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Kremer C, Berger A, Bernstein K, Korach T, Mogilner A. Weight Trends After Spinal Cord Stimulation Therapy for Chronic Pain. Neuromodulation 2024; 27:1428-1434. [PMID: 39453290 DOI: 10.1016/j.neurom.2024.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/28/2024] [Accepted: 09/09/2024] [Indexed: 10/26/2024]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) therapy is an effective treatment for chronic pain, particularly in conditions such as postlaminectomy syndrome and complex regional pain syndrome (CRPS). Rare case reports described significant weight loss in patients who underwent dorsal column SCS therapy for chronic pain. Recently, neuromodulation for obesity has become a novel field for research. We aimed to investigate weight trends among patients treated with SCS for chronic pain. MATERIALS AND METHODS We conducted a retrospective chart review in 342 patients treated with SCS or dorsal root ganglion stimulators at our institution between 2010 and 2023. Patients had their weight recorded before SCS implantation and at least once within 12 months after surgery. We also conducted interviews with 28 patients who experienced significant weight loss or had revision procedures owing to weight loss. RESULTS We found that 105 of 342 patients (30.7%) experienced weight loss of ≥5% within a year of implantation, and 32 of 105 (30.5%, 9.4% of all patients) experienced weight loss of ≥ 10%. A multivariate regression analysis revealed a modest increase in the likelihood of weight loss among patients with CRPS (odds ratio [OR] = 1.17, 95% CI [1.04, 1.30], p = 0.007) and in those who achieved pain relief after implantation (OR = 1.22, 95% CI [1.05,1.40], p = 0.008). Of the 28 patients with significant weight loss who were interviewed, 12 (43%) could not explain the reasons for their weight loss, whereas eight (29%) reported decreased appetite. Leads placed at higher thoracic levels were associated with increased rates of weight loss (37.2% at T6-T8 and 22.3% at T8-T10; p = 0.038). CONCLUSIONS Our findings suggest that SCS therapy may affect weight in patients with chronic pain. Further studies are needed to investigate the potential role of SCS in weight modulation.
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Affiliation(s)
- Caroline Kremer
- Department of Neurological Surgery, New York University Langone Health Medical Center, New York University, New York, NY, USA.
| | - Assaf Berger
- Department of Neurological Surgery, New York University Langone Health Medical Center, New York University, New York, NY, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, New York University Langone Health Medical Center, New York University, New York, NY, USA
| | - Tom Korach
- Department of Neurological Surgery, New York University Langone Health Medical Center, New York University, New York, NY, USA
| | - Alon Mogilner
- Department of Neurological Surgery, New York University Langone Health Medical Center, New York University, New York, NY, USA
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2
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Herbozo Contreras LF, Truong ND, Eshraghian JK, Xu Z, Huang Z, Bersani–Veroni TV, Aguilar I, Leung WH, Nikpour A, Kavehei O. Neuromorphic neuromodulation: Towards the next generation of closed-loop neurostimulation. PNAS NEXUS 2024; 3:pgae488. [PMID: 39554511 PMCID: PMC11565243 DOI: 10.1093/pnasnexus/pgae488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 10/02/2024] [Indexed: 11/19/2024]
Abstract
Neuromodulation techniques have emerged as promising approaches for treating a wide range of neurological disorders, precisely delivering electrical stimulation to modulate abnormal neuronal activity. While leveraging the unique capabilities of AI holds immense potential for responsive neurostimulation, it appears as an extremely challenging proposition where real-time (low-latency) processing, low-power consumption, and heat constraints are limiting factors. The use of sophisticated AI-driven models for personalized neurostimulation depends on the back-telemetry of data to external systems (e.g. cloud-based medical mesosystems and ecosystems). While this can be a solution, integrating continuous learning within implantable neuromodulation devices for several applications, such as seizure prediction in epilepsy, is an open question. We believe neuromorphic architectures hold an outstanding potential to open new avenues for sophisticated on-chip analysis of neural signals and AI-driven personalized treatments. With more than three orders of magnitude reduction in the total data required for data processing and feature extraction, the high power- and memory-efficiency of neuromorphic computing to hardware-firmware co-design can be considered as the solution-in-the-making to resource-constraint implantable neuromodulation systems. This perspective introduces the concept of Neuromorphic Neuromodulation, a new breed of closed-loop responsive feedback system. It highlights its potential to revolutionize implantable brain-machine microsystems for patient-specific treatment.
