February 28, 1995
 
 
TO:  Steve Bilbao  <[log in to unmask]>
CC:  Parkinson's Disease List
 
 
Steve:
 
Thank you for your note on the PD List requesting medical data
concerning pallidotomy.  This, as you must know (by reading the Wall
Street Journal article), is a controversial subject here and elsewhere.
 I have some recollection that a MEDLINE search was posted on the List
some months ago; but I decided to do another such today, this in case
something new had been placed in the archives; and I came up with 20
citations, this for the period of 1985 to the present.  I was going to
send the entire 20 abstracts, but the file size would have been too
large for my e-mail server (I am limited to 32K), so I went through the
data output and deleted several of the citations, these either "letters"
(which did not have an abstract), or one or two articles which were
basically pure neurophysiology studies, involving animal models.  I came
up with the list below, and have split the file into two separate e-mail
messages.
.
I will make brief comments (trying to avoid "prejudice"; as you probably
know that I am a "conservative" when it comes to these operations).  The
articles are numbered as "1/L/1" etc., I refer to the last number when I
refer to numbering.
 
The "seminal" article is number 18, Laitinen's initial work
"resurrecting" Leksell's old surgeries in the fifties, and Laitinen's
work dates back to 1985.  The number of patients in that study was 38,
and the article was published in 1992.  Article number 5 is the work in
"The American Surgeon" published by Dr. Iacono and his associates at
Loma Linda, this comparing the results of 55 patients who underwent
pallidotomy and 5 who had fetal cell implantation.  A larger study of
fetal cell transplantation is currently getting underway, I believe, in
Atlanta.  Article number 9, a study using the Gamma Knife
(radiosurgery), reportedly has been viewed negatively by some as far as
results are concerned, and I believe that most do not consider the Gamma
Knife as being effective in this situation.  Another Laitinen article
(number 15) reports the results in 46 more patients; and a Letter
citation (number 11) is another contribution by Dr. Iacono.
 
My issue in all of this is that, in my view, this approach (pallidotomy)
is still "investigative" and is not a "cure" for PD.  At best, it may be
a way to relieve some of the symptoms of the disease; and, like the
"old" surgeries done in the past, *and* the drugs, the results may be
only temporary.  I continue to advise great caution and, if your father
is considering surgery, I would suggest that he have several opinions
before finally deciding.  Hope this helps.
 
Best wishes,
 
Bob
 
--------------------------------------------------------
 
 1/L/1
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1995 Knight-Ridder Info. All rts. reserv.
 
09176140   95106140
  Postanesthesia care of the pallidotomy patient.
  Parr-Day K
  J  Post  Anesth  Nurs (UNITED  STATES)   Oct  1994,  9  (5) p274-7,
ISSN
0883-9433   Journal Code: JS3
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE
  JOURNAL ANNOUNCEMENT: 9504
  Subfile:    NURSING
  The  pallidotomy patient presents a challenge in the PACU. The PACU
nurse
should  be  knowledgeable  about the pathophysiology of Parkinson's
disease
and   the  medications  used  to  treat  it.  Prevention  of
postoperative
complications  depends  on the PACU nurse's collection of baseline data
and
development   of   ongoing  assessment.  As  the  population  ages,  it
 is
conceivable  that  pallidotomies may be performed on a more frequent
basis.
The  PACU  nurse  has  the  opportunity  to  improve  the outcomes for
this
specific population of patients.
  Tags: Human
  Descriptors:  *Globus  Pallidus--Surgery--SU; *Parkinson
Disease--Surgery
--SU;     *Postanesthesia     Nursing--Methods--MT;    Parkinson
Disease
--Physiopathology--PP
 
 1/L/2
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1995 Knight-Ridder Info. All rts. reserv.
 
