Brainjacking: Implant Security Issues in Invasive Neuromodulation

A Novel Closed-Loop Electrical Brain Stimulation Device Featuring Wireless Low-Energy Ultrasound Power and Communication

OBJECTIVES

This study aimed to indicate the feasibility of a prototype electrical neuromodulation system using a closed-loop energy-efficient ultrasound-based mechanism for communication, data transmission, and recharging.

MATERIALS AND METHODS

Closed-loop deep brain stimulation (DBS) prototypes were designed and fabricated with ultrasonic wideband (UsWB) communication technology and miniaturized custom electronics. Two devices were implanted short term in anesthetized Göttingen minipigs (N = 2). Targeting was performed using preoperative magnetic resonance imaging, and locations were confirmed postoperatively by computerized tomography. DBS systems were tested over a wide range of stimulation settings to mimic minimal, typical, and/or aggressive clinical settings, and evaluated for their ability to transmit data through scalp tissue and to recharge the DBS system using UsWB.

RESULTS

Stimulation, communication, reprogramming, and recharging protocols were successfully achieved in both subjects for amplitude (1V-6V), frequency (50-250 Hz), and pulse width (60-200 μs) settings and maintained for ≥six hours. The precision of pulse settings was verified with <5% error. Communication rates of 64 kbit/s with an error rate of 0.05% were shown, with no meaningful throughput degradation observed. Time to recharge to 80% capacity was <9 minutes. Two DBS systems also were implanted in the second test animal, and independent bilateral stimulation was successfully shown.

CONCLUSIONS

The system performed at clinically relevant implant depths and settings. Independent bilateral stimulation for the duration of the study with a 4F energy storage and full rapid recharge were achieved. Continuous function extrapolates to six days of continuous stimulation in future design iterations implementing application specific integrated circuit level efficiency and 15F storage capacitance. UsWB increases energy efficiency, reducing storage requirements and thereby enabling device miniaturization. The device can enable intelligent closed-loop stimulation, remote system monitoring, and optimization and can serve as a power/data gateway to interconnect the intrabody network with the Internet of Medical Things.

What an International Declaration on Neurotechnologies and Human Rights Could Look like: Ideas, Suggestions, Desiderata

International institutions such as UNESCO are deliberating on a new standard setting instrument for neurotechnologies. This will likely lead to the adoption of a soft law document which will be the first global document specifically tailored to neurotechnologies, setting the tone for further international or domestic regulations. While some stakeholders have been consulted, these developments have so far evaded the broader attention of the neuroscience, neurotech, and neuroethics communities. To initiate a broader debate, this target article puts to discussion twenty-five considerations and desiderata for recognition by a future instrument. They are formulated at different levels of abstraction, from the big picture to technical details, seek to widen the perspective of preparatory reports and transcend the narrow debate about "neurorights" which overshadows many richer and more relevant aspects. These desiderata are not an exhaustive enumeration but a starting point for discussions about what deserves and what requires protection by an international instrument.

Mechanical behavior and microstructure of porcine brain tissues under pulsed electric fields

Pulsed electric fields are extensively utilized in clinical treatments, such as subthalamic deep brain stimulation, where electric field loading is in direct contact with brain tissue. However, the alterations in brain tissue's mechanical properties and microstructure due to changes in electric field parameters have not received adequate attention. In this study, the mechanical properties and microstructure of the brain tissue under pulsed electric fields were focused on. Herein, a custom indentation device was equipped with a module for electric field loading. Parameters such as pulse amplitude and frequency were adjusted. The results demonstrated that following an indentation process lasting 5 s and reaching a depth of 1000 μm, and a relaxation process of 175 s, the average shear modulus of brain tissue was reduced, and viscosity decreased. At the same amplitude, high-frequency pulsed electric fields had a smaller effect on brain tissue than low-frequency ones. Furthermore, pulsed electric fields induced cell polarization and reduced the proteoglycan concentration in brain tissue. As pulse frequency increased, cell polarization diminished, and proteoglycan concentration decreased significantly. High-frequency pulsed electric fields applied to brain tissue were found to reduce impedance fluctuation amplitude. This study revealed the effect of pulsed electric fields on the mechanical properties and microstructure of ex vivo brain tissue, providing essential information to promote the advancement of brain tissue electrotherapy in clinical settings.

