Articles – Page 51

A Report on a Visit to Sleep 2017 in Boston

WFN Junior Traveling Fellowship Award Recipient

By Oluwatosin Olorunmoteni

I am delighted to present my report on Sleep 2017. I had the privilege of attending this meeting through the sponsorship provided by the WFN as a recipient of a Junior Traveling Fellowship Award.

Oluwatosin Olorunmoteni at Sleep 2017 in Boston, Massachusetts.

Sleep 2017 was the 31st annual meeting of the Associated Professional Sleep Societies, LLC (APSS) comprising the Sleep Research Society (SRS) and the American Academy of Sleep Medicine. Although I developed interest in pediatric sleep medicine during the course of my training in pediatric neurology, I have not been able to take formal training in sleep medicine or attend a conference on sleep. I am exceedingly grateful to the WFN for making this dream come true.

Sleep 2017 was held June 3-7 at the Hynes Convention Center in Boston, Massachusetts. It was an educational and impactful experience for me.

On Saturday, June 3, I attended a half-day postgraduate course on EEG Essentials for the Sleep Practitioner. Following that, I had the privilege of participating in the SRS Leadership Workshop. The educational programs organized by SRS continued on Sunday, June 4, with the Trainee Symposia Series. These two trainee development programs by the SRS were my best sessions at the meeting as I had the privilege of meeting and learning from leaders in the field of sleep medicine. I also had opportunities of networking with colleagues.

Oluwatosin Olorunmoteni presented her abstract.

I presented my abstract on Monday, June 5. More than 1,200 abstracts were presented at Sleep 2017.

The abstract presentation afforded me the opportunity to meet specialists and colleagues in sleep medicine working on similar research areas. I also met a number of Nigerians in the diaspora. They suggested many ideas that can improve my future research. I also discussed the need for a sleep lab in my institution with many of them, and they offered useful suggestions on the way forward.

Sleep 2017 had many educational opportunities, which were highly beneficial especially for young professionals like me. There was never a dull moment as I attended sessions that included Invited Lectures, Conversation with Experts, Symposia, and Oral and Poster Presentations. I learned a lot from the pediatric sleep sessions, where discussions on actigraphy, pediatric narcolepsy, school start times, and parasomnias were discussed.

A major benefit of attending Sleep 2017 for me was the opportunity to visit the Boston Children’s Hospital where I saw the sleep lab. It further increased my quest to intensify efforts to get a functional sleep lab in my institution.

Despite the rainfalls, I was able to visit downtown Boston during the week. I also joined SRS trainees for a time out at the kickball game on Saturday.

I left Boston on Wednesday, June 7. I felt excited and fulfilled because Sleep 2017 was my best conference ever! I am grateful to the WFN for giving me this opportunity.

Oluwatosin Olorunmoteni is from Obafemi Awolowo University in ILE-IFE, Nigeria.

Peripheral Nerve Society Meeting in Sitges, Spain

Mitochondrial transport down dorsal root ganglion axons is impaired by saturated fatty acids, a likely mechanism leading to energy loss and axonal neuropathy in Type 2 diabetes. The slide is from a lecture from Prof. Eva Feldman’s lab.

The 13th Congress of the Peripheral Nerve Society (PNS) took place July 8-13, in Sitges, Spain. The PNS hosts annual congresses, and the next congress will be in July 2018 in Baltimore, Maryland. In 2019, it will take place in Genoa, Italy.

For the International Congress on Neuromuscular Diseases (ICMND) 2018 in Vienna, the Neuromuscular Congress of the Research Group on Neuromuscular Disease of WFN, it is planned that a joint session of the PNS and ICNMD will take place.

The Congress of the PNS is devoted to the peripheral nerves, not only on clinical entities, but building the gap between basic research and toward the clinical implications.

This year, there were 500 participants from more than 50 nations. The PNS has a strong emphasis on education, and about 100 young participants were sponsored to attend the meeting in order to present posters and platform presentations.

The scientific content contained many basic and translational aspects, such as the molecular aspects of node of Ranvier, the metabolic support of axons by Schwann cells, and the new models of auto-immunity to nodal components. Also, pain and ion channels were discussed in plenary lectures.

Sitges, Spain, proved to be an attractive site for the Peripheral Nerve Society Meeting with excellent meeting facilities and attractive beaches.

One of the concerns of the PNS is the research and treatment of inflammatory neuropathies. Treatment studies and open questions were discussed. Another important aspect is diabetic neuropathy, where worldwide an increase of diabetes as a noncommunicable disease is being observed. Mechanisms and possible treatments were discussed. The role of changing food habits, lack of exercise, and lifestyle seem to contribute to this development. A future strategy in a worldwide campaign against diabetic neuropathy was initiated.

