[MUSIC PLAYING]
Today on At The
Forefront Live we'll
talk about Parkinson's disease,
one of the most common movement
disorders.
It causes impaired or
involuntary movements
and can affect behavior, mood,
and other body functions.
When medication can no longer
safely control symptoms,
experts look for
other solutions.
Our experts at UChicago Medicine
offer deep brain stimulation
to treat patients who
have movement disorders.
DBS involves placing small
electrodes into the brain.
Dr. Tao Xie and neurosurgeon
Dr. Peter Warnke
join us to discuss the
diagnosis and management
of Parkinson's disease and
DBS as a treatment option.
Both of our experts will
take your questions.
That's coming up right now
on At the Forefront Live.
[MUSIC PLAYING]
And we want to remind our
viewers that today's program is
not designed to take the place
of a visit with your physician.
Let's start off
having each of you
introduce yourselves and
tell us what you do here
at UChicago medicine.
And Dr. Warnke we're
going to start with you.
Oh, thank you very much, Tim.
So I'm the Director
of Stereotactic
and Functional Neurosurgery
at the University of Chicago.
And I perform deep
brain stimulation
for Parkinson's disease, also
for other movement disorders,
and do all the epilepsy surgery
and some deep-seated functional
tumors.
So overall, all the important
functional eloquent areas
of the brain are covered
by functional neurosurgery.
Hello, everyone.
My name is Tao Xie.
I'm an Associate Professor of
Neurology and Mood Disorder
specializing in neurology.
I'm the Director of
the Mood Disorder
Clinic and DBS program.
I'm so glad to be here to
talk about Parkinson's disease
and DBS program.
Great.
So Dr. Warnke, I would be remiss
in saying that we are obviously
in a working medical center.
And you're working right now.
That's while you're
wearing a mask
and you have the
surgical cap on.
We appreciate you
making the time.
But we also appreciate you
always putting patients first.
And I know you've been
working with patients, even
this morning.
So thanks for being
in here right now.
So let's talk a little bit
about Parkinson's in general
to start with.
And I don't know, either one
of you can take this question.
But explain to us what
is Parkinson's and what
does it do to the body.
Dr. Xie.
OK, so Parkinson's disease is
a neurodegenerative disease
due to the progress test in the
specifically dopamine producing
neurons in the substantia
nigra specific region
in the brain, because that
neuron produces dopamine.
Dopamine is very important
for the movement.
With the death of this neuron
and the lack of a dopamine,
that's why patient
develop with the symptoms
of Parkinson's-- of
Parkinsonism syndrome.
Parkinsonism was
a cardinal symptom
of bradykinesia, which is a slow
movement and rigidity, which
is kind of stiff stiffness
feeling and also tremor.
The tremors mainly
occur when the patient
puts the hand at rest.
We call it resting tremor.
The symptom usually
gradual start.
For the majority of patient
it start around the age of 55.
And some can start up earlier.
And usually it start on
one side of the body,
most commonly it's
the upper body.
The most commonly noticed
symptom is that the tremor.
That's brought up a lot
of patient come to see us.
The tremor usually affects
of the finger or the thumb
and then the hand and then
that tremor can gradually
spread to the same
side of the leg
or then move to the other side.
The patient can also have other
symptoms, like I mentioned,
the stiffness.
The stiffness can also
focus on the shoulder.
And the some patient can be
misdiagnosed as frozen shoulder
or osteoarthritis.
And other symptoms the
patient feel slowly movement.
And then their facial
expressions also become plain.
It's lack of facial expression
and eye blink is reduced.
And their speech become like
monotonic and also softer.
Their writing becomes smaller.
And also when they
are walking, they
have reduced their
arms swing and they
have like a shuffling gait.
And also when they're
walking, the tremor
can also be more noticeable.
And they can have like this
hunched forward posture.
Besides just the motor
symptom, the patient
can also have like some
non-motor the symptom,
like loss of the smell
of function and REM
behavior, disorder like
acting out a dream even
before the motor symptom onset.
