Here is the transcript of Dr. Iacono on "Friday @ 4 ET".  This is a chat room
for members of AOL to ask a guest questions.  It starts on Friday at 4 PM EST
and last for an hour.  Here is the tramscript.
 
=========================================
 
 
Friday@4ET
A Presentation of ABC Beta
 
May 12, 1995
Guest:  Dr. Robert Iacono, neurosurgeon, Loma Linda Medical Center, Loma
Linda, CA
Host:   JenRogers
 
 
JenRogers:
Hi, I'm JenRogers, host of Friday@4ET...  Please allow me to introduce this
week's guest...
 
ABC's Prime Time Live, the New York Times, and the Wall Street Journal have
all recently featured the radical approaches to Parkinson's Disease taken by
Robert P.  Iacono MD, Associate Professor of Neurosurgery at Loma Linda
University Medical Center, in California.
 
Dr. Iacono and his Movement Disorders Team have pioneered pallidotomy, a
surgical procedure that can relieve tremor and restore mobility in Type A
Parkinson's.  And their work on brain chemistry has led them to use drugs
aggressively in the treatment of the condition; they maintain that many
Parkinson's patients in the country today are "pathetically under medicated,"
and may be receiving a useless or even harmful mix of drugs.
 
Dr. Iacono joins us this afternoon to take questions and comments about
current revolutions in neuroscience and surgery, especially in Parkinson's
Disease.  With him are several members of the Loma Linda Movement Disorders
Team, including Coordinator and Patient Education Specialist Tony
Schoonenberg, himself a Parkinson's patient for the past nine years, and
pallidotomy patient Don Berns.
 
Please use the Interact with Host button to send questions to Dr. Iacono.
 Every effort will be made to take as many questions as possible in the time
available.  Let's begin!
 
JenRogers:      Our first question...
Question:       What do you know about sub-thalamic stimulation?
 
Dr. Iacono:     Deep brain electrode stimulation?  This technique is rarely used.
 What happens is the abnormal outflow is interrupted by high frequency
stimulation.  Results have been fair to good.  It requires major surgery.
 The equipment costs 30,000 dollars and must be replaced every 3 years.  We
think it's interesting, but not practical, and doesn't compare to
pallidotomy.
 
JenRogers:      PMatt asks...
Question:       What are some early symptoms of Parkinson's disease?
 
Dr. Iacono:     Small handwriting with a tremor or rigidity in the hand.  Or,
shuffling feet and gait.  Or stiffness in the leg.  Or even depression.
 
JenRogers:      AMSPaul wants to know...
Question:       Are there any new medications for Parkinsonians in trials?  How
would these medications help?
 
Dr. Iacono:     We're interested in medications other than dopamine.  This
includes treating depression, sleep disturbance, and pain with anti-depression
 agents such as Paxil and zoloff.  These are things we're pursuing.
 
JenRogers:      Another question...
Question:       Patients with PD for > 15 years, are they candidates for the new
treatment?
 
Dr. Iacono:     Absolutely!  We've treated people with 25 year histories.  And
almost all the symptoms reverse despite the duration.  Disease type is more
important than duration.  Parkinson's is a two way street.
 
JenRogers:      Gait, balance, falling are common in elderly people with PD.  So
can you always expect improvements in these functions with pallidotomy?
 
Dr. Iacono:     They are the symptoms that are the hardest to treat with
medicine.  We see improvement following pallidotomy about 50 percent of the
time for the problem of falling down.  We have to always consider the idea of
other syndromes being involved, but some patients do very well.
 
JenRogers:      Scout8177 asks an easy one!
Question:       Where is the top hospital doing the operation?
 
Dr. Iacono:     Loma Linda!  We've done over 500 pallidotomies -- more than all
other surgeons combined.  That gives us confidence and experience in treating
a wide array of Parkinson's patients.
 
JenRogers:      Kpug asks...
Question:       How long ago was the first pallidotomy performed?  And how is that
person doing?
 
Dr. Iacono:     Dr. Laitinen from Stockholm had patients ten years ago who are
still doing as well as when he operated on them.  I started this operation
four years ago.  And the results are still excellent after four years.
 
JenRogers:      Blondejoy wonders...
Question:       What are the contraindications to this surgical procedure?
 
Dr. Iacono:     Being well-controlled on medication, there is no reason to
operate if someone's fine.  Systemic problems can arise, like with
anticoagulants.  Having MRI evidence of brain stem atrophy indicates a poor
chance of improvement, so we wouldn't operate.
 
