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Fulltext General neurology: Current challenges and future implications

Bassetti CLA, Accorroni A, Arnesen A, Basri HB, Berger T, Berlit P, et al.

Eur J Neurol, 2024 Jun;31(6):e16237.
PMID: 38545838 DOI: 10.1111/ene.16237

BACKGROUND AND PURPOSE: In the coming decades, the world will face an increasing burden of neurological disorders (ND) and an urgent need to promote brain health. These challenges contrast with an insufficient neurological workforce in most countries, as well as decreasing numbers of general neurologists and neurologists attracted to work in general neurology (GN). This white paper aims to review the current situation of GN and reflect on its future.
METHODS: The European Academy of Neurology (EAN) task force (TF) met nine times between November 2021 and June 2023. During the 2023 EAN annual meeting, attendees were asked to answer five questions concerning the future of GN. The document was sent for suggestions and eventually approval to the board and the presidents of the 47 national societies of the EAN.
RESULTS: The TF first identified four relevant current and future challenges related to GN: (i) definition, (ii) practice, (iii) education, and (iv) research. The TF then identified seven initiatives to further develop GN at both the academic and community level. Finally, the TF formulated 16 recommendations to promote GN in the future.
CONCLUSIONS: GN will remain essential in the coming decades to provide rapid, accessible, and comprehensive management of patients with ND that is affordable and cost-effective. There is also a need for research, education, and other initiatives aiming to facilitate improved working conditions, recognition, and prestige for those pursuing a career in GN.

Matched MeSH terms: Nervous System Diseases/therapy
Second regional plasmapheresis conference and workshop for Southeast Asia (SEA) on the immunomodulatory role of plasma exchange in central and peripheral nervous system disorders, Kuala Lumpur, Malaysia, 9th December 2017

Viswanathan S, Hung SKY, Goyal V, Apiwattanakul M, Thirugnanam UN, Abdullah S, et al.

J Clin Apher, 2018 Oct;33(5):559-568.
PMID: 29626354 DOI: 10.1002/jca.21630

In December 2017, 79 delegates attended the 2nd regional plasmapheresis conference and workshop for Southeast Asia (SEA) on the immunomodulatory role of plasma exchange in central and peripheral nervous system disorders in Kuala Lumpur, Malaysia. This meeting featured 6 plenary lectures, interactive sessions dedicated for experience sharing, case presentations, and a practical session for paramedics. Clinical experts and researchers from 7 SEA countries and India shared experience and challenges in treating autoimmune neurological disorders. While the spectrum of diseases and neurology practice remained largely similar, there was great disparities in accessibility of therapeutic plasma exchange (TPE) within SEA countries and between urban or rural settings. Costs, human resources, and healthcare policies are common challenges in providing sustainable TPE services. Novel techniques and innovative ideas in performing TPE were explored. A working consortium comprising of key opinion leaders was proposed to improve standards of TPE and enhance future research.

Matched MeSH terms: Central Nervous System Diseases/therapy; Peripheral Nervous System Diseases/therapy
Plasmapheresis in the University of Malaya Medical Centre, Malaysia

Chong HT, Tan CT

Ther Apher, 2001 Apr;5(2):147-9.
PMID: 11354300

Over the past 3 decades, plasmapheresis has been used more extensively for a variety of neurological and hematological disorders. We undertook a retrospective review to ascertain its safety, efficacy, and factor(s) that predispose to poor outcome. We reviewed 117 plasma exchanges in 24 patients with a mean age of 43 +/- 15 years; half were male. A total of 79% of the patients had neurological diseases, and the most common were chronic inflammatory demyelinating polyneuropathy, Guillain-Barré syndrome, and myasthenic crisis. Plasmapheresis was effective in 79% of the patients, especially for neurological indications. Complications occurred in 23% of the exchanges affecting 58% of the patients. Most complications were mild; sepsis was the most common (9.4% of exchanges), especially catheter related sepsis (6%), rash (4.3%), and hypotension (4.3%). Only 2 (8%) patients had severe complications that required mechanical ventilation. There were 5 mortalities (21%), 3 due to sepsis and 2 due to myocardial ischemia and arrhythmia, none of which occurred within 48 h of the last exchange. Patients with poor renal function had higher mortality. Overall, our figures agree with those from other institutions and indicate that plasma exchange is an effective and safe procedure, especially for a variety of neuroimmunological conditions.

Matched MeSH terms: Nervous System Diseases/therapy
Proceedings of the Inaugural Strategy Meeting for the Establishment of a Southeast Asia Regional Therapeutic Plasma Exchange Consortium for Neurological Disorders

Viswanathan S, Appiwatanakul M, Nayak A, Islam B, Khatri B, Pangeran D, et al.

Ther Apher Dial, 2019 Jun;23(3):289-297.
PMID: 30927331 DOI: 10.1111/1744-9987.12806

In conjunction with the third regional Southeast Asian (SEA) therapeutic plasma exchange (TPE) conference in Kuala Lumpur, Malaysia, 25 clinicians and researchers from SEA and South Asian countries attended the inaugural strategy meeting for the establishment of a regional TPE consortium for neurological disorders. The primary objective was to establish regional collaboration to improve delivery of TPE services in SEA. A pre-meeting survey was conducted to gather insights on disease spectrum, contextual practice challenges, and the need for a regional TPE consensus. Challenges identified include limited healthcare funding in support of diagnostic workup, TPE therapy, as well as development of clinical infrastructure and expertise capacity building. There was favorable interest in developing a working plan contextualized to this region. Strategies to overcome challenges were discussed. This included the need for a comprehensive referral system and network of regional TPE centers suited to local needs, supported by innovative TPE delivery programs.

