Articles – Page 62

Report on the 2015 St. Petersburg, Russia, Clinical Neurophysiology and Neurorehabilitation Meeting

By Vladislav Voitenkov, MD, PhD

Dr. Voitenkov during EMG symposium

The large scientific meeting, Clinical Neurophysiology and Neurophysiology, was held by the Scientific Research Institute of Children’s Infections in St. Petersburg, Russia, November 26-27, 2015. Held at the Mosckovskye Vorota Congress Center in St. Petersburg, the event attracted 395 participants.

The scientific program was dedicated to general problems of neurophysiology in Russia, Commonwealth of Independent States countries and the European Union, and to certain methods in neurophysiology and neurorehabilitation. The congress hosted plenary lectures and 10 symposiums in all. Plenary lectures included such themes as modern aspects of meningitis and encephalitis treatment and diagnosis in pediatrics, presented by Professor N. Skripchenko of the Scientific Research Institute of Children’s Infections, recent discoveries in the field of transcranial magnetic stimulation (TMS), including TMS-MRI fusion techniques, presented by Dr. B. Neggers, University Medical Center Utrecht Brain Center, the Netherlands, and the role and place of electrophysiology in modern medicine, presented by Professor L. Sumsky, Neurology Center, Moscow.

Dr. Neggers during TMS-MRI fusion workshop

Symposia themes were vast and issues included scientific and clinical aspects of electromyography, electroencephalography, neurorehabilitation, ultrasonography of the brain, muscles and peripheral nerves, neuro-orthopedics, electrophysiology and audiology, neurorehabilitation and nurses’ education. Special interest was dedicated to the TMS symposium, which gathered more than 100 participants and 12 speakers, including Professor J. Mally of the Institute for Neurorehabilitation in Sopron, Hungary. He presented material on TMS as a diagnostic and therapeutic tool. Professor N. Nazarenko of the Diagnostic Center for Altay Region, Barnaul, Russia presented data on TMS investigation in tick-borne encephalitis and many others.

The previous congress, which took place in 2015 was dedicated to more general topics and had a more classic design. This year’s event was more inclusive of the newest techniques, approaches and more advanced methods.

Professor Skripchenko on TMS findings in encephalitis in children

At the meeting, 126 speakers presented their data on the topics. Symposia included talks from leading Russian and international speakers, as well as presentations from early career researchers whose material has had a significant impact in their fields. Delegates for the congress gathered from Russia, Ukraine, Belorussia, Germany, Austria, the Netherlands and Hungary. Russian delegates came from more than 90 locations, including the Far East and Arctic Northern provinces of the country.

Professor Mally on non-invasive brain stimulation.

The meeting garnered positive and warm feedback from the delegates and speakers. The organizing committee is now deep into the planning of the next event, which will take place in St. Petersburg at the end of November 2016.

Vladislav Voitenkov, MD, PhD, is executive secretary of the Clinical Neurophysiology and Neurophysiology conference, Scientific and Research Institute of Children’s Infections, Federal Medical-Biological Agency of Russia.

Apply for Junior Traveling Fellowships

By Steven L. Lewis and Wolfgang Grisold

This year, the WFN will again offer Junior Traveling Fellowships for young neurologists representing countries classified by the World Bank as low or lower middle income to attend approved international meetings. The deadline for applications is March 15.

In total, there will be 30 awards. Applicants should hold a post not above that of an associate professor and be no older than 45 years of age. Candidates are asked to send the name and dates of the meeting they wish to attend, a CV and bibliography. Applicants must also send a letter of recommendation from the head of his or her department and an estimate of expenses, to a maximum of $1,440. No excess will be granted.

Applicants must actively participate in the meeting they attend (presentation, poster, etc.). WFN also encourages applicants to submit an abstract and attach a copy of the abstract to the application.

WFN’s Education Committee will review all applications and announce the awards soon thereafter.

Dr. Lewis is chair, and Dr. Grisold is co–chair of WFN’s Education Committee.

President’s Column

Raad Shakir

Is there a place for a general neurologist? The time has come for us to have a fresh look at our specialty and decide whether we need to modify how we train and practice. In most parts of the world, the answer to the question is simple: We need to continue to train general neurologists to cover a huge need. There are so few of us, that we cannot afford the “luxury” of subspecialization. However, in a minority of countries, the field has expanded to the degree that subspecialists are the norm. The issue is that, in such a diverse situation, for the vast majority of the world population, we are only providing basic neurological care. Do we have to accept the less optimal situation, or should we push hard for subspecialization to happen worldwide?

There is no doubt that in many parts of the world, the idea of a general neurologist is fast receding. The argument is that the enormous change in practice and the need to be able to deal with complicated issues is far beyond the capability of a generalist.

The explosions in genetics and imaging have led to the need for an in depth knowledge of a rapidly changing field. The generalist can decide on the primary clinical presentation and then what direct management is necessary. However, there will come a point where his or her abilities will not be sufficient to advise further.

If we take the example of acute neurological care: How many neurologists are capable of administering tPA in acute ischemic stroke or feel able to do so? The technology has been available for nearly two decades, and up till now, few centers, even in the developed world, are able fully to provide the required treatment not only in tPA provision but also more specialized intravascular thrombectomy. It is true that we need a highly sophisticated technical support from interventional radiology to neurosurgery. But the fact remains; there should be on-the-ground expertise far beyond the training and confidence of a general neurologist.

The field is now so complicated that a generalist feels uncomfortable in dealing and advising, for instance, on the use of disease-modifying therapy for MS. The plethora of licensed drugs makes it very difficult to advise on the suitability of certain long-term expensive medications. Moreover, side effects of disease-modifying drugs require care at special centers with neurologists and specialist nurses to look after the needs of patients.

Moving to other common conditions, such as epilepsy, we are all trained in the diagnosis of epilepsy, despite the complexity of seizure semiology. However, it is also true that in many cases, there are inevitable errors in diagnosis leading to erroneous management. Therefore, it is important that specialist epilepsy services are available for referral of the difficult, of the poorly controlled or for those needing surgical intervention. This means we need to train specialists in the field of epilepsy to provide accurate and appropriate care.

The world of movement disorders has really moved on. We are now in a new era of deciding on correct diagnosis and then advising on management. The field is even more complex with the availability of surgical interventions. It is true that a general neurologist is fully able to make a correct diagnosis of rather complicated Parkinsonism syndromes, but when it comes to decisions on the suitability for deep brain stimulation or Duodopa therapy, then expertise in the field is mandatory. This makes the need for specialist referral centers necessary if we are to offer full treatment packages to patients.

