Early Versus Delayed Bilateral Subthalamic Deep Brain Stimulation for Parkinson's Disease: A Decision Analysis
Identifieur interne : 000413 ( PascalFrancis/Corpus ); précédent : 000412; suivant : 000414Early Versus Delayed Bilateral Subthalamic Deep Brain Stimulation for Parkinson's Disease: A Decision Analysis
Auteurs : Alberto J. Espay ; Jennifer E. Vaughan ; Connie Marras ; Rob Fowler ; Mark H. EckmanSource :
- Movement disorders [ 0885-3185 ] ; 2010.
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- Pascal (Inist)
English descriptors
- KwdEn :
Abstract
The long-term benefits of subthalamic nucleus deep brain stimulation (STN DBS) applied earlier in the disease course, before significant disability accumulates, remain to be determined. We developed a Markov state transition decision analytic model to compare effectiveness in quality-adjusted life years (QALYs) of STN DBS applied to patients with PD at an "early" ("off time" 10-20%) versus "delayed" stage ("off time" >40%). A lifelong time horizon and societal perspective were assumed. Probabilities and rates were obtained from literature review; utilities were derived using the time trade-off technique and a computer-assisted utility assessment software tool applied to a cohort of 22 STN-DBS and 21 non-STN-DBS PD patients. Uncertainty was assessed through one- and two-way sensitivity analyses and probabilistic sensitivity analysis using second-order Monte Carlo simulations. Early STN DBS was preferred with a quality-adjusted life expectancy of 22.3 QALYs, a gain of 2.5 QALYs over those with delayed surgery (19.8 QALYs). Early STN DBS was preferred in 69% of 5,000 Monte Carlo simulations. Early surgery was robustly favored through most sensitivity analyses. Delayed STN DBS afforded greater QALYs when using utility estimates exclusively from non-STN-DBS patients and, for the entire group, if the rate of motor progression were to exceed 25% per year. Although decision modeling requires assumptions and simplifications, our exploratory analysis suggests that STN DBS performed in early PD may convey greater quality-adjusted life expectancy when compared to a delayed procedure. These findings support further evaluation of early STN DBS in a controlled clinical trial.
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Format Inist (serveur)
| NO : | PASCAL 10-0377365 INIST |
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| ET : | Early Versus Delayed Bilateral Subthalamic Deep Brain Stimulation for Parkinson's Disease: A Decision Analysis |
| AU : | ESPAY (Alberto J.); VAUGHAN (Jennifer E.); MARRAS (Connie); FOWLER (Rob); ECKMAN (Mark H.) |
| AF : | Department of Neurology, Movement Disorders Center, The Neuroscience Institute, University of Cincinnati/Cincinnati, Ohio/Etats-Unis (1 aut., 2 aut.); Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, University Health Network/Toronto, Ontario/Canada (3 aut.); Department of Medicine, University of Toronto/Toronto, Ontario/Canada (3 aut.); Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto/Toronto, Ontario/Canada (4 aut.); Department of Internal Medicine, Division of General Internal Medicine, Center for Clinical Effectiveness, University of Cincinnati Medical Center/Cincinnati, Ohio/Etats-Unis (5 aut.) |
| DT : | Publication en série; Niveau analytique |
| SO : | Movement disorders; ISSN 0885-3185; Etats-Unis; Da. 2010; Vol. 25; No. 10; Pp. 1456-1463; Bibl. 51 ref. |
| LA : | Anglais |
