Subthalamic nucleus deep brain stimulation: Summary and meta‐analysis of outcomes
Identifieur interne : 000564 ( Main/Corpus ); précédent : 000563; suivant : 000565Subthalamic nucleus deep brain stimulation: Summary and meta‐analysis of outcomes
Auteurs : Galit Kleiner-Fisman ; Jan Herzog ; David N. Fisman ; Filippo Tamma ; Kelly E. Lyons ; Rajesh Pahwa ; Anthony E. Lang ; Günther DeuschlSource :
- Movement Disorders [ 0885-3185 ] ; 2006-06.
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Abstract
Subthalamic nucleus (STN) deep brain stimulation (DBS) is currently the most common therapeutic surgical procedure for patients with Parkinson's disease (PD) who have failed medical management. However, a recent summary of clinical evidence on the effectiveness of STN DBS is lacking. We report the results of such a systematic review and meta‐analysis. A comprehensive review of the literature using Medline and Ovid databases from 1993 until 2004 was conducted. Estimates of change in absolute Unified Parkinson's Disease Rating Scale (UPDRS) scores after surgery were generated using random‐effects models. Sources of heterogeneity were explored with meta‐regression models, and the possibility of publication bias was evaluated. Patient demographics, reduction in medication requirements, change in dyskinesia, daily offs, quality of life, and a ratio of postoperative improvement from stimulation compared to preoperative improvement by medication from each study were tabulated and average scores were calculated. Adverse effects from each study were summarized. Thirty‐seven cohorts were included in the review. Twenty‐two studies with estimates of standard errors were included in the meta‐analysis. The estimated decreases in absolute UPDRS II (activities of daily living) and III (motor) scores after surgery in the stimulation ON/medication off state compared to preoperative medication off state were 13.35 (95% CI: 10.85–15.85; 50%) and 27.55 (95% CI: 24.23–30.87; 52%), respectively. Average reduction in L‐dopa equivalents following surgery was 55.9% (95% CI: 50%–61.8%). Average reduction in dyskinesia following surgery was 69.1% (95% CI: 62.0%–76.2%). Average reduction in daily off periods was 68.2% (95% CI: 57.6%–78.9%). Average improvement in quality of life using PDQ‐39 was 34.5% ± 15.3%. Univariable regression showed improvements in UPDRS III scores were significantly greater in studies with higher baseline UPDRS III off scores, increasing disease duration prior to surgery, earlier year of publication, and higher baseline L‐dopa responsiveness. Average baseline UPDRS III off scores were significantly lower (i.e., suggesting milder disease) in later than in earlier studies. In multivariable regression, L‐dopa responsiveness, higher baseline motor scores, and disease duration were independent predictors of greater change in motor score. No evidence of publication bias in the available literature was found. The most common serious adverse event related to surgery was intracranial hemorrhage in 3.9% of patients. Psychiatric sequelae were common. Synthesis of the available literature indicates that STN DBS improves motor activity and activities of daily living in advanced PD. Differences between available studies likely reflect differences in patient populations and follow‐up periods. These data provide an estimate of the magnitude of the treatment effects and emphasize the need for controlled and randomized studies. © 2006 Movement Disorder Society
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DOI: 10.1002/mds.20962
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<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Subthalamic nucleus deep brain stimulation: Summary and meta‐analysis of outcomes</title><author><name sortKey="Kleiner Isman, Galit" sort="Kleiner Isman, Galit" uniqKey="Kleiner Isman G" first="Galit" last="Kleiner-Fisman">Galit Kleiner-Fisman</name><affiliation><mods:affiliation>Parkinson's Disease Research Education and Clinical Center, Philadelphia VA Hospital, Philadelphia, Pennsylvania, USA</mods:affiliation></affiliation></author><author><name sortKey="Herzog, Jan" sort="Herzog, Jan" uniqKey="Herzog J" first="Jan" last="Herzog">Jan Herzog</name><affiliation><mods:affiliation>Department of Neurology, Christian‐Albrechts‐Universität Kiel, Kiel, Germany</mods:affiliation></affiliation></author><author><name sortKey="Fisman, David N" sort="Fisman, David N" uniqKey="Fisman D" first="David N." last="Fisman">David N. 