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Multiple Sclerosis (transcript)
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(ANNOUNCER)        
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an association of independent, locally-operated and community-based Blue Cross and Blue Shield plans, supporting solutions that make quality, affordable healthcare available to all Americans.

(MUSIC)

(DR. PETER SALGO)    
Welcome to Second Opinion, where each week you get to see firsthand how some of the country’s leading healthcare professionals tackle health issues that are important to you.  Each week our studio guests are put on the spot with medical cases like this one, based on real life experiences.  By the end of the program, you’ll learn the outcome of this week’s case and we hope that you’ll be better able to take charge of your own healthcare.  I’m your host, Dr. Peter Salgo, and today our panel includes our Second Opinion primary care physician, Dr. Lou Papa, from the University of Rochester Medical Center, special guest Vlad Stefanovic, Joyce Nelson from the National Multiple Sclerosis Society, Dr. Anne Cross from Washington University, Dr. Andrew Goodman from the University of Rochester Medical Center.  Let’s get right down to business, shall we?  Today our case is about Emma.  She is forty-two years old, a teacher, married with two school-age children.  She’s in her PCP’s office because she has been feeling dizzy.  She says she’s often in a lousy mood and has been noticing that she is really sensitive to heat.  She hasn’t had any changes of activities but feels fatigued and then even wakes up fatigued.  What — what are you thinking about, Lou?

(DR. LOU PAPA)         
Hmm.  Well, that’s a wide-ranging basket of things.  

(DR. PETER SALGO)      
Glad we could narrow this down for you.

(DR. LOU PAPA)         
So how much of that is new?  Just the dizziness is new?

(DR. PETER SALGO)     
You know, it sounds to me, just from the — the — the tone of this chart, it’s all new.

(DR. LOU PAPA)         
And you probably don’t have it there, but does she say exactly what she means by dizzy?

(DR. PETER SALGO)    
She said she feels more off balance when she’s hot —

(DR. LOU PAPA)        
Interesting.
(DR. PETER SALGO)     
…and when the humidity is high.  Her sister felt fatigue like this when she was diagnosed with Graves’ disease.

(DR. LOU PAPA)         
Mm-hmm.

(DR. PETER SALGO)     
She’s not experience — experiencing any spinning or tinnitus, or ringing in her ears.

(DR. LOU PAPA)         
Right.

(DR. PETER SALGO)    
She’s not been falling.

(DR. LOU PAPA)         
Mm-hmm.

(DR. PETER SALGO)    
But she says she feels uncoordinated, and one other positive finding, she has a history of adenocarcinoma of the breast, treated with mastectomy, lymph node dissection, but there’s no evidence, she says, from other physicians of ongoing disease.

(DR. LOU PAPA)      
Well, there’s a lot that could be going on there, a couple of things I worry about.   One, she has this family history of thyroid disease, so, yes, she could have thyroid — thyroid disease.  I worry about cardiovascular disease, because of this light-headedness, the heat sensitivity.  I worry about bradycardia.  I worry about low-output states.

(DR. PETER SALGO)     
In other words, a low heartbeat?

(DR. LOU PAPA)     
Low heart rate, a low heart pumping action.  That could be leading to some of those episodes.

(DR. PETER SALGO)    
Okay.

(DR. LOU PAPA)    
She has a history of breast cancer.  One of the things on the neurologic list would be, you know, breast cancer can come back and it come — can come back to the brain.  That’s a concern.  I worry about vascular disease in the brain, other neurologic diseases in the brain.  So I’d want to start by examining her, obviously, but focusing a lot on her thyroid, focusing on her neurological exam and her cardiac exam.

(DR. PETER SALGO)    
Well, I can give you some data.  Her physical exam is reported as normal.  Her mammogram, which they did order, was negative.  Thyroid function had a thyroid-stimulating hormone of one point nine.  Her ANA, her vitamin D, her FSH, her LH all seemed to be pretty normal.

(DR. LOU PAPA)     
Hmm.

(DR. PETER SALGO)    
Her doctor said, “You sound depressed,” put her on Zoloft for her mood and sent her home.  Would that have been enough for anybody else here?  What would you have done, anything different?