The diagnosis and management of genetically derived disorders is another major area for the specialist. The generalist is in many cases able to decide on the clinical phenotype, but that will need a further in-depth look at the genetics and will require a neurogeneticist to give advice on mode of inheritance and progression following appropriate DNA analysis. This is not an area to venture into without full training in clinical genetics, especially if there are predictive tests in healthy carriers and the implications of that on life and childbearing in future generations. The most important issue perhaps is the increasing possibility of the availability of stem cell and genetic modifications in combating many neurological conditions.

Many CME programs are aimed at updating the neurologist in dealing with the conditions faced in daily practice. If we look at the programs of the major international, regional and national neurological congresses, we see that specialists in various fields impart their knowledge and advice to general neurologists. This has led to a plethora of guidelines, with which neurologists are being bombarded, and, at times, it is very difficult to apply the most up-to-date pathways to every problem faced. These guidelines are aimed at practitioners in general, but in most parts of the world the contained technologies are, by and large, not available and therefore the supposed “best practice” is not applicable. This means that many neurologists looking after huge populations, however diligent they may be in keeping abreast of the latest guidelines, are totally unable to follow them and subsequently, their patients are disadvantaged.

Logically, it follows that postgraduate teaching material and guidelines have to take into account the fact that not all that is most up to date is applicable in all situations. The requirement of obtaining enough annual CME is only effective if it is targeted to the individuals concerned. The general neurology societies and continental associations have to produce guidelines which are for the general neurologist, and which may well be different in a way to those targeting the specialists in the field. This is rather difficult and may lead to confusion and errors.

Unfortunately, in many parts of the world, there is little opportunity for patients to see the neurologist of their choice. This is very common in both resource rich and poor countries. The healthcare systems in many, if not the majority of resource rich settings, provide neurological care in an anonymous way, and the patient referred with a specific problem may be seen by a general neurologist or by someone with a different special interest. In the grand scheme of things, this does not matter as neurologists know their field and can ask for advice as and when required.

However, in resource poor settings, the way in which patients are seen by neurologists varies considerably. Some neurologists sit in crowded outpatient clinics, where tens of patients wait in line, and where it is only possible to give each of them only a minuscule amount of time. In some settings, this is compensated for by the availability of inpatient beds, and what may seem like a complicated problem in the crowded outpatient setting can be admitted for a more detailed evaluation and more thorough investigation.

In other settings, neurology is by and large an outpatient service, with large, short-stay and smaller long-term inpatient facilities that vary according to locality and country. Looking after long-term disabled patients is dependent on the availability of ancillary services. Neurological rehabilitation is a separate specialty, which is totally dependent on the close collaboration with physiotherapists, occupational therapists, speech and language therapists, neuropsychologists and neurology nurse practitioners. Without that, delivery of a comprehensive package of care is not really complete. This approach may not satisfy the expectations of patients who, in the age of the smartphone, have access to the latest advances and will demand care, which may not be possible in their settings. This may well be useful for neurologists, as it will create pressure on health authorities to provide financial and manpower support to achieve better results. This is why it is crucial to work with patients’ groups to push for change at all levels.

Now we have to come to the crux of the matter: Do we now have a two-tier neurological practice, or is it a continuum of evolving care starting with the general neurologist and narrowing expertise to the highly skilled specialist? Moreover, how do international bodies like the WFN, as well as regional and national organizations, influence and promote the evolution? Alternatively, should we decide that the deficiencies we face are so enormous that they are insurmountable and we have to get on with improving what we have and let slow evolution take its course? There is probably some truth in the latter view as the financial cost across the world is so vast, that we have to keep plugging away with our programs and slowly increase the number of neurologists in resource poor settings, eventually leading to specialization in our field and reducing the huge treatment gap that now exists.

To answer the question raised in the first paragraph, for the time being, it is a clear, yes there is a place for a general neurologist.

Trainee Report on WFN Austrian Neurological Society Department Visit Program

Pictured, left to right: Professor Reinhold Schmidt, president of the Austrian Society of Neurology; Dr. Hanna Demissie Belay, assistant professor, department of neurology at Addis Ababa University, Ethiopa; Dr. Kalpesh Jivan (South Africa) and Professor Wolfgang Grisold, WFN secretary general.

First, I have the deepest appreciation and gratitude to the World Federation of Neurology and Austrian Neurological Society for endorsing the African Initiative and introducing and supporting the department visit program. I would like to thank Professor Wolfgang Grisold and Professor Eduard Auff for their kind welcome and for hosting me at the Medical University of Vienna in October 2015. I wish to express my sincere thanks to Professor Fritz Zimprich, who was my mentor and made my stay incredibly productive and interesting. I would also like to thank Tanjia Weinhart for effectively arranging my stay from the very beginning up to the end. I thank profusely all the hospital staff of AKH Wien for their kind help and cooperation throughout my stay.

I started my visit in the department of neurology with an introduction and warm welcome from all the staff and the head of the department. I started my training on the neurology ward, where, initially, I was overwhelmed by the size and complexity of the hospital. The department of neurology, alone, occupied two floors for inpatient services and another floor for outpatient services.

I spent my first week in inpatient services on the neuromuscular ward and later in the neurorehabilation unit. I was able to follow acute management of neuromuscular disorders and rare cases, including anti-NMDA receptor encephalitis, which I saw for the first time. I spent a day with the occupational therapists, speech therapists, physiotherapists and other members of the team. I was impressed to see how intense and well coordinated the rehabilitation process was. It further strengthened my conviction that rehabilitation is of utmost importance in the management of many neurological patients. During this time, I was introduced to techniques that I may also apply at my home department. I have decided to try establishing a neurorehabilitation unit in one of the hospitals affiliated with our university. Since my visit, I joined Addis Ababa University in Ethiopia as a faculty member. If successful, it will be the first of its kind in the country.

Among the highlights of my stay was the third week in which I spent in the epilepsy monitoring unit. I observed invasive electrode implantation, and I was lucky enough to attend awake epilepsy surgery. Witnessing something you have had only the chance to read about before was amazing. During the rest of the time, I attended the epilepsy clinic and followed a number of complex epilepsy cases.

I spent half days of week three on the electrophysiology units (NCS, EMG, EP and ultrasound). I was impressed to see how useful ultrasound examination could be in the evaluation of many neurological diseases. I plan to collaborate with our colleagues in the department of radiology to eventually establish a similar service at my home institution. I spent a few days with the neuro-interventionalist, where I observed certain procedures not practiced within our department.

I spent time at different specialty clinics and learned much from everyone involved. By week four, I attended different specialty clinics, such as the neuromuscular unit, as well as the multiple sclerosis, epilepsy, headache, vertigo and Parkinson’s disease clinics. Each unit was a stimulating experience. At the vertigo clinic, for the first time, I could see electronystagmography being performed on a patient. During a night shift, I learned how to evaluate and confirm brain death.

