Articles – Page 80

Featured Articles from JNS

John D. England

By John D. England, MD

Beginning with this issue of World Neurology, we will feature an “Editor’s Selection” of articles from the Journal of the Neurological Sciences (JNS). Elsevier, the publisher of JNS, has agreed to provide free access to these articles in PDF format to the members of the World Federation of Neurology. Simply click on the PDF of the article to access it.

For this issue, we will feature two recent articles:

Andreas Steck and members of the Education Committee of the World Federation of Neurology (WFN) provide the results of a survey, which examined the current global state of training in neurology. These results were compared with a previous survey done in 2006. The paper outlines the areas where advances have occurred and also indicates areas where improvements are needed. The findings provide important data which should be helpful in guiding the future training of neurologists around the world. The major disappointing aspect of the survey was that only 39 out of the 113 WFN member organizations provided answers to the survey. Most respondents were from Europe and Asia. Notable non-responders were Canada, France, India, Italy, Japan, United Kingdom and The United States.
Manuscript # JNS-D-13-00728

Maria Nagel and others from the University of Colorado, U.S. present a remarkable case of a patient suspected of having giant cell arteritis (GCA) whose temporal artery biopsy was initially negative for GCA. Further analysis demonstrated varicella zoster virus (VZV) antigen and VZV DNA in the temporal artery and adjacent skeletal muscle. More extensive pathological analysis of temporal artery sections adjacent to those containing VZV antigen showed classic features of GCA. These findings build upon the previous research from this group, which detected VZV in the temporal arteries of 5/24 patients with clinically suspected GCA. Taken together, these findings raise important questions about the role of VZV in both suspected and proven GCA. Manuscript # JNS-D-13-01090R1

We hope that this new feature of highlighted articles from JNS will be a useful addition for readers of World Neurology.

England is Editor-in-Chief, Journal of the Neurological Sciences.

Book Review: Breaking Down Neurophobia

By Sarah Matteson Kranick, MD

Sarah Matteson Kranick

A recent study asked medical students and internal medicine residents to rate eight medical subspecialties with regards to the students’ feelings of competency and perceived difficulty. The 150+ respondents identified neurology as the specialty in which they had least knowledge (p<0.001) and was most difficult (p<0.001). [Winchuk AV BMC Medical Education 2010]

Similar studies in Europe and elsewhere have led to much consternation in the medical education literature over an emerging epidemic of “neurophobia.” The demand for neurologists is predicted by the Workforce Task Force of the AAN to overtake supply by 2020, making “neurophobia” not just a problem for academic neurologists, but for all of primary medical education. Primary care doctors will be increasingly called upon to triage, diagnose and treat neurological disorders at a time when subspecialization is increasingly common among neurologists. How do we prevent “neurophobia” and increase the number of neurophiles among all of our medical students and medicine resident rotators?

BookReview_Cvr The new edition of “DeJong’s The Neurological Examination,” by William W. Campbell, will appeal to neurophiles. It has been modernized in many ways — the four-color edition is much easier on the eye, for one thing. There are more images accompanying the text, with clearer photographs and MRIs to supplement the clinical vignettes.

The text has been reorganized somewhat, but still follows the general neurological encounter as most of us practice it. This book is longer than the prior edition by almost 200 pages, but the expanded material is primarily clinical in nature, and the neuroscience underlying these observations remain mostly the same. Most of us in practice will appreciate the balance of anatomy and pathophysiology here, as we are typically consulting such texts when we have just seen a patient with bilateral cortical ptosis, for example, and we are trying to remember whether supranuclear cortical control of the levator muscles has a left or right predominance. This is the sort of question Campbell answers for us time and time again, with a concise description of the anatomy involved. The “voice” of this textbook will remind you of a favorite professor from residency, and makes me envious of Campbell’s students at USUHS.

Throughout this edition, links have been inserted to various videos of the neurological exam and clinical examples of abnormal neurological signs. Having the Kindle edition would certainly make these (hyper)links easier to use, although some reviewers on Amazon have noted that the Kindle edition makes viewing tables less ideal. Unfortunately, after typing in four examples of links from the print edition, I found non-working videos each time. Future editions would benefit from a webpage devoted to accompanying videos, or a DVD included in the print version.

Frequently DeJong’s is described as a book for residents, fellows or practicing neurologists. I agree that the level of detail is likely too much for medical students, and that basic neuroscience must be mastered before attempting to understand clinical neurology. This textbook, however, can play an important role in medical education at all levels.

For many of us neurophiles, it was the detection of some abnormal neurological sign in a patient we saw as medical students that started our lifelong interest in neurology. In the short span of a four-week clinical rotation, we cannot expect every student to have enough patient encounters to prevent neurophobia. Showing them how we practice the neurological exam, and what resources we use to put abnormal findings into context, like this text, may break down some of the intimidation that surrounds our specialty.

Kranick is chief of Neurology Consult Service, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Md.

DeJong’s The Neurological Examination
By William C. Campbell
830 pages

Parkinson’s Disease: Web-Based Education Program for Health Providers in Cameroon

Participants in the web-based program in Cameroon.

Due to rapid demographic changes, the prevalence of Parkinson´s disease (PD) is increasing in sub-Saharan (SS) countries.¹ In contrast to developed countries, evidence suggests that most patients with PD are underdiagnosed and untreated, with markedly increased mortality and shortage of qualified personnel.² In the last years, there has been renewed interest from the World Health Organization, telecomunications companies and medical associations about the use of telemedicine in Africa.³

To help increase access to care and to train providers around the world using technology, the International Parkinson´s disease and Movement Disorder Society (MDS) has sponsored pilot projects in care and education that can lay the foundation for reaching the majority of people with PD. In this regard, a telemedicine program for health providers has been developed at Hospital Laquintinie in Douala, a 3 million inhabitants city of Cameroon.