JenRogers:      A new question...
Question:       Can chemical changes due to Parkinson's be the root cause of
depression?  No "shock" or antidepressants have had any effect after (2)
years.
 
Dr. Iacono:     It's a good question.  Serotonin deficiency in PD patients
suggests that a degeneration of nerve cells that produce serotonin does occur
in this disease and might well cause their depression.
 
JenRogers:      PAckerSof asks...
Question:       Dr., what about the use of magnets?
 
Dr. Iacono:     In the future there may be potential for that, but right now it's
experimental.  But it's another possible method!
 
JenRogers:      LServin is here...
Question:       Is there any difference between early onset or late onset PD?
 
Dr. Iacono:     Late onset tends to show less tremor.  And we know that people
over 75 may have a more rapid progression of symptoms than younger patients.
 But we've operated on people up to 88, and some people can still respond and
have good improvements.
 
JenRogers:      GX4M1PJ is curious....
Question:       Is a thick tongue syndrome and slurred speech a side effect of medic
ation or a symptom of the disease?
 
Dr. Iacono:     Symptom of the disease.
 
JenRogers:      An excellent question from Bentmiljr...
Question:       What is your opinion of the effectiveness of Eldepryl and Sinemet?
 
 
Dr. Iacono:     The consensus of our team and consulting neurologists is that
eldepryl is overrated.  It probably doesn't mitigate the disease and isn't a
therapeutic agent.  Also, it's expensive and you don't necessarily need more
than one a day.  I've never prescribed it.
 
JenRogers:      A follow-up question from ZeeBee3...
Question:       What are you recommending instead of Sinemet and Selegiline?
 
Dr. Iacono:     Sinemet is a very important first-line drug to be maintained in
most cases.  Amantadine, Permax, Parlodel -- these medicines are in many
cases very effective.  Zoloff treats sleep disturbance, as does Paxil.
 
JenRogers:      Dickins wants clarification...
Question:       Can you distinguish for me Type A Parkinson's from other types?
 
Dr. Iacono:     We find the shorthand of Type A and Type B is useful in talking
about two separate types.  Type A: tremor, rigidity, falling.  Type B: no
tremor, starts with difficulty walking and develops balance problems.
 Jankovic has said it's postural instability that's Type A.  We feel they can
benefit from pallidotomy, but have to be separated from normal PD patients.
 Type B isn't responsive to Sinemet in some cases.
 
JenRogers:      Jetlegs wants your opinion...
Question:       What is your opinion about the fetal cell transplants?  Some people
feel they are more positive -- with the pallidotomy being too destructive.
 
Dr. Iacono:     That's a misapprehension and a misconception, imho (in my humble
opinion).  My opinion is that fetal graft isn't as effective as pallidotomy.
 We don't need to pursue fetal graft therapeutically at this time because of
the success of pallidotomy.  Patients who don't respond to pallidotomy also
wouldn't respond to fetal graft.
 
JenRogers:      Georbutto would like to know...
Question:       Will patients still be required to take medication after
pallidotomy?
 
Dr. Iacono:     Yes.  A lot of patients have to be readjusted because afterwards
the medication is easier to take.  But the results of the surgery can wane if
the patient stops taking medication.  It takes pallidotomy PLUS Sinemet to
achieve results in akinesia in most cases.
 
JenRogers:      TAFalcon3 has an interesting question...
Question:       With the disease of AIDS booming, our research has taught us a lot
about other diseases.  What kind of other disorders benefit from research
into Parkinson's disease?
 
Dr. Iacono:     We're interested in dementia associated with PD.  The
neurochemistry of PD dementia in relation to Alzheimer's....
 
JenRogers:      LionDave wants help...
Question:       You mention being under medicated for Parkinson's.  What level of
medication do you prescribe for young age onset Parkinson's?
 
Dr. Iacono:     The patient usually has to medicate until he has dyskinesia.
 That's why we think in this type of PD the Pallidotomy is so useful.  Don
Berns had 15 years of medication, and is now asymptomatic.
 
Don Berns:      A year and a half ago I had a pallidotomy and it reversed all the
symptoms.
 
JenRogers:      Thbyrd1 asks for understanding...
Question:       My grandfather recently died with Parkinson's.  Can you perhaps
explain the reasons for the patient becoming unable to walk as a result of
the progression of the disease?
 
Dr. Iacono:     At the beginning, when L-Dopa can treat rigidity and slowness,
the brain is intact in relation to facilitation of walking.  But as the
disease progresses, the brain grows out of balance chemically, and L-Dopa
can't cover it.  Also, the brain stem can have physical damage, and then the
patient may not be able to stand or walk.  The disease may progress into
other symptoms, especially those involved with the brain stem.
 
