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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" ********************************************************