The long-term development of non-motor problems after STN-DBS.

OBJECTIVES: Stimulation of the subthalamic nucleus (STN-DBS) is an established treatment with long-term beneficial effects on motor symptoms in patients with Parkinson's disease (PD). The long-term development of non-motor problems after STN-DBS is not fully understood. In this study, we have studied how non-motor problems develop in patients with and without STN-DBS. MATERIALS AND METHODS: We collected data from a prospectively followed cohort of patients that had been operated with STN-DBS 6-9 years before final examination and compared our findings to the longitudinal development of non-motor problems in a non-operated, comparable reference population. RESULTS: In general, the non-motor problems of advanced PD seem to develop independently of treatment with STN-DBS. We found that depressions do not worsen after STN-DBS, and the Montgomery and Aasberg Depression Rating Scale score in operated patients was substantially reduced from pre-operatively to post-operatively. Further, fatigue may represent an important unrecognized side effect of long-term stimulation, as fatigue was found to increase rapidly in operated patients already a year after surgery and continued to increase trough the 6- to 9-year follow-up. CONCLUSIONS: The non-motor problems of advanced PD seem to develop independently of treatment with STN-DBS. This may influence the strategy for choice of when to perform this therapy for eligible patients.

Motor symptoms after deep brain stimulation of the subthalamic nucleus.

OBJECTIVES: Stimulation of the subthalamic nucleus (STN-DBS) is an established treatment with long-term beneficial effects on motor symptoms in patients with Parkinson's disease (PD). The efficacy of STN-DBS on non-dopaminergic motor symptoms remains less elucidated. In this study, we have examined short- and long-term impacts of STN-DBS on the development of the postural instability and gait difficulties (PIGD) phenotype, freezing of gait (FOG), and falls. MATERIALS AND METHODS: We collected data from a prospectively followed cohort of patients that had been operated with STN-DBS 6-9 years before final examination and compared our findings to the longitudinal development of the same symptoms in a non-operated, historical reference population. RESULTS: During short-term follow-up after surgery, we observed a marked improvement in mean UPDRS-motor score from 27 to 18. We also found clear improvements in tremor, bradykinesia, rigidity, and PIGD scores. However, 6-9 years after surgery, all patients had a dominating PIGD pattern of parkinsonism and 50% of the patients had developed FOG and/or had become recurrent fallers. The disease development in a group of patients with PD from the presurgery period had a similar trajectory as among the operated patients. In addition, mean annual change of both bradykinesia and PIGD scores was nearly identical in both study groups while tremor and rigidity had a significant better development in the operated patients. CONCLUSIONS: We found that STN-DBS induces an acute improvement of PIGD symptoms. The following long-term development was however characterized by a marked progression of non-dopaminergic symptoms.

Progression and survival in Parkinson's disease with subthalamic nucleus stimulation.

BACKGROUND: Treatment for Parkinson's disease (PD) is symptomatic. Surgical treatment with continuous high-frequency stimulation of the subthalamic nucleus (STN-DBS) is established as a safe symptomatic treatment with long-term beneficial effects. It has been postulated that STN-DBS could halt the progression of PD through a disease modifying or neuroprotective effect. OBJECTIVE: To investigate the postulated disease modifying or neuroprotective effect of STN-DBS by comparing the rate of deterioration of parkinsonism and mortality over time in two selected and matched groups of patients with PD with and without surgery. METHODS: Group A was derived from all patients who received STN-DSB surgery at Oslo University Hospital, from January 2001 to December 2007. Group B was derived from a prevalence study of PD in the Stavanger area of Western Norway in 1993. The two groups were individually matched and the disease progression measured by Unified Parkinson's Disease Rating Scale-motor scores, and the mortality was compared. RESULTS: The mean annual change based on baseline and last observation scores in individually matched groups was 0.97 (SD = 3.57) for the surgery group and 1.04 (SD = 3.33) for the controls and thus not significantly different, F(1, 104) = .21, P = 0.89. The long-term mortality was also similar in the two groups during long-term follow-up, hazard ratio = 1.76, CL 0.91-3.40, P = 0.091. CONCLUSION: This study gives no support to a postulated disease modifying or neuroprotective effect of STN-DBS in patients with PD.

Unmasking psychiatric symptoms after STN deep brain stimulation in Parkinson's disease.

BACKGROUND: Stereotactic implantation of electrodes for deep brain stimulation (DBS) in the subthalamic nucleus (STN) is a well-established treatment for Parkinson's disease. The treatment gives stable effect over years on the motor symptoms of Parkinson's disease. Psychiatric effects of STN-DBS have attracted increasing attention, with a growing number of reports on psychiatric side effects or exacerbations of known psychiatric disease. However, little is known about the possible unmasking of hidden psychiatric symptoms after surgery. AIMS: The aim of this clinical commentary is to illustrate unmasking of psychiatric disease by STN-DBS through the presentation of a case from our clinic. PATIENT: A patient with Parkinson's disease underwent implantation of STN stimulation electrodes with good results on his motor symptoms. He did not disclose his previous psychiatric history. Soon after the onset of stimulation he developed affective symptoms with manic, aggressive and depressive behaviour, and also an attempted suicide. The stimulation was reduced and his dopaminergic medication increased after the attempted suicide. His previous history of depression and anxiety was now revealed. He received psychiatric attention, and the affective symptoms resolved. The effect of the stimulation on motor symptoms remained stable. CONCLUSIONS: The unmasking of previous psychiatric problems after STN stimulation may be an underestimated problem. It is necessary to fully penetrate the psychiatric anamnesis, especially in patients with a strong wish to be operated and a consequent reluctance to reveal previous problems. Patients with a previous history of a psychiatric disorder are not the best candidates for implantation of STN electrodes.

[Prostate-specific membrane antigen. A new sensitive molecular indicator in metastasizing prostatic cancer]. / Prostataspesifikt membranantigen. Ny sensitiv molekylaer indikator ved metastaserende cancer prostatae.

Prostate cancer is the most common malignant disease in men in western societies. Extracapsular spread of carcinoma is found in approximately half of the patients that are treated by radical prostatectomy. Recently, a new prostate-specific membrane glycoprotein was cloned and sequenced. A highly sensitive and specific nested reverse transcriptase polymerase chain reaction has been developed to detect early occult haematogeneous micrometastatic prostate cells. We analysed venous samples from 17 patients with metastatic prostate cancer using a modified reaction assay. This showed presence of micrometastatic prostate cells in 14 patients. Molecular detection of circulating prostatic epithelial cells could improve clinical staging and treatment of early prostate cancer.