By Nguyen Huu Cong

Nguyen Huu Cong

Through the aid of the World Federation of Neurology (WFN) and the American Academy of Neurology (AAN), the continuum courses have been carried out for many years in Vietnam. The courses are conducted one to two times a year, with the topics chosen by members of the executive committee of the Ho Chi Minh City Neurological Association, based on the issues delivered annually by the WFN and AAN. These courses are usually organized in Ho Chi Minh City, the largest city in Southern Vietnam. On May 6, the course took place for the first time outside Ho Chi Minh City in the Mekong Delta.

The Tien Giang Neurological Association (TNA) was founded one year ago in My Tho, a beautiful small town in the Mekong Delta and the capital of Tien Giang Province. It now has 60 members. Most of them are neurologists from the surrounding provinces in the Mekong Delta, but some are internists working in rural areas without neurologists. Dr Nguyen Van Thanh, chief of the department of neurology at Tien Giang Hospital and president of the Tien Giang Neurological Association, is actively working and running the association.

The Vietnamese Association of Neurology and the Ho Chi Minh City Neurological Association have been assisting the TNA by sending our experts to attend lectures there. This year’s continuum course, held at Tien Giang General Hospital, covered the topics of epilepsy, as presented in Continuum: Lifelong Learning in Neurology, Vol. 19, Issue 3, June 2013. The lecturers were Prof. Pierre Jallon, former professor of neurology at the University of Geneva; Le Van Tuan, MD, PhD; and Tran Quang Tuyen MD, from the Ho Chi Minh City Neurological Association. The lectures focused on these articles:

1. The 2010 Revised Classification of Seizures and Epilepsy
2. Antiepileptic Drug Treatment: New Drugs and New Strategies
3. EEG and Epilepsy Monitoring

Prof. Pierre Jallon presented the old and new definitions, compared previous to revised classifications and analyzed the advantages of new terms and concepts and their limitations. Then the professor also talked about the differential diagnosis, especially in difficult cases from the features of syncope convulsions, hypoglycemia and psychogenic nonepileptic seizure. Subsequently, Dr. Le Van Tuan introduced the article, “Antiepileptic Drug Treatment: New Drugs and New Strategies,” speaking about the targets of epilepsy treatment, classical AEDs and newer medications available in our country. He also showed how to select antiepileptic drugs appropriate for each types of seizure. The topic of AED treatment fascinated all of the attendees, and they started a fervent conversation with the lecturer. Dr. Tran Quang Tuyen introduced the usefulness of video EEG in supposing epilepsy diagnosis. On this occasion, Drs. Le Van Tuan Tran Quang Tuyén, took turns to report on the situation of using EEG in Vietnam for epilepsy monitoring. Once again, many questions related to clinical practice were asked of the lecturers. After the presentations, attendees were encouraged to discuss the contents of the articles, “Patient Management Problem” and “Patient Management Problem — Preferred Responses.”

The discussion lasted past the fixed hours. At the end of the course, Dr. Nguyen Van Thanh, president of the TNA, expressed the gratitude of the Tien Giang Association members to the lecturers, AAN and WFN. The participants showed their gratitude in kind and suggested similar educational courses in the Mekong Delta in the future.

The CME course with Continuum — Lifelong Learning in Neurology has contributed to improving the knowledge of epilepsy in our neurologists in Tien Giang and the surrounding provinces.

The issues of the Continuum: Lifelong Learning in Neurology, with articles written by experts from the American Academy of Neurology, are useful for our neurologists, especially young members of our associations in Vietnam. We are planning to organize one additional course in August 2015 on “Peripheral Nervous System Disorders.” We believe that afterward we will continue to have the assistance of the World Federation of Neurology.

By Vida Demarin, MD, PhD, FAAN, FAHA, FESO

55th INPC Opening Ceremony.

The 55th International Neuropsychiatric Congress  (INPC) May 27-30 in Pula, Croatia, was held under the auspices of the president of the Republic of Croatia, her excellency Kolinda Grabar Kitarovic.

The organizer of the congress is the Society for Neuropsychiatry, and the co-organizers are the department of medical sciences of the Croatian Academy of Sciences and Arts and the Central and Eastern European Stroke Society.

