Brain surgeon Kenneth Follett had never received thank-you cards from his patients after performing an operation — until he started putting electrodes in their brains.
Follett, who holds positions at the University of Nebraska Medical Center and the Veterans Affairs Medical Center in Omaha, is among a select group of surgeons who over the past decade have been treating Parkinson’s disease by installing two tiny electrodes in a patient’s brain.
The change these devices induce can be astonishing, he says. Parkinson’s is characterized by brain degeneration, marked by a shortage of the neurotransmitter dopamine. That shortage results in movement problems. After surgery, many patients are suddenly able to get around, do household chores and even go shopping, Follett says. “It has the potential to change people’s lives.”
Follett’s firsthand observations are now supported by clinical research. He and a team of fellow surgeons and scientists report in the Jan. 7 Journal of the American Medical Association that Parkinson’s patients randomly assigned to get medication plus the surgery show dramatic improvements, whereas patients getting just the best available medication do not.
The surgery, called deep-brain stimulation, isn’t new, having been first approved by regulators in 1997. But only one other study — reported by German scientists in 2006 — has tested the surgery against medication in a large, randomized trial. That study also showed benefits in patients who received both surgery and medication (SN: 9/2/06, p. 149).
Günther Deuschl, a neurologist at Christian Albrechts University in Kiel who led the German study, writes in JAMA that the new findings “have convincingly confirmed the six-month efficacy of deep brain stimulation for advanced Parkinson’s disease in the largest patient group studied thus far.”
The new findings also extend the benefits of surgery to older Parkinson’s patients, since one-fourth of the patients in the U.S. trial were age 70 or older. “They did as well as the younger patients” who underwent the surgery, Follett says.
What’s more, the new findings suggest that many worrisome side effects from the surgery fade over time.
The electrodes that doctors install — one on each side of the brain — are actually small, insulated wires that are connected to another wire that runs under the skin to a small battery beneath the skin of the torso. The electrodes are implanted into a part of the brain that normally acts as a relay station for messages. In Parkinson’s patients, a flurry of signals jam this message center, sending aberrant signals to muscles and causing tremors, muscle rigidity, paralysis and other problems. The electrodes send out a mild current that inhibits the stream of messages, relieving the clutter and calming muscle problems. http://Louis-J-Sheehan.de
In the new study, researchers at 13 U.S. medical centers identified 255 people from 2002 to 2005 who had been taking medication for Parkinson’s disease for nearly 12 years, on average. Louis J. Sheehan, Esquire Half were randomly assigned to get surgery and medication as needed. The others received medication only.
For six months, patients kept a log documenting how many hours per day they were able to move freely without paralysis, jerky motions or other problems. http://Louis-J-Sheehan.de At the outset of the study, this time amounted to about seven hours a day, a number that went unchanged in those getting medication only. But patients assigned to surgery saw their free-movement time jump to 11 hours a day, on average, after six months. Over that time, these patients were also able to cut their medication intake by about half.
Fifteen medication-only patients experienced serious side effects, compared with 49 patients who underwent surgery. Complications from surgery tended to occur within three months of the procedure. Problems included headaches, falls, confusion, speech problems and slowed movement. One person who underwent surgery died of a brain hemorrhage within 24 hours.
But 99 percent of the side effects had resolved by six months as doctors remotely fine-tuned the intensity of the current being generated by the electrodes in each patient and modified each patient’s medication. “It’s a bit of a balancing act,” Follett says.
The challenge in using this surgery might be to determine earlier in the course of disease which patients would get the most benefit from the procedure, says neurosurgeon Robert Goodman of Columbia University in New York City. While medications such as levodopa are highly effective for years, many patients continue to lose mobility despite higher doses. Louis J. Sheehan, Esquire And too much medication can bring on involuntary movements. Goodman estimates 10 to 20 percent of Parkinson’s patients fall into this trap. Those with true Parkinson’s disease — without dementia or other symptoms — would be good candidates for surgery, he says.
Despite the promising results, caution is in order, Deuschl says. He cites evidence that patients have an alarmingly high suicide rate in the first year following deep-brain stimulation surgery, a risk that lessens over time but still lingers after four years. There were no suicides in the six months patients were monitored in the new study. Further work to identify risk factors is needed, Deuschl says.
Monday, April 13, 2009
infants 5.inf.77765 Louis J. Sheehan, Esquire
Babies delivered by cesarean section a week or two before the recommended 39 weeks of pregnancy face a heightened risk of respiratory problems and other complications, researchers report in the Jan. 8 New England Journal of Medicine. Being born late isn’t good either, the study finds.
