Fifth Congress of the European Academy of Pediatric Societies

By Nino Gogatishvili

With the support of World Federation of Neurology I attended the Fifth Congress of the European Academy of Pediatric Societies Oct. 17-21 in Barcelona.

The organizing societies were the European Academy of Pediatrics (EAP), The European Society of Pediatric and Neonatal Intensive Care (ESPNIC) and The European Society for Pediatric Research (ESPR).

The excellent organization of the congress made it possible for pediatric professionals from around the world to gain unparalleled access to the best scientific research programs. The scientific program was varied. Abstract topics included: primary care and general pediatrics, neonatology, neonatal brain and development, neonatal pulmonology, neonatal cardiovascular, neonatal nutrition and gastroenterology, neonatal infection, adolescent health, pediatric surgery, cardiology and cardiac surgery, gastroenterology and hepatology/nutrition, neurology and developmental pediatrics, pulmonology/allergy/immunology/asthma, intensive care and pediatric emergency care medicine, hematology and oncology, nephrology, infectious diseases, endocrinology/diabetes/metabolism and pharmacology.

My poster, PO-0834, “Long-Term Developmental Outcome of Children Prenatally Exposed To Antiepileptic Drugs” was presented on Oct. 19. My abstract also was published: N.Gogatishvili, T.Ediberidze, G Lomidze, N Tatishvili, S Kasradze. Arch Dis Child 2014; 99:Suppl 2 A526 doi: 10.1136/archdischild-2014-307384.1466

I am grateful for the support of World Federation of Neurology that permitted me to attend this important congress and obtain experience that will help me in my work.

Gogatishvili is with the Institute of Neurology and Neuropsychology, Tbilisi, Tbilisi State Medical University, Tbilisi, Georgia.

NSRG Teaching Courses in Latin America

Figure 1. Participants of the NSRG Course in Lima

By Prof. Dr. Med. Manfred Kaps

The Latin American Chapter of the NSRG organized teaching courses in Lima, Peru, and Mendoza, Argentina, in October. According to the NSRG teaching concept to offer a high level of theoretical knowledge and sufficient practical skills, both two-day courses included lectures and at least 50 percent practical training in small groups of no more than seven participants.

Figure 2. Mendoza in October 2014.

The strictly limited number of participants allowed individual mentoring and exchange among all participants and proved functional. At the closing ceremony when the local course directors Prof. Ana Valentia, Dra. Sylvia Cocorullo and Prof. Manfred Kaps as NSRG delegate delivered the participation certificates, there was lots of cheer and enthusiasm.

Figure 3. Participants of the NSRG Course in Lima.

The next NSRG accredited courses will take place in 2015 in Mexico, Brazil and of course during the XXII World Congress of the WFN in Santiago, Chile.

Kaps is professor of neurology at Justus-Liebig-University in Giessen, Germany.

MS: The First MENACTRIMS Congress

By Bassem I. Yamout, MD, FAAN

The First Congress of The Middle East North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS) was held Oct. 17-18 in Dubai. MENACTRIMS is an independent organization that facilitates communication and creates synergies among clinicians and scientists to promote and enhance research and improve clinical outcomes in multiple sclerosis (MS) in the Middle East and North Africa regions.

It was founded on Dec. 8, 2012, by nine eminent neurologists: Saeed Bohlega and Mohamad Jumaa from KSA, Riad Goueider from Tunisia, Raed Roughani from Kuwait, Maurice Dahdale from Jordan, Jihad Inshasi from the Emirates, Saher Hashem from Egypt, Issa Alsharuqui from Bahrain, and me from Lebanon. The prevalence of MS has been steadily increasing over the last few decades in the Middle East/North Africa region, reaching as high as 80/100,000 in some countries. The challenges posed by such a medical burden created the need for an official regional scientific committee to address all emerging issues related to MS in this region of the world.

The First MENACTRIMS Congress was the first major endeavor of the newborn MENACTRIMS organization, and with more than 500 attendees, including new practitioners as well as experienced MS specialists from all over the Middle East, North Africa and neighboring countries, it turned out to be the largest scientific MS event in the region’s history. Speeches were given at the opening ceremony by Dr. Bassem Yamout, president of MENACTRIMS; Dr. Raad Shaker, president of the World Federation of Neurology; Dr. Xavier Montalban, president of ECTRIMS; Dr. Suhayl Dhib-Jalbut, president of ACTRIMS; and Dr. Saeed Bohlega, president-elect of the Pan Arab Union of Neurological Societies.

The meeting hosted plenary sessions, scientific debates, clinical courses and symposia, focusing on biomarkers, epidemiology, immunopathogenesis, differential diagnosis, genetic and environmental factors, neuroimaging, OCT, pregnancy and Neuromyelitis Optica. More than 30 international and regional speakers shared their scientific and clinical experience with the audience, and 57 posters were presented during the meeting covering both local and international research.

