Gagandeep Singh, MD, DM

Epilepsy affects an estimated 12 million people in South Asia. More than half of this population is comprised of young people. Besides the sizable quantum of disability adjusted life years (DALYs) there is a hidden burden associated with epilepsy as these young people are often unable to complete their education, get appropriate jobs, and marry.

Experts attending the WFN grant-supported meeting on “Arranged Marriages in People With Epilepsy in South Asia.”

Marriage, a socially compelling and momentous occasion in the lives of people with epilepsy as in the case of others, has not received the attention it requires from a psychosocial research perspective. To complicate matters, some of the unique social attributes of marriage in much of South Asia pose an enormous challenge in the lives of young people with epilepsy.

Two features deserve mention:

• Marriages in the region are universal. That is, over 95 percent of the people choose to get married in comparison to the 60 percent in the rest of the world.
• An overwhelming majority of marriages are arranged. That is, the parents/elders in the family find and finalize marital partners. The problem with arranged marriages is that the prospective bride and groom do not meet before marriage, and hence are unable to reveal significant discrediting traits to their prospective partners. Epilepsy is often hidden for fear of breakdown of marital negotiations. The consequences of hiding epilepsy during marital negotiations are immense and include breakdown of marital negotiations and poor marital satisfaction and outcome (an increased rate of divorce) in addition to serious health implications for the individual with epilepsy. Sadly however, these consequences have not been formally studied.

A highly considerate World Federation of Neurology (WFN)-International League Against Epilepsy (ILAE) grant enabled us to form a working group to tackle the immensely intricate and problematic issue of arranged marriages in people with epilepsy in South Asia. We were able to initiate a clinic-based knowledge, attitudes, and practice survey of unmarried and married people with epilepsy in the following centers in South Asia: Dayan and Medical College, Ludhiana (GS) Vedanta Hospital, Gurgaon (Dr. Atman Ram).

Further, the grant enabled us to meet on Aug. 12, 2017, at Hyderabad to discuss the findings of the survey. Investigators from each site attended the meeting. In addition, a social scientist (Dr. Manjistha Banerjee), neuropsychologists (Dr. Urvashi Shah and Dr. Parveen), social activists (Yashoda Wakankar), neurologists (Dr. Pravina Shah, Dr. Manjari Tripathi, Dr. Hitant Vohra, Dr. Archana Verma, Dr. Sanjaya Fernando, Dr. Lekhjung Thapa, Dr. Siby Gopinath, Dr. Sudhir Sharma and myself), statisticians (Namita), and other experts also took part.

An overarching theme for discussion was the gender bias in marital prospects, outcome, and satisfaction. Unmarried women with epilepsy seem to be disproportionately affected in comparison to young men with epilepsy. Besides discussing the findings of the survey, the group also discussed and initiated the development of a quality of marriage in epilepsy (QOMIE) scale for marital satisfaction, specifically for people with epilepsy and the merits and pitfalls of a web-based marriage portal specifically for people with epilepsy in the region.

We would like to express our gratitude to the WFN for funding this important social venture, which we hope to take forward in keeping with the resolution adopted by the World Health Assembly in 2015 to fight stigma and discrimination faced by people with epilepsy.

Use of Continuum® in the residency training curriculum in Nigeria

By Prof. Njideka U. Okubadejo

Neurology training at the Lagos University Teaching Hospital (LUTH) Nigeria is conducted using the guidelines of and under accreditation of the West African College of Physicians and the National Postgraduate Medical College of Nigeria.

The training features two stages: Junior Residency (initial 24 months in internal medicine, inclusive of a mandatory three-month rotation in neurology) and Senior Residency (specifically, for specialization in neurology, an additional 36 months in general neurology, including rotating through relevant subspecialties).

The LUTH program is one of the largest in Nigeria, and has an average of 90 resident doctors in internal medicine at any point in time. Of these, about half are junior residents, five are neurology senior residents, and the rest are senior residents in various specialties, such as cardiology and endocrinology who mandatorily undertake rotations in neurology also. The Neurology Unit also trains residents rotating from neurosurgery, ophthalmology, family medicine, anesthesia, and psychiatry.

The training format includes clinical teachings (outpatient and inpatient setting), self-directed learning, didactic lectures, grand rounds, postgraduate seminars, journal reviews, and conference attendances.

