Conclusion Report on the Congress of PAUNS and the Saudi Neurology Society Meeting

From left: Prof. El Tammawy, previous president of the Pan Arab Union of Neurological Societies (PAUNS) president; Prof. Bohlega (current PAUNS president); and Prof. Adnan Awada, Lebanese Neurology Society president, at the Gala Dinner.

From left: Prof. El Tammawy, previous president of the Pan Arab Union of Neurological Societies (PAUNS) president; Prof. Bohlega (current PAUNS president); and Prof. Adnan Awada, Lebanese Neurology Society president, at the Gala Dinner.

The 14th Congress of the Pan Arab Union of Neurological Societies (PAUNS) and the 22nd Saudi Neurology Society Meeting was held from Jan. 22-24 at the Hilton Jeddah in Saudi Arabia. The great success of the last PAUNS meeting in Egypt in March 2013 paved the way to move the flag to Saudi Arabia with the hope that all would enjoy the highly scientific and learning social activities planned for the event. The theme for the congress was “Broadening the Horizon of Neurology in the Arab World.”

PAUNS aims to organize a unique and important neurology conference in order to present the latest surgical techniques, research and management strategies in neurology. In addition to the presentations by thought leaders from around the world, the conference brings physicians and other clinicians together in networking opportunities that allow them to share their insights. The purpose of the conference also is to share state-of-the-art technology and techniques with clinicians in an effort to improve patient outcomes. It also provided a forum for experts and opinion leaders to share their findings and showcase the latest technologies and innovations in the field, as well as highlight the importance of advancements in neurology and medicine.

The 14th Congress of PAUNS and the 22nd Saudi Neurology Society Meeting explored the latest surgical techniques, research and management strategies in neurology.

The 14th Congress of PAUNS and the 22nd Saudi Neurology Society Meeting explored the latest surgical techniques, research and management strategies in neurology.

Neurological societies from the Arab world exchanged knowledge and experience about practice, education and academic endeavors for a brighter future. One session was devoted to address neurology in the Arab world. In this session, Prof. Raad Shakir, of the United Kingdom and president of the World Federation of Neurology, presented “Burden of Neurological Disorders in the Arab World.” Other talks included “Neurology Research in the Arab World: Opportunities and Challenges.” There were joint symposia with European Academy of Neurology, and speakers from Europe and the Middle East took turns presenting and addressing queries from the participants. A number of ongoing research results also were presented.

The meeting was open to all registrants (854 attendees) to ensure adequate exposure to the workshops for the delegates. Distinguished guest speakers and world-renowned neurologists also were in attendance, including as Prof. Gunther Deuschl, Germany and president of European Academy of Neurology; Prof. Dirk Dressler, Germany; Prof. Aziz Shaibani, United States; Prof. Sean Hill, Switzerland; Prof. Helmuth Steinmetz, Germany, Prof. Dieter Schmidt, Germany; Dr. Edward Cupler, United States and Saudi Arabia; Prof. Messoud Ashina, Denmark; Dr. Hamidon Basri, Malaysia; Dr. Suhail Alrukn, United Arab Emirates; Prof. Bassem Yamout, Lebanon; Prof. Maurice Dhadaleh, Jordan; and many more.

The scientific program consisted of workshops on headache, neurophysiology, movement disorder, transcranial doppler and long-term EEG monitoring), satellite symposia and abstract presentations. Two well-known neurologists from the Middle East, Prof. Aziz Shaibani, who is now based in Houston, and Prof. Hani T.S. Benamer, who is based in the United Kingdom, were given recognition for the successful books they have written:

  1. A Video Atlas of Neuromuscular Disorders, by Prof. Aziz Shaibani
  2. Neurological Disorders in the Arab World, by Prof. Hani T.S. Benamer

The PAUNS Board Meeting was held to elect the following new board members:

President: Saeed A. Bohlega, Saudi Arabia. Secretary General: Waleed Khoja, Saudi Arabia. Vice-Presidents: Mostafa El Alawi Faris, Morocco; Mohammad Abdul Ghani, Egypt; Abdallah Younes, Jordan; Rashad Abdul-Ghani, Yemen; and Chakir Khamis, Lebanon. Treasurer: Adel Al-Jishi, Bahrain.

