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NEUROLOGICAL THERAPEUTICS: PRINCIPLES AND PRACTICE. VOLUMES I AND II

Richard W. Orrell
DOI: http://dx.doi.org/10.1093/brain/awh122 1456-1457 First published online: 27 May 2004

NEUROLOGICAL THERAPEUTICS: PRINCIPLES AND PRACTICE. VOLUMES I AND II
Edited by John H. Noseworthy
2003. Pp. 2864. London: Martin Dunitz
Price £275. ISBN 1‐85317‐623‐0

This is a substantial two‐volume work which is well presented. The book is divided into 14 sections, with 271 chapters written by 345 authors. There is a total of 2864 pages. The majority of the authors are from the USA, with particular focus on the Mayo Clinic.

To list the 14 section titles gives some indication of the scope of the text: Principles of therapeutics; Pain: headache, spine and limb pain; Seizure disorders; Cerebrovascular disease; Neuro‐oncology; Inflammatory and infectious disease; Critical care neurology; Neurological complications of systemic illness; Pediatric and adolescent neurology; Cranial nerve disorders, neuro‐otology and neuro‐ophthalmology; Peripheral nerve disorders (including anterior horn cell and autonomic nervous system); Muscle disease; Movement disorders; Neurobehavioural disorders: cognitive rehabilitation, behavioural management and pharmacologic therapies.

The book is written from the perspective of the USA, with some chapters relating solely to US practice and local issues. For example, in the chapter on ‘Legal and regulatory issues for people with epilepsy’, driving regulations are given for each of the US States and the District of Columbia, but not for other countries. In other chapters, where patient organizations and other contacts are given, these relate only to the USA.

The preface states that the book was created to address the need for a comprehensive textbook focused primarily on therapeutics and directed to busy neurologists and students of neurology. The text was to provide a reference that would be both authoritative and accessible for daily use. With such a large number of chapters and authors, there is variability in the achievement of these and other stated objectives in different chapters. The chapters are interesting and informative as individual essays, but I suspect the book is more accessible to experienced neurologists—with some time to spare—rather than early students of neurology.

The book presents as a large textbook of neurology that includes discussion of therapy, which all such books should. It is not unique, in that its aims are similar to those of Neurological Disorders, Cause and Treatment edited by Thomas Brandt and colleagues, which has recently been published in its second edition, in one volume of 1574 pages.

There are some unusual chapters that are not normally found in neurology textbooks, such as ‘Domestic violence in neurological practice’. It is suggested that poorly characterized pain syndromes without physical findings, such as chronic back or neck pain, pain typical of fibromyalgia, abdominal or pelvic pain, and chronic headaches, may be the illness presentation of domestic violence, and physicians should normally ask women patients about possible abuse. There are other idiosyncrasies, including the suggestion in the chapter ‘Migraine’ that migraine influenced ‘Nietzsche to develop the concept of the Aryan superman appropriated by Hitler to help justify his reign of terror’.

The book is helpful in that in places it includes more details of neurosurgical management than are normally found in neurology textbooks. There is also a section on paediatric and adolescent neurology. As might be expected from the Mayo Clinic, the section on peripheral nerve disorders is generally strong. However, taking the chapter on ‘Motor neuron diseases’ as an example, some of the deficiencies of such a large work, dealing with many rare and unusual conditions, in more depth than a relatively common neurological condition such as amyotrophic lateral sclerosis (ALS) are revealed. The chapter is nine pages in length and includes discussion of other motor neuron diseases. (The references alone for the chapter on ‘Tardive dyskinesia and related disorders’ occupy 11 pages.) The text initially suggests that both riluzole and gabapentin have small benefit in ALS, but later states that gabapentin has no benefit. In the table of treatment by symptoms, riluzole is recommended as the first‐line treatment for progression of weakness, and vitamin E (2000 units daily) as second‐line treatment. There is little critical discussion of the efficacy of riluzole, and clinical trial evidence and European approval is based on prolongation of life, without demonstrated effect on progression of muscle weakness. There is no discussion to substantiate the suggestion of vitamin E as second‐line treatment, and I am not aware of any evidence other than common usage based on its antioxidant effect. Modafinil is tabulated as second‐line treatment for fatigue in ALS, which would be controversial in British practice. An earlier chapter on ‘Evidence based medicine’ discusses systematic reviews, but the Cochrane Review of riluzole in ALS is not discussed or referenced.

I also looked specifically at facioscapulohumeral dystrophy (FSHD). The index pointed me to a chapter on ‘Neurological examination of the infant and child’, where there is mention but no detail of the condition. In reading the whole book, I found the relevant text in a chapter on ‘Muscular dystrophies’ in another section. (There are other deficiencies or frustrations in the indexing, which is a critical aspect of such a large two‐volume work.) In the section on FSHD, the section on genetics is not clear, especially with regard to its diagnostic use. A pilot trial of the β2 agonist albuterol is mentioned, showing a 12% improvement in muscle strength over 3 months. This was published in 1998. The use of albuterol is not discussed further, and the advice on its use is not clear. The full study, published in 2001, showed no improvement in the primary outcome of composite muscle strength score, and albuterol is not currently recommended for treatment of FSHD. The most recent references in this chapter are from 1999. (In the chapter on ‘Stroke prevention’ there is a note that the manuscript was accepted in April 1999, and five additional references are added, without discussion in the text, to bring the references to 2002.)

The chapters are well illustrated, with an unusual selection of some figures reproduced again in colour at the front of each volume. The inclusion of blue ink for headings and tables gives a refreshing appearance to the layout. Other particularly interesting sections are those on ‘Neuro‐oncology’ and ‘Cranial nerve disorders, neuro‐otology and neuro‐ophthalmology’, although their interest lies in the clarity of general presentation rather than therapeutic aspects specifically. A chapter on ‘Functional diseases affecting the cranial nerves’ gives a concise and clear summary of hysteria, although I am not certain that it has advanced my ability to treat these patients.

In conclusion, this is an impressive attempt to include everything that may relate to neurology and therapeutics in two large volumes. There is variability in the extent to which the objective of making informed therapeutic decisions is achieved. The book may work well for a neurologist based in the USA. For the non‐American neurologist the format may be less helpful, but it does have much of interest; and it educates and informs. Best of all was the generally short length of the chapters, and their self‐contained style, making the book easy to browse and dip into.

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