Improving the WFN Website

By Walter Struhal, Surat Tanprawate and Chiu Man

The World Federation of Neurology (WFN) is an active worldwide organization that promotes and advocates for neurology on all continents. We have started to re-engineer the website to shed light on this broad spectrum of activities.

The design of the website in recent years has been analogous to an information booklet on the WFN. We want to transform the current website into a vivid and timely information platform, which should allow WFN officials and WFN partners to interact with the website audience. We will not change the design, to keep the corporate identity stable, but the website logistics will change considerably.

Here are some of the expected changes.

A new registration feature will allow individuals to subscribe to WFN new.
Short introductory texts will guide the user through all areas of the website.
The content of WFN’s publications (World Neurology and Journal of the Neurological Sciences) will be embedded and promoted through the website; contents of both publications will be presented in short video introductions as well as being indexed for searchability within the site.
WFN Committees, Applied Research Groups, partners and initiatives will have access to this information platform to keep the world updated on progress in their areas of responsibility.
Content from past congresses will be accessible through an online archive, and online teaching and training tools will be promoted.
WFN officials will have the opportunity to present their work for WFN, eventually also through short video messages.
Many more details will be adapted.

An essential concept of the new website will be to integrate social media much more strongly into WFN’s online experience. Social media allows us to quickly and effectively interact with our audience.

To help us achieve this, we have introduced three social media channels:

Facebook (facebook.com/wfneurology), Twitter (twitter.com/wfneurology) and LinkedIn (http://linkd.in/1uckYLK). These groups already serve as discussion platforms and user numbers are constantly growing.

We Need Your Help

We want the website to serve your needs in advocating your WFN projects and activities. To do so, we have to get the information flowing. Please help us make your great work visible. We will serve your needs, by promoting your initiatives and ideas.

It really won’t take long. Consider that one of the most popular microblogging services, Twitter, basically only supports messages up to 140 characters, so your statements should be short and concise. So in only the few minutes you invest, we might make your work visible to the world. Send your info to walter.struhal@akh.linz.at.

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

Donna Bergen

By Donna Bergen, MD

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

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

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

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

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

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

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

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

Bergen is with the Rush University Medical Center in Chicago.

GYTN: Training Young Neurologists in Argentina

A new working group seeks to share learning with young neurologists

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

Matias J. Alet

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

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

Liseli Dario

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

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

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

Martin Bertuzzi Fiorella

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

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

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

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

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

WFN Matters

Raad Shakir

By Raad Shakir

Following the Council of Delegates meeting in Boston, the World Federation of Neurology (WFN) trustees decided to invite Prof. Steve Lewis, Chicago, to act as a co-opted trustee. Lewis also chairs the WFN Education Committee. The Education Committee is therefore represented at the trustee level to inform and coordinate all educational activities.

The nominating committee under the chairmanship of Prof. Marianne de Visser (Netherlands) will seek names of interested members of societies to be nominated for the two positions of treasurer and elected trustee. The elections will take place in Santiago during the 21st World Congress of Neurology. As stated in my last column, the COD approved the establishment of the new position of WFN treasurer.

Figure 1. WFN President Raad Shakir speaking during the opening speech at the 20th Chinese Neurological Society congress. The banner on screen reads: “Zhong hua shen jing bing xue fen hui 20 nian,” meaning “Chinese Society Neurology, CSN in Recent 20 Years.”

Over the summer, negotiations with Elsevier, our publisher, have continued. The proposal was to establish a spinoff open-access e-journal. This has been agreed and the journal shall be named eNS (eNeurological Sciences). The WFN is delighted that Prof. Bruce Ovbiagele, Medical University of South Carolina, has agreed to serve as editor, and the editorial board is being finalized. Open access e-journals are becoming ubiquitous, and ours will be operational during 2014.

The contract for Journal of the Neurological Sciences is being finalized, and a new 10-year contract is expected to be signed by the end of 2014. This gives the WFN more scope in publications, being affiliated with two journals.

The 2014 WFN grants have been agreed upon, and the recipients are being informed. We are grateful to the ILAE, WSO and the American Academy of Neurology for their support in partnering with the WFN in the awards. It is important to emphasize that the WFN Education Committee under the chairmanship of Lewis is monitoring the progress of all grants and some of the forthcoming grants reports will be submitted to the editor of World Neurology for his consideration. The budget for 2015 grants is already allocated, and the start of applications will be announced on the WFN website.