09136035   95066035
  Treatment of Parkinson's disease.
  Aminoff MJ
  Department  of Neurology, University of California, San Francisco,
School
of Medicine 94143-0114.
  West J Med (UNITED STATES)   Sep 1994,  161 (3) p303-8,  ISSN
0093-0415
Journal Code: XN5
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE; REVIEW; REVIEW, TUTORIAL
  JOURNAL ANNOUNCEMENT: 9502
  Subfile:   AIM; INDEX MEDICUS
  Pharmacotherapy   with   levodopa   for   Parkinson's   disease
provides
symptomatic  benefit,  but  fluctuations  in  (or  loss  of)  response
may
eventually  occur.  Dopamine agonists are also helpful and, when taken
with
low  doses  of  levodopa,  often  provide sustained benefit with fewer
side
effects;  novel  agonists  and  new  methods  for  their administration
are
therefore  under  study.  Other  therapeutic strategies are being
explored,
including  the  use  of  type  B monoamine oxidase inhibitors to reduce
the
metabolic breakdown of dopamine, catechol-O-methyltransferase inhibitors
to
retard  the  breakdown of levodopa, norepinephrine precursors to
compensate
for   deficiency   of   this  neurotransmitter,  glutamate  antagonists
 to
counteract the effects of the subthalamic nucleus, and various
neurotrophic
factors  to influence dopaminergic nigrostriatal cells. Surgical
procedures
involving  pallidotomy  are  sometimes  helpful.  Those  involving
cerebral
transplantation  of  adrenal  medullary  or fetal mesencephalic tissue
have
yielded  mixed  results;  benefits  may  relate  to  the presence of
growth
factors  in  the  transplanted  tissue.  The transplantation of
genetically
engineered  cell  lines  will  probably  become the optimal
transplantation
procedure.  The  cause  of Parkinson's disease may relate to oxidant
stress
and the generation of free radicals. It is not clear whether treatment
with
selegiline  hydrochloride (a type B monoamine oxidase inhibitor) delays
the
progression  of  Parkinson's  disease,  because the drug also exerts a
mild
symptomatic  effect.  Daily  treatment  with vitamin E (a scavenger of
free
radicals)  does  not  influence  disease  progression,  perhaps  because
of
limited penetration into the brain.  (57 Refs.)
  Tags: Animal; Human
  Descriptors:  *Parkinson  Disease--Therapy--TH;
Antioxidants--Therapeutic
Use--TU;    Antiparkinson   Agents--Therapeutic   Use--TU;   Brain
Tissue
Transplantation;  Fetal  Tissue  Transplantation;  Parkinson
Disease--Drug
Therapy--DT;   Parkinson  Disease--Prevention  and  Control--PC;
Parkinson
Disease--Surgery--SU
  CAS Registry No.: 0   (Antioxidants); 0   (Antiparkinson Agents)
 
 
 1/L/4
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1995 Knight-Ridder Info. All rts. reserv.
 