The Gala Dinner was held at the Park Hyatt Hotel garden facing the famous King Fahad Fountain, the highest man-made fountain in the world.

The success of these events would not have been possible without the vision and hard work of the of the Organizing Committee, our colleagues, strong support of our sponsors, and, of course, King Faisal Specialist Hospital and Research Centre with the institution’s leadership headed by Chief Executive Officer His Excellency Dr. Qasim Al Qasabi.

 

A Willingness to Help

By Raad Shakir

Raad Shakir

Raad Shakir

Summer in the Northern Hemisphere is a holiday season, and it is a time for reflection on what has happened during the first half of the year. The theme of this column is the willingness of many of our neurological societies to lend a hand to those hard-working colleagues who practice in less prosperous parts of the world.

There are two endeavors, which I would like to concentrate upon. There is a huge need for exposure to modern technology and method of practice, which is not available in the developing world. This can be fulfilled by short-term visits to centers of excellence. The WFN started enquiring from member societies to see the feasibility of such programs and, as importantly, to explore the possibility of funding. The response thus far has been most rewarding. It started with the Turkish Neurological Society fully funding a four- to six-week visit for two neurologists from Africa nominated by the WFN. The program is now in its third year and was soon followed by the Austrian and the Norwegian neurological societies.

Members of the neurophysiology training team in Rabat, Morocco, with Prof. Mostafa Elaloui, head of department (second row, far left) and Mohamed Albakay Mali, the first WFN fellow (second row, second from left).

Members of the neurophysiology training team in Rabat, Morocco, with Prof. Mostafa Elaloui, head of department (second row, far left) and Mohamed Albakay Mali, the first WFN fellow (second row, second from left).

This just reinforces the purpose of the WFN in being a catalyst for training and international collaboration. Our three member societies have provided the funding and the time to welcome young African neurologists to their neurological departments and provide them with intense exposure to the latest technologies and guide them in ways of improving their practices in their home departments.

The WFN is in negotiation with other societies in the developed world to follow suit and take more young individuals not only from Africa, but also from all other parts of the world. The program can perhaps be best applied within regions or partnering two or three of the six regions of the WFN. This is the function of the Regional Liaison Committee of the WFN. Perhaps the best working example of regional department-to-department visits is the European region, and the European Academy of Neurology has shown its willingness to extend the program across the Mediterranean to involve the EAN associate member countries. I have to say that such acts of real interaction in international training only demonstrate the openness and generosity of neurological associations in aiding neurologists who just happen to be in a part of the world which lacks funding and organization.

WFN Education Committee accreditation visit at Qasr El Aini University Hospital in Cairo, Egypt.

WFN Education Committee accreditation visit at Qasr El Aini University Hospital in Cairo, Egypt.

If we take this further, reciprocity is perhaps one of the answers. Many young neurology trainees from the more developed world would love the opportunity to train for short periods in the developing world. This will enrich their experiences both professionally and socially. Although this is now widely practiced, it is mostly, if not exclusively, on a personal basis. Committing neurological societies in the developing world to be involved and responsible as hosts would be most helpful to those who need guidance when joining a neurological service in the developing world. This double link is the aim of the WFN.

The second activity, which is most important, is training neurologists on their own continents. This has started in Africa by the Moroccan Society of Neurology. Rabat was visited and accredited as a WFN Training Center, and the first intake of training started in September 2014. World Neurology is advertising for the second training intake this year. Again the generosity and willingness to help is most evident. The University of Mohammed V in Rabat is offering the training for free with no tuition fees required. The WFN is providing living expenses for trainees. This has worked well and should continue to prosper. What is on offer is either a fully certified four-year training program culminating in an exit examination and a diploma from the University of Rabat or a one-year training fellowship for those who have been trained elsewhere and wish to subspecialize in a specific field.

Figure 1. African trainees in Dakar, Senegal.

Figure 1. African trainees in Dakar, Senegal.

In view of the great need in Africa, the WFN entered negotiations with the Egyptian Neurological Society. This was most successful as the University of Cairo, one of the oldest in North Africa, which has kindly agreed to do the same, as there is an urgent need for Anglophone training in addition to the Francophone training in Rabat. The department in Qasr El Aini’s sprawling teaching hospital was inspected and accredited by the WFN Education Committee. Again the cost to the WFN is minimal, and the trainees will start in September 2015.

