• vertigo

Traditions are an important part of Christmas (and this is your Christmas edition). There is a tradition (of which we at Practical Neurology thoroughly approve) that all talks, and most articles, on dizziness and vertigo should start with a quotation from Bryan Matthew’s book, the original ‘Practical Neurology’. In his inimitable style, he captured the therapeutic nihilism and the consequent dejected mood of the neurologist in the early 1960s faced with the challenge of a patient presenting with giddiness. How times have changed. Read the essential quotation and how half a century of vestibular research has demystified dizziness (page 492) and enabled patients to be cured (frequently) or at least helped (usually).

Our clinical challenges have changed with developments in science and in society.

Neurologists recognise that the history is often the most important part of the diagnostic phase of the consultation, and explaining the diagnosis and discussing the next steps are significant parts of the therapeutic phase. So what happens, as often is the case with widespread migration, if the patient does not speak English? How should we tackle this? How do we use an interpreter most effectively? Ben Turner shares his expertise developed from working in the East end of London (page 536) where many patients come from different parts of the world.

Comparing UK practice with that in other countries can make us appreciate how many of our approaches are ‘traditional’ (ie, they follow a tradition) rather than being evidence based. Martin Turner and colleagues discuss tracheostomy in motor neurone disease on page 467, a procedure relatively rarely done in the UK but much more widely performed elsewhere, notably Japan. The different approaches arise from a range of medical and cultural factors, and this paper helps us to understand the issues and explore how to tackle the difficult series of steps that can follow inserting a tracheostomy.

The subspecialty of movement disorders has a strong tradition of making a diagnosis on clinical grounds and of using brain imaging sparingly. But when should we scan? Lou Wiblin presents an unusual and treatable cause of Parkinsonism (page 518) and Rui Araújo and colleagues discuss when we should consider scanning in this situation, encapsulating the dilemma in a traditional Hamlet-themed title (page 462).

Deep brain stimulation (DBS) can dramatically help some people with Parkinson’s disease and other conditions. Fahd Baig and colleagues provide a practical guide for those neurologists for whom this is not a specialist interest but who will nevertheless see people who might need DBS or have it already (page 502). Diana Wei and colleagues provide an up-to-date review of the management of cluster headache on page 521.

The publication of new guidelines rarely seems to change practice immediately; the old traditions remain. Change is usually slower than expected and any changes often seem patchy, even within a department. Josephine Mayer and colleagues explore why this is and how we can improve matters (page 529).

Our ‘Editor’s choice’ is an update for neurologists on borderline personality disorder by Katherine Hall and Paul Moran (page 483). This is more frequently diagnosed nowadays and is becoming better understood, even with some treatments being offered (which the authors have helpfully dejargonised).

As always we have several clinical cases; a patient with multiple presentation of multifocal plasmacytoma that proved difficult in both diagnosis and management (page 511); a patient who needed both immunosuppression and treatment for an opportunistic infection (page 508); and an illustration of thrombosis of the vein of Labbé (page 541).

A Fo Ben provides assorted Christmas crackers in Carphology (page 553). And we are joining (although in a small way) the British Medical Journal’s tradition of lighter hearted articles in their Christmas edition with a Christmas Corner. Going south we discover whether Australasian neurological after-dinner speeches are more long-winded than those in the UK and if the Antipodean diners have any idea what to expect (page 552). Going north, we are provided with Neurological Scottish neologisms, old words lent new meaning to capture some neurological ideas we had never thought we needed. Suffice it the say the editors are completely amnestic to the authors’ implied Boquhan (see page 465 to find out what on earth we mean).

Finally, we thank all our authors, reviewers and editorial board members and to wish you all a Merry Christmas and a Happy New Year.