WFN Neuroinfection Series: A Success Story Continues

By Dr. Chandrashekhar Meshram

Chandrashekhar Meshram

The Tropical and Geographical Neurology Specialty Group of the World Federation of Neurology, in collaboration with the Forum for Indian Neurology Education (FINE), organized a neuroinfection webinar series held every Saturday from July 18 to Sept. 5. It was first educational activity of its kind by a WFN specialty group. The event was formally inaugurated by Prof. Raad Shakir, immediate past president of the WFN and chair of the WFN specialty groups, in the presence of WFN Secretary General Prof. Wolfgang Grisold. The series was dedicated to Prof. Jagjit Singh Chopra. In the last session, tribute was paid to the late Prof. Amilton Barreira, who was secretary general of the specialty group. Dr. Chandrashekhar Meshram, president of the Tropical and Geographical Neurology Specialty Group of the WFN, was the course director.

Talks were given by Hector Garcia on neurocysticercosis, by Erich Schmutzhard on cerebral malaria, by Marco Tulio Medina on Zika and other arbovirus infections, by Riadh Gouider on  neurobrucelloisis, by Serefnur Ozturk on encephalitis, by Jeremy Day on cryptococcal meningitis, by Prof. Avindra Nath on the approach to neurologic infections, and by Prof. Joseph Berger on fungal meningitis.

Interesting and challenging cases of dengue, rabies, Japanese encephalitis, leprosy, tuberculous myelitis, CJD, neurocysticercosis, amoebic encephalitis, HIV, SSPE,  neurobrucellosis, strongyloidosis, JC virus granule cell neuronopathy, cryptococcal infection in the immunocompromised host, histoplasmosis, antiphospholipid antibody syndrome, cerebral venous sinus thrombosis, aspergillosis, scrub typhus myositis, neurosyphilis, listeria encephalitis, mucormycosis, and H1N1 encephalitis were  presented and discussed during the series. The complexities in manifestations, course, and treatment in different cases were the highlights of the series. There were analytical interactions from the faculty and audience.

Sarosh Katrak, S.Prabhakar, John England, Gustavo Roman, Chris Kennard, Wolfgang Grisold, Hadi Manji, Deanna Saylor, Steven Lewis, Kiran Thakur, Davis Garcia-Azorin, B. S. Singhal, Augustina Charway-Felli, JMK Murthy, Marianna de Visser, and Jacques Reis chaired the sessions.

Participants were from different countries across the globe, and more than 1,400 delegates registered for the series. Regular participants were from India, Sri Lanka, Bangladesh, Pakistan, Brazil, Peru, Honduras, South Africa, Ghana, Kuwait, UAE, Sudan, Zambia, and the United States. Participants interacted with the faculty through question and answer sessions.

Reports of the sessions were published in Indian newspapers as part of public education activities.

Those who missed live attendance at the sessions can watch the videos on YouTube, the links to which are available on the WFN website. https://wfneurology.org/2020-09-10-wfn-fine

Second Neuroinfection Series Happening Now

Encouraged by the success of this series, the Tropical and Geographical Neurology Specialty Group, in collaboration with Indian Academy of Neurology and FINE, planned the second WFN Neuroinfection series with eight sessions that began on Sept. 26. WFN President Prof. William Carroll inaugurated this second series. Organization of the sessions rotated between Asia-Oceania,  PAFNS, the AAN ID group, Europe-EAN ID group, and the Pan Africa and Pan Arab regions. Those interested in presenting cases should contact the respective moderator for the session.

Registration is free. Link for registration can be found at: https://forms.gle/BX3xyKcztAWzLGyu6

Registered delegates will be informed about the details of the session by email before each session.

Link to join the program: https://us02web.zoom.us/j/87248087732  

Password: wfnni

Each session takes place at 1 p.m. GMT/UTC and can also be watched on YouTube.