Several papers and posters addressed issues of genetic neuropathies. Increasingly, chemotherapy-induced neuropathies are attracting attention, not only in regard to prevention, but also pain treatment and management.

Neuropathic pain was a topic, and ion channels, particularly the PIEZO2, STOML3 channel, were explained and discussed. They will have an impact on our understanding of neuropathic pain. Also, the poster sessions contained several reports on treatment of neuropathic pain.

Daily poster sessions were filled with attendees. Many discussions and interactions took place. Many interesting and often rare observations were displayed and discussed. For scientific papers and merits, traditional prizes (as, for example, the PK Thomas prize) were awarded by the PNS.

In the final ceremony, Steven S. Scherer took over the presidency from Mary M. Reilly.

The congress was held in a nice venue–the Melia Hotel Sitges. Traditionally, as is familiar to all PNS meetings, the atmosphere was good and open, and interactions were encouraged. It was excellently organized, and provided a useful platform to exchange ideas and to engage in networking.

25 Years of Russian-German Neurological Cooperation

By Profs. Peter Wolf and Alla B. Guekht

Inauguration photo from the association’s founding in 1992. Front row from the left: Profs. Peter Wolf, F. Manz, K. Schimrigk, Levon Badalyan, E. Gusev, and B. Guekht.

A meeting on Diseases of the Nervous System — Mechanisms and Treatment was held April 6-7 in Moscow to celebrate the 25th anniversary of the Association for Promotion of German-Russian Cooperation in Neurology.

This association, whose name was later changed to the Russian-German Neurological Society, is perhaps not well known in global neurology, but played an important role in the first period after the European system shifts of 1989-1990. Until then, for about half a century, there had been extremely few possibilities for neuroscientists of West Germany and the Soviet Union to meet and exchange their views or to publish in each other’s journals.

The scientific developments on both sides of the Iron Curtain often went different ways, and the post-World War II generations in East and West took little notice of each other. This was quite a change from earlier traditions, and symptomatic of the general disruption within Europe.

The new possibilities were first explored by Prof. Jefim Salganik of Gütersloh, a German neurologist who was born in the Soviet Union and had studied medicine in Moscow. He contacted and then visited Prof. Levon Badalyan of Moscow, who had been an opponent for his doctoral thesis.

In consequence, a visit of a group of neurologists from northern Germany was organized in February 1991. They met with a group of leading Russian neurologists and their disciples for a seminar, which was held in Moscow and Yaroslavl, Russia. It became an unforgettable experience for all participants. Transportation, lodgings, translations, and meeting facilities, including something as unusual at the time as video demonstrations, needed a lot of improvisation.

All difficulties were overcome by the local organizers, and the hospitality was overwhelming. There was great mutual curiosity about the methods and traditions that had developed, and time set aside for discussion was never sufficient. Thus, the last papers were delivered and discussed on the bus, as all drove back together to Moscow through the white winter landscape. It was one of the occasions where enduring friendships arise among people who until then had been foreigners to each other.

Both sides expressed a strong interest in establishing a platform for future exchange and meetings. Also, in the German group, many were strongly aware of Nazi Germany’s barbarous actions, especially in Eastern Europe. The German group found it their duty to be the first to reach out to Russian colleagues and integrate them into the common European agenda.

When in 1992 the Russian group was received in Germany for a second scientific encounter, the association was founded and registered in Germany, where it also came to function as a commission of the German Neurological Society. Leading neurologists from both countries (Profs. Badalyan, Gusev, Guekht, Schimrigk, Wolf, Haass, Salganik, Manz, and many others) contributed to the establishment and further development of the society.

In the following years, annual meetings alternating between the two countries took place, and informal fellowships for the training of young neurologists were privately organized. More colleagues became interested and joined the society. Over the years, as international contacts and exchange possibilities multiplied, the general meetings lost their uniqueness
and became rarer. However, in some subspecialties, bilateral cooperation intensified and deepened, especially in stroke, epilepsy, and neuromuscular diseases, where several early association members became national and international key players.

The 25th anniversary meeting was a welcome occasion to update newer research and to remember an initiative reflecting very well the spirit and optimism of the early 1990s, which definitely made a change for European neurology.

Prof. Peter Wolf is from Dianalund and Florianópolis, and Prof. Alla B. Guekht is from Moscow.

Report of the Department Visit Program to Turkey

By Dr. Leonard Ngarka

From right to left: Prof. Recep Aygul, Prof. Serefnur Öztürk, Dr. Hakan Ekmekci, Dr. Leonard Ngarka, medical students, and Resident Dr. Azer Mammadli, during ward rounds.