The Congress was endorsed by the World Federation of Neurology (WFN), European Academy of Neurology, WFN Applied Research Group on the Organization and Delivery of Care, European Psychiatric Association and Croatian Stroke Society. The main sponsors of the congress were the Ministry of Science, Education and Sports of the Republic of Croatia, City of Graz, City of Pula and Istria County. There were more than 350 participants from Austria, Albania, Bosnia and Herzegovina, Montenegro, Kosovo, the Czech Republic, Croatia, China, Greece, Iran, Italy, Ireland, Hungary, Macedonia, Germany, Poland, Romania, Russia, South Korea, Slovenia, Serbia, Thailand, Ukraine, United Kingdom and the United States.

From left: Prof. Hrvoje Hecimovic; Prof. Vida Demarin, INPC president; and Prof. Raad Shakir, WFN president.

The congress kicked off with an academic lecture on “WFN: The Way Ahead,” given by our special guest, Prof. Raad Shakir, president of the WFN. The main theme was “Highlights in Neurology — What Have We Learned in the Last 55 Years” in stroke, post-stroke depression, multiple sclerosis, epilepsy, headache and pain and neurorehabilitation, presented by experts in the field, Professors Franz Fazekas, Kurt Niederkorn, Francesco Paladin, Wai Kwong Tang, Vesna Å eric and Vida Demarin.

Main topics in psychiatry were “Evolutionary Perspectives in Psychopathology” and “Controversies and News in Psychiatry,” organized by Prof. Karl Bechter and Francesco Benedetti. There were also numerous symposia, in particular: Challenging Child and Adolescent in Modern Society, Fourth European Summer School of Psychopathology, International Sports Psychiatry Meeting, Eighth International Symposium on Epilepsy, Fourth Symposium on the Interface Providers in Neurorehabilitation, Symposium on the Activities of the Association of Public Health Andrija Å tampar, and symposia about stress management and acute stroke treatment.

Joint meetings with Alps-Adria Neuroscience Section, WFN Applied Research Group on the Organization and Delivery of Care, and Central and Eastern European Stroke Society, chaired by Professors Leontino Battistin and Vida Demarin on the current status of stroke management in the region and on perspectives and new approaches in neurorehabilitation, also were organized as a part of the INPC. Prof. Anna Czlonkowska from Warsaw gave a special lecture on Wilson’s Disease, with original data from their registry.

During the congress, there were 66 lectures within 14 symposia, which were given by 55 lecturers from around the world, and a poster session with many interesting posters. Awards for best posters were given by the City of Graz and by INPC Kuratorium.

We are proud of this unique congress, being one with the longest traditions in the world. During the past 55 years, INPC has become a beloved place of meeting, a venue for continuing education in topics of neurology, psychiatry and related disciplines, and a point of scientific and professional exchange of experience for a large number of scientists and professionals from all over the world, continuing on the original idea of sciences and humanity. We hope to keep this success in the upcoming years.

By Douglas J. Lanska, MD, MS, MSPH, FAAN

Douglas Lanska

In 1873, Norwegian physician Gerhard Armauer Hansen (1841-1912) [below]discovered rod-shaped bodies — Mycobacterium leprae — in leprous nodules. Initially unable to stain these bodies, he only tentatively suggested that they resembled bacteria, which led to a later priority dispute with Albert Neisser (1855-1916) when Neisser was able to stain the organisms and then claimed priority for the discovery. Although Hansen was convinced that leprosy was an infectious disorder, he was unable to cultivate the organism and unable to transmit the disease to animals, despite 12 failed attempts to transmit the disease to rabbits by inoculation.

In 1875, Hansen had been appointed as medical officer of health for leprosy in Norway and as the resident physician at the Bergen Leprosy Hospital. After corresponding with German physician and pioneering microbiologist Robert Koch (1843-1910) in Breslau, Hansen decided to attempt human-to-human inoculations, and specifically to inoculate leprous tissue from a patient with lepromatous (multibacillary) leprosy into patients with tuberculoid (paucibacillary) leprosy [below right] to determine whether he could produce manifestations of lepromatous leprosy.

