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Dr. Suresh Mehta

Psychiatrist, Pune

Dr. Suresh Mehta Psychiatrist, Pune
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I want all my patients to be informed and knowledgeable about their health care, from treatment plans and services, to insurance coverage....more
I want all my patients to be informed and knowledgeable about their health care, from treatment plans and services, to insurance coverage.
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Dr. Suresh Mehta is a renowned Psychiatrist in Tilak Road, Pune. You can consult Dr. Suresh Mehta at Dr. Suresh Mehta@Dhanwantari Hospital in Tilak Road, Pune. Don’t wait in a queue, book an instant appointment online with Dr. Suresh Mehta on Lybrate.com.

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Sector 27, Tilak Road, Pradhikaran, Nigdi. Landmark: Near Lokmanya Hospital & Near Spencer Daily & Bell Chowk.Pune Get Directions
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My son is 18 yrs old. His behaviour is changed and a annoyed person. He annoyed with parents. He is failing in education.

M.D,Psychiatry
Psychiatrist, Amritsar
Get her examined from local psychiatrist. Start tab dicorate er500 mg at night it wil decrease his anger.
2 people found this helpful
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I am 43 years old ,I am not able to sleep properly in night because of unnecessary issues thinking in mind and because of this I am not taking sleep properly. I have back pain since last 1 month . Due to this I am disturbing . Request you help me out of this. Because of this I am lot of in depression and Pressure , not able to understand how tackle the situation .

MA - Clinical Psychology, P.G. Diploma in Guidance and Counseling, BA In Psychology
Psychologist, Mumbai
Stress can cause pain in back. As you are facing sleep disturbances pls start meditation. Deep breathing excersise just before sleep. There music available for sleep pls try those. Calm yourself before bed time. Read if you like reading. If not able to help then opt for professional help.
1 person found this helpful
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From morning to evening my sister talking talking talking not stopping. She is complaining about everyone at home all brothers, sisters (late) father and mother etc. Because she is alone and no issues, no husband and his pension she is getting for more that 28 years still she is not satisfied she has something - no one is helping her (but all her relatives are settled and having their own family - but she does not wanted to accept it) what to do?.

DHMS (Hons.)
Homeopath, Patna
Hello, she is under depression with schizophrenia. She should follow the underlying tips to overcome. • tk, plenty of water to hydren her body eliminating toxin. • it's essential for her to go for meditation to reduce her stress nourishing her body to calm her nerve to ease her condition. • she should be well fed without skipping her diet, avoiding gastric disorder. •she should tk homoeo medicine:@ Ignatia 200 -3 thrice. @ kali phos6x -4 tabs, thrice.•report, fortnightly. •your feedback matters for further follow-up, please. Tk care.
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I am 23 years old. I had stammering problem since the age of 7. I had attended speech therapy clas. But it is not during. please suggest me he the stammering will cure.

