OCTOBER 2009 World Neurology

01_2_3_6_7_14_15wfn9_9.qxp 9/10/2009 1:54 PM Page 1

VOL. 24 • NO. 5 • OCTOBER 2009 World Neurology

THE OFFICIAL NEWSLETTER OF THE WORLD FEDERATION OF NEUROLOGY WFN, WHO Take on ICD-10 Revisions INSIDE WCN 2009 Named Orations honor BY DONNA C. BERGEN, M.D. Eddie and Piloo Chair, Public Relations and WHO Liaison Committee, WFN Bharucha, B.S. Singhal, ollaboration between the World Federation of Neurology Melvin D. Yahr, and and the World Health Organization has moved into the im- Richard L. and Mary Cportant area of disease classification. Masland, for their life- Although systems of disease classification were begun as early as long contributions to the the 18th century, since its founding in 1946 the WHO has been re- field of neurology. sponsible for preparing and updating the International Lists of Dis- PAGE 5 ERGEN

eases and Causes of Death (ICD). In fact, the ICD is more than 100 B years old, making it older than the WHO. One of the WHO’s ear- liest official actions was to approve the ICD-6. ONNA Krasnoyarsk Krai . D

R The capital city of this

Since then, the WHO has periodically revised the ICD codes. The D current ICD-10, which is being used in most countries, was ap- remote Siberian region is proved in 1990 by the World Health Assembly, which consisted of a hub of research, clinical OURTESY the health ministers of the WHO member states. The codes are C practice, and training for used as universally recognized diagnostic labels by clinicians, by epi- The WFN’s Dr. Donna Bergen and Dr. Johan Aarli (front, 3rd and neurologists. demiologists charting disease prevalence and incidence, by re- 5th from left) with representatives from international neurological PAGE 8 searchers, and by public health officials and health care planners organizations at a meeting of the WHO’s ICD-11 committee in responsible for resource allocation and training programs. Min- Geneva. Dr. Raad Shakir (front, 3rd from right) was the chair. The istries of health use the code when reporting causes of death and meeting was convened by Dr. Shekhar Saxena (front, 5th from Going Global disease rates to the WHO, and some health systems use the dis- right) and Dr. Tarun Dua (front, 4th from left) of the WHO. The Multiple Sclerosis ease codes in reimbursement for health care. (Some countries, no- International Foundation tably the United States, still use the ICD-9 version.) Brain Research Organization, International Child Neurology As- and the World Stroke In June, the ICD-11 Committee was convened in Geneva by Dr. sociation, World Federation of Neurosurgical Societies, Interna- Organization hone plans Shekhar Saxena and Dr. Tarun Dua of the WHO’s Programme for tional Neuropsychological Society, International League Against for raising worldwide Neurological Diseases and Neuroscience, Department of Mental Epilepsy, International Headache Society, Multiple Sclerosis Inter- awareness of the diseases Health and Substance Abuse, the WHO division that is responsible national Federation, World Stroke Organization, and Movement for disorders of the nervous system. The meeting was chaired by Disorder Society. Dr. Johan Aarli represented the WFN. The revi- and promoting research Dr. Raad Shakir of Imperial College, London. Representatives sion will include three versions: for primary health care workers, and clinical collaboration. from a range of international neurological organizations partici- PAGE 12 pated, including Alzheimer’s Disease International, the International See ICD-10 • page 14 Neurological Complications Seen in 4 Children With H1N1

BY MIRIAM E. TUCKER Disease Control and Preven- the four patients had abnormal County since April 22, including Two of the children—a 17- Elsevier Global Medical News tion (CDC) in a report of four findings on electroencephalog- 44 who were hospitalized. year-old black male and a 10- children with neurological raphy. In all four patients, There were no deaths reported. year-old Hispanic male—had andemic influenza A(H1N1) complications associated with H1N1 influenza viral RNA was Of all the confirmed cases, 83% been previously healthy. The Pvirus should be considered H1N1 influenza virus infection detected in nasopharyngeal were in patients who were older child was admitted with in the differential diagnosis for seen in Dallas County, Texas, specimens but not in cere- younger than 18 years of age. a fever, cough, headache, dizzi- children who present with in- U.S.A., during May 2009. All brospinal fluid, the CDC said Of seven possible cases of neu- ness, and weakness and later fluenzalike illness accompanied four children, who were aged 7- (MMWR 2009;58:773-8). rological complications, three developed disorientation and by unexplained seizures or men- 17 years, were admitted with The four children were were excluded either because confusion. The younger child tal status changes. signs of influenzalike illness among a total of 405 persons they were found to have alter- had had a 3-minute tonic-clonic That recommendation was (ILI) and seizures and/or al- with confirmed pandemic flu native etiologies or because they made by the U.S. Centers for tered mental status. Three of seen at all hospitals in Dallas did not meet the case definition. See H1N1 • page 15

Place your classified advertisement today! WORLD NEUROLOGY now offers job advertisements to an international print readership of over 25,000 neurologists and to a much larger on-line readership through the Publications section of the World Federation of Neurology web site at www.wfneurology.org. For Europe, [email protected] or Fax us on +44 (0)207 4244433 For U.S., contact Robert Zwick at [email protected] or call 973-290-8226 01_2_3_6_7_14_15wfn9_9.qxp 9/10/2009 1:57 PM Page 2

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

EDITOR IN CHIEF’S COLUMN WCN 2009 Neurologists at the Movies First Advocacy Session Is eurologists are people, too, and advocates of the idea that many chron- often go (or should go) to the ic, often vague, neurological symptoms Planned for Bangkok Nmovies for entertainment and fun. may be due to a chronic Lyme infection. Sometimes the movies have medical or No use that the American Academy of he World Federation of Neurology our specialty based on the conditions even neurological themes. In these cir- Neurology and the Infectious Disease So- Twill offer the first session of its kind in their home countries and how to cumstances, we might well have a spe- ciety of America, upon careful and de- on advocacy training on Oct. 29 at the present one’s original project to rep- cial interest. How are the patients that tailed review of all the evidence, have 2009 World Congress in resentatives of media and we see portrayed on the big screen? In concluded that Lyme disease is general- Bangkok. government. addition, of course, our ly not responsible for the Course faculty will in- The course is a Scientif- friends, colleagues, and even symptoms complained clude the president of the ic Session and does not re- our patients may well want about. Physicians are por- World Neurology Founda- quire preregistration or ad- to know what we do think trayed as nonsympathetic tion, Dr. Michael Finkel, ditional charges. about a particular movie. and the scientific method as Dr. Mohammad Wasay, Dr. It will be very useful to Lay groups are often excited misguided. This is an im- Man Mohan Mehndiratta, individuals as well as na- about movies that illustrate portant area to know about. Dr. Wolfgang Grisold, tional societies that wish their disease; the movie Many patients feel very American Academy of to follow the example of makes their problem better strongly that their symp- Neurology staff, and inter- the Indian Academy of known and increases sym- toms are due to chronic national graduates of the DR. MICHAEL FINKEL, M.D. Neurology and establish a pathy for the symptoms Lyme disease, and this AAN’s Palatucci Advocacy section on advocacy. they have. BY MARK movie will strengthen their Leadership Forum. Questions regarding the session can What’s the advantage of a HALLETT, M.D. belief. Proper treatment of They will present a structured pro- be directed to Dr. Finkel at mfinkel@ movie review? The review the patient will require tak- gram that will teach attendees how worldneurology.org or Melissa Larson lets us know about the film, to help us ing this belief into account. Often som- best to advocate for their patients and at [email protected]. ■ make a decision as to whether we want atization is the underlying disorder. to go. If we don’t go, then we are at least The movie on Tourette syndrome, somewhat knowledgeable about the “Phoebe in Wonderland,” is an enjoyable film. In addition, we can get an expert’s story, but the lead character seems to Council of Delegates Meeting: viewpoint on the film. That sort of edu- have mainly obsessive compulsive disor- cation can certainly increase our under- der and impulsive behaviors. In fact, al- Register if You Want to Vote standing of the disorder that is being por- though the diagnosis of Tourette syn- trayed, point out subtleties that we might drome is made, the patient does not he 2009 Council of Delegates will return it to the WFN head office as miss, and increase our enjoyment over- have any tics! Again, the movie maker Tbe held in Bangkok during the soon as possible. If you have not yet re- all. On page 19 of this issue of World has the wrong diagnosis, and the movie- World Congress of Neurology on Oct. ceived such a form, please contact the Neurology, we have two movie reviews goers may well be misled. So for both 25 from 10:00 a.m to noon, followed by head office at [email protected]. by experts: John Halperin reviews a movies, the neurologist has an opportu- a lunch from noon to 1:00 p.m. Please also note that if you fail to reg- movie on chronic Lyme disease, and nity, and, perhaps even a responsibility, to If necessary, the Council will recon- ister your society for the Council of Don Gilbert reviews a movie on Tourette correct any misconceptions these movies vene for a second session on Oct. 29 Delegates meeting or to ensure that syndrome. might create. from 2:00 p.m. to 4:00 p.m. your dues payments are fully up to The movie on chronic Lyme disease, We watch so you don’t have to—but All delegates are required to com- date, your delegate will be ineligible to “Under Our Skin,” is a documentary by you may well want to, anyway. ■ plete a delegate attendance form and cast a vote at this year’s elections. ■

GLOBAL MEDICAL RESEARCH WORLD Publisher Peter F. Bakker ELSEVIER GLOBAL MEDICAL NEWS NEUROLOGY A Division of International Medical News Group President IMNG Alan J. Imhoff WORLD FEDERATION OF NEUROLOGY WORLD NEUROLOGY, an official publication of the World Federation Editor in Chief Mary Jo M. Dales Editor in Chief Dr. Mark Hallett (U.S.A.) of Neurology, provides reports from the leadership of the WFN, its Executive Editors Denise Fulton, Kathy Scarbeck EDITORIAL ADVISORY BOARD member societies, neurologists around the globe, and news from Managing Editor Renée Matthews Dr. Pierre Bill (South Africa); Dr. William M. Carroll (Australia); the cutting edge of clinical neurology. Content for WORLD NEUROLOGY Clinical News Editor Jeff Evans Dr. Jagjit S. Chopra (India); Dr. Michael Finkel (U.S.A.); is provided by the World Federation of Neurology and Elsevier Global Dr. Osvaldo Fustinoni (Argentina); Dr. Francesc Graus (Spain); Medical News. Dr. Alla Guekht (Russia); Dr. Theodore Munsat (U.S.A.); Circulation Analyst Barbara Cavallaro Dr. Daniel Truong (U.S.A.); Dr. Alexandros Tselis (U.S.A.) Disclaimer: The ideas and opinions expressed in WORLD NEUROLOGY Executive Director, Operations Jim Chicca WFN OFFICERS do not necessarily reflect those of the World Federation of Neurol- Director, Production and Manufacturing Yvonne Evans President: Dr. Johan A. Aarli (Norway) ogy or the publisher. The World Federation of Neurology and Else- Production Manager Judi Sheffer First Vice-President: Dr. Vladimir Hachinski (Canada) vier Inc., will not assume responsibility for damages, loss, or claims Secretary-Treasurer General: Dr. Raad Shakir (United Kingdom) Creative Director Louise A. Koenig of any kind arising from or related to the information contained in ELECTED TRUSTEES this publication, including any claims related to the products, drugs, EDITORIAL OFFICE Dr. Gustavo Romano (U.S.A.); Prof. Werner Hacke (Germany); or services mentioned herein. 5635 Fishers Lane, Suite 6000 Dr. Ryuji Kaji (Japan) Rockville, MD 20852 Editorial Correspondence: CO-OPTED TRUSTEES Send editorial correspondence to +1-240-221-4500 Fax: +1-240-221-2541 Dr. Roger Rosenberg (U.S.A.); Dr. Niphon Poungvarin (Thailand) WORLD NEUROLOGY, 5635 Fishers Lane, Suite 6000, REGIONAL DIRECTORS Rockville MD 20852, U.S.A.; [email protected]; US ADVERTISING Dr. Alfred K. Njamnshi (Pan Africa); Dr. Jacques De Reuck Phone +1-800-798-1822 Rory Flanagan (Europe); Prof. Riadh Gouider (Pan Arab); Dr. Amado San Luis 60 Columbia Rd., Building B (Asian-Oceania); Dr. Robert Griggs (North America); Dr. Ana Address Change: Fax change of address to +1-973-290-8245 Morristown, NJ 07960 Mercedes Robles de Hernandez (Latin America) POSTMASTER: Send change of address (with old mailing label) +1-973-290-8222 Fax +1-973-290-8250 [email protected] EXECUTIVE DIRECTOR to WORLD NEUROLOGY, Circulation, 60 B, Columbia Rd., 2nd Fl., Keith Newton Morristown NJ USA 07960 World Federation of Neurology INTERNATIONAL ADVERTISING Hill House, Heron Square WORLD NEUROLOGY, ISSN: 0899-9465, is published bimonthly by Martin Sibson Richmond, Surrey, TW9 1EP, UK Elsevier Inc., 60 B, Columbia Rd., 2nd Fl., Morristown NJ 07960. Business Development Executive Tel: +44 (0) 208 439 9556/9557 Fax: +44 (0) 208 439 9499 Phone +1-973-290-8200; fax +1-973-290-8250. Elsevier Pharma Solutions [email protected] London, UK EDITOR OF THE JOURNAL OF THE NEUROLOGICAL SCIENCES ©Copyright 2009, by the World Federation of Neurology +44 (0) 207 424 4963 Dr. Robert Lisak (U.S.A.) [email protected] 01_2_3_6_7_14_15wfn9_9.qxp 9/10/2009 2:01 PM Page 3

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

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

For immediate access to the journal articles, visit www.sciencedirect.com! 04_5_8thru13wfn9_9.qxp 9/10/2009 2:23 PM Page 4

