A pharmacokinetic-pharmacodynamic model for intrathecal baclofen in patients with severe spasticity.

AIMS: Intrathecal baclofen (ITB) has proven to be an effective and safe treatment for severe spasticity. However, although ITB is used extensively, clinical decisions are based on very scarce pharmacokinetic-pharmacodynamic (PKPD) data. The aim of this study was to measure baclofen CSF concentrations and clinical effects after administration of various ITB boluses in patients with spasticity and to create a PKPD model for ITB. METHODS: Twelve patients with severe spasticity received four different bolus doses of ITB (0, 25, 50, 75 µg and an optional dose of 100 µg), administered via a catheter with the tip at thoracic level (Th) 10. After each bolus, 10 CSF samples were taken at fixed time intervals, using a catheter with the tip located at Th12. Clinical effect was assessed by measuring spasticity with the Modified Ashworth Scale (MAS). These data were used to develop a PKPD model. RESULTS: All patients achieved an adequate spasmolytic effect with ITB doses varying from 50 to 100 µg. No serious side effects were observed. CSF baclofen concentrations, as well as the clinical effects, correlated significantly with ITB doses. The PK model predicted a steep spinal concentration gradient of ITB along the spinal axis. The clinical effect could be predicted using a delayed-effect model. CONCLUSIONS: ITB is an effective and safe therapy with, however, a steep concentration gradient along the spinal axis. This means that the administered baclofen is staying mainly around the catheter tip, which stresses the importance to position the ITB catheter tip closely to the targeted spinal level.

Sympathetic regulation of cerebral blood flow in humans: a review.

Cerebral blood flow (CBF) is regulated by vasomotor, chemical, metabolic, and neurogenic mechanisms. Even though the innervation of cerebral arteries is quite extensively described and reviewed in the literature, its role in regulation of CBF in humans remains controversial. We believe that insufficient attention has so far been focused on the potential role of the innervation of the cerebral vasculature in cerebral autoregulation in humans. We have performed an extensive search and selection of available literature on electrical, chemical, and surgical manipulations of the sympathetic innervation of cerebral arteries, and the effects of circulation sympathetically active agents on CBF. Studies on (surgical) ganglion block show a role of sympathetic tone in preventing increases in CBF in humans, which are consistent with the view based on animal studies. Both direct innervation of the cerebral arteries from cervical ganglia and stimulation of adrenergic receptors by circulating sympathomimetics prevent sudden increases of CBF associated with hypertension and hypercapnia. We postulate that under normal physiological conditions neurogenic control has little influence on cerebral autoregulation as other methods of control (vasomotor, chemical, and metabolic) are dominant. In severely challenging circumstances, such as delayed cerebral ischaemia after subarachnoid haemorrhage, these methods might be overwhelmed, increasing the relative importance of neurogenic, sympathetic control of CBF. This insight might lead to future therapeutic possibilities.

Electrical neuromodulation for patients with cardiac diseases.

In this review we discuss the position of electrical neuromodulation as a safe and reversible adjuvant therapy for treatment of patients with chronic cardiac diseases who have become refractory to conventional strategies. In patients with chronic refractory angina, electrical neuromodulation, independent of the applied modality, has shown to reduce complaints of angina, to enhance exercise capacity, to improve quality of life and to employ anti-ischaemic effects. To date, electrical neuromodulation seems to be one of the best adjuvant therapies for these patients. In addition, neuromodulation in the treatment of heart failure and resistant arrhythmias is the subject of several ongoing studies.

Tolerance to continuous intrathecal baclofen infusion can be reversed by pulsatile bolus infusion.

STUDY DESIGN: Pilot study. OBJECTIVE: To study the effect of pulsatile bolus infusion of intrathecal baclofen (ITB) on daily ITB dose, in patients showing dose increases, probably due to tolerance. SETTING: Department of neurology and neurosurgery, University Medical Center Groningen, the Netherlands. METHODS: Data on dosages and clinical efficacy were gathered from four patients who were switched from continuous to pulsatile bolus infusion of ITB, because of the probable diagnosis of tolerance to ITB. RESULTS: Switching from continuous to pulsatile bolus infusion resulted in a decrease of the daily ITB dose, while the clinical effect could be kept stable, without introducing adverse events. CONCLUSION: Pulsatile bolus infusion of ITB seems to be an effective and safe treatment strategy to reverse the need for increasing ITB dosages in patients with the probable diagnosis of tolerance to ITB.