MBBS, MD - Psychiatry, MBA (Healthcare)
Psychiatrist, Davanagere
Hi there, I am very glad for your question. Exercises for stammering Exercises are effective in treatment of physiological causes of stammering. In general, exercises are meant to provide strength to the organs associated with speech including tongue, lips, jaw, trachea and lungs. Many people who stammer have found these exercises to be beneficial in reducing the intensity and in some cases, completely curing stammering problem. The exercises should preferably be done every night in a secluded area, before going to bed. An exercise regimen comprising of the following exercises are beneficial in treatment and cure of stammering. Stammering Exercise #1 Loudly and clearly pronounce the vowels A, E, I, O and U. Be overly articulate and distort your face strongly, every time you utter the vowels. Stammering Exercise #2: Open your jaws as wide as you can without exerting hard. While the jaws are still open, lift your tongue upwards to touch the roof of mouth with the tip of your tongue. While still in contact with the roof of your mouth, drag the tip of your tongue towards the back of your mouth. When your tongues get stretched to the maximum (without hurting), hold there for few seconds. Next pull out your tongue outside the mouth and stretch it downwards as if attempting to touch the chin. Hold in that position for few seconds. Repeat 4-5 times. Stammering Exercise #3: Deep breathing exercise are very effective in curing speech disorders like stammering as they help to strengthen the respiratory organs and to relax neuromuscular tension that builds up in the body. Stammering can be controlled by learning to voluntarily control the rhythm of words by implementation of specific breathing patterns. There can be many variants of deep breathing exercises and one can choose any or all exercises which he/she is comfortable doing. Some of the variants are: A) Inhale deeply through mouth and exhale slowly, immediately after inhalation. B) Inhale deeply through mouth and push your tongue outside the mouth while exhaling. C) Inhale deeply through mouth, at the same time, press your chest muscles inward. Exhale slowly You can have your own variations of these deep breathing exercises, as long as they provide some respiratory motion, swelling of the abdomen and workout for chest and other speech organs. Do not overdo any exercise and bring variations, every one or two minutes. Stammering Exercise #4: Reading exercises are helpful in identification of patterns of repetition of syllables that cause stammering and thus reduce bottlenecks of fast reading. For this exercise, take a text and read it fast without laying emphasis on the quality of speech. Speedy reading will help a subconscious identification of each word. Prefer the speed to the quality of speech. Let the words be wrongly spoken and do not stop on any particular word or syllable. This exercise, if continued for 2-3 months is very effective in relaxing muscular tension and correcting all obstructions of the speech. Stammering Exercise #5 Singing is a very effective exercise for stammering. Singing helps the sufferer learn to better control breath and the phonatory muscles. Another very effective treatment for stammering involves participation in theatrical activities. Theatre helps shed down several inhibitions and is very effective remedy for stammering. Lifestyle Changes to Treat Stammering Fighting inferiority complex: Developing confidence in ones own ability to speak correctly is probably the only real solution to cure stammering. However building self-confidence when one makes nervous mistakes in every sentence is not easy. Inferiority complex is natural in people who stammer. Dealing with this complex is the most paramount task in overcoming stammering. Talking openly when the person approaches with the subject is vital in handling this complex. Maintaining a relaxed environment at home gives the child an opportunity to speak without stress. Watch out your breath: As a general thumb rule, one should breathe from the belly and not from the chest. Breathing from the belly naturally calms down and relaxes nervous and muscular tension and is a helpful habit in curing stammering and related disorders. Family support: Family support is of vital importance in treatment of stammering. Family members should use all possible means to deliver the person of his state of anxiety which is the only cause of stammering in a large number of cases. Family members must: Not punish or react harshly on a person who is stammering Listen carefully, when such a person speaks Adapt to speak slowly and not interrupt when a person stammers Be patient and wait for the person to complete words Not complete sentences or words when such a person is trying to speak. Consulting a speech therapist: Speech therapy has been used to cure or reduce the intensity of stammering. Speech therapist try to diagnose the causes of stammering and accordingly prescribe exercises, medications and/or scalpel intervention in certain cases. In case of physiological defects, speech therapy is compulsory to treat stammering. While speech therapist mainly concentrate on speech corrections, they may also adopt psychotherapies like hypnosis, impoco, role plays or cognitive behavioral therapy, if diagnosis suggests a psychological cause for stammering. Many therapist also use acupuncture, yoga spa treatment and other relaxation techniques to assist in treatment of stammering. Many cities have specialized speech therapy centers which offer intensive cures and therapies for stammering. Hearing aid: There are also some hearing aids that help to reduce or eliminate stammering. The electronic device records the user’s voice using a microphone and sends it back to his ears after a delay of about split seconds or at a slightly different frequency. Simultaneous speaking and the ability to listen to how it is heard by others is very effective in helping one who stammers correct his errors. Though familiarization with the device may take up to a few months, they often succeed in breaking the psychological barrier that prevents normal speech. Once the barrier is broken and the practitioner gains confidence, he/she can start speaking normally without using the device. Food for those who stammer While there are no particular foods that can be used to cure stammering, some food are known to be beneficial for speech organs. For instance, chewing Indian gooseberry, Almonds, Black pepper, Cinnamon and dried dates are known to clear speech congestions. Thus they can be taken internally in moderate quantities to address symptoms of stammering. Other recommendations for Treating Stammering Stammering is known to be aggravated by fatigue, anxiety or nervousness. A positive environment at home and at workplace is of paramount importance in helping a Person who stammers cure his disorder. Above all, stammering can not be cured overnight. It takes time and patience but the rewards at the end of it all are really worth the time. Stammering Trivia What’s common amongst Aristotle, Churchill, Darwin, Moses and Rousseau? Ans: They all stammered! I hope this helps. I wish you a very quick and speedy recovery.
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I'm suffering from anxiety neurosis. To treat it who is better whether psychologist or psychiatrist. And how much time take if psychologist handle this case, and also if psychiatrist takes how much time.

MD - Psychiatry
Psychiatrist, Chennai
Rather than worrying who is apt to treat anxiety neurosis. It is ideal for you to get the severity of anxiety disorder evaluated, if the symptoms are mild, you can be treated by CBT (Cognitive Behavior Therapy) alone or medications. If the symptoms are moderate a combination of CBT and medicines, if severe medications first and after improvement CBT can be planned. Medications are given only by a psychiatrist as well as diagnosis ruling our medical causes for anxiety is done by a psychiatrist. CBT can be given by psychiatrist or clinical psychologist, who are trained in the procedure. Hope this helps you to decide. All the best.
3 people found this helpful
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How can I concentrate any work, since I always refuses to complete it. Why it so?