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Lyons</name><affiliation><mods:affiliation>Parkinson Disease and Movement Disorder Center, University of Kansas Medical Center, Kansas City, Kansas, USA</mods:affiliation></affiliation></author><author><name sortKey="Pahwa, Rajesh" sort="Pahwa, Rajesh" uniqKey="Pahwa R" first="Rajesh" last="Pahwa">Rajesh Pahwa</name><affiliation><mods:affiliation>Parkinson Disease and Movement Disorder Center, University of Kansas Medical Center, Kansas City, Kansas, USA</mods:affiliation></affiliation></author><author><name sortKey="Lang, Anthony E" sort="Lang, Anthony E" uniqKey="Lang A" first="Anthony E." last="Lang">Anthony E. Lang</name><affiliation><mods:affiliation>Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital, Toronto, Canada</mods:affiliation></affiliation></author><author><name sortKey="Deuschl, Gunther" sort="Deuschl, Gunther" uniqKey="Deuschl G" first="Günther" last="Deuschl">Günther Deuschl</name><affiliation><mods:affiliation>Department of Neurology, Christian‐Albrechts‐Universität Kiel, Kiel, Germany</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Movement Disorders</title><title level="j" type="sub">Official Journal of the Movement Disorder Society</title><title level="j" type="abbrev">Mov. Disord.</title><idno type="ISSN">0885-3185</idno><idno type="eISSN">1531-8257</idno><imprint><publisher>Wiley Subscription Services, Inc., A Wiley Company</publisher><pubPlace>Hoboken</pubPlace><date type="published" when="2006-06">2006-06</date><biblScope unit="volume">21</biblScope><biblScope unit="issue">S14</biblScope><biblScope unit="supplement">14</biblScope><biblScope unit="page" from="S290">S290</biblScope><biblScope unit="page" to="S304">S304</biblScope></imprint><idno type="ISSN">0885-3185</idno></series><idno type="istex">B70E5BDEFB40543E258EF53A6014665B417ADAE8</idno><idno type="DOI">10.1002/mds.20962</idno><idno type="ArticleID">MDS20962</idno></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0885-3185</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Parkinson's disease</term><term>deep brain stimulation</term><term>meta‐analysis</term><term>outcome</term><term>subthalamic nucleus</term><term>systematic review</term></keywords></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Subthalamic nucleus (STN) deep brain stimulation (DBS) is currently the most common therapeutic surgical procedure for patients with Parkinson's disease (PD) who have failed medical management. However, a recent summary of clinical evidence on the effectiveness of STN DBS is lacking. We report the results of such a systematic review and meta‐analysis. A comprehensive review of the literature using Medline and Ovid databases from 1993 until 2004 was conducted. Estimates of change in absolute Unified Parkinson's Disease Rating Scale (UPDRS) scores after surgery were generated using random‐effects models. Sources of heterogeneity were explored with meta‐regression models, and the possibility of publication bias was evaluated. Patient demographics, reduction in medication requirements, change in dyskinesia, daily offs, quality of life, and a ratio of postoperative improvement from stimulation compared to preoperative improvement by medication from each study were tabulated and average scores were calculated. Adverse effects from each study were summarized. Thirty‐seven cohorts were included in the review. Twenty‐two studies with estimates of standard errors were included in the meta‐analysis. The estimated decreases in absolute UPDRS II (activities of daily living) and III (motor) scores after surgery in the stimulation ON/medication off state compared to preoperative medication off state were 13.35 (95% CI: 10.85–15.85; 50%) and 27.55 (95% CI: 24.23–30.87; 52%), respectively. Average reduction in L‐dopa equivalents following surgery was 55.9% (95% CI: 50%–61.8%). Average reduction in dyskinesia following surgery was 69.1% (95% CI: 62.0%–76.2%). Average reduction in daily off periods was 68.2% (95% CI: 57.6%–78.9%). Average improvement in quality of life using PDQ‐39 was 34.5% ± 15.3%. Univariable regression showed improvements in UPDRS III scores were significantly greater in studies with higher baseline UPDRS III off scores, increasing disease duration prior to surgery, earlier year of publication, and higher baseline L‐dopa responsiveness. Average baseline UPDRS III off scores were significantly lower (i.e., suggesting milder disease) in later than in earlier studies. In multivariable regression, L‐dopa responsiveness, higher baseline motor scores, and disease duration were independent predictors of greater change in motor score. No evidence of publication bias in the available literature was found. The most common serious adverse event related to surgery was intracranial hemorrhage in 3.9% of patients. Psychiatric sequelae were common. Synthesis of the available literature indicates that STN DBS improves motor activity and activities of daily living in advanced PD. Differences