MENACTRIMS is the youngest sister of a large family of international MS societies, which includes our elder sister ECTRIMS of nearly 30 years, ACTRIMS, LACTRIMS, PACTRIMS and RUCTRIMS. One of our main objectives is to cooperate with all international MS organizations to promote research and improve medical care in the field of MS.

Yamout is professor of Clinical Neurology, president, MENACTRIMS and director of the Multiple Sclerosis Center Clinical Research at the American University of Beirut Medical Center in Lebanon.

The Controversial Story of Aspirin

Figure 1. Felix Hoffmann

Edward Stone and aspirin

By JMS Pearce, MD, FRCP

For almost a century, aspirin, one of the most important drugs of the 20th century, was the mainstay of symptomatic analgesia, used universally in the treatment of headaches, arthritis, painful neurological and other maladies. Its introduction is usually credited to Felix Hoffmann’s (1868-1946) synthesis of salicylic acid in 1897. (See Figure 1.) But this is a controversial story. The use of salicylates dates back at least to c. 400 BC when Hippocrates (440-377 B.C.) prescribed the bark and leaves of salix, the willow tree (rich in salicin) to reduce pain and fever. It also was mentioned by Dioscorides (c. 100 A.D.) and later by Pliny the Elder and Galen.

In 1826, Henri Leroux isolated “salicin” from willow bark. However, it had fallen into disuse for centuries until the Reverend Edward Stone rediscovered its efficacy.

The Reverend Edward Stone (The Reverend was formally known as Edward, but was referred to as Edmund by his close friends and family.) was born in Lacey Green, Princes Risborough, Buckinghamshire, on Nov. 5, 1702¹. He went to Wadham College, Oxford, in 1720. In June 1728, he was ordained to take up the curacy of Charlton-on-Otmoor, Oxfordshire, where he remained until 1730 when he was elected a Fellow of Wadham. In 1745, he moved to Chipping Norton, Oxfordshire, as chaplain at Bruern Abbey.

Dried Willow Bark

Figure 2. Proc Royal Soc 1763, Edmund Stone: Willow bark

On April 25, 1763, Stone wrote to George Parker, second earl of Macclesfield, and president of the Royal Society in a letter read before the Royal Society on June 2, 1763, describing the use of dried willow bark as a remedy for fevers and agues². (See Figure 2.)

He explained that he had suffered from “aguistic intermitting disorders,” which may have been malaria. In 1757, he had “accidentally” tasted willow bark and noted its extreme bitterness and its resemblance to Peruvian bark (cinchona tree, source of quinine). Arguing from the doctrine of signatures —”that many natural maladies carry their cures along with them, or that their remedies lie not far from their causes,” Stone concluded that the willow tree that “delights in a moist or wet soil” might provide an antidote for agues that chiefly abound in that environment.

He experimented by gathering willow bark from pollarded willows, dried it for more than three months in a bag on the outside of a baker’s oven, pounded and sifted it. He dosed himself, using tiny amounts, but finding that the powder had a salutary effect, increased the dose to two scruples (One scruple equals 1/24 ounce, about 1.25 gm) every four hours. To his delight, “the ague was soon removed.”

Stone gave powdered willow bark over several years to about 50 people complaining of agues or fevers; it was successful in many of them. But, when fevers failed to respond to willow bark, he added quinine, which he found more effective. It’s unclear, however, if any of these patients had malaria. Thus, had Stone accidentally discovered a source of salicylate, the precursor of aspirin.

In January 1764, a fire at Bruern Abbey ended Stone’s chaplaincy there. He died intestate in Chipping Norton on Nov. 26, 1768, and was buried at Horsenden on Dec. 2, 1768.

After Stone’s report to The Royal Society², willow bark was advised in some herbals, and pharmacists tried to extract salicylic acid from willow bark and meadowsweet (Filipendula ulmaria). Side effects of salicylate were troublesome but were reduced when, in 1853, acetylsalicylic acid or aspirin was made by Hoffman from acetyl chloride and sodium salicylate.

It is usually stated that Hoffmann (See Figure 1.) developed aspirin to help his rheumatic father; but it was not until 1897 that under instruction from Arthur Eichengrün (1867-1949) he synthesized acetylsalicylic acid, which was named aspirin, for the Bayer company. (See figure 3.) Hoffmann’s close associate, Heinrich Dreser (1860-1924), dismissed the market potential of aspirin on the ground that it had an “enfeebling” action on the heart. (“The product has no value.³“) He was preoccupied at the time with the potential of Bayer’s new drug — heroin⁴.

