25^th SUMMER STROKE SCHOOL

Lecturers and participants of the 25th Summer Stroke School.

This year in Dubrovnik, under the auspices of the Department of Medical Sciences – Croatian Academy of Sciences and Arts, our traditional 25th Summer Stroke School was held from June 9-13. The event was organized by Inter-University Centre in Dubrovnik, Croatian Stroke Society, Zagreb Institute for the Culture of Health, School of Medicine University of Zagreb, Central and Eastern European Stroke Society and the Applied Research Group on Delivery and Care of the World Federation of Neurology.

Directors of Summer Stroke School are: Prof. Vida Demarin (Croatia), Prof. Roman Haberl (Germany), Prof. Kurt Niederkorn (Austria), Prof. Tatjana Rundek (U.S.) and Prof. Zlatko Trkanjec (Croatia). The course brought together top experts from all over the world:  Natan Bornstein (Israel), David Russell (Norway), Moise Desvarieux (U.S.), Yoshikazu Yonei (Japan) who, together with  above mentioned course directors, shared their knowledge and experience with participants during the whole week, both from clinical work as well as from their rich scientific life.

The aim of this course is to contribute to the global fight against stroke, by increasing the knowledge, exchanging experiences and supporting the cooperation among the 60 participants from all over the world, from Albania, Bosnia and Herzegovina, Serbia, Macedonia, and Slovenia as well as from distant Kazakhstan, Zambia and Japan. Also, participants had the unique opportunity to exchange national data on stroke and discuss specific problems that are unique in some countries and together try to solve problems related to stroke, be they medical, economic or other nature.

During the week, participants presented interesting cases of stroke patients; there have been a total of 32 lectures and 30 presentations of interesting cases by the participants themselves.  It was a fruitful and unforgettable experience for all of us.

Development, Opportunity, Hope and Challenges

By Amadou Gallo Diop and Riadh Gouider

Figure 1. Evolutions, by the time, of economy data and number of neurologists and facilities in Sub-Saharan Africa (South Africa and Maghreb not included).

At the end of 2014, 15 new young neurologists will contribute to increase the number of rare specialists in Sub-Sahara-African countries. These new cohorts have been trained in Dakar, Abidjan and Addis-Ababa. They originate from Benin, Burkina Faso, Cameroon, Comoros, Ivory Coast, Ethiopia, Mali, Mauritania, Niger, Rwanda, Senegal and Togo. Their professors are from African universities with the support (by short visiting professorship collaboration) of French and North American colleagues. The four-year content of their training program was very broad, similar to any courses worldwide and composed of all aspects of neurology, including neuro-anatomy, neurophysiology, basic neuroscience, semiology, pathologies and strategies of care. Courses focus on the most prevalent neuro-conditions in the African continent and how to adapt ideal management to the local socio-economic realities. Practical training was obtained with clinical outpatient and inpatient tasks, under the auspices of assistant and senior professors. In neurological departments, but also in other services such as cardiology, psychiatry, internal medicine, pediatrics and some ground visits and duties in provinces or suburban areas. That type of course is applied to selected MDs who intend to specialize in neurology since two decades in Africa. Before the 1990’s, African neurologists were, in majority trained abroad in ex-colonizing countries i.e. France, UK, Belgium, Portugal, Germany, Russia or Switzerland.

The good news is that in 50 years, from 1974 – 2014, the number of neurologists has multiplied by more than 30 while the population has multiplied by three in Sub-Saharan Africa. It’s crucial and very interesting to see that the same situation is noted regarding the economy. One can see that the Growth Development Product has followed the same dramatic evolution, rising from $461 billion in the 70’s to up to $1,500 in 2008. The continent faces the third fastest GDP growth after the “Dragons” and Petrol-Middle-East Region as shown in Figure 1 (courtesy furnished by Pr Perucca, Pdt of the ILAE). The same remark can be done about diagnostic facilities (EEG, EMG, and neuro-imaging facilities). That let us see that when the general economic situation improves, the “neuro-conditions” improve in term of human and material resources. This is encouraging and is a reason for being more optimistic.

A training course in neurology and epileptology in Dakar, with trainees and faculty coming from different continents.

But there is still so much to achieve. While WHO recommendations is to reach at least the ratio of one neurologist for 50,000 people in a state, the fact in Sub-Saharan Africa is, in the “best” case, one for 500,000 (Ivory Coast and Senegal). In Ethiopia, the ratio was one for 10 million people 10 years ago; it is now one for 5 million. All the French-speaking countries have now at least one neurologist. Few countries have just one neurologist. Nowadays, only very rare sub-African countries do not have even one single neurologist (Cape Verde Islands, Gambia, Equatorial Guinea, Guinea-Bissau, Liberia, Sao Tome and Principe). One can remark that the majority of them are Portuguese-speaking states. Many countries have tenfold more native neurologists in North America, Europe or the Gulf countries than locally. In 15 years, few immigrant neurologists still residing abroad are initiating annual or bi-annual short-term periodic come-back-home for teaching and supporting somehow research, equipment and care.

It’s also very encouraging to see that the number of training courses has dramatically increased these last years. If we consider all training courses dedicated to the nervous system and co-organized by Pan-African Association of Neurological Sciences (which will soon become African Academy of Neurology), Society for Neurosciences in Africa, and almost a dozen of international bodies (WFN, IBRO, EFNS (now EAN), ILAE and IBE, AAN, SFN, WSO, PAUNS, HIS, ICNA, MDS) their number and quality is increasing. They occur every year in English or French.