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Affiliation(s)
| | - Nhan Duy Truong
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW 2006, Australia
- Sydney Nano Institute, The University of Sydney, Sydney, NSW 2006, Australia
| | - Jason K Eshraghian
- Department of Electrical and Computer Engineering, University of California, Santa Cruz 95064, USA
| | - Zhangyu Xu
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW 2006, Australia
| | - Zhaojing Huang
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW 2006, Australia
| | | | - Isabelle Aguilar
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW 2006, Australia
| | - Wing Hang Leung
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW 2006, Australia
| | - Armin Nikpour
- Central Clinical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Omid Kavehei
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW 2006, Australia
- Sydney Nano Institute, The University of Sydney, Sydney, NSW 2006, Australia
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3
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Ham H, Kim KS, Lee JH, Kim DN, Choi HJ, Yoh JJ. Acoustic deep brain modulation: Enhancing neuronal activation and neurogenesis. Brain Stimul 2024; 17:1060-1075. [PMID: 39218349 DOI: 10.1016/j.brs.2024.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 08/14/2024] [Accepted: 08/28/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Non-invasive deep brain modulation (DBM) stands as a promising therapeutic avenue to treat brain diseases. Acoustic DBM represents an innovative and targeted approach to modulate the deep brain, employing techniques such as focused ultrasound and shock waves. Despite its potential, the optimal mechanistic parameters, the effect in the brain and behavioral outcomes of acoustic DBM remains poorly understood. OBJECTIVE To establish a robust protocol for the shock wave DBM by optimizing its mechanistic profile of external stimulation, and to assess its efficacy in preclinical settings. METHODS We used shockwaves due to their capacity to leverage a broader spectrum of peak intensity (10-127 W/mm2) in contrast to ultrasound (0.1-5.0 W/mm2), thereby enabling a more extensive range of neuromodulation effects. We established various types of shockwave pressure profiles of DBM and compared neural and behavioral responses. To ascertain the anticipated cause of the heightened neural activity response, numerical analysis was employed to examine the mechanical dynamics within the brain. RESULTS An optimized profile led to an enhancement in neuronal activity within the hypothalamus of mouse models. The optimized profile in the hippocampus elicited a marked increase in neurogenesis without neuronal damage. Behavioral analyses uncovered a noteworthy reduction in locomotion without significant effects on spatial memory function. CONCLUSIONS The present study provides an optimized shock wave stimulation protocol for non-invasive DBM. Our optimized stimulation profile selectively triggers neural functions in the deep brain. Our protocol paves the way for new non-invasive DBM devices to treat brain diseases.
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Affiliation(s)
- Hwichan Ham
- Department of Aerospace Engineering, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, South Korea
| | - Kyu Sik Kim
- Department of Biomedical Sciences, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Jee-Hwan Lee
- Department of Mechanical Engineering, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, South Korea
| | - Do-Nyun Kim
- Department of Mechanical Engineering, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, South Korea
| | - Hyung-Jin Choi
- Department of Biomedical Sciences, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Department of Brain and Cognitive Sciences, Seoul National University, Gwanak-ro 1, Gwanak-gu, Seoul, 08826, South Korea; Neuroscience Research Institute, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Wide River Institute of Immunology, Seoul National University, 101 Dabyeonbat-gil, Hwachon-myeon, Gangwon-do, 25159, South Korea.
| | - Jack J Yoh
- Department of Aerospace Engineering, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, South Korea.