The needs are great. The WFN has therefore entered negotiations with two other major centers in Africa. Two have applied to be training centers: Dakar, Senegal, with its long tradition of training in West Africa (Figure 1), and Cape Town, South Africa, with its history of training African neurologists (Figure 2). This will make four Training Centers, two Francophone and two Anglophone. In all these cities, trainees will receive their training in exactly the same way as local trainees, and at the successful conclusion will be certified as specialists by the awarding institution and by the WFN, having been trained in an accredited program.

Figure 2. African neurologists trained in Cape Town, South Africa.

Figure 2. African neurologists trained in Cape Town, South Africa.

As these programs grow, there will be a definite need for diversifying funding. At this moment, the WFN is just about able to fund a small number of trainees. However, as the numbers increase in an exponential manner, we need to find outside sources of finance. The WFN is trying to approach funding and philanthropic organizations for support. I would be most grateful for all of our readers to advise the WFN and me directly or through their national societies if they can think of a possible source of funding we can approach.

In the two examples, neurological societies in the developed and the developing world have come up trumps. They have demonstrated their willingness to help in constructive and practical manners with ways of collaborating with their fellow neurologists. They do this with a great degree of selflessness and with the guiding principle of promoting our specialty. For that, my fellow WFN trustees and I are most grateful.

 

Cognitive Aging: A Report From the Institute of Medicine

By Dan G. Blazer, MD, MPH, PhD, Kristine Yaffe, MD, and Jason Karlawish, MD
Review and Commentary by Rita A. Shapiro, DO, FAAN, FACP

There is intense individual and public concern over cognitive decline in aging. What may seem like minor forgetfulness when young can result in intense fear of progressive cognitive decline and loss of independence for older individuals. In the U.S. and throughout most of the world, human life expectancy and the number of older adults continues to grow. Ongoing analysis and planning, including inventions that promote healthy aging and cognition, are crucial. Cognitive decline impacts individuals and families as well as society. Treatment and supportive measures consume a high portion of health care dollars and resources by health care providers, social and other services, and public health.

The Institute of Medicine convened a committee in 2014 chaired by Dr. Dan Blazer, a renowned geriatric psychiatrist, of 16 experts from a wide range of disciplines to study and make recommendations regarding the public health aspects of cognitive aging (CA). Dr. Blazer authored the report. By design, the committee did not focus on Alzheimer’s disease or other dementias or on basic science. The authors distinguished CA from cognitive impairment.

The CA report was written for a broad audience, including the general public; health care and human services providers; local, state and national policy makers; researchers; foundations and nonprofit organizations. The 2015 full report and a briefer version can be viewed at: http://iom.nationalacademies.org/Reports/2015/Cognitive-Aging. The multifaceted recommendations included definitions and terminology for CA, epidemiology and surveillance, prevention and intervention opportunities, education of health professionals and the public, as well as increasing public awareness.

Terminology for cognition is variable and not yet standardized. The authors defined cognitions as “the mental functions involved in attention, thinking, understanding, learning, remembering, solving problems and making decisions that are needed for individuals to successfully negotiate the world.” They point out that cognition is multidimensional and involves more than memory alone. CA is a lifelong process of “gradual, ongoing, yet highly variable changes in cognitive functions that occur as people get older.” Cognitive health was “exemplified by an individual who maintains his or her optimal cognitive function with age.”

Key features of CA are:

  1. Inherence in humans and animals
  2. Occurs across the spectrum of individuals
  3. Highly dynamic variable process within and between individuals
  4. Biology is just beginning to be understood but involves structural and functional brain changes.

CA is “not a clinically defined neurological or psychiatric disease such as Alzheimer’s disease and does not inevitably lead to neuronal death and neurodegenerative dementia (such as Alzheimer’s disease). Risk and protective factors include health and environmental factors throughout the lifespan influencing cognitive aging; modifiable and nonmodifiable factors (genetics, culture, education, medical comorbidities, acute illness, physical activity and other health behaviors) and the influence of development (beginning in utero, infancy and childhood) on cognitive aging. The recognition of developmental influences on cognition later in life is a newer concept.

