PRESIDENT’S COLUMN:
When Neurology Is Under the Spotlight

Raad Shakir

Raad Shakir

Over the last three months, the world has been facing a most serious and devastating epidemic. The World Health Organization (WHO) declared Zika virus infection as a Public Health Emergency of International Concern (PHEIC). This has triggered a massive international response not only in the Americas, but also across the world. Cases of Zika virus infection are being reported in the thousands across the northern parts of South and Central America. To date, the WHO reports the infection to be present in 62 countries between 2007 and 2016. The transmission is not only reported in Latin America, but in Cape Verde, and recently Vietnam reported mosquito-borne Zika virus infection.

The issue is compounded by the fact that the symptoms of the Zika virus infection are mild, and none disabling. However, the neurological complications are most serious. Zika virus infection is described as the most devastating viral infection during pregnancy. The reported microcephaly is most serious, and we have no idea what the future holds for those babies born to mothers without obvious microcephaly. One can reasonably conclude that the reported Zika virus isolated from post mortem cases of invasion of brain and spinal cord suggests that we may be facing a future group of affected children with many neurological complications of as yet unknown nature.

Figure 2- left to right, Dr. Iledefonso Rodriguez Leyva, Dr. Karina Velez Jimenez, Professor Raad Shakir, Dr. Minerva Lopez, Dr. Steven L. Lewis, during the WFN visit to neurology training programs in Mexico City.

Figure 2- left to right, Dr. Iledefonso Rodriguez Leyva, Dr. Karina Velez Jimenez, Professor Raad Shakir, Dr. Minerva Lopez, Dr. Steven L. Lewis, during the WFN visit to neurology training programs in Mexico City.

The second neurological condition which has increased in those affected with Zika virus infection is Guillain-Barre syndrome. This, in a way, is expected following a viral infection. The seriousness of the condition is made much worse by the lack of local availability of supportive treatment. Generally, at least a fifth of GBS patients may require respiratory support, which is compounded with lack of availability of IV immunoglobulin. The cost of both modalities is prohibitive. In some parts of Latin America, the use of plasma exchange is the way GBS is treated rather than IV immunoglobulin. Even with this, many locations in affected areas do not have the facilities or the training to use plasma exchange machines. This puts lives at risk.

One has to remember that the diagnosis and management of GBS requires neurological expertise, which is scarce to say the least. It would be reasonable to state that the 1 in 20 mortality rate reported in the developed world will be much higher for those affected by GBS in the currently Zika virus affected areas.

All this prompted the WFN to mount a concerted effort to tackle the problem. The WFN Zika Virus Working Group was formed, and the committee is chaired by John England, MD, New Orleans. The membership includes experts in child neurology and GBS, with neurologists from the most affected countries in South and Central America. See more at www.wfneurology.org/committees?tab=16016.

Meeting of the WFN with some of the members of the Zika Working Group at the American Academy of Neurology Annual Meeting in Vancouver on April 18, 2016. From left to right: Raad Shakir, MD; David Bearden MD; Ildefonso Rodriguez-Leyva, MD; Miguel Osorno Guerra, MD; Minerva Lopez Ruiz, MD; Karina Velez Jimenez, MD; Allen Aksamit, MD; and Russell Bartt, MD; Also participating in the meeting, but not in the photo, were William Carroll, MD, Wolfgang Grisold, MD, Steven Lewis, MD, and Marco T. Medina, MD.

Meeting of the WFN with some of the members of the Zika Working Group at the American Academy of Neurology Annual Meeting April 18 in Vancouver. From left to right: Raad Shakir, MD; David Bearden MD; Ildefonso Rodriguez-Leyva, MD; Miguel Osorno Guerra, MD; Minerva Lopez Ruiz, MD; Karina Velez Jimenez, MD; Allen Aksamit, MD; and Russell Bartt, MD; Also participating in the meeting, but not in the photo, were William Carroll, MD, Wolfgang Grisold, MD, Steven Lewis, MD, and Marco T. Medina, MD.

Meeting of the WFN with some of the members of the Zika Working Group at the American Academy of Neurology Annual Meeting April 18 in Vancouver. Meeting of the WFN with some of the members of the Zika Working Group at the American Academy of Neurology Annual Meeting April 18 in Vancouver.

The WFN is also an active contributor to the WHO committee on Zika. This committee met in Geneva, and according to Dr. England’s executive summary, “Collaborative interdisciplinary research on Zika infection and its neurological complications is already being organized, but funding is severely lacking at this time. As an important first step to enhance research collaboration and provide for transparent data sharing, the Neurovirus Emerging in the Americas Study (NEAS), www.neasstudy.org/en/home/, is being organized and is supported by an approved Johns Hopkins Medical Institutions IRB protocol. Researchers are encouraged to visit the NEAS website for additional information. The situation is rapidly evolving; therefore, all information is subject to modification as we learn more about this emerging crisis.”

