Dear friends, Some of you may recall my posts of several months ago expressing interest in simultaneous, bilateral pallidotomy on behalf of my wife, Aviva. Well, the penny has dropped and she has a date for surgery with Dr. Iacono of Loma Linda on March 1. The following explains our decision. Blessings to all, David ------------------------------------------------------------------ Postoperative Patient Follow-up Survey For Pallidotomies Performed On Parkinsonian Patients of Dr. Robert P. Iacono 11/22/93-11/21/94 by: David S. Devor January 5, 1995 This survey was precipitated by the need to resolve a conflict bearing on the future well-being of my wife, Aviva, who is suffering greatly in her tenth year of affliction with Parkinson's disease. On the one hand, we were encouraged by the spectacular results claimed by Dr. Iacono for the simultaneous bilateral procedure he has pioneered. On the other hand, we have been receiving negative feedback from quite a number of neurologists from around the world, some of them quite celebrated, admonishing us to distance ourselves from Dr. Iacono. While Iacono's claims did sound almost too good to believe, the invective against him seemed inconsistent with patient recovery anecdotes we had heard and with the fact that he was continuing to routinely perform large numbers of pallidotomies from within one of America's major medical centers. Since we didn't wish to abandon the hope Iacono represents, we felt that the only solution was to perform an independent survey of his patients concerning the results of their surgery in spite of the significant cost and effort. (We are situated in Israel and the bulk of Iacono's patients are in the U.S. so I anticipate a phone bill approaching $1,000.) Just about everyone with whom we consulted said Dr. Iacono would use the usual pretexts (including "patient confidentiality") to withhold the list from us. But after explaining our predicament to Dr. Iacono, he without prevarication or hesitation agreed to send us the list. This list, Dr. Iacono says in his cover letter, contains "consecutive series of operative patients during the year 1994." It also says that the list is "unedited." My follow-up seemed to confirm the unedited nature of this list in that I found that in addition to disappointed and disgruntled patients, it contained one person scheduled for pallidotomy who, upon hearing negative reports on Dr. Iacono, canceled out at the last moment to get his pallidotomy done elsewhere. Still another was scheduled for surgery when, at the last moment, it was determined that his condition did not indicate pallidotomy. The list contains 165 entries arranged consecutively, by date, beginning with one dated 11/20/93 and ending with one dated 11/21/94. The list includes telephone numbers and I have attempted to phone everyone on the list except three whom I already knew to have had positive results. On a daily basis I went back to unresponsive numbers during the 2 week period between Dec. 25, 1994 and Jan. 5, 1995. Eleven names appeared twice. These were cases who went back for a second procedure within the year, i.e., the completion of a non-simultaneous bilateral pallidotomy. Two cases (referred to above) turned out to be last minute cancellations and 33 numbers were unobtainable or belonged to correspondents who were not available during the period in question. (These included disconnected numbers or no answer, wrong numbers, answering machines, fax signals, people on travel, etc.). I actually spoke to a total of 113 households. Over half the time I got to speak with the patient him/herself and the rest of the time with spouses and very occasionally a "care giver" or friend, son or daughter. In a few cases, both spouses participated in the call (using an extension or speakerphone). Only one case refused to give details and one hung up refusing to hear why I called. Of the 17 names freely given out by Dr. Iacono's office as references, only 3 appeared on this list (one of which appears 3 times), the rest having had their procedures either before 11/22/93 or after 11/21/94. Knowing these could only be positive, as mentioned above, I refrained from calling them. Just under half of those I contacted had undergone simultaneous, bilateral pallidotomies, a slightly smaller number had unilaterals and about 10% had two consecutive procedures. Perhaps 5% had thalamotomies (mostly for tremor) in addition to their pallidotomies. I failed to record which procedure in about 15% of the cases. At the beginning of each call, I indicated I was speaking from Israel, that my wife was a candidate for a simultaneous, bilateral pallidotomy by Dr. Iacono, that neurologists were against Dr. Iacono performing the procedure and that we were seeking independent feedback to help us come to a decision. While my principal purpose in taking this survey was to learn how many had been injured by the procedure and to help me estimate what risk was involved, I could not remain indifferent to the eagerness of patients to tell their stories and offer their experience in a bid to be helpful to my wife. And since I was obviously hoping for positive results from this survey and found these hopes encouraged, I feel a similar impulse to pass this news along. All those I interviewed were generous with information and all those who felt they were helped, or even marginally helped, recommended that my wife get the same help they did. Of the 9 who felt they were not helped by the procedure, 5 said that they were sorry they underwent it and 5 of the 9 (not all the same ones) felt they had actually been harmed by the procedure. Of these, 4 gave an explicitly negative recommendation. There were 4 patients with hemorrhaging that occurred during or shortly after surgery with related seizures that mitigated the benefits of the surgery. Only one case of hemorrhaging was felt to have completely overshadowed the benefits of surgery. Since the main purpose of this survey is to estimate risk, the following is a summary of the negatively affected patients listed according my survey case number: 32. Lost mobility after the procedure. 