We encourage delegates from different countries  participate and present the cases.•

 

 

International Congress on Neuromuscular Diseases (ICNMD) Went Digital for 2020

By John D. England, Wolfgang Grisold and Juan J. Vilchez

Wolfgang Grisold

John D. England, MD

John D. England, MD

The COVID-19 pandemic has disrupted almost everything, including international meetings. ICNMD 2020, which was scheduled to take place in Valencia, Spain, in July 2020, was cancelled because of global travel restrictions.

The unprecedented situation necessitated the development of new strategies for holding the meeting. The ICNMD team decided to provide a virtual (digital), brief, topic-focused update on neuromuscular diseases for 2020. Since many new diagnostic and therapeutic options are increasingly available, an interim update was deemed to be important. Specific examples for which new therapies are available include spinal muscular atrophy (SMA), hereditary ATTR (hATTR), amyloidosis, and myasthenia gravis. Many additional therapies are in various stages of development.

The challenge was to organize and dedicate speakers who could present time-sensitive information on myopathies, neuropathies, neuromuscular transmission, and motor neuron disease, as well as satisfy the requirements of an EACCME-accredited meeting. Time also was dedicated for excellent industry-sponsored presentations, similar to satellite symposia in face-to-face meetings.

With the help of professionals from International Conference Services Ltd, the development and fulfillment of ICNMDigital 2020 went extremely well. ICNMDigital achieved an impressive attendance of over 796 delegates from more than 58 countries. The program featured 27 speakers in 12 scientific sessions across four thematic days. In addition, several Industry-Supported Symposia were presented. Feedback from attendees was very positive, and most participants suggested that some form of virtual presentations remain a part of future meetings.

As validation of the sucess of the conference, we offer the following comments from participants:

“We hope that 2021 will give us the possibility to organize the live congress again in Valencia, and definitely we have learned that virtual sessions and hybrid constructions will be useful and necessary in the future.”

“ICNMDigital met the challenge to organize in a very short time frame an exciting congress with outstanding content. The technical staff was incredibly helpful to make it a successful and smooth experience. Two thumbs up for organizers and all people with hands on!” –Laurent Servais

“I was fortunate to be able to give a talk alongside Mary Reilly, one of the best inherited neuropathy researchers in the world. Her talk brought a great crowd and set us on the right track. Davide Pareyson was a wonderful moderator, and we had incredible questions from the audience. The virtual format worked well, and I think encouraged even more thoughtful questions, which is what helps everyone learn. The ICNMD conference pulled off a great conference given very difficult circumstances.” – Brian Callaghan

As a reminder, the live ICNMD 2021 meeting is scheduled for May 28-June 1, 2021 in Valencia, Spain. Faculty from ICNMDigital 2020 will again join with the addition of new experts/sessions addressing updates and breakthroughs in research. A special session on COVID-19 is planned. All previously accepted abstracts remain on the schedule for ICNMD 2021. In addition, the ICNMD 2021 website will reopen for new or updated abstract submissions. See www.icnmd.org for details.  •

 

 

Parkinson’s Disease in Africa: A South African Perspective

A Report in Relation to World Brain Day 2020

By Dr. Marcelle Smith and Dr. Patty Francis

The African continent has been experiencing rapid changes in recent decades, with increases in life expectancy. The average healthy life expectancy increased from 46.1 years in 1990 to 55.2 in 2017.1 This is still far below the average life expectancy in high-income countries of over 70 years.2 However, this has been sufficient to increase the burden of age-related and neurodegenerative conditions such as Parkinson’s Disease (PD).

Marcelle Smith, Patty Francis

There is a belief that PD is less prevalent in African countries, but incidence or prevalence studies for Africa are lacking. Most of the available studies are specific to individual countries. Williams et al. reviewed all the literature on PD in Sub-Saharan Africa published up to May 2016. The authors observed a prevalence of PD ranging from 7/100,000 in Ethiopia to 67/100,000 in Nigeria.3

African countries experience unique challenges when it comes to diagnosis and treatment of PD. Firstly, there are far fewer neurologists in African countries compared to high-income countries, 0.03/100 000 in Africa versus 4.84/100,000 in Europe as per the WHO Neurology Atlas. The WHO recommends at least one neurologist per 100,000 people.4 Approximately 270 million Africans live in countries where there are less than five neurologists per country. Less than 50% of Sub-Saharan African countries have a neurological society.5 This limited access to neurologists leads to underdiagnosis and treatment of patients with neurological disorders such as PD.

