ecolier
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Welcome to TSRMedics™ JOURNALclub
TSRMedics™JOURNALclubn is the section for discussion of published / yet-to-be-published medical journal articles that may be of interest to medics / potential medics.

This week I am talking about Deep Brain Stimulation, from an article published on Practical Neurology

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Deep brain stimulation: practical insights and common queries
Fahd Baig, Thomas Robb, Lucy Mooney, Caroline Robbins, Caroline Norris, Neil Barua, Konrad Szewczyk-Krolikowski, Alan Whone

What is deep brain stimulation?
Surgical implanation of electrodes into parts of the brain to improve patients' symptoms. The electrodes are conencting to a pulse generator in the chest in adults. The patient is given a device which controls the pulse generator.

What diseases can DBS treat?
The most common clinical applications are Parkinson's disease (PD), essential tremor and dystonia. Some centres offer DBS for Tourette's syndrome and obsessive-compulsive disorder.

How are patients with DBS selected?
According to NHS England criteria and local expertise, with inidividual counselling to ensure realistic expectations. Implanatation techniques can cary between different centres and therefore the risks could be very different.

What happens after DBS?
Following implanation, there is a period of systematically exploring the settings to reach the optimum setting - for maximum clinical benefit and minimum side effects. Patients can also vary the DBS setting according to their activity.

For PD, drug treatment may still be needed after DBS but may be reduced depending on the target of the DBS. This dosage may need adjusting as the disease progresses. In some ways the DBS itself can be imagined to be a form of PD medication which is being continuously delivered. Follow up will usually be at the DBS implanation centre and the local team.

Symptoms of PD and essential tremor may respond promptly to DBS but dystonia symptoms could take months to improve. It has not been discussed in the journal why this is the case.

Side effects of a DBS
Implanation of DBS is a form of neurosurgery - therefore the complications are similar to other types of brain operations including cerebral haemorrhage (bleed in the brain) 1.1% and ischaemic stroke 0.4%. After discharge there is a risk of infection (look for fever, changes around the wound, headaches, changes in behaviour, alteration in conscious levels and new focal neurological symptoms).

If there is an infection, the electrodes and/or pulse generator may have to be removed and re-implanted after a delay. To minimise complications, patients should be carefully selected.

Other side effects can include hardware failures, such as faulty equipment, loose connection or broken leads (after a fall or trauma). This will lead to a sudden worsening of symptoms. Batteries can be rechargeable (lasting more than 15 years) or non-rechargeable (lasting 2-5 years). The patient controlled device will show the level of charge remaining, and a low battery warning will show up months before charge runs out.

If the batteries run out entirely despite the alert, PD patients could have an akinetic crisis while dystonia patients could have a dystonic storm. Both these complications can be life-threatening and need to be treated as a medical emergency.

Other investigations after a DBS implanation
MRI scanning is possible with some but not all DBS devices - some may allow for certain parts of the body to be scanned (e.g. head but not nelow beck). If the system is a hybrid (mixed component from different manufacturers) then it is certainly not MRI compatible. The risk is because of hardware heating up due to the magnetic field, damaging surrounding tissues (including the brain!). If an MRI is required, it is suggested that the doctor contact the DBS centre for further information. If it is compatible, the device must have its voltage set to 0V and switched off (or to "MRI mode") prior to the scan.

X-ray including DEXA scans and mammograms may also not be possible with some DBS devices. Make sure that if a chest XR / mammogram is carried out that the pad is not placed to put pressure on the device or leads.

There have also been reports that even CT scan could affect the DB stimulation settings and even damage the stimulator. It is therefore recommended that the device is switched to "MRI mode" before a CT scan.

Finally, the DBS should also be turned off for neurophysiology investigations as it can affect the recordings.

Surgical precautions for patients with DBS
Most centres recommend preventative antibiotics for patients with DBS during dental, gastrointestinal or genitourinary procedures where there is a risk of infection.

Surgical diathermy should be avoided for some DBS devices, especially monpolar electrocautery. Any surgical laser could also impact the DBS, so it must be switched off before operations involving those. The laser should be as far as the hardware as possible.

Therapeutic diathermy e.g. microwave / ultrasound treatment is completely contraindicated in any patient with DBS hardware. This can lead to electrodes causing tissue (brain!) damage and there have been reports of permanent injury and death.

Finally, DBS patients who is going for radiotherapy will need individual discussion between the DBS team and oncologists as there is a risk that the radiation can permanently damage the DBS hardware. It is planned on an individual basis.

Are there any other precautions?
When travelling, security scanners may switch the DBS on or off, or cause a change in the stimulation. It is therefore important that patients should keep a good distance away from them. It has been reported that even theft detectors near shop doors can trigger this. Make sure that patients always carry their device registration card and take the controller in the hand luggage so the DBS can be switched off if necessary.