| EA : | The long-term benefits of subthalamic nucleus deep brain stimulation (STN DBS) applied earlier in the disease course, before significant disability accumulates, remain to be determined. We developed a Markov state transition decision analytic model to compare effectiveness in quality-adjusted life years (QALYs) of STN DBS applied to patients with PD at an "early" ("off time" 10-20%) versus "delayed" stage ("off time" >40%). A lifelong time horizon and societal perspective were assumed. Probabilities and rates were obtained from literature review; utilities were derived using the time trade-off technique and a computer-assisted utility assessment software tool applied to a cohort of 22 STN-DBS and 21 non-STN-DBS PD patients. Uncertainty was assessed through one- and two-way sensitivity analyses and probabilistic sensitivity analysis using second-order Monte Carlo simulations. Early STN DBS was preferred with a quality-adjusted life expectancy of 22.3 QALYs, a gain of 2.5 QALYs over those with delayed surgery (19.8 QALYs). Early STN DBS was preferred in 69% of 5,000 Monte Carlo simulations. Early surgery was robustly favored through most sensitivity analyses. Delayed STN DBS afforded greater QALYs when using utility estimates exclusively from non-STN-DBS patients and, for the entire group, if the rate of motor progression were to exceed 25% per year. Although decision modeling requires assumptions and simplifications, our exploratory analysis suggests that STN DBS performed in early PD may convey greater quality-adjusted life expectancy when compared to a delayed procedure. These findings support further evaluation of early STN DBS in a controlled clinical trial. |
| CC : | 002B17; 002B17G |
| FD : | Maladie de Parkinson; Pathologie du système nerveux; Etude comparative; Analyse décision; Simulation; Stimulation cérébrale profonde |
| FG : | Pathologie de l'encéphale; Syndrome extrapyramidal; Maladie dégénérative; Pathologie du système nerveux central |
| ED : | Parkinson disease; Nervous system diseases; Comparative study; Decision analysis; Simulation; Deep brain stimulation |
| EG : | Cerebral disorder; Extrapyramidal syndrome; Degenerative disease; Central nervous system disease |
| SD : | Parkinson enfermedad; Sistema nervioso patología; Estudio comparativo; Análisis decisión; Simulación |
| LO : | INIST-20953.354000194762830180 |
| ID : | 10-0377365 |
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Vaughan</name><affiliation><inist:fA14 i1="01"><s1>Department of Neurology, Movement Disorders Center, The Neuroscience Institute, University of Cincinnati</s1><s2>Cincinnati, Ohio</s2><s3>USA</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ></inist:fA14></affiliation></author><author><name sortKey="Marras, Connie" sort="Marras, Connie" uniqKey="Marras C" first="Connie" last="Marras">Connie Marras</name><affiliation><inist:fA14 i1="02"><s1>Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, University Health Network</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>3 aut.</sZ></inist:fA14></affiliation><affiliation><inist:fA14 i1="03"><s1>Department of Medicine, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>3 aut.</sZ></inist:fA14></affiliation></author><author><name sortKey="Fowler, Rob" sort="Fowler, Rob" uniqKey="Fowler R" first="Rob" last="Fowler">Rob Fowler</name><affiliation><inist:fA14 i1="04"><s1>Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>4 aut.</sZ></inist:fA14></affiliation></author><author><name sortKey="Eckman, Mark H" sort="Eckman, Mark H" uniqKey="Eckman M" first="Mark H." last="Eckman">Mark H. Eckman</name><affiliation><inist:fA14 i1="05"><s1>Department of Internal Medicine, Division of General Internal Medicine, Center for Clinical Effectiveness, University of Cincinnati Medical Center</s1><s2>Cincinnati, Ohio</s2><s3>USA</s3><sZ>5 aut.