VOL. 24 NO. 4 World Neurology · 2016. 10. 13. · Elsevier Pharma Solutions London, UK +44 (0) 207...

6709667032

67096.photo.c

B Y R E N É E M AT T H E W S

Else vier Global Medical Ne ws

Intravenous recombinant tis-sue plasminogen activator canbe safely administered 3-4.5hours after acute ischemicstroke and could improve out-comes in some patients, ac-cording to a joint advisorystatement from the AmericanHeart Association and the

American Stroke Association.Current guidelines stipulate

that intravenous recombinant tis-sue plasminogen activator(rTPA) be administered within 3hours of symptom onset to im-prove neurological outcomes,but many patients do not receiveit because they present for treat-ment after the 3-hour window.

However, Dr. Gregory J. delZoppo and his coauthors, writ-

ing on behalf of the AHA StrokeCouncil, emphasized that pa-tients who are eligible for rTPAtherapy within the 3-hour win-dow should be treated accordingto the council’s 2007 guidelines.“Delays in evaluation and initia-tion of therapy should be avoid-ed, because the opportunity forimprovement is greater with ear-lier treatment,” they wrote in anonline article (doi:10.1161/

STROKEAHA.109.192535).That said, they noted that

rTPA should be used in “eligiblepatients” 3-4.5 hours after stroke.Eligibility criteria for the ex-tended treatment period wouldbe the same as those for the 3-hour cut-off, except if patientsalso conformed to one of the fol-lowing: They were older thanage 80; were taking anticoagu-lants, regardless of their inter-

national normalized ratio; had abaseline National Institutes ofHealth Stroke Scale score greaterthan 25; or had a history of bothstroke and diabetes.

Dr. Joseph P. Broderick, pro-fessor and chair of neurologyat the University of CincinnatiNeurosciences Institute andAcademic Health Center, said

B Y D A N I E L WA L D V O G E L , M . D. ,

P H I L I P P O. VA L K O, M . D. , A N D

C L A U D I O L . B A S S E T T I , M . D.

The Swiss Neurological Society cele-brated its 100th anniversary last year.Since its founding in 1908, the society’shistory has mirrored neurology’s emer-gence as a specialty separate from psychia-try and internal medicine. At the sametime, the society played an important rolein advancing the fledgling specialty duringtwo world wars by continuing to publishnew work by neurologists from elsewherein Europe, and most notably, Jewish neu-rologists and German neurologists whowere persecuted in their own country.

Today, the society has 313 active members,7 honorary members, and 15 correspondingmembers. It meets twice a year, and takespride in offering theme-based courses andlectures with distinguished speakers.

The current president of the society, Dr.Claudio L. Bassetti, succeeded Dr. MaxWiederkehr, a neurologist in private practice.Dr. Wiederkehr’s tenure exemplified thestrong ties in Switzerland between academ-ic neurologists and those in private practice.Most neurologists in private practice havespent years of continuous work at teachinghospitals, ensuring a high level of compe-tence in neurologists in private practice.

Even before the SNS, Switzerland hadmade important contributions to the clini-cal and experimental neurosciences (see boxon p. 8). The founding date of the society isconsidered to be Nov. 5 of 1908, when mem-bers of an action committee—Robert Bing,Paul Dubois, Paul-Louis Ladame, Constan-tin von Monakow, Louis Schnyder, Schu-mann, Alfred Ulrich, Otto Veraguth, EmilVilliger, and Gustav Wolff—met in the Swisstown of Olten. The SNS was officially con-

stituted on March 13, 1909, in Berne.The movement was initiated by Robert

Bing (1878-1956), who had completed post-doctoral work at Basel University on spi-nocerebellar pathways and opened a neu-rological outpatient clinic. He had con-vinced Dubois and von Monakow of theneed for a society for the specialty.

The importance of establishing a spe-cialist society for neurology at that timeshould be seen in the context of the pro-tracted and arduous attempts to disengageneurology from psychiatry and internalmedicine.

The giant strides made in neuroanatomyand clinical neurology in the second half ofthe 19th century fueled calls in Europe andthe United States for independence. Theturn of the century saw the emergence ofautonomous specialist societies in numer-ous countries. The world’s first specialistneurological society, the American Neuro-logical Association, was founded in 1875 byWilliam A. Hammond in the United States;the Neurological Society of London wasfounded in 1886 and renamed the Neuro-logical Society of the United Kingdom in1905. In 1899, Jules Déjérine and a largegroup of Jean Martin Charcot followersfounded the Société de Neurologie de Paris,

NeurologyWorld

VOL. 24 • NO. 4 • AUGUST 2009

Window for rTPA Therapy in Stroke Pushed to 4.5 Hours

Swiss Society Celebrates 100 Years

T H E O F F I C I A L N E W S L E T T E R O F T H E W O R L D F E D E R A T I O N O F N E U R O L O G Y

See rTPA • page 12

See Swiss • page 8

Place your classifiedadvertisement today!

WORLD NEUROLOGY now offers job advertisements to an international printreadership of over 25,000 neurologists and to a much larger on-line

readership through the Publications section of the World Federation ofNeurology web site at www.wfneurology.org.

E-mail us at [email protected] or Fax us on +44 (0)207 4244433

Dr. Claudio L. Bassetti is the president ofthe SNS, which had a defining role inEuropean neurology during two world wars.

CO

UR

TE

SY

SW

ISS

NE

UR

OL

OG

ICA

LS

OC

IET

Y

I N S I D E

Thailand—WCN 2009World experts are linedup to speak on innovationin neurology at this year’sCongress in Bangkok,writes Dr. NarapornPrayoonwiwat, chair ofthe Scientific Program. PA G E 5

PolandProf. Irena Hausmanowa-Petrusewicz, the notedPolish neurologist, washonored by her peers at ameeting on biocyberneticsin Warsaw.PA G E 6

LaosCanadian neurologist, Dr.Robert Lee, describes hisvolunteer work in Laos,including development ofa new curriculum fortraining doctors thatincludes neurosciencecomponents.PA G E 1 1

67448 67092

2 • WORLD NEUROLOGY WWW.WFNEUROLOGY.ORG • AUGUST 2009

WORLD FEDERATION OF NEUROLOGYEditor in Chief Dr. Mark Hallett (U.S.A.)

EDITORIAL ADVISORY BOARDDr. Pierre Bill (South Africa); Dr. William M. Carroll (Australia); Dr. Jagjit S. Chopra (India); Dr. Michael Finkel (U.S.A.); Dr. Osvaldo Fustinoni (Argentina); Dr. Francesc Graus (Spain);Dr. Alla Guekht (Russia); Dr. Theodore Munsat (U.S.A.); Dr. Daniel Truong (U.S.A.); Dr. Alexandros C. Tselis (U.S.A)

WFN OFFICERSPresident: Dr. Johan A. Aarli (Norway)First Vice-President: Dr. Vladimir Hachinski (Canada)Secretary-Treasurer General: Dr. Raad Shakir (United Kingdom)

ELECTED TRUSTEESDr. Gustavo Romano (U.S.A.); Prof. Werner Hacke (Germany); Dr. Ryuji Kaji (Japan)

CO-OPTED TRUSTEESDr. Roger Rosenberg (U.S.A.); Dr. Niphon Poungvarin (Thailand)

REGIONAL DIRECTORSDr. Alfred K. Njamnshi (Pan Africa); Dr. Jacques De Reuck(Europe); Prof. Riadh Gouider (Pan Arab); Dr. Amado San Luis(Asian-Oceania); Dr. Robert Griggs (North America); Dr. AnaMercedes Robles de Hernandez (Latin America)

EXECUTIVE DIRECTORKeith NewtonWorld Federation of NeurologyHill House, Heron SquareRichmond, Surrey, TW9 1EP, UKTel: +44 (0) 208 439 9556/9557 Fax: +44 (0) 208 439 [email protected]

EDITOR OF THE JOURNAL OF THE NEUROLOGICAL SCIENCESDr. Robert Lisak (U.S.A.)

WORLDNEUROLO GY

GLOBAL MEDICAL RESEARCHPublisher Peter F. Bakker

ELSEVIER GLOBAL MEDICAL NEWSA Division of International Medical News Group

President IMNG Alan J. Imhoff

Editor in Chief Mary Jo M. Dales

Executive Editors Denise Fulton, Kathy Scarbeck

Managing Editor Renée Matthews

Clinical News Editor Jeff Evans

VP, Medical Education Sylvia H. Reitman

Circulation Analyst Barbara Cavallaro

Executive Director, Operations Jim Chicca

Director, Production and Manufacturing Yvonne Evans

Production Manager Judi Sheffer

Creative Director Louise A. Koenig

EDITORIAL OFFICE5635 Fishers Lane, Suite 6000Rockville, MD 20852+1-240-221-4500 Fax: +1-240-221-2541

US ADVERTISINGRory Flanagan60 Columbia Rd., Building BMorristown, NJ 07960+1-973-290-8222 Fax [email protected]

INTERNATIONAL ADVERTISINGMartin SibsonBusiness Development ExecutiveElsevier Pharma SolutionsLondon, UK+44 (0) 207 424 [email protected]

WORLD NEUROLOGY, an official publication of the World Federationof Neurology, provides reports from the leadership of the WFN, itsmember societies, neurologists around the globe, and news fromthe cutting edge of clinical neurology. Content for WORLD NEUROLOGYis provided by the World Federation of Neurology and Elsevier GlobalMedical News.

Disclaimer: The ideas and opinions expressed in WORLD NEUROLOGYdo not necessarily reflect those of the World Federation of Neurol-ogy or the publisher. The World Federation of Neurology and Else-vier Inc., will not assume responsibility for damages, loss, or claimsof any kind arising from or related to the information contained inthis publication, including any claims related to the products, drugs,or services mentioned herein.

Editorial Correspondence: Send editorial correspondence toWORLD NEUROLOGY, 5635 Fishers Lane, Suite 6000, Rockville MD 20852, U.S.A.; [email protected];Phone +1-800-798-1822

Address Change: Fax change of address to +1-973-290-8245

POSTMASTER: Send change of address (with old mailing label)to WORLD NEUROLOGY, Circulation, 60 B, Columbia Rd., 2nd Fl.,Morristown NJ USA 07960

WORLD NEUROLOGY, ISSN: 0899-9465, is published bimonthly byElsevier Inc., 60 B, Columbia Rd., 2nd Fl., Morristown NJ 07960.Phone +1-973-290-8200; fax +1-973-290-8250.