Robert Koch. Public domain. Courtesy of the U.S. National Library of Medicine.

While Hansen had already achieved some professional renown for his studies of leprosy, his patients found him aloof and high-handed. On Nov. 3, 1879, while on rounds at the Bergen Leprosy Hospital, Hansen instructed a 33-year-old patient with the “anesthetic type of leprosy,” Kari Nielsdatter Spidsøen, to accompany him to his office as he indicated he wanted to speak to her. There, she saw that he had a sharp-cutting instrument in his hand which he brought up to her eye, while she held him off with her arms. After she was calmed down by one of the other doctors in the room, Hansen succeeded in his goal of inoculating leprous material from another patient under the conjunctiva of her eye with a cataract knife.

Gerhard Armauer Hansen. (Public domain. Courtesy of the U.S. National Library of Medicine)

The patient reported this to the hospital pastor, Pastor Grönvold, who in turn forwarded the complaints to legal authorities who charged him with causing bodily harm to an innocent patient. According to the transcript of the court proceedings, Hansen “admitted that he was not justified in carrying out the operation as he had neither obtained her permission in advance, nor told her of his aim in doing it. He had omitted seeking informed consent for the procedure “as he took for granted that the [patient] would not regard the experiment from his point of view, and if something happened [e.g., a lepromatous lesion developed that might threaten her vision], he was sure he could get the affection under control.”

Despite the criminal complaint against him, Hansen boldly expressed to the court his self-righteous belief that he was justified in these actions: … even if the subject should have some pain, because he had chosen a subject who had suffered from leprosy for many years, and therefore would not be exposed to a new disease. He was quite sure that there was no risk of loss of vision, even if the inoculation should have resulted in a nodule. He himself had several times extirpated nodules from eyes without any trouble, and had succeeded in saving the eyesight. … The great scientific and national importance of finding the answer to the question [of the transmissibility of leprosy] had therefore forced him to act as he did.

Maculo-anesthetic (tuberculoid or paucibacillary) leprosy (left) and lepromatous (multibacillary) leprosy (right). Tuberculoid leprosy is characterized by hypopigmented skin macules and anaesthetic patches from damaged peripheral nerves, while lepromatous leprosy is characterized by symmetric skin lesions, nodules, plaques and thickened dermis with detectable nerve damage typically late in the illness. (From Walker, 1905)

Although Hansen’s colleagues supported him with various post hoc justifications, it was clear to the court (with Hansen’s own admission) that, in his zealousness to prove the infectious nature of leprosy, he had misused his position of authority by trying to intentionally transmit a disease to a patient placed in his care without the patient’s consent.

Hansen was convicted and in consequence lost his post at the Leprosy Hospital in Bergen, but in a legal-political compromise he retained his position as chief medical officer for leprosy in Norway. The case had little effect, though, on Hansen’s professional reputation, and he continued with his scientific studies. Nevertheless, as Norwegian microbiologist and historian Thomas M. Vogelsang (1896-1977) concluded, the legal decision emphasized “that even a celebrated scientist is bound to obey the law of the land, and that it is the court’s duty to protect every citizen also against encroachments from more influential persons.”

References
Blom K. Armauer Hansen and human leprosy transmission: Medical ethics and legal rights. Int J Lepr 1973;41:199-207.
Lock S. Research ethics – a brief historical review to 1965. J Intern Med 1995;238:513-520.
Marmor MF. The ophthalmic trials of G.H.A. Hansen. Survey Ophthalmol 2002;47:275-287.
Vogelsang TM. Gerhard Henrik Armauer Hansen: 1841-1912: The discoverer of the leprosy bacillus. His life and his work. Int J Lepr 1978;46:257-332.
Walker NP. An Introduction to Dermatology. Third edition. Philadelphia: William Wood and Co.

By Torrey Boland, MD

Torrey Boland

Despite the publication of evidence-based practice parameters for the declaration of brain death by the American Academy of Neurology (AAN) in 1995 and updated in 2010, there remains much variation worldwide in how the actual determination of brain death is performed. Not only does the practice, but also the perceptions of brain death, vary widely across countries.

In 2002, an international review identified significant variations in the practice of determining brain death. However, studies such as this have reported primarily on higher-income regions.