(DR. GOODMAN)     
Well, I’m concerned when I hear that somebody’s off balance, and — and I, as a neurologist, of course, would do a detailed neurologic exam, and that would include some — some challenges to — to balance, like standing on one foot and walking one foot in front of the other.

(DR. PETER SALGO)    
Over the course of a year, she and her doctor worked on Zoloft doses.  It’s a year later.  Now she has headaches.  Her legs are restless at night.  She tells her doctor now that she’s been having trouble walking, and she describes her difficulty as walking through mud.  She adds that she sways when she’s tired, and in the year interval that they’ve been working with the Zoloft, she said she’s become more moody, more irritable in spite of — of everything.  What do you want to do?

(DR. ANNE CROSS)     
Well, I — I’d like to know more about what has happened in the interim.  Has this been episodic?  Has it been continual and progressive?  Have — and I’d certainly want to do another neurologic exam.

(DR. PETER SALGO)    
Well, they do a physical exam, and in the office the exam showed she was — and this is a quote — vaulting with her left leg and dragging her right toe compared to the left.  She’s right-handed, but her leg strength on the right was less than on the left, and her reflexes were brisk and symmetrical.  Any red flags here?

(DR. LOU PAPA)    
Well, she has neurologic findings.  She has obvious neurologic findings.  I can’t say what it’s due to, but it still raises the concern if there’s ischemic disease, if there’s demyelinating disease, if there’s metastatic disease —

(DR. PETER SALGO)    
All right.  Let’s — let’s get some definitions.  Ischemic disease, not enough blood?

(DR. LOU PAPA)    
Right.  So there’s…

(DR. PETER SALGO)     
Demyelinating disease, that there’s something wrong with the nerves themselves?

(DR. LOU PAPA)    
With the nerves, their functioning, right, or if there’s space-occupying lesions in her brain.

(DR. PETER SALGO)    
A mass, a tumor?

(DR. LOU PAPA)    
Right.

(DR. PETER SALGO)     
Emma says to her doctor, at this point, she’s worried about her breast cancer.  She says, “Could my cancer have metastasized or spread to my brain?”  That a reasonable concern?

(DR. GOODMAN)    
Absolutely.

(DR. LOU PAPA)    
Yep.

(DR. PETER SALGO)    
All right.  What would you then do?

(DR. LOU PAPA)    
I want a scan.

(DR. PETER SALGO)    
They did.  They got an MRI and an LP, a spinal tap, at the same time.

(DR. LOU PAPA)    
Mm-hmm.

(DR. PETER SALGO)    
The good news is there was no breast cancer in her brain, but there are three lesions in her brain and one in her cervical spinal cord, which are consistent with something that you mentioned, Lou, demyelination.  So no cancer but some demyelination in her brain.  What on earth is this?  Somebody want to help me here?

(DR. ANNE CROSS)    
Well, this could be the beginning of multiple sclerosis, which is the most common demyelinating disease in the central nervous system.

(DR. PETER SALGO)    
Well, she’s told, by her doctor, that she has MS.  Define it for me.

(JOYCE NELSON)    
As best we know, it is a — a disease of the central nervous system —

(DR. PETER SALGO)    
Okay.

(JOYCE NELSON)    
— the spine, the brain, and — and it — it could be caused by a cascade of events that may have occurred even in — in childhood that would set something off in later life.  So we — we believe there are some environmental or — or some kind of triggers that happen —

(DR. PETER SALGO)    
Mm-hmm.

(JOYCE NELSON)
early in life.

(DR. PETER SALGO)
Are there different kinds of MS?  What are we talking about here?

(DR. GOODMAN)
So MS is notoriously variable and, at times, very difficult to diagnose, and I think we’re seeing that in — in this case, Peter.  It can be quite subtle and a lot of different types of doctors can — can — can certainly miss it.  So what is my —

(DR. PETER SALGO)
Yeah, what is myelin, anyway?