The WHO situation report on April 7, 2016 concludes “The global prevention and control strategy launched by the World Health Organization (WHO) as a Strategic Response Framework encompasses surveillance, response activities, and research. This situation report is organized under those headings.”

The WFN Zika virus committee met on Monday, April 18th in Vancouver during the 68th AAN meeting to further discuss the issues. The following questions were put to the experts for a response.

  1. Do we have a diagnostic ELISA test or the like, for quick diagnosis?
  2. Can individuals have the neurological complications without exhibiting the febrile illness, and if so how can we be sure of diagnosis?
  3. Do we know the spectrum of all the fetal neurological deficits?
  4. How long is the period of viral human-to-human infectivity after the Zika virus infection illness?
  5. Do we have a registry of morbidity and mortality related to GBS resulting from Zika virus infection?
  6. It is important to understand whether the variant of GBS associated with Zika is different than other varieties of GBS.
  7. Is there a registry of cases of neurological Zika virus infection other than GBS?
  8. Any report on vaccine development?
  9. Is Zika virus present in breast milk and what is the risk to breast-fed infants?
Pres-Column-Fig1_NeurologyAtlas_1

Legend Fig. 1 Neurology Atlas 2015. Editor’s note: The data in the Neurology Atlas figure are a draft and the definitive data may be different when the final WHO version is produced.

One can easily see that the brunt of the neurological complications fall in the child neurology world. The WFN is working very closely with the International Child Neurology Association to collaborate and come up with a joint stance in combating this most devastating viral infection during pregnancy. The ICNA is dedicating a session of its forthcoming world congress to Zika viral infection.

The division of mental health, substance abuse, and neurosciences in the WHO is very keen on informing member states on the importance of neurological expertise in the fight against Zika virus infection. This has brought into focus the dire lack of neurologists both for adults and children across the world. The second edition of the Neurology Atlas jointly produced by the WHO and the WFN has demonstrated in its figures that the mean number of neurologists per 100,000 people is 0.7 in the Americas, compared to 6.6 in Europe (Fig1). The figures are more poignant as the Pan American region includes the U.S. and Canada. The logical conclusion is that there is a vast shortage in the areas affected by Zika virus infection.

The WFN is collaborating with the Canadian Neurological Society to join the worldwide program for short-term training of young neurologists and in this case neurologists will be chosen from Latin America for short training periods in Canada. The WFN has already had such a program with four European countries for training African Neurologists, and now the program is branching out to the Americas.

In March 2016, the neurology training program in Mexico has been inspected and accredited by the WFN, and a similar short-term training will start. Mexico already trains young neurologists from across Central America (Fig2).

Perhaps Zika virus infection has produced a momentum for all of us to demonstrate our willingness to cooperate and act quickly in the face of this pandemic. We are at the beginning of a long, difficult, and tortuous road.

World Brain Day 2016

Brain Health in an Aging Population: “The Aging Brain”
By Mohammad Wasay, MD, FRCP, FAAN, and Wolfgang Grisold, MD

An Aging Population

World-Brain-Day-imageThe global share of older people (age 60 and over) is more than 800 million (12 percent of the population) and is growing, with the expectation that it will reach more than two billion (21 percent of the population) by 2050. Currently 70 percent of the world’s older population lives in developed and developing countries, but by 2025, 80 percent of the older population will be living in less developed countries. Older persons are projected to exceed the number of children in 2047. It has already started in developed countries. In 2015, Japan became the first country in the world where more adult diapers than baby diapers were sold.

Population aging has major social, health, and economic consequences. The prevalence of non-communicable diseases and disability increases with age. Poverty is high among older persons. There is increased pressure on social support systems for older persons. The growing burden of diseases and disability, and reducing financial and social support in an aging population will be among the huge challenges for societies and governments with respect to their social and health care systems in coming years.

Brain Diseases in the Aging Population

The prevalence of a number of neurological diseases increases with age, including stroke, dementia, and Parkinson’s disease. It is estimated that 10 to 20 percent of people aged 60 to 80 years suffer from one or more of these diseases. More than 30 percent of persons who are 80 years or older suffer from at least one neurological disease.

Disability due to neurological diseases and other musculoskeletal diseases is very high and growing. It is estimated that more than 20 percent of people over 60 years old need support for activities of daily living.

The economic burden of this is huge. It is estimated that almost half of the health care expenditure is related to the care of older persons in developed countries today, and it is projected to become two-thirds by 2030. The same trends are expected in developing and less developed countries by 2050.

The medical community, however, must be cautious on the wording when “burden” with regards to costs of the aging populations is mentioned. We need to be aware that the word “burden” has a potentially negative connotation, which rather should be replaced with a more positive wording— which we feel is better stated as a responsibility.

World Brain Day Theme: “Brain Health in an Aging Population”

It is clear that brain health is going to be the most important determinant of social and economic well being of older persons in the future. On the one hand, health care authorities are deeply concerned with the current status and future trends of our growing population, but little has been done to handle these growing needs.

The World Federation of Neurology has stepped forward to dedicate this year’s World Brain Day to the aging population and has chosen the motto: “The aging brain.” Our intention for this World Brain Day is to increase awareness about the treatment and prevention of brain and neuromuscular diseases affecting mostly elderly persons. The first step of prevention is to improve concepts and means of brain health also among the younger population in order to help prevent brain disease later in life and to improve the quality of life for older persons.

Disease prevention is the concept. However, a much larger number of individuals will be affected by diseases of the brain and the neuromuscular system, which are not (yet) preventable. Thus it is also the duty of society to care for the elderly with progressed neurological disease, and to provide the framework for quality of life, dignity, and the necessary care.

In this group of patients, the focus has to shift from the aspect of a curative condition, towards the inevitable death of all individuals. The concept of palliative care and hospice needs to be implemented in the aging population and in neurological care.

How Can we Improve Brain Health and Prevent or Treat Neurologic Diseases and Care for Persons with Advanced Brain Disease?

Stroke and vascular dementia are among the most important neurological diseases affecting persons of higher age. For these conditions, there are preventable and modifiable risk factors. Education, cognitive exercises, physical activity, and nutrition are important areas of intervention for prevention and slowing down of cognitive decline. Parkinson’s disease is a neurodegenerative disorder, but effective symptomatic treatment is available.

Emotional health is as important as cognitive health in elderly persons. Quality of life and a lack of disability can be associated with emotional well-being. Effective interventions are available for maintenance and promotion of emotional health.

Despite prevention strategies, age is a non-modifiable risk factor, just as effects of degenerative and hereditary diseases on the brain and the neuromuscular system. Supportive, palliative care, and the hospice concept need to be integrated into the concept of neurological care in dealing with an aging population.

WFN and National Societies Activities

To raise awareness with respect to the aging brain and neurologic diseases in the elderly, the WFN is asking its members to use this year‘s “Day of the Brain” to advocate and campaign in their country for these emerging problems.

The WFN public awareness and advocacy committee will prepare publicity material for this campaign, which includes logos, banner ads for web sites, handbills, brochures, posters, billboards, and presentations.

There will be a press conference. A template press release will be prepared and circulated to delegate societies. They can be adapted for local use with respect to national/regional data, priorities, or by adding quotes from national/regional experts.

The most important target of this campaign is the public. We need to create simple messages in local languages and promote them via print, electronic and social media, billboards, banner, events, etc.

Other important areas of intervention are health care authorities and policy makers. Our campaign should result in policy and priority shift at the national or local level. We have to plan targeted activities to facilitate this outcome.

Another important area of intervention is awareness and training of general practitioners, nurses, and paramedical staff.

Involvement of the media is a must. Celebrities or scientists could be a part of this advocacy campaign.

Delegate societies are strongly encouraged to organize awareness activities that may include press conferences, media briefing sessions involving local media, seminars, conferences, public awareness sessions, presentations at local schools, colleges, universities, posters, essays, drawing competitions, and newspaper and magazine articles.

Collaborators

As in the past, the WFN will work with various health entities, and professional and welfare organizations to promote awareness for World Brain Day.

The WFN is hoping for your collaboration to improve the health and future of patients with an aging brain. Please follow our website, www.worldneurologyonline.com and our social media. If you have suggestions, or ideas for World Brain Day 2017, please do not hesitate to contact us at wbd2016@wfneurology.org.

 

 

