August 2013 – Page 2

Fifth Examination of the European Board of Neurology

The European Board Examination in Neurology took place during the ENS Congress in Barcelona June 7, 2013. Twenty-nine candidates attended the examination. These individuals were from Europe (Belgium, Cyprus, Germany, Italy, Portugal, Spain and Turkey) and from outside Europe (Canada, India, Iraq, Jordan, Saudi Arabia, Singapore, South Africa and United Arab Emirates).

The successful participants were then awarded the fellow of the UEMS/EBN (European candidates), or they received a diploma of the UEMS/EBN. This distinction is necessary, as all European candidates have a locally certified clinical training in an EU/EEA country or Turkey, whereas the other candidates do not have this. The EFN honored the candidates by introducing them to the audience before the ENS presidential symposium.

Twenty-five candidates passed the examination and became either fellows of the UEMS/EBN or they received a diploma of the UEMS/EBN. The examination has been a joint development of the ENS and EFNS with the contribution of questions by the MDS, the ESO and several other societies and individuals. Also e-Brain donated questions that were adapted and are used in the question pool.

The pattern and methodology of the UEMS/EBN examination previously consisted of 120 MCQs and an oral examination, and also a voluntary case presentation. All of the questions that were used went through a rigorous quality assessment by the education committee, the Department of Medical Education of the Ege University in Turkey (Caliskan) and a final editing by the examination committee. The 120 MCQs also were weighed according to topics.

The oral examination was replaced by EMQs (extended matching questions), which are case scenarios with eight to 20 possible correct answers. The EMQs test knowledge and examine clinical reasoning. The procedure of development of this new type of examination was time-consuming and could only be completed with the help of several individuals, who are mentioned on the website.

In addition to the quality assessment, each part of the examination, the MCQ and EMQ, are exposed to establishing a passing limit, based on the Nedelsky (MCQ) and the Angoff (EMQ) methods.

Finally, the case presentation is now a mandatory part of the examination where the candidates have to present a case of their choice and thus receive extra points for presentation, being judged by two examiners.

Based on the experience of the previous examinations, a suitable surrounding, staff and a system of electronic evaluation were available, which made the results clear and final shortly after the end of the presentation.

Presently, the UEMS/EBN is considered an equal to the national examination by Austria and Belgium, and it is hoped that similar to other sections of the UEMS, the examination will either partly or as a whole replace the national examinations. For the first time, this year the UEMS/EBN examination will be open to candidates worldwide.

The process of the examination and examples can be seen at the UEMS/EBN website.

The UEMS/EBN examination took place for the fifth time and will be taking place next year in Istanbul, at the joint congress of the ENS and EFNS. Both societies, which will soon merge and form the EAN, have contributed by supporting the European board examination by hosting the examination, delivering questions from their scientific panels and also supporting its development, which was funded by the European board of neurology.

Symposium: Developing Neurology in the World

The Japanese Society of Neurology (JSN) held its annual meeting in the state-of-the-art Tokyo Forum May 29-June 1. There were 6,713 participants. The meeting was primarily in Japanese with enough English language sessions to make a non-Japanese speaker fully occupied with excellent sessions from Japanese and invited speakers. There were many highlights throughout.

The inclusivity and international openness of our Japanese colleagues as well as their willingness to open up and collaborate with neurologists from across the globe were exemplified in organizing a Symposium on Developing Neurology in the World. This was the brainchild of Professor Hidehiro Mizusawa, president of the JSN and the congress. Following consultations, five invited speakers in addition to our host participated. The regions represented were Asia, by Man Mohan Mehndiratta (India), president of Asian Oceania Association of Neurology (AOAN) and WFN regional director; Africa represented by Amadou Gallo Diop (Senegal), co-director Africa Initiative WFN; South America represented by Renato Verdugo (Chile), president of WCN 2015; Central America represented by Marco Medina (Honduras), regional director WFN; and me representing Europe and international collaboration. The meeting was co-chaired by Ryuji Kaji (Japan), head of the Asia WFN. The symposium was honored by the attendance and participation of Professor Jun Kimura, past-president WFN.

Figure 1. Training centers in Africa. Red stars are those with a good percentage of African trainees from outside the country. (Diop)

The meeting was opened by Ryuji Kaji with comments on the situation of neurology in Japan and the WFN Asia Initiative. This was followed by Hidehiro Mizusawa, who gave a historical perspective followed by an impassioned commitment to internationalization: “It is quite important we are communicating constantly and simultaneously with other countries and other peoples, and appreciate other ways of thinking around the world. This is internationalization.” Mizusawa talked about the collaboration with AOAN, EANF (East Asia Neurology Forum), AAN and WFN.