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4
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Fernández-Aranda F, Granero R, Jiménez-Murcia S. Editorial: Neurological, psychological and endocrine markers of eating disorders and obesity. Front Nutr 2023; 10:1289370. [PMID: 37899820 PMCID: PMC10613052 DOI: 10.3389/fnut.2023.1289370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023] Open
Affiliation(s)
- Fernando Fernández-Aranda
- CIBER Physiology of Obesity and Nutrition (CIBEROBN), Carlos III Health Institute, Madrid, Spain
- Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Clinical Psychology Unit, University Hospital of Bellvitge, Barcelona, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Roser Granero
- CIBER Physiology of Obesity and Nutrition (CIBEROBN), Carlos III Health Institute, Madrid, Spain
- Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Department of Psychobiology and Methodology, Autonomous University of Barcelona, Barcelona, Spain
| | - Susana Jiménez-Murcia
- CIBER Physiology of Obesity and Nutrition (CIBEROBN), Carlos III Health Institute, Madrid, Spain
- Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Programme, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Clinical Psychology Unit, University Hospital of Bellvitge, Barcelona, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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Ghosh S, Sinha JK, Ghosh S, Sharma H, Bhaskar R, Narayanan KB. A Comprehensive Review of Emerging Trends and Innovative Therapies in Epilepsy Management. Brain Sci 2023; 13:1305. [PMID: 37759906 PMCID: PMC10527076 DOI: 10.3390/brainsci13091305] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/09/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023] Open
Abstract
Epilepsy is a complex neurological disorder affecting millions worldwide, with a substantial number of patients facing drug-resistant epilepsy. This comprehensive review explores innovative therapies for epilepsy management, focusing on their principles, clinical evidence, and potential applications. Traditional antiseizure medications (ASMs) form the cornerstone of epilepsy treatment, but their limitations necessitate alternative approaches. The review delves into cutting-edge therapies such as responsive neurostimulation (RNS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS), highlighting their mechanisms of action and promising clinical outcomes. Additionally, the potential of gene therapies and optogenetics in epilepsy research is discussed, revealing groundbreaking findings that shed light on seizure mechanisms. Insights into cannabidiol (CBD) and the ketogenic diet as adjunctive therapies further broaden the spectrum of epilepsy management. Challenges in achieving seizure control with traditional therapies, including treatment resistance and individual variability, are addressed. The importance of staying updated with emerging trends in epilepsy management is emphasized, along with the hope for improved therapeutic options. Future research directions, such as combining therapies, AI applications, and non-invasive optogenetics, hold promise for personalized and effective epilepsy treatment. As the field advances, collaboration among researchers of natural and synthetic biochemistry, clinicians from different streams and various forms of medicine, and patients will drive progress toward better seizure control and a higher quality of life for individuals living with epilepsy.