©Copyright 2009, by the World Federation of Neurology

EDITOR IN CHIEF’S COLUMN WCN 2009

AuthoritarianNeurology

Neurologists have to assume dif-ferent personalities from timeto time depending on the cir-cumstance: empathetic, fatherly,motherly, didactic, and even author-itarian. Not, of course, as authori-tarian as neurosurgeons. Surgeons,by their very nature, are differentfrom neurologists andbeing authoritariancomes naturally. Someneurologists may haveto force it.

A good example ofuseful authoritarianismis found on page 13 inthis issue of WORLDNEUROLOGY in RobertDaroff ’s story about therenowned neurologist,Fred Plum. A strong per-sonality can take chargeand move things in the right direc-tion, and Dr. Daroff illustrates howby doing so, Dr. Plum not onlychanged the outcome of a singleevent, but in another circumstancechanged the course of Dr. Daroff ’slife.

I have a personal example of aforceful personality: Raymond D.Adams. A young boy I was takingcare of at the Brigham and Women’sHospital in Boston had frequent jawopening movements. The move-ments appeared to be fully involun-tary and did not have any urge at on-

set or relief afterward that wouldhave suggested a tic. I had done a se-ries of tests and had a number oftherapeutic failures. Dr. Adams wasa visiting professor at the time, and Ishowed him the patient. He lookedthe boy in the eye and said sternly,“Don’t do that.” And the boy never

did it again. A rapid cureof a likely stereotopy.

Another situation inwhich there is a role forthe authoritarian neu-rologist is in dealingwith conversion disor-ders. (An article aboutindividualizing one’s ap-proach to a patient witha psychogenic move-ment disorder is on page5 of this issue.) One ofthe frequent require-

ments on the part of the neurologistis to be authoritarian. Patients oftendo not want to believe that their dis-order has a psychiatric etiology, andthey want to continue looking for anorganic problem. If the physicianseems uncertain, patients mightsense that uncertainty and will notaccept the diagnosis. They will thencontinue to doctor-shop to find thebrain tumor. Of course, if there isreally uncertainty, further investiga-tions are warranted. But when cer-tain, be authoritarian—it can behelpful. ■

BY MARKHALLETT, M.D.

B Y N I P H O N P O U N G VA R I N, M . D.

President, World Congress of Neurology

Iwould like to share some good newswith you about the situation in Thailand,specifically in Bangkok, where we will holdour World Congress of Neurology Oct. 24-30 this year.

Enhanced security measures have beenimplemented at all international airportsand major hotels to ensure the completesafety and well-being of over-seas visitors to Thailand.

The Thai government is like-ly to announce free insurancefor all international visitors be-tween May and the end of No-vember this year. The insur-ance coverage would mean thatin the unlikely event of any po-litical disorder leading to travelor event disruption, all WCN at-tendees from overseas would becovered for travel disruption,hospitalization, and medical ex-penses up to 10 days. The government isproposing to underwrite the insurance pol-icy with a budget of U.S. $295 million. Assoon as the insurance coverage is passed intolaw, we will inform you by e-mail.

I am also honored and pleased to informyou that Thailand’s Princess Maha ChakriSirindhorn will preside at our opening cer-emony on Sunday, Oct. 25.

The WCN 2009 organizing committeehas been working hard to create a strongand inclusive program for those who willbe attending. To date, we have receivedmore than 1,000 abstracts from researchersand clinicians in more than 80 countries.

With so many preparations in place, itwould be very unfortunate if some of ourmembers decided not to come based onmisconceptions about Thailand.

Here is what the media did not reportduring the protests last year and early thisyear: No tourists were injured nor wastheir safety compromised; the protests wereprimarily in front of Government Houseand in isolated locations far from hotels andcongress venues; and even during the iso-

lated disruptions, business con-tinued in almost all of the cityand is now back to normal.

Today there is a new unity inThailand. There is a bottom-upcommitment from the peopleand a top-down commitmentfrom the government to ensurethat all visitors have a wonder-ful, trouble-free, experiencehere. Spanish tennis player,Rafael Nadal, has said he willbring his family for a holiday inThailand before joining the PTT

Thailand Open tennis championship inBangkok from Sept. 26 to Oct. 4. So perhapsI could ask you, my fellow neurologists, toalso give Thailand a sporting chance!

We are committed to improving the hu-man condition through our work. The de-velopment of neurology, especially its ex-pansion in poorer countries, can only beserved if we unite, like the people of Thai-land, to do what is right. So I ask you toshow your commitment to the advance-ment and expansion of neurological sci-ence and register for the Congress atwww.wcn2009bangkok.com. I look for-ward to greeting you all in Bangkok. ■

Good News Update

NIPHON POUNGVARIN, M.D.

Leading resources in clinical neurology!

Volume 9 Issue 2 January 2008 ISSN 1389-9457

Editor-in-Chief:SudhansuChokroverty

Field EditorsR.P. AllenC. GuilleminaultP. LevyL. Ferini-StrambiO. Bruni

Associate EditorsR.P. AllenC. BassettiA. CulebrasR.A. FerberR. GrunsteinC. GuilleminaultJ. HednerW. HeningS. KatayamaP. LevyM. MahowaldJ. MontplaisirM. SandersM. ThorpyT. Young

Official Journal of the World Association of Sleep Medicineand International Pediatric Sleep Association

Official Journal of the European Paediatric Neurology Society

Volume 10, Number 1January 2006

SEIZURE

Volume 15, Number 8, December 2006 ISSN 1059-1311

The Official Journal of Epilepsy Action

sleepmedicineREVIEWS

W

1

REM

2

3

4

W

1

REM

2

3

4

Vol. 131, Nos. 1–2 30 January 2007 ISSN 1566-0702

Clinical Neurologyand Neurosurgery

Volume 108, issue 7, October 2006 ISSN 0303-8467108(7) 621–720

ReviewNeuromuscular disorders in critical illness – L. Pandit, A. Agrawal (Mangalore, India) 621

Original articlesLaterality does not influence early mortality in MCA ischemic stroke – I. Mateo, A. Pinedo, I. Escalza, J.C. Garcia-Monco (Vizcaya, Spain) 628Vascular cognitive impairment in patients with late-onset seizures after an ischemic stroke – J. De Reuck, M. De Clerck, G. Van Maele

(Ghent, Belgium) 632Cardiovascular risk factors in patients aged 85 or older with ischemic stroke – A. Arboix, M. Miguel, E. Císcar, L. García-Eroles,

J. Massons, M. Balcells (Barcelona, Spain) 638The interleukin-10 levels as a potential indicator of positive response to interferon beta treatment of multiple sclerosis patients –

H. Bartosik-Psujek, Z. Stelmasiak (Lublin, Poland) 644Medically refractory epilepsy associated with temporal lobe ganglioglioma: Characteristics and postoperative outcome – A. Radhakrishnan,

M. Abraham, V.V. Radhakrishnan, S.P. Sarma, K. Radhakrishnan (Trivandrum, India) 648Alleviation of intracranial air using carbon dioxide gas during intraventricular tumor resection – T. Beppu, K. Ogasawara, A. Ogawa

(Morioka, Japan) 655Clinico-pathological and immunohistochemical characteristics associated to recurrence/regrowth of craniopharyngiomas – M.L. Tena-Suck,

C. Salinas-Lara, R.I. Arce-Arellano, D. Rembao-Bojórquez, D. Morales-Espinosa, J. Sotelo, O. Arrieta 661

Case reportsRespiratory failure in a patient with antecedent poliomyelitis: Amyotrophic lateral sclerosis or post-polio syndrome? – S.-i. Terao, N. Miura,

A. Noda (Aichi, Japan), M. Yoshida, Y. Hashizume, H. Ikeda, G. Sobue (Japan) 670Bilateral C5 motor paralysis following anterior cervical surgery—a case report – K.S. David, R.D. Rao (Milwaukee, WI, USA) 675Correlation of magnetic resonance images with neuropathology in acute Wernicke’s encephalopathy – Y.-T. Liu, J.-L. Fuh, J.-F. Lirng, A.F.-Y. Li,

D.M.-T. Ho, S.-J. Wang (Taipei, Taiwan) 682Subacute aseptic meningitis as neurological manifestation of primary SjÖgren’s syndrome – R. Rossi, M. Valeria Saddi (Nuoro, Italy) 688Thin corpus callosum and amyotrophy in spastic paraplegia—Case report and review of literature – B. Winner, C. Gross, G. Uyanik,

W. Schulte-Mattler, R. Lürding, J. Marienhagen, U. Bogdahn (Regensburg, Germany), C. Windpassinger (Graz, Austria), U. Hehr, J. Winkler (Regensburg, Germany) 692

Camptocormia or Pisa syndrome in multiple system atrophy – J. S awek (Gdańsk, Poland), M. Derejko (Warszawa, Poland), P. Lass, M. Dubaniewicz (Gdańsk, Poland) 699

“Frontal variant Alzheimer’s disease”: A reappraisal – A.J. Larner (Liverpool, UK) 705Transient tetraplegia after cervical facet joint injection for chronic neck pain administered without imaging guidance – J.G. Heckmann,

C. Maihöfner, S. Lanz, C. Rauch, B. Neundörfer (Erlangen, Germany) 709Adie’s pupils in paraneoplastic ganglionopathy with ANNA-1 – J.V. Campellone, A. Hageboutros (Camden, NJ, USA) 712

Book reviewsHead injury: Pathophysiology and Management – D. Van Dam (Wilrijk, Belgium) 715

(Contents continued on OBC)

For a complete list of neurology products, detailed information on the titles above and online access to the journal articles, visit

www.elsevier.com/clinicalneurology

Acute Pain

Alzheimer’s and Dementia

Autonomic Neuroscience: Basic and Clinical

Brain & Development

Clinical Neurology and Neurosurgery

Clinical Neurology News

Clinical Neurophysiology

Epilepsy & Behavior

Epilepsy Research

European Journal of Paediatric Neurology

European Journal of Pain

Experimental Neurology

Journal of Clinical Neuroscience

Journal of Neuroimmunology

Journal of the Neurological Sciences

Journal of Pain

Journal of Pain and Symptom Management

The Lancet Neurology

Neurobiology of Aging

Neuromuscular Disorders

Neuroscience & Biobehavioral Reviews

Neurotherapeutics (NeuroRX)

Pain

Parkinsonism and Related Disorders

Pediatric Neurology

Regional Anesthesia and Pain Medicine

Seizure: European Journal of Epilepsy

Sleep Medicine

Sleep Medicine Reviews

Surgical Neurology

The offi cial journal of the World Federation of Neurology THE journal for the prompt publication of studies on the interface between clinical neurology and the basic sciences.And did you know.. Journal of the Neurological Sciences is your ultimate resource for the latest developments and research on Vascular Dementia, Stroke and Multiple Sclerosis!

www.elsevier.com/jns

Neurology cluster ad US DM 06.09.indd 1 17/6/09 17:08:12

67212 62951.graphic


PRESIDENT’S COLUMN

WFN and the Africa InitiativeThe main mission of theWorld Federation of Neu-rology today, as I see it, isto reduce the global burden as-sociated with neurological dis-orders.