The incidence and management of tolerance in intrathecal baclofen therapy.

STUDY DESIGN: Retrospective study. OBJECTIVES: To study the incidence and management of tolerance in patients treated with intrathecal baclofen (ITB) therapy. SETTING: Department of neurology and neurosurgery, University Medical Center Groningen, The Netherlands. METHODS: Medical records of all patients who had received an implantable ITB pump at our clinic during 1991-2005 were reviewed. RESULTS: A total of 37 patients (representing 116 pump years) were included. Mean follow-up time was 38 months (range 3-120 months). Baclofen dose increased in the first 18 months after implantation (P<0.05), and then stabilized around a mean dose of 350 microg per day. Eight patients (22%) developed tolerance, defined as a dose increase of >100 microg per year. No predictive factors for development of tolerance could be determined. Three different treatment regimens for tolerant patients were analyzed. Altering the infusion mode from simple to complex continuous (n=6) had no effect on the development of tolerance. Pulsatile bolus infusion (n=1) and a drug holiday (n=2) were both effective in reducing the daily baclofen dose. Patients who needed surgical revision of the pump system because of mechanical failures (n=11) showed a significant dose decrease during the first month after revision, indicating that the preoperative dose increase most likely had been caused by the pump failure. Pump-related complications occurred once per 10.5 years of ITB treatment. Drug-related side effects had an annual risk of 13.8%. The reported events were mostly mild. CONCLUSIONS: ITB therapy is effective and safe, also in the long term and causes tolerance in only 22% of the treated patients.

CME for neurosurgeons in the Netherlands: the "quality" conferences.

In 1993 the Netherlands Society for Neurosurgery started a yearly event, a "Quality Conference", specifically devoted to continuous medical education (CME). These conferences differ from "normal" scientific meetings, in the choice for specific topics, in the preparation with inquiries among all the Dutch neurosurgical centres, and in the way the results of these inquiries are discussed, preceded by lectures concerning the chosen topic by guest faculty and Dutch neurosurgeons. Each year's principal guest delivers the "Beks Lecture", named after the former professor in Neurosurgery in Groningen, Jan Beks. On several occasions, the foreign guests suggested to present this format for a larger neurosurgical forum. Therefore, it was decided to describe the various aspects of this format for CME in the Netherlands in a paper for Acta Neurochirugica. Examples of topics are given, a summary of two recent inquiries are presented and discussed, and the way of organizing such a conference including finance and the obligatory character are described.

The additive effect of co-occurring anxiety and depression on health status, quality of life and coping strategies in help-seeking tinnitus sufferers.

OBJECTIVE: Evaluating the effect of anxiety and depression on clinical measures of general health, tinnitus-specific quality of life, and coping abilities. DESIGN: Two hundred sixty-five chronic, subjective tinnitus sufferers were divided into four psychological symptom groups according to cut-off scores on anxiety and depression subscales of the Hospital Anxiety and Depression Scale: (1) no-symptoms, (2) anxiety-only, (3) depression-only, and (4) anxiety-plus-depression. General health-related quality of life (SF-36), tinnitus-specific quality of life (tinnitus reaction questionnaire and tinnitus handicap inventory), and coping abilities (tinnitus coping style questionnaire) were assessed and analyzed across these four psychological symptom groups, which did not differ on age, gender, marital, and working status. RESULTS: Statistically significant and clinically relevant differences on general health-related and tinnitus-specific quality of life and coping abilities were identified when comparing anxiety-plus-depression subgroup with the subgroups anxiety-only, depression-only, or no-symptoms. Highest associations were seen between the anxiety-plus-depression subgroup and impaired quality of life and maladaptive coping. CONCLUSIONS: Our results demonstrate the additive effect of both anxiety and depression in impairing general health-related and tinnitus-specific quality of life and application of coping strategies, and reiterate the need for investigating both symptoms in the clinical evaluation of tinnitus patients.

Intraoperative neurophysiological assessment of disabling symptoms in DBS surgery.

