[Pacemaker, organ or walking stick? Pre-op association with and post-op subjective perception of a deep brain stimulation device]. / Herzschrittmacher, Organ oder Gehstock? Vorher-Nachher-Befragung zur subjektiven Wahrnehmung eines Gerätes zur Tiefen Hirnstimulation.

AIM OF THE STUDY: This study was conducted in a pre-post design with a survey of patients who had undergone deep brain stimulation (DBS) as treatment for a neurological movement disorder. The aim of the study was to compare patients' expectations and beliefs before a DBS intervention with patients' subjective experience of this intervention. METHODOLOGY: The longitudinal study of patients (n=132) with an indication for DBS therapy was based on a written survey at the time points of preoperative screening (pre-op) and one-year follow-up (post-op). RESULTS: Preoperatively, a clear majority of respondents believed DSB to be similar to a pacemaker intervention, but one year after the intervention less than one third did so, as they compared DBS to using a walking stick or glasses. CONCLUSION: The experience of DBS in the patient's own body seems to be comparable by means of individually different associations, whereby the comparison with non-invasive aids predominates postoperatively. The discussion of these descriptions in the educational interview can contribute to a realistic horizon of patients' expectations before DBS.

The effects of hydrocortisone and yohimbine on human behavior in approach-avoidance conflicts.

RATIONALE: Balancing approach of positive and avoidance of negative stimuli is essential when faced with approach-avoidance conflicts, e.g., situations with both positive and negative outcomes. This balance is disturbed in several mental disorders, e.g., excessive avoidance in anxiety disorders, and heightened approach in substance use disorders. Since stress is assumed to impact these disorders' etiology and maintenance, it seems crucial to understand how stress influences behavior in approach-avoidance conflicts. Indeed, some studies suggested altered approach-avoidance behavior under acute stress, but the mechanism underlying these effects is unknown. OBJECTIVES: Investigate how the pharmacological manipulation of major stress mediators (cortisol and noradrenaline) influences task-based approach-avoidance conflict behavior in healthy individuals. METHODS: Ninety-six participants (48 women, 48 men) received either 20mg hydrocortisone, 20mg yohimbine, both, or placebo before performing a task targeting foraging under predation in a fully crossed double-blind between-subject design. Moreover, we investigated effects of gender and endogenous testosterone and estradiol levels on approach-avoidance behavior. RESULTS: While biological stress markers (cortisol concentration, alpha amylase activity) indicated successful pharmacological manipulation, behavior in approach-avoidance conflicts was not affected as expected. Although yohimbine administration affected risky foraging latency under predation, we found no main effect of hydrocortisone or their interaction on behavior. In contrast, we found gender differences for almost all behavioral outcome measures, which might be explained by differences in endogenous testosterone levels. CONCLUSIONS: The investigated major stress mediators were not sufficient to imitate previously shown stress effects on approach-avoidance conflict behavior. We discuss potential reasons for our findings and implications for future research.

[Capable or incapable of giving consent? Assessing a patient's capacity to consent: Procedures and challenges in daily clinical practice]. / Einwilligungsfähig oder nicht? Zur Praxis der Prüfung von Einwilligungsfähigkeit im klinischen Alltag und deren Herausforderungen.

