The Official Newsletter of the World Federation of Neurology
The WFN Nominating Committee announces the candidates for the following positions. The Council of Delegates will vote during the WFN elections at the upcoming World Congress of Neurology in Kyoto, Japan.
President
Vice President
Elected Trustee
By W. (Bill) M. Carroll, MB, BS, MD, FRACP, FRCP(E)
W. (Bill) M. Carroll, MB, BS, MD, FRACP, FRCP(E)
Recently, there has been an explosion of health awareness recognized by individuals, nations, and the global community. The decade of the brain was followed by the human genome project, accompanied by the near eradication of malaria and polio. Yet, we now stand at the threshold of even more rapid advances on many fronts.
3-D printing of the human heart is being used in planning cardiac surgery. Next-genome sequencing is revolutionizing old concepts of disease. Gene therapy shows success in some inherited neuropathies (spinal muscular atrophy) and myopathies (Duchenne muscular dystrophy). Precision medicine is no longer an aspiration in some diseases and countries, and the ability to use publicly accessible data via expanding cloud technologies is yielding unexpected information and the repurposing of medications. Conversely, the cost of drug development, especially in bringing them to market, is becoming prohibitive, exacerbating the accessibility of therapies in many countries.
For the thoughtful and the less fortunate, it is obvious that the developing progress, while exciting and to be celebrated, is creating problems that need to be addressed. The increasing burden of non-communicable diseases (NCD) adds up to what can only be viewed as a potential tsunami for the economies of the world. These NCDs include mental (neurological) and substance-abuse disorders; musculoskeletal disorders; neurodegenerative conditions such as dementia, stroke and Parkinson’s disease; poor lifestyle choices in diet and exercise; and the effects of unhealthy environments1 together with the changing demographic of aging populations in so-called developed countries.
Those people and countries least able to afford the advances and/or mobilize services to adjust to them will see a widening gap, not only in these areas of disease but also in their ability to respond to the periodic recrudescence of infectious disease. This was seen with the outbreaks of Ebola, MERS, SARS, and, most recently, the Zika emergency. It is not by chance that the recent waves of mass migration have occurred as much because people seek better lifestyles (and health services) as fleeing armed conflict.
It is in this environment that those in the neurological fraternity need to mobilize and prepare measures at a number of levels that will mitigate the consequences of these changes. To begin, we must look at the magnitude of the problems facing us. Then, we will evaluate the resources we have available. Finally, we will view three illustrations of how those resources can be optimized to provide the organizational readiness for rapid and effective action as well as long-term planning on a national, regional, and global scale.
The Problem
The global burden of neurological disease figures as a relatively small fraction of the global burden of all disease (GBD) for a range of reasons2. Although not included in the WHO 2014 global status report on NCDs3, stroke and dementia are of major concern to clinicians and national health systems.
The annual stroke toll is approximately 15 million, with one-third being fatal and another third permanently disabling. Indeed, stroke mortality is double that of HIV/AIDS, malaria, and tuberculosis combined, emphasizing the rising burden of brain NCDs. With rates of dementia estimated to triple from 47.5 million to 115 million worldwide by 20504, it is clear that the world faces a rising impost on resources.
Currently, the total burden of mental, neurological, and substance abuse (MNS) is now reckoned to be 258 million disability-adjusted life years — a measure of overall disease burden expressed as the number of years lost due to ill health, disability, or early death. That is up from 182 million in 1990, which has been equated to a $8.5 trillion (U.S.) loss of economic value now, and which will increase again by a factor of two by 20305.
With the addition of other NCDs to stroke and dementia, it is clear that the world neurological fraternity must act in concert and alert governments. Those other NCDs include age-related Parkinson’s disease and other chronic neurodegenerative disease, perinatal injury largely due to asphyxia, childhood developmental and degenerative disease, schizophrenia, high levels of traumatic brain disease, all causes of epilepsy, substance and alcohol abuse, and rising neuroinflammatory disease of the brain and spinal cord.
While world neurological expertise has been steadily advancing partly in parallel with the recognition of the increasing challenges on the horizon and partly with the advances in medical science, it is far from equitably distributed. When the widening gap between well-developed countries with comprehensive health care and those less developed populations and health care systems is appreciated, the likelihood for an emergency is evident6.
Resources
There are a number of valuable resources available. These include measures of the GBD and specific problem areas, such as the NCDs, BNCDs, and MNSs, as well as WHO monitoring for more acute challenges to health through national health departments and WHO’s regional structural organization. (The WHO regional organization mirrors approximately that of the WFN). The periodic assessments of the GBD by the WHO and the Atlas of Neurology (a joint WHO-WFN project) provide the broad sweep, big picture view of resources and needs.
The WFN itself plays an important and growing role in the equalization of access to neurological care both through regional organization support and neurological education. The establishment of the African Academy of Neurology (AFAN) and its first meeting in Tunis this year are illustrative. It joins the expanding roles of other WFN regional organizations, including the Pan American Federation of Neurological Societies (PAFNS), the Australasian and Oceanian Association of Neurology (AOAN), the Pan Arab Union of Neurological Societies (PAUNS), the American Academy of Neurology (AAN), and the European Academy of Neurology (EAN).
Neurological training, the improvement in access to neurological care, and an increasing awareness of the importance of brain health in the general population are furthered by World Brain Day (WBD)7 and the biennial World Congress of Neurology (WCN). The WFN, in partnership with AFAN, has followed the World Federation of Neurosurgical Societies (WFNS) program to train young African specialists. The WFN plans to have four regional training centers in Africa — two each for the Francophone and Anglophone regions. Additional emphasis of WFN involvement at a global level was given by WFN President Raad Shakir as chair of the Neurosciences Topic Advisory Group for the WHO-sponsored International Classification of Disease (ICD-11), due for release in 2018.
