Brain, Vol. 123, No. 5, 1063-1064,
May 2000
© 2000 Oxford University Press
Book reviews |
ADVANCES IN MULTIPLE SCLEROSIS.
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University Department of Clinical Neurology, Radcliffe Infirmary, Woodstock Road, Oxford, UK
Advances in Multiple Sclerosis is composed of reviews that cover topics associated in the main with recent advances. It is divided into five sections covering genetics, immunology, magnetic resonance imaging, treatment and the organization of care in multiple sclerosis.
It opens with `What the specialist in multiple sclerosis needs to know about genetics', and achieves this in a concise up-to-date overview. A short summary on the genetic control of EAE follows that adds little to our understanding of multiple sclerosis. However, such research is likely to have future relevance in understanding and identifying genes in polygenic diseases in general.
The Immunology section is highly recommended, containing a selection of stimulating topics. Complement and its relationship to oligodendrocyte injury is an area that has recently been focussed on and this summary includes a lot of the authors' own considerable contribution to such research. Cytokines and cerebrospinal fluid is a difficult area to summarize due to the many, and often contradictory, observations that have been reported; moreover, it is difficult to unravel what is cause and what is effect. A good overview follows on the important subject of the immunological findings in multiple sclerosis at clinical onset, i.e. when the chances of identifying aetiological mechanisms for the disease are best. A lot of the data discussed is unpublished work of the authors. Cross-talk between the cells of the immune and nervous system in disease and health does make for some bold statements regarding the cause of damage in multiple sclerosis without references, although such details are often discussed later on in this chapter. It explains the process of myelin/oligodendrocyte loss without discussing the difficult issue around whether this is a normal mechanism to clear already damaged tissue, an aberrant immune reaction aimed at the CNS that causes primary destruction, or is due to bystander damage. It summarizes macrophage/astrocyte/cytokine networks extremely well. Finally, there is an outstanding, well-balanced and succinct overview of role of autoantibodies in cytokine regulation.
Better editing might have reduced the amount of overlap in the MRI section. A neat story is told, in the opening chapter, outlining MRI techniques and the correlation of abnormalities with the different stages of pathology. Much of the evidence is of course indirect. Emphasis is placed on hypointense T1 lesions—which represent a specific interest of the authors. The chapter on MRI and disease course and activity starts by a summary of the pathological associations and hence repeats a substantial amount of the preceding chapter. The consistency between these two sections, however, demonstrates how well both authors have represented a consensus view. The section on MRI association with the short- and long-term clinical picture is clear and useful. It explains the factors that are likely to reduce MRI and clinical correlations with the exception of the dissociated effects of treatments (such as ß-interferon) on MRI and relapse rate. This chapter is well written and thoroughly referenced. The next chapter clearly demonstrates that the `normal appearing white matter' is not normal using many different techniques and outlines why this observation is important. Again there is some overlap with the other chapters in this section in the explanation of the different imaging techniques in use. The final chapter on MRI explains eloquently diffusion imaging, anisotropy, the usefulness of such measurements and the future challenges.
An outstanding choice of subjects follows in the Therapy section. A concise clear overview relates the background theories of multiple sclerosis pathology with the strategies for the new designer drugs in development—this is a chapter well worth reading. `Gene therapy' explains the different methods of delivering genes into somatic cells, the advantages and disadvantages of these, and the sorts of treatments that could be used in such systems of delivery in multiple sclerosis. It also summarizes the work to date in this area (mainly animal models). The evidence for an association between viral infection and multiple sclerosis is then examined. Studies suggesting infectious triggering of relapses are outlined and the discrepancy between the types of infections reported to be associated is demonstrated. The possible immunological mechanisms and the limited trials of anti-viral agents (completed and ongoing) are discussed.
The final section is on the organization of multiple sclerosis care. Some of these chapters were brief due to the small amount of new information available to report and thus may have been better delayed for future editions. The chapter on multiple sclerosis clinical practice guidelines explains the process of establishing American guidelines. These are set in a rigorous manner with a predetermined methodology and should be of immense interest throughout the world, although differences in health care systems may affect the relevance. The difficulties in evaluating the effectiveness of multiple sclerosis rehabilitation and the recent studies attempting to do this are set out. Standard setting and assessment of service provision and needs is briefly discussed. An update of outcome measures emphasizes the importance of patient input to measuring outcome, i.e. self-reported data, and includes a good clear practical summary of the generic and multiple sclerosis-specific scales. It also gives insight into the methodological issues around measuring abstract outcomes and the importance on setting and then assessing the success of aims when setting up new scales. Preliminary data only of the home-care multiple sclerosis project in Rome is given and the lack of need for a 24-hour service is demonstrated. There follows three chapters on the Norwegian Multiple Sclerosis National Competence Centre, on multiple sclerosis (atypical) in China and on the international interaction on guidelines for multiple sclerosis diagnosis, management and education. Finally, it ends with an overview of the highly successful Canadian experience of multiple sclerosis clinics and collaborative research and a brief mention of MS-COSTAR. Perhaps an overview of all multiple sclerosis databases would have been an appropriate topic.
Overall, this is a highly interesting and readable compilation of topics. The chapters are concise demonstrating good editorial input and author restraint. It is most relevant to multiple sclerosis neurologists, although non-multiple sclerosis specialists reading the MRI section would certainly come away with a good comprehension of this recent complex and expanding area.
Notes
By Sten Fredrikson and Hans Link. 1999. London: Martin Dunitz Publishers. Price £65. Pp. 232. ISBN 1-85317-871-3.
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