between available studies likely reflect differences in patient populations and follow‐up periods. These data provide an estimate of the magnitude of the treatment effects and emphasize the need for controlled and randomized studies. © 2006 Movement Disorder Society</div></front></TEI><istex><corpusName>wiley</corpusName><author><json:item><name>Galit Kleiner‐Fisman MD</name><affiliations><json:string>Parkinson's Disease Research Education and Clinical Center, Philadelphia VA Hospital, Philadelphia, Pennsylvania, USA</json:string></affiliations></json:item><json:item><name>Jan Herzog MD</name><affiliations><json:string>Department of Neurology, Christian‐Albrechts‐Universität Kiel, Kiel, Germany</json:string></affiliations></json:item><json:item><name>David N. Fisman MD, MPH</name><affiliations><json:string>Center for Health and Well‐Being, Princeton University, Princeton, New Jersey, USA</json:string></affiliations></json:item><json:item><name>Filippo Tamma MD</name><affiliations><json:string>Clinica Neurologica, Centro Parkinson, Ospedale San Paolo–Milano, Italy</json:string></affiliations></json:item><json:item><name>Kelly E. Lyons PhD</name><affiliations><json:string>Parkinson Disease and Movement Disorder Center, University of Kansas Medical Center, Kansas City, Kansas, USA</json:string></affiliations></json:item><json:item><name>Rajesh Pahwa MD</name><affiliations><json:string>Parkinson Disease and Movement Disorder Center, University of Kansas Medical Center, Kansas City, Kansas, USA</json:string></affiliations></json:item><json:item><name>Anthony E. Lang MD</name><affiliations><json:string>Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital, Toronto, Canada</json:string></affiliations></json:item><json:item><name>Günther Deuschl MD</name><affiliations><json:string>Department of Neurology, Christian‐Albrechts‐Universität Kiel, Kiel, Germany</json:string></affiliations></json:item></author><subject><json:item><lang><json:string>eng</json:string></lang><value>subthalamic nucleus</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>deep brain stimulation</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>Parkinson's disease</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>meta‐analysis</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>outcome</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>systematic review</value></json:item></subject><articleId><json:string>MDS20962</json:string></articleId><language><json:string>eng</json:string></language><abstract>Subthalamic nucleus (STN) deep brain stimulation (DBS) is currently the most common therapeutic surgical procedure for patients with Parkinson's disease (PD) who have failed medical management. However, a recent summary of clinical evidence on the effectiveness of STN DBS is lacking. We report the results of such a systematic review and meta‐analysis. A comprehensive review of the literature using Medline and Ovid databases from 1993 until 2004 was conducted. Estimates of change in absolute Unified Parkinson's Disease Rating Scale (UPDRS) scores after surgery were generated using random‐effects models. Sources of heterogeneity were explored with meta‐regression models, and the possibility of publication bias was evaluated. Patient demographics, reduction in medication requirements, change in dyskinesia, daily offs, quality of life, and a ratio of postoperative improvement from stimulation compared to preoperative improvement by medication from each study were tabulated and average scores were calculated. Adverse effects from each study were summarized. Thirty‐seven cohorts were included in the review. Twenty‐two studies with estimates of standard errors were included in the meta‐analysis. The estimated decreases in absolute UPDRS II (activities of daily living) and III (motor) scores after surgery in the stimulation ON/medication off state compared to preoperative medication off state were 13.35 (95% CI: 10.85–15.85; 50%) and 27.55 (95% CI: 24.23–30.87; 52%), respectively. Average reduction in L‐dopa equivalents following surgery was 55.9% (95% CI: 50%–61.8%). Average reduction in dyskinesia following surgery was 69.1% (95% CI: 62.0%–76.2%). Average reduction in daily off periods was 68.2% (95% CI: 57.6%–78.9%). Average improvement in quality of life using PDQ‐39 was 34.5% ± 15.3%. Univariable regression showed improvements in UPDRS III scores were significantly greater in studies with higher baseline UPDRS III off scores, increasing disease duration prior to surgery, earlier year of publication, and higher baseline L‐dopa responsiveness. Average baseline UPDRS III off scores were significantly lower (i.e., suggesting milder disease) in later than in earlier studies. In multivariable regression, L‐dopa responsiveness, higher baseline motor scores, and disease duration were independent predictors of greater change in motor score. No evidence of publication bias in the available literature was found. The most common serious adverse event related to surgery was intracranial hemorrhage in 3.9% of patients. Psychiatric sequelae were common. Synthesis of the available literature indicates that STN DBS improves motor activity and activities of daily living in advanced PD. Differences between available studies likely reflect differences in patient populations and follow‐up periods. 