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      Neuropsychiatric Disease and Treatment (submit here)

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      Clinical utility of implantable neurostimulation devices as adjunctive treatment of uncontrolled seizures

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          Abstract

          About one third of patients with epilepsy are refractory to medical treatment. For these patients, alternative treatment options include implantable neurostimulation devices such as vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation systems (RNS). We conducted a systematic literature review to assess the available evidence on the clinical efficacy of these devices in patients with refractory epilepsy across their lifespan. VNS has the largest evidence base, and numerous randomized controlled trials and open-label studies support its use in the treatment of refractory epilepsy. It was approved by the US Food and Drug Administration in 1997 for treatment of partial seizures, but has also shown significant benefit in the treatment of generalized seizures. Results in adult populations have been more encouraging than in pediatric populations, where more studies are required. VNS is considered a safe and well-tolerated treatment, and serious side effects are rare. DBS is a well-established treatment for several movement disorders, and has a small evidence base for treatment of refractory epilepsy. Stimulation of the anterior nucleus of the thalamus has shown the most encouraging results, where significant decreases in seizure frequency were reported. Other potential targets include the centromedian thalamic nucleus, hippocampus, cerebellum, and basal ganglia structures. Preliminary results on RNS, new-generation implantable neurostimulation devices which stimulate brain structures only when epileptic activity is detected, are encouraging. Overall, implantable neurostimulation devices appear to be a safe and beneficial treatment option for patients in whom medical treatment has failed to adequately control their epilepsy. Further large-scale randomized controlled trials are required to provide a sufficient evidence base for the inclusion of DBS and RNS in clinical guidelines.

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          The world health report 2001 - Mental health: new understanding, new hope

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            Vagus nerve stimulation therapy for partial-onset seizures: a randomized active-control trial.

            The purpose of this multicenter, add-on, double-blind, randomized, active-control study was to compare the efficacy and safety of presumably therapeutic (high) vagus nerve stimulation with less (low) stimulation. Chronic intermittent left vagus nerve stimulation has been shown in animal models and in preliminary clinical trials to suppress the occurrence of seizures. Patients had at least six partial-onset seizures over 30 days involving complex partial or secondarily generalized seizures. Concurrent antiepileptic drugs were unaltered. After a 3-month baseline, patients were surgically implanted with stimulating leads coiled around the left vagus nerve and connected to an infraclavicular subcutaneous programmable pacemaker-like generator. After randomization, device initiation, and a 2-week ramp-up period, patients were assessed for seizure counts and safety over 3 months. The primary efficacy variable was the percentage change in total seizure frequency compared with baseline. Patients receiving high stimulation (94 patients, ages 13 to 54 years) had an average 28% reduction in total seizure frequency compared with a 15% reduction in the low stimulation group (102 patients, ages 15 to 60 year; p = 0.04). The high-stimulation group also had greater improvements on global evaluation scores, as rated by a blinded interviewer and the patient. High stimulation was associated with more voice alteration and dyspnea. No changes in physiologic indicators of gastric, cardiac, or pulmonary functions occurred. Vagus nerve stimulation is an effective and safe adjunctive treatment for patients with refractory partial-onset seizures. It represents the advent of a new, nonpharmacologic treatment for epilepsy.
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              Changes in racial-ethnic disparities in use and adequacy of mental health care in the United States, 1990–2003.

              This study examined changes in white-black and white-Latino disparities in the use of any mental health care and minimally adequate mental health care. Using data from the 1990–1992 National Comorbidity Survey (NCS) and the 2001–2003 National Comorbidity Survey Replication (NCS-R), this study examined changes by race-ethnicity in use of mental health care among individuals age 18 to 54 with a 12-month mood or anxiety disorder. The sample consisted of 1,198 NCS respondents and 929 NCS-R respondents. Changes in disparities were estimated in the use of any mental health care in the general medical sector, the specialty mental health sector, and in total. Changes in disparities were also estimated in the use of minimally adequate mental health care (in total only). Disparities in the use of any mental health care increased over time, particularly between non-Latino whites and non-Latino blacks in the general medical sector and between non-Latino whites and Latinos in the specialty mental health sector. Disparities in the use of minimally adequate mental health care persisted between whites and blacks over time but were not detected between whites and Latinos in either period. The findings of greater racial-ethnic disparities in the general medical and specialty mental health sectors indicate that more targeted policies and programs are needed to increase use of mental health care in these health sectors among persons from racial-ethnic minority groups. The persistence of white-black disparities in the use of minimally adequate mental health care warrants further examination.
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                Author and article information

                Journal
                Neuropsychiatr Dis Treat
                Neuropsychiatr Dis Treat
                Neuropsychiatric Disease and Treatment
                Neuropsychiatric Disease and Treatment
                Dove Medical Press
                1176-6328
                1178-2021
                2014
                14 November 2014
                : 10
                : 2191-2200
                Affiliations
                [1 ]College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
                [2 ]School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK
                [3 ]Children’s Epilepsy Surgery Programme, The Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
                [4 ]Department of Neuropsychiatry, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
                [5 ]Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and UCL, London, UK
                Author notes
                Correspondence: Andrea E Cavanna, Department of Neuropsychiatry, The Barberry National Centre for Mental Health, 25 Vincent Drive, Birmingham B15 2FG, United Kingdom, Tel +44 121 301 2280, Email a.e.cavanna@ 123456bham.ac.uk
                Article
                ndt-10-2191
                10.2147/NDT.S60854
                4238748
                25484587
                02006dfc-0bfa-49b0-83c1-cbc741e18712
                © 2014 Cox et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Neurology
                deep brain stimulation,epilepsy,implantable neurostimulation device,responsive neurostimulation,seizures,vagus nerve stimulation

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