From The Editors

By Steven L. Lewis, MD, Editor, and Walter Struhal, MD, Co-Editor

Walter Struhal

Walter Struhal

STEVEN L. LEWIS

Steven L. Lewis

We are pleased to introduce this issue of World Neurology, which includes topics of interest to all readers. In this issue, Raad Shakir, MD, the president of the WFN, reports on the work being done to address the Zika virus epidemic, including efforts via the World Health Organization (WHO) and the WFN. Mamta Bhushan Singh, MD, and Michael F Finkel, MD, discuss the challenges and issues involved in tackling the problem of epilepsy in the developing world. Mohammad Wasay, MD, and Professor Wolfgang Grisold, MD, the secretary-general of the WFN, review the background and planning for this year’s day of the brain, World Brain Day 2016: Brain Health in an Aging Population. J. Eduardo San Esteban, MD, discusses the past, present, and hopes for the future of Pan American neurology and collaboration to address neurological diseases throughout the Americas. Also in this issue, Morris Freedman, MD, trustee of the WFN, with colleagues from the WFN and the Canadian Neurological Society, announce a new joint initiative between our two organizations for neurology trainees or junior faculty from Central or South America to visit the Montreal Neurological Institute for a four-week department visit. Similarly, in this issue, the WFN and the German Neurological Society announce a new department visit program for two African colleagues to visit the department of neurology in the St. Josef-Hospital in Bochum (University Clinic of the Ruhr University) and the department of neurology at the Hospital of Ulm University for four weeks. As an example of the outcome from such a visit, Kalpesh Deraji Jivan, MD, from South Africa writes an enthusiastic report from his four-week visit to the neurology intensive care unit at Innsbruck Medical University in Austria, sponsored by the WFN and the Austrian Neurological Society. Vera Bril, MD, discusses the plans for the upcoming 14th International Congress on Neuromuscular Diseases being held in collaboration with the WFN in July 2016 in Toronto. Finally, in our regular columns, John D. England, MD, editor-in-chief of the Journal of the Neurological Sciences, provides his editor’s update and selected free-access articles from the two most recent issues of the journal; John F. Brandsema, MD, reviews a recent book on Duchenne muscular dystrophy; and M. J. Eadie, MD, provides a biography of a pioneer in the epidemiology of multiple sclerosis.

We hope you enjoy reading this issue of World Neurology. Within this issue, Dr. Grisold and the editors also announce a call for articles on neurologic education for future issues. We look forward to these and other submissions of interest to the readers of World Neurology.

14th International Congress on Neuromuscular Diseases to Feature the World’s Leading Experts

By Vera Bril, MD

VERA BRIL, MD

VERA BRIL, MD

The 14th International Congress on Neuromuscular Diseases (ICNMD 2016), under the auspices of the World Federation of Neurology, will be held in Toronto, Canada from July 5–9, 2016 at the Sheraton Centre Toronto Hotel. The ICNMD is the formal meeting of the Research Group on Neuromuscular Diseases, formally affiliated with the World Federation of Neurology. It has been 14 years since the ICNMD Congress was held in Canada, with Vancouver, British Columbia, hosting the 2002 Congress.

Building on the success of preceding Congresses, in Vancouver, Istanbul, and Naples, it was decided at the previous meeting in Nice, France (ICNMD 2014) that the Congress be moved to a two-year cycle instead of meeting every four years.

While much encouragement and progress is going on in the field of neuromuscular diseases, especially with the recent support of the ALS Ice Bucket Challenge, the disease remains a huge global health problem.

The Congress will address all aspects from muscular dystrophies, other myopathies, myasthenia gravis, polyneuropathies, spinal cord disorders, and neurofibromatosis, to name just a few of the major themes within the Congress. The Congress will include updates on understanding of the genetics, pathogenesis, evaluation, and treatment of neuromuscular disorders.

The Scientific and Program Committee invited some of the world’s leading experts in the field of neuromuscular diseases, with the hope that at the end of the Congress, attendees will have garnered the most up-to-date information available in neuromuscular disorders.

The Congress is CME Accredited from the University of Toronto. For the total number of credits, please visit the Congress website.

The Program and Scientific Committee has worked tirelessly to plan an exemplary and intellectual program to inspire, educate, and support those individuals and organizations that fight against neuromuscular diseases.

The Congress will unofficially start on Tuesday, July 5 with a full day of Teaching Courses. These courses will be small classroom-sized sessions with a focus on the practical applications and knowledge of specific topics.

An Opening Ceremony is scheduled for Tuesday evening, and from Wednesday, July 6 to Saturday, July 9, the Congress will host workshops that offer multidisciplinary exploration of focused topics related to neuromuscular diseases.

There will be four exciting Plenary Sessions that will feature experts in their fields. Topics include genetics, hot topics, muscular dystrophy, and motor neuron disease.

Toronto is one of the most multicultural diverse cities in the world, where more than 140 languages are spoken, and microcosms of different cultures are thriving in unique cohesion. Only a short distance to world renowned attractions like Niagara Falls and the Canadian wilderness, ICNMD 2016 promises to be a highly rewarding meeting on a social and intellectual basis.

For more details around the scientific program, and registration, please visit the Congress website at http://icnmd2016.org. 

Vera Bril, MD, is president of the 14th International Congress on Neuromuscular Diseases (ICNMD) 2016, professor of neurology, Krembil Family chair in neurology, program medical director, Krembil Neuroscience Program, University Health Network, head of neurology, University Health Network, Mt. Sinai Hospital, deputy physician-in-chief, finance, University Health Network, Mt. Sinai Hospital, Toronto.