I presented the current status of the EFNS training. The EFNS has 45 member societies plus nine associate member societies. The European Board of Neurology (EBN) is under the umbrella organization of the European Medical Specialists Board (UEMS). This represents 34 countries and holds board examinations in English. The latest was in Stockholm in September 2012 with fellowships to those candidates from the EU and diplomas for those from outside the EU. The curriculum and the examination are well structured and quite advanced. There was a lot of interest from the audience in the way it has been organized and conducted.

Figure 2. The number of residency placements in neurology in the Neurosure group of South American countries according to a survey performed by Ricardo Nitrini, 2012, and presented during the last Congress of the Brazilian Academy of Neurology. (Verdugo)

The EFNS has many other activities not only in Europe but also in the Mediterranean basin and Africa. These take many shapes including teaching courses. The next one was in July in Senegal in collaboration with the WFN and IBRO. Many other activities were discussed including fellowships to junior and senior neurologists as well as the department-to-department program. Electronic teaching, e.g. eBrain, is another excellent resource. This is available free to all low and lower-middle-income countries across the world.

The global scene is still lagging and the vast discrepancies in neurological training and specialization are there for all to see. This is exemplified in the WHO neurology atlas, which was published jointly with the WFN in 2004. A second edition is in progress. The WFN’s role in training is a prime function of the organization. This has been carried out in accreditation and certification of training programs; site visits; and advice on setting up training with subsequent accreditation and certification. The ultimate goal is to create Regional Boards of Neurology under the auspices of regional directors and their councils.

The Asian view was presented by Man Mohan Mehndiratta. Asia is the largest continent with a population of 4.2 billion. Neurology is growing across the region at a varying pace. Neurology training is not harmonized, and the Indian experience was detailed. The establishment of the Indian Academy of Neurology (IAN) in 1991 has resulted in a huge advance in training and research. The programs in Australia/New Zealand, China, Japan, Singapore, Indonesia, Philippines, Malaysia, Thailand and Korea were mentioned, and the possibility as well as the utility of an integrated program were discussed.

Asia is the largest continent with a population of 4.2 billion. Neurology is growing across the region at a varying pace. Neurology training is not harmonized, and the Indian experience was detailed.

The success story of AOAN in establishing its organizational structure and operational pathways has to be highlighted. This happened primarily because of the enthusiasm and diligence of regional neurologists. The WFN helped in seeding the process, and the success was cemented following that June 2012 meeting in Melbourne. This was an example for all to see, the full support of Australia/New Zealand society ANZAN with their Asian colleagues being instrumental in the development of the regional organization.

Africa and its needs were presented by Gallo Diop. His insights and intimate knowledge of all parts of Africa was detailed. The population of 1 billion is not served well at all. With life expectancy of 53 years and 42 percent of the population less than 15 years old, the task is daunting. The huge treatment gap with a low number of neurologists is a major problem. Neurological training is limited to the North and South with few in the Sub-Saharan region. (See Figure 1.) The locations in Red are those who train Africans from outside their own country. “African neurologists must be trained in Africa,” Diop said. A short complementary period spent in a center outside Africa is additional. This is where the WFN can help in setting up and supporting within-Africa training and short placements in subspecialties following certification.

Raad Shakir (left) and Hidehiro Mizusawa.

Renato Verdugo presented the current status in South America. The training programs are few, and the percentage of neurologists among medical practitioners is small. The location and spread of neurological residency training programs in Neurosur countries (see Figure 2) shows the dearth of such opportunities and the need for more integration. This is probably, in a way, easier as we are dealing with two languages in the whole region. The need for integration and exchange programs is essential.

Marco Medina presented the Central America perspective. The training programs in Guatemala, Cost Rica and Honduras were presented. The Honduras program is a success story of the collaboration of the Honduran Neurological Society and the WFN.

The issue of the process to try to establish a Pan American Federation of Neurological Societies (PAFNS) was presented. Congresses have been held every four years, and there is as yet no established regional organization. The process started at the WCN in Marrakesh and is continuing. Integrated training across the region is the ultimate goal.

One cannot forget the role of major organizations in developing neurology across the world. The American Academy at its annual meetings and programs is a major source of education and contributes to the spread of neurological science and practice. The collaboration was indeed mentioned, as was the academy’s generous contribution to WFN activities including the use of Continuum as an education tool which continues to flourish.

To conclude, there are many daunting and huge needs across the world. Our Japanese hosts were most thoughtful in holding such a gathering to look at the issues and try to intervene when and where feasible. This is commendable and welcomed. There are, however, many success stories; the phenomenal success of the EFNS and its regional and international involvement is an example to follow. The AOAN success in its organization is a step in the right direction, the African needs and the way the continent is trying to organize its affairs is impressive as well as the South/Central American efforts to establish their institutions and policies.

Neurology can only progress with such exchange of ideas and by creating the building blocks for the practical implementation of policies.

Shakir is Secretary-Treasurer General of the World Federation of Neurology.

