Although as a neurologist with a subspecialty emphasis in multiple sclerosis I admit to a certain bias, I would venture the opinion that few areas of neurology have matched the progress seen, especially in the therapeutic arena, in multiple sclerosis (MS), the subject of this issue of Continuum. Guest editor Dr Bruce Cree has assembled a blend of senior MS clinician-investigators and many of the bright lights among the younger generation of MS specialists to provide a thorough review of this subject.
Understanding a disease needs to begin with reliable diagnosis. Although the hallmark of MS diagnosis remains the demonstration of lesions disseminated in time and space, Dr Cree, himself, updates us on the evolution of our diagnostic thinking in the first article. A key feature of this process is dependency on modern magnetic resonance imaging. Advances in MRI techniques, both in the clinic and in the research environment, have greatly facilitated our understanding of the biology of MS, in addition to having a role in establishing diagnosis. Drs Robert Bermel and Robert Fox update us on this important subject.
The progress in MS therapeutics in less than 2 decades has been remarkable, and several articles in this issue address this aspect of patient management. We have come a long way since one of my former mentors, the late Dr Labe Scheinberg, widely considered the originator of the concept of the MS comprehensive care center, lamented the attitude of neurologists toward patients with MS as "diagnose and adios." Drs Ben Greenberg and Bhupendra Katri and Mr John Kramer address the critically important matter of disease-modifying therapy (DMT), emphasizing not only currently available therapy but the exciting variety of drugs-including several oral agents-that hopefully will gain approval over the next few years. Although many of our patients with MS are taking immunomodulatory drugs approved by regulatory agencies, a huge percentage use complementary or alternative treatments in addition to, but sometimes instead of, DMT. Dr Allen Bowling brings us up to speed on the countless agents and techniques in this treatment category. While therapy to lessen or eliminate the progress of MS is vital, it is also critical to try to improve patients' quality of life with management of specific symptoms. Dr Clyde Markowitz enlightens us in this area. Neuro-ophthalmic features of MS are common, complex, and fascinating. Indeed, one could almost say that to understand the eye findings in MS is to understand neuro-ophthalmology. The details of these important clinical phenomena are cogently reviewed by a team led by Teresa Frohman and also including Drs Jennifer Graves, Laura Balcer, Steven Galetta, and Elliot Frohman.
A variety of biological aspects of MS is also covered in this Continuum issue. Drs Federica Esposito and Philip De Jager update us on the fast-moving developments in understanding the genetics of MS; Drs Amer Awad and Olaf Stüve explain the current concepts of immunopathogenesis; and Dr Elizabeth Crabtree-Hartman addresses the clinical and biological aspects underlying the well-known fact that MS is much more common in females than in males. Recently, we have seen heightened awareness of the occurrence of MS in children. Understanding MS in the pediatric population has the potential to inform us about some key aspects of the disease. Drs Ellen Mowry and Emmanuelle Waubant guide us through this emerging area. Another exciting recent development in the field of demyelinating disease has been the recognition of the association between an antibody to aquaporin 4, a major water channel in the CNS, and neuromyelitis optica. This discovery has led to the recognition of a spectrum of disorders associated with this antibody. Dr Dean Wingerchuk, who has been a major contributor in this area, educates us on this subject.
Although we have made great progress in the treatment of relapsing-remitting MS, we have been stymied thus far in our quest for a successful therapy for primary progressive MS (PPMS). However, PPMS, affecting about 10% to 15% of the total MS population, is an important subject, which is addressed by Dr Kathleen Hawker.
In addition to the principal articles in this issue, as usual Continuum features contributions on ethics and practice. In the former section, Drs Jill Conway and Norman Kachuk address the vexing issue of what to do when the patient and doctor differ on risk considerations of therapy, an important matter that will become increasingly frequent with the advent of new agents that are perhaps better, but more risky, than the very safe injectable therapies we have been using for years. In the practice section, Drs Christopher Bever Jr and Troy Desai address the increasing need for physicians to be comfortable in accessing online resources to help manage patients. Practice needs are also helped by the coding table provided by Dr Todd Janus.
Complete fulfillment of the learning experience offered by a typical issue of Continuum requires your working through the Patient Management Problem (PMP) and the multiple-choice questions (also available for completion online). The PMP for this issue has been prepared by Dr Tracy DeAngelis and the questions by Drs Steven Lewis and Joanne Lynn. Finally, this issue is accompanied by an edition of Quintessentials, an interactive series of case vignettes prepared by Dr Joy Derwenskus. Completing this exercise will solidify the practical knowledge provided by Dr Cree and the very talented group of contributors he has recruited. We are indebted to them all.
-Aaron E. Miller, MD