I was invited to give a talk on the practice of neurology in Ethiopia. I got to talk about my country, the burden of neurological disease in our setting, how neurology is being practiced, which neurological disorders are common and how we manage them. The audience was attentive, and the post-talk discussion was very lively. It allowed me to share my experiences and describe working conditions on “the other side of the world.”

I also had the privilege to visit another hospital, Kaiser Franz Josef Spital and attend a tumor board session, guided by Professor Wolfgang Grisold. I found it to be interesting, and it can easily be adapted to a set up like ours.

My stay in Vienna was not only formally educational, but it also gave me the opportunity to meet neurologists from Austria and share experiences.

My weekends were always full, and Vienna fascinated me with its timeless beauty, culture and artistic attractions. It felt like heaven to walk in the park of Schönbrunn during a windy day in October. I was impressed with the antiquely furnished imperial apartment, the Sissi Museum and the silver collection of the Hofburg Palace. I was also speechless to see all the paintings by pioneering expressionists, such as Klimt, Schiele and Kokoschka at the beautiful palace of the Belvedere. I attended an Edvard Munch exhibition hosted by the Albertina Museum. It was also in Vienna that I attended my first opera.

During this visit, I witnessed that neurology or neuroscience is a fast-growing field, and each of us from different parts of the world can contribute a lot. I had only slight difficulties with the language barrier, and even then someone was always beside me to help. People were kind enough to try their best to communicate in English. Even though the duration of the stay seemed short, it is enough to meet the goal of the observership program. However, I believe the program to be so important that I suggest the number of young neurologists sponsored should be increased.

As a recommendation, I think the WFN can also think about exchange programs, whereby neurologists from developed countries pay a visit to African institutes and we can share our experiences. It is my hope that this program will continue and flourish in the future. It is encouraging and inspiring to young neurologists. It will also open a door for future collaborations and joint research projects.

In general, I can say with confidence that this program is successfully fulfilling its goal of fostering global neurological education.

Dr. Demissie Belay is an assistant professor in the department of neurology at Addis Ababa University in Ethiopa.

From The Editors

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

Walter Struhal

Steven L. Lewis

We are pleased and honored to be taking on the editorship of World Neurology, the official newsletter of the World Federation of Neurology (WFN). We would like to thank President Raad Shakir and the officers and trustees of the WFN, as well as the members of WFN’s Publication Committee, for entrusting us with this responsibility. We also wish to give our sincere thanks to Dr. Donald Silberberg for his outstanding editorial leadership of World Neurology for the last three years, as well as for providing the two of us with the benefit and generosity of his ongoing guidance and knowledge as we take on this position, and for having done the work alone that is now deemed necessary for two people to perform.

We have planned a number of new initiatives for the readers of World Neurology, including contributions from authorities on breaking neurological topics that affect neurologist readers worldwide, such as the article in this issue about the Zika virus epidemic from Avi Nath, MD, and James Sejvar, MD. We also plan to develop new sections and columns over the coming issues to cover such entities as global neurological training and many other topics of interest to all neurologists worldwide.

Our plans for World Neurology include offering additional content formats (e.g., video). We will tighten the interconnection with WFN´s online footage and are currently working on implementing social media into World Neurology. This new feature will provide a convenient way to interact with other readers and discuss our articles.

We look forward to continuing to make World Neurology a trusted and sought-after resource for news and information of interest to all neurologists throughout the globe. We are also happy to field any suggestions from readers about ways to continue to make this publication evolve and be as valuable as possible for all neurologists worldwide.

Neurological Board Certification in Europe

By Jan B.M. Kuks

Jan B.M. Kuks

Young neurologists can rise to the challenge in Denmark on May 27, 2016. On that day, the 8th European Board Examination in Neurology will take place in Copenhagen.

Medical specialties in Europe are working together with the European Union of Medical Specialists (UEMS) (www.uems.eu), an organization containing 43 specialist-sections, one of these being the European Board of Neurology (EBN). Setting standards for training and practice is among the organization’s key activities. Therefore, the EBN is involved in developing harmonized models for the high-level training of the next generation of neurologists, in order to improve standards of clinical practice and, hence, patient care throughout Europe.

To achieve this, the EBN set up a core curriculum for the training of young neurologists, and — as testing drives learning — a board exam is provided as well.

Professor Wolfgang Grisold, now WFN secretary general, was the founder of this process and organized the first EBN examination in 2009. The 8th examination will take place at the site of the European Academy of Neurology (EAN) Congress. This illustrates the close cooperation between the UEMS Board of Neurology and the Academy of Neurology in Europe, an alliance without which a European training program for Neurologists would not exist.

Education in these times is not only for transferring knowledge, but is also directed toward achieving other competencies.

Successful candidates of the 7th EBN Exam in Berlin June 19, 2015 displaying their certificates

As in earlier days, the ability to retrieve knowledge from memory may be essential for clinical practice. But don’t we all use electronic devices in our clinics and on our ward rounds to find up-to-date knowledge as soon as possible for practicing evidence-based medicine and to offer our patients the latest achievements in our field? Is there any specialist in neurology who does not regularly want to have the opportunity for a peek inside an anatomical atlas, a handbook of neurophysiology or whatever textbook, before making a decision in clinical practice? So, today, we can’t restrict ourselves to information known by heart. We should be able to combine it with recent facts and developments. The ability to handle knowledge will become more and more important. This is the reason we offer our candidates the opportunity to take their own favorite textbooks (and in the future, electronic devices) to the examination to solve higher-order, open-book questions derived from real life, as they do in real life. Beside the great textbooks, guidelines and electronic courses from the EAN are the basis for the questions provided.

This isn’t all. Further competencies important for being a good specialist are described in several systems, such as in the CanMEDs roles (www.royalcollege.ca). In this system, a neurologist should not just be a medical expert, and the EBN exam should not be confined to testing neurological knowledge. Testing abilities in other CanMEDs roles like communicator, health advocate, professional and scholar comprise another and more essential part of the EBN examination.

Candidates taking the written test on the 7th EBN Exam in Berlin

How should we test these abilities within the other competencies? Does this need just another couple of multiple choice questions? We feel that this cannot be achieved by written computer examinations. For example, public health or global health issues (being a heath advocate) have their national emphases, and ethical points of view vary in different countries. Thus, there is no absolute truth to be tested. A face-to-face discussion is more suitable than making a choice in the closed format of a multiple-choice question for testing these competencies. Therefore we invite our candidates to prepare themselves properly for a discussion by writing essays for an oral examination. Being a scholar demands the ability to make one’s own vision clear and to dive into a problem to be solved in a scientific way. Therefore we ask our candidates to make a critical appraisal of a topic of their own choice to be presented for an oral discussion.

