To Chopaka and back again

Moon over Chopaka

ln recent years my brother Bill, and I have made an annual trip to fly fish at a lake called Chopaka.  Chopaka is a remote lake in the north central part of our state perched near the Canadian/US border. I have always enjoyed camping and fishing but this time I found myself wanting to back out as the time approached. Not going anywhere is an option that increasingly enters my mind when there is a choice.  Aging, feeling tired from Parkinson's and the drugs that go with it, may contribute to such feelings.  Thankfully I opted not to take the easier choice and managed to be enthusiastic and garnered the strength to make the trip to Chopaka with my brother.

The drive to and from Chopaka is lengthy and is in the end difficult and hazardous.  The good part is that brother Bill does the driving and I get to ride with a very good driver, enjoy the scenery and the company of one of the people I admire most.  After spending our first night in a motel, we followed highway 97 East and North to the town of Tonasket. From there the final 20 miles to the lake finishes with at least 10 miles of steep, rough and just plain nasty road.  This stretch of the road is in non maintained condition with no covering of gravel and which means it is down to driving on sharp bedrock.  Early on this portion of the road is very steep and to make things more difficult there is an assortment of rocks baseball size and larger that have fallen on the road after rain or livestock or wild life knocks them loose from the rocky and nearly vertical wall that rises on our left.  On the right it is a near vertical drop off with no guard rail.  Thankfully the road soon levels a bit and pine forest complete with grazing cattle filled in around us. The thrill of being in the mountains of the Okanagan country of Washington state has begun to settle in.  the theme from the classic 1956 western movie, "The Big Country" begins to play in my head.  No matter how old I become or whether Parkinson's is trying to take charge of my ambition being among mountains like this will always be a thrill.

Eventually the road forked and after some hesitation we took the left fork and climbed a bit more and from here got our first sight of the lake which now stretched out below us lying among green meadows and open forest of Ponderosa pine. It is always a site so grand that it sweeps away the fatigue of the long and difficult drive.   Bill descended this final stretch carefully with our tent trailer in tow, down to the Chopaka Lake campground. Cool weather and slower than normal fishing meant that there were plenty of sites to choose when we arrived, including our favorite site of previous years in the grass near the shallow end of the lake.  We carefully parked the truck and the tent trailer that was intended to be our mountain home for the next several days. Then we busied ourselves unloading gear and completing a variety of tasks needed to set up camp prior to putting on the fly fishing gear and hitting the water.

I have always enjoyed the birds of Chopaka and quickly spotted some old friends and maybe some new ones hanging about: redwing blackbirds, western tanagers, goldfinches, swallows,  bold and lovely robins and ducks with many babies trailing. I noticed that the June sun carried some heat as I walked rocky path to the pit toilet that would be our amenities for the next several days. Along the way a young and small snake earnestly slithered across my path holding his head high like a determined child and yet his appearance was a bit more sinister that the typical garter or gopher snake. I focused in on his triangular head and later identified him as a member of the Western rattlesnake family.  Still very young, he as yet had no rattles. I thought about the snake but we kept our eyes open and did not see him again, nor any more of his family.

Bill preps the rods

With an afternoon of fishing ahead I put on chest high, breathable and leaky waders. I also had a cap to protect my face from the sun and a pair of polarized sunglasses to protect my eyes. I finished preparations and selected my favorite rod. A rod I had finished myself from a blank made by a company simply known as Sage.  The rod remains a prize possession from years gone by when sans tremor I carefully wrapped and finished it myself.  Bill helped me pick out a fly and tied it on for me since my own ability to tie on flies and threading gear is sometimes both difficult and slow.   I access the lake via a float tube that surrounds me and keeps me above waterline. Nothing fancy but it works. I keep close in and fish for rainbow trout feeding on insects among the weeds.  It seems PD has had some effect on my legs ability to kick and propel.  Strangely my left leg wanted to drag. I stayed close in and got off the water when the wind picked up. That first day the wind increased and churned the water into whitecaps and I was driven off the water early and got no fish.