The Neurology Association of South Africa comprises 87 neurologists in full-time private practice, 28 in full-time public sector practice and six members in limited practice. 27 registrars are currently in training. This gives a crude estimate of one neurology service provider per 400,000 population in South Africa.

Many African countries are also overburdened by malaria, TB, HIV, and other infectious outbreaks, e.g. Ebola. Hence very few facilities and resources are dedicated to non-communicable illnesses. Medication is only available to 12.5% of Africans with PD compared to 79% in Europe.5 60% of Africans live off less than $2 a day and are unable to afford the necessary treatment themselves.6

South Africa’s population was estimated at 59,308,690 people at mid-year 2020, according to UN data. Between 16-17% of these have private medical insurance, while the rest are dependent on state facilities for health care. Only three PD medications are available in state hospitals at present: levodopa, amantadine, and dopamine agonists. South Africa’s largest private medical funder’s formulary includes biperiden, pramipexole, amantadine, levodopa/decarboxylase inhibitor, and rasagiline.

It is estimated that over 160,000 patients with PD have had deep brain stimulation (DBS) surgery worldwide. This is increasing at a rate of approximately 12,000 per year.7 Three tertiary state neurological centers in South Africa are equipped to perform DBS but still struggle with funding for devices. Four private sector practices offer DBS, although these are general neurology practices with a special interest in movement disorders. No singular movement disorders center exists due to the absolute necessity to cover the entire spectrum of neurology given the ratio of neurologist to patients.

In a recent survey, 74% of South African neurologists report they have referred patients for DBS for the management of a movement disorder.8 Roughly, only one in four (27.37%) neurologists felt they had enough knowledge of, and experience with, the indications for referral for DBS.8 Most South African neurologists refer to the few available DBS centers for Parkinson’s Disease (61.05%).8 However, one of these centers reported performing only five procedures over the last five years. Adequate treatment may allow PD sufferers to continue working and providing for their families for longer.

Most PD sufferers present with the tremor predominant phenotype, which is most common in high-income countries as well. There are, however, certain clinical characteristics unique to African cohorts. In 2016, Mahne et al. from South Africa demonstrated that the akinetic-rigid variant is encountered more frequently in Black patients compared to white patients and can be found in up to a third of all patients.9 This result was replicated by Smith and Modi in a larger cohort. The authors further demonstrated that Black patients appear to develop PD symptoms at an earlier age and develop cognitive impairment more frequently than their American and European counterparts.10 A recent study out of Ethiopia by Melke et al. has also demonstrated a higher prevalence of Parkinson’s disease-related sleep disorders compared to high-income countries.11

African populations have greater levels of genetic diversity and population substructure compared to non-African populations. Africans have also developed many genetic adaptations that have evolved in response to factors such as diverse climates and exposure to infective diseases.12 This makes Africa a prime place to study genetic diversity and its impact on different diseases. In the last two decades, research of PD genetics in Sub-Saharan Africa has gained momentum. In 2009, Bardien et al. concluded that mutations in the Parkin gene, a common cause of genetic PD worldwide, were not an important cause of PD in South Africa.13 The G2019S mutation in the LRRK2 gene is the most common mutation associated with PD. However, a 2019 study from Du Toit et al, revealed that none of the 91 Black South African participants in their study had this mutation.14 This shows that some of the most common PD-associated genetic mutations globally are not truly relevant in Sub-Saharan African populations. The mutations specific to PD in this populations have yet to be discovered and hold much potential for further research.

The dearth of genetic studies in African countries can, like many other problems on the continent, be attributed to a scarcity of resources. An in-depth look into PD genetics may provide answers to whether characteristics specific to PD in African countries does in fact have a genetic and ethnic foundation, or if it is related to poverty and other challenges experienced by low-income and under-resourced populations.