The course is a web-based program that will provide participants with access to specialized education in the field of movement disorders, which is currently unavailable in their region. Local neurologists and professors at the University of Douala, including Jacques Doumbe, MD, chairman of the Department of Neurology (Hospital Laquintinie), and Erero Njiengwe, PhD (University of Douala) have significantly contributed to the implementation of this course at Hospital Laquintinie in Doula, Cameroon.

The course consists of 12 lectures over the course of a year, which will connect participants with experts in the field of movement disorders using live video, slides, chat and audioconferencing. The participants will have the opportunity to receive MDS membership and its benefits, including special education to certify them to use the MDS rating scales. Two courses have been launched — one designed for doctors (neurologists, neurology residents, primary care and internists) and another one for other health professionals (nurses, physiotherapists and psychologists).

The course will be taught by professors from Hospital Universitario de Burgos, Hospital 12 de Octubre, Hospital Clinico San Carlos, Hospital Sant Pau and Hospital Central de Asturias all from Spain; Rush University Medical Center, Columbia University, Rochester University, all in the United States, Parkinson Victoria Association, Health Sciences University all in Australia,Hospital Universitario Asturias, Spain, North Tyneside General Hospital in Great Britain and Hospital Galway and Parkinson Galway Association in Ireland. The main objectives of this pilot telemedicine education program will be to analyze the feasibility and adherence from participants, as well as satisfaction of users.

However, telemedicine for PD strategy development in Africa is challenging. It is still expensive, and most of the SS countries have inadequate and communication technologies infrastructure, which creates difficult implementation and little access to the population. Telemedicine also needs to demonstrate success and sustainability, and this type of initiative has to survive beyond the end of the initial funding period. Therefore, networking provides opportunities to spread the cost of infrastructure of telemedicine development between the local governments, business, foreign education providers and health sectors; therefore the cost burden should not be borne by just one sector. Telemedicine for PD should be recognized to remove or at least mitigate the barriers that society and physical geography imposes, especially rural areas in Africa, and to be culturally appropriate if they are to be adopted and sustained.

References

Dotchin CL, Msuya O, Walker RW. The challenge of Parkinson’s disease management in Africa. Age Ageing 2007;36:122-7.
Dotchin C, Walker R. The management of Parkinson’s disease in sub-Saharan Africa. Expert Rev Neurother;12:661-6.
Scott RE, Mars M. Principles and framework for eHealth strategy development. J Med Internet Res. 2013 Jul 30;15(7):e155. doi: 10.2196/jmir.2250.

Coordinator
Esther Cubo MD, PhD

Academic Collaborators
Jacques Doumbe, MD; Erero Njiengwe, PhD; Sixto Cubo, PhD

Computer Engineers Team
Centro Servicios Avanzados (CSA), Burgos (Spain), Paul Onana, Computer Engineer, Douala (Cameroon)

Faculty Members

Ray Dorsey, MD; Christopher G. Goetz, MD; Katie Kompoliti, MD; Leo Verhagen, MD, PhD; Ellan Louis, MD; Richard Walker, MD; German Moris; Maria José Catalan, MD, PhD; Emily Wang, PhD; Meg Morris, PhD; Victor McConvey, RN; Antonio Campolungo, RN; Marie Cahill; Patrick Browne, RN; Jose Maria Trejo Gabriel y Galán MD, PhD

Sponsor
International Parkinson´s disease and Movement Disorder Society, through the Telemedicine Task Force

Neurology Training for Non-Neurologists in West Africa Sept. 15-18, 2013

Organizers of the neurology training: Albert Akpalu (left), Korle Bu Teaching Hospital in Accra, Ghana, and Roberto Cilia, Parkinson Institute, Milan, Italy.

This course was jointly funded by the Movement Disorder Society (MDS) and the World Federation of Neurology. Additional co-sponsors were the Fondazione Grigioni per il Morbo di Parkinson (Italy) and the Society of Worldwide Medical Exchange (U.S.). This was the first neurology course designed for medical doctors who are not specialized in neurology. It was also open to neurologists interested in training in the field of movement disorders and dementia.

Participants were invited from throughout West Africa. Thirty-six participants attended the course, from Ghana (24), Nigeria (6), Sierra Leone (3), Gambia (2), and Cameroon (1).

The international faculty consisted of 16 international and local members, including neurologists, geriatricians, nurse specialists, a neuropsychologist, a physiotherapist, a nutrition specialist and a general practitioner from rural Ghana. The opening ceremony included guests such as the representative of the Minister of Health and of the nursing system in Ghana, the Italian Ambassador in Ghana, the chairman of Internal Medicine Department of the Teaching Hospital in Accra.

The course was run in English and included slide presentations and practical sessions with assessment of patients. Slide sessions focused on Parkinson’s disease (PD), dementia and other neurodegenerative disorders, covering epidemiology, diagnosis, pharmacological and non-pharmacological therapy. For the practical sessions with patients, participants were divided into small groups of five to six each, under the guidance of a faculty member, aiming to teach how to perform a neurological examination, neuropsychological scales screening for global and frontal-lobe cognitive functions and examples of physical therapy focused on gait and balance. Twelve patients attended these sessions, including PD, Lewy body dementia, Alzheimer’s disease and spino-cerebellar ataxia. In a session titled Bring Your Own Patient,” participants presented a patient from their own clinic and discussed with faculties the most relevant diagnostic and management challenges.

There were joint sessions with the PD Nurse Specialist Course, organized by Richard Walker (chair of the MDS Task Force on Africa).

Doctors and nurses had the opportunity to interact and share experiences about caring for patients. In particular, we included a Beyond the Neurologist session, dealing with the importance of a multidisciplinary approach to patients, especially in settings where medications are limited.

Educational material has been prepared and released for this course, including basic information about motor and non-motor features of PD and/or dementia. These booklets were drafted by different health care professionals (nurses, nutrition specialist, physiotherapists, neuropsychologists) and were full of pictures and photographs to be suitable for patients and caregivers with low education.