Among fly fishers there is constant talk of insect hatches and the impact they have on the feeding patterns of the rainbow trout that inhabit the lake.  The kinds of flies that are hatching dictates the pattern of fly chosen to trick the fish into thinking they are chomping on a natural snack.  I like to fish the reedy shoreline for trout feeding on the numerous insects that hatch among them. I make short casts that allow my fly to touch the water gently just in front of the reeds and occasionally is followed a flash of action and a quick tug at the end of my line that race the pulse like nothing else in the world.  On day two my luck turned a bit better and the following two days I got two fish a day.  Thank goodness PD tremors are resting tremors and I can bring fish in and retrieve line pretty good.  I have to be very careful when I hold my rod in my right hand and do not pay attention to the tremors.  That combination can produce some pretty mean snarls of leader, fly and line in an amazingly short period of time.

The nights were chilly, reaching down into the 40's but Bill kept the inside of his tent trailer quite warm. Three of the four days we were  out I slept poorly.  After going to sleep at 10 PM I would wake up before 1 AM and lie in the warmth of my sleeping bag and think about much but PD continues to be a dominant topic. I also wonder why elements of my faith gnaw at me during these nights and continue to raise questions that seemingly have no answers. Answers I do not have and underscore the need for faith. Trips outside were frequent during the night and were both annoying and inspiring.  Annoying in that a sense of urgency drives you out and into the cold of the high mountain night.  The inspiring part was stepping out into a crisp full moonlit night in the mountains with legions of frogs providing a full musical score.  

During the course of of nearly 4 days of fishing we were confronted with an assortment of weather and both the good and bad of insect life.  At times the wind blew up white caps on the water while I sat in my camp chair and sipped a brew.  There were times of 80 degree heat when I smeared on mosquito repellent to keep the pesky blood biters at bay.  There were also the periods of beauty and tranquility on the lake, when the callibaetis hatched and the the trout came up from somewhere in the depths and began to rise for a taste of this most natural snack.  Or the simple pleasure of basking in the sun and stretching out in comfort while again enjoying the taste of an ice cold ale.  I also recognize that if not for my brother and my decision to go in spite of the effort that Parkinson's presents that I would not have these memories.  Memories to savor while I sit at my desk dreaming of colorful rainbow trout and the elusive callibaetis and prepare these notes to share them with others.

Shaky in Coupeville

Good bye Chopaka for another year

Pesticides, Family and Rural Life

My brother, mother and I  circa 1955

Heredity, genes and environmental toxins are keys to understanding what is currently known about the cause of Parkinson's Disease.  In my personal quest for cause I have examined how my life history of exposure to environmental toxins fits in with the factors listed above. 

The Search for Cause
It is known that a small percentage of patients acquire Parkinson’s by directly inheriting it. The inherited disease is usually seen in families of Mediterranean descent who carry specific genes that produce it. (Tanner 1)  Genes are the working units of heredity and each contains DNA coded to manufacture protein for a specific purpose. Inherited genes that cause Parkinson’s are called causal genes. Causal means that If you inherit one of them you will get Parkinson’s. It will need no help from any outside source. (Gwinn 1) 

In the majority of cases of PD the cause is more of a mystery and requires a bit of speculation based on information that is currently known.  With this in mind it is now believed that both environmental and genetic factors play a role in causing the disease in non inherited PD. (Tanner 1)  Specific gene variations have been identified as being associated with PD. These genes alone are not thought to cause the disease independently. It is believed that these “associated genes” must combine with environmental toxins and/or other genes to cause the disease.  Those who have these genes may never get PD but they may. (Gwinn 1) (Tanner 1) Once the damage is done to associated genes and the process known as Parkinson’s is set in motion it cannot be stopped.  