I was delighted when I received the news of my selection for the WFN-Turkish department visit program in October 2016. It didn’t actually take place until Feb. 18, 2017, due to visa procedures. I am grateful to Prof. Alfred Njamnshi and Prof. Serefnur Öztürk, as well as Burak Tokdemir, who facilitated my visa acquisition.

I arrived at the University of Selcuk, University Faculty of Medicine in Konya, Turkey, on Feb. 17, and immediately settled into my accommodations. The next day, I was warmly received by the staff of the Neurology Department under the leadership of Prof. Öztürk, who presented the service. I was handed a detailed program for my stay there. Each working day ran from 9 a.m. to 5 p.m., with a break between noon and 1:30 p.m.

During the four weeks, I spent each day from 9 a.m. to noon seeing patients hospitalized in the department, including those in Neurointensive Care. For the first week, the period from 1:30 p.m. to 5 p.m. was spent in outpatient consultation with the different consultant neurologists, and we received 18-25 follow-up cases and six to eight new cases per day. This exposed me to the manipulation of recent drugs and protocols in the management of patients with neurological disorders.

Selcuk University Faculty of Medicine, Neurology Department team, including all staff in front of the Neurology Department (in-patient service).

The remainder of my afternoons were spent in clinical neurophysiology labs: EMG, EEG, and polysomnography labs for the second, third, and fourth weeks, respectively. I carried out nerve conduction studies on patients who came during this period and did a good number of needle EMGs. All of these were conducted under the supervision of Prof. Recep Aygul and Dr. Hakan Ekmekci. My participation in the EEG sessions has improved my reading and interpretation of EEGs, especially video and sleep EEGs. During the last week of my stay, I had introductory lessons on evoked potentials and polysomnography, of which I did a few and assisted in their interpretation.

I participated in several staff meetings with other departments, including with neuroradiology and interventional radiology specialists to discuss cases of carotid artery stenosis; with endocrinologists, and ear, nose, and throat specialists to discuss the management of patients with sleep disorders; and with the department of psychiatry. There were other presentations in the department among residents and students, and I made a presentation on peripheral nerve disease and entrapment neuropathies.

My experience in Turkey was exceptional, and the memories will last long. It was an exposure to up-to-date science, to culture, and a challenge to pursue excellence. This visit has significantly impacted my clinical practice. I have adapted some of the protocols from Konya (Parkinson’s disease and other movement disorders) in patient care back here in Cameroon. I am presently assisting in doing EMGs in a hospital close to ours in order to continue the training and keep the skills I acquired.

Even though insufficient infrastructure, equipment, and drug availability remain a major setback in Africa, one thing stands: quality training is the bedrock for research and quality patient care and development on this continent. This visit has contributed to improving the quality of my training.

I wish to express my heartfelt gratitude to the World Federation of Neurology, the Turkish Neurological Society, and the Neurology Department of Selcuk Medical Faculty for giving me this opportunity. I wish to thank Profs. Öztürk and Aygul, Dr. Ekmekci, and the neurology residents and staff of this department for making my stay memorable.

In Memoriam: Prof. Franz Gerstenbrand (1924-2017)

We have the sad duty of sharing the news of the passing of Prof. Franz Gerstenbrand.

Prof. Franz Gerstenbrand

Franz Gerstenbrand was born in 1924 in Hof (Moravia, Czech Republic). He completed his medical training in only four years under difficult post-war circumstances in Vienna. His specialty training was at the Psychiatric-Neurological University Department of Vienna University Hospital (Psychiatrisch-Neurologische Universitäts-Klinik Wien), chaired by Prof. Hans Hoff. As a pupil of Prof. Hoff, Prof. Gerstenbrand had great interest in traumatic brain injury and was the first to initiate a unit for traumatic brain injury treatment in Vienna. He also had a keen interest in child neurology.

In 1967, Prof. Gerstenbrand published his habilitation treatise on traumatic apallic syndrome, Das Traumatische Apallische Syndrom. This book for many years was regarded as standard literature on traumatic vegetative state in German-speaking countries, and it made him well known in Central Europe.

Franz Gerstenbrand months before becoming a medical student in Vienna.

Prof. Gerstenbrand was appointed in 1976 as first chair to the University Clinic for Neurology in Innsbruck. He quickly recognized the upcoming needs and advantages of subspecialities within neurology. In the following 18 years, he helped initiate numerous subspecialities, including neurointensive care, neuroimaging, and caring and advocating for stroke patients. All of those initiatives were innovative in the second half of the 1970s. His decisions laid the foundation for the outstanding reputation of the University Clinic for Neurology in Innsbruck.

He was an active clinical researcher, publishing more than 780 papers. He also co-edited 12 textbooks and monographs.

