Take home messages:
- Genetic panels (simultaneously-run, hundreds of genes) are nearly here; result interpretation remains unclear
- Stem cells are useful models of neurological disease; a role in clinical therapeutics is less clear
Those attending this year’s ABN in Glasgow were treated to a warm and Scottish welcome. 615 delegates, including a significant number of medical students, junior doctors and non-physicians enjoyed a packed four-day schedule of Neurology. The conference contained a full programme of lectures, teaching/science sessions and specialist symposia, supplemented with lunchtime debates, Neuro-Ophthalmology “Breakfast with the Experts” and early morning fora. The social events in the evening introduced us to many elements of Scottish fare: bagpipes, Haggis, Clootie pudding and whisky.
Outreach and specialist registrar (SpR) training components started the conference, with parallel sessions for medical students, GPs (‘Need to Know’ Neurology) and SpR trainees. SpR trainees were treated to a pair of interactive sessions on difficult consultations and managing peripheral nerve disease, followed by a brave variety of talks including the NMJ for neurologists (Arup Malik), Balancing Your Career with Family Life (Tracey Baird) and The Drug Discovery Pipeline. The quiz, organised by Jonathan Schott was entertaining and illuminating, not least for demonstrating the breadth of understanding of Cockney Rhyming Slang and ‘txt-speak’ in the neurological audience. Martin Rosser’s public lecture, ‘Supercomputer – the brain and what happens’ when it crashes was an excellent demonstration of public engagement, conveying complex concepts with clarity and humour, including to those of us with more idea about what a brain might do rather than a supercomputer.
A range of excellent lectures and teaching/science sessions included Headache, Functional Disorders, Stem Cells in Neurology, Dementia and Specialist Updates. The 19th Gordon Holmes lecture was given by Mark Hallett on the pathophysiology of psychogenic movement disorders. Followed by further discussion of functional disorders by Mark Edwards, Jon Stone and Alan Carson, this session explored methods of making a positive diagnosis, the value of a video camera to fully capture the effect of distraction in functional movement disorders, and effective management of affected patients.
A dedicated session on ‘Stem Cells in Neurology’ reflects the growth in popularity of stem cells as models of many neurological diseases and as potential therapeutic agents. Siddharthan Chandran emphasised the potential for stem cells as models for identifying ‘druggable targets’. We heard from Roger Barker on the history of stem cell transplantation in Parkinson’s disease, the huge variability in outcomes in early studies, and current attempts to identify what factors determine a successful transplant in the ‘Trans-euro’ study. Finally, Keith Muir gave an update on the use of stem cells in stroke, just days ahead of his presentation at the European Stroke Conference with promising early results in five stroke patients treated with stem cells in a phase I trial. Concerns were voiced on the availability of clinical stem cell therapies advertised to patients who are willing to pay, despite the lack of evidence for benefit and potential for harm.
In the Dementia session, we were re-introduced to the cognitive history and examination by Chris Butler, and provided with some excellent video examples of patients with amnestic and non-amnestic cognitive complaints by Nick Fox. Huw Morris brought us up to speed on current genetic approaches to diagnosis, and emerging faster and less expensive methods of genomic analysis. As more genetic polymorphisms are identified as risk factors for cognitive and other neurological disorders and analysis becomes available on a direct-to-patient basis, a growing role for genetics is likely; however, difficult questions about data interpretation remain unresolved.
Parallel symposia covered a variety of neurological topics: stroke; audit/training; Parkinson’s disease; general neurology; multiple sclerosis; epilepsy and neuro-immunology. Of the numerous excellent presentations, one very practical presentation by Ellen Campbell and colleagues in Belfast provided data on the risk of major congenital malformations with different anti-epileptic medications over a fifteen-year period and 5510 cases. Similar levels of major congenital malformations were noted in 304 cases of levetiracetam monotherapy compared with carbamazepine and lamotrigine (n=1718 and 2198 respectively). Carbamazepine and valproate (n=1290) both demonstrated a dose-dependent effect of risk of major malformations, but valproate, even at low doses (<600mg daily) was associated with greater risk of major congenital malformation than high dose lamotrigine (>400mg daily).
A fascinating adjunct to our study of human neurology was the talk by Jacques Penderis on veterinary neurology. This was a fascinating insight into some of the specific challenges of diagnosis in a multitude of species in the absence of our most-valued resource, the history. We were introduced to an intoxicating mix of video-genic cases, including infectious agents, complications of inbreeding (Chiari-like malformation as a complication of extreme bradycephaly) and founder effect (Episodic Falling in the Cavalier King Charles Spaniel, a microdeletion on canine chromosome 7). In addition, spontaneous diseases found in both animals and humans were presented, such as the neurometabolic disorder L-2-hydroxyglutaric aciduria, with a similar phenotype of learning disability, seizures and ataxia and with a shared genetic basis (L2HGDH).
Two lectures provided historical context to current modes of healthcare and physician training. David Chadwick considered the evolving process of providing healthcare to our patients in the ABN Medallist Lecture, and Geraint Fuller shared his journey into neurology. As a trainee, I was struck by two heartening features about a career in neurology: first, the inspiring effects of neurological friendships; second, the enduring rewards of seeking answers to neurological puzzles.
On the final day, a series of great case presentations competed for the ACNR-sponsored prize. This was awarded to Owen Pickrell for a case of West African sleeping sickness with an interesting context of 29-years latency and very elevated titres of VGKC and NMDA antibodies. Along similar lines of testing diagnostic prowess, John Paul Leach was in the CPC hot seat on the last afternoon, but I think all were tested with an unusual case of Vanishing White Matter Disease.
Well-organised, with an array of first-class presentations, interested delegates – and speakers – at all stages of training, this year’s meeting was highly enjoyable and stimulating. Onto another Celtic nation in 2014, Wales.
Read Teva’s debate from the ABN, Does Progressive Multiple Sclerosis start on Day 1?
ACNR 2013; 13:4:30