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Disord.</title><idno type="pISSN">0885-3185</idno><idno type="eISSN">1531-8257</idno><idno type="DOI">10.1002/(ISSN)1531-8257</idno><imprint><publisher>Wiley Subscription Services, Inc., A Wiley Company</publisher><pubPlace>Hoboken</pubPlace><date type="published" when="2006-06"></date><biblScope unit="volume">21</biblScope><biblScope unit="issue">S14</biblScope><biblScope unit="supplement">14</biblScope><biblScope unit="page" from="S290">S290</biblScope><biblScope unit="page" to="S304">S304</biblScope></imprint></monogr><idno type="istex">B70E5BDEFB40543E258EF53A6014665B417ADAE8</idno><idno type="DOI">10.1002/mds.20962</idno><idno type="ArticleID">MDS20962</idno></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2006</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>Subthalamic nucleus (STN) deep brain stimulation (DBS) is currently the most common therapeutic surgical procedure for patients with Parkinson's disease (PD) who have failed medical management. However, a recent summary of clinical evidence on the effectiveness of STN DBS is lacking. We report the results of such a systematic review and meta‐analysis. A comprehensive review of the literature using Medline and Ovid databases from 1993 until 2004 was conducted. Estimates of change in absolute Unified Parkinson's Disease Rating Scale (UPDRS) scores after surgery were generated using random‐effects models. Sources of heterogeneity were explored with meta‐regression models, and the possibility of publication bias was evaluated. Patient demographics, reduction in medication requirements, change in dyskinesia, daily offs, quality of life, and a ratio of postoperative improvement from stimulation compared to preoperative improvement by medication from each study were tabulated and average scores were calculated. Adverse effects from each study were summarized. Thirty‐seven cohorts were included in the review. Twenty‐two studies with estimates of standard errors were included in the meta‐analysis. The estimated decreases in absolute UPDRS II (activities of daily living) and III (motor) scores after surgery in the stimulation ON/medication off state compared to preoperative medication off state were 13.35 (95% CI: 10.85–15.85; 50%) and 27.55 (95% CI: 24.23–30.87; 52%), respectively. Average reduction in L‐dopa equivalents following surgery was 55.9% (95% CI: 50%–61.8%). Average reduction in dyskinesia following surgery was 69.1% (95% CI: 62.0%–76.2%). Average reduction in daily off periods was 68.2% (95% CI: 57.6%–78.9%). Average improvement in quality of life using PDQ‐39 was 34.5% ± 15.3%. Univariable regression showed improvements in UPDRS III scores were significantly greater in studies with higher baseline UPDRS III off scores, increasing disease duration prior to surgery, earlier year of publication, and higher baseline L‐dopa responsiveness. Average baseline UPDRS III off scores were significantly lower (i.e., suggesting milder disease) in later than in earlier studies. In multivariable regression, L‐dopa responsiveness, higher baseline motor scores, and disease duration were independent predictors of greater change in motor score. No evidence of publication bias in the available literature was found. The most common serious adverse event related to surgery was intracranial hemorrhage in 3.9% of patients. Psychiatric sequelae were common. Synthesis of the available literature indicates that STN DBS improves motor activity and activities of daily living in advanced PD. Differences between available studies likely reflect differences in patient populations and follow‐up periods. These data provide an estimate of the magnitude of the treatment effects and emphasize the need for controlled and randomized studies. © 2006 Movement Disorder Society</p></abstract><textClass xml:lang="en"><keywords scheme="keyword"><list><head>Keywords</head><item><term>subthalamic nucleus</term></item><item><term>deep brain stimulation</term></item><item><term>Parkinson's disease</term></item><item><term>meta‐analysis</term></item><item><term>outcome</term></item><item><term>systematic