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It is often said that neurology is a diagnostic specialty. Colleagues in other specialties sometimes characterise neurologists as being interested in diagnosis but not in treatment. A superficial glance at the contents of this issue might add weight to that idea—but look a little deeper and you can see this is anything but the case. Myelin oligodendrocyte glycoprotein (MOG)-associated disease (anti-MOG to its friends—in particular, Jackie Palace who reviews it with her team on page 187) was recognised only relatively recently and, as a less common form on neuromyelitis optica, it can be challenging to diagnose. But the essential thing is to diagnose it—because the treatment and prognosis differ from the conditions that it easily mistaken for—even if the treatments are relatively familiar agents of immunosuppression.
Diagnosing amyloid neuropathy would seem just the sort of characteristic neurological behaviour that our colleagues are getting at. This diagnosis can be difficult, and even having thought of it—what can we do? Mary Reilly and colleagues advise us on how to reach a diagnosis on page 250. And at the end of it, remarkably, our patient may be offered treatment for a genetic condition.
The treatment of encephalitis is surely straightforward—start the acyclovir? But no, Michel Toledano and Nick Davies (page 225), in their exploration of its mimics and chameleons, illustrate that the diagnosis is anything but simple and needs thought. Who would have thought, for example, that NMDAR encephalitis might result from herpes simplex encephalitis, presenting as an apparent acyclovir-resistant relapse? Once again, without a diagnosis, we would risk giving treatment but quite possibly for the wrong disease.
Anu Jacob and colleagues (page 264) describe a patient with a cerebral dural arteriovenous fistula whose presentation mimicked transverse myelitis. Again, a situation where getting the correct diagnosis is difficult but essential, given the radically different treatments required. We asked Robin Howard to put this report into a wider context in an editorial. Cases where this differential diagnosis of myelopathy has been missed crop up surprisingly frequently in medicolegal practice, reflecting its importance.
Our medical colleagues might be surprised to see Practical Neurology featuring a paper on the best management of atrial fibrillation. Prevention traditionally holds a minor role in neurological management, in stark contrast to its importance in the fields of diabetes, or heart and chest disease. However, with atrial fibrillation being such a common and important preventable cause of stroke, neurologists do need to look out for this diagnosis and to have a reasonable grounding in its best management. David Werring and colleagues (page 208) provide the neurologist’s definitive practical guide to its assessment and management.
It can be difficult to help people with progressive ataxia. Few ataxic disorders have a significant treatment option, so perhaps for these conditions our cynical colleagues have a point: that our focus is the diagnosis. However, for people who have to live with a long-term disability, knowing what it is and what to expect can definitely help, as well as making sure that all the simple things have been done to help. The review by Rajith de Silva and colleagues (page 196) extracts the best from their recently published national guidelines on the investigation and management of progressive ataxias in adults.
There is an increasing recognition that the way in which we explain functional disorders to patients is an important part of their treatment. Mark Willis and Claire Rockcliffe-Fidler (page 259) take a neuropsychological perspective in their ‘How to do it’ paper, recommending, among other tips and metaphors, that we consider showing people with dissociative (non-epileptic) seizures a video of an impala whose dissociative behaviour in the jaws of a leopard eventually allows its escape.
We are always pleased to receive updates that will help us in particular and challenging situations. Angela O’Neal provides all that a neurologist needs to know about obstetric anaesthesia and its complications (page 238), which will certainly help our confidence when assessing such cases on the maternity unit.
We have a Book Club discussion of an autobiographical account of life after a stroke, and Carphology provides a few gems to lighten our load. Plenty to read before we get back to the clinic or ward to diagnose—and then treat—much to the surprise of our medical colleagues.
Competing interests None declared.
Patient consent for publication Not required.