09109958   95039958
  New medical and surgical treatments for Parkinson's disease.
  Klockgether T; Loschmann PA; Wullner U
  University of Tubingen, Germany.
  Curr   Opin  Neurol (UNITED  STATES)   Aug  1994,  7  (4)  p346-52,
ISSN
1350-7540   Journal Code: BX4
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE; REVIEW; REVIEW, TUTORIAL
  JOURNAL ANNOUNCEMENT: 9502
  Subfile:   INDEX MEDICUS
  This  article reviews new medical and surgical treatments for
Parkinson's
disease  (PD).  Catechol-O-methyl-transferase  (COMT) inhibitors
supplement
the  variety  of  antiparkinsonian  drugs interacting with the
dopaminergic
system.  Clinical  studies  show that COMT inhibitors prolong the action
of
levodopa  in  patients  with  the  "wearing  off"  phenomenon. The
atypical
antipsychotic drug clozapine is the treatment of choice for the
alleviation
of  levodopa-induced  psychosis.  Clozapine  also has beneficial effects
on
tremor   and   levodopa-induced  dyskinesias.  Thus,  COMT  inhibitors
and
clozapine  provide  new  opportunities  for  the treatment of patients
with
longstanding   PD  and  fluctuating  responses  to  levodopa.
Experimental
evidence  in  animals  suggests that glutamate antagonists have
symptomatic
and   neuroprotective  actions  in  PD.  At  present,  however,  only
weak
antiglutamatergic  drugs  that  have  low  specificity,  such as
memantine,
amantadine,  and  budipine are available for clinical studies.
Neurotrophic
factors,   in   particular  ciliary  neurotrophic  factor  and  glial
cell
line-derived   neurotrophic  factor,  are  among  the  most  promising
new
approaches for neuroprotection in PD. Problems of bioavailability,
however,
thus  far  preclude their use in patients. An improved understanding of
the
pathophysiology  of  parkinsonism  has  led to a renaissance of
stereotaxic
surgery.  The  subthalamic  nucleus  is a potential new target for
surgical
intervention.  Ventroposterior  pallidotomy  has  been shown to improve
not
only  rigidity  and  tremor, but also akinesia. The techniques for
thalamic
interventions   have   been   refined   by   introducing  chronic
thalamic
stimulation.  Future transplantation approaches to PD will focus on the
use
of  genetically  modified  cells  carrying  genes for
dopamine-synthesizing
enzymes  or neurotrophic factors. Animal studies show the feasibility of
in
vivo gene transfer for the treatment of PD.  (53 Refs.)
  Tags: Animal; Human
  Descriptors:   *Parkinson   Disease--Therapy--TH;   Antiparkinson
Agents
--Adverse  Effects--AE;   Antiparkinson  Agents--Therapeutic Use--TU;
Brain
Tissue   Transplantation;   Catechol   Methyltransferase --Antagonists
and
Inhibitors--AI;    Catechol   Methyltransferase--Physiology--PH;
Clozapine
--Adverse  Effects--AE;   Clozapine--Therapeutic  Use--TU;  Corpus
Striatum
--Drug  Effects--DE;  Corpus Striatum--Physiopathology--PP; Disease
Models,
Animal; Dopamine Agents--Adverse Effects--AE;  Dopamine
Agents--Therapeutic
Use--TU;  Electric  Stimulation; Excitatory Amino Acid
Antagonists--Adverse
Effects--AE;    Excitatory  Amino  Acid  Antagonists--Therapeutic
Use--TU;
Levodopa--Adverse  Effects--AE;   Levodopa--Therapeutic  Use--TU;
Parkinson
Disease--Etiology--ET;  Parkinson Disease--Physiopathology--PP;
Stereotaxic
Techniques;   Substantia   Nigra--Drug   Effects--DE;    Substantia
Nigra
--Physiopathology--PP; Thalamic Nuclei--Physiopathology--PP
  CAS  Registry  No.:  0   (Antiparkinson Agents); 0   (Dopamine
Agents); 0
 (Excitatory   Amino   Acid   Antagonists);   0     (Levodopa);
5786-21-0
 (Clozapine)
  Enzyme No.: EC 2.1.1.6   (Catechol Methyltransferase)
 
 1/L/5
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1995 Knight-Ridder Info. All rts. reserv.
 
09100649   95030649
  Stereotactic  pallidotomy  results  for Parkinson's exceed those of
fetal
graft.
  Iacono RP; Lonser RR; Mandybur G; Morenski JD; Yamada S; Shima F
  Division   of   Neurosurgery,   Loma  Linda  University  Medical
Center,
California.
  Am Surg (UNITED STATES)   Oct 1994,  60 (10) p777-82,  ISSN 0003-1348
Journal Code: 43E
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE; REVIEW; REVIEW, MULTICASE
  JOURNAL ANNOUNCEMENT: 9501
  Subfile:   INDEX MEDICUS
  Fetal  graft  research  and renewed interest in Leksell's
postero-ventral
pallidotomy  (PVP)  stimulated  reconsideration  of  surgical  therapy
for
Parkinson's  disease  (PD),  particularly with regard to improving
akinetic
symptoms  previously  thought  resistant to surgical lesions. Review of
our
series and other published results of PVP and fetal graft show that PVP
has
beneficial  effects  on both akinetic and hyperkinetic symptoms that
better
the  results  reported  for fetal graft implantation and other
conventional
stereotactics.  Presented are the results of 60 consecutive patients, 55
of
whom underwent PVP, and 5 who underwent fetal graft implantation. Using
the
Unified  Parkinson's  Disease  Rating Scale (UPDRS), we found that PVP
gave
significant  (P  <  0.05)  reductions  in akinetic symptomatology
including
freezing,  arising  from  a chair, posture, gait, postural instability,
and
bradykinesia.  Fetal  graft  patients  had  significant  reductions  in
two
akinetic  symptoms:  bradykinesia  and postural instability. PVP's
dramatic
therapeutic  effects  on  akinesia  may  be  explained  by  interruption
of
amplified  collateral  inhibitory  output  from  the pallidum to brain
stem
locomotor   centers   such   as   the   pedunculopontine  nucleus,
whereas
interruption  of collaterals to ventral lateral thalamus by PVP may
account
for the elimination of hyperkinesia. The excellent results of PVP
represent
a significant advance in the surgical treatment of PD.  (33 Refs.)
  Tags: Comparative Study; Human
  Descriptors: *Fetal Tissue Transplantation; *Globus
Pallidus--Surgery--SU
;  *Parkinson  Disease--Surgery--SU; *Stereotaxic Techniques; Activities
of
Daily  Living;  Adult;  Aged; Gait; Magnetic Resonance Imaging; Middle
Age;
Parkinson  Disease--Complications--CO;   Parkinson
Disease--Diagnosis--DI;
 Parkinson  Disease--Physiopathology--PP;  Posture;  Retrospective
Studies;
Severity of Illness Index; Treatment Outcome
 
 
 1/L/9
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1995 Knight-Ridder Info. All rts. reserv.
 
08845021   94160021
  Gamma  Knife  thalamotomy  and  pallidotomy  in  patients  with
movement
disorders: preliminary results.
  Rand RW; Jacques DB; Melbye RW; Copcutt BG; Fisher MR; Levenick MN
  Neurosciences  Institute,  Hospital  of  the Good Samaritan, Los
Angeles,
Calif.
  Stereotact Funct Neurosurg (SWITZERLAND)   1993,  61 Suppl 1 p65-92,
ISSN 1011-6125   Journal Code: SFN
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE
  JOURNAL ANNOUNCEMENT: 9406
  Subfile:   INDEX MEDICUS
  The  Leksell  Gamma  Knife  is  a  useful  and  safe  method  to
perform
thalamotomy  and  pallidotomy  in  selected older patients with
Parkinson's
disease  and related movement disorders. In this preliminary report, 2
of 3
patients  with  severe  intention tremor were relieved of their symptoms
by
thalamotomy,  as  were  4  of 7 patients with Parkinson's tremor. Four
of 8
patients  had  significant  improvement of contralateral rigidity
following
pallidotomy.
  Tags: Case Report; Female; Human; Male
  Descriptors:  *Globus  Pallidus--Surgery--SU; *Parkinson
Disease--Surgery
--SU;  *Parkinson Disease, Symptomatic--Surgery--SU;
*Radiosurgery--Methods
--MT;  *Thalamus--Surgery--SU;  Aged;  Aged,  80  and over; Globus
Pallidus
--Pathology--PA;  Magnetic  Resonance  Imaging; Middle Age; Muscle
Rigidity
--Pathology--PA;   Muscle  Rigidity--Surgery--SU;  Neurologic
Examination;
Parkinson Disease--Pathology--PA; Parkinson Disease,
Symptomatic--Pathology
--PA;     Postoperative     Complications--Diagnosis--DI;
Postoperative
Complications--Pathology--PA;  Thalamus--Pathology--PA;  Treatment
Outcome;
Tremor--Pathology--PA;  Tremor--Surgery--SU
 
 
(Continued)
 
--
********************************************************
 
Robert A. Fink, M. D., F.A.C.S.   Phone: 510-849-2555
Neurological Surgery              FAX:  510-849-2557
2500 Milvia Street  Suite 222
Berkeley, California 94704-2636
USA
 
E-Mail:  [log in to unmask]
CompuServe:  72303,3442
America Online:  BobFink          "Ex Tristitia Virtus"
 
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