4 • WORLD NEUROLOGY WWW.WFNEUROLOGY.ORG • OCTOBER 2009

PRESIDENT’S COLUMN Bangkok 2009 and Beyond hope that this land than in the home country. signals the need to scale up medical ser- frequent disorders. We are talking about column reach- Nevertheless, the Thai neurologists vices for mental, neurological, and sub- some of the most common disorders, Ies the WFN have managed to prepare for this world’s stance use disorders. The program is de- such as epilepsy, stroke, migraine, pe- membership in largest scientific event in neurology in a signed for low- and lower-middle–income ripheral neuropathies, and Parkinson’s time for the professional, open, and well-balanced countries. By doing this, the WHO has disease. A general practitioner has to be World Neurolo- way. Most participants have already taken an important step to show its re- updated on these disorders. gy Congress that bought their tickets and made hotel sponsibility for the great global burden of Neurology needs a better contact with BY JOHAN A. opens on Oct. 25. reservations for this unique week in neurological disorders. primary health care. Rural community AARLI, M.D. All of us are Bangkok. Hopefully, many guests will The WHO and WFN have clearly health centers may develop into the crit- deeply indebted also have the opportunity to explore this demonstrated that there are inadequate ical link only if they have contact with to the Neurological Society of Thailand exotic, beautiful, and cultured country. resources for patients with neurological neurological centers. This could form for its hard work in preparing for this im- The congress presents a unique possi- disorders living in low-income or devel- the backbone of a national program for portant event. bility for neurologists from all regions of oping regions. Most patients still have no neurology care. More than any previous WCN host so- the world to receive information and be access to a neurologist. They may see But there are many medical schools ciety, the Thai organizers have had their updated on developments in the neuro- general practitioners, nurses, or health that have no neurologist to give medical share of unexpected obstacles in the sciences. The main topic themes are care workers who may have some or no students even basic training in neurolo- planning of the congress. Global air trav- stroke, multiple sclerosis, epilepsy, de- training in diagnosis and care of com- gy. What then about the training of nurs- el has fallen off as the financial crisis has mentia, movement disorders, and pain. mon neurological disorders. A lack of re- es and auxiliary health personnel? hit economies around the world. Pas- There will be plenary lectures, named liable diagnostic and therapeutic tools To establish adequate neurological senger volumes have declined, and meet- lectures, debate sessions, invited lectures, adds to the problem. care, three sets of critical elements are es- ings and international conventions have industry-sponsored satellite symposia, If there is no neurologist available, it is sential: basic public health service and taken the hardest hit, though this is now free papers, poster sessions, and the 3rd our mission to see that the available health primary health care, neurology training slowly improving. We have seen some Tournament of the Minds. workers also have a basic training in neu- at all medical schools, and a national neu- political unrest, but law and order have The WCN 2009 will also be a meeting rology. But to do that, we need a com- rology service system. The three are in- been restored. And as if this was not ground for discussions on the relation- prehensive system of neurological care at terwoven and depend upon each other. enough, the WHO declared the influen- ship between neurology and public the primary care level, including training Basic public health service and primary za A(H1N1) a pandemic, but considers health. I would like to prepare the par- of primary health-care workers. We need health care is essential to develop mod- the overall severity of the pandemic to be ticipants for debates on the role of WFN general practitioners and health workers ern neurology in countries lacking a moderate. This means that most people in joining WHO’s work on the develop- to find out what neurology is and is not. medical infrastructure. Thailand is a recover from infection without the need ment of clinical neurology. Such training in diagnosis and man- good example of a once developing for hospitalization or medical care. There The WHO Mental Health Gap Action agement of common and treatable neu- country that has developed into a mod- is no reason to assume that the risk of Programme, starting almost simultane- rological disorders for health providers is ern highly developed nation. I look for- contracting influenza is higher in Thai- ously with the Bangkok congress, clearly essential. We are not talking about in- ward to meeting you in Bangkok. ■ Develop Rational Plan for Managing Chronic Pain

BY BETSY BATES on a tricyclic antidepressant because of the side effect of However, he generally prefers to manage chronic pain Elsevier Global Medical News weight gain, despite it’s efficacy in chronic headache.” patients (where possible) on acetaminophen (1 g, 4 Some medications can have multiple effects that are times daily) while using a program aimed at function, ain and depression are common bedfellows, en- particularly useful in treating certain patients, such as activity through functionally directed therapy, includ- Ptwined in a complex relationship of situational and those with diabetic neuropathy who are already taking ing cognitive-behavioral psychotherapy. neurophysiological connections that are not yet fully a selective serotonin reuptake inhibitor (SSRI) agent such That said, acetaminophen “won’t work on opioid-de- understood. as fluoxetine for depression. In this case, a pain special- pendent patients,” he warned. “Almost nothing will Numerous studies point to frequent comorbidity, yet ist may want to switch the patients’ SSRI to the sero- work until the dependence is treated.” physicians treating patients who present with one con- tonin-norepinephrine reuptake inhibitor duloxetine, Within the larger context of chronic pain, patients dition often fail to assess for the other. which is U.S. Food and Drug Administration–approved with generalized pain syndromes deserve special con- It is unknown whether depression is the “cause or the for the treatment of painful diabetic neuropathy, de- sideration, Dr. Clark said. consequence” of chronic pain in some circumstances. pression, generalized anxiety disorder, and fibromyalgia. Central sensitization appears to be the common de- This emphasizes the need for a patient with chronic Another option, the anticonvulsant pregabalin, an ago- nominator among fibromyalgia, interstitial cystitis, dif- pain to be comprehensively assessed for both condi- nist of the alpha 2 delta subunit in voltage-gated calci- fuse low back pain, chronic fatigue syndrome, irritable tions, said Dr. Charles E. Argoff, professor of neurolo- um channels, is indicated for diabetic neuropathy and bowel syndrome, and headache syndromes, with re- gy and director of the Comprehensive Pain Program in Europe may be used for generalized anxiety disorder. sulting amplified pain sensations. at Albany (N.Y.) Medical College. Dr. Michael Clark, a psychiatrist who directs the Johns “The most important thing is that you don’t want to But this is challenging to do in the real world because Hopkins Pain Treatment Program in Baltimore, said he give these patients a little bit of everything and think “so much of taking care of people is based on the last is “pretty nonbiased when it comes to drug selection that’s the answer: a little bit of occupational therapy, a 1,000 people you have taken care of and what your ex- and pretty pragmatic with regard to a person’s indi- little bit of physical therapy, a little bit of psychother- periences have been in addition to your textbooks and vidual situation.” By the time patients see him, they apy and psychopharmacology. Throwing ingredients the mentorship you receive during training.” may have been prescribed an array of the newer, more into a soup without a recipe is not the answer. These Neurologists can manage patients’ depression and expensive drug choices, so he may turn to a tricyclic an- patients need to have someone design a rational plan anxiety if they feel comfortable doing so or refer the tidepressant (such as amitriptyline or doxepin) or an an- for their care,” Dr. Clark said. person for treatment in the community. Depression and tiseizure medication such as divalproex or lamotrigine. Dr. Streltzer reported no relevant financial conflicts anxiety that remain untreated will limit the usefulness “Often, no one else has tried these medications in with regard to this story. Dr. Clark has served on the of any pain treatments, Dr. Argoff said in an interview. these patients, and I’m comfortable with using them,” speakers bureau or as a consultant for Eli Lilly & Co., That does not necessarily mean, however, that treat- Dr. Clark said, explaining that rare side effects, careful maker of duloxetine, and Pfizer Inc., maker of pregabalin. ing a depressed patient with chronic diabetic neuropa- titration, and blood monitoring are not daunting, once Dr. Argoff has received grant support from several thy will only require prescribing a serotonin-norepi- one has familiarity with them. companies involved in pain therapeutics. He also serves nephrine reuptake inhibitor such as duloxetine. Dr. Jon Mark Streltzer, professor of psychiatry at the on the speakers bureau and advisory boards and is a “The point is that there are many considerations to be University of Hawaii, Honolulu, maintains that the con- consultant to various companies in the field, including made, but there is no clear-cut, routine, easy, slam-dunk troversy surrounding long-term, high-dose opioid use Eli Lilly and Pfizer. ■ solution,” Dr. Argoff said. If someone is depressed, has for chronic pain is a matter of difference among indi- migraines, and is obese, “I wouldn’t necessarily put them viduals, rather than a specialty-specific perspective. Jeff Evans contributed to this article. 04_5_8thru13wfn9_9.qxp 9/10/2009 2:25 PM Page 5

OCTOBER 2009 • WWW.WFNEUROLOGY.ORG WORLD NEUROLOGY • 5 Honorees in the WCN 2009 Named Orations Research Centre at Austin Health in ty of Pennsylvania Medical School, and A primary component of a World Congress of Neurology is the Named Ora- Heidelberg, both in Australia. served residencies in neurology and psy- tions. They are funded by donations from their colleagues, held in trust ac- chiatry at Pennsylvania Hospital, inter- counts managed by the World Neurology Foundation. The Foundation and Melvin D. Yahr, M.D. (1917-2004) spersed by service in the Air Force dur- World Neurology have worked with the families of these truly remarkable hu- Dr. Melvin D. Yahr was a lifelong New ing World War II. He then joined the man beings to create brief biographies that explain why they are so honored by Yorker. He received his undergraduate faculty of the new Bowman Grey their colleagues. This year, all four speakers have donated their honoraria to and medical degrees at New York Uni- School of Medicine in Winston-Salem, the Foundation for the purchase of tool kits as part of the 2009 Tool Kits for versity, a free education at that time. He N.C., U.S.A. Africa distribution for Uganda. The Foundation is seeking donations for its de- admitted to playing the clarinet in a jazz From 1959 to 1968 he was the direc- sired shipment to Nigeria for 2009. combo to earn extra money, although he tor of the National Institute of Neu- insisted that he played badly. After three rological Diseases and Blindness, and years of military service, he joined the was part of the team that crafted the Eddie Bharucha (b. 1916) and Piloo rabies. He is a member of the WHO Expert neurology department at Columbia- merit-based peer-review system that is Bharucha (1917-2001) Advisory Panel on Rabies and director of Presbyterian Medical Center. He was the foundation of American medical Dr. Eddie Bharucha received medical the WHO Collaborating Center for chairman of the department of neurol- research. He then became chair of the degrees in Mumbai and London. He Research and Training in Viral Zoonoses. ogy at Mount Sinai Hospital in New department of neurology at the Col- trained at Queen Square and Maida Vale York from 1973 to 1992, and continued lege of Physicians and Surgeons of Co- in London, at the Neurological Institute B.S. Singhal, M.D. (b. 1933) his clinical practice and research until his lumbia University in New York; in Dr. B.S. Singhal completed his medical death in 2004 at the age of 86. 1973, he became H. Houston Merritt training at Grant Medical College and Sir Professor of Neurology, emeritus. J. J. Group of Hospitals in Mumbai, and Dr. Masland mentored many of the trained in neurology in London. most gifted research neurologists of two He has served as president of the Neu- generations, including Carlton Gajdusek,

AMILY rological Society of India and the Indian Leonard Kurland, J. Kiffin Penry, and F Epilepsy Association; established the William F. Caveness. Parkinson’s Disease Foundation of India; He is best known for leading the Na- HARUCHA

B is founder fellow of the Indian Academy tional Collaborative Perinatal Project, a of Neurology, the Association of Physi- nationwide study of pregnancy and child cians of India, and the International Med- development between 1959 and 1966. AMILY OURTESY F

C ical Science Academy; and is a member of The study followed more than 50,000 AHR

the American Academy of Neurology, the Y women from the time of their pregnan- in New York under Dr. Houston Merritt, American Neurological Association, the cies until their children reached the age and in Boston under Dr. Denny Brown. French Neurological Society, and the As- of 8. OURTESY

Dr. Bharucha established the first de- sociation of British Neurologists. He has C Dr. Masland was president of the partment of neurology in India in 1946. served on the Dr. Yahr and colleague, Dr. Margaret Hoen American Epilepsy Society and the New His contributions covered a spectrum of research com- York Neurological Society. He was pres- neurological disorders, including vita- mittee of the Based on research in the late 1950s min deficiencies, tuberculosis, epilepsy, World Federa- showing that depletions of the chemical cerebral palsy, and hereditary neu- tion of Neu- messenger dopamine could set off Parkin- ropathies. His descriptions of craniover- rology, and son’s disease, Dr. Yahr conducted and tebral anomalies and the neurological was regional published the first clinical trials of L-dopa manifestations of acute hemorrhagic director of the in the late 1960s. These studies changed conjunctivitis are seminal. He was a joint Asian-Ocean- the outlook for people with Parkinson’s editor of the Handbook of Neurology, ian Chapter of disease. By 1972, barely 3 years after his president of the Neurological Society of the WFN from study was published, about half of the na- India, and a vice-president of the World 2005 to 2009. tion’s 1.5 million people with Parkinson’s EDLEY

Federation of Neurology. In 1970, he co- Dr. Singhal disease were taking it. Today, L-dopa, de- P ED

founded the Indian Epilepsy Association is the chair of neurology at the Bombay spite some side effects, is by far the most T and was its secretary until 1991. Hospital Institute of Medical Sciences in common treatment for Parkinson’s. He Mumbai. He is widely respected for his was the first scientific director of the OURTESY