But the challenges are still huge. The Sub-Saharan Region of Africa still needs many more neurologists for filling the gap. Every professor who has ever lectured in Africa is amazed by how motivated and thirsty for learning the trainees are. Many volunteers come and spend a few days with young MDs specializing in neurology and neurosciences for theoretical lessons and clinical activities. The ultimate goal is to increase, by massive training, the number of neurologists in Sub-Saharan Africa. Let us share this formula from Sam Kinyangui (cited by Charles Newton, Kenya) and which could be our common vision about Neuro-Training in Sub-Saharan Africa: “Attract, Train, and Retain.” At this moment, several universities have set up curricula for training in neurology: Dakar since 50 years, Abidjan since 20 years and more recently: Addis Ababa, Cotonou, Kinshasa, Lome, Yaounde and some Nigeria’s cities which university teaching hospitals are training grounds. They do not partake in the final diploma because the two awarding bodies are The West African Post Graduate Medical College, and the National post Graduate Medical college, if we refer to Pr Ogun, Nigeria. Four to six new trained neurologists from new training sites (Lome, Cotonou, Yaoundé) will graduate from 2015 and 2016. Individually, or under the auspices of bilateral academic cooperation or the umbrella of international neuro-institutions, the short visiting professorships, in cooperation with local faculty, should be encouraged by any mean (finances, teaching materials and slides, neuro examination means and books).

BOOK REVIEW

Oxford University Press, 2014.

This book reviews the history of the first 50 years of the WFN which was officially founded in 1957. One question immediately comes to mind: Why 1957? There may be a debate about the “date of birth” of neurology, but everybody agrees that it was firmly established as a discipline by the first part of the 20th century or even before that time. In subsequent years, there were several meetings attended by international members, even though the two World Wars forced the cancellation of some of these meetings. Why then did we have to wait until 1957 to see the foundation of WFN?  One probable reason is that international collaboration, like international travel, was much less common than it later became. It took the strength and charisma of one man, Ludo van Bogaert, to carry through the creation of the federation. Note that in its early years, WFN was “worldly” only in name: Asia, Africa and Oceania were barely represented. Yet it was certainly quite international. A picture in the first pages of the book shows that of 10 delegates participating in an early WFN organizational meeting, one was from Cuba, one from Iran while a third was a neurosurgeon representing India. Iran and India were the only two Asian countries present in the initial years of WFN. In its first years, WFN survived mainly thanks to a grant from the US-based National Institutes of Health (NIH).

In this nicely presented volume, Dr. Aarli who has actively participated in the activities of WFN for many years, including a term as president, describes the state of neurology before 1957 and narrates how WFN took shape, evolving gradually into today’s structure and organization. He then describes in varying amounts of detail the organization of the Research Committee and the Research Groups, at first called “Problem Commissions.” Subsequent pages of the volume provide details about the regional neurological associations and the relationship with the World Health Organization. The volume continues with a chapter which further illustrates the close ties of neurology with world events. The Indian neurologist Noshir Wadia went to jail and Jun Kimura (Kyoto, Japan) almost went to jail. Both were absolutely innocent:  Wadia had been kidnapped and jailed by the police of the Portuguese dictator Salazar in retribution of India having annexed the tiny enclave of Goa; and the charges of embezzlement brought against Kimura were completely unjustified. Both Wadia and Kimura played important roles in developing neurology and neuroscience in their respective countries and within the WFN. The book concludes with a review of the International Congresses that took place since 1957, first every four years and now every two years. A short but exciting epilogue is written by Vladimir Hachinski who, as president until 2013, perfectly embodied the motto Continuity and Change. This epilogue provides an interesting view into the future of WFN now under the helm of Raad Shakir.

One of the interesting features of Dr. Aarli’s narrative is the glimpses it provides into the features and developments of the world at large during those years. It reminds us of how much things have changed in this relatively short space of less than 60 years. For instance, we hear about the relations between the German Neurological Societies when a wall divided the Federal Republic and its Eastern counterpart, the German Democratic Republic. The relations ranged from nonexistent to acrimonious. We witness the very gradual entry of African countries into the WFN as they became independent in the early 60’s. In one of the most thrilling parts of the book, we read about the “slow boat to China.” Dr. Aarli built on the efforts of his predecessors, John Walton and Jun Kimura, and managed a diplomatic exploit. That is certainly what it took to reach the point where delegates from the People’s Republic of China, the Hong Kong Neurological Society and the Taiwanese Neurological Society agreed to sit together. A picture showing the presidents of the three societies posing next to Dr. Aarli illustrates that truly historic moment.

Dr. Aarli reminds us of that decentralization was always a theme of WFN, but different players interpreted the concept differently. On one hand, decentralization could provide a more equitable division of labor among the WFN members and thus Ludo van Bogaert and Pearce Bailey vigorously advocated it from the beginning. Others such as Hans Hoff from Austria and Russell DeJong from the USA feared that it could lead to fragmentation of the Federation. Regional societies now exist, but they have evolved in different fashions. The Asian Oceanian Association (AOAN) has attracted countries such as Mongolia and Myanmar to join both AOAN and WFN, but we are not told much about the Congresses of AOAN, which are held every two years. Similarly not much is said about the Pan Arab Union of Neurological Societies (PAUNS), which had its first meeting in Cairo in 1975. Recent PAUNS meetings have taken place in Damascus in 2010 and in Sharm el-Sheikh in 2013. In Europe, on the other hand, the regional society has developed considerably. The earliest European association known initially as Pan European included mostly neurologists from what was known as Eastern Europe and it did not have much prestige until it evolved into the European Federation of Neurological Societies (EFNS) in 1991. The other European scientific society, the European Neurological Society (ENS) was created in 1986 and its first meeting organized by Gérard Saïd (Kremlin-Bicàªtre) and Pierre Rondot (Sainte-Anne) took place in Nice in 1988 with P.K. Thomas as first president. ENS was modeled on the American Neurological Association (ANA) and conceived as a body of scientists elected because of their merit and not their nationality.  The two societies have merged in the spring of 2014 into the European Academy of Neurology (EAN). It is presided by Günther Deuschl and will have its first meeting in Berlin in 2015. This process is in great part due to the determination of the presidents (particularly Franz Gerstenbrand, Jes Olesen, Jacques DeReuck and Richard Hughes for EFNS and Gustave Moonen, Josè
Ferro and Claudio Bassetti for ENS) and also to the creation of the Journal, the European Journal of Neurology (François Boller and Per Soelberg Sörensen, founding editors; Anthony Shapira current editor) which will be the official organ of the EAN. Under the auspices of Gustavo Roman and others, an effort is under way to develop an American Federation of Neurological Societies.