The course was a great success and participants’ feedback was positive in large part due to the practical sessions with patients and the interactive sessions. Each participant was given a DVD including all the slide presentations of the course, the UPDRS and the cognitive screening scales, the two educational booklets and photographs of the course. An email list was created including all the participants as well as the Italian and Ghanaian faculty, to share information and help in challenges of everyday clinical practice.

One of our aims was to make this course an opportunity to boost the education in the field of neurodegenerative disorders in developing countries. We promoted two initiatives:

The entire course was professionally videotaped to make it available online.
We provided two travel grants for the MDS events in 2014, the International Congress in Stockholm and the MDS summer school.

Course Organizers

Roberto Cilia (Italy)
roberto.cilia@gmail.com; roberto.cilia@icp.mi.it

Albert Akpalu (Ghana)
a_akpalu@yahoo.com

Teaching Center Update

By Wolfgang Grisold and Raad Shakir

Wolfgang Grisold

The WFN mission is to foster quality neurology and brain health worldwide. One of the cornerstones of this mission is to sponsor and support worldwide concepts of education. This is the function of the WFN Education Committee. In addition to other valuable tools as congresses, symposia, departmental visits and traveling fellowships.

The WFN has developed the concept of worldwide approved teaching centers. These centers should fulfill standards defined by the WFN in order to fulfill the role for training neurologists and perform this in a standardized internationally recognized manner. Moreover, these centers will be able to train neurologists from low income countries to further their education and improve their clinical and research abilities.

Raad Shakir

Once these centers are approved, they can offer training fellowships, in a neurological subspecialty as well as a full training program to produce neurologists who will go back and serve in their own countries. The WFN approval will therefore carry the stamp of international recognition on the status and performance of a training program.

The department visit process has been adapted from the UEMS (UEMS.net) department visitation process. This process assesses training centers, their hospital resources and equipment, and the training facilities, and has a system of assessing the opinions of all persons involved in the training process using standardized questionnaires. In addition to structured personal interviews, a randomly selected person from all groups is involved in the process. The analysis of the questionnaires and of the structured interviews are all part of the report, which also includes the activities of the hospital, access to other related fields (e.g., neurosurgery) and the completeness of the training program. The report concludes on the status of the present situation and also gives recommendations for further improvement and development.

The WFN Education Committee (Chair Steven Sergay and Co-Chair Wolfgang Grisold) has developed a structured and a well-organized questionnaire, which covers all aspects of a neurological training center. Prior to any visit, the size, structure as well as the personnel are to be explored. In addition, residents, trainers and hospital staff will be asked to answer standardized questionnaires, aimed at various educational aspects.

The NeurologyCenter in Rabat was the first neurological center worldwide to apply for this status.

The WFN committee consisted of Wolfgang Grisold (trustee, co-chair of the Education Committee), Raad Shakir (then WFN secretary-treasurer general) and Riadh Gouider (president of the Pan African Association of Neurosciences Societies). The visitors were welcomed by the faculty of the hospital and academic members of RabatUniversity. All information and facts about the hospital and the Moroccan neurology training system were presented.

The Rabat neurological department consists of several sections: an outpatient’s service which is closely associated with neurosurgery, neuroradiology, neuropathology and with the national center of rehabilitation and neurosciences.

The practical visit was guided through the neurological departments, as well as the laboratories, including histopathology, chemistry and genetics. During the visit, patients and trainees, as well as post-graduate and undergraduate students, were met and some questions and discussion were carried out.

The visit also included the electrophysiology laboratories, where practical teaching was observed. The associated departments of neurosurgery and neuroradiology were well equipped, modern CT, MRI, angiography suites and gamma knife were all observed. There is also a newly adapted rehabilitation unit. The outpatient and emergency as well as the consultation system of the hospital were looked at in detail. The academic research unit of the university provides laboratories including an animal house with space for scientific cooperation, which are open to projects from the neurological department.

The structure of the visit was supplemented by interviews with residents, teaching professors and hospital staff. These interviews were performed in a standardized written format, which was distributed prior to the visit to faculty and current residents. In addition, three teachers and four residents were randomly selected and attended personal interviews. They were asked standardized questions. Also the director of the hospital was personally interviewed. The visiting WFN committee carried out the confidential interviews. A résumé was contained in the report.

Based on the visit, including discussions, there were presentations of the faculty, and detailed analysis of the various aspects of the department. The visiting committee was fully satisfied that the Hospital Center Ibnou Sina, Rabat, is fully compliant with all aspects of a WFN training center. It will be able and willing to train not only its own national neurologists, but neurologists from Africa and elsewhere and will be providing one year fellowships, as well as a full four year training programs.

The concept of WFN teaching centers will be further developed, and the WFN website will provide a detailed definition of teaching centers, as well as the requirements, questionnaires and application details. Being a WFN teaching center is a sign of excellence and clearly conveys international recognition of the teaching center in that it fulfills all of the criteria in its structure, equipment and the teaching facilities needed to participate in the important role of neurology education in the future.

Theodore L. Munsat (1930-2013)
An Outstanding Legacy with the WFN

By Marco T. Medina, Dean of the National Autonomous University of Honduras

Marco T. Medina

The World Federation of Neurology (WFN) lost an outstanding leader on Nov. 22, 2013, with the death of Professor Theodore Leon Munsat (“Ted”), in Waltham, Mass., U.S., at age 83.

Munsat was Emeritus professor of Neurology at Tufts University School of Medicine and served the WFN in several capacities as trustee, chairman of the WFN Education and Research Committees, chairman of the WFN ALS Research Group and founding director of the WFN Seminars in Clinical Neurology. He was president of the American Academy of Neurology (AAN) 1989-1991, chairman of the Continuing Educational Committee of the AAN and founding director of AAN’s premier continuing medical education journal Continuum: Lifelong Learning in Neurology^{1, 2}.

