Brain, Vol. 123, No. 11, 2363-2364,
November 2000
© 2000 Oxford University Press
Book reviews |
MANUAL OF NEUROLOGIC THERAPEUTICS. Sixth edition.
By Martin A. Samuels. 1999. Philadelphia: Lippincott Williams & Wilkins. Price $34.95. Pp. 499. ISBN 0-7817-1830-9.
Colchecter General Hospital, Colchester, UK
This compact volume was written by the former trainees of a world authority on myasthenia gravis. Although the cover shows a novel cartoon of our favourite synapse, no part of the nervous system is overlooked, with all neurological therapies reviewed over nearly 500 pages. Although labelled `spiral manual', it is bound like a normal paperback, and is well made. The pages of the review copy didn't fall out with repeated reference.
This is a reference book that offers relatively terse advice in numbered paragraphs, whose headings and key messages are in bold type. There are many tables, but no pictures or images. One-third of the book has seven chapters on neurological symptoms, including one on backache. The other two-thirds is 10 chapters on neurological diseases. The chapter `Problems associated with chronic neurological diseases' covers drugs and appliances, but not nursing or physical therapies. None of the text is referenced, but each chapter ends with a list of selected readings. The chapter on multiple sclerosis has accumulated 78 references, whereas movement disorders ends off with a relatively rigid five.
A GP's 18-year-old daughter with presumed meningo-coccal meningitis prompts me to check modern management: the index lists `meningitis, viral' and `meningitis, epilepsy and'. The relevant text is inconsistently indexed as `Bacterial meningitis'. Thirty pages later, including four pages on how to do the lumbar puncture, I'm unsure whether my patient's minor impairment of consciousness constitutes a focal sign and thus indicates imaging. Fortunately, I think I already know which antibiotics to choose from the dozens listed for parenteral or intrathecal use, together with dose adjustments according to renal function, and the half lives of six different aminoglycosides. Should I be giving steroids? These appear to be indicated for infants and children, and `some experts' recommend them for adults. I decide to do something the book doesn't recommend: consult a microbiologist who knows about local antibiotic resistance patterns.
The headache chapter omits to mention the International Headache Society (IHS) classification. The text describes classic and common migraine, migraine associée and migraine dissociée, as well as complicated migraine and lower half headaches. Tension headache is but a subgroup of psychogenic headache. That depression is not invariable in chronic daily headache is noted with disappointment. The differential diagnostic difficulty resulting from the loose definitions here, provide potent support for the overlooked IHS criteria which allow accurate and reproducible headache diagnosis.
North American neurologists must have a different casemix from us in the UK: why else would there be 30 pages on bacterial meningitis and only seven and a half on multiple sclerosis? A search for controversy here is rewarded with `lumbar puncture ... should be performed diagnostically in all suspected cases' and `physical therapy is of little benefit in diminishing spasticity'. Advice on steroid use in acute exacerbations, offers a clear preference for intravenous methyl prednisolone. This is recommended as 250–500 mg every 12 hours for 3–7 days, with an oral taper over a month and 7 days precisely. Oral prednisolone comes less highly recommended, though high-dose oral methyl prednisolone is not mentioned. There is no guidance on which exacerbations require steroids, or how often it may be safe to repeat the treatment. Avascular necrosis of a major joint is not mentioned, though it is reassuring to know I should not worry about osteoporosis. Do we all give routine antacids or cimetidine, as recommended here? I was hoping also for some guidance on the use of interferons and copolymer, on the outside chance that they ever become properly available on the NHS. No advice is offered on choosing Betaseron, Avonex or Copaxone. Treatment failure should trigger consideration of one of the other two, in no recommended sequence: even, apparently, in the face of steady disease progression. There's no mention of Rebif, presumably because it is not yet licensed in the US. Such strictures do not prevent recommendation of amantadine, pemoline, and fluoxetine for multiple sclerosis fatigue. The words `off label' do not appear and neither is there any mention of lifestyle or psychological advice for this common and troublesome symptom.
It is common knowledge that interferons lose efficacy in crossing the Atlantic eastwards, while phenytoin (dilantin) gains tolerability in the opposite direction. So I won't criticise the discussion of how to dilantinize a patient. But if I were to dilantinize a young woman then I would be concerned that she might later dilantinize her embryo. There is no mention of preconceptual counselling. Folic acid supplementation is appropriately and unconditionally recommended in a single sentence at the start of a section that otherwise discusses only eclampsia and its management. Have I overlooked the importance of folate in eclampsia? The lack of evidence for safe use of most anticonvulsants in pregnancy is noted. A table lists `safety in pregnancy' for all anti-convulsants in the following categories: abnormalities reported, not safe, probably unsafe, unknown, unsafe. These are listed here in alphabetical order, to avoid any possible confusion over their relative clinical significance. Valproate is rated `abnormalities reported (neural tube defects)' with no mention of neurodevelopmental delay. Perhaps the author's young female patients opt for lamotrigine, which has the relative convenience of being monitored only by clinical response, with `unknown' safety in pregnancy. Those patients wanting valproate are presumably discouraged by the recommendation of carnitine supplements, 3-monthly blood tests for amylase and blood count, liver function 6-monthly. In any case, we are recommended `as many AEDs as possible be discontinued in pregnancy, particularly in the first trimester'. I always thought that was a trimester too late; this book is reassuring for my patients who seem to prefer postconceptual, to preconceptual counselling.
A highlight of this small volume is the final appendix `Patient information guide'. In 15 pages there are 158 US addresses and 68 websites for self help, on 93 disorders from Acoustic Neuroma to Wilson Disease. Buy the book to visit the websites before your patients do. Those concerned about Cornelia de Lange Syndrome will have to use the website, because it isn't in the index.
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