Book Review

Parkinson's Disease: Diagnosis and Clinical Management

N Engl J Med 2002; 347:1387-1388October 24, 2002

Article

Parkinson's Disease: Diagnosis and Clinical Management
Edited by Stewart A. Factor and William J. Weiner. 714 pp. New York, Demos Medical Publishing, 2002. $175. ISBN: 1-888799-50-1

Parkinson's disease affects about a million people in the United States, a number that will increase as the population ages. It has been a force in the transformation of neurology from a specialty restricted to diagnosis into one with active therapies. It is at the center of controversies about stem-cell therapy, gene therapy, and sham surgery on the brain. Neurosurgical treatments have progressed from destructive lesions of the basal ganglia to stimulation of the thalamus and subthalamus. Gene therapy and the taming of programmed cell death (apoptosis) are therapeutic targets. Almost all the progress in this field has been made in the past 50 years, especially the past decade.

Parkinson's disease has been at the forefront of clinical trials and advances in molecular genetics. As with the dementias and amyotrophic lateral sclerosis, torrents of information have accumulated, and management has become intricately interdisciplinary. Parkinson's can now form the basis of a medical career, and special centers have been developed worldwide for patient care and research.

Surprisingly, there has been no major monograph devoted to Parkinson's disease alone. Factor and Weiner fill this gap with a jumbo book containing 11 sections comprising 58 chapters by 87 contributors, all recognized authorities.

In the first section, on history, a timeline records the amazing advances of the 20th century — including the discoveries of Arvid Carlsson, Oleh Hornykiewicz, George Cotzias, and others who found that lack of dopamine is the central feature in the pathophysiology of Parkinson's disease. In addition to levodopa replacement, drug therapy now includes two inhibitors of the degrading enzyme catechol-O-methyltransferase as well as many dopamine agonists, cholinergic drugs, and other agents. Neuroprotective agents are sought to thwart progression of the disease.

Nevertheless, levodopa induces dyskinesias, which can be as disabling as the original symptoms of the disease. Drug effects also fluctuate in distressing “off” and “on” periods. In addition, drugs can cause psychosis, which adds to the problems of depression and dementia that seem to be integral nonmotor manifestations of the disease. The limitations of drug therapy have led to surgical procedures. All available medical and surgical treatments relieve symptoms but do not retard the progression of the disease.

The clinical sections of the book cover all these areas very well. There are detailed chapters on individual symptoms, clinical pharmacology, and other diseases that include prominent parkinsonian features (multiple-system atrophy, progressive supranuclear palsy, corticobasal degeneration, and Lewy-body disease). Sound advice is provided on quality of life, caregiving, and financial considerations. Separate chapters deal with constipation, insomnia, daytime somnolence, and somnolence at the wheel of a car. I cannot think of a major subject that has been omitted.

If there is to be a second edition, however, one problem should be corrected. In 1997, the first gene for Parkinson's disease was identified; the gene product is α-synuclein. Then came a second one, parkin, and a third, ubiquitin carboxy-terminal hydrolase L1. These familial diseases account for only 5 percent of cases of parkinsonism, but they are clues to the pathogenesis of the common sporadic form. Unfortunately, the discussion of this topic is fragmented, with two separate chapters on genetics, two on pathogenesis (one each on oxidative damage and apoptosis), and one on cellular pathology. These chapters are each written well, but perhaps because of the authors' divided responsibility and delayed publication, there is scant mention of the aggregation of synuclein, the role of parkin as a ubiquitin ligase, or the role of the ubiquitin proteasome system in pathogenesis. These considerations now dominate theories of pathogenesis.

When so many authors are involved, some heed deadlines and others do not. As a result, references stop at 1998 in some chapters and at 1999 in most others. Few chapters cite works published in the year 2000 or later. Authors who submit chapters on time suffer when publication is delayed for two or three years. That delay invites competition from review journals and electronic texts, which can be updated annually and are less vulnerable to tardy submission of manuscripts. Online resources are gaining in popularity and will continue to be consulted as research papers continue to pour forth.

But the textbook field is not totally devoid of competition. The popularity of another multiauthored book, Parkinson's Disease and Movement Disorders (Joseph Jankovic and Eduardo Tolosa, editors), is documented; it is now in its third edition (1998), and the fourth edition is expected in November 2002. Many experts have written chapters for both books. Like Factor and Weiner's book, the competing book will have to be revised every few years, and we will see whether the revisions are submitted on time.

Which book is preferred? Or is neither? I am not a reliable guide, because, years ago, I predicted the end of giant books. They seemed destined to be replaced by electronic texts and review journals that would always be up to date and accessible without charge on the World Wide Web. However, instead of disappearing, books are selling better than ever, according to publishers. Books, even the mammoths, are more portable and can be taken places where computers cannot. And PubMed Central, with its dreams of a nirvana of free online journals, has been slow to emerge.

Parkinson's Disease will appeal to specialists in movement disorders, primary care physicians, geriatricians, neurosurgeons, and trainees in all these fields.

Lewis P. Rowland, M.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032
lpr1@columbia.edu