Munsat was born in Portland, Maine, in 1930, to Leo and Ethel Munsat. When he was a child, the Munsat family moved to Rutland, Vt. He graduated from Rutland High School in 1948. He received his BA degree in chemistry at the University of Michigan, and in 1957, his MD degree from the University of Vermont, and then completed an internship at Mt. Sinai Hospital in New York, followed by a neurology residency with Houston Merritt at the New York Neurological Institute, Columbia Presbyterian Medical Center. He completed his training with Augustus S. Rose at the University of California in Los Angeles (UCLA). After serving in the Navy for two years, he returned to UCLA in 1963 as assistant professor of Neurology and director of the Muscular Dystrophy Clinic where he worked with Carl Pearson. In 1970, he moved to the University of Southern California, first as associate professor, and then, in 1973, as professor of Neurology. In 1975, he took a 12-month sabbatical in Newcastle upon Tyne, U.K, with Lord Walton. In 1976, he became chairman of Neurology at Tufts University and the New England Medical Center¹.

He was a worldwide leader in ALS research and as chairman of the WFN ALS Research Group that published important international diagnostic guidelines. He authored more than 200 scientific articles and books, including classic texts as Amyotrophic Lateral Sclerosis: A Guide for Patients and Families, Post-Polio Syndrome and Quantification of Neurological Deficits. He received many honors during his long career, including the A.B. Baker Award for Education of the AAM, the Sheila Essey Award for ALS Research, the Lifetime Achievement Award of the WFN Research Group on Neuromuscular Diseases and the degree of Doctor of Medicine, Honoris Causa, by the University of Marseilles¹.

Munsat as the WFN chairman of the Education Committee developed a number of successful educational programs around the world:

Ted Munsat

A continuing medical education (CME) program using the journal Continuum, generously donated by the American Academy of Neurology, and the WFN Seminars in Clinical Neurology. More than 42 developing countries participated in this program, including Argentina, Bangladesh, Brazil, Bulgaria, Cameroon, Chile, Columbia, Congo, Croatia, Cuba, Cypress, Czech Republic, Egypt, Ethiopia, Guatemala, Honduras, Hungary, India, Iraq, Jordan, Kenya, Lebanon, Lithuania, Macedonia, Mexico, Mongolia, Nigeria, Panama, Peru, Romania, Russia, Serbia, Slovenia, Sri Lanka, Syria, Tunisia, Uganda, Uruguay, Vietnam, Venezuela, Yemen, and Zambia with an extraordinary local impact^3-7.
Support for Neurologic Training program and WFN Certification: Munsat founded programs for the WFN to provide assistance in establishing neurology training programs where there were none, helping further develop existing programs and providing a certification process for programs that wished to have an external review. He worked with programs in Ethiopia, Honduras, Guatemala, Mexico, Peru, etc.^3,5,8.

The first pilot program was the Honduras Neurology Training (HNT) Program. Munsat and Professor Alberto Portera Sanchez from the WFN Education Committee visited Honduras in July 1998 for the first time, and after an evaluation, they concluded: “It is our recommendation that a training program in neurology should be established at the Hospital Escuela. We believe that there is a pressing need for more neurologists to address the unmet health needs of the people of Honduras. The relevant members of the medical school faculty have expressed their strong support of such a program. More than adequate human and structural facilities are currently available. There is no reason why this program could not be a program of unqualified excellence and effectiveness.”

After the initial visit, the National Autonomous University of Honduras established the country’s first Neurology Training Program in 1998. This program was established using a problem- and epidemiological-oriented methodology with oversight by an external WFN review board. By 2013, the program resulted in a 50 percent increase in the national neurologist ratio per inhabitant, significantly improving the quality of patient care and promoted research in the neurosciences. During 10 years, Munsat and Sanchez have visited and evaluated annually the HNT program. The legacy of Munsat in our program and country is invaluable^5,8.

Neurologic care where there is no neurologist. With Gretchen Birbeck, he supported the development of training materials for nonphysician health care providers and established a program for non-physician neurologist clinical officers in Zambia and Malawi^3,9.
The WFN Africa Initiative. Munsat,Johan Aarli, Gretchen Birbeck, Gallo Diopp and others started this initiative Six sub-Saharan countries started their participation in the WFN Continuing Education program: Cameroon, Uganda, Zambia, Nigeria, Ethiopia, and Kenya. He helped on the development of the Ethiopia Neurology training program³.
London WFN Education Committee meetings: Since 1993 Munsat organized successful planning meetings in London with members representing WFN regions around the world.
WFN Seminars in Clinical Neurology. Munsat founded the Seminars in Clinical Neurology because of the lack of educational material specifically designed and directed to neurology health care givers practicing in low resource environments³.

It was a great privilege and honor for me to have met and worked with Munsat. He was gentle, gracious mentor with a warm and sincere personality, who loved helping others every chance he had. He inspired me as well several generations of residents and neurologists all around the world, and he left an outstanding legacy with the WFN.