INTRODUCTION: Neurophysiological assessment can provide quantitative measures for the selected motor signs that have been targeted for surgery and may be helpful in predicting the therapeutic effects of deep brain stimulation (DBS) on pathological tremor, motor performance, and rigidity. OBJECTIVE: To present a survey and demonstrate the contribution of neurophysiological assessment of side effects and effects on disabling motor symptoms at various steps of DBS surgery, and to confirm its role for optimal target localization, as an adjuvant to anatomic imaging. MATERIAL AND METHODS: The data result from 192 nuclei in 118 procedures on patients with Parkinson's disease (84), essential tremor (24), Hallenvorder Spatz dystonia (4), multiple sclerosis (4), and Holmes tremor (2). The intraoperative neurophysiological monitoring (IOM) protocol consists of semimicroelectrode recording (for subthalamic nuclei), whereas accelerotransducers and spectral analysis allow assessment of tremor, finger tapping (FT), diadochokinesis (DDK), and determination of the distance between DBS electrodes and internal capsule (IC). Rigidity is assessed by surface EMG recordings in combination with a goniometer. RESULTS: The determination of the functional distance between the DBS electrode and the IC is based on the activation functions of axons in the IC. We show the high sensitivity of accelerometers for tremor over a large part of the body, the relationship between clinical scores and spectral frequencies of FT and DDK. Parkinsonian rigidity can be assessed from surface EMG (sEMG) by means of a balance coefficient, which can detect negative rigidity, for low unified Parkinson's disease rating scale (UPDRS) scores (0-2) and quantified EMG when negative rigidity is excluded. CONCLUSION: Accelerometer and sEMG recording have shown their value for intraoperative assessment of disabling motor symptoms and side effects during surgery, to optimize the target position electrodes for DBS. The combination with contemporary signal analyzing techniques permit intraoperative monitoring without a significant delay. IONM improves sensitivity and adds objective neurophysiological data.

Spinal cord stimulation for ischemic heart disease and peripheral vascular disease.

Ischemic disease (ID) is now an important indication for electrical neuromodulation (NM), particularly in chronic pain conditions. NM is defined as a therapeutic modality that aims to restore functions of the nervous system or modulate neural structures involved in the dysfunction of organ systems. One of the NM methods used is chronic electrical stimulation of the spinal cord (spinal cord stimulation: SCS). SCS in ID, as applied to ischemic heart disease (IHD) and peripheral vascular disease (PVD), started in Europe in the 1970s and 1980s, respectively. Patients with ID are eligible for SCS when they experience disabling pain, resulting from ischaemia. This pain should be considered therapeutically refractory to standard treatment intended to decrease metabolic demand or following revascularization procedures. Several studies have demonstrated the beneficial effect of SCS on IHD and PVD by improving the quality of life of this group of severely disabled patients, without adversely influencing mortality and morbidity. SCS used as additional treatment for IHD reduces angina pectoris (AP) in its frequency and intensity, increases exercise capacity, and does not seem to mask the warning signs of a myocardial infarction. Besides the analgesic effect, different studies have demonstrated an anti-ischemic effect, as expressed by different cardiac indices such as exercise duration, ambulatory ECG recording, coronary flow measurements, and PET scans. SCS can be considered as an alternative to open heart bypass grafting (CABG) for patients at high risk from surgical procedures. Moreover, SCS appears to be more efficacious than transcutaneous electrical nerve stimulation (TENS). The SCS implantation technique is relatively simple: implanting an epidural electrode under local anesthesia (supervised by the anesthesist) with the tip at T1, covering the painful area with paraesthesia by external stimulation (pulse width 210, rate 85 Hz), and connecting this electrode to a subcutaneously implanted pulse generator. In PVD the pain may manifest itself at rest or during walking (claudication), disabling the patient severely. Most of the patients suffer from atherosclerotic critical limb ischemia. All patients should be therapeutically refractory (medication and revascularization) to become eligible for SCS. Ulcers on the extremities should be minimal. In PVD the same implantation technique is used as in IHD except that the tip of the electrode is positioned at T10-11. In PVD the majority of the patients show significant reduction in pain and more than half of the patients show improvement of circulatory indices, as shown by Doppler, thermography, and oximetry studies. Limb salvage studies show variable results depending on the stage of the trophic changes. The underlying mechanisms of action of SCS in PVD require further elucidation.

Time of Flight-Secondary Ion Mass Spectrometry on isolated extracellular fractions and intact biofilms of three species of benthic diatoms.

