Articles – Page 60

President’s Column

By Raad Shakir

Raad Shakir

Now the 22nd World Congress of Neurology (WCN) in Santiago, Chile, is over with huge success both scientifically and socially. There is a specific and enduring success story I would like to mention in this column. In every WCN, the program committee makes a specific point of bringing together all brain health sister disciplines to be present and to participate. So in the Congress, the World Psychiatric Association, World Federation of Neurosurgical Societies, International Child Neurology Association, World Federation of Neurorehabilitation and International Brain Research Organization were all present.

These organizations constitute the umbrella for brain health. The World Congress of Neurology in Santiago had sessions for each of these organizations, which were well attended and presented a showcase for each one of them. The WFN leaves the convening of the sessions and the choice of topics to the federations. It is absolutely correct that they should feel free to inform attending neurologists on what they think is of interest to us in their fields.

Representatives from the World Brain Alliance and sister organization in the Global Neurology Network met during the World Congress of Neurology (WCN) Nov. 3, 2015 in Santiago, Chile.
Front row (from left): Ingrid Tein, president, International Child Neurology Association; Gunther Deuschl, president, European Association of Neurology; Rana Karabudak, Neuroimmunology; Bill Carroll, vice-president and Global Neurology Network chair, WFN; Stephanie Clarke, president, World Federation of Neuro-rehabilitation, Raad Shakir, president, WFN; Yong-Kwang Tu, president, World Federation of Neurosurgical Societies; Cathy Rydell, CEO, American Academy of Neurology; Tarun Dua, medical officer, Program for Neurological Diseases, World Health Organization; Terrence Cascino, president, American Academy of Neurology; and Riadh Gouider, trustee, WFN.
Back row (left to right): Renato Verdugo, president, WCN Santiago; Steven Lewis, WFN co-opted trustee and editor continuum, American Academy of Neurology; Erik Wolters, president, International Association of Parkinsonism and Related Disorders; Riccardo Soffietti, European Association of Neuro-Oncology; Sam Wiebe, International League Against Epilepsy; Geoff Donnan, World Stroke Organization; Alan Thompson, Multiple Sclerosis International Federation; Amadou Gallo Diop, trustee, WFN, chair, Africa Intiative; Mark Hallet, president, International Federation of Clinical Neurophysiology; Claudia Trenkwalder, World Association of Sleep Medicine; and Jes Olesen, International Headache Society.

The World Brain Alliance (WBA) is therefore moving full steam ahead, and the collaboration is now so close that the time has come for tackling major issues, which can be dealt with jointly. Forming small working groups to tackle specific common disorders is underway. Three topics already have been agreed upon, those being dementia, epilepsy and traumatic brain injury. It is absolutely correct that working together, the WBA is a much more powerful entity rather than each of us acting separately. Moreover, in many situations we are tackling the same issues at the international level. The World Health Organization is going ahead on Global Coordination Mechanism on Noncommunicable Diseases (GCM NCDs). The place for neurology NCDs was not initially prominent, in spite of the fact that generally brain disorders cause major death and disability more than HIV, malaria and tuberculosis put together.

The role of the WBA is to fill the gap and inform, as well as educate public health authorities on the devastating effects of brain health disorders, whether they are neurological, mental, developmental or substance (NMDS) use issues. The shortcomings of neurological health provisions were highlighted yet again in the second edition of the Neurology Atlas 2015. This is a combined effort between WHO and WFN. The Atlas was presented in a preliminary manner at the World Congress. It will be published in early 2016. It gives details of the current status of manpower, service provisions, social support and drug availability for neurological, neurosurgical, child neurology and rehabilitation facilities across the world.

For the WBA to gel with our specialty sister organizations in the Global Neurology Network, a joint meeting with the representatives of all organizations present in Santiago was arranged. These global neurology associations convened sessions at the WCN and were represented at the highest level. The World Stroke Organization, International League Against Epilepsy, International Parkinson’s and Movement Disorders Society, MS International, Alzheimer’s International, International Headaches Society, Peripheral Nerve society, Neuro-ophthalmology, Neuro-Otology, Neuro oncology, History of Neurology all had sessions which were of most interest to participants.

The issues of brain health are crucial to the major exposure we would like to have at the highest level of international health care. If we are going to influence public policy, we need to be at the forefront of issues when decision-makers look into allocating budgets and resources. The only way to do this is for NMDS to be looked at together. Then the combined grouping is big enough to compete for funding and support, compared with similar big groupings such as cancer or cardiac diseases.

PC_Atlas The big drive of WHO toward global coordinating GCM NCDs is gathering pace. Although the scope of the process is not yet complete, one can see WHO trying to listen to all stakeholders, and the matter of WHO dealing with disease management is now a reality. The United Nations has produced the declaration on NCDs and 17 Sustainable Development Goals (SDGs) in 2015. In all these initiatives and targets, brain health should be at the forefront, and we as neurologists should push hard to have neurological issues right in the middle of governmental thinking. Financial support for our patients will only come if we have clear publically supported initiatives in a language that makes sense and shows targets, which are realistic and achievable.

The WHO GCM NCDs is an excellent platform to put forward our views on how to achieve early diagnosis and prevention of neuro NCDs. The issue, which attracts WHO and its agencies, is prevention and coping with various disorders at the primary care level. This is fine and commendable, however, in our world there is a follow on to this, which is management of many disorders, which are chronic, and for many lifelong. The fact that NMDS cause major disability adjusted life years is an important fact, which always should be at the front of all measures carried out by health authorities. It is also true that the cost of coping with NMDS conditions will be beyond health budgets even with high-income, let alone low- and middle-income economies.

The emphasis on management, including prevention, is a change in WHO thinking, which we need to embrace and welcome. WHO is receptive and recognizes that advances in genetics and imaging have created a new era in early diagnosis and at times preclinical recognition, which means specialists are needed and in numbers so there shall be no difference in care between various income groups. There is no doubt that recommendations to national governments at the GCM NCDs to train more doctors are commendable and welcome. We should also bring forward the idea that although a figure of 50 percent of those young doctors were recommended to be in primary care, there is an urgent need to increase the number of specialists in brain diseases across the world. It is true that this may be a long-term policy and to a degree wishful thinking, but if we look at the SDGs, many of which are long term but all of them have been approved at the highest level of the United Nations.

The way ahead is long but brain health, when presented to decision-makers, has so far been received with a positive and understanding attitude. We should all work at every level to promote brain health.

Report on the 23rd Annual Conference of the Indian Academy of Neurology

By Gagandeep Singh, Arabinda Mukherjee and Pardeep Kumar Maheshwari

The Taj Mahal plays as backdrop as delegates gather during the Clean India campaign held during the conference.

The 23rd Annual Conference of the Indian Academy of Neurology (IAN) was held Oct. 1–4, 2015, at Agra, the city of Taj, in India. Planning the IAN scientific program with sizeable professional body of clinical neurologists in India is always a challenging task for two reasons. For one, India is a country with 1.28 billion people with about 1,800 neurologists, which amounts to one neurologist for 7,00,000.

This entails providing each neurologist with updated knowledge so as to be able to deal with a wide range of neurological disorders, including tropical infections and toxin-induced disorders, besides the usual neurological conditions managed by Western neurologists. The demand on neurologists requires the ability to deal with a large patient pool with diverse neurological conditions. At the same time, recent technological and conceptual advances require that neurologist have the ability to provide state-of-the-art tertiary care to patients who require such care.