Environmentally a number of specific chemicals and occupations that put people in close contact with them have been linked to a higher risk of Parkinson’s. Possible chemical exposure and increased PD risk frequently appear in the news media and literature. Pezzoli and Cered, after an extensive review of controlled studies of PD and chemical exposure concluded that:

PD risk was increased by exposure to any-type pesticides, herbicides, and solvents.  The risk associated with rural living was(also) found to be significant.

Other substances that have been identified with increased risk of PD include fungicides and the villain of Vietnam, agent orange.  A drug of abuse called MPTP is known to produce Parkinson’s by itself.  Recently welding has been identified as a higher risk of PD occupation

With this information in mind I reviewed periods of my life in an effort to highlight how easily exposure to chemical risk factors for PD may have occurred.  Keep in mind that many of these things happened a long time ago and my memory creates an approximation at best.

Rural Living
My family moved to a small acreage when I was 5 years old.  Our new home had a beautiful cherry orchard on it and the orchard was a source of both pride and supplemental income for our family. Unfortunately A major freeze in 1955 killed all of our trees. Dad was a determined man and he soon replanted the acreage with new trees and Cherries remained a part of our lives. 

Organic was not thought of in the 1950's and difficult pests such as the cherry fruit fly mandated  insecticidal spraying at routine intervals. My Dad paid a man to do the spraying in the early years.  When I think about it I can still see the man arriving on his tractor, clothed in rain slicker clothing and towing a big tank full of spray on wheels.   A noisy pump was attached to the large tank of spray and it powered a sprayer behind the tank that produced a soaking fantail of pesticide spray.  The man would start the pump and then slowly drive the tractor with its fountain like sprayer up and down each row of trees, soaking everything on both sides. My mother did what she could to protect us from exposure to the spray and kept my brother and I in the house while the man did his job.

I spent endless hours in the cherry orchard in my childhood years. I recall eating ripening cherries, that still had the dried spray patterns on their skins. I had been warned about spray, but I rarely bothered even to rinse the cherries I picked from the trees.  Myself and other neighborhood children played in the irrigation ditches that ran down the rows of trees as if they were clean mountain streams.  We swam in the open irrigation ditches that ran through nearby farmland.  The ditches without doubt carried agricultural chemical carrying runoff.  I could easily say that my childhood years in rural eastern Washington were something very special.  I could also say that due to my own carelessness those years were loaded with exposure to significant quantities of pesticides and other farm chemicals. I never imagined that there might be a day of reckoning much later in life.

So what about my brother who is four years older than me and is free of Parkinson’s?  Why would one who grew up next to me and is an agent orange exposed Vietnam veteran remain free of the disease?  The answer is likely found in the genes we inherited.  Just as I am color blind and he is not, I must carry the genes that when activated went on to cause the disease and he must not carry them.  Also I cannot think of any childhood friends who currently have Parkinson’s disease. This may mean that none of them possessed the genes either.  Even more important, I really do not know what happened to most of them.

Hospital Pharmacy
Other periods of chemical exposure also nag at me, especially the many years of working in hospital pharmacy.  In those years I worked around chemotherapeutic drugs and often reconstituted and prepared the drugs for administration. Exposure risks are very real in this environment. A group of Canadian researchers looking for contamination simply swabbed the hands of pharmacy personnel working in a chemotherapy preparation environment.  Detectable amounts of contamination was found. (Astrakianakis et al 1)  The protection provided for those of us who worked with chemotherapeutic drugs in 80's, 90's and even the 2000's was very inadequate by today's standards. 

I have to admit that I have not been able to find a connection between long term exposure to chemotherapeutic drugs and PD but I remain suspicious.  These drugs are highly toxic and both acute and chronic health risks have been attributed to them. (The National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC)1)

I have thought of many additional exposures to chemical toxins in my life.  These span the home ownership years and range from diazinon to Penta, a now banned wood preservative. 