And some also come
with constipation.
And as the disease
progression, all the symptoms
become more prominent, and
also the actual symptom
like a gait problem, freezing
gait, loss of balance,
and then difficulty swallowing
and the cognitive impairment,
all this can become an issue,
including anxiety, depression
and other non-motor
pain and then sleep
cycle change, et cetera.
Dr. Xie, do we know what
actually causes Parkinson's?
Yeah, pathology
wise, it's caused
by abnormal accumulation of a
protein called alpha-synuclein.
Because they kind of fall
of order normally and then
form certain--
we call it aggression.
And then deposit it
in the cell body.
And the damage of
the cell function
eventually gradually
kill the cells.
And then the-- this
is the major cause
of the protein we've found it.
But there's also other proteins
that can also damage the cell.
And so far only
10% the patient we
find a genetic cause of that.
90% of the patient is sporadic.
So we found that young
onset people more likely
have a genetic cause of
it and later onset, age
of 50 or above, are less likely
to have it at least so far.
So overall, we think
it's most likely
for the majority
of patients it's
a combination genetics, of
course, and environment toxin
exposure.
Toxin including baseline
epidemiological study
like pesticides, et cetera.
So Dr. Warnke, there
are different types
of movement disorders, correct?
What are some of the other ones?
So the other ones
are essential tremor,
which is a clearly
genetic disease where
the criteria are to have
a positive family history.
And another criterion is that
it is chemical sensitive,
so it responds very
well to a little bit
of alcohol, which some patients
then use to mask and cover
the tremor.
And that's one thing.
Another one is
dystonia, which is also
genetically caused in some
cases, in other cases not.
And all of those are amenable
to a deep brain stimulation
to disrupt the pathological
circuits in the brain.
So let's talk a little bit more
about deep brain stimulation
and what exactly that is.
I mentioned it briefly in the
introduction on the program.
But if you can kind of
walk us through that.
And Dr. Warnke,
we'll start with you.
And just tell us what that
is and how that works,
if you will, please.
Yeah and that's a
very good question,
because most people are very, I
would say, irrationally afraid.
This is brain surgery.
But it is the most
scientifically proven
and the most non-invasive
brain surgery you can think of.
Deep brain stimulation
means that computer
guided based on an MRI
scan, and in our case
at the University of Chicago
with a pin drop CT scan,
we design a target.
And we know exactly, for
example on Parkinson's disease,
it's in the so called
substantiac nucleus.
And in a subportion of that,
we designed this target,
and then calculate with the
patient in a stereotactic
frame, so the head cannot move.
Then we calculate how to
get there avoiding vascular
structures, vessels, any
eloquent areas to most safely
get there.
And the precision we use is in
the range of 0.3 millimeters.
So that's how precise you
can position your electrodes.
And that is needed to
get effective treatment.
Having an the
intraoperative CT scan
makes this an extremely
safe procedure,
because each step of the way,
when we implant the electrode,
we know exactly where
we are in the brain.
Interesting.
So-- I'm sorry go ahead.
What we also do
during this surgery
is we test the physiological
function of these nerve cells
that we want to influence
with deep brain stimulation.
So we record from
individual cells
and look for the typical pattern
we see in Parkinson's patients.
Once we've found that,
we know we are exactly
in the right spot.
Then we implant the
therapeutic electrode,
which then later is connected
to a very small battery
under the clavicle.
And then we can program
this from outside.
That's the standard
classical procedure,
which is established by very
good evidence since 20 years.
So you mentioned you put
that into the clavicle.
And does it-- it
provides that's that--
I guess, it's kind of a
minor electrical current.
Is that correct?
Yes.
That is-- it's a trick--
How often does it do that?
It's permanently stimulating.
That's the current
situation is for which
we have all the data is
we permanently stimulate.
To elaborate, in the
future there will be--
and systems are experimentally
available already,
to only stimulate when the
patient is symptomatic,
what's called a closed loop
system, which would be perfect.
It only stimulates when the
patient develops a tremor
or has frozen movements.