Simulation-based research for digital health pathologies: A multi-site mixed-methods study

Background

The advance of digital health technologies has created new forms of potential pathology which are not captured in current clinical guidelines. Through simulation-based research, we have identified the challenges to clinical care that emerge when patients suffer from illnesses stemming from failures in digital health technologies.

Methods

Clinical simulation sessions were designed based on patient case reports relating to (a) medical device hardware errors, (b) medical device software errors, (c) complications of consumer technology and (d) technology-facilitated abuse. Clinicians were recruited to participate in simulations at three UK hospitals; audiovisual suites were used to facilitate group observation of simulation experience and focused debrief discussions. Invigilators scored clinicians on performance, clinicians provided individual qualitative and quantitative feedback, and extensive notes were taken throughout.

Findings

Paired t-tests of pre and post-simulation feedback demonstrated significant improvements in clinician's diagnostic awareness, technical knowledge and confidence in clinical management following simulation exposure (p < 0.01). Barriers to care included: (a) low suspicion of digital agents, (b) attribution to psychopathology, (c) lack of education in technical mechanisms and (d) little utility of available tests. Suggested interventions for improving future practice included: (a) education initiatives, (b) technical support platforms, (c) digitally oriented assessments in hospital workflows, (d) cross-disciplinary staff and (e) protocols for digital cases.

Conclusion

We provide an effective framework for simulation training focused on digital health pathologies and uncover barriers that impede effective care for patients dependent on technology. Our recommendations are relevant to educators, practising clinicians and professionals working in regulation, policy and industry.

Security vulnerabilities in healthcare: an analysis of medical devices and software

The integration of IoT in healthcare has introduced vulnerabilities in medical devices and software, posing risks to patient safety and system integrity. This study aims to bridge the research gap and provide valuable insights for addressing healthcare vulnerabilities and their mitigation mechanisms. Software vulnerabilities related to health systems from 2001 to 2022 were collected from the National Vulnerability Database (NVD) systematized by software developed by the researchers and assessed by a medical specialist for their impact on patient well-being. The analysis revealed electronic health records, wireless infusion pumps, endoscope cameras, and radiology information systems as the most vulnerable. In addition, critical vulnerabilities were identified, including poor credential management and hard-coded credentials. The investigation provides some insights into the consequences of vulnerabilities in health software products, projecting future security issues by 2025, offers mitigation suggestions, and highlights trends in attacks on life support and health systems are also provided. The healthcare industry needs significant improvements in protecting medical devices from cyberattacks. Securing communication channels and network schema and adopting secure software practices is necessary. In addition, collaboration, regulatory adherence, and continuous security monitoring are crucial. Industries, researchers, and stakeholders can utilize these findings to enhance security and safeguard patient safety.

Cybersecurity in neural interfaces: Survey and future trends

With the joint advancement in areas such as pervasive neural data sensing, neural computing, neuromodulation and artificial intelligence, neural interface has become a promising technology facilitating both the closed-loop neurorehabilitation for neurologically impaired patients and the intelligent man-machine interactions for general application purposes. However, although neural interface has been widely studied, few previous studies focused on the cybersecurity issues in related applications. In this survey, we systematically investigated possible cybersecurity risks in neural interfaces, together with potential solutions to these problems. Importantly, our survey considers interfacing techniques on both central nervous systems (i.e., brain-computer interfaces) and peripheral nervous systems (i.e., general neural interfaces), covering diverse neural modalities such as electroencephalography, electromyography and more. Moreover, our survey is organized on three different levels: (1) the data level, which mainly focuses on the privacy leakage issue via attacking and analyzing neural database of users; (2) the permission level, which mainly focuses on the prospects and risks to directly use real time neural signals as biometrics for continuous and unobtrusive user identity verification; and (3) the model level, which mainly focuses on adversarial attacks and defenses on both the forward neural decoding models (e.g. via machine learning) and the backward feedback implementation models (e.g. via neuromodulation and stimulation). This is the first study to systematically investigate cybersecurity risks and possible solutions in neural interfaces which covers both central and peripheral nervous systems, and considers multiple different levels to provide a complete picture of this issue.