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Affiliation(s)
- Shampa Ghosh
- GloNeuro, Sector 107, Vishwakarma Road, Noida 201301, India
- ICMR—National Institute of Nutrition, Tarnaka, Hyderabad 500007, India
| | | | - Soumya Ghosh
- GloNeuro, Sector 107, Vishwakarma Road, Noida 201301, India
| | | | - Rakesh Bhaskar
- School of Chemical Engineering, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
| | - Kannan Badri Narayanan
- School of Chemical Engineering, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
- Research Institute of Cell Culture, Yeungnam University, 280 Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
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6
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Rolle CE, Ng GY, Nho YH, Barbosa DAN, Shivacharan RS, Gold JI, Bassett DS, Halpern CH, Buch V. Accumbens connectivity during deep-brain stimulation differentiates loss of control from physiologic behavioral states. Brain Stimul 2023; 16:1384-1391. [PMID: 37734587 PMCID: PMC10811591 DOI: 10.1016/j.brs.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Loss of control (LOC) eating, the subjective sense that one cannot control what or how much one eats, characterizes binge-eating behaviors pervasive in obesity and related eating disorders. Closed-loop deep-brain stimulation (DBS) for binge eating should predict LOC and trigger an appropriately timed intervention. OBJECTIVE/HYPOTHESIS This study aimed to identify a sensitive and specific biomarker to detect LOC onset for DBS. We hypothesized that changes in phase-locking value (PLV) predict the onset of LOC-associated cravings and distinguish them from potential confounding states. METHODS Using DBS data recorded from the nucleus accumbens (NAc) of two patients with binge eating disorder (BED) and severe obesity, we compared PLV between inter- and intra-hemispheric NAc subregions for three behavioral conditions: craving (associated with LOC eating), hunger (not associated with LOC), and sleep. RESULTS In both patients, PLV in the high gamma frequency band was significantly higher for craving compared to sleep and significantly higher for hunger compared to craving. Maximum likelihood classifiers achieved accuracies above 88% when differentiating between the three conditions. CONCLUSIONS High-frequency inter- and intra-hemispheric PLV in the NAc is a promising biomarker for closed-loop DBS that differentiates LOC-associated cravings from physiologic states such as hunger and sleep. Future trials should assess PLV as a LOC biomarker across a larger cohort and a wider patient population transdiagnostically.
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Affiliation(s)
- Camarin E Rolle
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Grace Y Ng
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA; Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Young-Hoon Nho
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
| | - Daniel A N Barbosa
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
| | - Rajat S Shivacharan
- Department of Neurosurgery, Stanford University School of Medicine, 453 Quarry Road Office 245C, Stanford, CA 94304, USA
| | - Joshua I Gold
- Department of Neuroscience, University of Pennsylvania, 3700 Hamilton Walk, Richards D407, Philadelphia, PA 19104, USA
| | - Dani S Bassett
- Departments of Bioengineering, Physics and Astronomy, Electrical and Systems Engineering, Neurology, and Psychiatry, University of Pennsylvania, 210 S. 33rd St, Skirkanich Hall 240, Philadelphia, PA 19104, USA; Santa Fe Institute, 1399 Hyde Park Rd, Santa Fe, NM 87501, USA
| | - Casey H Halpern
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania Hospital, Spruce Building 3rd Floor, 801 Spruce Street, Philadelphia, PA 19107, USA; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, USA
| | - Vivek Buch
- Department of Neurosurgery, Stanford University School of Medicine, 453 Quarry Road Office 245C, Stanford, CA 94304, USA.
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7
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Basu I, Yousefi A, Crocker B, Zelmann R, Paulk AC, Peled N, Ellard KK, Weisholtz DS, Cosgrove GR, Deckersbach T, Eden UT, Eskandar EN, Dougherty DD, Cash SS, Widge AS. Closed-loop enhancement and neural decoding of cognitive control in humans. Nat Biomed Eng 2023; 7:576-588. [PMID: 34725508 PMCID: PMC9056584 DOI: 10.1038/s41551-021-00804-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/02/2021] [Indexed: 12/20/2022]
Abstract
Deficits in cognitive control-that is, in the ability to withhold a default pre-potent response in favour of a more adaptive choice-are common in depression, anxiety, addiction and other mental disorders. Here we report proof-of-concept evidence that, in participants undergoing intracranial epilepsy monitoring, closed-loop direct stimulation of the internal capsule or striatum, especially the dorsal sites, enhances the participants' cognitive control during a conflict task. We also show that closed-loop stimulation upon the detection of lapses in cognitive control produced larger behavioural changes than open-loop stimulation, and that task performance for single trials can be directly decoded from the activity of a small number of electrodes via neural features that are compatible with existing closed-loop brain implants. Closed-loop enhancement of cognitive control might remediate underlying cognitive deficits and aid the treatment of severe mental disorders.