More generally, other areas are developing, which will enhance the ability to respond to challenges. Increasingly rapid communication through electronic media, including social media, draws attention to emerging problems. The maturation and expanding expertise of neurological subspecialties and their involvement in wider educational activities (e.g. the International League Against Epilepsy, the World Stroke Organization, and the Movement Disorders Society) as well as the added interest of the larger regional neurological organizations, such as the AAN and EAN, provide a rich resource of intellectual and monetary capital.
Over the last few years, the WFN has provided a focal point for those involved in the medical care of neurological disease through two similar, though importantly different, groups. The first is the World Brain Alliance (WBA). Originally chaired by Vladimir Hachinski, MD, when he was WFN president, it is now chaired by Dr. Shakir. The WBA members include, in addition to the WFN, global organizations that usually do not include neurologists, such as the WFNS, the International Brain Research Organization (IBRO), the World Psychiatric Association (WPA), the International Child Neurology Association (ICNA), and the World Federation of Neurorehabilitation (WFNR). The second group is the Global Neurology Network (GNN) for which the WFN is the current convener and whose members mainly include neurological disease-specific organizations from around the world. Many were originally part of the WFN but have grown to be independent organizations. They include the World Stroke Organization (WSO), the International League Against Epilepsy (ILAE), the Multiple Sclerosis International Federation (MSIF), the Treatment and Research in Multiple Sclerosis (TRIMS) Group, Alzheimer’s Disease International, the Movement Disorder Society, the International Headache Society, the International Society for Clinical Neurophysiology, the Peripheral Nerve Society, and the Tropical Disease Group. Closely associated with this category of disease-specific organizations are both large regional organizations supporting all neurological subspecialties, such as the AAN and the EAN, and the smaller WFN-affiliated regional organizations, such as the AOAN, PAUNS, PAFNS, and AFAN.
Together, these two groups create an impressive global alliance of neurological expertise. It is an alliance appropriately suited to provide global disease-specific advice to international organizations, such as the WHO and the U.N., and to advocate with these organizations and national governments. It is an alliance worthy of the term Global Neurology Alliance.
Recent Examples of United Action
The most critical function of a global alliance of neurological organizations is the ability to formulate, organize, and execute rapid and effective policy or reaction. A powerful advocacy initiative that can mobilize governments and NGOs is of enormous value to those under threat, and it is the rapidity of communication and the common understanding of the advocating group that empower these initiatives as a force for good.
Underlying this ability are two fundamentals. The first is an intimate understanding by the subspecialty organization in the national, regional, and global spheres of all matters affecting practitioners and patients. The second is the intercommunication among the various subspecialty organizations facilitated by the GNN. Regular meetings, updates on activities, and a common understanding of the means to reach their constituencies contribute to the effectiveness of the network.
Recent examples of where this alliance has been called to mobilize and has proven its worth are the 2015 Zika virus outbreak, the WHO initiative on NCDs, and the crisis over the WHO classification of stroke as a circulatory rather than neurological disease.
The outbreak of the arthropod-borne (Aedes aegypti) Flavivirus crisis, known as Zika virus, in April 2015 in Brazil, was designated by the WHO in February 2016 as a public health emergency of international concern (PHEIC)8.
Zika was first found in Uganda in 1947, and the first outbreak of disease occurred in Micronesia in 2007. The South American outbreak was much worse. The primary infection was often asymptomatic or relatively banal, comprising arthromyalgia, a light rash, or a low-grade fever. The major secondary effects were of brain neuronal migration injuries to the fetuses of pregnant women manifesting often, but not solely, as microcephaly, and a postinfectious neuropathy resembling Guillain-Barré syndrome.
Given the unknowns with this outbreak and the urgency to gather information, a committee, headed by John England, MD, was constituted, assisting the global investigation of the outbreak. The committee was supported by WFN resources through the regional organization in South America, the expertise within the organization, and the rapidity with which the WFN could respond to assist. PHEIC status was ceased in November 2016.
The NCD initiative, launched in 2011 by the WHO following the GBD report highlighting the impact of NCDs9, concentrated on cardiovascular disease, cancer, diabetes, and respiratory disease. Omitted were major illnesses central to brain health, such as dementia and stroke. The omission was questioned by the global neurological fraternity. The WFN, through its role as WBA convener and led by Dr. Shakir, waged a campaign to have brain NCDs included in the initiative5.
How did such a situation arise? It seems that because the WHO viewed stroke and dementia not to be brain diseases but rather as circulatory and mental disorders, respectively, they were not included as risks to brain health. There are historical reasons for this view, which were defended by the WHO, but ICD-11 brought this matter to a head. In doing so, it also provides an illustration of the value of a global neurological alliance.
The ICD is revised every decade. ICD-10 was adopted in 1990, and in 2007 the revision ICD-11 was commenced under the supervision of the Revision Steering Group, which took advice from a number of Topic Advisory Groups (TAGs). The ICD-11 Neurology TAG was constituted in 2011 under the leadership of Dr. Shakir. Soon after this process commenced, stroke was apparently accepted as a disease of the brain. When the beta version of ICD-11 was published in 2016, the neurological and stroke fraternities were astounded to find that stroke had been changed to a circulatory disease.
Clarity as to the reason stroke had been omitted from the NCD initiative had arrived. Stroke was not a brain disease. The decision galvanized the neurological and stroke communities. After considerable effort, it was determined that the powerful statistics group within the WHO had been at the forefront of the opposition to the change initiated by the Neurology TAG. While the grounds for such opposition were reasonable and based on a desire to obtain the best longitudinal epidemiological data, it effectively “hid” the impact of stroke in the global community and paid little heed to the growing evidence of the contribution of cerebrovascular disease to dementia and NCDs in general.