C.S.C, D.C.H, M.B.B.S
General Physician,
CONCENTRATION TIPS Here’s some tips to get into a state of deep concentration where work / or studies flow easily so that you can do well in examinations/ and or do your work well. 1) Cut Off the Noise Getting into a state of concentration can take at least fifteen minutes. If you are getting distracted every five, you can’t possibly focus entirely on your work. Request that people don’t interrupt you when working on a big project. If you are required to answer phones and drop-in’s immediately, schedule work when the office is less busy. 2) Structure Your Environment The place you work can have an impact on your ability to focus. Try to locate yourself so you are facing potential distractions such as doors, phones or windows. This way you can take a glance to assess sounds that would otherwise break your focus. 3) Clarify Objectives Know what your goal is clearly before you start. If you aren’t sure what the end result is, the confusion will make it impossible to focus. 4) Divide Blobs. If you have a large project that needs work, clearly identify a path that you will use to get started working on it. If the sequence of actions isn’t obvious, it will be difficult to concentrate. Taking a few minutes to plan not only your end result, but the order you will complete any steps, can save hours in wasted thinking. 5) Know the Rules Get clear on what the guidelines are for the task ahead. What level of quality do you need? What standards do you need to follow? What constraints are there? If the rules aren’t clear from the outset, you will slip out of concentration as you ponder them later. 6) Set a Deadline Deadlines have both advantages and disadvantages when trying to force concentration. A deadline can make it easier to forget the non-essential and speed up your working time. If you give yourself only an hour to design a logo, you will keep it simple and avoid fiddling with extravagant designs. Time limits have disadvantages when they cause you to worry about the time you have left instead of the task itself. 7) Break down Roadblocks Roadblocks occur whenever you hit a tricky problem in your work. This can happen when you run out of ideas or your focus wavers. Break down roadblocks by brainstorming or planning on a piece of paper. Writing out your thought processes can keep you focused even if you might become frustrated. 8) Isolate Yourself Become a hermit and stay away from other people if you want to get work done. Unless your work is based on other people they will only break your focus. Create a private space and refuse to talk to anyone until your work is finished. Put a sign on your door to steer away drop-ins and don’t answer your phone. 9) Healthy Body, Sharper Mind What you put into your body affects the way you concentrate. Nobody would expect peak performance if they showed up drunk to work. But if you allow yourself to get chronic sleep deprivation, overuse stimulants like caffeine or eat dense, fatty foods your concentration will suffer. Try to cut out one of your unhealthy habits for just thirty days to see if there is a difference in your energy levels. I’ve found even small steps can create dramatic changes in my ability to focus. 10) Be Patient Before I write an article, I often sit at my desk for a fifteen or twenty minutes before I put finger on the keyboard. During this time I feel a strong urge to leave or do something else. But I know that if I am patient, I’ll stumble upon an idea to write about and enter a state of flow. Without a little patience, you can’t take advantage of flow when it rushed through you. If you need strong concentration I recommend periods of 90-120 minutes. Any less than that and you will waste too much time getting started before the flow can continue. More than this is possible to sustain focus, but you will probably benefit from a quick break. These are the general guidelines for concentration, studying well or.
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My friend was a very nice guy before 2 years before. When he started taking alcohols and stuffs (marijuana. Gradually his character changed a lot. Now he is emotionless, insensitive,arrogant, rude,depressed, totally changed. What can we do now?

MBBS, MD - Psychiatry
Psychiatrist, Mumbai
Use of drugs and alcohol make a person aggressive and cause personality changes. It also causes serious health problems like liver and kidney failure, stomach ulcers and nutritional problems, etc. Your friend will need to be assessed by a psychiatrist with experience in deaddiction. Apart from helping him stop the drugs and alcohol, other problems like behavioral issues and aggression can also be treated. You can consult me for further management.
4 people found this helpful
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Parkinson s Disease

MBBS, DNB, Fellowship in Neurosurgery
Neurosurgeon, Kolkata
Parkinson s Disease

Deep brain stimulation in Parkinson’s disease

Abstract: Deep brain stimulation (DBS) is a widely accepted therapy for medically refractory Parkinson’s disease (PD). Both globus pallidus internus (GPi) and subthalamic nucleus (STN) stimulation are safe and effective in improving the symptoms of PD and reducing dyskinesias. STN DBS is the most commonly performed surgery for PD as compared to GPi DBS. Ventral intermediate nucleus (Vim) DBS is infrequently used as an alternative for tremor predominant PD patients.

Patient selection is critical in achieving good outcomes. Differential diagnosis should be emphasized as well as neurological and nonneurological comorbidities. Good response to a levodopa challenge is an important predictor of favorable long-term outcomes. The DBS surgery is typically performed in an awake patient and involves stereotactic frame application, CT/MRI imaging, anatomical targeting, physiological confirmation, and implantation of the DBS lead and pulse generator. Anatomical targeting consists of direct visualization of the target in MR images, formula-derived coordinates based on the anterior and posterior commissures, and reformatted anatomical stereotactic atlases. Physiological verification is achieved most commonly via microelectrode recording followed by implantation of the DBS lead and intraoperative test stimulation to assess benefits and side effects. The various aspects of DBS surgery will be discussed.

Key words: deep brain stimulation (DBS); Parkinson’s disease(PD),  stereotaxis

Introduction

Parkinson's disease is a slowly progressive, neurodegenerative disease characterized by tremor, rigidity, bradykinesia and postural instability. It is the most common movement disorder in middle or late life with a prevalence of about 0.3% of the general population, rising to 1% in people over 60 years of age. Approximately 130 000 people suffer from it in the UK and it presents an increasing burden in our ageing population. Pathological findings in Parkinson's disease demonstrate greatly diminished neuromelanin pigmented neurons in the substantia nigra of the basal ganglia with associated gliosis, and Lewy bodies present in many remaining neurons.