So taking a European Board Exam for Neurology is not being dependent on having a lucky day; it can be prepared for in advance, and candidates can develop abilities over a long period of time to be successful.

The validity of the examination needs the input of the scientific experts at the European Academy of Neurology. The reliability of the outcome depends on the number and quality of the participating candidates. A statistical evaluation to eliminate “bad questions” only can be realized in a group of sufficient size. Establishing a passing score can be determined by specialists prior to the test. However, modification of such a score may be necessary after getting data from a sufficient number of adequate participants.

We are happy to see the number of participants grow each year. The exam becomes attractive to more candidates from inside, but also from outside Europe — many of whom want to take the exam to increase the possibility of moving between European countries or to test their abilities on a European level. In this respect, Turkey, Belgium and Italy now take a leading role by sponsoring their young neurologists to take the EBN exam, in addition to their national exit exams.

Unfortunately, by now, board exams do not yet have a legal value in Europe, and this restrains many young neurologists from taking the examination. With increasing interest in Europe and the cooperation between European countries, we are likely to establish a goal of a European exam to be taken as an exit test in order to work as a neurologist in the European continent in the near future. Striving for such a pretentious goal forces us to look at the American board exams for neurology to try to reach their high quality level, while keeping the European flavor in our own tests.

More information about the EBN Examination can be found on our website: www.uems-neuroboard.org. We would be delighted to welcome you there.

Jan B.M. Kuks is professor of clinical neurology and medical education, University Medical Centre Groningen, Netherlands, and chair of the Examination Committee European Board of
Neurology.

Neurological Manifestations of Zika Virus Infection: What Neurologists Need to Know

By Avindra Nath, MD, and James Sejvar, MD

James Sejvar, MD

Avindra Nath, MD

In recent years, there has been an emergence of several major viral infections with devastating neurological consequences, including West Nile virus, dengue, chikungunya, enterovirus D68, Ebola and now Zika virus. Increased global travel and climate change, leading to changing patterns of vector distribution and behavior are among the major reasons for the emergence of these infections. Zika virus is the most recent epidemic that is having devastating effects on human populations in affected regions, and is rapidly spreading across the South American continent.

Epidemiology

Zika virus was first identified from a primate in 1947 in the Zika forest of Uganda.¹ The first human cases occurred in Africa and then in Southeast Asia in the 1960s.^2,3 During the intervening years, Zika virus was associated with isolated cases or small outbreaks mainly in Africa. In 2007, there was an outbreak in Yap, the Federated States of Micronesia, where nearly three-quarters of the population was infected.^{4, 5} This represented the largest outbreak of Zika virus infection to that point. In 2013, there was an epidemic in French Polynesia, which was associated with a reported increase in cases of the autoimmune peripheral nerve disorder Guillain-Barre syndrome, although a causal association between Zika virus and Guillain-Barre syndrome was never established.

In December 2014, Zika virus was first detected in Brazil. Although it is unknown how it was introduced into Brazil, some hypothesize that a traveler attending the 2014 football/soccer World Cup introduced the virus. The outbreak in Brazil was fast moving and large. Tens of thousands of people became ill, and likely millions of people were infected. Similar to French Polynesia, shortly after the beginning of the Zika virus outbreak, clinicians began reporting larger-than-expected numbers of Guillain-Barre syndrome. Many of these people had reported a febrile rash illness compatible with Zika in the days or weeks before their weakness onset. In addition, clinicians in Brazil noted a 20-fold increase in microcephaly in 2015, compared to previous years, with microcephalic babies born approximately eight to nine months after the first recognition of Zika virus. Some of the infants’ mothers reported a rash illness compatible with Zika virus infection while pregnant, leading to the suspicion that the microcephaly was somehow associated with Zika virus infection.

Nearly 90 percent of the cases of microcephaly occurred in the northeastern region of the country,^{6, 7} areas experiencing some of the heaviest burdens of Zika virus infection as well. French Polynesian health authorities reported an unusual increase in central nervous system malformations in babies born during a Zika virus outbreak on the islands from 2014 to 2015.⁶ The infection has now spread across most of South America and Mexico. To date, few cases have been reported in the United States among travelers returning from Zika virus-affected regions.^{8, 9}

Virology and Pathophysiology

Zika virus is a positive-sense, single-stranded RNA virus (genome 10.7 K nucleotides) belonging to the flaviviridae family, which includes dengue, yellow fever, Japanese encephalitis, St. Louis encephalitis and West Nile virus. It has the ability to cross the placenta and cause developmental brain abnormalities in children, suggesting that the virus likely infects neural stem cells. The severity of brain malformations may be related to the stage of fetal development at the time of infection. Microcephaly would be the most common manifestation, but if infection were to occur in earlier stages of fetal development, anencephaly or lissencephaly may occur.

The pathophysiology of ascending paralysis and myelitis in adults is unknown. However, mice injected with the virus can develop paralysis, suggesting direct invasion by the virus, although an immune-mediated, post-viral syndrome is also possible. It remains unknown if once infected and recovered if an individual develops long-term immunity or not, and if recurrent infections or relapses can occur. Questions regarding long-term viral persistence in tissue reservoirs also remain unanswered.

Transmission

The virus is transmitted by the Aedes species of mosquitoes ¹⁰, in particular Aedes aegypti, the vector involved with transmission of dengue, a closely related flavivirus. Additionally, experimental evidence suggests the virus can be transmitted by Asian tiger mosquitoes (Aedes albopictus) ^{11, 12}, which can survive in cold temperatures. Most arboviruses have an intermediary host or “reservoir.” For West Nile virus, birds, particularly corvids, serve as these reservoirs. For Venezuelan, Western and Eastern equine encephalitis viruses, horses serve this role, and for Japanese encephalitis virus, it is primarily pigs. However, the transmission of Zika virus generally occurs directly between humans and mosquitos. There is some evidence that human-to-human transmission may occur through sexual intercourse, and the virus has also been detected in saliva, so the potential for oral transmission also exists. The virus has been isolated from the amniotic fluid of pregnant women and blood and tissues of newborns, suggesting materno-fetal transmission.¹³So far, an intermediary host has not been identified.

Clinical Manifestations

Female Aedes aegypti mosquito

The majority of Zika virus infections — 80 percent — are clinically asymptomatic.⁴ Among persons who develop symptoms, Zika virus infection is generally considered to be mild, causing fever, rash and body aches. Some may develop conjunctivitis. Symptoms usually last one week.