WFN President Raad Shakir greets Shabana Azmi during the inaugural ceremony.

A unique solution to this paradox is to have neurologists who practice high-technology neurology provide continuing education to neurologists involved largely in community care. This allows the Academy to be self-sufficient and caters to the educational needs of all. The scientific program of IANCON 2015 reflected the principle to ensure that public perception within the nation, as well as internationally, befitted. The distinguished guests included Shabana Azmi, a noted film actor and social activist, and WFN President Prof. Raad Shakir, president, World Federation of Neurology.

The Conference featured 14 breakfast and lunch symposia, a CME, four breakfast symposia, two guest lectures, four orations and 267 papers.

To cater to the tastes of trainee neurologists, a barbecue quiz — with an initial countrywide online round and a final round during the conference — and a clinic-pathological conference were other hallmarks of the conference.

Even as India needs many more neurologists, the number is increasing with 171 trained neurologists added each year. The scenario is certainly encouraging, as the IAN is becoming a stronger constituent of the World Federation of Neurology, the support of which we gladly acknowledge.

Gagandeep Singh is IAN secretary, Arabinda Mukherjee is IAN president and Pardeep Kumar Maheshwari is IANCON 2015 organizing secretary.

A Note of Thanks to Don Silberberg

By Raad Shakir

Raad Shakir

Since Don took over as editor of World Neurology (WN) in April 2013, we have seen a steady improvement in the quality of our newsletter with the publication of each of the 16 issues he has overseen. In his first editorial, he stated that the new electronic format would permit ready coordination among the two WFN publications, the Journal of Neurosurgery and WN, and the WFN website.

Part of the challenge, he said, would be to avoid all but essential redundancy among the three, and that has clearly been achieved through the World Neurology Editorial Advisory Board, which was created, and in other ways. In fact, so successful has this been that we have been able, during his editorship of World Neurology, to launch a third publication — the new open access journal, eNeurologicalSci (eNS), a sister journal to WFN’s longtime flagship scientific journal, the Journal of the Neurological Sciences (JNS). No doubt, we shall begin to seamlessly blend this too into the system, as it develops and grows as part of the WFN’s publications portfolio.

Don set out his plans to publish important news from the WFN, reports of WFN activities in the field and reports from the WFN’s committees and officers, but beyond this, he also targeted abstracts of articles that seemed to be the most important to global neurology. All of this has been an unqualified success, for which the trustees and I, and indeed the WFN as a whole, are most grateful.

World Neurology is now on sound footing for his successor to take it forward to the next stage. There is still much work to be done in developing the email database, as we all know, and we have begun to address that issue as well. Don will be succeeded by Prof. Steven Lewis of Chicago, Illinois, USA, as editor and Walter Struhal of Innsbruck, Austria, as co-editor.

I simply wish to express our collective gratitude for the contribution Don Silberberg has made and to thank him for his continuing efforts on behalf of the WFN. I hope the experience has been an enjoyable one and that Don has found the organization to have a useful role to play in neurology.

From the Editor-In-Chief

By Donald H. Silberberg

Donald H. Silberberg

This issue of World Neurology is the last for which I will serve as editor. Fulfilling this role for the past three years has been an exciting endeavor. I greatly appreciate that I was invited, and that I accepted the challenge and opportunity to develop World Neurology as an online publication.

In late 2012, then WFN President Vladimir Hachinski invited me to assume the position as editor-in-chief and oversee the transition from paper to an online newsletter. Rhonda Wickham and her colleagues at Ascend Integrated Media, World Neurology’s publishing partner, taught me what I needed to know, and, in general, they helped to make the transition to electronic distribution smooth. In addition to my thanks to Rhonda, I am indebted to Vladimir Hachinski and WFN President Raad Shakir for their support and interesting contributions, and also at WFN to Keith Newton for managing the calendar and carefully proofing galleys. Peter Koehler has unfailingly personally contributed, or he asked a colleague to contribute important articles on the history of neurology and neurological sciences for every issue.

As Raad Shakir notes in his gracious article about the transition to the editorship of Steven Lewis, effective for the March 2016 issue, generating a comprehensive list of email addresses has remained a persistent problem. I am hopeful all the member organizations of WFN will help Steven address this.

So, as I finish my three-year term, I also want to thank the many other individuals who have contributed articles, book reviews, ideas and guidance. I have enjoyed my tenure, and I wish Steven Lewis the best as he assumes the editorship.

Brain Health: Why Time Matters in MS

Figure 1. We recommend a therapeutic strategy based on regular monitoring that aims to maximize lifelong brain health while generating robust real-world evidence.

By Gavin Giovannoni, MD, on behalf of the MS Brain Health Steering Committee.

The goal of treating patients with multiple sclerosis (MS) should be to maximize lifelong brain health. This is the central theme of a new international consensus report from a multidisciplinary author group. Brain Health: Time Matters in Multiple Sclerosis calls for greater urgency at every stage of diagnosing, treating and managing MS. Its recommendations aim to facilitate a therapeutic strategy that minimizes disease activity (Figure 1), involving:

Shared decision-making
Early intervention
Improved treatment access
Proactive monitoring

The report was launched during a symposium, “Is the MS Community Ready to Promote Brain Health?” on the eve of the European Committee for Treatment and Research in Multiple Sclerosis Congress Oct. 6, 2015.

Professor Tim Vollmer outlined the brain health perspective on MS, presenting recent data underpinning its scientific basis. People with relapsing–remitting MS can lose brain volume up to seven times faster on average than age-matched controls, according to a 2015 meta-analysis of clinical trials.¹ Up to a point, this damage can be compensated for by neurological reserve — the brain’s finite capacity to reroute signals or adapt undamaged areas to take on new functions.^2,3 Preserving neurological reserve protects against cognitive decline⁴ and physical disability progression⁵ in people with MS. Once neurological reserve is exhausted, however, the long-term progressive phase of the disease will be unmasked, Vollmer argued. Adopting a therapeutic strategy that preserves neurological reserve by minimizing disease activity therefore should be of primary concern when people with MS and their clinicians make treatment decisions.

Shared decision-making relies on education. People with MS need to understand the potential long-term effects of the disease as early as possible after diagnosis, stressed George Pepper. As co-founder of the patient forum Shift.ms, Pepper stated that engaging people with MS in their own health care could be “the blockbuster drug of the 21st century.”⁶ He concluded by encouraging health care professionals to help people with MS to take active roles in treatment decisions and disease management, starting at the time of diagnosis.

Early intervention is vital, in order to preserve cognitive function. This was emphasized in a joint presentation by Dr. Gisela Kobelt and Professor Helmut Butzkueven, who examined MS from economic and real-world perspectives. Dr Kobelt presented some of her own economic data demonstrating that the greatest effects of the disease on employment occur at relatively low levels of physical disability.⁷ Professor Butzkueven concurred, and referred to results from a recent study showing that people with cognitive impairment at diagnosis were three times more likely to reach a Kurtzke Expanded Disability Status Scale score of 4.0 and twice as likely to develop secondary progressive MS 10 years after diagnosis.⁸ This underscores the importance of the report’s recommendation of aiming to alter the disease course through lifestyle measures and early treatment with a disease-modifying therapy.