Prof. Gerstenbrand was involved in many international collaborations, including one with the Institute for Biomedical Problems, Moscow, which led to the first Austrian-Russian space neurology collaboration. His team developed a series of experiments that were performed by a number of cosmonauts, including the first and only Austrian cosmonaut, Franz Viehböck.

In 1962, he initiated the Danube Symposium — a clear-sighted decision to bring together East and West European neurology. His strong belief was that Central and Eastern European neurology needed to be represented with a single voice. The Danube Symposia are still held each year.

Networking

Dr. Gerstenbrand (second row on the far left) at the Psychiatric-Neurologic University Clinic.

Throughout his life, Prof. Gerstenbrand advocated networking and collaboration within neurology. In 1991, immediately after the fall of the Iron Curtain, his strong advocacy and initiatives resulted in the foundation of the European Federation of Neurological Societies (EFNS), and he served as its first president. Those efforts were supported by Lord Walton, who at that time served as WFN president. EFNS was exceptionally successful, bringing together neurologists from all European countries. Part of the success was his strong belief that all European countries should have access and equal status in the organization. The EFNS was followed by the European Academy of Neurology.

As specialist with his teacher, Prof. Hans Hoff.

Until recently, his thoughts and efforts were directed in supporting areas of the world that lacked neurologists, and where training was needed. His last efforts were directed in supporting areas in Asia and Africa. For many decades, he had strong cooperation with Myanmar. Only days after his funeral, colleagues from Austria traveled to Myanmar to teach an initiative he was arranging in his last weeks. As he had foreseen many neurology developments, Prof. Gerstenbrand had foreseen his own death. In his last weeks, he made arrangements for his funeral and bought a grave at the same cemetery near the grave of Hans Hoff, his admired teacher.

Prof. Gerstenbrand has received numerous awards, including honorary doctorates from Charles University in Prague and Aristotle University of Thessaloniki, the Valeriy Gagarin Medal of the Russian space organization, and several of the most prestigious medals in Austria.

His life was dedicated to advocating neurology, and many of his pupils have been successful clinicians, leaders, and advocates. Prof. Gerstenbrand was a model for generations of neurologists in Central Europe.

We express our condolences to his wife Gudrun, his children, and his grandchildren.

Update on the Kasralainy Stroke Unit at Cairo University

By Prof. Ahmed Abdelalim

A stroke physician and assistants performed a transcranial duplex.

Egypt has the 15th largest population in the world, with approximately one-quarter of its citizens clustered in its capital, Cairo. Stroke medicine in Egypt has been facing many difficulties with implementation due to the economic problems and an inadequate number of stroke neurologists.

Kasralainy Medical School is the largest medical center in the Middle East, with a capacity of over 5,000 beds providing medical services to more than
2 million people per year, half of which are served in the emergency department. The first stroke unit was established over 20 years ago, but could not satisfy the need due to the rapidly growing population and difficulties with the insurance system.

The plan for a new stroke center was then created with great ambitions of going beyond offering medical services to providing stroke training and research opportunities to Egyptian, African, and Middle Eastern neurologists and to help raise community awareness. Over the years, the neurology department has sent many of its young members to European stroke centers, through grants, to be trained on modern stroke medicine together with in-house training on advanced life support and neurocritical care skills. Today, these neurologists have become the core of the new stroke unit and trainers to their younger colleagues.

The stroke team, including stroke nurses and administrative personnel.

In 2010, the hospital administration granted the place and funds to establish the new stroke unit. Due to the political circumstances in 2011, the project was halted until 2015, when the Kasralainy administration, led by Prof. Fathy Khodair, dean of the medical school, showed a great interest and determination to fulfill the project. In August 2016, the stroke unit was ready for a new start.

The new stroke unit has a capacity of 36 beds, which includes 14 intensive care (with ventilation capability), 14 intermediate care, four isolation, two thrombolytic therapy, and two resuscitation beds, with the capacity of providing thrombolytic stroke therapy concurrently for four or more patients. This makes the unit the largest high-dependency stroke unit in the Middle East fully run by neurologists, offering thrombolytic therapy and thrombectomy to all Egyptians free of charges. The unit provides advanced acute stroke treatment services, including neurosurgery, neurointervention, advanced neuroimaging, and neuro-rehabilitation for 1,500-2,000 patients per year.

The Kasralainy Medical School stroke unit.

The opening of the new stroke unit received another boost thanks to the new policy on supporting and promoting stroke medicine, together with the efforts of the Stroke Chapter of the Egyptian Society of Neurology, Psychiatry, and Neurosurgery to coordinate between stroke units on a national level and promote the use of guidelines and hospital-based registries. The training and research opportunities are further supported and extended by the WFN accreditation of the neurology department at Cairo University as a training center for English-speaking African neurologists.