The full spectrum of neurological complications from this viral infection remains unknown. The epidemiological association between microcephaly and the infection seems strong. In Brazil, annual reported rates of microcephaly would generally be somewhere around 150 cases per year. Reportedly, between October 2015 and January 2016, more than 3,500 babies were born with the condition. CT brain scans show evidence of widespread calcification. Other malformations, such as anencephaly and lissencephaly, might also occur. It remains uncertain if other organs may be involved in addition to the brain. However, the differential diagnosis of microcephaly is broad. Hence, when presented with a patient with microcephaly, it remains important to consider other common causes, such as genetic, craniostenosis, and infections, such as toxoplasmosis, rubella, varicella zoster virus and cytomegalovirus. Intrauterine cerebral anoxia, exposure to drugs, alcohol and other toxins, malnutrition and metabolic disorders such as phenylketonuria can also cause microcephaly. Patients with microcephaly often have developmental delay, difficulty with gait and balance, mental retardation, seizures and hyperactivity.

Guillain-Barre syndrome appears to be a recurring possible complication of Zika virus infection. Following the introduction of Zika virus into French Polynesia, clinicians began reporting larger-than-expected numbers of Guillain-Barre syndrome cases on the island.¹⁴ Following the introduction of Zika virus to Brazil in December 2014, again, reports surfaced of large numbers of Guillain-Barre syndrome cases. In Brazil, few cases of Guillain-Barre syndrome had laboratory confirmation of Zika virus, but currently the primary method of diagnostic testing is through the detection of viral RNA through polymerase chain reaction. In Guillain-Barre syndrome, by the time the clinical features of limb weakness develop, it is unlikely that there would still be circulating virus, and, as such, detection of viral RNA would not be expected. Less commonly, some patients have been thought to have a myelitis or polio-like manifestations. Currently, it is unclear if these are all related or if indeed both spinal cord and peripheral nerves can be involved. Thus, in Brazil, epidemiologic evidence and the close temporo-spatial clustering of both Guillain-Barre syndrome and Zika virus cases provides intriguing circumstantial evidence for an association.

In other cases in which the virus was newly introduced, reported increases of Guillain-Barre syndrome cases have invariably appeared, including in Colombia, Venezuela and, more recently, El Salvador, which reported 46 Guillain-Barre syndrome cases in a five-week period from December 2015 to early January 2016. That is nearly three times more than the country would normally see in that timeframe. Laboratory substantiation of an association between Zika virus and Guillain-Barre syndrome has proved challenging, however. As noted, by the time of onset of weakness, the virus would be expected to be cleared from the body, and molecular techniques to identify the virus or viral RNA would not be expected to be positive. Detection of Zika virus-specific antibodies would provide evidence of current or prior infection. However, that method also has its challenges. Dengue virus is a closely related flavivirus to Zika, and invariably co-circulates in all areas currently associated with Zika virus. However, dengue virus infection has also rarely been associated with Guillain-Barre syndrome, and laboratory testing by serology is challenging due to the substantial cross-reactivity of antibodies between Zika virus and dengue virus.

Since these viruses are carried by the same mosquito vector and co-circulate at the same times of the year, it can be challenging to differentiate between infection with the two viruses.¹⁵ Development of a robust serologic assay that can reliably differentiate Zika virus from dengue and other closely related flaviviruses will be crucial in order to provide laboratory evidence of Zika-associated Guillain-Barre syndrome, as well as other late complications of Zika virus. Currently, the nature of the neuropathy is not known, as results of electrodiagnostics to determine the clinical sub-type of Guillain-Barre syndrome possibly associated with Zika virus has been rarely reported. It would be important to know if it is axonal or demyelinating and if it is immune mediated. This could affect treatment and prognosis. Recovery from demyelinating neuropathies is generally better than those due to axonal injury. Isolated reports suggest that the neuropathy may be demyelinating and may respond to treatment with intravenous immunoglobulin.¹⁴

Laboratory Diagnosis

Viremia occurs only during the first few days of the illness, but if blood samples are obtained during that time, virus can be detected by polymerase chain reaction.¹⁶ Following this phase, IgM antibodies can be demonstrated by ELISA or Western blot analysis. Previous epidemics have noted that there is cross reactivity between antibodies to Zika and other arboviruses such as dengue.⁵ The Centers for Disease Control and Prevention (CDC) has issued guidelines for the testing of infants born with possible Zika virus infection.¹⁷

Treatment and Prevention

Currently, there is no effective treatment or vaccine against the virus. Hence, prevention is key with control of mosquito populations and prevention of mosquito bites. Travel advisories have been issued for pregnant women not to travel to areas experiencing Zika virus outbreaks. For individuals who suffer from the neurological consequences of the infection, long-term supportive and symptomatic treatment is key. The socio-economic impact of the infection, particularly if the association between Zika virus and microcephaly holds true, will likely be huge and felt for decades. While the large number of cases of microcephaly is tragic, whatever the eventual cause turns out to be, it will result in large numbers of children with developmental disorders and begs for the need to train personnel in a wide variety of health disciplines, including neurology, rehabilitation, specialized nursing, social services, etc., to care for and treat this population. Ongoing surveillance for Zika virus in the Americas and elsewhere, to monitor its continued spread, as well as documentation of infection among travelers returning from affected areas will be critical. Development of more robust serologic assays that can differentiate Zika virus from other closely related flaviviruses will be an important tool to substantiate an association between Zika virus and devastating neurologic conditions, such as Guillain-Barre syndrome and microcephaly. Ultimately, the long-term epidemiologic pattern of Zika virus will be important to monitor.

References:

Weinbren, M.P. and M.C. Williams, Zika virus: further isolations in the Zika area, and some studies on the strains isolated. Trans R Soc Trop Med Hyg, 1958. 52(3): p. 263-8.
Simpson, D.I., Zika Virus Infection in Man. Trans R Soc Trop Med Hyg, 1964. 58: p. 335-8.
Olson, J.G., et al., Zika virus, a cause of fever in Central Java, Indonesia. Trans R Soc Trop Med Hyg, 1981. 75(3): p. 389-93.
Duffy, M.R., et al., Zika virus outbreak on Yap Island, Federated States of Micronesia. N Engl J Med, 2009. 360(24): p. 2536-43.
Lanciotti, R.S., et al., Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007. Emerg Infect Dis, 2008. 14(8): p. 1232-9.
Control, E.C.f.D.P.a., Rapid risk assessment: Zika virus epidemic in the Americas: potential association with microcephaly and Guillian Barre syndrome. 10 December 2015.
Bogoch, II, et al., Anticipating the international spread of Zika virus from Brazil. Lancet, 2016.
Control, C.f.D., CDC telebriefing: Zika virus travel alert. 15 January 2016.
Hennessey, M., M. Fischer, and J.E. Staples, Zika Virus Spreads to New Areas – Region of the Americas, May 2015-January 2016. MMWR Morb Mortal Wkly Rep, 2016. 65(3): p. 55-8.
Li, M.I., et al., Oral susceptibility of Singapore Aedes (Stegomyia) aegypti (Linnaeus) to Zika virus. PLoS Negl Trop Dis, 2012. 6(8): p. e1792.
Grard, G., et al., Zika virus in Gabon (Central Africa)–2007: a new threat from Aedes albopictus? PLoS Negl Trop Dis, 2014. 8(2): p. e2681.
Wong, P.S., et al., Aedes (Stegomyia) albopictus (Skuse): a potential vector of Zika virus in Singapore. PLoS Negl Trop Dis, 2013. 7(8): p. e2348.
Pan American Health Organization and World Health Organization. Epidemiological Alert: Neurological syndrome, congenital malformations, and Zika virus infection. Implications for public health in the Americas. http://www.paho.org, 1 December, 2015.
Oehler, E., et al., Zika virus infection complicated by Guillain-Barre syndrome–case report, French Polynesia, December 2013. Euro Surveill, 2014. 19(9).
Carod-Artal, F.J., et al., Neurological complications of dengue virus infection. Lancet Neurol, 2013. 12(9): p. 906-19.
Faye, O., et al., One-step RT-PCR for detection of Zika virus. J Clin Virol, 2008. 43(1): p. 96-101.
Staples, J.E., et al., Interim Guidelines for the Evaluation and Testing of Infants with Possible Congenital Zika Virus Infection – United States, 2016. MMWR Morb Mortal Wkly Rep, 2016. 65(3): p. 63-7.

Avindra Nath, MD, is intramural clinical director and a senior investigator with the Section of Infections of the Nervous System, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland. James Sejvar, MD is a neuroepidemiologist with the division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia. The authors have no financial relationships relevant to this article to disclose. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or National Institutes of Health.

Teaching Courses Expand Education at WCN

By Wolfgang Grisold

Table 1: Teaching Courses The free early morning teaching courses have remained the most visited teaching courses, despite the early hour. Teaching courses on education, advocacy and career received little attendance, yet these topics are inherent topics of the WFN. Also, palliative care received little attention as teaching courses. This shows that the topic needs promotion within the scientific sessions. All teaching courses will be available on the WFN website after the Congress.

The WCN took place Oct. 31-Nov 5, 2015, at the CasaPiedra Conference Center in Santiago, Chile, with 3,500 delegates from 112 countries participating and creating a joint sense of neurology worldwide. The lectures from the World Health Organization (WHO) and the presentation of the new WHO Atlas of Neurology showed the disparity of neurological workforces around the world and documented the importance of the WFN activities in the work with global organizations. One of the goals and aims of the WFN is to spread neurological development and neurological science and update participants on current issues, but also to highlight new neurological fields of development.

Scientific sessions and topics are an excellent venue and bring participants close to the leading persons in the field. This concept was successfully used in plenary lectures and scientific main topic sessions.

The WFN also has long kept the tradition of offering teaching courses at its congress. This concept has been broadened since Marrakesh, as the WFN teaching courses now are being offered on all days of the congress. The teaching courses were co-chaired by Sergio Castillio (local committee, Chile) and Wolfgang Grisold (teaching course committee, WFN). The topics presented include many general and common topics, such as stroke, dementia, epilepsy and others.

Also, several courses with hands-on opportunities were offered to include and engage participants in practical issues, such as EMG, ultrasound and botulinum toxin treatment. Experience at the WCN in Marrakesh and Vienna has shown that these types of highly interactive teaching courses, despite often technical issues and difficulties, are well appreciated by attendees.

In Chile, 36 teaching courses were held. The list (Table 1) shows the topics presented, which helped to disseminate educational news and expert knowledge. Teaching courses offer attendees the advantage of being in a smaller group and interacting with renowned experts. This facilitates a climate of interaction by allowing questions and discussion of opinions.

Dr. Freedman lectures on education.

One special component of the WCN teaching courses are the early morning free teaching courses, a one-hour teaching session presented by a single expert in the field. This expert has the privilege to create his or her talk in the form of a lecture, deviating from the usually shorter teaching course lectures, and allowing the speaker to emphasize and shape the message that he or she considers important. Despite the early time of these teaching courses, the number of participants was between 100 and 200 per course (and 339 for the topic of epilepsy). The topics included MS (95), chronic inflammatory demyelinating polyneuropathy (125) and the top 10 advances in neurology (95).

Cynthia L. Harden presents a morning teaching course on epilepsy.

Knowledge, skills and tutoring from experienced lecturers cover many aspects of neurology. The issue of palliative care is a topic with an increasing scientific basis1. Still palliative care is often confounded with end of life care, or worse, a situation of helplessness. The WFN has established a Research Group on this topic, and the Teaching Course on palliative care was an important step in establishing this important topic into our future curricula.

Dr. Nitrini speaks on education in Latin America.

All neurologists, working in any part of the world, also are aware of the importance of training, lecturing and teaching, and also that the diversity of careers from hospital to consultant level and from academic career to nonacademic career is wide. For this reason, a teaching course on education in neurology covered the topics on how to establish a curriculum, as well as how to integrate neurologic knowledge and procedures into the national situation, politics and legislation. It is important to define new learning strategies and teaching methods, to eventually support or replace the traditional apprenticeship model of neurologic education. Also the classic concept of knowledge, skills and competence will need to include aspects of professionalism and attitude. Knowledge is acquired in an incremental, almost pyramidal way. Yet, individuals and institutions also will need to adapt to new developments, and this procedure of systemic approach to replace old content or procedures is termed unlearning

Several speakers and participants gather for a photo opp.

One lecture by Dr. Freedman focused on the merging and growing possibilities of e-learning. He presented his own experience with video conferences worldwide and gave important clues to enlarge the scope of this project.

The local flavor of Latin American neurology was presented by Prof. Nitrini of Brazil, who outlined educational activities in Latin America. He discussed the rise of impact factors among publications from Latin America in the past years.

Within the topic of applied teaching and education, translation was discussed by Prof. Camfield of Canada. This term describes the often difficult transfer of young patients from pediatric neurology into adult neurology. Translation also has been well described in other fields of pediatrics and demonstrates a clash of concepts between different concepts of patient care and involvement of careers.

Prof. Raad Shakir outlines the role of the WFN in the Palatucci course.