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Affiliation(s)
- Ishita Basu
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ali Yousefi
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Departments of Computer Science and Neuroscience, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Britni Crocker
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Rina Zelmann
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Angelique C Paulk
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Noam Peled
- Department of Radiology, MGH/HST Martinos Center for Biomedical Imaging and Harvard Medical School, Boston, MA, USA
| | - Kristen K Ellard
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - G Rees Cosgrove
- Department of Neurological Surgery, Brigham & Womens Hospital, Boston, MA, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Uri T Eden
- Department of Mathematics and Statistics, Boston University, Boston, MA, USA
| | - Emad N Eskandar
- Department of Neurological Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Darin D Dougherty
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sydney S Cash
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Alik S Widge
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA.
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8
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Parker JJ, Rolle CE, Shivacharan RS, Barbosa DAN, Feng A, Huang Y, Kakusa BW, Prieto T, Jaffe RA, Williams NR, Halpern CH. Appetitive Mapping of the Human Nucleus Accumbens. Biol Psychiatry 2023; 93:e15-e19. [PMID: 36509559 DOI: 10.1016/j.biopsych.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/09/2022] [Accepted: 09/16/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Jonathon J Parker
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Cammie E Rolle
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Rajat S Shivacharan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Daniel A N Barbosa
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Austin Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Bina W Kakusa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Tom Prieto
- Department of Neurology, Stanford University School of Medicine, Stanford, California
| | - Richard A Jaffe
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Casey H Halpern
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
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9
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Pilot study of responsive nucleus accumbens deep brain stimulation for loss-of-control eating. Nat Med 2022; 28:1791-1796. [PMID: 36038628 PMCID: PMC9499853 DOI: 10.1038/s41591-022-01941-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/08/2022] [Indexed: 11/08/2022]
Abstract
Cravings that precede loss of control (LOC) over food consumption present an opportunity for intervention in patients with the binge eating disorder (BED). In this pilot study, we used responsive deep brain stimulation (DBS) to record nucleus accumbens (NAc) electrophysiology during food cravings preceding LOC eating in two patients with BED and severe obesity (trial registration no. NCT03868670). Increased NAc low-frequency oscillations, prominent during food cravings, were used to guide DBS delivery. Over 6 months, we observed improved self-control of food intake and weight loss. These findings provide early support for restoring inhibitory control with electrophysiologically-guided NAc DBS. Further work with increased sample sizes is required to determine the scalability of this approach. Nucleus accumbens, low-frequency, responsive deep brain stimulation improved self-control of food intake and weight loss in two patients with binge eating disorder and severe obesity
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10
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Barbosa DAN, Kuijper FM, Duda J, Wang AR, Cartmell SCD, Saluja S, Cunningham T, Shivacharan RS, Bhati MT, Safer DL, Lock JD, Malenka RC, de Oliveira-Souza R, Williams NR, Grossman M, Gee JC, McNab JA, Bohon C, Halpern CH. Aberrant impulse control circuitry in obesity. Mol Psychiatry 2022; 27:3374-3384. [PMID: 35697760 PMCID: PMC9192250 DOI: 10.1038/s41380-022-01640-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 01/09/2023]
Abstract
The ventromedial prefrontal cortex (vmPFC) to nucleus accumbens (NAc) circuit has been implicated in impulsive reward-seeking. This disinhibition has been implicated in obesity and often manifests as binge eating, which is associated with worse treatment outcomes and comorbidities. It remains unclear whether the vmPFC-NAc circuit is perturbed in impulsive eaters with obesity. Initially, we analyzed publicly available, high-resolution, normative imaging data to localize where vmPFC structural connections converged within the NAc. These structural connections were found to converge ventromedially in the presumed NAc shell subregion. We then analyzed multimodal clinical and imaging data to test the a priori hypothesis that the vmPFC-NAc shell circuit is linked to obesity in a sample of female participants that regularly engaged in impulsive eating (i.e., binge eating). Functionally, vmPFC-NAc shell resting-state connectivity was inversely related to body mass index (BMI) and decreased in the obese state. Structurally, vmPFC-NAc shell structural connectivity and vmPFC thickness were inversely correlated with BMI; obese binge-prone participants exhibited decreased vmPFC-NAc structural connectivity and vmPFC thickness. Finally, to examine a causal link to binge eating, we directly probed this circuit in one binge-prone obese female using NAc deep brain stimulation in a first-in-human trial. Direct stimulation of the NAc shell subregion guided by local behaviorally relevant electrophysiology was associated with a decrease in number of weekly episodes of uncontrolled eating and decreased BMI. This study unraveled vmPFC-NAc shell circuit aberrations in obesity that can be modulated to restore control over eating behavior in obesity.