As can be expected, the development of WFN was far from being always smooth. Dr. Aarli displays the full extent of his elegant diplomacy when he discusses some of the rougher moments of the WFN: “conflicts, problems” and “the usual suspects” are alluded to in ways that will be well understood by WFN insiders. He refers to a real or narrowly avoided catastrophe as “an unforeseen event.” And all the players are hardworking, true leaders full of ideals and integrity. Of course this is true in most cases. However, it is amusing to read the descriptions of some of the same people given elsewhere, for instance the admirable and highly readable book “A Fragmented Memoir: Life and the Teeming Brain” (Bacchante Books, 2013, by John Moossy.) Moossy, a neurologist and neuropathologist, former editor-in-chief of the Journal of Neuropathology and Experimental Neurology lived through many of these events including a  one year stay at  van Bogaert’ Bunge Institute. Moossy freely distributes high praises to some such as van Bogaert himself and the late Charles Poser, also a very important player in the creation and evolution of WFN. On the other hand, he does not hesitate to use much sharper words for people who played a dominant role in the development of WFN, but who he did not like as much. It is not clear whether Giancarlo Guazzi, an important collaborator of van Bogaert from 1958 to 1968, played any role in the early years of the WFN. Actually Guazzi is not mentioned in the book, but he is indirectly alluded to when we are told that van Bogaert received a Honoris Causa Doctorate in Siena (unfortunately misspelled), Guazzi’s alma mater.

In conclusion, this book is a great tribute to a great organization. This reviewer fully shares the words of Lord Walton who writes in his preface: “Posterity will be very grateful to Prof. Aarli for this historical work of scholarship.”

By Kiran Thakur, MD

Kiran Thakur

Before the introduction of the measles vaccine in the United States in 1963, more than 500,000 cases of measles and at least 500 measles-associated deaths were reported annually^1,2. Although measles elimination was declared in 2000, importations of cases from endemic areas of the world continue to occur, leading to secondary measles cases and outbreaks. This year, the United States is experiencing a record number of confirmed measles cases, with 592 cases and 18 outbreaks reported to the Centers for Disease Control’s (CDC’s) National Center for Immunization and Respiratory Diseases (NCIRD) between Jan. 1 and Aug. 29, 2014³. (See Figure 1.) Recent increases in the incidence of measles in the United States are attributed to the importation of measles virus through travel to other countries, including the Philippines, where there is a large, ongoing measles outbreak. Approximately 20 million cases of measles occur each year globally, and importations into the United States continue to pose a risk for measles cases and outbreaks. This is also coupled with greater rates of transmission because of unvaccinated or incompletely vaccinated United States citizens, a significant portion of which are children⁴.

The large number of cases this year emphasizes the need for health care providers to have a heightened awareness of the potential for measles and the importance of vaccination to prevent infection, in particular in young children and travelers who are susceptible to severe infection. Health care providers should maintain a high level of suspicion for measles among febrile patients who present with rash, cough, coryza, and/or conjunctivitis. Patients should be asked about recent travel abroad and/or contact with returning travelers, and their vaccination status.

Figure 1. United States (U.S.) measles cases by year.

In particular, neurologists should be aware of the early and late neurological manifestations of the infection. Although neurological symptoms and signs have not been reported among the 592 cases in the United States reported this year, neurologists should be aware of the potential early and late central nervous system (CNS) complications of the infection. CNS manifestations are indeed rare, but devastating when they occur. The most common CNS manifestation of measles infection is acute measles encephalitis (AME) occurring in approximately 0.1 percent of cases⁵. In AME, the virus replicates within neurons and triggers a lymphocytic infiltration within the brain parenchyma and meninges⁶. AME typically occurs during the exanthem phase of the systemic illness, but can rarely precede the onset of rash. Cerebrospinal fluid (CSF) typically shows a lymphocytic pleocytosis and mildly elevated protein⁷. Treatment for AME is largely supportive and prognosis is guarded as approximately 20 percent of patients die, with at least one quarter of survivors developing permanent neurologic sequelae⁸. Post-measles encephalomyelitis (PME) occurs in approximately one in 1,000 patients, occurring within two weeks of the onset of rash and is characterized by seizures and focal neurological deficits. Periventricular demyelination, induction of immune responses to myelin basic protein, and absence of measles virus in the brain suggest that PME is an autoimmune disorder triggered by measles virus infection⁹. Other CNS complications that occur months to years after acute infection are measles inclusion body encephalitis (MIBE) and subacute sclerosing panencephalitis (SSPE), both of which are caused by persistent measles virus infection. MIBE is a rare, but fatal complication associated with progressive neurological deterioration that affects individuals with defective cellular immunity and typically occurs months after infection. SSPE is a rare delayed complication of measles that occurs in about one in 10,000–100,000 patients and is characterized by seizures and progressive deterioration of cognitive and motor function followed by death 5–15 years after measles virus infection¹⁰. On histopathology, neurons, oligodendrocytes, astrocytes and microvascular endothelial cells are infected¹¹. SSPE most often occurs in people infected with measles virus before two years of age.

