Brain, Vol. 123, No. 4, 663-664,
April 2000
© 2000 Oxford University Press
Editorial |
Enumerating neurology
Department of Neurology, University of Wales College of Medicine, Heath Park, Cardiff, UK
The last decade has seen huge advances in technology and in the understanding of pathological mechanisms in human disease. After this period of rapid change, it is appropriate for investigators to pause to survey the burden of neurological disease that surrounds them, and to ask questions concerning the practical application of these new technologies and their relevance within the broader spectrum of neurological disease.
Previous attempts to enumerate neurological disease were made during the 1980s (Marsden, 1981
), when concerns arose regarding the role of neurologists given the limitations of clinical resources. Recognizing the considerable logistics of community-based epidemiology, most investigators have chosen to examine a pre-selected population or to summarize information culled from multiple single-disease studies (Kurtzke, 1982). These have resulted in a number of reports concerning neurological practice within a district general hospital or regional neurology clinic. By contrast, few attempts have been made to record accurately disease burden within a large unselected community-based population. Since that time there have been substantial changes in what is perceived as the clinical responsibility of neurologists.
The United Kingdom provides a favourable environment for epidemiological studies, largely because of the structure and delivery of health care and the compact nature of the population. These provide a number of advantages for investigators who have previously provided definitive information on a number of neurological diseases (Sander, 1990; The Scottish Motor Neuron Disease Research Group, 1992; Robertson, 1995). However, the diverse burden of neurological disease has rarely been addressed. In this issue MacDonald and colleagues, building on previous work, have provided a rare and detailed insight into the burden of neurological disease with five urban practices (MacDonald et al., 2000). Taking on an ambitious task in view of the large population (over 100 000), they have provided a unique prospective record of neurological disease over a period of 18 months. In addition, lifetime prevalence rates are given for a further sizeable subset of this population. The larger size and prospective nature of this analysis compared with previous studies has been possible because of advances in information technology (in particular computer registration of patient details), but also through the contribution of a large group of clinical collaborators and help from nearly 50 medical students. Despite the huge task involved in reviewing the records, the authors have been able to assure the quality of data by sub-sampling and applying a number of quality controls.
Undoubtedly there is some selection bias, including ethnicity and age structure as well as the questionable effect of performing a study such as this in the vicinity of a major neuroscience centre by a group with an established interest in epilepsy. However, these are unlikely to have had any great impact on the overall figures, and this is confirmed by the representative nature of figures compared with previous work addressing the frequency of single diseases. Practical limitations resulted in some notable exclusions, including dementia, migraine and tension headache, leading to difficulties in comparing these results with other studies. However, this study strikingly underlines the huge burden of neurological disease within our society: 625 per 100 000 population per year consult their family doctor regarding a neurological disorder, rates between the sexes being similar. Six per cent of the population have had a neurological disorder during their lifetime. By nature of the way the data were collected, these figures are likely to underestimate the true figure, particularly since they exclude a number of conditions for which neurological advice is commonly sought.
The hierarchy of disease incidence and prevalence is also illuminating. Cerebrovascular disease is predictably at the head of the list, followed, in order of frequency, by diabetic polyneuropathy, compressive neuropathies, epilepsy, Parkinson's disease and other neuropathies. This compares with headache, epilepsy, multiple sclerosis and non-organic disease in hospital-based neurological clinics (Wiles, 1996). Although the discrepancy between community and specialist neurology clinic may be related to a number of factors, including local referral practices, clinical accessibility and length of waiting lists, this is likely to change as the impact of new treatments becomes apparent and the popular demand for specialist assessment increases.
Epidemiological studies such as these are important because they are social statements of disease burden. They remind us of the relative impact of neurological disease and provide an insight into the referral practice of primary care physicians. The information contained in this paper should be of great value to those planning delivery of clinical services, considering the future role of the neurologist or assessing the need for particular investigative resources.
References
Kurtzke JF. The current neurological burden of illness and injury in the United States. Neurology 1982; 32: 1207–14.
MacDonald BK, Cockerell OC, Sander JWAS, Shorvon SD. The incidence and lifetime prevalence of neurological disorders in a prospective community-based study in the UK. Brain 2000; 123: 665–76.
Marsden CD. The work of neurologists. J Neurol Neurosurg Psychiatry 1981; 52: 429–30.
Robertson N, Compston DAS. Surveying multiple sclerosis in the United Kingdom. J Neurol Neurosurg Psychiatry 1995; 58: 2–6.
Sander JW, Hart YM, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet 1990; 336: 1267–71.[Web of Science][Medline]
The Scottish Motor Neuron Disease Research Group. The Scottish motor neuron disease register: a prospective study of adult motor neuron disease in Scotland. Methodology, demography and clinical features of incident cases in 1989. J Neurol Neurosurg Psychiatry 1992; 55: 536–41.
Wiles CM, Lindsay M. General Practice referrals to a department of neurology. J Royal Coll Phys 1996; 5: 426–31.
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