As I recently engaged in the ever-pleasant pastime of browsing through a bookstore, I encountered the flap of a book by Tracy Kidder, Mountains Beyond Mountains (New York: Random House, 2003), whose title is based on a Haitian proverb, Beyond mountains there are mountains. This seemed to mean apt metaphor for the neurology of organ transplantation. Just as medical scientists and practitioners conquer the daunting problem of replacing a vital organ, a new problem to solve-a new mountain to climb-suddenly looms. Often that new challenge is a neurologic complication. Dr Karen Roos and her able faculty in this issue of Continuum will guide you in scaling those rugged cliffs successfully.
Why an issue devoted to the neurology of organ transplantation? The ability to replace many of the body's critical organs has been one of the great medical triumphs of the last half-century. For a long time successful organ replacement was mostly limited to renal transplantation. More recently, however, successful transplantation of bone marrow, liver, heart and lungs (each alone or even together), and pancreas has been accomplished. The procedures, while certainly not routine, have become increasingly common. Although most are performed in large tertiary medical centers, neurologists outside such institutions will increasingly encounter these patients as they return to their own communities, still facing potentially daunting neurologic hurdles. Furthermore, some of the knowledge imparted in this issue of Continuum will have wider application to patients with other critical illnesses, as well as those who are immunosuppressed for other reasons.
Many readers already know that the editorial staff of Continuum is committed to bringing you a cyclical curriculum of "meat and potatoes" neurology. That is, over a 3-year timeframe, issues will cover 12 core subjects, indeed those dozen that will account for the vast majority of questions on the American Board of Psychiatry and Neurology recertification examination, now required every 10 years for new and recent diplomates. As part of this commitment, the February 2004 issue of Continuum focused on dementia, and issues later this year will cover movement disorders, epilepsy, and multiple sclerosis. Regard Neurologic Complications of Organ Transplantation as the intermezzo, the citrus sorbet that cleanses the palate between courses. The subject matter may be less frequently encountered, but the problems are no less important.
Scale the mountain as Dr Widjicks helps you understand the serious changes in consciousness that often follow major organ transplantation. Continue on as Drs Lacomis and Campellone explain the peripheral nervous system complications and Dr Sila discusses the potential cerebrovascular consequences. Drs O'Neill and Schiff will inform you about the unique post-transplant lymphoproliferative disorders of the central nervous system that complicate these procedures. Finally, Dr Roos herself will help you complete the trek and emerge with a clear understanding of the unique, often opportunistic, infections that may afflict transplant recipients. So, get out your ropes and pylons and enjoy the climb!
Aaron E. Miller, MD