According to the NeurologyAtlas, which was prepared bythe World Health Organization(WHO) and the WFN in 2004,

the available resources are insufficient for this purpose.In addition, there are significant disparities across re-gions and income groups, with low-income countrieshaving extremely scanty resources.

Dr. Margaret Chan, the director-general of theWHO, and Jean Ping, thechair of the Commission ofthe African Union, have bothpointed out that Africa is fac-ing a dramatic public healthcrisis. What sets Sub-SaharanAfrica apart, compared withmany parts of the world, isthe lack of a neurology in-frastructure.

The WHO has estimatedthat there is an average of 0.03 neurologists per 100,000individuals in Africa, compared with 4.84 in Europe. Atthe same time, the burden of neurological diseasecontinues to grow. With a population of about 700 mil-lion, around 45% live on less than U.S. $1 a day. Themedical infrastructure is poorly developed and hasneared collapse in some areas. The AIDS epidemic pre-sents an additional socioeconomic problem.

This is the background for the Africa Initiative, aprogram launched by the WFN in December 2006 todevelop neurological services across the continent.The Initiative is a collective term for describing vari-ous WFN activities related to that purpose.

Those activities comprise training new neurolo-gists, establishing educational programs in neurology,supporting new national neurological associations, as-sistance in fund-raising for neurology in Africa, trav-eling fellowships, support of public health activities inSub-Saharan Africa, and collaboration with the WHO,the European Federation of Neurological Societies(EFNS), and the International Brain Research Orga-nization (IBRO).

The major goals of the Initiative are to strengthen ex-isting units and establish new centers of excellence inneurology. Educational activities are central to the pro-gram and include training opportunities for would-beneurologists and those who are already in practice.

At the initiation of the program, Prof. Amadou Gal-lo Diop in Dakar, Senegal, noted the importance ofworking with Africa: Go and ask the people in Africa,what are the realities, what are your needs, how do youwant the project to be managed, what kind of supportare you waiting for?

International institutions need to work in partner-ship with Africa to meet the growing burden of neu-rological disorders. This is where we had to start. Weformed the WFN Africa Committee, a team that in-cludes African neurologists. The Committee sets thedirection of the Initiative, moving forward with thesupport of WFN’s Task and Advisory Force for Neu-rology in Africa, a group of international experts inneurology.

In addition, the Africa Initiative depends on politi-cal will and commitment from local decision makers,which are additional challenges for the WHO and ourAfrican colleagues.

How many neurologists are there in Sub-Saharan

Africa? Prof. Gallo Diop has prepared a directory—much like that of the American Academy of Neurolo-gy Membership Directory and Resource Guide or theEFNS directory—and has put the number at 267 for2009. The last estimate, from 1996, was 121.

In 2008, the first Ethiopian neurology residentscompleted their training at Addis Ababa University.That country now has 14 neurologists for a popula-tion of about 80 million people. Of the 10 existing res-idents, half were from outside the capital. Even withinherent uncertainties, the number of neurologists inAfrica is increasing, and it is encouraging that newneurologists have now been trained in South Africa forAngola and Namibia.

We also have many more African national neuro-logical associations as WFNmembers. It is encouragingthat Burkina Faso,Cameroon, Democratic Re-public of Congo, Guinea,Libya, Nigeria, Senegal,Uganda, and Zambia have be-come new WFN membersthrough their national associ-ations, in addition to theAfrican countries that have

been members for some time.The long-term goal for the WFN is that all countries

on the continent should train their own neurologists.There are medical schools in Africa where there is noneurologist, and new candidates receive no basic clin-ical training in neurology. We need a minimum of neu-rologists on the teaching staff.

The Federation can do little in national health poli-tics, but again, the WHO is a powerful force for set-ting the agendas of health planners and ministers ofhealth, and its current spotlight on diseases of the ner-vous system is a hopeful development. WFN is point-ing out the need for neurological expertise at medicalschools in Africa.

New specialists tend to stay in the places where theyhave been trained—such as North America, Europe,Australia, and Japan—so the Federation is working tohave training centers on the African continent in thosecountries that lack training possibilities. For French-speaking countries, there is a generous offer from Ser-vice de Neurologie, Hôpital des Spécialités, in Rabat,Morocco, to train specialists in neurology from otherAfrican countries. Candidates from English-speakingcountries have a similar possible partnership with cen-ters in South Africa andEgypt.

Africa is a huge con-tinent, and there arefive regions withinSub-Sahara—North,East, West, Central,and South. There is al-ready a move towardforming African Re-gional Training Cen-tres of Excellence inNeurology, in whichthe WFN Africa Com-mittee will have a deci-sive action.

Many Europeancountries have tradi-tionally had close andbilateral cultural con-tact with African coun-tries. For example, theEFNS, which has a

close collaboration with the WFN, organized the Re-gional Teaching Course in Dakar, Senegal, in June2008 as part of its educational program. The traineescame from 18 African countries and had selected thetopics for the course, which was a great success. Thenext EFNS teaching course takes place in Addis Aba-ba, Ethiopia, in June.

The Initiative also has close contact with the IBRO,which promotes international collaboration and inter-change of scientific information on brain research.IBRO has been actively involved in the program, alsoat the Dakar meeting and again in Addis Ababa, un-derscoring the fact that brain research is an importantpart of the Initiative.

We have also established an African Department-to-Department Cooperation program, modeled afterthe highly successful EFNS program, which promotesinternational collaboration and interchange of scien-tific information on brain research and allows foryounger neurologists to visit and learn at other de-partments. The Federation is also establishing travel-ing support and fellowships for younger neurologistsand has covered the travel costs for a number ofAfrican neurologists so that they can attend interna-tional congresses.

A problem in many developing countries is the diffi-culty of integrating neurology into primary health ser-vices, as Dr. Robert Lee notes on page 10 in his articleabout his experiences as a volunteer in Laos. Since med-ical resources are often centralized in or around bigcities, many patients in rural areas still have no accessto a neurologist.

In Zambia, Dr. Gretchen Birbeck, of Michigan StateUniversity, East Lansing, U.S.A., is organizing a train-ing program that has been run by WFN and the Uni-versity of Zambia, based at Chainama College ofHealth Sciences, near Lusaka. Neurologists from theUnited States pay regular teaching visits to the college.In Senegal, funding is being provided for a neuro-car-avan project, which is overseen by Prof. Gallo Diop asa way of taking neurology care into rural areas. In Su-dan, Dr. Osheik Seidi has recently organized the firstclinical neurology skills course.

Although the WHO, WFN, EFNS, Pan African As-sociation of Neurological Sciences, or any other neu-rology nongovernmental organization have the re-sources to carry these initiatives alone, much is beingobtained by strengthening neurological care within ex-isting health care systems and by international col-laboration. ■

BY JOHAN A.AARLI, M.D.

EDUCATIONAL ACTIVITIES ARE CENTRALTO THE AFRICAN PROGRAM, AND

INCLUDE TRAINING OPPORTUNITIES FORWOULD-BE NEUROLOGISTS AND THOSE

WHO ARE ALREADY IN PRACTICE.

Projected Deaths Caused by Meningitis

Note: Data are from “The Global Burden of Disease: 2004 Update.”Source: World Health Organization

0 30 60 90 120 150

20152008

Europe

The Americas

Western Pacific

Eastern Mediterranean

Southeast Asia

Africa

Deaths (in thousands)

D A T A W A T C HE

LS

EV

IER

GL

OB

AL

ME

DIC

AL

NE

WS

6709366466

PHOTO SOCIETY DR NAME - STYLE

AUGUST 2009 • WWW.WFNEUROLOGY.ORG WORLD NEUROLOGY • 5

WCN 2009 SCIENTIFIC SESSIONS

‘Innovation’ Theme Threads Through Program B Y N A R A P O R N P R AYO O N W I WAT, M . D.

Chair, Scientif ic Program, WCN 2009

The scientific program for the upcoming WorldCongress of Neurology is central to the Congressbeing a success. In this edition of WORLD NEU-ROLOGY, I would like to share some highlights of whatwe have planned for the Congress, which takes placeOct. 24-30 in Bangkok.

The theme for the scientific program is “Innovationin Neurology,” and we have invited numerous interna-tional experts to speak about the innovations and latestresearch advances in stroke, epilepsy, neurogenetics,neurovirology, behavioral neurology, multiple sclerosis,dementia, movement disorders, and headache and pain.We hope these sessions will be a rich source of infor-mation for the attendees and will provide them with use-ful practical guidance in the clinical or research setting.

The organizing committee is proud to announce thatNobel Laureate, Dr. Stanley B. Prusiner, who won the1997 Nobel Prize for physiology and medicine for hisdiscovery of prions, will deliver an address on the lat-est developments in a session on prion disease.

Dr. Johan A. Aarli, the President of the World Feder-

ation of Neurology, will speak about the urgent need tobring good neurological care to people in developingcountries. Dr. Vladimir Hachinski, the First Vice-Presi-dent and an internationally respected authority in themodern debate on stroke, will discuss theglobal agenda on stroke. This devastatingcondition affects a large proportion of theworld’s population, particularly in Asia,where access to treatment is limited.