James Parkinson, in his original 1817 Essay on The Shaking Palsy, gave an account of six patients in which he noted signs of tremor, festinating gait and flexed posture.  Nearly two centuries from Parkinson's observations, and almost four decades after Cotzias' dramatic demonstration of levodopa's efficacy, the limitations and complications of levodopa treatment for Parkinson's disease have become well documented Five years after initiation of therapy, a majority of patients develop medication related motor complications, namely levodopa induced dyskinesias (LID) and motor fluctuations. Deep brain stimulation (DBS) has been developed primarily to address these treatment related motor complications and therapeutic failures.

Pathophysiology of PD

The loss of dopaminergic neurons in the substantia nigra, the main functional characteristic of PD, affects the circuit described above and leads to the cardinal motor symptoms of PD. While the exact mechanism of this process is unknown, animal research as well as human recordings have provided functional and biochemical evidence that bradykinesia in PD results from excessive activity in the STN and the GPi. This leads to an exaggerated beta (10-30 Hz) synchronization within and between structures in the basal ganglia circuitry  that could also contribute to rigidity and akinesia.

The pathophysiology of rest tremor in PD is less clear and probably more complicated. This symptom most likely results from a dysfunction of both the striato-pallidal-thalamocortical and the cerebellodentato-thalamocortical circuits, with hyperactivity and hypersynchronization between central oscillators.

Possible mechanism of action of DBS

DBS acts through delivering an electrical current in a specific target area of the brain. This current can be modulated through modification of voltage, frequency and duration of each electrical pulse delivered. The delivered energy creates an electrical field of variable size and shape according to the parameters used for stimulation. Although initially believed to stimulate the target, thus the name of the whole process, it seems that

DBS actually excites the neuronal fibers, but inhibits the neural cells. In fact, GPi DBS decreases the GPi mean firing rate back to a normal range in animal models as well as PD patients, and high frequency DBS has a similar effect as dopamine replacement therapies, and promotes faster (about 70 Hz) nonhypersynchronous activity in the basal ganglia, correlated with clinical improvement. This might be achieved through stimulation of bypassing inhibitory pathways, synaptic inhibition, depolarizing blockade, synaptic depression, and simulation-induced disruption of pathological network activity. Overall, this leads to modifications of the firing rate and pattern of neurons in the basal ganglia, as well as local release of neurotransmitters such as glutamate and adenosine. In addition, it seems that DBS also increases blood flow and stimulates neurogenesis. Over the last few years, functional imaging, specifically functional magnetic resonance imaging (fMRI), positron emission tomography (PET) and single-photon emission computed tomography (SPECT), has been used in an attempt to clarify the mechanism of action of DBS. In fMRI, blood-oxygen-level-dependent (BOLD) signals are acquired, and oxygenated blood marks areas of neural stimulation or inhibition. On the other hand, PET and SPECT allow for imaging of multiple activity markers, such as blood flow, glucose and oxygen metabolism. While fMRI is less powerful than nuclear medicine techniques, it provides a much better spatial and temporal resolution. Because of the suspected inhibitory DBS effects in electrophysiological studies, reduced STN blood flow or glucose metabolism would have been expected on functional imaging. However, the opposite has been found to be true in an overwhelming majority of imaging studies to date. In addition, BOLD activation in the area surrounding the electrode has been reported, despite the electrode imaging artifact preventing direct observation of the STN around the electrode. This discrepancy between apparent STN inhibition in single-cell studies and activation in imaging studies might be explained by a few hypotheses. First, electrophysiological recordings identify short neuronal modulation (in the order of milliseconds) while neuroimaging methods may reflect the summed activity changes over seconds to minutes. Second, non-neuronal contributions to the change in blood flow and/or glucose metabolism cannot be excluded, and could confound the results of neuroimaging.

Finally, it is possible that PET and fMRI actually detect the increased activity in the axons, rather than in the cell bodies. Complicating matters further, some imaging studies after STN DBS have showed increased

activity in the GPi while others reported decreased activity in that nucleus. In summary, it is still unclear how exactly DBS affects the firing rate and pattern of neurons and how these changes actually modify the symptoms of Parkinson’s disease. DBS is presently more of an empirically proven treatment in search of physiological explanation.

The effect of DBS on the cardinal symptoms of PD have been established in three randomized controlled clinical trials --- 

TABLE 1

Author, year

 

No of patients

Follow up

Target

Results

Deuschl et al., 2006

156

6 months

BL STN

QOL better with DBS, motor symptom better with DBS

 

Weaver et al., 2009

255

6 months

BL STN or GPi

Dyskinesia free ON time better with DBS

 

Williams et al., 2010

366

12 months

BL STN  or GPi

QOL better with DBS

 

 

PATIENT SELECTION for DBS in PD

Patient selection is a critical first step as poorly chosen candidates may not have optimal benefits and have increased morbidity. Several factors must be considered before determining if a patient is an appropriate candidate for DBS surgery. A multidisciplinary approach involving the neurosurgeon, neurologist, and neuropsychologist is important to determine the appropriate surgical candidate. It is also important that the diagnosis of idiopathic PD be confirmed prior to proceeding with DBS surgery. Key to this assessment is evaluating the surgical candidate in both the on and off medication states with a corroborating levodopa challenge. Perhaps the best prognostic indicator of a patient’s suitability for DBS surgery is their response to levodopa.In general, a levodopa challenge following a 12-hour medication withdrawal should provide at least a 33% improvement in the motor section of the Unified Parkinson’s Disease Rating Scale (UPDRS).

