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BOOK REVIEWS Diagnostic Testing in Neurology edited by Randolph W. Evans, 505 pp., ill., Philadelphia, WB Saunders, 1999, $95 In this multiauthored volume, Evans and the contributing authors present the accumulating evidence regarding the use of diagnostic tests in neurology. The stated goal of the book is to provide the clinician with relevant information that allows judicious use of such tests in clinical practice. Because making a judicious choice requires a clear under- standing of the differential diagnosis, a great deal of space is devoted to the presentation of neurologic symptoms and to describing the range of disorders that cause them. The book is arranged conveniently for the practicing clinician. Sections cover such broad topics as pain, central disorders, neuromuscular disorders, and neurologic mani- festations of systemic disease. Chapters within these sec- tions explore either particular disorders or common presenting symptoms and signs. This unconventional orga- nization is practical for clinicians who must decide which tests will support their impression of a specific disease or help to distinguish between a variety of illnesses that pre- sent with similar complaints. The style of individual chapters varies considerably, re- flecting both the scope of the topic and the interests of the authors. Some chapters reflect a public health perspective, exposing the low yield of certain diagnostic procedures in the evaluation of certain symptoms. Others focus on symp- tom presentation, differential diagnosis, and the available investigative techniques. The core of each chapter explores how various studies add to diagnostic certainty. When applicable, the sensitiv- ity and specificity of particular diagnostic tests are pre- sented. For other tests, recommendations from consensus reports are described. However, in certain subspecialty fields, the individual approach of the author is presented, perhaps for lack of more definite standards. There is a long section on the clinical and electrodiagnostic aspects of neuromuscular disease, which includes chapters on au- tonomic function and on disorders of micturition and sex- ual function. The book makes good use of tables, dia- grams, and images. However, some diagrams were adopted from consensus statements, and nomenclature or defini- tions found in these diagrams were not easily identified in the text. References are up to date. In summary, this is a very useful reference work. The book will be a valuable source for both the general neu- rologist seeking to sharpen his diagnostic precision and the subspecialty neurologist confronting a patient with an illness outside of his expertise. Chad Christine, MD Ethical Dilemmas in Neurology (Major Problems in Neurology, Vol 36) edited by Adam Zeman and Linda L. Emanuel, 219 pp., London, WB Saunders, 2000 This collection of 17 short essays, edited by a British neu- rologist and a British-American medical ethicist, is in- tended to stimulate critical thinking about ethical prob- lems that arise in the practice of neurology. The editors correctly offer the caveat that the book is not intended to be a systematic textbook in neurological ethics but rather a series of analyses and commentaries that test and fortify professional common sense. For proper disclosure, I note that I am the author of a current textbook on neurological ethics. The editors have selected a series of interesting topics for consideration and each essay title is composed in the form of a question. Topics chosen include consent, truth telling, confidentiality, clinical trials, rationing of expen- sive treatments, advance directives, withdrawal of treat- ment, euthanasia, and brain death. The authors selected to discuss these topics were divided between the UK and the USA (plus two others), and include a number of well- known experts. Some topics unusual for such a volume include the ethical conflict between public and private practice in the UK, the ethics of conducting research on human embryos and animals (Peter Singer predictably supports the former but not the latter), and the military physician’s conflict of agency in caring for patients with the Gulf War syndrome. The quality of the essays is generally high but variable. Particularly strong essays included those discussing situa- tions in which consent should be obtained for an HIV test, instances in which it is ethically justified to breach confi- dentiality, and when and why advanced directives should be used. I found the chapter on ethical issues in random- ized clinical trials to be well written for the topics discussed but lacking due to the omission of two topics fundamental to research ethics: the concept of clinical equipoise and the use of placebos. © 2000 John Wiley & Sons, Inc. 1776 Book Reviews MUSCLE & NERVE November 2000

Diagnostic testing in neurology

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BOOK REVIEWS

Diagnostic Testing in Neurologyedited by Randolph W. Evans, 505 pp., ill., Philadelphia, WBSaunders, 1999, $95

In this multiauthored volume, Evans and the contributingauthors present the accumulating evidence regarding theuse of diagnostic tests in neurology. The stated goal of thebook is to provide the clinician with relevant informationthat allows judicious use of such tests in clinical practice.Because making a judicious choice requires a clear under-standing of the differential diagnosis, a great deal of spaceis devoted to the presentation of neurologic symptoms andto describing the range of disorders that cause them.