Improved treatment access will ultimately come from demonstrations of cost-effectiveness. Assessing the difference that treatment makes to long-term health and economic burden is of vital importance in a chronic progressive disease. To date, however, long-term economic evaluations largely have been based on models owing to a lack of data, explained Dr. Kobelt.

By monitoring disease activity and recording data in registries, health care professionals can generate robust real-world evidence that can be used to inform individual treatment decisions. Butzkueven demonstrated the power of registry data to compare the effectiveness of different disease-modifying therapies in propensity-matched people with MS.⁹ The overall conclusion was that the biggest change in long-term health and economic outcomes could come from targeted intervention to maximize lifelong brain health — and that real-world registry data should be generated and used to test whether this is the case. (See Figure 1)

Summing up, Symposium Chair Giovannoni stated: “I’d like every clinician, every health care professional, to think that someone with MS is giving us their brain to protect. It’s our responsibility to make sure that they get to old age with a healthy brain, so that they can withstand the ravages of aging. As a treatment philosophy, it’s as simple as that.”

Health care professionals who believe in this treatment philosophy are invited to pledge their commitment to embrace the recommendations of the report. Download the full report.

References

Vollmer T et al. J Neurol Sci, 357 (2015):8-18.
Rocca MA et al. Neuroimage, 18 (2003):847-55.
Rocca MA, Filippi M. J Neuroimagin;17 Suppl 1 (2007):s36–41.
Sumowski JF et al. Neurolog, 80 (2013):2186-93.
Schwartz CE et al. Arch Phys Med Rehabil, 94 (2013):1971-81.
Rieckmann P et al. Mult Scler Relat Disor, 4 (2015):202-18.
Kobelt G et al. J Neurol Neurosurg Psychiatr, 77 (2006):918-26.
Moccia M et al. Mult Scler (2015): doi:10.1177/1352458515599075.
Spelman T et al. Ann Clin Transl Neuro, 2 (2015):373-87.

Gavin Giovannoni, MD, provided this piece on behalf of the MS Brain Health Steering Committee.

Acknowledgement

Independent writing and editing assistance for the preparation of this article was provided by Oxford PharmaGenesis, Oxford, UK, funded by grants from AbbVie and Genzyme and by educational grants from Biogen, F. Hoffmann-La Roche and Novartis, all of whom had no influence on the content.

Report on the XXII World Congress of Neurology

By William M. Carroll, MD

William M. Carroll

The XXII World Congress of Neurology opened Nov. 1, 2015, at the CasaPiedra Conference Center in Santiago, Chile. A total of 3,500 delegates were registered from 110 countries, and this Congress brought a significant rise in the number of participants under age 35 compared to those attending Vienna and Marrakesh. This demographic added a youthful look to the Congress. Delegates enjoyed the intimate Chilean décor of the CasaPiedra, comprehensive scientific and teaching course programs, and opportunities for social, educational and cultural discourse.

Opening Ceremony

The XXII World Congress of Neurology opens with a lively Chilean cultural performance.

The World Congress Sunday evening opening was one of the most enjoyable ceremonies for a long time. Not only was the cultural performance informative, lively and just the right duration, but so were the preceding addresses by World Federation of Neurology President Raad Shakir and World Congress of Neurology President Renato Verdugo, and the following address by Dr. Michelle Bachelet, president of Chile. A pediatrician by training, Dr. Bachelet spoke firmly on the need for global action on stroke and dementia, leading causes of the noncommunicable neurological disease burden in the world. She also highlighted the efforts of the Chilean Government through its Program of Explicit Guarantees in Health Care, which targets these and other noncommunicable disease states, such as traumatic brain injury, Parkinson’s disease and multiple sclerosis. She emphasized that the program was primarily preventative but also provided structured care.

Raad Shakir emphasized the need for both the fostering of quality neurology and equality of health care worldwide, Renato Verdugo gave an illuminating and much appreciated background on the history of Chile and the Chilean peoples.

Scientific Program

Michelle Bachelet, president of Chile, addresses the Congress.

Earlier that day, Dr. Oleg Chestnov, Assistant Director-General of Noncommunicable Diseases and Mental Health at the World Health Organization (WHO), led a WHO Symposium. A former gastroenterologist, his opening address was replete with illustrative and amusing anecdotes. Importantly, he highlighted the lack of neurologists as evidenced in the upcoming latest edition of the Atlas of Neurology (a joint WHO and WFN initiative), and the WHO Action Plan 2013–2017 concentrating on noncommunicable diseases. Dr Chestnov drew attention to the following points.

Epilepsy is now a WHO Assembly agenda item where the goals are to strengthen effective leadership, improve provisioning of care, integrate epilepsy into primary health care services and increase access to medications.
It is estimated that in 2015, 47 million people globally have dementia, and this figure will double every 20 years. The global cost in 2010 was estimated at $US604 billion.
Finally, he acknowledged the importance of the First Ministerial Conference on Global Action Against Dementia held earlier this year.

2013 Nobel Laureate in Physiology and Medicine Prof. Thomas Südhof presents a lecture on neurexins.

This important plenary session was completed by an authoritative review by Prof. Ingrid Scheffer of Melbourne, Australia, describing how genetics is influencing the management of epilepsy.

The scientific program was by all accounts one of the highlights of the meeting. Throughout, there were superb plenary lectures and symposia on all major neurological topics, providing clear insight into the robust pursuit of knowledge of basic science and its translation to clinical practice. It is only possible to mention a few of these.

Prof. Charlotte Cordonnier of Lille, France, addressed the vexatious issue of cerebral microhemorrhages and their relation to amyloid angiopathy, their management and risks with current stroke prophylaxis. Their investigation with the use of 7T Tesla to define stroke risk and new prospective studies defined lesser risks from ischaemic prophylaxis therapy for certain defined stratified groups.

World Health Organization (WHO) Assistant Director-General of Noncommunicable Diseases and Mental Health Oleg Chestnov leads a WHO symposium.

Prof. Jes Olesen in presenting the Yahr Award Lecture reviewed the current state of headache research and treatment, describing the new version of the International Headache Classification, to be incorporated in ICD11, and then aspects of migraine. He drew attention to three monogenic loci for familial hemiplegic migraine. He contrasted this with the 42 loci identified in the International Headache Genetics Consortium Genome-Wide Association Study in common migraine, nine of which also affect gastrointestinal tract musculature. In reviewing treatment, he lamented the lack of medications to reduce migraine aura, especially tonabersat because of the high cost the effectiveness of the angiotensin-II receptor antagonist candesartan as prophylactic, the need for calcium gene related peptide monoclonal antibodies for chronic migraine and the development of headache centers to hasten research and its translation to clinical care.

Profs. Michael Brainin, Geoffrey Donnan and Nick Ward gave an overview of the long-term perspective in stroke, tackling early diagnosis, secondary prevention and brain recovery in a high-class exposition, respectively.

Prof. Shoji Tsuji receives recognition for scientific achievements from WFN President Raad Shakir.

Prof. Neil Scolding’s thoughtful and practical lecture on the role of cell therapy in central nervous system disorders was a useful update in this much-anticipated therapeutic approach. Dr. Jon Stone’s lecture on the identification and management of functional disorders also was a well-received review of the current state of this sometimes difficult to manage topic. This theme also was the basis for the excellent review given by Prof. Mark Hallett of the National Institutes of Health during the Victor and Clara Soriano Award Lecture. His talk combined the electrophysiological study of motor acts with the psychology of the perception of functional and normal movements. Prof. Giacomo Rizzolatti updated the conference on mirror mechanisms and their clinical relevance together with the essential role of mirror neurones in this concept.

