Therapy in Neurology: Expert Clinicians' Views

The clinical neurologist has abundant personal experience with the diagnosis and management of common neurological disorders. In addition, we all have been reading fairly effectively since grade school. Some of us are more or less capable of adequately interpreting the medical literature. Even for those of us who are quite astute at analyzing outcome data, there remains a need for experts, who are not only up-to-date with the current clinical trials (and, in fact, are involved with the design and performance of recent and future clinical trials) but who also have a busy clinical practice in their area of expertise. Many of us in the trenches appreciate hearing from the experts who are in more specialized trenches. We wish to know how they view the literature, their interpretation of recent developments and ``progress,'' and how they utilize diagnostic and therapeutic options in their own clinical practice. Therefore, for this issue of Seminars in Neurology we have selected individuals who have very focused expertise, who are involved with the design and performance of clinical trials in their area, who are busy clinicians, and who are highly respected by their colleagues in the field of neurology. These individuals are often asked not just what is new in the literature but rather ``What would you actually do with this patient?''

We believe that the contents of this issue will serve the reader in several ways. First, it will allow the clinician to gauge whether they are up-to-date in the areas reviewed. The readers will also gain a perspective on the current literature and trends in the areas discussed. Perhaps of greatest importance, the reader will have access to the ``best judgment'' of the clinical experts and will be able to share in the opinions, experiences, and biases of those busy clinicians.

Karen Roos is well known to the readers of Seminars in Neurology, and with this issue assumes the role as Co-Editor in Chief. She is a terrific editor (far better than I) and will no doubt serve the readers of Seminars with skill, grace, and enthusiasm in the coming years. However, I am most pleased to have her be willing to share some of her secrets to a successful practice in the specialty of central nervous system (CNS) infections by discussing a variety of pearls and pitfalls that are well known to our own residents and fellows at Indiana. She is giving us a view of how she functions in her busy practice in dealing with common and, at times, very complicated patients with suspected CNS infection.

David Mattson heads up the multiple sclerosis program at Indiana University, where he is Professor of Neurology. He has given us a piece that bridges the gap between the literature on treatment options in multiple sclerosis (MS) and how to utilize these data and options in the daily practice of MS patients.

Dr. Jorge Asconape is Associate Professor of Neurology at Indiana University and an epileptologist who has a particular interest in the new anticonvulsant medications as well as the gamut of toxicity, drug interactions, and decision making with the use of new and old anticonvulsants.

Dr. John Kissel is Professor of Neurology at Ohio State University. John is a well-known expert in neuromuscular disease, and 2 years ago he was Guest Editor for an issue of Seminars in Neurology on muscular dystrophy. Having had the privilege of working with Dr. Kissel in a variety of venues, including the American Academy of Neurology neuromuscular update courses, and in speaking with an array of physicians and patients, it is clear that when John Kissel speaks everyone else becomes quiet and listens. As a so-called ``neuromuscular expert'' myself, if John is about to say something I become silent with the masses and try to take in everything he has to say. For that reason his discussion of the inflammatory myopathies is of particular importance in that it emphasizes a number of misconceptions and management problems that are all too common.

Dr. Alfredo Lopez is Clinical Lecturer of Neurology and codirector of the stroke program at Wishard Health Services. There are many papers on stroke in the diagnostic and management arena; treatment options abound, such that the interpretation of the data can lead one many different directions. As such, it is helpful to have Dr. Lopez restate some of the common questions that he is asked by other physicians and give us his answers, including emphasis on some of the recent papers and observations.

In his article on recognition and diagnosis of dementia, Dr. David Geldmacher provides the general neurologist and also the referring physicians (primary care) with a collage of data, observations, and recommendations concerning a practical and effective approach to evaluation and diagnosis of patients with dementia. Dr. Geldmacher is Associate Professor of Neurology at Case Western Reserve University and Clinical Director of the University Memory and Aging Center, University Hospitals of Cleveland. Having myself an inborn allergy to the Medicine of Coding (an ``MC'' degree), Dr. Geldmacher's contribution, in combination with our trend of downward financial spirals, has led me to rethink my allergy situation. We can ignore these coding issues and, given the current financial trends, can assume that sooner or later we'll go bankrupt if we're in the profession of caring for patients or we can listen to people like David and learn from them that proper coding might allow us to stay afloat even if we are spending precious time in discussions and counseling with our patients. In the end, paying attention to the ``business of neurology'' may actually let us practice better neurology (or perhaps diminish the erosion of quality contact with patients).

Dr. Ann Hake is a Clinical Assistant Professor of Neurology who works in the Alzheimer's program. She is involved with applied clinical trials in the diagnosis and treatment of Alzheimer's disease, and she is a pure specialist in the trenches in trying to manage these difficult patients. Her views on the approach to treatment will hopefully reinforce those aspects of care that most of us are doing effectively and improve some areas in which we may be struggling. We thank Ann very much for sharing her daily thought processes.

As director of an amyotrophic lateral sclerosis (ALS) clinical trials program and codirector of a busy multidisciplinary clinic for the management of ALS, I have tried to provide a summary of the important literature, present some of the consensus views on diagnosis and management of motor neuron disease, and also offer my own approach to dealing with these challenging patients. We are all familiar with the comments from medical students that patients with Lou Gehrig's disease (and many other chronic neurologic disorders) have conditions for which we diagnosis but have no treatment. Obviously, nothing can be farther from the truth. We spend much of our day treating and managing a variety of features of motor neuron disease.

Dr. Dan Rusyniak and his colleagues Christopher Holstege and Michael Baylor have provided the Historical Note for this issue of Seminars in Neurology. While this is the one paper that does not discuss a common neurological disorder, it is nonetheless an eye-opener and something with not only historical interest but with what may be increasing practical importance as the use of absinthe has its resurgence. Dr. Rusyniak is Assistant Professor in toxicology and emergency medicine with a joint appointment in neurology, and he is providing this follow-up contribution as a result of the success of his recent paper in Seminars on pearls and pitfalls in neurotoxicology. We thank Dr. Rusyniak and his colleagues from Virginia for sharing such an interesting Historical Note.

Karen Roos and Nancy Eckerman also contribute a timely Historical Note, which serves to alert our profession of the risk of what only a year ago would have sounded absurd-smallpox, and in particular to appreciate the important issues surrounding the smallpox vaccine and its neurological complications. Nancy Eckerman is The Special Collection Librarian at the Ruth Lilly Medical Library (at the IU School of Medicine) and I'm honored that she has an appointment in the Department of Neurology. Nancy has been a loyal and assiduous colleague over the years and is a great asset for anyone interested in Medical History.

To all of these experts we are grateful for their fine work-not only years worth of managing patients in the trenches but also their contribution to the state of the art by design and participation in therapeutic trials. We also thank them for having the courage to put their personal views and biases into writing for us. (In the era of evidence-based medicine it is always a bit treacherous to write something in the way of an opinion or guideline if the papers are not there to ``prove'' that one is correct.) I would also encourage my colleagues in the trenches to contact any of these individuals for help. I have found them all incredibly understanding of every question, no matter how simplistic, that I have posed in the past. I know that they will bend over backward to help you out.