The Association of British Neurologists autumn meeting was held on 12 October, barely a stone’s throw from the National Hospital for Neurology and Neurosurgery. The meeting was well-attended by upwards of 200 delegates, and opened by the ABN president Mary Reilly.
The first session took on an almost accidental theme of neurology absorbing areas of traditionally psychiatric practice. Michael Zandi gave an update on autoimmune encephalitis; he described the unreliability of some autoantibodies, and therefore the renewed importance of the clinical diagnosis. This was highlighted with voltage-gated potassium channel complex antibody: they may be artificially elevated in, for example, snake handlers, with regular exposure to dendrotoxin; testing for LGI1 and CASPR2 would be more reliable. He also outlined the identification of some new autoantibodies, including anti- IgLON5, dipeptidyl-peptidase 6 and neurexin 3. Finally, he explored the question of whether some first-episode psychosis was actually autoimmune encephalitis, and described the initial stages of an ongoing trial aimed to assess this.
Orla Hardiman proceeded to discuss the future of motor neuron disease (MND), with insights gained from the use of an MND register in Ireland. She described how little progress had been made on developing disease-modifying agents, but underscored how the multiple disease mechanisms underlying MND would be unlikely to uniformly respond to a single agent. She went on to explain how use of the register had identified a higher incidence of psychiatric and developmental conditions in families of patients with MND, including bipolar disorder, autism, suicide and schizophrenia; indeed, amyotrophic lateral sclerosis and schizophrenia had been shown to share some susceptibility genes. The neurological absorption of psychiatry continued!
Nicholas Fox gave an update on dementia, a condition still shared between psychiatry and neurology. Considering the increased uptake of private, home-delivered genetic testing, he offered a reminder of the important susceptibility genes: specifically, ApoE- 4. The search for biomarkers continues, with debate surrounding the relevance of amyloid accumulation before clinical presentation – perhaps Alzheimer’s disease can be diagnosed before Alzheimer’s dementia; clinical trials are ongoing.
Session 2 began with Anton Emmanuel discussing neurogastroenterology, perhaps another specialty set to succumb to the neurological advance. He described his work in patients with spinal cord injury, and how treatment for bowel function and continence needs to be individualised. It was interesting to learn about the interaction of gut health and psychological stress: the ability of mice to tolerate stress was diminished by elimination of the gut biome, and a restrictive diet increased anxiety and worsened confusion.
Exciting developments in acute stroke care were subsequently presented by Iris Grunwald. She described the development of a mobile stroke unit, including a CT scanner, which is now in use in East Anglia. By effective use of telemedicine and teleradiology, it has facilitated early stroke treatment in 60% of patients referred, versus 4% of those who had to come to hospital. The hope is that this will allow efficient triage to appropriate centres (including need for thrombectomy) and consequently improve outcomes.
The Autumn Lecture was delivered by Gordon Plant, following an enthusiastic citation from Hadi Manji. It was romantically titled ‘The Season of Mists and Mellow Fruitfulness of John Keats,’ and opened with a reflection on the literary association of autumn with advancing age. As suggested by the title, his preferred metaphor was Keats’, where autumn was the time to reap the bounty of previous seasons, which he described both personally and professionally. His recent identification of the phenomenon of smartphone blindness (often misdiagnosed as a transient ischaemic attack) confirmed autumn was indeed a fruitful season.
Session 3 opened with a brief update on the Shape of Training, and was followed by David Bennett discussing neuropathic pain. He used some inherited pain disorders, such as inherited erythromelalgia, to highlight the role of the Nav1.7 ion channel in pain, and in particular speculating whether other as-yet-unidentified mutations in the channel could act as risk factors for neuropathic pain. A recent systematic review had confirmed current management is well-supported by the evidence, but patients often did not reach therapeutic doses.
A fascinating insight into veterinary neurology from Holger Volk of the Royal Veterinary College followed. His presentation focused mainly on seizures and epilepsy, and contrasting the reaction of online audiences to videos of either pets (sympathy) or humans (ridicule) having seizures. He highlighted the continuing use in animals of certain anti-epileptic drugs now unfashionable in human medicine (for example phenobarbital) and how owner preference results in a large number of affected animals going untreated. LGI1 and CASPR2 made a cameo appearance, and Dr Volk closed with a warning on selecting pets for their paedomorphic traits, noting a preponderance of hydrocephalus secondary to dysfunctional skull anatomy.
Alasdair Coles opened the final session with an update on new therapies in multiple sclerosis (MS). Noting the high number of biologics coming to market, he highlighted that the goal of therapy was now improvement in function, rather than slowing of progression. The challenges now surrounded what effect these new therapies have on secondary progression, and ensuring greater access to these therapies. Professor Coles finished by demonstrating how the costs of MS drugs (including non-biologics) had risen steeply in comparison to non-MS drugs, and how none of the trials in support of biologics occurred outside of pharmaceutical companies.
Jon Sussman provided a refresher on myasthenia gravis, reporting improvements in prognosis with earlier immunosuppression. He advocated the use of prednisolone, and encouraged faster rates of dose increases. He also described new data on thymectomy: patients receiving thymectomy were able to maintain remission on lower doses of prednisolone, with a commensurate increase in strength. More patients following thymectomy were able to stop steroids altogether. Dr Sussman recommended use of thymectomy in new generalised myasthenia and in seropositive ocular disease.
The final talk was delivered by Fiona Godlee, editor of the BMJ, titled ‘Fewer Tests, Choosing Wisely’. Noting improvements in life expectancy alongside increases in health spending (although much progress was due to public health measures), she contrasted the similarly-increasing levels of over-diagnosis. Features of the phenomenon include an increase in incidence of a diagnosis with stable mortality (as seen with pulmonary embolism); risk factors being called diseases (such as pre-diabetes); and a shift in diagnostic definitions without greater benefit. Commenting on dementia, she explained that the expectation that treating pre-dementia will improve outcomes (described by Dr Godlee as a ‘leap of faith’) was not yet supported by the evidence. These extra diagnoses could be a burden for patients with no obvious gain. Building on Alasdair Cole’s comments, she closed by lamenting the lack of raw data for many of the interventions we use, and argued that drug companies should not be allowed to test their own products.
This closed what had been a day of interesting, engaging and provocative talks, with descriptions of detailed neuroscience and their application to clinical practice.
The ABN next meets in Birmingham for their Annual Meeting on 9-11 May 2018.