review</term></item></list></keywords></textClass><textClass><keywords scheme="Journal Subject"><list><head>article category</head><item><term>VIII</term></item></list></keywords></textClass></profileDesc><revisionDesc><change when="2006-06">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><original>false</original><mimetype>text/plain</mimetype><extension>txt</extension><uri>https://api.istex.fr/document/B70E5BDEFB40543E258EF53A6014665B417ADAE8/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="Wiley, elements deleted: body"><istex:xmlDeclaration>version="1.0" encoding="UTF-8" standalone="yes"</istex:xmlDeclaration><istex:document><component version="2.0" type="serialArticle" xml:lang="en"><header><publicationMeta level="product"><publisherInfo><publisherName>Wiley Subscription Services, Inc., A Wiley Company</publisherName><publisherLoc>Hoboken</publisherLoc></publisherInfo><doi registered="yes">10.1002/(ISSN)1531-8257</doi><issn type="print">0885-3185</issn><issn type="electronic">1531-8257</issn><idGroup><id type="product" value="MDS"></id></idGroup><titleGroup><title type="main" xml:lang="en" sort="MOVEMENT DISORDERS">Movement Disorders</title><title type="subtitle">Official Journal of the Movement Disorder Society</title><title type="short">Mov. Disord.</title></titleGroup></publicationMeta><publicationMeta level="part" position="65"><doi origin="wiley" registered="yes">10.1002/mds.v21:14+</doi><titleGroup><title type="supplementTitle">Deep Brain Stimulation for Parkinson's Disease</title></titleGroup><numberingGroup><numbering type="journalVolume" number="21">21</numbering><numbering type="journalIssue">S14</numbering><numbering type="supplement" number="14">14</numbering></numberingGroup><creators><creator xml:id="sped1" creatorRole="sponsoringEditor"><personName><givenNames>Anthony E.</givenNames><familyName>Lang</familyName></personName></creator><creator xml:id="sped2" creatorRole="sponsoringEditor"><personName><givenNames>Günther</givenNames><familyName>Deuschl</familyName></personName></creator><creator xml:id="sped3" creatorRole="sponsoringEditor"><personName><givenNames>Ali R.</givenNames><familyName>Rezai</familyName></personName></creator></creators><coverDate startDate="2006-06">June 2006</coverDate></publicationMeta><publicationMeta level="unit" type="article" position="100" status="forIssue"><doi origin="wiley" registered="yes">10.1002/mds.20962</doi><idGroup><id type="unit" value="MDS20962"></id></idGroup><countGroup><count type="pageTotal" number="15"></count></countGroup><titleGroup><title type="articleCategory">VIII</title><title type="tocHeading1">VIII</title></titleGroup><copyright ownership="thirdParty">Copyright © 2006 Movement Disorder Society</copyright><eventGroup><event type="firstOnline" date="2006-06-29"></event><event type="publishedOnlineFinalForm" date="2006-06-29"></event><event type="xmlConverted" agent="Converter:JWSART34_TO_WML3G version:2.3.2 mode:FullText source:FullText result:FullText" date="2010-03-09"></event><event type="xmlConverted" agent="Converter:WILEY_ML3G_TO_WILEY_ML3GV2 version:3.8.8" date="2014-02-02"></event><event type="xmlConverted" agent="Converter:WML3G_To_WML3G version:4.1.7 mode:FullText,remove_FC" date="2014-11-01"></event></eventGroup><numberingGroup><numbering type="pageFirst">S290</numbering><numbering type="pageLast">S304</numbering></numberingGroup><correspondenceTo>Department of Neurology, University of Pennsylvania, Parkinson's Disease Research Education and Clinical Center, Philadelphia VA Hospital, 3900 Woodland Avenue, MS #127, Philadelphia, PA 19104</correspondenceTo><linkGroup><link type="toTypesetVersion" href="file:MDS.MDS20962.pdf"></link></linkGroup></publicationMeta><contentMeta><countGroup><count type="figureTotal" number="11"></count><count type="tableTotal" number="4"></count><count type="referenceTotal" number="76"></count><count type="wordTotal" number="9072"></count></countGroup><titleGroup><title type="main" xml:lang="en">Subthalamic nucleus deep brain stimulation: Summary and meta‐analysis of outcomes</title><title type="short" xml:lang="en">Summary and Meta‐Analysis of Outcomes</title></titleGroup><creators><creator xml:id="au1" creatorRole="author" affiliationRef="#af1" corresponding="yes"><personName><givenNames>Galit</givenNames><familyName>Kleiner‐Fisman</familyName><degrees>MD</degrees></personName><contactDetails><email normalForm="galit.kleiner-fisman@med.va.gov">galit.kleiner‐fisman@med.va.gov</email></contactDetails></creator><creator xml:id="au2" creatorRole="author" affiliationRef="#af2"><personName><givenNames>Jan</givenNames><familyName>Herzog</familyName><degrees>MD</degrees></personName></creator><creator xml:id="au3" creatorRole="author" affiliationRef="#af3"><personName><givenNames>David N.