The best way I know to ruin a good career in neurology is to advocate a treatment for multiple sclerosis.
-H. Houston Merritt (by attribution)
Fortunately, these remarks allegedly made a few decades ago by the late H. Houston Merritt, one of the 20th century's giants of American neurology, no longer ring true. To be sure, current treatments for multiple sclerosis (MS) are only partially effective. Nonetheless, we have clearly entered a modern era of MS therapeutics, with a burgeoning cadré of medications that impact the course of the disease.
In this CONTINUUM, Drs Anne Cross and Robert Naismith have organized a team in which young players in the MS arena have joined a group of seasoned veterans to craft an issue that will update our readers on a variety of important aspects critical for understanding MS. Logically, the issue begins with a discussion of the diagnosis and differential diagnosis of MS. In recent years an international panel, initially led by the late British MS investigator W. Ian McDonald, has revised the criteria for the diagnosis of MS. These criteria, now commonly referred to as the McDonald criteria, were subsequently revised in 2005. Drs John Rinker and Cross in the first chapter thoroughly familiarize the reader with this diagnostic scheme, as well as review those conditions that can be confused with MS.
The next few chapters will refresh your understanding of some of the scientific aspects of MS, always remaining focused on clinical implications of the findings. Current concepts of the immunopathogenesis of MS can seem bewilderingly complex. Drs John Rose and Noel Carlson have managed the feat of explaining contemporary ideas about the pathogenesis of MS in a thorough, yet lucid, fashion. The nature versus nurture arguments regarding the cause and course of MS have long been debated. Clearly, both genetic and environmental factors seem implicated, as discussed in the chapter by Drs Ari Green and Emmanuelle Waubant. Next, Dr Claudia Lucchinetti, who has herself been spearheading a major ongoing bicontinental investigation of the pathology of MS, provides her insights in the chapter, "Advances in the Neuropathology of Multiple Sclerosis: Evolving Pathogenic Insights."
The late Dr Labe Scheinberg, considered by many to be the father of comprehensive care in MS, was often quoted as saying that the attitude of physicians in dealing with patients with MS was "diagnose and adios." Even after the introduction of modern neuroimaging, he lamented that the approach became, "MRI and goodbye." These implications that neurologists could do little to help people diagnosed with MS have been dramatically altered by the introduction of disease-modifying therapies (DMTs), beginning with the US Food and Drug Administration approval of interferon beta-1b in 1993. The USFDA has now approved six agents for the treatment of MS and dozens more are in clinical trials. Drs Lahar Mehta and Andrew Goodman review this subject, discussing the details of each agent and providing guidance about the selection of drugs. They also present information on potential future therapy. The management of MS, however, is not limited to the prescription of DMTs. These drugs are incompletely effective in preventing further disease activity and do nothing to reverse existing neurologic dysfunction. Hence, an important aspect of the neurologist's role is to help improve patients' symptoms and, thereby, their quality of life through a variety of interventions. Dr Steven Schwid provides a comprehensive discussion of this subject in his chapter, "Symptomatic Management of Multiple Sclerosis."
Don't neglect to look at the provocative contribution to Ethical Perspectives in Neurology by Dr Darin Okuda, as well as the new section on Practice Issues in Neurology by Dr Jonathan Hosey, this time with a focus on the development and use of guidelines. As always, your understanding of the subject will be greatly enhanced by working through the patient management problem provided by Dr Schwid and the multiple-choice questions developed by Drs Ronnie Bergen and Julie Hammack.
Because of my personal subspecialty interest in MS, I have particularly enjoyed editing this issue of CONTINUUM. I am sure you will share my enthusiasm and my appreciation for the work of Drs Cross, Naismith, and faculty.
-Aaron E. Miller, MD