Time of Flight-Secondary Ion Mass Spectrometry (ToF-SIMS) was used to study compositional characteristics of Extracellular Polymeric Substances (EPS) and compared these to characteristics of the EPS-matrix of intact diatom biofilms. Three benthic diatoms species were investigated, Cylindrotheca closterium, Navicula mutica and Nitzschia cf. brevissima. Comparison of the ToF-SIMS spectra of sequentially extracted EPS-fractions by cluster analysis and multidimensional scaling analysis (MDS) indicated that soluble and bound EPS were not distinguishable based on their ion spectra. On the contrary the water insoluble bicarbonate soluble (WIBS)-EPS-fraction formed a distinct cluster showing that this material was compositionally different from the other EPS-fractions. Ion spectra of the EPS-fractions were dissimilar to results obtained from intact biofilms. This suggested that during the extraction procedure, the structure of the EPS irreversibly changed, which alters the fragmentation patterns of the extracellular surface layer. Furthermore, from the examination of the positive ion spectra it was shown that the overall composition of EPS in the intact biofilms was different between diatom species. In spite of these differences, several common peak patterns were shared between different species. This suggests the presence of common structural components in the EPS of these diatoms that may play a role in building the surface EPS-layer.

Chronic stimulation of the subthalamic nucleus increases daily on-time without dyskinesia in advanced Parkinson's disease.

We assessed the efficacy of chronic stimulation of the subthalamic nucleus (STN-DBS) in 20 patients with Parkinson's disease (PD) by means of clinical assessments and patient diaries 12 months after surgery. STN-DBS reduced the UPDRS part III off-medication score by 33%, and successively improved complete daily on-time without dyskinesia at 12 months significantly. In conclusion, our study demonstrates the efficacy of chronic STN-DBS on motor features in a selected population of advanced PD patients. In addition to clinical assessments, patients' diaries serve as an essential tool to evaluate the functional motor status after STN-DBS.

Effect of water temperature on biofouling development in reverse osmosis membrane systems.

Understanding the factors that determine the spatial and temporal biofilm development is a key to formulate effective control strategies in reverse osmosis membrane systems for desalination and wastewater reuse. In this study, biofilm development was investigated at different water temperatures (10, 20, and 30 °C) inside a membrane fouling simulator (MFS) flow cell. The MFS studies were done at the same crossflow velocity with the same type of membrane and spacer materials, and the same feed water type and nutrient concentration, differing only in water temperature. Spatially resolved biofilm parameters such as oxygen decrease rate, biovolume, biofilm spatial distribution, thickness and composition were measured using in-situ imaging techniques. Pressure drop (PD) increase in time was used as a benchmark as to when to stop the experiments. Biofilm measurements were performed daily, and experiments were stopped once the average PD increased to 40 mbar/cm. The results of the biofouling study showed that with increasing feed water temperature (i) the biofilm activity developed faster, (ii) the pressure drop increased faster, while (iii) the biofilm thickness decreased. At an average pressure drop increase of 40 mbar/cm over the MFS for the different feed water temperatures, different biofilm activities, structures, and quantities were found, indicating that diagnosis of biofouling of membranes operated at different or varying (seasonal) feed water temperatures may be challenging. Membrane installations with a high temperature feed water are more susceptible to biofouling than installations fed with low temperature feed water.

Competition for pollinators and intra-communal spectral dissimilarity of flowers.

Competition for pollinators occurs when, in a community of flowering plants, several simultaneously flowering plant species depend on the same pollinator. Competition for pollinators increases interspecific pollen transfer rates, thereby reducing the number of viable offspring. In order to decrease interspecific pollen transfer, plant species can distinguish themselves from competitors by having a divergent phenotype. Floral colour is an important signalling cue to attract potential pollinators and thus a major aspect of the flower phenotype. In this study, we analysed the amount of spectral dissimilarity of flowers among pollinator-competing plants in a Dutch nature reserve. We expected pollinator-competing plants to exhibit more spectral dissimilarity than non-competing plants. Using flower visitation data of 2 years, we determined the amount of competition for pollinators by different plant species. Plant species that were visited by the same pollinator were considered specialist and competing for that pollinator, whereas plant species visited by a broad array of pollinators were considered non-competing generalists. We used principal components analysis to quantify floral reflectance, and found evidence for enhanced spectral dissimilarity among plant species within specialist pollinator guilds (i.e. groups of plant species competing for the same pollinator). This is the first study that examined intra-communal dissimilarity in floral reflectance with a focus on the pollination system.

Neurostimulation as a new treatment for severe tinnitus: a pilot study.