So you don't use battery time
and stimulation all the time.
Interesting.
So we are getting some
questions from viewers.
And I want to throw
a few of these at you
and see what your thoughts are.
The first one is from a viewer.
Is medical cannabis
useful for Parkinson's?
And I don't know who
wants to take that one.
But either one of you.
That's for Dr. Xie.
OK, all right, so again,
this is a very good question.
We commonly get this question
from patients' family.
And so far there's no clear
evidence from our field
to show that has a
specific effect on patient
with Parkinson's
disease and the symptom.
However, anecdotally,
the patient's family
can often tell me that
after they take it,
that their tremor become less.
I guess it is probably
because the medication--
that drug can calm them down.
And then because, you
know, the anxiety,
stress can always affect the
tremor, make the tremor worse.
So I think that probably there's
the indirect effect instead
of a direct effect.
Interesting.
So Dr. Warnke, when we talk
about deep brain stimulation,
can you treat other movement
disorders with that as well
or is this just primarily
for Parkinson's?
No, this is very effective
for its essential tremor,
in a different part
of the brain, though.
But it is very, very
effective to suppress
the essential tremor,
which is important
because these patients
can't write checks.
They can't write letters.
They can't use
their hand anymore.
And as soon as you
turn the DBS system on,
the tremors almost
completely disappears
and they get their normal
function of life back.
The other disease
is dystonia, where
it is also very effective.
Again, we use a different area.
And we can treat dystonia
very effective with DBS
stimulation in an area
called the pallidum.
And I've got to say
this, Dr. Warnke,
I know you've been in
surgery this morning.
I think you're joining this
probably from the locker room,
so we're getting a little
noise in the background.
It's from the OR directly.
Oh, OK, from the OR direct.
There we go.
So that's something we
haven't done before.
But again, appreciate
you doing this.
Let's talk a little
bit about the criteria
that a patient has
to meet for surgery.
When somebody comes
to you and they've
got a problem like this,
Dr. Warnke or Dr. Xie,
I'm not sure who wants
to take this, what
criteria do they need to meet?
Dr. Xie first, then
I'll take a turn.
All right, thank you.
So you now in terms
of a treatment,
usually we start on medication.
And all this
dopamine medication,
whatever the drug
is the right choice.
Some is dopamine precursor,
converter to dopamine--
to compensate for the loss
of a dopamine in the brain
or we can use a dopamine agonist
or we can use a medication
to suppress the degradation of
a dopamine or other mechanism.
Usually this medication
works very well initially.
But as the disease
progress, some symptoms
become very
difficult to control,
like a motor fluctuation
or dyskinesia,
which is excessive movement.
And then the patient
need to take excessive
and medication
and the medication
accumulate, and can cause
also medication side
effects, such as
a hallucination,
and blood pressure
drop, et cetera.
And some patients even though
the kind of symptom Parkinson's
disease like slowness
in movement and rigidity
usually responded
very well by tremor
may not always respond
to any medications.
So for the patient responded
to medication very well,
however the motor frustration
dyskinesia cannot be well
controlled by
medication adjustment.
They can consider DBS.
And also for a patient with a
medication refractive tremor,
the tremor cannot be
controlled by medication,
they can also consider with
the condition that the patient
presents with at least four year
history of Parkinson's disease.
And that would allow you
to have a good confidence
level for the diagnosis PD.
Because you know
Parkinson's disease
respond to DBS well, but
not other Parkinsonisms.
And then also had
the patient has
to have reasonable
cognitive function
without significant dementia.
And then the patient had
to have a good motor steps
without uncontrolled
depression, anxiety,
severe anxiety, or psychosis.
And also systematic
disease should
allow them to tolerate
to the surgery very well.
And also the patient should
have good family support
because after surgery
they need to follow up
to do the programming.
And they should also have a
reasonable expectation of what
a symptom DBS is aimed for.
Is it for tremor,
for dyskinesia,
or for something else because
DBS treats a certain symptom
but not all the symptom.