The ongoing “revolution” of stroke medicine in Egypt has made the floor ready for great success for the new stroke treatment policy, with a better acute stroke treatment service and reduction of the national and regional burden of stroke. The new Kasralainy stroke unit is ready to play its leading role.

Prof. Ahmed Abdelalim is the director of the Stroke Unit, Faculty of Medicine at Cairo University.

The Need for World Congresses

By Raad Shakir

Raad Shakir, MD

Reasons for attending and participating in congresses vary. There are those who like to travel and meet neurologists from other parts of the world, which they will never do even if they visited their countries. There are others who are attracted by the lure of the big names of speakers, the organizing associations, and the attractiveness of the cities. For world congresses, the attendees come in the thousands because the meetings transcend national, regional, or specialty categories. This means that there is something for everyone.

If you look at national neurological society meetings, they tend to have few outside speakers, but the attendees are colleagues, perhaps in the same institution or the one next door. You tend to know most attendees, and it serves not only to listen to what others are doing in their research or how they practice, but to hear about gossip and job opportunities and to obtain postgraduate certification.

Perhaps another advantage/disadvantage is that of language. Many national meetings are in the local language, which is well and good. The advantage is that neurologists will have a better understanding of what is being said and will be clearly advised on practice parameters and guidelines. On the other hand, the language of medicine and science is English and many national associations’ congresses will either have sessions in English or have completely changed their language to English.

The reasoning is clear. If a neurologist or a neuroscientist would like to publish internationally, then the only way to get a recognized indexed paper is to use the English language.

In essence national congresses are all well and good, but they lack an international outlook and global interaction.

The second level is that of major regional international associations’ congresses, which are geographically distributed. There are six such congresses; two are annual and four are biennial. Some of these are well attended and professionally organized. However, in some regions with nascent associations, the concepts are still developing. The big regional organizations’ congresses are attended from outside their regions, and this is important for interaction. Such organizations certainly encourage work to be presented as well as out-of-region attendance to boost their figures and standing.

Looking at the plethora of specialty meetings and congresses, they obviously concentrate on specific topics. The degree of interest varies enormously. The speakers are obviously well known in their fields, but perhaps at times tend to concentrate on fine detail, which may not be of major interest to the audience. The attendance by and large relies on support from various sources to register and travel. The major advances in the specific field tend to be presented. Even if the neurologist is interested in the field in question, after a day or so the topics become a bit repetitious and some, if not the majority, will lose interest.

Specialty congresses, however, have a pivotal role to play in educating not only neurologists, but to propagate neuroscience in specific fields. Scientists may not have the funds to attend big international jamborees as their travel funds come from grants that rightly limit their ability to travel. Over the last decade or two, there has been an explosion in attendance of other health care professionals who find attending specialty meetings vital. Nurses, therapists, pharmacists, and psychologists, to name a few, all need to listen to advances in their chosen field of specialty. These fields tend to be by and large covered in specialist congresses. The majority of such practitioners will shy away from large general international congresses.

Drug industry-sponsored congresses and meetings tend either to be directed at a local group of medical practitioners or a targeted audience chosen by the sponsors. Governmental rules are rightly restricting sponsorship because public opinion is clearly against such practices. There is certainly a place for informing neurologists on the availability of certain drugs in their locality, and there is definitely a role to be played by the pharmaceutical industry. However, this has to be limited and controlled, rather than left to a self-governing code of practice.

In many parts of the world, governments will forbid pharmaceutical company sponsorships within the same country. As an example, if a meeting on a specific topic is being organized in a certain city, only neurologists from that city and not from other parts of the country, let alone internationally, can be sponsored to attend.

Presentations in pharmaceutical industry-sponsored meetings and symposia are primarily viewed as being at least partially one-sided. The majority of speakers declare their financial interests and do their best to provide non-biased views in their presentations. However, we cannot escape the fact that neurological public opinion tends to take the presentations with a pinch of salt. Even at major international congresses, sponsored symposia are separated from the main themes of the congress and portray a different point of view.

We have to remember another issue of funding congress attendance. In many parts of the world, the neurologist, as well as any other medical practitioner, can claim tax relief on congress attendance as part of the annual continuing medical education (CME) requirement. This practice in some localities is limited by governments to national meetings, and in some instances to international congresses, which carry certificates of approval from major international medical institutions. This practice has to be strict, as it deprives governments from taxation.