Of course, we will also address contro-versial issues. For example, Peter Sander-cock, D.M., and Dr. Louis R. Caplan, will de-bate whether good old aspirin is still the“best antiplatelet for stroke prevention,” andAlastair Compston, Ph.D., MBBS, and Dr.Vanda A. Lennon will explore conflictingopinions on whether Devic disease, a com-mon demyelinating disease in the East, is thesame as its Western counterpart, multiple sclerosis.

In the field of epilepsy, Dr. Samuel F. Berkovic andDr. Michael R. Johnson will provide some clarity as towhether or not one should do a genetic work-up forepileptic patients. And Dr. Serge Gauthier and Dr.Rachelle S. Doody will talk about whether a diagnosis

of predementia, or mild cognitive impairment, mightbe as simple as checking for a biomarker and whetherneuropsychometric testing is reliable.

Other compelling areas of neurology will be coveredas well. In addition to the daily main themeson stroke, multiple sclerosis, epilepsy, neu-rodegenerative diseases, and headache andpain, there will be parallel sessions on infec-tions, imaging, neurosonology, stem cells,movement disorders, genetic diseases, neu-ropathy, myopathy, and more. There will alsobe presentations on the relationship betweenneurology and the creative arts and artists,and ethics and palliative care.

Delegates will have the opportunity tocontribute to the scientific programthrough abstracts based on their research.There will also be many platform presen-

tations and abundant space for poster presentations.Finally, remember that there will be time for fun as

well as learning. Teams representing the various coun-tries in attendance at the Congress participate in a pop-ular event: the 3rd Tournament of the Minds. We willarrange a special prize for the winning team. ■

B Y J E F F E VA N S


WA S H I N G T O N — Clinicians who seepatients with a psychogenic movementdisorder must be cautious in how theyframe their explanation of the cause andsource of their condition to avoid alien-ating patients, according to Dr. Jon Stone.

Because it may be hard for a majorityof patients to accept, at least initially, thattheir movement disorder has a psycho-logical etiology, it may be best to give amechanistic, or functional, explanationthat says there is a problem with theirnervous system, eventhough it is not damaged.That method is probably thepreferred approach, unlessthe clinician feels that the pa-tient is ready to accept a psy-chological explanation, saidDr. Stone, a consultant neu-rologist at Western GeneralHospital, Edinburgh, Scot-land, and an honorary seniorlecturer in neurology at theUniversity of Edinburgh.

Psychogenic movement disorder(PMD) diagnoses may be difficult for pa-tients to accept because they feel verystrongly that they do not have a psycho-logical problem. This is borne out instudies that have shown that about aquarter of all patients with conversionsymptoms endorse stress or psychologi-cal factors as a potential cause of theirsymptoms; probably less than 10% wouldendorse it as the main cause, Dr. Stonesaid at an international conference spon-sored by the Movement Disorder Society.

Some patients may have a secret fearthat they are going “crazy” and may beparticularly sensitive to being told that

their problems are psychological in na-ture. They may interpret this to meanthat the clinician thinks they are fakingtheir problem and are in control of theirsymptoms, which is the “diametric op-posite of their experience” in which theymay at times be in control and othertimes not be in control.

Dr. W. Curt LaFrance Jr., of Brown Uni-versity, Providence, R.I., U.S.A., com-mented in a discussion session at the con-ference that “the key process here forneurologists to hear is, ‘What is going tobuild rapport and not alienate my pa-tient?’ We really need to address that be-

fore asking ‘What do we callthis thing?’”

Some findings suggest thata physician’s explanation ofthe diagnosis could affect pa-tients’ outcomes. One studyof patients with psychogenictremor found that their out-come was correlated withtheir level of perceived satis-faction with their physician(CNS Spectr. 2006;11:501-8).Another study of patients

with psychogenic nonepileptic seizuresshowed that when patients were relievedat their diagnosis, they had much betteroutcomes than when they reported angeror confusion (Seizure 2003;12:287-94).

“Giving a PMD diagnosis is more help-ful than not giving any diagnosis at all.That’s more important than saying, ‘Youdon’t have XYZ,’” Dr. Stone said. “I thinkwhen you can try to pick apart the rea-sons why [presenting the diagnosis] cango wrong, it helps you to navigatearound those reasons.”

He discussed some of the advantagesand disadvantages to each approach:� Psychological explanation. This ap-

proach may hasten patients’ acceptanceof the diagnosis as well as their ability tomake links between their physical symp-toms and emotions. There also is muchmore information available on the In-ternet that bases descriptions of PMDson psychological theory. Patients maythen more readily accept a referral forpsychological treatment to improve theircondition, Dr. Stone said.

Dr. Anthony Lang, professor of neu-rology at the University of Toronto, saidin a discussion at the meeting that he findsit “very useful to introduce the concept ofneuropsychiatry to the patient. ... It dis-turbs the current opinion ofwhat psychiatry is to the pa-tient and raises the idea thatin fact psychiatrists deal withbrain dysfunction.”

However, Dr. Stone notedthat the psychological expla-nation could increase the like-lihood that a patient will beconcerned that the clinicianthinks they are crazy or imag-ining or feigning their symp-toms. This might erode thedoctor-patient relationship and make itdifficult to discuss even less controversialthings during the visit.� Functional and mechanistic explana-tion. An attempt to explain how a pa-tient’s symptoms have arisen may avoidthe concerns that the patient has with apsychological explanation, while also leav-ing the door open to multiple potentialcauses of her symptoms, including psy-chological reasons, because this approachdoes not assume any particular etiology.

Some patients may view a descriptionof their nervous system as malfunction-ing, but undamaged, to be more re-versible than a psychological problem

that is rooted in the past, he said.But the mechanistic explanation not

only could delay a patient’s appreciationof psychological factors and their needfor treatment but also increase the like-lihood of the patient interpreting the di-agnosis as an organic disease.� ‘Medically unexplained’ explana-tion. “I don’t think this [explanation]works very well,” Dr. Stone said, becauseit is untrue to say that you don’t knowwhat it is if you do recognize it.

A randomized trial in the primary careliterature found much better outcomesafter 2 weeks if patients had been given

a positive explanation fortheir unexplained symp-toms, compared with thosewho had been told it wasuncertain what conditionthey had (Br. Med. J. [Clin.Res. Ed.] 1987;294:1200-2).� Combined approaches toexplanation. If a physicianplans on seeing a patientmore than once, it may bebest to use a functional andmechanistic explanation as a

default in an initial appointment and thenintroduce psychological factors in a sub-sequent visit when the patient feels com-fortable and knows that their symptomsare being taken seriously. A minority ofpatients who will accept a psychologicalexplanation on the first visit may be iden-tified by asking patients what they thinkis the cause of their symptoms.

But overall, a patient’s acceptance ofthe diagnosis “may have more to dowith the way you say it rather than whatyou say,” suggested Dr. Stone, who dis-closed that he has received honoraria inthe form of travel expenses from Sanofi-Aventis and Janssen. ■

Individualize Psychogenic Movement Disorder Diagnosis

JON STONE, M.D. ANTHONY LANG, M.D.

NARAPORNPRAYOONWIWAT, M.D.

67180 67149 67183


Calendar ofInternational

Events20096th Congress of the EuropeanFederation of IASP Chapters (EFIC)Sept. 9-12Lisbonhttp://www2.kenes.com/efic/Pages/Home.aspx

13th Congress of the EuropeanFederation of NeurologicalSocieties (EFNS)Sept. 12-15Florence, Italyhttp://www.kenes.com/efns2009

2009 World Congress onHuntington’s DiseaseSept. 12-15Vancouver, Canadahttp://www.worldcongress-hd.net

134th Annual Meeting of theAmerican Neurological AssociationOct. 11-14Baltimore, U.S.A.http://www.aneuroa.org/2009_Baltimore

19th World Congress of NeurologyOct. 24-30Bangkok, Thailandhttp://www.wcn2009bangkok.com

The Sixth International Congresson Vascular DementiaNov. 19-22Barcelonahttp://www.kenes.com/vascular

XVIII WFN World Congress onParkinson’s Disease and RelatedDisordersDec. 13-16Miami Beach, U.S.A.http://www.kenes.com/parkinson

20103rd International Congress on Gait& Mental FunctionFeb. 26-28Washington, D.C., U.S.A.http://www2.kenes.com/gait/pages/home.aspx

6th World Congress forNeuroRehabilitation (WCNR2010)Mar. 21-25Viennahttp://www.wcnr2010.org/

14th Congress of the EuropeanFederation of Neurological SocietiesSept. 25-28Genevahttp://www2.kenes.com/efns2010/Pages/home.aspx

7th World Stroke CongressOct. 13-16Seoul, Koreahttp://www2.kenes.com/Stroke2010/Pages/Home.aspx

B Y A L A N M c C O M A S, M . D.

Brain stimulation is one of themost exciting and scientifically re-warding areas of neurological re-search, and it was therefore fitting thatit was chosen as the topic for the 102ndInternational Centre for BiocyberneticsSeminar held in Warsaw on May 11-13to honor the noted Polish neurologist,Prof. Irena Hausmanowa-Petrusewicz.The conference was sponsored by thePolish Academy of Sciences throughthe Institute of Biocybernetics and Bio-medical Engineering.

It was a special honor for the atten-dees that Prof. Hausmanowa-Petruse-wicz was also one of the chairs, the oth-er being myself. She began her medicalstudies in Warsaw and returned to thatcity after World War II to commencewith her neurological training.

After receiving a DSc in 1951, she be-gan her illustrious research career inneuromuscular disorders that saw herbecome a world authority on spinalmuscular atrophy during a career thathas spanned almost 65 years. As head ofthe department of neurology in theWarsaw Academy of Medicine, Prof.Hausmanowa-Petrusewicz trainedmore than a hundred neurologists andsupervised many graduate students. Sheretired from her university position in1988, and currently directs the Divisionof Neuromuscular Diseases of the Pol-ish Academy of Sciences.

The conference began with a surveyof biomagnetism and bioelectricity inthe animal kingdom presented by Adri-an Upton (Hamilton, Canada). Thenfollowed historical reviews of brainstimulation by Roger Lemon and JohnRothwell (both of London), and ananalysis of transcranial magnetic stim-ulation (TMS) effects on cortical cir-cuitry by Robert Chen (Toronto). VahéAmassian (New York) described how, byusing TMS to temporarily block func-tion, he and Ivan Bodis-Wollner (New

York) had been able to deduce the timespent in different cortical and subcorti-cal areas when a word was read andthen quickly spoken.