Figure 3. Arthur Eichengrün

Arthur Eichengrün, whose job it was to discover new products at Bayer, refused to accept Dreser’s rejection of acetylsalicylic acid and pressed for its development^5,4. This was later produced commercially by Hoffman and Dreser in 1899, marketed by Bayer as “aspirin,⁶” whose name derived from Spiraea, then the Latin name for meadowsweet.

However, in 1949, Eichengrün claimed⁷ that he had instructed Hoffmann to synthesize acetylsalicylic acid, and Hoffmann had done so without understanding the purpose of the work. In 1944, while incarcerated in Theresienstadt concentration camp, Eichengrün had typed a letter (in the Bayer archives⁸) claiming his objective had been to obtain a salicylate without the adverse effects (gastric irritation, tinnitus) of sodium salicylate. Eichengrün tried aspirin himself, with no ill effects. Its real clinical potential was shown when with Dr. Felix Goldmann, he recruited physicians to secretly test it, they found it was successful in several painful conditions⁹. Eichengrün did not boast of his prime role in the discovery. Hoffmann lived until 1946, notably without publishing his own account of the discovery of aspirin; he mentioned repeatedly that Dreser had set the drug aside.

Hoffmann’s role was important but was restricted to the synthesis of aspirin: prompted by Eichengrün, who “deserved credit for the invention of aspirin.⁵”

References:

1. Mann R. ‘Stone, Edward (1702-1768)’, rev. Ralph Mann, Oxford Dictionary of National Biography, Oxford University Press, 2004; online edition, Jan 2008 [http://www.oxforddnb.com/view/article/38014, accessed 27 Sept 2014]

2. Stone E. ‘An account of the success of the bark of the willow in the cure of agues’, Philosophical Transactions Royal Society, 53 (1763), 195-200

3. Dreser H. Pharmakologisches über aspirin (Acetylsalicylsäure). Pflugers Arch 1899; 76: 306-318.

4. Askwith R. How aspirin turned hero. Sunday Times [London]. 1998 Sep 13.

5. Sneader, W. The discovery of aspirin: a reappraisal. BMJ 2000;321: 1591-4.

6. Fairley PA., The conquest of pain (1978) Aspirin Foundation, The amazing story of aspirin (1981) Foster, Alum. Oxon

7. Eichengrün A. 50 Jahre Aspirin. Pharmazie 1949; 4: 582-584.

8. Bayer-Archiv. 271/2.1 Personal data on Eichengrün. Dr A. Eichengrün, Aspirin, KZ Theresienstadt. 1944:2. Cited by Sneader,5.

9. Pearce JMS. The disputed origins of aspirin. In: Fragments of Neurological History. London, Imperial College Press. 2003.

Pearce is Emeritus Consultant Neurologist at the Department of Neurology, Hull Royal Infirmary, UK.

Dr. Peter J Koehler is the editor of this history column. He is neurologist at Atrium Medical Center, Heerlen, The Netherlands. Visit his website at www.neurohistory.nl.

Editor’s Update and Selected Articles From JNS

John D. England, MD

By John D. England, MD

The Journal of the Neurological Sciences (JNS) is a broad-based journal that publishes articles from a wide spectrum of disciplines, ranging from basic neuroscience to clinical cases. JNS strives to publish papers with novel, unique and original observations.

Along these lines, members of our Editorial Board are encouraged to identify and foster the submission of manuscripts that demonstrate the highest quality research. We also strive to satisfy the desires and needs of our readership, and I have received many requests to increase the number of review articles that cover topics in clinical neurology as well as basic neuroscience.

JNS has always welcomed well written and relevant review articles, and I wish to re-emphasize this point to prospective authors. Dr. Daniel Truong, who is the associate editor for Reviews and Commentary, has updated the suggested format for review articles submitted to JNS.

Whatever the topic, the review should be richly referenced and include summary text boxes, tables and diagrams or figures. The idea is to make the reviews easily readable and educational. Authors who might be interested in writing and submitting review articles to JNS can find specific requirements and suggestions within the JNS website.

In our ongoing attempt to enhance accessibility of JNS articles to members of the World Federation of Neurology (WFN), we have selected two more “free-access” articles, which are profiled in this issue of World Neurology.

In this issue, we feature two paired articles regarding the ALS-Plus syndrome.

