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At this time of the year, editorials traditionally reflect on the year’s highlights and note whether last year’s predictions have come to pass, before making further forecasts. Were our predictions correct? Sadly no, we certainly did not anticipate what 2020 would bring.
Who can predict what will happen next? A vaccine may soon be here. Perhaps only now we are appreciating the true value of the vaccines that are already available, representing as they do the culmination of many decades of trials and experience, and reducing the burden of neurological disease, notably polio and meningitis. However, neurologists are sometimes asked about vaccination, typically by patients with immune-mediated neurological disorders, especially multiple sclerosis, or those taking immunosuppressive agents. In this issue, Saúl Reyes and colleagues discuss the issues relating to vaccination and multiple sclerosis (page 435). We can only hope for an addendum regarding COVID-19 very shortly.
Some predictions made with confidence despite COVID-19: patients will still develop neurological disorders; neurologists will continue to perform a neurological examination (with appropriate precautions) and will still undertake investigations to make diagnoses. While there are some excellent books on neurological examination available, neurologists and trainees alike always want to hear the key tips that senior neurologists (Richard Stark in this issue (page 483)) choose to pass to the next generation. Standard reflex testing covers most major myotomes—but not the L5 root. But the medial hamstring reflex does just this (please see page 466 for the technique, with video). Michael Halmagyi and colleagues review the use of nystagmus glasses (page 444) concluding with, ‘examining a dizzy patient without using nystagmus glasses is like examining a weak patient without using a tendon hammer’. Such glasses can be expensive, but fortunately, Pramod Dhonde and colleagues tell us how to make an inexpensive version, easily available to all (page 498). Clinical examination is essential in assessing functional disorders, and a clinical sign gave the key to the diagnosis of functional weakness in a patient in intensive care (page 470).
Another prediction: someone in your neuroradiology meeting will ask whether the brainstem ‘looks like a hummingbird’. Such colourful terminology is common in radiology. But when is it useful? Do the trident signs (either of them) really resemble tridents and what do they mean? Inna Page and Frank Gaillard provide a careful discussion of some such signs and explain how useful they really are in practice (page 457). Amyloid PET is a neuroradiological technique that is becoming more widely available and used; Magdalena Kolanko and colleagues update us on what it can offer in clinical practice (page 448). The interpretation of radiological investigations often identifies grey areas—an abnormality might seem clear cut on some scans but not so in others and this is often something that is discussed in neuroradiology meetings. We tend to think less critically about the doing blood tests and about interpreting their results—yet we should do so; not all positive tests mean the same thing, as Jackie Palace and Geraint Fuller argue on page 428 in ‘Don’t do the blood* test’.
We feature a range of clinical cases in this issue. Christian Lueck discusses neuroretinitis (page 430) and Siew Yap and colleagues (page 499) describe why we should ask about pet cats and look for their bacteria (Bartonella henselae). We have two patients with different encephalopathies: posterior reversible encephalopathy syndrome (page 480) and post-contrast encephalopathy (page 476). Sabino de Oliveira and colleagues draw our attention to a phenocopy of Huntington’s disease that often presents as parkinsonism (page 473) and we have a Test Yourself on a confused patient with deranged liver function. In most countries, patients with these presentations would be admitted under general medical services, who then might seek neurological advice through a liaison neurology service. Such services vary widely within the UK and round the world. As this is the main way for patients acutely unwell with neurological disorders to access specialist expertise, it is important that we optimise this service: Geraint Fuller discusses how we might do this on page 488.
Most neurologists will have seen doctors or other health professionals who have fasciculations with concerns about motor neurone disease. Dr Laurent Vercueil describes his personal experience of this presentation, its impact had on him and his relief on discovering the prior description of the fasciculation anxiety syndrome in clinicians (FASICS) (page 508). Matthew Kiernan, editor of our sister journal JNNP and author of this description, discusses it further on page 433.
We have a ‘Letter from Bangladesh’ (page 503) describing neurological services there. We also have a more tongue in cheek ‘Letter from our virtual neurological world’ (page 506), detailing the neurological signs encountered during internet interactions—something that will chime with many readers’ experience of ‘Zoom encephalopathy’ induced by hours of screen time. Carphology has a slightly Christmassy feel, Neurology Book Club provides neurologists’ families with more ideas for their Christmas present and we are delighted to feature our first Neurological Crossword (from Sam Nashef, a Guardian crossword compiler, on page 511).
Our 2016 Reader’s Survey indicated some demand for crosswords and cartoons, so this year you get a crossword. Dare we make a final prediction for next year? Or is that a challenge?
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