Response and Safety Outcomes in Treatment-Resistant Depression After Subcallosal Cingulate Gyrus Deep Brain Stimulation: Long-term Follow-up Study

Objective: To replicate previous findings and to investigate related clinical factors of long-term benefits and safety of subcallosal cingulate gyrus deep brain stimulation (SCG-DBS) for treatment-resistant depression (TRD).

Methods: Sixteen patients with TRD (with either major depressive disorder or bipolar disorder, DSM-IV and DSM-5 criteria) receiving chronic SCG-DBS were followed for up to 11 years (January 2008 to June 2019). Demographic, clinical, and functioning data were collected pre-surgery and during the follow-up. Response was defined as a ≥ 50% decrease from baseline in the 17-item Hamilton Depression Rating Scale (HAM-D₁₇) score, and remission was defined as ≤ 7 in the HAM-D₁₇ score. The Illness Density Index (IDI) was used as a longitudinal measure of treatment effects. Survival analyses were performed for response outcomes and relapses.

Results: Depressive symptoms were significantly decreased over time (F = 2.37; P = .04). Response and remission rates were 75% and 62.5% at individual endpoint. Based on Kaplan-Meier curve analysis, 55% of patients reached remission in 139 days. IDI curves showed sustained clinical improvements as measured with HAM-D₁₇ and Clinical Global Impression and sustained functioning improvement as measured with Global Assessment of Functioning scores. The procedure was generally safe and well tolerated (122 adverse events across 81 patient-years, of which 25 were related to SCG-DBS). Two patients committed suicide long after surgery.

Conclusions: SCG-DBS produced a robust and protracted improvement in most patients, which reinforces the possibility that SCG-DBS could be an alternative for patients with treatment-resistant unipolar or bipolar depression. Identification of clinical and neurobiological response predictors should guide the continuation of DBS for TRD, to obtain its indication soon.

[Complications related with implanted devices in patients with Parkinson's disease treated with deep brain stimulation. A study of a series of 124 patients over a period of 16 years]

INTRODUCTION

Establishing protocols of the best candidates for deep brain stimulation in patients with Parkinson's disease and a greater knowledge of the technique have increased its safety profile. Yet, the complications related with implanted devices still occur with a far-from-negligible frequency and have both an economic and clinical impact.

AIM

From a broad series of patients undergoing deep brain stimulation included consecutively for the treatment of their Parkinson's disease, data concerning the complications related with implanted devices were gathered and compared with those in the literature.

PATIENTS AND METHODS

Altogether 124 patients with a total of 242 implanted electrodes and 252 generator replacements were included in the study. Mean follow-up time was 8.4 years (range: 3-16 years). Data on all the complications related with implanted devices were collected retrospectively.

RESULTS

Findings showed that 23 implanted device-related complications occurred (17.7% of the patients): 12 (9.6%) had culture-positive ulcers, five (4%) had culture-negative ulcers, four (3.2%) were left with infections following generator replacement, one (0.8%) had a generator malfunction, and electrode migration took place in one (0.8%). Significant differences were observed as regards the effectiveness of the treatment involving surgical revision of the ulcers, which suggests that the culture-negative ulcers responded to the surgical revision better than the culture-positive ulcers (80% healing versus 16.6%; p = 0.028).

CONCLUSIONS

The results observed in the series were comparable to those in the existing literature. The presence of culture-positivity in the ulcers is a factor forecasting surgical revision.

[Stimulation of the occipital nerve in the treatment of drug-resistant cluster headache]

AIM

To evaluate the occipital nerve stimulation therapy in as a treatment for drug-resistant cluster headache.

PATIENTS AND METHODS

Prospective study of four patients, three males and one female. Mean age of 42 years. Patients complained of a cluster headache lasting between one and 16 years, with suboptimal control of the attacks with medication. In all cases octopolar electrodes were placed percutaneously in the occipital region bilaterally. Follow-up of 6 months.

RESULTS

At 6 months, there was a 56% (range: 25-95%) reduction in the frequency, a 48.8% (range: 20-60%) decrease in the intensity and a 63.8% (range: 0-88.8%) reduction in the duration of the attacks. Worsening or progression of the illness was not observed in any case. All patients referred a 15.4% (range: 6-31.5%) improvement in their quality of life compared to their previous basal situation in SF-36. In all cases but one there was a significant reduction in the amount and dosage of medication required. Postoperative complications were not observed. All patients would recommend the procedure.

CONCLUSIONS

Occipital nerve stimulation may be considered a safe and effective therapeutic option in the drug-resistant cluster headache. However, studies with more patients and a longer follow-up are required to evaluate the efficacy of the technique.

Desensitization of endothelial P2Y1 receptors by PKC-dependent mechanisms in pressurized rat small mesenteric arteries

BACKGROUND AND PURPOSE

Extracellular nucleotides play a crucial role in the regulation of vascular tone and blood flow. Stimulation of endothelial cell P2Y1 receptors evokes concentration-dependent full dilatation of resistance arteries. However, this GPCR can desensitize upon prolonged exposure to the agonist. Our aim was to determine the extent and nature of P2Y1 desensitization in isolated and pressurized rat small mesenteric arteries.

EXPERIMENTAL APPROACH

The non-hydrolyzable selective P2Y1 agonist ADPbetaS (3 microM) was perfused through the lumen of arteries pressurized to 70 mmHg. Changes in arterial diameter and endothelial cell [Ca(2+)](i) were obtained in the presence and absence of inhibitors of protein kinase C (PKC).