Prof. Kazuo Fujihara from Sendai, Japan, reviewed the current state of understanding of neuromyelitis optica spectrum disorders, highlighted the relatively uniform worldwide prevalence of this condition, the recently published Consensus Diagnostic Criteria and the increasing role of AQP4 seropositivity in the diagnosis.

Prof. Alan Thompson, of the University College London, gave an impeccably balanced update on the current state of research and treatment, the global initiative in progressive multiple sclerosis and the recent report of the first large-scale phase III trial of early anti B-cell treatment to modify the disease course.

Delegates gather to share ideas during
the Congress.

Prof. Thomas Südhof, 2013 Nobel laureate in physiology or medicine, treated delegates to an enthralling lecture on “Neurexins and Company: Towards a Molecular Logic of Neural Circuits,” describing their role in the function and dysfunction of neural networks in schizophrenia, autism and intellectual disability.

On the last day, the final Tournament of the Minds was held. The final teams buzzed in for their first right to answer to a question with a penalty for an incorrect answer. It was contested by the United Kingdom, Australia and Japan, and finished in that order. Congratulations to the United Kingdom team, which finished well ahead of the scheduled time for the completion of this session. The tournaments was followed by the closing ceremony with the presentation of a gavel to Prof. Yoshikazu (Kaz) Ugawa, President of the XXIII World Congress of Neurology, from the XXII World Congress of Neurology President Renato Verdugo, in order to have the 2017 Congress called to order.

Summary

A total of 272 oral lectures, and 36 teaching courses with three or four lectures each were presented; 1,230 posters were displayed from 1,668 abstracts, and there were five satellite symposia.

There were four named lectures:

Yahr Award Lecture: Prof. Jes Olesen, “New Concepts in headache”
Victor and Clara Soriano Award Lecture: Prof. Mark Hallett, “The Physiology of Will”
The Fulton Society Symposium-Soriano Award Lecture: Prof. Giacomo Rizzolatti, “The Mirror Mechanism and Its Clinical Relevance”
Bharucha Award Lecture: Prof. Richard Hughes, “Guillain-Barré Syndrome and CIDP: One disease or Many?”

The World Federation of Neurology also presented medals to two distinguished recipients. The first was for Service to Neurology and was presented to Dr. Michel Dumas for services to the development of neurology in Africa and elsewhere. The second was awarded to Prof. Shoji Tsuji of Japan for scientific achievements in neurology. Dr. Gallo Diop, WFN trustee, and Prof. Roger Rosenberg, University of Texas Southwestern, read the citations, respectively.

Social Event Program and WFN Business

The welcome reception was held immediately after the opening ceremony and was well attended. The Chilean networking event was held out of the city at a well-known winery and was enjoyed by the participants, after they recovered from the long bus ride inflicted by the Santiago evening traffic rush.

At the World Federation of Neurology Council of Delegates meeting held Nov. 1, a number or reports were presented, elections held and votes taken. Among these was the tightest decision for a WCN venue so far. For the XXIV World Congress of Neurology in 2019, Dubai triumphed with the slimmest of margins over Cape Town. Either would have been a fitting site for the XXIV World Congress of Neurology, a likely reason for the closeness of the final result. Dr. Richard Stark was elected to the new position of treasurer allowing Prof. Wolfgang Grisold to have more time for the secretary general’s role. Dr. Morris Freidman of Canada defeated an exceptional field of candidates for the position of elected trustee. The WFN wishes these new members of its executive team an enjoyable and productive term.

An issue, which arose and caused the trustees and organizers considerable concern, was the procurement of visas for the Chile World Congress of Neurology. Many delegates were forced to go to extreme lengths to obtain a visa. A number were unable to complete this, and even some of those who did obtain a visa were restricted to the duration of the Congress. The Council of Delegates recognized the difficult circumstances members of many national societies found themselves in as a consequence of the large flows of migrants in many parts of the world. In the future, the World Federation of Neurology hopes not only to have those bidding for future venues to declare freedom from restricted access to them, but also to identify and forewarn delegates of any practical difficulties they may encounter. These items will be placed on the website well before each upcoming World Congress of Neurology.

Finally, at the Trustees Meeting held during the XXII World Congress of Neurology, the suggestion made at the Kyoto site visit in September 2015 to restrict the number of faculty members to just more than 200 was endorsed with twin aims. The first was to control the cost of the World Congress of Neurology, but also to move to full funding of faculty members. The World Federation of Neurology recognizes that the best calibre lecturers are in a competitive environment and that it must make the invitation to the World Congress of Neurology most desirable.

Conclusion

As the curtain closes on the XXII World Congress of Neurology in Santiago, Chile, we should remember the spirit of giving so generously displayed by the Chilean society, the high level of educational endeavor, the friendships made and renewed, and the scientific, topical and cultural discussions that are part of the intangible benefits we and our colleagues derive from the World Congress of Neurology as we look forward to the XXIII World Congress of Neurology in Kyoto in 2017.

William M. Carroll, MD, is WFN First Vice President and Chair of the Congress Committee.

Candidates for the WFN 2015 Election

One new officer post — of treasurer — and one elected trustee post are to be filled at the Council of Delegates Annual General Meeting in November during the World Congress of Neurology in Santiago, Chile. The Nominating Committee has recommended the following candidates to the membership:

Recommended candidates

Treasurer
Prof. Richard Stark
(Australia)

Prof. Andreas Steck
(Switzerland)

Elected Trustee
Prof. Morris Freedman (Canada)

Prof. Steven Lewis
(United States)

Additional Candidate for Elected Trustee
Nominated under Article 6.3 of the WFN constitution
Dr. Daniel Truong
(United States)

Candidates’ biographical details and statements of their goals and objectives for the organization are below.

Candidate Statement for WFN Treasurer

Richard Stark, MD

Richard Stark

I am honored to be considered as a candidate for treasurer of the World Federation of Neurology (WFN). I am familiar with the dedication of the executive and staff through my involvement in past World Congresses of Neurology (WCN) from 2005 to 2015. I have been a member of the Tournament Committee and have seen firsthand the culture of generous willingness to donate time and effort in the preparation of this aspect of the conference, as well as the teaching and scientific programs. I know from these past experiences that I can work well with current members of the executive.

My nomination made me consider the role of WFN, and note its mission statement. This states “the mission of the WFN, as a UK registered charity, is to foster quality neurology and brain health worldwide, a goal we seek to achieve by promoting global neurological education and training, with the emphasis placed firmly on under-resourced parts of the world.” I strongly support these aims.

The treasurer of an organization such as WFN carries a heavy burden of responsibility. There are numerous stakeholders, including all of the member societies, each of which will have their own view as to the priorities the WFN should pursue. The funds of WFN accrue as the result of efforts of all of its members, and all expect the funds to be used appropriately and efficiently. It is self-evident that the processes for dealing with the funds must be transparent and equitable.

Every edition of World Neurology demonstrates the wide range of the WFN’s efforts to enhance neurological knowledge and improve neurological services to patients around the world. Initiatives of this type require funding so that inevitably the choice of projects undertaken must be approached prudently.