                     In our institute, we follow a simple chart(below) for screening of patients for DBS in PD.

 

 

  1.  

Age<75 years

 

  •  

No

  1.  

Idiopathic PD ( No PSP/MSA/NSD etc)

 

  •  

No

  1.  

Levodopa responsive  

                      

  •  

No

  1.  

Poor/adverse response to drug          

 

  1.  Increased off period                                                              

 

  1. Disabling dyskinesia                                                              

 

 

  1. Disabling motor fluctuations                 

 

 

Yes

 

Yes

 

 

Yes

 

 

No

 

No

 

 

No

  1.  

Degree of disability(UPDRS part III score)>25

 

  •  

No

  1.  

Neuropsychology, MMSE>24

 

  •  

No

  1.  

LEVODOPA CHALLENGE RESPONSE POSITIVE                                                   

 

(30% improvement in UPDRS after 12-hours off medication)

 

  •  

No

  1.  

Advanced  co-morbidity

 

Yes

  •  
  1.  

long term anticoagulation

 

Yes

  •  
  1.  

Willing for surgery and programming

 

  •  

No

 

 

PREOPERATIVE MANAGEMENT

A full medical assessment is a necessary part of the preoperative evaluation, as advanced PD patients tend to be elderly with significant comorbidities. Major issues are---

 

Anticoagulation/antiplatelets--- The risk of discontinuing medications that affect anticoagulation and

platelet aggregation should be weighed against the potential benefits in the quality of life offered by DBS surgery. However, timely discontinuation of these latter medications is mandatory for stereotactic surgery since intracerebral hematomas are the most serious of all potential complications from DBS. Any anticlotting medications, including aspirin, ticlopidine, clopidogrel, and all nonsteroidal anti-inflammatory drugs should be discontinued at least 7 to 10 days preoperatively to ensure the return of normal blood clotting function.

Arterial hypertension can also increase the risk of intracranial bleeding during stereotactic procedures and must be controlled in the weeks prior to surgery.

A prolonged discussion on the short- and long-term effects of DBS on Parkinson’s disease should be carried out with the patient, family, and caregivers.

The night prior to DBS surgery, the antiparkinsonian medications are typically held to pronounce the Parkinson’s symptoms at the time of surgery to see the clinical effects on symptoms during surgery and the families must be counselled regarding their role in facilitating the patient.

Target selection

The two main targets considered for DBS in PD are the STN and the GPi. current tendency is to prefer targeting the STN because of a greater improvement in the OFF phase motor symptoms as well as a higher chance to decrease the medication dosage and a lower battery consumption linked to the use of lower voltage in the STN compared to the GPi DBS. GPi can be the preferred target if LID is the main complaint. GPi DBS might be preferred for patients with mild cognitive impairment and psychiatric symptoms. Because STN DBS might have a higher rate of cognitive decline and/or depression and worsening of verbal fluency in some studies.

Surgical technique

The basic components of DBS implantation surgery involve frame placement, anatomical targeting, physiological mapping, evaluation of macrostimulation thresholds for improvement in motor symptoms or induction of side effects, implantation of the DBS electrode and implantable pulse generator (IPG).

Head-frame placement

The CRW frame is the most commonly used followed by the Leksell frame. Placement of the frame is done under local anesthesia unless anxiety or uncontrollable movements necessitate the use of sedation or general anesthesia.

Leksell stereotactic frame  placed over the head of a patient showing the correct method for placement of the Leksell head-frame. The frame should be placed parallel to orbito-meatal line in order to approximate the AC-PC plane. It is attached to the patient’s head using four pins under local anesthesia.

Imaging and anatomic targeting

Computerized Tomography (CT) scans and MRI are the two main imaging modalities used for targeting when performing DBS implantations. A thin cut stereotactic CT (_2 mm slices with no gap and no gantry tilt) is obtained after frame placement and is then fused with the stereotactic MRI on a planning station (Stealth station). The advantage of fusing the CT with MRI is the ability to avoid image-distortions inherent to MR imaging adding to the stereotactic accuracy. To better define the STN, T2-weighted images (TR 2800, TE 90, flip angle 90˚, slice thickness 2.0 mm) were obtained.

The AC and the PC were marked and the centre of the AC–PC line determined. The next step is planning the entry point and trajectory. The strategy here is to avoid surface and sub-cortical vessels. After trajectory planning, the patient is placed supine on the operating table and the frame attached to the table using an adaptor. Prophylactic antibiotics are given at least 30 min prior to incision. The head is prepped and draped in a sterile fashion. Under local anesthesia, a burr-hole is placed on the calculated entry point marked on the skull. The entry point is determined by the calculated arc and ring angles. Hemostasis is achieved with bone wax and bipolar cautery.

A Medronic Stim-Loc anchoring device (Medtronic, Minneapolis, MN) burr-hole base ring is then placed on the burr-hole and secured with two screws which are used at the end of the procedure to anchor the DBS electrode.