Implementation

The American Academy of Neurology’s (AAN’s) Continuum Lifelong Learning in Neurology® has been provided by a joint program of the World Federation of Neurology (WFN) and AAN to our training program for about nine years. During the early years of its use, neurology residents and the trainers (consultant neurologists) used the journal as part of the recommended reading and material for postgraduate seminars.

Over the course of the last four years, with increased appreciation of the systematic, logical, and comprehensive nature of the journal articles, the unit has formalized the use of Continuum in these ways:

• Continuum-Based Early Bird Seminars: This is a year-round postgraduate seminar held on most Tuesday mornings from 8 a.m.– 9:30 a.m. The seminar topic is preselected from Continuum, topics are distributed to be read by all, and presented by one of the neurology senior residents. The seminar is attended by 10 to 12 residents rotating through the unit at the time, with consultants in attendance also. The format is via PowerPoint presentation, with interactions (questions, clarifications), and a brief post-test of a few (four to five) multiple-choice questions (MCQs) based on the content for the day. The residents have indicated that the sessions are valuable, and have improved their understanding and knowledge because of the combination of functional/anatomical/pathophysiological basis, real-world symptoms-based algorithms/approach to common neurological complaints, updates on classifications, diagnostic criteria, and evidence-based treatment guidelines. In addition, the post-reading MCQs and patient management problems with responses improve the understanding of the material.
• Incorporation of Continuum Into Training Curriculum: As the chair of the Neurology Subspecialty of the National Postgraduate Medical College of Nigeria, in our recent curriculum revision, I have included the Continuum journal as part of the recommended reading material for all residents training in neurology. This is in recognition of the invaluable content delivered by global experts in each subject, and the realization that, with this exposure, our residents have access to a journal that is easily the best educational content for any training or practicing neurologist. Examiners at the postgraduate examinations have continued to be impressed by the level of knowledge displayed by our trainees, and how well rounded and balanced they are in their clinical approach, diagnostic evaluation, and grasp of evidence-based treatment modalities. Much of this is a testament to the ease of access to the comprehensive, up-to-date, yet clinically relevant compilation of neurology contained in the Continuum series. In the foreseeable future, as there is a plan to harmonize training curricula of all of the postgraduate medical colleges across the West African sub-region, it is highly probable that this existing curriculum recommendation will be reflected in the West African Neurology Training curriculum as well.

Recommendations

I strongly appeal that the program be continued. The level of confidence that comes from knowing that one is learning from global experts, and the knowledge is at par with what other neurologists globally are learning, is a boost to the confidence of our trainees and ourselves.

I also appeal that to further enhance the use of this access program, institutional access is considered for participating institutions to enable the residents have access to electronic versions of the journal. This would remove the need to make copies for individual readers and also make it easier to study the material in this electronic age. I understand that there would need to be restrictions to ensure that the access is not misused. •

Prof. Okubadejo is a consultant neurologist at the Lagos University Teaching Hospital and subspecialty chair (neurology) at the National Postgraduate Medical College of Nigeria.

Berne, Switzerland, 1931

By Peter J. Koehler

Specialization in medicine started during the second half of the 19th century. Several causes have been presented, including an increase in occupational diversity in Western society, the change from humoral to solid medicine, the appearance of theories on localized lesions versus diffuse causes (reflected for instance by monographs on diseases of one organ), the foundation of asylums and hospitals for particular diseases, and (later on) the fact that certain areas of medicine became too large to be dealt with by one type of physician. Although there was considerable opposition to this change, specialization continued as can be observed by the increasing number of specialized societies and journals, the publication of large specialized handbooks, the introduction of specialties in the medical curriculum, and the organization of congresses for specialist physicians.

Neurology as medical specialization was not among the first new specialties, and in many countries arose associated with psychiatry (which was an early specialization). Other diseases, nowadays belonging to neurology, were taken care of in internal medicine departments or special outpatient clinics arising from internal medicine (for instance outpatient clinics for electrotherapy).