Many clinical and pathological studies indicate that ALS is a more heterogeneous disease than previously recognized. In fact, even patients who appear to exhibit a clinically pure motor system disease often have neuropathological evidence of multisystem disease. In the largest series of cases to date, Leo McCluskey, et al, assessed the frequency of the “ALS-Plus” syndrome in a consecutively ascertained series of 550 patients with ALS. Their criteria for ALS-Plus was a clinical diagnosis of ALS combined with deficits of ocular motility, cerebellar signs, extrapyramidal features or autonomic dysfunction. Cognitive impairment was also assessed, but determined separately. Selected patients had genetic testing and high-resolution MRI of brain. Seventy-five (13.6%) patients had ALS-Plus syndrome. Fourteen additional patients had evidence of cognitive deficit (ALS-FTD). Cognitive impairment, bulbar-onset and pathogenic genetic mutations were more common in the patients with ALS-Plus syndrome compared to patients without ALS-Plus syndrome. The patients with ALS-Plus syndrome also had a shorter survival.
McCluskey L, Vandriel S, Elman L, Van Deerlin VM, Powers J, Boller A, et al. ALS-Plus syndrome: Non-pyramidal features in a large ALS cohort. J Neurol Sci 2014;345:118-124.
In an accompanying editorial, Benjamin Brooks provides an historical perspective and comments upon the importance of the article for the field of ALS research. He determines that McCluskey and colleagues have performed a “masterful clinical study of a modern series of ALS-Plus from a single center.” He suggests that this study provides a clinical framework for accurate classification of ALS-Plus syndrome. Studies such as this one indicate that “atypical” ALS is not as atypical as we believed and should stimulate more thought and research within the field.
Brooks BR. ALS-Plus – Where does it begin, where does it end? J Neurol Sci 2014;345:1-2.

England is editor-in-chief of the Journal of the Neurological Sciences.

Building partnerships for global health: NIH’s Fogarty International Center

Donna Bergen

By Donna Bergen, MD

The Fogarty International Center (FIC), as part of the U.S. National Institutes of Health (NIH), supports global health research and research capacity building through its own programs and through partnerships with the rest of NIH and outside organizations. To meet its goal of improving global health through research, FIC strives to build partnerships between health research institutions and individual scientists in the U.S. and abroad, and to train young scientists.

Fogarty and 17 other NIH components sponsor a Global Health Program for Fellows and Scholars, which offers an opportunity for young investigators from the U.S. and from low- and middle-income countries (as defined by the World Bank) to learn new research skills, build collaborations and advance their careers. Applicants apply directly to specific “support centers,” which are U.S. academic institutions with special expertise in global health, and which are funded through competitive grants.

These support centers are the University of California at Berkeley, the University of California Global Health Institute, the University of North Carolina at Chapel Hill, the University of Washington and Vanderbilt University. Applications for FIC training grants are awarded through these support centers. These support centers identify and select candidates, and provide mentoring, technical and administrative assistance to the fellows and scholars in their year abroad.

The $20 million project is funded by the National Institutes of Health, with the goal of granting 400 health scientists on year-long research fellowships at 27 low- and middle-income country sites. The goal is to build consortia that will develop and support global health research training programs, which will provide intensive mentoring for participants and diverse clinical research experience in many sites. Some Fellows are trained in their own countries, with close mentoring from collaborating colleagues at other centers; others work directly through one of the support centers with one of the many other institutions that contribute to this project, enabling both U.S. and low- and middle-income trainees to participate in the program

Training is focused on disorders with major impact in low income countries, and on the growing problem of non-communicable diseases in all countries. With neurological conditions making up more than 10 percent of the burden of death and disability worldwide, neurologists moving into a career in international health should find the program of great interest.

If you are interested in learning more about the Fogarty fellowship, here are two useful sites.

http://www.fic.nih.gov/Programs/pages/scholars-fellows-global-health.aspx

http://www.fic.nih.gov/Programs/Info/Pages/scholars-fellows-faqs.aspx.

Bergen is with the Rush University Medical Center in Chicago.

GYTN: Training Young Neurologists in Argentina

A new working group seeks to share learning with young neurologists

By Matàas J. Alet, MD; Lisei Dario, MD; and Martin Bertuzzi Fiorella, MD

Matias J. Alet

The Group of Young Training Neurologists (GYTN) is a working group under the representation of the Neurological Society of Argentina (SNA). The group was funded in 2011 with the aim of creating a network of neurology residents and young neurologists around the country. The purpose of GYTN is to create a platform where people can share information and experiences during their education process.

The GYTN contemplates different activities. Conferences are conducted the last Friday of every month in the SNA auditorium. They are conducted on-site and online. Our meetings are divided into two parts. During the first part, we select a neurological case and discuss it, with special emphasis on syndromic diagnosis and differential diagnosis. Later, the case is uploaded to the SNA web page in the GYTN sector. The second part of the meeting is used for different purposes. Currently, we are focusing on the exposition to be presented at the annual SNA congress. The subject that has been chosen for this year is Neurological Manifestation of Infectious Diseases. Three cases will be presented for two experts in the topic and an interactive discuss with the public will be made.