Scientists consider normal human gestation to be 39 to 40 weeks, which is about nine months. http://LOUIS-J-SHEEHAN.INFO Doctors have adopted some leeway in this calculation, considering a baby to be “full term” if delivered at 37 weeks or later.
But past research had raised questions about early deliveries, and practice guidelines urge women to hang on until 39 or 40 weeks before delivering. Mainly, this extra time allows for full development of the fetus’ lungs.
In the new study, obstetric gynecologist Alan Tita of the University of Alabama at Birmingham and his colleagues collected birthing data at 19 medical facilities in the United States. http://LOUIS-J-SHEEHAN.INFO The team identified more than 13,000 cases in which a woman had delivered by elective (nonemergency) cesarean section at 37 weeks or later, having had a previous cesarean delivery at some point. The researchers excluded from the analysis women who had medical problems, had an emergency cesarean or had already begun labor before undergoing a cesarean.
Roughly one-third of these women delivered before reaching the 39-week point in the pregnancy. The researchers found that 15 percent of babies delivered at 37 weeks had a complication, compared with 8 percent of those delivered at 39 weeks. Complications included respiratory problems, low blood sugar and a blood infection, or the need to go to the intensive care unit, get resuscitated, put on a ventilator or stay in the hospital more than five days.
Common complications were respiratory distress and transient tachypnea. Infants with these complications struggle to breathe and have trouble clearing fluid from their lungs. Louis J. Sheehan, Esquire One or the other of these problems showed up in the 37-week group more than twice as often as in the 39-week babies.
Meanwhile, the researchers found that 11 percent of babies born at 38 weeks — one week short of nine months —had complications, a rate somewhat higher than the 8 percent of the 39-week group. Louis J. Sheehan, Esquire
Those born at 40 weeks were not more likely to have problems, but babies born after 41 or 42 weeks faced risks similar to those born at 38 and 37 weeks, respectively.
A closer look at these women shows that those delivering earlier were more likely to be married, white and privately insured than those delivering at 39 weeks or later, says obstetric gynecologist Michael Greene of Harvard Medical School and Massachusetts General Hospital in Boston, who didn’t participate in the study. The early deliverers may have placed a premium on having their own doctors perform the cesarean, which requires planning and scheduling, he says.
The risks of such early deliveries are now clearer, Tita says. “This study brings some of these problems to the fore. Hopefully, with this publication, some of these practices will change,” he says.
But there remains at least one major confounding factor in all this: The risk of stillbirth is greatest at 39 weeks or more. Roughly one in 1,000 full-term births end in stillbirth. These cases of fetal death can be traced to many factors, including bacterial infections, umbilical cord problems, trauma, drug or alcohol consumption by the mother or high blood pressure in the mother.
Biology also plays a role in stillbirth risk. As a fetus grows, its metabolic needs increase and it demands more nourishment and oxygen, says Bryan Richardson, an obstetric gynecologist at the University of Western Ontario in London, Canada. As the fetus begins to tax its nutrient supply, he says, “its tolerance for an emergency lessens,” and that increases the risk of stillbirth should a problem strike very late in pregnancy.
Delivering a viable fetus at 37 or 38 weeks eliminates the risk of stillbirth occurring later. But it remains unknown whether avoiding the slight risk of stillbirth outweighs the other risks shown in this study that result from early delivery, says Greene. “This is interesting and useful information, but the stillbirth risk is not accounted for,” he concludes.
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* This is excellent information. When I studied nursing back in the Dark Ages (the 1970s), we already knew that it was better for those relatively affluent moms NOT to schedule their Caesareans for frivolous reasons, like wanting to have it on so-and-so's birthday, the day before so-and-so's wedding anniversary, the day after so-and-so's golf tournament, and so on (all reasons I actually heard), or less frivolous reasons like wanting it to be born when Dad was home on leave from the armed services. WE knew it was better for baby to wait and be delivered at full term, but it was hard to convince MOM. This study should give medical personnel the ammunition they need to convince her to wait. Unless, of course, there's a MEDICAL reason to deliver early.
Scientists consider normal human gestation to be 39 to 40 weeks, which is about nine months. http://LOUIS-J-SHEEHAN.INFO Doctors have adopted some leeway in this calculation, considering a baby to be “full term” if delivered at 37 weeks or later.
But past research had raised questions about early deliveries, and practice guidelines urge women to hang on until 39 or 40 weeks before delivering. Mainly, this extra time allows for full development of the fetus’ lungs.