BACKGROUND/OBJECTIVES: The capacity of patients to give consent (CTC) is an indispensable prerequisite for informed consent to medical measures. When there is doubt about a patient's CTC, careful assessment is therefore required. Despite a broad theoretical discussion about the conception of CTC and possible procedures for its assessment, there is often a lack of orientation towards binding standardized procedural guidelines in everyday clinical practice. As a consequence, the results of CTC assessments are inconsistent, revealing both interdisciplinary and interindividual variability. In order to improve the quality of CTC assessment, more detailed knowledge about the procedures as well as the problems of CTC testing is needed. Therefore, the aim of this explorative telephone survey was to get an impression of the actual procedures that clinicians apply when in doubt about a patient's CTC. In particular, participants in the survey were asked about the weighting of individual CTC criteria and the difficulties with their application. METHODS: Based on structured questionnaires, telephone interviews with 26 physicians working in German hospitals in the fields of neurology, anaesthesiology, surgery, internal medicine, gynaecology, and reconstructive/aesthetic surgery were conducted. The answers were documented using the paper-and-pencil method, and answers to open questions were summarized with the help of a qualitative data analysis software and a thematic coding scheme. RESULTS: The majority of respondents reported that "sometimes to very often" they had doubts about their patients' CTC, with the examination being mostly conducted in an individual approach without formalized, standardized specifications. Regarding the question about the weighting of the seven assessment criteria proposed in the questionnaire, their importance was predominantly evaluated as being in the range of "partially important" to "very important". Difficulties in the clinical assessment were indicated in relation to the patients themselves, the relationship between physicians and patients, and the assessment situation. The perception of difficulties in the examination of CTC is apparently independent of the relevance attributed to the specific criterion for CTC. DISCUSSION AND CONCLUSION: Overall, the results show a high level of agreement with the relevance of the seven CTC criteria included in the survey, but at the same time revealed various verification difficulties. Some of the respondents would like to have more support in determining their patients' CTC. The survey results suggest that precise training and adequate time resources are paramount to this sensitive medical context.

The Deep Brain Stimulation Impairment Scale: A useful complement in assessment of well-being and functioning in DBS-patients - Results from a large multicentre survey in patients with Parkinson's disease.

BACKGROUND: Deep Brain Stimulation (DBS) has been proven to alleviate motor symptoms in Parkinson's Disease (PD). Regarding non-motor symptoms, however, inconsistencies have been reported, on whether DBS causes reductions in well-being and functioning. To assess motor and non-motor impairment in DBS-patients, the Deep Brain Stimulation Impairment Scale (DBS-IS) has been developed. Yet, the extent to which the DBS-IS detects impairment in DBS-patients and thus could serve as a useful tool that complements the PDQ-39 (gold standard) in assessment of well-being and functioning in PD-patients has not been shown. OBJECTIVES: By comparing DBS and non-DBS-patients we aimed to identify DBS-specific symptoms. We thereby aimed to show in how far the DBS-IS complements the PDQ-39 in assessing well-being and functioning in PD patients under DBS. METHODS: In a cross-sectional study, 186 DBS-patients were matched (for age, disease duration and sex) to 186 non-DBS-patients (N = 372) and the two groups were compared regarding well-being and functioning: Impairment was assessed via DBS-IS and overall Quality of Life (QoL) was assessed via PDQ-39. Additionally, we analyzed differences in impairment between age and disease duration clusters. RESULTS: DBS-patients showed significantly higher total impairment (DBS-IS) and significantly higher impairment on the subscales Postural Instability and Gait difficulties and speaking difficulties than non-DBS-patients. Impairment increased with age and disease duration and, overall, differences in impairment rose by age. Overall QoL (PDQ-39) was non-significantly lower in DBS-patients. CONCLUSION: Since there is evidence that the PDQ-39 misses some DBS-specific symptoms, the DBS-IS is recommended to complement the PDQ-39 when assessing DBS-patients.

Ethics in times of physical distancing: virtual training of ethical competences.

Ethics teaching in medicine, nursing and other health care professions does not only consist of knowledge transfer that can be easily implemented digitally. Rather, it focuses on specific ethical competences (such as arguing and articulating one's own moral position) and attitudes (such as empathic patient orientation, critical self-reflection, and ambiguity tolerance), for whose development interactive formats are superior. Competence-oriented ethical learning goals are important for the development of professionalism, but require time, space and personal exchange. Due to contact restrictions and the widespread cancellation of (face-to-face) courses in the wake of the corona pandemic, ethics teaching was forced to keep its distance in many places, which posed great challenges. This article is based on an exchange of experiences from members of the working group ethik learning of the Academy for Ethics in Medicine about ethics teaching in times of physical distancing. Recommendations will be given on how ethical competence can be successfully taught in the context of exclusively digital teaching. Starting with the question what is at risk of being lost in digital teaching, the potentials of digital formats are explored and illustrated with concrete practical examples. Beyond ethics teaching, the article also aims to provide ideas and suggestions for other specialist and cross-sectional areas where interactive formats are central.