Dr. Piloo Bharucha trained as a pedia- gentle style, positive approach, and in- Parkinson’s Disease Foundation. C trician and obtained her medical degrees credible work ethic. He has contributed In 1948, he married Felice Turtz, a mar- in Mumbai and London. She founded the nearly 200 papers to national and inter- riage that lasted 44 years until her death in ident of the WFN from 1981 to 1989, department of pediatrics at the King Ed- national journals and recognized a form 1992. They had four daughters. His daugh- bringing to developing countries the bat- ward VII Memorial Hospital in Mumbai. of leukodystrophy unique to the Indian ter Carol remembers that, no matter who tles against mental retardation, epilepsy, Her interests were preventive pediatrics, subcontinent. His many awards include the patients were, or how hopeless their and head injury. child welfare, and immunization. Po- the Priyadarshini Academy National situation seemed, her father was always During his spare time, Dr. Masland liomyelitis immunization became her Award for Excellence in Medicine, the engaged, positive, and supportive. built a 33-foot Herreshoff ketch. He crusade. She revitalized the Indian Acad- Wockhardt-Harvard Medical Interna- launched the wooden sailboat in 1967 emy of Pediatrics and served as its pres- tional Award for Neurology, and the Dr. The 2009 Melvin D. Yahr Lecture will be and vacationed on it between Cape Cod ident. She and Dr. Eddie Bharucha mar- B.C. Roy Indian National Award. Dr. presented by ROGER N. ROSENBERG, and the Chesapeake Bay for 30 years. Dr. ried in 1947, and had three sons. She was Singhal is married to Dr. Asha Singhal. M.D., on Oct. 29 at 8:30 a.m. He is the Masland and his wife, Mary Wootton a persistent fighter for everything she The Singhal Oration was established Zale Distinguished Chair and professor of Masland, a speech and language pathol- believed in, whether it was the plight of by Dr. Sorab Bhabha to honor Dr. Sing- neurology and director of the U.S. National ogist, had four children. ill children or animals, the welfare of the hal’s lifelong contributions to neurolog- Institutes of Health’s Alzheimer’s Disease underprivileged, or the environment. To- ical education and research, his clinical Center at the University of Texas The Richard L. and Mary Masland Lecture gether with Eddie, she orchestrated an ef- excellence, and his devotion to patient Southwestern Medical Center at Dallas, will be given by David Dodick, M.D., on fort to repeal a law that linked epilepsy care. Dr. Bhabha was a neurologist, a U.S.A. He is a past-president of the Oct. 30 at 8:00 a.m. He is professor of with insanity and provided grounds for friend and colleague of Dr. Singhal, and American Academy of Neurology, a trustee neurology at the Mayo Clinic in Phoenix, nullifying marriage. helped establish this lecture before his of the World Federation of Neurology, and Ariz., U.S.A. He is president-elect of the death from ALS in 2006. editor in chief of Archives of Neurology. American Headache Society and editor in The 2009 Bharucha Oration will be given chief of Cephalalgia. by THIRAVAT HEMACHUDHA, M.D., The 2009 Singhal Oration will be given by Richard Lambert Masland, M.D. professor of neurology at the faculty of SAMUEL F. B ERKOVIC, M.D., on Oct. 28 at (1910-2003) —DIANA M SCHNEIDER, PH.D., medicine, Chulalongkorn University, 8:00 a.m. He is Laureate Professor in the Dr. Richard Lambert Masland was Public Relations Committee, WFN, and a Bangkok, Thailand, on Oct. 26 at 9:15 department of medicine at the University born in Philadelphia, U.S.A. He attend- Member of the Board of the World a.m. His main research interest is human of Melbourne and director of the Epilepsy ed Haverford College and the Universi- Neurology Foundation. 01_2_3_6_7_14_15wfn9_9.qxp 9/10/2009 2:04 PM Page 6

6 • WORLD NEUROLOGY WWW.WFNEUROLOGY.ORG • OCTOBER 2009 Smoking May Speed Progression of MS in Some

BY JEFF EVANS ers had a significantly higher median Ex- least in part reversed by quitting,” the re- tween ex-smokers or never smokers. Elsevier Global Medical News panded Disability Status Scale (EDSS) searchers wrote. The authors cautioned that because score than did patients who never At the end of 2 years and 5 years, the they did not include healthy control sub- he clinical course and disease status smoked. The score in never smokers sig- researchers found no association be- jects, they “could not determine the spe- of multiple sclerosis patients ap- nificantly increased with the number of tween smoking status and worsening of cific effect of smoking on MRI measures Tpear to be worsened by current pack-years smoked. Current and ex- EDSS score, regardless of the type of MS in patients with MS; some general con- smoking, and in some cases, by the past smokers were significantly more likely at at baseline, after adjusting the analyses sequences of smoking could have been amount of smoking in former users, ac- baseline to have a primary progressive for age at baseline, sex, disease duration, mistakenly attributed to MS progression.” cording to a cross-sectional survey and course of MS, rather than an initially re- and treatment. None of the researchers reported any longitudinal analysis of more than 1,400 lapsing course (such as RRMS or SPMS), During follow-up on MRI, current financial disclosures. They received patients at one center. than were never smokers. The odds ra- smokers displayed significantly greater funding for the study from the Partners “Although causality remains to be tio for a primary progressive course was worsening of T2-weighted lesion volume Multiple Sclerosis Center, the National proved, these findings suggest that pa- 2.4 for current smokers and 1.9 for ex- and brain parenchymal fraction than did Institute for Neurological Disorders tients with [multiple sclerosis] who quit smokers, both of which were adjusted never smokers. However, no differences and Stroke, and the National Institutes smoking may ... delay the progression for age, sex, and disease duration. on these measures could be detected be- of Health. ■ of MS,” wrote Brian C. Healy, Ph.D., The researchers also evaluated mark- and his colleagues at Harvard Medical ers of disease severity on MRI, which Comment School, Boston. were not examined in previous reports. Two previous studies that have exam- Current smokers had a significantly low- Several recent studies, including bly important pathogenetic effect of ined whether cigarette smoking is asso- er brain parenchymal fraction on MRI two meta-analyses (Curr. Opin. Neu- posttranslational modification (e.g., ciated with the progression of relapsing- than did never smokers, although no dif- rol. 2007;20:261-8; and Ann. Neu- hydroxylation, citrullination, deami- remitting MS (RRMS) to secondary ference could be seen in the volume of rol. 2007;61:288-99 and 504-13) dation, oxidation, methylation) of progressive MS (SPMS) or greater clini- T2-weighted lesions between current demonstrated adverse influences of proteins/ peptides that provoke im- cal disability arrived at opposing conclu- smokers and never smokers. No differ- smoking on incidence and disease munity to neo-antigenicity by “self- sions (Brain 2005;128:1461-5; Neurology ence could be detected in brain progression in multiple sclerosis (ei- alteration”. Several inhaled noxious 2007;69:1515-20). But the substantially parenchymal fraction between ex-smok- ther conversion from a first demyeli- factors, including tobacco smoke, larger sample size of the present study ers and never smokers, but ex-smokers nating event to clinically definite or induce posttranslational modifica- gives it “more statistical power to assess had a significantly greater T2-weighted from relapsing to chronic progres- tions that trigger immune reactions the relationship between smoking and lesion volume than did never smokers. sive MS). The current study by Dr. to such modified autoantigens. MS progression,” the investigators wrote In a longitudinal analysis of 891 pa- Healy and his associates adds to As with other environmental fac- (Arch. Neurol. 2009;66:858-64). tients with median follow-up time of 3.3 these observations. tors, such as infections, it is likely In the current study, 1,465 MS patients years, Dr. Healy and his associates ob- Although negative effects of that such a vicious immunological cy- completed a questionnaire about their served a conversion from RRMS to SPMS smoking on MS progression are gen- cle may depend on individual genetic smoking history. Overall, 257 were cur- in 20 of 154 current smokers, 20 of 237 erally moderate, they are of utmost susceptibility. The future scientific rent smokers, 428 were ex-smokers, and ex-smokers, and 32 of 500 never smokers. importance because smoking is the challenge will be to unravel the link 780 were never smokers. The researchers The current smokers progressed signif- only known modifiable MS risk fac- between environmental factors (such used only smoking status at baseline in icantly faster from RRMS to SPMS than tor. But why or how does smoking as smoking) and (auto-) immunity. their analyses, but any bias introduced by never smokers. This risk did not change harm MS patients? this assumption “is likely small” because appreciably after controlling for baseline Speculations on direct neurotoxic- —DR. THOMAS BERGER, during follow-up few patients started EDSS score. The rate of conversion from ity or immunostimulation of most head of the Neuroimmunological and smoking for the first time (7) or stopped RRMS to SPMS, however, was similar be- tobacco components seem too sim- Multiple Sclerosis Clinic & Research smoking (57). tween ex-smokers and never smokers. ple. Concepts from autoimmune Unit at the Innsbruck (Austria) The results of analyses derived from This finding “provides evidence that rheumatic diseases point to a possi- Medical University. baseline data showed that current smok- the adverse effects of smoking may be at

LETTERS BoNT in migraine and headache de- phasizes a psychogenic etiology, and a spite evidence for its inefficacy. “functional” explanation in which the BoNT: Opinion vs. Evidence port a beneficial effect of BoNT in the Peer Tfelt-Hansen, M.D., Rigmor Jensen, emphasis is on mechanism (reversible We were under the impression that rec- treatment of some types of headaches. M.D., and Jes Olesen, M.D. change in function of the nervous sys- ommendations for treatment of neuro- However, data from clinical trials are in- Glostru, Denmark tem) rather than etiology. logic disorders published in WORLD NEU- conclusive (for CDH) or negative (for These options also reflect different ROLOGY were evidence based. We were EM and CTTH).” Dr. Silberstein replies: ways of thinking about the problem. Re- therefore amazed to find the article by Dr. He questions the reasons for this dis- The results of a large phase III clinical search using functional imaging (Brain Stephen D. Silberstein on the safety and crepancy and spends the rest of the ar- program evaluating botulinum neuro- 2001;124:1077-90) and neurophysiology efficacy of botulinum neurotoxin, which ticle trying to explain it, citing study de- toxin A versus placebo as headache pro- (Ann. Neurol. 2006;59:825-34) is chal- did not seem to adhere to that expecta- sign and patient- and treatment-related phylaxis in 1,384 adults with chronic mi- lenging the purely psychogenic view of tion (“BoNT for Headache: What You factors. graine were scheduled to be presented etiology that has dominated for over 100 Need to Know,” December 2008, p. 4). The article ends with the comment, in September 2009 at the International years. The first quarter of the article ad- “my clinical experience shows that Headache Congress in Philadelphia, The article implies that a “function- dresses a 2008 evidence-based review by some headache patients benefit signifi- U.S.A. (Cephalagia, in press). These data al” explanation is simply a useful device the therapeutics and technology assess- cantly from BoNT treatment,” then he provide level 1 evidence of the effec- to keep a patient happy until they can ment subcommittee of the American announces that BoNT is effective for tiveness for botulinum neurotoxin A accept a purely psychogenic explana- Academy of Neurology (Neurology chronic migraine in as yet unpublished for the prophylaxis of headaches in tion. Using a “functional” explanation in 2008;70:1707-14). phase III trials. adults with chronic migraine. this way would be bordering on decep- The subcommittee recommended This is not evidence-based medicine tion. The point I had intended to get that BoNT injection probably is ineffec- and such personal statements should Revisiting the Etiology of PMD across was that a functional explanation, tive in the treatment of episodic mi- certainly be abandoned in general treat- In his article “Individualize Psychogenic as well as being easier for patients to un- graine (EM), that there is insufficient ev- ment recommendations. The author Movement Disorder [PMD] Diagnosis” derstand, may actually be better theo- idence to support or refute a benefit of disregards the data from systematic re- (August 2009, p. 5), reporter Jeff Evans retically as well. BoNT for the treatment of chronic dai- views and presents his personal views has misunderstood the message I was Whilst psychological factors are un- ly headache (CDH), and that BoNT in- and explanations. Despite the negative trying to get across about the way in doubtedly important in these symp- jections should not be considered in pa- evidence, he advocates the use of BoNT which we think of PMD and communi- toms, the pure psychogenic etiological tients with EM and chronic tension-type for headache. cate this to patients. model may be wrong and in need of re- headache (CTTH). Such a paper in the official publication There are several ways of explaining vision. Dr. Silberstein then states that “basic of the World Federation of Neurology these symptoms to patients, including a Jon Stone, Ph.D., FRCP science data and clinical experience sup- will encourage the widespread use of “psychological” explanation which em- Edinburgh, Scotland 01_2_3_6_7_14_15wfn9_9.qxp 9/10/2009 2:11 PM Page 7

VJ+PVGTPCVKQPCN%QPITGUUQP /GPVCN&[UHWPEVKQPU 1VJGT0QP/QVQT(GCVWTGUKP 2CTMKPUQP¶U&KUGCUG 4GNCVGF&KUQTFGTU $CTEGNQPC5RCKP &GEGODGT

MDPD 2010 offers specialists in the treatment of Parkinson’s disease and related disorders a unique opportunity to study the latest available information in the ﬁ eld. Leading scientists and clinical experts will present current basic and clinical research on: Cognitive dysfunction and dementia "ARCELONA Psychosis Depression Pain Autonomic dysfunction Sleep impairment Neuroimaging Mental problems Cortical and subcortical neurodegenerative processes underlying clinical manifestations " YYYMGPGUEQOOFRF

1-3 Rue de Chantepoulet, P.O. Box 1726, CH-1211 Geneva 1, Switzerland

Tel: +41 22 908 0488, Fax: +41 22 906 9140, E-mail: [email protected] -GPGU+PVGTPCVKQPCN#NNTKIJVUTGUGTXGF 04_5_8thru13wfn9_9.qxp 9/10/2009 2:58 PM Page 8

8 • WORLD NEUROLOGY WWW.WFNEUROLOGY.ORG • OCTOBER 2009

NEUROLOGY IN PRACTICE A Thriving Specialty in Krasnoyarsk Krai rasnoyarsk is the scientific center of Siberia, with have been implemented through the World Federation comparable with those in Moscow polyclinics and oth- Krasnoyarsk State Medical University, which is of Neurology and the education committee of the er big industrial cities in Russia. But these methods are Knamed after Prof. V.F. Vojno-Yasenetsky, forming ARSN. These programs are important as a means of de- available only in big hospitals. Krasnoyarsk is a vast re- the hub of research, academic training, and clinical livering educational materials and information about gion, and patients in its remote rural areas are treated practice in the Krasnoyarsk Krai. new developments and advances in the specialty to all in their local hospitals by specialists from the Krasno- The field of neurology is particularly dynamic here. neurologists, especially those in remote areas. Online yarsk Regional Clinical Hospital who travel to the ar- Numerous projects that are important for the devel- CME conferences, training seminars, and clinical analy- eas on an air medical service. opment of neurological science, practice, and care ses of difficult diagnostic cases in neurological practice If necessary, seriously ill patients are transferred to have flourished with help from the All-Russian Society are important for postgraduate education of our neu- neurological departments or the intensive care unit of of Neurologists (ARSN) and specialists from the Kras- rologists and are carried out regularly. Krasnoyarsk Regional Clinical Hospital by air medical noyarsk State Medical University, elsewhere in the service or emergency ambulance. The most difficult country, and from overseas. Pediatric and Adult Care situation with emergency neurological care is in dis- There are 501 neurologists in tant northern districts, because the region, with more than half BY NATALIA A. SHNAYDER, M.D., PH.D. the connection with settlements of them based in the industrial BY SEMEN V. in winter is possible only by avi- cities of Krasnoyarsk, Norilsk, Dr. Shnayder is head of the PROKOPENKO, M.D., PH.D. ation and in summer, by river Achinsk, and Kansk and Mi- department of medical genetics transport. nusinsk. The regional branch of and clinical neurophysiology at Dr. Prokopenko is head In the last 3 years, specialists at the ARSN has a membership of the Institute of Postgraduate of the department of larger hospitals in the region have 343 pediatric and adult neurolo- Education at Krasnoyarsk State neurology, also at the begun using telemedicine in their gists, and the Krasnoyarsk Re- Medical University in the Krasnoyarsk State consultations for difficult-to-treat gional Society of Clinical Neu- Russian Federation. Medical University. neurological patients and those in rophysiologists has 61 members. remote areas. In 2009, the region’s Annually, there are more than 10 training seminars As in other regions of Russia, there is a special system ministry of health care introduced teleconsultations and for neurologists, several regional and interregional of pediatric neurology in Krasnoyarsk Krai focusing on teleconferences both in health care institutions and in neurological conferences, and at least one ARSN con- diagnostics, prophylaxis, treatment, and rehabilitation in remote rural hospitals. Key specialists from the Kras- ference in Krasnoyarsk. There are many conferences on children and teenagers with the diseases of the nervous noyarsk Regional Clinical Hospital, Krasnoyarsk State rehabilitation and epilepsy as well as teleconferences system. Generally, these neurologists are former pedi- Medical University, and specialized diagnostic centers in with neurological centers in Germany, Switzerland, and atricians who have received special professional re- Krasnoyarsk participate in this form of care. other countries. training or completed and internship in pediatric neurology and/or pediatric and adult neurology. They Subspecialty Focus Training work in children’s outpatient departments and hospitals. Neurological science and practice in Krasnoyarsk focus Most of the region’s neurologists train at the Institute In Krasnoyarsk, there are specialized pediatric neu- on neurorehabilitation, epileptology, and neurogenet- of Postgraduate Education of Krasnoyarsk State Med- rological wards only in children’s hospitals, with sepa- ics. Krasnoyarsk is one of eight territories selected to ical University in the departments of neurosurgery and rate neurological departments for children aged 1-3 pilot a federal program aimed at improving stroke care. neurology; neurology, which includes a course in tra- years and aged 3-18 years. There are 40-60 beds in these The Centre of Neurology and Neurorehabilitation, ditional medicine; and medical genetics and clinical neu- wards. Often, there is a demand for more beds, so they with its modern methods of rehabilitation, is one of rophysiology. They can also train at other institutes in are added as needed—though never more than 10. On those venues. Three hospitals—Krasnoyarsk Regional Siberia, Moscow, St. Petersburg, and other cities. average, a neurologist working in the children’s wards Clinical Hospital No. 1, Urban Hospital of Krasnoyarsk, Programs for continuous medical education (CME) takes care of 20 patients a day. and the Central Regional Hospital in Minusinsk— are The average length of a hospital stay for these chil- part of the program. A stroke-care register has been dren is about 2 weeks. In Krasnoyarsk Regional Chil- started at Clinical Hospital No. 51 in Zheleznogorsk. dren’s Hospital and in children’s hospitals of industri- At the beginning of this year, the Centre of Epilep- al cities, the specialized neurological help is provided tology, Neurogenetics, and Brain Research was estab- in the wards for internal medicine (and, if needed, for lished at the University Clinic at Krasnoyarsk State Med- infectious diseases). Neurologists in outpatient depart- ical University. Data on the epidemiology of epilepsy ments examine about 24 children a day. are being collected with guidance from specialists at Adult patients with neurological diseases are treated Russian State Medical University in Moscow. This effort

MITRENKO in the neurological wards in the hospitals and outpa- is seen as an important component in efforts to improve D tient departments. Usually, they stay in the neurologi- care for patients with this disease. ■ IANA

D cal departments for about 16 or 17 days. Neurologists who work in outpatient departments and polyclinics for adults in the rural districts of Krasnoyarsk

OURTESY About the Region

C Krai see about 24-26 patients a day. Moreover, neurolo- EEG training in Krasnoyarsk State Medical University’s gists also visit patients with acute neurological patholo- rasnoyarsk Krai—“krai” means region or department of genetics and clinical neurophysiology. gy at home. Patients with brain trauma are treated in the Karea—is a federal subject of Russia. It is the departments of neurosurgery of big clinics or in the de- second largest territory of Russian Federation af- partments of surgery in central district hospitals. ter the Sakha Republic, occupying an area of 903,400 square miles. From Isolation Centers to Telemedicine Krasnoyarsk Krai lies in the middle of Siberia Compared with hospitals in Krasnoyarsk, neurological and belongs to Siberian Federal District, stretch- care in more remote regions is of a lower quality as they ing from the Sayan Mountains to the south along have no modern diagnostic and laboratory equipment. the Yenisei River to Taymyr Peninsula in the Historically, there are territorial isolation centers in the north. The administrative center of the region is ROKOPENKO

P settlements of central and eastern Siberia, where there the city of Krasnoyarsk. is a prevalence of hereditary disorders. So in an effort to The most recent data (2002) put the population EMEN improve diagnostics, care, and education in neurology, 3,023,525. Most of the population is Russian, . S R

D the department of medical genetics and clinical neuro- with the indigenous Siberian peoples making up physiology and the Centre for Medical Genetics were no more than 1% of the population. founded in 2006 as part of the Institute of Postgraduate Krasnoyarsk Krai is an important industrial re- OURTESY

C Education at Krasnoyarsk State Medical University. gion that includes the cities Krasnoyarsk, Norilsk, A patient undergoes analysis of gait with simulation In Krasnoyarsk and Norilsk, the departments and Achinsk, Kansk, Zheleznogorsk, and Minusinsk. at the Krasnoyarsk Centre of Rehabilitation. wards are equipped with modern diagnostic techniques 09_12_16thru20wfn9_9.qxp 9/10/2009 3:00 PM Page 9

OCTOBER 2009 • WWW.WFNEUROLOGY.ORG WORLD NEUROLOGY • 9 Sleeping Sickness: Africa’s ‘Neglected Disease’ Every aspect of the disease—diagnosis, staging, problematic issues in HAT. The WHO in preventing the PTRE is controversial, al- criteria for late-stage disease are the iden- though I personally would prescribe them. therapy, follow-up—presents a unique challenge. tification of trypanosomes in the CSF or An alternative drug for late-stage gambi- a CSF white blood cell count (WBC) of ense disease is eflornithine (DFMO), uman African trypanosomiasis, bance with alteration of the normal greater that 5/mcL. But not everyone ac- which was first shown to be effective in which is also known as sleeping sleep/wake cycle with a constant urge to cepts this definition, and in West Africa 1981 but then became an “orphan drug.” Hsickness, is a major killer disease in sleep, and polysomnography demon- a cutoff point of 20 CSF WBC/mcL is Because of efforts by Médecin Sans Fron- 36 countries in sub-Saharan Africa, strates sleep structure abnormalities. often used. Others have suggested a com- tières, working closely with the World where 60 million people are at risk for There may also be motor disturbances, promise figure of 10 WBC/mcL, but the Health Organization and the pharmaceu- the disease and up to 50,000 people die such as pyramidal weakness, extrapyra- actual presence of CSF trypanosomes is tical industry, DFMO, which is expensive, annually from the infection. midal features, cerebellar ataxia, myelopa- unequivocal proof that the CNS has was again made available for treatment of Human African trypanosomiasis thy, peripheral motor neuropathy, muscle been invaded. HAT. Eflornithine is less toxic than melar- (HAT) is caused by protozoan parasites fasciculation, and also frontal lobe features Although both CT and MRI scan ab- soprol, but needs to be given intravenously of the genus Trypanosoma brucei, and is such as pout and palmarmental reflexes. normalities have been shown in the few over 14 days, which is not always practical transmitted by the bite of the blood- Sensory disturbances can also occur, as patients who have been studied in West- in field hospitals. It is not without side ef- sucking tsetse fly of the genus Glossina. may a variety of neuropsychiatric symp- ern hospitals, such facilities are not avail- fects and completely ineffective for treat- Although HAT was almost brought toms. Various types of visual involvement able in field conditions and are therefore ing rhodesiense infection. It has recently under control mainly as a result of ef- have also been described. Untreated or un- primarily of value in investigating pa- been suggested that a combination of fective surveillance tients who have recently returned from eflornithine and nifurtimox is probably the measures in the BY PETER G.E. KENNEDY M.D., PH.D., D.SC. Africa. There are about 50 cases a year of optimum drug treatment for gambiense 1950s, there have HAT diagnosed outside Africa, mainly in disease. After effective treatment, all pa- been several resur- Dr. Kennedy is the Burton Chair of Western travellers returning from vaca- tients with HAT require regular follow-up, gencies and epi- Neurology and head of the Division of tions to East African game reserves. but this can be neither easy nor feasible. demics since then, Clinical Neurosciences at the University What are the prospects for better di- with a steady increase of Glasgow, Scotland, and an honorary Toxic Drugs Hamper Treatment agnosis and treatment of sleeping sick- in the number of cas- consultant neurologist at the Institute of Drug treatment of HAT is highly unsat- ness? Despite many decades of underin- es, largely due to dis- Neurological Sciences, Southern isfactory and essentially relies on the use vestment in HAT, there is now an ruption of social and General Hospital in Glasgow. of four drugs, none of which can be giv- increasing awareness of the importance surveillance infra- en orally and which are so toxic that it is and seriousness of the problem with in- structure, especially during successive successfully treated patients will rapidly unlikely that they would have passed creasing financial input from the devel- wars in affected regions. However, there deteriorate with seizures, cerebral ede- currently rigorous safety standards had oped world including from the Bill and is good evidence that the number of ma, incontinence, and death. Typical au- they been introduced in recent years. Melinda Gates Foundation, WHO, the new cases is decreasing again because of topsy findings in such patients will show Early-stage rhodesiense disease is treat- U.S. National Institutes of Health, and improved patient surveillance. a widespread meningoencephalitis, an ex- ed with intravenous suramin, and early- the Wellcome Trust. Despite the fact that HAT is associat- tensive infiltration of cerebral white mat- stage gambiense disease is treated with ed with a very significant morbidity and ter with inflammatory cells and pathog- intramuscular pentamidine. For late-stage Looking Toward an Ideal Solution mortality, it is one of the world’s “ne- nomic Mott cells, which are plasma cells rhodesiense disease, the only effective For better diagnosis, a rapid, user-friend- glected diseases.” Drug treatment for containing immunoglobulin M eosino- drug at present is intravenous melarso- ly, inexpensive, reliable, and preferably HAT is outdated and highly toxic, and philic inclusions. Extensive data from both prol (Mel B), a highly toxic arsenical drug noninvasive method of staging for both this highly unsatisfactory situation re- patients and a mouse model of the disease that was first used in 1949. It is given ei- types of HAT is urgently needed. There flects the chronic lack of financial in- have implicated the key roles of pro- and ther as 2-4 courses of three times week- are no new treatment drugs on the hori- vestment from the developed world into counterinflammatory cytokines, astrocyte ly injections or, more recently, as a 10-day zon and a promising oral drug for ear- new drug development for both stages of activation, and trypanosome-induced im- course of injections. Although melarso- ly-stage disease, DB 289, has been with- the disease. If untreated, or inadequate- mune responses in causing the brain dam- prol is generally effective treatment for drawn near the end of a phase III clinical ly treated, the disease is invariably fatal. age (J. Clin. Invest. 2004;113:496-504). late-stage HAT, in about 10% of patients, trial because of unexpected liver and re- There are two forms of the disease: it is followed by a severe posttreatment nal toxicity. What is required, ideally, is East African HAT caused by Trypanosoma No General Criteria to Aid Diagnosis reactive encephalopathy (PTRE), 50% of a safe, inexpensive, oral drug that is ef- brucei rhodesiense (T.b. rhodesiense), and Sleeping sickness is diagnosed by identi- whom will die. Melarsoprol treatment fective for both early- and late-stage the West African variant caused by T.b. fying parasites in the peripheral blood or has an overall fatality rate of 5%, which HAT. Such an advance would obviate gambiense, which accounts for about 95% lymph node aspirates in the case of is remarkable. the current dilemmas associated with of cases of HAT. The disease caused by rhodesiense disease, and by serological The role of prophylactic corticosteroids CSF diagnosis of late-stage disease. ■ rhodesiense has a faster tempo than gam- means using the Card agglutination try- biense disease and leads to death if un- panosomiasis test (CATT) in the case of treated in several weeks to a few months, gambiense disease because in the latter whereas the course of gambiense disease case, there are usually few detectable may last many months to years. parasites in the blood. There are no clinical suspicion criteria Two Stages and a Range of Symptoms that can reliably distinguish the two dis- There are two stages of HAT, the early ease stages, which may appear to merge (stage 1), or hemolymphatic stage, which into each other. All patients with proven occurs 1-3 weeks after the initial insect HAT therefore require a lumbar punc- bite, and then the late (stage 2), or en- ture to examine the cerebrolspinal fluid /CDC OSER

cephalitic stage, when the parasites cross (CSF) as that is the only current method M the blood-brain barrier to enter the CNS of diagnosing CNS involvement. Accu-

