MIAMI BEACH -- Operator errors are responsible for more than half of the failures of deep brain stimulation to lessen essential tremor or Parkinson's symptoms, according to the findings of one study presented at the American Academy of Neurology annual meeting.

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Many of these patients benefit when deep brain stimulation (DBS) is repeated at movement disorder centers by more experienced physicians.

The Food and Drug Administration approved a DBS system (Activa, manufactured by Medtronic Inc.) to treat patients with essential tremor or Parkinson's disease in August 1997.

The agency expanded the system's indication to include patients with dystonia in April 2003.

Although DBS improves quality of life for many patients, some do not respond. Incorrect diagnosis, surgical lead misplacement, and device-related errors are among the preventable problems identified by Michael S. Okun, M.D., and his associates.

"There has been a surge in centers providing DBS after its FDA approval and an increasing number of patients presenting to experienced DBS centers with complaints," said Dr. Okun, codirector of the Movement Disorders Center at the University of Florida in Gainesville.

"About 12 patients per year are seen by centers of excellence for these referred problems," he said.

A lack of consensus on patient screening, provider training, and the best multi-disciplinary approach contribute to the failure rate, Dr. Okun said.

In addition, there is no consensus on the management of complications, some of which spur referral of the patient to an experienced DBS center for management.

The records of 41 consecutive patients who were treated at the University of Florida movement disorders center or the movement disorders center at the Beth Israel Medical Center in New York City were reviewed.

The patients' average age was 63 years. Thirty patients (73%) saw a movement disorders specialist prior to DBS implantation, and five patients (12%) had significant cognitive dysfunction before implantation.

The patients underwent the following types of DBS implantation: 21, bilateral subthalamic nucleus; 8, unilateral subthalamic nucleus; 8, unilateral ventral intermediate nucleus; 1, unilateral globus pallidus interna; 1, bilateral ventral intermediate nucleus; and 1, bilateral globus pallidus interna.

All of the study participants saw a movement disorders neurologist upon referral.

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More than one-third, 36%, of patients had no improvement, and 15% had minimal improvement. However, "51% had significant improvement or were rescued with good outcomes," Dr. Okun said at the meeting.

"The reasons for DBS failures were not only surgical," Dr. Okun said.

The researchers identified a timeline of preventable problems associated with DBS surgery. "It is quite interesting because many things were quite correctable," Dr. Okun said. "There is an expertise factor we can improve on."

Preventable problems included:

* Incorrect diagnosis (10 instances).

* Inadequate medication trial/dementia (10).

* Misplaced leads (19).

* Inadequate de
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