Matched MeSH terms: Nervous System Diseases/therapy*
Fulltext A call for a global COVID-19 Neuro Research Coalition

Winkler AS, Knauss S, Schmutzhard E, Leonardi M, Padovani A, Abd-Allah F, et al.

Lancet Neurol, 2020 06;19(6):482-484.
PMID: 32470416 DOI: 10.1016/S1474-4422(20)30150-2
Matched MeSH terms: Nervous System Diseases/therapy
National response to neurological diseases in Malaysia: planning for the future

Abdullah JM, Hussin AM, Tharakan J, Abdullah MR, Saad R, Kamari Z, et al.

Southeast Asian J Trop Med Public Health, 2006 Jul;37(4):798-805.
PMID: 17121309

The number of cases of neurological disease is expected to rise in the next 10 years, making this the second leading cause of morbidity and mortality after heart disease in Malaysia. The lack of human resources in the neurological field currently serving the Malaysian population may cause a deficiency in specialized care, especially in rural areas where neurological and neurosurgical care may be lacking. Thus, a resolve was made to increase the numbers of specialists by the Universiti Sains Malaysia (USM) with the help of the Ministry of Health of Malaysia. A study was made to evaluate the number of referral centers needed in strategic parts of Malaysia. Our calculation was based on service demands and operative procedures following the guidelines of the Association of British Neurologists (ABN) where 15 minutes of service time was equivalent to 1 unit. Based on 2 million population covered in the state of Kelantan by this University Hospital, 4.27 neurologists are needed to meet service demands with a consultant to population ratio (CPR) of 1:468,384, compared to 7.46 neurosurgeons, with a CPR of 1:268,097. According to the current service demands, one neurologist has to work more than 407 hours per year and one neurosurgeon 1,219 hours per year in our hospital. Hospitals with a larger catchment area would need to have more neurologists and neurosurgeons for optimal care in their area. Thus, more neurologists and neurosurgeons are needed to be produced, since the existing numbers are too small for quality care in Malaysia.

Matched MeSH terms: Nervous System Diseases/therapy*
Harnessing neuroplasticity: modern approaches and clinical future

Sasmita AO, Kuruvilla J, Ling APK

Int J Neurosci, 2018 Nov;128(11):1061-1077.
PMID: 29667473 DOI: 10.1080/00207454.2018.1466781

Background and purpose: Neurological diseases and injuries to the nervous system may cause inadvertent damage to neuronal and synaptic structures. Such phenomenon would lead to the development of neurological and neurodegenerative disorders which might affect memory, cognition and motoric functions. The body has various negative feedback systems which can induce beneficial neuroplastic changes in mediating some neuronal damage; however, such efforts are often not enough to ameliorate the derogatory changes. Materials and methods: Articles discussing studies to induce beneficial neuroplastic changes were retrieved from the databases, National Center for Biotechnology Information (NCBI) and MEDLINE, and reviewed. Results: This review highlights the significance of neuroplasticity in restoring neuronal functions and current advances in research to employ this positive cellular event by inducing synaptogenesis, neurogenesis, clearance of toxic amyloid beta (Aβ) and tau protein aggregates, or by providing neuroprotection. Compounds ranging from natural products (e.g. bilobalides, curcumin) to novel vaccines (e.g. AADvac1, RG7345) have been reported to induce long-lasting neuroplasticity in vitro and in vitro. Activity-dependent neuroplasticity is also inducible by regimens of exercises and therapies with instances in human studies proving major successes. Lastly, mechanical stimulation of brain regions through therapeutic hypothermia or deep brain stimulation has given insight on the larger scale of neuroplasticity within the nervous system. Conclusion: Harnessing neuroplasticity may not only offer an arm in the vast arsenal of approaches being taken to tackle neurological disorders, such as neurodegenerative diseases, but from ample evidence, it also has major implications in neuropsychological disorders.

Matched MeSH terms: Nervous System Diseases/therapy*
The establishment of in-house neurology driven therapeutic plasma exchange infrastructure in a resource-limited public hospital in Malaysia: Adopting and integrating evidenced-based health care technology through time

Viswanathan S, Hiew FL

J Clin Apher, 2019 Aug;34(4):434-444.
PMID: 30829434 DOI: 10.1002/jca.21696

There has been an increase in the use of therapeutic plasma exchange (TPE) in immune-mediated neurological disorders in recent years. However, accessibility and availability of TPE remains low and costly, especially for a country with limited healthcare funding like Malaysia. With expanding clinical indications in neurological disorders, and increasingly expensive conventional immunomodulatory treatment such as intravenous immunoglobulin and monoclonal antibodies, TPE remains an effective part of first or second-line treatment. In this article, we detailed the historical aspects of the use of TPE in neurological disorders in Malaysia over the last four decades and discussed the challenges behind the establishment of the first in-house neurology-driven TPE service in the country. Local TPE database from a national neurology centre in Kuala Lumpur over the past 20 years was analyzed. We observed a remarkable three folds increase in the use of TPE at our center over the past 10 years (total 131 TPE treatments) compared to a decade prior, with expanding clinical indications predominantly for central nervous system demyelinating disorders. Besides using membrane filtration method, centrifugal technique was adopted, providing new opportunities for other clinical beneficiaries such as a neurologist driven "in-house TPE unit". However, there were real world challenges, especially having to provide services with limited funding, human resources, and space. In addition, much has to be done to improve accessibility, availability, and sustainability of TPE services at our center and nationwide. Nevertheless, even with limited resources and support, it is possible with concerted efforts to work within the confines of these limitations to establish a safe, successful, and sustainable TPE service.

Matched MeSH terms: Central Nervous System Diseases/therapy