Manic episode with psychotic symptoms induced by subthalamic nucleus stimulation in a patient with Parkinson's disease.

Deep brain stimulation of the subthalamic nucleus (STN-DBS) is an established therapy for Parkinson's disease (PD). A manic episode with psychotic symptoms induced by STN-DBS occurred in a previously psychiatrically healthy patient, focusing on the role of STN-DBS in influencing not only motor but also emotional behaviour.     

Acute psychotropic effects of bilateral subthalamic nucleus stimulation and levodopa in Parkinson's disease.

High-frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves the motor symptoms of Parkinson's disease (PD). Opposite changes in mood, such as mania or depression, have been reported after surgery, but it is not known whether these side effects are specifically related to STN DBS. To learn whether STN DBS also influences the limbic loop, we investigated acute subjective psychotropic effects related to levodopa or bilateral STN DBS. After a median postoperative follow-up of 12 months, 50 PD patients completed the Addiction Research Center Inventory (ARCI), assessing subjective psychotropic effects in four conditions: off-drug/on-stimulation; off-drug/off-stimulation; on-drug/off-stimulation; and on-drug/on-stimulation. Both levodopa and STN DBS improved all the ARCI subscales, indicating subjective feelings of well being, euphoria, increase in motivation, and decrease in fatigue, anxiety, and tension. A suprathreshold dose of levodopa was significantly more effective than STN DBS, using the same electrical parameters as for chronic stimulation, on four of the five ARCI subscales. We concluded that 1) both STN DBS and levodopa have synergistic acute beneficial psychotropic effects in PD, 2) the psychotropic effects of both treatments need to be considered in the long-term management of chronic STN DBS, and 3) the results indicate an involvement of the limbic STN in mood disorders of PD.     

Evidence for reduced traumatization during laparoscopic versus conventional cholecystectomy: Different changes in histamine levels related to special phases of operation

The role of histamine in injury due to trauma or surgical treatment is more than doubtful after more than 70 years of investigation. A comparison of histamine released during conventional versus minimal invasive surgery seems especially useful to elucidate the role of histamine in such important events of the daily clinical life.Histamine is released during conventional cholecystectomy in patients of high age, a special group of risk for perioperative morbidity and mortality. In animal experiments, it was shown that this histamine release is due to technical differences between the two types of operation. Hence histamine release seems to be a suitable parameter for the stimulus-induced approach to stress and trauma. Histamine is localized in high concentrations especially in abdominal tissues. After its release it may cause direct actions at a susceptible myocardium, pulmonary parenchyma or gastrointestinal mucosa. However, histamine release is also a proxy variable for mast cell irritation, stimulation and mediator release. This should not be forgotten when the role of histamine is discussed in shock, ARDS, DIC and other clinically relevant or even life-threatening events in routine surgical care.     

Paclitaxel-eluting stents for the treatment of chronic total coronary occlusions: a strategy of extensive lesion coverage with drug-eluting stents.

The recanalization of a chronic total coronary occlusion (CTO) is hampered by a high rate of lesion recurrence. The goal of the present study is to assess the effect of paclitaxel-eluting stents in CTOs in a strategy of extensive stent coverage and the optional use of additional bare metal stents (BMSs). In 82 consecutive patients, a CTO (duration > 2 weeks) was successfully recanalized with implantation of one or more Taxus stents. These patients underwent a repeat angiography after 5.0 +/- 1.5 months and were assessed by quantitative angiography. The patients were compared with 82 clinically and lesion-matched patients from a consecutive series of 148 patients with CTOs treated by BMS in the preceding time period. In 21 of the 82 patients, additional lesions in the target artery not directly related to the original occlusion site were treated with BMSs (hybrid approach). The history of diabetes, extent of coronary artery disease, clinical symptoms, and angiographic features were similar in the Taxus and BMS group. Periprocedural adverse events were 3.3% with Taxus and 3.3% with BMS, but 12 months MACE was significantly lower in the group with exclusive use of Taxus (13.3% vs. 56.7%; P < 0.001), mainly due to a lower target lesion revascularization of 10.0% as compared to 53.4% (P < 0.001). There was only one late reocclusion with Taxus (1.7%) as compared to 21.7% with BMS (P < 0.05). However, in the hybrid group, the MACE rate was considerably higher, with 33.3%. Our data of a 80% reduction of target vessel failure as compared to BMS, with a lower risk of late reocclusions without increased acute adverse events, demonstrate the benefit of paclitaxel-eluting stents in CTOs. However, diffuse atherosclerosis in CTOs should be covered completely by the drug-eluting stents.     

Effect of subthalamic nucleus stimulation on levodopa-induced dyskinesia in Parkinson's disease

Article abstract-The authors studied the effect of bilateral subthalamic nucleus stimulation on levodopa-induced dyskinesias in 24 consecutive parkinsonian patients with disabling dyskinesias. The improvement in the three subtypes of levodopa-induced dyskinesias was significant from the third postoperative month and was mainly due to the decrease in the daily dose of levodopa allowed by the stimulation-induced improvement in the motor score.     

Neuropsychological changes between "off" and "on" STN or GPi stimulation in Parkinson's disease

BACKGROUND: In a previous study on a consecutive series of 62 patients with PD, the authors showed that bilateral subthalamic or pallidal continuous high-frequency deep brain stimulation (DBS) affects neither memory nor executive functions 3 to 6 months after surgery. OBJECTIVE: To investigate the specific effects of DBS by comparing the performance of patients with the stimulator turned "on" and "off." METHODS: The performance of 56 patients on clinical tests of executive function was compared after 3 and 12 months of DBS of the subthalamic nucleus (STN; n = 48) or the internal globus pallidus (GPi; n = 8) with the stimulator "on" or "off." Global intellectual efficiency, verbal learning, and mood were also evaluated with the stimulator "on." The performance of another group of 20 patients was compared after 6 months of DBS of the STN (n = 15) or the GPi (n = 5) with the stimulator "on" or "off" on more experimental tests recently shown to be more sensitive to l-dopa therapy. RESULTS: When the stimulator was "on," STN patients showed a mild but significant improvement in psychomotor speed and working memory. In comparison with the presurgical state, STN patients had no cognitive deficit at 12 months, except for lexical fluency. There was no differential effect of STN or GPi stimulation. CONCLUSIONS: 1) The specific effect of DBS seems to mimic the action of l-dopa treatment in the cognitive as in the motor domain; 2) the surgery associated with DBS does not appear to affect the cognitive performance of patients with PD 12 months later, except for a mild deficit in lexical fluency.