PARKINSON'S NEWSLETTER of the Delmarva Chapter, American Parkinson Disease Association February 1997 4049 Oakland School Road Salisbury, Maryland 21804-2716 1-410-543-0110 FAX (410)749-1034 e-mail [log in to unmask] OF GENERAL INTEREST: FEBRUARY MEETING IS ABOUT HOW TO SURF THE INTERNET AND USE LISTSERV (LOCAL MEET BUT RELEVANT TO THE LISTSERV. RULES FOR SPENDING DOWN FOR MEDICAID ARE CHANGED? A LOOK BACK AT 1996 & PARKINSON'S REGIONAL INTEREST: VIRGINIA DECLARES APRIL PD AWARENESS MONTH LOCAL INTEREST: DEATHS, MEMORIALS, GIFTS, FUTURE MEETINGS DISCLAIMER: USUAL + JESUS SEES YOU MEETING TUESDAY FEBRUARY 25 AT 1:00 IC-NET, 1520 U.S. 13 SOUTH, SALISBURY SEE PARKINSON'S AND THE INTERNET The February meeting will be held at the office of IC-NET, a shore based access to the Internet. This is a chance to see what resources are available on the Internet and some of the uses of ~cyberspace.~ The emphasis will be on the parkinsn(misspelled with an ~o~ left out on purpose since many computer file names are limited to eight letters) listserv, which is a worldwide Parkinson's disease support bulletin board based in Canada and free to its about 1,500 members (called subscribers), and on other Parkinson's sites. The Internet has far more than just Parkinson's disease information. I am on a joke network. I automatically get a listing of ~cheapie~ air fares. Through the internet, I contacted two old college friends I had not heard from in over forty years. We were in school together in Illinois, but I found one in California and one in Michigan. On Valentine's Day I was at Robert Wood Johnson Medical School for my experimental drug (Entacapone) check-up and helped a nurse ~surf the Internet~ for information about Marfan's syndrome(a genetic problem totally unrelated to Parkinson's). My neurologist is in New Jersey, and we communicate between visits by e-mail. I am due for experimental testing at the University of Pennsylvania next month. We handle the details by e-mail. The presentation will be done on a large screen, and you will be invited to ~surf~ on your own afterwards. You do not have to own a computer to ~get on line,~ for the Wicomico County library has computers hooked to the Internet. DIRECTIONS TO IC-NET Coming from Salisbury, go south on Salisbury Boulevard [Business Route 13], pass Salisbury State University, pass Edgehill Pharmacy, and pass Kay Avenue. Get into the right lane, and turn right as you pass the Dollar Store. IC-NET is a low grey building. It was the Ponderosa restaurant in years gone by. If you miss the turn, you will have to make a big loop, since Route 13 has a median strip dividing north and south bound traffic. There is lots of parking. Cookies with fancy coffee or soft drinks will be served. SPENDING DOWN FOR MEDICAID HAS CHANGED! As a part of the recent medical care changes, the Health Insurance Portability and Accountability Act of 1996 provides that applicants and advisers who knowingly and willfully transfer or dispose of assets in order for an individual to become eligible for Medicaid assistance may face up to one year in jail and a $10,000 fine as well as denial or postponement of Medicaid benefits. The Medicaid program is a joint state and federal program and has been severely abused in the past by many who gave their assets to family members and then filed for Medicaid benefits because they were impoverished. The AARP is lobbying to have this part of the law repealed, but with the budget problems of the federal and state governments, repeal is unlikely. Medicaid was designed to help those in need rather than guarantee an inheritance. Jail is probably a poor substitute for a nursing home. A LOOK BACK AT 1996 AND PARKINSON'S There were no dramatic breakthroughs, but there was modest progress in most areas: DRUG THERAPY: The reason why PD drugs take so long to reach the market is that, in a slowly progressive disease, trial subjects must be tracked for years to ensure that (a) the benefits are lasting, and (b)long-latency adverse effects don't sneak in. SELEGILINE (Deprenyl, Eldepryl, Jumex): Despite more numerous and thorough trials than any other PD drug, debate over efficacy and safety rages on. The most convincing opinion is that the drug is beneficial to some, and that the mortality scare was premature. TOLCAPONE and ENTACAPONE: These inhibit Catechol-O-Methyl Transferase (COMT), a natural enzyme that destroys dopamine. In trials, they prolonged the effect of levodopa (Sinemet) and reduced its required dosage. Final FDA approval of these drugs is imminent. PRAMIPEXOLE: This dopamine agonist completed formal trials and awaits FDA approval. CABERGOLINE: This long-acting dopamine agonist has passed some effectiveness trials. It is generally well tolerated and offers the prospect of reducing levodopa dosage to once daily. This drug will not be marketed at first specifically as a Parkinson's medication, but it may be cross prescribed. LEVODOPA ETHYLESTER (LDEE): This injectable form avoids the wearing-off fluctuations due to poor solubility of the oral form, as well as the nausea that bothers many PD patients. DIET SUPPLEMENTS: Often natural enzymes are thought to be insufficient in normal diets, and sometimes they get formal trials in the attempt to join the profitable