</sZ></inist:fA14></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">INIST</idno><idno type="inist">10-0377365</idno><date when="2010">2010</date><idno type="stanalyst">PASCAL 10-0377365 INIST</idno><idno type="RBID">Pascal:10-0377365</idno><idno type="wicri:Area/PascalFrancis/Corpus">000413</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a">Early Versus Delayed Bilateral Subthalamic Deep Brain Stimulation for Parkinson's Disease: A Decision Analysis</title><author><name sortKey="Espay, Alberto J" sort="Espay, Alberto J" uniqKey="Espay A" first="Alberto J." last="Espay">Alberto J. Espay</name><affiliation><inist:fA14 i1="01"><s1>Department of Neurology, Movement Disorders Center, The Neuroscience Institute, University of Cincinnati</s1><s2>Cincinnati, Ohio</s2><s3>USA</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ></inist:fA14></affiliation></author><author><name sortKey="Vaughan, Jennifer E" sort="Vaughan, Jennifer E" uniqKey="Vaughan J" first="Jennifer E." last="Vaughan">Jennifer E. Vaughan</name><affiliation><inist:fA14 i1="01"><s1>Department of Neurology, Movement Disorders Center, The Neuroscience Institute, University of Cincinnati</s1><s2>Cincinnati, Ohio</s2><s3>USA</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ></inist:fA14></affiliation></author><author><name sortKey="Marras, Connie" sort="Marras, Connie" uniqKey="Marras C" first="Connie" last="Marras">Connie Marras</name><affiliation><inist:fA14 i1="02"><s1>Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, University Health Network</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>3 aut.</sZ></inist:fA14></affiliation><affiliation><inist:fA14 i1="03"><s1>Department of Medicine, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>3 aut.</sZ></inist:fA14></affiliation></author><author><name sortKey="Fowler, Rob" sort="Fowler, Rob" uniqKey="Fowler R" first="Rob" last="Fowler">Rob Fowler</name><affiliation><inist:fA14 i1="04"><s1>Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>4 aut.</sZ></inist:fA14></affiliation></author><author><name sortKey="Eckman, Mark H" sort="Eckman, Mark H" uniqKey="Eckman M" first="Mark H." last="Eckman">Mark H. Eckman</name><affiliation><inist:fA14 i1="05"><s1>Department of Internal Medicine, Division of General Internal Medicine, Center for Clinical Effectiveness, University of Cincinnati Medical Center</s1><s2>Cincinnati, Ohio</s2><s3>USA</s3><sZ>5 aut.</sZ></inist:fA14></affiliation></author></analytic><series><title level="j" type="main">Movement disorders</title><title level="j" type="abbreviated">Mov. disord.</title><idno type="ISSN">0885-3185</idno><imprint><date when="2010">2010</date></imprint></series></biblStruct></sourceDesc><seriesStmt><title level="j" type="main">Movement disorders</title><title level="j" type="abbreviated">Mov. disord.</title><idno type="ISSN">0885-3185</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Comparative study</term><term>Decision analysis</term><term>Deep brain stimulation</term><term>Nervous system diseases</term><term>Parkinson disease</term><term>Simulation</term></keywords><keywords scheme="Pascal" xml:lang="fr"><term>Maladie de Parkinson</term><term>Pathologie du système nerveux</term><term>Etude comparative</term><term>Analyse décision</term><term>Simulation</term><term>Stimulation cérébrale profonde</term></keywords></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">The long-term benefits of subthalamic nucleus deep brain stimulation (STN DBS) applied earlier in the disease course, before significant disability accumulates, remain to be determined. We developed a Markov state transition decision analytic model to compare effectiveness in quality-adjusted life