(DR. GOODMAN)
Myelin is — is a — a fatty tissue that wraps around nerve fibers.  In — in this case, we’re talking about the central nervous system, so brain, spinal cord, optic nerves.  These are the places where — where MS hits, and our best understanding about MS is that the — the immune system, normally protects us from infections, goes on the attack for reasons, as Joyce mentioned, we don’t fully understand, but goes on the attack and actually causes irritation or inflammation in the myelin, and that results in symptoms.  Myelin is — is — is critical in nerve function, because the nerve signals actually are enhanced because of the insulation, a fact of — of the myelin.  So if the —

(DR. PETER SALGO)
So it’s like the wires in your house with the —

(DR. GOODMAN)
If the insulation breaks down, then the nerve signals don’t get through properly, in a coordinated and rapid fashion.

(DR. PETER SALGO)
Mm-hmm.  Now, I don’t want to — I don’t want to let this opportunity go, because we were talking about what the brain looks like, what an MRI looks like, and I know you brought a picture to share with us.

(DR. GOODMAN)
Well, what we see here is — is what’s called an — an enhanced or contrasted MRI, and what — what happens here is that the patient is undergoing the MRI and one set of pictures is taken without intravenous contrast, and then this picture is after contrast has been administered.  It lights up, as we see in this picture.  In the upper right hand, there’s a — a white — large white spot.  That indicates there’s an area of inflammation at that spot, and on the other side, on the left side, a smaller white area, again an area of active inflammation.  And these both happen to be in areas where there’s densely — densely-packed myelin, and so these are areas where there’s inflammation in a myelinated area and these would be typical abnormalities for somebody with active MS.  These can go away, these can get better over time, but unfortunately they can also leave scars where the inflammation had been.  If somebody is — is struggling with new symptoms, and if they had an MRI with active disease, I would try to ameliorate those symptoms with the use of high-dose corticosteroids for a brief period of time, a burst of steroids to try and bring down the inflammation that we — we see on the scan.

(DR. PETER SALGO)
Now, she’s had some symptoms which seem to have come and gone a little bit, if I interpret this correctly.  Is that typical of MS?

(DR. GOODMAN)
That waxing and waning is actually quite typical early on in MS.  So that’s one pattern.  Another pattern, much less common, is — is what we call now primary progressive MS, where, in fact, there aren’t — there aren’t attacks or exacerbations but just a — a slow worsening over a period of — of — of months and years.

(DR. PETER SALGO)
 Now, Vlad, while — while he’s been describing all of this, you’ve been nodding.

(VLAD STEFANOVIC)
Yeah.  About a month and a half before I was to be married, I woke up and the room was spinning.  It didn’t stop spinning for a month, month and a half.  

(DR. PETER SALGO)
That’s dreadful.

(VLAD STEFANOVIC)
I lost sixty pounds, because I couldn’t keep anything down.  At about halfway through the month, my ear started experiencing, I guess, tinnitus.  There was this huge roar inside my ear, where I couldn’t hear anything.  I actually immediately thought that I had MS, because my father had MS.

(DR. PETER SALGO)
Ah.

(VLAD STEFANOVIC)
And I figured this is it.  So —

(DR. PETER SALGO)
That must’ve been terrifying.

(VLAD STEFANOVIC)
It was, it was.  I had an ear, nose and throat person do an MRI, because I told her I suspected that.

(DR. PETER SALGO)
Mm-hmm.

(VLAD STEFANOVIC)
And she showed me the MRI and she showed me the lesions, but she couldn’t tell me what it was, and pretty much I went to the neurologist at my HMO.  He couldn’t really tell me what it was, either.  I — I still knew what it was, but nobody was telling me, and — and I asked that neurologist, “If I do have MS, what do you do about it?”  And he said, “We — pretty much what we do is we watch you for five years, and that way we’ll see what the course of the disease is going to be.”

(DR. PETER SALGO)
Now, how long ago was this?

(VLAD STEFANOVIC)
This was ’94.

(DR. PETER SALGO)
That’s a long time ago.  How long did your symptoms last?  Did they get better?