Patient advocacy is an emerging concept, which empowers physicians to not only be involved in the provision of the best medical care, but also to advocate for patients in the micro- and macro-environment. This concept in neurology is carried forward by the American Academy of Neurology (AAN) Palatucci courses in the United States, and the AAN and WFN implemented a joint AAN-WFN one-day course in Chile. Topics on advocacy, press work and presentations were given to a small, but soon to be powerful group. Also WFN President Raad Shakir presented his concept of worldwide engagement of the WFN in health matters.

A good turnout attends a day programming.

A good turnout attends a day of programming.

Last but not least, some of the most important targets of education are patients and caregivers. Despite the importance of these groups, patient awareness days are, surprisingly, often not included in congresses. Since WCN 2015, the WFN implemented a patient day into it congresses. This year’s topics included stroke, epilepsy, MS and dementia, and WFN Past-President Vladimir Hachinski served as convenor and engaged in the discussion.

Footnote

Oliver DJ, Borasio GD, Caraceni A, de Visser M, Grisold W, Lorenzl S, Veronese S, Voltz R. “A consensus review on the development of palliative care for patients with chronic and progressive neurological disease.” Eur J Neurol. (Oct 1, 2015): doi: 10.1111/ene.12889).

European ‘Wanderjahr’: Postgraduate Training in Nervous Diseases for Americans in the 1880s

By Peter J. Koehler

Thomas Neville Bonner (1923–2003)

“Medical students constitute the only class of students who in any considerable number follow the good old German custom of supplementing their regular course of study (Lehrjahre) by a season of travel (Wanderjahre) for the purpose of seeing how people in other places perform that work which is to occupy the remainder of their lives.” — Henry Hun, 1883

Since 2010, we have published a number of short papers on international relationships and exchange in the neurological community. It is of interest to note that the leading centers of medical education changed over the past centuries and thereby advanced international exchange. Italian (Padua) and French (Paris, Montpellier) universities were popular in the 16th and 17th centuries. Leiden (the Netherlands with Boerhaave and Albinus) became popular in the early 18th century, and later, during that century, the center moved to Edinburgh (with Whytt, Cullen and the Monros). Then, in the beginning of the 19th century, it was clearly Paris that, following the revolution, became a center of integrated medicine and surgery, attracting foreign students.

Henry Hun’s Guide to American Medical Students in Europe

Of particular interest in the second half of the 19th century is the great number of foreign (American, Russian, Japanese, Scandinavian, etc.) students and physicians, who visited German-speaking countries between 1870 and 1914. The American medical historian Thomas Neville Bonner (1923–2003) stated that in this period, over 10,000 American physicians studied in Vienna, where some of the courses were given in English. He called it “the German magnet” and noted that “at least a third and perhaps a half of the best known men (and women) in American medicine of this era received some part of their training in a German (or Austrian) university: (Bonner, p.23).

The well-known American internist William Henry Welch, one of the founding professors of Johns Hopkins Medical School, opined that it was “conventional Mecca of American practitioners” and advised to “stick to Germany, where I find all the opportunities for learning pathology which I could desire.” It is of no surprise that American medical education was influenced by returning physicians. Johns Hopkins University Medical School was organized according to the German model. In this period of increasing specialization in medicine, it was important for physicians to improve their knowledge in Europe.

Henry Hun

As improvement of medical practice was considered more important than research, smaller numbers of (mostly younger) Americans visited other German universities, including Leipzig (Carl Ludwig), Heidelberg, Breslau and Strasburg, with the purpose to do scientific work. Although a minority, the latter persons were important for the origin of medical research in the U.S. The majority went for postgraduate training, in particular for improving skills in a clinical specialty. Some of the courses were organized to train the practical use of the ophthalmoscope, microscope, laryngoscope and stethoscope. In April 2011, I discussed the European peregrination of Bernard Sachs between 1878 and 1884.

Features of Specialization in Medicine/Neurology

Education/Medical Curriculum
Neurological Practice/Special Hospitals
Instruments
University Chairs
Societies
Journals/Monographs
Success of Specialization Determined by:
Economic Reward
Social Prestige
Ideology of Progress
Influence of Public, etc.

A Guide for Medical Students in Europe

Theodore Meynert

In this issue, I wish to discuss a particular book that was published to help American students and physicians finding their way in Europe, notably Henry Hun’s Guide to American Medical Students in Europe (1883). Henry Hun (1854–1924) was a lecturer on diseases of the nervous system at the Albany Medical College. His father, Thomas Hun, one of the founders of this college, stayed in Europe for his postgraduate studies for six years (1830s), and although professor of the Institutes of Medicine, he gave lectures on the nervous system (in a period before specialization in neurology started). Henry’s older brother Edward (1842–1890) became chair of diseases of the nervous system in Albany and was among the original members of the American Neurological Association, Which was founded in 1875. Following graduation from Harvard Medical School, Henry Hun followed postgraduate courses in several European cities for over two years. He became professor of diseases of the nervous system at Albany in 1884. In the preface to his Guide, he noted that “Every year, a large number of Americans go to Europe to complete their medical studies. Unfortunately the great majority of these students have very little definite information about the different universities or about the way in which medicine is taught abroad, and on this account they lose much valuable time in getting to work.” The book has 151 pages, and, although we know he himself visited Vienna, Heidelberg, Berlin, Paris and London, most of the book is on German (speaking) universities and hospitals. As he did not visit all places described in the book himself, he received information from colleagues, acknowledging them in the preface: “For a large part of the information in the book, I am indebted to the kindness of many friends.” He admitted that some American centers provide good opportunities too.

Some students go to New York or the other large cities of America, but by far the greater number go to Europe, and especially to Germany. The reason for this is not difficult to understand. In our large cities, and especially in New York, there are certain clinics and opportunities of study that are probably unsurpassed in the world. But there is, undoubtedly, no place where a student can attend so many excellent clinics with so little loss of time, or where he can so well train his eyes and hands in methods of diagnosis and treatment, as in Vienna; while, if he is less anxious for clinical study, and wishes to train himself in laboratory work and methods, he can nowhere accomplish this so well as in Germany (Hun, p.1-2).

Expenses, language and cultural activities

The Guide offered all kind of information, including the expenses to be expected. “By exercising the very strictest economy, a medical student could study in Germany for a year (one semester being spent in Vienna, the other in a smaller town) for between $700 and $800.” As for Berlin: ‘The cost of living in the best pensions varies from 120 to 200 marks ($30 to $50) per month” (Hun, p.35). And of course, the language needed consideration. “Even though the student has a fair knowledge of the German language, and can read it without much difficulty, he will find it greatly to his advantage to live in a German family for a couple of months, and to work at the language before he commences to attend lectures.” However, he noted “the majority of the instructors can speak English more or less perfectly.” He even paid attention to the cultural activities, such as art and music. “If Munich or Dresden be selected as the cities in which to learn German, the spare hours of the day may be devoted to the picture galleries,” and “the Germans are a very music-loving people, and if the student is interested in music he can combine the study of that branch with the study of German.”