Opportunities in Global Neurology for Trainees

Jori Fleisher, MD

The past several decades have seen a groundswell of interest in the practice of neurology in low- and middle-income countries. As established clinicians, researchers and groups such as the World Federation of Neurology, American Academy of Neurology and the European Federation of Neurological Societies (EFNS) turn their attention to improving the care of neurology patients around the globe, tremendous opportunities for international collaborations have arisen. Even more recently, our specialty has seen a rise in individual efforts, or “bottom-up” approaches to global involvement, with the impetus frequently coming from trainees.

The unification of organizational interests with the growing demand for international opportunities by trainees could not come at a more opportune time. Currently, neurologic disorders account for more than 8.7 percent of premature deaths and years lived with disability worldwide.1 Stroke alone accounts for 4.1 percent of all disability-adjusted life years (DALYs), followed by Alzheimer’s disease and other

Sarah Wahlster, MD

dementias, epilepsy, migraine, Parkinson’s disease, CNS infections and neoplasms. Importantly, these estimates do not include traumatic brain injury, a major cause of premature death and disability particularly in rapidly developing nations. Such statistics take on even greater urgency in light of the dearth of neurologists in low- and middle-income countries. In one study, 23 African nations averaged one neurologist per 5 million population, with 12 countries having none.2

In parallel with growing epidemiologic recognition, neurologists and trainees have found more avenues for clinical involvement abroad. Numerous models exist, from brief visiting professorships, global brigades and mobile clinics to long-standing inter-institutional collaborations. Here, we briefly reflect on our experiences with several models and future directions.

Many opportunities are available at individual medical schools for students to spend a week or more abroad, shadowing in hospitals or freestanding clinics, or setting up makeshift clinics to provide acute, primary care to all comers. As a starry-eyed trainee, these rotations can be inspiring, yet raise concerns. In one author’s experiences (JF), during 10- to 14-day-long trips to Central America and Jamaica, such makeshift clinics were erected and provided care to hundreds of patients who might otherwise be untreated. In addition to such ubiquitous primary care concerns of headache and low back pain, countless individuals with intestinal parasites, malaria and other tropical diseases were treated. Such trips inevitably raise the question of sustainability, and whether we are instantiating a culture of “duffle bag medicine” that does more harm than good.3 For example, a day laborer and father of six in his early 40s presented to our Jamaican clinic with early-onset Parkinson’s disease. As a student, one’s initial thrill at recognizing clinical signs and making a diagnosis is quickly overshadowed by the knowledge that the one-month supply of carbidopa-levodopa available may only offer the patient 30 days of false hope.

Some of these shortcomings can be overcome with careful pre-trip collaboration with local practitioners. Arrangements can be made in advance for patient referrals, and the visiting clinicians can arrive with a working knowledge of local treatment patterns and availability. Short trips and pop-up clinics often spark a more deep-seeded commitment to global health that will shape participants’ careers. Furthermore, relationships formed between visiting trainees and local providers can be nurtured into fruitful partnerships in the future.

To that end, longer-term collaborative relationships have been formed, yielding additional opportunities for trainees. A key component to ensuring sustainability in these relationships is to work closely with local providers and carefully elicit their input about the needs at their institutions. These partnerships can be focused on building collaborative research projects as well as fostering a didactic exchange and improving medical education.

One example of such a formal collaboration is the Botswana-UPenn Partnership. Established as a means of building clinical and research capacity in Botswana in response to the HIV epidemic, this decade-long connection has fostered the growth of primary care residency programs in Botswana, countless research studies, and the Global Health Equities Residency Track at the University of Pennsylvania’s various residency programs.

While medical students and residents can apply to spend a single rotation in Botswana, the track provides U.S. trainees with in-depth training on the geo-socio-political context of the nation in which they will practice. Two four- to six-week-long rotations are spent on the medical wards in Botswana, providing clinical care and engaging in a scholarly pursuit. Working with partnership-affiliated attending physicians and local practitioners, trainees are incorporated into ward teams or able to provide specialty consultation services. Extended and repeated stays provide invaluable insight into the epidemiology of disease, team practices, as well as the challenges of providing the best possible care with the available diagnostic and therapeutic modalities. Neurologic in-patients tend to be plentiful, comprising about 30 percent of all medical admissions, with stroke, epilepsy, meningitis, Guillain-Barre, myelopathies and CNS complications of HIV/AIDS, among the most common chief complaints.

While rotating at a partner site, there are numerous opportunities to contribute to the medical education, clinical care and research efforts in collaboration with local providers. Such collaborations have infinite future directions. Investing in the education of trainees and students at the site is a first and crucial step to improve the care of neurological patients in a sustainable fashion. At partner sites with no local neurologist, one way to support local providers is to create a targeted curriculum, based on the most commonly seen, treatable conditions and available resources. Also, participating in teaching initiatives at the local medical school and inspiring young trainees in these areas to pursue a career in neurology can potentially improve neurological care within the country.