Flexible Electrodes for Brain-Computer Interface System

Brain-computer interface (BCI) has been the subject of extensive research recently. Governments and companies have substantially invested in relevant research and applications. The restoration of communication and motor function, the treatment of psychological disorders, gaming, and other daily and therapeutic applications all benefit from BCI. The electrodes hold the key to the essential, fundamental BCI precondition of electrical brain activity detection and delivery. However, the traditional rigid electrodes are limited due to their mismatch in Young's modulus, potential damages to the human body, and a decline in signal quality with time. These factors make the development of flexible electrodes vital and urgent. Flexible electrodes made of soft materials have grown in popularity in recent years as an alternative to conventional rigid electrodes because they offer greater conformance, the potential for higher signal-to-noise ratio (SNR) signals, and a wider range of applications. Therefore, the latest classifications and future developmental directions of fabricating these flexible electrodes are explored in this paper to further encourage the speedy advent of flexible electrodes for BCI. In summary, the perspectives and future outlook for this developing discipline are provided.

A Real-Time Non-Implantation Bi-Directional Brain-Computer Interface Solution Without Stimulation Artifacts

The non-implantation bi-directional brain-computer interface (BCI) is a neural interface technology that enables direct two-way communication between the brain and the external world by both "reading" neural signals and "writing" stimulation patterns to the brain. This technology has vast potential applications, such as improving the quality of life for individuals with neurological and mental illnesses and even expanding the boundaries of human capabilities. Nonetheless, non-implantation bi-directional BCIs face challenges in generating real-time feedback and achieving compatibility between stimulation and recording. These issues arise due to the considerable overlap between electrical stimulation frequencies and electrophysiological recording frequencies, as well as the impediment caused by the skull to the interaction of external and internal currents. To address those challenges, this work proposes a novel solution that combines the temporal interference stimulation paradigm and minimally invasive skull modification. A longitudinal animal experiment has preliminarily validated the feasibility of the proposed method. In signal recording experiments, the average impedance of our scheme decreased by 4.59 kΩ , about 67%, compared to the conventional technique at 18 points. The peak-to-peak value of the Somatosensory Evoked Potential increased by 8%. Meanwhile, the signal-to-noise ratio of Steady-State Visual Evoked Potential increased by 5.13 dB, and its classification accuracy increased by 44%. The maximum bandwidth of the resting state rose by 63%. In electrical stimulation experiments, the signal-to-noise ratio of the low-frequency response evoked by our scheme rose by 8.04 dB, and no stimulation artifacts were generated. The experimental results show that signal quality in acquisition has significantly improved, and frequency-band isolation eliminates stimulation artifacts at the source. The acquisition and stimulation pathways are real-time compatible in this non-implantation bi-directional BCI solution, which can provide technical support and theoretical guidance for creating closed-loop adaptive systems coupled with particular application scenarios in the future.

CYBER-AIDD: A novel approach to implementing improved cyber security resilience for large Australian healthcare providers using a Unified Modelling Language ontology

Purpose

This paper proposes a novel cyber security risk governance framework and ontology for large Australian healthcare providers, using the structure and simplicity of the Unified Modelling Language (UML). This framework is intended to mitigate impacts from the risk areas of: (1) cyber-attacks, (2) incidents, (3) data breaches, and (4) data disclosures.

Methods

Using a mixed-methods approach comprised of empirical evidence discovery and phenomenological review, existing literature is sourced to confirm baseline ontological definitions. These are supplemented with Australian government reports, professional standards publications and legislation covering cyber security, data breach reporting and healthcare governance. Historical examples of healthcare cyber security incidents are reviewed, and a cyber risk governance UML presented to manage the defined problem areas via a single, simplified ontological diagram.

Results

A clear definition of 'cyber security' is generated, along with the 'CYBER-AIDD' risk model. Specific examples of cyber security incidents impacting Australian healthcare are confirmed as N = 929 over 5 years, with human factors the largest contributor. The CYBER-AIDD UML model presents a workflow across four defined classes, providing a clear approach to implementing the controls required to mitigate risks against verified threats.

Conclusions

The governance of cyber security in healthcare is complex, in part due to a lack of clarity around key terms and risks, and this is contributing to consistently poor operational outcomes. A focus on the most essential avenues of risk, using a simple UML model, is beneficial in describing these risks and designing governance controls around them.