There followed initial correspondence to Lancet10 by the WFN and WSO, and the formation of an ad hoc advisory group through the recruitment of national departments of health to voice opposition to the way stroke was handled by the WHO. A number of important face-to-face and telephone meetings took place, as well as a review of the evidence, from the WSO perspective, of why stroke should not be classified as only a circulatory disease. Through an innovation introduced in ICD-11, multiple parenting was possible. This, together with the weight of argument, has seen stroke, as of April 2017, classified as a cerebrovascular disease in the current beta version of ICD-11—an event described by many as momentous. (See the President’s Column.)
Conclusion
It is no accident that these external initiatives of the WFN and partners have been successful. The ability to respond rapidly, to gather expertise, and to plan and implement the agreed approach, while maintaining the flexibility to adapt to developments, are the prime reasons. That there has been an immediate sense of shared purpose, and the acknowledgement that together we are better able to present the arguments firmly and authoritatively, has no doubt assisted. The foresight of the originators of these two groups has to be praised, as does the leadership of the current WFN president and the members of the WBA and GNN.
With the world facing continuing uncertainties, it is likely we shall see more reasons to be grateful for the contributions made by these groupings and to possibly have periodic joint meetings. In practice, these groups and their membership represent a truly global neurological alliance. •
W. (Bill) M. Carroll, MB, BS, MD, FRACP, FRCP(E), is first vice president of the WFN and is the WFN convener for the Global Neurology Network.
References:
By Mohammed Wasay, MD, and Wolfgang Grisold, MD
This year’s World Brain Day commemorates the foundation of the WFN. The prior World Brain Day topics were aimed at epilepsy and dementia, and now it is aimed at stroke. We are partnering this time with the World Stroke Organization (WSO), which puts great global effort into the prevention and treatment of stroke.
The topics of this World Brain Day should be the awareness of stroke, the symptoms, the prevention, and the new evidence for optimized treatment. Neurorehabilitation is increasingly becoming important.
World Brain Day is supported by the Public Awareness committee jointly with the WSO to make this day a success. As in the previous World Brain Days, a special logo will be produced, as well as material for local use, which can be used with the regional societies. Prior to World Brain Day, a template for press mailings will be distributed to help the local organizations. Closer to World Brain Day, a webinar will be accessible and, with invited participants from the press, will spread the news.
Despite these activities and help, the success of World Brain Day depends on your local activities. Please make the World Brain Day your own, use all of the material we provide, and ask for more if needed. Experience has shown that this international day has created much press attention, but local activities and information make the difference.
Please involve patients, caregivers, the public, and interested patient groups who will be interested in this topic. Stroke care faces many global inequalities, in regard to infrastructure, care, and support!
Needless to say, we are eagerly awaiting your reports of your local events, so we can publish them in World Neurology. Also, please post your activities on social media.
By Dr. Mohammad Bassam Hayek
A workshop about epilepsy was presented during a training course funded by the World Health Organization.
Aleppo, Syria, was subjected to a comprehensive war that directly affected all of its humanitarian services. Before July 2012, the difficulties were limited, with most related to security and transport problems.
However, by the end of July, the city had been torn into two large sections. With daily bombardments and clashes, the city’s population plummeted from 4.5 million to 1.5 million. Coinciding with this, the city experienced a complete absence of electricity, a severe decline in health services, and an insufficient number of beds available for hospitalization of stroke patients in government hospitals.
The quality of service provided by the private sector decreased. No MRI device was in service, either in the governmental or private sectors. Seventy percent of the CT machines no longer worked.
A number of neurologists (about 12 out of 30 doctors) left because of the security chaos. There were no neurologists in the area controlled by the armed people. Patients had to travel for several days to see a neurologist.
This was accompanied by the interruption of the supply of most neurological drugs from local markets, especially antiepileptics (valproate, carbamazepine, and phenytoin) and all antiparkinson drugs.
A hospital with 40 beds, built in 1943 and rehabilitated in 2014, has a physiotherapy and rehabilitation department with an EEG machine.
In addition to the unavailability of the necessary anticoagulants for stroke, one of the most important challenges was the loss of records for the treatment of multiple sclerosis (MS). About 900 patients had been periodically reviewed for free medical service and treatment (interferon beta of all kinds). Patients were dispersed, some migrated, and others had new attacks without finding the right medication (methylprednisolone) or the correct diagnosis.
All physiotherapy services disappeared. Although there were a number of therapists, the work was futile.
Due to the many injuries associated with shrapnel and peripheral nerve trauma, neurophysiologists for electromyogram and nerve conduction velocity tests were needed. There also was the occurrence of a number of cases of flaccid paralysis, and it was difficult to find treatment.
Turning the Corner
In January 2013, life was unbearable, and the city seemed to be gloomy without electricity or water, along with the decline of all basic services.
By 2014, a road to the city opened, bringing supplies to the besieged population. Small, private generators within neighborhoods delivered a limited supply of electricity. An MS committee was reorganized, and up to 365 patients were treated for free with beta interferon, but the drugs were from generic companies.
Initially, one MRI was returned to service. In the private sector, three private devices are now operating. However, there are no devices in government hospitals that can be used for free. The average cost of providing an MRI is $60. (The average monthly salary is $100.)
With the passing of time, the service situation stabilized, and the security improved. The U.N.’s international organizations reached the city and helped improve the health system.