China and India

Figure 2. Chinese Neurological Society Audience in the main auditorium.
Art: WFNmatters-3.jpg

I had the privilege to be invited to Xiamen, China, to represent the WFN at the 20th Chinese Society of Neurology (CSN) meeting Sept. 18-21, 2014. I had the honor of addressing the congress at the opening ceremony. (See Figure 1.) There were 4,200 delegates with 3,000 abstracts presented. I was impressed by the enthusiasm and determination of our Chinese colleagues in their efforts to produce the highest quality research and teaching courses. (See Figure 2.)

Business meetings with Prof. Chuanqinag Pu, current president; Prof. Chuan Zhen Lu, past president; and Prof. Liylin Cui, president-elect were engaging and fruitful. (See Figure 3.) I am happy to report that there is initial agreement on introducing the CME program to China. This is most timely; as of 2015, the Chinese post-graduate neurology program is changing to a nationwide training curriculum to replace the current one, which is Hospital/University-based with varied curricula and outcomes. The matter is awaiting the final approval of the Chinese Medical Association.

I had the opportunity to talk to many trainees who were eager to move to the new program. The WFN offered to help in every way possible in this massive endeavor across China. The WFN offer includes CME training programs appraisal as well as course evaluations and, if needed, accreditation. Our Chinese colleagues were keen on international recognition of their new training program, and I am sure that regional organizations across the world will be happy and willing to help and advise.

Figure 3. From left to right: Prof. Chuanqiag Pu, CSN president, Prof. Liying Cui, president-elect CSN, Raad Shakir, president WFN, and Prof. Chuan Zhen Lu, past president CSN.

From the first, to the second most populous country on earth. I have been asked to participate in the annual Indian Academy of Neurology meeting in Chandigarh Nov. 6-9, 2014. This gives the WFN the opportunity to see how our Indian colleagues are progressing with their neurological training, research and care provision.

India is the No. 1 user of the WFN-administered CME program. The leader is Prof. Sarosh Katrak (Mumbai) and the latest six monthly figures continue to show excellent utilization. This is one of the best examples of interregional collaborations. The American Academy of Neurology donates the program to the WFN, which administers and distributes the material across the world.

The Indian Academy of Neurology is planning a four-day congress with a varied and most interesting program. The scope is huge with teaching courses, guest lectures, pearls in neurology, neuroradiology rounds, video sessions, debates, clinical-pathological cases and a session titled, “My Most Interesting Case.” Faculty from all parts of India and from across the world participate.

With China and India, the two largest populations in the world are moving full steam ahead with their neurology training and research. The close collaboration with the WFN only strengthens the relationship and brings together a large number of neurologists. The future of neurology in both countries is assured.

World Congresses

The preparations for the World Congress in Santiago are progressing extremely well. The scientific program and the teaching courses are complete. The variety is most impressive. I have to register the WFN gratitude to Professor Renato Verdugo, president of the congress and all our Chilean colleagues as well as Prof. Donna Bergen, chair of the WFN Scientific Program Committee for their hard work and perseverance. The result is impressive. Chile is an amazing and welcoming country, and we all look forward to seeing many neurologists from across the world.

The preparations for Kyoto 2017 are well under way. The Japanese Neurological Society in collaboration with the Asian Oceanian Association of Neurology (AOAN) is moving ahead with the formation of all committees. The WFN Scientific Program Committee is led by Prof. Werner Poewe (Austria), and the local Scientific Program Committee is chaired by Prof. Yoshikazu Ugawa.

The WFN Congress Committee is in the process of assessing possible sites for the WCN 2019. Its report will be available well before voting takes place during the Council of Delegates meeting in Santiago on Nov. 1, 2015.

Neurology in World Regions 2014

Events have moved on rapidly during this year. Two of the six WFN regions have seen major changes; in Europe with the birth of the European Academy of Neurology (EAN); and in Latin America with the impending incorporation of the Pan American Federation of Neurological Societies (PAFNS).

The Asian Oceanian Association of Neurology is consolidating its membership and activities and is involved in the preparations for WCN 2017 in Kyoto.

The Pan Arab Union of Neurological Societies (PAUNS) is holding its next biennial meeting in January 2015 and is planning a major change in its constitution and operational activities.

The Pan African Association of Neurosciences (PAANS) is in the process of redefining its membership and coming up with a neurology-only organization, as African Neurosurgeons have gone their own way being part of our sister organization the World Federation of Neurosurgical Societies (WFNS). The proposed name for the new organization is under discussion but the African Academy of Neurology is a likely contender.

The North American region continues its most valuable support for all other regions in providing education, CME as well as financial support for activities in the developing world.

All of these activities bode well for the WFN in 2015. We are all excited by the prospect of our second World Congress in South America, and I am sure that I speak on behalf of the WFN trustees and administration in wishing neurologists and their families across the world a happy, healthy and productive 2015.

WFN Training Centers

Wolfgang Grisold

By Wolfgang Grisold and Steven Lewis

A worldwide concept for regional training

The mission of the World Federation of Neurology (WFN) is to foster quality neurology and brain health worldwide by promoting global neurological education and training. The WFN Education Committee has developed a concept paper to define the standards and requirements for WFN Training Centers worldwide. The purpose is to establish worldwide standards of neurological care and at the same time improve local training in neurology.

WFN Training Centers will provide excellent training in neurology regionally in all parts of the world. To be accredited by the WFN, centers must be public, openly accessible university centers. Neurology must be a department on its own, closely connected to related fields, such as neurosurgery, internal medicine, psychiatry, radiology and neuropathology.

Departments should have a defined structure of experience in general neurology, dealing with the most common neurological diseases worldwide, and also addressing local neurological needs. Training must be performed in inpatient and outpatient services. In addition, electrophysiology, neuro-ultrasound and CSF analysis should be available in the department. The objective of the training course should be the independent, unsupervised practice of neurology by the trainees after the termination of their training.

The center needs to provide the WFN with a detailed plan of the training, the teaching staff and the availability of departmental facilities and structural facilities for the WFN trainees, including a detailed description of housing and accommodations, legal issues, working permit and insurance.

Prior to the establishment of a WFN Training Center, the center must follow the accreditation process set by the WFN. This includes the submission of a formal application and detailed report about the center, written and face-to-face interviews with center staff and a site visit by representatives of the WFN.

The WFN, as a charity registered in the U.K., will only grant accredited status to a center after a thorough examination. The WFN expects that the Training Centers will conduct their programs in a responsible and economic way, in line with the WFN’s charitable aims.

Training Centers make regular reports to the WFN about the development of the trainees and confirm the end of training or other agreed milestones. WFN Training Center accreditation is for a period of two years and can be renewed.

Positions for future trainees at WFN Training Centers will be announced on the WFN website and on social media. The selection of candidates will be made by a committee composed of local/regional representatives and members of the WFN Education Committee.

Visit the WFN website for more information about WFN Training Centers.

Neurodevelopmental Disorders in India: From Epidemiology to Public Policy

Donald H. Silberberg

By Donald Silberberg, MD

Epidemiologic studies address many needs, ranging from contributing to the understanding of disease pathogenesis to stimulating the development of public policy that addresses health needs. A successful example of the potential for new information to stimulate public policy is the nationwide study of the prevalence of neurodevelopmental disorders in India, carried out by members of the International Clinical Epidemiology Network (INCLEN).

When I suggested the study 10 years ago, almost no data was available for India or for neighboring countries. After successfully obtaining funding from the U.S. National Institutes of Health (NIH), the voluntary health organization Autism Speaks and The Government of India, Dr. Narendra Arora, then the newly appointed executive director of INCLEN, hosted meetings in New Delhi in order to develop the study.

The investigators included, in addition to Dr. Arora, MKC Nair, director of the Child Development Center, Medical College Thiruvananthapuram, Kerala; Sheffali Gulati, pediatric neurology chief, All India Institute of Medical Sciences, New Delhi; Vinod Bhutani, neonatologist, Stanford University, Palo Alto, California; Maureen Durkin, anthropologist/epidemiologist, University of Wisconsin, Madison; and Jennifer Pinto-Martin, epidemiologist, School of Nursing, University of Pennsylvania. Dr. Arora wisely involved the National Trust, part of the Ministry of Social Justice and Empowerment, Government of India, a choice that undoubtedly contributed to our success in helping to develop public policy.

The main objectives of our research were:

To estimate the prevalence of Neurodevelopmental Disorders (NDDs) among children aged 2-9 years, among urban, rural, hilly areas and tribal communities in India
To gather data on risk factors for NDDs
To develop and disseminate screening and diagnostic methodology for India and other countries in which individuals with NDDs have been underrecognized.

The domains studied were: Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Intellectual Disability, Epilepsy, Learning Disability, Neuromuscular Disorders, Cerebral Palsy, Speech and Language Disorders, Hearing, and Vision Impairment.

Increasingly robust screening questionnaires were developed, expanding on the well-known “10 Questions” screen¹. More than 50 clinicians and social scientists contributed to the design and execution of the study. Analysis of the data derived from the original 39-question Neurodevelopmental Screening Tool (NDST) used in gathering data from 4,000 families from six regions of India revealed that optimal sensitivity and specificity was achieved by using only 11 questions.

The questionnaire that was finally used is described in several publications^2,3,4,5. Countrywide results (excluding tribal data) revealed that from 10 percent (hilly areas), 13 percent (urban areas), to 18 percent (rural areas) of children ages 2-9 years were found to have one or more NDD. The tribal prevalence was 4.96 percent, perhaps reflecting lower infant and child survival.

The study was supported by: NIH (USA) Grant R21 HD53057, MKC Nair (PI), J. Pinto-Martin and D. Silberberg (Co-PIs), S Gulati, Network Coordinator); Autism Speaks (USA); The National Trust (Government of India) and INCLEN. Importantly, the NIH funding was obtained via the Fogarty International Center’s “Brain Disorders Across the Lifetime” program. (See Dr. Donna Bergen’s article on page 4).

On the basis of the methodology and results, The Government of India has undertaken two initiatives:

Questions regarding disability were included for the first time in the 2011 Census of India.
A national program for screening, diagnosis and treatment of NDDs was launched in 2013, the Rashtriya Bal Swasthya Karyakram (RBSK; National Child Health Program). The program is funded with more than $400 million, in order to develop 630 centers for screening and subsequent care of those found to have a neurodevelopmental disorder. Activities to achieve implementation are under way in many regions of India.

This outcome serves as a case study of epidemiology as “translational research,” a term ordinarily used to describe the process of bringing research laboratory results to the bedside. Clearly, epidemiology can be used to serve advocacy, as we work to improve neurologic health in all regions of the world.

References:

1. Zaman, Sultana S., Khan, Naila Z., Islam, Shaheen, Banu, Sultana, Dixit, Shanta, Shrout, Patrick, and Durkin, Maureen. “Validity of the ‘10 Questions’ for Screening Serious Childhood Disability: Results from Urban Bangladesh.” International Journal of Epidemiology 19, no. 3, (1990): 613-620.

2. Juneja, Monica, Mishra, Devendra, Russell, Paul S. S., Gulati, Sheffali, Deshmukh, Vaishali, Tudu, Poma, Sagar, Rajesh, Silberberg, Donald, Bhutani, Vinod K., Pinto, Jennifer M., Durkin, Maureen, Pandey, Ravindra M., Nair, Mkc, Arora, Narendra K., and Inclen Study Group. “INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD): Development and Validation.” Indian Pediatrics 51, no. 5 (2014): 359-365.

3. Mukherjee, Sharmila, Aneja, Satinder, Russell, Paul S. S., Gulati, Sheffali, Deshmukh, Vaishali, Sagar, Rajesh, Silberberg, Donald, Bhutani, Vinod K., Pinto, Jennifer M., Durkin, Maureen, Pandey, Ravindra M., Nair, Mkc, Arora, Narendra K, and INCLEN Study Group. “INCLEN Diagnostic Tool for Attention Deficit Hyperactivity Disorder (INDT-ADHD): Development and Validation.” Indian Pediatrics 51, no. 6 (2014) 457-462.

4. Konanki, Ramesh, Mishra, Devendra, Gulati, Sheffali, Aneja, Satinder, Deshmukh, Vaishali, Silberberg, Donald, Pinto, Jennifer M., Durkin, Maureen, Pandey, Ravindra M., Nair, Mkc, Arora, Narendra K., and INCLEN Study Group. “INCLEN Diagnostic Tool for Epilepsy (INDT-EPI) for Primary Care Physicians: Development and Validation.” Indian Pediatrics 51, no. 7 (2014): 539-543.