(Ann. Neurol. 2008;64:116-26). In the rate staging of HAT is absolutely crucial ELANIE early stage, the parasites spread in the because the drugs used for treating CNS M bloodstream, lymph nodes, and systemic disease are so toxic. If drug treatment is AND .D. .D.

organs causing a variety of nonspecific mistakenly withheld from a patient who H symptoms, including malaise, headache, has CNS disease then the patient will die, ,P ILVA

arthralgia, headache, and fatigue. In- but giving highly toxic CNS drug thera- S

volvement of the heart, liver, spleen, py for early-stage disease carries the high DA skin, eyes, and endocrine system may risk of severe drug toxicity. This is one of J. also occur. Lymphadenopathy is typical the key dilemmas in managing patients with sleeping sickness.

of gambiense disease. LEXANDER

The range of symptoms and signs dur- Unfortunately, there is no general con- ©A ing the late stage is very wide. In most cas- sensus as to what criteria best define late- There have been several resurgencies in HAT since the 1950s, largely due to es, there is a characteristic sleep distur- stage disease, and this is one of the most disruption of social and surveillance infrastructure, especially in war-torn regions. 04_5_8thru13wfn9_9.qxp 9/10/2009 2:38 PM Page 10

Author Guide Publishing in scholarly journals

Why publish with Elsevier?

125 years of publishing expertise For the past 125 years, the name Elsevier has been synonymous with excellence in publishing. That tradition carries on today. Every year, Elsevier accepts and publishes more than 250,000 journal articles. More than 20% of the key international scientific publications recognised by the Institute for Scientific Information (ISI) are published by Elsevier. www.elsevier.com/aboutelsevier World-renowned publications Among the thousands of journals and books published by Elsevier are some of the world’s most prominent and respected medical, scientific and technological publications. These include The Lancet, Cell, Tetrahedron Letters and a host of others. A prominent class of peers Those authors who publish with Elsevier can take pride in knowing that the most honoured scholars, scientific leaders and educators - from Galileo to Jules Verne and Stephen Hawking - have also published with Elsevier. Your rights: our responsibility At Elsevier, our authors are our life’s blood. That’s why we’re dedicated to protecting Authors’ rights and ensuring that any and all legal information and copyright regulations are addressed. Benefits to authors We also provide many author benefits, such as free PDFs for most journals, a liberal copyright policy, special discounts on Elsevier publications and much more. In addition, Elsevier is committed to the highest standards of electronic archiving and information sharing, to ensure that articles are available for future reference. Elsevier’s service to the community Elsevier recognises its responsibility to the community and the world at large. We take pride in our different corporate responsibility programmes. www.elsevier.com/philanthropy

For more information visit: www.elsevier.com/authors 04_5_8thru13wfn9_9.qxp 9/10/2009 2:45 PM Page 11 09_12_16thru20wfn9_9.qxp 9/10/2009 3:02 PM Page 12

12 • WORLD NEUROLOGY WWW.WFNEUROLOGY.ORG • OCTOBER 2009

Calendar of World Stroke Day: What You Can Do International Events BY JEYARAJ D. PANDIAN, M.D. secondary prevention are the use of an- (Stroke 2008;39:2407-20). tiplatelets, warfarin in atrial fibrillation, The WSO promotes World Stroke 2009 he incidence of stroke is a global endarterectomy for carotid stenosis, Day to raise awareness of stroke—a 19th World Congress of Neurology health problem. It is the leading and cholesterol reduction. preventable and treatable catastrophe. Oct. 24-30 Tcause of adult disability and the Among the various strategies, rapid The theme this year “Stroke—What Bangkok, Thailand second leading cause of mortality diagnosis, implementation of early pre- Can I Do?” This question implies that www.wcn2009bangkok.com worldwide. ventive treatment, early recognition of everyone can do something about A recent review of stroke incidence complications and mobilization im- stroke. Individuals can learn their risk European Charcot Foundation and case fatality from 21 days to 1 prove the overall outcome of these pa- for stroke and do something about it; University Classes in Multiple month post stroke showed a divergent, tients. Management of these patients in they can learn the symptoms of stroke Sclerosis VI statistically significant trend in stroke in- acute stroke care units has a greater im- and what to do about them; and they Nov. 11 cidence rates over the past 4 decades, pact at community level than do other can help advance the stroke cause in Lisbon with a 42% decrease in stroke incidence treatments such as aspirin and rTPA many other roles: as physician, nurse, www.charcot-ms.eu in high-income countries and a greater (Lancet 2008;371:1612-23). health care professional, patient, care- than 100% increase in stroke incidence Stroke care services are not uniform- giver, donor, business person, citizen, European Charcot Foundation in low- to middle-income countries. ly developed across the world. Even in volunteer, policy maker, or member of Symposium: A New Treatment Era During 2000-2008, the overall stroke developed countries, a small proportion government. The theme has been de- in Multiple Sclerosis incidence rates in low- to middle-in- of patients receive thrombolysis. In developed to prompt action against stroke Nov. 12-14 come countries have, for the first time, veloping countries, well-organized stroke at the personal, family, or group level. Lisbon exceeded the level of stroke incidence in and emergency transport services are This year, we are encouraging people www.charcot-ms.eu high-income countries by 20% (Lancet lacking, many treatments are unafford- to run World Stroke Day events. The Neurol. 2009;8:355-69). In developing able, and sociocultural factors may in- WSO will be delivering tools, such as The Sixth International Congress countries, stroke affects individuals in fluence access to care. Moreover, public lists of ideas for activities and media re- on Vascular Dementia the most productive part of their lives awareness of stroke is lacking in both de- leases. There will also be awards for the Nov. 19-22, 2009 where the average age of stroke patients veloped and developing countries. best, most innovative activities to rec- Barcelona is 15 years younger than that in high-in- The World Stroke Day proclamation ognize efforts that heighten stroke www.kenes.com/vascular come countries. was issued 2004 at the World Stroke awareness. To register your interest in Stroke treatment has shown rapid Conference in Vancouver. It was re- running a World Stroke Day event, send XVIII WFN World Congress on advances. Proven therapies include launched in 2006 at the Stroke Confer- an e-mail to [email protected] Parkinson’s Disease and Related management of acute stroke patients in ence in Cape Town when the Interna- or visit www.world-stroke.org. ■ Disorders a stroke unit, intravenous thrombolysis tional Stroke Society and the World Dec. 13-16 with recombinant tissue-type plas- Stroke Federation merged to form a sin- DR. PANDIAN is professor of neurology Miami Beach, U.S.A. minogen activator (rTPA), use of aspirin gle organization, the World Stroke Or- and head of research at the Betty Cowan www.kenes.com/parkinson within 48 hours and decompressive ganisation (WSO). Since then, World Research and Innovation Centre at surgery for malignant middle-cerebral Stroke Day is held each year on Octo- Christian Medical College in Ludhiana, artery infarction. Effective measures for ber 29—on the “birthday” of the WSO India. 2010 3rd International Congress on Gait & Mental Function Feb. 26-28 Foundation’s Quest for Global MS Awareness Washington D.C. www2.kenes.com/gait/pages/ he Multiple Sclerosis International launched in September last year at the ciety Research funding database with home.aspx TFoundation aims to stimulate and fa- World Congress on Treatment and Re- data on annual MS research funding by cilitate international collaboration in search in MS in Montreal. It raises aware- our member societies to help us and our 3rd International Conference on research to better understand the nature ness and encourages exploration of the member societies determine global Hypertension, Lipids, Diabetes & of MS, develop better treatment and re- validity and robustness of data on epi- funding trends and patterns, inform fu- Stroke Prevention habilitation of people with MS, and in- ture research funding de- March 4-6 form relevant communication and ad- cisions, and develop in- Berlin vocacy initiatives. ternational collaborative www.kenes.com/strokeprevention Through the International Medical BY ALAN THOMPSON, M.D. initiatives. This past sum- and Scientific Board, the MSIF focuses mer, we organized an MS 6th World Congress of on a number of research programs and Dr. Thompson is chair of the Research Coordination Neurorehabilitation (WCNR2010) activities to achieve this aim. MSIF International Medical and meeting that brought to- March 21-25 We offer several awards for research in Scientific Board. He is director of gether key players in the Vienna MS. In 2007, we launched the McDonald the Institute of Neurology at the global MS medical and www.wcnr2010.org/ Fellowships, which enabled five young re- University College London. scientific community to searchers from developing countries to review global MS research 14th Congress of the European carry out a 2-year research project at an demiology and services for people with spending and anticipate and prepare for Federation of Neurological MS center of excellence. Another three MS (www.atlasofms.org/index. aspx). future challenges and opportunities. Societies fellowships were awarded in 2008. Also We have also commissioned a report Issue 13 of MS in Focus, on tremor September 25-28, 2010 last year, we awarded seven Du Pré into the global economic impact of MS, and ataxia in MS, came out in March. Geneva Grants for researchers to learn new skills containing data on the personal, social, Most issues of this biannual publication www2.kenes.com/efns2010/ through collaborative research projects, and economic costs of MS for use in are available free in English, German, Pages/home.aspx we launched the International Research raising awareness of the impact of MS and Spanish (www.msif.org/ msinfocus). Meeting Grants (www.msif.org/en/re- and argue for the allocation of scarce re- We also published an online update of 7th World Stroke Congress search/msif_research_awards/index. sources for the benefit of individuals, MS: The Guide to Treatment and Man- Oct. 13-16, 2010 html) and we supported the 9th Gordon communities, and society as a whole. agement, which now includes a new Seoul Conference on “Development and Dis- The MSIF Research Alumni Pro- chapter on unconventional therapies. www2.kenes.com/Stroke2010/ eases of Myelin” in Lucca, Italy. gramme was launched in April 2008 to We coordinate work of the Interna- Pages/Home.aspx From 2005 to 2007, MSIF collaborated foster a lifelong relationship between re- tional Pediatric Multiple Sclerosis Study with the World Health Organization to search alumni and MSIF, and promote Group (IPMSSG) and facilitated and European Headache and Migraine gather data from 112 countries on the scientific communication and forma- part-funded the first research sympo- Trust International Congress epidemiology of MS and the availability tion of a global MS research network. sium of this group in Toronto, Canada, Oct. 28-31 and accessibility of resources to diag- We have 36 alumni (www.msif. org/en/ in April this year (www.ipmssg.org). www2.kenes.com/ehmtic/Pages/ nose, inform, treat, support, and reha- research/msif_research_alumni/in- Finally, we were instrumental in setting Home.aspx bilitate people with MS. The Atlas of MS dex.html). up and coordinating global activities of publication and new Web site were In 2008, we developed a Member So- the first World MS Day on May 27. ■ 04_5_8thru13wfn9_9.qxp 9/10/2009 2:50 PM Page 13

Clinical Neurology News® Presents Developments in Migraine Therapy 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.

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

With Paul Winner, DO, FAAN Clinical Professor Nova Southeastern University Ft. Lauderdale, Fl.

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

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

2009 Copyrighted Production of Elsevier/International Medical News Group. Interview Content Copyright 2009 GlaxoSmithKline. www.clinicalneurologynewsnetwork.com/migraine 01_2_3_6_7_14_15wfn9_9.qxp 9/10/2009 2:15 PM Page 14

14 • WORLD NEUROLOGY WWW.WFNEUROLOGY.ORG • OCTOBER 2009

MEETING UPDATE FROM THE LANCET NEUROLOGY AOAN Elects President In Some, DBS Improves At Delhi Congress Dystonia-Choreoathetosis CP he 12th Asian and Oceanian Con- naka invited neurologists to a planning ilateral pallidal deep brain stimula- portant. The two patients who did the best gress of Neurology and the Asian meeting in Tokyo, Japan, and the asso- tion may hold promise as a treat- had optimal placement and stimulation of Tand Oceanian Association of Neu- ciation was established on June 26, 1961. Bment for some patients with dys- the globus pallidus internus, whereas the rology meeting were held in October The statutes stipulate that the Asian tonia-choreoathetosis cerebral palsy, results were poorer in patients whose elec- 2008 in New Delhi, India. and Oceanian Congress of Neurology according to results of a small pilot study trodes were implanted suboptimally—2 or At that meeting, I was elected the (AOCN) be held every 4 years. reported by Marie Vidailhet, Ph.D., of 3 mm outside the globus pallidus inter- 13th president of the Asian and Ocean- On Sept. 14, 1962, the association’s Groupe Hospitalier Pitié-Salpêtrière, nus—spreading the electrical current be- ian Association of Neurology (AOAN). board was chosen, and it included rep- Paris, France, and her colleagues in the yond the target site,” he explained. I would like to thank everyone for their resentatives from Australia, Hong French SPIDY-2 Study Group. Another factor for success seemed to participation and support during the Kong, India, Japan, Korea, New Dystonia-choreoathetosis cerebral pal- be patient selection. Those with mobile Zealand, Philippines, the Re- sy (CP) is a form of CP characterized by dystonia seemed to do better than those BY CHING-PIAO TSAI, M.D. public of China (Taiwan), and severe disabling movement disorders with static dystonia, though that obser- Thailand. The AOCN inaugur- with little or no spasticity and little or no vation needs to be validated by further Dr. Tsai is professor and al was held in October 1962 in cognitive impairment. study, he noted. Future steps are to reim- section chief at the Neuro- Tokyo, under the leadership of “This is the first demonstration that BP- plant the electrodes in four of the five pa- logical Institute at the Dr. Okinaka. DBS [bilateral pallidal deep brain stimu- tients with poor outcomes and subopti- Taipei Veterans General Membership has increased lation] can im- mal placement Hospital and National over the years from the initial 9 prove patients of electrodes. “If Yang-Ming University in member countries to the current with this type of they improve, Taipei, Taiwan. 18. Current members are Aus- CP. So far, no then this will be tralia, Hong Kong, India, Japan, drug or therapy a strong argu- meeting. I look forward to serving the South Korea, New Zealand, Philippines, has proven to be ment that place- association during my tenure. I hope to Malaysia, Pakistan, Saudi Arabia, Israel, effective. The ment of elec- keep members connected by sending Indonesia, Singapore, Sri Lanka, Tai- modest improve- trodes is a out regular newsletter updates, and I wan, Thailand, and Mongolia—with ment in this pilot critical factor for encourage you to visit our new Web Vietnam recently becoming the 18th. study is the be- success.” site at http://www.aoan-neuro.org/. The founding AOAN mission state- ginning of a new The investiga- Also at the meeting, Dr. William Car- ment, as proposed by Dr. Carroll, is to: era for patients DR. VIDAILHET DR. POLLAK tors plan to con- oll of Australia was elected vice-presi- Ǡ Promote development of clinical with CP,” said se- tinue to study dent and Dr. Man Mohan Mehndiratta neurology and neurological science in nior author Dr. Pierre Pollak of Joseph the 13 patients using formal scales and to (India) secretary treasurer. The com- the Asian and Oceanian region; Fourier University Hospital in Grenoble, implant more CP patients outside of a mittees will be headed up by Dr. Ǡ Assist, as required, in the develop- France (Lancet Neurol. 2009;8:709-17). trial setting. “It may be possible to extend Lawrence Wong of Hong Kong (edu- ment of training programs and re- BP-DBS is effective for patients with BP-DBS to patients with some intellec- cation); Dr. Mohammad Wasay, Pak- search efforts in member and potential primary dystonia, which encouraged tual impairment and abnormal move- istan (research); and Dr. Mehndiratta member nations of the region; the investigators to study the proce- ment. We have operated on one patient (membership). The regional director for Ǡ Facilitate cooperative exchange pro- dure in dystonia-choreoathetosis CP. with an intellectual deficit and some ab- the World Federation of Neurology is grams for trainee and qualified neu- The multicenter prospective pilot study normal movements. This procedure is Dr. Amado San Luis of the Philippines. rologists and neuroscientists; enrolled 13 adults with dystonia- safe for cognition but won’t improve it, The AOAN was founded almost 50 Ǡ Participate with activities promoted choreoathetosis CP with no cognitive so we can propose stimulation of the years ago after Dr. Charles M. Posner, a by the WFN; impairment, little spasticity, and only globus pallidus internus for patients with WFN representative, toured the region Ǡ Respect the aims and aspirations of slight abnormalities of the basal ganglia severe dystonia and some intellectual and suggested neurologists form an as- member organizations in providing on magnetic resonance imaging. Pa- impairment,” Dr. Pollak said. sociation to foster the advancement and support and advice; and tients were treated with neurostimula- In an accompanying editorial, Dr. Stef- exchange of neuroscientific informa- Ǡ Promote friendship among regional tion of the internal part of the globus fen Berweck of Children’s Hospital, Uni- tion within the region. Dr. Shigeo Oki- neurologists and neuroscientists. ■ pallidus for 1 year and then evaluated versity of Munich, Germany, wrote that for improvement in movement, func- the “pilot study on BP-DBS is encourag- tional disability, pain, and mental ing, but it remains a challenge to advise health–related quality of life. an individual patient with dystonia- Focus on Disease Classification The mean improvement on the Burke- choreoathetosis CP about whether to ICD-10 • from page 1 Fahn-Marsden dystonia rating scale was undergo this treatment.” 24%, which is about half of the magni- “BP-DBS was tested in a highly select- neurology specialists, and researchers. notype, for example, have been reshuf- tude of mean improvement achieved by ed subgroup of patients with CP. We do For the first time, the revision process fled to reflect their specific genetic caus- DBS in primary dystonia (about 52%). not know in how many patients within will be fully transparent. A beta draft is es, new disorders have been discovered, Patients also showed improvements in the spectrum of CP this approach sig- expected in 2011, and it will be field test- and some diagnostic categories have body pain (P = .04), emotional role (P nificantly improves health status. We ed at various sites around the world for been redefined to reflect new under- =.06), and mental health (P = .05), with have to be careful not to raise unrealis- feasibility, reliability, clinical utility, and standing of their causes and risk factors. no deterioration in cognition or mood. tic hopes in patients and families,” he said validity. Committee members will be Many hope computerized health data One-year outcomes on the Burke- (Lancet Neurol. 2009;8:692-3). seeking and choosing these sites over management will facilitate more fre- Fahn-Marsden dystonia rating scale were Dr. Berweck also noted that patients the next half year. The penultimate quent remodeling of the ICD-11 codes variable in the 13 patients, with 3 show- should be counseled that the after-care draft will be posted on the WHO Web to keep up with the growth of neuro- ing no improvement, 5 showing some will take several visits within the first year site, and interested parties and the pub- scientific and clinical knowledge. The improvement (2 in the same range as in after implantation to optimize therapeu- lic will be invited to respond. It is hoped absolute need to track epidemiological primary dystonia—greater than 50% im- tic effects through adjustment of stimu- that the final version will be submitted disease data over time requires each provement), and 5 only mildly improved lation parameters. The decision to have to the World Health Assembly in 2014. modification of the ICD to be “map- (less than 50% on the rating scale). The this procedure should be made between Advances in neurogenetics, molecular pable” onto the previous version, a func- investigators sought to determine char- the physician and the patient, he wrote. biology, neuroimmunology, and other tion simple for computers but highly acteristics associated with improved out- — Alice Goodman fields have prompted dramatic changes complex for those devising each new come, but Dr. Pollak said that is difficult in disease classifications. Categories of classification. (See http://who.int/clas- with such a small number of patients. Ms. Goodman is a freelance writer for The disorders once classified by clinical phe- sifications/icd/en.) ■ “Placement of the electrodes is very im- Lancet Neurology. 01_2_3_6_7_14_15wfn9_9.qxp 9/10/2009 2:18 PM Page 15

OCTOBER 2009 • WWW.WFNEUROLOGY.ORG WORLD NEUROLOGY • 15

Comment

Influenza A and B viruses are known to 5 days after the onset of the infection— caring for children should remain vigilant cause encephalitis or encephalopathy, but classified as encephalopathy. However, vi- for this complication of influenza virus in- they are rare complications. It is assumed rological evidence is rarely documented in fection. Influenza virus–associated CNS that influenza virus causes neurological the CSF. dysfunction may be more common than symptoms in two main ways: first, by direct The neurological manifestations vary previously recognized, but the prognosis is invasion of nervous tissue, usually pre- from mild cases of transient cortical dys- not always grave. senting with neurological manifestations function, such as excessive sleep, stupor, within 4 days of onset—classified as en- hallucination, inappropriate behavior, and —DR. YHU-CHERING HUANG, cephalitis—or second, by an immune re- seizure (with or without fever) to severe cas- division of pediatric infectious diseases at action affecting nervous tissue that usual- es of necrotizing encephalitis with neuro- Chang Gung Children’s Hospital and Chang YHU-CHERING ly presents with neurological manifestations logical sequelae or even death. Clinicians Gung Memorial Hospital, Kweishan, Taiwan. HUANG, M.D., PH.D. Antiviral Timing May Be Key H1N1 • from page 1

seizure and subsequent postictal mental state. While he was hospitalized, he had a 30- to 40-minute partial complex seizure. Brain magnetic resonance imaging was consistent with encephalopathy. A third child, a 7-year-old white male with a history of febrile seizures, presented to the emergency room following a seizure, 2 days of cough, nasal con- gestion, and fatigue. A brain MRI showed nonspecific white matter abnormalities, and localized cerebral dysfunction was evident on electroen- cephalography. The fourth patient, a black male aged 11 years with a history of asthma, had fever, fatigue, headache, abdominal pain, th and vomiting. Neurological examina- 7 WORLD tion of this patient revealed ataxia. He also had a seizure after hospital admis- STROKE CONGRESS sion and later experienced visual hallu- cinations. He had difficulty responding COEX Center, Seoul, Korea, October 13-16, 2010 to questions and required supplemental oxygen. An electroencephalograph was consistent with encephalopathy, but a Stroke CT scan was normal. Antiviral therapy included oseltamivir A Preventable and Treatable Disease in all four patients and rimantadine in all but the 11-year-old. All four children re- WSC 2010 provides leading medical covered fully, with no neurological sequelae at discharge. professionals with future strategies to This is the first report of patients with improve the care of stroke victims. MAIN TOPICS: neurological complications of the H1N1 Join the challenge to combat the influenza virus infections. The severity • Carotid Disease of the complications in these four pa- second most common cause of • Alternative Medicine • Primary Prevention tients was less than described in two pre- death worldwide. vious studies of neurological complica- • Subcortical Stroke tions associated with seasonal influenza, • Advances in Neuroimaging • Stroke Burden in Asia which have included reports of severe • Organizing Stroke Care Services static encephalopathy and death. • Vascular Cognitive Impairment The frequency of neurological com- • Acute Revascularization plications with pandemic flu is not • ABC Stroke Education Program known, but it is likely that additional cas- Abstract Deadline: April 12, 2010 • Public Awareness/Advocacy es in children will be reported as the pan- • Unrupture Aneurysm/AVM demic continues, especially because chil- www.stroke-congress.com • Critical Care dren appear to be infected with the • Long Term Complications of Stroke H1N1 virus more often than adults, the CDC noted. The center also added that antiviral treatment should be initiated as soon as possible for any patient who is hospi- Congress Organizers 1-3 Rue de Chantepoulet, PO Box 1726, CH-1211 Geneva 1, Switzerland talized with neurological symptoms Tel:+ 41 22 908 0488; Fax:+ 41 22 906 9140; E-mail: [email protected] Web: www.stroke-congress.com and suspected influenza infection of any type. ■ © Kenes International 2009. All rights reserved.

Jeff Evans contributed to this report. 09_12_16thru20wfn9_9.qxp 9/10/2009 3:04 PM Page 16

16 • WORLD NEUROLOGY WWW.WFNEUROLOGY.ORG • OCTOBER 2009 Is There a Universal Theme Underlying the Challenges to Medicine? A synopsis of the American Academy of Neurology long-term memory formation and thus greed, and power. Preeminently, our de- lasting behavior modification. Eric Kan- finition must include personal responsi- president’s address in Seattle, U.S.A., April 2009. del defined both the molecular basis of bility, because if we do not accept re- long-term memory formation by the sponsibility, we will surrender our he World Federation of Neurolo- commitment to competence, respect, synthesis of a new mRNA and protein, responsibility to others. gy’s mission is to advance research education, and collaboration and that we and its epigenetic impact on our genome Societal complexity requires more Tand the standard of neurological promote access to care (“Medical Pro- (“In Search of Mind,” New York: W.W. than one method of dialogue in health practice. The dawning of our informa- fessionalism in the New Millennium: A Norton & Co., 2006). Our understand- care policy debates. It is our responsibil- tion age and our escalating ease of trav- Physician Charter” [Ann. Intern. Med. ing of epigenesis, reflecting in part the ity to speak for the House of Medicine. el have reconfirmed with unambiguous 2002:136:243-6]). Yet this is not enough; consequences and the causes of our so- We must sit at the negotiating table, not clarity, that national boundaries are ir- the charter is about our behavior and not cial evolution, confirms our inescapable as agents of the government, politicians, relevant to science and dis- duty and responsibility to our larger ge- economists, or managers of the prob- ease and that sharing experi- BY STEPHEN M. SERGAY, M.B. B.CH. netic future, vastly different from eu- lems created by uninformed policy. We ence and knowledge can add genics. Because of this, it is necessary for will be most effective when, conversant value to all. Dr. Sergay is immediate past- us to inform planners of their responsi- with the details of our medical philoso- From the beginning of president American Academy bility to consider the deeper conse- phy, we become the voice of our ethos, time, the House of Medicine of Neurology and immediate quences of their actions. and educate our politicians and econo- in every region of the world past–North American Regional mists in advance of their decision mak- has existed in an unstable Director of the WFN. He is a Defining Our Ethos ing, of the potential impact of their equilibrium with the scientif- general neurologist practicing But our ethos has not been fully defined, planning on those who deliver medical ic, religious, social, political, in Tampa, Florida, U.S.A. and it needs to be. It is not an abstrac- services and those whom we serve, our and economic concerns of tion but rather a set of behavioral prin- patients. We must work to encourage the day. We do not differ from our pre- the most significant component of our ciples that determine how we respond to policies that strengthen and not those decessors in having to embrace these professionalism and the principal influ- the sick. It is our character, behavioral that weaken our ethos, because of our challenges, and in doing so, we merely ence on our motivation and behavior, characteristics, internal motivators, belief, that by so doing, the health care define one component of the work to our ethos. physician-patient relationship require- we plan for will have a greater chance of which we have dedicated our lives. This The philosophy of doctoring closely ments, the ethics of our professionalism, spawning better quality research, edu- commitment to the greater good, a con- resembles the Greek concept of eudai- and our guardianship of appropriate au- cation, and care delivery, all performed spicuous necessity for doctors in the monism, first discussed by Socrates. This tonomy for physicians and patients. Our most cost effectively. ■ past and at present, will undoubtedly has led to the development of content- ethos has not been, nor will it be, forev- continue to be required of every future ment theory and the concept of the op- er impenetrable, and therefore our def- Adapted from Neurology, Sergay S.M., generation. portunity for human flourishing. Hu- inition must incorporate integrity to “Doctoring 2009: Embracing the man flourishing is not a consequence of counter human weaknesses such as envy, Challenge. Neurology” (in press). Similarities Amid Challenges honor, wealth, or power; rather, it flows A life in medicine has always been mean- from rational activity in a complete or ingful and captivating, summoning from meaningful life, filled with virtues of its devotees the most noble of human character, such as honesty, integrity, per- AAN Presents Award for qualities, and it is neither self-serving nor sonal responsibility, intellect, and rational arrogant to believe that this has never judgment. Many consider this search for been more engrossing. Yet these chal- contentment inherent in humans as so- Neuroepidemiology lenges continue, and despite vast and cial animals after satisfying our basic sur- specific regional and national differences, vival drives. Contentment theory is now r. Edgard B. Ngoungou from Li- with the cooperation of the Institute many similarities exist. a component of economic and social Dbreville, Gabon, received the 2009 of Neuroepidemiology and Tropical For example, economic circumstances planning in many countries, and the va- Bruce S. Schoenberg International Neurology in Limoges, France. affect each of us differently. Local op- lidity of incorporating this thinking has Award in Neuroepidemiology from During the past 25 years, the portunities for physician research and been confirmed by economists, philoso- Dr. Joseph Zunt of the University of WFN’s Research Group on Neuro- training and the manner in which we are phers, psychologists, and more recently, Washington, Seattle, at the annual epidemiology has held a 1-day annu- able to administer to patients vary for biologists. meeting of the American Academy of al meeting concurrently with the many additional reasons, including the Neurology in Seattle, U.S.A. AAN meeting. Beginning in 1984, the disparities in the ratio of physicians to A Larger Humanistic Whole He presented the results of an epi- abstracts of the invited lectures, pa- population size. Medical care quality is jeopardized when demiologic study on the role of pers, and posters presented at the an- Is there a universal theme enmeshed contentment theory is not a component malaria infection in causing epilepsy nual meeting have been published in in these challenges? Is there a soft un- of health policy decisions, and the im- in Africa. The study was conducted the journal, Neuroepidemiology. derbelly of health care delivery, re- pact of its absence is borne predomi- search, and education? What is the nantly by our ethos. In defending our breaking point? And if there is, will ethos, we as biologists and neurologists defining and understanding it empow- in particular, are strengthened by emerg- er physicians and strengthen our entry ing concepts in neuroscience research, into health care debates around the which provide a window to our behav- world? ior and confirm that doctrinaire eco- I believe that all of these threats im- nomic and social planning, when not peril the behavioral attributes of the part of a larger humanistic whole, is doctor and are felt most on our charac- suboptimal. ter, which has been developed over cen- This necessity for concurrent eco- turies giving birth to the philosophy or nomic and social planning is suggested ethos of doctoring. Our ethos is the uni- by human capability on a preconceptu- versal, its application, of course, vary- al cellular level to recognize expecta- ing from country to country and from tions, intentions, and motivation (Riz- time to time. It is our responsibility zolatti, G., Sinigaglia, C., Anderson, F.,

alone to inform our policy makers of “Mirrors in the Brain,” New York: Ox- AAN this. ford University Press, 2008) and also, The physician’s charter is considered value, utility, and numerosity (Nature, OURTESY

by many to be the basis of medicine’s 1999;400:233-8). We also understand that C contract with society, and it requires our meaningful planning can lead to new 09_12_16thru20wfn9_9.qxp 9/10/2009 3:08 PM Page 17

Leading resources in clinical neurology!

Acute Pain The ofﬁ cial journal of the Alzheimer’s and Dementia World Federation of Neurology Autonomic Neuroscience: Basic and Clinical THE journal for the prompt publication of studies Brain & Development on the interface between clinical neurology and Clinical Neurology and the basic sciences. Neurosurgery And did you know.. Journal of the Neurological Clinical Neurology News Sciences is your ultimate resource for the latest developments and research on Vascular Clinical Neurophysiology Dementia, Stroke and Multiple Sclerosis! Epilepsy & Behavior Epilepsy Research www.elsevier.com/jns European Journal of Paediatric Neurology European Journal of Pain Experimental Neurology

Volume 10, Number 1 Volume 9 Issue 2 January 2008 ISSN 1389-9457 January 2006 Journal of Clinical Neuroscience Journal of Official Journal of the European Paediatric Neurology Society \UNNYVNMRLRWN

Editor-in-Chief: Associate Editors Neuroimmunology Sudhansu R.P. Allen Chokroverty C. Bassetti A. Culebras Field Editors R.A. Ferber R.P. Allen R. Grunstein C. Guilleminault C. Guilleminault P. Levy J. Hedner L. Ferini-Strambi W. Hening O. Bruni S. Katayama Journal of the Neurological P. Levy M. Mahowald J. Montplaisir M. Sanders M. Thorpy T. Young Sciences Journal of Pain

Ofﬁcial Journal of the World Association of Sleep Medicine and International Pediatric Sleep Association Journal of Pain and Symptom Management

Volume 15, Number 8, December 2006 ISSN 1059-1311 Lebkc['( DkcX[h( 7fh_b(&&. ?IID'&.-#&-/( The Lancet Neurology Neurobiology of Aging sleepmedicine Neuromuscular Disorders SEIZURE REVIEWS Neuroscience & Biobehavioral Reviews Neurotherapeutics

W REM 1 2 3 4 (NeuroRX)

W REM 1 2 ;Z_jehi#_d#9^_[\0 3 Pain 4 The Official Journal of Epilepsy Action @[WdAh_[][h C_Y^W[bL$L_j_[bbe Parkinsonism and Related Disorders Volume 108, issue 7, October 2006 ISSN 0303-8467 Vol. 131, Nos. 1–2 30 January 2007 ISSN 1566-0702 108(7) 621–720 Clinical Neurology Pediatric Neurology and Neurosurgery

Review Neuromuscular disorders in critical illness – L. Pandit, A. Agrawal (Mangalore, India) 621 Original articles Regional Anesthesia and Laterality does not influence early mortality in MCA ischemic stroke – I. Mateo, A. Pinedo, I. Escalza, J.C. Garcia-Monco (Vizcaya, Spain) 628 Vascular cognitive impairment in patients with late-onset seizures after an ischemic stroke – J. De Reuck, M. De Clerck, G. Van Maele (Ghent, Belgium) 632 Cardiovascular 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) 638 The 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) 644 Medically refractory epilepsy associated with temporal lobe ganglioglioma: Characteristics and postoperative outcome – A. Radhakrishnan, Pain Medicine M. Abraham, V.V. Radhakrishnan, S.P. Sarma, K. Radhakrishnan (Trivandrum, India) 648 Alleviation of intracranial air using carbon dioxide gas during intraventricular tumor resection – T. Beppu, K. Ogasawara, A. Ogawa (Morioka, Japan) 655 Clinico-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 reports Respiratory 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) 670 Bilateral C5 motor paralysis following anterior cervical surgery—a case report – K.S. David, R.D. Rao (Milwaukee, WI, USA) 675 Seizure: European Journal Correlation 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) 682 Subacute aseptic meningitis as neurological manifestation of primary SjÖgren’s syndrome – R. Rossi, M. Valeria Saddi (Nuoro, Italy) 688 Thin 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. S2awek (Gdan´sk, Poland), M. Derejko (Warszawa, Poland), P. Lass, M. Dubaniewicz (Gdan´sk, Poland) 699 of Epilepsy “Frontal variant Alzheimer’s disease”: A reappraisal – A.J. Larner (Liverpool, UK) 705 Transient 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) 709 Adie’s pupils in paraneoplastic ganglionopathy with ANNA-1 – J.V. Campellone, A. Hageboutros (Camden, NJ, USA) 712 Book reviews Head injury: Pathophysiology and Management – D. Van Dam (Wilrijk, Belgium) 715 (Contents continued on OBC) Sleep Medicine Sleep Medicine Reviews Surgical Neurology

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 09_12_16thru20wfn9_9.qxp 9/10/2009 3:09 PM Page 18

18 • WORLD NEUROLOGY WWW.WFNEUROLOGY.ORG • OCTOBER 2009

OBITUARY John Alexander Simpson (1922-2009)

BY PETER O. BEHAN, M.D. He was appointed the James Watson Lecturer of the journey to include a visit to Glasgow and the Simpsons. Royal Faculty of Physicians and Surgeons of Glasgow, a Iain was a good general physician, and wrote and Felix, qui potuit rerum cognoscere causas. Honeyman Gillespie Lecturer at Edinburgh, an Abbott studied not only on myasthenia gravis but the chorea Virgil, The Georgics, Book II Lecturer at Newcastle, and later a fellow of the Royal So- related to hypothyroidism, the dermatological alter- ciety at Edinburgh. Other appointments included that of ations and hypocalcaemia, and several findings related ohn A. Simpson, professor of neurology at the Uni- honorary consultant neurologist to the army, to the civ- to abnormal nerve conduction velocities. He was versity of Glasgow from 1964 to 1987, died in May il service commission, chairman of the Scottish Coun- among the first who noted the neurophysiological ab- Jat the Royal Infirmary in cil for the Neurological Services normalities of the Eaton Lambert Syndrome. Glasgow, Scotland, from a rela- and of the Scottish Epilepsy Asso- He was in demand to give many guest lectures, ac- tively acute illness. He was the es- ciation, and a member of the Re- cepted invitations to visit neurology departments teemed international authority search Committee of the Muscular throughout Australia, India, Europe, and Japan, and on myasthenia gravis and played Dystrophy Group of Great Britain. contributed to now classic textbooks of muscle and a major role in the modern de- At the time he became head of neurological disease. He also peer-reviewed several velopment of neurosciences in the Glasgow department, there journals and had more than 94 original papers on neu- Scotland, particularly in Glasgow. had been enormous changes in romuscular neurological diseases published. Iain, as he was known, came the structure of neuroscience in He clearly was of the “old school” and looked after his from a long Scottish lineage that Scotland—with the Institute of patients well. They became part of his family to the ex- includes the 18th century polit- Neurological Sciences being es- tent that he could recount their marriages and achieve- AMILY ical cartoonist James Gillray. F tablished at the Southern General ments. He was a kind, caring, decent fellow of whom it He is a good example of Hospital in Glasgow, where Dr. was an honor to be considered one of his friends. He de- IMPSON

serendipity and major advances S Bryan Jennett, professor of neuro- lighted in making a solid and sound diagnosis of ex- in science. In 1960, while he held surgery, and Dr. J. Hume Adams, tremely rare diseases, and he imparted this knowledge so a Medical Research Council trav- professor of neuropathology, were that his students were, like Byron’s hero, wax to receive OURTESY

eling fellowship at the National C among the main contributors. and marvel to retain. Patients with myasthenia gravis Hospital for Nervous Diseases at Dr. John Simpson, renowned clinician Iain had come to Glasgow from could expect to see him at any time of the day or night Queen’s Square, London, he ob- and researcher and valued colleague. the University of Edinburgh, where taking as he did a personal interest in their treatment. served the increased association he had been chief of neurology and No account of Iain would be complete without de- of myasthenia gravis with other diseases, thought at that had built up an active department with a sound reputa- scribing his addiction to and pleasure in sailing and Scot- time to be autoimmune in etiology. He published his hy- tion. He was ideally equipped to develop neurology in tish fiddle music. He once told me that for him, the pothesis in the Scottish Medical Journal, and that paper Glasgow, and his department there became a showpiece greatest pleasures was drinking hot soup followed by is regarded as the seminal paper that directed research in 1967 for the International Congress of Electromyog- a large quantity of malt whisky after a successful sail. into the immunological etiology of myasthenia gravis. raphy, a subject he excelled in and contributed to. This Iain left behind a department in excellent health, and It was logical, therefore, that Iain should pursue his in- was the beginning of many occasions when Iain and his his advice and warm friendship will be sadly missed. ■ terest in neurology and head up the University of Glas- wife, Elizabeth, would generously entertain visiting neu- gow’s department of neurology, where the main re- rologists and neuroscientists. Indeed, Iain’s kindness to ob- DR. BEHAN is professor emeritus of neurology at the search interest was muscle diseases. scure authors often had grateful individuals plan their University of Glasgow.

