Surgery for Parkinson disease in the United States, 1996 to 2000: practice patterns, short-term outcomes, and hospital charges in a nationwide sample

2003 ◽  
Vol 99 (5) ◽  
pp. 863-871 ◽  
Author(s):  
Emad N. Eskandar ◽  
Alice Flaherty ◽  
G. Rees Cosgrove ◽  
Leslie A. Shinobu ◽  
Fred G. Barker
Keyword(s):  
Surgical Treatment ◽  
Parkinson Disease ◽  
Practice Patterns ◽  
The United States ◽  
Hospital Charges ◽  
Short Term ◽  
Content Type ◽  
The Us ◽  
Fine Print ◽  
Deep Brain

Object. The surgical treatment of Parkinson disease (PD) has undergone a dramatic shift, from stereotactic ablative procedures toward deep brain stimulaion (DBS). The authors studied this process by investigating practice patterns, mortality and morbidity rates, and hospital charges as reflected in the records of a representative sample of US hospitals between 1996 and 2000. Methods. The authors conducted a retrospective cohort study by using the Nationwide Inpatient Sample database; 1761 operations at 71 hospitals were studied. Projected to the US population, there were 1650 inpatient procedures performed for PD per year (pallidotomies, thalamotomies, and DBS), with no significant change in the annual number of procedures during the study period. The in-hospital mortality rate was 0.2%, discharge other than to home was 8.1%, and the rate of neurological complications was 1.8%, with no significant differences between procedures. In multivariate analyses, hospitals with larger annual caseloads had lower mortality rates (p = 0.002) and better outcomes at hospital discharge (p = 0.007). Placement of deep brain stimulators comprised 0% of operations in 1996 and 88% in 2000. Factors predicting placement of these devices in analyses adjusted for year of surgery included younger age, Caucasian race, private insurance, residence in higher-income areas, hospital teaching status, and smaller annual hospital caseload. In multivariate analysis, total hospital charges were 2.2 times higher for DBS (median $36,000 compared with $12,000, p < 0.001), whereas charges were lower at higher-volume hospitals (p < 0.001). Conclusions. Surgical treatment of PD in the US changed significantly between 1996 and 2000. Larger-volume hospitals had superior short-term outcomes and lower charges. Future studies should address long-term functional end points, cost/benefit comparisons, and inequities in access to care.

Bilateral stimulation of the subthalamic nucleus in patients with Parkinson disease: a study of efficacy and safety

2002 ◽  
Vol 96 (4) ◽  
pp. 666-672 ◽  
Author(s):  
Tanya Simuni ◽  
Jurg L. Jaggi ◽  
Heather Mulholland ◽  
Howard I. Hurtig ◽  
Amy Colcher ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Bilateral Stimulation ◽  
Content Type ◽  
Preoperative Status ◽  
Fine Print ◽  
Deep Brain ◽  
Stimulation Of

Object. Palliative neurosurgery has reemerged as a valid therapy for patients with advanced Parkinson disease (PD) that is complicated by severe motor fluctuations. Despite great enthusiasm for long-term deep brain stimulation (DBS) of the subthalamic nucleus (STN), existing reports on this treatment are limited. The present study was designed to investigate the safety and efficacy of bilateral stimulation of the STN for the treatment of PD. Methods. In 12 patients with severe PD, electrodes were stereotactically implanted into the STN with the assistance of electrophysiological conformation of the target location. All patients were evaluated preoperatively during both medication-off and -on conditions, as well as postoperatively at 3, 6, and 12 months during medication-on and -off states and stimulation-on and -off conditions. Tests included assessments based on the Unified Parkinson's Disease Rating Scale (UPDRS) and timed motor tests. The stimulation effect was significant in patients who were in the medication-off state, resulting in a 47% improvement in the UPDRS Part III (Motor Examination) score at 12 months, compared with preoperative status. The benefit was stable for the duration of the follow-up period. Stimulation produced no additional benefit during the medication-on state, however, when compared with patient preoperative status. Significant improvements were made in reducing dyskinesias, fluctuations, and duration of off periods. Conclusions. This study demonstrates that DBS of the STN is an effective treatment for patients with advanced, medication-refractory PD. Deep brain stimulation of the STN produced robust improvements in motor performance in these severely disabled patients while they were in the medication-off state. Serious adverse events were common in this cohort; however, only two patients suffered permanent sequelae.