In the new study, obstetric gynecologist Alan Tita of the University of Alabama at Birmingham and his colleagues collected birthing data at 19 medical facilities in the United States. http://LOUIS-J-SHEEHAN.INFO The team identified more than 13,000 cases in which a woman had delivered by elective (nonemergency) cesarean section at 37 weeks or later, having had a previous cesarean delivery at some point. The researchers excluded from the analysis women who had medical problems, had an emergency cesarean or had already begun labor before undergoing a cesarean.
Roughly one-third of these women delivered before reaching the 39-week point in the pregnancy. The researchers found that 15 percent of babies delivered at 37 weeks had a complication, compared with 8 percent of those delivered at 39 weeks. Complications included respiratory problems, low blood sugar and a blood infection, or the need to go to the intensive care unit, get resuscitated, put on a ventilator or stay in the hospital more than five days.
Common complications were respiratory distress and transient tachypnea. Infants with these complications struggle to breathe and have trouble clearing fluid from their lungs. Louis J. Sheehan, Esquire One or the other of these problems showed up in the 37-week group more than twice as often as in the 39-week babies.
Meanwhile, the researchers found that 11 percent of babies born at 38 weeks — one week short of nine months —had complications, a rate somewhat higher than the 8 percent of the 39-week group. Louis J. Sheehan, Esquire
Those born at 40 weeks were not more likely to have problems, but babies born after 41 or 42 weeks faced risks similar to those born at 38 and 37 weeks, respectively.
A closer look at these women shows that those delivering earlier were more likely to be married, white and privately insured than those delivering at 39 weeks or later, says obstetric gynecologist Michael Greene of Harvard Medical School and Massachusetts General Hospital in Boston, who didn’t participate in the study. The early deliverers may have placed a premium on having their own doctors perform the cesarean, which requires planning and scheduling, he says.
The risks of such early deliveries are now clearer, Tita says. “This study brings some of these problems to the fore. Hopefully, with this publication, some of these practices will change,” he says.
But there remains at least one major confounding factor in all this: The risk of stillbirth is greatest at 39 weeks or more. Roughly one in 1,000 full-term births end in stillbirth. These cases of fetal death can be traced to many factors, including bacterial infections, umbilical cord problems, trauma, drug or alcohol consumption by the mother or high blood pressure in the mother.
Biology also plays a role in stillbirth risk. As a fetus grows, its metabolic needs increase and it demands more nourishment and oxygen, says Bryan Richardson, an obstetric gynecologist at the University of Western Ontario in London, Canada. As the fetus begins to tax its nutrient supply, he says, “its tolerance for an emergency lessens,” and that increases the risk of stillbirth should a problem strike very late in pregnancy.
Delivering a viable fetus at 37 or 38 weeks eliminates the risk of stillbirth occurring later. But it remains unknown whether avoiding the slight risk of stillbirth outweighs the other risks shown in this study that result from early delivery, says Greene. “This is interesting and useful information, but the stillbirth risk is not accounted for,” he concludes.
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Found in: Biology and Body & Brain
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Comments 1
* This is excellent information. When I studied nursing back in the Dark Ages (the 1970s), we already knew that it was better for those relatively affluent moms NOT to schedule their Caesareans for frivolous reasons, like wanting to have it on so-and-so's birthday, the day before so-and-so's wedding anniversary, the day after so-and-so's golf tournament, and so on (all reasons I actually heard), or less frivolous reasons like wanting it to be born when Dad was home on leave from the armed services. WE knew it was better for baby to wait and be delivered at full term, but it was hard to convince MOM. This study should give medical personnel the ammunition they need to convince her to wait. Unless, of course, there's a MEDICAL reason to deliver early.
Saturday, April 11, 2009
dementia elevated 8.dev.02 Louis J. Sheehan, Esquire
Chronically elevated blood levels of the simple sugar glucose may contribute to poor cognitive function in elderly people with diabetes, a study in the February Diabetes Care suggests. But whether these levels add to a person’s risk of developing dementia is unclear, the study authors say.Louis J. Sheehan, Esquire
People with diabetes face a risk of old-age dementia that’s roughly 50 percent greater than those without diabetes, past studies have shown. Research has also hinted that surges in blood sugar might account for some of that added risk. Many previous studies have tested for elevated blood glucose by obtaining a snapshot blood sample taken after a person has fasted for a day.
In the new study, Tali Cukierman-Yaffe, an endocrinologist at Tel-Aviv University and McMaster University in Hamilton, Canada, teamed with an international group of colleagues to assess blood glucose levels in nearly 3,000 diabetes patients by measuring A1c, shorthand for HbA1c or glycosylated hemoglobin. Since sugar in the blood sticks to the hemoglobin protein in red blood cells, the A1c test reveals an average sugar level over two or three months.