NFC-Powered Implantable Device for On-Body Parameters Monitoring With Secure Data Exchange Link to a Medical Blockchain Type of Network

Implantable devices represent the future of remote medical monitoring and administration of both chemical and physical therapies to the patients. Although some of these devices are already in the market, the security mechanisms deployed inside them to withstand deliberate external influence are still decades away from the robust digital data security schemes employed in modern distributed networks these days. Medical data theft, spoofing, and disclosure pose serious threats that can ultimately lead to individual and social stigmas or even death. In this article, we present a small-form and batteryless implantable device with acquisition channels for biopotential (30-dB gain and 16-Hz bandwidth), arterial pulse oximetry, and temperature (0.12°C accuracy) recordings, suitable for cardiovascular, neuronal, and endocrine parameters assessment. The proposed device is powered by the near-field communication (NFC) interface with an external mobile phone, with a power consumption of 0.9 mW and achieving the full operation for distances close to 1 cm under the skin. In situ encryption of the acquired physiological signals is performed by a lightweight and short-term symmetric-key distribution scheme with data stream hopping, in order to ensure secure data transference over the air between the patient and trusted entities only, complemented by data storage, processing, and recovery through a medical blockchain type of network that involves the main stakeholders inside a medical community.

When brain devices go wrong: a patient with a malfunctioning deep brain stimulator (DBS) presents to the emergency department

A man in his 50s attended the emergency department with an acute deterioration in his Parkinson's symptoms, presenting with limb rigidity, widespread tremor, choreiform dyskinesia, dysarthria, intense sadness and a severe occipital headache. After excluding common differentials for sudden-onset parkinsonism (eg, infection, medication change), an error on the patient's deep brain stimulator was noted. The patient's symptoms only resolved once he was transferred to the specialist centre so that the programmer could reset the device settings. Due to COVID-19-related bed pressures on the ward, there was a delay in the patient receiving specialist attention-highlighting the need for non-specialist training in the emergency management of device errors.

Developments in the mechanistic understanding and clinical application of deep brain stimulation for Parkinson's disease

INTRODUCTION. Deep brain stimulation (DBS) is a life-changing treatment for patients with Parkinson's disease (PD) and gives the unique opportunity to directly explore how basal ganglia work. Despite the rapid technological innovation of the last years, the untapped potential of DBS is still high.

AREAS COVERED. This review summarizes the developments in the mechanistic understanding of DBS and the potential clinical applications of cutting-edge technological advances. Rather than a univocal local mechanism, DBS exerts its therapeutic effects through several multimodal mechanisms and involving both local and network-wide structures, although crucial questions remain unexplained. Nonetheless, new insights in mechanistic understanding of DBS in PD have provided solid bases for advances in preoperative selection phase, prediction of motor and non-motor outcomes, leads placement and postoperative stimulation programming.

EXPERT OPINION. DBS has not only strong evidence of clinical effectiveness in PD treatment, but technological advancements are revamping its role of neuromodulation of brain circuits and key to better understanding PD pathophysiology. In the next few years, the worldwide use of new technologies in clinical practice will provide large data to elucidate their role and to expand their applications for PD patients, providing useful insights to personalize DBS treatment and follow-up.

Ethical Considerations in the Implantation of Neuromodulatory Devices

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.

Ethical considerations in the surgical and neuromodulatory treatment of epilepsy

Surgical resection and neuromodulation are well-established treatments for those with medically refractory epilepsy. These treatments entail important ethical considerations beyond those which extend to the treatment of epilepsy generally. In this paper, the authors explore these unique considerations through a framework that relates foundational principles of bioethics to features of resective epilepsy surgery and neuromodulation. The authors conducted a literature review to identify ethical considerations for a variety of epilepsy surgery procedures and to examine how foundational principles in bioethics may inform treatment decisions. Healthcare providers should be cognizant of how an increased prevalence of somatic and psychiatric comorbidities, the dynamic nature of symptom burden over time, the individual and systemic barriers to treatment, and variable sociocultural contexts constitute important ethical considerations regarding the use of surgery or neuromodulation for the treatment of epilepsy. Moreover, careful attention should be paid to how resective epilepsy surgery and neuromodulation relate to notions of patient autonomy, safety and privacy, and the shared responsibility for device management and maintenance. A three-tiered approach-(1) gathering information and assessing the risks and benefits of different treatment options, (2) clear communication with patient or proxy with awareness of patient values and barriers to treatment, and (3) long-term decision maintenance through continued identification of gaps in understanding and provision of information-allows for optimal treatment of the individual person with epilepsy while minimizing disparities in epilepsy care.