About half of the remaining papersdealt with TMS, including its applicationto evaluating motor pathways in spi-nocerebellar ataxia (Maria Rakowicz,Warsaw) and, via the motor cortex, to thetreatment of chronic pain ( Jean-PascalLefaucheur, Rechdi Ahdab, and DanielCiampi de Andrade [Créteil, France]).Sergei Nikitin, Alexey Kurenkov, and AdaArtemenko (Moscow) covered usingTMS to evaluate cortical excitability inmigraine, and I reported unique findingswith TMS in a patient with a severe andcomplex form of this condition.

Maria Rakowicz and Jakub Antczak(Warsaw) reported how they used repet-itive TMS, as opposed to single-shock, totreat sleep disorders in parkinsonism,and Stefan Rowny and Sarah Lisanby(both of New York) discussed using thesame modality to treat depression. An-dres Lozano (Toronto) and his team ob-tained impressive results, also for de-pression, by using implanted electrodesin the anterior cingulate gyrus.

Several Polish groups presented paperson deep brain stimulation. MiroslawZabek and Michal Sobstyl (Warsaw) re-ported impressive results using bilateralpallidal stimulation in dystonia and sub-thalamic nucleus stimulation in ad-vanced parkinsonism. The subthalamicnucleus was also the target in parkin-sonian patients treated by Tomasz Man-dat, Henryk Koziara, Pawel Nauman,Tomasz Tykocki, and Wieslaw Bonicki(Warsaw), who reported good resultswith DBS as therapy for dystonia.

Movement disorders were also thesubject of a presentation by Mark Hal-lett (Bethesda, Md., U.S.A.), who hadused TMS to investigate the corticalpathophysiology of parkinsonism andfocal hand dystonia. In another talk,Prof. Hallett showed how TMS could beused to study cortical plasticity in a va-

riety of neurological disorders.Among other presentations, Dr. Up-

ton reviewed his pioneering results inepilepsy with feedback stimulation, andthen with vagal, cerebellar, and deepbrain stimulation. Robert Fischell (Bal-timore, U.S.A.) demonstrated the use ofa hand-held magnetic stimulator he haddesigned and that he said had been usedsuccessfully in migraine patients. Healso reported on a self-contained devicesmall enough to be implanted in theskull and capable of detecting and ar-resting incipient seizure activity. JeanDelbeke (Brussels) described a differentapplication of brain stimulation: to elic-it spatially distinct phosphenes by opticnerve stimulation in blind patients.

A notable feature of the meeting wasthe quality and excellence of the dis-cussions. And finally, it would be remissnot to mention the superb social pro-

gram our Polish hosts organized for us,including a performance of Verdi’s Rigo-letto at the National Opera House. ■

DR. MCCOMAS is professor emeritus in thedepartment of medicine and the division ofneurology at McMaster University,Hamilton, Canada. He was founding headof the neurology division, where he is stilla researcher. He is currently finishing ahistory of neurophysiology.

Hausmanowa-Petrusewicz Honored

Prof. Hausmanowa-Petrusewicz, thehonoree, and the author, Dr. McComas.

CO

UR

TE

SY

DR

. M

AR

KH

AL

LE

TT

Iused my Junior Travelling Fellowshipfrom the World Federation of Neu-rology to attend the 2009 annual meet-ing of the American Academyof Neurology in Seattle, U.S.A.

At a colloquium titled “Crit-ical Thinking for Critical Is-sues,” I learned much aboutmanaging a neurology prac-tice, including setting up anelectronic health record sys-tem. Although it was impossi-ble to cover all of the scientificplatform and plenary sessions,I gained new insights, knowledge, andskills from each session I attended.

I also participated in a course on in-fections of the nervous system, direct-

ed by Dr. Russell E. Bartt of Rush Uni-versity Medical Center in Chicago,U.S.A. I now have a better under-

standing of the diagnostic work-up forcentral nervous system tuberculosisand of the different manifestations ofneurosyphilis, both common and seri-

ous public health issues in Peru.Dr. Bruce A. Cree, of the University

of California, San Francisco, conducteda course in multiple sclerosis, where Ilearned about new therapies for MS, atwhat stage they should be started, andhow to differentiate demyelinating dis-ease subtypes.

The nine poster sessions provided agood opportunity to interact with resi-dents and fellows from various countries,and I was encouraged to prepare a posterfor next year’s meeting in Toronto.

On my return, I did a presentationfor my colleagues to share with themwhat I had learned at the meeting.

I hope to be able to travel to other in-ternational meetings in the future. ■

Travelling Fellow: Learning Excursion to Seattle

MEETING ROUND-UP

BY ERIK GUEVARA SILVA, M.D.

Dr. Silva is a resident inneurology at the NationalInstitute of NeurologicalSciences in Lima, Peru.

6709667096.side

67096.photo.a 67096.photo.b


which was renamed Société Française deNeurologie in 1949. In 1907, theGesellschaft Deutscher Nervenärzte andthe Società Italiana di Neurologia werefounded.

At the first SNS meeting in Berne, theattendees adopted the new society’sgoals, which were to promote neurolo-gy as a science and maintain close ties be-tween it and related fields such as anato-my, physiology, internal medicine,surgery of the nervous system, psychol-ogy, and psychiatry; the cultivation ofpersonal relations between the society’smembers; and the promotion and repre-sentation of the practical interests ofneurology such as the development ofneurological training and research.

The members met regularly untilWorld War I broke out in 1914. After a hia-tus of 2 years, they met again in Berne. Atthat meeting, von Monakow and Duboisresigned and were elected honorary pres-idents. It was the last SNS meeting to haveits minutes published in the Correspon-denzblatt für Schweizer Aerzte, afterwhich reports were published in the SwissArchives of Neurology and Psychiatry.

The International PlatformIn 1928, the American Neurological As-sociation asked the SNS to stage the 1stInternational Neurological Congress(INC) in Berne in the fall of 1931, mark-ing the society’s debut as a player on theinternational society forum.

The unfavorable standing of neurolo-gy vis-à-vis psychiatry and internal med-icine was high on the agenda for the firstINC. Representatives from Germany,France, Austria, Czechoslovakia, theNetherlands, and the United States unan-

imously adopted the following resolu-tion, proposed by the German neurolo-gist Gottfried Foerster: “Neurology is to-day a fully independent specialty.Unfortunately, however, there are coun-tries which do not sufficiently recognizethis fact. This congress urges the relevantauthorities of the countries in questionto do their utmost to further the positionof neurology.”

At that time in Europe, neurologywas an independent compulsory part ofmedical studies only in Russia, Bulgaria,Estonia, Romania, and Norway. The firstINC was regarded as a step toward an-choring neurology as a specialty in itsown right, in which Switzerland hadplayed an important and honorable role.The congress is also regarded as the firstin the history of the World Federation ofNeurology, which was officially foundedin 1957.

SNS meetings were held regularly dur-ing World War II, and it was also duringthis time that Mieczyslaw Minkowskiwas elected president of the society. Theelection of a Jew as president of the SNSwas noted as proof of the society’s “in-trepidity and independence.”

Before and during the war, manyprominent German neurologists—KurtGoldstein, Walther Riese, and OttoLöwenstein, among others—took refugein Switzerland from persecution in theirhome country. The Archives played aspecial role during this time by beingprobably the only European neurologi-cal journal to continue publishing arti-cles in German by a range of foreign,particularly Jewish, authors.

From 1950 onward, the SNS met twiceyearly at meetings that were often staged

jointly with foreign neurological soci-eties. The first such joint meeting tookplace in July 1950 in conjunction with theItalian Neurological Society in Lugano,Switzerland, and the two societies heldsubsequent joint meetings in 1975 in Stre-sa, Italy, and 1980 in Sion, Switzerland.

The SNS held other joint meetingswith societies from Britain, Belgium, theNetherlands, Germany, France, Austria,Poland, and Sweden. The main themesof the meetings reflect developments inthe specialty over succeeding decades.

Merging the Academic and ClinicalIn 1908, there were only two neurolog-ical outpatient clinics run on a private ba-sis throughout Switzerland, one inZurich and one in Basel, but no inpatientfacility. Most internists and psychiatrists,including Auguste-Henri Forel in Zurich,were opponents of an independent sta-tus for neurology. As a result, in mostSwiss university clinics, inpatient care ofneurological patients and the teaching ofneurology were in the hands of in-ternists and psychiatrists until the mid-20th century, in time increasingly assist-ed by consultant neurologists.

The first independent neurological in-patient facility (12 general and 2 privatebeds) and thus neurological clinic inSwitzerland, opened in Zurich in 1952under Minkowski. Other neurologicalinpatient services that were still a part ofmedical departments opened in Basel in1951, Geneva in 1953, Lausanne in 1954,and Berne in 1958. Non–university-affil-iated neurological clinics with inpatientfacilities were established in St. Gallen in1972, Aarau in 1974, and Lugano in 1980.In a broader context, the first inpatientneurological clinic worldwide wasopened in the United Kingdom in 1859at the National Hospital for the Para-lyzed and Epileptics in Queen’s Square,London, and in France in 1862 at theSalpêtrière in Paris.

Today, there are five university hospi-tals in Switzerland with independentneurological departments (Geneva, Lau-sanne, Berne, Basel, and Zurich), threeneurological departments at major re-gional hospitals (Aarau, St. Gallen,Lugano), and four neurological wardswithin the departments of internal med-icine at regional hospitals (Lucerne,

Münsterlingen, Winterthur, Sion). There is a limited number of indepen-

dent neurological beds at the above hos-pitals—roughly 300—for a population of7.5 million. This shows that a lot of neu-rological inpatients are still cared for bycolleagues from internal medicine in co-operation with neurological consultantsand that outpatient care for neurologicalpatients is of particular significance.

All neurological departments have es-tablished stroke teams, but independentneurological intensive care units are stilllacking. There are more than 20 neuro- rehabilitation hospitals in Switzerland, anindication of their growing importance.

Today, the neurological postgraduateeducation lasts a minimum of 6 years,that is, 4 years of clinical neurology, 1year of clinical neurophysiology, and 1year of training in internal medicine. Be-fore practicing neurology, the candidatemust pass a board examination that con-sists of a written and two oral examina-tions. Later, CME credits are required.