Since mid-2014, medicine has become available in an acceptable, but insufficient manner. Currently, most essential neurological drugs are available. The most important are antiepileptic drugs (carbamazepine, sodium valproate, lamotrigine, levetiracetam, and clonazepam), but the supply is unstable. There are still difficulties in securing antiparkinson drugs, especially levodopa.
Continuing medical education and training have declined. The health sector has not prioritized the provision of services.
However, there have been improvements since 2015. The road from Aleppo to Damascus has become safer. Scientific activity has slowly returned, but fear still prevails over some doctors.
Some of the government hospitals are open, including a free neurology clinic at Ibn Khaldoun Hospital. There is free EEG service at three locations, and rehabilitation at one of the public hospitals is open to neurologic patients.
Training of neurologists of all ages is still an important need. This can be accomplished in seminars, scientific conferences, and specialized training programs. Neurological drugs through the World Health Organization are still needed. •
Dr. Mohammad Bassam Hayek is a neurologist in Aleppo, Syria. He is vice president of the Syrian Society of Neurosciences and general director of Ibn Khaldoun Hospital.
By Robert Schmidhammer, MD, and Wolfgang Grisold, MD,
Dr. Hanno Millesi
University Professor Dr. Hanno Millesi, a doyen of modern nerve surgery, died April 28, 2017, in Vienna, Austria. He was 90.
Dr. Millesi was born in Austria in 1927. He finished his medical studies in Innsbruck in 1951, and started his career in surgery at the University of Vienna. He was one of the founders of plastic and reconstructive surgery in Austria, and chaired the department at the University of Vienna until his retirement in 1995. He has a long list of international achievements, including being a member of the Sunderland Society, the International Society for Reconstructive Microsurgery, and the World Society for Reconstructive Microsurgery. He has a long list of publications and books, and was actively involved in peripheral nerve research until his death.
Original sketch of a complex reconstruction of the brachial plexus, by Dr. Millesi (approximately 2005). (PHR: Phrenic nerve; C5: nerve root with neuroma; ACC: Accessory nerve; PMA: pectoralis major muscle; FAP: Posterior fascicle, SPSC Suprascapular nerve, lines depict sural nerve grafts (transplants); MC musculocutaneous nerve; IC Intercostal nerves.)
Dr. Millesi had an eminent interest in surgery of the peripheral nerves, and was one of the pioneers in using autologous nerve transplant, which revolutionized the concept of nerve repair. He also developed the methodology of microsurgical neurolysis, which aims to decompress nerve fascicles.
He remained active in the field of research until his death. In his last years, he was devoted to tissue and environment of peripheral nerves, in particular nerve gliding. Increasingly, he incorporated the new imaging methods, in particular high-resolution ultrasound, in his concepts.
Dr. Millesi was a dedicated physician, and was appreciated for his lexical knowledge and his ability to consult and advise. He was tireless with regard to patient issues and any aspects of peripheral nerve.
Dr. Millesi was not only an excellent surgeon and scientist, but he also was a good example of collaboration between the fields of neurology and plastic and reconstructive surgery. His concepts of nerve surgery, re-innervation, and applied neuroplasticity taught neurology a lot. These concepts have advanced the knowledge of nerve repair and reconstruction from a static approach to a highly dynamic field.
Robert Schmidhammer, MD, is a university professor at Millesi Center in Vienna. Wolfgang Grisold, MD, is WFN secretary general and a professor at Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in Vienna.
By Marina Alpaidze, MD, PhD, and Alexander Razumovsky, PhD, FAHA
Participants at the third regional WFN NSRG meeting. (From left) Aleksandr Dzhanashvili, MD, PhD; Eva Bartels, MD, PhD; Ekaterina Titianova, MD, PhD, DSc; Natan Bornstein, MD, PhD; Alexander Razumovsky, PhD, FAHA; and Marina Alpaidze, MD.
The WFN Neurosonology Research Group (NSRG) is dedicated to the promotion of science and research as well as education and training in the field of ultrasonic techniques (carotid duplex and transcranial Doppler) and their clinical utilization. Therefore, international cooperation and the dissemination of scientific information within the field of neurosciences and neurosonology is part of the WFN NSRG activities.
On Oct. 22, 2016, the Georgian Chapter of the WFN NSRG successfully conducted its third regional meeting in Tbilisi, Georgia. The meeting included participants from the neighboring country of Azerbaijan. The one-day course was designed for individuals who are interested in performing and interpreting neurosonology studies.
The faculty discussed the current status of neurosonology and specific clinical applications, such as its clinical utilization on patients with dementia or an undetermined etiology of stroke. Relatively new aspects of neurosonology applications were discussed for patients with neuromuscular disorders and consequences of traumatic brain injury. Well-known neurologists and neurosonology experts delivered the lectures. These individuals included:
This third Georgian meeting was guided and directed under the auspices of the NSRG of the WFN and accredited by the Tbilisi Medical University Continuing Medical Education (CME) Board for 10 CME hours.
By Giordani Rodrigues dos Passos, MD
Giordani Rodrigues dos Passos, observer (left), Mrs. Vanessa Spyropoulos, clinical nurse specialist in the MS program, and Dr. Yves Lapierre, director of the MNH Multiple Sclerosis Clinic.
One month after completing my neurology residency in Brazil, I had the opportunity in March to participate in the Canadian Department Visit Program, during which I served as an observer at the Montreal Neurological Institute (MNI).
The administrative staffs of the WFN and the MNI were excellent, both before and during my stay in Montreal. My schedule was arranged by Dr. Anne-Louise Lafontaine, who made sure to take my main interests into account.
My activities included:
My main interest is MS, which is roughly 10 times more prevalent in Canada than it is in Brazil. From a clinical perspective, this observership was remarkable because I saw several dozen MS patients, covering a wide range of clinical aspects and treatment strategies.
