanghai, China
| | - Sam Eljamel
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Centre of Neurosciences Department of Neurosurgery, Ninewells Hospital and Medical School Dundee, Dundee, Scotland, UK
| | - Michael Schulder
- Department of Neurosurgery, Hofstra North Shore LIJ School of Medicine, North Shore University Hospital, Manhasset, NY, USA
| | - Michael Kaplitt
- Member of the Psychiatric Surgery Committee of the ASSFN and Department of Neurological Surgery, Weill Cornell Medical College, NY, USA
| | - Emad Eskandar
- Member of the Psychiatric Surgery Committee of the ASSFN and Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Rezai
- Past President, American Society of Stereotactic and Functional Neurosurgery (ASSFN), Department of Neurosurgery, American Society of Stereotactic and Functional Neurosurgery (ASSFN), Ohio State University, Ohio, USA
| | - Joachim K Krauss
- President of ESSFN and WSSFN, Department of Neurosurgery, Medical University of Hannover, Hannover, Germany
| | | | - Rick Schuurman
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Pedro Ruiz
- President of WPA, Department of Psychiatry and Behavioral Sciences, Miami Miller School of Medicine, Miami, USA
| | - Jin Woo Chang
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- President of Asian Australasian Society for Stereotactic & Functional Neurosurgery Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Paul Cosyns
- Committee of Neurosurgery for Psychiatric Disorders, Belgium, Kortenberg, Belgium
| | - Nir Lipsman
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Juergen Voges
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University Magdeburg and Leibniz-Institute for Neurobiology, Magdeburg, Germany
| | - Rees Cosgrove
- WSSFN Committee on Neurosurgery for Psychiatric Disorders
- Department of Neurosurgery, Brown University, Providence, RI, USA
| | - Yongjie Li
- Department of Neurosurgery, Xuanwu Hospital, Beijing, China
| | - Thomas Schlaepfer
- Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’. This Working Group is organised by the Europäische Akademie GmbH (Bad Neuenahr-Ahrweiler, Germany, http://www.ea-aw.de). It consists of an interdisciplinary and international team of neurosurgeons, neurologists, psychiatrists, neuropsychologists, bioethicists, philosophers and legal scholars, analysing ethical issues arising from the application of Deep Brain Stimulation for Psychiatric Disorders. Questions such as critical issues around regulatory processes and ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation have been comprehensively studied and the results have been published under common authorship
- Chair of the Focus Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’, Chair of the Task Force on Brain Stimulation of the World Federations of Societies of Biological Psychiatry, Chair of the Section of Experimental Brain Stimulation Methods of the German Association of Psychiatry, Psychotherapy and Psychosomatics and member of the Operational Committee on Sections of the World Psychiatric Association. He is professor of Psychiatry and Psychotherapy at the University of Bonn, Germany, and Associate Professor of Psychiatry and Mental Health at The Johns Hopkins University, Baltimore, MD, USA
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Abstract
Neuroethics Now welcomes papers addressing the ethical application of neuroscience in research and patient care, as well as its impact on society.
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Trimper JB, Wolpe PR, Rommelfanger KS. When "I" becomes "We": ethical implications of emerging brain-to-brain interfacing technologies. FRONTIERS IN NEUROENGINEERING 2014; 7:4. [PMID: 24575002 PMCID: PMC3921579 DOI: 10.3389/fneng.2014.00004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 01/25/2014] [Indexed: 11/30/2022]
Affiliation(s)
- John B Trimper
- Department of Psychology, Emory University Atlanta, GA, USA
| | - Paul Root Wolpe
- Neuroethics Program, Center for Ethics, Emory University Atlanta, GA, USA ; Departments of Medicine and Pediatrics, Emory University Atlanta, GA, USA
| | - Karen S Rommelfanger
- Neuroethics Program, Center for Ethics, Emory University Atlanta, GA, USA ; Department of Neurology, Emory University Atlanta, GA, USA
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Johansson V, Garwicz M, Kanje M, Halldenius L, Schouenborg J. Thinking Ahead on Deep Brain Stimulation: An Analysis of the Ethical Implications of a Developing Technology. AJOB Neurosci 2014; 5:24-33. [PMID: 24587963 PMCID: PMC3933012 DOI: 10.1080/21507740.2013.863243] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Deep brain stimulation (DBS) is a developing technology. New generations of DBS technology are already in the pipeline, yet this particular fact has been largely ignored among ethicists interested in DBS. Focusing only on ethical concerns raised by the current DBS technology is, albeit necessary, not sufficient. Since current bioethical concerns raised by a specific technology could be quite different from the concerns it will raise a couple of years ahead, an ethical analysis should be sensitive to such alterations, or it could end up with results that soon become dated. The goal of this analysis is to address these changing bioethical concerns, to think ahead on upcoming and future DBS concerns both in terms of a changing technology and changing moral attitudes. By employing the distinction between inherent and noninherent bioethical concerns we identify and make explicit the particular limits and potentials for change within each category, respectively, including how present and upcoming bioethical concerns regarding DBS emerge and become obsolete. Many of the currently identified ethical problems with DBS, such as stimulation-induced mania, are a result of suboptimal technology. These challenges could be addressed by technical advances, while for instance perceptions of an altered body image caused by the mere awareness of having an implant may not. Other concerns will not emerge until the technology has become sophisticated enough for new uses to be realized, such as concerns on DBS for enhancement purposes. As a part of the present analysis, concerns regarding authenticity are used as an example.