To perform neurophysiological tests,candidates must pass a separate exami-nation. A candidate qualifies if she/hehas had at least 9 months training at a cer-tified institution and performed at least800 EEGs (for the EEG certificate) or 500ENMGs (or the ENMG certificate). The“certificate of qualification for cere-brovascular disorders“ also requires 9months of special training, as well as theproof of 500 ultrasound examinationsperformed by the candidate, who also hasto pass written and oral tests. Withoutthese certifications of qualification, theexaminations will not be reimbursed bythe insurance companies. ■

DR. WALDVOGEL works in private practiceat the Hirslanden Klinik St. Anna,Lucerne, and is a consultant in movementdisorders in the department of neurologyat the University of Zürich. DR. VALKO isa resident in neurology at the University ofZürich. DR. BASSETTI is director of theneurological outpatient clinics and vice-chairman of neurology at the UniversityHospital in Zürich. He currently serves aspresident of the Swiss Neurological Societyand the European Sleep Research Society,and is the scientific director of theEuropean Neurological Society Meetings.

After Independence, ExpansionSwiss • from page 1

Robert Bing convinced his peers of theneed to form a neurological society.

PH

OT

OS

CO

UR

TE

SY

SW

ISS

NE

UR

OL

OG

ICA

LS

OC

IET

Y

Constantin von Monakow is considereda pioneer in neurology in Switzerland.

Even before the SNS was foundedin 1908, Swiss physicians and sci-entists had made important contribu-tions to the clinical and experimentalneurosciences. Among these notedpioneers were:� Johann Jakob Wepfer (1620-1695),a physician and anatomist, whowrote a classic work on stroke titled“Apoplexia” (1658). He was the firstto interpret stroke as the result ofcerebrovascular disease and made adecisive contribution with anatomi-cal, methodological, and clinicalstudies;� Albrecht von Haller (1708-1777),a biologist and the pioneer of bio-electricity theory who introduced theterms stimulus, irritability, sensibility,and contractility. Daniel Bernoulli(1700-1782) and Charles-Gaspar de laRive (1770-1834) also published im-portant neurophysiological and ex-perimental work;�� Samuel Auguste André DavidTissot (1728-1797), who wrote athree-volume neurological handbooktitled, “Traité des nerfs et de leursmaladies” (1778-1780), on pain and

migraine, and a book, “Traité del’Épilepsie” (1770) that contains clini-cal observations on epilepsy that arestill valid today;� Wilhelm His (1831-1904) an illus-trious neuroanatomist, who was thefirst to describe nerve cell and nervefiber as independent units; � Constantin von Monakow (1853-1930) epitomized the Zurich neuro-biological school and ranked as oneof the leading neuroscientists of histime. In addition to his monumentalworks, “Gehirnpathologie” (1897)and “Die Lokalisation im Grosshirnund Abbau der Funktionen DurchKortikale Herde” (1914), he is consid-ered the pioneer of Swiss neurologyfor many reasons. In 1886, he found-ed a private laboratory of brainanatomy, which ranked as the firstscientific institution for neurosciencein Switzerland and became a canton-al university institute in 1910. In1887, he founded, at his own ex-pense, the first neurological outpa-tient clinic in Switzerland, which in1913 became the University Policlinicfor Nervous Diseases.

LAYING THE FOUNDATIONS

The ultimate resources to be kept up to date on the latest research in Alzheimer’s and Parkinson’s Diseases

Offi cial Journal of the World Federation of Neurology Research Group on Parkinsonism and Related Disorders

For immediate access to the journal articles, visit www.sciencedirect.com!

Offi cial Journal of the World Federation of Neurology

www.elsevier.com/jns www.elsevier.com/prd

6652866528.side

66528.photo62981.graphic


PERSPECTIVE

A Canadian Neurologist in LaosSince 1999, I have been spending amonth or 2 each year working inLaos as a volunteer with a partner-ship program involving the University ofCalgary (Canada), the University ofHeath Sciences in Vientiane, the capitalcity of Laos, and the Lao ministry ofhealth. The main objective of the pro-gram has been to produce physicians whohave the specific knowledge and skills todeal with the health problemsencountered in rural Laos.

Initially, the project focusedon a major revision and mod-ernization of the medicalschool curriculum. Theschool, which has been in ex-istence for more than 40 years,had a curriculum modeled onEuropean medical schoolsfrom the mid-20th century.

Teaching consisted almost entirely oflectures and was organized according totraditional disciplines, with little integra-tion between the basic biomedical sci-ences and clinical medicine. Moreover,there was little emphasis on the country’smost common medical problems.

The new curriculum has been in placefor 6 years. It uses an interdisciplinary,systems-oriented approach, with the em-phasis on clinical problem solving. Theimplementation has not been an easytask. Resources are very limited, classsize has been increasing steadily, and theteachers are overworked and underpaid.

Attempts to introduce small-group learn-ing have met with limited success, andnone of the students owns a textbook.Only a small percentage can read orspeak English, but most Lao students canread Thai and a limited selection of Thailanguage textbooks is available.

Although very little of what I have beendoing in Laos has involved wearing myneurology hat, I have worked with Lao

teachers to develop the neuroscience com-ponents of the new curriculum andhelped prepare them to teach medical stu-dents clinical skills, including the neuro-logical examination. In a country that didnot have a single neurologist until 2008, itwas inevitable that I would be asked to seesome patients, and I have had the oppor-tunity to see patients with some unusualand fascinating neurological problems.

Over the past 5 years, I have also beenworking with colleagues from Calgaryand Laos to develop a postgraduate train-ing program in family medicine, a spe-cialty that had been unknown in Laoswhere traditionally, doctors were sent towork in rural districts after completingmedical school. In a way, this has takenme back to my roots as a rural familydoctor in northern Ontario, where I spentsome time early in my career before re-turning to Toronto to train in neurology.

The family medicine training programhas been designed specifically to preparedoctors for work in the rural districts ofLaos. The second year of training is spentin the provinces, of which 6 months is acommunity medicine experience.

During that time, the residents go insmall groups of four or five to live in arural community where they conduct adetailed survey of every household toidentify the major health problems in thecommunity and then work with the vil-lagers to prioritize the problems andplan specific interventions.

I have had the opportunity to travelwith some of my Lao colleagues to visiteach group of residents while they areworking in the villages and to reviewtheir progress. This has been a rewardingexperience and has given me an appreci-ation of the health problems in a poor de-veloping country, which I would other-wise not have gained had I worked as aneurologist at a large academic center.

As I have mentioned, when I first wentto Laos in 1999, there was no neurologistor neurosurgeon in the entire country.There are now two neurosurgeons. OneLao doctor who had previously trained ininternal medicine returned to Laos in the

spring of 2008 after 2 years of neurologytraining at the University of Malaysia inKuala Lumpur. A second Lao doctor iscurrently being trained in Kuala Lumpurand will return a year from now.

Diagnostic facilities in Laos are still verylimited. There are four CT scanners in Vi-entiane, but because the cost of a scan iswell beyond the means of most Lao fam-ilies, many patients who require one donot have it done. Angiography is not avail-able, either, and there is still no MRI scan-ner. Patients who can afford to might goto neighboring Thailand for an MRI.

Neurological and neurosurgical prob-lems are common. In cities and towns,where most people travel by motorbike,serious head injuries have been a majorconcern. A helmet law was introduced re-cently, and members of the medical com-munity hope itcan be effectivelyenforced and thenumber of dev-astating motor-bike relatedbrain injuries re-duced.

Stroke andbrain tumors arealso seen regular-ly, as are cerebralmalaria and oth-er CNS infec-tions, which arecommon causesof death in chil-dren. And tuber-culosis is stillquite prevalent.During one visit, I saw four young peopleover a 2-week period with paraplegia, pre-sumably due to spinal TB, although it is al-ways difficult to confirm the diagnosis.

Epilepsy is well recognized and, par-ticularly in the rural areas, is often un-treated—even phenobarbital is not avail-able in Laos. Other problems such asheadache, dizziness, and psychogenic dis-orders are probably as prevalent as theyare in developed countries.

I recall one case of headache in par-ticular: I was visiting a Hmong village ina remote area of northern Laos near theChinese border, where I happened tomeet the wife of the village chief.

She was a delightful, hospitablewoman who, when she learned I was amedical doctor, told me about herheadaches that had been bothering herfor some time. She had been to a tradi-tional healer and to the hospital but hadnot obtained any relief. She was suffi-ciently concerned that she had decided togo to Vientiane to see a specialist. To cov-er the expenses of the journey, she wasgoing to have to sell her water buffalo,one of her few material possessions.

After several minutes of history takingthrough an interpreter, a classic descrip-tion of migraine emerged. I felt confi-

dent in reassuring her that she did nothave any serious brain disease and lefther with a small supply of aceta-minophen—triptans are not available inLaos, but she would be able to get moreacetaminophen at the local district hos-pital. I have not been able to obtain anyfollow-up, but hopefully she still has herprized buffalo and is not incapacitated byheadaches or concerns about what mightbe causing them. ■

BY ROBERT LEE, M.D.

Dr. Lee is a professor emeri-tus and former chairman ofthe department of clinicalneurosciences at the Univer-sity of Calgary, Canada.

Laos is a small, mountainous,landlocked nation in SoutheastAsia with a population of about 6million, 85% of whom live in ruralareas that are often quite remotefrom medical services. The largestcity is its capital, Vientiane, withan estimated population of210,000 in the city itself and some700,000 in Vientiane Prefecture.There are 49 recognized ethnic mi-norities, many of whom speaktheir own language, which may bequite different from Lao, the na-tional language.

By all criteria, Laos remains avery poor country. On the most re-cent United Nations Human Devel-opment Index, it was ranked 133out of 177 countries. The GDP isestimated to be U.S. $490 per capita.Government salaries for physiciansrange from $60 to $90 a month.

The country is still sufferingfrom the devastating effects of thewar in Southeast Asia, which endedin 1975. Large areas of the coun-tryside remain littered with clusterbombs which, despite the efforts ofseveral international mine disposalprojects, kill or injure many peopleeach year.

About LaosA new family medicine program that trains Lao doctors to workin rural areas now includes a neuroscience component.