The amount of PD research in African countries has increased significantly in the last two decades; however, the studies have not been directly comparable because of inconsistence among study designs.15 As African neurologists we need to strive for collaboration between different countries across the continent to find solutions to our continent’s unique challenges.

GBA mutations have emerged as the most common risk factor in PD.16 Some of the clinical features including early age of onset and cognitive impairment are also more common in patients of African origin compared to Caucasians. A genetic study investigating the prevalence of the GBA mutation in PD patients in Africa may yield interesting results.

Academic centers across Africa are collaborating more and more with one another as well as overseas centers through shared congresses and research. An example of this is the combined annual meeting of the Neurological Association of South Africa and the African Academy of Neurology in 2019. Collaboration is the key to improving care for our continent’s Parkinson’s disease population and to better understand the unique aspects of Parkinson’s disease in Africa. •

Dr. Marcelle Smith, MBChB (Stell), MMEDNeurol (Wits), FCNeurol (SA), Wits Donald Gordon Medical Center and Sandton Mediclinic, Johannesburg, South Africa.

Dr. Patty Francis, BScHONS (UCT), MBChB (WITS), FCNeurol (SA), neurology consultant, Private Practice Netcare Umhlanga Hospital, Durban, South Africa.

References:

  1. Wiysonge, C S. People in Africa live longer. But their health is poor in those extra years.
  2. Duffin, E. (2019). Life expectancy in Europe in 2019, Statista.com.
  3. Williams, U. et al (2018). Parkinson’s Disease in Sub-Saharan Africa: A Review of Epidemiology, Genetics and Access to care, J Mov Disord, 11(2), pp.53-64
  4. WHO. (2004). Neurology atlas, Country resources for neurological disorders [online]. Available from who.int
  5. Bower, J H. et al (2014). Addressing neurologic needs in sub-saharan Africa: An opportunity for multisociety cooperation, Neurology, 83(13), pp. 1270-1209.
  6. Dotchin, C.L., et al (2007). The challenge of Parkinson’s Disease in Africa, Age and Ageing, 36(2), pp.122-127.
  7. Lee, DJ et al (2019). Current and future directions of deep brain stimulation forneurological and psychiatric disorders, J Neurosurg, 131, pp.333-342.
  8. Huth , M. B. et al (2019). South African Neurology Survey 2019 Johannesburg: Neurological Association of South Africa.
  9. Mahne, A.C. et al (2016). Clinical findings and genetic screening for copy number variation mutations in a cohort of South African patients with Parkinson’s Disease, SAMJ, 206(6)
  10. Smith, M and Modi, G. (2016).The clinical profile of idiopathic Parkinson’s Disease in a South African hospital complex- the influence of ethnicity and gender, African Journal of Neurosciences, 35(1)
  11. Melka, D et al (2019). Prevalence of sleep disorders in Parkinson’s Disease patients in two neurology referral hospitals in Ethiopia, BMC Neurology, 19(205)
  12. Campbell, M. C. and Tishkoff, S. A. (2010). African Genetic Diversity: Implications for Human Demographic History, Modern Human Origins, and Complex Disease Mapping, Annu Rev Genomics Hum Genet, 9, pp.403-433.
  13. Bardien,S et al (2009). Molecular analysis of the parkin gene in South Africa patients diagnosed with Parkinson’s disease, Parkinsonism Relat Disord, 15(2),pp.116-21
  14. Du Toit,N. (2019). Frequency of LRRK2 G2019S mutation in South African patients with Parkinson’s Disease, Neurogenetics, 20(4), pp.215-218.
  15. Oluwole, O G. et al (2018). Parkinson’s Disease in Nigeria: A review of published studies and recommendations for future research, J Mov Disord, 11(2), pp. 53-64.
  16. Barkhuizen, M. et al (2016). Advances in GBA-associated Parkinson’s Disease- Pathology, presentation and therapies, Neurochemistry international, 93, pp.6-25

 

 

A Great Time at The Neuro

My Report of the Canadian Department Visit Program (2019)

by Guillermo Delgado-García, MD

A snowy Montréal received me on a Saturday in mid-November; the previous morning I sat my annual examination and then I was there—3,700 kilometers from Mexico City. After touring Montréal’s museums, Monday arrived and I visited Dr. Anne-Louise Lafontaine, chief of the Department of Neurology of the McGill University Health Centre at the Montreal General Hospital. Dr. Lafontaine was extremely kind, welcomed me warmly, and asked me about my plans for the observership and also for the future.

