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It seems incredible now, but in the late 1980s hospitals in areas with high rates of HIV infection were full of young men with AIDS, many with neurological complications. The HIV epidemic seemed set to spread and one could foresee the management of neurological complications of HIV becoming a large part of neurological practice. Fortunately, public health interventions and highly effective antiretroviral treatments have dramatically changed this. While HIV is still a mimic for many conditions and remains a diagnostic challenge its effect on other pathologies is rather less than one might expect – as illustrated in the case of leprosy reported by Clare Galtrey and colleagues (see page 135 ).
As the threat of HIV receded in the late 1990s, the exponential rise of new variant Creutzfeldt–Jakob disease (CJD) in the UK threatened another neurological epidemic. Once again this fortunately did not develop, presumably because of the public health measures. However, the threat renewed the focus on all forms of CJD, both scientifically and clinically. The UK units in Edinburgh and London collaborated to provide a national surveillance service and to provide excellent clinical and diagnostic input to neurologists who contact them. Simon Mead and Peter Rudge (see page 113 ) provide us the benefit of this experience in describing the mimics and chameleons of CJD. A tricky differential but one we do not have to consider as frequently as once we feared.
How often do you ask your patients about their hobbies? When considering patients for surgery, particularly epilepsy surgery, we worry about language lateralisation and potential motor deficits but do we think sufficiently about the impact the surgery might have on their musicality, the appreciation or performance of music (which your patients may regard as being rather more than just a ‘hobby’)? Melissa Maguire discusses these issues on page 86 – and other links between music and epilepsy (including low-level evidence for the antiepileptic effect of Mozart).
In contrast, Ray Wynford-Thomas and Rob Powell (see page 122 ) work from structure to function and tell us all about that odd bit of cortex that doesn’t quite make it to the surface of the brain – the insula (or Island of Reil) – what does it do and what we do we need to know about it? For some it is the fifth lobe of the brain, adapting emotions and behaviour to changes in the external environment, in what Walter Bradford Cannon (1871–1945) once called, ‘The wisdom of the body’.
We have two very practical reviews to help the jobbing neurologist. Alexander McGeachan and Chris McDermott (see page 96 ) update us on managing oral secretions in neurological disease, to help our patients with difficult drooling and other salivary problems. Simon Cronin and colleagues provide tips to help the neurologist to assess referrals on the renal unit (see page 104 ).
In this edition we have a Test Yourself (from Gemma Maxwell and colleagues, see page 154 ) and a Clinicopathological Conference (CPC) – from the Edinburgh course (Fiona Moreton and colleagues, see page 159 ). Both provide the opportunity to think through challenging clinical cases and of course in the CPC you can pit your wits against the discussant, Robert Brenner, who talks us through his take on the case. But please try to avoid looking at the answers first….
As always, we have an assortment of difficult cases, neurological rarities, striking images and the latest in the Neuromythology series, along with reports from Book Club and Carphology. Everyone can find something useful and practical somewhere in this issue.
Competing interests None declared.
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