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Affiliation(s)
- Daniel A N Barbosa
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Fiene Marie Kuijper
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Duda
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Allan R Wang
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Samuel C D Cartmell
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sabir Saluja
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tricia Cunningham
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Rajat S Shivacharan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Mahendra T Bhati
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Debra L Safer
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - James D Lock
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Robert C Malenka
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
- Nancy Pritzker Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Ricardo de Oliveira-Souza
- Department of Specialized Medicine, Gaffrée e Guinle University Hospital, The Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nolan R Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Murray Grossman
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James C Gee
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer A McNab
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Cara Bohon
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Pennsylvania Hospital, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, PA, Philadelphia, USA.
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11
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Mahajan UV, Ojukwu DI, Azagury DE, Safer DL, Cunningham T, Halpern CH. Can responsive deep brain stimulation be a cost-effective treatment for severe obesity? Obesity (Silver Spring) 2022; 30:338-346. [PMID: 35088556 DOI: 10.1002/oby.23324] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A first-in-human responsive deep brain stimulation (rDBS) trial (NCT03868670) for obesity is under way, which is based on promising preclinical evidence. Given the upfront costs of rDBS, it is prudent to examine the success threshold for cost-effectiveness compared with laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS Efficacy and safety data on LRYGB and safety data on rDBS were collected for established indications through a literature search. The success threshold was defined as minimum BMI reduction. Treatment costs were calculated via Medicare national reimbursement data. RESULTS LRYGB had a mean BMI reduction of 13.75 kg/m2 . Based on adverse events, LRYGB was a less-preferred health state (overall adverse event utility of 0.96 [0.02]) than rDBS (0.98 [0.01]), but LRYGB ($14,366 [$6,410]) had a significantly lower treatment cost than rDBS ($29,951 [$4,490]; p < 0.0001). Therefore, for rDBS to be cost-effective compared with LRYGB, the multiple models yielded a success threshold range of 13.7 to 15.2 kg/m2 . CONCLUSIONS This study established a preliminary efficacy success threshold for rDBS to be cost-effective for severe obesity, and results from randomized controlled trials are needed. This analysis allows for interpretation of the economic impact of advancing rDBS for obesity in light of ongoing trial results and suggests an attainable threshold is needed for cost-effectiveness.