BACKGROUND: Tinnitus is an uncomfortable symptom for the patient and an embarrassing one for the consulted physician. So far, there is no treatment that can be considered well established in terms of providing long-term reduction of tinnitus in excess of placebo effects. There is considerable evidence of pathophysiological similarity between tinnitus and chronic pain. Some forms of chronic pain can be treated by neurostimulation. OBJECTIVE: This study was designed to investigate the feasibility of neurostimulation of the cochlear nerve in order to reduce tinnitus. STUDY DESIGN: Pilot study. SETTING: Tertiary referral center. PATIENTS: Five patients with therapeutically refractory tinnitus were selected for this study. INTERVENTION: Placing a stimulation lead around the cochlear nerve through the suboccipital approach and connecting the stimulation lead to a pulse generator. MAIN OUTCOME MEASURES: The patients experienced 1) an absence of major or minor complications, such as death, meningitis, cranial nerve deficit, and vestibular problems; 2) tolerance of the procedure as considered by the patient; 3) relief of tinnitus in at least one patient. RESULTS: Implantation of the neurostimulation system was accomplished in each patient without any difficulty. None of the patients considered the treatment unbearable. No major or minor complications occurred in this study. Subjective tinnitus reduction was accomplished in four patients. CONCLUSION: Our preliminary data show that neurostimulation of the cochlear nerve is feasible, is bearable for the patient, and is a safe treatment modality without major complications. The effects on tinnitus are promising.

Early non-destructive biofouling detection and spatial distribution: Application of oxygen sensing optodes.

Biofouling is a serious problem in reverse osmosis/nanofiltration (RO/NF) applications, reducing membrane performance. Early detection of biofouling plays an essential role in an adequate anti-biofouling strategy. Presently, fouling of membrane filtration systems is mainly determined by measuring changes in pressure drop, which is not exclusively linked to biofouling. Non-destructive imaging of oxygen concentrations (i) is specific for biological activity of biofilms and (ii) may enable earlier detection of biofilm accumulation than pressure drop. The objective of this study was to test whether transparent luminescent planar O2 optodes, in combination with a simple imaging system, can be used for early non-destructive biofouling detection. This biofouling detection is done by mapping the two-dimensional distribution of O2 concentrations and O2 decrease rates inside a membrane fouling simulator (MFS). Results show that at an early stage, biofouling development was detected by the oxygen sensing optodes while no significant increase in pressure drop was yet observed. Additionally, optodes could detect spatial heterogeneities in biofouling distribution at a micro scale. Biofilm development started mainly at the feed spacer crossings. The spatial and quantitative information on biological activity will lead to better understanding of the biofouling processes, contributing to the development of more effective biofouling control strategies.

Ontogenesis of embryonic porcine ventral mesencephalon in the perspective of its potential use as a xenograft in Parkinson's disease.

Human fetal neural dopaminergic tissue can be transplanted and can ameliorate neurological deficiencies in patients with Parkinson's disease (PD). Donor tissue from other species has been used experimentally for several years in animal experiments and is now being considered an attractive alternative, particularly from a donor species that breeds in large litters, e.g., the pig. We have studied the early ontogenetic development of the mesencephalic dopaminergic system in the pig, utilising an anti-tyrosine hydroxylase (TH) immunocytochemical technique, and demonstrated the earliest appearance of its cell bodies at embryonic day 20 (E20). We compared the porcine data with those of human fetal development, as revealed by the same technique. Embryonic dopaminergic cell groups resembling the A8, A9, and A10 of the rat are present in the pig and differentiate into the homologous cell groups of human, although interesting quantitative differences are apparent. In the pig, prolonged presence of immature characteristics of TH-immunoreactive (TH-i.r.) cell bodies was observed, notwithstanding the early outgrowth of TH-i.r. axons into the ganglionic eminence. In the human, on the other hand, cell divisions and maturation of dendrites have progressed to a further degree than in the pig, before such distinct outgrowth of axons takes place. In pig embryos of 28 days, cells in the ventral mesencephalon had differentiated into TH containing neurons, which indicates their potential to synthesize dopamine. In spite of their differentiation, these cells still showed immature morphological features (rounded cell bodies with undifferentiated, short processes). Dopamine synthesis by these cells was demonstrated in previous studies by the high performance liquid chromatographic technique (HogenEsch et al. [1993] Can. J. Neurol. Sci. 20(suppl. 4):P.S. 235). In a separate paper, we have described that these porcine 28-day dopaminergic cells retain their potential for development and outgrowth in culture (van Roon et al. [1995] Res. Neurol. Neurosci. 7:199-205). We conclude that the ventral mesencephalon in pig embryos of 28 days is a potential source of dopaminergic neurons to be used as a xenograft in PD.

GABA-ergic component of rat embryonic ventral mesencephalic grafts: an in-vitro study.