Earlier this year, several researchers reported in Neurology the results of the largest study to date attempting to assess and characterize both the practices in determination of brain death worldwide as well as the perceptions of brain death among countries. This study aimed to gather data not only from high-income countries, but to gather a comprehensive worldwide dataset. It confirmed that significant variations continue to exist worldwide in both the perception and practice of declaration of brain death. This lack of agreement could become challenging as organ transplantation networks are becoming increasingly internationalized, and supports the need for a stronger international consensus on brain death.

The authors conducted an electronic survey, which was distributed to individuals who practiced medicine and had interactions with patients who could become brain dead. The target participants comprised physicians in 123 countries. The survey sought to query individuals with knowledge and expertise in brain death within each country. Included in the survey were members of the Neurocritical Care Society; country representatives of the World Federation of Neurology, who were asked to either complete the survey or forward it to appropriate colleagues, authors of publications on brain death; and international personal contacts of the authors. Responses were tallied from 91 countries, including the African, Eastern Mediterranean, European, Pan-American, Southeast Asian and Western Pacific World Health Organization regions.

The findings of the study showed that there remains significant variability in both the perception of brain death as a concept as well as dissimilarity in the practice of the declaration of brain death. Most countries noted a legal provision (70 percent) and an institutional protocol for the declaration of brain death (77 percent), but high-income countries were significantly more likely to have an institutional protocol than low-income countries.

In addition, the majority of countries in Africa lacked institutional brain death guidelines. Legal provisions for brain death were more likely in countries with organized transplant networks, even when adjusting for income. This may be related to advances in medical technology, which has led to an increase in organ transplantation in more middle- and low-income countries. This rise in transplantation indicates a corresponding need for understanding of the concept of brain death.

A small portion of countries (14 percent) reported a lack of brain death declarations in their hospitals, citing a lack of intensive care or advanced technology, lack of expertise in brain death, and uncertainties regarding the concept of brain death. This may represent a need for further
medical education in some areas of the world. Interestingly, 57 percent of respondents disagreed with the statement that brain death equates to cardiac death. This response did not appear to be associated with country income level, which may reflect variations among individuals related to personal or cultural beliefs. Nearly all physicians from countries with designated transplant networks agreed that brain death was an established concept at their hospitals.

Variations in the practice of declaring brain death were noted as well. While the majority (66 percent) of respondents reported that an attending physician trained in neurology, neurosurgery or intensive care must make the determination of brain death, 25 percent of those polled stated that a resident-level trainee could independently declare brain death. Discrepancies were noted in the clinical examination, with more than half of the countries citing an institutional protocol that was discordant with the 2010 American Academy of Neurology criteria. Apnea testing was another area in which much variability existed, with differences in blood gas requirements, number of tests required and equipment.

There did not seem to be an association between the use of ancillary testing and country income level. The authors hypothesized that this finding may be explained by the increased use of ancillary tests by physicians who are unfamiliar with brain death, as the AAN practice parameter does not require ancillary testing in straightforward cases.

While this study depended on the responses of individuals, there may be a bias in the nature of self-reported perceptions and practices. The results may not reflect each country as a whole, and there may be regional differences within each country that were not assessed. In addition, the survey was presented in English only, which may have led to some misinterpretation in the questions by responders. In the lowest income countries, the need for a policy surrounding the declaration of brain death may be irrelevant as there are more urgent public health issues. Overall, however, this study represented a large, diverse and worldwide sample.

Variations in brain death declaration both in practice and as a concept persists despite advances in communication and education worldwide. This study identifies the challenges in developing a worldwide consensus on the determination of brain death. It is unclear whether creating an international standard for brain death is a feasible goal. In addition to variations in medical education, cultural beliefs and legal codes worldwide, there are also individual differences in practice and beliefs, as evidenced by variations in practice within the United States, which may be related to individual biases and opinions. This study highlights the need for the international community to work together to create a more uniform approach to brain death, especially as the practice of organ donation continues to expand.

Reference
Wahlster S, Wijdicks EFM, Patel P, et al. Brain death declaration. Neurology 2015; 84:1870-1879.