Much of the WFN’s income derives from its scientific meetings, and the financial successes of these depend in large part on the extent of support from pharmaceutical and related industries. The enthusiasm of pharmaceutical companies depends, in turn, on the nature of their products and the stage of commercial development of each product. These factors are, of course, outside the control of the WFN.

The management of the WFN’s finances, therefore, require an astute and flexible approach aimed at maximizing income, using income as available to fund projects around the world and efficient administration. Prudence requires that projected income streams be realistic and take into account uncertainties related to pharmaceutical industry support.

As treasurer of the Sydney 2005 World Congress of Neurology (which was a huge financial success and has contributed to WFN’s capacity to fund ongoing projects) and of the Australian Association of Neurologists (1997-2003) during a period of its growth, I am well aware of the challenges facing an organization such as the WFN and of the need for careful and prudent management of its finances. These positions naturally involved efforts to maximize income from industry, as well as other sources, so I am familiar with what is required to achieve success in these areas. The experience of being treasurer of WCN 2005 also highlighted the need to be acutely aware of the potential effects of fluctuations in exchange rates and other consequences of the globalization of economies. WCN 2005 took place at a time of substantial exchange rate volatility, and the measures that had been put in place to minimize adverse impacts of this volatility contributed to the financial success of the conference.

The WFN has a strong tradition of efficient use of funds. This, of course, contrasts with the situation in some other high profile international organizations and relies on the generous donation of time from the executive, as well as the hard work of administrative staff. This efficiency must continue.

If elected, I undertake to work diligently with the executive to ensure that the financial management of the WFN allows it to pursue its aims and objectives as effectively as possible.

Candidate Statement for WFN Treasurer

Andreas Steck, MD

Andreas Steck

I am a professor emeritus of neurology and former head of the department of neurology, University of Basel, Switzerland. I have been a member of the Executive Committee of the European Neurological Society (ENS) since the foundation of the society and was also president of the ENS. I was in charge of its finances and served as treasurer. I chaired the Evaluation Committee of the ENS fellowship program and was a member of the Examination Committee of the European Board of Neurology. My research interests have centered on neuroimmunological aspects of neurological diseases, such as multiple sclerosis, inflammatory neuropathies and paraneoplastic syndromes.

I am currently the president of the Scientific Council of the International Foundation for Research in Paraplegia in Geneva and chair the Neuromuscular Research Association Basel. I am a member of several international societies, such as the Neuromuscular Research Group of the WFN and a faculty member of F-1000. I am a past editor of the Swiss Archives of Neurology and Psychiatry, a former president of the Swiss Neurological Society and a regular reviewer of scientific journals. I am a fellow of the American Neurological Association and a fellow of the European Academy of Neurology.

Large international organizations, such as the WFN, need a strong management structure to sustain the challenging demands in a rapid moving world. This has led to the decision to separate the post of secretary-treasurer general into two, one of secretary general and the other of treasurer. In high insight, this is a natural evolution toward more transparency, and most scientific societies today follow this model. The newly created function of treasurer is an important position of trust and responsibility situated between the president, secretary general, trustees and member societies.

Over the years, the WFN has experienced increased operating expenses, in particular through its worldwide initiatives, grants and spending on member activities, which help to realize its main goals as a global scientific society. In this respect, an important role of the treasurer is to keep the WFN on a sound and sustainable financial basis, while allowing the WFN to meet its growing support needs by encouraging new projects and co-sponsorships with other institutions or scientific societies. While the WFN is by essence a global player, there are an increasing number of large international neurological societies taking regional and supranational coordinating roles. An example of this is the newly created European Neurological Society (EAN). The two existing European neurological societies, the European Neurological Society (ENS) and the European Federation of Neurological Societies (EFNS), have now joined forces to build the EAN. The newly established organization has inherited funds of the two previous ones. This puts it in an excellent position to take on new challenges, such as a recently initiated partnership program across the Mediterranean to involve associate member countries. The newly formed Pan American Federation of Neurological Societies (PAFNS) is representing neurology in Latin America a region in full development, where the 22nd World Congress of Neurology (WCN) is taking place in Santiago, Chile. The 23rd WCN will be organized by the Asian Oceanian Association of Neurologists and take place in Kyoto, Japan.

The WFN should take advantage of the unique opportunity to collaborate with these international societies to advance our field. The challenge for the WFN in the coming years will be to coordinate its global involvement by interacting not only with national, but also new international scientific organizations. In order to maintain a sustainable growth, the cooperation’s projects should be well planned to avoid overlapping programs. A better integration and coordination of the WFN applied research groups would help foster quality neurology worldwide. Efforts should be made to streamline the budgeting process and assure that management accounting allows for an ongoing monitoring of income and expenditures.

The sources of finances for the WFN include membership dues and income from congresses and publications. Moving the World Congress of Neurology from a four-year to a two-year cycle has brought in more money. Going to a one-year cycle of meetings would allow not only for continuity in organization and strengthening of corporate identity, but also would further increase income, a welcome move in a time of shrinking resources. Engaging with partners to share costs should bring additional sources of revenue.

As a long-standing member of the Executive Committee of the ENS, where I was in charge of the finances, I bring the needed managerial experience. I am convinced that I can fulfill this important function of treasurer to the satisfaction of the WFN and its members.

Candidate Statement for Elected WFN Trustee

Morris Freedman, MD

Morris Freedman

I have had the privilege to serve as Canadian delegate to the World Fedeartion of Neurology (WFN) since 2007, as a member of the WFN Education Committee since 2010 and as co-chair of the eLearning Task Force of the Education Committee, alongside Prof. Riadh Gouider from Tunisia. I am also honored that the Canadian Neurological Society has nominated me for the important position of WFN trustee.

Background and Achievements

By way of background, I am chair of the International Development Committee of the Canadian Neurological Sciences Federation, and I have served as president of the Canadian Neurological Society, Canadian Congress of Neurological Sciences (now Canadian Neurological Sciences Federation) and Federation of National Specialty Societies of Canada.

At the hospital level, I am head of neurology, executive medical director of the Centre for Memory and Neurotherapeutics, and director of the Sam and Ida Ross Memory Clinic at Baycrest Health Sciences. At the university level, I am a professor in the Division of Neurology, department of medicine, and director of the Behavioral Neurology Section, Division of Neurology, University of Toronto.

My clinical focus is behavioural neurology. I am also a scientist at the Rotman Research Institute of Baycrest Centre. My research is aimed at both improving our understanding of the mechanisms underlying cognitive impairment due to frontotemporal dementia and Alzheimer’s disease and development of cognitive test procedures. For example, my colleagues and I have contributed to the use of clock drawing as a bedside cognitive assessment tool.

I have taken an active international leadership role in education. Since 2005, I have focused on eLearning using videoconferencing as an electronic medium to bring together health care professionals from across the globe within a virtual classroom. This has been done within the context of international videoconference rounds in behavioral neurology. The goal is to develop greater international communication and links in behavioral neurology, and to transfer knowledge at the basic science and clinical levels internationally through joint educational programs. American, Canadian, Cuban, Israeli, Jordanian, Russian, Saudi Arabian, South African, Spanish and Swiss (World Health Organization) hospitals have participated. The audiences are multidisciplinary and include neurologists, psychiatrists, geriatricians, family physicians, nurses, social workers, occupational therapists and psychologists, as well as trainees in these disciplines. I was awarded the prestigious Colin Wolf Award from the Faculty of Medicine, University of Toronto, for this initiative.

An important development that was modeled on the international behavioral neurology videoconference rounds was the formation of an international neurology resident initiative in 2008, i.e., the Neurology International Residents Videoconference and Exchange (NIRVE), which promotes international collaboration among neurology residents. Participating sites have included Brazil, Canada, Chile, Ethiopia, France, Jordan, Nigeria and Russia. In addition to the rounds, NIRVE has led to resident exchange visits between Russia and Canada.

More recently, I have collaborated with Prof. Riadh Gouider to create a new series of international videoconference rounds in behavioral neurology involving Africa and Canada, which was supported by a WFN grant awarded during Dr. Vladimir Hachinski’s term as WFN president.

Goals

My goal as WFN trustee is highly focused and directly related to the mission of the WFN. This is to promote “global neurological education and training with the emphasis placed firmly on under-resourced parts of the world.” I hope to achieve this goal through innovative eLearning programs, which will include a significant expansion of our network of international sites for video conference rounds that target neurologists, allied health care professionals and trainees in neurology and related disciplines. The focus will be expanded from our highly successful behavioral neurology series to include a broad spectrum of areas within neurology with the opportunity of adaptation of new technologies. The ongoing programming series will involve both developing and developed countries so that knowledge can be transferred from one to the other in both directions.

I recognize the financial challenges facing under-resourced parts of the world, and the barriers that this poses for successful knowledge transfer through eLearning. However, in keeping with the mission of the WFN to promote global neurological education and training in these regions, I will apply all the resources at my disposal to help fulfill this mission with full emphasis on under-resourced regions.

I have a vision, a clear sense of direction and the focus to facilitate knowledge transfer for enhancing brain health across the world, especially where it is needed the most. Those who know me say that I am an excellent team player and organizer, qualities that are essential for success of the outlined goals. This success will require extensive collaboration and coordination involving many people with diverse needs, across many countries, to promote the WFN’s mission in global neurological education and training.

Candidate Statement for Elected WFN Trustee

Steven L. Lewis, MD

Steven L. Lewis

It would be an honor and a great privilege to be elected by the delegates as a trustee of the World Federation of Neurology (WFN). In support of my candidacy, I will begin this statement by providing some biographical information about my qualifications and experiences, which have led to my current involvement with this critically important organization.

I am currently professor of neurological sciences at Rush University Medical Center in Chicago, where I also serve as associate chairman, head of the Section of General Neurology and director of the neurology residency training program. My undergraduate education was at Yale University, where I received my degree in molecular biophysics and biochemistry. I received my medical education at Stanford University School of Medicine, and I performed my medical internship and neurology residency at the University of Chicago.

My national activities in neurology include my current chairmanship of the Neurology Residency Review Committee of the Accreditation Council for Graduate Medical Education, the committee that oversees training requirements and makes accreditation decisions regarding all neurology residency training programs in the U.S. I also recently chaired the Neurology Milestones Committee that developed the training milestones for all U.S. neurology residency trainees.

I have been highly involved with the American Academy of Neurology (AAN) for many years, including being current chair of the AAN Examination Subcommittee and section co-editor for continuing medical education (CME) for Neurology. I was vice-chair of the AAN Education Committee, and I chaired the AB Baker Section of Neurologic Educators. Three years ago, I had the privilege of being appointed by the AAN as editor-in-chief of Continuum: Lifelong Learning in Neurology, the AAN’s official CME journal.

Fortuitously for me, my work as editor-in-chief of Continuum also has led to my entry into significant involvement with the WFN and its support of global neurologic education. A joint program of the AAN and the WFN provides Continuum to 45 neurological societies whose Continuum user groups include thousands of participants worldwide who would otherwise be unable to access this important educational resource. This program, supported by a generous donation from the AAN and its publisher, Wolters Kluwer of 400 print copies of each issue as well as free online access for every participant, has been extremely highly received, and Continuum has served as a critically important educational tool for neurologists in training and in practice worldwide.

Two years ago, I had the privilege of being appointed as chair of the WFN Education Committee, allowing me to expand my involvement further beyond Continuum into the many other global educational efforts of the WFN, including growth of the WFN teaching centers, the awarding of WFN traveling fellowships and other endeavors. Most recently, Dr. Wolfgang Grisold (WFN secretary treasurer-general) and I have begun the first steps in development of a global educational curriculum for neurological training, to be developed with the assistance and input of the members of the WFN Education Committee. We feel that the WFN is in a unique position to develop such a curriculum to enhance neurological training worldwide.

One year ago, I was asked to serve as a WFN co-opted trustee, a position that has given me the opportunity to be even more highly involved in this important organization. I especially feel privileged to have been able to work closely with and learn from such esteemed mentors as Dr. Raad Shakir, president; Dr. William Carroll, first vice-president; Dr. Wolfgang Grisold, secretary treasurer-general; and Dr. Riadh Gouider and Dr. Amadou Gallo Diop. Their knowledge and experience in global neurology, and their combined histories with and institutional knowledge of the WFN, have been invaluable in my personal development to become an effective member of this organization.

In my roles and experiences with the WFN thus far, coupled with my communication with neurologists globally as Continuum editor-in-chief, I have been impressed by the remarkable similarities of the needs of neurologists worldwide, while also being keenly aware of the important differences in available resources and in access to care. The WFN should continue to play in integral role in enhancing access to quality neurologic education and training and to foster neurological health, including via continued partnerships with national neurologic organizations to access publications and educational programs (such as the partnership with the AAN for Continuum); continued involvement with the World Health Organization; an increased number of partnerships to provide regional teaching centers for neurologic training (such as is now in place in Rabat and Cairo, and currently being developed in Cape Town and Dakar) and department visits for brief subspecialty training experiences (as currently in place in Turkey, Austria and Norway); increased recognition of the availability of travel stipends and research grants to provide as many individuals as possible with access to these important (and sometimes life-changing) opportunities; and continued development of global initiatives, such as the development of a global educational curriculum. The WFN also can continue to increase its visibility to individual members of all neurologic societies, which will further our constituents’ access to our initiatives.

My background and experience as a neurological educator, editor and general clinical neurologist, I feel, provides a unique set of qualifications to help continue and even further enhance the role of the WFN and its 117 professional neurological society members to promote neurologic education and training with the goal to improve global neurological health. I would be honored and privileged to become an elected trustee of the WFN and to serve its members faithfully.

Candidate Statement for WFN Elected Trustee

Daniel Truong, MD

headshot_Truong The national neurology societies of Bulgaria, China, Germany, Hungary, Kazakhstan, Kuwait, Mexico, Pakistan, Rumania, Saudi Arabian, Slovenia, the United States and Vietnam have honored me by nominating me for the trustee position.

I was born in North Vietnam and moved with my family to South Vietnam in 1955 as a result of the war. I was one of the first Vietnamese to come to Germany in 1967 to study medicine at the University of Freiburg. I specialized in neurology and psychiatry. Marriage brought me to the U.S. in 1982, where I continued my training in neurology, first with a residency at the Medical University of South Carolina and later with a fellowship at Columbia University and London’s National Hospital for Nervous Disease.