(VLAD STEFANOVIC)
They got better, after a while, and then I got new symptoms and those lasted for a while, and those got better and then I got new symptoms, and those lasted for a while and those got better.  So I had multiple attacks.

(DR. PETER SALGO)
I guess the question in your mind and the question in Emma’s mind must be is this curable.

(JOYCE NELSON)
Not curable.

(DR. PETER SALGO)
Not curable.

(JOYCE NELSON)
Not curable, treatable —

(DR. PETER SALGO)
Okay.

(JOYCE NELSON)
— in many cases, not all cases.

(DR. GOODMAN)
I prefer to say not yet —

(JOYCE NELSON)
Not yet —

(DR. GOODMAN)
— curable.

(JOYCE NELSON)
— curable.

(DR. PETER SALGO)
You’re talking about real treatments here —

(JOYCE NELSON)
Absolutely.

(DR. PETER SALGO)
    •    that really work.

(JOYCE NELSON)
Absolutely very, very real treatments that — that really work in — in a certain percentage of the population, and this is part of the challenge is that, depending on the course of the disease, for some people the — the — the treatments appear to be very effective, and for a significant portion of the — of the people they’re — they’re partially effective or effective for a while or not effective.

(DR. PETER SALGO)
And when you tell somebody that this person has MS, what typically do they say, how do they feel?

(DR. ANNE CROSS)
In general, my observations have been that patients are depressed for six to twelve months afterwards.  Some patients seem to accept the diagnosis right away, other people don’t, so we have to try to treat the whole patient in addition to offering the medications that we have.

(DR. LOU PAPA)
A lot of patients, when they’re — at least that I’ve seen — automatically assume they’re going to be in a wheelchair, that they’re going to spend their life in a wheelchair, they’re going to end up having somebody else care for them when they’re diagnosed with MS, and that’s their biggest fear.

(DR. PETER SALGO)
Now, Vlad, you’ve got a cane.

(VLAD STEFANOVIC)
Yes.  I just started using a cane a few months ago.

(DR. PETER SALGO)
Okay.

(VLAD STEFANOVIC)
My disease has progressed, and my left leg is having quite a bit of problems.  The distance that I can walk is reduced now.  But I can tell you how some people feel when they’re first diagnosed, because I ran a support group for a while when I was in Cambridge.  They — some of them think they’re going to die and they’re scared, and they want somebody to tell them that it’s going to be okay.

(DR. PETER SALGO)
So, initially, though, they did nothing for you, they watched.

(VLAD STEFANOVIC)
Well, my wife was an RN, and she decided that what that neurologist said is — was pretty ridiculous.  She said, “That’s not acceptable,” and she found a great doctor and he said, you know, “That’s not the truth” and he — and he — I went on Avonex.  I went on one of the interferons.  And I was great.  I was — I did fine for like nine years, nine, ten years, and then that stopped.

(DR. PETER SALGO)
All right.  They put her on Avonex.  What is Avonex?

(DR. GOODMAN)
So Avonex is a — one of the formulas of interferon that is — that is in current use that

(DR. PETER SALGO)
Kind of drug that worked pretty well for you at first?

(VLAD STEFANOVIC)
Yes.

(DR. PETER SALGO)
Right?

(DR. GOODMAN)
But to be clear, it’s more of a preventative treatment.  It’s not really meant to make people feel immediately better.  It’s a long-term treatment to prevent new lesions from occurring.

(DR. PETER SALGO)
Well, while on the Avonex, she got some side effects.  She got flu-like symptoms, including fever, chills, generalized muscle aches, and fatigue.  So they changed her drugs.

(VLAD STEFANOVIC)
Those were horrible.

(DR. PETER SALGO)
You got those.  Tell me about them.

(VLAD STEFANOVIC)
Oh, my God, I couldn’t — I ended up learning that if I took Benadryl the night before the shot, I could sleep through those side effects, but those first few weeks, oh, it was horrible.  It was like having a flu every week.

(DR. PETER SALGO)
Well, they put her on a different drug.  They added — or they changed her to Copaxone.  Tell me about that.

