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CONTINUUM Multiple Sclerosis: Teaching Us About More Than MS and Its ABCs

Lewis, Steven L. MD, FAAN

doi: 10.1212/01.CON.0000433292.61209.60
Editor's Preface


I thank Drs Fox and Rae-Grant for so successfully meeting the challenge of providing thorough, practical, and up-to-date information that we can use to make the most informed decisions in the care of our patients with MS and other CNS demyelinating diseases.

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A CONTINUUM issue on multiple sclerosis (MS) in 2013 needs to cover the many issues regarding the diagnosis and management of the variety of CNS demyelinating diseases-not just MS-that we commonly encounter in our neurologic practices. At the same time, however, it also needs to ensure that we are informed regarding the most recent clinical information specific to MS, such as the newest diagnostic criteria and all of the remarkably expanding available treatment options. With this issue, Guest Editors Robert J. Fox, MD, FAAN, and Alexander D. Rae-Grant, MD, FRCP(C), from the Cleveland Clinic, along with their team of expert authors, have fulfilled these needs in a volume that will assist us in providing the most informed and up-to-date care of our patients with MS and other demyelinating diseases of the CNS.

This issue begins with a discussion by Drs Bogdan Popescu, Istvan Pirko, and Claudia Lucchinetti on the pathology of MS and other inflammatory demyelinating diseases and, in particular, how the heterogeneity of patterns of MS pathology is providing new insights into the pathogenesis of MS itself. Next, Drs Ilana Katz Sand and Fred Lublin provide a practical and up-to-date review of the newest diagnostic criteria for MS, which in some cases now allow for the diagnosis of MS at the time of the initial clinical event with a single contrast-enhanced brain MRI if the MRI meets criteria for dissemination in time and space; equally important, though, the authors also remind us of the many challenges of MS diagnosis, its critical differential diagnoses, and the important red flags for alternative diagnoses.

Next, Drs Dean Wingerchuk and Brian Weinshenker review the syndromes of acute disseminated encephalomyelitis and isolated myelitis syndromes followed by a thorough discussion of neuromyelitis optica, including its historical underpinnings; pathophysiology; clinical, imaging, and laboratory features (eg, aquaporin-4 antibodies); diagnosis and differential diagnosis; prognosis; and treatment of this common and potentially disabling disease.

Dr Mark S. Freedman next provides a state-of-the-art review of each of the currently-and newly-available pharmacologic therapies for MS, as well as those on the near horizon. His thorough review of the study outcomes (and risks) of each of these agents-most of which have not been assessed in head-to-head studies against other therapies-will provide each of us with a more informed approach to our therapeutic plans for patients with MS. On an entirely different MS-related note, the article that follows by Dr Rae-Grant is a quick and entertaining read informing and/or reminding us of some of the unusual clinical symptoms and syndromes that are important to recognize and can be diagnostically helpful in patients with MS. Dr Francois Bethoux then reviews the assessment and management of MS-related gait disorders, an important issue in the quality of life of MS patients.

Next, Dr Tanuja Chitnis reviews the clinical approach, diagnosis, and treatment of the variety of CNS demyelinating diseases that may occur in children, including optic neuritis, transverse myelitis, acute disseminated encephalomyelitis, neuromyelitis optica, and MS. Drs Ruth Ann Marrie and Heather Hanwell then discuss the physical and mental conditions that can occur in association with MS that are important for us to keep in mind-given their potential adverse impact on patient outcomes-as we evaluate and follow our patients. Dr Eric C. Klawiter then provides a well-illustrated and practical review of the important current role of MRI in the diagnosis and monitoring of our patients with MS, including a peek at newer imaging techniques that may soon find their way into our clinical practices to enhance our care of these patients. Finally, Drs Robert A. Bermel and Laura J. Balcer review the diagnosis, differential diagnosis, and management of visual impairment, especially optic neuritis, in MS.

In this issue’s Ethical Perspectives section, Drs Andrew Solomon and Eran Klein clarify the many issues involved in the (likely not uncommon) situation of “undoing” the diagnosis of MS in a patient who has been carrying that misdiagnosis for a number of years. In the Practice section, Drs Daniel Ontaneda and Robert Fox discuss risk mitigation strategies we can use as we choose from the increasing array of pharmacologic treatments available for MS (including, for example, risk stratification and monitoring for progressive multifocal leukoencephalopathy related to natalizumab and cardiac side effects related to fingolimod). Dr Todd Janus next outlines special considerations involved in coding for patients with MS.

As with each CONTINUUM issue, a number of opportunities exist for CME. Reading the material, answering the Multiple-Choice Questions crafted by Drs Eduardo Benarroch and Joseph Safdieh, and reviewing the explanatory discussions will assess and enhance your knowledge of the material, and you will be able to earn up to 10 AMA PRA Category 1 CME Credits™. An alternative opportunity allows you to obtain up to 12 AMA PRA Category 1 CME Credits specifically approved by the American Board of Psychiatry and Neurology (ABPN) for self-assessment by completing and submitting the Self-Assessment Pretest before reading the material and completing the postreading Multiple-Choice Questions. The Patient Management Problem, written by Drs Fox and Rae-Grant, describes the case of a 37-year-old woman beginning from her first clinical demyelinating event and continuing through the course of her disease. By following her case and answering multiple-choice questions corresponding to important diagnostic, monitoring, and therapeutic decision points along her course (reinforcing many of the issues addressed throughout the issue), you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.

I thank Drs Fox and Rae-Grant and all of the authors of this issue for so successfully meeting the higher educational challenge of providing thorough, practical, and up-to-date information that we can use to make the most informed diagnostic, therapeutic, and monitoring decisions in the care of our patients with MS and other CNS demyelinating diseases.

-Steven L. Lewis, MD, FAAN


© 2013 American Academy of Neurology