Adrenal Medullary Transplants as a Treatment for Advanced Parkinson\u27s Disease

Abstract: Open autologous adrenal medullary to caudate nucleus transplantation was performed in 12 patients with advanced Parkinson\u27s disease (PD). Ten of these patients had diurnal response fluctuations including €œwearing off\u27€™and €œon/off\u27€™phenomena. All of the patients were no longer satisfactorily responding to levodopa/carbidopa and dopamine agonists. The mean age of the patients was 55.1 years (range 37€65 yrs); mean duration of PD was 11.7 years (range 4€40 yrs); mean stage €œon\u27€™was 3.3 (range 2€4); mean stage €œoff\u27€™was 4.8 (range 4€“5). Mean duration of follow up from surgery was 10.4 months (range 2€17 months). Three patients improved dramatically with major changes in their lifestyle. The course of improvement in these 3 patients was different in each, implying that different mechanisms were responsible for the improvement. One of the patients died unexpectedly. In this patient, there were no surviving adrenal cells. Three patients improved moderately. Patients reported that they were €œon\u27€™longer and had to take medication less often and were less dependent on individual doses of levodopa/carbidopa. The improvement has been sustained in two patients. However, in one of these patients there had to be frequent changes in scheduling to maintain the improvement. Two patients after technically successful inplants did not improve. One of these patients subsequently died. In this patient there were a few surviving adrenal medullary cells. Four patients suffered major complications. One patient had a cerebral infarction and two had cerebral hemorrhages. One of these patients has shown a good recovery. One patient with autonomic insufficiency had a cardiac arrest with cerebral anoxia one week after surgery. This patient has shown a partial recovery. Open adrenal medullary inplantation can influence the course of PD. However, the results are too inconsistent and the risks too high for this procedure to become standard treatment. Increased knowledge about the factors governing successful inplantation and modifications in the procedure to reduce its risks are outgrowths of the surgery. Autologous adrenal medullary inplantation must be viewed as a step in the successful development of neural transplantation

Reasons for Outpatient Referrals from Generalists to Specialists

OBJECTIVE: To determine the relative importance of medical and nonmedical factors influencing generalists’ decisions to refer, and of the factors that might avert unnecessary referrals. DESIGN: Prospective survey of all referrals from generalists to subspecialists over a 5-month period. SETTING: University hospital outpatient clinics. PARTICIPANTS: Fifty-seven staff physicians in general internal medicine, family medicine, dermatology, orthopedics, gastroenterology, and rheumatology. MEASUREMENTS AND MAIN RESULTS: For each referral, the generalist rated a number of medical and nonmedical reasons for referral, as well as factors that may have helped avert the referral; the specialist seeing the patient then rated the appropriateness, timeliness, and complexity of the referral. Both physicians rated the potential avoidability of the referral by telephone consultation. Generalists were influenced by a combination of both medical and nonmedical reasons for 76% of the referrals, by only medical reasons in 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, generalists felt that training in simple procedures or communication with a generalist or specialist colleague would have allowed them to avoid referral. Specialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists rated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate. Generalists and specialists failed to agree on the avoidability of 34% of referrals. CONCLUSIONS: Generalists made most referrals for a combination of medical and nonmedical reasons, and many referrals were considered avoidable. Increasing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost