Articles – Page 64

Meeting of Headache and Pain Management

By Gallo Diop

Gallo Diop

The first Turkish-African Meeting of Headache and Pain Management was held May 2-6 in Istanbul, Turkey. It was convened by the Turkish Headache Society and organized by Prof. Hayrunnisa Bolay from Gazi University, Ankara. There was major support from the Turkish International Cooperation Agency (TIKA). It was held under the auspices of and with support from the International Headache Society (IHS). In attendence was Alan Rapoport, president; three other board members of the IHS (Hayrunnisa Bolay, Peter Goadsby, Andy Charles); Dimos Mitsikostas, president of the European Headache Federation; Zaza Katsarava, vice president of the European Headache Federation; and Aksel Siva, president of Turkish Headache Society. This scientific neuro-event was attended by almost 70 senior and young neurologists from different African countries (Botsawana, Djibouti, Egypt, Ethiopia, Kenya, Morocco, Nigeria, Senegal, Sudan), Germany, Georgia, Greece, Denmark, U.K., U.S., and the hosting country Turkey, represented by headache experts from universities of Istanbul and of Gazi (Ankara). The key highlights were:

To promote the cooperation and interactions among headache specialists from IHS, headache societies across African countries and Turkey
Aim to educate young leaders and train clinicians to alleviate pain and increase quality of life of people with headache disorders in Pan Africa
To learn more about the current conditions and requirements for headache in Africa
To increase skills for and knowledge about headache and pain management
Leading international faculty to teach about headache and pain
Particularly useful for young neurologists, algologists, senior residents and other medical doctors who care for patients with headache and painful conditions
Membership to IHS will be provided to participants without charge if they are from a country listed as one of the 100 poorest countries in the world.

The meeting covered a wide range of important topics related to headache and pain medicine. The first part of the event ran on the website and involved the theoretical reading of basic papers and live international webinars. The second part of the meeting brought together more than a dozen world-renowned headache and pain experts to teach and mentor the junior physicians from Africa and Turkey. Teaching lectures, interactive sessions, case-based learning and practical interventional courses took place in Istanbul during four days. Professors assistant, professors and residents from African universities took part in lectures, cases presentations and discussions.

Day 1

Day 1 was the opening with welcome statements from Bolay, trustee of IHS and convener of the meeting; Prof. Najib Kissani, neurologists at the of University of Marakesh, Morocco; Rapoport, president of International Headache Society from the University of California, Los Angeles; and Siva, president of Turkish Headache Society, from Istanbul. It was followed by lectures.

Attendees of the first Turkish African Headache and Pain Meeting with IHS staff.

Yohannes W. Woldeamanuel, trained in neurology in Ethiopia (2009-2013), is an IHS scholarship awardee and post-doctoral fellow at the Stanford Headache Program. He reported on ‘’Burden of Headache in Africa and Emerging Challenges.” Woldeamanuel emphasized that headache was the 13th cause of YLDs in 2010; migraine represents 15 percent of Africa’s DALYs. In Africa, it is noted a great number of seconday-type headaches from infectious disorders (WHO, 2011, Atlas of Headache Disorders and Resources in the World; Woldeamanuel, 2014, J. Neur. Sci., 342). He suggested collecting more population data with incidence and prevalence rates, prospective research to increase awareness about pain and headache, and more research about traditional management.

Prof. Kissani reported on ‘’Headache in Morroco.” Even if the ratio is better than many African
countries, there is still great lack of specialists for taking care of pain. Prevalence of migraine in Morocco is estimated to 13 percent. Eighteen percent of patients suffering from headache have at least visited one or many healers (Kissani et al, 2009). Results of research supported by ‘’Lifting the Burden: The Global Campaign to Reduce the Burden of Headache Worldwide” Initiative revealed that 85 percent of the 3,600 interviewed people reported more than one headache last year. About 22.5 percent of them suffered from chronic headaches: tension type (48 percent) and migraine (26 percent). Fifty percent used modern medications (55 percent paracetamol; 10 percent aspirin; cost: $22/month). (Some use of combinations also are reported). Ten percent reported consulting traditional healers.

Hellen Kariuki, professor of physiology at Nairobi University, reported on ‘’Natural Traditional Methods to Overcome Pain.” She reported about the dramatic and rapid change of Africans’ lifestyle. Plants are rich sources of pain management around the world. She described some plants that are used by local tribes as painkillers. She discussed how to benefit from these findings and local oportunities to concretely improve management of pain in developing countries.

Rachid Bezad, professor of gynecolgy (Morocco), discussed ‘’The Contribution of Morocco and Africa to Medicine” and described the health system in Morocco and the opportunities of training and cooperation offered by his country.

Days 2-4

Days 2-4 were dedicated to various lectures, cases presentations and practical courses (such as group learning with patients suffering from headaches and practical training in invasive analgesia techniques, peripheral nerve blocks, trigger point injection and acupuncture). Various thematic topics were developed during exciting lectures: classification and evaluation of headache; how to investigate headache patients in restructed resource-setting; choice of treatment options; migraine headache and its mechanisms and management; chronic daily headache and its neurobiology and differential diagnosis; history taking of headaches and pain by specialists; secondary headaches; headaches attributed to infections; women and headache; headache in children and adolescents; chronic pain disorders; and invasive treatment in headache and pain.

From left to right, Aksel Siva, Mustafa, Dr. Ozge, Pr Ndiaye; Alan Rapoport, Hayrunnisa Bolay, Dr. Uluduz and Gallo Diop.

The meeting was successful in all aspects: organization, scientifc program, and social and friendship environment.

This educational meeting was an excellent opportunity to learn about the diagnosis and management of headache and pain disorders, new developments in the science of headache medicine and the care of headache sufferers.

Through the meeting, everybody has learned more about the current conditions in and requirements for headache in Africa. The meeting will promote the cooperation and interactions among headache specialists from the IHS, various headache societies across African countries, Turkey and worldwide.

It was a contributive additional action for the vision of World Federation of Neurology to promote, via its Africa Initiative, training and exchanges as a leveraging opportunity for trainees and specialists continuing professional development in Africa. This meeting comes also as an additional contribution of Turkish Neurology Society in regard to this aim, because this country is already offering (over three years) two scholarships per year, for a month short-term training in neurology departments of Turkish universities for young African neurologists.

Next plans will aim to educate young leaders and increase skills for and knowledge about headache and pain management to alleviate pain and increase quality of life of people with headache disorders throughout Africa. A short- and long-term plan of action has been discussed and will increase the implication of Turkey, IHS and other specialties to fulfill training needs in Africa, in addition to their various contributions during the Regional Teaching Courses organized by European Academy of Neurology and WFN in Africa for 8 years. For more information, visit www.tahpm.org.

Cognitive Impairment and Parkinson’s Disease Dementia, Second Edition

The medical book publishing industry is challenged nowadays to turn out products quickly and efficiently, lest the rapid dissemination of today’s scientific advances through the Internet render the content of a book out of date on arrival. The second edition of Murat Emre’s “Cognitive Impairment and Dementia in Parkinson’s Disease” has avoided this fate, in large part because of the organizational skill of the editor and his recruitment of the same authoritative thought leaders that contributed to the first edition in 2010. Hence, this continuity of authorship has allowed for a seamless update of the topics covered before.

The co-authors of each of the 22 well- written chapters have handled their assignments with balanced attention to recent discoveries and to the potential for practical application. There is also a healthy regard for the concept that all roads of investigation ultimately lead back to the patient, whose struggle to cope with the twin burdens of progressive motor and cognitive impairment in Parkinson’s disease (PD) has not been significantly helped by a true breakthrough in treatment since the introduction of levodopa in the 1960s. The failure to develop more effective symptomatic or game-changing, disease-modifying therapies has been one of the great disappointments of modern-day clinical research despite years of valiant effort.

As Dr. Emre observes in his elegant introduction, cognitive impairment as an essential feature of PD was mostly unrecognized by James Parkinson in his essay on the Shaking Palsy (1817) because lack of treatment doomed its victims to a severe physical disability and a shortened lifespan. The stark reality of cognitive impairment in advanced PD became apparent only after the remarkable benefit of levodopa enabled people with PD to function better physically and thereby live longer. Well-designed, long-term cohort studies in the early part of this century revealed not only the shocking news that 70-80 percent of people with PD would develop dementia as they aged and progressed, but also that subtle cognitive abnormalities, particularly in executive function, were prevalent in a sizeable minority at early stages of the disease.

This book thoughtfully reviews the important developments in clinical and basic research of the last two decades, and it highlights new and refined information that has emerged in the five years since the first edition was published. References are up to date as of 2013 with a sprinkling of 2014, the year of publication. Early chapters on epidemiology, natural clinical history and neuropsychological assessment are comprehensive and succinct. The differential diagnosis of dementia in the setting of parkinsonism can be difficult, but the neuropsychological profile of cognitive dysfunction in PD, showing the typical executive, visuo-spatial, attention and memory deficits of PD sets it apart generally from Alzheimer’s disease, wherein disturbances of memory and language are the classic hallmark findings.

The histopathology of PD is the focus of several chapters, which emphasize the near unanimity of opinion that misfolded alpha-synuclein is the key molecular abnormality and the main component of the signature intracytoplasmic inclusion Lewy body. The clinical and pathological continuum of Parkinson’s disease dementia (PDD) and dementia with Lewy bodies (DLB) is also effectively explained, including elements of the debate over the contribution of the plaques and tangles of Alzheimer disease (AD) as a minority component of PDD/DLB pathology. Current evidence suggests (without being close to consensus) that DLB, which is defined arbitrarily as dementia occurring within a year of the onset of parkinsonism, has a pathological substrate of alpha-synuclein and Alzheimer plaque (sans tangles), whereas the substrate for PDD — dementia beginning more than a year after the onset of parkinsonism — is more likely to be alpha-synclein alone. Another chapter covers the neurochemistry of PD and PDD and the central relevance of the well-known deficiencies of dopamine and acetylcholine as they relate to the evolution of dementia.

The ferment in biomarker research — a relatively new phenomenon with great promise for predicting cognitive outcomes in the preclinical and early clinical stages of PD and for identifying subgroups for targeting in clinical trials of new therapies — is included in several chapters. Also since the first edition, official criteria for Parkinson dementia and mild cognitive impairment (MCI) in PD have been established under the auspices of the International Parkinson and Movement Disorder Society, using the model of the Petersen criteria for pre-Alzheimer MCI. Several chapters on recent findings in brain imaging are well executed, although it could be argued that all imaging should have been condensed into a single chapter. One of the hottest areas of research in the basic science of PD is the rapidly expanding field of Parkinson genetics. The chapter on the genetic basis of PDD is excellent and comprehensive.

Ian McKieth and Murat Emre join forces in the pentultimate chapter to discuss management of PDD and DLB, and the result is a masterful presentation of a humane message about the time-honored clinical fundamentals of taking a good history, listening empathically and caring long term for the patient and family.

Finally, the closing brief chapter by John Hardy is a sobering statement of how far we still must go before truly meaningful treatment comes into view. He acknowledges the substantial “incremental” progress in molecular biology and genetics of the last decade. The identification of numerous potentially causative somatic and mitochondrial genetic loci in some patients clears some of the fog around pathogenesis, although these advances apply only to a small fraction of the much larger universe of patients with PD, for whom genetic markers are nowhere to be found. Moreover, it is far from clear which pathogenetic pathways are influenced by alterations in the genome or, perhaps more important, how the growing number of these changes interact to produce disease and which ones are the most critical in the pathogenetic cascade. In short, the goal of a cure is “still beyond the near horizon.”

“Cognitive Impairment and Dementia in Parkinson’s Disease” is a solid achievement. The authors have created an informative and useful compendium of the universally accepted wisdom as well as the latest more controversial advances in the field. It is easy for an armchair reviewer to find fault with even the best publications, but there are a few minor shortcomings here. First, the list of contributors should have included the specific disciplines of each person in addition to their institutional affiliations. Second, some of the references at the end of each chapter were duplicated or unrelated to the citations in the text. Third, redundancy across chapters was generally appropriate for emphasis of the most important concepts and facts, but more careful editing could have minimized useless redundancy. Fourth, the importance of impaired olfaction in preclinical PD and the voluminous body of research devoted to it was all but ignored; olfaction received only a brief paragraph in one of the early chapters and no attention was paid in the chapter on biomarkers. And fifth, there was no mention of the so-called “prion hypothesis” that has been invoked in the last several years to explain how alpha-synuclein pathology spreads rostro-caudally throughout the brain as the disease progresses and leads to the development of dementia. These small quibbles hardly detract from the many assets of this fine contribution to the growing shelf of literature on one of the most pressing problems in clinical neurology.

WHO Global Dementia Strategy: Implications for Neurologists

Raad Shakir

In 2006, “Neurological Disorders: Public Health Challenges” was published by the World Health Organization (WHO), with WFN participation¹. It is clearly stated: “There is ample evidence that pinpoints neurological disorders as one of the greatest threats to public health.” Dementia was well covered as a major challenge. Rita Levi-Montalcini, Nobel Laureate 1986, wrote the foreword to the book. She stated: “The burden of neurological disorders is reaching a significant proportion of countries with a growing percentage of the population over 65 years old.”

Neurologists across the world deal with various disorders of the brain with vast numbers of individuals affected. For example, every year, 15 million people worldwide suffer a stroke, nearly 6 million die and 5 million are left permanently disabled. Every six seconds a stroke kills someone. Stroke claims more than twice as many lives as AIDS. In fact, stroke continues to be responsible for more deaths annually than those attributed to AIDS, tuberculosis and malaria combined. The burden of stroke now disproportionately affects individuals living in resource-poor countries. Epilepsy affects 50 million people across the world, and seven out of 10 receive no medication. Parkinson’s disease affects 6.3 million; MS affects 2.5 million; and, in addition, neurologists deal with monumental numbers of those complaining of headaches and all other disorders affecting the nervous system. Moreover, the WFN has always applied the principle that there is no health without brain health.

Figure 1. Jeremy Hunt, MP. United Kingdom, Secretary of State for Health (right) and Raad Shakir, President WFN

The first WHO ministerial conference on Global Action Against Dementia was held March 16-17, 2015, in WHO headquarters in Geneva. More than 400 participants attended. The conference was hosted by the WHO and organized by the UK government and the OECD. This is an important milestone in the global action on dementia. One would have thought that neurology would be one of the cornerstones of the global action both in the early detection, confirming a devastating diagnosis, participating in research into diseases of the brain causing dementia and being part of the ambition to have a cure by 2025. It is for all these reasons the World Federation of Neurology representing more than 45,000 neurologists worldwide was delighted to attend and express its views.

Neurological disorders, whether affecting the central or peripheral nervous system, are the major cause of death and disability. The aim of the WFN is to have more training for medical graduates in the field of neurology so that the best possible service can be provided to those afflicted with neurological diseases. However, the inclusion of neurological diseases in the UN NCD declaration of 2011 is only marginal (Item 13bis) in spite of the significance and the devastation caused by diseases of the nervous system². In the WHO departmental structure, neurology falls under the department of mental health and substance abuse, which seems no longer applicable. The creation of a WHO department of brain health, in order to encompass all forms of dementia, neurodegenerative noncommunicable diseases and the whole of mental health and neurology/neurosurgery is long overdue.

The World Alzheimer Report 2013³ rightly emphasized the complexity and difficulties encountered. Perhaps one missing element in its overarching, supporting and research recommendations is that governments should do their best to have specialists in the field of brain diseases involved early in the diagnosis and management of dementia. Moreover, those neurologists with scientific interests should be the ones working in translational clinical research aiming at discovering a disease modifying therapy or ultimately a cure. Just as we cannot underestimate the role of neuroscientists in this endeavor, that of clinicians has to be equally important. Advances in early diagnosis and clinical trials have been galloping over the past few years⁴.

As for the recent Ministerial Conference on Dementia, U.K. Secretary of State for Health Jeremy Hunt gave an eloquent speech on combating dementia. (See Figure 1.) This is most appropriate as the U.K. was the sponsor of the G8 Declaration on Dementia in December 2013⁵. The establishment of the World Dementia Council and the appointment of the World Dementia Envoy followed.

The two-day deliberations of the topic were most informative, and many expressed the view that a “pandemic” is staring the world in the face. The fact that the numbers will triple from the current 47.5 million by 2050⁶ is frightening, and work needs to be very quick and productive. However, the difficulties of producing new drugs in the field of neurodegenerative disorders were emphasized and the complexities of various causes of dementia are clear to see. The only plausible way forward for research is to combine work on neurodegenerative disorders and look at all possible causes and their pathologies.

The G8 global action against dementia is committed to the “ambition to identify a cure or a disease modifying therapy for dementia by 2025.” The WHO ministerial conference was an extension and a report on the endeavor so far. The WHO and its partner organizations are now moving to confront this most threatening of neurological diseases.

The role of neurologists alongside psychiatrists collaborating with primary care physicians cannot be underestimated. This way, we will create a closely knit group working with patient organizations and governments to try and achieve the G8 ambition to deal with the complexity of all the causes of dementia. Training more young medical graduates in the field of nervous system diseases will create subspecialists who can make an accurate diagnosis and follow the proper pathway in recruiting individuals affected by various neurodegenerative conditions in the correct trials if we are going to achieve the ambition expressed in the G8 declaration. Time and direction are of the essence.

Shakir is the president of the World Federation of Neurology.

References

Neurological Disorders: Public Health Challenges. WHO 2006.
United Nations General Assembly. 2011 High-level Meeting on Prevention and Control of Non-communicable Diseases. http://www.un.org/en/ga/ncdmeeting2011/ (accessed April 24, 2015)
World Alzheimer Report 2013. Journey of Caring. An Analysis of Long-term Care for Dementia. Published by Alzheimer’s Disease International (ADI) London. September 2013.
Bateman R. Alzheimer’s Disease and Other Dementia; Advances in 2014. Lancet Neurology; 2015; 14:4-5.
UK Department of Health. G8 Dementia Summit Declaration. https://www.gov.uk/government/publications/g8-dementia-summit-agreements/g8-dementia-summit-declaration.
The Lancet Neurology. WHO Takes up the Baton on Dementia. Lancet Neurol 2015; 14:455.Editorial.

The Diamond and the Rose

By Richard Peatfield

Richard Peatfield

During the last 40 years, the world of headache has been blessed with two remarkable men: Dr. Seymour Diamond and Dr. Frank Clifford Rose. They have both recently published autobiographies. Rose’s autobiography is, of course, posthumous following his death in 2012, while Seymour, just the elder, is still enjoying his retirement at the age of 89.

Although living and working in different environments on different continents, Diamond and Rose have striking similarities over and above their lively personalities. They were born within 16 months of one another of Jewish immigrant stock. Rose’s parents settled in the East End of London after getting married and having two children in Romania. Rose was the youngest of seven surviving siblings.

Diamond’s parents, by contrast, had arrived in Chicago as children from Slovakia and from the Ukraine. He was the youngest of their four children. Both had that combination of inherent talent and industry that enabled them to move out of their original backgrounds.

I think it is fair to say that Rose’s path was advantaged by the grammar school and the university system of his time in Britain, while Diamond grew up in the challenging environment of wartime America. Never is this more clear than in their early clinical training. Rose was able to do all of his jobs within London, whereas Diamond tells the tale of his in-laws driving him, his new wife and all of their possessions from Chicago to Arkansas and then to Ohio every year or so.

Both spent the bulk of their careers as practicing physicians with interests in headache, though Diamond was never a board-certified neurologist as he had been accredited in family medicine and had not done a residency program in neurology.

Both set up dedicated migraine clinics. Rose’s clinic is dedicated to Princess Margaret, while Diamond’s bears his own name. Both wrote and edited a large numbers of books and conference proceedings.

Both were superb administrators and used their talents in a wider field. Rose was the more international, playing a major role in the evolution of the International Headache Society and serving as secretary treasurer general of the World Federation of Neurology.

Diamond, in contrast, devoted much of his energy to the inpatient and outpatient facility he established in Chicago and developed a nationwide reputation as a physician “who cared.” He was one of the first to try tricyclic antidepressants in headache patients and was the leading light in many of the trials of drugs that are currently part of the every physician’s drug armamentarium.

Diamond played a major role in the evolution of the American Association for the Study of Headache and was its chief executive for many years. His autobiography makes it clear that his relationship with the neurological establishment was often fraught. Nevertheless, it is a tribute to his diplomatic skills that the American Headache Society (as it is now called) covers such a broad spectrum of practitioners from neurologists and pediatricians to physiotherapists, psychologists and other colleagues. He also initiated the influential patients’ own National Migraine (now Headache) Foundation.

Rose, in contrast, was more of a neurological polymath, with interests not only in headache but also in motor neurone disease, Parkinson’s disease and stroke. He was perhaps more dependent on his junior colleagues on both the clinical and academic fronts. Diamond’s concentration on one symptom attracted devoted patients from all over the continent. Both were renowned for their approachability.

Diamond’s autobiography was written in conjunction with a medical journalist, in the third person in somewhat more popular style, with many fascinating personal details, including his prowess at Bridge and his innocent dealings with the local mafia. Rose wrote his in the first person, and his voice and characteristic energy come through.

They were both devoted to their wives and children. Diamond and his wife, Elaine, had three girls, of whom one now runs the eponymous Clinic in Chicago after his retirement. Rose and his wife, Angela, had three boys, all established in careers away from medicine.

Both autobiographies give fascinating insights into medical training during and immediately after World War II, as well as into the evolution of the clinical and academic world of headache on each side of the Atlantic. Both are fitting tributes to two outstanding men.

The Headache Godfather: The Story of Dr. Seymour Diamond and How He Revolutionized the Treatment of Headaches By Seymour Diamond and Charlie Morey. Skyhorse Publishing, Inc., New York 2015 ISBN-10: 1629145386 $24.95

Autobiography: By Any Other Name By Clifford Rose Privately printed 2014 [Copies may be available for £12 + p&p. Expressions of interest should be made to r.peatfieldimperial.ac.uk]

Neurodevelopmental Disorders in India: From Epidemiology to Public Policy

By Donald Silberberg, MD

Donald H. Silberberg

Two remarkable meetings took place in March in Durban, South Africa. On March 25, the National Institutes of Health (NIH) (U.S.) convened a workshop on implementation science, that is, how to use research findings, whether epidemiologic, basic science, clinical or economic studies, to influence public policy. In a previous editorial, I referred to this as “translational research,” the concept of moving from research data to utilization.

Investigators supported by the Fogarty International Center (FIC), NIH, presented the results of studies that are beginning to achieve this, in Burkina Faso, Democratic Republic of the Congo (DRC), Nigeria, South Africa, Uganda and Zambia. Discussion centered on both impediments in achieving implementation, and on what has worked in some locales. All of the presenters and discussants agreed that further efforts are needed to develop approaches that will use research findings to improve neurologic and psychiatric health in every country, and the need to provide this information to all investigators in low- and middle- income countries. Interested investigators should watch for future notices from the FIC.

The NIH workshop was followed by the 12th International Conference of the Society of Neuroscientists of Africa (SONA). In addition to basic and clinical neuroscience presentations by invited speakers from Italy, South Africa, Spain, Sweden, the U.K. and the U.S., investigators from all regions of Africa presented 157 posters and platform talks. At least half of these dealt with clinically relevant topics, ranging from studies of trypanosomiasis in the DRC, to pain following traumatic spinal cord injury in Zimbabwe. The abstracts can be viewed at www.sona2015.com. The next meeting, in 2017, will be held in Uganda. This meeting is clearly designed to include clinical neurologists as well as neuroscientists.

WFN at AAN Congress 2015

By Raad Shakir

WFN/AAN leadership meeting 67th Annual AAN Congress, Washington, DC, 2015. From left to right, Gallo Diop, Ralph Sacco, Terence Cascino, William Carroll, Tim Pedley, Catherine Rydell, Raad Shakir, Riadh Gouider, Steve Lewis and Wolfgang Grisold.

The AAN is the largest single neurological association in the World Federation. The relationship goes back to the inception of the WFN. The WFN would not have existed without the generous assistance of $126,000 from the National Institutes of Health. This was only possible through the efforts of Dr. Pearce Bailey Jr., the first secretary general of the WFN and the second president of the AAN.

The AAN meeting this year was in Washington, DC, attended by 13,000 with a significant percentage of international delegates. There were 2,678 abstracts. The depth and breadth of the topics and the availability of teaching material is impressive.

Annual meetings of the leaderships of both organizations have become a tradition to discuss bilateral relations and international affairs. This year, there were several issues on the agenda, including joint support for African neurologists and full support for the burgeoning Pan American Federation of Neurological Societies bringing together Latin American neurologists. This organization is to encompass all neurological associations in Latin America and represents the Latin American region as one of six WFN regional organizations.

There was discussion on the creation of a Ted Munsat Award for Training and Education. The late Dr. Munsat was a past president of the AAN and chaired the WFN education committee for many years. There was agreement on creation of the fund, and this will be followed by more detailed discussions in the next few months.

The WFN last year created a regional liaison committee chaired by the AAN President Dr. Tim Pedley. This committee met and heard presentations from the six regions of the WFN. Closer collaboration between regions is the purpose of this committee and this is being achieved.

There is no doubt that neurological needs in Africa are paramount, and this was reflected in the leadership meetings and a special Pan African meeting, which was convened by the AAN and attended by stakeholders, including the leaderships of the two organizations and others including Dr. James Bower, Dr. Farah Mateen (chair, Global Health section) and Evelin Sipido representing the European Academy of Neurology with its special interest in annual courses for African neurologists.

Prof. Gallo Diop (Senegal) eloquently presented the needs and offered solutions with measures to ease the huge deficiency of neurologists in Africa. A tentative plan to train neurologists in Africa was discussed with the aim of opening four training centers, two in Francophone and two in Anglophone countries. Rabat and Cairo are already in operation, to be followed by Dakar and Cape Town.

The long-standing partnership between AAN and WFN continues from strength to strength. The AAN and the publisher donate the hard copies to the WFN, and the WFN distributes the course globally. It is now used in 47 countries. Dr. Steve Lewis is the editor and is a WFN co-opted trustee.

At the end of the meeting, Dr. Terence L. Cascino took over as president of the AAN, and Dr. Ralph L. Sacco was elected as president-elect.

No report on the 67th Annual Meeting of AAN could be complete without a special mention of the erudite lecture given by outgoing president Dr. Tim Pedley (link below). The title was “Moving the Academy Forward: Challenges and Opportunities,” and the talk was mesmerizing. His views on neurology as a nonprocedural specialty were spot on. Although the content understandably relates to the U.S. health care system, there are lessons for us all across the world. Indeed, our spectrum and capabilities have markedly improved but the challenges have also grown. The shortage of neurologists in the face of an aging population with increasing numbers of those affected by neurodegenerative diseases is frightening, and in a way it is now recognized by governments as the World Health Organization has emphasized in a recent meeting on dementia that this condition and its cost will cripple world economies in 30 years.

The close ties binding the WFN and the ANN will only grow stronger over the coming years.

https://www.youtube.com/watch?v=ya6mJ3rc2Gs&feature=youtube?

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A New Name & Diagnostic Criteria

Maggie McNulty

In March 2015, a report from the Institute of Medicine (IOM) was published in the Journal of the American Medical Association to redefine the illness known as Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS).

Over the years, clinicians and researchers have developed different diagnostic criteria for ME and CFS; however, the two terms describe conditions with similar symptoms. In the World Health Organization’s “International Classification of Diseases,” 10th Revision, both ME and CFS are coded the same and classified as disorders of the nervous system (ICD G93.3). The term “benign myalgic encephalomyelitis” was first used in the 1950s in London when describing an outbreak in patients who experienced a variety of symptoms, including “malaise, tender lymph nodes, sore throat, pain and signs of encephalomyelitis.”

The cause was never found, but it appeared infectious in etiology, and the term “benign myalgic encephalomyelitis” was used to reflect “the absent mortality, the severe muscular pains, the evidence of parenchymal damage to the nervous system and the presumed inflammatory nature of the disorder.” Then in 1970, two psychiatrists reviewed reports of 15 of these outbreaks and concluded that the outbreaks “were psychosocial phenomena” caused by mass hysteria or altered medical perception of the community.

However, the idea that the condition was psychogenic in origin was refuted by Dr. Melvin Ramsay. In 1986, he was the first to publish diagnostic criteria for ME and, at this point, the term “benign” was dropped as the disease often was severely disabling for those patients afflicted. Around the same time, in the mid-1980s, there were two outbreaks of an illness that resembled mononucleosis characterized by “chronic or recurrent debilitating fatigue and various combinations of other symptoms, including sore throat, lymph node pain and tenderness, headache, myalgia and arthralgias.” This illness was at first linked to the Epstein-Barr virus (EBV); however, further research ruled out this as the cause, and, in 1988, the term “chronic fatigue syndrome” was coined by the Centers for Disease Control and Prevention (CDC).

ME/CFS is characterized by symptoms of profound fatigue, cognitive dysfunction, sleep abnormalities, autonomic manifestations, pain and other symptoms that are worsened by any type of exertion. The syndrome affects women more than men with an average age of onset of 33 years with a wide range of distribution ranging from 10 to 77 years old.

ME/CFS is a common disorder that is currently estimated to affect 836,000 to 2.5 million Americans. Despite the prevalence of this disorder, less than one-third of medical school curricula and only 40 percent of medical textbooks include information regarding this syndrome. This likely contributes to delays in diagnosis time for these patients (e.g., 29 percent of patients report symptoms for >5 years prior to receiving a diagnosis), and it is estimated that 84 to 91 percent of people with this condition have not yet been diagnosed.

Table1 There is significant economic burden associated with this condition as one quarter of patients are bed- or house-bound at some time during their illnesses. ME/CFS patients have been found to be more functionally impaired than patients with other disabling illnesses, such as diabetes mellitus, congestive heart failure, hypertension, depression, multiple sclerosis and end-stage renal disease. Unemployment rates range from 35 to 69 percent in these patients. ME/CFS patients have loss of productivity and high medical costs that lead to an estimated economic burden of $17 billion to $24 billion yearly.

In general, ME/CFS is a condition that is poorly accepted as its pathophysiological mechanisms are poorly understood, and many contest the characteristics needed to make a diagnosis. There continue to be many misconceptions regarding ME/CFS, including that it is a psychogenic illness. Many times, patient symptoms are met with skepticism or even dismissal. After diagnosis, many people with ME/CFS report being subject to hostile attitudes from their health care providers. The cause of ME/CFS is currently unknown; however, symptoms may be triggered by different infections or other prodromal events, including “immunization, anesthetics, physical trauma, exposure to environmental pollutants, chemicals and heavy metals and, rarely, blood transfusions.”

The IOM was asked by the Department of Health & Human Services, the National Institutes of Health, the Agency for Health Care Research & Quality, the CDC, the Food & Drug Administration and the Social Security Administration to convene an expert panel to review the evidence basis for ME/CFS. This was a comprehensive committee of 15 members that convened in September 2013 and took into account data from patients, clinicians and researchers while also reviewing almost 1,000 public comments. This was followed by a comprehensive literature review to help identify new diagnostic criteria to be used by clinicians. Based upon their work, a new name was recommended to replace ME/CFS. Previous studies have shown that the term “chronic fatigue syndrome” can negatively affect patients and medical professionals’ perceptions of the illness and trivialize the seriousness of the disease. “Myalgic encephalomyelitis” is also inappropriate as there is no evidence of encephalomyelitis in these patients, and myalgia is not a core symptom of this disease. The new name that has been recommended for use is systemic exertion intolerance disease (SEID); this new name is felt to encompass the central characteristic of the disease: the fact that exertion of any kind can negatively affect patients in multiple different organ systems.

A new set of diagnostic criteria was also developed by the group with the intent to ease the process of making a diagnosis of ME/CFS (SEID) and hopefully, decrease the time to make a diagnosis for many patients. The new diagnostic criteria that were developed by the IOM committee are detailed in Table 1. The core features include: fatigue and impairment, post-exertional malaise (PEM) and unrefreshing sleep. All of these features need to be present for one to be diagnosed with ME/CFS (SEID).

Fatigue as defined in the dictionary is “weariness from bodily or mental exertion.” Sufficient evidence has been found that fatigue is profound in ME/CFS (SEID). Dramatic examples of reports of fatigue in patients with ME/CFS (SEID) include feeling “too exhausted to change clothes more than every 7-10 days” and experiencing “exhaustion to the point that speaking is not possible.” More commonly, patients report fatigue as “exhaustion, weakness, a lack of energy, feeling drained and an inability to stand for even a few minutes.” The fatigue must be associated with a significant reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social or personal activities. This degree of fatigue must also persist for more than six months.

Another core symptom, post-exertional malaise (PEM), is found consistently in patients with ME/CFS (SEID) and felt to help distinguish it from other conditions. A patient’s symptoms worsen after exposure to physical or cognitive stressors that were previously well tolerated prior to onset of the disease. Descriptions provided by patients after an exertional task include “crash,” “exhaustion,” “flare-up,” “collapse,” “debility” or “setback.” PEM may occur within 30 minutes of an exertional task or be delayed up to seven days after an exertional task with the duration of PEM lasting hours to months. In studies comparing ME/CFS (SEID) patients with healthy controls, 86 percent of patients report minimum exercise makes them tired compared to 7 percent of controls. Additionally, 85 percent of ME/CFS (SEID) patients report that they feel drained after mild activity compared to 2 percent of healthy controls.

The third and final core symptom is unrefreshing sleep for which 92 percent of ME/CFS (SEID) patients report compared to 16 percent of controls. The typical sleep-related symptoms described by ME/CFS (SEID) patients include difficulty falling asleep, frequent or sustained awakenings, early-morning awakenings and nonrestorative or unrefreshing sleep (persistent sleepiness despite adequate duration of sleep). Primary sleep disorders such as sleep-disordered breathing, restless legs syndrome and narcolepsy should be considered and evaluated for if clinically indicated as treatment of these disorders can be effective in reducing or relieving symptoms of unrefreshing sleep. However, a polysomnogram is not required to diagnose ME/CFS (SEID). Currently, there is no strong evidence to identify ME/CFS (SEID)-specific sleep pathology despite some studies revealing differences in sleep architecture in a subset of ME/CFS (SEID) patients compared to healthy controls.

In addition, there are two supportive criteria included in the new definition, of which one of two is required to be present to meet a diagnosis of ME/CFS (SEID). These include cognitive impairment and/or orthostatic intolerance. Common features of cognitive impairment that are seen in ME/CFS (SEID) include complaints of problems remembering, difficulty expressing thoughts, difficulty paying attention, slowness of thought, absent-mindedness and difficulty understanding. It is suggested that slowed information processing plays a central role in the cognitive impairment associated with ME/CFS (SEID). This deficit can lead to significant disability that results in loss of employment as well as functional capacity in social environments. Neuropsychological testing has found that patients with ME/CFS (SEID) display deficits in working memory compared with healthy controls with reduced verbal and visual memory being the most consistent finding. The second feature, orthostatic intolerance, refers to worsening of symptoms upon assuming and maintaining an upright position. Symptoms are typically improved but may not be alleviated by lying down or elevating their feet. There is sufficient evidence that indicates a high prevalence of orthostatic intolerance in patients with ME/CFS (SEID) based on bedside orthostatic vital signs, tilt table testing or by patient reported worsening of symptoms with standing in day-to-day life.

The committee also described additional frequent findings found in ME/CFS (SEID) patients, which include pain, immune impairment, infection and miscellaneous symptoms. Pain was found to be common in patients who had ME/CFS (SEID) with complaints of headaches, myalgias and arthralgias being most common. There was sufficient evidence found that supported the finding of immune dysfunction in these patients with data revealing poor NK cell cytotoxicity that correlated with illness severity in ME/CFS (SEID). This finding, however, is not specific to ME/CFS (SEID). Additionally, there was evidence that ME/CFS (SEID) can occur after infection with EBV, but there was not sufficient evidence to conclude that all cases of ME/CFS (SEID) are caused by EBV. Less frequent symptoms that were found in patients with ME/CFS (SEID) include gastrointestinal impairments, genitourinary impairments, sore throat, painful or tender axillary/cervical lymph nodes and sensitivity to external stimuli (e.g., foods, drugs, chemicals).

In summary, ME/CFS (SEID) is a serious, chronic, complex and systemic disease that often significantly limits the day-to-day activities of those affected. It is characterized by a prolonged, significant decrease in function; fatigue; post-exertional malaise; unrefreshing sleep; difficulties with information processing, especially under time pressure; and orthostatic intolerance. A thorough history, physical examination and targeted evaluation are necessary and can be sufficient to make a diagnosis. Despite the high prevalence of this condition with associated high economic burden, little research has been conducted to study the etiology, pathophysiology and effective treatment of this disease. Moving forward, it will be vital to distinguish this disease against other complex fatiguing disorders as the majority of previous research has compared ME/CFS (SEID) patients to healthy controls. Additional research into ME/CFS (SEID) is essential for further progress to be made, and the term “chronic fatigue syndrome” should no longer be used due to the associated stigma, which often precludes patients from receiving appropriate care. It is critical that we do our part to help stop the stigma associated with this condition and provide optimal care of these patients.

Maggie L. McNulty is an assistant professor at Rush University Medical Center, Department of Neurological Sciences.

Neurology Practice: The Fundamentals

Raad Shakir

While visiting various countries and looking at neurology practice, I became convinced that the fundamentals are by and large the same. The work neurologists perform in their daily practice is duplicated across the world. I have been privileged as WFN president to be able to attend annual congresses of neurological societies in countries as diverse as China, Macau, India, Sri Lanka, Morocco, Egypt, Sudan, Saudi Arabia, United Arab Emirates, Turkey, Albania (Figure 1), Chile and most recently Norway (Figure 2).

The diversity is clear. As the health care systems are so different, it makes one wonder if the practice is therefore affected. There are noticeable differences. The organization of patient’s care is either through state, insurance funding, self-pay or on many occasions a combination. As we know from the Neurology Atlas 2004, the lower income economies have a much higher probability of self-pay provision of care than in richer countries (Figure 3). This puts a huge slant on the availability of neurological care and the difficulty in accessing specialist opinion.

Figure 1. Left to right. Antonio Federico (Sienna Italy), Jera Kruja President Albanian Society of Neurology, Raad Shakir (WFN President), Mira Rakacolli Dean Faculty of medicine Tirana University.

If we start with numbers of patients seen by a neurologist in a working day, in many instances, there are no outpatient appointment systems and patients appearing in clinics have traveled long distances. On many occasions, this involves relatives bringing patients and expecting hospital admission. This may well be needed on many occasions, as the neurological status is so advanced, patients need to have inpatient care. Neurologists and neurology trainees work in crowded clinics making basic decisions, and the more detailed assessments will be carried out when a patient is admitted to a hospital bed. This practice is the only way to cope with large outpatient loads, which would be unthinkable in other settings. The reasons are lack of neurologists and facilities for a more time-requiring approach at outpatient clinics. The other perhaps related reason is the centralization of neurological care in big cities. Neurologists in such settings make quick decisions on the facts as they see them. In nearly all patients, there are no written referral letters of background information; it is quite admirable to see real coalface practice with decisions made on few available facts as they present.

Figure 2. Left to right. Anne Hege Aamodt President of Norwegian Neurological Association, Olga Bobrovnikova Renowned Pianist, MS sufferer and European Brain Council Ambassador, Raad Shakir WFN President, Hanne F Harbo Head Norwegian Brain Council. (photographer, Lise Johannessen Norwegian Medical Society).

In other settings, there is huge utilization of day care facilities for performing a battery of investigations within a working day. In such settings, the care is supplemented by the availability of infusion suites, EEG/video telemetry, procedures such as lumbar punctures, muscle and nerve biopsies, detailed imaging and neurophysiological assessments, which can be performed within a day care setting. This is only possible in the presence of a well-developed administrative support and the involvement of supporting services such as radiology, laboratory and advanced nursing skills.

The relationship of neurology to general medicine is strong in many settings as the acute care at emergency departments is provided by general physicians, emergency care specialists and in other settings, neurologists are available in the emergency departments for onsite consultation and further care. This has been made more available with the introduction of Hyper Acute Stroke Units (HASUs). In some settings, patients with suspected stroke are brought to emergency departments where they would be assessed by neurologists for their suitability for thrombolysis. This is a huge advance in stroke care and has the other advantage of putting neurology services at the forefront of acute medical care. The increase in the workload requires increasing staff numbers, and this is possible in some settings but not others. The success of thrombolysis treatment in acute stroke depends on pre-hospital and in-hospital health workers. Figure 4 shows the acute stroke team at Oslo University Hospital in Norway (courtesy of Professor Espen Deitrichs).

Figure 3. Bars to the left show that 84.2% of funding of Neurological care in Low income countries is out-of-pocket. Neurology Atlas WHO/WFN 2004.

Many other neurological services are struggling with the new practice due to several factors apart from finance; logistics and the availability of a high-powered ambulance and paramedic services lead many to be behind in their ability to provide modern care. The decision-making process of a paramedic in perhaps the two most important non-traumatic emergencies, i.e. heart attack and brain attack, lead to a major lack of highly trained individuals for this type of work. In many countries, this shortage of staff is leading to inferior care.

The multidisciplinary approach to care with integrated multispecialty teams in acute care delivery with availability of interventional neuro-radiologists is limiting the ability for neurology to deliver. In many instances, the availability of endovascular treatment of acute stroke is severely limited by lack of facilities. Using telemedicine in some locations has made a great difference in acute provision of neurological care. Acute thrombolysis is being achieved utilizing telemedicine in some locations.

Figure 4. The Pre and In hospital acute stroke team at Oslo University Hospital in Norway (courtesy of Professor Espen Deitrichs).
Photo: Fundamentals_fig5.jpg

The care for neurological patients with long-term needs is crucial, and this is not really available unless there is some sort of health care system, which allows regular follow-up services. In many countries, this is possible but in others it is not. The recent WHO executive board resolution on epilepsy on Feb. 2, 2015 (http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_R8-en.pdfs) is a good example on the lack of neurological long-term care and the continued existence of a massive treatment gap. This declaration should be translated to actual on the ground care provision. Continued support for conditions such as epilepsy, parkinsonism, dementia, multiple cclerosis, migraine and genetically determined conditions and many others remain woeful. The WHO can inform governments of the availability of “cheap” anti-epilepsy drugs as an example, but neurologists should aim to provide optimal up to date care for their patients. The premise that some treatment is better than nothing, although understandable and reflects current status, is not an ultimate goal to aim for. Neurologists should endeavor to put brain health at the top of the political agenda. However, we are delighted that the WHO executive has put brain health at the top of the agenda as it aims to reduce the treatment gap when, as an example, we know that seven out of 10 patients with epilepsy do not receive regular medication at all. I am sure that I speak of behalf of all neurologists who would not accept second- or even third-tier level of management for their patients, but would approve of the WHO executive declaration as a first step in the right direction.

Figure 5. CME Continuum utilization in 45 countries up-to August 2014. WFN six monthly report August 2014. Helen Gallagher WFN CME coordinator.

Returning to the fundamentals of neurology, it is my conviction that neurologists from all over the world offer their services in basically the same manner if given equivalent circumstances. This is clear from observing training programs and the eagerness of young trainees to learn. The knowledge base is nearly universal. The WFN is in a position to see this when we administer the American Academy of Neurology Continuum CME program to 45 countries. This is happening today in war-ravaged countries and in those with low income to the degree of the existence of real malnutrition. The evaluations sent by the WFN tutors are a shining testament to the eagerness and the excellent performance of trainees from various backgrounds across continents (Figure 5).

To end on a positive note, neurology is prospering and need continuous momentum to keep brain health at the top of the health agenda of decision-makers.

Raad Shakir
London UK

Redefining Recovery from Aphasia by Dalia Cahana-Amitay and Martin Albert

BOOK REVIEW

By Murray Grossman, MD
Cahana-Amitay D and Albert M (2015)
Redefining Recovery from Aphasia
New York: Oxford University Press
281pages, with preface and index

Language is an incredibly complex process. Yet we speak and under- stand effortlessly in order to live our lives daily. The disruption of language following a stroke is a devastating blow to an individual’s day-to-day functioning because of our extreme dependence on this modality of communication. Aphasia is extraordinarily costly to individuals and to society. Nevertheless, aphasia following a stroke is common.