Deep brain stimulation in Parkinson disease: a metaanalysis of patient outcomes

2005 ◽  
Vol 103 (6) ◽  
pp. 956-967 ◽  
Author(s):  
Frances Weaver ◽  
Kenneth Follett ◽  
Kwan Hur ◽  
Dolores Ippolito ◽  
Matthew Stern
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Patient Outcomes ◽  
Motor Function ◽  
Brain Stimulation ◽  
Multiple Time ◽  
Content Type ◽  
Study Characteristics ◽  
Fine Print ◽  
Deep Brain

Object. Deep brain stimulation (DBS) to treat advanced Parkinson disease (PD) has been focused on one of two anatomical targets: the subthalamic nucleus (STN) and the globus pallidus internus (GPI). Authors of more than 65 articles have reported on bilateral DBS outcomes. With one exception, these studies involved pre- and postintervention comparisons of a single target. Despite the paucity of data directly comparing STN and GPI DBS, many clinicians already consider the STN to be the preferred target site. In this study the authors conducted a metaanalysis of the existing literature on patient outcomes following DBS of the STN and the GPI. Methods. This metaanalysis includes 31 STN and 14 GPI studies. Motor function improved significantly following stimulation (54% in patients whose STN was targeted and 40% in those whose GPI was stimulated), with effect sizes (ESs) of 2.59 and 2.04, respectively. After controlling for participant and study characteristics, patients who had undergone either STN or GPI DBS experienced comparable improved motor function following surgery (p = 0.094). The performance of activities of daily living improved significantly in patients with either target (40%). Medication requirements were significantly reduced following stimulation of the STN (ES = 1.51) but did not change when the GPI was stimulated (ES = −0.02). Conclusions. In this analysis the authors highlight the need for uniform, detailed reporting of comprehensive motor and nonmotor DBS outcomes at multiple time points and for a randomized trial of bilateral STN and GPI DBS.

Psychiatric symptoms in patients with Parkinson disease presenting for deep brain stimulation surgery

2005 ◽  
Vol 103 (2) ◽  
pp. 246-251 ◽  
Author(s):  
Valerie Voon ◽  
Jean Saint-Cyr ◽  
Andres M. Lozano ◽  
Elena Moro ◽  
Yu Yan Poon ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
General Population ◽  
Parkinson Disease ◽  
Brain Stimulation ◽  
Psychiatric Symptoms ◽  
Content Type ◽  
Axis I ◽  
Depression Scales ◽  
Fine Print ◽  
Deep Brain

Object. Postoperative psychiatric symptoms have been associated with subthalamic deep brain stimulation (DBS) for Parkinson disease (PD), and preoperative psychiatric vulnerability, the effects of surgery, stimulation, medication changes, and psychosocial adjustment have been proposed as causative factors. The variables involved in whether preoperative psychiatric symptoms improve or worsen following surgery are not yet known. In the present study, preoperative psychiatric symptoms were systematically assessed in patients with PD presenting for routine preoperative psychiatric assessment. Methods. Forty consecutive patients with PD presenting for DBS were interviewed using the Mini International Neuropsychiatric Inventory. Current depressive symptoms were quantified using clinician- and patient-rated depression scales. Seventy-eight percent of patients had at least one lifetime or current Axis I psychiatric diagnosis. The prevalence of depression was 60% (95% confidence interval [CI] 45–85), psychosis 35% (95% CI 25–50), and anxiety 40% (95% CI 25–55). These prevalence rates were comparable to or greater than those in the general population of patients with PD. Twenty-three percent of patients required psychiatric treatment for current symptoms prior to being considered eligible for DBS. Conclusions. As part of the selection process for surgery, members of the study population were chosen for their lack of overt dementia or other active disabling psychiatric symptomatology. The incidence rates of psychiatric disorders, including those diseases occurring in the general population affected with PD, were greater than expected. Data in the present study lead one to question the reliability of patient-rated depression scales as the sole instrument for assessing depression. The authors highlight the need for evidence-based guidelines in the management of these preoperative symptoms as well as the involvement of psychiatric personnel in the assessment and management of these symptoms.

