The concept of each article’s author providing his or her clinical “approach“ to various disease presentations and scenarios (in multiple sclerosis as well as other demyelinating diseases) has served as the basic underpinning of this issue since its inceptionand development by Dr Krieger.
Nowhere else in neurology, with the exception perhaps of stroke, has the management of a disease evolved so much since the last issue of Continuum devoted to the subject as in multiple sclerosis (MS). In this issue of Continuum, Guest Editor Dr Stephen C. Krieger has brought together a group of world-class experts to help us diagnose and organize our approach to the management of our patients with MS (as well as other disorders of white matter) in this new era characterized by a marked expansion of treatment options, each with a unique risk-benefit ratio and evolving place in our therapeutic armamentarium.
The issue begins with an overview of the new paradigm of care of MS and related disorders by Dr Krieger, who discusses how the approach to the goals of therapy in demyelinating disease has changed in concert with the remarkably evolving management options. In fact, the concept of each article’s author providing his or her clinical “approach” to various disease presentations and scenarios (in MS as well as other demyelinating diseases) has served as the basic underpinning of this issue since its inception and development by Dr Krieger.
Next, Dr Darin T. Okuda discusses the not uncommon scenario in which patients present to us with incidental lesions on MRI that may (or may not) suggest MS and the current thinking about the radiologically isolated syndrome. Dr David E. Jones reviews how to approach the choices of management of our patients with early relapsing MS using our many currently available disease-modifying therapies. Drs Mark S. Freedman and Carolina A. Rush share their approach to the management of patients with severe, highly active, and aggressive MS, discussing options that I suspect many readers will likely wish to defer to specialized MS centers but need to be aware of as potential options for our patients with these presentations. Drs Mary Alissa Willis and Robert J. Fox next provide their recommendations with regard to the management of our patients with progressive MS.
Dr Regina Radner Berkovich discusses the management of acute MS relapses using the currently available therapeutic options. Next, Dr Patricia K. Coyle reviews the many modalities (including lifestyle modifications) for management of the symptoms that affect the quality of life of our patients with MS. Dr Michelle Fabian then reviews the considerations involved with regard to pregnancy in patients with MS. Dr Aaron E. Miller (my predecessor as Editor-in-Chief of Continuum) discusses how to approach the common scenario of patients switching (or discontinuing) each of the disease-modifying MS therapies and addresses the question of whether it is ever safe to discontinue disease-modifying therapy in an apparently stable patient.
Dr Ilana Katz Sand then discusses the diagnosis and her approach to management of neuromyelitis optica (NMO) spectrum disorders, disorders with significant morbidity and mortality that require accurate diagnosis and prompt management to improve our patients’ outcomes. Drs Sona Narula and Brenda Banwell provide their approach to demyelinating diseases occurring in children, including MS, NMO spectrum disorders, and acute disseminated encephalomyelitis. In the final review article of the issue, Dr Adeline Vanderver reviews the diagnosis and management of the heritable leukoencephalopathies that may be seen in adults, which, although individually uncommon, represent conditions (some of which have specific treatment) that can present in any of our offices and need to be distinguished from the more common acquired inflammatory/demyelinative disorders that they mimic.
In the Ethical Issues article, Drs Ludo J. Vanopdenbosch, David J. Oliver, and Joseph S. Kass discuss the complex issues that arise when a patient expresses the wish to die, emphasizing the importance of communication and collaboration with the palliative care team. In the Practice Issues article, Dr Lily Jung Henson discusses the importance of health literacy and its relationship with patient outcomes in MS. Drs Pearce J. Korb and Augusto Miravalle review the considerations neurologists need to be aware of with regard to diagnostic and procedural coding in encounters with patients with MS and other demyelinating diseases.
As with every Continuum issue, a number of opportunities exist for CME. By taking the Postreading Self-Assessment and CME Test, written by Drs Adam Kelly and D. Joanne Lynn, after reading the issue, you may earn up to 12 AMA PRA Category 1 CreditsTM toward self-assessment and CME. The Patient Management Problem, written by Dr Claire S. Riley, follows the case of a 32-year-old woman presenting with her first symptoms of central nervous system demyelination and evolving into relapsing MS. By following her case and answering multiple-choice questions corresponding to diagnostic and therapeutic decisions along the course of her disorder, you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.
Please join me in sincerely thanking Dr Krieger for recruiting such outstanding expert colleagues and for providing us with such an organized, clear, thoughtful, and modern approach to the diagnosis and management of the wide variety of clinical scenarios we encounter in our patients with MS and other demyelinating diseases.
—Steven L. Lewis, MD, FAAN