Research initiatives may improve diagnostic and therapeutic options in countries with limited resources. Also, scholarly pursuits can be fostered through organized mentorship as well as joint authorship of case reports and research studies. New advances in technologies also lead to a wealth of opportunities for continuous interaction and collaborative efforts between sites. The Partners Neurology Residency Program has initiated a recurring series of teleconferences with their partner sites in Uganda and Mexico, during which residents and faculty at both sites discuss interesting cases, provide neurological consultation or share didactic conferences. Another advantage of telemedicine is the potential to share neuroimaging studies, EEG data files and pathology images. While difficulties with the Internet connection in developing countries remain a major challenge for videoconferencing and the transfer of larger files, continuous communications via email and emerging technology can foster a frequent exchange between sites and perpetuate sustainable connections.

Numerous other models exist for global neurology collaborations, including Medical Education Partnership Initiatives (MEPI), NIH/Fogarty program, established visiting professor programs, AAN’s Global Health Section, and WFN’s International Working Group of Young Neurologists and Trainees. Furthermore, opportunities for participation increase as students and residents advance in their training.

The most critical step in any collaboration, however, is to ensure mutual understanding and benefit, with an eye toward building capacity for neurologic care in developing nations. Barriers to such programs include funding, limited or no pre-trip training for clinicians causing misunderstandings once in country, and poor resource sharing.

In addition to international partnerships, we recognize the tremendous potential for collaborations among globally minded neurology departments and trainees in the developed world to facilitate these exchanges, share resources and foster funding opportunities. We are currently laying the groundwork for a Neurology Global Health Consortium by uniting interested and experienced neurologists from across the U.S. By gathering the collective wisdom of individuals with experience in clinical practice, education and research abroad, we hope to learn from each other and serve as a resource for other interested trainees.

To learn more about the proposed consortium, contact Wahlster at swahlster@ partners.org. To learn more about additional opportunities, contact Fleisher at jori.fleisher@uphs.upenn.edu.

Fleisher works in the Department of Neurology at the University of Pennsylvania, and Wahlster is with the Partners Neurology Residency Program at Brigham and Women’s Hospital, Massachusetts General Hospital, Harvard Medical School.

References

1. Murray CJ, Vos T, Lozano R et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: A systematic analysis for the global burden of disease study 2010. Lancet 2012;380(9859):2197-2223.

2. Bower JH, Zenebe G. Neurologic services in the nations of Africa. Neurology 2005;64(3):412-415.

3. Roberts M. A piece of my mind. duffle bag medicine. JAMA 2006;295(13):1491-1492.

Research Group on Neuroethics

Franz Gerstenbrand

Ethics in neurology are the basis of all practical work as well as for research activities. In a critical analysis of the used ethical principles, it has to be stated that the contemporary ethical laws are missing different religious, traditional and cultural requirements. The contemporary ethics are based on the philosophy of Socrates, Plato and Aristotle, with the incorporation of the Christian philosophy of Saint Augustinus and Thomas Aquinas and should be called Western Ethics. But Western Ethics must not be acceptable worldwide. The ARG Neuroethics decided to found a task force with the aim to harmonize the ethical principles in neurology including transcultural considerations. As members of the task force, representatives of the Buddhism and Hinduism, the Islamic and Mosaic religions and the different Christian communities are invited.

As a continuous activity of the ARG Neuroethics, the organization of teaching courses and informative workshops has to be mentioned. The organizers of neurological congresses and symposia are asked to include special lectures and training courses in the program. The great lack of ethical knowledge in scientific reports about new treatment programs or research projects is shameful fact and has to be strictly changed. A continuing ethical education is necessary.

The ARG Neuroethics is asking for more active cooperation and for helpful support to follow the education for a better knowledge in ethical thinking and moral responsibility. The aim for a worldwide acceptable basis for ethical principles in modern neurology needs great knowledge and an intensive preparatory work in philosophical, moral and ethical issues.

Gerstenbrand is chairman of the Research Group on Neuroethics. He can be reached at f.gerstenbrand@aon.at.

Organization and Delivery of Neurological Services

Members of the WFN Applied Reserach Group (ARG) from many different countries are active in their regions. In 2012, we were focused mainly on Central and Eastern European countries, and we organized several meetings.

As part of these activities, members of the ARG were active in their research, related to importance of delivery of neurological services, educational activities and spreading the knowledge to our colleagues in many parts of the world. Vida Demarin was active at the Eighth Congress of the Society for the Study of Neuroregeneration and Neuroplasticity (SSNN) in March 2012 in Dubrovnik; Management of Pain in November 2012 in Moscow; Neurological Meeting on Stroke in March 2012 in Ljubljana, Slovenia; Challenges on Stroke in April 2012 in Belgrade, Serbia; and Neurological Symposium on Headache in May 2012 in Tuzla, Bosnia and Herzegovina, to mention just a few of them.