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Marceglia S, Fumagalli M, Priori A. What neurophysiological recordings tell us about cognitive and behavioral functions of the human subthalamic nucleus. Expert Rev Neurother 2014; 11:139-49. [DOI: 10.1586/ern.10.184] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ethical considerations in deep brain stimulation for psychiatric illness. J Clin Neurosci 2014; 21:1-5. [DOI: 10.1016/j.jocn.2013.04.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 04/05/2013] [Accepted: 04/06/2013] [Indexed: 01/03/2023]
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Maier F, Lewis CJ, Horstkoetter N, Eggers C, Kalbe E, Maarouf M, Kuhn J, Zurowski M, Moro E, Woopen C, Timmermann L. Patients' expectations of deep brain stimulation, and subjective perceived outcome related to clinical measures in Parkinson's disease: a mixed-method approach. J Neurol Neurosurg Psychiatry 2013; 84:1273-81. [PMID: 23715910 DOI: 10.1136/jnnp-2012-303670] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To study patients' expectations of subthalamic deep brain stimulation (STN-DBS) and their subjective perceived outcome, by using qualitative and quantitative methods in Parkinson's disease (PD). METHODS PD patients were prospectively examined before and 3 months after surgery. Semistructured interviews regarding preoperative expectations and postsurgical subjective perceived outcome were conducted. These were analysed using content analysis. For statistical analyses, patients were classified according to their subjective perceived outcome, resulting in three different subjective outcome groups (negative, mixed, positive outcome). The groups were used for multiple comparisons between and within each group regarding motor impairment, quality of life (QoL), neuropsychiatric status and cognitive functioning, using standard instruments. A logistic regression analysis was conducted to find predictors of subjective negative outcome. Receiver operating characteristic curves were used to analyse cut-off scores for predictive tests. RESULTS Of the 30 PD patients participating, 8 had a subjective negative outcome, 8 a mixed and 14 a positive outcome. All groups significantly improved in motor functioning. Patients with subjective negative outcome were characterised by preoperative unrealistic expectations, no postsurgical improvement in QoL, and significantly higher presurgical and postsurgical apathy and depression scores. Higher preoperative apathy and depression scores were significant predictors of negative subjective outcome. Cut-off scores for apathy and depression were identified. CONCLUSIONS The mixed-method approach proved useful in examining a patient's subjective perception of STN-DBS outcome. Our results show that significant motor improvement does not necessarily lead to a positive subjective outcome. Moreover, PD patients should be screened carefully before surgery regarding apathy and depression. (DRKS-ID: DRKS00003221).
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Affiliation(s)
- Franziska Maier
- Department of Neurology, University of Cologne, , Cologne, Germany
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Williams NR, Okun MS. Deep brain stimulation (DBS) at the interface of neurology and psychiatry. J Clin Invest 2013; 123:4546-56. [PMID: 24177464 DOI: 10.1172/jci68341] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Deep brain stimulation (DBS) is an emerging interventional therapy for well-screened patients with specific treatment-resistant neuropsychiatric diseases. Some neuropsychiatric conditions, such as Parkinson disease, have available and reasonable guideline and efficacy data, while other conditions, such as major depressive disorder and Tourette syndrome, have more limited, but promising results. This review summarizes both the efficacy and the neuroanatomical targets for DBS in four common neuropsychiatric conditions: Parkinson disease, Tourette syndrome, major depressive disorder, and obsessive-compulsive disorder. Based on emerging new research, we summarize novel approaches to optimization of stimulation for each neuropsychiatric disease and we review the potential positive and negative effects that may be observed following DBS. Finally, we summarize the likely future innovations in the field of electrical neural-network modulation.
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Alam M, Chen X, Fernandez E. A low-cost multichannel wireless neural stimulation system for freely roaming animals. J Neural Eng 2013; 10:066010. [DOI: 10.1088/1741-2560/10/6/066010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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A history of deep brain stimulation: Technological innovation and the role of clinical assessment tools. SOCIAL STUDIES OF SCIENCE 2013. [PMCID: PMC3785222 DOI: 10.1177/0306312713483678] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Deep brain stimulation involves using a pacemaker-like device to deliver constant electrical stimulation to problematic areas within the brain. It has been used to treat over 40,000 people with Parkinson’s disease and essential tremor worldwide and is currently undergoing clinical trials as a treatment for depression and obsessive–compulsive disorder. This article will provide an historical account of deep brain stimulation in order to illustrate the plurality of interests involved in the development and stabilization of deep brain stimulation technology. Using Latour’s notion of immutable mobiles, this article will illustrate the importance of clinical assessment tools in shaping technological development in the era of medical device regulation. Given that such tools can serve commercial and professional interests, this article suggests that it is necessary to scrutinise their application in research contexts to ensure that they capture clinical changes that are meaningful for patients and their families. This is particularly important in relation to potentially ethically problematic therapies such as deep brain stimulation for psychiatric disorders.
