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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 >=== message truncated === > > > > >_________________________________________________________ >Do You Yahoo!? >Get your free @yahoo.com address at http://mail.yahoo.com >