Despite the high cost and common occurrence of aphasia, progress in developing successful treatments for aphasia has been slow. It has proved difficult to demonstrate that traditional speech and language therapies are better at improving communication skills than friendly social interactions. Thus, novel approaches to treatment and recovery from aphasia are desperately needed.

In this timely book, Cahana-Amitay and Albert outline an alternate approach to recovery from aphasia. Their perspective is based on the view that language is not a modular entity, but instead interacts with multiple facets of non-linguistic cognition. This includes domains such as executive functioning, visual processing, attention, memory, emotion and praxis. In turn, the authors observe that brain regions involved in language are highly interconnected with brain regions subserving these other aspects of cognition. The authors coin the phrase “neural multifunctionality” to characterize this multifaceted clinical and functional neuroanatomic approach to language.

In nine chapters, Cahana-Amitay and Albert lay out their approach to language and recovery from aphasia. The first chapter situates their volume in the context of the extensive literature describing recovery from aphasia. The second chapter outlines the authors’ multifunctionality approach to the functional neuroanatomy of language following stroke. In subsequent chapters, Cahana-Amitay and Albert discuss the relationships between language and each of the other domains of cognitive functioning that interact with language. Each chapter defines a domain of cognition, reviews cognitive aspects of the domain and its interaction with linguistic functioning, and then defines the functional neuroanatomy of the cognitive domain. Treatments for aphasia that focus on each domain of cognition are then reviewed.

In the chapter concerned with executive functioning, for example, the authors consider the ways in which language and executive functioning interact, and review disorders of executive functioning observed in aphasic patients such as perseverations, disorders of discourse, and semantic control impairments. Neural correlates of discourse and executive functions in aphasia are then reviewed. The chapter concerned with attention addresses “basic attention” concerned with vigilance and arousal, and “complex attention” selective and alternating attention. After discussing the relationship between attention and language, Cahana-Amitay and Albert examine the neural underpinnings of attention-language interactions and treatments of attention in language.

The chapter devoted to memory examines the role of working memory and other forms of memory in language processing, and the effects of working memory deficits on language functioning. The authors then consider the contribution of memory systems to aphasia treatments and recovery from aphasia as well as learning and anatomic structures implicated in aphasia therapies. In the chapter examining the role of emotion in recovery from aphasia, Cahana-Amitay and Albert examine altered emotions in aphasia, such as depression and anxiety, and interventions focusing on depression and anxiety. The chapter concerned with praxis assesses the breakdown of gesture in aphasia and the intimate connection between gestural and linguistic forms of communication in theories of apraxia. Finally, the authors consider the role of visual processing in recovery from aphasia, including the effects of visual scenes and audiovisual stimulation in language processing, and the role of visually mediated cueing in recovery from aphasia.

In the final chapter, Cahana-Amitay and Albert marshal evidence from the previous chapters to support their neural multifunctionality hypothesis. They conclude that findings from lesion, neuroimaging and electrophysiological studies support their contention that non-linguistic functions need to be incorporated into language models of the intact brain, and that recovery from aphasia must take into account the role of non-linguistic functioning.

Cahana-Amitay and Albert are experienced aphasiologists at the Harold Goodglass Aphasia Research Center of Boston University and the Boston Veterans Administration Medical Center. The authors provide a comprehensive landscape of language and the brain based on functional neuroanatomic theories that have been evolving over the past two decades. The authoritative voice of these authors compels us to reconsider classic approaches to aphasia, and develop novel forms of speech therapy that are organized around the principle of multifunctionality.

Dr. Grossman is professor of neurology, Penn Frontotemporal Degeneration Center, University of Pennsylvania

Editor’s Update and Selected Articles from the Journal of the Neurological Sciences (JNS)

By John D. England, MD

John D. England, MD

The Journal of the Neurological Sciences (JNS) is a broad-based journal that publishes articles from a wide spectrum of disciplines, ranging from basic neuroscience to clinical cases. Because JNS is the official journal of the World Federation of Neurology (WFN), the Editorial Board welcomes submissions from around the world. We also strive to publish papers with unique and original observations. In order to satisfy this latter goal, only the best manuscripts are accepted for publication in JNS.

I frequently receive correspondence asking why manuscripts are rejected. The most frequent reason for rejection is that the manuscript does not receive a high enough priority score when the scientific methodology and conclusions are assessed. In view of these criteria for acceptance, my first advice to authors is to design and perform their scientific studies in as rigorous and as thorough a manner as possible. Additionally, original and novel observations are more likely to attain higher scores by reviewers.

As a last but very important point, authors should write the manuscript as clearly and concisely as possible. The English syntax and grammar should be polished and well-edited. When we receive manuscripts that are poorly written, we always send them directly back to the authors for revision prior to more formal review. We cannot publish manuscripts that are poorly written even if the underlying scientific methodology and observations are sound.

JNSJan We recognize that English is not the native language of many of our authors, and we will allow re-submission of manuscripts that require editing. My suggestion for authors is to have their manuscripts edited by someone who has excellent command of the English language. If you do not have ready access to such a person, please utilize one of the many excellent “English editing” services. In fact, Elsevier will provide this online service to authors for a modest fee.

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

1) Aaron Berkowitz, et al., provide a well-written and richly referenced review on the neurologic manifestations of neglected tropical diseases (NTDs). They focus the review on 17 diseases that the World Health Organization has designated neglected tropical diseases. These diseases disproportionately affect the world’s poorest populations and cause significant morbidity and mortality. In fact, at least 1 billion people around the world are affected by these diseases. Most of these diseases have significant neurologic manifestations. Importantly, these diseases can be controlled using relatively low-cost but strategic plans.
Berkowitz AL, Raibagkar P, Pritt BS, Mateer FJ. Neurologic manifestations of the neglected tropical diseases. J Neurol Sci. 2015;349:20-32.

2.) Edward Mader, et al., provide an interesting and unique case description of a young woman with biopsy-proven tumefactive multiple sclerosis and acute hepatitis C virus 2a/2c who was successfully treated with interferon beta-1a. Although this report is based upon only one case, the observations are potentially very important. The report raises the possibility that a link exists between hepatitis C infection and multiple sclerosis, and it also suggests that interferon beta-1a may be effective treatment for some patients with hepatitis C infection. One particularly reasonable suggestion is that patients with acute CNS demyelination be screened for hepatitis.
Mader EC, Richeh W, Ochoa JM, Sullivan LL, Gutierrez AN, Lovera JF. Tumefactive multiple sclerosis and hepatitis C virus 2a/2c infection: Dual benefit of long-term interferon beta-1a therapy? J Neurol Sci. 2015;349:239-242.

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