Liseli Dario

The online forum is called FAREN, an acronym for “Foro Argentino de Residentes de Neurologàa,” meaning, “Argentine Forum for Neurology Residents.” To keep it active, we publish clinical cases once a month. Those cases are based on neuro-imaging, which are discussed between neurologists and neurology residents from different parts of the country.

We also produce information for the management of neurological emergency situations. We seek to unify the work across different training residents and to update the way to proceed in an emergency based on the latest publications.

FAREN is a useful way to publish activities of scientific interest and job opportunities. We want neurolologists around the country to be aware of the latest academic and professional information, improving access to such opportunities.

Martin Bertuzzi Fiorella

We also are conducting a survey of the country’s residences of neurology. The purpose is to obtain up-to-date information from residents and neurologists working in our country, as well as the welfare and academic needs of each of the centers that are conducting training features.

Another initiative of the group is to strengthen the links between young neurologists. To do this, we have initiated contact with the International Working Group of Young Neurologists of the World Federation of Neurology (IWGYNT). The goal is to achieve the global inclusion of young neurologists from Argentina in the activities of the World Federation, and to provide the first Latin American representative to the organization, which currently has members in Africa, Asia, Europe and Oceania.

The intention of this article is to inform all neurologists of the work of our group, and especially those who are in the training stage. We hope that other groups with similar ideals and proposals get to know us, and if they are interested they can contact us to share commentaries, experiences or any other types of information. As we find ourselves in the early years of our group, that linkage will be crucial for us, because we have much to learn from those more experienced teams.

Contact Information
E-mail: faren2011@gmail.com
Group site on the SNA page
Forum on Facebook (FAREN)
Skype: faren-sna@hotmail.com

Alet is a neurology resident at Hospital General de Agudos J. M. Ramos Mejàa. Dario is a neurology resident at Sanatorio Trinidad Mitre. Fiorella is a neurology resident at the Hospital Italiano de Buenos Aires. All are based in Buenos Aires.

International Neurology Forum in Kazakhstan

By Aida Kondybayeva, MD

Aida Kondybayeva

For years, the World Federation of Neurology (WFN) has reached out to Kazakhstan and its neurology community. However, language barriers made it difficult to establish a connection. After a two-year effort by Prof. Daniel Truong and Saltanat Kamenova, with the valuable assistance of Aida Kondybayeva, the International Neurology Forum for Parkinsonism and Related Disorders was held in Kazakhstan. The forum was hosted by the Asfendiyaroy Kazakh National Medical University and was attended by more than 120 Kazakh neurologists.

Prof. Aikan Akanov, rector of the university, opened the forum by thanking the organizers and emphasizing the importance of the event for Kazakhstan. Internationally known speakers included Profs. Erik Wolters from the Netherlands, Truong from the United States and Carlo Colosimo from Italy. Speakers from Kazakhstan included Guram Pichkhadze from the Virtual Institute of Neuroscience, Saltanat Kamenova, chairwoman of the department of neurology at the university and Marat Asimov, chairman of the department of medical psychology.

All of the lectures were translated in real time for the audience. The topics discussed were broad and included the diagnosis, pathology and neuropsychology of

Opening statement of the International Neurology Forum by Prof. Aikan Akanov on Sept. 23, 2014, with Prof. Guram Pichkhadze, Erik Wolters and Daniel Truong.

Parkinson’s disease, tremor and dystonia, as well as the management of these disorders. In addition to the presentations, several workshops were offered, led jointly by Profs. Shelekov, Truong, Perlenbetov and Nurmagambetova.

The meeting was supported with a grant from the International Association for Parkinsonism and Related Disorders (IAPRD). All participants received a free textbook as a gift from the IAPRD. On the last day of the forum in her closing remarks, Prof. Kamenova noted the importance of this event for doctors and young neurologists of Kazakhstan and thanked Profs. Wolters and Truong for their noble mission in the development of the educational program.

Kondybayeva is with the Asfendiyarov Kazakh National Medical University.

A Continuing Journey: The Fight Against Stroke in India

Rohit Bhatia

By Rohit Bhatia, MD, DM, DNB

The stroke epidemic has arrived in India. While we were busy combating the scourge of infections and deficiency diseases, non-communicable diseases (NCDs) including stroke stealthily crept up on us.

With a population of 1.2 billion today and growing, India finds itself staring at a stroke epidemic (See “The Stroke Fact Sheet in India.” on page 8.) ^1,2. In addition to strokes due to conventional risk factors, cardio-embolic stroke due to rheumatic valvular heart disease, cerebral venous thrombosis, and strokes related to tuberculous meningitis still remain important causes of stroke, especially in the young Indian population. (See Figure 1.)