Transient dystonia following magnetic resonance imaging in a patient with deep brain stimulation electrodes for the treatment of Parkinson disease

2003 ◽  
Vol 99 (4) ◽  
pp. 772-774 ◽  
Author(s):  
Jörg Spiegel ◽  
Gerhard Fuss ◽  
Martin Backens ◽  
Wolfgang Reith ◽  
Tim Magnus ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Deep Brain Stimulation ◽  
Magnetic Resonance ◽  
Mr Imaging ◽  
Parkinson Disease ◽  
Resonance Imaging ◽  
Content Type ◽  
Ballistic Movements ◽  
Fine Print ◽  
Deep Brain

✓ Data from previous studies have shown that magnetic resonance (MR) imaging of the head can be performed safely in patients with deep brain stimulators. The authors report on a 73-year-old patient with bilaterally implanted deep brain electrodes for the treatment of Parkinson disease, who exhibited dystonic and partially ballistic movements of the left leg immediately after an MR imaging session. Such dystonic or ballistic movements had not been previously observed in this patient. In the following months, this focal movement disorder resolved completely. This case demonstrates the possible risks of MR imaging in patients with deep brain stimulators.

Movement-related neurons of the subthalamic nucleus in patients with Parkinson disease

2002 ◽  
Vol 97 (5) ◽  
pp. 1167-1172 ◽  
Author(s):  
Aviva Abosch ◽  
William D. Hutchison ◽  
Jean A. Saint-Cyr ◽  
Jonathan O. Dostrovsky ◽  
Andres M. Lozano
Keyword(s):  
Receptive Field ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Receptive Fields ◽  
Median Number ◽  
Content Type ◽  
Pooled Data ◽  
Somatotopic Organization ◽  
Fine Print ◽  
Deep Brain

Object. The subthalamic nucleus (STN) is a target in the surgical treatment of Parkinson disease (PD). Little is known about the neurons within the human STN that modulate movement. The authors' goal was to examine the distribution of movement-related neurons within the STN of humans by using microelectrode recording to identify neuronal receptive fields. Methods. Data were retrospectively collected from microelectrode recordings that had been obtained in 38 patients with PD during surgery for placement of STN deep brain stimulation electrodes. The recordings had been obtained in awake, nonsedated patients. Antiparkinsonian medications were withheld the night before surgery. Neuronal discharges were amplified, filtered, and displayed on an oscilloscope and fed to an audio monitor. The receptive fields were identified by the presence of reproducible, audible changes in the firing rate that were time-locked to the movement of specific joint(s). The median number of electrode tracks per patient was six (range two–nine). The receptive fields were identified in 278 (55%) of 510 STN neurons studied. One hundred one tracks yielded receptive field data. Fourteen percent of 64 cells tested positive for face receptive fields, 32% of 687 cells tested positive for upper-extremity receptive fields, and 21% of 242 cells tested positive for lower-extremity receptive fields. Sixty-eight cells (24%) demonstrated multiple-joint receptive fields. Ninety-three cells (65%) with movement-related receptive fields were located in the dorsal half of the STN, and 96.8% of these were located in the rostral two thirds of the STN. Analysis of receptive field locations from pooled data and along individual electrode tracks failed to reveal a consistent somatotopic organization. Conclusions. Data from this study demonstrate a regional compartmentalization of neurons with movement-related receptive fields within the STN, supporting the existence of specific motor territories within the STN in patients suffering from PD.

Long-term follow up of bilateral deep brain stimulation of the subthalamic nucleus in patients with advanced Parkinson disease

2003 ◽  
Vol 99 (3) ◽  
pp. 489-495 ◽  
Author(s):  
Galit Kleiner-Fisman ◽  
David N. Fisman ◽  
Elspeth Sime ◽  
Jean A. Saint-Cyr ◽  
Andres M. Lozano ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Content Type ◽  
Over Time ◽  
Fine Print ◽  
Deep Brain