As you are all probably aware, the upcoming 23rd World Congress of Neurology (WCN) is being held Sept. 16-21, 2017, in Kyoto, Japan. We are all grateful for the Japanese Society of Neurology for hosting us. This is the showcase of global neurology. The biennial nature of the congresses makes them that bit different, and the general nature of the program is an attraction to many. The basic principle is to involve all six regional organizations and all of the specialties in neurology. Each one is asked to provide a program with conveners and speakers so that the essence of the specific field is distilled into one congress. Moreover, each congress is hosted by a national neurological society, and the competition is quite fierce. Holding the WCN is a privilege to the national society and its region. Congresses bring benefit to the society and the region. This has been seen time and again.

The WFN makes sure that our congresses are not, in the old sense, carbon copies, but have a basic structure and a distinct local flavor. Kyoto is no different. The Asian region’s competition was fierce, but the WFN council of delegates voted to award the congress to Kyoto. The WFN system of egalitarian democracy is unique in that the WFN leadership can only watch the delegates vote and decide. The choice and the decision is theirs.

Once the decision is made, the WFN works closely with the host society to produce the scientific program, teaching courses, and social programs. The role of the WFN and its congress organizer is to closely advise the host society on how the whole congress is constructed using previous experience, but adding a local touch.

The WCN is therefore a balanced and an appetizing mixture of all types of congresses — national, regional, specialty, and industry-sponsored meetings. The attendee is presented with the best of several worlds in a concise and a most perfectly packaged setting.

There is no doubt that it is a unique opportunity. I urge all of you to attend.

Filling the Gap: Report of the International Tropical Neurology Conference

By Chandrashekhar Meshram and Gagandeep Singh

Gagandeep Singh

Chandrashekhar Meshram

Tropical neurology is a pertinent subspecialty of neurology. However, in the past, it did not receive the attention it deserved. In the World Federation of Neurology (WFN), tropical neurology was introduced as one of the major themes during the World Congress of Neurology in New Delhi in 1989. A research group was formed and some outstanding international meetings were held, but only for a short period of time. The enthusiasm eventually waned, and there were no further meetings. Likewise, the Journal of Tropical and Geographical Neurology, initiated by Dr. Charles Poser, also faded quickly.

An international tropical neurology conference, held March 24-26, 2017, in Mumbai, India, was an effort to fill the gap. It was organized by the Indian Academy of Neurology under the aegis of the WFN. Dr. R. S. Wadia served as the organizing president, while Dr. Chandrashekhar Meshram was the organizing secretary. The conference, dedicated to Prof. Noshir H. Wadia, was inaugurated by WFN President Dr. Raad Shakir.

The 2017 Conference

Speakers of the International Tropical Neurology Conference 2017 demonstrated the revived interest in the topic.

The last credible meeting on tropical neurology was held in the mid-1990s. The organizers were mindful of the over 20-year gap. Nevertheless, the congress was an outstanding success. Attended by nearly 1,000 delegates, with 46 speakers eminent from Austria, Brazil, Honduras, India, Malaysia, Peru, Sri Lanka, South Africa, Tanzania, U.K., U.S., and Vietnam, the congress has completely filled the long gap. The topics discussed included neurology of common infections, cerebral malaria, Ebola virus, konzo, sarcocystosis, nodding syndrome, rabies, Zika virus, and bacterial meningitis, among others. Debate, CPC, neuroradiology, and neuropathology sessions were also part of the scientific program. There were standalone symposia on central nervous system tuberculosis, the neurology of HIV, encephalitis, poisoning, and neurocysticercosis. Seventy-nine papers were presented. Dr. Shakir highlighted the role of the WFN in training and education in the developing world.

Not only did the congress prove to be an academic bestseller, it achieved what could be, as well as what could not be, accomplished in the 20-year gap: reigniting a flame of interest in tropical and geographical neurology and resurrection of the WFN Research Group on Tropical Neurology. The research group was revived with Dr. Meshram, president, and Dr. Amilton Barreira, secretary general, in leadership roles.

Mission Objectives

The Research Group on Tropical Neurology was formed with a mission to foster research collaboration into poorly understood aspects of neurological disorders prevalent in the tropics and to disseminate knowledge at international and regional levels in this neglected area of neurology. One of the ways of achieving the mission objectives would be to organize regular biennial meetings of the Tropical Neurology Research Group in different locations, with a local emphasis on tropical disorders. The Research Group also will strive for representation of tropical neurological disorders in the scientific program of the World Congress of Neurology. An eventual undertaking should rightfully be the revival of the Journal of Tropical and Geographical Neurology.

Acknowledgements are due to all those who contributed to the Congress, including the eminent faculty, but most of all to the WFN for its generous support and to Dr. Shakir for the constant encouragement.