The dura is then cauterized and opened exposing the underlying surface of the brain. The microdrive is then assembled and cannulae inserted 10 mm above the target to avoid lenticulostriate vessels found deeper. Gel- foam and fibrin glue is applied on dural hole to minimize cerebrospinal fluid (CSF) loss and air entry into the skull. Subsequently, microelectrode recording and stimulation is undertaken.

Microelectrode recording/ Mapping

Microelectrode mapping is used to precisely define the target STN and its boundaries as well as nearby critical structures. We believe microelectrode mapping is crucial in order to give one the best chance for optimal placement of the DBS lead given anatomical inaccuracies due to image distortion and intraoperative brain shifts secondary to CSF loss, and pneumocephalus that can lead to inaccuracies in defining the initial target coordinates and shifts in the target itself once the skull is opened. Microelectrode mapping is performed using platinum-iridium glass coated microelectrodes dipped in platinum black with an impedance of around 0.3–0.5 Mo. These platinum-iridium microelectrodes are capable of recording single unit activity and can also be used for micro-stimulation up to 100 mAwithout significant breakdown in their recording qualities.

As the recording electrode was advanced, entry into the STN was identified by a sudden increase in the density of cellular discharge, with the characteristic irregular pattern of discharge—spikes of different sizes, occurring at random intervals. On coming out of the STN a quiet period (background noise) was seen followed by recording from the substantia nigra if the recording was continued far enough, described as high frequency (50–60 spikes/s) discharge pattern.11 Characteristic STN recordings (visual and audio) were identified and the depth of the STN activity was noted. Identification of STN activity was only based on the visual identification. The centre of the point of best electrical activity was selected as the final target. The microelectrode was replaced with a permanent quadripolar macroelectrode (Medtronic electrode no. 3389) to target the centre of the STN electrical activity. The proximal part of this electrode consists of four nickel conductor wires insulated with a polytetrafluoroethylene jacket tubing. The distal part has four metallic noninsulated contacts of 1.5 mm spaced at 0.5 mm intervals. The diameter of the distal electrode is 1.27 mm. Based on the clinical response any of the four contacts can be used for stimulation. Macrostimulation using the DBS electrode itself is then used to determine benefits and side effects. In most cases lateral skull x rays were obtained at this point with image intensifier carefully positioned to locate the target point in the centre of the Leksell-G frame rings.

Initial programming is always refined by using intra-operative macrostimulation data and a mono-polar review to identify the thresholds of stimulation for improvement in parkinsonian motor signs as well as the thresholds for inducing side effects at the level of each contact. The four variables that are used in programming are choice of contacts (0, 1, 2 or 3 used either as the cathode or anode), frequency of stimulation (hertz), pulse-width (ms) and amplitude (voltage).

POSTOPERATIVE MANAGEMENT

In the immediate hours after surgery, it is important to keep arterial blood pressure in the normal range. In addition, the patient’s preoperative drug regimen should be restarted immediately after surgery to avoid problems with dopaminergic withdrawal. Patients should undergo postoperative CT scans and/or MRI scans to assess the electrode location and intracranial status. In addition, plain X-rays are obtained to assess the location and geometry of the leads and hardware. Parkinson’s medications may need to be adjusted depending on the patient’s status. Cognitive and behavioral changes may occur in the postoperative period, particularly in older patients. Patients can be discharged as early as 24 hours after surgery, depending on their neurological and cognitive status.

Conclusion

For the last 50 years, levodopa has been the cornerstone of PD management. However, a majority of patients develop motor fluctuations and/or LID about 5 years after the initiation of therapy. DBS of the STN or the GPI grant to patients with PD improved quality of life and decreased motor complications, and has been approved as such by the Food and Drug Administration in the US in 2002. We reviewed the experience and available literature on DBS for Parkinson’s disease over the last decade and arrive at the following understandings.

The success of DBS surgery depends on the accurate placement of the leads and meticulous programming of the stimulation. Therefore, it is best accomplished by an experienced team of neurosurgeon, neurologist, and support staff dedicated to the treatment.

Reports of surgical complication rates and long-term side-effects of DBS are very variable, so benefits and potential adverse results should not be under- or over-emphasized.

While essentially equal in improving the motor symptoms of PD, STN and GPi might have their own benefits and risks, and the choice of the target should be individualized and adapted to the patient’s situation.

Knowledge to further improve DBS treatment for Parkinson’s disease, such as a more scientific and reliable protocol on programming, strategies to minimize cognitive and psychiatric complications, and the better

long-term maintenance of the implanted device, are still lacking.

Data on the impact of DBS on non-motor symptoms affecting the quality of life of PD patients, such as pain, speech or gastro-intestinal complaints, are still scarce. Further research in these areas will help make this useful treatment even more beneficial.

3 people found this helpful

I am addicted to drug and no matter how hard I try I can't quit it. It's become so serious. What should I do?