Rates of CNS manifestations due to measles infection have dramatically declined since the introduction of the measles vaccine, though with the resurgence of measles outbreaks around the world, and the increase in refusal of vaccines in resource-rich nations, the risk of these complications is now heightened. As travel to worldwide destinations becomes more accessible, neurologists should be aware of the potential neurological effects of acquired infections abroad, including measles and other neurotropic infections. Clinicians should also be aware of the increasing susceptibility to infection in those who are not vaccinated, including young children.

References:

1. Campbell H, Andrews N, Brown KE, et al: Review of the effect of measles vaccination on the epidemiology of SSPE. Int J Epidemiol 36: 1334-1348, 2007 4

2. Hinman AR, Orenstein WA, Papania MJ: Evolution of measles elimination strategies in the United States. J Infect Dis 189(suppl 1):S17-S21, 2004

3. http://www.cdc.gov/measles/hcp/index.htm Accessed September 4th, 2014

4. Verla-Tebit E, Zhu X, Holsinger E, et al. Predictive value of immunization records and risk factors for immunization failure in internationally adopted children. Arch Pediatr Adolesc Med 2009;163:473-479

5. Schneider-Schaulies J, Meulen V, Schneider-Schaulies S. Measles infection of the central nervous system. Journal of Neurovirology 2003;9: 247–252

6. Johnson RT, Griffin DE, Hirsch RL, et al: Measles encephalomyelitis—clinical and immunologic studies. N Engl J Med 310:137-141, 1984

7. Johnson RT, Griffin DE, Hirsch RL, et al: Measles encephalomyelitis—clinical and immunologic studies. N Engl J Med 310:137-141, 1984

8. Perry RT, Halsey NA: The clinical significance of measles: A review. J Infect Dis 2004;189(suppl 1):s4-s16

9. Johnson RT, Griffin DE, Hirsch RL, et al. Measles encephalomyelitis—clinical and immunologic studies. N Engl J Med 1984; 310: 137–41.

10. Bellini WJ, Rota JS, Lowe LE, et al. Subacute sclerosing panencephalitis: more cases of this fatal disease are prevented by measles immunization than was previously recognized. J Infect Dis 2005; 192: 1686–93.

11. Allen IV, McQuaid S, McMahon J, et al. The significance of measles virus antigen and genome distribution in the CNS in SSPE for mechanisms of viral spread and demyelination. J Neuropathol Exp Neurol 1996;55:471–480.

By Girish Modi

Girish Modi

According to data from the World Health Organization (WHO), almost   75 million people worldwide have been infected by the HIV virus. About 36 million people are estimated to have died as a result of being infected. At the end of 2012, globally 35.3 million [32.2–38.8 million] people were living with HIV. In the young, economically active adult population (15 – 49 years) 0.8 percent are living with HIV.

Sub-Saharan Africa bears the brunt of this burden and remains the most severely affected. In Sub-Saharan Africa, one in every 20 adults are HIV infected accounting for 71 percent of the people living with HIV worldwide.

In South Africa, the total number of persons living with HIV increased from an estimated 4 million in 2002 to 5.26 million by 2013. For 2013, an estimated 10 percent of the total population is HIV positive. Also, 17 percent of South African women in their reproductive ages are HIV positive.

These statistics are important to help understand the impact they have had on the practice of clinical medicine in Sub-Saharan Africa and for us here in South Africa. In the teaching public hospitals in South Africa, 40-60 percent of medical admissions are in some way linked to HIV infection. In the non-teaching rural hospitals, these figures are much higher.

Naturally, neurology has been affected and to a large extent has borne the brunt of this epidemic. Neurological involvement in HIV is described to affect 40-75 percent of HIV infected patients admitted to the medical wards in a tertiary care setting¹. In a prospective study of 506 in-patients at the Helen Joseph Hospital, Johannesburg, South Africa, 75 percent of patients had some clinical neurological involvement, and in 11 percent neurological disease was the sole presenting feature. The neurological presentation of the patient is dependent and to an extent determined by the immunological state of the patient.

Seizures and Epilepsy in HIV

Seizures in HIV can occur at any stage of the infection and have been described in patients with presumed acute HIV induced seroconversion illnesses through to advanced disease or AIDS.

Incidence data on seizures in HIV infection has mostly been focused on new onset seizures (NOS). All the studies have been hospital-based and most are retrospective. The incidence ranges from 2-20 percent. The differences in incidence can be explained by the different inclusion and exclusion criteria in the studies and the specific groups surveyed. The relatively low incidence of two percent was from a study in New York where patients with provoked seizures were excluded.  The high incidence of 20 percent came from Bangalore in India where the study population group was pre-selected in that all their patients had a pre-existing neurological disorder.

In terms of seizure types, in these study populations, generalized seizures were  by far the commonest occurring in 58-100 percent of patients. This high proportion may be due to the under-reporting of focal origin seizures that cause immediate secondary generalization or inaccurate details from eyewitnesses. Focal seizures may in some patients indicate the presence of an underlying focal brain lesion but they have also been described in patients with diffuse disease. Status epilepticus also occurs in this population group and has been described in 8-18 percent of patients.

In terms of causes, NOS in HIV positive persons can be categorized or grouped into:

• Focal brain lesions (FBL)
• Meningitis
• Metabolic causes
• No identifiable cause (NIC)

The majority of patients with NOS have a specific underlying cause for their seizure.

The most commonly identified causes are focal brain lesions (FBLs) and meningitis. FBLs occur in 30-50 percent of patients. FBLs can be infectious; neoplastic; demyelinating or due to cerebrovascular disease.  Toxoplasmosis has been identified as the commonest infectious cause of FBLs in patients with HIV and occurs in up to 88 percent of patients presenting with NOS in most of the studies that have been published. However, in populations where tuberculosis is endemic, this has been found to be the commonest cause of FBL in HIV patients with NOS. CNS lymphoma is recognized as the second most common cause of FBL and has been reported in up to 11 percent of patients. Other reported causes of FBL include Progressive Multi-focal Leukoencephalopathy (PML); neurocysticercosis and strokes.