Figure 1. Types of strokes (arrows): (a) bilateral arterial infarcts in a patient with rheumatic heart disease and atrial fibrillation (b) venous infarct in a post-partum patient with superior sagittal sinus thrombosis (c) intracerebral hemorrhage in a hypertensive patient, (d) arterial embolic infarction due to large artery athersoclerosis and carotid stenosis (e) and (f) perforator artery infarction in patient with tubercular meningitis.

The recently published Prospective Urban Rural Epidemiology (PURE) study from 18 low-, middle- and high-income countries showed that incidence of major cardiovascular disease was highest in low-income countries, despite the fact that these countries had the lowest risk-factor burden³.

Challenges in stroke care include a limited number of trained neurologists who are mostly urban, a large number of patients who are mostly rural, a lack of knowledge and awareness both about stroke risk factors and treatment in the general public and prohibitive cost of stroke care. There is a lack of uniformity and standardization of secondary and tertiary stroke care while availability of primary care in stroke is extremely unreliable. The stroke epidemic did catch us by surprise and in an unprepared state, but the situation is gradually beginning to improve and we are optimistic about the future. (See Figure 2.)

Acute stroke care has barriers, including recognition, pre-hospital delays, physician expertise, lack of ambulance services, cost of tPA and lack of critical care facilities. Although thrombolysis (using tPA) continues to be available only in urban private or academic hospitals, there has been a recent rise in the number of stroke patients getting the benefit of this treatment.

Figure 2. Recovering stroke patients at the Stroke Clinic, Neurosciences Center, AIIMS.

In the year 2009, 1,648 patients were thrombolysed, while in 2011, the number rose to 2,975 and a center in northwest India reported a four-fold increase in rates of thrombolysis². About 100 centers in India currently have facilities to provide intravenous thrombolysis, and the numbers are likely to rise with awareness and experience.

In the national capital region, the cost barrier is gradually being offset for eligible patients by the provision of free tPA by the government in state-run academic hospitals, including All India Institute of Medical Sciences (AIIMS), New Delhi. The National Program on Prevention and Control of Cardiovascular Diseases, Diabetes and Stroke⁴ (NPCDCS) launched in 2008 by the ministry of health and family welfare (See “Major Components of NPCDCS.”) addresses NCD prevention by risk reduction, early diagnosis and appropriate management through health promotion programs for the general population and high-risk groups.

Figure 3. Map of India showing the National Program on Prevention and Control of Cardiovascular Diseases, Diabetes and Stroke (NPCDCS Program), Government of India. Red dots indicate places where it is currently implemented. Stars indicate the Indian states⁴.

At present, the NPCDCS program is implemented in 100 districts across 21 Indian states, and it is expected to be rolled out in 640 districts by 2017 under the 12th five-year plan. (See Figure 3.) Developing and running dedicated stroke units in the face of the extremely limited health resources is a challenge; 35-40 stroke units currently exist, mainly in bigger cities and more often in private hospitals.

Improving Access to Stroke Care

Reaching out to remotely located patients remains difficult, and telestroke is recognized as a potential solution⁵. Telemedicine has been successfully used by the Indian Space Research Organization (ISRO) to meet the needs of remote Indian hospitals⁶.

The telemedicine network implemented by ISRO in 2001 presently stretches to around 100 hospital countrywide, with 78 remote rural/district health centers connected to 22 speciality hospitals in major cities, thus providing treatment to more than 25,000 patients, including stroke patients. (See Figure 4.) A major telestroke initiative has been taken up by the state of Himachal Pradesh (HP). Telestroke Management Program has been piloted for the first time in HP in collaboration with AIIMS. Under this program, 18 primary stroke centers are being set up in HP state hospitals, which have CT scan facilities. One hundred and twenty state doctors have been trained and six patients already have been successfully treated under this program. Success of this program will pave the path for comprehensive treatment of stroke patients in more parts of the country.

Research in stroke medicine is another area that has seen improvement with increasing national and international collaborative efforts and improved funding opportunities. The Indian Council of Medical Research (ICMR), Department of Biotechnology (DBT) and Department of Science and Technology (DST) of the Government of India have increased support for basic and clinical stroke research.

The WHO stroke STEPS I version 7 was tested in the Indian Collaborative Acute Stroke Study (ICASS). During 2002-2004, 2,162 acute stroke cases were identified in the study. Analysis of results confirmed that the incidence of stroke was rising with the advance in age. Presently, there are eight stroke registries based in various states of India. Each registry has independently set up a stroke surveillance system based on the WHO STEPS guidelines⁷.

Figure 4. Indian Space Research Organization (ISRO) telemedicine network⁶.