So we have a few more questions
coming in from viewers.
And one comment.
I'm going to do the comment
or read the comment first.
Then we'll get to some
more of the questions.
This one is this is
aimed at Dr. Xie.
It says Dr. Xie has been a
real godsend for my husband's
condition.
So thank you Dr. Xie.
That's a very nice comment from
one of your patient's spouses.
Question from a viewer.
What are toxins,
other than pesticides,
that might cause Parkinson's?
And I have no idea which one
of you wants to take that one.
Well there were a couple.
I think, but the pesticides we
should be a little bit careful.
This is very
epidemiological data.
There's no 100%
clear cause effect.
One toxin, which
is actually a drug,
which is MTPT which people doing
drug abuse use is very well
known and very well established
and that can cause Parkinson's.
Actually, we use this in
experimental Parkinson's models
to test new treatments.
So that's proven.
The other ones are just
on a very large scale
if you look at
large populations,
you see more patients
having Parkinson's
that are exposed to this.
That's for an association.
That doesn't prove that this
toxin causeed the Parkinson's.
Another question from a viewer.
And I'm probably going
to mispronounce this,
so bear with me.
Would a patient suffering
from tardive dyskinesia,
which is a side
effect of prolonged
exposure to past medicines
that and now no longer
on those specific
meds, benefit from DBS?
And is DBS covered by insurance?
Yeah, it's tardive dyskinesia.
And yes, definitely
DBS is very effective.
Again, in the same area where
we treat dystonia patients,
which is called the pallidum.
It's very effective particularly
for these neuroleptic induced
dyskinesias.
Great.
Dr. Xie, are there medications
for Parkinson's that
don't cause hallucinations?
Oh, yeah, so I think
this is a good question,
because the hallucinations
in Parkinson's patients not
necessarily just
from medication.
It's also from an
advanced disease state
and with some
cognitive impairment.
So they all can cause
a certain degree
the risk of a hallucination.
But, you know, the most likely
one is dopamine agonist.
They're more likely
particularly for elderly people.
Dr. Warnke, how is
UChicago Medicine unique
and in our approach to care
for Parkinson's patients
compared to other
medical centers?
Yes, we have a
longstanding interest,
and that comes from my work
at other places as well,
to use biological indications,
biological imaging.
So part of the diagnostic is
to use SPECT scans, PET scans.
And what we want to do
is refine the indication
and predict the outcome to DBS.
Not every patient has
100% fantastic outcome.
That is clear at all fields
of medicine the same.
But we want to find the
biological parameters that
predict the best outcome,
either it be glucose metabolism.
Or using functional
imaging, we want
to stimulate not only
some nerve cells,
we also want to stimulate
some nerve fibers that connect
different parts of the brain.
And it's these connections
which have gone array,
to say, in Parkinson's disease.
So we can use more
sophisticated imaging.
And having a CT scanner in
the operating room available,
we can fuse those images into
our program, into our planning,
and target the areas where we
think we get the best outcome.
So in other words, it's a
little bit like in oncology,
it's personalized medicine.
Not every Parkinson's patients
has the same connections
in their brain.
We want to find the connections
which have gone array
and target specifically those.
Great.
And Dr. Warnke, final question,
is DBS a one time surgery
or is that something you
have to do periodically?
No, the implantation of the
depth electrodes into the brain
is a one time procedure.
Now things are changing.
The batteries now have
a much longer life.
And we also have batteries
that we can record from.
But from time to time every 6,
7 years, actually some battery
systems last up to 12 years,
you have to replace the battery.
That, mind you, is a 10
minute outpatient procedure.
Interesting.
Well, Dr. Warnke,
Dr. Xie, thank you
very much for your time today.
We're going to take
a quick break now.
And when we return, we'll visit
the UChicago Medicine Blood
Donation Center and speak
with Dr. Chancey Christenson
about the need for donors.
That's coming up next.
Thank you.
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Children's, at the forefront
of kids medicine.
And welcome back.
We were live in the
OR a little bit ago.
