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Does this sound familiar? A medical student is asked how to treat a particular neurological disorder and gives a one-word answer: the name of a single drug. Frustratingly, treatment is rarely that simple—even for conditions like dopa-responsive dystonia (the diagnosis of which is reviewed see page 340), where the clue in the name that suggests that this should be straightforward. The medical student's single word answer usually prompts a discussion about different types of treatment beyond the ‘headline’ drug or other intervention. This leads to a recognition that, in addition to disease specific treatments (if they exist), there are treatments to help to control symptoms and also a range of supportive strategies that are not disease-specific.
For many patients with neurological disease, the disease-specific treatments are limited and symptom management is the key. Some symptoms respond to drug treatments, but often there are no drug treatments available or they have only limited effect. Are there other options and do they have the sort of evidence base that we would expect for a pharmaceutical treatment? Are there other ways we can help our patients cope with their symptoms?
Mindfulness is a non-drug intervention that you may well have come across in newspapers or other non-medical literature. As it seems to be useful for all sorts of things, a cynic might think of it as the latest fad or fashion—but it does have a scientific and experimental basis in clinical trials. Neils Detert reviews mindfulness for the neurologist (see page 369) and summarises the evidence for the use of mindfulness in patients with neurological problems: and it seems hold much promise. Spatial neglect has no specific treatment, yet there are strategies that can help: Korina Li and Paresh Malhotra review these (see page 333).
While non-specific management strategies are usually the last ones that medical students consider, they are often the biggest issues for junior doctors on the wards. The bleep goes off and they are asked to ‘sort out’ a patient with impaired higher function, following an episode of encephalitis or head injury, who keeps trying to wander off the ward. This is a tricky issue medically, but they will also need to keep in mind the legal basis of their treatment now, in part, relating to their deprivation of liberty. This deprivation of liberty has been the subject of recent legal rulings in the UK. Gillian Ashby reviews the current legal situation after the Supreme Court ruling, ‘A gilded cage is still a cage’ (see page 361), and Derick Wade provides an editorial commentary on this legal quagmire (see page 330).
Just as the treatment of many neurological conditions cannot be reduced to a single drug, investigation results usually require interpretation. Sui Wong takes us through the interpretation of visual fields (see page 374); Pearl Jones helps us to interpret autonomic function testing in patients with syncope (see page 346) and Nick Kane reviews the role of somatosensory evoked potentials in patients with coma (see page 352). We have a range of rare and challenging diagnoses as case reports and images. We also have a neurological letter from the South Atlantic (see page 396) and a very curious Test Yourself (see page 389).
People with neurological disorders seem to appear increasingly in contemporary fiction: the main protagonist in Emma Healey's novel, ‘Elizabeth is Missing’ has dementia and this is discussed in Book Club (see page 405).
Maybe it is overly optimistic to hope that our monosyllabic medical student will read Practical Neurology. But if she did, we hope she would have appreciated that neurological practice is nuanced, not black and white, but lighter and darker grey. Clinical neurology still is still an art as well as a science.
The art of neurology is perhaps exemplified by Oliver Sacks (1933–2015) who recently died. Much can be learned from his careful and empathetic descriptions of his patients and their neurological problems and his attempts to help them understand and come to terms with their disabilities. How many students have become neurologists inspired by his writings? He will be much missed.