years (QALYs) of STN DBS applied to patients with PD at an "early" ("off time" 10-20%) versus "delayed" stage ("off time" >40%). A lifelong time horizon and societal perspective were assumed. Probabilities and rates were obtained from literature review; utilities were derived using the time trade-off technique and a computer-assisted utility assessment software tool applied to a cohort of 22 STN-DBS and 21 non-STN-DBS PD patients. Uncertainty was assessed through one- and two-way sensitivity analyses and probabilistic sensitivity analysis using second-order Monte Carlo simulations. Early STN DBS was preferred with a quality-adjusted life expectancy of 22.3 QALYs, a gain of 2.5 QALYs over those with delayed surgery (19.8 QALYs). Early STN DBS was preferred in 69% of 5,000 Monte Carlo simulations. Early surgery was robustly favored through most sensitivity analyses. Delayed STN DBS afforded greater QALYs when using utility estimates exclusively from non-STN-DBS patients and, for the entire group, if the rate of motor progression were to exceed 25% per year. Although decision modeling requires assumptions and simplifications, our exploratory analysis suggests that STN DBS performed in early PD may convey greater quality-adjusted life expectancy when compared to a delayed procedure. These findings support further evaluation of early STN DBS in a controlled clinical trial.</div></front></TEI><inist><standard h6="B"><pA><fA01 i1="01" i2="1"><s0>0885-3185</s0></fA01><fA03 i2="1"><s0>Mov. disord.</s0></fA03><fA05><s2>25</s2></fA05><fA06><s2>10</s2></fA06><fA08 i1="01" i2="1" l="ENG"><s1>Early Versus Delayed Bilateral Subthalamic Deep Brain Stimulation for Parkinson's Disease: A Decision Analysis</s1></fA08><fA11 i1="01" i2="1"><s1>ESPAY (Alberto J.)</s1></fA11><fA11 i1="02" i2="1"><s1>VAUGHAN (Jennifer E.)</s1></fA11><fA11 i1="03" i2="1"><s1>MARRAS (Connie)</s1></fA11><fA11 i1="04" i2="1"><s1>FOWLER (Rob)</s1></fA11><fA11 i1="05" i2="1"><s1>ECKMAN (Mark H.)</s1></fA11><fA14 i1="01"><s1>Department of Neurology, Movement Disorders Center, The Neuroscience Institute, University of Cincinnati</s1><s2>Cincinnati, Ohio</s2><s3>USA</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ></fA14><fA14 i1="02"><s1>Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, University Health Network</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>3 aut.</sZ></fA14><fA14 i1="03"><s1>Department of Medicine, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>3 aut.</sZ></fA14><fA14 i1="04"><s1>Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>4 aut.</sZ></fA14><fA14 i1="05"><s1>Department of Internal Medicine, Division of General Internal Medicine, Center for Clinical Effectiveness, University of Cincinnati Medical Center</s1><s2>Cincinnati, Ohio</s2><s3>USA</s3><sZ>5 aut.</sZ></fA14><fA20><s1>1456-1463</s1></fA20><fA21><s1>2010</s1></fA21><fA23 i1="01"><s0>ENG</s0></fA23><fA43 i1="01"><s1>INIST</s1><s2>20953</s2><s5>354000194762830180</s5></fA43><fA44><s0>0000</s0><s1>© 2010 INIST-CNRS. All rights reserved.</s1></fA44><fA45><s0>51 ref.</s0></fA45><fA47 i1="01" i2="1"><s0>10-0377365</s0></fA47><fA60><s1>P</s1></fA60><fA61><s0>A</s0></fA61><fA64 i1="01" i2="1"><s0>Movement disorders</s0></fA64><fA66 i1="01"><s0>USA</s0></fA66><fC01 i1="01" l="ENG"><s0>The long-term benefits of subthalamic nucleus deep brain stimulation (STN DBS) applied earlier in the disease course, before significant disability accumulates, remain to be determined. We developed a Markov state transition decision analytic model to compare effectiveness in quality-adjusted life years (QALYs) of STN DBS applied to patients with PD at an "early" ("off time" 