Munsat is survived by his wife, Carla Munsat; his daughter, Amy Munsat, his son, Peter Munsat and six grandchildren. •

References

Rowland TL. Theodore L. Munsat MD: President American Academy of Neurology. Neurology 1987;37:548-9
Munsat TL, Mancall EL, DesLauriers MP. The AAN launches a new education program: CONTINUUM lifelong learning in neurology. Neurology 1994;44:771-2.
Munsat T, Aarli J, Medina M, Birbeck G, Weiss A. International Issues:educational programs of the World Federation of Neurology. Neurology. 2009;10;72(10):e46-9.
Gusev EI, Konovalov AN, Volodin NN, Munsat T, Fedin AI, Khaass A, Gekht AB, Diankina MS, Martynov MIu, Kamchatnov PR, Beliaeva IA, Lebedeva AV, Kovaleva IIu.[Continuing medical education in Russian neurology and neurosurgery]. Zh Nevrol Psikhiatr Im S S Korsakova. 2009;109(5):5-9.
Medina MT, Munsat T. Neurology education in Latin America and the World Federation of Neurology. J Neurol Sci. 2010; 15;298:17-20.
Medina MT, Munsat T. Continuing medical education in developing countries. J Neurol Sci. 2003; 15;190:1-2.
Correale J, Allegri RF, Pelli-Noble RF. Background of the Sociedad Neurologica Argentina: current state and concerns about neurologic education. Neurology. 2013;80:1978-80
Medina MT, Munsat T, Portera-Sánchez A, Durón RM, Becker CA, Holden KR; WFNEducation Committee. Developing a neurology training program in Honduras: a joint project of neurologists in Honduras and the World Federation of Neurology. J Neurol Sci. 2007;253:7-17.
Birbeck GL, Munsat T. Neurologic services in sub-Saharan Africa: a case study among Zambian primary healthcare workers. J Neurol Sci. 2002;200:75-8.

WCN 2013 Report

By Donna Bergen, MD
Co-Chair, Scientific Program Committee

The 21st WFN World Congress of Neurology was held Sept. 21-26 in Vienna, with more than 6,300 attending from 135 countries. It was the joint meeting with the European Federation of Neurological Societies, and constituted the EFNS’ annual meeting for 2013. The Austrian Society of Neurology was the local host, with its president Eduard Auff, MD, presiding.

The joint production made for a particularly diverse, stimulating and memorable congress. More than 350 of the world’s leading neuroscientists and educators provided more than 75 scientific sessions on virtually all aspects of neurology, and led over 60 teaching courses and workshops.

Few other conferences provide a venue for neurologists from all subspecialties to meet and learn, and for young neurologists and trainees to listen to and to talk with leading scientists who may otherwise be just names in textbooks and journals. Accessibility was a major goal of the organizers, with a sliding conference fee scale designed to make it easier for those from countries with limited resources, young neurologists and trainees to attend. The WFN also provided travel bursaries enabling 150 junior neurologists from low resource countries to attend the Congress.

One of the highlights of the meeting was the opening plenary session, when Nobel Laureate Eric Kandel gave a remarkable talk on three innovative Viennese artists of 1900: Gustav Klimpt, Egon Schiele and Oskar Kokoschka. In his recently published book, Vienna and the Age of Insight, Kandel related their artistic choices to new theories of mind of Freud [another Viennese], and used 21st century discoveries in functional brain mapping to explain perceptual and aesthetic responses to viewing a painting. Other plenary sessions were an opportunity to hear masterful synopses of developments in neurogenetics by John Hardy, PhD, (UK), the neurology of aging by Ayrton Massaro, MD, (Brazil), and recanalization in acute stroke by Werner Hacke, MD, (Germany), among others.

For the first time, the main scientific sessions included joint sessions with member organizations of the World Brain Alliance such as the World Psychiatric Association and the World Federation of Neurosurgical Societies. Members of the recently formed network of international neurological subspecialty organizations also convened main sessions in their areas, bringing together the world’s top neuroscientists in nearly every aspect of neurology. Reflecting its growing relationship with the WFN, the World Health Organization presented a session summarizing current programs aimed at neurological disorders such as its Non-Communicative Disease Initiative, which includes stroke as an important global target for prevention and care in the coming years.

The teaching courses took place on each day of the congress, each day covering the main topic of the next day’s scientific sessions. The courses were attended by more than 4,500 participants. Workshops on EMG, magnetic stimulation and ultrasound of nerve, muscle and intra- and extracranial arteries offered hands-on experience and an opportunity to confer with experts in these fields. Although most of the courses were aimed at consultant neurologists, there was a course especially for young neurologists, and crucial issues such as advocacy, how to write a paper and palliative care were also covered. An analysis of attendance will help guide programming of the WCN 2015 in Chile.

The Tournament of the Minds is a traditional contest, testing the neurological knowledge of teams nominated by their national societies. The final round was fought between Australia/New Zealand, Chile, India and the United Kingdom. Twenty questions brought the finalists down to the UK and Australia/New Zealand, with the latter winning the contest, medals and a large trophy. The tournament will be repeated in Chile at WCN 2015.

The social program organized by the local host society included a concert at the stunning Wiener Musikverein Concert Hall. The conductor of the orchestra was Norbert Pfafflmeyer, a practicing neurologist, and the program included the premier of a waltz composed by Vladimir Hachinski, who just finished his term as president of the WFN. The Heurigen evening at a traditional wine bar gave attendees a taste of the latest Austrian vintage and the local cuisine, and of course the splendors and history of Vienna were there to enjoy every day.

Abstracts of the platform and poster presentations presented at WCN 2013 will be published in the Journal of Neurological Sciences, the WFN’s affiliated journal.

1The next World Congress will take place in Santiago, Chile, in two years. During WCN 2013, the WFN Council of Delegates chose Kyoto, Japan, to be the site of the following Congress in 2017.

Broadening Our Horizons
WFN: 2010-2013

By Vladimir Hachinski

Vladimir Hachinski

Missions set goals and guide actions. The greatest change that took place in the past four years was an expansion of the WFN mission to “foster quality neurology and brain health worldwide.” To accomplish this required partners, so we invited representatives from all of the major brain organizations for a meeting in Geneva on March 30, 2011, that resulted in the World Brain Alliance composed of:

European Brain Council (EBC)
International Brain Research Organization (IBRO)
World Federation of Neurology (WFN)
World Federation of Neurosurgeons (WFNS)
World Federation of Neurorehabilitation (WFNR)
World Psychiatry Association (WPA)
International Child Neurology Association (ICNA)
International League Against Epilepsy (ILAE)
World Stroke Organization (WSO)
Alzheimer’s Disease International (ADI)

The World Brain Alliance activities can be summarized as an ABC.

