Bill....

Outstanding commentary.based upon keen
and accurate observations.

Thanks for taking the time share your thoughts
with us.  I, for one, sincerely appreciate your efforts.

Barb Mallut
[log in to unmask]

From: William Harshaw <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: Tuesday, August 17, 1999 5:44 AM
Subject: Re: Reflections ...


Poetic licence.  No intent to injure or hurt. Sorry if it had that
effect.

Bill
-----Original Message-----
From: Carole Hercun <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: Tuesday, August 17, 1999 6:46 AM
Subject: Re: Reflections ...


>"The brain...spoils and rusts". Certainly a striking
>image, but a dark one. Its rather like being hit with
>a truck when you read it as early in the AM as I am. I
>think I was actually struck speechless for a moment,
>especially after all the posts yesterday re: cognitive
>impairment vs. dementia. Poetic license or do you feel
>that damaged by the disease?    Carole H.
>
>
>--- William Harshaw <[log in to unmask]> wrote:
>>     Reflections on Therapy
>> for
>> Parkinson's Disease:
>> Medication and Neurosurgery
>> by
>> Bill Harshaw
>>
>> Parkinson's Disease is associated with free radicals
>> which in turn are
>> associated with the deposition of iron.  The human
>> brain is encased in fat.
>> For a person with Parkinson's, the brain, which is
>> the source of the highest
>> creativity and reasoning, spoils and rusts
>>
>>  The two procedures I had - the pallidotomy in 1993
>> and deep brain
>> stimulation the following year - are much in the
>> news as Parkinson's
>> patients search out possible ways to mitigate their
>> symptoms and improve the
>> quality of their lives.  Media accounts of these
>> procedures focus on the
>> successes, sometimes spectacular, and give less
>> coverage to the patients
>> whose lives have not increased in quality.
>>
>>  Neurosurgery as a therapy for Parkinson's disease
>> continues to be both
>> experimental and controversial. Pallidotomy,
>> thalamotomy, deep brain
>> stimulation and foetal transplants haven't yet
>> reached the status of bypass
>> surgery for cardiac patients - the gold standard.
>> But it is useful to
>> remember that they are all based on what the noted
>> American physician Lewis
>> Thomas calls ‘halfway technologies'.He does not use
>> this term derisively,
>> but to point out that they do not represent a cure,
>> only better symptom
>> management.
>>
>>  Foetal transplant surgery is to the doctors an
>> extension of the current
>> ‘gold standard' of treatment, ‘dopamine replacement
>> therapy', as represented
>> by the L-dopa based medications.   However, it has a
>> number of ethical and
>> moral hurdles to clear before  becoming acceptable
>> to society generally.
>> The other procedures fall into the general category
>> of what surgeons do
>> best: "if its broke, fix it" (with apologies to Bert
>> Lance).
>>
>>  To put neurosurgery in the context of the universe
>> of treatment for
>> Parkinson's it is important to remember that
>> pallidotomy and thalamotomy
>> have been around for fifty years.  They were the
>> therapy of choice for
>> advanced PWPs.untl the mid 1960s when L-dopa was
>> discovered to be
>> efficacious.  As L-dopa gained acceptance, its
>> superiority to all other drug
>> therapies became apparent.  Neurosurgery went into
>> eclipse, not to have a
>> renaissance for a quarter century, a period which
>> saw the development of two
>> generations of a new type of drug - dopamine
>> agonists - which increase and
>> prolong the effectiveness of L-dopa.
>>  A quarter century's use of L-dopa as the medication
>> of choice demonstrated
>> its superiority in symptom management; it also
>> revealed the drug's
>> shortcomings - dyskinesia and psychiatric
>> side-effects in advanced patients
>> who were on high doses being among the more
>> significant.. In the early
>> 1990s, technological advances, the miniaturization
>> of surgical instruments,
>> a more nuanced and comprehensive understanding of
>> neuroanatomy, a new era in
>> neuroimaging and the need to provide some sort of
>> relief to advanced
>> patients led  to a renewal of interest in
>> neurosurgery - the old operations
>> being done more successfully and with greater
>> precision and the invention of
>> DBS by Alim Benabid and his colleagues in Grenoble
>> France.  Almost
>> paralleling the surgical innovation was the
>> development of a third
>> generation of agonists which, if they live up to
>> their press releases, will
>> provide a meaningful advance on current drug
>> therapy.  The procedures and
>> the drugs are at the limit of human knowledge.
>>
>>   Foetal transplantation is considered separately.
>> As a class of surgery,
>> it belongs with organ transplants - heart, lungs,
>> kidney ... the list goes
>> on.  It first showed its face in the late 1970s and
>> has been developing
>> quickly since then.  At times the pace of progress
>> seems slow to patients,
>> but the rate of change of progress has been nothing
>> short of exponential.
>> Results of a recent double blind study are every bit
>> as good as were
>> expected and parallel the results of other the types
>> of surgery   .
>>
>>  Comparing the state of therapy for Parkinson's
>> today to what it was a mere
>> quarter-century ago, the progress is staggering.
>> Before L-dopa, the
>> medications available were a variety of drugs which
>> were serendipitously
>> found to be beneficial as therapy.  They were really
>> pretty primitive. Now,
>> there is L-dopa, three generations of agonists,
>> neurosurgery and a whole new
>> array of research projects, any one of  which has
>> the potential to advance
>> treatment markedly.
>>
>>  It should be noted that every therapy has its
>> drawbacks, called side
>> effects, which range from the trivial to the
>> serious.  Some of these side
>> effects are major enough to prevent certain patients
>> from using some
>> therapies.  Indeed, there is a website on the
>> internet devoted to patient
>> accounts.
>>
>>  The implications of these advances on a broad field
>> of new and newly
>> adapted drug and surgical therapies is that
>> physicians will have several
>> arrows in their quiver when presented with a patient
>> with symptoms that
>> previously would have been intractable.  The other
>> aspect is the hope that
>> these developments engender.
>>
>>  The American philosopher John Searle noted in a
>> 1995 article:
>>
>> As far as we know the relevant processes take place
>> at the micro levels of
>> synapses, neurons and cell assemblies.  All our
>> conscious life is caused by
>> these lower level processes, but we have only the
>> foggiest idea of how it
>> all works.
>>
>> The doctors know that lesioning works and that
>> chronic stimulation works,
>> yet they do not know how or why.  That should give
>> some cause for pause.
>> The same comment can be made, to a degree, with
>> respect to drug therapy.  We
>> don't know why some drugs are  more effective than
>> others.
>>
>>  Perhaps Parkinson's disease will, in the end, be
>> found to be not one
>> condition, but a cluster of conditions with several
>> common characteristics
>> and each one having unique properties which set it
>> apart.  The existence of
>> progressive supra-nuclear palsy and multi-system
>> atrophy are two cases in
>> point.  That is why it is a very good thing that
>> there are half a dozen
>> agonists on the market and three types of surgery -
>> lesioning, stimulation
>> and transplant. One agonist or type of surgery may
>> be more effective than
>> others in different varieties of the condition.
>>
>>  Research is also yielding results on discovering
>> the causes of Parkinson's.
>> PD is caused by the death of the cells comprising
>> the substantia nigra which
>> produce dopamine.  It is not known what causes the
>> cells to die.  The
>> prevalent current hypothesis is the so-called
>> ‘double hit' theory - which
>> seems to be the case with other neurodegenerative
>> conditions as well - an
>> hereditary or genetic predisposition which can be
>> hit by an environmental
>> toxin, thus providing the double hit.  The toxin
>> could be anything from
>> pesticide and fertilizer to industrial pollutants
>> and
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>
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