Now we're going live
from our blood donation
center with Dr. Chancey
Christenson Welcome Dr.
Christenson.
Thank you for taking
time out of your day
to talk to us a little
bit about blood donations
and how critically important
that is to what we do here
at UChicago Medicine.
Well, thanks for having me.
It's always nice to
talk about blood.
Yeah.
I know you do.
And this is a big topic
with you, obviously.
important are blood donations
to our patients and patients
in need cross
Chicago, particularly
in this time of COVID?
Sure, so I think before
COVID, there was always
a need for blood, right.
You know we're the number--
we're the level 1 trauma center
for the South Side of Chicago.
We have an amazing
cancer center.
We have these groundbreaking
transplants, including
double and triple transplants.
We have a children's hospital.
We have a labor and delivery.
So there's always
been a need for blood.
You know, your average
liver takes 10 units.
Your average gunshot
wound takes 10 units.
Your average car can
take 15 to 20 units.
So there's always been this
back room need for blood.
I think COVID really helped
demonstrate the critical need
for blood during--
really to keep
everything running.
So during the
height of the surge,
there was at the max was a 40%
decrease at the national level.
So we were getting
60% of the inventory
that we would expect from
every major supplier.
For several months, it was
a 75% fulfillment rate.
So the only way we're really
to keep blood in the hospital
was the fact that all of the
elective surgeries and all
the procedures were canceled.
And so the fact that really
highlights that having blood
helps keep the doors
of the hospital open.
You know having
access to blood really
helps the other
doctors do their jobs.
And so we're really
a critical supply.
And I'm so glad you
brought that up.
And the way you phrased that
is so important, because we're
back at full
capacity in business,
right now, maybe not
full capacity, but pretty
darn close.
And we are at a
business right now.
For business right now, we're
taking all kinds of patients
in.
Obviously, the hospital
is a safe place.
So you need to be busy.
And I think you are pretty busy.
But how are we doing right
now as far as blood donations?
We're doing really well.
Everything has been come back
to sort of the normal levels.
And certainly, you know,
the national suppliers
is supplying at the same level.
So it's been really helpful.
I also want to add that
thanks to the generosity
of the University
of Chicago community
during the height of it, during
the start of the March, April,
May time period, we're able to
collect almost five times more
in a month than we normally do.
And that really helped
make up the deficit
from the national shortage
that we were undergoing.
So right now things
are looking good.
And you know it's a
pretty easy process
if you do want to be a donor.
It's not painful.
It's not a difficult
thing to do.
And you're in the
blood donation center
right now, which is pretty neat.
Can you show us
around a little bit
and just kind of tell us
what we're looking at here?
Sure so this would be your
basic blood donation chair.
So you come in, the whole
process usually takes
about half an hour at the most.
So you come in.
You get some paperwork done.
We have to screen
you the day of.
We try to make sure that--
we'll do a finger stick
and then we'll get--
you'll get your blood drawn.
You get a lot of snacks.
We have great friendly
staff that always comes by.
Additionally, I don't know
if you can see it over there,
but that white machine
is to help for platelets.
And so platelets is
a little bit longer.
They are in a lot
more short supply.
But what happens is that
basically the machine will help
only take out the platelets.
It will return everything
else to you as well.
So platelet donations
take about 90 minutes.
But, you know, it's
always in short supply.
The platelets are-- they
only last five days.
And, you know, one
benefit is certainly
that people may be squeamish
for different reasons
about donating blood.
And they may feel faint,
maybe they feel woozy
from times they've donated.
If you donate platelets,
you don't have that effect
because you get your same
red blood cells back.
We only really
take the platelets.
And so it really is a lot better
for a lot of the patients,
a lot of the donors as well.
So what is the difference
between just donating
regular blood and platelets?
I mean, I know what you
just said, you get it back.
But what is the
need for platelets?
I guess, that's the
more important question.
Sure, so the platelets
really help you clot.
And so, I mean, they really
form the actual clot itself.