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Affiliation(s)
- Uma V Mahajan
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Disep I Ojukwu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Dan E Azagury
- Section of Minimally Invasive and Bariatric Surgery, Department of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Debra L Safer
- Stanford Adult Eating and Weight Disorders Program, Department of Psychiatry, Stanford University Medical Center, Stanford, California, USA
| | - Tricia Cunningham
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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12
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Neuroimaging and modulation in obesity and diabetes research: 10th anniversary meeting. Int J Obes (Lond) 2022; 46:718-725. [PMID: 34934178 PMCID: PMC8960390 DOI: 10.1038/s41366-021-01025-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/29/2021] [Accepted: 11/09/2021] [Indexed: 11/29/2022]
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13
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Rao VR. Chronic electroencephalography in epilepsy with a responsive neurostimulation device: current status and future prospects. Expert Rev Med Devices 2021; 18:1093-1105. [PMID: 34696676 DOI: 10.1080/17434440.2021.1994388] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Implanted neurostimulation devices are gaining traction as therapeutic options for people with certain forms of drug-resistant focal epilepsy. Some of these devices enable chronic electroencephalography (cEEG), which offers views of the dynamics of brain activity in epilepsy over unprecedented time horizons. AREAS COVERED This review focuses on clinical insights and basic neuroscience discoveries enabled by analyses of cEEG from an exemplar device, the NeuroPace RNS® System. Applications of RNS cEEG covered here include counting and lateralizing seizures, quantifying medication response, characterizing spells, forecasting seizures, and exploring mechanisms of cognition. Limitations of the RNS System are discussed in the context of next-generation devices in development. EXPERT OPINION The wide temporal lens of cEEG helps capture the dynamism of epilepsy, revealing phenomena that cannot be appreciated with short duration recordings. The RNS System is a vanguard device whose diagnostic utility rivals its therapeutic benefits, but emerging minimally invasive devices, including those with subscalp recording electrodes, promise to be more applicable within a broad population of people with epilepsy. Epileptology is on the precipice of a paradigm shift in which cEEG is a standard part of diagnostic evaluations and clinical management is predicated on quantitative observations integrated over long timescales.
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Affiliation(s)
- Vikram R Rao
- Associate Professor of Clinical Neurology, Chief, Epilepsy Division, Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
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14
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Vedam-Mai V, Deisseroth K, Giordano J, Lazaro-Munoz G, Chiong W, Suthana N, Langevin JP, Gill J, Goodman W, Provenza NR, Halpern CH, Shivacharan RS, Cunningham TN, Sheth SA, Pouratian N, Scangos KW, Mayberg HS, Horn A, Johnson KA, Butson CR, Gilron R, de Hemptinne C, Wilt R, Yaroshinsky M, Little S, Starr P, Worrell G, Shirvalkar P, Chang E, Volkmann J, Muthuraman M, Groppa S, Kühn AA, Li L, Johnson M, Otto KJ, Raike R, Goetz S, Wu C, Silburn P, Cheeran B, Pathak YJ, Malekmohammadi M, Gunduz A, Wong JK, Cernera S, Wagle Shukla A, Ramirez-Zamora A, Deeb W, Patterson A, Foote KD, Okun MS. Proceedings of the Eighth Annual Deep Brain Stimulation Think Tank: Advances in Optogenetics, Ethical Issues Affecting DBS Research, Neuromodulatory Approaches for Depression, Adaptive Neurostimulation, and Emerging DBS Technologies. Front Hum Neurosci 2021; 15:644593. [PMID: 33953663 PMCID: PMC8092047 DOI: 10.3389/fnhum.2021.644593] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
We estimate that 208,000 deep brain stimulation (DBS) devices have been implanted to address neurological and neuropsychiatric disorders worldwide. DBS Think Tank presenters pooled data and determined that DBS expanded in its scope and has been applied to multiple brain disorders in an effort to modulate neural circuitry. The DBS Think Tank was founded in 2012 providing a space where clinicians, engineers, researchers from industry and academia discuss current and emerging DBS technologies and logistical and ethical issues facing the field. The emphasis is on cutting edge research and collaboration aimed to advance the DBS field. The Eighth Annual DBS Think Tank was held virtually on September 1 and 2, 2020 (Zoom Video Communications) due to restrictions related to the COVID-19 pandemic. The meeting focused on advances in: (1) optogenetics as a tool for comprehending neurobiology of diseases and on optogenetically-inspired DBS, (2) cutting edge of emerging DBS technologies, (3) ethical issues affecting DBS research and access to care, (4) neuromodulatory approaches for depression, (5) advancing novel hardware, software and imaging methodologies, (6) use of neurophysiological signals in adaptive neurostimulation, and (7) use of more advanced technologies to improve DBS clinical outcomes. There were 178 attendees who participated in a DBS Think Tank survey, which revealed the expansion of DBS into several indications such as obesity, post-traumatic stress disorder, addiction and Alzheimer’s disease. This proceedings summarizes the advances discussed at the Eighth Annual DBS Think Tank.