mainstream of Parkinson's drugs. If the results aren't advertised, it usually means they didn't do so well. There are clinical trials (recent or current) of NADH, DHEA, Coenzyme Q-10, other holistic medicines, and vitamins. NEURAL REGENERATION: A cure for PD must include restoration of lost brain neuron function and prevention of subsequent neuron loss. Researchers are exploring the progressiveness of apoptosis, or programmed cell death. They are finding that neurons of the central nervous system, contrary to former beliefs, can regenerate in the presence of certain growth factors. If the neural failure of PD can be traced to a particular mutant gene, there is then the possibility of grafting new cells lacking the mutant sequence, which can be made to grow and restore the deficient neural pathway, and which will escape the degeneration of PD. There is a current trial in humans of a surgically injected Glial-cell-Derived Neurotrophic Factor (GDNF) which has shown promise so far in rats and monkeys. Guilford Pharmaceuticals of Baltimore has developed a new class of drug (neuro- immunophilins) which helps regenerate brain cells in rats and mice whose brains had been damaged by MPTP(a chemical known to produce Parkinsonism) and can be taken by mouth. Numerous new drugs and delivery systems are in various early stages of testing. A skin patch with a new dopamine agonist is being tested in Virginia. Nicotine patches designed to help smokers kick their habit are being tried as an anti-Parkinson medication. 1996 SURGERY: PALLIDOTOMY: This surgery has become increasingly popular and available. Most no longer consider it to be experimental. THALAMOTOMY: This operation is having a revival following discovery that the sub-thalamic nucleus is a source not only of tremor but also of other major PD symptoms. DEEP-BRAIN STIMULATION (DBS): Modern miniaturization in electronics has made possible manufacture of a ~pacemaker-like~ device which controls the pallidus or ventral intermediate nucleus of the thalamus by an implanted electric shock generator. Human trials appear successful. FETAL CELL TRANSPLANTS: Fetal implants continue as experimental with at least one controlled trial underway. To overcome ethical objections and the scarcity of aborted human cells, pig fetal brain cells and laboratory developed cells are in experimental stages. Human fetal cells available for transplantation are expected to be increasingly scarce with formal FDA approval of the French abortion drug RU- 486. CAUSES OF PD: Workers still looking for environmental factors such as geography, lifestyle, diet, and exposure to toxins came up with various statistical correlations, but nothing definite and conclusive. Familial clusters, some impressively large, suggest a genetic origin, but the majority of PD patients have no known family linkage. Some think familial PD is a distinct type of the disease. Young-onset or juvenile PD seems to have greater family linkage than the more common form which develops later in life. HEREDITY: Heredity is being looked to as a cause from at least two directions. Late in 1996 a formal announcement was made concerning a very large Italian family with enough Parkinson's disease patients to assure researchers that some Parkinson's is at least partly genetic in origin. Researchers at the University of Virginia are working on the idea that PD is inherited by way of defective mitochondrial cells rather than strictly by genes. ESSENTIAL TREMOR: ET is getting much more attention, aimed both at its cause and the site of its origin in the central nervous system. It seems to be much more frequent than PD and often may be misdiagnosed as PD. From the number of family links, researchers are almost certain that ET is hereditary. While the thalamus has long been seen as the origin of tremor, recent work implicates other sites, particularly the cerebellum. The influence of alcohol (delirium tremens usually called ~DT's~) on the cerebellum and on the tremor of ET supports the notion. DIAGNOSTIC AND STUDY TOOLS: Clinical diagnosis should get much more sophisticated than the traditional "classic triad" symptoms of rigidity, bradykinesia, and tremor. Tests of memory, smell, or color perception may detect PD long before movement troubles appear. Positive response to levodopa remains the most useful sign, because it affects directly the choice of treatment. Non-invasive scanning techniques such as Positron Emission Tomography (PET), improved Magnetic Resonance Imaging (MRI), and Single-Photon-Emission Computed Tomography (SPECT) are still very costly diagnostic tools but are becoming more common in detailed mapping of activity in the brain. For the time being, clinical judgment still is the major diagnostic procedure. MEDICAL CARE: The system of medical care delivery in the United States is changing rapidly, even here in Salisbury. We are seeing a growth of the Health Maintenance Organizations (HMO's) which is supposed to slow the ever rising cost of medical care and at the same time deliver better care to patients. Some of the ~better care to patients at lower cost~ demanded by the HMO's such as out- patient mastectomies have brought in government intervention for the safety of the public. Use of a primary physician as a ~gatekeeper~ between patients and specialists such as movement disorder neurologists can create an artificial barrier between Parkinson's patients and the best medical care. Most HMO plans somewhat limit the patients' choices in selecting health care. Patients in an HMO can go outside the HMO system if they are willing and able to pay for services without using the insurance. Some HMO organizations are aware of the Parkinson's patients' special needs. Dr. Jack Himes of Peninsula Regional Medical Center told me about a recent managed care conference he attended where there was a recommendation which would require the HMO to keep two Parkinson's experts on its panel of specialists. More control over the patients and medical practitioners has arrived in Salisbury, and even more is probably coming in 1997. A substantial proportion of primary care providers (some with specialties), physical therapists, rehabilitation facilities, and nursing home facilities have come under ownership or control of the Genesis system, and Mallard Landing (the retirement community to be built on Johnson Road slated for construction start this spring) will be under Genesis control. POLITICS: The Udall bill to provide additional federal funding for Parkinson's medical research failed to reach the floor of the House of Representatives to be voted on in the last session of congress in spite of its being co-sponsored by over half of the house members and passage in the senate. We are trying to revive the bill for reintroduction in both houses of congress in early 1997. Primary house and senate sponsors from both parties are working for us. Our own politics are not in good order. Managements of the American Parkinson Disease Association, the National Parkinson Foundation, and the Parkinson's Action Network do not seem to be willing to work together and present a united front to our national government leaders. The hostility and divisiveness among the major national Parkinson's organizations are an embarrassment to the Parkinson's disease patients. Their squabbles are at our expense! MORE REALLY BAD NEWS: There were at least fifty thousand newly diagnosed Parkinson's patients in the United States in 1996. Our exact number is impossible to calculate since Parkinson's is not a reportable disease in most states. According to most estimates, there are over a million of us in the U.S.A. There are millions of us world-wide. REGIONAL INTEREST VIRGINIA HAS PD AWARENESS MONTH George Allen, the Governor of Virginia, has issued a Certificate of Recognition proclaiming April 1997 as Parkinson's Disease Awareness Month. I will bring the certificate to the next meeting. It's nice to know that others care about our problem. LOCAL INTEREST PHYLLIS U. GIORDANO Mrs. Phyllis Giordano of Salisbury, a long-time Parkinson's patient, died at home February 10. She was able to attend support group meetings with her husband Frank until about a year and a half ago. She will be missed. GIFTS & MEMORIALS A gift from Lois Whittaker in memory of her husband John Russell Whittaker of Hebron, who died of Parkinson's complications August 8, 1996, has been received. Gifts have also been received from Dale Severence of New York and Betty Franke of St. Michaels. The money will be put to good use. MARCH MEETING TO BE AT AGH IN BERLIN The March support group meeting will be held at the Atlantic General Hospital in Berlin. At the January meeting we had about as many people as the room would hold. If we expand more we may need to look for more space. We do not have a program lined up for March yet. We could have a strictly support group meeting, another Internet session, a travel specialist as a main speaker, a session on Parkinson's and politics, a session on Parkinson's drugs - good and bad - or a program suggested by you. I have asked a local neurologist to speak at our April meeting at Asbury Methodist Church in Salisbury, but I do not have a definite ~O.K.~ Most APDA chapters are having their Walk-A- Thons in May. Other Maryland chapters and Johns Hopkins have decided to walk in the fall.DISCLAIMER (in 6 point type) At the suggestion of the new APDA Director of Chapter Operations: The information and reference material contained herein concerning research being done in the field of Parkinson's disease and answers to readers' questions are solely for the information of the reader. It should not be used for treatment purposes, but rather for discussion with the patient's own physician. A burglar entered a house on a dark night intent upon stealing anything of value. As he moved in the dark he heard a voice say ~Jesus sees you.~ As he moved further into the house, he again heard a voice say ~Jesus sees you.~ The voice had an unusual quality. He pulled out his flashlight and found the voice belonged to a parrot. The parrot repeated the admonition, ~Jesus sees you.~ The burglar sighed with relief and asked the parrot, ~What is your name?~ The parrot replied, ~Homer.~ The burglar then laughed and asked, ~What idiot would name a parrot ~Homer~?~ The parrot answered, ~The same idiot who named his Rottweiler ~Jesus~!~ Will Johnston And here's to long "ons" and short "offs" WILL JOHNSTON 4049 OAKLAND SCHOOL ROAD SALISBURY, MD 21804-2716 410-543-0110 Pres A.P.D.A. DelMarVa Chapter