Our gorgeous city of Dubrovnik was the host of the 23rd Summer Stroke School with international participation June 4-8. For the first time, the summer school was under the auspices of Croatian Academy of Sciences and Arts. The usual and proud auspicates are Inter-University Center Dubrovnik, Croatian Stroke Society, Medical School University of Zagreb, Central and Eastern European Stroke Society and Research Group on Delivery of Neurological Services (RGODNS) of World Federation of Neurology (WFN). The joint meeting of ARG ODNS and the 23rd Summer Stroke School was organized in Interuniversity Center in June 2012 in Dubrovnik.

The aim of the course was to support the cooperation and promote exchange of knowledge and experience among participants from different countries. This meeting shed new light on epidemiology of stroke, its primary and secondary prevention, diagnostics, therapy and rehabilitation. All participants had a unique opportunity to share their national stroke data and discuss about specific stroke problems of their country. Countries of the East and West Europe had an opportunity to work together on solving problems related to stroke, whether they were medical, economical or of some other nature. We can’t skip mentioning that all the hard work was awarded by rich social program during the evenings. We look forward to 2014 course already.

All participants had a unique opportunity to share their national stroke data and discuss about specific stroke problems of their country. Countries of the East and West Europe had an opportunity to work together on solving problems related to stroke.

The 52nd International Neuropsychiatric Pula Congress (INPC) was held June 20-23, 2012 under the auspices of the Croatian president Ivo Josipovic. The congress is traditionally held in Verudela Hotels Brioni and Histria, and organizers are: Kuratorium International Neuropsychiatric Pula Congress, Sestre Milosrnice University Hospital Center, Zagreb, and this year, the Department of Medical Sciences of the Croatian Academy of Sciences and Arts. The main sponsors of the congress were the Ministry of Science, Education and Sports of the Republic of Croatia, the city of Graz, the city of Zagreb and Istria County. This year, more than 350 international particpants attended the congress.

The main themes of the congress were recent achievements in restorative neurology, new advances in psychopathology — the interaction of biological and psychological factors. The theme of the joint meeting of the International Neuropsychiatric Pula Congress in the Section of Neuroscience Alps-Adria was discussions about different therapeutic procedures. Besides the main topic during this year’s congress, numerous symposia were also held: roundtables and workshops in collaboration with the Central and Eastern European Stroke Society (CEESS), World Federation of Neurology, Research Group on Delivery of Neurological Services (WFN RG ODNS) and one topic symposium related to dilemmas in therapies for different neurological disease (stroke, multiple sclerosis, epilepsy and Parkinson’s disease) and the Croatian branch of the Italian Cochrane Centre (CBICC) on the topic: Introduction to the Cochrane systematic review and application of evidence-based medicine in everyday practice, the meeting of the European Society of young neurologists and residents (European Association of Young Neurologists and Trainess – EAYNT), European Summer School of psychopathology in Pula, fifth Pula International Symposium on Epilepsy, neuro-otological course of vertigo, the European standards for doctoral studies in the field of neurology, a symposium on forensic psychiatry, the German Symposium on the ongoing training in neuropsychiatry (Deutschsprachiges Neuropsychiatrisches Fortbildungs Symposium), a symposium on the quality of life of psychiatric patients, a symposium on connecting providers in neurorehabilitation, a symposium on the role and experiences of nurses in the care of patients with incontinence, symposium on deep brain stimulation, interactive school about headache and symposium on palliative care.

We are proud to announce that this year’s 53rd INPC Congress in Pula June 19-22, 2013, had the endorsement of the WFN. We are grateful for all efforts related to ARG organization and its activities.

Battistin is president of the ARG OSNS, and Demarin is the secretary-general of the ARG ODNS.

Highlights of the 53rd International Neuropsychiatric Pula Congress

The 53rd International Neuropsychiatric Pula Congress (INPC) was held June 19-22, 2013, under the auspices of the Croatian President Prof. dr. Ivo Josipovic. The congress is traditionally held in Verudela Hotels Park Plaza Histria and Brioni, and organizers are: Kuratorium International Neuropsychiatric Pula Congress and the Department of Medical Sciences of the Croatian Academy of Sciences and Arts. The supporting organizations of the Congress are: World Federation of Neurology, WFN Applied Research Group on the Delivery of Neurology Services, International Interdisciplinary Medicine Association, European Psychiatric Association, Central and Eastern European Stroke Society.

This year, the congress was endorsed by WFN. The main sponsors of the congress were the Ministry of Science, Education and Sports of the Republic of Croatia, the City of Graz and the City of Zagreb. More than 350 participants attended representing Australia, Austria, Bosnia, Croatia, Czech Republic, Germany, Great Britain, Herzegovina, Hungary, India, Italy, Lithuania, Macedonia, Montenegro, New Zeeland, Poland, Romania, Russia, Serbia, Slovenia, South Korea, Spain, Sweden, Switzerland, Thailand, Turkey, Ukraine, the United States, and many more.