BHARAT JYOTI, MRACGP, INCEPTOR, MD-PhD, MD - Psychiatry, FIPS, Fellow of Academy of General Education (FAGE), DPM, MBBS
Psychiatrist, Bangalore
you need to decide and undergo deaddiction process whatever it is. I is possible to workout. There are replacement therapies/ keeping sober/ etc. Your age is more vulnerable to addiction and you need to understand the disease is a BRAIN DISEASE and not only psychological. You may need to undergo counselling and treatment of a minimum of three months duration.
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Feeling guilty and completely lost of my mind. Don't know what is to be done in my life. Feeling lonely though an married. None of them are understanding or sharing their needs for a Change. Out of control till killing situation What can be done. Need a pathway. Don't know what to do.

Bachelor of Ayurveda, Medicine and Surgery (BAMS)
Ayurveda, Fazilka
Think positive do not loose heart do meditation and yoga do kapalbhati pranayam for pcos problem safe ayurvedic treatment available for pcos and strenthning mind cionsult me through Lybrate.
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What is the caste why parents were strong on it. How to convey them more than that only love can make life happy and healthy relationship?

Masters of Philosphy, Master of Science, Bachelor of Sciences
Psychologist, Kolkata
Hello lybrate-user caste and creed are created by society. Nothing to worry about it. If you love your partner genuinely and he too loves you genuinely, then don't think too much, go ahead.
1 person found this helpful
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How Do Drugs/Alcohol Hijack Our Kids?

MBBS, MD - Psychiatry
Sexologist, Mumbai
How Do Drugs/Alcohol Hijack Our Kids?

The most commonly encountered two facts about the drug or alcohol use by our addicted kids are drugs/ alcohol are something which they really like those are something which they find really hard to give up. They know that the drug can kill them in a long run, but still they go with the immediate rewards by consuming the drug. The whole addiction thing is about being in the moment and choosing what your brain craves for right now at the expense of other rewards and possibilities. So what we observe is that drug hijacks a person's rational thinking for the long term consequences.


Addiction has to do with changes in the brain that come about gradually, become more and more central, more and more powerful as the time passes by. The drug use becomes the axis of the person, around which the other activities in life takes turn. It takes on the central meaning and role in the person's life in such a way that the most irrational idea about taking the drug or alcohol may seem to the person the most rational in that particular situation, as the drug compromises the person's clear thinking. So yes an addict can make choices for his drug cravings but the way they make choices is the thing we must think about. In an addict the brain does what it needs to do, but in a very non-adaptive way. In simple words addiction hijacks the very parts of the brain that are supposed to fix it.


Craving is the fundamental psychological experience of an addict because of which addiction occurs. Dopamine serves as the fuel for craving and is the common pathway for all kinds of addictions. Natural goodies like the food and sex certainly release dopamine in brain and follow the progression from liking to wanting i. E. Wanting more of those. As per studies, among the natural rewards sex can provide a person with the maximum natural high of upto 200% dopamine levels in brain. But the drugs cause a higher than 200% dopamine levels, which thus is the magic mark for addictive processes to occur. Also with repeated drug use there are changes in the arrangement of the inner landscape of synaptic architecture in brain, such that the thoughts, the images, the memories about the drug use behavior takes over many parts of the cortex of brain and thus the person see the drug cues wherever he gets a dopamine rush, be it with sex or food or social gatherings. Thus dopamine drives the person with a feeling of craving for the drug. Also with repeated dopamine increments of higher than natural amounts, there is maladaptive learning in brain in form of the shrinkage of dopamine cells, decrease in dopamine receptors and depletion of the dopamine stores. Thus the real natural goodies like sex or food are than not able to give a dopamine high and the only way left is to have more drugs. The person becomes impulsive and compulsive in his drug taking behavior. Repetition compulsion feedback loop keeps the person going after the drug use, narrowing the sense of meaningful world for the person. This causes a vicious cycle of incremental drug intake and thus addiction. Dopamine pathways are subdued by chronic drug use and thus the drug addicts are never able to keep up with their promises of staying away from the drug.


But then our brains have enormous reparative capacity and so a lot of the things that drugs do to damage the brain are probably reversible. One of the things that last the longest are the memories associated with drug use and the learning/ operant conditioning that occurs with it. The acute memory of brain over stimulation with drug is captured in amygdale which designates an important part of the instinctual brain i. E. The brain part which can't be controlled. So if a drug related cue is presented to a recovering addict, all that they can remember is the greatest high which they ever had with the drug. Thus the person remains preoccupied and thinks about the drug even when not using it. When this occurs, it is for the lifetime and we can't undo it. Their amygdale are going to light up seeing the drug cues for rest of their lives. This is why we say recovery from drug is a lifelong experience. Studies show a much faster depletion of our brain neurotransmitters by drug use (less than 12 months), than their replenishment in recovery from addiction (5 to 7 years). Thus during recovery an ongoing treatment for the imbalanced brain neurotransmitters and the visible symptoms due to the same is always essential.

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I used to lose temper and get angry very easily these days. Although I was not like this before. This is creating problems in my love life. Kindly suggest something.