Stroke: Back to Where It Belongs

By Raad Shakir, MD

Raad Shakir, MD

If someone anywhere in the world had a stroke or a TIA in the last 60 years, the World Health Organization (WHO) coding system placed the event under either vascular diseases or episodic symptoms, not in the appropriate central nervous system chapter of ICD-10. This situation started with ICD-7 in 1955 and has continued since. It skews all statistics of neurological diseases produced by the WHO. ICD-10 has been in use since 1990, and a total revamp is long overdue. The information is not only stale and old, but incorrect. Codes such as “slow virus infection” for prion diseases are expected to be used in the 21^st century?

The WHO Department of Mental Health and Substance Abuse, where neurology sits, commissioned a Neurosciences Topic Advisory Group (Neurology TAG) in 2009. I have had the privilege of chairing the TAG, which expanded to involve specialists from all neuroscience specialties. The tasks were huge and detailed. The aim was to produce ICD-11, which will both serve the needs of the non-specialists as well as those working in highly developed institutions.

Brain imaging studies capture the evolution of acute ischemic stroke in two patients.

Perhaps the most important ICD-10 anomaly the TAG faced was the situation of cerebrovascular diseases (CVDs) and their future placement in ICD-11. Attempting change of the basic architecture of ICD-10 required a major case to be made on the reasoning and practicality of changing an existing status. CVDs fell under Circulation Disorders on the premise that they are a disease of vessels. Statisticians, following the principle of ascribing disorders to their basic etiology, followed this procedure, ignoring the fact that all of the effects of CVDs are neurological and that the initial interaction of the neurovascular bundle is fundamental to the pathophysiology. Moreover, in ICD-10, other ischemic disorders affecting the eyes, bowels, and kidneys fall under the affected organs. Transient ischemic attacks were classified under episodic disorders separate from CVDs.

This situation is not only incorrect, but it has led to massive confusion of reporting the fact that a leading cause of death is not placed as a disease of the brain. The first act the TAG performed was to contact and agree with our cardiology colleagues as cardiac events were lumped with CVDs, skewing their statistics as much as ours. They were asked to approve a total separation of cardiac and brain diseases for the benefit of both. This was successfully established with the Cardiology TAG in 2011. It, of course, remains that cardiogenic causes of CVDs are appropriately reported in both sections.

Where to Place CVDs?

The WHO statisticians were informed, and we had “initial acquiescence” until the middle of 2016, when a major statistician’s review of ICD-11 was carried out by the WHO Department of Informatics and Statistics. At that time, statistics advisers had second thoughts, which again placed all CVDs under the circulation section of the Joint Linearization for Mortality and Morbidity section of ICD-11.

This decision needed to be reversed, which required intensive lobbying to make the point that stroke is a brain disease. It has to be emphasized that the ICD is “owned” by the WHO statisticians, and our role as clinicians is advisory.

Be that as it may, the TAG had to pursue this matter vigorously and provide the scientific reasoning for the change. WFN and the World Stroke Organization (WSO) acted in a closely coordinated manner. Professor Bo Norrving, past president of the WSO, and I, the representatives of the Neurology TAG, used all possible avenues to make the case for the WHO Department of Informatics and Statistics. In addition to the production of scientific evidence on the etiology of stroke and the interactions between vessels and brain parenchyma, we needed to mobilize other players to reinforce the message of the importance of stroke being classified as a brain disease for resource allocation and training of staff—medical, nursing, and others—to combat the scourge of CVDs.

The issue is vital for the future of neurology, and The Lancet published two letters, one from us¹, and the second a reply from the WHO Department of Informatics and Statistics². We had put forward the argument for stroke moving to the central nervous system, while the ICD classification team put forth its reasoning, quoting continuity and the fact that CVDs were placed in ICD-7 in 1955.

This meant going to governments, as they are the ultimate power in the WHO structure. We are most grateful for the support, such as a most powerful letter from Veronica Skvortsova, the minister of Health of the Russian Federation, addressed to the WHO director general. Dr. Skvortsova is herself a neurologist and therefore is fully aware of this anomaly in ICD-10. We also are most indebted to the health ministries of Austria and New Zealand for their support.

We were hugely supported by patient organizations that wrote to the WHO and to neurologists from across the world for their support. Following all of this effort, a request came from the ICD classification team asking us to have another face-to-face meeting. This was conducted Dec. 21, 2016, in Geneva. The daylong meeting was most interesting as it started with the assertion of the statisticians on the importance of continuity and stability of statistics over decades. This is something crucial to us all. However, explanations were provided with regard to the need for radical change and why it is crucial to rectify a previous anomaly. The WHO technical department where neurology sits was represented by Dr. Tarun Dua, who made the case for the need to place CVDs under the nervous system diseases chapter of the ICD-11. The Neurology TAG was represented by Dr. Norrving and me. The meeting ended without an immediate outcome. We did not know the meeting’s conclusions for more than three months. The WHO ICD team had to clear its decisions with its statistics consultants from around the world. This is perfectly understandable as many computer systems have to be retuned, and this will need time and finance.