A number of elements stood out for me relating to the functioning of the MNI and the health care system in Canada. They included:
Dr. Anne-Louise Lafontaine (center), chief of the Department of Neurology of the McGill University Health Center, and Giordani Rodrigues dos Passos (third from the right), observer, with neurology residents and medical students during rounds at the Montreal General Hospital.
Health care and research are closely integrated with mutual benefits.
The MNI is remarkably able to communicate its actions and achievements to the scientific community as well as the patients and society as a whole. This increases its ability to raise additional funds for research.
Multidisciplinary teams at the clinics and in the wards improve significantly both the neurologists’ work and patient outcomes.
Canadian neurology residents receive more in-depth training on neuroanatomy, pathophysiology, and semiology than most of their Brazilian counterparts.
Many of these elements could be implemented in my workplace, an 800-bed university hospital in southern Brazil. What I learned at the MNI will improve my practice as a neurologist and researcher in the coming years. It also will serve as a lesson when I have opportunities to participate in my hospital’s institutional decisions.
Dr. Jack Antel (left), professor at McGill University and president of the Americas Committee for Treatment and Research in Multiple Sclerosis, and Giordani Rodrigues dos Passos, observer, at the Montreal Neurological Hospital.
A minor drawback of my observership was the March break, which took place during my first couple of weeks there. During this time, some of the clinic’s work was suspended, and some of the attending neurologists were away from the hospital. Even though I was able to find alternative clinical or academic activities to fill my schedule, I suggest the next observers be advised of the March break and encouraged to choose another month for their MNI visit.
Overall, this was an inspiring, career-changing experience. I recommend the Canadian Department Visit Program for other young neurologists. I congratulate the WFN, the Canadian Neurological Society, and the MNI for fostering education in neurology, and I am grateful for this opportunity. •
Giordani Rodrigues dos Passos, MD, works in the Department of Neurology at São Lucas Hospital in Porto Alegre, Brazil.
By Dr. Boubacar Maiga
The staff of the Department of Neurophysiology of Mohamed-V University of Rabat Sitting (from left): Prof. Halima Belaidi, Dr. Fatiha Lahjouji, and Prof. Nazha Birouk. Standing (from left): Dr. Bouchra Kably, and Profs. Alassane Dravé, Youannes Debebe, Boubacar Maiga, Fatima Hassane Djibo, Reda Ouazzani, and Leila Errguig.
I would like to thank the WFN for giving me the opportunity to have a fellowship in clinical neurophysiology at the University Mohamed-V in Rabat in Morocco. I would like to express my sincere gratitude to Prof. Mustapha El Alaoui Faris, the coordinator of the Rabat Center, for his advice and follow-up during my successful training. I also thank Prof. Reda Ouazzani, the head of the Department of Clinical Neurophysiology, for his warm welcome and nice teaching. I also thank the department team: Profs. Nazha Birouk, Halima Belaidi, and Leila Errguig, and Drs. Fatiha Lahjouji and Bouchra Kabli.
My training took place every week, from 9 a.m. to 3 p.m., Monday through Friday. I performed all of the neurophysiological explorations under the supervision of Prof. Ouazzani. In the department, I had the same activities as the Moroccan residents in neurology and neurophysiology.
Video EEG: I participated in the recording, reading, and interpretation of video EEGs for patients with epilepsy. I interpreted the EEGs alone at first, and then I discussed the EEG patterns with one of the professors in the department.
EMG: Initially, I practiced EMG under the supervision of the professors. Then, I practiced EMG alone and discussed the protocol and patterns with one of the professors in the department.
The first six months were focused on EEG and epilepsy, and the focus in the last six months was on EMG and neuromuscular diseases.
Scientific Activities
I attended the departmental conference from 2:30 to 4 p.m. on Thursdays. There, we discussed interesting EMG and EEG cases selected from Monday through Wednesday. The last Friday of every the month, we held a multidisciplinary conference in the morning involving all of the neurology departments of the hospital. An oral presentation was made by each department, and the presentation was debated. In the afternoon, we had a multidisciplinary conference that included neurologists, neurosurgeons, and neuroradiologists at the National Center of Neurosciences and Rehabilitation inside the hospital Hôpital des spécialités.
Congresses and Meetings
With the support of the Moroccan Society of Neurology, I had the opportunity to attend the following meetings and congresses:
To enhance my knowledge on the theoretical level, I enrolled in the University Diploma on EMG and on EEG.
I am satisfied with my fellowship in the Department of Neurophysiology at Rabat. Thank you for the scientific environment and the availability of the whole team of the department. I had an excellent stay in Rabat, during which I gained knowledge in both EEG and epileptology, as well as in EMG and in neuromuscular diseases.
I believe I will be able to pass on the knowledge in neurophysiology that I acquired in Rabat to my colleagues in Mali and help improve the practice of neurophysiology in my country.
I am planning to use EEG and EMG at the teaching hospital of Point G to support the clinical evaluation needs of patients with epilepsy. I will do an EEG evaluation of study participants in a research project on autism in Mali. I am currently designing a study on EEG biomarker identification in autistic children.
By M. J. Eadie
M. J. Eadie
In Northern Hemisphere countries, from about 1860 onward, the specialty of clinical neurology emerged after increasing numbers of medical graduates focused their interests and restricted their clinical practices to the study and management of organic disease of the nervous system. A similar process occurred in Australia, but lagged by some four decades so that the specialty of clinical neurology there became firmly established only by the mid-20th century.
Several factors contributed to the Australian delay. European migration to the country began in 1788. Initially, the migration was composed largely of convict settlements, with free settlers beginning to arrive a few decades later. The Australian population sites that developed were far from Northern Hemisphere cities and educational institutions and also were considerable distances from each other. The individual sites needed to become large enough before specialist medical practice was feasible in them.