FROM THE JOURNAL OF THE NEUROLOGICAL SCIENCES Tracking Dementia Risk in Atomic Bomb Survivors

BY ALEX TSELIS, M.D., PH.D. the basic mechanisms of neurodegener- Yamada and her colleagues described a tion dosage, in the dose range to which ative diseases and generate epidemio- study in which they examined the risk of the subjects had been exposed. The au- he effects of radiation on the brain are logic hypotheses. dementia in survivors of the atomic thors noted that the findings might have Twell recognized from the experience Radiation necrosis can occur several bombings of Hiroshima and Nagasaki in been subject to certain biases but that its with radiation therapy to the brain in months or even years after radiation 1945. The researchers are based at the strengths included its prospective, popu- cancer patients. Not much is known therapy. Postradiation brain atrophy can Radiation Effects Research Foundation lation-based nature. The findings were in about these effects, but the basics are be accompanied by disabling cognitive Adult Health Study (RERF), a joint line with results in other populations. clear: Ionizing radiation breaks DNA deficits. The radiation doses Japan-United States research Dr. Yamada, a physician and epidemi- molecules, fragments RNA, generates in these patients are in the organization with laborato- ologist, has been in charge since 1983 of free radicals, denatures proteins, and range of hundreds to thou- ries in the two cities. the analysis of the RERF study to inves- thus damages or kills cells. sands of centigrays, often They estimated the radia- tigate the long-term effects of exposure Things become more complicated at given in a sequence of fraction doses the subjects were to radiation from the atomic bomb the multicellular level. Different cells have tions to minimize toxicity. exposed to depended on the blasts. The study is one of the largest and different susceptibilities to radiation dam- What happens at lower ra- distance from the explosion longest-running cohort studies in the age, they may be affected by or affect diation doses—can such syn- and shielding by the terrain. world. Another study based on these neighboring cells, they may acquire neo- dromes arise years later with The subjects were then di- data has shown no increase in the inci- plastic properties, and/or their loss or dys- a slowed tempo? Can other vided into three tertiles of dence and prevalence of Parkinson’s dis- function may or may not strongly affect relevant tissues be damaged radiation dose with about ease in this population. An attempt to ex- the organ (thus loss of neurons is more with very late effects? DR. MICHIKO YAMADA 500-800 subjects in each amine a similar hypothesis for significant than that of hepatocytes). An important example group, serially evaluated for amyotrophic lateral sclerosis was unsuc- Clinically, radiation damage to the would be radiation vasculopathy. Most cognitive problems, then assigned a di- cessful because of the small number of brain comprises several well-described often, this is extracranial large-vessel dis- agnosis of dementia classified as vascular subjects with the disease. ■ syndromes in patients who are treated ease, a form of accelerated atherosclero- or Alzheimer’s type. The radiation doses with radiation therapy. Acute, early-de- sis usually involving a carotid artery and were in the range of milligrays, roughly DR. TSELIS is an associate professor of layed, and late-delayed encephalopathies resulting in cerebrovascular disease. Does a tenth of the doses used for radiation neurology at Wayne State University in are all well-defined, if not completely un- radiation predispose to the development therapy (J. Neurol. Sci. 2009;281:11-4). Detroit, U.S.A. He is the book review editor derstood. The late effects are of particu- of dementia—vascular or Alzheimer’s? The findings showed no increase in the for the Journal of the Neurological lar interest because they can tell us about In an interesting paper, Dr. Michiko risk of either dementia type with radia- Sciences. 09_12_16thru20wfn9_9.qxp 9/10/2009 3:12 PM Page 19

OCTOBER 2009 • WWW.WFNEUROLOGY.ORG WORLD NEUROLOGY • 19

MOVIE REVIEWS Lyme Documentary Misleading, Perhaps Irresponsible “Under Our Skin,” directed by Andy Finally, the authors who wrote the In- illness and a conspiracy to conceal it. How can we resolve this dilemma? Abrahams Wilson fectious Disease Society of America Of importance to the neurology com- Guidelines adopted by the 8, 000-member (IDSA) Lyme disease treatment guide- munity, is that these physicians—none of IDSA and the 21,000-member American hy, you may ask, is there a movie lines are repeatedly accused of being whom has any neurological expertise— Academy of Neurology have only served review in WORLD NEUROLOGY? tainted by conflicts of interest. This po- have focused on what they perceive (in- to bolster the sense of solidarity in perse- WA reasonable question. sition is bolstered by focusing on the correctly, in most instances) to be neu- cution of the “Lyme-literate community.” “Under Our Skin” is a documentary- Connecticut attorney general’s lawsuit rological manifestations of their patients’ The IDSA agreed to have its guidelines re- style film about chronic Lyme disease and that alleged that the IDSA violated an- symptoms. This is terrifying for the pa- reviewed to determine if it will need up- the debate surrounding it. With lovely cin- titrust law in promulgating its guide- tients, who often become convinced that dating. Since the “Lyme-literate physi- ematography and sobering music, it de- lines. Not mentioned is the fact that that they have a progressive nervous sys- cians” all derive substantial income from picts a number of clearly suffering patients the lawsuit was settled with no finding tem–destroying illness, which can only be treating patients with “chronic Lyme dis- and the “Lyme-literate physi- cured with these physicians’ ease” the overseeing ethicist felt this con- cians” who have treated them. BY JOHN J. HALPERIN, M.D. unique ministrations. stituted an undue conflict of interest and The treating physicians are These physicians and their excluded them from the new review pan- seen talking to their patients Dr. Halperin is the medical director of supporters argue that the el. Needless to say, they are already protest- with great empathy as they ex- the Atlantic Neuroscience Institute and IDSA guidelines ignored a ing that the review will be unfair. plain the rationale for their ap- chair of the department of neurosciences “vast worldwide literature” in Does this case have implications be- proach. We even see a patholo- at the Overlook Hospital, both in support of “chronic Lyme dis- yond Lyme disease? For those physicians gist who, mad scientist–like, Summit, New Jersey, U.S.A., and ease.” Curiously though, who participate in guideline develop- applies molecular biologic tech- professor of neurology at Mount Sinai when they published their ment, volunteering innumerable hours niques in a laboratory in his School of Medicine in New York. own “evidence-based guide- reviewing articles, weighing evidence, home basement, studying a lines,” they included no refer- debating conclusions while trying to do well-worn 1940s volume on syphilology. of either an antitrust violation or of any ences to anything except Class IV anec- this in as fair and rational a way as pos- He reasons that “just as general paresis of meaningful conflicts of interest. dotal evidence substantiating the sible, this movie is like being the guest of the insane is indistinguishable from The movie continues with scenes of existence of this entity, or validating pro- honor at a Salem witch trial. The intru- Alzheimer’s disease,” Lyme disease can multiple legal proceedings in which the longed antibiotic treatment. In a contrast sion of this irrational debate into poli- be responsible for multiple sclerosis (MS), medical establishment and the IDSA that epitomizes the tension between ev- tics—with legislatures and state attor- amyotrophic lateral sclerosis (ALS), authors are portrayed as persecuting idence-based medicine and anecdotal ob- neys general inserting themselves into Parkinson’s, and Alzheimer’s disease. the “ Lyme-literate physicians”—appar- servation, a physician leader of this the substance of medical decision mak- Of course, there are excerpted au- ently either because all medical experts group has defined evidence-based med- ing—could have a profoundly chilling ef- thoritative quotations and interviews— want to help the health insurance in- icine as “a treatment approach that al- fect on future guideline development. carefully edited—to support the film- dustry save money or because these lows physicians to take into account their Equally important, at a time when makers’ premise. (Though the plot also supposedly conflicted physicians stand own values, clinical expertise, and patient American health care is rightly criticized requires villains, and unfortunately, I to make windfall profits from patents values in addition to published research for spending too much on tests and treat- make a cameo appearance in what re- they hold related to this disease [sic]. from level 1 studies.” ment with limited, if any, impact on sembles an array of wanted posters.) It would be easy to dismiss this film as At a time when many physicians feel health outcomes, it is remarkable that Several experts were interviewed to artfully crafted propaganda; however their traditional autonomy is rapidly van- this “controversy” has resulted in legisla- provide “balance.” For example, an in- that would ignore its important lessons. ishing, is it surprising that some view it tures legitimizing treatment that is both ternationally respected infectious disease As Dr. Bernard Raxlen (the antibiotic- as their right to treat however they see costly and demonstrably of no meaning- expert states that few of the patients re- wielding psychiatrist) says in the film, fit, particularly when reinforced daily by ful benefit. As the United States debates ferred to him for chronic Lyme disease “Something funny is going on here.” devoted patients who are willing to pay changes in health care, is this helpful? have anything to suggest they ever had So what is it exactly? out of pocket for their treatment? This This movie makes good theater but it the infection; his 30-second excerpt is jux- As the film makes obvious, there is a sig- mutually reinforcing alliance of physi- is far removed from reality. Sadly, it serves taposed with a Simpson’s clip. Other ex- nificant population of patients who are cians and patients has been tremen- to perpetuate unfortunate medical care pert comments are rebutted—in one in- not satisfied with the diagnoses and treat- dously politically skillful. Their support- that subjects patients to unnecessary and stance, by a psychiatrist who has given up ment provided by conventional medicine. ers include numerous politicians who significant risk, and reflects a process that the practice of psychiatry to treat “chron- As they have sought a sympathetic ear, have even enacted legislation legitimiz- is clearly detrimental to the ideal of pro- ic Lyme patients” with antibiotics, and in they have helped sustain a group of physi- ing their unorthodox treatment and who viding patients with effective, safe, and ap- another by the office manager of a cians who are apparently convinced they instituted the unprecedented antitrust propriate care. And that is why there is a “Lyme-literate physician.” have unearthed both an unprecedented suit against the IDSA. movie review in WORLD NEUROLOGY. ■ Artful and Entertaining—Despite the Tic-less Tourette

“Phoebe in Wonderland,” written and directed by outs, rehearsals, and performance. The idiosyncratic The plot’s juxtaposition of Phoebe’s tensions in bal- Daniel Barnz, featuring Elle Fanning, Patricia school drama teacher (Clarkson) recognizes Phoebe’s ancing external school rules and her internal obsessive Clarkson, and Felicity Huffman ability to connect with the character of Alice. Unfor- compulsive disorder rules and of Alice’s frustration at tunately, Phoebe’s traits become magnified as tryouts Wonderland rules works well as a scaffold for the explo- rtistic license, commercial exaggeration, or simple ig- and then rehearsals progress, resulting in severe anxi- ration of Phoebe’s character and the effects of her symp- Anorance in movie scriptwriting ety and compulsions. toms on her family and classmates. Her situational social often generate an inaccurate view Ultimately, a psychiatrist disinhibition, such as when she spits at a peer or shouts of medical conditions. However, BY DONALD L. GILBERT, M.D. diagnoses her with “Gilles “Fat, you’re fat; you’re fat,” at a stout neighbor, depicts sometimes art succeeds where de la Tourette syndrome,” the impulsiveness and social impairments we see in documentaries fail in giving us Dr. Gilbert is the director of an epiphany for the fami- some children and adults with Tourette. The anguish of empathy for disease sufferers. the Movement Disorders ly but a surprise to me, her mother (Huffman) and the stressed parental dialogue The movie “Phoebe in Won- and Tourette Clinics at the since I observed lots of ob- around Phoebe’s symptoms worked particularly well. derland,” while inaccurate diag- Cincinnati Children’s sessive compulsive behav- So, while the film risks misinforming viewers that nostically, succeeds in this way. Hospital Medical Center in iors and not tics in the compulsions equal tics, I recommend suspending your The plot centers around a sensi- Ohio, U.S.A. film. Still, the film does DSM-IV and enjoying the writing, acting, and cine- tive girl, Phoebe (Fanning), who capture some essence of matography in “Phoebe in Wonderland.” In the wishes to land the leading role in the school play, “Al- the irrepressible imps in Tourette, a view confirmed to process, you gain some insight into the imps in Tourette ice in Wonderland,” and her ensuing struggles with try- me by several parents of children with the syndrome. syndrome. ■ 09_12_16thru20wfn9_9.qxp 9/10/2009 3:13 PM Page 20

Books and journals with a global perspective

'%%. Hardback/1488 pages ISBN: 9780123694089 $225.00

BUY ONLINE TODAY AT: elsevierdirect.com/ 9780123694089

'%%, Hardback/680 pages ISBN: 9780123693662 $140.00

BUY ONLINE TODAY AT: elsevierdirect.com/ 9780123693662

“excellent, well-referenced book” “A timely and useful reference” 6jc^fjZ\adWVaeZgheZXi^kZdcgVW^Zhl]ZgZYd\gVW^Zh^hgZhedch^WaZ :meZgianXdkZghi]ZV\Zcihi]ViVgZgZhedch^WaZ[dgZbZg\^c\ [dg`âa^c\bdgZeZdeaZi]VcnZaadl[ZkZg!YZc\jZ[ZkZg!dg?VeVcZhZZcXZe]Vaî^h VcYcZ\aZXiZYY^hZVhZhVcYi]dhZi]ViXVcWZjhZYVhW^di]gZVih DkZg,bâa^dceZdeaZVgZediZci^VaanZmedhZYidi]Zk^gjhVccjVaanVcYVWdji :meaV^chi]ZkVXX^cZYZkZadebZcieVi]lVn!kVXX^cZ *%!%%%eZdeaZ!]Va[d[i]ZbX]âYgZc!Y^Zd[gVW^ZhZVX]nZVg bVcj[VXijg^c\VcYgZ\jaVidgn^hhjZhi]ViVgZXgî^XVa 8dkZghWVigVW^Zhl]^X]^hcdli]Zbdhiegdb^cZcihdjgXZd[]jbVcgVW^Zh 8]VeiZghXdciV^cbVehd[i]ZldgaYh]dl^c\l]ZgZi]Vi ^ci]ZCZlLdgaYVcYLZhiZgc:jgdeZ eVgi^XjaVgY^hZVhZ^hcVijgVaan[djcY )%jeYViZYbViZg^VaâajhigViZhcZlVeegdVX]Zhidi]Zi]ZgVend[]jbVc gVW^ZhVcY^hhjZh^ckdak^c\dg\VcVcYi^hhjZigVcheaVciVi^dc

The Journal of the Neurological Sciences provides a medium for the prompt publication of studies on the interface between clinical neurology and the basic sciences. Emphasis is placed on sound scientiﬁc developments which are or will soon become relevant to the clinician.

lll#ZahZk^Zg#Xdb$_ch

The Journal of Neuroimmunology affords a forum for the publication of works applying immunologic methodology to the furtherance of the neurological sciences. The scope of the Journal is broad, covering both research and clinical problems of neuroscientiﬁc interest.

lll#ZahZk^Zg#Xdb$_c^