Development and validation of the deep brain stimulation impairment scale (DBS-IS).

BACKGROUND: Bilateral deep brain stimulation of the subthalamic nucleus (STN-DBS) has considerable influence on motor and non-motor symptoms in Parkinson's disease (PD). While improvements in motor functioning can be easily assessed with general quality of life questionnaires, the measurement of specific STN-DBS-associated impairments often remains insufficient. Hence, we aimed to develop a questionnaire that measures STN-DBS-related impairments. METHODS: The development of the (STN-)DBS Impairment Scale (DBS-IS) consisted of four steps. First, 30 semi-structured interviews before, three and twelve months after STN-DBS-surgery were performed to create 76 items that relate to motor and non-motor functioning in STN-DBS PD patients. Second, pilot-testing led to a rewording of the questions for better understanding. Third, a first multicentre survey was performed to reduce items by applying principal component analysis (PCA). Fourth, a second multicentre survey was conducted to examine factor structure, reliability (internal consistency) and validity. RESULTS: After the first survey (N = 215), the PCA lead to a reduction of 54 items. After the second survey (N = 391), exploratory factor analysis determined six factors with 22 items: 1. Postural instability and gait difficulties (5 items), 2. Cognitive impairment (5 items), 3. Speaking problems (3 items), 4. Apathy (3 items), 5. Impulsivity (3 items), and 6. Difficulties related to the DBS device (3 items). High reliability was reported for all subscales (Cronbach's alpha 0.71-0.90). Similarly, construct validity was high (r > 0.50, p < 0.001). CONCLUSIONS: With this new questionnaire patients can be followed-up and STN-DBS-specific problems might be adequately measured. Also, comparisons between patients with and without STN-DBS might be possible.

Safe Administration of Botulinum Toxin Type A Injections During Pregnancy: A Report of Two Cases.

Local injections of botulinum toxin type A (BoNT/A) are safe and efficacious to treat focal and segmental dystonia. However, there are no adequate studies in humans regarding the safety of BoNT/A during pregnancy. Despite the fact that 25 case reports have been published on patients who received BoNT/A injections during a total of 31 pregnancies, in only 3 patients were the injections continued beyond the first trimester. We report on 2 females with cervical and segmental dystonia who received BoNT/A injections during pregnancy beyond the first trimester and gave birth to 2 healthy children.

Myopathy causing camptocormia in idiopathic Parkinson's disease: a multidisciplinary approach.

Extreme forward flexion of the spine, named camptocormia (CC), and head drop syndrome (HD) may be among the most disabling symptoms in Parkinson's disease (PD). This study aims to eludicate the etiology of PD-associated CC and HD via a multidisciplinary approach (clinical examination, electromyography, MRI, genetic analysis, muscle morphology) centering on the histology of the paraspinal muscles. We studied 17 patients with the clinical diagnosis of PD and CC or head drop syndrome and six controls. We performed muscle biopsies of paraspinal muscles and deep neck extensor muscles. Mean age at onset of postural abnormality was 66 years and mean latency between onset of parkinsonian symptoms to first signs of CC or head drop was 7 years. The electromyogram of paraspinal muscles was abnormal in 13-14 patients. Histopathology revealed chronic myopathic changes in 14 of 17 biopsies, consisting of abnormal variation in fiber size, increase in internal nuclei, and increase in connective tissue, myofibrillar disarray and similarities to protein surplus myopathies. Interestingly, heterozygous variants in the Parkin gene were found in 2 of 9 investigated patients. We conclude that CC and HD in PD are predominantly myopathic. Aberrant protein aggregation may link PD and CC.