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Editorial Reviews

 

This book is unique. Written by a renowned and skilled physician, who was himself diagnosed with multiple sclerosis 24 years earlier, this volume contains a great deal of useful information based on the published literature and, more importantly, on the author’s direct personal knowledge. Whereas the former is often incomplete, sometimes too broadly prescriptive, and occasionally just wrong, Dr. Farr’s own experience provides a wealth of practical suggestions that are likely to be of great value to those who find themselves in similar straits. As one would expect from a fine, academic scientist, Dr. Farr is scrupulous in clearly differentiating among the sources of his recommendations and in specifying what is his own opinion, especially when it differs from that in the literature. Dr. Farr’s book contains a great deal of material that cannot be found elsewhere. This is not because other books have not been written but because they have not been written by someone possessing analytical skills and personal experience.

This book is very important.  Although Dr. Farr makes it clear that he is attempting to manage complications rather than to cure or modify the underlying disease, his writing is imbued with positivity. The book imparts not only scientific and personal knowledge, but it is also strongly supportive to patients and their caregivers. It emphasizes that even in advanced disease, there are problems and issues over which the patient retains control. It lets sufferers and families know that they are not alone; that there may indeed be approaches that they had not previously considered; and that even in the face of devastating illness, it is possible to be upbeat and to accomplish many things. By precept and by example, Farr teaches that one should not give up. However, and very importantly, he also notes (Chapter 40) that it can be important to ask for help and thereby gives permission to the patient to do so.

In Chapter 1, Dr. Farr lays out some particularly meaningful techniques for interpreting the published literature on MS. Here the reader benefits from the author’s considerable expertise in epidemiology. These approaches are useful in many fields and will contribute to anyone’s understanding of the entire medical literature.

The book is largely based on a form of N-of-one clinical trials, in which individual subjects are used to assess the value of interventions. Dr. Farr cites a reference, and I would like to add: Lillie EO, et al: The n-of 1 clinical trial: the ultimate strategy for individualizing medicine? Per Med 2011;8:161-73 (doi:10.2217/pme.11.7; and this is a public access document). N-of-one trials are often conducted in a blinded fashion, in which the subject/patient does not know which intervention is being administered at any given time. Such blinding is obviously impossible in Dr. Farr’s situation. The format is most valuable, but it must be considered in light of the fact that every patient is different.

Dr. Farr’s style is inviting and refreshing. Although dealing with a devastating illness, he spices up his writing with humor. The book is replete with quotations from and references to literature, history, and the performing arts. It draws the reader in with its question-and-answer format.

An important consideration brought forth in the book is that many of these complications are multifactorial and that multiple responses may be required. Furthermore, many strongly interact with one another and indeed may be synergistic in the symptoms that they cause (e.g. Chapter 38). This is heavily stressed in dealing with disorders of function by bladder and bowel. For example, there is considerable information related to constipation in Chapter 9, which is titled Increasing Bladder Problems.”  Thus, although Dr. Farr suggests on page xxx of the Introduction that one might only refer to selected sections, I would advise the reader to approach the book in its entirety because doing so will reveal hidden, relevant gems, solutions that might not otherwise be considered by the reader and that might be missed by reading only certain sections. Some definitions of terms used throughout occur only later in the book (e.g. hemiparesis, p. 268). Although methylprednisolone is described throughout the book, the possibility that it may be the cause of insomnia is not mentioned until Chapter 16, which specifically deals with this complication.  Setting up the book to be useful in sections and correctly stressing the “interrelatedness” of issues means that a complete reading will involve some repetition, but the value strongly exceeds this small problem.

Some of the included suggestions are relatively simple, e.g. urinating immediately before a meal (p. 121) or pouring half a bottle of liquid laxative into another container to facilitate self-administration of individual doses. Others are far more complex and appear to have required considerable practice. Some approaches to one problem, particularly those involving medications, may make others worse. Dr. Farr importantly stresses that one is always choosing between the value of an intervention and its costs. Although most of us do this every day, and usually unconsciously, he rightly points out that in the complex world of multiple sclerosis, these should be mindful decisions and should be subject to reevaluation over time. It will be necessary for the patient to prioritize among outcomes (p. vii Introduction).

Dr. Farr stresses that every person with MS is different, and that a successful solution for one may not work for another. In dealing with pain, he wisely suggests that “trial and error may be required.” He also notes that what may have been less successful at one point in the course of his disease actually worked better when tried again later.

Brand and generic names for medications are used irregularly throughout the book. Especially for over-the-counter drugs, it might be useful to follow the practice of The Medical Letter and provide the generic term followed by the brand names, for example: bisacodyl (Dulcolax®) or docusate sodium (Colace®, Dioctyl®, Docusol®, DulcoEase®, Norgalax®), which would facilitate purchases. This is less important for prescription-only drugs, but health-care providers may refer to a medication by either name, for example, oral methylprednisolone might also be referred to as Medrol®, Medrol®, Dosepak®, or Methylpred-DP®. This issue might be resolved by including a drug glossary at the end of the book. A glossary of medical terminology would also be useful.

Multiple Sclerosis: Coping with Complications is a powerful book that will contribute to affected readers and their caregivers on many levels.  Dr. Farr is to be congratulated on its comprehensive and sympathetic approach and on his strength and courage in producing it.

 

Michael F. Rein, MD MACP
Professor Emeritus
Harrison Distinguished Educator
University of Virginia