Meningitis has been described in 10-22 percent of patients presenting with NOS.  Cryptococcal meningitis is the most frequent cause of meningitis except again in regions where tuberculosis is endemic.

The other aetiologies that need to be considered include metabolic abnormalities; medication side-effects and HIV-Associated Dementia (HAD).

In 6-46 percent of patients, NIC can be found for the seizure presentation and it is presumed that primary cerebral HIV infection is responsible. In keeping with this, SPECT scan studies have shown focal temporal lobe abnormalities.

Numerous abnormal electroencephalographic (EEG) findings have been reported in HIV-infected individuals presenting with seizures. The abnormalities have been both focal and generalized and are most commonly non-specific e.g. generalized slowing. Non-specific abnormalities have been well described in asymptomatic HIV-positive individuals and their significance in this setting is uncertain. Focal abnormalities on EEG do not necessarily signify an underlying focal lesion.

Seizures recurrence risk as expected from the potential causes listed above is high and therefore treatment even with a new onset first seizure requires medical intervention. Valproate has been described to increase viral replication but it has also been shown to be beneficial in HIV infected seizure patients and is therefore widely used. Phenytoin and carbamazepine induce the hepatic p450 system and interact with anti-retrovirals adversely and are therefore not recommended. Gabapentin, Levetiracetam and Lamotrigine do not have such interactions are preferred in the setting of HIV and seizures. Availability in resource limited regions is an issue with these anti-epileptics.

In an acute setting, standard epilepsy protocols should be adhered to. Long-term anti-epileptic therapy needs to be initiated in the majority of patients but this can be a difficult decision. Evidence-based guidelines (American Academy of Neurology) have been formulated for patients that require both HAART and anti-epileptics. The guidelines do not however specify when anti-epileptics should be initiated or how long they should be continued for.

Epilepsy and HIV remains a daunting neurological challenge.

By Dr. Man Mohan Mehndiratta, Dr. Natasha Singh Gulati, Dr. Ashok Kumar, Dr. Bhawna Sachdeva and Dr. Madhu Sinha

Figure 1. A: Dr. Man Mohan Mehndiratta, director (JSSH) in India and Prof. Raad Shakir, president, World Federation of Neurology, from London addressing the delegates through video conferencing. B: Expert panelists from various hospitals in New Delhi for World Brain Day at Janakpuri Superspeciality Hospital, New Delhi C: Prof. Mohammad Wasay, chairman advocacy subsection World Federation of Neurology from Pakistan addressing the delegates through video conferencing. D and E: Patients and their caregivers attending the program.

The brain: the body’s most complex organ harbors about 80 million neurons and controls every thought and action¹. It can be affected by various diseases and disorders affecting about one billion people worldwide and causing around 6.8 million deaths annually. Neurological diseases and disorders have now been declared as a global epidemic. Knowledge and awareness of brain diseases by individuals and communities can play a crucial role in the prevention, detection and treatment, thus emphasizing outreach public health approach². Recognizing the magnitude of the burden and disability and mortality consequent to neurological disorders the World Federation of Neurology (WFN) took the initiative to celebrate the first World Brain Day on July 22, 2014¹. To take this forward and foster brain health in our community, we celebrated World Brain Day (WBD) at our Institute, Janakpuri Super Speciality Hospital (An Autonomous Post Graduate Institute under N.C.T of Delhi) in Janakpuri, New Delhi, under the aegis of Indian Academy of Neurology (IAN). (See Figure 1.) In India, the day was also celebrated in cities like Indore, Nagpur, Kolkata and Bangalore.

Programs like these are very beneficial in a developing country like India where there are many barriers to the neurological education and care such as poor neurologist to population ratio, geographical barriers, illiteracy, lack of trained staff and inadequate resources³. These barriers pose a great challenge to our health care system, which can be overcome by such advocacy campaigns.

The objective of this program was

1. To emphasize the types of neurological disorders and their frequency and severity
2. To inform that most of these disorders are preventable and curable
3. To answer the queries and problems of the patients and their caregivers and understand their needs
4. To alleviate the myths and misconceptions related to these disorders
5. To serve as a platform for various national and international experts to interact with the patients and their caregivers through video conferencing and panel discussions

More than 250 persons with neurological disorder and their caregivers attended the program and asked the queries related to neurological disorders and patients felt satisfied to get the answer and to interact.

A highlight of WBD celebration was address by Prof. Raad Shakir, president, WFN, from London and Prof. Mohammad Wasay, chairman advocacy subsection, WFN, through video conferencing and distinguished faculty comprising of neurologists, epilepsy surgeon, psychiatrist and neurosurgeon from the public and corporate hospitals. Prof. Shakir and Wasay answered the issues raised by the public and the faculty members had an introduction session with the president.

Dr. Man Mohan Mehndiratta, director (JSSH) and past president, Indian Academy of Neurology, briefed about WBD and its importance, vision and mission of the institution.

Doctors from various hospitals were invited to interact with the patients. Dr. C.S. Meshram, president, IAN, could not make it because of other commitments.

The expert panelists who attended the program include: Dr. Sumit Singh, senior consultant neurologist, Medanta, Medicity, Gurgaon; Dr. Shamsher Dwivedi, Prof. and HOD, Neurology, Fortis Gurgaon; Dr. Anuj Mittal, HOD, Psychiatry, Deen Dayal Upadhaya Hospital, Delhi; Dr. (Brig.) S.P.Gorthi, senior consultant neurologist, R & R, Army Hospital, New Delhi; Dr. Rajeev Anand, senior consultant neurologist, B.L.Kapoor Hospital, New Delhi; Dr. Vikash Gupta, senior consultant, neurosurgeon, B.L.Kapoor Hospital, New Delhi; Dr. Subodh Gupta, neurosurgeon, Deen Dayal Upadhaya Hospital, Delhi; Dr.Solanki, neurosurgeon, B.R.Ambedkar Hospital; Dr. Nilesh Kurwale, epilepsy surgeon, All India Institute of Medical Sciences, New Delhi; and Rehabilitation Experts, JSSH.