10-20%) versus "delayed" stage ("off time" >40%). A lifelong time horizon and societal perspective were assumed. Probabilities and rates were obtained from literature review; utilities were derived using the time trade-off technique and a computer-assisted utility assessment software tool applied to a cohort of 22 STN-DBS and 21 non-STN-DBS PD patients. Uncertainty was assessed through one- and two-way sensitivity analyses and probabilistic sensitivity analysis using second-order Monte Carlo simulations. Early STN DBS was preferred with a quality-adjusted life expectancy of 22.3 QALYs, a gain of 2.5 QALYs over those with delayed surgery (19.8 QALYs). Early STN DBS was preferred in 69% of 5,000 Monte Carlo simulations. Early surgery was robustly favored through most sensitivity analyses. Delayed STN DBS afforded greater QALYs when using utility estimates exclusively from non-STN-DBS patients and, for the entire group, if the rate of motor progression were to exceed 25% per year. Although decision modeling requires assumptions and simplifications, our exploratory analysis suggests that STN DBS performed in early PD may convey greater quality-adjusted life expectancy when compared to a delayed procedure. These findings support further evaluation of early STN DBS in a controlled clinical trial.</s0></fC01><fC02 i1="01" i2="X"><s0>002B17</s0></fC02><fC02 i1="02" i2="X"><s0>002B17G</s0></fC02><fC03 i1="01" i2="X" l="FRE"><s0>Maladie de Parkinson</s0><s2>NM</s2><s5>01</s5></fC03><fC03 i1="01" i2="X" l="ENG"><s0>Parkinson disease</s0><s2>NM</s2><s5>01</s5></fC03><fC03 i1="01" i2="X" l="SPA"><s0>Parkinson enfermedad</s0><s2>NM</s2><s5>01</s5></fC03><fC03 i1="02" i2="X" l="FRE"><s0>Pathologie du système nerveux</s0><s5>02</s5></fC03><fC03 i1="02" i2="X" l="ENG"><s0>Nervous system diseases</s0><s5>02</s5></fC03><fC03 i1="02" i2="X" l="SPA"><s0>Sistema nervioso patología</s0><s5>02</s5></fC03><fC03 i1="03" i2="X" l="FRE"><s0>Etude comparative</s0><s5>09</s5></fC03><fC03 i1="03" i2="X" l="ENG"><s0>Comparative study</s0><s5>09</s5></fC03><fC03 i1="03" i2="X" l="SPA"><s0>Estudio comparativo</s0><s5>09</s5></fC03><fC03 i1="04" i2="X" l="FRE"><s0>Analyse décision</s0><s5>10</s5></fC03><fC03 i1="04" i2="X" l="ENG"><s0>Decision analysis</s0><s5>10</s5></fC03><fC03 i1="04" i2="X" l="SPA"><s0>Análisis decisión</s0><s5>10</s5></fC03><fC03 i1="05" i2="X" l="FRE"><s0>Simulation</s0><s5>11</s5></fC03><fC03 i1="05" i2="X" l="ENG"><s0>Simulation</s0><s5>11</s5></fC03><fC03 i1="05" i2="X" l="SPA"><s0>Simulación</s0><s5>11</s5></fC03><fC03 i1="06" i2="X" l="FRE"><s0>Stimulation cérébrale profonde</s0><s4>CD</s4><s5>96</s5></fC03><fC03 i1="06" i2="X" l="ENG"><s0>Deep brain stimulation</s0><s4>CD</s4><s5>96</s5></fC03><fC07 i1="01" i2="X" l="FRE"><s0>Pathologie de l'encéphale</s0><s5>37</s5></fC07><fC07 i1="01" i2="X" l="ENG"><s0>Cerebral disorder</s0><s5>37</s5></fC07><fC07 i1="01" i2="X" l="SPA"><s0>Encéfalo patología</s0><s5>37</s5></fC07><fC07 i1="02" i2="X" l="FRE"><s0>Syndrome extrapyramidal</s0><s5>38</s5></fC07><fC07 i1="02" i2="X" l="ENG"><s0>Extrapyramidal syndrome</s0><s5>38</s5></fC07><fC07 i1="02" i2="X" l="SPA"><s0>Extrapiramidal síndrome</s0><s5>38</s5></fC07><fC07 i1="03" i2="X" l="FRE"><s0>Maladie dégénérative</s0><s5>39</s5></fC07><fC07 i1="03" i2="X" l="ENG"><s0>Degenerative disease</s0><s5>39</s5></fC07><fC07 i1="03" i2="X" l="SPA"><s0>Enfermedad degenerativa</s0><s5>39</s5></fC07><fC07 i1="04" i2="X" l="FRE"><s0>Pathologie du système nerveux central</s0><s5>40</s5></fC07><fC07 i1="04" i2="X" l="ENG"><s0>Central nervous system disease</s0><s5>40</s5></fC07><fC07 i1="04" i2="X" l="SPA"><s0>Sistema nervosio central patología</s0><s5>40</s5></fC07><fN21><s1>242</s1></fN21><fN44 i1="01"><s1>OTO</s1></fN44><fN82><s1>OTO</s1></fN82></pA></standard><server><NO>PASCAL 10-0377365 INIST</NO><ET>Early Versus Delayed Bilateral Subthalamic Deep Brain Stimulation for Parkinson's Disease: A Decision Analysis</ET><AU>ESPAY (Alberto J.); VAUGHAN (Jennifer E.); MARRAS (Connie); FOWLER (Rob); ECKMAN (Mark H.)