The book is arranged conveniently for the practicingclinician. Sections cover such broad topics as pain, centraldisorders, neuromuscular disorders, and neurologic mani-festations of systemic disease. Chapters within these sec-tions explore either particular disorders or commonpresenting symptoms and signs. This unconventional orga-nization is practical for clinicians who must decide whichtests will support their impression of a specific disease orhelp to distinguish between a variety of illnesses that pre-sent with similar complaints.

The style of individual chapters varies considerably, re-flecting both the scope of the topic and the interests of theauthors. Some chapters reflect a public health perspective,exposing the low yield of certain diagnostic procedures inthe evaluation of certain symptoms. Others focus on symp-tom presentation, differential diagnosis, and the availableinvestigative techniques.

The core of each chapter explores how various studiesadd to diagnostic certainty. When applicable, the sensitiv-ity and specificity of particular diagnostic tests are pre-sented. For other tests, recommendations from consensusreports are described. However, in certain subspecialtyfields, the individual approach of the author is presented,perhaps for lack of more definite standards. There is along section on the clinical and electrodiagnostic aspectsof neuromuscular disease, which includes chapters on au-tonomic function and on disorders of micturition and sex-ual function. The book makes good use of tables, dia-grams, and images. However, some diagrams were adoptedfrom consensus statements, and nomenclature or defini-tions found in these diagrams were not easily identified inthe text. References are up to date.

In summary, this is a very useful reference work. Thebook will be a valuable source for both the general neu-

rologist seeking to sharpen his diagnostic precision andthe subspecialty neurologist confronting a patient with anillness outside of his expertise.

Chad Christine, MD

Ethical Dilemmas in Neurology (MajorProblems in Neurology, Vol 36)edited by Adam Zeman and Linda L. Emanuel, 219 pp.,London, WB Saunders, 2000

This collection of 17 short essays, edited by a British neu-rologist and a British-American medical ethicist, is in-tended to stimulate critical thinking about ethical prob-lems that arise in the practice of neurology. The editorscorrectly offer the caveat that the book is not intended tobe a systematic textbook in neurological ethics but rathera series of analyses and commentaries that test and fortifyprofessional common sense. For proper disclosure, I notethat I am the author of a current textbook on neurologicalethics.

The editors have selected a series of interesting topicsfor consideration and each essay title is composed in theform of a question. Topics chosen include consent, truthtelling, confidentiality, clinical trials, rationing of expen-sive treatments, advance directives, withdrawal of treat-ment, euthanasia, and brain death. The authors selectedto discuss these topics were divided between the UK andthe USA (plus two others), and include a number of well-known experts. Some topics unusual for such a volumeinclude the ethical conflict between public and privatepractice in the UK, the ethics of conducting research onhuman embryos and animals (Peter Singer predictablysupports the former but not the latter), and the militaryphysician’s conflict of agency in caring for patients withthe Gulf War syndrome.

The quality of the essays is generally high but variable.Particularly strong essays included those discussing situa-tions in which consent should be obtained for an HIV test,instances in which it is ethically justified to breach confi-dentiality, and when and why advanced directives shouldbe used. I found the chapter on ethical issues in random-ized clinical trials to be well written for the topics discussedbut lacking due to the omission of two topics fundamentalto research ethics: the concept of clinical equipoise andthe use of placebos.© 2000 John Wiley & Sons, Inc.

1776 Book Reviews MUSCLE & NERVE November 2000

Page 2: Diagnostic testing in neurology

To me, as an American physician, the book has a dis-tinctly British flavor. Most of the law discussed in variouschapters is UK law, and most of the cited precedents andstandards are British. This orientation is understandablegiven the editors’ and authors’ backgrounds. However, Iwas disappointed that none of the 22 authors cited any ofthe numerous position papers and guidelines on ethicalissues in neurological practice published in Neurology overthe past 12 years by the Ethics Committee of the AmericanAcademy of Neurology. Perhaps these statements were un-

known to the authors because none of them is an Ameri-can neurologist.

The editors have succeeded in assembling a thought-provoking volume of essays highlighting the complexitiesof ethical issues in neurological practice and research.Readers will benefit from carefully pondering the impor-tant questions raised in these essays.

James L. Bernat, MD

Book Reviews MUSCLE & NERVE November 2000 1777