</givenNames><familyName>Fisman</familyName><degrees>MD, MPH</degrees></personName></creator><creator xml:id="au4" creatorRole="author" affiliationRef="#af4"><personName><givenNames>Filippo</givenNames><familyName>Tamma</familyName><degrees>MD</degrees></personName></creator><creator xml:id="au5" creatorRole="author" affiliationRef="#af5"><personName><givenNames>Kelly E.</givenNames><familyName>Lyons</familyName><degrees>PhD</degrees></personName></creator><creator xml:id="au6" creatorRole="author" affiliationRef="#af5"><personName><givenNames>Rajesh</givenNames><familyName>Pahwa</familyName><degrees>MD</degrees></personName></creator><creator xml:id="au7" creatorRole="author" affiliationRef="#af6"><personName><givenNames>Anthony E.</givenNames><familyName>Lang</familyName><degrees>MD</degrees></personName></creator><creator xml:id="au8" creatorRole="author" affiliationRef="#af2"><personName><givenNames>Günther</givenNames><familyName>Deuschl</familyName><degrees>MD</degrees></personName></creator></creators><affiliationGroup><affiliation xml:id="af1" countryCode="US" type="organization"><unparsedAffiliation>Parkinson's Disease Research Education and Clinical Center, Philadelphia VA Hospital, Philadelphia, Pennsylvania, USA</unparsedAffiliation></affiliation><affiliation xml:id="af2" countryCode="DE" type="organization"><unparsedAffiliation>Department of Neurology, Christian‐Albrechts‐Universität Kiel, Kiel, Germany</unparsedAffiliation></affiliation><affiliation xml:id="af3" countryCode="US" type="organization"><unparsedAffiliation>Center for Health and Well‐Being, Princeton University, Princeton, New Jersey, USA</unparsedAffiliation></affiliation><affiliation xml:id="af4" countryCode="IT" type="organization"><unparsedAffiliation>Clinica Neurologica, Centro Parkinson, Ospedale San Paolo–Milano, Italy</unparsedAffiliation></affiliation><affiliation xml:id="af5" countryCode="US" type="organization"><unparsedAffiliation>Parkinson Disease and Movement Disorder Center, University of Kansas Medical Center, Kansas City, Kansas, USA</unparsedAffiliation></affiliation><affiliation xml:id="af6" countryCode="CA" type="organization"><unparsedAffiliation>Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital, Toronto, Canada</unparsedAffiliation></affiliation></affiliationGroup><keywordGroup xml:lang="en" type="author"><keyword xml:id="kwd1">subthalamic nucleus</keyword><keyword xml:id="kwd2">deep brain stimulation</keyword><keyword xml:id="kwd3">Parkinson's disease</keyword><keyword xml:id="kwd4">meta‐analysis</keyword><keyword xml:id="kwd5">outcome</keyword><keyword xml:id="kwd6">systematic review</keyword></keywordGroup><abstractGroup><abstract type="main" xml:lang="en"><title type="main">Abstract</title><p>Subthalamic nucleus (STN) deep brain stimulation (DBS) is currently the most common therapeutic surgical procedure for patients with Parkinson's disease (PD) who have failed medical management. However, a recent summary of clinical evidence on the effectiveness of STN DBS is lacking. We report the results of such a systematic review and meta‐analysis. A comprehensive review of the literature using Medline and Ovid databases from 1993 until 2004 was conducted. Estimates of change in absolute Unified Parkinson's Disease Rating Scale (UPDRS) scores after surgery were generated using random‐effects models. Sources of heterogeneity were explored with meta‐regression models, and the possibility of publication bias was evaluated. Patient demographics, reduction in medication requirements, change in dyskinesia, daily <i>offs</i>, quality of life, and a ratio of postoperative improvement from stimulation compared to preoperative improvement by medication from each study were tabulated and average scores were calculated. Adverse effects from each study were summarized. Thirty‐seven cohorts were included in the review. Twenty‐two studies with estimates of standard errors were included in the meta‐analysis. The estimated decreases in absolute UPDRS II (activities of daily living) and III (motor) scores after surgery in the stimulation ON/medication <i>off</i> state compared to preoperative medication <i>off</i> state were 13.35 (95% CI: 10.85–15.85; 50%) and 27.55 (95% CI: 24.23–30.87; 52%), respectively. Average reduction in <sc>L</sc>‐dopa equivalents following surgery was 55.9% (95% CI: 50%–61.8%). Average reduction in dyskinesia following surgery was 69.1% (95% CI: 62.0%–76.2%). Average reduction in daily <i>off</i> periods was 68.2% (95% CI: 57.6%–78.9%). Average improvement in quality of life using PDQ‐39 was 34.5% ± 15.3%. Univariable regression showed improvements in UPDRS III scores were significantly greater in studies with higher baseline UPDRS III <i>off</i> scores, increasing