Congresses for General Medicine

Figure 1. Members of the International Medical Congress, London, 1881. (Courtesy: Wellcome Images)

International congresses for (general) medicine were organized regularly, one of the best known being the one in 1881 in London. According to a report in the BMJ of Aug. 13, 1881, “3,000 men have been gathered in Congress throughout the week, and among them the choicest spirits of the age.” (See Figure 1.) Indeed, well-known names were mentioned, including Pasteur, Lister, Bastian, Bigelow, Erichsen, and Crichton Browne. It was at this congress that the famous discussions on cerebral localization, following Broca’s 1861 clinical findings and the electrical stimulation experiments by Fritsch and Hitzig in 1870, took place and David Ferrier demonstrated his experimental monkeys, urging Jean-Martin Charcot to exclaim that the monkey resembled hemiplegic patients. The large number of visitors at the congress was another indicator of the necessity of future meetings in smaller groups.

1907 Amsterdam Congress; Not Just Neurology

Figure 2. Harvey Cushing (picture taken a few years following the congress; Wellcome Images)

One of the first, possibly the first, neurology meeting, the International Congress for Psychiatry, Neurology, Psychology, and Care for the Insane was organized in Amsterdam in 1907. Even at this early specialized congress, 805 delegates were present (21 nationalities, price for registration 10 guilders/3 $).

Many well-known neurologists met, including the Belgian Arthur van Gehuchten, the Germans Arnold Pick and Hugo Liepmann, and the Swiss Constantin von Monakow. In 1914, the Swiss were organizing an international meeting solely for neurology in Berne. The correspondence between Swiss neurologist Constantin von Monakow and his Dutch colleague and friend Cornelis Winkler tells about the organization in September of that year.

On Aug. 1, 1914, Winkler wrote to Monakow: “I think that if the international relationships will not relax soon, I will not be able to come to Switzerland.” In a post scriptum to the letter, he noted, “I believe this Aug. 1, 1914, will become a historical day.” On the same day, Monakow wrote to him, “The war, the dreaded European war is imminent, and Switzerland too, is preparing to send troops to the threatened borders.” He realized that his colleagues in Europe were engaged in “obvious national and economic tasks and have other thoughts than discussing scientific questions; and that will probably mean – although we have not yet decided definitely – that the Berne Congress that has been prepared so well, will probably not take place.”

Although dozens of letters about resurrecting the International Brain Commission (founded in London in 1903 and an important platform for international communication with respect to neurology, including the basic fields) have been written between neurologists/ neuroanatomists during the period 1918-1931, the organization of the congress finally took place in 1931, now considered the first in a long series, such as the 23rd meeting in Kyoto, Japan (2017).

Proceedings of the Congress

Figure 3. Sir Charles Scott Sherrington (courtesy: Wellcome Images)

It is a pleasure to leaf through the Proceedings of the congress (published in 1932 by Stämpfli, Switzerland). The book was put together by a team of neurologists (Bernard Sachs and Henry Alsop Riley of New York, Charles Dubois, R.F. Fischer, and Pierre Schnyder of Berne), and chaired by Bernard Brouwer of Amsterdam. The introduction was written in four different languages (English, French, German, and Italian).

During the opening ceremonies on Monday, Aug. 31 (1931 at the Casino of Berne), the rector of the local university conferred honorary degrees of medicine to Harvey Cushing (see Figure 2), the famous founder neurosurgeon, who had done experimental research (with Theodor Kocher and Hugo Kronecker) in Berne 30 years previously, and to Sir Charles S. Sherrington (see Figure 3), the well-known neurophysiologist (who would be awarded the Nobel Prize in 1932).

The laudatios were read in Latin. The presidential address, also printed in the four languages, was given by Bernard Sachs, who at the time was also president of the American Neurological Association.

“The purpose of this congress is primarily to establish personal contact and to unite the neurologists of the entire world in the attempt to find a solution to the many important problems engaging their attention; to indicate other problems that will call for study in the immediate future, and to emphasize the important relation that neurology bears to every branch of medical and surgical science. Neurology is the fundamental specialty of medical art. Without a thorough appreciation of its truths, medical and surgical science is like a ship floundering about in a turbulent sea without helm or rudder.”