(DR. ANNE CROSS)
That’s glatiramer acetate.  It’s the —

(DR. PETER SALGO)
Oh, that really explains a lot.  Do you want to help me out on this?

(DR. ANNE CROSS)
It’s a random polymer of four amino acids that are very common in myelin basic protein, which is a antigenic target within myelin in the central nervous system.

(DR. PETER SALGO)
Right.

(DR. ANNE CROSS)
This is a drug that we actually don’t know how it works fully, but it appears to decrease the relapse rate of relapsing remitting MS, and it appears to probably slow down progression, as well, but again not a cure.

(DR. PETER SALGO)
I’m hearing a repeating mantra here.  When you get these drugs, the object is not to feel better than you’re feeling now — maybe the steroids will do that —

(DR. ANDREW GOODMAN)
The steroids —

(DR. PETER SALGO)
— but the drugs will keep you from getting worse and change the ballistic course of your disease.  Is that a fair statement?

(DR. GOODMAN)
Well, that’s the hope.  In some people, they seem to respond in a very sensitive way to these treatments and — and may, in fact, not have any more attacks, but in others they’re really only partially effective or not effective at all.  We’re — we’re trying to rebalance the immune system with interferon or with glatiramer acetate, so that it’s not predisposed to — to — to cause these areas of inflammation.

(JOYCE NELSON)
I think also I understand that — that — that — that the unpredictability of the disease, whether — whether or not this therapy is going to work, how long it’s going to work, “Am I going to be able to — am I going to be able to stay employed?  What’s the impact this is going to have on our family?” I think — I think makes multiple sclerosis particularly difficult, because it’s not an individual disease.  It really is a family disease.

(DR. PETER SALGO)
Mm-hmm.

(JOYCE NELSON)
It’s a — it’s a — it’s a chronic, often progressive — you don’t know what the progression is going to be, and so it’s that unpredictability to say this was, you know, six weeks before your marriage.  I — I’m wondering if you even said, you know, “Should we get married?  Should we go forward?  Should we have children?”  I mean, these are the kinds of things that — that people talk about that don’t get fixed with a shot every week.

(VLAD STEFANOVIC)
I did and my wife was like, “No matter what, I’m still with you,” so it was like, wow, great person.

(DR. PETER SALGO)
That’s pretty amazing.

(VLAD STEFANOVIC)
Yeah.

(DR. PETER SALGO)
That’s great.

(VLAD STEFANOVIC)
Yeah, I found a good one.

(DR. PETER SALGO)
I’ll fill you in a little bit more about Emma.  While on the Copaxone, she had another MRI, and the MRI showed she had a new enhancing lesion.  So she went off the drug, not so, but she did go off the drug, and a later MRI showed two more lesions.  Now what?

(DR. ANNE CROSS)
I’d like to know how long she was on the Copaxone before the MRI was done.  If it was done very shortly after she began, then maybe it’s not reflective of that particular medication.  I actually think it might be worth a try thinking back to the beta interferons again, because she was removed from that due to — to intolerance of the drug, not, as far as I could tell, due to it not working.  So we learned through the years that if you start patients very, very slowly on interferons, give them quarter dose for a while, then half dose —

(DR. PETER SALGO)
Mm-hmm.

(DR. ANNE CROSS)
— that can help them tolerate it, and maybe she would be able to tolerate one of the interferons.

(DR. PETER SALGO)
So I want to stop for just a moment and sum up what we’ve been discussing.  The progress, the severity and specific symptoms of multiple sclerosis can vary from patient to patient and cannot necessarily be predicted, and many forms of multiple sclerosis — I think we need to really emphasize this — are very highly treatable.  Is that a fair statement?  All right.  Then, let’s keep going, because we’re discussing Emma.  She has what they’re calling relapsing remitting MS.  What does Emma’s diagnosis mean to her in terms of day-to-day life, in terms of expectancy, making plans, things like that?