A = Advocacy
B = Brain Year
C = Cooperation

I took part in a high ministerial meeting in Moscow in April 2011, then a consultation with the president of the United Nations General Assembly in June in New York and then a session of the General Assembly that adopted the Non-Communicable Diseases resolution in September 2011. Subsequently, I continued to be involved with the WHO, including participating in meetings of the Executive Committee.

In addition to my own activities with the WHO, Raad Shakir has chaired and Donna Bergen has participated in the expert panel advising on the revision of the International Classification of Diseases 10 (ICD10) regarding brain disorders. A major achievement has been the acceptance by the WHO of the recommendation of the subcommittee on cerebrovascular disorders chaired by Bo Norrving, of which I was a part, that stroke cease to be part of cardiovascular disorders and be classified under brain disorders in the ICD-11.

The Brain Year is a project of the European Brain Council, led ably by Mary Baker. The intent is to proclaim a World Brain Year Europe 2014 at the European Parliament in Brussels. It is hoped that it will be followed by the World Brain Year Americas 2015, World Brain Year Asia 2016, and so on.

In terms of cooperation, the major initiative has been in the neurospecialty network founded and led by Werner Hacke, and now headed by William Carroll. This aims to bring together all of the specialties related to the brain. This complements the work done by Donna Bergen, chair of the Applied Research Committee, rationalizing research groups within the WFN whereby some have become largely irrelevant and have been dissolved while others have grown to become major organizations that now are reconnecting with the WFN.

A tangible proof of the new cooperative spirit is that several of the sessions of the World Congress of Neurology were co-sponsored by the Movement Disorders Society, the World Stroke Organization, the International League Against Epilepsy, the International Child Neurology and a session with the WHO.

Grassroots

We initiated a process whereby we offer modest amounts of money to individual neurologists who had ideas for projects that meet the criteria of value, viability, synergy and evaluation. The first year all of the projects were funded by the WFN. The second year, we asked leaders of other brain organizations to be part of the review process. This resulted in leadership of the different organizations learning about what each was doing, allowing for cooperation and avoiding overlap. Last year, there were 10 Grants-in-Aid, half of them were co-funded and half of them were in Africa. This year, the total value of the 11 grants was $419,000, five co-funded and seven in Africa.

The geographic location of the Grants-in-Aid was based on the criteria alone so that it is encouraging that the largest number ended up being in the area of the greatest need, namely in Africa. The high quality of the projects makes it likely that some of them will produce enough pilot data to allow for applications to larger funding agencies such as the Fogarty Foundation.

Public Awareness and Action Committee

The Public Awareness and Action Committee headed by Mohamed Wasay is trying to establish a World Brain Day inspired by the highly successful World Stroke Day, that I proclaimed when I was vice president of the WFN in Cape Town on Oct. 29, 2006, along with a World Stroke Agenda to which all of the major organizations dealing with stroke contributed.

Publications

During this administration at the recommendation of the Publications Committee, chaired by Christopher Kennard, a new editor was selected for the Journal of Neurological Sciences. Robert Lisak who served as editor for 15 years steadily increased the journal’s impact factor and circulation for which the WFN is immensely grateful. He was succeeded by John England who has co-opted highly capable associate editors in the areas of global neurology, translation research, outcomes research and practice standards that will give the journal a distinctive personality and a higher profile.

World Neurology is now totally digital, being capably edited by Donald Silberberg. World Neurology is in dynamic interaction with the website that has been modernized, updated and made more useful under the editorship of Pete Engel and with the gifted technical capabilities of Chu Man. Wolfgang Grisold has been active in the website in close coordination with the activities of the Education Committee.

World Neurology Congresses: Accelerating the Cycle

As vice president, I initiated the process that resulted in moving the World Congresses from a four-year cycle to a two-year cycle. This has allowed for neurology to go where it is most needed. The main aim of congresses is to take neurology to parts of the world where it becomes accessible to neurologists and others interested in the nervous system who have no means of traveling internationally. The more frequent congresses also have allowed continuity in organization and the scientific program committee and have brought in more frequent income in an era of shrinking resources.

Finance

Our finances are sound, thanks to our able Secretary-General Raad Shakir and proceeds from a combination of successful congresses and sound investments. Our expanded activities also have required that we revamp the budgeting process, and we have implemented management accounting, whereby it is possible to monitor our income and expenditures on an ongoing basis that will allow for easier planning in the future.

The Standards and Evaluation Committee

As part of our expanded mission, we established standards, so that anything endorsed by the WFN stands for quality and value. This began as a working group headed by Aksel Siva, aided by Sarosh Katrak, and initially by Charles Warlow and later by Werner Hacke and has now been established as a new committee of the WFN. The higher standards have made the WFN’s endorsements more valuable.

Continental Initiatives

Africa: My predecessor, President Johan Aarli made it his mission to do more with Africa, the continent in the greatest need of neurology.

It was at his behest that the first congress on the African continent took place in Marrakesh in 2011. Our Moroccan colleagues, led by Moustafa El Aloui, not only hosted an exemplary congress, but used the proceeds from the congress to establish a foundation to further neurological endeavors. Similarly, the WFN devoted part of its income to be used in Africa.

The WFN has been a participant of the annual neurology courses in Africa along with European Federation of Neurological Societies (EFNS), International Brain Research Organization and others. The training neurology center in Rabat has now been approved by the WFN, and discussions are under way with colleagues in Ghana and Tanzania for the possibility of setting up a training program in an English-speaking African country.

At the initiative and with funding from the Turkish Neurological Society, a program for visiting trainees has been established between Turkey and East Africa.

The high proportion of grassroots grants funded in Africa reflects both the great need and great opportunities to advance neurology in Africa.

Asia: We began the Asia Initiative led by Ryuji Kaji with modest help from the WFN, helping organize an infrastructure for the now thriving Asian Oceanian Association of Neurology.

