• clinical neurology

Second opinions are important in neurology. We provide them all the time, mainly through ward consultations but also as outpatient referrals from non-neurological colleagues. And we also frequently seek opinions from neurological colleagues with subspecialty interests. Sometimes a second opinion is aimed at a specific intervention or evaluation—for example, assessment for epilepsy surgery. Perhaps more often it is because we are at a loss: one of our colleagues has a rule to refer if he still does not know what is going on having seen the patient three times, appreciating the benefit of a fresh pair of eyes. But occasionally it is proactive self-defence. A surgical colleague sensing patient frustration or potential complaint advises, “I know just what you need: you need a second opinion.” Getting in first before the patient summons the courage to ask for it promises a happier outcome.

Whatever the context, obtaining further opinions gives an excellent learning opportunity. Because we have wrestled with the clinical problem so long and so deeply, when the resolution does come it is all the more satisfying and memorable. Although it is difficult to recreate this in print, we try with our ‘Clinicopathological conferences’ and ‘Test Yourself’ cases. Most of the unusual cases in Practical Neurology will have already been the focus of multiple second opinions, although the published report does not always manage to capture the uncertainty and cognitive dissonance behind the case, to recreate the real impact on learning in the authors’ clinical practice.

In this edition, Gordon Plant and his team provide an interesting solution to this problem in their paper, ‘Remember the retina’ ( see page 84 ). They take several unusual conditions that they have encountered and summarise the clinical pictures as they presented to the referring clinician; they then provide their expert and specialist assessment and discuss each of the conditions. We feel sure you will find their novel and practical approach helpful.

Choosing the neurologist to give a second opinion can be difficult. We seek colleagues with greater expertise in relevant areas hoping that patient presentations which seem unusual to us will be readily recognisable and more straightforward to them: or to thoroughly mix our metaphors (and split our infinitives), our hen’s tooth is their bread and butter. So when Stuart Vegas and colleagues reported a series of patients with autoimmune necrotising myopathy and HMGC antibodies induced by statins, we invited David Hilton-Jones to include the case in his review on ‘statin myopathy’ ( see   page 97 )—providing a second opinion if you will. Similarly, Fady Joseph ( see   page 82 ) has set in context the serological uncertainty behind Liqun Zhang and Antony Pereira’s case of chorea in antiphospholipid syndrome ( see   page 132 ).

Providing further expert opinions are Jasvinder Singh and colleagues ( see   page 106 ), using their experience to give a practical approach to patients with epilepsy and psychosis, and Paresh Malhotra and colleagues ( see   page 115 ) sharing their expertise of seeing patients with neurological complications of renal dialysis and transplantation. We have several other cases where the solution has emerged to a difficult clinical problem, ranging from paraneoplastic trismus ( see   page 146 ) to various postinfective syndromes. Undoubtedly each case report developed through the series of second opinions obtained on the road to the final diagnosis.

One group of patients for whom we shall undoubtedly be seeking many second opinions in the near future are those with genetic conditions where therapies are beginning to become available. This radical new field promises to help many patients with hitherto untreatable conditions. Although general neurologists may not be providing these interventions, they do need to understand the principles behind them. Alex Rossor and colleagues provide a clear background to these new genetic therapies—particularly antisense oligonucleotides—explaining how they work and their limitations ( see page 126 ).

This issue of Practical Neurology contains a very special paper in which Hannah Cock describes her son’s neurological illness and how her experiences have influenced her own clinical practice ( see   page 170 ). She reminds us that it is patients and their families who provide the opinions that really matter.

As ever, we are interested in your thoughts about the format and content of Practical Neurology—we always value a second opinion.