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Affiliation(s)
- Vinata Vedam-Mai
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Karl Deisseroth
- Department of Bioengineering, Stanford University, Stanford, CA, United States.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States
| | - James Giordano
- Department of Neurology and Neuroethics Studies Program, Georgetown University Medical Center, Washington, DC, United States
| | - Gabriel Lazaro-Munoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, United States
| | - Winston Chiong
- Weill Institute for Neurosciences, Memory and Aging Center, University of California, San Francisco, San Francisco, CA, United States
| | - Nanthia Suthana
- Department of Neurosurgery, David Geffen School of Medicine and Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, United States.,Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, United States.,Department of Psychology, University of California, Los Angeles, Los Angeles, CA, United States.,Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, United States
| | - Jean-Philippe Langevin
- Department of Neurosurgery, David Geffen School of Medicine and Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, United States.,Neurosurgery Service, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
| | - Jay Gill
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, United States
| | - Wayne Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Nicole R Provenza
- School of Engineering, Brown University, Providence, RI, United States
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, United States
| | - Rajat S Shivacharan
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, United States
| | - Tricia N Cunningham
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, United States
| | - Sameer A Sheth
- Department of Neurological Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Nader Pouratian
- Department of Neurosurgery, David Geffen School of Medicine and Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, United States
| | - Katherine W Scangos
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
| | - Helen S Mayberg
- Department of Neurology and Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Andreas Horn
- Movement Disorders & Neuromodulation Unit, Department for Neurology, Charité - University Medicine Berlin, Berlin, Germany
| | - Kara A Johnson
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States.,Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
| | - Christopher R Butson
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States.,Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, United States
| | - Ro'ee Gilron
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Coralie de Hemptinne
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States.,Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Robert Wilt
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Maria Yaroshinsky
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Simon Little
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Philip Starr
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Greg Worrell
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Prasad Shirvalkar
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States.,Department of Anesthesiology (Pain Management) and Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Edward Chang
- Department of Neurological Surgery, Kavli Institute for Fundamental Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Jens Volkmann
- Neurologischen Klinik Universitätsklinikum Würzburg, Würzburg, Germany
| | - Muthuraman Muthuraman
- Section of Movement Disorders and Neurostimulation, Biomedical Statistics and Multimodal Signal Processing Unit, Department of Neurology, Focus Program Translational Neuroscience, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Sergiu Groppa
- Section of Movement Disorders and Neurostimulation, Biomedical Statistics and Multimodal Signal Processing Unit, Department of Neurology, Focus Program Translational Neuroscience, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Andrea A Kühn
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Matthew Johnson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, United States
| | - Kevin J Otto
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States
| | - Robert Raike
- Restorative Therapies Group Implantables, Research and Core Technology, Medtronic, Minneapolis, MN, United States
| | - Steve Goetz
- Restorative Therapies Group Implantables, Research and Core Technology, Medtronic, Minneapolis, MN, United States
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Peter Silburn
- Asia Pacific Centre for Neuromodulation, Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Binith Cheeran
- Neuromodulation Division, Abbott, Plano, TX, United States
| | - Yagna J Pathak
- Neuromodulation Division, Abbott, Plano, TX, United States
| | | | - Aysegul Gunduz
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States.,J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States
| | - Joshua K Wong
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Stephanie Cernera
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States.,J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States
| | - Aparna Wagle Shukla
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Adolfo Ramirez-Zamora
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Wissam Deeb
- Department of Neurology, University of Massachusetts, Worchester, MA, United States
| | - Addie Patterson
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Kelly D Foote
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Michael S Okun
- Norman Fixel Institute for Neurological Diseases and the Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville, FL, United States
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