Latin America: The formation of a Latin American initiative led by Gustavo Roman resulted in the Latin American Federation of Neurological Societies and in the democratic election of a regional director: Marco Medina.

Regarding the established continental regional neurological societies, namely the North American region (Canada and the United States) and the European Federation of Neurological Societies, our administration made a point of having good and direct relationships with them. Specifically, we initiated an annual meeting of the leaders of the WFN and the AAN (Berch Griggs, Bruce Sigsbee, Timothy Pedley and Cathy Rydell) that has fostered better understanding and greater cooperation between the two organizations. Similarly, it has been a pleasure to deal with the president of the EFNS, Richard Hughes, who was most cooperative in co-sponsoring the World Congress of Neurology in Vienna and in dealing with matters of mutual interest.

Education Committee

The single largest activity of the WFN is directed by the Education Committee. It has been led in an exemplary, complementary way by Stephen Sergay and Wolfgang Grisold who have organized, rationalized and focused the efforts of the Education Committee. Some of their achievements include the accreditation visits to training programs such as the one in Trujillo, Peru, and the activities reported under the Africa Initiative.

The WFN: An Organization for All Ages and Career Stages

As vice president, I facilitated the incorporation of a young neurologists group led by Walter Struhal with the aim of making the WFN an organization for all ages and career stages. I am happy to report that there has been a considerable expansion in the participation of younger neurologists, particularly in regard to the website and using modern technology for communication and education. We also introduced a discount on the congress registration for senior neurologists in an attempt to make the World Congress of Neurology attractive and affordable throughout a full career span.

Leadership Training

Although the administration was elected for a four-year term, we divided it into two halves. For the initial two years, the committees and initiatives were kept small so that the member could get to know each other and learn to work together. For the second two years, the committees and initiatives were expanded and a number of vice chairs were appointed, typically younger individuals, more women and more individuals from different parts of the world. The two-year cycle gives opportunities for promotion to the most active individuals and the possibility of being involved in different committees and initiatives in sequence.

Conclusion

It is not for me to judge what we have achieved, except that it resulted from a collective effort.

I would like to thank Vice President Hacke, Secretary-General Raad Shakir, and fellow Trustees, Donna Bergen, Wolfgang Grisold, Ryuji Kaji, Gustavo Roman and Stephen Sergay, in the central office, Keith Newton, Laura Druce and Helen Gallagher and in my office, Rebecca Clarke and the many around the world who know that they have made a difference.

I am particularly grateful to our Austrian colleagues under the leadership of the World Congress of Neurology, Eduard Auff who hosted a magnificent event. It would be hard to imagine a more splendid congress to culminate my presidency. I was especially privileged to have my Dream Waltz (orchestrated by Jason Stanford) premiered at the Musikverein as part of the Gala Concert. It is not too often that one can say that one’s presidency ended literally on a high note.

I congratulate President-Elect Raad Shakir, Vice President-Elect William Carroll, Secretary-General-Elect Wolfgang Grisold, elected Trustee Gallo Diop and continuing elected Trustee Gustavo Roman and wish them every success in fulfilling the mission of the WFN to “foster quality neurology and brain health worldwide.”

A Life with Grace: Caring for Children Who Have Severe Neurological Impairment

BOOK REVIEW

By Lawrence W. Brown, MD

In a totally unscientific anecdotal analysis, I have found that child neurologists are the most caring and empathetic physicians of all specialists. Unfortunately, most of us have neither the time, the training nor the resources to provide comprehensive care for all of our patients with severe neurological impairment.

A Life with Grace; Caring for Children Who Have Severe Neurological Impairment goes a long way in showing that it is possible to act collaboratively with parents and other members of the care team in order to provide a humane and realistic approach to intellectual disabilities and other static and progressive encephalopathies. This book may be directed at parents and caregivers, but it strikes a responsive chord in many health care providers like myself who accept and encourage a family-centered approach that redefines palliative care far beyond end-of-life support. Rather, it can aim to ensure the best possible quality of life for the child while accepting that medicine does not have all the answers. And even when we think we know the right approach, it is essential to accept families as partners in the decision-making process.

The most successful chapters are symptom-oriented discussions such as pain, seizures, GI complaints and respiratory problems. It doesn’t matter if the underlying diagnosis is Trisomy 21 or Rett syndrome since identification of a disruptive symptom such as pain and its differential diagnosis is similar in all neurologically impaired children who cannot communicate or even localize the problem. The author is frank about her opinion that favors an empirical approach, which minimizes testing and offers treatment based on likelihood of diagnosis and availability of effective non-invasive interventions. At the same time, Hauer suggests that there is a role for intensive investigations if the symptoms persist despite the first steps.

In a book written to a lay audience, there is a plethora of information including worrisome side effects and drug interactions, but little advice on how to prioritize among choices — while confusing, this is reasonable if one understands that expert diagnosticians must look at the individual child and negotiate the options with skill and finesse. She also offers some practical algorithms for specific symptoms (with validated scales where available), a time frame for the recommended clinical trial, the importance of regular assessment of outcome and a sensible guide to discontinuing medication when the treatment has failed to achieve its goals. Perhaps equally important is the emphasis (both to parents and neurologists) on non-pharmacological approaches from simple comfort measures such as massage, repositioning and reduced total volume with slower tube feeding to alternative strategies such as acupuncture.

Child neurologists may particularly appreciate the discussion that recognizes that almost any CNS symptom (from spasticity to dystonia to seizures) can worsen as a result of any factor altering comfort — pain illness, constipation, disrupted sleep, medication toxicity, etc. It is equally important to recognize that many behaviors that could be seizures in children with severe neurological impairment (even in those with definite epilepsy) have non-epileptic explanations for their arching, posturing, exaggerated startle reactions and staring.