disease duration prior to surgery, earlier year of publication, and higher baseline <sc>L</sc>‐dopa responsiveness. Average baseline UPDRS III <i>off</i> scores were significantly lower (i.e., suggesting milder disease) in later than in earlier studies. In multivariable regression, <sc>L</sc>‐dopa responsiveness, higher baseline motor scores, and disease duration were independent predictors of greater change in motor score. No evidence of publication bias in the available literature was found. The most common serious adverse event related to surgery was intracranial hemorrhage in 3.9% of patients. Psychiatric sequelae were common. Synthesis of the available literature indicates that STN DBS improves motor activity and activities of daily living in advanced PD. Differences between available studies likely reflect differences in patient populations and follow‐up periods. These data provide an estimate of the magnitude of the treatment effects and emphasize the need for controlled and randomized studies. © 2006 Movement Disorder Society</p></abstract></abstractGroup></contentMeta></header></component></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Subthalamic nucleus deep brain stimulation: Summary and meta‐analysis of outcomes</title></titleInfo><titleInfo type="abbreviated" lang="en"><title>Summary and Meta‐Analysis of Outcomes</title></titleInfo><titleInfo type="alternative" contentType="CDATA" lang="en"><title>Subthalamic nucleus deep brain stimulation: Summary and meta‐analysis of outcomes</title></titleInfo><name type="personal"><namePart type="given">Galit</namePart><namePart type="family">Kleiner‐Fisman</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Parkinson's Disease Research Education and Clinical Center, Philadelphia VA Hospital, Philadelphia, Pennsylvania, USA</affiliation><description>Correspondence: Department of Neurology, University of Pennsylvania, Parkinson's Disease Research Education and Clinical Center, Philadelphia VA Hospital, 3900 Woodland Avenue, MS #127, Philadelphia, PA 19104</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Jan</namePart><namePart type="family">Herzog</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Department of Neurology, Christian‐Albrechts‐Universität Kiel, Kiel, Germany</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">David N.</namePart><namePart type="family">Fisman</namePart><namePart type="termsOfAddress">MD, MPH</namePart><affiliation>Center for Health and Well‐Being, Princeton University, Princeton, New Jersey, USA</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Filippo</namePart><namePart type="family">Tamma</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Clinica Neurologica, Centro Parkinson, Ospedale San Paolo–Milano, Italy</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Kelly E.</namePart><namePart type="family">Lyons</namePart><namePart type="termsOfAddress">PhD</namePart><affiliation>Parkinson Disease and Movement Disorder Center, University of Kansas Medical Center, Kansas City, Kansas, USA</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Rajesh</namePart><namePart type="family">Pahwa</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Parkinson Disease and Movement Disorder Center, University of Kansas Medical Center, Kansas City, Kansas, USA</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Anthony E.</namePart><namePart type="family">Lang</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Morton and Gloria Shulman Movement Disorders Center, Toronto Western Hospital, Toronto, Canada</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Günther</namePart><namePart type="family">Deuschl</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Department of Neurology, Christian‐Albrechts‐Universität Kiel, Kiel, Germany</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="article" displayLabel="article"></genre><originInfo><publisher>Wiley Subscription Services, Inc., A Wiley Company</publisher><place><placeTerm type="text">Hoboken</placeTerm></place><dateIssued encoding="w3cdtf">2006-06</dateIssued><copyrightDate encoding="w3cdtf">2006</copyrightDate></originInfo><language><languageTerm type="code" authority="rfc3066">en</languageTerm><languageTerm type="code" authority="iso639-2b">eng</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType><extent unit="figures">11</extent><extent unit="tables">4</extent><extent unit="references">76</extent><extent unit="words">9072</extent></physicalDescription><abstract lang="en">Subthalamic nucleus (STN) deep brain stimulation (DBS) is currently the most common therapeutic surgical procedure for patients with Parkinson's disease (PD) who have failed medical management. However, a recent summary of clinical evidence