Patients need to be careful and may need to avoid sports that may involve the chest being struck with force (e.g. boxing or martial arts). They should also wear helmets if there is a risk of head injury.

Around the home and workplace, patients need to avoid induction cooking hobs and heaters, theft detectors, large audio speakers, arc welding equipment, power lines and generators. They may also need to be careful around older cordless phones and mobile phones. Electric and hybrid cars may also cause intereference - consider before travelling in such a vehicle.

Please post any questions if you have any, and post suggestions for future journal clubs.
Last edited by ecolier; 1 year ago
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Ghotay
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A relative of mine has Parkinsons and asked their neurologist about DBS. They're in their early 60s, fit with no comorbidities. Seems to me as a non-neurologist to be a reasonable candidate and as likely a patient to benefit from it as anyone. From what I can gather their neurologist basically told them "Yeah nah, we don't do that here". I know patients can sometimes get the wrong end of the stick, but I'm curious if you know anything about the availability of this as a treatment, and the guidelines for selection?
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ecolier
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(Original post by Ghotay)
A relative of mine has Parkinsons and asked their neurologist about DBS. They're in their early 60s, fit with no comorbidities. Seems to me as a non-neurologist to be a reasonable candidate and as likely a patient to benefit from it as anyone. From what I can gather their neurologist basically told them "Yeah nah, we don't do that here". I know patients can sometimes get the wrong end of the stick, but I'm curious if you know anything about the availability of this as a treatment, and the guidelines for selection?
It depends on the local guidelines, but NHS England have listed some criteria also: https://www.england.nhs.uk/wp-conten...04/d03-p-b.pdf (page 6).
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Notoriety
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Why do two of the authors have doctorates in research and how would you become involved in these sort of research groups, such as being the docs who try out the methods on patients? Do ordinary doctors often write articles?
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ecolier
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(Original post by Notoriety)
Why do two of the authors have doctorates in research and how would you become involved in these sort of research groups, such as being the docs who try out the methods on patients? Do ordinary doctors often write articles?
Usually the first (and second) authors have the most to contribute, and the last author is the consultant / person responsible for the team.

It is pretty much optional these days to do a PhD or not to - especially for our specialty where consultant vacancies are everywhere. There are still many people who will choose to do it though - hence the qualification.

Most of the time, it's "the right place at the right time"; however there are also doctors working specifically as "Research Fellows" so constantly have to participate in research. They would need to constantly publish and carry out research to ensure that they are employed!

This article though isn't really an original research piece (e.g. a randomised control trial / meta-analysis) - this is more a summary of the available information on DBS. Perhaps in the future I will review a journal article that's actually original research.

Finally, yes ordinary doctors do get involved - more likely / more opportunities if you are in an academic training programme; but even though in a "normal" training programme like me do have opportunities. It is more likely during registrar training though, because you are at one hospital / with one firm for longer.
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Notoriety
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(Original post by ecolier)
Usually the first (and second) authors have the most to contribute, and the last author is the consultant / person responsible for the team.

It is pretty much optional these days to do a PhD or not to - especially for our specialty where consultant vacancies are everywhere. There are still many people who will choose to do it though - hence the qualification.

Most of the time, it's "the right place at the right time"; however there are also doctors working specifically as "Research Fellows" so constantly have to participate in research. They would need to constantly publish and carry out research to ensure that they are employed!

This article though isn't really an original research piece (e.g. a randomised control trial / meta-analysis) - this is more a summary of the available information on DBS. Perhaps in the future I will review a journal article that's actually original research.

Finally, yes ordinary doctors do get involved - more likely / more opportunities if you are in an academic training programme; but even though in a "normal" training programme like me do have opportunities. It is more likely during registrar training though, because you are at one hospital / with one firm for longer.
Thanks for the explanation and for the interesting OP.

It is sort of difficult to understand medical research to people outside of the med circle -- interesting to see all the intricacies of behind-the-scenes medicine.
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GANFYD
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(Original post by ecolier)
Perhaps in the future I will review a journal article that's actually original research.
My son had to do a journal review and I suggested several things he might consider and he went "Mum, you haven't even read the article". Told him there was no need and sample size, bias, confounding variables, etc, etc are inherent to all research. He did pretty well in his assessment and I have never forgotten the stuff I learned for MRCGP when I sat it! Peer review is, without doubt, the most useful part of any research
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ecolier
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(Original post by GANFYD)
My son had to do a journal review and I suggested several things he might consider and he went "Mum, you haven't even read the article". Told him there was no need and sample size, bias, confounding variables, etc, etc are inherent to all research. He did pretty well in his assessment and I have never forgotten the stuff I learned for MRCGP when I sat it! Peer review is, without doubt, the most useful part of any research
:yy: :yes:
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