The chapter on seizures is valuable for child neurologists with recommendations for tube-fed children, guidelines for rectal administration of drugs and the restrained use of blood levels. One disappointment is the brevity of the discussion on medically refractory epilepsy in this population. I would have preferred to see more emphasis on surgery since this is still the only real option for cure. Even though limited resection is less likely to be successful in severely involved children, there are many examples of excellent outcomes in selected cases of tuberous sclerosis and cortical dysplasia in patients with intellectual disability and autism. Beyond focal resection, it is equally important in a book emphasizing quality of life to more fully discuss the value of the ketogenic diet, vagus nerve stimulator and corpus callosotomy — all of which can be life-changing in the well-chosen patient.

The least successful chapters come early in the book – what I call Neurology 101. Indeed, it is necessary to review static versus progressive disorders, but to highlight a handful of examples trivializes the complexity of the diagnostic challenges and is confusing in the overlap of distinguishing symptoms. In the era of molecular genetics and pharmacogenomics, it is insufficient to list 12 random genetic disorders or to spend two pages explaining brain pathology in children with all of the conditions that can lead to severe neurological impairment.

There are many valuable points that can help the treating neurologist in areas that are at the edge of his or her knowledge. These include GI issues from the risk of diarrhea from excessive sorbitol in liquid medications to constipation not only as a source of pain, but also as a cause of urinary retention and bladder infections. In addition, there are consequences of delayed GI motility including distension, abdominal pain and chronic diarrhea. There are equally valuable pointers in the respiratory chapter such as techniques to manage dyspnea from stimulation by a fan to repositioning and use of benzodiazepines to reduce anxiety as well as the recognition that treatment of excessive secretions with anticholinergics must balance the goal of reduced secretion with the risk of thicker secretions that are more difficult to mobilize and can worsen constipation.

Particularly helpful for physicians as well as parents are the case examples spread throughout the book. These address the decision points that go into a fully informed plan to address critical issues like whether to perform tracheotomy or spinal surgery, how to manage recurrent respiratory crises and even withdrawal of support respecting life without extending death.

In summary, this is a unique and valuable resource for parents and neurologists alike. It beautifully manages the almost impossible by speaking at a high level without excessive scientific jargon and incorporating a glossary of medical terms for the laymen while including timely and extensive peer-reviewed references at the end of each chapter for physicians.

Brown is at the Children’s Hospital of Philadelphia, Philadelphia, PA.

International Working Group of Young Neurologists and Trainees Report

2012 APAYNET workshop participants in Melbourne, Australia.

Young neurologists, future advocates of the brain are ready to embrace the 2013 WCN congress theme, globalization of neurology.

We agree with Vladimir Hachinski that neurologists are the true guardians of the brain.

The International Working Group of Young Neurologists (IWGYNT) held its inaugural meeting at the 2009 World Congress of Neurology in Bangkok and is ready to embrace the concept of globalization.

We represent the common interests of young neurologists and neurologists in training worldwide within the World Federation of Neurology.

IWGYNT continues to establish and foster networking between young neurologists and trainees across the globe.

We wholeheartedly support international exchange programs across the globe.

In 2009, panels of delegates were organized to represent each continent (two delegates per continent). These delegates continued their hard work to achieve the mission representation, networking and exchange programs for young neurologists and trainees.

Asia Pacific Association of Young Neurologists and Trainees (www.apaynet.org) was born as a result of IWGYNTs advocating for international young neurology. APAYNET continues to be the only organization in Asia to specifically represent the interests and young neurologists and trainees in Asia Pacific region. We were following the footsteps of European Association of Young Neurologists and Trainees (EAYNT) who were quite successful in this mission in Europe in the recent years.

Young neurologists need good clinical training. Not all centers in Asia Pacific region have the necessary facilities to train young neurologists in their area of interest, so the trainee may have to spend time in another country. Our group will try their best to facilitate this process to make improve post-graduate training across the region.

Activities

Since 2011, APAYNET representatives delivered lectures and workshops on matters for junior neurologists and trainees at local and regional meetings. In 2012, there were two major activities.

APAYNET was invited to represent World Federation of Neurorehabilitation (WFNR) young neurologists interest group at the 2012 WFNR congress in Melbourne. Tissa Wijeratne chaired the workshop, which focused on post stroke spasticity. It was a huge success: 15 trainees participated; delegates from several Asia Pacific countries were present. The participants enjoyed the workshop. The inaugural APAYNET workshop, chaired by Wijeratne, conducted in conjunction with the 13th Asian Oceania Congress of Neurology in Melbourne in 2012.

The workshop opened by an online presentation on neurology training and teaching in Europe, journey of European neurologists and trainees by Walter Struhal, Bruce Campbell from Australia and New Zealand, Surat Tamprawate from Thailand, Hans Tu from Royal Melbourne Hospital and Western Hospital, Jong Seok Bae from Korea and Hemal Horadagoda from Sri Lanka.

Arthur Wesley Thevathasan, a young upcoming star in the movement disorders field in Melbourne from Australia, Professor Man Mohan Mehindiratta from India were among the speakers.

One main issue of this workshop is how to create more training and learning opportunities for the young neurologists and trainees in the region.

Stroke is the leading cause of adult disability in Sri Lanka, which has a population of 23 million. Sri Lanka health care workforce is trying their best to improve stroke care in the country to keep up with the rest of the world in the recent years. There is a strong need for ongoing stroke care training and education in Sri Lanka to enhance this process further.

2013, APAYNET conducted a series of stroke master classes in Sri Lanka.

The World Stroke Organization endorsed Stroke Master Class series in Sri Lanka. Wijeratne, Darshana Sirisena (Young Neurologist from Sri Lanka) and Nirodha De Silva (young physician with an interest in stroke from Sri Lanka) were the key organizers. All aspects of stroke care and management were covered during the stroke master class series. Despite a lot of challenges, more than 500 Sri Lankan doctors, nurses and allied health staff took part in this highly successful stroke master class series.