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Clinical Proceedings of Neurology Update-2023

By Mubarak Ali

Karachi: Four papers were presented by speakers in the first scientific session of the recently concluded Neurology Update 2023 organized by Pakistan Society of Neurology on second day of the conference December 16th 2023.

Dr. Athar Javed, Dr. Mughis Shirani, Dr Mohsin Zaheer, Dr. Fowzia Siddiqui,
Dr. Arsalan Ahmed, Dr. Ahsan Nauman and Dr. Khalid Sher speaking at the Interna-tional Neurology Update organized by Pakistan Neurology Society at Karachi from March 15th March 18th 2023.

Dr. Ahsan Numan was the first speaker who discussed recently approved therapeutic & diagnostic options in neurology and reviewed the last five years literature. Artificial Intelligence, ChatGpt, he stated can help in early detection and screening. AI has lot of advantages but don’t have clear preventive strategies, he added.

Prof. Arslan Ahmed discussed genetic testing for diagnosis of rare inherited neurological disorders. He traced the history of Genetic testing and informed that this facility first became available in the First world countries. The Duchenne muscular dystrophy gene was discovered in 1986 followed by several neurological disorders including the discovery of SOD1 gene for familial ALS. Modern day next generation sequencing (NGS) is a much faster technology and genetic test result can be available in 14 to 28 days. There are several genetic reference laboratories in USA, Europe China and other developing countries offering genetic testing for targeted gene panels like epilepsy and neuromuscular panel. There is a dire need to establish our own reliable reference labs for genetic testing in Pakistan. It will be more accessible for our patients and save cost as well, he remarked.

Dr. Wajid Jawaid (Moderator), Dr. Mian Ayaz ul Haq alongwith Dr. Muhammad Adnan Aslam chairing a session on second day of the Neurology Update conference organized by Pakistan Neurology Society held at Karachi from
March 15th 18trh 2023.

Dr. Fowzia Siddiqui discussed comparative efficacy and Anti-Seizure drugs. Epilepsy, she stated is a complex disorder of which seizure is a symptom. The term anti-seizure medication is being replaced with the term antiepileptic drug because such drugs provide symptomatic treatment only and have not demonstrated to alter course of epilepsy. More than thirty ASDs are available for clinical use, however proportion of drug refractory epilepsy remains the same. However safety and tolerability has improved with better pharmacokinetics, minimal drug interactions besides better understanding of synergistic ASD combinations.

Dr. Khalid Sher talked about monoclonal Antibodies and their efficacy in treatment of neurological disorders. The production of monoclonal antibodies (mAbs), he said, was first described in 1975 when Kojler and Milstiuen developed methods for their isolation from hybridoma cells. In last four decades several mAbs have been developed and approve by FDA. mAbs have evolved to become more efficacious and less immunogenic. He discussed in detail monoclonal antibodies used in neurological disorders and their safety profile.
In the second session Dr. Zarine Mughal discussed preventing stigma in epilepsy, Challenges and answers. Epilepsy, she stated is as old as mankind. A major challenge for patients with epilepsy is their caretakers and care givers is the multitude of ways that epilepsy is perceived and misperceived.

The unpredictable nature of seizure, the feeling of helplessness of those who witness them results in patients with epilepsy being stigmatized and isolated. Epilepsy stigma persists because it is not properly addressed by the society. If done, it is not sustained and effective. Setting may be different, but the knowledge regarding causes of epilepsy is still limited and needs worldwide epilepsy awareness. Epilepsy stigma is universal, spreading with immigration. She presented the activities of Comprehensive epilepsy control programme of Pakistan started in 2001 by likeminded individual’s professionals and nonprofessionals. Pakistan awareness project will be a great international model and will be lovely to develop further to promote as something that could be adapted and developed elsewhere. She dedicated her presentation to Late Prof. Hasan Aziz, Emeritus Professor of Neurology, Jinnah Postgraduate Medical Centre, and founder of Neurology Research & Patient Welfare Fund.

The Surge of HIV in Pakistan, concerns for Neurologists was the topic of presentation of Prof. Muhammad Athar Javed. The main form of transmission of HIV, he sated are sexual contact, from the mother to the fetus, breast feeding and sharing syringes. The first reported case in the world emerged in 1980’s. Since then over 75 million people around the globe and approximately 39 million are estimated to be living with HIV at the end of 2023. In 2022 six hundred thirty thousand patients died from HIV related causes and 1.3 million acquired HIV. Pakistan stands at 35th position and India 3rd with the most number of patients affected by the disease.

As of September 2023 Pakistan have two hundred ten thousand HIV cases, registered with NACP 63,202, women 41,000 men 170,000, children below 15 years are 4600. Talking about neurological manifestation he said the HIV affects both CNS and PNS. Fifty percent have clinically apparent neurological disease, 20% of HIV patients present with neurological manifestation at the time of diagnosis and 90% patients have neuropath logical changes on autopsy. Our target of 2025 is that 95% HIV (PLHIV) should have a diagnosis and should be taking antiretroviral treatment and must achieve a suppressed viral load.

Dr. Mughis Sheerani discussed emerging trends in treatment of Multiple Sclerosis. He pointed out that a master clock in the brain coordinates all the biological clocks in a living thing keeping the clock in sync. The master clock is group of about 20,000 nerve cells (Neurons) that forms suprachiasmatic nucleus or SCN. The SCN is in the hypothalamus and receives direct input from the eyes. Medications should be started as early as possible to decrease the chances of disability and slow down the progression.

Several new medications are now available for different types of multiple sclerosis and medication can be chosen according to the tolerability and nature of the illness. Important consideration should be easy availability and cost of medication. he stated. Dr. Mohsin Zaheer speaking about Circadian Rhythm Disorders and Neurological Health said that it can influence important functions in our bodies such as hormone release, eating habits, digestion and body temperature. Lack of sleep reduced cellular of misfolded neurotoxin proteins which are involved in major neurodegenerative diseases like Alzheimer’s disease and Parkinson’s disease. Lack of sleep also affects the glymphatic system, a glial dependent metabolic waste clearance pathway causing accumulation of misfolded faulty proteins in synaptic compartments resulting in cognitive decline.

Deciphering the precise relationship between the circadian system and neurological disease contributes to comprehending the clinical manifestation and the development of novel therapeutic approaches. Circadian system modulates many aspects of the pathophysiology of neurological disorders such as cortical excitability, immune response and pathological protein synthesis. Patents with neurological disease show rhythm disorders of melatonin, cortisol and CCG’s. Differential timing of medication doses, circadian rhythm improvement by zeitgeber and pharmaceutical targeting CCGs are expected to improve outcomes and perhaps even slow down the progression of these disabling neurological diseases, he added.

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