(VLAD STEFANOVIC)
It’s almost impossible to make plans.  I mean, at — I don’t know.  At the time when I — before I started the — the interferons, I didn’t know from day to day whether I was going to wake up and I wasn’t going to be able to — whether I would have double vision, whether I wouldn’t be able to drive, whether I could hear.  I lost taste for a while in my tongue.  I — I mean, there are so many different things that can go wrong.  I started the Avonex and things — life was a lot easier and I could start making plans, and then that started to sort of wear off.  And then I did start the Tysabri, and that seemed to be going well for a while.  And then I started progressing again.

(DR. PETER SALGO)
Do you make plans for the future?

(VLAD STEFANOVIC)
I think you have to plan for the future.  I mean, you have to plan financially for the future, like what’s going to happen to my wife and kids if I, for some reason, can’t work, if I have to go on disability, even if I have to go into a nursing home.  So —

(DR. PETER SALGO)
Not pleasant.

(VLAD STEFANOVIC)
No, it’s horrible.

(DR. PETER SALGO)
And all of this hits Emma.  What about her family?

(JOYCE NELSON)
Often, of course, the roles will change within a family.  So children will take on more responsibility.  I’ve talked to people where — where kids have actually ended up being almost care givers for their own parents, young children, nine or ten years old.  So the roles in a family will shift.  And — and someone who’s going through the — the kind of depression that MS can bring is going to have an impact on a family, as well.

(DR. PETER SALGO)
Dr. Goodman, you do this all the time.  You’ve been in this field for a long time.  What keeps you in the business?  What keeps you looking at this disease?

(DR. GOODMAN)
Well, you heard me say not yet before, because — because we are really making a lot of progress in — in therapies with MS —

(DR. PETER SALGO)
Mm-hmm.

(DR. GOODMAN)
— and understanding the — the immune system, and — and because of that we have new approaches at attacking the problem and we’ve made a lot of headway.

(DR. PETER SALGO)
That’s great.

(DR. GOODMAN)
And so I’m very hopeful with — with additional research, often funded by the NIH and the MS Society, that we’ll — we’ll continue to make progress.

(DR. PETER SALGO)
Let’s get back to the case.  It’s five years later.  Emma is now in her neurologist’s office complaining of persistently poor vision, and it’s interfering with her work.  She’s unwilling to try Tysabri because of the once month IV infusions, and she worries about the side effects.  She’s willing to consider Neurontin to deal with the periodic movements that are affecting her sleep here.  Is that her only option?

(DR. ANNE CROSS)
Well, one option would be to consider getting herself involved in a clinical trial of a new agent.  I mean, there are several on the horizon and there are several clinical trials ongoing around the country.  So hopefully she would not be too far away from a clinical trial that she might fit into.

(DR. PETER SALGO)
Well, they gave her Ampyra — which she agreed to take.  She tells her doctor that she’s hopeful.  How is Ampyra different?

(DR. ANNE CROSS)
Well, that’s a symptom medication, and it’s very helpful in many people.  It — it speeds up conduction through — through demyelinated nerve fibers.  So patients can actually function better, but it’s not a — and — and they’re — and it’s a very good drug and there’s nothing else right now in its category, but it’s not a drug that’s going to change the long-term outcome of the disease that — as far as we know.

(DR. GOODMAN)
But to be clear, it is not a substitute for what we call disease-modifying or immunomodulating —

(DR. PETER SALGO)    
Let’s stop just for a minute and sum up a few more things.  Research, clinical experience are incrementally making treatments for multiple sclerosis more successful.  Giving individuals a better quality of life is apparently what’s been going on or, to sum it up, as you’ve said and you’ve said, there’s some hope here.

(DR. GOODMAN)
Yes, there — there — there’s always going to be hope because we’ve made some progress, and — and — and we’ve got to take it, of course, to the next level and to the next level.  We don’t have treatments for progressive disease at this point, but, as Dr. Cross said, there are clinical trials going on, new avenues being explored, and — and absolutely there — there’s hope.

(DR. PETER SALGO)
Do you feel it?