In the latter third of the 19th century, accounts of neurological disorders peculiar to Australia began to emerge. For example, children were being diagnosed with lead poisoning, and those who ate finger cherry fruit experienced acute bilateral visual failure. There were reports of disorders, such as leprosy, beriberi neuritis, and tick bite paralysis, not often seen in temperate climates. With few exceptions, Australian authors did not publish again on the same topic.
However, in the 1880s in Melbourne, John William Springthorpe became interested in epilepsy, and in the 1890s, S. Jamieson wrote on both syphilis and peripheral neuritis.
George Edward Rennie
The first man to take a major continuing interest in clinical neurology in Australia was George Edward Rennie (1861-1923). Originally from Sydney, he received his medical education (MB and MD) at the University College London and returned to Sydney. By 1898, Dr. Rennie became an honorary physician to the Royal Prince Alfred Hospital. He resigned that appointment and returned to London. He took the membership of the Royal College of Physicians, returned to Sydney in 1900, and re-ascended the honorary consultant ladder at his hospital to become its senior physician (from 1912 to 1921).
Dr. Rennie seems not to have carried out any significant original research, but wrote on neurological topics, such as the functional anatomy of the cerebellum, meralgia paraesthetica, the physiology of voluntary movement, the curability of epilepsy, the treatment of peripheral nerve diseases, the effects of spinal cord transection, and the possibility that occupation and peripheral trauma might determine the site of syphilitic cerebral pathology. He provided the neurological input to the main teaching hospital of Australia’s largest city but, with writings on topics such as pneumonia, tuberculosis, pernicious anemia, childhood deafness, and endocrine topics, he never restricted his activities to clinical neurology.
Alfred Walter Campbell
Alfred Walter Campbell
Alfred Walter Campbell (1868-1937) was the first person in Australia to practice purely as a clinical neurologist. He was born on a pastoral property in southern New South Wales, educated locally, and, at the age of 18, traveled to Edinburgh, Scotland, for medical studies. He graduated with an MB CM in 1889.
After short-term appointments in British psychiatric institutions and some months in Vienna with Richard von Krafft-Ebing, he spent a year at the State Asylum in Prague, where his histological research on “alcoholic neuritis” brought him an Edinburgh MD degree in 1892. He then became medical officer and resident pathologist at the Lancaster County Asylum (Rainhill), near Liverpool, where he spent the next 13 years publishing a considerable amount of neuropathological investigation into various topics, such as the degeneration of spinal tracts connected to the cerebellum. He was the sole author of all of this work, except for a lengthy account of the pathology of herpes zoster, co-authored with (the subsequently Sir) Henry Head. Head supplied the clinical data to correlate with Dr. Campbell’s histological findings in the nervous systems of 21 zoster sufferers. A map of the distribution of the human dermatomes resulted. Dr. Head’s role in this great achievement is still remembered, while Dr. Campbell’s is forgotten.
From about 1900 on, Dr. Campbell systematically investigated the histology of the entire normal human cerebral cortex, as a preliminary to searching for histological changes in the cortex that might correlate with mental illness, something that macroscopic pathology had failed to do. He studied serial sections from tissue blocks from 50 to 60 gyri per hemisphere in five hemispheres, staining alternate sections for myelinated nerve fibers and neuronal cell bodies, and in a further three hemispheres for nerve fibers only. He also sought retrograde cortical histological changes where altered brain function resulted from lesions below the cortex. He identified 12 histologically distinct areas in the cerebral cortex.
The future Nobel Laureate C.S. Sherrington, then professor of physiology in nearby Liverpool, read the findings on Dr. Campbell’s behalf to the Royal Society of London (1903 and 1904). The abstracts appeared in the society’s Philosophical Transactions, but the full paper was too extensive for publication. The society regarded the work highly enough to subsidize its publication by Cambridge University Press as Histological Studies on the Localization of Cerebral Function. The monograph appeared in late 1905, some three years before Korbinian Brodmann’s similar investigation was published.
Before his monograph was in print, Dr. Campbell returned to Australia, never leaving his homeland again except to serve with the Australian Army Medical Corps in Egypt during World War I. One factor in his abandoning his British career at his moment of triumph probably was his 1906 marriage in Sydney to a woman he had known since his rural childhood.
In Sydney, neuropathology was largely closed off to him by Froude Flashman and Oliver Latham in the State Asylum Service, while Dr. Rennie did much of the clinical neurology. Dr. Campbell began consultant practice in a mix of neurology and neuropsychiatry, with the latter progressively fading from his activities. He held honorary consultant positions at the Sydney Children’s and Coast Hospitals, and after World War I, to the Repatriation Department. He continued some neuropathological work, studying a gorilla brain given to him by Dr. Sherrington, and investigating in conjunction with Cleland the pathology and pathogenesis of a viral encephalitis termed Australian X disease, now believed to have been Murray Valley encephalitis. He also sought histological evidence consistent with localization of function in the human and Australian animal cerebellar cortex. He published those findings in so obscure a site that they went almost entirely unnoticed.
His other papers in Australia were more clinical. In 1937, he became ill with a malignancy, dying late in that year. He left behind no local school of clinical neurology. Sydney medicine, long reluctant to accept specialization within internal medicine, was not ready for it. Dr. Campbell’s reserved personality probably worked against him, and his earlier scientific attainments were little appreciated in his homeland.