The authors discuss the shortcomings of normative data and recommend the development of better tools to assess CA and cognitive trajectories. “Cognitive aging is not easily defined by a clear threshold on cognitive tests since many factors, including culture, occupation, education, environmental context and health variables (e.g., medications, delirium) influence test performance and norms.” The authors explained that for an individual, comparing cognitive performance is best assessed at several points in time.

Cognitive aging also was characterized by an impact on daily life:

  1. Day-to-day functions, such as driving, making financial and health care decisions, and understanding instructions given by a health care professional, may be affected.
  2. Experience, expertise and environmental support aides (e.g., lists) can help compensate for declines in cognition.
  3. The challenges of cognitive aging may be more apparent in environments that require individuals to engage in highly technical and fast-paced or times tasks, in situations that involve new learning, and in stressful situations … and may be less apparent in highly familiar situations.

The potential impact of CA on driving, decision-making and understanding health care instructions is discussed.

The report aids in rectifying some common incorrect assumptions about older adults such as “it’s all downhill” or that cognitive decline is inevitable, although only a small minority of older adults develop dementia. The authors note the wide heterogeneity among older adults and variability with CA. Some cognitive functions show decline (e.g., speed of information processing, some aspects of attention and memory), others are relatively stable (e.g., sustained attention, crystalized intelligence), and some may improve (e.g., wisdom, expertise, life satisfaction).

Subsequent chapters address the important issue of risk factors and what is known about prevention and intervention for cognitive decline. Information is provided on each known modifiable factor, including lifestyle, physical environment, education, intellectual engagement, social engagement, diet, exercise, vitamins and supplements, toxins and substance abuse. An extensive section is devoted to health and medical factors, including control of cardiovascular risk factors.

Two important, often preventable factors include adverse effects of medications to be avoided in elders (revised Beers Criteria) and delirium (preventable 30 percent to 50 percent of the time). Particular mention is made about benzodiazepine risks and drugs with anticholinergic properties, including antihistamines, which are over-the-counter in many products and often taken to induce sleep. The authors explain additional measures to help prevent hospital association delirium, which is associated with adverse outcomes and can have significant residual effects.

People are worried about cognitive decline and emphasis is given to public education about cognitive aging, including measures to maintain cognitive health. The need for additional research and better understanding is a recurrent theme for each topic about CA.

The committee reviewed the existing evidence for a variety of interventions, some which have been commercially promoted, including cognitive training, medications, supplements and transcranial direct current stimulation. The authors recommend the development of policies and regulatory review of cognition-related products. Advertising may be misleading, and products costly for the involved individual.

It is proposed that core competencies and curricula in CA be developed and implemented for health professionals and that cognitive health be promoted during medical visits. Effects of CA on driving, health care, financial and consumer decisions are addressed with recommendations to help older adults “avoid exploitation, optimize their independence, improve their function in daily life, and aid their decision-making.” Driving resources are provided to help promote safe driving or aid in deciding if it is time to stop driving.

Although additional study is needed, the report also contains information about what can be done now. Consistent with the title, the report concludes with Opportunities for Action. The recommendations involve a wide audience, including individuals and families; communities; health care professionals, associations and systems; public health agencies; organizational, media and consumer groups; researchers and funders; policymakers; regulators; consumer advocacy groups and the private sector. The concluding remarks advised the continued strengthening of efforts in Alzheimer’s disease and other degenerative dementias, while still attending to the vast majority of older adults who may experience cognitive decline without a neurodegenerative disease and who want to maintain cognitive health. The committee “hopes that a commitment to addressing cognitive aging by many sectors of the society will bring about further effective interventions, greater understanding of risk and protective factors, and a society that values and sustains cognitive health.”

Reviews and Commentary

Rita A. Shapiro

Rita A. Shapiro

The action guide for individuals and families contained excellent information and advised talking to their health care providers about risk factors and prevention of cognitive decline. However, it did not appear to promote discussion of cognitive symptoms with the provider for diagnostic assessment. The potential exists for older individuals and families to attribute all symptoms to cognitive aging even when significant impairment is present. Although concepts of CA, mild cognitive impairment and preclinical neurodegenerative disease are changing, and boundary areas are discussed well in the full report, the action guide for patients and families does not contain recommendations to “talk to your doctor” (or other health care provider) about all cognitive symptoms to make sure they are compatible with cognitive aging.