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Abstract
Optogenetics field of optogenetics has provided new insight into neuronal communication and complex brain function. Now, scientists eagerly anticipate clinical application of this technology, with the hope that it will help improve treatments for various neurological disorders. However, the translational hurdles are high. In this Perspective, we highlight the technical, practical, and regulatory hurdles that lie ahead along the path towards making optogenetic neuromodulation therapies a reality in the clinic.
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Affiliation(s)
- Justin C Williams
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI 53706, USA.
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Jebari K, Hansson SO. European public deliberation on brain machine interface technology: five convergence seminars. SCIENCE AND ENGINEERING ETHICS 2013; 19:1071-1086. [PMID: 23263902 DOI: 10.1007/s11948-012-9425-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 12/10/2012] [Indexed: 06/01/2023]
Abstract
We present a novel procedure to engage the public in ethical deliberations on the potential impacts of brain machine interface technology. We call this procedure a convergence seminar, a form of scenario-based group discussion that is founded on the idea of hypothetical retrospection. The theoretical background of this procedure and the results of five seminars are presented.
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Affiliation(s)
- Karim Jebari
- Royal Institute of Technology, Stockholm, Sweden.
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Clausen J. Bonding Brains to Machines: Ethical Implications of Electroceuticals for the Human Brain. NEUROETHICS-NETH 2013. [DOI: 10.1007/s12152-013-9186-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ethics of the electrified mind: defining issues and perspectives on the principled use of brain stimulation in medical research and clinical care. Brain Topogr 2013; 27:33-45. [PMID: 23733209 DOI: 10.1007/s10548-013-0296-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 05/15/2013] [Indexed: 12/19/2022]
Abstract
In recent years, non-pharmacologic approaches to modifying human neural activity have gained increasing attention. One of these approaches is brain stimulation, which involves either the direct application of electrical current to structures in the nervous system or the indirect application of current by means of electromagnetic induction. Interventions that manipulate the brain have generally been regarded as having both the potential to alleviate devastating brain-related conditions and the capacity to create unforeseen and unwanted consequences. Hence, although brain stimulation techniques offer considerable benefits to society, they also raise a number of ethical concerns. In this paper we will address various dilemmas related to brain stimulation in the context of clinical practice and biomedical research. We will survey current work involving deep brain stimulation, transcranial magnetic stimulation and transcranial direct current stimulation. We will reflect upon relevant similarities and differences between them, and consider some potentially problematic issues that may arise within the framework of established principles of medical ethics: nonmaleficence and beneficence, autonomy, and justice.
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Rogers WA, Johnson J. Addressing within-role conflicts of interest in surgery. JOURNAL OF BIOETHICAL INQUIRY 2013; 10:219-225. [PMID: 23519587 DOI: 10.1007/s11673-013-9431-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 12/10/2012] [Indexed: 06/01/2023]
Abstract
In this paper we argue that surgeons face a particular kind of within-role conflict of interests, related to innovation. Within-role conflicts occur when the conflicting interests are both legitimate goals of professional activity. Innovation is an integral part of surgical practice but can create within-role conflicts of interest when innovation compromises patient care in various ways, such as by extending indications for innovative procedures or by failures of informed consent. The standard remedies for conflicts of interest are transparency and recusal, which are unlikely to address this conflict, in part because of unconscious bias. Alternative systemic measures may be more effective, but these require changes in the culture of surgery and accurate identification of surgical innovation.
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Affiliation(s)
- Wendy A Rogers
- Philosophy Department and Australian School of Advanced Medicine, Macquarie University, Sydney, NSW 2109, Australia.
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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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Gionfriddo MR, Greenberg AJ, Wahegaonkar AL, Lee KH. Pathways of translation: deep brain stimulation. Clin Transl Sci 2013; 6:497-501. [PMID: 24330698 DOI: 10.1111/cts.12055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Electrical stimulation of the brain has a 2000 year history. Deep brain stimulation (DBS), one form of neurostimulation, is a functional neurosurgical approach in which a high-frequency electrical current stimulates targeted brain structures for therapeutic benefit. It is an effective treatment for certain neuropathologic movement disorders and an emerging therapy for psychiatric conditions and epilepsy. Its translational journey did not follow the typical bench-to-bedside path, but rather reversed the process. The shift from ancient and medieval folkloric remedy to accepted medical practice began with independent discoveries about electricity during the 19th century and was fostered by technological advances of the 20th. In this paper, we review that journey and discuss how the quest to expand its applications and improve outcomes is taking DBS from the bedside back to the bench.
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Affiliation(s)
- Michael R Gionfriddo
- Mayo Graduate School, Mayo Clinic Center for Translational Science Activities, Rochester, Minnesota, USA
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Bell E, Racine E. Ethics guidance for neurological and psychiatric deep brain stimulation. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:313-25. [DOI: 10.1016/b978-0-444-53497-2.00026-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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