My journey with the World Federation of Neurology (WFN) began in 2002, when I was given the honor to serve as a member of the Publication Committee. I was entrusted with the task of improving upon World Neurology. At the time, the newsletter was printed in India and mailed to subscribers worldwide. It arrived six months later by regular mail due to the cost of airmail. To reduce costs and expedite circulation, I proposed the transition to an Internet-based newsletter with regional interests. This proposal was later implemented as the current World Neurology.

My association with the WFN gave me the opportunity and cover to safely develop educational programs for Vietnam, as Vietnam had just begun opening its doors to the West. I implemented the format of the International Neurology Forum, consisting of a short course focused on one topic lasting one to two days. This format was the product of repeated observations that physicians from developing countries did not demonstrate high retention of new techniques learned from broad, lengthy meetings. However, when trained collectively in a large group in their own countries, there was a much higher chance that their practice patterns would change. I organized this format in subsequent forums in developing countries, such as Mongolia, Indonesia, Uzbekistan and Kazakhstan.

Over the years, I also have served on the Fundraising Committee, Membership Committee, Education Committee and Editorial Boards of World Neurology and the Journal of Neurological Sciences. I firmly believe that the furthering of scientific medicine requires a global effort. I have joined with my other three colleagues to edit a textbook, International Neurology, with the contributions from more than 200 neurologists from 80 countries around the world.

Reasons for Candidacy

As the WFN continues its endeavor to foster quality neurology and brain health worldwide, it serves as the bridge connecting different national neurology societies together. Its collective knowledge and strong moral standing lend the support to different national neurology societies to become a professional society with its own standing and as a pillar of democracy in their countries. I believe that I will be able to assist WFN to promote and sponsor initiatives that can leverage growth in neurology in regions of need, such as Africa, Central Asia, parts of Eastern Europe and Southeast Asia. Toward this goal, I believe that the WFN communications processes can be further improved to push for low-cost education in developing countries.

Goals

To protect and grow the visibility of the WFN brand;
To continue to modernize WFN communication and processes;
To reach out and partner with other similarly aligned interests to assist the WFN in achieving its goals; and
To assist in developing education programs worldwide.

Personal Qualities and Experience

The role of trustee requires a balance of experience, energy and teamwork. I believe I will contribute effectively to the stable growth of the WFN, the fulfillment of its mission and the achievement of the stated goals. Listed are some of the positions that I have held, or currently occupy, supporting my candidacy:

Clinical professor, neurology, University of California, Riverside
Chair, Education Committee, International Association for Parkinsonism and Related Disorders
Member, Education Committee, WFN (2013- present)
Member, Publication and Website Committee, WFN (2002-2012)
Member, Fundraising Committee, WFN (2005-2009)
Member, Membership Committee, WFN (2005-2007 and 2012-2013)
Member, Research Committee on Parkinson’s Disease, WFN, (2004- 2010).
Member, Membership Committee, WFN (2009-2013)
Member, Lawrence C. McHenry Award Subcommittee, American Academy of Neurology (2007-2011)
Member, International Subcommittee, American Academy of Neurology (2013-2015)
Member, Congress Fundraising Committee, International Association for Parkinsonism and Related Disorders (2013-2015)
Member, Liaison/Public Relations Committee, Movement Disorder Society (2006-2010)
Member, Strategic Planning Committee, Movement Disorder Society (2014-2015)
Member, International Committee, American Academy of Neurology (1995-1997)
Ad Hoc reviewer, American Academy of Neurology (2007-2008)
Section editor, Journal of Neurological Sciences (2013-present)
Section editor, Journal of Neural Transmission (2008-present)
Editorial board, Journal of Neural Transmission (2006-2008)
Editorial board, Journal of Parkinsonism and Related Disorders (2005-2013)
Editorial board, Journal of Neurological Sciences (2006-2013)
Editorial board, Future Neurology (2007-present)
Editorial board, World Neurology (2003- 2013)
Section editor, Neurology International (2009-present)
Editorial board, Romania Journal of Neurology (2013-present)

Editor’s Update and Selected Articles From the Journal of the Neurological Sciences

By John D. England, MD, Editor-in-Chief

John D. England

The editorial staff of the Journal of the Neurological Sciences (JNS) and Elsevier have been working closely with the organizers of the upcoming XXII World Congress of Neurology (WCN) to provide easy access to the 1,461 abstracts being presented there. All of the abstracts will be published in JNS and will be available online as open access just before the congress begins.

Additionally, there will be a congress app, which will include a link to the journal to ensure that attendees can view all the abstracts. The congress venue will have WiFi in the public areas. Attendees without smartphones or mobile devices will be able to access the abstracts at Internet and abstract viewing stations. I believe that these processes will enhance everyone’s educational and social experiences at the congress. I look forward to meeting with many of you at the WCN 2015 in Santiago, Chile.

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

Wildea Lice de Carvalho Jennings Pereira, et al., provides a comprehensive review of neuromyelitis optica (NMO). Ever since the discovery of the specific antibody against aquaporin-4 (anti-AQP4), which is associated with NMO, there has been great interest in this disease. Most of the major neurology and neuroscience journals, including JNS, publish several original articles each year describing new aspects of NMO. This article is very useful and timely, since it summarizes the current knowledge of the epidemiological, clinical and immunological aspects of the disease. It also describes the currently recommended treatment strategies for NMO. W.L. de Carvalho J. Pereira, E.M.V. Reiche, A.P. Kallaur, D.R. Kaimen-Maciel, “Epidemiological, Clinical and Immunological Characteristics of Neuromyelitis Optica: A Review,” J. Neurol. Sci. 355 (2015): 7-17.
Joerg-Patrick Stubgen provides a summary of the types of peripheral neuropathies that are associated with lymphoma. Clinically-evident “dysimmune” neuropathies occur in approximately 5 percent of patients with lymphoma; however, electrophysiologically-evident neuropathies have been reported in as many as 35 percent of patients with various types of lymphoma. And, these prevalence assessments do not include the frequent treatment associated (largely chemotherapy-induced) peripheral neuropathies. The spectrum of peripheral neuropathies associated with lymphomas is wide, and the etiology is complex and poorly understood. As emphasized in the article, accurate clinical diagnosis of the type of neuropathy and proper categorization of lymphoma are both important to ensure selection of the most appropriate and effective treatment strategies. J-P.Stubgen, “Lymphoma-associated Dysimmune Polyneuropathies,” J. Neurol. Sci. 355 (2015): 25-36.

John D. England, MD, is editor-in-chief of the Journal of the Neurological Sciences.

Early Works Identify Writer’s Cramp Culprits

By Peter J. Koehler

Peter J. Koehler

Considering that book printing was invented in the early 15th century (Johannes Gutenberg, Mainz, Germany) and the copying of texts before that period had to be done by hand, one wonders whether writer’s cramp has been described in the middle ages.

As far as I now, it has not been referred to before the description by the Italian physician Bernardino Ramazzini (1633-1714) who, in 1713, published a book on occupational diseases and since then has been considered the father of occupational medicine. His book De Morbis Artificum Diatriba (Diseases of Workers) indeed contains a large number of occupations with associated disorders. In the chapter “Diseases of Secretaries, Clerks, Writers and Copyists,” Ramazzini started to refer to the ancients, who had more copyists and writers than in his days, and to the Roman writer and naturalist Pliny, who, on his journeys, was usually accompanied by a writer with a book and tablets.