Presentations

Figure 4. Representatives of the various participating countries in Berne (1931); sitting from left to right: 1 Gheorghe Marinescu (?) 2 Max Nonne 3 Charles Sherrington 4 Bernard Sachs 5 6 and 7: unknown. Standing from left to right 1 unknown 2 Robert Bing 3 Otto Marburg 4 Ottorino Rossi 5 C.U. Ariëns Kappers 6 Henry Markus (?) 7 George Guillain 8 Robert Wartenberg or François Naville (?) 9 unknown 10 Henri Claude (?) 11 Ludo van Bogaert (?) 12 unknown 13 Henry Alsop Riley 14 unknown.

A number of scientific sessions was held during the congress. “Diagnostic and Therapeutic Procedures (Surgical and Otherwise) in Brain Tumors” with presentations by (among others) Clovis Vincent (the Paris neurosurgeon), Robert Foster-Kennedy (New York neurologist who was eponymized with the syndrome combining optic atrophy on one side and papilledema on the other), Wilder Penfield (neurosurgeon from Montreal), Otfrid Foerster (neurosurgeon from Breslau), and Harvey Cushing (with a lecture titled, “The Surgical Mortality Percentages Pertaining to a Series of 2,000 Verified Intracranial Tumors”). A peculiar presentation was the one by Tracy J. Putnam on “Organo-Therapy in Brain Tumors,” not that strange in a period that organotherapy (the use of animal tissue extracts, a precursor of endocrinology) culminated after the introduction of insulin in the early 1920s. Other sessions were on “Muscle Tonus; Anatomy, Physiology and Pathology,” “Neurological Surgery – Therapy,” “Clinical Neurology,” “Clinico-Pathology” (with a demonstration of two educational films on hydrocephalus and Wilson’s disease by the Viennese neurologist Otto Marburg), “Investigative Neurology” (with a film presentation by Walter Rudolf Hess of Zurich, later Nobel Prize laureate, 1949, on localized brain stem stimulation), “Acute Non-Suppurative Infections of the Nervous System” (with presentations by Constantin von Economo, who died a few month after the congress, on encephalitis and Friedrich Lewy on inclusion bodies), “Brain Tumors and Allied Subjects,” “Neuro-Pathology,” “Investigative Neurology” (with C.U. Ariëns Kappers of Amsterdam on “The Brain of Prehistoric and Recent Races,” and Robert Bárány on “The Theory of the Cortical Mechanisms of Association”), and “Clinical and Pathogenetic” (with Robert Wartenberg, then still working in Freiburg in Breisgau, on “Neuritis in the Hand”). The session “Constitutional Problems – Neuroses” could be considered a remnant of the past practice of neurology (with a presentation by the famous Ivan P. Pawlov of Leningrad, on “Experimental Neuroses”), although the association between neurology and psychiatry would continue for decades in many countries. Two sessions on traumatic brain injury included presentations by Charles P. Symonds  of London (“The Effects of Injury Upon the Brain”) and Harold G. Wolff / Maurice Levine of Boston on cerebral circulation. The last sessions were on multiple sclerosis/infections, brain tumors, experimental investigative neurology, clinical and biological (issues) with films on extrapyramidal arm reflexes (by Th. B. Wernöe of Copenhagen), and a film on movement disorders of the lower extremities by F. de Quervain (Berne). A picture of the various international representatives was made during the congress. (See Figure 4.)

Neurology an Independent Specialization

Figure 5. Chairman of the Congress New York neurologist Bernard Sachs (public domain).

On the evening of Friday, Sept. 4, a special conference titled, “Relation of Neurology to General Medicine and Psychiatry in Universities and Hospitals of the Various Countries” was organized at the Bellevue-Palace hotel. Neurologists/neuropsychiatrists from several countries spoke about the situation in their own country (Max Nonne on Germany, Constantin von Economo on Austria, Mieczyslaw Minkowski on Switzerland, Jean Lépine on France, Theodore Weissenburg on the U.S., Ottorino Rossi on Italy, and Bernard Brouwer on the Netherlands). Following the discussion, the chairman, Bernard Sachs, (See Figure 5.) asked the assembly to vote the resolution, as proposed by Otfrid Foerster: “Neurology represents an entirely independent specialty in medicine. Unfortunately, this fact has not been sufficiently recognized in various countries. The First International Neurological Congress hopes that the Universities and Hospital Authorities of the various states will take active steps to further the progress of Neurology.” The resolution was accepted unanimously. The influence of the congress and conference may be recognized by the foundations of several independent university chairs and neurological societies in several European countries.