I am left to wonder how the things  we are learning about "causal genes, associated genes"and environmental toxins could be of value to others.  Therapeutic intervention in the roles inherited "causal" genes play in the genesis of PD will require further research.  The influence of the array of chemicals that have become environmental toxins have on "associated" genes can be modified at least in part by our own choices and actions.  More importantly we can have a part in warning the generations yet to come that poisoning our environment with environmental hazards is not without consequences.  And most urgently: Teach your children well.

Shakey in Coupeville



Sources

• What Causes Parkinson Disease?Medscape interviews Caroline Tanner, MD, PhD, on major advances in the understanding of Parkinson disease, along with potential therapeutic approaches. Medscape Neurology, July 2012

• Genetics and Parkinson's Disease: What Have We Learned?  By Katrina Gwinn, M.D.
Originally published in the winter 2009 issue of PDF's Newsletter, News & Review.

• Exposure to pesticides or solvents and risk of Parkinson disease.  Pezzoli G, Cereda E.Neurology. 2013 May 28;80(22):2035-41. doi: 10.1212/WNL. [PubMed - indexed for MEDLINE]

• Can J Hosp Pharm. 2011 Sep-Oct; 64(5): 327–332. Pilot Evaluation of Dermal Contamination by Antineoplastic Drugs among Hospital Pharmacy Personnel.  George Astrakianakis, PhD, Quinn Danyluk, MSc, CIH, Winnie Chu, Chun-Yip Hon, MSc(A), CIH, CRSP, is a PhD candidate in the School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia. At the time this study was performed, he was also with Disability Management and Safety, Vancouver Coastal Health, Vancouver, British Columbia

• Welding Fumes May Cause Early Parkinson-Like Brain DamageA study shows damage to the dopamine system in the brain of healthy welders and manganese-laden fumes may be the culprit. News, Medscape Medical News, April 2011

New Life and Parkinson's Research

Fish on! Bill at Chopaka Lake, Washington

Refuse to be average. Let your heart soar as high as it will.
A W Tozer


The doctor, a movement disorder specialist at the University of Washington, looked directly at me and said "you have Parkinson's".  "Are you sure?"  I questioned.  He quickly responded: "as sure as a human being can be."  He then added that I was unique since I had presented without being on any medication.  His nurse who had hustled off a few minutes prior, now returned and handed my wife, Carolyn, a lot of stuff for us to read and watch at home. The doctor continued and said that I might be an ideal candidate for a new study being sponsored by the Michael J. Fox foundation.  He said the study is considered important and is ambitious.  He also added that they are looking for newly diagnosed patients who are not yet on medication.  He explained further, that if I chose to participate, I would be asked to wait for 6 months prior to starting any medicine and then added, "if you can stand to wait that long."

Once home the materials the nurse had gathered for us at the clinic were helpful and contained significant details about the Fox foundation study and I learned it was called PPMI. PPMI or Parkinson’s Progression Markers Initiative is a broad multi site study with locations in the United States, Europe and Australia.  It has been designed to search for biological markers that would indicate both the presence and progression of PD. A valid marker when identified would be valuable in diagnosing the disease early.  Perhaps more importantly it could be a breakthrough research tool for use in drug trials aimed at determining whether medications actually act to modify the progress of the disease.  These are ambitious goals.  The study uses neurologic imaging, blood, urine, spinal fluid and clinical and behavioral tests in the quest to achieve their goals.

Among the materials I had been given I found that the Washington State Parkinson’s Disease Registry collects information about PD patients and then as appropriate connects them with the research community. I punched in the number.

 The Registry was my first contact with anyone connected with Parkinson’s research and it was very positive.  The young woman on the other side of the phone call was personable and led me through a series of questions designed to identify the specific symptoms I was experiencing.  She asked my age and the date of diagnosis and who made the diagnosis and what other doctors had I seen.  I mentioned to her that I might be interested in the Fox Foundation study I had been told about by my doctor and she said she would contact them.