Deep brain stimulation and electromagnetic interference

Deep brain stimulation (DBS) has evolved into an approved and efficacious treatment for movement, obsessive-compulsive, and epilepsy disorders that are refractory to medical therapy, with current investigation into other disease conditions. However, there are unintentional and intentional sources of external electromagnetic interference (EMI) that can lead to either malfunctioning or damaged DBS devices, as well as injury to human tissue. Comprehensive studies and guidelines on such topics in the medical literature are scarce. Herein, we review the principles behind EMI, as well as the various potential sources of interference, both unintentional (e.g. stray EMI fields) and intentional (e.g. MRI scans, "brainjacking"). Additionally, we employ the Manufacturer and User Device Facility Experience (MAUDE) database to assess real-world instances of EMI (e.g., airport body scanners, magnetic resonance imaging (MRI), and electrosurgery) affecting DBS devices commonly implanted in the United States (US).

Assessing the Risks Posed by the Convergence of Artificial Intelligence and Biotechnology

Rapid developments are currently taking place in the fields of artificial intelligence (AI) and biotechnology, and applications arising from the convergence of these 2 fields are likely to offer immense opportunities that could greatly benefit human health and biosecurity. The combination of AI and biotechnology could potentially lead to breakthroughs in precision medicine, improved biosurveillance, and discovery of novel medical countermeasures as well as facilitate a more effective public health emergency response. However, as is the case with many preceding transformative technologies, new opportunities often present new risks in parallel. Understanding the current and emerging risks at the intersection of AI and biotechnology is crucial for health security specialists and unlikely to be achieved by examining either field in isolation. Uncertainties multiply as technologies merge, showcasing the need to identify robust assessment frameworks that could adequately analyze the risk landscape emerging at the convergence of these 2 domains.This paper explores the criteria needed to assess risks associated with Artificial intelligence and biotechnology and evaluates 3 previously published risk assessment frameworks. After highlighting their strengths and limitations and applying to relevant Artificial intelligence and biotechnology examples, the authors suggest a hybrid framework with recommendations for future approaches to risk assessment for convergent technologies.

Neuromodulatory hacking: a review of the technology and security risks of spinal cord stimulation

BACKGROUND

Spinal cord stimulation (SCS) is a neuromodulatory technique used to relieve chronic pain. Previous instances of malicious remote control of implantable medical devices, including insulin delivery pumps and implantable cardiac defibrillators, have been documented. Though no cases of neuromodulatory hacking have been recorded outside of the academic setting, an understanding of SCS technology and the possible consequences of manipulation is important in promoting safety.

METHODS

We review the components and implantation protocol of a SCS system, the functionality and technological specifications for SCS systems in the global market based on their device manuals, and patient- and clinician-specific adjustable factors. Furthermore, we assess documented instances of implantable medical device hacking and speculate on the potential harms of targeting SCS systems.

RESULTS

SCS systems from Abbott Laboratories, Boston Scientific, Medtronic, and Nevro have unique functionality and technological specifications. Six parameters in device control can potentially be targeted and elicit various harms, including loss of therapeutic effect, accelerated battery drainage, paresthesia in unintended locations, muscle weakness or dysfunction, tissue burn, and electrical shock.

CONCLUSIONS

Based on the history of implantable medical device hacking, SCS systems may also be susceptible to manipulation. As the prevalence of SCS use increases and SCS systems continuously evolve in the direction of wireless control and compatibility with mobile devices, appropriate measures should be taken by manufacturers and governmental agencies to ensure safety.

Technology of deep brain stimulation: current status and future directions

Deep brain stimulation (DBS) is a neurosurgical procedure that allows targeted circuit-based neuromodulation. DBS is a standard of care in Parkinson disease, essential tremor and dystonia, and is also under active investigation for other conditions linked to pathological circuitry, including major depressive disorder and Alzheimer disease. Modern DBS systems, borrowed from the cardiac field, consist of an intracranial electrode, an extension wire and a pulse generator, and have evolved slowly over the past two decades. Advances in engineering and imaging along with an improved understanding of brain disorders are poised to reshape how DBS is viewed and delivered to patients. Breakthroughs in electrode and battery designs, stimulation paradigms, closed-loop and on-demand stimulation, and sensing technologies are expected to enhance the efficacy and tolerability of DBS. In this Review, we provide a comprehensive overview of the technical development of DBS, from its origins to its future. Understanding the evolution of DBS technology helps put the currently available systems in perspective and allows us to predict the next major technological advances and hurdles in the field.