It is interesting to note that the “Ladies reception committee” (mainly wives of Swiss delegates) is mentioned in the Proceedings with a report of the “Receptions and excursions.” The second International Neurological Congress would be held in London (1935), after the Association of British Neurologists had been founded in 1932 (at the house of Gordon Holmes).

Peter J. Koehler is editor of the History Column. (Visit his website at www.neurohistory.nl.)

By A. Buguet, P. Spencer, and J. Reis for the Environmental Neurology Research Group.

The Second International Meeting on Environmental Health Strasbourg (RISE 2017) was held Nov. 29-Dec. 1, 2017, at the Council of Europe in Strasbourg, France. The conference welcomed WFN President Prof. Raad Shakir and WFN General Secretary Prof. Wolfgang Grisold. As in 2016, the 2017 conference tackled the unresolved mechanisms and effects of air pollution and other environmental exposures on the brain and nervous system.

Pollutants in the air take many forms, including gases, fumes, liquid droplets, and solid particulate matter of various sizes. Inhaled fine and ultra-fine particulate matter can enter the lungs, cross the alveolar wall, enter the blood stream, and reach neural tissue either directly (circumventricular organs, sensory, and autonomic ganglia) or after passage across the blood-brain/nerve barriers.

An alternative route to the brain is from the nose and across the ethmoid wall to reach the olfactory pathway, whereupon particles can be transported retrogradely to cerebral structures. Particles that are swallowed may traverse the gut wall and enter the blood stream. Particulates that enter neural tissue trigger oxidative stress, neuroinflammation, and cellular damage.

Relapses in multiple sclerosis are linked to ambient air pollution. Whether chemical pollutants can trigger disease-inducing expression of latent neurotropic viruses is an unexplored question.

Chronic Exposure

Speakers emphasized that chronic exposure to polluted ambient air has important links with neurological disease during development, childhood, adult life, and advanced age. Specific chemicals and mixtures used in industry or to induce euphoria are established causes of peripheral neuropathy and cognitive deficits in children and adults. Chronic exposure to polluted air is an accepted risk factor for ischemic stroke, probably via a cardiovascular mechanism.

There are major concerns that air pollution increases the risk for disorders of neurodevelopment and brain maturation, resulting perhaps from epigenetic changes that may also have consequences for neurological health in later life and old age. Persistent epigenetic changes (DNA methylation) may be induced by naturally occurring substances, such as methyl donors in nutritional foods and manmade chemicals that become environmental pollutants.

Genetic, prenatal, and environmental risk factors have been linked to neuroendocrine disturbances during pregnancy (for example, thyroid gland and hormones) resulting in autism spectrum disorders, the incidence of which has increased and now affect males more than females (3:1).

Neurodegenerative Disease Links

Food and medicinal use of plants containing a potent methylating agent chemically related to substances found worldwide in preserved food and cigarette smoke (e.g. nitrosamines) has been linked to the prototypical neurodegenerative disease Western Pacific ALS-Parkinson Dementia Complex.

Tobacco use is a risk factor for Alzheimer’s disease and ALS, but not for Parkinson disease, possibly because nicotine is protective of dopaminergic neurons. High-incidence apparently sporadic ALS has been found in a village in the French Alps.

We were honored to receive lectures from both Prof. Shakir and Prof. Y. Le Maho, member of the Académie des Sciences (Paris).

Prof. Shakir pointed out recent changes in the field of neurology. He underlined the recent decision by the World Health Organization (WHO) regarding the previous misclassification of stroke, the second cause of death globally, and other neurological diseases. (At last, the WHO has recognized the pertinence of the WFN’s factual position: a tremendous achievement!)

Biodiversity

Prof. Le Maho, who had been invited to broaden the scope of the conference, lectured on biodiversity. Apart from nutrition, biodiversity renders multiple services to man. It is the source of medical and therapeutic innovations, and of information on restorative processes, on the control of scavengers and pests, on soft chemistry for the development and fabrication of new materials, and even on the use of plants to reduce pollution and increase air quality. The impact of global warming on biodiversity further weakens species endangered by human activities.

One of the main lessons is that human impacts on the environment are irreversible. We should learn from biology when addressing environmental impacts on the brain.