Neuroanatomy and Nervous Diseases

Wilhelm Erb

Most important of all, were his advises about specialization and for the aim of this essay, neuroanatomy and nervous diseases will be discussed. With respect to Vienna, he advised to go to the well-known neuroanatomist and psychiatrist Theodore Meynert.

Prof. Meynert lectures every day, except Saturday, from 12 to 1. On three days, he gives systematic lectures on the functions of the brain and their disorders. These lectures are very interesting, but very difficult to understand. Twice a week he exhibits patients. On Saturday, from 10 to 12, he demonstrates the anatomy of the brain. He also allows students to work in his laboratory on the finer anatomy of the nervous system. His work and lectures are very interesting, but he is very irregular in his attendance (p.19).

“But the study of nervous diseases is not satisfactory in Vienna,” although Moriz Benedikt gave good courses on electro-diagnosis and therapeutics. Hun considered Berlin and Heidelberg (Friedreich, Erb) the most important universities for nervous diseases. In Berlin the use of electricity in diagnosis and treatment was given by Martin Bernhardt (of the Bernhardt-Roth syndrome, a.k.a. meralgia paresthetica) and Ernst Julius Remak (son of Robert Remak). Hun expressed mixed feelings about the course of nervous disease by Carl Wernicke. They were “very good, but rather abstruse lectures on the general principles of nervous diseases, without much regard to any special diseases. He does not show many patients.” He also mentioned the lectures given by Carl Westphal, demonstrating that psychiatric and nervous diseases at most German universities were still taught as one discipline.

On the first two days, he shows insane patients. Pn the last day, he shows patients with nervous disease. He devotes the first part of each exercise to a systematic lecture, and, in the last part, he exhibits two or three patients. Prof. Westphal devotes himself rather to showing the disease in its clinical aspect than to discussing the nature of the process taking place in the brain, and in this respect the course is in decided contrast to that of Prof. Meynert in Vienna (Hun, p.44).

As for physiology, he, of course, referred to the famous physiologist Emile du Bois-Reymond, who “gives experimental lectures on physiology, and he allows students to work in his physiological laboratory. He has a very handsome and well-arranged lecture-room and laboratory.” Hun also referred to Hermann Munk.

In Heidelberg Nikolaus Friedreich (of the well-known hereditary ataxia) and Wilhelm Erb were Hun’s favorites. “Prof. Friedreich used to hold an excellent medical clinic. He visited the wards daily with the students. He assigned cases to the students and criticized their examinations. He also gave systematic lectures on the theory and practice of medicine. His successor, Prof. Erb, will probably conduct the clinic in the same way, and will doubtless devote much time to the discussion of nervous diseases’.

French and English centers only form a small part of Hun’s book. Various Paris hospitals are described, but for nervous diseases the Salpàªtriè
re was mentioned noting that “Prof. Charcot was last year appointed professor of nervous diseases, and this year he will hold a clinic of diseases of the nervous system at the Salpàªtriè
re on Thursday and Sunday.” In London, of course the National Hospital (for the paralyzed and epileptic) was mentioned including “Physicians, Dr. Ramskill, Radcliffe, Hughlings-Jackson and Buzzard; physicians for outpatients, Drs. H. Charlton Bastian, AY. R. Gowers, and D. Ferrier Assistant Physicians, Drs. J. A. Ormerod and P. Horrocks.”

Well-known Scientists who Visited European countries, German speaking in particular

Moses Allen Starr: Erb, Meynert, Nothnagel (Charcot)
James Jackson Putnam: von Rokitansky, Meynert (H. Jackson)
William Gibson Spiller: Obersteiner, Oppenheim, Edinger (Dejerine, Gowers)
Switzerland
Monakow -> Gudden

Russia

Kozhevnikov -> Germany
Korsakow -> Meynert
Sechenov -> MD in Vienna, Helmholtz, Du Bois-Reymond, Ludwig
Bekhterev -> Flechsig (Leipzig), Du Bois-Reymond, Meynert, Westphal, Charcot, Wundt
Pavlov -> Ludwig (Leipzig), Heidenhain (Breslau)

Sweden

Henschen -> Ludwig and Cohnheim
England
Sherrington -> Goltz
Head -> Ewald Hering (Prague)

Italy

Luciani -> Leipzig

Holland

Ariëns Kappers -> Edinger

It is clear from the above that American neurology in the late 19th century was influenced by European, in particular German, knowledge in a high degree. Around the turn of the century, interest in American medical knowledge led to the start of migration in opposite direction. Several high-ranking German visitors, among whom neuroscientists, visited the U.S., including Ehrlich, Forel, Freud, Helmholtz,

Hirschberg, Robert Koch, Carl Ludwig, Waldeyer, Sauerbruch and many others would follow.

Further reading:

Bickel MH. Thomas N Bonner (1923–2003), medical historian. J Med Biogr, (2014):Jul 1.

Bonner TN. American Doctors in German Universities. Lincoln: Nebraska University Press, 1963.

Hun H. Guide to American Medical Students in Europe.
Lanska D. Henry Hun (1854–1924). J Neurol Neurosurg Psychiatry,70 (2001):349.

CALL FOR SUBMISSIONS
Special Issue on ‘Neurological Diseases in South America’

This is a call for submissions of papers to a forthcoming special issue of eNeurologicalSci (eNS) on “Neurological Diseases in South America,” which will be published in July 2016. The guest editors of this issue welcome submissions of original manuscripts and reviews that deal with basic, clinical and epidemiological studies addressing research on neurological disorders in South America.

In particular, we invite research focusing on regional specific features related to epidemiology, diagnosis, clinical manifestations, and treatment strategies and outcomes. All submissions will be peer reviewed and selected for publication based on scientific merit, novelty, timeliness and topical balance.

Before submission, authors should carefully read over the journal’s Author Guidelines.

Prospective authors should submit an electronic copy of their complete manuscript through the journal Manuscript Tracking System.

For more information, visit the website.

Editor-in-Chief

Bruce Ovbiagele, MD, MSc, FRCP (London), FAAN, Pihl Professor and Chairman of Neurology, Medical University of South Carolina

Special Issue Guest Editors

Paulo Caramelli, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil

Adriana Conforto, Hospital das Clinicas/Sao Paulo University and Hospital Israelita Albert Einstein, Sao Paulo, Brazil

Renato J. Verdugo, Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile

Ricardo Allegri, Neurological Research Institute Raú
l Carrea, Buenos Aires, Argentina