And so you know, we have a
lot of chemotherapy patients.
We have a lot of burn patients.
We have a lot of
major surgeries.
So if you think about
it, if you give blood,
sort of it can be manufactured
into three things--
platelets, red
cells, and plasma.
If you give platelets
then we just
get just the platelets alone.
The real advantage
is also for platelets
is that when we make platelets
from red blood cells,
we have to pool six
of them together
and then you make one big dose
of six combined platelets.
Obviously, if we can just
get it from one person,
which is what the
machine can do.
The machine the
platelet machine can
get the equivalent of six
platelet donors in one person.
And so there's a lot
less infectious risk.
There's a lot less that
exposure to different donors.
So it really is a lot
safer for the patients
for donating just the
one platelet unit.
Let's talk about
safety for a minute.
But before we get
to that, actually
do we need to make two comments.
You do have snacks there.
And you also have TV
for people to watch.
So you keep them entertained
while they're there.
And your staff is
really, really nice.
I've met--
Yeah, they're the best part.
Yeah, I mean, I met
several of them.
And they're great.
They're great
people to deal with.
So when people come in,
they'll feel very welcome.
And it's just-- it's really
a positive experience.
I think that's
sort of the best--
I think that's the best example
of what we here at The Blood
Donation Center have.
You know, I think sometimes you
can go to other blood drives.
And sometimes you can't be--
you know, you go to
a van and maybe they
give you like a stale
cookie or, you know,
they're just trying
to rush it through.
I think here we're much more of
a mom and pop shop, you know.
We don't sell the units anybody.
All the units are used in house.
So really we try to cultivate
it that we're family,
that we're a team, that we
really work together with all
the rest of the hospital.
So we really try to make the
experience the best we can,
because we always want
people to come back.
It's very important point
that the blood that's donated
here stays here and is used
for patients here at UChicago
Medicine.
So Southsiders, if you
want to come in and donate,
you're helping your neighbors
out and potentially yourself
even.
But it's really-- it's
a great place to come.
A couple of quick
points that I think we
need to make before we go.
People are nervous I think
a little bit with COVID.
You are being very careful
in protecting people.
Talk to us just a little bit
about that if you will, please.
Sure, the safety of
our donors is really
the most important thing for us.
You, know we really try
to make sure, you know,
because people are willing to
take the time and their energy
to come and donate and they're
also coming to donate blood.
So we can't expect them
to have more things.
And so I think, we try and
take every precaution we can.
You know, we try and keep
people socially distanced,
making them wear a mask.
We have rigorous cleaning
of the equipment.
We try to make people have
an appointment to make sure
that we have the maximum number
of people within the space.
And so we really focus on
the safety of the donors
as much as we can to try and
protect against anything.
And if somebody
wants to do this,
so they just reach out
to the medical center
and make an appointment?
Is that the easiest way?
Sure, so we have the University
of Chicago Blood Donation,
it's a subset of the web page.
And so you can go to that.
We have scheduling.
You can also call
here at 773-702-6247
to schedule an
appointment as well.
We're working at some other
more high tech things.
But, you know,
right now, we just
say call and make
an appointment.
We have everyone spaced
at about half an hour.
We are trying to develop a
capability for remote screening
similar to, you know, a
virtual health visit as well.
It's just it's a slightly
different process for donors.
And so we're still
trying to set that up.
But that will help as well.
You guys have a lot of
exciting things coming
and we really, really appreciate
you taking the time out
of your day to do
this, that's fantastic.
That's all the time we
have for the program.
We'll have, of course,
another At The Forefront Live
coming up next week.
Please remember to check
out our Facebook page
for our schedule of programs
coming up in the future.
Also if you want
more information
about UChicago
Medicine, take a look
at our website at
UChicagoMedicine.org.
And as Dr.
Christenson just said,
you can also find the blood
donation page there as well.
If you need the appointment, you
can us a call at 888-824-0200.
And remember you can schedule
your video visit by going
to the website as well.
Thanks again for
being with us today.
And I hope you
have a great week.
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