CO

UR

TE

SY

DR

. R

OB

ER

TL

EE

Projected Years of Healthy Life Lost Due to Multiple Sclerosis

Note: Data are from “The Global Burden of Disease: 2004 Update.”Source: World Health Organization

0 100 200 300 400 500

2015

2008

Africa

Eastern Mediterranean

The Americas

Europe

Southeast Asia

Western Pacific

Disability-adjusted life years (in thousands)

EL

SE

VIE

RG

LO

BA

LM

ED

ICA

LN

EW

S

D A T A W A T C H

Free podcasts let you hear the latest information on migraine headaches. Each podcast provides top news on headaches and an interview with a leading expert.

For free new Developments in Migraine Therapy podcasts, go to www.clinicalneurologynewsnetwork.com/migraine or subscribe by downloading iTunes® media player free from iTunes.com, select ‘Podcasts,’ and enter ‘Developments in Migraine Therapy’ into the Podcast Directory search field.

This program series is developed in conjunction with and sponsored by

www.clinicalneurologynewsnetwork.com/migraine

This Podcast Also Features:Ten Minutes of Exercise Reduces Chronic Pain

Clinical Neurology News®

Presents

Developments in Migraine Therapy

With Paul Winner, DO, FAANClinical ProfessorNova Southeastern University Ft. Lauderdale, Fl.

Podcast Episode 2: A Twelve-Month Study of the Tolerability and Safety of a Combination Treatment for Acute Migraine

2009 Copyrighted Production of Elsevier/International Medical News Group. Interview Content Copyright 2009 GlaxoSmithKline.

www.clinicalneurologynewsnetwork.com/migraine

6652967032 cont

66529.photo


the guidelines highlight the importanceof emergency department physiciansweighing whether a patient should betreated with tPA. “The longer out yougo, the more patients arebeing considered. It willhave an impact simply byincreasing the awarenessamong treating physiciansthat tPA is an option.”

The additional exclusioncriteria “make it more com-plex in terms of the deci-sion making for physicians,who ideally would like tohave one set of criteria touse to decide whether ornot to treat,” he said in aninterview. Ancillary care for patients be-ing treated in the extended period shouldalso follow the 2007 guidelines (Stroke2007;38:1655-711).

Dr. Broderick, who was not involved inthe guidelines, disclosed that he is a pri-mary investigator for the InterventionalManagement of Stroke III trial sponsored

by the U.S. National Instituteof Neurological Disorders andStroke. Genentech, whichmarkets alteplase as Activasein the United States, is sup-plying rTPA; and ConcentricMedical, EKOS Corp., andCordis Neurovascular, are sup-plying catheters for the trial.

The relative utility and ef-ficacy of the treatment dur-ing the longer time frame,compared with other meth-ods of thrombus dissolution,

have not been well established and re-quire further study, said Dr. del Zoppoof the University of Washington, Seattle,and associates.

The recommendation was largely basedon data published in 2008 from ECASS III.In that multicenter, prospective, random-ized, placebo-controlled trial, 418 patientswere enrolled to best medical treatmentwith rTPA between 3 and 4.5 hours afterstroke, and 403 to best medical treatmentplus placebo. Exclusionary criteria werethe same as the guidelines, aswas ancillary care, except thatpatients received prophylacticanticoagulant therapy for deepvein thrombosis within 24hours of receiving rTPA.

The treatment group re-ceived 0.9 mg/kg of alteplaseto a maximum of 90 mg.Symptomatic intracranial he-morrhage, a common com-plication after thrombolysis,was diagnosed in 10 (2.4%) ofthe rTPA patients and 1 (0.2%)of the patients on placebo. This incidencewas consistent with that in other trials, theauthors wrote.

The frequency of the primary efficacy

outcome—a score of 0 or 1 on the mod-ified Rankin Scale score 90 days afterrTPA treatment—was significantly high-er in rTPA patients (52.4%) than in place-bo patients (42.5%). In addition, therewas no significant difference in mortali-ty between the two groups, although itwas slightly higher in the placebo group.

Dr. del Zoppo said he hadno financial conflicts of in-terest. Some of the authorshave received researchgrants or research supportfrom Boehringer IngelheimGmbH, Genentech, NovoNordisk A/S, and Concen-tric Medical Inc.; one is onthe speakers bureau or hasreceived honoraria fromBoehringer, and another is aconsultant with Genentech.Boehringer Ingelheim mar-

kets alteplase as Actilyse outside of theUnited States and Japan. ■

Jeff Evans contributed to this article.

Outcomes Could Be ImprovedrTPA • from page 1

NEUROLOGICAL STORY

Friend, Mentor, and a Force in the Field Fred Plum is a neurological icon whois known for his many contributionsto our specialty. He was assertive andforceful—and authoritarian when hedeemed it necessary. He was also braveand fearless. While he was chief of neu-rology at the University of Washingtonin Seattle caring for polio patients, he hadhimself curarized, catheterized, andplaced in an iron lung so that he could ex-perience their treatment firsthand. And,while studying cerebral circulation withthe Kety-Schmidt technique, which in-volved catheterization of a carotid arteryand jugular vain, he had that procedureas well for the same reason.

An encounter I shared with Plum at theUniversity of California, San Francisco(UCSF) in the late 1960s, was a definingmoment inwhat became alifelong friend-ship and profes-sional alliancebetween us.

I finished myneurology resi-dency at YaleUniversity inNew Haven,Conn., U.S.A., in 1965 and then spent 2years of obligate military service with theU.S. Army. In academic year 1967-1968, Iwas a neuro-ophthalmology fellow underDr. William F. Hoyt at UCSF. Sometimein early 1968, Dr. Robert A. Fishman,chair of neurology at UCSF, received acall from Plum, who was en route toJapan and faced a long delay in San Fran-cisco. He asked Fishman if he couldmake rounds with the neurology resi-dents. However, they had already startedtheir afternoon clinic, so Plum ended uprounding with Fishman and the neuro-ophthalmology team—Hoyt, three fel-

lows, and an ophthalmology resident.The first patient we saw was a young

encephalopathic African Americanwoman from Oakland, across the bayfrom San Francisco. She was carrying a di-agnosis of “subacute encephalitis,” theterm used at the time until it was later de-termined to be due to the herpes simplexvirus. The woman’s husband was stand-ing at her bedside when we entered. Hewas a giant of a man, wearing a jacketwith a Black Panther insignia. The BlackPanther Party had been formed in 1966 inOakland to uplift the black communityand in so doing, achieve racial equali-ty. However, unlike the nonviolent civilrights movement led by Martin LutherKing Jr., the Black Panthers were aggres-sively militant and often at odds with the

authorities.F i s h m a n

asked the manif he wouldleave the roomwhile we ex-amined hiswife. He re-sponded, withgreat anger,that he would

not, shouting, “You can do what you needto do, but I am going to stay here with mywife.” It was a tense moment, and we fellinto a general state of concerned inaction.

Plum then stepped forward, extendedhis hand, and said, “Sir, I’m Dr. Fred Plumfrom New York City. Your physicians areso concerned about your wife’s healththey asked me to see her, since I am an ex-pert in this type of neurological problem.But please realize that we can’t talk freelyand openly amongst ourselves with you inthe room. It is in your wife’s best interestthat you step outside. We’ll be happy tospeak with you when we are finished.”

As Plum spoke, the man’s eyes filledwith tears and he said meekly, “I’m sor-ry; I was out of line. Please do what youcan to help my wife.” He left the room.Plum had swiftly and effectively redi-rected our attention to the patient. I wasastounded by how bravely and gra-ciously he had taken control during thattension-filled moment.

Several years later, when I was on thefaculty of the University of Miami, Plumspent a few days with us as visiting pro-fessor. When I drove him back to the air-port, I asked if he remembered the BlackPanther incident. He recalled it vividly,and we discussed it at length. We subse-quently became close friends, and, inaddition, he became a strong active sup-porter of my career.

Plum often asked me to review articlesfor the Archives of Neurology, of whichhe was the editor. He appointed me to itseditorial board in 1976. At that time, theArchives was owned by the AmericanMedical Association and was the official

journal of the American NeurologicalAssociation (ANA). For reasons best leftfor another forum, Plum and the entireeditorial board, myself included, quit theArchives and founded the Annals of Neu-rology in 1977, which became the officialpublication of the ANA and the ChildNeurology Society. When Plum institut-ed a Neurological Progress section in theAnnals, he made me the founding editor.

At the 1985 World Congress of Neu-rology in Hamburg, Germany, Plum ap-proached me at the opening banquetand asked if I would like to be the edi-tor of Neurology, the official journal ofthe American Academy of Neurology.

“How about Bud?” I asked, referring toits editor at the time, Dr. Lewis Rowland.He replied that Rowland was finishing his10-year term at the end of 1986, and thathe (Plum) was chair of the search com-mittee. I told him that I always thoughtof myself as an Annals person and hadnever considered a switch to Neurology.He then mentioned the names of sever-al prominent neurologists who had ap-plied for the position. I remarked thatthey were all fine academic neurologistswho would serve the journal well. At thispoint, Plum did something emblematic ofpower and control. He grabbed andsqueezed my upper arm and, addressingme by my last name, said, “Daroff, thisisn’t a pissing contest. This is what’s bestfor American neurology. They aren’t, andyou are. Do you want the job?” Needlessto say, I assumed the editorship whenRowland stepped down in January 1987.

I’ve had many wonderful mentors overthe years to whom I am indebted, butnone promoted me as actively as did FredPlum. When I think about him and ourrelationship, my thoughts always returnto the day he soothed the angryyoung Black Panther from Oakland. ■

Dr. Fred Plum underwent procedures tounderstand his patients’ experiences.

CO

UR

TE

SY

JA

NE

TC

HA

RL

ES

BY ROBERT B. DAROFF, M.D.

Dr. Daroff is professor andchair emeritus of the depart-ment of neurology at CaseWestern Reserve UniversitySchool of Medicine in Cleve-land, U.S.A.

GREGORY J. DEL ZOPPO, M.D.

JOSEPH P. BRODERICK, M.D.

6665666702

AUGUST 2009 • WWW.WFNEUROLOGY.ORG WORLD NEUROLOGY • 13

B Y S U S A N L O N D O N


S E A T T L E — Older adults in the gen-eral population have an elevated risk offractures related to osteoporosis if theytake certain antiepileptic drugs, accord-ing to a population-based analysis.