The program continued for more than two hours and still the patients had keenness to ask several questions related to various neurological disorders. Patients, rehabilitation experts, doctors, nurses and technical staff joined for refreshment after the event. Initial feedback from patients and their caregivers included appreciation for the program and a number requested more awareness programs in future.

The Internet is a leading source of disseminating public awareness worldwide both for people seeking health information and those who access it for entertainment and social networking purpose as they are passively influenced by health associated content⁴. The function’s videos and photographs are on the video-sharing website YouTube⁵ and social networking site Facebook⁶.

In conclusion: raising awareness is an ongoing effort which is never done so IAN will continue to build strong grassroots movement all over the country to increase public understanding about neurological disorders and diseases to combat this global epidemic. The World Day program in our hospital as well as other cities in India has paved the way for future programs.

References

1.     World Federation of Neurology. Fostering quality neurology and brain health world wide. Available at:  http://www.wfneurology.org/world-brain-day Accessed on 8th August 2014.

2.     Gourie-Devi M. Organization of neurology services in India: unmet needs and the way forward. Neurol India. 2008 Jan-Mar;56(1):4-12.

3.     Mehndiratta MM, Mehndiratta P, Gulati NS, Wasay M. Heterogeneity in Neurological Education and care in Asian and Oceanian region. Neurology (in press 2013).

4.     England MJ, Liverman CT, Schultz AM, Strawbridge LM. Epilepsy across the spectrum: promoting health and understanding. A summary of the Institute of Medicine report. Epilepsy Behav. 2012 Oct;25(2):266-76

5.     World Brain Day Celebration at Janakpuri Super specialty Hospital, New Delhi on 22nd July 2014. Available at: https://www.youtube.com/watch?v=kceBkyP4uHs . Last Accessed on 23rd August 2014

6.     World Brain Day Celebration at Janakpuri Super specialty Hospital, New Delhi on 22nd July 2014. Available at: https://www.facebook.com/pages/Janakpuri-Superspeciality-Hospital/465836126847575?ref=br_tf . Posts to page. Last Accessed on 23rd August 2014

By Vida Demarin       

Public health action during World Brain Day in Croatia.

In celebration of the first World Brain Day, the Croatian Stroke Society in cooperation with Zagreb’s Institute for the Culture of Health, Associations of People’s Health Andrija Å tampar, Society for Neuropsychiatry and the Student Council of the Faculty of Medicine in Zagreb, organized a public health action in Zagreb, Croatia, on July 27, 2014.

The public health action, which was held on Kvaternik’s square in the center of the city of Zagreb, was to celebrate World Brain Day by promoting the activities of the associations and to raise the awareness among community that brain diseases are mostly

Volunteers measuring stroke risk factors.

preventable and that actual perception of the brain should be changed. The day’s activities included measuring stroke risk factors such as blood pressure, blood sugar and body mass index. More than 250 people have measured their stroke risk factors, and more than 1,000 promotional materials were distributed during a day.

TV broadcasting with Prof. Vida Demarin during public health action.

Prof. Vida Demarin, president of the Croatian Stroke Society and the Zagreb’s Institute for the Culture of Health, was a guest at a TV and a radio show dedicated to celebration of World Brain Day. She pointed out the necessity of such activities in promotion of brain health and prevention of brain diseases.

The community response was more than great, even though it was time of summer vacations in Croatia, which encourages us to continue with such activities in the future.

By Dr. Chandrashekhar Meshram and Dr. Sanjeev Thomas

On July 22, 2014, the World Federation of Neurology (WFN) launched the first World Brain Day – Our Brain, Our Future. It was dedicated to bring more attention to the importance of human brain in health and disease and highlight the need to prevent the neurological and psychiatric illnesses prevalent in the society. In India, the first World Brain Day was celebrated under the aegis of Indian Academy of Neurology all over the country with great enthusiasm. The banners, brochures and press release from WFN were circulated to all IAN members. The event helped in spreading the awareness regarding brain health, brain diseases and their prevention. A breakdown of how different centers celebrated activities follows.

Nagpur

Dr. Chandrashekhar Meshram, president, Indian Academy of Neurology, convened the meeting of neurologists, neurosurgeons, physicians, psychiatrists and media. It was decided that looking at the magnitude of the issue deserves more than one day so the activities were held for the whole week. A press conference was held on July 18 and a press release in English and local languages was distributed to media. Accordingly, on July 22, a symbolic rally walkathon was organized in the city which was flagged off by Commisioner of Police, K.K. Pathak. Three hundred persons including doctors, school children and senior citizens wearing World Brain Day t-shirts and caps, holding banners and playcards participated in the rally despite the rain. An interview with Dr. Meshram was broadcasted by Aii India Radio.

Three billboards carrying the message of World Brain Day were displayed at prominent places in the city.

Lectures for common public and interactive sessions were organized at ESIS Hospital, Government Medical College and Hospital, Indira Gandhi Medical College and Hospital and Lata Mangeshkar Hospital on July 23-30, respectively. Dr. Poornima Karandikar, Dr. Pravir Waradkar, Dr. Avinash Joshi, Dr. Fulare and Dr. Anand Saoji delivered the lectures and answered questions .

On July 25, a program was organized at Dayanand College. Dr. Meshram presented Talks on Brain Health Supreme Wealth and Neurosurgeon Dr. Nilesh Agrawal presented on Head Injury. It was attended by 500 college students, their parents and teachers.