JenRogers:      Stubble wants to know...
Question:       Dr., how do you feel about your critics who have suggested that desp
ite this procedure's history in Europe, the jury is still out, so to speak,
on the long term effects of doing a procedure that permanently disables brain
cells?
 
Dr. Iacono:     Such criticism has to do with a misunderstanding of the brain
cells in question.  Pallidotomy performed on a patient without PD would have
no effect on that person's behavior or movement.  In PD, the brain becomes so
abnormal that other areas of the brain can't balance it.  With a pallidotomy,
the overactive areas are reduced to the point where the brain can re-balance.
 This may reduce the hyperglutamate activity, for example, which would be
even more dangerous for the brain.
 
Dr. Iacono:     Another answer is that we see people with fifty percent of the
day in an off-period.  And we think that when the brain is off there is
degeneration.  When we put the patient into activities, there could be
improvement.  So despite the fact that it's destructive, the lesion is
discrete, which may in the end be advantageous.  It doesn't compare to
destroying a tumor in the brain.  It's not nearly that destructive..  it has
to do with bringing the brain back into normal balance.
 
JenRogers:      A question many are asking...
Question:       Does insurance cover the operation?
 
Dr. Iacono:     Yes, most policies do.  Medicare, MediCal, and we're working with
several HMOs.
 
JenRogers:      Here's a new one..
Question:       Are there dangers to a patient also being treated for lymphoma --
as far as medication?
 
Dr. Iacono:     I've had only one patient with both diseases, and I'm not sure of
the relationship between them.
 
JenRogers:      LukeTAW asks..
Question:       What age grouping makes up the majority of those affected?
 
Dr. Iacono:     The average age is 70.  The average age of onset is 55.
 
JenRogers:      DuckyzGir...
Question:       Please define pallidotomy.  I'm a medical transcriptionist...I like
to know WHAT I'm typing ...  not just how to spell it correctly.
 
Dr. Iacono:     LOL!  Check procedure code 61720.
 
JenRogers:      G Hobson is next...
Question:       Are any of these treatments effective with patients of Benign
Essential Tremor?
 
Dr. Iacono:     Yes, Dr. Pat Kelly showed that there can be an effective
procedure for patients with an essential tremor.  He is at NYU.
 
JenRogers:      Vickienumbers wonders...
Question:       Is Parkinson's hereditary?
 
Dr. Iacono:     In 98% of patients it's not.  There are a handful of cases of
maternal inheritance patterns.  But we don't understand the relationship
completely.
 
JenRogers:      A PD patient in the audience is asking...
Question:       My midday medication isn't as effective as early morning; what
could be the cause?
 
Dr. Iacono:     Did you have milk for breakfast?  (or for lunch, for that matter?)
 ** Don't have milk or milk products!!  ** Milk and foods with high protein
will block the Sinemet.  Milk blocks transport of L-Dopa into the brain for
up to four hours.  Even a very small portion of milk will do that.  Even the
amount you'd find in a serving of ranch dressing!
 
JenRogers:      Dawahine asks..
Question:       What qualifies a patient for the pallidotomy?
 
Dr. Iacono:     Does he have Parkinson's?  Is the medication failing?  That's abou
t it.
 
JenRogers:      Here's one for Don Berns...
Question:       How are you doing today?
 
Don Berns:      I'm doing so well it's unbelievable!  I played golf today!  Doing
everything I'd wanted to do before.  If you were in the same room with me
you'd have no idea I have Parkinson's.  Haven't had any regression since the
surgery...  In fact I've improved.
 
JenRogers:      Here's a new one...
Question:       How has the procedure been received by your peers?
 
Dr. Iacono:     I think it surprised a lot of people.  There's been some
polarization because of the history of pallidotomy in the '50s and '60s.  But
that was a different operation.  Now, the addition of L-Dopa plus the operatio
n is the way to go.  Also, Adrenal and Fetal grafts were a tough act to
follow -- they left a lot of people disappointed.  There hasn't been enough
neurology publication yet to show people how reliable this operation is!  More
 and more, we get positive feedback from all over the country.  The
acceptance and understanding is going to extend well into the future.
 
Don Berns:      The results speak for themselves!
 
JenRogers:      Many here in the East are asking...
Question:       How would you rate Emory in Atlanta for this procedure?
 
Dr. Iacono:     They are one of the top places doing it.  They are doing an
excellent job of pursuing the science behind pallidotomy.  Unfortunately,
they can only do a limited number of patients, but I think many people will
benefit from what they are doing.
 