46. Wasn't helped, because he probably has "Parkinson's Plus." 52. Initial, significant improvement, then deterioration. Now better in some respects and worse in others but still glad he did it. 60. Had no improvement, probably because he "couldn't keep awake" during the procedure to cooperate with the surgeon but still would "recommend" the procedure. 65. Much helped at first but died of pulmonary embolism and heart attack one week later, which may have been caused by the surgery. 72. Could walk before the procedure, now can't. Blames it on the fact that an "assistant" and not Dr. Iacono himself operated. Is against the procedure. 92. Hemorrhaged in an airplane the day following surgery and has subsequently suffered deterioration. Definitely against the procedure. 95. A friend reported that this individual is in hospital and "not doing well." At the time of the procedure his brain stem was found to be small and the brain in general, in this 64 year old, was found to be atrophied resembling someone in his 90's. 97. Enjoyed temporary relief but now worse off "perhaps because of the procedure." In about 25% of cases, I thought to inquire as to the attitude of the individual's neurologist before and after the procedure. In most cases, the neurologist was initially against the procedure and/or Dr. Iacono. Neurologist's reactions to their patient's marked improvement (which characterized the results of most patients [at least 80%]) ranged from amazement, through embarrassed refusal to comment, to indications of adjustment to a new reality and acceptance. In quite a few cases, patients refrained (sometimes contemptuously) from returning to their neurologists after surgery. The majority (about 80%) of patients I interviewed expressed their enormous appreciation for Dr. Iacono and his team and not infrequently referred to their improved condition as "very positive," "greatly improved" "wonderful," "marvelous," "tremendous, "a rebirth" and even "miraculous." Estimates of the degree of improvement in this group ranged from 20% to 100% with most in the higher values. Surprisingly, this was true in the case of even patients in their late 60's, 70's and even 80's. Most typical were the expressions of relief to be again able to turn over in bed, shower and dress alone, eat normally (without making a mess) or to be able to abandon crutches, walkers and wheelchairs in order to walk, write and work normally or almost normally, and even drive a car, immediately or shortly after surgery. Dyskenesia, tremor, inner tremor, rigidity, freezing, stiffness, cramping, sweating, imbalance, dizziness, incontinence, stooped posture, restricted dexterity were typically said to have largely if not completely disappeared. Significant speech improvement and relief from depression were reported in only a few cases. Almost all patients reported a reduced need for medication. While a few cases reported some wearing off of benefits of pallidotomy within a few months, a similar number reported continued improvement with the passage of time. (There is only a 12 month perspective to be had from this study.) A majority of those who had one side only done, expressed their intention to have the other side done either "soon" or at some future time if and when their Parkinson's significantly spread to the other side. Several offered "help" and/or asked me to call or visit them when I come to the U.S. and to report the results of my wife's surgery, if we decided in the affirmative. Dr. Iacono was typically characterized as being "conscientious," "marvelous," "a fine individual," "a wonderful doctor," "a wonderful young man," and by one patient, "an angel in disguise." The odd patients who characterized him as "egotistical," "a hot dog," etc., were quick to add that "he knows what he's doing" and "in the operating room he's all business." Lastly, now that I've had some independent feedback concerning the results of Dr. Iacono's work, I wish to speculate a little on possible reasons for the disparity in attitude among neurologists and patients concerning Dr. Iacono's work and character. It seems that most neurologists have great difficulty in believing that consistently positive and often spectacular reversal of Parkinson's symptoms, such as those claimed by Dr. Iacono, are possible or that one can perform pallidotomies as frequently as does Dr. Iacono without injuring a large percentage of patients. Dr. Iacono's strikingly counterintuitive claims, uninhibited display of confidence, independence of spirit and apparent disregard for establishment sensibilities, understandingly strains credulity and undermines sentiments of solidarity in mainstream medicine. To the credit of dissenting neurologists, it should be said that there has not been very much scientific data published on the results of Iacono's work. It is my understanding that Dr. Iacono is taking a hiatus from surgery in order to correct this oversight. I will not attempt here to account for Dr. Iacono's singular success. This I will leave to him. In spite of expert advice, I personally find the results of my survey sufficiently unambiguous to want to put the future well-being of my wife, Aviva, into Dr. Iacono's hands. My rough notes, taken in handwriting during each telephone conversation, are available for examination by any interested neurologist. Contact: David S. Devor 8 Mevo Hamaavak French Hill tel: 972/2/814941 Jerusalem 97877 fax: 972/2/823276 Israel email: [log in to unmask]