The National Stroke registry of the ICMR is being run by the National Center for Disease Informatics and Research, Bangalore, where staff members have started the process of collating data on stroke patients from institutions and individual specialists who have registered with the program. The Indian Stroke Prospective Registry (INSPIRE) is a large, multicenteric prospective pilot registry run by the division of clinical trials, St. John’s Research Institute, Bangalore, with the objective of determining etiologies, clinical practice patterns and outcomes of stroke in India.

By April 2012, the study had enrolled 5,301 patients from 49 cities in 19 states. Data from these registries will provide evidence on mortality and morbidity indicators in India, which could help plan an effective stroke management program. In collaboration with Erasmus University Netherlands, AIIMS has jointly launched a large cOHORT study comprising 15,000 people above the age of 50 in rural and urban populations to prospectively examine the causes of stroke and dementia in the Indian population. The Department of Biotechnology has generously funded this endeavor with INR 340 million.

Increasing Stroke Awareness

Education programs are being carried out by hospitals and stroke support groups especially around the World Stroke Day to educate and disseminate information on stroke⁸. Initiatives include patient awareness programs with lectures and interactions focused on stroke symptoms, the concept of “time is brain,” the need to reach a hospital early and preventive strategies to reduce stroke occurrence; banners, advertisements and write-ups in newspapers along with talk shows on TV and radio channels are also used.

Figure 5. Educational workshop on stroke conducted by Department of Neurology AIIMS.

Studies have shown that lack of physician awareness delayed arrival of stroke patients to a specialized center. CMEs, physician training programs and conferences are regularly held across the country emphasizing the need for recognition and timely therapy and to appraise doctors regarding the newer developments on cerebrovascular disorders. (See Figure 5.) The Indian Stroke Association (ISA) has been organizing a stroke summer school since two years ago to train junior neurologists and physicians.

The annual meetings of ISA are well attended with invited national and international faculty and deliberations on various aspects of stroke. The national guidelines for the management of stroke in India were developed with an aim to close the gap between best and pragmatic practice. A recent study from an academic hospital in North India observed that education to the emergency staff led to an increased rate of thrombolysis and shortened door to needle time. It is encouraging to see that students trained at academic centers are now promoting stroke awareness and timely treatment in smaller cities.

The Future of Stroke Care in India

We will never be able to treat every stroke in the country for a long time to come. So where should our emphasis lie? Preventing as many strokes as possible will probably be the best stroke care that we can provide. At present, many, if not most, strokes are a consequence of modifiable risk factors such as obesity, hypertension and smoking.

Spreading awareness on a war footing and reducing preventable strokes immediately is required. Implementation of mass screening has been recommended to reduce the burden of stroke through identification of people at high risk. Simple, practical and cost-effective measures such as identification and treatment of hypertension in the community will go a long way. Focus also should be on effective implementation, monitoring and evaluation of present stroke programs. A stroke prevented is a much happier situation than a stroke treated.

References:

1. http://www.sancd.org/Updated%20Stroke%20Fact%20sheet%202012.pdf. Stroke in India Factsheet (Updated 2012). Accessed September 6, 2014.

2. Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. Journal of Stroke. 2013;15:128-34.

3. Yusuf S, Rangarajan S, Teo K, Islam S, Li W, Liu L, Bo J, Lou Q, Lu F, Liu T, Yu L, Zhang S, Mony P, Swaminathan S, Mohan V, Gupta R, Kumar R, Vijayakumar K, Lear S, Anand S, Wielgosz A, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Yusoff K, Ismail N, Iqbal R, Rahman O, Rosengren A, Yusufali A, Kelishadi R, Kruger A, Puoane T, Szuba A, Chifamba J, Oguz A, McQueen M, McKee M, Dagenais G; PURE Investigators. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med. 2014;28:818-27.

4. http://health.bih.nic.in/Docs/Guidelines/Guidelines-NPCDCS.pdf. Accessed September 5, 2014.

5. Srivastava PV, Sudhan P, Khurana D, Bhatia R, Kaul S, Sylaja PN, Moonis M, Pandian JD. Telestroke a viable option to improve stroke care in India. Int J Stroke. 2014 Jul 18. [Epub ahead of print].

6. http://www.telemedindia.org/isro.html. Accesssed October 4, 2014.

7. Bonita R, Beaglehole R. Stroke prevention in poor countries. Time for action. Stroke 2007;38:2871-2872.

8. World Stroke Day celebrations: report from India. International Journal of Stroke. 2009;4:231–232.

Additional professor: Pranjal Sisodia, MSc, PhD Scholar, Department of Neurology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India.

To correspond with the author, write to him at rohitbhatia71@yahoo.com.