The shortcomings of current norms are extensively discussed, along with the need for better norms. Current norms affect clinical diagnosis, particularly when applied to a single individual at one point in time. Concepts likely will be refined better in future clinical criteria, but for 30 years ones relevant to Alzheimer’s disease (NINCDS-ADRDA 1984, NIA/AA and DSM5) have required significant impairment in social or occupational functioning or when functional independence is compromised. Additional comments about how the authors reconciled the concept of functional impairment would be helpful to the office clinician trying to make a clinically accurate diagnosis. The report is well-referenced and offers extensive recommendations in each chapter and in the conclusion. They are not prioritized, and each professional group or sector will need to decide which are most important to initiate.

Overall, this published report on cognitive aging “Progress in Understanding and Opportunities for Action” was true to its title and the first of its kind to comprehensively address the topic. The knowledge base of human cognition continues to expand, and there likely will be future refinements. The summary and chapter on “Characterizing and Assessing Cognitive Aging” stands alone as current and thorough for physicians and neuropsychologists. Cognitive aging is an important public health issue, and this report is unique in its scope and call to action. It will be considered a valued resource for many.

Rita A. Shapiro, DO, FAAN, FACP, is an assistant professor in the department of neurological sciences at Rush University Medical Center, Chicago.

References

Cognitive Aging: Progress in Understanding and Opportunities for Action, Institute of Medicine of the National Academies, Committee on the Public Health Dimensions of Cognitive Aging, Dan G. Glazer, Kirstine Yaffe, and Catharyn T. Liverman, Editors, 2015

JAMA. Published online April 15, 2015. doi:10.1001/jama.2015.4380

 

World Brain Day 2015 Focuses on Epilepsy

By Mohammad Wasay, MD, FRCP, FAAN

A World Federation of Neurology (WFN) initiative has transformed into a collaborative movement between the World Health Organization, the International League Against Epilepsy and the International Bureau of Epilepsy. This year, July 22 marked a special day in the history of neurology advocacy.

National societies prepared activities, including press conferences, media briefings, CME seminars, public awareness gatherings, awareness walks, epilepsy camps and various other activities for individuals with epilepsy and their families. National neurology societies collaborated with national epilepsy societies and patient support groups for World Brain Day activities.

The WFN Public Awareness and Advocacy Committee prepared a World Brain Day poster, brochure and PowerPoint presentation for media briefing. Banners for display on websites and Facebook pages also were available for promotion of this global activity. Press releases were issued in many languages to all major global newspapers and news agencies.

The main objective of World Brain Day is to promote brain health by preventing and caring for neurological diseases. This year’s theme was epilepsy. All of our awareness campaigns were dedicated toward epilepsy care.

The goal was to reach about 100 million people around globe through these multilingual, multimedia campaign jointly organized by WFN, the World Health Organization, International League Against Epilepsy and International Bureau for Epilepsy.

Mohammad Wasay, MD, FRCP, FAAN, is chair of the Public Awareness and Advocacy Committee.

Applied Research Group in Neurological Infections Launches

By Kiran Thakur, MD, and Sarosh Katrak, MD, DM, FRCP(E)

Neurological infections continue to ravage populations in developing and developed countries. In many regions, central nervous system (CNS) opportunistic infections due to AIDS and tropical diseases remain a major contributor to morbidity and mortality.

In resource-rich settings, where new immunomodulatory medications are being frequently used, CNS infections are being increasingly recognized. There are a growing number of emerging and re-emerging neurotropic infectious diseases, and proper diagnosis and management often require neurologic expertise that may not be available in certain global regions.

Despite significant scientific advances in the field, the burden of undiagnosed neurological infections remains unacceptably high. Major research gaps exist in our understanding of the pathogenesis and cost-effective diagnostics, as well as the CNS penetration and optimal treatment schedules of many neurological infections.

As co-chairs of the newly established applied research group in neurological infections, we are excited to enhance the education, training and research in neurological infections to the global neurology community. The World Federation of Neurology is well positioned to make a major impact in this field through its representation of more than 100 countries, many of which have neurologists with expertise in neurological infections.