Object. The use of deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been associated with a marked initial improvement in individuals with advanced Parkinson disease (PD). Few data are available on the long-term outcomes of this procedure, however, or whether the initial benefits are sustained over time. The authors present the long-term results of a cohort of 25 individuals who underwent bilateral DBS of the STN between 1996 and 2001 and were followed up for 1 year or longer after implantation of the stimulator. Methods. Patients were evaluated at baseline and repeatedly after surgery by using the Unified Parkinson's Disease Rating Scale (UPDRS); the scale was applied to patients during periods in which antiparkinsonian medications were effective and periods when their effects had worn off. Postoperative UPDRS total scores and subscores, dyskinesia scores, and drug dosages were compared with baseline values, and changes in the patients' postoperative scores were evaluated to assess the possibility that the effect of DBS diminished over time. In this cohort the median duration of follow-up review was 24 months (range 12–52 months). The combined (ADL and motor) total UPDRS score during the medication-off period improved after 1 year, decreasing by 42% relative to baseline (95% confidence interval [CI 35–50%], p < 0.001) and the motor score decreased by 48% (95% CI 42–55%, p < 0.001). These gains did diminish over time, although a sustained clinical benefit remained at the time of the last evaluation (41% improvement over baseline, 95% CI 31–50%; p < 0.001). Axial subscores at the time of the last evaluation showed only a trend toward improvement (p = 0.08), in contrast to scores for total tremor (p < 0.001), rigidity (p < 0.001), and bradykinesia (p = 0.003), for which highly significant differences from baseline were still present at the time of the last evaluation. Medication requirements diminished substantially, with total medication doses reduced by 38% (95% CI 27–48%, p < 0.001) at 1 year and 36% (95% CI 25–48%, p < 0.001) at the time of the last evaluation; this decrease may have accounted, at least in part, for the significant decrease of 46.4% (95% CI 20.2–72.5%, p = 0.007) in dyskinesia scores obtained by patients during the medication-on period. No preoperative demographic variable, such as the patient's age at the time of disease onset, age at surgery, sex, duration of disease before surgery, preoperative drug dosage, or preoperative severity of dyskinesia, was predictive of long-term outcome. The only predictor of a better outcome was the patient's preoperative response to levodopa. Conclusions. In this group of patients with advanced PD who underwent bilateral DBS of the STN, sustained improvement in motor function was present a mean of 2 years after the procedure, and sustained reductions in drug requirements were also achieved. Improvements in tremor, rigidity, and bradykinesia were more marked and better sustained over time than improvements in axial symptoms. A good preoperative response to levodopa predicted a good response to surgery.

Intra-Palestinian tensions will mount

2016 ◽  
Keyword(s):  
United States ◽  
Peace Process ◽  
Central Committee ◽  
The United States ◽  
Short Term ◽  
Content Type ◽  
Popular Support ◽  
The Us ◽  
Trump Administration

Significance In the short term, it strengthened the party chairman and Palestinian president, Mahmoud Abbas. Abbas prevented his major rival, Mohammad Dahlan, and his supporters from attending. He was unanimously re-elected, and at least 16 of the 18 seats on the Central Committee also went to Abbas loyalists. Despite expectations, there were no efforts to bring in new blood or name a deputy to succeed the 81-year-old Abbas. Impacts Reactions to an incoming Trump administration in the United States could undermine the Israeli-Palestinian peace process. If the US Embassy relocates to Jerusalem, the Palestinian reaction will be violent. While the situation remains frozen, both Hamas and Fatah will lose further popular support. Competition among potential successors to Abbas will intensify.

Neurosurgical workforce trends in the United States

2005 ◽  
Vol 102 (2) ◽  
pp. 202-208 ◽  
Author(s):  
Oren N. Gottfried ◽  
Richard L. Rovit ◽  
A. John Popp ◽  
Kristin L. Kraus ◽  
Arlene Stolper Simon ◽  
...  
Keyword(s):  
United States ◽  
The United States ◽  
Content Type ◽  
The Past ◽  
Time Period ◽  
The Us ◽  
The Mean ◽  
First Time ◽  
Second Period ◽  
Fine Print