J. Froude Flashman
J. Froude Flashman (1870-1917) followed a career course similar to Dr. Campbell’s. In 1910, he moved from neuropathology into consultant neurological and pathological practice in Sydney, largely to provide for his family. His original contributions to neuropathology, though appreciable, were not of the magnitude of Dr. Campbell’s. Dr. Flashman died of pneumonia while serving in the Australian Army Medical Corps in 1917 in France, soon after taking the MRCP qualification. Unfortunately, he did not have time to influence the development of Australian clinical neurology.
Leonard Bell Cox
Leonard Bell Cox
A young Melbourne medical graduate, Leonard Bell Cox (1894-1976) took the Edinburgh MRCP qualification (in hematology) before returning home after front-line service in France during World War I. In Melbourne, he first held appointments in pathology while building up practice as a physician. From 1925 onward, he increasingly devoted himself to clinical neurology, holding a formal appointment as a neurologist to the Alfred Hospital in that city. Among other investigations, he published some significant neuropathological research, including a major and influential study, “The Cytology of the Glioma Group With Special Reference to Inclusion of Cells Derived From the Invaded Tissue,” that appeared in the American Journal of Pathology (1933), and a co-authored monograph (with Jean Tolhurst) on Human Torulosis.
Edward Graeme Robertson
With the advent of Dr. Cox, leadership in the development of Australian clinical neurology shifted from Sydney to the country’s second city, Melbourne. There, (Sir) Sydney Sewell (1880-1949) held hospital consultant neurological appointments from a little before World War I, but afterward shifted his interest into the area of tuberculosis. Before doing that, he had encouraged Edward Graeme Robertson (1903-1975) to train in neurology in London where, after some distinguished clinical research work, he had already been appointed to a consultant post in neurology before returning to the Royal Melbourne Hospital in the mid-1930s. By that time, there also were physicians with major neurological interests, virtually de facto neurologists, in most of the Australian state capital cities, and the speciality of clinical neurology had arrived at its stage of self-sustaining expansion.
References:
M.J. Eadie is with the University of Queensland, Brisbane, Australia.
By Tissa Wijeratne, MD
Tissa Wijeratne, MD (right), with one of his mentors from his time as a student in Sri Lanka.
Born and raised in what I describe as “the jungle,” my life started in one of the remotest parts of Sri Lanka: a village called Kirioruwa-Bandarawela in the central mountainous area. Electricity, hot water, television, and telephone were all miles away from us at the time.
I fondly recall days spent reading in the shade of a tree in the rice fields that surrounded my family home — the place where sky and earth met, almost kissing each other daily. The mountains were covered with a layer of lush tea bushes. Our home sat on the top of one of these mountains.
As a young boy, I would spend hours reading my favorite magazine, the Mihira, a children’s weekly.
Fast forward several decades. I am now the director of stroke services, neuroscience research unit, director of academic affairs, and director of international affairs at a leading public health service and a leading academic institution in Melbourne, Australia. I have just been appointed to chair of the Department of Neurology at Western Health in Australia to promote better brain health through my leadership.
I have become the first Sri Lankan-born neurologist to lead an academic department of neurology in Australia.
The Journey
I was always dreaming, ravenously reading, thinking … trying to discover new things that others hadn’t, with a view to make life better for my fellow men and women.
I fell in love with the idea of medicine when I realized that the potential to change human life for the better was immeasurable.
I was accepted in to medical school at the University of Peradeniya in 1987 as a merit student. This was purely an accident. I had no idea that I could end up in medical school while I truly loved biology as a high school student. I preferred to do the biology track as I truly enjoyed learning about biology and chemistry. In the end, I did well and secured a ticket to get in to the medical school.
The day before I departed for the university, the whole village visited my parents with whatever treasure they could carry.
“We are very proud of you, son. Be a good doctor, and come back to the village. We will need you one day,” they said.
I still recall my father’s deep voice while he was walking me to the railway station to get to the University premises from Bandarawela.
“I am very proud of you. I have no doubt you will go all the way. It is very important for you to remember your roots,” he said. “Whatever you become, every time you come home, you are one of us, one of them.” (He pointed to a fellow villager who was working along a farm yard.) “You should always be very humble,” he said.
University life was a dream come true for me. There was no rice field to work; no need to offer physical labor on the farm. It was a heaven made for learning. I easily picked up high marks at the university exams.
I recall coming back to the village and sharing my experience with other boys and girls. The gates were open for them to enter universities away from the village.
Most of the boys and girls worked hard to get to the university.
Uprising
The good times did not last long. Things changed for the worse in a few months.
Suddenly, it was a tough time in Sri Lanka. I did not see this coming. It was depressing. Part-way through my first year of medical school life, a national youth uprising in 1987 resulted in several years of chaos in the country, with educational establishments closed for the period of insurgency.
Many of my batch mates were killed. They were suspected to have links with the youth-uprising group.
During what became a three-year hiatus, I tried to come to terms with the fact that I was not going to become a physician. I took solace in reading as much as I could, while helping my parents farm the surrounding rice fields and gardens in my rural village.
I really missed the university life. I missed the library the most. So, I began to convert my thoughts into words. I started to write.
I wrote poems and stories. In the end, many leading national newspapers and magazines in Sri Lanka published them one by one. In the end, I became well known in Sri Lanka, with over 3,000 written pieces. I would sit under a tree in the rice fields and write. My thoughts at that time were that if I could not be a physician, maybe I would become a journalist.
In 1990, the youth uprising was crushed, and the universities reopened. I faced a fork in the road. Should I continue with the new path and take up the post as deputy editor for a leading national science weekly in Sri Lanka, or return to my much-loved medical school and finish what I had started?
Ultimately, I chose medicine. I continued to work with media on a part-time basis, a decision that enabled me to pursue my tertiary studies without financially burdening my family. In my third year at the University of Peradeniya Medical School, I decided that the brain was the most fascinating organ in the whole body.
