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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