JenRogers:      Kjack2's question is a sort of follow-up...
Question:       Where have you performed the procedures??
 
Dr. Iacono:     I first learned about it directly from Dr. Laitinen.  I visited
him in Sweden in '89 and '90.  And I've only performed it at Loma Linda.  The
corollary to that question is that Dr. Shima, in Japan, and I have cooperated
on both science and surgery, And he's done a lot to make pallidotomy popular
and well-accepted there.
 
JenRogers:      Smithbe wants some further information...
Question:       The article I read stated that this procedure works best (or
perhaps only) for people whose dysfunction is limited to one side of their
body.  Could you say more about this?  What percentage of the total
population with Parkinson's has dysfunction on one side?
 
Dr. Iacono:     This sounds important....  Most of the symptoms of arms and legs
are affected opposite the lesion, but many akinetic symptoms, including
walking and balance, improve after a one-sided lesion.  Most patients of PD
are affected on both sides -- that's why I'm working on patients bilaterally.
 Don Berns is the first person to have bilateral pallidotomy, and he has 100%
improvement on both sides.
 
JenRogers:      A specific question from one of our audience members...
Question:       What is the best treatment approach for a mid-70's female with PD &
senile dementia?
 
Dr. Iacono:     Many patients have degrees of cognitive impairment.  This is
different from Alzheimer's dementia.  Following pallidotomy, many
intellectual impairments are reversible.  The details of medications to use
should be left to a consultation with us.  I don't want to prescribe things
over the phone!  :-)
 
JenRogers:      Nvr asks...
Question:       Is there any relation between hemipelagic migraine and Parkinson's?
 
 
Dr. Iacono:     That's a long shot.  We don't know of any correlation.  But some
types of PD have serotonin dysregulation as some common ground.
 
JenRogers:      A question that several in the audience are asking...
Question:       What are the risks of the surgery?
 
Dr. Iacono:     They include bleeding through the brain, which can cause a
stroke.  This happens about 3% of the time.  Transient weakness and visual
impairment are less serious side effects because we can treat them effectively
.
 
JenRogers:      BillPurdy inquires...
Question:       Can the doctor comment on any new, effective treatment for
"restless leg syndrome"?
 
Dr. Iacono:     No.  The only thing we're pursuing is serotonin agents like
Zoloff in the evening.  Tryptophan in the diet (e.g.  bananas) is important
in the evening, and possibly a magnesium supplement.
 
JenRogers:      JMorri929 wonders...
Question:       Is there any link between Parkinson's and bi-polar disorder?
 
Dr. Iacono:     Not that we know of.
 
JenRogers:      We're getting to the end, I'm afraid...  This will have to be the
next-to-last question...
 
Question:       What is the success rate and how much does it cost?  What is the wai
ting time for an appointment?
 
Dr. Iacono:     The success rate is about 80%.  That means 80% of patients have 80
% symptom relief.  The operation costs less that $20,000 and is covered by
insurance.  The waiting list is case-dependent and is between two and six
months from paperwork to surgery.
 
JenRogers:      Our last question for today's session, from an audience member...
Question:       As a chemist, I am very interested in optically active compounds in
medicine.  What is being done to more fully research various biologically
active enantiomers?  Thanks.
 
Dr. Iacono:     Unfortunately, very little is being done in this field, but
there's room for new chemistry and new pharmacology.  Steve Wimack, at North
Carolina Univ., has come up with a new treatment which we feel is extremely
hopeful.
 
JenRogers:      Okay, this really is the last question!  It's from RMorelli...
Question:       Dr., how are the first 20-30 pallidotomy patients doing, and how
long ago was your most recent operation?
 
Dr. Iacono:     The most recent were three patients I did the day before
yesterday.  They're all doing well and are at home.  The earlier ones are
showing great stability.  In the first 20-30 I did, the results were more
sporadic.  But many of those patients are doing very nicely.
 
JenRogers:      Thanks so much for a fascinating session!
 
Dr. Iacono:     We'd love to do this again!  This is great!!
 
JenRogers:      Please come back whenever you're able!!  Audience members, if your
question was not asked, post it in the Iacono folder on the Friday@4ET
message board...  Dr. Iacono and the Loma Linda Movement Disorders Team will
answer!!!  Keyword: FRIDAY
 
Please be back here next week when our guest in the ABC Beta Odeon will be
talk show icon DICK CAVETT.  See you on Friday@4ET!  Until then, have a safe
weekend and a great week!!  BYE!!!
 
 
c1995 CapCities/ABC
 
 
 
Regards,
Alan Bonander