MBBS, MD (AIIMS, Gold Medalist), Diploma in CBT (Glasgow)
Psychiatrist, Delhi
Since this is a recent development, it will need some kind of treatment. But recent onset also means that it will respond very well to treatment. Depending upon the severity and your choice, either medicines or counseling can be done. Please revert back if interested. Thanks!
1 person found this helpful
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I have body pain specially knees and back perpetually. Can you suggest some effective home remedies or natural remedies to ease the pain I'm 62 Years old, have hypo thyroid and obese. Can you help me with short remedies for all above.

Master of Physiotherapy, Bachelor of Physiotherapy
Physiotherapist, Chennai
You may feel like resting, but moving is good for your back. Exercises for lower back pain can strengthen back, stomach, and leg muscles. They help support your spine, relieving back pain. Always ask your health care professional before doing any exercise for back pain. Depending on the cause and intensity of your pain, some exercises may not be recommended and can be harmful.
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I am very depressed now because of many stresses so that I feel always illness and weaknesses please help me and having also some internal health problems.

MBBS, MD - Psychiatry, MBA (Healthcare)
Psychiatrist, Davanagere
Good Morning ~ Stresses can take the best of a person and make him into a depressed or anxious person who is non functional. It seems like you have recognized the fact that you are depressed. One way you can probably approach the situation is to find ways to cope better with the stresses that you are having. You will find time to ponder over the subject and come up with unique solutions if you do mindfulness meditation. I believe that you also will get rid of the internal health problems (you have not mentioned what they are), if you focus on distracting your mind from weaknesses and concentrate on issues that are helpful for bringing you back into a non-depressed state. Medications are helpful, however I recommend reading more about depression so as to come to proper conclusions regarding the necessity for treatment from a psychiatrist.
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Hi doctor. I have some problem in my brain. At midnight I have some unusual dreams. Seeing those dreams my brain starts thinking fast about my past. Though I dont remember about my past but my brain continues to do so. I just wanted to consult you about my problem. Everyone says its just a night mare but I think you will surely be able to help me.

MD - Psychiatry, MBBS
Psychiatrist, Patna
It happens in case of some traumatic experiences in past. Our conscious brain does not want to recall that unfortunate event/experience but our subconscious mind has that remembrance. That is why although we claim to forget it comes in dream. Forgetting painful memories is a kind of defense mechanism of brain to reduce the stress. Try to avoid thinking about it and about the past. Have healthy meal at time, have regular exercise, meditation, yoga etc. Listen some relaxing music at evening, have adequate rest and recreation. At evening have early and light dinner, wear comfortable loose clothing and have a comfortable, mosquito free bed in a comfortable environment. Then you will have sound sleep and less dreams.
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I love a person who younger than me we both love each other. He want to marry me but my family is not agree for this. I can not live without him. And he also. Kya shadi m age bahut matter krti h?

DPM, MBBS
Psychiatrist, Bhopal
See do not see this problem superficially, stay cool n calm and think about each and every aspect of yor relationship, you would get the answer.
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Hi my wife is suffering from symptoms like crying laughing thinking some thing murmuring to one self lost in another thought asking or think things which never happened doesn't like being confronted.

BASM, MD, MS (Counseling & Psychotherapy), MSc - Psychology, Certificate in Clinical psychology of children and Young People, Certificate in Psychological First Aid, Certificate in Positive Psychology
Psychologist, Palakkad
Dear lybrate user. From the given description it seems like psychosis. Psychosis may occur as a result of a psychiatric illness such as schizophrenia. In other instances, it may be caused by a health condition, medication or drug use. Possible symptoms include delusions, hallucinations, talking incoherently and agitation. The person with the condition usually isn't aware of his or her behaviour. Treatment may include medication and talk therapy.
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My brother in law has psychological problem since childhood now he makes too much noise at home. He is 35 years old. We are giving him lozapin100 mg in the evening.is it ok?

B.Sc(Hons) Mumbai Univ., ND, MD - Alternate Medicine, Aroma Therap., Bach Flower Rem, Mental Health Cert.
Alternative Medicine Specialist, Mumbai
Hi I will prescribe some harmless but effective flower remedy available in homoeopathy shops. Try to buy original medicines. Mix 4 drops of Holly + 4 drops of Impatiens + 3 drops of Vervain + 3 drops of White chestnut + 3 drops of Vine. Mix these with 100 ml water and drink it every night once before sleeping. If any problems consult me online.
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Sir, me ek ladki se saadi karne Waala hoon, engagement ho gaya, ladki moti aur mere jaisi sundar nahi hai. Uski English badi weak hai, spell mistake, me iss shadi ko rokun ya shadi karoon. Is ladki se jhagda bhi bahut ho raha hai. Respect se baat nahi kar rahi hai. Me future soch ke dar rha hu, kaise ise jhelunga.

Masters in Clinical Psychology
Psychologist, Lucknow
Hi lybrate-user, basic respect and understanding is important for marriage, you both need to sit down and talk about your expectations. Abhi se itna negative ja raha hai to usko rokna pardega ya to use manage kare ya fir soch samajh kar koi step le. Hum ap ko sirf guide kar sakte hai final decision aap ka hai. Aagar sari situation ko dekh kar lagta hai cheeze thik nahi hai please take step immediately instead of spoiling yours and her life. Aap mujhe consult kare pre marital counseling ke liye. Will guide you. All the best.
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