KEY RESULTS

ADPbetaS evoked rapid dilatation to the maximum arterial diameter but faded over time to a much-reduced plateau closer to 35% dilatation. This appeared to be due to desensitization of the P2Y1 receptor, as subsequent endothelium-dependent dilatation to acetylcholine (1 microM) remained unaffected. Luminal treatment with the PKC inhibitors BIS-I (1 microM) or BIS-VIII (1 microM) tended to augment concentration-dependent dilatation to ADPbetaS (0.1-3 microM) and prevented desensitization. Another PKC inhibitor, Gö 6976 (1 microM), was less effective in preventing desensitization. Measurements of endothelial cell [Ca(2+)](i) in pressurized arteries confirmed the P2Y1 receptor but not M(3) muscarinic receptor desensitization.

CONCLUSIONS AND IMPLICATIONS

These data demonstrate for the first time the involvement of PKC in the desensitization of endothelial P2Y1 receptors in pressurized rat mesenteric arteries, which may have important implications in the control of blood flow by circulating nucleotides.

[The effectiveness of gravitational valves in the prevention of over-drainage in adult patients with hydrocephalus]

AIM

To evaluate the effect of gravitational valves on over-drainage in hydrocephalus in adults.

PATIENTS AND METHODS

We performed a retrospective study of the shunt systems placed in patients over the age of 18 years between 1998 and 2006. Patients were divided into two groups: non-GV group (without gravitational valve) and GV group (with a gravitational valve, Aesculap-Miethke 5/35). The complications that occurred during the first year following the placement of the shunt system were recorded.

RESULTS

Of a total of 137 patients, 91 were from the non-GV group and 46 belonged to the GV group. Mean age: non-GV group, 62.1 years; and GV group, 64.2 years, without any significant differences. In 80 patients the aetiology was chronic adult hydrocephalus, 19 were due to expansive processes, 15 due to vascular causes, eight pseudo tumours, six post-traumatic injuries and nine were due to other causes. In the non-GV group, 9.89% presented over-drainage, whereas there were no cases in the GV group; the difference was statistically significant (p = 0.029). In the rest of the complications there were no significant differences between the two groups. The total complications in the non-GV group were 25.27% and in the GV group, 6.52%, and there were significant differences (p = 0.01), although, above all, at the expense of over-drainage, because if this complication was excluded, then the differences were no longer significant (p = 0.175).

CONCLUSIONS

In our series, the use of gravitational valves in the prevention of over-drainage in adult hydrocephalus proved to be more effective than employing valves without the gravitational device.

[Satisfaction with locoregional anesthesia in women who had undergone cesarean section]

OBJECTIVES

To compare satisfaction with local-regional and general anesthesia in women undergoing cesarean, the possible influence of time of evaluation and recall of the anesthesiologist.

PATIENTS AND METHODS

Retrospective study performed in all women who delivered by cesarean in the 6 first months of 1997. The women were assigned to two groups according to type of anesthesia, local-regional or general. Their satisfaction with anesthesia was evaluated by questionnaire 48 to 72 hours after surgery and two weeks after release. Most items required discrete-point answers, including a satisfaction of a scale of 0 to 10. During the second interview we also evaluated satisfaction with the procedure and hospital in general, as well as recall of the anesthesiologist. Group homogeneity was based on demographic, sociocultural, obstetric and surgical variables.

RESULTS

In a context of high satisfaction with anesthesia, 189 (76%) of the 247 women receiving local-regional anesthesia gave high evaluations to the anesthesia (8.90 +/- 1.5; mean: 10), compared with 58 (24%) of those receiving general anesthesia (8 +/- 2; mean 8.5) (p = 0.001). Both groups were homogeneous except for the distribution of emergencies, which occurred more often in those receiving general anesthesia (p < 0.001). Women who had received local-regional anesthesia expressed greater willingness to repeat or recommend the technique (p < 0.001). The highest score in this group was from women receiving intradural anesthesia along with fentanyl for local anesthesia, with significant differences only in comparison to epidural anesthesia. The differences in responses between the first and second interview were scarce. The hospital received a lower evaluation than did either anesthesia or surgery (p < 0.001). The anesthesiologist, who was less well recognized than the obstetrician was remembered better among women receiving local-regional anesthesia (p = 0.008).

CONCLUSIONS

Local-regional anesthesia can improve levels of satisfaction over that of general anesthesia among women undergoing cesarean surgery, and contributes to maintaining recall of the anesthesiologist. These results may be related to the fact of being conscious during the birth of a child.

[Prophylaxis of intraoperative nausea and vomiting with sub-hypnotic dose of propofol during intradural anesthesia in cesarean section]

OBJECTIVES

To determine the preventive and therapeutic effect of 10 mg of propofol administered after delivery on the incidence of intraoperative nausea and vomiting (IONV) during intradural anesthesia for cesarean delivery.

PATIENTS AND METHOD

Controlled, randomized double blind study of 60 women (ASA I-II) receiving intradural anesthesia for elective or deferred emergency cesarean delivery. The propofol group received 10 mg i.v. immediately after fetal extraction. The control group received an equal volume of Intralipid. The presence of IONV after administration of the prophylactic bolus was treated with a second bolus, and if nausea had not subsided completely after two minutes, treatment was topped up with dehydro-benzoperidol.

RESULTS

The control group included 31 women and the propofol group 29, of whom 3 were excluded. Control variables were similar in the two groups. There were no significant differences in the incidence and severity of IONV between the two groups (22.5 versus 23%). The top-up antiemetic drug was used in the same number of patients in each group.

CONCLUSIONS

Although 10 mg propofol has been described as an effective direct antiemetic, episodes of IONV were neither prevented nor reversed by its use during intradural anesthesia for cesarean delivery.