Vida Demarin, MD, honorary president of the INPC Congress, and Bosko Barac, MD.

The main theme of this year’s congress was Depression and Pain — What Is the Link? The theme of the joint meeting of the International Neuropsychiatric Pula Congress in the Section of Neuroscience Alps-Adria offered discussions about different therapeutic approaches. Beside the main theme during this year’s congress, numerous symposiums were also held: the Second European Summer School of Psychopathology in Pula, the Sixth Pula International Symposium on Epilepsy, the Second Interface Providers in Neurorehabilitation Symposium, the First Pula Neuro-interdisciplinary School, psychiatric symposia on Law on Psychotherapy, Forensic Psychiatry, CSF Signaling and CSF Biomarkers, neurological symposia on Music and Rhythm in Restoring the Brain, Advanced Treatment of Parkinson´s Disease and Diagnosis and Treatment of Low Back Pain. On Wednesday evening, the traditional academic lecture was given by Professor Luigi Agnati, who presented the latest findings on the Volume Transmission Mode and Potential Clinical Impact.

This year’s International Neuropsychiatric Pula Congress has once again proved that there is a need and interest to organize such a congress where multidisciplinary approaches to numerous interesting topics in the field of both neurology and psychiatry is maintained, and which has during more than half a century maintained the continuity of meeting that has become known as “The Pula School of Science and Humanism,” as it was often emphasized by prominent speakers, honored guests and participants of the oldest international congress in the field of neurology, psychiatry and neuropsychiatry.

Report from the European Stroke Conference

I’m deeply grateful to the WFN for awarding me the Junior Traveling Fellowship in 2013 to visit the European Stroke Conference held May 27-31, in London.

Shaily Singh

The conference was attended by more than 3,500 delegates from around the world. Following is the brief outline of the meeting and its structure and discussion items.

The meeting was broadly divided into different themes, with parallel symposia, teaching courses, debates and controversies, oral paper sessions, poster presentations and plenary lectures.

The various themes were acute stroke treatment both interventional and medical, intracerebral hemorrhage, translational neuroscience, arteriopathies, childhood stroke, rehabilitation, small vessel disease, imaging, neuroprotection, outcomes and quality of health services, risk factors, anticoagulation in stroke, and alternative therapies to name a few.

The plenary sessions were on the awards on stroke research and also new trial results announced, including INTERACT 2, SPS3, STITCH 2, imaging results of IST3, etc.

A huge number of research papers and posters were presented during this meeting.

There were parallel halls for oral presentations with different themes to select the area of stroke one is interested in. The timing, discipline and attendance was par excellence.

I had one abstract accepted as first author and was a co-author on one other.

Special e-poster sessions with presentations and question-and-answer sessions were undertaken for the first time for highly rated abstracts. There was a lot of interaction during my e-poster presentation and new ideas generated.

Overall, this meeting was an excellent feast of stroke academics and gave me a great opportunity to present our institutional research, to interact with other stroke researchers from around the world and to collaborate for future research.

Singh is assistant professor of Neurology at the Institute of Human Behavior and Allied Sciences In Delhi, India.

Neurology Nursing in Kenya: The Current State and the Way Forward

Jolynne Mokaya

Neurological disorders make up at least 25 percent of the global burden of disease and are responsible for an even greater proportion of persons living with disability (Silberberg and Katabira, 2006). Factors such as malnutrition, adverse perinatal conditions, malaria, human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS), meningitis, demographic transitions, increased road traffic accidents and persistent regional conflicts have increased the prevalence of neurological disorders in Sub-Saharan Africa (Silberberg and Katabira, 2006).

A study of Parkinson’s disease carried out in rural Tanzania showed that prevalence rates were higher than what has been previously reported from Sub-Saharan Africa. The crude prevalence rates were 30/100,000 (men), 11/100,000 (women) and 20/100,000 (combined) showing only a slight difference when compared to the prevalence rates with the U.K. population. This illustrates the fact that neurological diseases are equally a problem in Africa as they are in the Western world. Many Parkinson’s disease patients and many individuals with other neurological diseases in Sub-Saharan Africa may never be diagnosed or treated, with consequent reduction in their life expectancy and quality of life (Dotchin et al., 2008)

With the current increase of neurological diseases globally, health care professionals are expected to see an increasing number of patients living with neurologic conditions including dementia, stroke, epilepsy, Alzheimer’s and Parkinson’s disease. Policymakers, therefore, must help ensure there are properly trained clinicians available to provide high-quality care (American Academy of Neurology Professional Association). The World Health Organization identified a shortfall of 4.3 million trained health workers in 2006, with the biggest disparity in Sub-Saharan Africa.

Kenya has an estimated population of 41 million, most of whom live in the rural areas (Index Mundi, 2012). Medical standards, such as income distribution, reveal huge differences between various segments of the population. Like many developing nations, there are too few health care providers for the growing population, and only 30 to 40 percent of all Kenyans have access to improved sanitation, clean water and decent health care (InterNations, nd).