Kinnier Wilson and Anglo-French Neurology in the Early 20th Century

HISTORY OF NEUROLOGY

By Edward H. Reynolds

Edward H. Reynolds

Samuel Alexander Kinnier Wilson (SAKW) (1878-1937) is distinguished throughout the neurological world for 1) the disease that bears his name, 2) his scholarly two-volume textbook which was published posthumously in 1940, and 3) his founding in 1920 of the Journal of Neurology and Psychopathology, now known as the Journal of Neurology, Neurosurgery and Psychiatry.

Born in New Jersey, to a Scottish mother and an Irish missionary Presbyterian Minister father, he returned to Scotland for his education. He graduated from the Edinburgh Medical School in 1902 and obtained a BSc with First Class Honors in Physiology in 1903. With a Carnegie Fellowship, he immediately proceeded to Paris for a year to study neurology under Pierre Marie at the Bicàªtre Hospital, followed by a few months in Leipzig. In 1904 he was appointed House Physician to the National Hospital for the Paralyzed and Epileptic in London and remained at the National Hospital for the rest of his career, as resident medical officer, registrar, pathologist, assistant physician, and finally full physician in 1921. In 1919, SAKW was also appointed junior neurologist to King’s College Hospital, one of the first of such posts in the UK to incorporate the word “neurologist.”

Samuel Alexander Kinnier Wilson (1878-1937).

In 1931, Sherrington invited SAKW to participate in a symposium on muscle tone at the first International Congress of Neurology in Berne. Sherrington and SAKW were elected as president and secretary-general respectively of the second International Congress of Neurology in London in 1935, but Sherrington later had to withdraw due to ill health. In 1933 Sherrington and his joint Nobel Prize (1932) winner, Adrian, both proposed SAKW for the fellowship of the Royal Society.

Pierre Marie (1853-1940). SAKW’s first influence in Paris.

Guided by his future father-in-law Alexander Bruce (1854-1911), an Edinburgh physician, with an interest in neurology, who also founded a neurological journal (Review of Neurology and Psychiatry 1903-1916), SAKW understood that Paris was the leading world neurological center at the turn of the 20th century. Hence, his seminal year (1904) influenced by Marie, Babinski, Dejerine and Meige among others, before proceeding to the National Hospital, Queen Square. He published his famous Edinburgh thesis on hepatolenticular degeneration (later called Wilson’s disease) in 1912, not only in Brain but also in Revue Neurologique. Furthermore he presented his work in French to the Société de Neurologie de Paris on Jan. 25, 1912, where it was very well received, but I cannot trace any record of a presentation to any UK society, such as the Section of Neurology of the Royal Society of Medicine in London. Just as Charcot had been a regular visitor to the UK in the late 19th century, so SAKW was a frequent visitor in the new century to France, where Crouzon, Guillain and Léri were particular friends and collaborators.

Octave Crouzon (1874-1938). SAKW’s contemporary and friend in Paris. (Courtesy of Emmanuel Broussolle).

It is interesting that even at the 17th International Medical Congress in London in 1913 the French delegation was the dominant influence in the Section of Neurology/Neuropathology, the proceedings of which were published in detail in Revue Neurologique but not in any English journal. Following that Congress SAKW and nine other British physicians were elected “Membres Correspondants Etrangers” of the Société de Neurologie de Paris, which had been founded in 1899.

In the last 25 years, I have had the privilege of working with SAKW’s son, James KW, a Cambridge-based assyriologist, on the subject of Babylonian neurology and psychiatry. Through James KW, I have learnt most about his father’s French connections. I have in my possession SAKW’s original seven-page brochure listing the members of the Société de Neurologie de Paris for 1926. It now includes 76 Paris-based neurologists, 60 French neurologists from beyond Paris and 128 international members from around the world, mainly Europe and the U.S./Canada, including 14 from the UK. Although the Neurological Society of London had been founded earlier in 1886 and had evolved in 1907 into the Section of Neurology of the Royal Society of Medicine, it had remained a small almost exclusively London-based Society. When the Association of British Neurologists (ABN) was founded in 1933, it had only 25 members.

References

Reynolds EH. Kinnier Wilson and Sherrington. J Neurol Neurosurg Psychiatry 2008;79:478-9.

Reynolds EH. Kinnier Wilson’s French connections. Rev Neurol 2014 Jun 3. pii: S0035-3787(14)00840-6. doi: 10.1016/j.neurol.2014.03.011.

Edward Reynolds is consultant neurologist and former director of the Institute of Epileptology, King’s College, London, and former president of the International League against Epilepsy. Peter J. Koehler is the editor of this history column. He is neurologist at Atrium Medical Centre, Heerlen, The Netherlands. Visit his website at http://www.neurohistory.nl