The Future of Cardiovascular Stents: Bioresorbable and Integrated Biosensor Technology

Cardiovascular disease is the greatest cause of death worldwide. Atherosclerosis is the underlying pathology responsible for two thirds of these deaths. It is the age-dependent process of "furring of the arteries." In many scenarios the disease is caused by poor diet, high blood pressure, and genetic risk factors, and is exacerbated by obesity, diabetes, and sedentary lifestyle. Current pharmacological anti-atherosclerotic modalities still fail to control the disease and improvements in clinical interventions are urgently required. Blocked atherosclerotic arteries are routinely treated in hospitals with an expandable metal stent. However, stented vessels are often silently re-blocked by developing "in-stent restenosis," a wound response, in which the vessel's lumen renarrows by excess proliferation of vascular smooth muscle cells, termed hyperplasia. Herein, the current stent technology and the future of biosensing devices to overcome in-stent restenosis are reviewed. Second, with advances in nanofabrication, new sensing methods and how researchers are investigating ways to integrate biosensors within stents are highlighted. The future of implantable medical devices in the context of the emerging "Internet of Things" and how this will significantly influence future biosensor technology for future generations are also discussed.

The state of research on cyberattacks against hospitals and available best practice recommendations: a scoping review

BACKGROUND

The health sector has quickly become a target for cyberattacks. Hospitals are especially sensitive to these sorts of attacks as any disruption in operations or even disclosure of patient personal information can have far-reaching consequences. The objective of this study was to map the available literature on cyberattacks on hospitals and to identify the different domains of research, while extracting the recommendations and guidelines put forth in the literature.

METHODS

Four databases (PubMed, Web of Science, ProQuest, and Scopus) were searched using standardized and adapted search syntax in order to identify relevant manuscripts published between 1997 and 2017. These were screened by two reviewers and included or excluded based on inclusion and exclusion criteria. Data from articles were then extracted and analyzed.

RESULTS

The search identified 818 records of which 97 were included. Of the 97, 32% were published in 2017 while around 40% of the articles were published prior to the last three years. Six domains of research emerged through the analysis, which are included here: context and trends in cybersecurity (27.8%), connected medical devices and equipment (29.9%), hospital information systems (14.4%), raising awareness and lessons learned (6.2%), information security methodology (15.4%), and specific types of attacks (6.2%).

CONCLUSION

There is a generally growing interest in the research field, but the available literature remains limited in number. There are important aspects of cybersecurity (e.g. cloud storage and access management) as well as specific medical fields that rely on various medical devices that have been neglected. Recommendations are available, but comprehensive guidelines and standardized best practice measures are still necessary.

Deep brain stimulation: An overview of history, methods, and future developments

Deep brain stimulation has already revolutionised the clinical management of treatment-resistant movement disorders and offers novel treatment options for an increasing range of neurological and psychiatric illnesses. In this article, we briefly review the history of deep brain stimulation, particularly focusing on the last 50 years, which have seen rapid development in the safety and efficacy of deep brain stimulation. We then discuss the current state of the art in deep brain stimulation, focusing on emerging indications and recent technological advances that have improved the field. Finally, we consider the future developments in technology, technique, and research that will impact deep brain stimulation; particularly focusing on closed-loop stimulation techniques and emerging techniques such as optogenetics, cybersecurity risk, implantation timing, and impediments to undertaking high-quality research.

Brainjacking in deep brain stimulation and autonomy

'Brainjacking' refers to the exercise of unauthorized control of another's electronic brain implant. Whilst the possibility of hacking a Brain-Computer Interface (BCI) has already been proven in both experimental and real-life settings, there is reason to believe that it will soon be possible to interfere with the software settings of the Implanted Pulse Generators (IPGs) that play a central role in Deep Brain Stimulation (DBS) systems. Whilst brainjacking raises ethical concerns pertaining to privacy and physical or psychological harm, we claim that the possibility of brainjacking DBS raises particularly profound concerns about individual autonomy, since the possibility of hacking such devices raises the prospect of third parties exerting influence over the neural circuits underpinning the subject's cognitive, emotional and motivational states. However, although it seems natural to assume that brainjacking represents a profound threat to individual autonomy, we suggest that the implications of brainjacking for individual autonomy are complicated by the fact that technologies targeted by brainjacking often serve to enhance certain aspects of the user's autonomy. The difficulty of ascertaining the implications of brainjacking DBS for individual autonomy is exacerbated by the varied understandings of autonomy in the neuroethical and philosophical literature. In this paper, we seek to bring some conceptual clarity to this area by mapping out some of the prominent views concerning the different dimension of autonomous agency, and the implications of brainjacking DBS for each dimension. Drawing on three hypothetical case studies, we show that there could plausibly be some circumstances in which brainjacking could potentially be carried out in ways that could serve to enhance certain dimensions of the target's autonomy. Our analysis raises further questions about the power, scope, and necessity of obtaining prior consent in seeking to protect patient autonomy when directly interfering with their neural states, in particular in the context of self-regulating closed-loop stimulation devices.