Public (government service), private and missionary hospitals are the three major providers of health care in Kenya, with public hospitals being the major health care providers to the majority of the Kenyan population (Amayo, 2006). Kenyatta National Hospital is the largest public hospital, with 7.5 percent of all medical cases seen in this hospital being neurological illnesses (Kwasa 1992).

The HIV/AIDS pandemic has evolved to being the major clinical challenge of neurology practice in Kenya due to the rise of neurological complications associated with it. More than 60 percent of all hospital beds are occupied by HIV-related illness in public hospitals. On the other hand, non-communicable diseases with their neurological sequelae are becoming epidemic due to the changing pattern of lifestyle. Once considered rare, multiple sclerosis is now being diagnosed frequently, and age-related diseases are on the rise as the population ages offering major management challenges (Amayo, 2006).

With awareness of the massive burden associated with neurological disorders, it is recognized that neurological services and resources are disproportionately scarce especially in low income and developing countries (WHO, 2005). The situation in Kenya is worse; currently, there are only 11 neurologists with most of them in private practice and working in Nairobi. In Kenya, the majority of health care providers are nurses who receive little or no training in how to diagnose and treat the common neurologic conditions that present to them every other day. There is not a single nurse trained in neurology, nor is there a training institution of neurology for nurses in Kenya. Lack of mentorship makes it difficult for most nurses to be involved in neurology, and it is sad that the majority of nurses are not aware that they could specialize in neurology (Hooker, 2013).

Nurses bring an important voice and point of view to management and policy discussions. It is crucial to involve them not only in hospital management and patient care but also in being part of various organizations, societies and bodies promoting neurology worldwide.

Training of nurses is particularly important globally. In low income countries such as Kenya where few physicians exist, nurses are involved in making diagnostic and treatment decisions.

Previous training of nurses in Kenya concentrated on the cadre of enrolled nurses and registered nurses. However, with the increasing development of the society, a higher level of training for nurses has become necessary to meet the challenging demand for high-quality nursing care (NNAK, 2009). The health sector reforms that are currently being introduced in Kenya not only require highly qualified nurses but also highly specialized nurses for effective and successful implementation (Muga et al, nd). It is crucial and essential for nurses to be endowed with the necessary knowledge, skills and attitudes to be able to give quality service.

Availability of funds, scholarships, training opportunities and mentorship programs should also be made available to nurses and other health care providers in low income countries and regions with few or non-specialists in neurology, to encourage and have more health care providers train and specialize in neurology. •

References

1. Amayo E., (2006).Neurological letter from Kenya. Practical Neurology; Vol 6(4):261 doi:10.1136/jnnp.2006.097519

2. American Association of Neurology Professional Association. The critical role of neurologists in our health care system. (www.aan.com/advocacy/issues/tools/109.pdf, accessed 30 may 2013)

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Mokaya is a final year student in the bachelor’s degree program in Nursing Sciences at the University of Nairobi. The University of Nairobi is the pioneer institution of university education in Kenya, situated in Nairobi. It is committed to quality through teaching, research and creative works, fostering an intellectual culture that bridges theory with practice, and producing holistic graduates prepared for a life of purpose, service and leadership.

The Forced Migration of German-Speaking Neuroscientists

“Vienna’s culture was one of extraordinary power, and it had been created and nourished in good part by Jews. My life has been profoundly shaped by the collapse of Viennese culture in 1938. … The sense of loss is heightened by the fact that Vienna was my birthplace, my home.”

– Eric Kandel, In Search of Memory (2007)

Frank W. Stahnisch, MD, MSc (Courtesy of the University of Calgary)

If one looks at cultural influences on modern brain research from a historical perspective, it is useful to take into account the ground-breaking developments in 20th century clinical neuroscience that emerged through the forced migration of German-speaking neurologists, neuropathologists and neurosurgeons after the rise of Nazism and Fascism in Central Europe. Following the massive expulsion of Jewish and politically opposed neuroscientists from the German-speaking countries to North America after 1933 (a development that saw approximately 600 researchers and physicians with neurological training and scientific experience driven into exile), the various relationships between neurology, psychiatry, pathology and experimental psychology underwent gradual readjustment.

The effect this process had on the pre-existing research cultures in the U.S. and Canada was the rapid transformation of the brain research field into one of the most prolific areas of biomedical knowledge production. The founding of the National Institutes of Health in 1948 and particularly the research conducted by the National Institutes of Mental Health and the National Institute of Neurological Diseases and Blindness in Bethesda, Md., since the 1950s were landmark events that mark this transformation phase in the formation of early neuroscience. This was a period when many émigré doctors and neuroscientists became relicensed and intended to resume their work in clinical care in North American postwar neuroscience institutions.

