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Five-minute Practitioner: May 2007

Only got five minutes? Then just read these key points on: multiple sclerosis, Parkinson's disease, peripheral neuropathy and drug misuse

Only got five minutes? Then just read these key points on: multiple sclerosis, Parkinson's disease, peripheral neuropathy and drug misuse

Multiple sclerosis

Multiple sclerosis (MS) is a chronic inflammatory and degenerative disease of the CNS that often presents in young people. The most common subtype is relapsing–remitting MS.

The NICE guideline advises that the diagnosis of MS should be made by a doctor with specialist neurological experience. The difficulty in diagnosing relapsing-remitting MS is that the key criteria require evidence of dissemination in time and space, and these are often not evident when patients initially present to doctors.

A common presentation is a clinically isolated syndrome. This indicates inflammatory pathology localised to a single area of the CNS.

When a patient presents with a clinically isolated syndrome, it is important to ask directly for a past history of any of the other common symptoms. Patients with syndromes suggestive of MS should be referred to a neurologist for further evaluation. An MRI scan is usually arranged, together with blood tests to help exclude alternative diagnoses (for example, systemic lupus erythematosus, sarcoidosis and Lyme disease).

Some patients with relapsing-remitting MS run a benign course, accumulating minimal disability even after many years. This appears to be more common in young women, with fewer relapses and long remissions early in the course of the disease and complete recovery in between. Optic neuritis rather than weakness at onset seems to be a predictor of a better prognosis. However, after 10 years of relapsing-remitting MS, about 50% of patients will have converted to a pattern of secondary progressive MS.

Parkinson's disease

All patients with suspected PD should be referred quickly and untreated to a specialist with expertise in the differential diagnosis of PD.

Paucity and slowness of movement (akinesia and bradykinesia) must be present in order to make the diagnosis. The patient must also have muscular rigidity, rest tremor or postural instability in order to make the diagnosis of parkinsonian syndrome.

Depression affects about 40-50% of people with PD and can predate the motor symptoms. Dementia develops in 48–80% of people with PD.

Peripheral neuropathy

Peripheral neuropathies are common. Diabetes, alcohol, leprosy and HIV infection are the most common causes worldwide. Prevalence depends upon age and geography, and is between 2.4 and 8%. Diabetic neuropathy is the most common peripheral neuropathy in the UK.

Patients with peripheral neuropathy usually present with dysfunction of motor, sensory or autonomic nerves. The typical presentation comprises slowly progressive, distal sensory alterations, weakness and wasting.

A detailed family history across at least three generations is essential.

If an initial history, examination and first-line investigations fail to reveal a cause the patient should be referred to a neurologist.

Drug misuse

In the UK, four million people a year use illicit drugs, and one million of these use heroin and cocaine. Illicit drugs are involved in a third of fatal road traffic accidents and homicides. There are an estimated 250,000-300,000 problem drug users in England and the most recent figures show that 125,500 of these are receiving treatment.

Smokers are 12 times more likely to be dependent on another substance than non-smokers, and people with alcohol-related harm are six times more likely than those who use alcohol safely.

Drug dependence is treated by a combination of pharmacotherapeutic and psychosocial interventions. Trials report benefits of drug misuse treatment; for example, in the National Treatment Outcome Research Study, rates of injecting dropped from 61% to 29-37% depending on the setting. Although abstinence is the ultimate harm reduction, it is difficult to achieve – hence the focus on modifying behaviours.

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