“Studies have shown that antiepilep-tic drugs [AEDs] are associated with anincreased risk of bone loss and frac-tures,” Jane McChesney said at the an-nual meeting of the American Academyof Neurology. “But population-baseddata assessing the association betweenAEDs and osteoporotic-related fracturesare scarce.

“This study found that AEDs, exceptfor fatty acid derivatives, are associatedwith an increased risk of osteoporotic-related fractures in men and womenover age 50,” she said. “This is of con-cern as many of these AEDs are . . . alsowidely used in older adults for neuro-pathic pain, headaches, and psychiatricconditions.”

In the study, Ms. McChesney, who isa nursing student at the University ofCalgary, Alberta, Canada, and her col-leagues analyzed population-based datafrom Manitoba province for the years1996-2004.

Individuals were included in the studyif they were at least 50 years of age andhad continuous health care coverage

during the study period. They were ex-cluded if they had taken osteoprotectivemedications in the year before a fractureor were residents of long-term care fa-cilities. Fractures were ascertained fromdiagnostic codes and were limited tovertebral, wrist, and hip fractures thatwere not related to severetrauma.

With the fracture dateused as the index date, eacholder adult with a fracturewas matched with threefracture-free older adults byage, sex, ethnicity, and num-ber of comorbidities. Use ofAEDs, defined as dispensa-tion of a prescription to theindividual in the previous 4months, was assessed from adrug database containingpharmacy dispensations for theprovince.

Analyses were based on 15,792 olderadults who had had a fracture and47,289 older adults who had not, Ms.McChesney said. Overall, 70% were fe-male, 62% were aged 70 years or older,and 67% had three or more comorbidi-ties. Fractures most commonly oc-curred in the wrist (52%), the hip (26%),and vertebrae (22%).

After adjustment for social and de-mographic characteristics, home care,and comorbidities known to affect frac-ture risk, older adults had elevated odds

of fracture if they used carbamazepine(odds ratio, 1.9), clonazepam (1.3),gabapentin (1.6), phenobarbital (2.2),and phenytoin (2.1). In contrast, theirodds were not elevated if they used val-proic acid.

It is not known if osteoprotectiveagents are beneficial in thiscontext, she conceded, andthat would be an importantfocus of additional research.Ms. McChesney had no dis-closures to make in relationto the study.

The study adds anotherpiece of evidence to the is-sue of bone health withAED use, Dr. IoannisTsiropoulos said in an in-terview.

Other population-basedstudies on the same subject have beenpublished (Epilepsia 2004;45:1330-7;Epilepsia 2008;49:2092-9; Neurology2006;66:1318-24). The current studyuses a similar design and methodologyto analyze data from prescription and di-agnosis registers.

The modest increase in fracture risk as-sociated with any AED use shown in thepresent study confirms previous results.The same applies to risk estimates for in-dividual AEDs, provided monotherapyresults are reported.

However, risk with use of valproicacid was not significantly increased, con-

trary to findings in other studies (Epilep-sia 2004; Neurology 2006), said Dr.Tsiropoulos of the department of clini-cal neurophysiology and epilepsies at St.Thomas’ Hospital, London.

He questioned why the source pop-ulation was restricted to older adultseven though bone changes occur withAED use in children and youngeradults. He also wondered why resi-dents of long-term care facilities, whoare expected to have a higher fracturerisk, were excluded. The use of osteo-protective drugs also could have beentreated as a confounder instead of as anexclusion criterion.

“Further research is needed. The in-crease in fracture risk with AED usehardly needs further confirmation. How-ever, additional research may be war-ranted on the equivocal results of the pa-rameters of AED use that may modifythe risk, as well as mechanisms of actionassociated with risk modification by in-dividual AEDs.

The study’s result supports the notionthat the effect of valproic acid on boneis not related to inhibition of liver en-zymes, but rather to its activity as a hi-stone deacetylase inhibitor (BMC Ge-nomics 2007;8:362), a mechanism ofaction apparently shared by newerAEDs as well (Epilepsia 2004),” Dr.Tsiropoulos said. ■

Jeff Evans contributed to this article.

AEDs Linked to Bone Loss, Fracture Risk

IOANNIS TSIROPOULOS, M.D.

B Y S U S A N L O N D O N


S E A T T L E — Treatment of re-lapsing-remitting multiple scle-rosis with orally administeredfingolimod results in a signifi-cantly lower annualized relapse,compared with interferon-beta-1a, based on the results of aphase III trial.

A significantly lower percent-age of patients who received fin-golimod at either of two dosagesdid not experience relapse in theinternational, randomized, dou-ble-blind, TRANSFORMS trial.However, safety concerns re-garding two deaths from dis-seminated herpes zoster and her-pes zoster encephalitis thatoccurred in the higher-dose fin-golimod group will be addressedin a related ongoing study, saidDr. Jeffrey Cohen, a neurologistat the Cleveland Clinic.

Fingolimod, also known asFTY720, has two mechanismsof action: It promotes retentionof lymphocytes in lymph nodes(away from the central nervoussystem), and it modulates sphin-gosine-1-phosphate (S1P) re-ceptors in neural cells.

The researchers randomly as-signed 431 patients to oral fin-

golimod 0.5 mg once daily, 425to oral fingolimod 1.25 mg oncedaily, and 435 to intramuscularinterferon-beta-1a (IFNbeta-1a)30 mcg once weekly.

The patients were 36 yearsold on average, and two-thirdswere women, Dr. Cohen re-ported at the annualmeeting of the Ameri-can Academy of Neu-rology. They had hadMS for about 7.5 yearson average, and theirmean Expanded Dis-ability Status Scalescore was 2.2. Nearlyhalf (45%) had not pre-viously been treatedwith disease-modifying agents.

The annualized relapse rate at12 months—the trial’s primaryendpoint—was 0.33 in the IFN-beta-1a group, 0.16 in the low-er-dose fingolimod group, and0.20 in the higher-dose group.This corresponded to a signifi-cant 52% and 38% reductionwith fingolimod at the lowerand higher doses, respectively.

The findings were essentiallythe same in per-protocol analy-ses, and in analyses restricted totreatment-naïve and treatment-experienced patients.

The percentage of patients

who did not experience any re-lapses was significantly greaterwith lower-dose (83%) and high-er-dose (80%) fingolimod thanwith IFNbeta-1a (69%).

On magnetic resonance imag-ing, compared with their coun-terparts treated with IFNbeta-

1a, patients treated with thelower and higher doses of fin-golimod had a smaller meannumber of new or newly en-larged T2 lesions (1.5 and 1.4 vs.2.1) and gadolinium-positive T1lesions (0.23 and 0.14 vs. 0.51).

The percentage of patientswho had a confirmed progres-sion of disability did not differbetween groups (8% with IFN-beta-1a and 6% with the fin-golimod groups). Serious ad-verse events occurred in 6% ofthe IFNbeta-1a group, 7% ofthe lower-dose group, and 11%of the higher-dose group.

None of the patients treatedwith IFNbeta-1a developedbradycardia or atrioventricularblock—known effects of the firstdose of fingolimod—but 1% and4% of those treated with lower-and higher-dose fingolimod did.

Localized skin cancers oc-curred in 0.4% of the IFNbeta-1a group, 1.4% of the lower-dose group, and 0.5% of thehigher-dose group. Study drugdiscontinuation due to adverseevents was more common withthe higher dose of fingolimod(10%) than with the lower dose(6%) and with IFNbeta-1a (4%).The only deaths were the two inthe higher-dose group.

An ongoing 2-year trial inwhich fingolimod is being com-pared with with placebo “willgive us a much better indicationof the benefit-risk profile,” saidDr. Cohen, who disclosed that hehas received personal compensa-tion for activities with Novartis(make of fingolimod) and BiogenIdec (maker of IFNbeta-1a). No-vartis Pharma AG in Basel,Switzerland, funded the study.

IFNbeta-1a in the TRANS-FORMS trial and the currentfirst-line disease modifying drugsinterferon-beta and glatirameracetate have shown treatment re-

sults consistent with the first piv-otal trials and favorable long-term safety, but there are still un-met needs in MS. Adherence toinjections is decreasing over time,and the need for greater efficacyis constantly present, Dr. EvaHavrdová of the department ofneurology at Charles University,Prague, said in an interview.

“There are several oral drugsin the [pipeline], fingolimod be-ing one, from which a lot is ex-pected. The safety profile andpossible prevention of side-ef-fects must be clearly communi-cated to both patients and neu-rologists, with the need formore education in the field ofneuroimmunology.

“Further safety data fromlong-term monitoring of pa-tients from all these trials will bedecisive for accepting fin-golimod—as well as other oraldrugs—as a first line option inMS,” said Dr. Havrdová, who isa primary investigator in a place-bo-controlled study of fin-golimod and has received edu-cational grants and speakershonoraria from Biogen Idec,Bayer, Teva, and Serono. ■

Jeff Evans contributed to thisarticle.

Oral Fingolimod Bests IFNbeta-1a in MS Study

Long-term patientsafety data willbe decisive foracceptingfingolimod as afirst-line option intreating MS.

DR. HAVRDOVÁ

6714767094

65053


FROM THE JOURNAL OF THE NEUROLOGICAL SCIENCES

Neurological Complications in Lung TransplantationB Y A L E X T S E L I S, M . D. , P H . D.

Organ transplantation is a well-estab-lished treatment for several other-wise fatal diseases but it is very in-vasive, both surgically and physiologically,and can result in a number of complica-tions. Transplants have been performedfor more than a half century, and some ofus might recall the international excite-ment when the first human heart trans-plant was performed in December 1967.

By today’s standards, those early pro-cedures were primitive, and the clinicalmanagement crude. The prominence ofneurological complications was evidentfrom early on, though with more proce-dures being done for more diseases, theavailability of more intensive and selec-tive immunosuppression, and improvedperioperative support, the spectrum ofcomplications has changed over the years.

This is especially true for the neuro-logical complications of transpl

VOL. 24 NO. 4 World Neurology · 2016. 10. 13. · Elsevier Pharma Solutions London, UK +44 (0) 207...

Documents

Transcript of VOL. 24 NO. 4 World Neurology · 2016. 10. 13. · Elsevier Pharma Solutions London, UK +44 (0) 207...