We hope to engage experts in neurological infections in collaborative research and educational projects and those interested in improving their knowledge of neurological infectious diseases. We encourage those interested in participating to become members and participate in the educational and research endeavors of our group.

Research Goals

  • Surveillance of emerging and re-emerging neurological infections
  • Continued vigilance in understanding the burden of CNS opportunistic infection risk in patients on immunomodulatory therapies
  • Surveillance of undiagnosed infectious diseases in the global community
  • Enhanced pathogen discovery testing globally, with increased access to advanced testing in resource-limited settings
  • Drug-development trials, including studies on CNS penetration of medications for neurological infections and setting drug-dosing and treatment protocols specific for CNS infections

Training and Educational Goals

  • Develop and enhance educational sessions on neurological infections at the World Congress of Neurology meetings
  • Training sessions in neuroinfectious diseases for general practitioners and neurologists
  • Develop training modules on neurological infections with a focus on acute meningitis/encephalitis, chronic meningitis, opportunistic infections in immunosuppressed patients, viral encephalitis and tropical neurology
Kiran Thakur, MD, is an assistant professor in the department of neurology at Columbia University College of Physicians and Surgeons, New York, and Sarosh Katrak, MD, DM, FRCP(E), is director of the department of neurology at Jaslok Hospital and Research Centre, in Mumbai, India.

AFNA, AKUH Team Up for Training, Telemedicine

By Esmatullah Hamed, MD

Esmatullah Hamed

Esmatullah Hamed

Trained neurologists are lacking in Afghanistan. Neurological disorders are one of the major disease burdens in this part of the world, and training in this area is scarce. EEG interpretation both in children and adults is a specialized job, and grave errors can occur in patient management when misinterpretations occur.

The Afghan Neurological Association (AFNA) was established to promote the development of clinical neurology and neurological science throughout the country and to promote friendship among neurologists in Afghanistan and the region.

The AFNA formed collaborations with Aga Khan University Hospital (AKUH) Karachi for assessment and identification of strategic training requirements based on the country’s key health care needs. The program is evolving with training arms supporting residents and physicians.

The program not only focuses on the training aspect of physicians, but it also reaches patients in the far parts of Afghanistan with the (FMIC) Medical Institute for Children conducting telemedicine neurology clinics. This effort gives patients access to a modern health facility and expert neurologists in Kabul. To get expert opinions, telemedicine clinics also are conducted with AKUH Karachi.

Regular conferences and workshops are major components of the AFNA, AKU collaboration.

Regular conferences and workshops are major components of the AFNA, AKU collaboration.

One of the major components of training and sharing knowledge is through regular conferences and workshops. A major function of such meetings of neurology is to facilitate the sharing of knowledge and to help develop ongoing working relationships that can lead to many advances for all. Although publications and electronic communications provide essential ways to communicate, an international meeting offers unparalleled access to peers whose workplaces and problems are far from home, but may be extremely informative.

Both information sharing and clinical and research collaboration become real possibilities. Clinical collaboration today often takes the form of setting up periodic videoconferences, supplementing important opportunities to visit each another.

In this regard, the second Neurology Certificate Course was conducted via video conference June 6-9 in Kabul in collaboration with the FMIC, the Afghan Neurological Association and Aga Khan University in Karachi.

AFNA, AKUH meetings of neurology facilitate knowledge sharing and help develop ongoing working relationships.

AFNA, AKUH meetings of neurology facilitate knowledge sharing and help develop ongoing working relationships.

Seventeen speakers from neurology, neurosurgery, psychiatry and radiology departments participated, among which 14 were from the Aga Khan University and three speakers from Kabul. The World Federation of Neurology and the Asian Ocean Association of Neurology provided funding for this course.

The lectures covered a broad spectrum of neurological disorders, including stroke, central nervous system infections, headaches, epilepsy, neurological Investigations, coma and brain death.

Seventy residents and physicians participated in the conference from different parts of Afghanistan. The levels of interest were clear by the high level of engagement during the each question-and-answer period at the end of each session, participant feedback after the course revealed that the participants highly appreciated the course and called on planners for more frequent courses.

Esmatullah Hamed, MD, is president of the Afghan Neurological Association and consultant neurologist at the French Medical Institute for Children, Kabul, Afghanistan.
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