on the effectiveness of STN DBS is lacking. We report the results of such a systematic review and meta‐analysis. A comprehensive review of the literature using Medline and Ovid databases from 1993 until 2004 was conducted. Estimates of change in absolute Unified Parkinson's Disease Rating Scale (UPDRS) scores after surgery were generated using random‐effects models. Sources of heterogeneity were explored with meta‐regression models, and the possibility of publication bias was evaluated. Patient demographics, reduction in medication requirements, change in dyskinesia, daily offs, quality of life, and a ratio of postoperative improvement from stimulation compared to preoperative improvement by medication from each study were tabulated and average scores were calculated. Adverse effects from each study were summarized. Thirty‐seven cohorts were included in the review. Twenty‐two studies with estimates of standard errors were included in the meta‐analysis. The estimated decreases in absolute UPDRS II (activities of daily living) and III (motor) scores after surgery in the stimulation ON/medication off state compared to preoperative medication off state were 13.35 (95% CI: 10.85–15.85; 50%) and 27.55 (95% CI: 24.23–30.87; 52%), respectively. Average reduction in L‐dopa equivalents following surgery was 55.9% (95% CI: 50%–61.8%). Average reduction in dyskinesia following surgery was 69.1% (95% CI: 62.0%–76.2%). Average reduction in daily off periods was 68.2% (95% CI: 57.6%–78.9%). Average improvement in quality of life using PDQ‐39 was 34.5% ± 15.3%. Univariable regression showed improvements in UPDRS III scores were significantly greater in studies with higher baseline UPDRS III off scores, increasing disease duration prior to surgery, earlier year of publication, and higher baseline L‐dopa responsiveness. Average baseline UPDRS III off scores were significantly lower (i.e., suggesting milder disease) in later than in earlier studies. In multivariable regression, L‐dopa responsiveness, higher baseline motor scores, and disease duration were independent predictors of greater change in motor score. No evidence of publication bias in the available literature was found. The most common serious adverse event related to surgery was intracranial hemorrhage in 3.9% of patients. Psychiatric sequelae were common. Synthesis of the available literature indicates that STN DBS improves motor activity and activities of daily living in advanced PD. Differences between available studies likely reflect differences in patient populations and follow‐up periods. These data provide an estimate of the magnitude of the treatment effects and emphasize the need for controlled and randomized studies. © 2006 Movement Disorder Society</abstract><subject lang="en"><genre>Keywords</genre><topic>subthalamic nucleus</topic><topic>deep brain stimulation</topic><topic>Parkinson's disease</topic><topic>meta‐analysis</topic><topic>outcome</topic><topic>systematic review</topic></subject><relatedItem type="host"><titleInfo><title>Movement Disorders</title><subTitle>Official Journal of the Movement Disorder Society</subTitle></titleInfo><titleInfo type="abbreviated"><title>Mov. Disord.</title></titleInfo><name type="personal"><namePart type="given">Anthony E.</namePart><namePart type="family">Lang</namePart></name><name type="personal"><namePart type="given">Günther</namePart><namePart type="family">Deuschl</namePart></name><name type="personal"><namePart type="given">Ali R.</namePart><namePart type="family">Rezai</namePart></name><genre type="Journal">journal</genre><subject><genre>article category</genre><topic>VIII</topic></subject><identifier type="ISSN">0885-3185</identifier><identifier type="eISSN">1531-8257</identifier><identifier type="DOI">10.1002/(ISSN)1531-8257</identifier><identifier type="PublisherID">MDS</identifier><part><date>2006</date><detail type="volume"><caption>vol.</caption><number>21</number></detail><detail type="issue"><caption>no.</caption><number>S14</number></detail><detail type="supplement"><caption>Suppl. no.</caption><number>14</number></detail><extent unit="pages"><start>S290</start><end>S304</end><total>15</total></extent></part></relatedItem><identifier type="istex">B70E5BDEFB40543E258EF53A6014665B417ADAE8</identifier><identifier type="DOI">10.1002/mds.20962</identifier><identifier type="ArticleID">MDS20962</identifier><accessCondition type="use and reproduction" contentType="copyright">Copyright © 2006 Movement Disorder Society</accessCondition><recordInfo><recordContentSource>WILEY</recordContentSource><recordOrigin>Wiley Subscription Services, Inc., A Wiley Company</recordOrigin></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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