Bernardo Ramazzini

In Ramazzini’s own environment, secretaries and clerks of princes, magistrates and merchants were paid to keep the books, and registers and were “subject to several diseases that depend either to the sitting position that they are obliged to conserve for long periods, or from the continuous movement of the same hand, or finally from the mental effort necessary not to make errors in their calculations.”¹ He continued to describe the necessity to hold the quill continuously and move it for writing, and that it fatigues the hand and even the whole arm, due to the continuous contraction of the muscles. Ramazzini was acquainted with a writer, who had been writing his entire life, by which he had gathered some fortune. He experienced at first a considerable lassitude in his whole arm that resisted against all kinds of remedies, and that ended in a complete paralysis of that arm. He taught himself to write with his left hand, but, after some time, the arm became afflicted with the same disease.

Bernardo Ramazzini’s De Morbis Artificum Diatriba (Diseases of Workers)

Ramazzini added that the mental efforts, to which clerks are subject, may result in migraines, colds and swelling of the eyes. To prevent these diseases, the author advised to do exercises in the evening and during holy days. Interestingly, he also wrote that “the use of tobacco may diminish their headaches,”¹ and for the paralysis of the hands, they should wash them with aromatic wine or liquors.

The well-know Scottish surgeon Charles Bell — of Bell’s palsy — may have presented an early observation in the 1833 edition of his Nervous System of the Human Body,² where, under the title “Partial Paralysis of the Muscles of the Extremities,” he wrote that it is an obscure object … an affection of the muscles which are naturally combined in action.” Bell found the action necessary for writing gone, or the motions so irregular, as to make the letters be written in zigzag, while the power of strongly moving the arm, or fencing, remained.

Charles Bell

In German language, the disease was referred to as mogigraphie and schreibekrampf. Georg Hirsch, physician at Königsberg, was among the early German authors on the subject. “The most particular form of partial abnormal muscle movement is the writer’s cramp, for which I propose as technical name mogigraphia, in analogy to Mogilalia.”³

The extraordinary disease could not be localized in the muscles, but was believed to arise from a general nerve irritation that is only present in muscles fatigued after much writing. The thumb and secondly the index finger are most often involved, with the text noting the illness is described easily as shaking, or as stiffness, mostly as a hasty flexion movement. He also referred to Moritz Reuter, who told about a 30-year-old famous composer “to whom, since 10 years, every time when playing the piano, the right middle finger fails by upcoming spasm,” possibly referring to Robert Schumann.³ The origin of writer’s cramp was thought to be in the spinal cord (hence the book’s name, spinal neurosis), and a section of a tendon was sometimes suggested.

Georg Hirsch’s chapter on mogigraphie

Guillaume B.A. Duchenne de Boulogne, the well-known French physician, who used to visit Paris hospitals to apply electric therapy for all kinds of diseases, described several cases of writer’s cramp in his De l’électrisation Localisée.⁴ Case 213, Matthieu Guérin, age 62, was a cashier, who, in 1852, started to complain of cramps in his right hand each time when he wrote for a certain period of time. He suffered from pain and fatigue in his thumb and index finger, which forced him to hold the quill tightly. The fatigue would spread through his entire arm. He did not experience any symptoms when using his hand for other tasks. He was treated by six vesicatories and by douches with aromatic vapors without any relief. Two years later he was not able to hold the quill anymore, and he had taught himself to write with his left hand.

Charles Bell’s The Nervous System of the Human Body (1833 American edition)

Then he started to suffer from spasms in his right shoulder and neck, at first only when writing, but later continuously. At last, he was forced to give up his job as a cashier. In 1859, he presented at the clinic of Auguste Nélaton, where Duchenne was consulted. He treated the patient with electricity and an apparatus to keep his head to the other side. “Aujourd’hui, aprè
s la quinziè
me séance, le malade peut àªtre consideré comme guéri,” which means he was cured from the cervical dystonia following the 15th treatment session, but the writer’s cramp did not disappear.⁴

Guillaume B.A. Duchenne de Boulogne

Introducing other cases of crampe des écrivains, he wrote that the affliction was known in Germany with the name schreibekrampf. He had noticed that the muscles involved could vary. In a stockbroker, he observed flexion of the index finger as soon as he had written a few words. In an office worker at the war ministry, the first two fingers took an opposing position upon writing. Duchenne also saw supination of the hand. The treatment of what he called spasme fonctionnel was usually disappointing. He applied local faradisation during 12 years in 30 or 35 cases, but only saw two successful cases.

Duchenne’s De l’électrisation Localisée (Second edition, 1861)

Duchenne also observed a case of primary writer’s tremor, noting that “Mr. X … , lawyer, 26 years old … writing about three hours a day, was affected, in the course of the month of January 1860, by tremors of the right hand, with trouble making letters. … Even the idea of writing seems to lead to tremor, that also increases when someone is looking at it. … The tremor is provoked by no other use of the hand than that of writing.”⁴

Duchenne’s case 213, Matthieu Guérin

Obviously, writer’s cramp has been a disorder that existed for centuries, has been described in many countries and most probably already existed prior to Ramazzini’s description. Perhaps other than (medical) sources should be consulted to find them.

Duchenne’s patient treated with an apparatus to keep his head to one side

Patissier Ph. Traité des Maladies des Artisans et Celles que résultent des diverses professions, d’aprè
s Ramazzini. Paris, Bailliè
re, 1822.
Bell C. Nervous system of the human body. Washington, Green, 1833, p. 221, case no. 86.
Hirsch G. Beiträge zur Erkenntnis und Heilung der Spinal-Neurosen. Königsberg, Bornträger, 1843, p. 430.
Duchenne GB. De l’à‰lectrisation localisée et de son application à la physiologie, à la pathologie et à la thérapeutique. 2nd ed. Paris, Balliè
re, 1861.

Report From the Congress of the European Academy of Neurology

By Nino Gagatishvili, MD

Nino Gogatishvili

I was awarded a World Federation of Neurology travel grant, which enabled me to attend the important and interesting First Congress of the European Academy of Neurology, June 20-23, 2015, in Berlin, Germany. I am grateful for the support of World Federation of Neurology.

The well-organized congress offered an interesting scientific program, which included symposia, classroom teaching courses, hands-on courses, special sessions, satellite symposia, focused workshops, interactive sessions and practical courses. As a new congress feature, all posters were presented only as e-posters.

Within the poster area, 12 large screens, 18 mid-size screens and 25 computer stations were available so presenters and participants were able to interact with each other. There were two types of poster sessions: posters with discussions and flash posters.

During the posters with discussions, a chairperson presented and discussed each presentation with the presenter and audience. Each presenter had three minutes of presentation time and approximately two minutes of discussion. My poster presentation with discussion was “Cognitive Outcomes of Children with Fetal Antiepileptic Drug Exposure at the Age of 3-6 years — Preliminary Data” during the Child and Developmental Neurology session [©2015 European Journal of Neurology, 22 (Suppl. 1),120-483.] I enjoyed the great opportunity to receive remarks from my colleagues from Europe about our study.

Nino Gogatishvili, MD, is a pediatric neurologist and a PhD student at the Institute of Neurology and Neuropsychology, Tbilisi, Georgia.