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‘No man is an island entire of itself…’.1
We can be certain that John Donne was not thinking about the inter-relationships between medical specialties when he wrote those lines in 1642 but such is the resonance of the ideas that we can easily see their relevance to our practice. A recurring issue in neurological training is the extent and depth of neurology’s links with other general medical specialties. In the USA and much of Europe, trainees progress much more directly into neurological training, with clearer water between neurology and general medicine. In the UK, Australia and New Zealand, however, there is more of a bridge, with neurologists expected to have had considerable general medical training before specialising. Changes in training already underway in the UK will further increase neurologists’ general medical training; the bridge is becoming a causeway.
No matter how neurologists are trained, general medical issues are and will always be important in neurology. The health of the brain and nervous system depends on other organ systems maintaining the milieu intérieur. Indeed, from a neurologist’s cephalocentric perspective, that is almost the main role of the other systems. Donne was right, as this issue of Practical Neurology illustrates many times over.
Dearbhla Kelly and Peter Rothwell explore the neurology of hypertension, a major risk factor for many neurological disorders (page 100). The endocrine system, and particularly that involving oestrogen and progestogen, influences migraine in ways often difficult to disentangle. For example, pregnancy may help migraine but the combined oral contraceptive—the hormonal mimic of pregnancy—may worsen it; Shazia Afridi steers us through this minefield (page 115). We have articles that highlight the importance of immunological disorders in neurology and the issues that arise in their management. Claire Rice and Neil Scolding show us how to diagnose primary cerebral vasculitis (page 109), a particularly protean and challenging condition. Chinar Osman and colleagues discuss how to use plasma exchange in people with neurological disease (page 92), something maybe to consider more often as an alternative to intravenous immunoglobulin given the challenges in maintaining its supply. Many people with immunological disease receive cyclophosphamide, with potential impact on their fertility. Our oncology colleagues, who use this drug more often and at higher doses than neurologists, are very familiar with this, but we need to be too; David Ledingham and colleagues discuss this on page 148.
Many of the problems our patients face may not seem to be core neurological business, though authors in this issue may persuade us to take on these issues. Sexual dysfunction is a major problem for both women and men with multiple sclerosis, though often these concerns remain hidden and need to be specifically sought. Vivien Li and colleagues provide a practical approach to assessing and helping people with these problems (page 122). Just as we risk missing out on helping people with MS with their sexual dysfunction if we don’t ask, so we might also fail to offer speech and language therapy to people with primary progressive aphasia through (perhaps unconscious) therapeutic nihilism. Anna Volkmer and colleagues (page 154) discuss the strategies that they use for people with these conditions.
Deafness can be associated with any kind of neurological disorder and people with profound deafness are at higher risk for developing some of these. The importance of the history in clinical neurology inevitably means that assessing people with significant deafness presents particular challenges. Matthew Harris and colleagues (page 132) discuss how they approach assessing Deaf patients in their dedicated cognitive clinics and how we might do this in general neurology clinics. They also remind us that Deaf spelt with a capital ‘D’ refers to the community using sign language, whereas deaf with lowercase ‘d’ refers to hearing impaired people who use spoken language. We also have case reports that involve a gastroenterological diagnosis (page 144) and an ophthalmological diagnosis (page 163).
Neurology clearly does overlap significantly with other medical specialties; our specialty is not an island. Donne scholars might be bemused that we have linked this discussion to his poem. However, many a trainee being bleeped on call will sympathise with the final sentiment of the poem: ‘…never send to know for whom the bell tolls; it tolls for thee’.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.