In order to establish the number, the viability and the developmental potential of GABAergic neurons present in dopaminergic ventral mesencephalic (VM) grafts from embryonic rat, we have studied the survival and development of these neurons in culture. The GABAergic fraction demonstrated a highly disproportionate survival in culture in relation to other VM neurons resulting in a drastic change in the neuronal composition of the dissociated VM grafts. The occurrence of a similar gradual dominance of GABAergic neurons at the site of intracerebral implantation, may affect the development of grafted dopaminergic VM neurons and their interaction with host striatal cells.

Fetal porcine ventral mesencephalon grafts: dissection procedure and cellular characterization in culture.

The objective of this study was to develop an optimal dissection procedure for fetal porcine ventral mesencephalon (VM) grafts and to characterize the cellular composition of such an explant, in particular with respect to the dopaminergic and GABAergic components. We have used a monolayer cell culture system to study and identify the various VM cell types. The in vitro development of the fetal VM cells and the effect of the addition of brain-derived neurotrophic factor (BDNF) was investigated during a culture period of 5 days. Extracellular dopamine levels were measured by means of high performance liquid chromatography (HPLC) with electrochemical detection (LCEC). Our results indicate that the ratio of dopaminergic to GABAergic neurons changed in favour of the dopaminergic component when a more selective dissection technique was used. Although addition of BDNF to the cultures appeared to exert trophic influences on all the cellular components of pig fetal VM, this effect was most pronounced on the TH-positive cells. Highest extracellular DA levels were found in the VM culture with the addition of BDNF and when a more selective dissection method was used. Our in vitro findings suggest that porcine fetal dopaminergic cells retain their potential for development and outgrowth after proper explantation and dissociation. Anticipating on the results of ongoing transplantation studies in rat, they suggest that pig fetal VM can be a suitable alternative for the use of fetal human VM as a graft for Parkinson's disease.

Cryopreservation of porcine fetal ventral mesencephalic tissue for intrastriatal transplantation in Parkinson's disease.

In this study we examined the efficacy of cryopreserving porcine fetal mesencephalic tissue. After microscopical dissection of the ventral mesencephalon (VM) from E28 pig fetuses, the collection of explants was randomly divided into two equal parts. One part was directly prepared as cell suspension. The other part was stored in hibernation medium for less than 2 days and then cryopreserved as tissue fragments and stored in liquid nitrogen. After 2 weeks up to 1 year, these tissue fragments were thawed and processed as cell suspensions. After cell counting and assessment of viability, these cell suspensions were used to examine survival, morphology, and neurite formation of the dopaminergic neurons in cell culture as well as after intrastriatal implantation in 6-OHDA-lesioned rats. Comparison of cryopreserved with fresh VM cell suspensions showed no significant difference with respect to cell viability and the average number of living cells per VM explant. The morphology of cultured dopaminergic neurons after cryopreservation was identical to that of fresh cells. After intrastriatal implantation, survival and outgrowth of cryopreserved dopaminergic neurons as well as functional effects did not differ from those of fresh cells. In conclusion, the cryopreservation technique we used proves to be a reliably effective method for storing porcine fetal VM tissue.

Clinical outcome of patients treated with spinal cord stimulation for therapeutically refractory angina pectoris. The Working Group on Neurocardiology.

OBJECTIVE: To determine morbidity and mortality characteristics in patients treated with electrical neuromodulation for refractory angina pectoris. DESIGN: A retrospective multicentre study of patients treated with spinal cord stimulation between 1987 and 1997; 21 centres were contacted and 14 responded. SETTING: Specialist centres worldwide. PATIENTS: Questionnaires were returned on 517 patients, of whom 71% were male. One was lost to follow up. Mean (SD) age was 63.9 (10.1) years. Duration of angina pectoris was 8.1 (6.3) years. RESULTS: Before spinal cord stimulation, 66% of the patients had experienced myocardial infarction, 68% had three vessel disease, and in 24% the left ventricular ejection fraction (LVEF) was /= 71 years were independent predictors of mortality. During spinal cord stimulation, New York Heart Association functional class improved from 3.5 to 2.1 (p < 0.01); 25 of the deceased patients (24%) and 32 survivors (8%) experienced myocardial infarction; hospital admissions were significantly (p < 0.001) more common in the deceased group (66% v 37%). CONCLUSIONS: The clinical outcome of patients with intractable angina is not adversely affected by the chronic use of neurostimulation.