The Mind
The human mind always fascinated me. In fact, I was often found in the canteen, unofficially tutoring many of fellow medical students from my own class, as well as the juniors, on brain anatomy and neurological pathways. I was popular for demystifying neurosciences as a student at that time. I was quite interested in depression, anxiety, memory, and wisdom, and I often spoke on these topics on national radio at the time.
I had been learning about my own mind since I was a child, perhaps since I was about 10 or 11 years of age. A lot of people do not know their own minds. Most of us either live in the past or future, not the present, and we become daydreamers. We forget what we need to do now. We forget to live in the moment. We ruminate in the past or future. This is the root cause for suffering among us.
I graduated with high marks and secured one of the most prestigious internship appointments in Sri Lanka, at the professorial University Medical Unit and University Surgical Unit at National Hospital in Colombo, Sri Lanka.
Then fate intervened. I met a girl, who later became my wife. Born in Sri Lanka, she had moved to Australia as a young student in medicine and, as a fellow medical graduate, was taking an elective at a Sri Lankan hospital when she and I met.
At the completion of my internship, I was handpicked to be the youngest junior lecturer at the University of Peradeniya, being trained in neurology and stroke medicine under the mentorship of Prof. Nimal Senayanake. This was a highly competitive position. Prof. Senayanake is well known to the World Federation of Neurology thanks to his significant contributions in neurotoxicology in the past.
Family
At the time, I was observing the brain drain happening around me as my peers left for the U.K., Australia, and America. I hated them. I strongly felt that they had a duty to serve in the less green parts of the world.
Because of my marriage, I had to leave Sri Lanka in the end. The guilt I felt at leaving my beloved homeland in 1998 cut deep. It was some months before I could make progress in establishing a new life in Australia with my wife.
In 1999, my wife and I moved to New Zealand as part of her training in psychiatry. I then had the good fortune of working with a remarkable young infectious diseases physician, Dr. Richard Everts, who pushed me to complete physician training in Australasia while I was contemplating a neurobiology PhD at the time.
For the first time in my life, I could practice what I read in textbooks. I couldn’t do that in Sri Lanka.
After completing my basic physician training in New Zealand and having our first child in North Island, we moved south, to Christchurch, where I undertook my advanced training in neurology with Prof. Tim Anderson and colleagues. Here, I developed my skills in movement disorders, stroke medicine, and headache medicine. I was on call for the EPITHET trial as an investigator 24/7 for nearly three years.
We then moved back to Australia, and I took up a post at the Royal Adelaide Hospital, where our second child was born. I underwent further training in stroke and movement disorders under the leadership of Prof. Philip Thompson, then president of the Movement Disorders Society.
In 2006, Prof. Robert Helme invited me to set up a stroke program, neuroscience research program, and movement disorders program at Western Health, where resources were limited.
I went on to develop the fastest-growing stroke service in Australia at Western Health. A number of PhD students completed their higher degrees through the Western Health neuroscience research program. Our collaborations generated 10 to 15 high-quality publications in high-impact factor journals annually.
Prof. Helme is a remarkable person. We owe him a lot. He inspired a department, helped me establish a research program at Western Health, and encouraged my interest in stroke medicine. He is still my mentor. We meet every six weeks or so over a coffee, and even though he criticizes me for not doing more, he always smiles at my achievements.
I go back to Sri Lanka with surprising frequency, to promote better brain health in Sri Lanka. I have conducted more than 150 master classes in stroke medicine, headache medicine, and movement disorders throughout Sri Lanka since 2007. I have trained a young neurologist/physician from Sri Lanka at Western Health almost every year since 2008. At present, another Sri Lankan neurologist from Kandy is training with me in Melbourne, Australia.
I spend almost 70 percent of my annual leave returning to Sri Lanka. To my knowledge, I am the only permanent visiting professor of neurology to be officially appointed to a Sri Lankan University.
Australia has one of the best health care systems in the world, and I am proud to be a part of it. We deliver state-of-the-art care for our patients regardless of how much is in their pocket.
I don’t believe in complaining or whining about what we don’t have. Not so long ago, I did not have any office space or a personal assistant at Western Health while I was leading one the biggest stroke services in Australia. I was using a dustbin along the corridor to lean on and sign paperwork. The stroke service head from Colombo National Hospital and two other physicians who visited me noticed this in 2009. Just because I am in Melbourne does not mean I have a silver spoon.
I believe I am a link between the developing world and the developed world. If someone turned back the clock to 1998, and I was given the option of staying in Sri Lanka or coming to Australia, I would still come. I always wanted to do something great for the world and fellow human beings, and the Australian health system has given me the opportunities I never would have had in Sri Lanka.
Last year, I was very sick. I almost lost my life. At one point, I was told that I was not going to live more than two months. I recall the sleepless nights I had earlier in the illness.
“Did I get it wrong? I could have done more private practice and paid off the mortgage. Why did I spend time traveling back and forth to Sri Lanka rather than building my wealth and CV?”
I knew the answer right away. This is the best way to live my life. There is nothing that makes us happier than giving and expecting nothing in return.
I enjoy perfect health at the moment. I will continue to do my very best to dedicate my life to making life better for my fellow human beings. I have no boundaries for this purpose.
There is much more to do in this world. There is much more to do in the Asia-Pacific region. The World Federation of Neurology is our platform to do this work and to get the job done.
Make sure you sign up for the advocacy workshop at the upcoming world congress in Kyoto.
I look forward to seeing you all in Kyoto. Let’s get together and promote better brain health.
Let us bring our very best to get the best possible care for our patients, irrespective of the resources we have.