From left to right: The author, Dr. Eliane Kobayashi, program director of the Frederick Andermann Clinical & Research Fellowship in Epileptology & EEG, and Dr. Dina Namiranian, a senior neurology resident, at the EEG lab.

Back at The Neuro, I looked for Dr. Eliane Kobayashi (Fig. 1) and found her at the weekly epilepsy rounds, held at the EEG lab, where cases are presented and discussed by a world-renowned multidisciplinary epilepsy team, including epileptologists, neurosurgeons, and neuropsychologists, among other highly trained professionals. At the end of the rounds, I introduced myself to Dr. Kobayashi, and she received me with open arms from the beginning. I then joined her team at the Epilepsy Monitoring Unit (EMU). This team was awesome, very friendly, and included Dr. Ghada Abbas (epilepsy/EEG fellow), Dr. Austin Zaloum (neurology resident), and Dr. Rafael Batista João (visiting epileptologist from Unicamp). The EMU is a place specially designed and equipped to care for adult patients undergoing long-term video EEG and is currently considered the gold standard for the diagnosis of epilepsy and seizure-like spells (Epilepsia. 2018;59:27-36).

On Wednesday mornings, I attended McGill’s neurology grand rounds in the de Grandpré Communications Centre, and afterward I stayed there with the neurology residents for the academic half-day activities. One afternoon that first week, I joined Dr. Kobayashi at the outpatient clinic, and there I also met Dr. Giovanni Pellegrino (epilepsy/EEG fellow), with whom Dr. João and I discussed the differences in neurological and epilepsy training in different parts of the world.

On Thursday morning, I met my supervisor, Dr. Birgit Frauscher, at the EEG lab. She was extraordinarily kind, generous, and inclusive all along. From that moment on, I started interpreting routine and prolonged EEGs with her at the reading room. That very day, she introduced me to her wonderful and diverse team from the Analytical Neurophysiology (ANPHY) Lab: Dr. Véronique Latreille, Dr. Petr Klimeš, Dr. Laure Peter-Derex, and Tamir Avigdor. This lab seeks to employ a variety of quantifiable tools in order to shed light on neurophysiological and pathological processes (mainly sleep and epilepsy). In the ANPHY lab, I was also introduced to high density EEG and other advanced source localization techniques.

After one of Dr. Gotman’s lab meetings. In the background, the evocative mural The Advance of Neurology (1955) by Mary (Filer) Spence-Sales can be seen (room 124). From left to right: Abdullah Azeem, Natalja Zazubovits, Tamir Avigdor, Dr. Petr Klimeš, Dr. Birgit Frauscher, the author, Dr. Jean Gotman, Dr. Véronique Latreille, Dr. Willemiek Zweiphenning, Dr. Andreas Koupparis and Dr. Nicolás von Ellenrieder.

That weekend Dr. Frauscher invited me to the First National Training Course on Sleep Medicine, which she organized and chaired. This two-day program was designed to provide a basic working knowledge of sleep medicine for Canadian neurology residents, and included a range of internationally renowned speakers and hands-on practical training on case interpretations of polysomnography. This course allowed me to interact with neurology residents from different universities, as well as with Canadian sleep experts.

 

The next week, I joined Dr. Frauscher at the outpatient clinic, where she introduced me to the very practical basics of vagal nerve stimulation in epilepsy. Furthermore, she let me get involved in preparing the next stereo EEG planning meeting and this was, in fact, my first real-life exposure to stereo EEG. Meanwhile on the scientific side, on Friday afternoons we all attended Dr. Jean Gotman’s lab meetings, which were both challenging and appealing.

