All the world’s a stage, and the stage for 2016 ABN meeting was a sparkling spring morning in Brighton. Reflecting the shared meeting with the British Paediatric Neurology Association, the theme was the seven ages of man. Continuing the spirit of the meeting, this report will review some chosen highlights in seven stages, covering both clinical and research sessions.
At first the infant, as Shakespeare wrote, although the opening session actually preceded even this stage, with a review of issues surrounding pre-conceptual counseling, an emerging area of importance for neurologists as genetic advances continue apace; Mary Porteous took us through this complex topic, describing the IVF techniques available and also the quite stringent criteria that patients must fulfill. A discussion of anticonvulsant management in pregnancy followed with John Paul Leach arguing that sometimes less is more, when considering monitoring drug levels and dose adjustments, in inimitable Glaswegian style.
“From birth to the teens: the mewling, puking and whining years” must have been one of the more unusual lecture remits that Richard Bowman, consultant paediatric ophthalmologist, has been given in his career but, together with Simon Hickman, Diego Kaski and Gordon Plant, it did not appear to faze him, as we were taken on a rapid tour of eye movement disorders, culminating in a smorgasbord of challenging spot diagnoses: look once, look twice and then look again was my slightly shameful take-home message from this important session on a difficult subject.
One of the more difficult ages of man is adolescence, as any parent of a teenager can attest, and more difficult again for adolescents with neurological disorders; this was acknowledged in the session on transition clinics, which offered practical tips on optimising history taking, for example, by using the examination as an opportunity for private discussion with both teenagers and parents. Advice was given on setting up services based on what young people actually want: opportunities to talk to other young people in similar situations are valued and boredom is anathema, according to Ros Quinlivan’s studies. The neurology of young adulthood session included a masterclass on avoiding misdiagnosis of cerebral palsy from Neil Wimalasundera; essentially, determine phenotype, determine aetiology, perform imaging and be alert if the ducks don’t line up, because there are treatable mimics.
Another thorny issue in practice at any age is CNS vasculitis, covered in a research presentation in the diagnostics session: unhelpfully, it appears that angiography results and brain biopsy contradict each other more often even than should occur by chance, rather like an angry toddler. In the absence of a clear gold standard test, as ever in neurology, the clinical picture must remain king.
Service organisation was addressed in a report from the Queen Square neuromuscular group in which a new clinic to streamline intravenous immunoglobulin delivery was shown to save thousands of pounds. I thought I might use this session to prove to our managers why attending the ABN represents good value for money. More food for thought in the cases session, a Sacksian collection of phantom limbs in Guillain-Barre, both PML and a germinoma mimicking neurosarcoidosis, tau imaging in frontotemporal dementia, hepatitis E related brachial neuritis and, finally, a voltage-gated potassium channel antibody-mediated spinal neuronitis resulting in head drop, spinal myoclonus and camptocormia. Of course, I may be a little biased but clinical neurology is surely the most fascinating of all medical specialties.
Professor Alistair Compston must think so, having devoted his life so successfully towards its forward progress. His ABN medallist lecture “A tale of three cities” took us on a journey through his extraordinary career, covering his achievements in advancing the field of MS genetics, the development of alemtuzumab therapy and more. The focus throughout his presentation was of the friends he made along the way and his self deprecating insistence that he had really only performed two rather lengthy experiments each lasting about 20 years. This however did not appear to convince the audience, judging by the prolonged and warm standing ovation he received. From other giants in their field, Ingrid Scheffer’s Gordon Holmes lecture described the cumulative results of 20 years of productive research in epilepsy genetics and explained how results are now starting to lead to the elusive goal of personalised medicine. The Practical Neurology lecture, given by David Pencheon, warned of ecological Armageddon, had members of the audience checking their carbon footprints in real time, and made me walk to the station, instead of taking a taxi, at the end of the conference.
And so into old age, a second childishness followed by mere oblivion, as Shakespeare rather depressingly put it. Aspects of the neurobiology of ageing were considered. Jonathan Schott described Macdonald Critchley’s astute clinical observations in the elderly from the last century and still used today, for example, the importance of not over-interpreting absent ankle jerks and loss of distal vibration sensation in this group. He showed how many of the original observations have subsequently been revalidated by modern studies. Carol Brayne reported interesting and surprisingly positive news for ageing males worrying about dementia (your correspondent was particularly attentive here), and Paul Ince described the results of brain bank studies, from which interesting discrepancies between the presence of Alzheimer pathology and the clinical picture have emerged. As the conference entered its 7th age, the final session contrasted differing approaches to the same presenting symptom from opposite ends of the age spectrum. First, Hugh Markus took us through management of young stroke in the context of carotid arterial dissection post-CADISS (antiplatelets as good as anticoagulants and a reassuringly low recurrence risk). Examples of diagnosis of muscle weakness from Mark Roberts and James Miller followed, due to Anoctamin-5 limb girdle and myotonic dystrophy. Finally, the tricky disentanglement of ataxia, especially in children, was tackled by Peter Baxter and Mark Wardle and included pertinent comments on the diagnostic problems posed by normal levels of clumsiness in 4 year-olds.
So, a varied and fascinating conference, with the usual mix of useful and practical pointers from national and international experts, special interest groups, up-to-date research developments and a chance to catch up with neurologist friends from posts and PhD years gone by. A chance too, perhaps, to reflect on the passing of time, its influences on our patients and the diseases that afflict them, and on ourselves. And, as we shift into the lean and slippered pantaloon and bid farewell to Brighton, we look forward to the next age of the ABN in Liverpool.