On July 26, a large public forum was organized at IMA Auditorium. Members of parliament Vijay Darda and Ajay Sancheti and Senior Neurologist Dr. G.M. Taori graced this occasion and addresed the gathering. Dr. Meshram highlighted the importance of World Brain Day celebration. Lectures on stroke, dementia, brain functions, epilepsy and head injury were delivered by Dr. Dinesh Kabra, Dr. Prafull Shembalkar, Dr. Poornima Karandikar, Dr. Sangram Wagh, Dr. Nilesh Agrawal and Dr. Lokendra Singh. Dr Nitin Chandak showed clippings of movies.The program was attended by about 400 people. Television channels covered the program and televised it.

On July 27, a painting competition for school children was organized in collaboration with Basoli group. 150 children from 65 schools displayed their creativity on the theme “Our Brain — Our Future.” 11 prizes were given to the students by Girish Gandhi and Dr. Meshram.

Visits to the Brain and Mind Museum were organized daily for students and common public. Specimens of human brain and some animal brains were shown, while brain structure, function and manifestations of various diseases were explained to visitors with the help of models and charts by neurologists, psychiatists and neurosurgeons.

World Brain Day and Brain Awareness week was celebrated under the aegis of Indian Academy of Neurology in collaboration with Nagpur Neuro Society, Indian Psychiatry Society Nagpur branch, Indian Medical Association Nagpur, Academy of Medical Sciences Nagpur, Nagpur Union of Working Journalists and Basoli Group.

The activities for the whole week were extensively covered by all newpapers in the city with publlication of articles, interviews, news items and photographs.

Janakpuri Superspeciality Hospital, New Delhi

World Brain Day was celebrated at Janakpuri Superspeciality Hospital on July 22, 2014, under the aegis of Advocacy Subsection of Indian Academy of Neurology. More than 250 persons with neurological disorders and their caregivers attended the program and asked the queries related to neurological disorders. The activity was organized by Dr. Man Mohan Mehndiratta, past president of Indian Academy of Neurology. Dr. Sumit Singh, Dr. Shamsher Dwivedi, Dr. Anuj Mittal, Dr. (Brig.) S.P.Gorthi, Dr. Rajeev Anand, Dr. Vikash Gupta,Dr. Subodh Gupta, Dr.Solanki and Dr. Nilesh Kurwale participated in the panel.

A highlight of the World Brain Day celebration was the address by Prof. Raad Shakir, president, WFN, from London, and Prof. Mohammad Wasay, chairman advocacy subsection, WFN, through video conferencing and distinguished faculty comprising of neurologists, epilepsy surgeon, psychiatrist and neurosurgeon from the public and corporate hospitals. Prof. Shakir and Wasay answered the issues raised by the public, and the faculty members had an introduction session with the president.

Army Hospital (R&R) Delhi Cantt

World Brain Day was celebrated by Army Hospital (R&R) Delhi Cantt on July 24, 2014, due to service commitments. The program was chaired by Maj. Gen. CS Narayanan, dean, Army Hospital (R&R) Delhi, and the following talks were delivered.

1. Neurology from Bench to Bedside – Brig. SP Gorthi, professor and head of department of neurology
2. Approach to Headache – Dr. Sumit Singh, professor neurology, Medanta Medicity
3. Deep Brain Stimulation in Movement Disorders – Dr. Vinay Goyal, professor neurology at AIIMS

The program was well attended.

A cap was released in honor of the occasion to popularize the day.

In addition, stroke club was organized on July 25 and multiple sclerosis meet was organized on July 28 as part of promotion of World Health Day.

The event was organized by Brig. S.P. Gorthi, Col. Y. S. Sirohi, Lt. Col. Pawan Dhul and the Neurology Team at Army Hospital (R&R) Delhi.

NIMHANS, Bangalore

National Institute of Mental Health and Neuroscience (NIMHANS) at Bangalore, a premiere institute in the country dedicated to the diagnosis and treatment of neurological and psychiatric disorders is also committed to promoting positive mental health. NIMHANS has established a unique facility “Center for Wellbeing” away from the hospital environment, but managed by NIMHANS’ senior faculties from the Departments of Social Psychology and Psychiatry to counsel the seekers in psychological stress. NIMHANS has been actively involved in assisting the Ministry of Health and Family Welfare, Govt. of India in planning and execution of National Mental Health Programs, especially in the areas of neurotrauma, epilepsy and psychiatric disorders. NIMHANS has also established Human Brain Bank for research and Neuropathology Brain Museum to promote public awareness about neurological disorders and the strategies to prevent them.

Keeping in the spirit of World Federation of Neurology, NIMHANS celebrated World Brain Day – Our Brain, Our Future on July 22, 2014.

An event was organized at Neurobiology Research Center, NIMHANS, addressing 200 school children and teachers who visited the Human Brain Museum. In addition, a few from the general public and senior citizens also joined the celebrations. We dedicated this first celebrations to the children in whom we are kindling curiosity in the field of neurosciences. The students were from Class X and XI, preparing to enter college, thus representing the young minds who can participate in leading the country.

Director/Vice Chancellor Prof. P. Satishchandra and In-charge Registrar Prof. S.K.Chaturvedi, professor of psychiatry, addressed the students highlighting the need to understand the brain-mind axis and their role in neuropsychiatric disorders. In addition, they stressed healthy living by proper food intake, exercise and strictly avoiding addiction forming drugs. The session was interactive; the students actively participated in the discussion.

Dr. S.K. Shankar, emeritus professor, neuropathology and principal coordinator of Human Brain Bank, addressed the gathering on the topic “Let Us Learn Neuroscience Together” talking through the evolution of nervous system in animals and human and human brain in disease states. Subsequently, the structure of the human brain and the internal anatomical areas with their physiological and psychological functions were demonstrated using the human brains collected at autopsy with informed consent of close relatives.