From that week on, I started attending The Neuro’s Killam Lectures, held on Tuesday afternoons, and also the weekly epilepsy conferences, held on Thursday afternoons. The Killam Lectures are supported by the Killam Trusts and are given by outstanding guest speakers whose research is of interest to the scientific community at The Neuro and McGill University. On the other hand, the epilepsy conferences included a case presentation, EEG review, and roundtable discussion.

In my third week, I worked with Dr. Frauscher and Dr. Zaloum at the EMU. It was an intense but also very rewarding week. In addition, I had the opportunity to attend the tribute to Dr. Frederick Andermann (1930-2019), where an international panel of renowned epileptologists gathered to present the latest advances in the field in an homage to Dr. Andermann, director of the epilepsy unit at The Neuro for 35 years and one of the world’s most distinguished epileptologists. This special event was both intellectually stimulating and moving. During the second half of my observership, I also had the honor to work under the supervision of Dr. Martin Veilleux at the EMU.

In addition to the impact of this observership on me in terms of clinical and scientific experience, I really want to highlight another aspect of my visit: the kindness and openness of all the people I met in The Neuro, as so perfectly exemplified by daily lab lunch with Dr. Frauscher and her team. Among those whom I have not mentioned by name above, Natalja Zazubovits and Abdullah Azeem from Dr. Gotman’s lab were eager to help all the time and their assistance was invaluable to me.

One morning there was an exception to my normal work week at The Neuro. On this occasion, I visited the Osler Library of the History of Medicine, a branch of the McGill University Library. This visit was only possible thanks to the immense generosity of Dr. Mary Yearl, the Osler librarian, since the Osler Library was temporarily closed due to a fire at the McIntyre Medical Sciences Building. Rare materials were rehoused in the McLennan Library Building and that was where Dr. Yearl patiently showed me the treasures and rarities of the Osler Library. She later took me to the Osler Room in the McIntyre Building and, even though it was empty, it was evident what Michael Bliss wrote in his book: the Osler Room was “a shrine, architecturally a cross between a church and a mausoleum.” (William Osler: A Life in Medicine, 1999)

Sir William Osler (1849-1919) has been one of my medical and intellectual role models for more than a decade, so this visit had a great impression on me. Although less and less read, many of his insights are still true for general neurology and even for epileptology. The following passage is an example of this: “It is well always to be suspicious of epilepsy developing in the adult, for in a majority of such cases the convulsions are due to a local lesion.” (The Principles and Practice of Medicine, 1892) When we said goodbye, Dr. Yearl told me that I could not leave Montréal without visiting Mont-Royal. Therefore, on my last day before returning to Mexico City, I walked down the Promenade Sir William Osler to the foot of Mont-Royal. It was a misty morning and a few drizzle drops fell from time to time. While there, the main staircase seemed endless to me but, 30 minutes later, I reached the Chalet du Mont-Royal. This trip was physically demanding but also unique, especially for my weakness for misty (and thus cryptic) landscapes.

My experience at The Neuro made me wonder about the unmet needs in my home country regarding the care of persons with epilepsy. I’m sure they are multiple and at different levels. Since my center is a public tertiary referral hospital, I think many of our most complex patients could benefit from long-term video EEG in an elective admission to a specialized inpatient setting (i.e., an EMU). Therefore, a first step might be to start an EMU here and, if successful, to extend this program to other strategic tertiary neurological services nationwide.

I finally want to acknowledge the World Federation of Neurology, The Neuro, and the Canadian Neurological Society for this great initiative that allowed me to experience the Canadian neurological system in an international environment, meet new colleagues, and foster future cooperation. I also want to thank Dr. F. Gonzalez-Crussi (Northwestern University), my long distance mentor, for his insightful comments on an earlier version of this report. •

Guillermo Delgado-García, MD, is a senior neurology resident and MSc student at the National Institute of Neurology in Mexico City.

 

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