(VLAD STEFANOVIC)
Kind of feeling less as I go along.  You know, I — like I said, I mean, this summer I’m thinking my kids are going to be playing soccer and I’m going to have a hard time getting out to the soccer fields.  I’ve been looking at this thing, where I know the neurologists are scared to even hear the — or not happy with the term, but CCSVI.  There was recently a study done by an Italian neurovascular person, and he discovered that people with MS have a narrowing in their jugular veins and that that could be part of the trigger involved with MS, or it may not be connected with MS at all.

(DR. PETER SALGO)
What do you think?

(DR. ANNE CROSS)
Well, this is chronic cerebro-spinal venous insufficiency.  That’s what the CCSVI stands for.  It’s an intriguing and not clearly understandable association with MS.  It definitely deserves more investigation.

(DR. PETER SALGO)
There are patients, who have heard about this, with MS who are clamoring to have this treated right away by vascular surgeons.

(DR. GOODMAN)
Right.

(DR. PETER SALGO)
Would you advise them to do so?

(DR. GOODMAN)
So I don’t recommend that yet.  I think it’s too new.  We really don’t — we really don’t know how safe the procedures are, and we really don’t know yet whether — whether or not it’s a reproducible finding let alone a treatable finding.

(DR. PETER SALGO)
Vlad, are you prepared to wait?

(VLAD STEFANOVIC)
I don’t have a whole lot of time to wait, actually.  I would like to see things move faster.  I just think this sounds fairly reasonable and I was hoping that research could advance a little bit faster for me.

(DR. LOU PAPA)
The — the problem you’ve got to be careful — and I’m not being prescriptive here just because I — this — this comes up regularly and a lot.  You understand you have a progression condition, you’re concerned, but at the same time we have this condition and a small group that’s done, especially because the nature of MS, it does get better on its own.  So you don’t know specifically if those patients really got better from that or not.  The second part of it is you don’t really know how many people who don’t have MS have this situation.  So there’s — you’re looking at a denominator that’s very difficult, plus you’re — the down side.  If somebody’s manipulating vessels that are draining from your brain, there could be catastrophic outcomes from that.

(VLAD STEFANOVIC)
For me, it — it makes sense to take risks in certain cases.  I mean, it’s a cost benefit analysis to me.  

(DR. LOU PAPA)
Absolutely.

(VLAD STEFANOVIC)
This risk is worth it based on whatever the benefit might be.

(DR. PETER SALGO)
I mean, for what it’s worth, I — I don’t think there’s any doctor in the world that doesn’t feel the pain you’re feeling and understand your impatience with your disease clock ticking.

(VLAD STEFANOVIC)
I agree with that.  I agree.

(DR. PETER SALGO)
By the same token —

(DR. LOU PAPA)
Yep.
(DR. PETER SALGO)
— nobody wants to hurt somebody, and so this requires a certain amount of care.  So I’m going to give you the last word.  Where do we stand today?

(JOYCE NELSON)
It is a time of hope, and there — along with the therapies that have been described and — and even with the radical new approaches that are on the horizon, the pipeline for — of — of research is — is full and there’s so much to offer for people for — for Emma when she comes in with a new diagnosis, so many things that were not even dreamt of twenty years ago and now ten years ago.  So it’s — it is absolutely a time of hope.

(DR. PETER SALGO)
Well, I want to thank all of you.  The clock, unfortunately, is our enemy too, and we are out of time.  But you can continue this conversation on our Web site, Second Opinion dash TV dot org, O-R-G, where you’ll find transcripts, videos, more about MS and other healthcare topics.  I want to thank you for watching, and I specifically want to thank all of you for being here.  And thank you for coming, as well.  It’s not easy to talk about a — a disease that you’ve got before, we hope, millions of people.

(VLAD STEFANOVIC)
No, it isn’t easy.

(DR. PETER SALGO)
Not easy at all.  I’m Dr. Peter Salgo, and I’ll see you next time for another Second Opinion.

(MUSIC)

(ANNOUNCER)
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an association of independent, locally-operated and community-based Blue Cross and Blue Shield plans, supporting solutions that make quality, affordable healthcare available to all Americans.

(ANNOUNCER)
Second Opinion is produced in association with the University of Rochester Medical Center, Rochester, New York.