Eric Kandel (left) at a medical conference at the NIMH in Bethesda, MD, circa 1965. (Courtesy NIH)

Stahnisch currently conducts a historical research project … that aims to document and analyze the impact of the forced migration of German-speaking neuroscientists.

Often whole research schools were expelled under the Nazi and Fascist governments: An illustrative example of this is the group of academic disciples and coworkers of the director of the clinical department of psychiatry at the Charité in Berlin, Karl Bonhoeffer (1868-1948). Nearly one third of his longtime research associates had to seek refuge in North America. This illustrious group of psychiatrists and neurologists included Paul B. Jossmann (1891-1978) who went to the Veterans Administration Outpatient Clinic in Boston; Lothar Bruno Kalinowsky (1899-1992) who shifted his work to the Mount Sinai Hospital in New York City; Franz Joseph Kallmann (1897-1965) who led the Genetics Laboratory of the New York State Psychiatric Institute between 1938 and 1961; Fred Quadfasel (1902-1981) who worked at the Hospital of the Veterans Administration in Boston; Herta Seidemann (1900-1984) who likewise went to New York City, where she assumed the post of a staff attending physician at Montefiore Hospital in Brooklyn, and Erwin W. M. Strauss (1891-1971) who was the only physician from the former Berlin group to settle in the traditionally southern state of Kentucky.

Karl Bonhoeffer, 1938

Stahnisch currently conducts a historical research project — funded by the Canadian Institutes of Health Research (CIHR) — that aims to document and analyze the impact of the forced migration of German-speaking neuroscientists to Canada and the United States after the 1930s and 1940s, while specifically focusing on theoretical concepts and scientific applications of interdisciplinarity in 20th-century neuroscientific research. The aims of the research project are: first, to describe the general research topic; second, to show how a new model can be applied to historiography and social studies of neuroscience; third, to provide a deeper understanding of the influence of Central-European émigré-researchers on the emerging field of neuroscience after WWII.

With this article, Stahnisch seeks assistance from the international community of neurologists regarding existing archival collections, personal papers and diaries, along with personal accounts by former colleagues, pupils and family members, in order to gain information about German-speaking émigré neuroscientists in North America.

For a preliminary article on the scope and depth of the research project, see: OEZG. 2010;21:36-68 (www.univie.ac.at/oezg/OeZG103.html#A2).

Stahnisch is a medical historian at the University of Calgary, Alberta, Canada. Visit the history of medicine and health care program at homhcp.ucalgary.ca.

The Past and the Present: Parents of the Future

Vladimir Hachinski

When Johan Aarli, my predecessor as president of the World Federation of Neurology (WFN), first mentioned that he was writing a history of the WFN, I realized that this was an important task. However, I did not expect that institutional history would be very exciting.

As Aarli began sharing the chapters that he was writing, I happily realized that I was totally wrong. It is a fascinating book that has gained from the author’s strategy of creating a context by describing what was occurring in the world, then what was happening in the world of the brain sciences and practice and then addressing the specific story of the WFN at different times.

One of his interesting findings is the crucially important role that the National Institute of Health played in the launching of the WFN. The book describes colorful personalities, crises and both generic and specific issues. One could easily conclude at times “same plot, different players.”

The past WFN president gives a lively account of the history of the WFN up to the end of his tenure. I offer a provisional account of the present of the WFN in the accompanying reprinted article that I wrote at the request of the Editor of the Canadian Journal of Neurological Sciences, Bryan Young. The future of the WFN will be determined in Vienna, where a new president, a new vice president, a new secretary-general and one new trustee will be elected. There are multiple candidates for all of the roles, reflecting a healthy interest of individuals in leadership positions for the WFN. Whether the new officers will build on the leadership role that the WFN has achieved with the major world brain organizations during this administration, or revert to a more traditional and limited role will be conditioned by the WFN’s past and present.

In addition to crucial elections, the World Neurology Congress in Vienna promises to be exceptional. The scientific program and teaching courses are of the highest quality, and the congress will be enhanced by the presence of another author: Eric Kandel, the Noble Prize winner, will speak about the highlights of his recent book “The Age of Insight.” Johan Aarli’s book on the history of the WFN, titled “The WFN: The First Half Century” will not yet be available, but can be ordered at the congress.

Vienna has its own attractions beyond that of the congress, and we expect a record number of attendees.

Looking forward to seeing you in Vienna!

Fifth Examination of the European Board of Neurology

Symposium: Developing Neurology in the World

Opportunities in Global Neurology for Trainees

Research Group on Neuroethics

Organization and Delivery of Neurological Services

Highlights of the 53rd International Neuropsychiatric Pula Congress

Report from the European Stroke Conference

Neurology Nursing in Kenya: The Current State and the Way Forward

References

The Forced Migration of German-Speaking Neuroscientists

The Past and the Present: Parents of the Future

See Also

Selected Articles from JNS

Issue Articles

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