Shortly after that conversation I received a call from a representative for the Fox Foundation’s PPMI study center located at the VA Medical Center in Seattle.  She affirmed that they were recruiting newly diagnosed PD patients to participate and had more questions, similar to those I had previously answered for the Registry.  She finished up and invited me to come to Seattle for a thorough examination intended to verify my diagnosis prior to actual enrollment in the study.

Why would I want to participate in a study that would take five years to complete and would require many time consuming trips to Seattle? Additionally it would require that I submit to many tests through the years, some of which made me a bit uncomfortable. The tests included spinal taps on a periodic basis for the duration. Ouch! Choosing to do this would not be in character for me since I have been neither an activist nor an organizational joiner.  Yet facing a future that had suddenly changed the outlook of the days ahead, I found myself thinking differently.  Carolyn and I read Michael J Fox's Lucky Man and watched Back To The Future and Doc Hollywood.

I accepted the opportunity to go to Seattle for PPMI testing.  We looked forward to spending a couple of days in our favorite city.  That is the beautiful city of Seattle on Puget Sound where our youthful romance had first flourished way back in the 1970’s.  Now we were returning for me to be subjected to extensive neurological exams including a new thing called a DaTscan (A dye that enables imaging of recptors in the brain that provides an identifiable pattern for Parkinson's).  Each of these tests on this particular trip were intended to verify my diagnosis.  Once my diagnosis was validated I would be given the opportunity to  participate in PPMI.  The two days presented a fairly intense schedule.  In spite of which we still found time in the evening to take a walk among the familiar streets of the city and go to dinner but we didn't quite feel like we were in our 20's again.

Carolyn accompanied me through most of the testing and we both enjoyed meeting an impressive array of intelligent, caring and personable people associated with the study.  A few days after the exams were completed the phone rang and the voice on the other end informed me that I met the criteria for participating in the PPMI study.  So there it was, I was officially part of what could be a game changing research study and later I even managed to wait six months prior to starting medication.  I felt good about it then and I feel good about it now. It did however dash any thoughts I might have that this disease just might not be for real.

At the time of enrollment in PPMI I was also enrolled in a study being conducted by PANUC
(Pacific Northwest Udall Center) also located at the VA Medical Center in Seattle.  This study follows PD patients over time and collects biological, genetic, behavioral, cognitive and movement information.  The data gathered supports projects conducted by PANUC which focus on complex Parkinson's problems that include movement, problems with memory, thinking, judgement and behavior. For this study Carolyn was asked to participate as a non PD control.

This month I will return to Seattle for my yearly DaTscan*, lumbar puncture, blood draws and a neurological physical exam.  There will also be an array of cognitive tests intended to profile the current state of my thinking capabilities.  Short term memory will be carefully tested by way of an assortment of repeat back the numbers questions and how many details can you remember from a story just read to you and much more.  This exam will be very near to the two year anniversary of enrolling in both studies and I feel just as good about it today as I did then.

In my life Parkinson's arrived as a surprise.  One that makes me think of a June morning when a Chopaka Lake rainbow came up from hiding in the depths among the weeds, broke the surface, grabbed my fly and gave me the fight of my life.  As it is with believing there is power in the gospel, Parkinson's has given me purpose and rebirth while in my 60's.  Like Michael J Fox, "I am a lucky man."

Shaky in Coupeville


Still more:

 DaTscan

*This year the FDA approved DaTscan™ (Ioflupane I 123 Injection) for use to produce images with something called single photon emission computed tomography (SPECT) imaging. This substance permits the detection of dopamine transporters (DaT) in the brains of adults who may have Parkinsonian syndromes (PS). Dopamine is the essential brain chemical that when depleted causes many of the classic symptoms of Parkinson's disease.

DaTscan is the first FDA-approved diagnostic imaging agent to help physicians evaluate  and differentiate neurodegenerative movement disorders, such as idiopathic (of unknown cause) Parkinson’s disease.