“Human Brain in Health and Disease” was conducted showing the real human specimens, including the human articulated skeleton. The faculty, post doctoral fellows of Department of Neuropathology, staff of Human Brain Bank and volunteers from Neurovirology Department explained the specimens in an interactive basis. Finally the young students were thrilled touching the real human brain, heart, lung, kidney and intestine and had the real feel of the organs in their hands.

Simultaneously, the College of Nursing, NIMHANS organized a day-long exhibition with health awareness posters in English/Kannada and human brain specimens in the outpatient section of the hospital. The exhibition was inaugurated by Prof.Lalitha, head of the Department of Nursing. The faculty and the tutors of nursing college actively participated taking the knowledge about the brain to the common man visiting the hospital for treatment.

The public greatly appreciated the opportunity to see and touch the real human brain and fruitful discussion about food habits, the common infections of nervous system and the useful strategies to prevent them.

The Director/Vice Chancellor visited the exhibition organized by the Nursing Department and appreciated their efforts for taking the knowledge to the common man.

NIMHANS, Bangalore, decided to continue the tradition with greater scientific inputs in the future as well.

St. Paul College, Kolkata

The Institute organized the World Brain Day in a prominent school locally at Burdwan on July 22.

It was attended by students from class six and above along with teachers. Dr. Shyamal Kumar Das and two of his residents gave nice speeches about nervous system and their importance including basic illness such as epilpesy, stroke, dementia, etc. The meeting was well organized by the school authorities. It was a very stimulating experience, and the students and teachers enjoyed the program.

We have planned to celebrate next year as well.

Calcutta Medical Research Institute, Kolkata

World Brain Day was celebrated at Calcutta Medical Research Institute, Kolkata, on July 22 under the aegis of World Federation of Neurology and Indian Academy of Neurology. The goal was to increase the awareness regarding common neurological diseases. The half-day program consisted of a seminar where eminent neurologists of the city discussed on topics like stroke, epilepsy, dementia and neurotrauma. The seminar was attended by about 75, including doctors, patients, social workers and press.The event was organized by Dr. Arabinda Mukherjee, president elect, Indian Academy of Neurology.

The event was extensively covered by print and electronic media like Times of India and Door Darshan TV .

Madras Medical College, Chennai

World Brain Day was celebrated at Madras Medical College. Dr. Bhanu, head, Institute of Neurology, welcomed the gathering. Dean Dr. Vimala delivered the presidential address. Dr. A.V. Srivasan, emeritus professor, Dr. Lakshmi Nrasimhan, Dr. S. Balasubramanian spoke on the importance of brain functions. The event had wide media coverage in The Hindu, dinamaalar, dinathandhi etc. About 200 people participated and benefitted.

It is a good initiative to talk more on protection than on treatment of illness, though that is also important.

Mumbai

The first World Brain Day with the theme of Our Brain – Our Future was celebrated by Epilepsy Foundation India, on the July 22, 2014. Chief guest Dr. B. K. Upadhyay, Jt. Commissioner of Police, (Traffic) inaugurated and Dr. Nirmal Surya chaired the program.

A total of 150 people attended the program, most of them were patients suffering with epilepsy and other neurological disorder and their caregivers.

Dr. Nirmal Surya, founder trustee and chairman of Epilepsy Foundation in his presentation, informed the audience about the brain, its function and its disorder and how the injury to brain can affect the individual life in local and regional language. He also explained about the early intervention and treatment in disease like stroke epilepsy and head injury.

Dr. B. K. Upadhyay, Jt. Commissioner (Traffic) Mumbai, Chief Guest was delighted to be part of this function. He mentioned the importance of protecting brain while riding a bike, using a seatbelt while driving car and obeying traffic rules. He made the audience aware about following four simple traffic rules and stressed the need to safeguard your brain like gold, which is the most important organ of body. In the end, there was a session where the audience participated to know more about brain and its disorders.

Varanasi

World Brain Day was celebrated at the Department of Neurology, Institute of Medical Sciences, Banaras Hindu University Varanasi, a central government university, on July 22 under the aegis of advocacy subsection of Indian Academy of Neurology.

About 150 persons with neurological disorders and their caregivers were present.

Prof. M.K. Thakur, Prof. R.K. Goel, Prof. Deepika Joshi, Prof. S.P. Singh, Dr. N.K. Agarwal, Dr. V.N. Mishra and Dr. R.N. Chaurasia participated in the activity. They addressed the public and gave knowledge about our brain and its importance in life and how we can keep our brain healthy and answered the questions asked by public.

Rohatak

On the occasion of World Brain Day, Dr. Pawan Sharma organized public awareness program in Rohtak.

Indore

On the occasion of the first World Brain Day Neuro-Club Indore and Rotary Club of Indore Uptown organized a series of lectures at secondary schools where Dr. Apoorva Pauranik addressed hundreds of adolescents (class 10-11-12) about the anatomy and physiology of brain along with introduction for common neurological diseases. The presentation and interaction was lively and interesting with the help of charts, posters and models. The curiosity, intelligence, inquisitiveness of the boys and girls was impressive.

Karimnagar

World Brain Day was celebrated in Vijaya Hospital. Dr. E. Pawankumar conducted awareness program on hospital premises on the  importance of brain and disorders of brain, mainly stroke, epilepsy and head injury and risk factors in our local language i.e telugu. Around 100 people were educated and given advice to prevent brain diseases.They really appreciated the program, and it was a grand success.

He prepared 4,000 posters about symptoms, risk factors, prevention and treatment of stroke and pasted it across various public places, offices and local hospitals in our entire district to bring awareness about stroke and received good feedback from many people.

The event was also celebrated at other centers, but they were late in sending the report.We would like to compliment WFN for this very impotant public health initiative. It was the best way to reach out to the people and interact with them.Some members expressed that they did not get enough time to organize the activity to their potential and expectations. We are sure next year the event will explode and reach greater heights as some members have already started planning.