Best surgical practices: a stepwise approach to the University of Pennsylvania deep brain stimulation protocol

Deep brain stimulation (DBS) is the treatment of choice for otherwise healthy patients with advanced Parkinson disease who are suffering from disabling dyskinesias and motor fluctuations related to dopaminergic therapy. As DBS is an elective procedure, it is essential to minimize the risk of morbidity. Further, precision in targeting deep brain structures is critical to optimize efficacy in controlling motor features. The authors have already established an operational checklist in an effort to minimize errors made during DBS surgery. Here, they set out to standardize a strict, step-by-step approach to the DBS surgery used at their institution, including preoperative evaluation, the day of surgery, and the postoperative course. They provide careful instruction on Leksell frame assembly and placement as well as the determination of indirect coordinates derived from MR images used to target deep brain structures. Detailed descriptions of the operative procedure are provided, outlining placement of the stereotactic arc as well as determination of the appropriate bur hole location, lead placement using electrophysiology, and placement of the internal pulse generator. The authors also include their approach to preventing postoperative morbidity. They believe that a strategic, step-by-step approach to DBS surgery combined with a standardized checklist will help to minimize operating room mistakes that can compromise targeting and increase the risk of complication.

Breath 13CO2 background enrichment during exercise: diet-related differences between Europe and America

A traditional North American diet contains a high percentage of carbohydrates (CHO) derived from C4 plants (maize, sugar cane), whereas a European diet contains primarily CHO derived from C3 plants (potato, sugar beet). The natural 13C enrichment of the first type of CHO is higher than that of the latter type. 13CO2 production from orally ingested C4 plant-derived CHO can, therefore, be used to quantify oxidation rates of orally ingested CHO at rest and during exercise. Recently it has been shown that oxidation rates assessed this way in North Americans should be corrected for an increase in breath background 13CO2 during exercise. We hypothesized that the indicated difference in metabolic origin of CHO would imply that no such correction is required for subjects on a European diet. We therefore studied changes from rest in breath 13CO2 enrichment in Dutch volunteers during cycle ergometry at 65% maximal work load (experiment 1, 2h, 6 subjects) and 70% maximal oxygen uptake (experiment 2, 90 min, 8 subjects) while ingesting water (experiments 1 and 2) and potato starch-derived glucose (experiment 2). Experiment 1 was done before and after careful instruction of the subjects to refrain from nutrient sources potentially containing CHO of C4 metabolic origin. No significant changes from rest 13CO2 enrichment were observed in tests with water and potato-derived glucose ingestion in subjects who excluded CHO of C4 metabolic origin from their diet.

The measurement of food iron absorption in man

1. The present study was considered as a first step to develop a method to measure food iron absorption from realistic common meals prepared and consumed by the subjects themselves in their own homes. The absorption of Fe from the meals was measured by means of the extrinsic-tag method modified to allow for a free choice of food items.2. The mean Fe intake was 2.79 mg and the mean Fe absorption approximately 0.30 mg. The Fe status of the subjects corresponded to 31.5% absorption from a reference dose solution containing 3 mg elemental Fe as ferrous ascorbate. The variation in food Fe absorption obtained in this field study was found to be of the same magnitude as that obtained in studies performed under more controlled conditions as in the laboratory.3. The conclusion was drawn that the proposed method could be used in realistic field studies aimed at, for example, explaining or preventing a high prevalence of deficiency. A sufficiently long run-in period and a careful instruction of the subjects was considered essential for the design of future field studies.