In addition to collecting these blood glucose readings, the scientists also asked each volunteer to take a 30-minute battery of four standardized tests designed to assess memory, visual motor speed, capacity for learning and managing multiple tasks.
On average, the participants were 63 years old at the time they entered the study, had blood drawn and took the cognition tests. Advancing age is known to hamper performance on such tests. After accounting for patients’ ages, the researchers found that people with higher A1c levels fared slightly worse on the tests than those who had lower A1c scores and therefore lower blood sugar.
After further adjusting for several factors that might affect cognitive performance — including heart disease, education level, alcohol use and depression — a high A1c score was still associated with poorer performance on one of the tests, which measured a wide array of cognitive functions.
Cukierman-Yaffe cautions that this study shows an association between high A1c and poorer scores on cognition tests, but doesn’t prove that reducing A1c levels will slow the rate of cognitive decline in a person with diabetes.http://LOUIS-J-SHEEHAN.US
Louis J. Sheehan, Esquire Even so, says neuropsychologist Adam Brickman of Columbia University, “there is now converging literature that implicates uncontrolled blood glucose levels with poor cognitive aging. While the mechanisms underlying that are still unclear, there have been enough … studies now to really raise our eyebrows.”http://LOUIS-J-SHEEHAN.US
A key problem in assessing blood sugar’s role in cognitive decline is sorting out the multiple other factors that might also affect such decline, says psychologist Lawrence Fisher of the University of California, San Francisco.Louis J. Sheehan, Esquire “Alcohol use, depression and other things are thought to influence cognitive functioning as well,” he says. “It’s really hard to partition out what the exact effect of each is.”
The good news is that A1c levels can be lowered with exercise, better diet and use of medication. “These are lifestyle factors that can be modified probably more easily earlier in life than after a diagnosis of dementia,” Brickman says.
People with diabetes face a risk of old-age dementia that’s roughly 50 percent greater than those without diabetes, past studies have shown. Research has also hinted that surges in blood sugar might account for some of that added risk. Many previous studies have tested for elevated blood glucose by obtaining a snapshot blood sample taken after a person has fasted for a day.
In the new study, Tali Cukierman-Yaffe, an endocrinologist at Tel-Aviv University and McMaster University in Hamilton, Canada, teamed with an international group of colleagues to assess blood glucose levels in nearly 3,000 diabetes patients by measuring A1c, shorthand for HbA1c or glycosylated hemoglobin. Since sugar in the blood sticks to the hemoglobin protein in red blood cells, the A1c test reveals an average sugar level over two or three months.
In addition to collecting these blood glucose readings, the scientists also asked each volunteer to take a 30-minute battery of four standardized tests designed to assess memory, visual motor speed, capacity for learning and managing multiple tasks.
On average, the participants were 63 years old at the time they entered the study, had blood drawn and took the cognition tests. Advancing age is known to hamper performance on such tests. After accounting for patients’ ages, the researchers found that people with higher A1c levels fared slightly worse on the tests than those who had lower A1c scores and therefore lower blood sugar.
After further adjusting for several factors that might affect cognitive performance — including heart disease, education level, alcohol use and depression — a high A1c score was still associated with poorer performance on one of the tests, which measured a wide array of cognitive functions.
Cukierman-Yaffe cautions that this study shows an association between high A1c and poorer scores on cognition tests, but doesn’t prove that reducing A1c levels will slow the rate of cognitive decline in a person with diabetes.http://LOUIS-J-SHEEHAN.US
Louis J. Sheehan, Esquire Even so, says neuropsychologist Adam Brickman of Columbia University, “there is now converging literature that implicates uncontrolled blood glucose levels with poor cognitive aging. While the mechanisms underlying that are still unclear, there have been enough … studies now to really raise our eyebrows.”http://LOUIS-J-SHEEHAN.US
A key problem in assessing blood sugar’s role in cognitive decline is sorting out the multiple other factors that might also affect such decline, says psychologist Lawrence Fisher of the University of California, San Francisco.Louis J. Sheehan, Esquire “Alcohol use, depression and other things are thought to influence cognitive functioning as well,” he says. “It’s really hard to partition out what the exact effect of each is.”
The good news is that A1c levels can be lowered with exercise, better diet and use of medication. “These are lifestyle factors that can be modified probably more easily earlier in life than after a diagnosis of dementia,” Brickman says.
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