5. Gulati, Sheffali, Aneja, Satinder, Juneja, Monica, Mukherjee, Sharmila, Deshmukh, Vaishali, Silberberg, Donald, Bhutani, Vinod K., Pinto, Jennifer M., Durkin, Maureen, Tudu, Poma, Pandey, Ravindra M., Nair, Mkc, Arora, Narendra K., and INCLEN Study Group. “INCLEN Diagnostic Tool for Neuromotor Impairments (INDT-NMI) for Primary Care Physician: Development and Validation.” Indian Pediatrics 51, no. 8 (2014): 613-619.

International Neurology Forum in Kazakhstan

By Aida Kondybayeva, MD

Aida Kondybayeva

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

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

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

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

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

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

Kondybayeva is with the Asfendiyarov Kazakh National Medical University.

A Continuing Journey: The Fight Against Stroke in India

Rohit Bhatia

By Rohit Bhatia, MD, DM, DNB

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

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

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

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

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

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

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

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

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

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

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

Improving Access to Stroke Care

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

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

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

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

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

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

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

Increasing Stroke Awareness

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

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

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

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

The Future of Stroke Care in India

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

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

References:

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

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

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

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

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

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

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

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

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

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

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

HISTORY OF NEUROLOGY

By Edward H. Reynolds

Edward H. Reynolds

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

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

Samuel Alexander Kinnier Wilson (1878-1937).

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

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

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

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

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

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

References

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

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

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

Turkey Brain Year Activities — Neurology for Public

Photo 1

The Turkish Brain Action Group was founded from suggestions of the European Brain Council in August 2013. Group members quickly organized a “Brain Year” in Turkey in 2014. The Turkish Brain Action Group consists of neurology, neurosurgery, psychiatry, and other disciplines related to neuroscience and patient organizations. Currently, 16 different societies presents in the action group.

Photo 2

The 2014 Brain Year Turkey opening conference moderated by Prof. Rana Karabudak, under the leadership of Turkish Neurological Society, was successfully held on Feb. 18, 2014, in Ankara, Turkey. The conference aimed to announce all the projects of Brain Year in 2014 and touch on the issues regarding the brain awareness in Turkey. (See Photo 1.) The invited speakers included the representatives from the Turkish Neurological Society’s board members, experienced members, vice chancellor of Hacettepe University of Medical School and the prominent representatives of the neurological sciences specialty societies.

Photo 3

The conference brought together up to 400 participants, including Turkish press, neurologists, neurosurgeons, medical students and members of cooperated societies. (See Photo 2.)

Photo 4

Our second meeting was held on March 12, 2014, in Ankara, Tukey. The meeting’s main topic, moderated by Prof. Serefnur Ozturk, was cerebrovascular diseases and mainly attended by medical students and delegates of the Patient Societies. (See Photo 3.) The event recorded and served from brain year web page as a continuing education. (See Photos 5, 6.)

Photo 5

On April 12, 2014 the Parkinson Disease Society held an event for the Brain Year. The Parkinson’s patients and the neurologists had a long walk against to Parkinson disease. This event received great attention from the press. (See Photo 7.)

Photo 6

An Awareness Symposium was held for the neurological diseases in May. The symposium brought together around 600 patient and patients’ relatives. They had a chance to have an interactive discussion platform to increase their knowledge. (See Photo 8.)

Photo 7

In addition to scientific activities, we have visited eight secondary schools and held mini conferences. We reached around 1,000 students and increased their knowledge on brain. Turkish press being so interested to all our events and this makes it more accomplished. (See Photo 9.)

Photo 8

In the coming days, our public service announcements will be placed on TV which will be a great opportunity to spread our word to Turkey. (See Photo 10.)

Photo 9

Turkish Neurological Society holding an annual congress every year with 1,500 participants. This year we are celebrating our 50th Congress and planed a special session on Brain Year in Turkey. During our national congress the contest results will be announced at the gala dinner and an outdoor event will be organized “Walking With the Neurons”.

Photo 10

The brain year website consists all the events and announcements and we use social media quite effectively with our Facebook and Twitter accounts.