Object. The purpose of this study was to evaluate the US neurosurgery workforce by reviewing journal recruitment advertisements published during the past 10 years. Methods. The number of available academic and private neurosurgical staff positions was determined based on recruitment advertisements in the Journal of Neurosurgery and Neurosurgery for the 10-year period from 1994 to 2003. Advertisements were evaluated for practice venue, subspecialization, and location. The numbers of active neurosurgeons and graduating residents also were reviewed. The number of advertised neurosurgical positions increased from 141.6 ± 38.2 per year from 1994 through 1998 to 282.4 ± 13.6 per year from 1999 through 2003 (mean ± standard deviation, p < 0.05). The mean number of academic positions increased from 50.6 ± 11.1 to 95 ± 17.5 (p <0.05), and the mean number of private positions rose from 91 ± 30.4 to 187.4 ± 6.8 (p <0.05). Subspecialty positions represented a mean of only 15.6 ± 5% per year during the first time period and 18.8 ± 3% per year in the second period (p = 0.22), and therefore the majority of positions advertised continued to be those for generalists. The number of practicing neurosurgeons declined after 1998, and by 2002 it was less than it had been in 1991. The numbers of incoming and matriculating residents during the study period were static. Conclusions. The number of recruitment advertisements for neurosurgeons during the last 5 years has increased significantly, concomitant with a severe decline in the number of active neurosurgeons and a static supply of residents.

Multilateralism risks will rise amid World Bank change

2019 ◽  
Keyword(s):  
Climate Change ◽  
United States ◽  
Renewable Energy ◽  
Private Sector ◽  
World Bank ◽  
The United States ◽  
Short Term ◽  
Content Type ◽  
Global Issues ◽  
The Us

Significance Kim's departure creates unforeseen turbulence at the institution, whose corporate commitments around climate change, gender and renewable energy are anathema to the current US administration. Impacts If the US nominee is an ideological conservative, World Bank relations with either the United States or other shareholders will be damaged. Short-term impacts on Bank operations will be minimal. Kim’s belief that he can affect “global issues” more in the private sector emphasises the importance of the Bank reviving its global role.

Implantation of bilateral deep brain stimulators in patients with Parkinson disease and preexisting cardiac pacemakers

2004 ◽  
Vol 101 (6) ◽  
pp. 1073-1077 ◽  
Author(s):  
Patrick B. Senatus ◽  
Shearwood McClelland ◽  
Anjanette D. Ferris ◽  
Blair Ford ◽  
Linda M. Winfield ◽  
...  
Keyword(s):  
Parkinson Disease ◽  
Cardiac Pacemaker ◽  
Dramatic Improvement ◽  
Cardiac Pacemakers ◽  
Content Type ◽  
Pulse Generators ◽  
Pacemaker Function ◽  
Stereotactic Frame ◽  
Fine Print ◽  
Deep Brain

✓ Deep brain stimulation (DBS) has become an important modality in the treatment of refractory Parkinson disease (PD). In patients with comorbid arrhythmias requiring cardiac pacemakers, DBS therapy is complicated by concerns over a possible electrical interaction between the devices (or with device programming) and the inability to use magnetic resonance imaging guidance for implantation. The authors report two cases of PD in which patients with preexisting cardiac pacemakers underwent successful implantation of bilateral DBS electrodes in the subthalamic nucleus (STN). Each patient underwent computerized tomography—guided stereotactic frame—based placement of DBS electrodes with microelectrode recording. Both extension wires were passed from the right side of the head and neck (contralateral to the pacemaker) to place the cranial pulse generators subcutaneously in the left and right abdomen. The cranial pulse generators were placed farther than 6 in from the cardiac pacemaker and from each other to decrease the chance of interference between the devices during telemetry reprogramming. Postoperative management involved brain stimulator programming sessions with simultaneous cardiological monitoring of pacemaker function and cardiac rhythm. No interference was noted at any time, and proper pacemaker function was maintained throughout the follow-up period. With bilateral STN stimulation, both patients experienced a dramatic improvement in their PD symptoms, including elimination of dyskinesias, reduction of “off” severity, and increase of “on” duration. With some modifications of implantation strategy, two patients with cardiac pacemakers were successfully treated with bilateral DBS STN therapy for refractory PD. To our knowledge, this is the first report on patients with cardiac pacemakers undergoing brain stimulator implantation.

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