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The COVID-19 pandemic has changed so much that it is easy to forget what life was like before it began. We already experience a slight shock on seeing pictures of large groups of people standing close to or even touching one another, before realising it is an old photo. We are also becoming accustomed to being ignored by colleagues because of a low-level mask-induced prosopagnosia. Too much change; we can have too much change.
However, we must change if we are to improve the care of patients with neurological disorders. Practical Neurology aims to publish papers to help us make those changes. During the pandemic, most neurologists are undertaking remote consultations and working out how best to do this. However, for neurologists working in isolated areas, this approach is not new; Callum Duncan and Angus MacLeod have provided a remote consultation service to the North of Scotland for many years and they share their experiences of video consultation from their ordinary times to help us in these extraordinary times (page 388). Safe ophthalmoscopy presents a particular challenge during the pandemic; André Jorge and colleagues illustrate their practical solution to this problem in low-risk patients (page 416).
Many of our papers try to nudge clinical practice rather than to transform it, and in this issue, we have a couple of examples. Incidental unruptured intracranial aneurysms are sufficiently common for all neurologists to encounter them occasionally and having to consider what to do. Shelley Renowden and Rick Nelson provide a comprehensive review that allows us to feel confident we have access to the best up-to-date guidance (page 347). Leonardo Ulivi and colleagues provide a practical guide to the management of cerebral venous sinus thrombosis (page 355), an area of cerebrovascular medicine with a rather thinner evidence base than its arterial equivalent. Sometimes, our papers aim to make neurologists think about what they do and why they do it. Muscle biopsy is sometimes an essential investigation, but in many situations, genetic and other tests have superseded it. Jon Walters and Atik Baborie show us where muscle biopsy fits into the modern diagnostic armamentarium (page 378).
Many neurological conditions are common enough that we are sufficiently familiar with them to make a diagnosis, but rare enough that we want to check there is nothing new that we should know about them. The tardive syndromes associated with psychotropic and other medicines fall into this category; Eoin Mulroy and colleagues bring us up to date on them (page 365). Some symptoms are not uncommon but are on the edge of neurology and thus may be confusing for neurologists because they usually present to another speciality. A good example is photopsia, a symptom that usually reflects ocular or optic nerve pathology and so appropriately presents to ophthalmologists. However, this is not always the case, and the practical neurologist needs to know enough to deal with this symptom. Jasvir Virdee and Susan Mollan provide an illustrative case and review of photopsia (page 406), and Mark Manford highlights the need to consider positive visual symptoms from a more neurological perspective (page 345). Few neurologists will have a standard approach to patients with ataxia–telangiectasia. Thus, May Yung Tiet and colleagues’ helpful summary of the condition (page 396) may not make an immediate change in practice but will be there when we encounter a case.
The changes discussed earlier are all positive. Unusually, however, we have one article that cogently argues that we stop doing something, in this case requesting serum anti-voltage-gated potassium channel complex antibodies; instead, we should request LGI1 and CASPR2 antibodies. Sophia Michael and colleagues illustrate how using this non-specific test potentially harms patients, contributing to misdiagnosis and inappropriate treatment (page 372). We need to change and stop doing this test.
The insights that our colleagues provide through the discussion of their own neurological illness can change the way we practise neurology. David Blacker recognised he was developing Parkinson’s disease. He provides a moving description of his attempts at first to ignore it, and then the courage he needed to acknowledge it and see a colleague, and finally how his new insights have changed is an approach to diagnosing and managing his patients (page 414).
Most of our papers discuss patient care, but we have one article that focuses on ‘neurologist care’. The ‘Grand Round’ has been an important part of neurological education and continuing professional development since the birth of our speciality. The opportunities it provides for exploring the clinical method and neurological reasoning have been essential in training and in the development of academic clinical neurology. But Grand Rounds are under pressure with falling attendances. Amy Ross Russell, Mary Reilly and Martin Turner provide an impassioned argument in support of the Grand Round and how the internet can improve its reach, illustrated with an elegant reimagining of a Tuesday Lesson at the Salpêtrière (you really must see this—page 342). Sometimes, we need change to keep things the same.