Two further medical statistics meetings took place. Finally, on March 31, I was informed by email: “The grouping ‘Cerebrovascular Diseases’ has moved into ‘Diseases of the Nervous System.’” This is a culmination of eight years of work and is the most logical outcome for our endeavors.

Now the world of neurology is correctly represented. This is immediately reflected in the soon-to-be-published “Global Burden of Disease” paper, where in 2015 “neurological disorders rank as the leading cause group of DALYs (disability-adjusted life years) and the second-leading cause of death in the world.” This means that resources will be appropriately allocated not only for CVDs but all neurological disorders. The WHO decision was truly momentous, and for that we are grateful. Stroke is back where it belongs.

References:

Shakir R, Davis S, Norrving B, Grisold W, Carroll WM, Feigin V, Hachinski V. Revising the ICD: stroke is a brain disease. Lancet 2016; 388:2475-6.
Boerma T, Harrison J, Jakob R, Mathers C, Schmider A, Weber S. Revising the ICD: explaining the WHO approach. Lancet 2016; 388: 2476-7.

From the Editors

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

Walter Struhal

Steven L. Lewis

We are pleased to introduce the May/June 2017 issue of World Neurology. The issue begins with the important news from WFN President Raad Shakir, who reports on the momentous and exciting decision by the World Health Organization to classify Stroke under the Central Nervous System chapter of the International Classification of Diseases (ICD-11). On the topic of stroke, Dr. Wolfgang Grisold, secretary-general of the WFN, and Dr. Mohammed Wasay, remind us that the topic of World Brain Day 2017 is devoted to stroke awareness, prevention, and management. Dr. William (Bill) Carroll, first vice president of the WFN, and the convener of the Global Neurology Network, provides the background and analysis underlying the need for a global neurology alliance to address the global burden of neurological disease.

Dr. Grisold and Riadh Goulder, MD, provide their report on the recent and highly successful first African Academy of Neurology (AFAN) Conference & 15th Pan Arab Union of Neurological Societies (PAUNS) meeting that was just held in March in Yasmine-Hammamet, Tunisia. Marina Alpaidze, MD, PhD, and Alexander Razumovsky, PhD, FAHA, report on the third WFN neurosonology teaching course that took place in October 2016 in Tbilisi, Georgia.

Dr. Mohammad Bassam Hayek, a neurologist in Aleppo, Syria, and the vice president of the Syrian Society for Neuroscience, provides us with an important on-the-scene update on the recent and current state of neurology and neurological care in Syria.

Giordani Rodrigues dos Passos, MD, reports on his recent eye-opening and successful participation in the Canadian/WFN Department Visit Program, where he visited the Montreal Neurological Institute in March. In another successful report from the Rabat/WFN Teaching Visit Program, Dr. Boubacar Maiga reports on his experience from his one-year fellowship in clinical neurophysiology at University Mohamed-V in Rabat, Morocco.

Drs. Jon Stone, Ingrid Hoeritzauer, and Mark Hallett provide us with a brief, up-to-date, and authoritative review of the current thinking with regard to the classification, pathophysiology, diagnosis, and management of functional neurologic disorders, including an invitation to learn and share more at the third International Conference on Functional Neurological Disorders to be held in September in Edinburgh. In this issue’s history column, Dr. M.J. Eadie provides us with a historical view of the emergence of clinical neurology in Australia, and the key neurologic figures who contributed to this rich history.

You also will find the nice reports and descriptions from each of the four candidate city venues for World Congress of Neurology 2021. Each city also will be presenting (for voting by
the Council of Delegates) at the upcoming World Congress of Neurology in Kyoto, Japan. Also in this issue is the announcement from the WFN Nominating Committee with regard to the listing of the candidates for WFN leadership and trustee positions to be voted on by the Council of Delegates in Kyoto. (Note: The statements from the candidates for president and vice president will appear in the upcoming [July/August] issue.)

Tissa Wijeratne, MD, provides an intriguing biographical sketch of his pathway and journey from the “jungle” of Sri Lanka to becoming a neurologist. Finally, Dr. Grisold and Robert Schmidhammer, MD, provide a heartfelt obituary for Dr. Hanno Millesi, a renowned peripheral nerve surgeon.

We sincerely hope that you will enjoy the many and varied contributions in this issue for and about neurology and neurologists around the globe.