</AU><AF>Department of Neurology, Movement Disorders Center, The Neuroscience Institute, University of Cincinnati/Cincinnati, Ohio/Etats-Unis (1 aut., 2 aut.); Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, University Health Network/Toronto, Ontario/Canada (3 aut.); Department of Medicine, University of Toronto/Toronto, Ontario/Canada (3 aut.); Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto/Toronto, Ontario/Canada (4 aut.); Department of Internal Medicine, Division of General Internal Medicine, Center for Clinical Effectiveness, University of Cincinnati Medical Center/Cincinnati, Ohio/Etats-Unis (5 aut.)</AF><DT>Publication en série; Niveau analytique</DT><SO>Movement disorders; ISSN 0885-3185; Etats-Unis; Da. 2010; Vol. 25; No. 10; Pp. 1456-1463; Bibl. 51 ref.</SO><LA>Anglais</LA><EA>The long-term benefits of subthalamic nucleus deep brain stimulation (STN DBS) applied earlier in the disease course, before significant disability accumulates, remain to be determined. We developed a Markov state transition decision analytic model to compare effectiveness in quality-adjusted life years (QALYs) of STN DBS applied to patients with PD at an "early" ("off time" 10-20%) versus "delayed" stage ("off time" >40%). A lifelong time horizon and societal perspective were assumed. Probabilities and rates were obtained from literature review; utilities were derived using the time trade-off technique and a computer-assisted utility assessment software tool applied to a cohort of 22 STN-DBS and 21 non-STN-DBS PD patients. Uncertainty was assessed through one- and two-way sensitivity analyses and probabilistic sensitivity analysis using second-order Monte Carlo simulations. Early STN DBS was preferred with a quality-adjusted life expectancy of 22.3 QALYs, a gain of 2.5 QALYs over those with delayed surgery (19.8 QALYs). Early STN DBS was preferred in 69% of 5,000 Monte Carlo simulations. Early surgery was robustly favored through most sensitivity analyses. Delayed STN DBS afforded greater QALYs when using utility estimates exclusively from non-STN-DBS patients and, for the entire group, if the rate of motor progression were to exceed 25% per year. Although decision modeling requires assumptions and simplifications, our exploratory analysis suggests that STN DBS performed in early PD may convey greater quality-adjusted life expectancy when compared to a delayed procedure. These findings support further evaluation of early STN DBS in a controlled clinical trial.</EA><CC>002B17; 002B17G</CC><FD>Maladie de Parkinson; Pathologie du système nerveux; Etude comparative; Analyse décision; Simulation; Stimulation cérébrale profonde</FD><FG>Pathologie de l'encéphale; Syndrome extrapyramidal; Maladie dégénérative; Pathologie du système nerveux central</FG><ED>Parkinson disease; Nervous system diseases; Comparative study; Decision analysis; Simulation; Deep brain stimulation</ED><EG>Cerebral disorder; Extrapyramidal syndrome; Degenerative disease; Central nervous system disease</EG><SD>Parkinson enfermedad; Sistema nervioso patología; Estudio comparativo; Análisis decisión; Simulación</SD><LO>INIST-20953.354000194762830180</LO><ID>10-0377365</ID></server></inist></record>Pour manipuler ce document sous Unix (Dilib)
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