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'This Handbook is a sparkling addition to the neurological library, a concise and clear guide to clinical practice in neurology, written in elegant prose, a tribute to Queen Square and to the contribution that both Hospital and Institute have made to neurology. It is the encapsulation of wisdom gained in a long career. For practitioners in the art of neurology, junior and senior this is required reading.'
--Simon Shorvon, National Hospital for Neurology & Neurosurgery, Queen Square
Neurology: A Clinical Handbook is a practical text, for both neurologists and general physicians, in the wards, the office or at home. This book spans the breadth of neurology and its challenges, for those who require a rapid resource in accessible language.
The Handbook is also aimed at those considering entering neurology, neurophysiology and neurorehabilitation and for medical trainees and consultants in many specialities. It is an invaluable source for the MRCP, a ready-made reference for clinical practice and for the specialist nurse and therapist.
The book deals with essentials - of neuroanatomy, clinical examination, mechanisms of neurological disease and the major issues of dementia and stroke in an ageing population. More specific aspects of neurology are also addressed, including the specialist fields of nerve and muscle disease, the spinal cord, headache and the cranial nerves, infection in the nervous system, MS and sleep disorders. The allied disciplines of neurorehabilitation, neuropsychiatry, neuro-oncology, uro-neurology, neuro-otology and neuro-ophthalmology are also covered.
The aim is to provide both an introduction and a summary - of general neurological practice and the specialist aspects of neurology and neuroscience.
Dr Charles Clarke has been a consultant neurologist since 1979 and has broad experience and interests throughout neurology. He worked at St Bartholomew's Hospital, the National Hospital for Neurology & Neurosurgery and in the front line of clinical practice at Whipps Cross Hospital, London and other district general hospitals. He has retired from the NHS and remains in practice. He was both the founding editor and an author of Neurology A Queen Square Textbook, now approaching its third edition, upon which this book is based.
The world over, one-third of all serious illness is caused by brain disease and a tenth by other neurological conditions. I introduce here the epidemiology and burden of neurological illness. Public Health plays a minor role in neurology. It needs more attention.
Incidence is new cases/100?000/year. Prevalence is the occurrence/1000 of the population, and lifetime prevalence the risk/1000 of acquiring a condition during life. These vary - between urban and rural settings and are linked to ethnicity, poverty, lifestyle/nutrition, vectors, war and sanitation. Data for specific age ranges are often more valuable than overall rates.
In the United Kingdom:
A population's age structure impacts heavily: there are more children and young adults in poor than in rich countries (Figure 1.2). Degenerative age-related disease is increasing: the world's population over 65 is to double between 2020 and 2030. Doubling time depends upon mortality rates, on the number of offspring per mother, and on cultural, financial and religious pressure. Examples are in Table 1.1.
Practical neurology is remarkably similar the world over - a neurologist in China, India or South America will be familiar with most conditions seen in Europe (Table 1.2). Variation between regions is determined largely by infections, such as malaria. Study of the full impact of Covid-19 is unknown and not discussed here.
Figure 1.1 Standardized prevalence and incidence rates of treated epilepsy in a population of 2?052?922 persons in England and Wales in 1995. (Bars indicate 95% CI.) Prevalence of treated epilepsy: overall 5.15/1000 people (95% confidence interval [CI] 5.05-5.25).
Source: Wallace et al. 1998.
Figure 1.2 Age structure in developed (Sweden) and developing (Costa Rica) countries.
Source: Worldwatch Database, 1996, Worldwatch Institute.
The cause of a neurological disease is rarely simple. A condition is either:
Table 1.1 Population size and doubling times.
Source: Data from The Population Reference Bureau, 2015
Table 1.2 Incidence and point prevalence.
Source: Data from various WHO sources; excludes shingles.
Generally, where primary causes are poorly understood, causation can be divided into
Most neurological conditions are products of multifactorial influences, each of which alone would not cause the disease. It is thus helpful to study risk factors.
Mortality rate: the number dying of a condition divided by the number in the population.
This information is of limited value without knowledge of the overall death rate.
Life expectancy (median survival age) is often lowered in neurological disease, but data are complex.
Taking epilepsy, one study followed over 500 cases for >10 years. The overall mortality ratio was 2.1. The hazard ratio (HR), or risk of death, for epilepsy overall, was 6.2. Life expectancy was reduced by some 2-10 years.
It is not enough to prolong survival. In high grade gliomas, radiotherapy is known to prolong life by about six months. Side effects are severe; the trade-off between survival and quality of life (QoL) is important. One study showed that how well a patient was before radiotherapy was a good indicator of disability-free life after it. For those already disabled, radiotherapy offered little gain.
Figure 1.3 Comparison of age-specific fertility rates in women with treated epilepsy and general UK population of women in 1993
.
This means all negative impacts, though the words are often used to define cost. Whilst cost studies produce fiscal measurements, it is absurd to measure QoL in cash. Utility measures such as quality-adjusted life years (QALYs) and disability-adjusted life years [DALYs] try to quantify this burden (Table 1.3).
The principal duty of a clinician is to provide individual care. However, doctors are now rightly involved in economic considerations. In any study of cost, analysis is of signal importance. Who was the study for, and who did it? The cost and burden for an individual have different parameters when compared with the effect on families, on health services and on society. Many studies are carried out from the point of view of society, with costs estimated in terms of lost employment, lost productivity and premature death, rather from the perspective of a patient, or their family.
Table 1.3 DALYs...
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