Cybersecurity in healthcare: A narrative review of trends, threats and ways forward

Electronic healthcare technology is prevalent around the world and creates huge potential to improve clinical outcomes and transform care delivery. However, there are increasing concerns relating to the security of healthcare data and devices. Increased connectivity to existing computer networks has exposed medical devices to new cybersecurity vulnerabilities. Healthcare is an attractive target for cybercrime for two fundamental reasons: it is a rich source of valuable data and its defences are weak. Cybersecurity breaches include stealing health information and ransomware attacks on hospitals, and could include attacks on implanted medical devices. Breaches can reduce patient trust, cripple health systems and threaten human life. Ultimately, cybersecurity is critical to patient safety, yet has historically been lax. New legislation and regulations are in place to facilitate change. This requires cybersecurity to become an integral part of patient safety. Changes are required to human behaviour, technology and processes as part of a holistic solution.

Anesthesiology, automation, and artificial intelligence

There have been many attempts to incorporate automation into the practice of anesthesiology, though none have been successful. Fundamentally, these failures are due to the underlying complexity of anesthesia practice and the inability of rule-based feedback loops to fully master it. Recent innovations in artificial intelligence, especially machine learning, may usher in a new era of automation across many industries, including anesthesiology. It would be wise to consider the implications of such potential changes before they have been fully realized.

Towards new human rights in the age of neuroscience and neurotechnology

Rapid advancements in human neuroscience and neurotechnology open unprecedented possibilities for accessing, collecting, sharing and manipulating information from the human brain. Such applications raise important challenges to human rights principles that need to be addressed to prevent unintended consequences. This paper assesses the implications of emerging neurotechnology applications in the context of the human rights framework and suggests that existing human rights may not be sufficient to respond to these emerging issues. After analysing the relationship between neuroscience and human rights, we identify four new rights that may become of great relevance in the coming decades: the right to cognitive liberty, the right to mental privacy, the right to mental integrity, and the right to psychological continuity.

Neuromorphic neural interfaces: from neurophysiological inspiration to biohybrid coupling with nervous systems

OBJECTIVE

Computation in nervous systems operates with different computational primitives, and on different hardware, than traditional digital computation and is thus subjected to different constraints from its digital counterpart regarding the use of physical resources such as time, space and energy. In an effort to better understand neural computation on a physical medium with similar spatiotemporal and energetic constraints, the field of neuromorphic engineering aims to design and implement electronic systems that emulate in very large-scale integration (VLSI) hardware the organization and functions of neural systems at multiple levels of biological organization, from individual neurons up to large circuits and networks. Mixed analog/digital neuromorphic VLSI systems are compact, consume little power and operate in real time independently of the size and complexity of the model.

APPROACH

This article highlights the current efforts to interface neuromorphic systems with neural systems at multiple levels of biological organization, from the synaptic to the system level, and discusses the prospects for future biohybrid systems with neuromorphic circuits of greater complexity.

MAIN RESULTS

Single silicon neurons have been interfaced successfully with invertebrate and vertebrate neural networks. This approach allowed the investigation of neural properties that are inaccessible with traditional techniques while providing a realistic biological context not achievable with traditional numerical modeling methods. At the network level, populations of neurons are envisioned to communicate bidirectionally with neuromorphic processors of hundreds or thousands of silicon neurons. Recent work on brain-machine interfaces suggests that this is feasible with current neuromorphic technology.

SIGNIFICANCE

Biohybrid interfaces between biological neurons and VLSI neuromorphic systems of varying complexity have started to emerge in the literature. Primarily intended as a computational tool for investigating fundamental questions related to neural dynamics, the sophistication of current neuromorphic systems now allows direct interfaces with large neuronal networks and circuits, resulting in potentially interesting clinical applications for neuroengineering systems, neuroprosthetics and neurorehabilitation.